ACUTE PERITONITIS 329 SURGERY OF THE PANCREAS The advance of pancreatic surgery has been greatly hindered by the difficulties of diagnosis and by the great danger attendant upon operation on this gland, particularly from leakage of the pancreatic secretion, which seriously irritates the peritonæum. The results of operations in chronic pancreatitis are encouraging. DISEASES OF THE PERITONÆUM, OMENTUM, AND MESENTERIC GLANDS The peritoneum is the inner lining of the abdomen and pelvis, and is reduplicated at various points so as to partially or completely envelop the various intrapelvic and intraabdominal organs. Clinical Varieties of Peritoneal Inflammation. The clinical varieties are ascites (hydroperitoneum), acute peritonitis (diffuse and localized), subphrenic abscess, chronic peritonitis, diffuse and localized (simple, tuberculous, syphilitic, gonorrhœal, and malignant). Peritonitis is an inflammation of the peritoneum, and on opening the abdomen in such cases we find clear or cloudy or hæmorrhagic effusion, creamy or foul pus, and plastic lymph deposits, and in case perforation of the intestine has taken place we may find fæcal matter in the abdominal cavity. Clinically, we recognize acute, subacute, and chronic peritonitis with periods of quiescence and periods of exacerbation of inflammatory symptoms. Peritonitis may result from injury with infection (including imperfect surgical technique), from an extension of an inflammatory process of a neighboring organ with or without perforation, and from metastasis through the blood and lymph channels in all infectious and septic processes. We have evidence of prenatal peritonitis in the shape of intraabdominal adhesions and bands. In the new-born septic peritonitis may develop from the navel. In childhood and adult life severe enteritis, appendicitis, typhoid ulcer, tuberculosis, trauma, and infection are the exciting factors in peritonitis. When the causative factor is unknown, we speak of idiopathic peritonitis. In the present state of our knowledge this term is too indefinite and unsatisfactory and had better be dropped. ACUTE PERITONITIS A primary, or idiopathic, peritonitis is supposed to occur as a terminal event in chronic nephritis, arteriosclerosis, and gout. Acute primary infection is theoretically as likely as the infection of any other serous membrane through the blood, but practically almost all of our cases of peritonitis are secondary, viz.: By extension of a neighboring inflammation, by perforation of gastrointestinal ulcers (simple, tuberculous, cancerous, stercoraceous, or typhoid, or due to intestinal stone), by rupture of any neighboring pus sac, as in appendicitis, pyosalpinx, and by pyæmic infestion (puerperal infection). Symptoms. When the patient is already ill and a slow spreading general peritonitis develops as a complication, the onset may be sudden or slow and insidious. The pain becomes general, the abdomen tender, distended, and tympanitic, and the patient's knees are drawn up to minimize. abdominal tension. The respiration is costal and rapid (30 to 40), vomiting may be persistent (green vomit), and the pulse is rapid and small (110 to 150). The temperature may be normal or subnormal or high. The urine contains much indican, and there is a tendency to collapse. The face is anxious, the skin is cold, and the mind may be quite clear. On examination the abdomen is found motionless or rigid, and on auscultation we may hear peristaltic restlessness, or in case of intestinal paresis we notice an absence of intestinal gurgling. The hepatic dulness soon disappears and an effusion may become manifest. Differential Points. In severe enterocolitis simulating peritonitis there is profuse diarrhoea with only moderate meteorism and abdominal rigidity. In intestinal obstruction there is no decided rise of temperature, no passage of flatus or fæces, and fæcal vomiting generally occurs. The high temperature and rigid abdomen are marked only in the later stages. In rupture of an ectopic gestation sac there is a characteristic previous history-no fever, breast signs, menstrual irregularities, with a small pulse and collapse after the rupture. Acute localized peritonitis occurs principally in three varieties: Pelvic peritonitis, peritonitis around the appendix, and subphrenic peritonitis or abscess. Pelvic peritonitis is discussed under Gynecological Memoranda. Appendicular abscess is discussed under Appendicitis. Treatment of Acute Peritonitis.-The management of acute general peritonitis depends upon circumstances and the underlying cause. Hot water or ice bags may be applied locally over the abdomen and full doses of opium may be given by the mouth, or morphine (gr. 1) and atropine (gr. 6) subcutaneously. The diet should be diluted milk, slimy gruel, white of egg in water, tea, peppermint tea, champagne, water ice, ice cream, tropon, 3j to a cup of tea, and ice to suck. If vomiting persists, rectal alimentation must be relied on, and one drop of tincture of iodine should be given in a teaspoonful of sweetened peppermint tea every hour. The lower bowel may be flushed with a pint of warm saline solution once or twice a day. When the infection is widespread, it may become necessary to open the abdomen and flush with hot salt water. There are no strict rules to guide us as regards indications for operative interference in diffuse peritonitis; each case must be judged upon its merits. A localized peritonitis and abscess formation require prompt incision and drainage. As a heart stimulant, camphor in oil, subcutaneously, or benzoate of sodium and caffeine, subcutaneously, is indicated. The PROGNOSIS in diffuse peritonitis is grave. The pulse is the best index to the gravity of the infection. A rapid pulse and incessant vomiting and high septic temperatures, all combined, give a fatal outlook. SUBPHRENIC AND CHRONIC PERITONITIS 331 SUBPHRENIC PERITONITIS (ABSCESS) A subphrenic abscess is an accumulation of pus between the liver and the diaphragm or between the stomach, the spleen, and the diaphragm. Causation.-Perforation of a gastric or duodenal ulcer. Upward extension of any intraperitoneal inflammation or abscess, or any form of suppuration taking its origin in the liver, gall bladder, stomach, spleen, circumrenal tissue, pancreas, appendix, intestine, hydatid cysts, or trauma. Downward extension of an empyema through the diaphragm. In some instances we have to deal with a subphrenic abscess containing air-pyopneumothorax subphrenicus. Subphrenic abscess occurs in adults and in children. The writer has seen two instances in children, one taking its origin from the perforated appendix in a girl of five and the other from a perforation of the ascending colon, left side abscess, in a girl of ten.. Both patients recovered after an operation. Symptoms of Subphrenic Abscess.-The symptoms may come on abruptly or insidiously. In addition to the general symptoms of sepsis, such as fever, chilis, and rapid pulse, there are localized pain and tenderness, vomiting, and embarrassed respiration. There may be bulging of the tissues on the side in which the abscess is located. Sometimes a succussion sound may be elicited. If the abscess contains air, there will be an area of tympanitic percussion sound between the liver and lung. Aspiration under such conditions may bring forth foul smelling air instead of pus. Often a swelling with local oedema is noticeable. A friction sound may be heard over the complementary pleural space (9th to 11th rib). If there is much pus, the liver dulness will extend unduly upward. Similar phenomena will be elicited on the left side, minus the liver dulness. Eventually the subphrenic abscess may rupture into the thoracic cavity and communicate with a bronchus. In suspected cases aspiration should be done in the 7th or 8th interspace in the mid-axillary line or immediately above the supposed liver dulness. Prognosis. The prognosis is grave. Early recognition and prompt. operation and drainage may save life. Incision should be made over the centre of the dull area or wherever the probatory puncture reveals pus or foul air. As a rule a resection of the 8th, 9th, or 10th rib in the mid-axillary line will be indicated, or an incision in the interspace between the 7th and 8th ribs in the anterior axillary line. Should this lead into the free thoracic cavity, a second puncture downward may be made in order to locate the pus. CHRONIC PERITONITIS The peritoneum may participate in the chronic inflammatory condition of organs in contact with it (localized chronic peritonitis) and may suffer by reason of chronic infection of the serous membrane itself, resulting in diffuse adhesive peritonitis. Apart from cancer and tuberculosis, a proliferative chronic peritonitis is described by Osler, which is found in chronic alcoholism and possibly in syphilis. The symptoms are persistent abdominal pain of a colicky character and occasionally intestinal obstruction due to fibrous bands. On opening the abdomen in such cases, the coils of the intestines are found matted together, the peritonæum is thickened, the omentum forms thickened masses, and a serous effusion may be present. The most interesting form of chronic peritonitis is the tuberculous variety, which is seen more often in children and is described in the pædiatric section of this book. CANCER OF THE PERITONÆUM AND OMENTUM This is usually secondary to malignant disease of the abdominal or pelvic organs, and is observed in persons past middle life. There is persistent ascites or bloody effusion, with loss of flesh and cachexia, and large nodules are felt on palpation. Differential Points.-Tuberculous peritonitis occurs mainly in children. In hydatid disease hooklets may be found in the puncture fluid. In doubtful cases an exploratory laparotomy is to be done. Cancer of the peritonæum is incurable. Morphine and opium should be given to allay the pain. THE OMENTUM AND MESENTERY These structures frequently participate in whatever befalls the peritonæum, and thus we observe syphilis, tuberculosis, and cancer of the omentum, the diagnostic features of which have been discussed. Cysts of the Omentum or Mesentery containing a brownish fluid have been observed. Hydatid cysts are rare. The TREATMENT is by aspiration and laparotomy. Thrombosis of mesenteric blood vessels gives symptoms of peritonitis. MESENTERIC AND RETROPERITONEAL GLANDS The lymph nodes in this region may become acutely inflamed or may undergo tuberculous, syphilitic, or malignant degeneration. Tabes Mesenterica, a tuberculous glandular enlargement, presents a distinct clinical picture and may be associated with tuberculosis of the peritoneum and intestine. Children suffering from this disease are puny, anæmic, and wasted, with a large tympanitic abdomen, diarrhoea, and fever. In cases difficult to diagnosticate the tuberculin test may be employed. A blood examination is of value, also a temperature record extending over two to three weeks. Indentable scybala should not be mistaken for enlarged glands. The prognosis is uncertain. The treatment is that of tuberculosis in general. CHAPTER XI THE CIRCULATORY SYSTEM SYNOPSIS: Remarks on the Clinical Pathology of the Circulation.-Congenital Heart Defects. Clinical Aspects of Hypertrophy and Dilatation.-Acute Circulatory Failure (Heart Strain, Shock, Collapse).—Endocarditis.—Pericarditis.-Pericardial Adhesions. (Continued in Next Section.) REMARKS ON THE CLINICAL PATHOLOGY OF THE CIRCULATION AN efficient circulation is of fundamental importance to the organism and depends upon the condition of the motor (heart) and the elasticity of the vessels. Vasomotor influence is exerted in such a manner that normally one organ may be hyperæmic and another anæmic without disturbing the general circulation. There is also an aspirating mechanism furnished by the right heart and the lungs, supplemented by the contractions of muscles and fascia. Owing to a well recognized reserve power, the accommodation of the heart muscle to the various demands made upon it is very complete in health. Great and continued expenditure of force is followed by hypertrophy of tissue, just as in the skeletal muscles. Thus, any impediment to the circulation, be it located in lungs, kidneys, liver, or blood vessels, will put a strain upon the heart and produce hypertrophy, that is, more heart muscle, in order to overcome the resistance. The so called reserve power in the heart is present in hypertrophic hearts as well as in normal hearts, although not in the same degree. When arterial pressure is permanently increased, there is danger of "rupture of capillaries (on exertion), particularly in arteriosclerosis. Unusual heart fatigue and heart strain may be followed by distention or dilatation of the heart. Recovery from distention may take place sooner or later, but occasionally a heart is thus permanently damaged. strain is particularly dangerous in chronic degeneration of the heart muscle or following acute infectious fevers, such as typhoid or diphtheria, and in pertussis, etc. The position and size of the heart are made out by means of inspection, percussion, palpation, auscultation, and direct vision through the agency of x rays. Such knowledge must be acquired at the bedside and cannot be learned from books. In transposition of the viscera the heart is sometimes located on the right side (dextrocardia). In a rhachitic thorax the position and size of the heart cannot be judged if the left nipple is taken as a guide. In such cases it is best to take our measurements from the midsternal line. The lungs cover the heart and large blood vessels, excepting a part of the right ventricle. The area of the uncovered heart is called the area |