PERITONITIS.
Acute: Chronic; general; local; idiopathic; traumatic; surgical; accidental; perforation; strangulation; cachexia; microbian almost always; aseptic foreign bodies escape into bowel: Castration; gastric or intestinal rupture or ulcer, enteritis, obstructions, cold storms, draughts, chills, all lower resisting power of tissue; generalization through peritoneal serum. Non-infective peritonitis from chemical irritants. Paves the way for microbes of ingesta. Rheumatic peritonitis, tuberculous, actinomycotic, microbes differ.
All inflammations of the peritoneum go under this general name. At the same time clinical and pathological distinctions have been made with the view of distinguishing more precisely different classes of cases. Thus it is described as acute and chronic, general and local, idiopathic and traumatic, surgical, accidental, or by perforation, by strangulation and by cachexiæ.
The advance of bacteriology has greatly simplified our views of the disease, as microbes are found to be at work in practically all cases. If we could exclude microbes from this membrane, peritonitis would be practically abolished, portions of aseptic powdered glass, sponge or gauze can be left in the abdominal cavity with comparative impunity, the tendency being, as shown in the dog, to coat themselves with a fibrinous exudate, and to make their way into the intestines through which they escape (Sternberg, Jalaguier and Manclaire). Hence it is that peritonitis is to a very large extent the result of a traumatism (castration, penetrating wound of the abdomen, contused wound of the abdomen), or of a rupture or ulceration of the stomach or intestine, through which the microbes make their way into the peritoneal cavity. In enteritis, congestions, strangulations, intussusceptions and obstructions of the bowels, the cause is the same, the microbes making their way with greater ease through the coats of the bowels in which the circulation and nutrition are impaired and the power of resistance diminished. Finally the occurrence of the disease as a consequence of exposure to cold or wet, of exposure in a cold rain or snow storm, of standing in a draught when perspiring, or plunging into cold water when heated and fatigued, or drinking ice cold water when in a similar condition, may in most cases be explained on the same grounds. The germs in this case had already gained access to the blood, but were helpless to accomplish much harm, until by chilling, the resisting power of the system was lowered and an occasion furnished for their successfully colonizing the peritoneum. Parallel cases are found in the frog which is immune from anthrax until it is heated, and in the chicken which is immune from anthrax until chilled. Reduce the vitality of the system and the germ which was already present, and up till now harmless, takes occasion to colonize more or less destructively.
This view also furnishes an explanation of the tendency of local peritonitis to become generalized. In the scanty liquid which bedews the surface of the abdominal organs, the microbes grow, multiply and spread; by the constant peristaltic movements of the bowels and their rolling upon each other this extension is largely favored; and the tendency to generalization will be in ratio with the potency of the invading germ, and the general or local weakening of the invaded tissues. With a limited infection wound in an otherwise healthy peritoneum and system, and invasion by a pus coccus only, the infection may not succeed in extending from its primary centre, but with a debilitated system, an extended enteritis, or when the invasion is made by septic germs it is likely to become speedily and fatally generalized.
Pernice has shown, however, that peritonitis may occur independently of infection. The injection into the cavity of concentrated mineral acids, acetic acid, phenol, nitrate of silver and other powerful antiseptics determine inflammation by their purely irritant action. By weakening the tissues of the bowels these in their turn pave the way for the escape of the microbes from the contents, and to the occurrence of a secondary infective inflammation.
Cases occur as a manifestation of rheumatism, tuberculosis, actinomycosis and other affections which will be treated at greater length under these respective heads.
The microbes would seem to vary greatly. Soula attributes infection of castration wounds mainly to the bacillus of malignant œdema which is 3 to 3.5 μ long and 1 to 1.1 μ broad often bearing a refrangent spore at one end (is sporeless in the peritoneal cultures), and growing out into chains in artificial cultures. They are anærobic, liquefying, motile, easily stained by aniline colors, but bleached by iodine.
In other forms of peritonitis the bacillus coli commune is found and probably comes from the intestinal contents where it is present in all our domestic animals.
In man Fränkel found the bacillus coli communis 9 times, streptococcus pyogenes 7 times, bacillus lactis aerogenes 2 times, micrococcus pneumoniæ crouposæ 1 time, staphylococcus pyogenes aureus 1 time. Flexner found the proteus vulgaris.