A system of practical medicine. By American authors. Vol. 1

by Unknown

The symptoms of GENERAL PERITONITIS.—This form generally begins with the usual symptoms of pelvic inflammation, but the tenderness, which at first was limited to the side of the uterus, gradually spreads over the entire abdomen. The abdominal pain is of a tearing, lancinating, sometimes colicky character. It is increased by the slightest bodily movement, by jarring of the bed, or even by the weight of the bed-clothes.

As a consequence of the peritoneal inflammation and of the accompanying exudation, the muscular walls of the bowels become paralyzed, and tympanitic distension results from the accumulation of gases. In the dependent portions of the peritoneal cavity it is often possible to demonstrate by percussion the presence of fluid exudation, though distinct fluctuation is rarely to be made out. The size of the abdomen is due much more to the tympanites than to the amount of effusion. Sometimes the liver, with the diaphragm, is pushed by the swollen bowels to the level of the fourth or third rib, and exercises such a degree of compression upon the posterior portion of the lungs as to place the patient in danger of suffocation. The respirations are jerky and attended with a moaning sound.

The loss of muscular power in the intestines permits the contents of the middle portion to pass unchecked toward the duodenum, and thence, upon accidental contractions of the abdomen, they may pass to the stomach and be ejected by vomiting. The first vomited matter has a dark-green color, and that ejected afterward presents the color of intestinal matter. Constipation at the outset may be subsequently followed by colliquative diarrhoea.

The fever begins, as a rule, though not always, with an intense chill, the temperature rises to 104°, and the pulse becomes small, hard, and resistant. Its frequency rapidly increases, varying from 120 to 160 beats to the minute. The skin is sometimes dry, sometimes dripping with perspiration. In fatal cases, as the end approaches, the temperature frequently falls, while the pulse becomes more rapid, the face assumes a pinched, anxious expression, sweat gathers upon the forehead, the extremities grow icy cold, and the patient dies in collapse. The duration of peritonitis averages not more than from four to six days.

In cases of recovery the pulse improves, the vomiting ceases, and the tympanites disappears. The diffuse exudation then becomes converted into circumscribed tumors, which on palpation are felt on the side of the pelvis and extending upward to the level of the umbilicus. Upon internal examination the uterus is often found depressed by the weight of the fluid, which likewise may bulge the cul-de-sac of Douglas into the pelvic cavity. Sometimes the exudation may become encysted above the pelvis and leave the contents of the latter free. In still other cases the uterus may become attached high up to the abdominal walls, so that the vaginal portion disappears and the os is reached with difficulty.

The peritoneal exudation may, as in pelvic inflammations, become absorbed and disappear. When, however, it is surrounded by loops of intestines it is apt to undergo purulent and septic changes, and the abscesses may then become discolored and filled with stinking gases. The patient, whose previous improvement has been watched with delight, now loses appetite, the pulse becomes frequent, the strength fails, and death may follow from septic fever or from rupture of abscess into the abdominal cavity.

In the pyæmic form—a still more deadly variety of peritonitis—the symptoms differ materially from those which have been recounted. As, however, it constitutes only a single one of the pathological changes connected with the poisoning of the blood through the lymphatic system, its consideration belongs properly to the study of the septic infection.

The symptoms of SEPTICÆMIA LYMPHATICA.—The symptoms of blood-poisoning in the infectious diseases of childbed vary to a considerable extent according to the channel through which the septic germs enter the general circulation. In the murderous epidemics which prevail in lying-in hospitals the lymphatics are, as a rule, the vessels primarily invaded. It is to this form that the cases already described belong, where, with diphtheritic patches upon the utero-vaginal canal and sero-purulent oedema of the parametrium, there are associated pyæmic peritonitis and deformation of the blood-corpuscles; or where, following the migrations of the round bacteria, the serous cavities become successively involved, septic vegetations gather upon the heart, and the glomeruli of the kidneys become choked with micrococci. The lymphatic form of septicæmia develops soon after labor, and is always ushered in by a chill. The temperature rises to 104° or even higher, and the pulse is thin and frequent. The abdomen swells rapidly, without being especially painful. Indeed, painless distension of the intestines is one of the characteristics of an acute invasion of the lymphatics. Peritoneal effusion is absent in cases which run a rapid course, and is distinctly recognizable only in a peritonitis of long continuance. The effusion is not so much due to exudation as to a transudation of serum with which micrococci are commingled. At the same time the tongue is moist, but slightly coated, and at times quite clean. Sometimes there is diarrhoea due to catarrh or to a diphtheritic affection of the colon. When the bowels have been constipated the administration of a purgative may provoke discharges which it may be found difficult to arrest. The skin is bathed in perspiration. At the beginning and during the course of the disease bleeding at the nose is of not infrequent occurrence.

Toward the end the pulse runs up to 140 to 160 beats, while in many cases the temperature falls. Immediately after death the heat of the body may for a short time exceed the highest point reached during life. The respirations are superficial and jerky. In many instances the face, the neck, and the fingers are blue from defective oxygenation of the blood. At the same time the skin becomes clammy and the extremities cold.

The sensorium, in cases which run a rapid course, is usually affected at an early period. The patients appear somnolent, are restless in bed, have light delirium, and respond only when spoken to loudly. As a rule, they make but little complaint, and, were it not for the dyspnoea, would have nothing to disturb their sense of comfort. Very few, even as death approaches, have any idea of the danger that threatens them. Now and then, in place of stupor, great restlessness, and even a maniacal condition, is developed. Albumen is usually found in the urine.