can be effectively employed in this stage, and to determine the measures most likely to prove effective. The object is either the destruction of the worms or their expulsion from the intestines. Cathartics are indicated for the latter object, but clinical experience has yet to ascertain what toxical anthelminthics are best suited to destroy this parasite. After the trichinæ have left the intestines, the opportunity for destroying or expelling them has passed. Recovery now depends on the ability of the system to endure them until they become encysted. Measures to palliate pain, to restore disordered functions, and to support the powers of life, are indicated, and the success of the treatment will depend on the judicious employment of measures for these ends.

The prevention of this disease is the great practical benefit to be derived from its discovery. The mode of prevention is sufficiently simple, viz., abstaining from meat, more especially the flesh of swine, not thoroughly

cooked.

Animals not entozootic, such as snakes, slugs, and lizards, are not infrequently exhibited to physicians as having passed from the alimentary canal. It is a popular notion that they may live and grow indefinitely within the stomach and intestines, and give rise to a variety of morbid symptoms. In the great majority of cases, the statements with respect to the passage of these animals are simply falsehoods, proceeding generally from a morbid exaggeration of that craving to become objects of curiosity and interest which enters largely into the mental constitution of many persons. In some cases, however, the statements are honestly made, persons being deceived. Prof. Dalton has recently performed a series of experiments to ascertain the duration of life of the common garden slug (Limax agrestis) and the water-lizard (Triton millepunctatus) after having been introduced within the stomach of the dog. The former were found completely dead at the end of nine and a half minutes, and no traces of them were discoverable when the dog was killed an hour after their introduction. The lizards were found perfectly dead, and about to undergo the digestive process, at the end of fifteen minutes. It is safe to set down all the cases referred to as cases of either self-deception or imposition.

CHAPTER X.

Acute General Peritonitis-Anatomical Characters-Clinical History-Pathological Character -Causation-Diagnosis-Prognosis-Treatment-Partial Peritonitis-Chronic Peritonitis

-Hydro-Peritoneum.

THE peritoneum, in structure and functions, does not differ materially from other serous membranes. This, like other serous membranes, may be the seat of inflammation. Inflammation here, as elsewhere, may be acute, subacute, or chronic. The whole or greater part of the membrane may be inflained, and the inflammation is then said to be general; or the inflammation may be more or less circumscribed, and is then distinguished as partial. Inflammation of this membrane, agreeably to the nomenclature of inflammatory affections, is termed peritonitis, and this name is in common use.

1 American Journal of Medical Sciences, April, 1865.

In

treating of peritonitis, it will be convenient to consider separately acute, general peritonitis, partial peritonitis, and chronic peritonitis. Some writers divide the disease into several varieties, according to its different causes or the circumstances under which it is developed. It will suffice to notice these diversities under the head of causation. Occurring as an epidemic in childbed, however, it claims separate consideration. But it does not fall within the scope of this work to consider puerperal peritonitis fully or separately. It is treated of at length in works on obstetrics and the diseases of women, and to these the reader is referred.

ACUTE, GENERAL PERITONITIS.

ANATOMICAL CHARACTERS.-The appearances after death, in different periods of the disease, are essentially the same as in other serous inflammations; for example, in pleuritis or pericarditis. Redness, arborescent and punctiform, chiefly from hyperemia in the subserous areolar tissue, exists, especially if death take place early. The degree of hyperæmia varies much in different cases, and is not to be taken as any criterion of the intensity, or otherwise, of the inflammation. Nor is redness from hyperæmia, be it ever so marked, alone adequate proof that inflammation existed. More or less of the inflammatory product, lymph, is always present. The quantity varies much in different cases. It is sometimes abundant, forming a coating more or less thick, extending over the solid and hollow viscera and the parietal portion of the membrane; in other cases, the quantity is moderate or small, adhering to the membrane in patches. It is apt to be most abundant at, and may be limited to, the portions of the intestines which are in contact with each other, frequently agglutinating them together and to the abdominal walls. The quantity is sometimes slight and spread over the surface in a thin layer so as to escape observation without close attention and scraping the serous surfaces. It is soft and gelatinous if recently exuded, and dense according to its age. The peritoneal sac usually contains effused liquid, the quantity varying much in different cases. The liquid is turbid from lymph, and contains flakes of lymph in more or less abundance. Occasionally it is reddened by the admixture of blood. The serous membrane is more or less opaque and softened. The subserous areolar tissue is morbidly brittle, so that the membrane is more easily detached than in health. In certain cases, and especially if the duration of the disease have been considerable, the peritoneal sac contains pus in more or less quantity. If the peritonitis be connected with perforation of the stomach or intestines, on opening the sac, fetid gas escapes, and the contents of these hollow viscera may be found within the serous cavity. Sphacelation of the membrane rarely if ever occurs, unless the peritonitis be connected with strangulation or invagination of the intestine. Ulceration from without is extremely rare. Lesions situated in other structures than the peritoneum, and involved in the causation of the peritonitis, are found in a large majority of cases-such as intestinal perforation, invagination, rupture of the urinary or gall-bladder, abscess of the liver or in other situations, etc. etc. Associated lesions are always to be sought for, if not at once apparent. Finally, if life be sufficiently prolonged, morbid adhesions of the intestines to each other, to the solid viscera, and of the opposing parietal and visceral portions of the membrane, are observed. These adhesions are due to the formation of adventitious tissue, as in inflammation of other serous membranes. The adhesions may be more or less extensive. They may consist of bands or bridles of newly-formed membrane, leaving spaces, or loops, in which portions of intestine are liable to become strangulated, thus giving rise to fatal obstruction. The adventitious

membranes resulting from inflammation here, as in other serous membranes, are firm and resisting in proportion to their age.

CLINICAL HISTORY.-Acute peritonitis is sometimes developed gradually. Abdominal pain and soreness progressively increasing, may be felt one, two, or three days before the local and general symptoms are sufficient to show the existence of the disease. But in most cases the attack is abrupt, and the disease quickly declared. Pain is usually a marked symptom. Commencing at a particular point, it extends over the whole abdomen. It is burning or lancinating in character. It is increased at times sufficiently to constitute marked exacerbations, and, not infrequently, in these exacerbations, the character of the pain is that of spasm or colic. Acute pain is produced by a deep inspiration. The respirations are usually shortened, and, by way of compensation, increased in frequency. The movements of the diaphragm are restrained, and those of the ribs proportionately increased; the breathing, in other words, is costal. Acts of coughing and sneezing occasion intense pain. Movements of the body are painful. The degree of suffering from pain varies in different cases. It is generally great, often extreme, occasionally moderate or slight, and this symptom may be wanting. Tenderness on pressure over the abdomen is usually marked. This symptom is very rarely wanting. The tenderness is often such that the slightest pressure is painful, but the degree of tenderness varies considerably in different cases. The pain and tenderness are frequently most marked in a particular circumscribed portion of the abdomen. These symptoms continue during the course of the disease. Owing to these symptoms the patient is apt to lie upon the back with the knees and thighs raised, in order to lessen the tension of the abdominal muscles and relieve the abdomen of the weight of the bedclothes. This decubitus, however, is by no means constant. The patient may lie on the side with the knees and thighs flexed, or even on the back with the lower limbs extended. More or less tympanites is generally present. The abdomen is often greatly distended and tense, and this condition persists during the course of the disease. If the tympanites be not great, the abdominal muscles, especially the rectus muscle on either side, is usually notably rigid and resisting. The bowels, as a rule, are con stipated, but the exceptions to this rule are not very infrequent. Constipation may exist at first, and subsequently diarrhoea occurs, and occasionally diarrhoea exists at the outset. Vomiting is a frequent and in some cases a prominent symptom. The acts of vomiting occasion great pain. In the latter part of the course of the disease, the contents of the stomach are apt to be ejected by regurgitation rather than by vomiting. Thirst is usually a prominent symptom.

The pulse is more or less accelerated. It is apt to become quite frequent, numbering 120 or 130 per minute; but in some cases the acceleration is moderate. It is generally small and sometimes hard or wiry. The sense of prostration is considerable or great. Perspiration is apt to occur. The countenance denotes gravity of disease; the expression is baggard and anxious. In some cases the upper lip is elevated and drawn tightly over the teeth. This appearance is characteristic, and, when present, points to the disease, but it is by no means uniformly present.

Difficulty in micturition is a frequent symptom, due probably in part to paralysis of the muscular tunic of the bladder, and partly to loss of power over the abdominal muscles in consequence of the abdominal distension. Moreover, the pain occasioned by the effort to micturate leads the patient to postpone it as much as possible. Retention of urine, requiring the use of the catheter, is not uncommon. Prof. Rogers, of the University of Louis

1

ville, has called attention to the occurrence of severe pain in the penis, in certain cases of peritonitis. This pain is sometimes extremely intense. I have observed this symptom in two cases, since the publication of Professor Rogers's paper, and I have met with several physicians who have observed it. In some of the cases reported by Prof. Rogers, priapism and intense venereal desire existed. It remains to be ascertained how frequently these symptoms are present. I have ascertained their existence in two cases, since their occurrence was pointed out by Prof. Rogers.

The intellect, in cases of acute peritonitis, is generally not disordered. Slight delirium sometimes occurs, especially in fatal cases, toward the close of the disease.

PATHOLOGICAL CHARACTER -Acute peritonitis, as regards pathological character, does not differ essentially from other acute serous inflammations.

CAUSATION.-Acute inflammation of the peritoneum, exclusive of puerperal peritonitis, is rare.. As a spontaneous or idiopathic affection, it is one of the rarest. The liability of the peritoneum to become inflamed is vastly less than of the pleura or the pericardium, a fact not easily explained, but which exemplifies a principle of conservatism, inasmuch as peritonitis is a much more serious disease than either pleuritis or pericarditis. In the great majority of cases, peritonitis is incidental to some other affection of the abdominal viscera. The most frequent cause, exclusive of its occurrence in childbed, is perforation of the alimentary canal. Perforation of the ileum. is incidental to the intestinal lesions of typhoid fever, and peritonitis thus produced is one of the occasional events pertaining to the clinical history of that form of fever. The intestinal ulcerations which occur in certain cases of tuberculosis, sometimes, although very rarely, lead to perforation, and, also, other ulcers situated in either the small or large intestine. Perforation from ulceration or sphacelation of the extremity of the appendix vermiformis of the cæcum is of not very rare occurrence; several examples have fallen under my observation. Perforation of the stomach is an occasional event in cases of gastric ulcer. Whatever be the seat of the perforation, the gaseous and other contents of the alimentary canal escaping into the peritoneal sac, peritonitis becomes at once developed. The escape of bile from rupture of the gall-bladder, or the cystic, hepatic, or common duct, gives rise to peritonitis. Other causes are the discharge of pus into the peritoneal cavity from hepatic or other abscesses, rupture of the urinary bladder or ureter, and the evacuation of hydatid cysts. Inflammation, at first local, may become general, as in certain cases of invagination and strangulation of intestine. Injections into the cavity of the uterus have been known to give rise to the disease, the liquid injected passing into the peritoneal cavity through the Fallopian tubes. In certain cases of puerperal peritonitis, the inflammation commences in the uterus and is propagated to the peritoneum. The disease may be produced traumatically by wounds of the abdominal walls, and violent contusions.

Excluding cases of acute peritonitis produced by these various causes, together with all cases of puerperal peritonitis, the remaining cases which occur are exceedingly few. Of the few which remain, probably in most the disease is developed in connection with renal disease. Acute peritonitis is one of the local affections incidental to the morbid conditions of the kidneys collectively called Bright's disease. Exposure to cold may give rise to it.

1 Western Journal of Medicine and Surgery, Louisville, August, 1855, vol. iv. Number 2.

I have known its occurrence to be fairly attributable to this canse. Prof. Palmer, of Louisville, informed me that in the neighborhood of Woodstock, Vermont, where he formerly resided, cases of acute peritonitis were not very uncommon among persons employed in the winter and spring to repair water-wheels damaged by ice, this occupation requiring them to work standing in water.

Occurring as an epidemic affection, in childbed, it doubtless proceeds from a special cause. During the prevalence of puerperal peritonitis, epidemic erysipelas has been observed to prevail, showing some pathological relationship between the two affections.

In autopsical examinations, the various local causes of peritonitis are to be sought for. Without care they may be overlooked. A small intestinal perforation will be likely to escape detection unless careful search be made, and is probably not infrequently overlooked.

DIAGNOSIS.—The diagnosis of acute peritonitis is not difficult in cases in which its diagnostic features are well marked, as they are in the majority of cases. These features are sometimes obscure or wanting, and it is then liable to be overlooked or confounded with other affections. From acute enteritis it is distinguished, generally, by a greater degree of pain, greater frequency of the pulse, more tenderness on pressure over the abdomen, more tympanites, rigidity of the abdominal muscles, absence of diarrhea, and the evidence, on all sides, of a graver malady. Rare as is acute peritonitis, acute enteritis, at least in the adult, is still more infrequent.

It is sometimes mistaken for functional colic. The pains, in some cases of peritonitis, are like those of colic. But colic lacks the continuous pain, the abdominal tenderness, the muscular rigidity, the tympanites, the frequency of the pulse, prostration, etc., of acute peritonitis. These symptoms, however, may not be immediately developed in peritonitis, and a little delay may, therefore, sometimes be necessary in arriving at a positive diagnosis.

Rheumatism, affecting the abdominal muscles, may give rise to certain of the local symptoms of acute peritonitis. Instances, however, of rheumatism limited to these muscles must be extremely rare. The diagnostic points, indicated by Genest, are as follows: In peritonitis, movements of the body occasion pain over the whole abdomen, whereas, in rheumatism, the pain is apt to be limited to certain muscles, and, perhaps, confined to one side of the abdomen. The same is true of tenderness on pressure. Moreover, in peritonitis the pain from pressure is proportionable to its amount, but in rheumatism, deep, firm pressure may be made without augmenting the pain.

Lumbo-abdominal neuralgia, with hyperesthesia of the abdominal walls or tegument, sometimes simulates closely peritonitis as regards certain local symptoms. The pain may be severe, the tenderness great, the decubitus on the back with the thighs and knees flexed, and, not infrequently, there is more or less tympanites. Cases presenting these symptoms are not uncommon. The patients are generally females, and manifest more or less hysterical phenomena. The general symptoms of acute peritonitis, frequency of pulse, prostration, etc., are wanting in these cases; but attention to certain points connected with the local symptoms will suffice for the differential diagnosis. The tenderness in the neuropathic affection is more superficial, the patient shrinks from the slightest touch, but firm, prolonged pressure with the open palm is often well borne, and may even afford relief, whereas, in peritonitis, the pain is always proportionate to the amount of pressure. The muscular rigidity of peritonitis is wanting. It is stated by. Valleix that

Valleix, op. cit.