lI^rcscnte^ to
of tbe
\nntvcreiti? of Toronto
Church of England
Missionary Society
THE PERITONEUM
VOL. II
THE PERITONEUM
VOL. II
DISEASES AND THEIR TREATMENT
BY
ARTHUR E. HERTZLER, M.D., FA.C.S.
SURCiEOX TO THE HaLSTEAD HOSPITAL, HaLSTEAD, KaXSAS ; ASSOCIATE PROFESSOR
OF Surgery, University of Kansas; Formerly Ppcofessor of Pathol-
ogy, Experimental Surgery, and Gynecology, University
Medical College, Kansas City, Mo.
ST. LOUIS
C. V. MOSBY COMPANY
1919
Copyright, 1919, By C. V. Mosby Company
Press of
C. V. Mosby Company
St. Louis
CONTENTS
VOL. II
PART I
CHAPTER X
PAGE
Classification op Peritonitis 381
The Area Involved, 382 ; Localized Peritonitis, 382 ; The Spreading
Type, 383; The Diffuse Type, 384; The Organ from Which the Infec-
tion Originates, 385 ; The Specific Causative Organism, 386.
CHAPTER XI
Etiology of Peritonitis . . . . ■ 389
Chemical Peritonitis, 389; Bacterial Peritonitis, 391; Varieties of Bac-
teria, 394 ; Streptococcus Pyogenes, 395 ; Bacillus Coli Communis, 396 ;
Staphylococcus, 397; Bacillus Pyocyaneus, 398; Mixed Infections, 398;
Anaerobic Bacteria, 398; Specific Forms of Peritonitis, 398.
CHAPTER XII
Pathogenesis op Peritonitis 401
Penetrating Wounds of the Abdominal Wall, 403 ; Hematogenous Infec-
tion, 404 ; Idiopathic Peritonitis, 405 ; Perforative Peritonitis, 407 ; Per-
foration of the Gut Wall by Mechanical Injury, 407; Perforation by
Ulceration, 407; Ulceration without Reaction, 408; Ulceration with Re-
action, 409 ; Ulceration with Adhesion Formation, 411 ; Infection within
the Wall of the Gut, 412; Lnfeetion by Stasis, 414; Infection by Nec-
rosis, 417; Perforation of Paraperitoneal Abscesses, 418; Location of
the Infection at a Distance from Its Source, 419.
CHAPTER XIII
General Symptomatology of Peritonitis 422
Pain, 422; The Reflex Pain, 422; The Reactive Pain, 423; Spontaneous
Pain, 425; Pressure Pain, 427; The Gastrointestinal Tract, 430; A'omit-
ing, 430; Meteorism, 431; Temperature, 434; Circulation, 434; The Exu-
date, 434; General Habitus, 435; Physical Characters of the Abdomen,
436.
ix
X CONTENTS
CHAPTEE XIA^
Diagnosis of Peritonitis 438
Pain, 439 ; Colic, 440 ; Tlirombosis, 440 ; Intraperitoneal Hemorrhage,
441; Pain Caused by Distention of Parenchymatous Organs, 442; Re-
ferred Pains, 442 ; Neuroses, 443 ; Rigidity, 443 ; Fever, 444 ; The Pulse
Rate, 444; Leucocytosis, 445; Tympany, 445.
CHAPTER XV
PFvOgnosis or Peritonitis 447
Prognosis Dependent on Time of Operation in Perforating Ulcer, 447;
Prognostic Value of Examination of Peritoneal Fluid, 448 ; Prognosis
According to Species of Organism, 448 ; Pain, 450 ; Fever, 451 ; The
Pulse Rate, 451 ; Leucocjiiosis, 451 ; Muscular Rigidity, 452 ; Tympany,
452; Sordes, 453; Singultus, 453; Vomiting, 453; Complications, 453.
CHAPTER XVI
Cause of Death in Peuitonitis 454
Septic Theory, 454; Nerve Theory, 455.
CHAPTER XVII
Treatment of Acute General Peritonitis 460
Historical, 460; Preventive Treatment, 462; Medical Treatment, 462;
External Application, 468 ; Operative Treatment, 469 ; Indications for
Operation, 469; Preparatory, 470; Preparation of the Skin, 471; Anes-
thetic, 471; Time of Operation, 472; Site of the Incision, 472; Manage-
ment of the Exudate, 473 ; Sponging, 473 ; Irrigation of the Peritoneal
Cavity, 473; Drainage, 475; Posture of the Patient, 486; Management
of Complications, 488; After-pain, 488; Gas, 488; Management of Ileus,
488; Drainage of Extraperitoneal Abscesses, 494; Drainage of Intra-
peritoneal Walled-off Abscesses, 498.
CHAPTER XVIII
Operations on the Peritonku-nf 503
General Principles of Peritoneal Sutures, 503 ; The Closure of Peritoneal
Incisions, 505; Suture in Hollow Viscera, 507; Suture of Adhesions, 510;
Covering by Transplant, 512 ; The Removal of Extraperitoneal Or-
gans. 514; The Suturing of Solid Viscera, 515.
CONTENTS XI
PART II
CHAPTER XIX
Appendicitis 516
Appendiceal Peritonitis, 516; Historical, 516; Etiology, 518;
Heredity, 518 ; Age, 519 ; 8ex, 519 ; Occupation, 520 ; Diet, 520 ; Trauma,
520; Fecal Concretions, 523; Foreign Bodies, 523; General Infections,
524; Pathogenesis, 524; Classification, 527; The Diffuse Exudative, 528;
The Ulcerative, 532 ; The Gangrenous, 534 ; Pathology, 536 ; Atrophy of
the Appendix, 537; Fibrosis of the Appendix, 537; Catarrhal Appendi-
citis, 538 ; Diffuse Exudative, 538 ; Gangrenous, 541 ; Symptoms, 541 ;
Pain, 541 ; Pain on Movement, 545 ; Pain on Pressure, 546 ; Muscular
Rigidity, 548 ; Vomiting, 549 ; Tympany, 550 ; Fever, 551 ; Pulse Rate,
553; Leueocytosis, 554; Diagnosis, 554; Differential Diagnosis, 556;
Kidney and Ureteral Colic, 556 ; Diseases of the Gall Bladder, 557 ;
Perforating Ulcers of the Stomach and Duodenum, 557; Acute Pan-
creatitis, 559 ; Diseases of the Urinary Bladder and Rectum, 559 ; Ty-
phoid Fever, 560 ; Female Sexual Organs, 562 ; Ectopic Pregnancy, 562 ;
Parametritis, 563 ; Ovarian Tumor with Twisted Pedicle, 563 ; Gonor-
rheal Perisalpingitis, 564; Ovarian Hemorrhage, 566; Dysmenorrhea,
566; Pyelitis of Pregnancy, 567; Genital Infections in the Male, 568;
Hernias, 568; Diseases of the Chest, 568, Chronic Appendicitis, 569;
Remittent Appendicitis (Postappeudicitis, Fenger), 570; Chronic Pro-
ductive Appendicitis, 572; Postappcndiceal Cicatrization, 575; Masked
Appendicitis, 576; Pseudoappendicitis, 578; Symptomatology, 578; Dif-
ferential Diagnosis, 579; Treatment, 581; Medical, 581; Time for Oper-
ation, 581; Indications for Operation, 582; Operation in the Pnterval,
582 ; Operation in the Attack, 582 ; Place of Operation, 583 ; Type of
Operation, 583 ; Early Stage, 583 ; Stage of Adhesions, 584 ; Stage of
Abscess Formation, 584; Diffuse Peritonitis, 584; Prognosis, 585; In-
terval Operations, 585 ; Acute Periappendicitis, 585 ; Periappendiceal
Abscess, 585; Spreading Peritonitis, 585.
CHAPTER XX
Cholecystitic Peritonitis 588
Pericholecystitic Hyperemia, 588; Pericholecystitic Peritonitis, 590;
Spreading Peritonitis Going Out from the Nonperforated Gall Bladder,
591 ; Peritonitis Following Perforation of the Gall Bladder, 593.
Xll CONTENTS
CHAPTEE XXI
Goxococcic Peritonitis 598
Historical, 598; Classification, 5!»9; Gonorrheal Perisalpingitis, 599;
Generalized Gonorrheal Peritonitis, 607.
CHAPTER XXII
PXEfMOCOCCIC Pekitoxitis 612
Historical, 612; Pathogenesis, 613; Pathologic Anatomy, 616; Fre-
quency, 617; Symptoms, 617; Localized, 617; Diffuse, 619; Predisposing
Causes, 620; Diagnosis, 620; Treatment, 622.
CHAPTER XXIII
Puerperal Peritonitis 625
Etiology, 627; Pathogenesis, 628; Pathology, 629; Clinical Signs, 630;
Diagnosis, 631; Prognosis, 632; Treatment, 632.
CHAPTER XXIY
Traumatic Peritonitis Without Rupture 634
Pseudoperitonitis, 631; Localized Peritonitis, 635; Diffuse Peritonitis,
635; Diagnosis, 636; Treatment, 636; Peritonitis from Traumatic Rup-
ture of the Gut, 637; Rupture of the Mesentery, 637; Postoperative
Peritonitis, 637 ; Prophylaxis, 638.
CHAPTER XXV
Fetal Peritonitis 641
CHAPTER XXVI
Tuberculosis of the Peritoneum 647
Historical. 617; Etiology, 648; Age, 649; Sex, 649; Heredity, 650; Gen-
eral Physical State, 650; Trauma, 651; Pathogenesis, 651; Primary
Form, 652; Secondary Form (Extension from Other Organs), 655;
Hematogenous, 658 ; By Contiguity, 658 ; By Continuity, 659 ; Pathologic
Anatomy, 6(50; Symptoms, 680; Diagnosis, 696; Prognosis, 701; Con-
servative Treatment, 705; Operative Treatment, 708; Pseudotubercu-
losis, 713; Polyserositis, 719; Chronic Hyperplasias of the Peritoneum,
720.
CHAPTER XXVII
Thrombosis and Embolism of the Mesenteric Vessels 734
Etiology, 734; Pathogenesis, 735; Pathology, 738; Symptoms, 739;
Diagnosis, 740; Treatment, 740.
CONTENTS XIU
CHAPTER XXVIII
Diseases and Injuries of the Great Omentum . ' 743
Inflammatory Tumors of the Omeutum, 743 ; Definition, 743 ; History,
743 ; Pathogenesis, 744 ; Pathology^ 745 ; Symptoms, 745 ; Diagnosis,
746 ; Treatment, 747 : Defensive Reactions of the Omentum, 749 ; The
Omentum as an Accessory Source of Xutrition, 749 ; Fat Xecrosis, 750 ;
Torsion of the Great Omeutum, 750 ; Definition, 750 ; History, 750 ;
Pathogeuesis, 752 ; Pathology, 754 ; Symptoms, 754 ; Diagnosis, 758 ;
Prognosis, 759 ; Treatment, 759 ; Injuries to the Omentum and Mesen-
tery, 759; Etiology, 759; Pathogeuesis, 7(50; Symptoms, 760; Diagnosis,
761 ; Prognosis, 761 ; Treatment, 761.
CHAPTER XXIX
Tumors of the Peritoneum 764
Classification, 764 ; Lymphatic Cysts of the Mesentery, 765 ; Frequency,
765; Size, 765; Age, 766; Pathogenesis, 766; Pathology, 768; Symptoms,
768 ; Diagnosis, 769 ; Prognosis, 769 ; Treatment, 770 ; Endotheliomata,
771; Pathology, 773; Symptoms, 775; Treatment, 775; Enterocystomata,
775 ; Location, 776; Pathogenesis, 776; Pathology, 777; Symptomatol-
ogy, 777; Prognosis, 778; Treatment, 778; Lipoma of the Mesentery,
778; Secondaiy Peritoneal Qs-sts, 780; Embryonal Qs'sts, 781; True Der-
moids, 781 ; Fetal Inclusions, 782 ; Teratoid Mixed Tumors, 783 ; Symp-
toms, 784; Treatment, 784; Tumors of the Retroperitoneal Space, 784;
Retroperitoneal Lipomata, 786; Etiology, 786; Pathogenesis, 787; Pa-
thology, 789; Symptoms, 790; Diagnosis, 791; Prognosis, 791; Treat-
ment, 792; Retroperitoneal Sarcoma, 793; Etiology, 793; Pathogeuesis,
794; Pathology, 794; Symptoms, 795; Diagnosis, 795; Prognosis, 797;
Treatment, 797; Tumors of the Omentum, 798; Lipomata, 798; Sarcomata
of the Omentum, 800; Pathogenesis, 801; Pathology, 801; Symptoms,
802 ; Diagnosis, 803 ; Treatment, 803 ; Fibromyoma of the Omentum,
803 ; Sarcoma of the Omental Bursa, 804 ; Tumors of the Gastrocolic
Omentum, 805 ; Wandering Tumors of the Peritoneal Cavity, 806 ; Sec-
ondaiy Tumors of the Peritoneum, 807; Pathogenesis, 808; Pathology,
814; Symptoms, 815; Diagnosis, 815; Prognosis, 816; Treatment, 817;
Pseudomyxoma Peritonei, 817; Pathogenesis, 818; Pathology, 824;
S\nnptonis, 828; Diagnosis, 830; Prognosis, 831; Treatment, 831.
ILLUSTRATIONS
FIG. PAGE
155. Perforating uk-iT of tlu' (luoileiium , 408
\')6. Acute perforation of the appendix 409
157. Iiitlammatory thickening of tlie appendix about an enterolith with
a perforation proximal to the foreign body 410
158. Slight inflianiniatory thickening of the appendix \Yith perforation at
the tip 410
159. Ulcerating duodenum in which perforation was prevented by the for-
ni-ation of omental adhesions 412
160. Small abscess within the gut wall covered with plastic exudate . . . 413
161. Necrosis of a loop of ileum in a case of strangulated femoral hernia . 414
162. Necrosis of the appendix from thrombosis of the appendicular artery . 418
l(i3. Perforation of the duodenum showing how the contents of the gut are
conveyed laterally to the colon and to the pelvis 419
164. Abscess within the l)road ligament drained through the vagina . . 494
165. Abscess situated far laterally in the broad ligament drained liy an
incision above Poupart's ligament 495
ll)(). Large broad ligament al)scess jioiiiting lioth in tlie vagina and over
Pou])art's ligament 495
167. Diainage of suljdiaphragniatic abscess below the costal margin . . 496
168. Subdiaphragmatic abscess drained transpleurally 496
169. Running suture coapting peritoneal surfaces 506
170. After the entire peritoneum has been closed as in Fig. 169, the same
suture continues liack, coapting the muscles to the point of beginning 508
171. Adhesions between sigmoid and broad ligament and between rectum and
uterus 510
172. The adhesions in Fig. 171 are so incised as to permit a covering of the
demuled area after the operation is completed 511
173. The adhesions severed in Fig. 172 have lieen united by Lembert sutures 512
174. Tlie |ieiitoneum is incised separately in or<ler to secuie the necessary
tissue for covering tlie denuded area 513
175. The flail ph^nned in Fig. 174 on being closed 514
17(). Early acute appendicitis with edema of the walls 529
177. Eaily acute ajipendicitis 529
178. An acutely inflamed ajipeiidix entirely surrounded by the indurated
omentum 530
179. Appendix in which tlie wall is nuich increased in tiiickness due to sev-
eral small abscesses 530
180. Acute appendicitis sliowing lyinijli and I'lnod vessels tilled with clots . 531
xiv
ILLUSTRATIONS XV
FIG. PAGE
181. Acute appendicitis in whit-li a small gangrenous area about to perforate
is seen near the blackened and thickened extremity of the organ . 531
182. Section from the wall of an appendix near a perforating ulcer . . . 533
183. Large enterolith in an appendix 534
184. Thrombosis of the mesenteric artery in a gangrenous appendix . . 535
185. Atrophic appendix imbedded in a fatty mesoappendix 538
186. Eemittent appendicitis 570
187. Adhesions of several loops of ileum about the cecum 571
188. Chronic induration of the wall of the appendix 573
189. Chronic appendicitis in which the lymph follicles remain prominent,
simulating hypertroi)hy of the tonsil 573
190. Section of a suliacutely inflamed appendix 574.
191. Large thickened api^endix 577
192. Dilatation of the vessels in the hepatocolic ligament 589
193. Pericholecystitis with adhesions which attach the gall bladder to the
colon 590
194. Beginning necrosis of the gall bladder 591
195. Gonorrheal perisalpingitis with adhesions to surrounding organs, sul)-
acute stage 602
196. Subiiiiliaiy tuberculosis of the omentum 667
197. Diffuse miliary tuljerculosis of the peritoneum 668
198. Fibrinous tuberculosis of the peritoneum 669
199. Adhesive caseous tuberculosis of the peritoneum 672
200. Caseous tuberculosis of the appendix 674
201. Outline of extreme abdominal distention in miliary tul)erculosis of the
peritoneum 684
202. Acute miliary tuberculosis of the ileocecal region 687
203. Primary peritoneal tuberculosis of the Fallopian tulje 688
204. Small subperitoneal cysts of the tube 690
205. Granulomatous nodules of the tube and ovary in an old infected tube
in a case of myoma of the uterus 691
206. Granulomatous nodules on a chronic pus tube and ovary 691
207. Foreign body giant cells from specimen shown in Fig. 205 .... 692
208. Microscopic section of the specimen shown in Fig. 206, showing foreign
body ''tubercle" developing on the surface of the tube . . . 692
209. Tuberculosis of a hernial sac 694
210. Chronic hyperplasia of the peritoneum 721
211. Termination of the vessels in gut 736
212. Attachment of the omentum to a myoma that had suffered a disturliatice
of luitrition 749
213. Fat necrosis in the ujiper j'art of flio omentum from a case of neciosis
of the pancreas ... 751
214. Fat necrosis of the omentum in a case of acute panoeatitis . . . . 7.')1
215. Torsion of the great omentum 755
216. Lpnph cyst of the ileocecal region 769
217. Mesenteric cyst 779
XVI ILLUSTRATIONS
riG. PAGE
218. Wandorinj)- tumor of the aUdominal cavity 805
219. Wandering tunidr uliicli lias secured secondary attachments to the omen-
tum 806
220. Cairinomatuus mass in gastrocolic omentum in a case of carcinoma of
tlie pylorus 807
221. The great omentum converted into a huge mass by secondary invasion
of carcinoma secondary to carcinoma of the stomach 808
222. Secondary tumor of the mesentery 809
223. Secondary glandular carcinoma of the omentum 810
224. Secondary carcinoma of the omentum from a papillary cystoma of the
ovary 811
225. Secondary carcinoma of the peritoneum of the anteiior abdominal wall 811
226. Colloid metastasis in the omentum 812
227. Syncytial masses of the omentum secondary to papillary cystoma of the
ovary 813
228. Miliary carcinosis of the peritoneum 816
229. Pseudomyxoma of the peritoneum 825
230. Pseudomyxoma of the peritoneum ; . . . 827
THE PERITONEUM
VOL. II
PART I
CHAPTER X
CLASSIFICATION OF PERITONITIS
Any disease which is an expression of end result or complication
of otliei' disease must necessarily present unusual problems in clas-
sification. Peritonitis, usually being the result of secondary inva-
sion into the peritoneal cavity of an infection arising from some
other oi'gan, partakes someAvhat of the characteristics of the dis-
ease of the organ from which the infection is derived. These dif-
ferences have to do with the suddenness with which the invasion
takes place, the location of the orgair with relation to the perito-
neal cavity, and, finally, the character of the organisms it is prone
to harbor. Notwithstanding the protean character of the primary
affections that may give rise to peritonitis, by keeping in mind the
topography of the infection and rate of onset, together with the
individual character of the disease of the organ primarily at fault,
a classification of the peritonitis is possible Avhich is adequate to
the needs of the surgeon. The pathologist with his own too lim-
ited knoAvledge of the disease in all its phases should not be too
free to find fault. If it Avere possible to do so, it would be desir-
able to classify the disease according to the offending organism.
This is in fact possible in a few instances, as in the case of pneu-
moeoccic, gonococcic and tulierculous peritonitis. In most instances,
however, the determination of the causative organism clinically is
381
382 THE PERITONEUM
usually not possible because of the multiplicity of the bacteria pres-
ent. In such instances the classification must be based on site
of origin, the method of invasion, and the topography of the disease.
Because of these interrelated factors it is much easier to analyze
the various forces at play in a concrete case at the bedside than
it is to separate them out for academic discussion.
From the foregoing it is evident that three basal factors for
classification, neither of which can be neglected in a clinical study,
present themselves for consideration. These are the area involved,
the organ from Avhich the infection spreads, and finally the type
of bacteria playing the dominant role.
The Area Involved. — In the first, the extent of the disease may
be made the basis of classification. The importance of the extent
of the disease to the clinician lies in the fact that, other things
being equal, the severity of the disease in a general way runs par-
allel Avith the area involved. The difficulty here lies in that the
disease is a process and not a state. Because of this, a given pa-
tient may belong in one group in one period of the disease and in
quite another at a different or terminal stage. These difficulties
are increased enormously by the fact that it is impossible to deter-
mine with exactness clinically in just what anatomic stage the
disease may be at any period of the observation. HoAvever, by
taking into account the organ from which the infection arises,
the manner of onset and rate of progress, surgeons are able in
a measure at least to prognosticate the future course of the dis-
ease. In this way certain inflammations, it can be determined, will
remain local, as in gonorrheal perisalpingitis, others again as in
periappendicitis, remain localized in the majority of cases or can
be made to do so by timely action. Others again, as in perforations
of an ulcer, will most certainly spread unless hindered by the most
energetic measures. We may divide the inflammations, therefore,
into localized, spreading and diffuse.
Localized Peritonitis. — A localized peritonitis in its strict sense
is one Avhieh has no tendency to spread beyond the tissues actually
involved, just as fibroma has not. In these cases there is usually
no complete solution of continuity of the organ involved, the peri-
toneum being set into a state of reaction by the dissemination of
the toxins of the infective process, and not by the diffusion of the
CLASSIFICATION OF PERITONITIS 383
bacteria themselves. The most familiar example of this type is
seen in appendicitis when the wall of this organ is inflamed, pro-
ducing a periappendicitis, hut in which there is no perforation of
its wall. If organisms do escape from the hollow of the organ,
this event is anticipated by the formation of adhesions with neigh-
boring structures and as a result of this precautionary reaction,
a spreading infection is avoided and the most serious result is the
formation of a localized abscess.
The Spreading Type. — The spreading type while advancing does
so against resistance. The organism places barriers before its ad-
A^ancement which the disease can not fully overcome. Here bac-
teria escape and by their multiplication gradually extend the proc-
ess over more and more of the surface of the peritoneum. The
extent of the spreading is then dependent on the relative virulence
of the organisms and the degree of resistance of the tissues. For
instance, in certain types of peritonitis following appendicitis the
infection begins at the' site of the appendix, becomes partially
walled off, hesitates for some liours or days, then spreads toward
the diaphragm or into and across the pelvis. The experienced
clinician can follow this progress in his mind's eye as accurately
as he can the progress of an erysipelatous lesion of the skin.
As opposed to these types, either because of slight virulence of
the invading organism or because of the slowness of invasion, are
those cases in Avhich the surrounding peritoneum walls off the in-
vading host at some stage of the progress, and thus protects the
surrounding peritoneum from further invasion. These become then
secondarily localized processes. The seriousness of this type is de-
pendent less on the extent of the disease than on the character of the
walling-off process. An abscess involving an area greater in extent
than either a diffuse or spreading peritonitis may be quite innocent of
harm because, being completely walled off by adhesions, it is essentially
extraperitoneal and the surgeon at operation is dealing really with an
abscess communicating with the surface. For instance, I observed not
long ago one child, with a huge abscess taking in one-third of the
abdominal cavity, recover ])r()inptly after drainage, and another
which died folloAving an infection of a much smaller area. The
former required three weeks for its development, while Ihe latter
384 THE PERITONEUM
ran its course in three days. On the other hand a spreading peritonitis
which has become localized may break through its walls and become
diffuse.
The Diffuse Type. — The diffuse type may be likened to the most
malignant sarcomata, against the spread of which the organism
is utterly helpless. The helplessness of the organism may be due
to the variety of the bacterium liberated into the peritoneal cavity,
to the coexistence of foreign substances, as fecal masses, with the
infecting organisms, to the presence of digestive ferments which
make adhesion formation impossible, or, finally, to the general
state of the individual, there being, as we say, a lessened constitu-
tional resistance, the meaning of Avhicli Ave sometimes know and
sometimes we do not.
A division of the disease according to the area involved is not
scientific, yet it is very useful in practice. The expert surgeon
learns to judge these factors, just as the trained oncologist in
viewing a tumor is able to say what its subsequent course will be.
In both instances it is often quite as much intuition as science
that leads to skill along these lines. A peritonitis involving a
very small area may be essentially diffuse because the organism
will not at any time be able to cope with it. This may find ex-
pression in the general appearance of the patient. Thus a per-
forated duodenal ulcer or a perforation of a typhoid ulcer gives
rise to a peritonitis which is essentially a diffuse peritonitis from
the beginning, for a knowledge of the pathogenesis indicates, and
clinical experience has proved, that .such lesions will continue to
spread. A spreading peritonitis of greater area than those above
noted may be less serious to the patient because the peritoneum
is ol)sti'Ucting in part its advance by the formation of adhesions.
This al)ility to cope with the disease on the pai't of the patient
may be read more in the general bodily reaction than in the phys-
ical examination of the abdominal region.
In considering the al)ove classification, therefore, the sui-gcon
must have in mind not extent but tendency. This tendency is
expressed by certain pathologic processes already considered in
the chaptei- on genernl pathology (Vol. I), but Avhich are not sub-
ject to inspection in the unopened abdomen and the observer must
base his deductions on the probable source of the infection, and
CLASSIFICATION OF PERITONITIS 385
the variety of the organism causing the infection, and the general
reaction of the patient. The above chissification alone, therefore,
is not sufficient for our clinical requirements.
The Organ from Which the Infection Originates. — The second
basis for classification is in a measure corollary to the preceding,
but since it frequently forms the basis of the determination of the
former it requires a separate consideration. It has to do Avith the
organ from Avhich the infection is derived. The importance of
such a determination has already been indicated. Perforations of
duodenal or typhoid ulcerations it was noted were followed by dire
consequences, while in other organs like lesions might be much less
so. The first problem for the surgeon, therefore, when confronted
by a patient exhibiting the signs of peritonitis is to determine the
organ at fault. This is so because this problem must often be
considered before the elemental diagnosis of peritoneal involvement
can be made. Thus it may be between gallstone colic and perforated
duodenal ulcer that a diagnosis must be made. That the importance
of the determination of the organ from which the infection has
arisen is the elementary factor is abundantly testified l)y the fact
that this nomenclature dominates the field. AVe speak of perforated
duodenal ulcer, but think of the inevitable spreading peritonitis.
Certain qualifying adjectives must be appended to the organ
from which the infection is derived in certain cases. Thus in
chronic ulcer a thickening of the gut wall is coincident with ad-
hesions to the surrounding peritoneum. We may therefore speak
* of a perigastritis, meaning a slowly developing peritonitis, or if
a collection of pus forms, a perigastric abscess, meaning a local-
ized suppurative peritonitis. A gall-bladder lesion may give rise
to a surrounding peritonitis which we call a pericholecystitis. It is
only after the inflammation extends beyond the organ that we resort
to the general term peritonitis.
So important is the determination of the organ from Avhich the
peritonitis springs that this classification will be made the basis
for discussion, for upon it depends the determination of that more
important factor, the clinical course. It is not important to de-
tail the various groups, for such division is entirely arbitrary and
to be complete must needs be coextensive AWth the possible sources
386 THE PERITONEUM
of peritoneal infection. An attempt at completeness need not be
made since each surgeon constructs his own. The more common
types, most readily recognized clinically, Avill be studied as entities.
The mention of appendiceal, perforating, and gonococcic will
call to mind the less frequent forms.
The Specific Causative Org-anism. — Finally, the actual agent pro-
ducing the infection may ])e made the basis of classification.
Though a bacterial classification might at first thought seem the
most scientific, it is not so. The reason for this is that the capacity
for harm of any organism is much influenced by the associated con-
ditions. As was noted in the chapter on general pathology the
addition of foreign bodies to infected material enormously enhances
the infectivity. The addition of excreta or secretions or ferments
inhibits the Avalling-off process and in this way allows free play to
the virulence of the organism. The chief difficulty, however, lies
in the fact that in most cases of peritonitis there is a multiplicity
of organisms. This must always be true of perforative cases. It
is only when a peritonitis results from an extension of a specific
process elsew^here that a single organism is at play.
The limitation of a classification based on the specific organism
is due therefore to the factors that surround an ethnologic classi-
fication of the American people. The vast I'ange of possibilities
is due not only to the great variety, but quite as much to the con-
ditions under which they develop. Two infinite variables inter-
acting present possibilities scarcely calculated to encourage hopes
for classification.
These remarks are not calculated, hoAvever, to discourage a study
of dominant types. The common organisms are the streptococcus,
staphylococcus, colon bacillus and less commonly the pneumococ-
cus, gonococcus and pyocyaneus. Even when a large number of
other bacteria are associated, the dominant type may still disclose
itself with sufficient clearness to enable the surgeon to determine
his course of action. For this reason a determination of the flora
in every case is of educative A^alue to the surgeon. The mere rec-
ognition of a condition as peritonitis, like carcinoma, is of value,
yet in both conditions extensive analytic studies broaden the con-
ception wonderfully.
CLASSIFICATION OF PERITONITIS 387
In those instances in which a single organism is at play, a bac-
terial diagnosis assumes a more dignified, even dominant role in
nomenclature, as in tuberculous peritonitis, less so in gonococcal
and pneumonic peritonitis. In the case of the latter organism a
clinical diagnosis is possible with a considerable degree of accu-
racy. In the cases of acute perforative peritonitis a preoperative
determination of the organism at fault is purely conjectural, and
the certain determination of the variety of organisms is a task for
the trained bacteriologist to work out from material obtained at
operation. Even with such material the problems have been un-
satisfactorily worked out as will be noted in the discussion of the
etiology. Surgeons have not been insistent on a more exact knowl-
edge because, save possibly in the case of pyocyaneus, their course
of after-treatment is but little influenced by the findings of their
laboratory confreres.
According to such a scheme, in every case of peritonitis the sur-
geon must place the disease in one of the categories of each of the
folloAving groups:
As to extent: 1. Localized. 2. Spreading. 3. Diffuse.
As to organogenesis: 1. Appendiceal. 2. Cholecystitie. 3. Gas-
trointestinal perforations. 4. Genitourinary. 5. Metastatic and
Thrombotic, etc.
As to causative organisms: 1. Streptococcus. 2. Colon Bacillus.
3. Staphylococcus. 4. Pneumococcus. 5. Gonococcus, etc.
A complete classification in a concrete case requires a considera-
tion of all these factors. In a given case, for instance a diseased
appendix, the organ indicates its source, the course of the disease
indicates Avhether or not it is spreading. Because of the organ at
fault it is probable that the colon bacillus is the dominant organ-
ism, a problem capable of final solution only after the abdomen is
opened. It is only Avhen the surgeon has habituated himself into
the making of such a classification in every instance that he obtains
that breadth of view necessary to the most efficient handling of the
therapeutic problem.
The foregoing is an outline of the essentials in the classification
of peritonitis. This Avill be augmented in individual cases by topo-
graphic or pathologic detail to suit the observer. A new classifi-
388 THE PERITONEUM
cation of peritonitis was to the early abdominal surgeon what the
invention of a new speculum was to the early gynecologists, each
invented his own and it Avas for him the best. Now, however, since
the more fundamental factors have become common property a
more simple classification is ample, leaving it to the knowledge of
the individual to vary the detail just as the nurse constructs for
each patient a temperature chart all his own.
CHAPTER XI
ETIOLOGY OF PERITONITIS
Generally speaking, the genesis of peritonitis is dependent upon
the advent of bacteria in the peritoneal cavity. The method of
entrance and variety of organism is subject to such great varia-
tion that the etiology of peritonitis is one of the most complex
problems in clinical medicine. The variety of organisms which
gains admittance into the peritoneal cavity is of considerable im-
portance in etiology, but the variation in virulence of any given
species is of equal importance. Tlie method by which tlie l)ac-
teria gain entrance is of even more importance than the variety
of organisms. These factors can best be studied in the discussion
of the various subdivisions of peritonitis which surgeons usually
employ. While bacteria constitute the chief, they are not the sole,
cause of peritonitis. Chemical substances may produce an inflam-
matory reaction, which, while seldom leading to the death of the
patient, often is followed by lasting minor disalnlities.
Chemical Peritonitis. — Chemical peritonitis has been the prod-
uct of laboratory experimentation, though in a few instances it
has a clinical significance. Croton oil, cantharides, iodine, and
turpentine have been the substances usually employed for the pur-
pose of the experimental production of tliis form. Pawlowsky
found that two and one-half drops of croton oil produced a fatal
hemorrhagic peritonitis in rabl)its. The same author found
that quantities as small as 0.1 gm. trypsin produced a fatal
hemorrhagic peritonitis. When any of the substances above men-
tioned are bi'ought into contact with the peritoneum, a hyper-
emia ensues, resulting in a great widening of the service vessels
and the assumption of function by the potential vessels. If tho
action is more intense, an exudation results both of leucocytes
and of serum. These processes have already been sufiiciently de-
scribed in the general chapter on inflammation. In the use of
such substances it may be an erroi' to speak of the fatality as be-
389
390 THE PERITONEUM
ing due to the peritonitis, possibly the peritonitis is but a concomi-
tant factor, death being due to the toxicity of the drug employed.
I am led to make this remark because in my own studies I was
amazed to find that a grain or two of magnesium sulphate in-
jected into the peritoneal cavity of a rabbit proved quickly fatal
without there being any observable change in the peritoneum itself.
The chief interest in this variety of peritonitis is that any chem-
ical substance introduced into the peritoneal cavity which acts
as an irritant invites the growth of bacteria. This is brought
about by the exudate which results from the irritation. The
same is true of physical agents. It has repeatedly been proved
that after the peritoneum has been irritated, infections become
established which in the unirritated peritoneum remained innox-
ious. Since the use of chemicals in the peritoneal cavity has been
discontinued, this influence is but little encountered. To appre-
ciate the importance of this question, one must read the literature
of the early antiseptic period.
The escape of fluids from hollow organs may cause a peritonitis.
Often these are contaminated with bacteria and because of these
a progressive peritonitis is produced. Ruptures of the urinary and
biliary bladders are familiar examples of this. Exudates from
strangulated tissue, as the omentum, cysts or tumors may pro-
duce marked reactions. In each of these instances the tissue re-
action overcomes the irritation unless the absorption of toxins
produces associated conditions.
The bursting of colloidal and pseudomucinous cysts is the
common physical and chemical cause of chronic reaction on the
part of the peritoneum. This variety will receive attention in a
separate chapter. The bursting of other aseptic cysts, e.g., echi-
nococcus, may give rise to more or less irritation, as may the burst-
ing of blood and lymph cysts which hnxe undergone certain chem-
ical changes before they rupture. The contents of blood and
lymph cysts which rupture Avithout previous infection are ab-
sorbed without reaction.
In certain instances a chronic reaction may arise from unknown
causes. These cases are collected in a separate section corollary
to the chapter on tuberculous peritonitis. Localized productive
reactions may result from inflammatory reactions in the neigh-
ETIOLOGY OF PERITONITIS 391
borhood of the peritoneum, themselves infective in character, but
in which the infectious material does not reach the peritoneal
cavity. This is seen most frequently in juxtaposition to ulcera-
tions of the digestive and biliary tracts.
Bacterial Peritonitis. — The very vast majority of peritonitides
are the result of the invasion of the peritoneal cavity by bacteria.
To such an extent is this true that Avhen the term "peritonitis" is
used without qualification this variety is meant.
Only with the development of modern bacteriology was an ad-
equate discussion of peritonitis possible. Soon after this develop-
ment the problem of peritonitis received the active attention of a
host of competent bacteriologists. As a matter of fact but little
has been added since the active campaign of the period ten or
twenty years subsequent to the discoveries of Koch.
As in any infection, the development of peritonitis depends
upon the kind and virulence of the organisms and the constitu-
tional and local resistance of the individual. The local and gen-
eral resistance to bacteria has been abundantly studied, and Ave
possess records of many researches calculated to clear up the prob-
lem. The fact remains that occasionally a postoperative perito-
nitis appears even in the hands of the most expert, the cause of
Avhich can not be traced. That bacteria are rapidly absorbed from
the peritoneal cavit}' is Avell known. After they reach the blood
stream they no doubt encounter the same resistance as when in-
jected directly into the blood stream. AVerigo studied this phase.
He found that bacteria so introduced soon found their Avay to the
liver, spleen, and lungs. Here, according to him, they are taken
up by the phagocytes. The length of time that elapses before this
takes place has been the subject of a varying interpretation.
Bail injected the bacteria into tlie pleural cavity and, instead of
studying them in the section as Werigo did, recovered them from
the tissues by cultural methods.
Recently Buxton studied the fate of bacteria introduced into
the peritoneal cavity. He employed typhoid bacilli, removing
fluid from the peritoneal cavity as Avell as plating tissues I'emoved
from the various organs. He concludes that the body fluids, un-
aided by the cells, have the power of destroying bacteria. Fol-
lowing this there is a slower destruction of tlie l)acteria due to the
392 THE PERITONEUM
action of phagocytes ou the surface of the peritoneum. Bail
and Buxton agree that the destructive action of the serum is less
after the cells appear. This loss Hoke attributes to the absorp-
tion of complement by the cells. Even in the organs Buxton con-
cludes that there is an active destruction by the serum at first and
later the phagocytes become active. The results above noted are
not constant. The disappearance from the peritoneum soon after
introduction does not prove that they have been destroyed because
inanimate bodies may suffer a like fate. ^Moreover the numbers
of bacteria are so great that an attempt at securing results by
plating must be subject to great error.
My own studies lead me to believe that relatively few of the
bacteria reach the blood or lymph stream but that the larger pro-
portion is destroyed by the serum. AVhen the peritoneal fluid is
almormally increased by previous irritation ])y a foreign body or
a chemical, this bactericidal power is lost and instead of the viru-
lence being decreased, it may actually be increased. Bacteria
placed into a peritoneal cavity for 30 minutes and then cultured
are less toxic to animals than the culture Avhich has not been so
placed. In order to determine the fate of bacteria it is necessary
to section peritoneal tissue. By this means large clumps of bac-
teria surrounded by fibrin and cells can be demonstrated.
Obviously when the subject is considered under clinical condi-
tions results are bound to be at variance. Here the individuality
of the organism as well as the patient is subject to the greatest
variation. In laboratory experimentation one can go back to the
original culture for comparison of virulence but when a clinical
problem arises either the source is unknown or is not available for
comparison. The problem is still more complicated because sub-
stances other than the bacteria are usually introduced at the same
time that the organisms gain entrance, and the trauma of the op-
eration either acts as or produces a foreign body which may prove
a continued source of irritation.
My own researches along this line, which were instituted for the
purpose of interpretation of the results of a study of pure cultures
under clinical conditions, failed to secure uniform results. It
seems to me, however, that the associated conditions such as trauma
from the operation or foreign bodies left, such as ligatures or dead
ETIOLOGY OF PERITONITIS 393
tissue, are as important as the strain and number of bacteria them-
selves. Whether or not such influences act by disturbing the bac-
tericidal activity of the serum or by inhibiting the activity of the
leucocytes is difficult to say. In the study just mentioned it would
seem that the serum is the important factor. Other studies lead
to a contrary conclusion. Thus a loop of colonic contents is more
apt to produce a reaction than cultures of bacteria from the same
material vhich contain many more bacteria. Fluid obtained from
the peritoneum under these conditions shows a smaller number of
leucocytes when the colonic contents are used. The explanation
seems to be that the intestinal contents inhibit the activity of the
leucocytes, possibly changing the reaction of the peritoneal fluid.
Since information olitained from the laboratory is uncertain,
obviously the details in concrete cases under clinical conditions
are difficult to secure. The problem presents the phase of the sub-
ject about Avliich information is most urgently desired.
The difficulties these problems present may Avell be understood
by references to the literature. The gi-eat variation of infectivity
became apparent early in the investigation of the etiology of
peritonitis. Grawitz, who was the first to make a comprehensive
study, found that suspensions of staphylococcus pyogenes aureus
injected into the peritoneal cavity were quickly absorbed without
harm unless there was a stagnation of peritoneal fluids or an
abrasion of the surface. Burginsky, repeating Grawitz 's expei'i-
ments, discovered that the results varied much with the virulence
of the organism. Cultures previously not virulent became so Avhen
repeatedly passed through animals and reeultivated. These re-
sults seem to contradict my own studies already quoted. My cul-
tures, it must be remembered, Avere obtained from the living ani-
mal or one just killed, Avhile this author recovered his cultures
from the animal dead of the infection.
Pawlowsky, evidently working Avith strains rivaling in virulence
the reinocnlated strains of Burginsky, found that very small
amounts of bacteria Avere capable of producing a peritonitis.
AVallgren likeAA'ise found that the degree of infectivity Avas due
to the virulence of the organism and that the i-apidity of the course
of the disease Avas much influenced liy the number of bacteria in-
troduced. Finallv Keichel's studies mav be mentioned. TTc found
394 THE PERITONEUM
that while the injection of 2 to 7 c.c. of a gelatin culture of staph-
ylococcus produced little or no disturbance, the injection of 100
c.c. of the same culture produced a hemori-hagic peritonitis in from
20 to 24 hours.
Without going further into detail it may be stated that suffi-
cient evidence has been presented to emphasize the importance of
virulence of a given strain of bacteria which gains entrance to the
peritoneal cavity.
The evidence of the importance of the second factor in Grawitz's
conclusions, namely, associated lesions, has been attested to by a
large number of workers. Among these may be mentioned Orth
and Waterhouse. These authors reporting on the same series of
experiments found that rabbits, cats, guinea pigs, and rats could
be injected Avithout harm. The failure of deleterious consequences
to arise was due to the fact that the bacteria were quickly absorbed
from the peritoneal cavity. If foreign bodies such as agar or
gelatin from the cultures were introduced, and particularly if
blood was allowed to accumulate, much smaller numbers of bac-
teria sufficed to produce a peritonitis. Rinnie, Reichel, Walthard,
Krafft, and Halsted showed that while a blood clot invites infec-
tion, in aseptic operations its presence may facilitate healing.
Tavel and Lanz, Sill)ersclimidt, and Wieland come to similar con-
clusions.
Noetzel, working Avith other bacteria, such as streptococci,
Proteus vulgaris, Bacillus coli, and Bacillus pyocyaneus came to
analogous^ conclusions. These, even more than Avhen staphylo-
cocci Avere employed, Avere capable of producing peritonitis in the
uninjured peritoneum. Because of the importance of the viru-
lence of the strain this author concluded that the active resistance
to bacteria Avas exerted in loco, according to him, due to the action
of the pei-itoneal fluids and to a lesser degree to the action of cells.
Wallgren ascribed an important role to the activity of the endo-
thelial cells of the peritoneum and blood vessels.
Varieties of Bacteria. — Under clinical conditions the bacterial
flora is nearly alAA'ays complex. Nevertheless a recounting of the
kinds encountered, together Avith a consideration of their charac-
teristics Avhen active in the peritoneum, so far as they have been
determined, may not be Avithout profit.
ETIOLOGY OF PERITONITIS 395
This is particularly true, for it may he stated as a general proposi-
tion, that those cases of peritonitis resulting from operation or
from penetrating Avounds of the abdominal wall are caused by the
streptococcus or staphylococcus, except in operations involving the
gut tract. Puerperal peritonitis is likewise usually caused by
one of these organisms. On the other hand cases arising from
spontaneous, operative or perforating wounds of the hollow organs
are apt to present an astonishingly complex flora. I have isolated
as many as a dozen different varieties from cases of diffuse peri-
tonitis, the most of which, I may say, could not be identified.
Streptococcus Pyog'enes, — This coccus, which is the most viru-
lent if not the most frequent variety encountered in peritonitis,
Avas first isolated l)y E. Fraenkel. He found this organism in ten
of fifteen cases of peritonitis; in only tAvo cases, however, Avas it
the only organism present. Predohl in the same year examined
fourteen cases of perforatiA^e peritonitis in Avhich four Avere due to
pure cultures of this coccus and in four other cases this Avas the
most prominent organism present. In four postoperative eases
this Avas the only organism present, AAhile in perforatiA^e cases a
mixture of organisms Avas present. It is Avorthy of note that the
obseiwations of both authors just quoted Avere made on post-
mortem material. A. Fraenkel likcAvise found the streptococcus
prominent in 31 cases examined. In 5 cases of puerperal peri-
tonitis it Avas the only organism present. LikcAvise Clivio and
Monti found streptococci in pure culture in 5 eases of puerperal
fever.
The characteristic biological features of this coccus make it pos-
sible that it is more often present than is recognized, because of
its sloAv groAvth on artificial media and the likelihood, therefore,
of its being overshadoAved by more rapidly groAving organisms.
At any rate a small chain coccus is more often present in peri-
toneal infections Avhen the exudate is examined on the slide than
Avhen plating is depended upon to demonstrate its presence.
While this by no means identifies them, the fact that such cocci
are most frequently found in those cases Avhich run a course char-
acteristic of the streptococcic infections lends probability to the
suspicion as to the identity of organisms occurring in chains ob-
served in smears.
396 THE PERITONEUM
The same holds true in the ol)jective findings in the peritoneal
cavity. Animals \\lien inoculated with this organism respond by
the production of a thin milky peritoneal exudate, not great in
amount, associated with little or no cellular infiltration unless the
organism is of attenuated virulence and the course of the disease
prolonged. This organism is more apt to be found in the paren-
chymatous organs soon after inoculation than are other varieties.
If associated with other organisms, as the staphylococcus or colon
bacillus, the characteristics of the streptococcus will be masked
and yet the deleterious effect of the streptococcus goes on unhin-
dered. In the more localized infections the organism shows the
result of its disposition to extend by way of the circulation. In
the human subject, as will be noted in the section on ''complica-
tions," abscesses in remote organs, notably in the liver, lungs, and
joints, are of relatively frequent occurrence. Animals do not sur-
vive the disease long enough for these secondary foci to develop
unless local areas of lessened resistance are produced by mechani-
cal or chemical means.
Bacillus Coll Communis. — This is the common organism encoun-
tered in perforations of the terminal ileum and colon. As soon
as the site of infection is reached the presence of this organism
is announced by the characteristic odor. In cultures this organ-
ism quickly covers the media to the obliteration of other organ-
isms. It is seldom the only organism present, however, though it
is the most common organism encountered. Fraenkel noted the
common association of this organism Avith the streptococcus.
Malvoz was also one of the earliest writers to recognize the im-
portance of this organism. Krogius found coli 35 times in 40
cases examined. Barbacci in 14 cases of perforative peritonitis
found this organism 13 times. Tavel and Lanz call attention to
the fact that because of the ease with which the colon bacillus
grows on ordinary culture media it may cover up less readily grow-
ing varieties. They believe this because smears stained by Gram
show many foi-nis that do not appear in the culture plate. That
the colon bacillus varies much in virulence is a matter of everyday
observation. De Klecki. in experiments on <h)gs, believes he has
demonstrated that in a loop of gut isolated 1)y ligature a more
virulent strain develops than is fonnd in nonconstricted portions
ETIOLOGY OF PERITONITIS 397
of the gut. This may be conceded since any stasis promotes growth
of bacteria. This same author believed that symbiosis with other
organisms increased its virulence. Various American authors
likewise emphasized the importance of the colon bacillus in the
production of peritonitis. Among these may be mentioned Fowler,
Hodenpyl, Park, and Richardson. In animals this organism is
characterized by an abundant exudate, rich in cells and granular
fibrin, leading to the agglutination of adjoining loops of gut. The
exudate shows the cells which have escaped for the most part in
a process of disintegration. My own studies are in accord ^^'ith
the conclusions of Tavel and Lanz. The colon bacillus alone is a
relatively innoxious organism as compared to the streptococcus.
In fact it seems to me that the presence of the colon bacillus limits
the spread of a concomitant coccus infection because of the dis-
position of the colon bacillus to produce an abundant exudate
which seems to counteract the negative chemotaxis (if one may
still use this term) and lessens the absorption of the cocci. The
earlier a diffuse peritonitis is analyzed the more apt is the strepto-
coccus to be found, hence the surgeon is more apt to find it than
the pathologist. The streptococcus likewise is more frequently
found in the tissue than in the exudate, a fact which Rosenow has
only recently emphasized.
Clinically the colon bacillus quickly produces a large amount of
stinking milky pus intermingled Avith flocculi which when attached
in large amount to adjoining loops of gut may produce an adhesion
readily separated by the finger. The abundant cellular content
usually shows varying degrees of degeneration.
Staphylococcus. — This organism is frequently found associated
with other oi'ganisms, rarely alone unless the infection reaches
the peritoneum from an adjoining region, as from a near-by ab-
scess. It is more frequently associated with the colon l)acillus
than with the streptococcus. Dudgeon and Sargent ascribe to this
organism a greater prominence than do most writers. According
to them it is frequently present as a forerunner of other organ-
isms. They even frequently find it in peritoneal cavities Avhich
at no time have been the site of active disease. Later in the dis-
ease when complete walling off has occurred and but a sinus re-
mains, the staphylococcus is very apt to be found. In fact it may
398 THE PERITONEUM
])e that the staphylococcus epidermidis albus may, like the bacteria
of the soil, actually serve a useful purpose. A sluggish wound in-
fected by this organism reacts, forming a fibrinous exudate which
results in cicatrization.
Bacillus Pyocyaneus. — This organism not infrequently makes its
appearance late in the course of an infection. It manifests its
presence by the green-blue color of the pus. Its presence tends
to produce a sinus Avhich may discharge indefinitely.
Mixed Infections. — A pure culture is rarely found in peritonitis
\vhen it is the result of perforation of the gut tract. The above
mentioned varieties in varying combinations furnished the most
frequent organisms. Besides these may be mentioned the Bacillus
foetidus liquifaciens, Proteus vulgaris, Diplococcus intestinales,
and a host of organisms which even expert bacteriologists have
failed to identify. Achard and Broca in 20 cases found mixed
infections in 13, and v. Mayer found mixed cultures in all appen-
diceal peritonitides. Krogius in 40 cases found all Init three to be
mixed infections. This author found a large number of nameless
forms. In 35 of his 40 cases he found bacilli with rounded ends with
a vacuolated capsule which did not stain by Gram, which he could
not identify.
Anaerobic Bacteria. — The presence of organisms on the smear
which failed to develop in plate culture led numerous authors to
suspect that anaerobic organisms might be present. Vellian and
Zeber were the first to investigate this variety of organisms
thoroughly. In 22 cases investigated they failed to demonstrate
anaerobes in only one case. The species they isolated Avere as fol-
lows: B. fragillus, B. ramosus, B. perfringens, B. fusiformis, and B.
mueosus. They blame the anaerobes particularly for those cases in
which there is gangrenous perforation with the production of
stinking pus. I do not believe this. Any organism that early in-
volves the appendiceal artery may produce a gangrenous appendix.
Specific Forms of Peritonitis. — In certain forms of peritonitis
a single bacterium is the active agent, resulting in a picture clin-
icall.v distinct from those heretofore considered. Most prominent
of these is tul)erculous peritonitis. The gonocoecus also gives ri'-'c
to a clinically recognizable picture. As much may perhaps be said
of the pneumococcus and influenza bacillus to Avhich may possibly
ETIOLOGY OF PERITONITIS 399
be added the Spirochete pallida. The facts of interest relating to
these organisms will he considered under the specific discussion
of the disease they engender.
BibliogTapliy
AciiARn ANT) Broca: Bacteriolooie de viiigt eas d'appeudic-ite suppurop, Bull.
et mem. Soe. med. d. hop. d. Paris. 1897, 3. s., xiv, 442.
Bail: Untersuehungen iiber Typhus- und Choleraimmunitat, Arch. f. Hyg., 1905,
lii, 272.
Barbacci: Due casi di peritonite primitiva da diploeoeeo: contribute alio studio
delle loealizzazioni extva-polniouari di (|uesto microorgauismo, Sperimentafe
Firenze, 1892, 305; 825.
II bacterium coll commune e le peritonite da pcrforazione, Spcrimentate Fir-
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BuKGiNSKY: Ueber die pathogene Wirkung des Staphylokokkus aureus auf
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Fowler: A Preliminary Note upon the Relation of the Bacterium Commune
Coll to Appendicitis, New York Med. Jour., 1893, Iviii, 434.
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Wein klin, Wchnschr., 1891, iv, 241; 265; 258.
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der Peritonitis, Charitc-Ann., 1884, 1886, xi, 770.
Halsted: Treatment of Wounds with Especial Reference to the Value of the
Blood Clot in the Management of Dead Sjiaces, Johns Hopkins IIosp.
Rep., 1891, ii, 255.
Hodenpyl: On the Aetiology of Appendicitis, New York Med. Jour., 1893,
Iviii, 777.
HoKE: Ueber Komplementbindung duich Organzellen, Centrullil. f. Bakteriol.,
I Al)t., 1903, xxxiv, 692.
DE Klecki: Recherches sur la pathogenic de la peritonite d'orgiue intestinale:
etude de la virulence du colibacille, Ann. de I'Inst. Pasteur, 1895, ix, 710.
Krafft: Ueber die friihzeitige operative Behandlung der durch Perforation des
AVunnfortsatzes hervorgerufenen Peritvplditis stercoralis, Samml. klin.
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Krogits: ijber die vom Processus vermiformis ausgehende diffuse eitrige Peri-
tonitis und ihre chirurgische Behandlung, Jena, Fischer, 1901.
Malvoz: Le bacterium eoli commune comme, agent habituel des peritonites
d'origiue intestinale. Arch, de mod. exper. et anat. jiath., 1891, iii, 593.
V. Mayer: Etude sur la pathogenie de 1 'appendicite a repetition, Rev.
med. do la suisse Rom., 1897, xvii, 209.
Noetzel: Ueber peritoneale Resori>ti()n und Infection, Arch. f. kliiu Ciiir., 1898,
Ivii, 311.
Ortii: Experimentelles iiber Peiitonitis, Zentralbl. f. Chir., 1S89, xvi, 849.
Park: The Importance to the Surgeon of Familiarity with the Bacillus Coli
Communis, Ann. Surg., 1893, xviii, 293.
Pawlowsky: Zur Lehre von der Aetiologie, der Entstehungsweise u. den Fomien
der acuten I'eritonitis, Virchows Arch. f. patli. Anat., 1889, cxvii, 469.
400 THE PERITONEUM
Beitrage zur Aetiologie und Entstehungsweise der akuten Peritonitis, Zen-
tralbl. f. Chir., 1887, xiv, 881.
Predoiil: Untersuclningen zur Aetiologie der Peritonitis, Miinchen. med.
Wchnschr., 1890, xxxvii, 22.
Eeichel: Beitriige zur Aetiologie und cliirurgischen Therapie der septischen
Peritonitis. Deutsch. Ztsch. f. ehir., 1890, xxx, 1.
Ueber Immunitat gegen das Virus von Eiterkokken, Arch. f. klin. Chir., 1891,
xlii, 237.
Richardson: Remarks on Surgical Treatment of Appendicitis, Boston Med.
and Surg. Jour., 1892, cxxvii, 105.
Remarks upon Appendicitis Based upon a Personal Experience of 181 Cases,
Am. Jour. Med. Sc, 1894, cvii, 1.
RiNNlE: Ueber den Eiterungsprocess und seine Metastasen, Arch. f. klin. chir.,
1889, xxxix, 1.
ROSENOW: Bacteriology of Appendicitis and Its Production by Intravenous
Injection of Streptococci and Colon Bacilli, Jour. Infect. Dis., 1915,
xvi, 240.
SiLBEESCHMiDT : Experimentelle Untersuchungen iiber die bei der Entstehung
der Perforationsperitonitis \virksanien Factoren des Darm-Inhalts, Mitth.
a. Klin. u. med. Inst. d. Schweiz., 1894, I. R. Hft. 5. 429.
Tavel and Laxz: Uel)er die Aetiologie der Peritonitis, ein Beitrag zur Lehre
■der Continuitats Infectioncn und der Contiguitats-Entzundungen, Mitth.
a. Klin. u. med. Inst. d. Schweiz. 1893, I R., Hft. i, i-xii, 1.
Veillon and Zi^ber: Recherchcs sur ciuelques microlies strietement anaerobies
et leur role en pathologie. Arch, de med. cxper. et d 'anat. path., 1898,
x, 517.
Wallgben : Experimentelle Untersuchungen iiber peritoneale Infection mit
Streptococcus, Bicitr. z. ]<ath. Anat., 1899, xxv, 206.
WALTHAR.D: Experimenteller Beitrag zur Kenntnis der Aetiologie der eitrigen
Peritonitis nach Laparotomie, Arch. f. exper. Path. u. Pharmakol., 1891,
xxx, 275.
AVaterhouse : Experimentelle Untersuchungen iiber Peritonitis, Vircho"\vs Arch.
f. path. Anat., 1890, cxix, 342.
Welch: The Bacillus Coli Communis; the Conditions of Its Invasion of the
Human Body; and Its Pathogenic Properties, Med. News. 1891, lix, 668.
Werigo : Developpement du eharbon chez le lapin d 'apres les tableaux micro-
scopiques du foie et de la rate, Ann. de I'Inst. Pa.steur, 1894, viii, 1.
Wieland : Experimentelle Untersuchungen iiber die Entstehung der circumserip-
ten und diffusen Peritonitis mit specieller Beiiicksichtigung der bakterien-
freien intraperitonealen Herde, Mitth. a. Klin. u. med. Inst. tl. Schweiz.,
1895, 2 R., 339.
CHAPTER XII
PATHOGENESIS OF PERITONITIS
Broadly speaking, peritonitis is the reaction of the peritoneum
against any condition Avhich destroys or threatens the integrity of
any part of it. This effect, as we have seen, may be produced by the
action of physical or chemical agents or by the products of bacteria.
Physical and chemical agents are of minor interest because re-
actions produced by them are limited by the duration and degree
of their action and are incapable of producing a progressive dis-
ease, save as they may be associated with, or set up, bacterial proc-
esses. So infrequently is this type a matter of interest that it may
be said that its importance is largely academic. However, the
reaction to these agents has played an important role in experi-
mental pathology and much of this has been repeated inadvertently
by the surgeon in his therapeutic endeavors, mostly it may be added
in the form of antiseptics, and by means that have been employed
in the prevention of adhesions or for the control of hemorrhage.
The usual source of spontaneous chemical or i^hysical irritation
is the bursting of hollow organs normally free from bacteria into
the peritoneal cavity. Among these may be mentioned the biliary
and urinary bladder and the thoracic duct. The rupture of cysts
permitting the escape of their contents may act in a similar man-
ner. Among these may be mentioned cysts of the ovaries and less
commonly parasitic cysts, notably echinococcus.
Peritonitis in its practical relations, however, we may say with-
out equivocation, is due to the invasion of the peritoneal cavity by
pathogenic organisms. This simple statement declares the funda-
mental factor, but the disease as manifest in the human subject pre-
sents the greatest variations due to the difference in the character
of the organisms and the conditions under which they gain access.
Because of the amazing range of these variations, so simply stated,
this becomes the keynote to the proper understanding of the in-
flammations within the peritoneal cavity. Variations in species of
bacteria and the Vastly different degree of virulence they present is
401
402 THE PERITOXEUM
comi^licatecl by the fact that various strams of the same order pre-
sent no less a degree of variability. The complexity of the picture
produced l)y this variability of the invading organisms is vastly
complicated by the manner of their introduction into the peritoneal
cavity. If the invasion is slow and the defensive forces have time
to mobilize, the results are less disastrous than Avhen the invasion
is rapid and the infective agent enters the peritoneal cavity in the
absence of an anticipatory reaction. In the latter instance the
progress of the infection is unhindered. We have, therefore, two
variables, l)oth infinite in their range, and it does not require a
mathematical mind to perceive that the product of these two vari-
ables is an infinitely inconstant picture.
Though this great variation in type of disease exists, it is possible
to distinguish certain groups due to a similarity of causative organ-
isms and the like circumstances in their introduction, as was noted
in the chapter on etiology. It is the purpose of this section to de-
fine as closely as possible groups of like clinical course. It is only
by possessing a clear notion of the fundamental factors that the
surgeon is enabled to meet conditions in the most comprehensive
way. While a sharper division is not possible, the desirability of
the nearest possible approach is generally recognized by the disj^o-
sition of the surgeon to designate the lesion according to the cir-
cumstances of its genesis and neglect the existence of the causative
organisms, and even the presence of the overshadowing peritonitis,
in his nomenclature. By this he bears testimony to the fact that a
knowledge of the pathogenesis is necessary as a foundation for his
therapeutic endeavors. As examples may be mentioned, appendi-
citis, perforated peptic ulcer, pericholecystitis, and pelvic peri-
tonitis. All these threaten the patient with the same condition of
spreading peritonitis, but he endeavors to separate them by desig-
nating the source of the infection rather than the nature of the
disease itself. So different are these, grossly speaking, that the as-
tute diagnostician is usually able to succeed in his endeavors at
broad specific determination. AVhile such endeavors are usually
lacking in finesse it is by their consideration that we are guided
with least error in our efforts to locate the source of the infection
and so to divert from the patient the impending disaster.
While the examination of the fundamentals of the variables al-
PATHOGENESIS OF PERITONITIS 403
ready noted can best be considered in the abstract, concrete dis-
cussions of diseases can not be avoided because only in this way
can proper grouping of the otherwise too numerous factors be
achieved.
The fundamental factors which govern the development of a
peritonitis are simple. The well-being of the individual demands
that the peritoneal cavity remain free from bacteria. Bacteria ex-
ist on all sides, being separated only by a wall of living tissue.
The problem in pathogenesis is to study by what means bacteria
gain access to the forbidden field of the peritoneum, and how they
set up their nefarious business.
Any means that will penetrate the walls flanking the peritoneum
may cause peritonitis. Bacteria are ubiquitous and those in the gen-
eral environment of the body will gain access to the peritoneal
cavity when there is a solution of continuity as by a wound, such
as a gunshot, or a puncture or from the action of a disease. The
solution of continuity need not be continuous. The bacteria may
gain entrance at some distant point and be transmitted to the peri-
toneum by the blood or lymph stream. The first avenue is usually
obvious, the latter in its very existence may be uncertain, even
speculative. The superlative source of bacteria in peritonitis, how-
ever, are the hollow organs it covers and of these the gut tract is pre-
eminent. Each of these methods of entrance may now be studied
in turn.
Penetrating- Wounds of the Abdominal Wall. — When there is a
gross solution of continuity of the abdominal wall bacteria may be
carried into the peritoneal cavity by the traumatizing agent, as
by clothing carried by a ])ullet, or by some secondary agent, as the
surgeon's efforts to determine the extent of the injury, or from
some protuberant viscus accumulating infection from the environ-
ment and afterward retreating into the peritoneal cavity, either
spontaneously because of changing intraabdominal pressure, or by
manual replacement by the first aid attendant.
Penetrating wounds of the abdominal wall are astonishingly lit-
tle likely to he attended by serious consequences. Every surgeon
knows that injuries to the abdominal wall of even great extent are
recovered from with surprisingly little disturbance, if a hollow
viscus is not injured. Tliis immunity from grave consequences is
404 THE PERITONEUM
due to the fact that bacteria, while existent in large numbers on
every object, as compared to the intestinal content, are rare curi-
osities. Nor is this the chief factor. The bacteria of the external
environment are in a large measure nonpathogenic, and even those
of pathogenic heredity are so attenuated in their virulence by the
unfavorable environment in Avhicli they have existed that they are
but a minor menace to vound surfaces possessed of a normal
capacity for combat.
Usually, too, large wounds are quickly sealed by natural protec-
tive factors. The abdominal contents, with the protecting omen-
tura, quickly fall over the wound and by the time the blood flowing
from the Avound in the abdominal Avail has had time to coagulate,
adhesion of viscera to the abdominal injury has already taken
place and further admission of infection is precluded. The rela-
tively innocuous bacteria that have been carried in by the trauma-
tizing force are quickly taken to account by the uninjured perito-
neum of the remainder of the abdominal caA'ity.
It is only AA^hen bacteria of unusual virulence are introduced, or
foreign bodies laden with bacteria remain in the peritoneal cavity,
that an infective process gains foothold. The influence of the pres-
ence of a foreign body in aiding relatively innocuous bacteria in
exciting inflammation has already been noted in the section on
general pathology. In fact, generally speaking, all that has been
learned in experimental peritonitis may be applied to the elucida-
tion of the question under consideration.
Hematog'enous Infection. — Under hematogenous infection AAe are
AA'ont to classify those cases of peritonitis the source of infection of
AA'hich lies at a distance. Perhaps there is some basis for such a
classification, for the peritoneum is sometimes iuA^oh^ed in pneu-
monia, and it is but fair to assume that the blood or lymph stream
has couA^eyed the organisms. These aaIII be considered in a separate
section. The same may be said of influenzal infections. There is
much eA'idence that tonsillitis may produce an invoh-ement of the
lymjAatic apparatus of the appendix AA'ith subsequent infection of
the peritoneum. To Avhat extent the blood stream may furnish
direct transportation from some primary focus to the peritoneum
is not knoAA-n. In rare instances peritonitis folloAvs infections by
pus or other organisms in distant regions. I haA^e seen diffuse
PATHOGENESIS OF PERITONITIS 405
gangrene of the gut follow moist gangrene of an extremity. How
the infection gains access to the peritoneal surface is not fully
understood, most likely by producing thromboses in the vessels with
subsequent rupture into the peritoneal cavity. The escape of bac-
teria by exudation through the unruptured peritoneum has also
been assumed.
Cases are recorded in which a fatal peritonitis has followed ery-
sipelas at a distance and peritonitis following scarlet fever has
been recorded in a number of instances (e. g., Aubree). Corollary
to this are numerous cases of erysipelas of the cord in the newborn
Avhich are followed by peritonitis. Here the extension is no doubt
direct through the walls of the hypogastric vessels. Moore made a
collected report on this type. Additional cases are reported by
Breton.
Even before the discovery of the streptococcus by Fehleisen,
V. Leyden described a streptococcus in his case of peritonitis folloAv-
ing erysipelas. Since the modern development of bacteriology, this
organism alone or in association with others has been described,
most frequently in alleged hematogenous infections.
That the bacteria reach the peritoneum by way of the blood-
stream is likely. So far as the erysipelatous cases go it is inter-
esting to note that Achalme got positive blood cultures in all of
13 fatal cases of that disease.
Idiopathic Peritonitis. — This caption is meant to include cases
of peritonitis the origin of Avhich is indeterminable. Despite every
effort to discover the source of the infection, the best that can be
done in certain rare instances is to secure ourselves ])ehind such
a classification. It is, of course, never a clinical classification be-
cause only the most painstaking autopsy can give the necessary
exclusion of other foci to warrant its adoption. Though rare, oc-
casionally throughout literature cases of peritonitis are recorded
in which the source of the infection does not appear even after the
most painstaking study. It is significant that these cases have be-
come progressively less as knowledge and exactness of investiga-
tion have become greater. Nevertheless, cases occur in Avhich there
seems to be no detail lacking, yet the source of infection was not
revealed. In such cases it is perhaps Avarranted to use the much
maligned term "idiopathic."
406 THE PERITOXEUM
The first case belonging to this group in Avliich tlie data is fairly
satisfying -was recorded by Behier and Hardy. BigeloAv recorded
a case, the earliest satisfactory one in American literature. As
an example of this type of disease the one recorded by Leyden may
be cited. Following a diffuse diarrhea a generalized peritonitis
developed Avhich at autopsy showed no primary lesion. Meunier,
and Milian and Harrenschmidt report tAvo similar cases.
In all the cases recorded the disease was first manifested by a
diffuse diarrhea followed by the signs of a generalized peritonitis.
It would seem that the disease must therefore be a primary intes-
tinal infection and that bacteria pass through the intestinal wall,
a sort of discontinuous perforation as it Avere. In puerperal peri-
tonitis such a condition commonly exists. I have had tAvo cases
belonging to this category. Both (females) began AA'ith chill fol-
loAA'ed by profuse choleriform diarrhea, AA-hich AA-as promptly fol-
lowed by signs of diffuse peritonitis resulting fatally the fourth
and sixth days, respectively. At autopsy there Avas a diffuse in-
flammation of the peritoneum, moderate exudate, some fibrinous
deposits, and excessive intestinal distention. In one of these the
distention Avas so intense as literally to fix the diaphragm. Each of
these cases presented a streptococcus pyogenes and an unnamed
diploeoccus. Both of these Avere maiden ladies of middle life.
There is a suggestive sameness in the recorded cases correspond-
ing in the main Avith these personal observations. Curiously
enough, females alone seem to be affected. The significance of
this, if it has any, does not appear.
It is possible that a general septicemia developed from some
unknoAA'n source or that there Avas a primary bacterial dysentery.
In this latter event, it is possible that there is a common source
in such cases for both dysentery and peritonitis, though the autopsy
does not reveal it. I haA^e seen intense choleriform diarrhea attend
erysipelas of the face Avithout peritonitis l)ut Avith perisigmoiditis.
One needs to go back to the early literature on peritonitis in
order to find any considerable number of ease records. Surgeons
noAV seem to question tlie propriety of recording cases of peri-
tonitis the origin of Avhich can not be demonstrated.
Guttmann in 82 cases of peritonitis desci'ibed 8 cases as idio-
pathic. Litten belicA'cs that idiopathic cases occur, though they
PATHOGENESIS OF PERITONITIS 407
are rare. Grawitz in 867 autopsies had 13 spontaneous cases. It
may be possible that idiopathic peritonitis may occur from small
local foci, the existence of which may be obscured by their loca-
tion. It -would differ from the hematogenous type then only by
the fact that the focus is unkno-wn.
Perforative Peritonitis. — Nearly all cases of peritonitis arise be-
cause of a perforation of some hoUoAv viscus which constantly har-
bors bacteria. This perforation may result from violence as in
gunshot injuries or other trauma or from surgical manipulations.
In the vast majority of instances the infection escapes through a
solution of continuity due to some disease process, which destroys
the continuity of the wall of the gut. An ulcerous process may
destroy the Avail or an infection beginning in the wall may gradu-
ally destroy it, or the wall may become necrotic because of some
sudden complete stoppage of nutrition to a certain segment, or
such a degree of nutritional disturbance may exist that bacteria
escape through a wall yet capable of regeneration and, finally,
some form of local infection may rupture into the peritoneal cavity.
Perforation of the Gut Wall by Mechanical Injury. — A force act-
ing from Avithout may produce an opening into the gut permitting
the escape of intestinal contents. When the opening is small, the
elasticity of the submucosa may roll in the mucosa in such a man-
ner as to actually close it to further jDassage of gut contents. Some-
times the great omentum becomes attached to the margin of the
opening, efTectually closing it, or several coils of gut may adhere
about an opening and prcA'cnt the escape of the contents.
The usual fate of a perforation is to permit the escape of gut
contents consisting of fecal masses and bacteria. As noted in the
section on general pathology it is the mechanical irritation of the
gut contents that plays an important part in producing the most
favorable conditions for the development of the bacteria that es-
cape from the gut. A spreading peritonitis, therefore, is the rule
Avhon a gut is perforated permitting the escape of the contents.
Perforation by Ulceration. — In this condition there is a solution
of continuity of the Avails of the holloAv viscera as a result of disease
or foreign bodies. The virulence of the infection resulting is de-
pendent on the rate of dcA'clopment of the ulctM'alive ]U'Ocess and
the degree of reaction Avhich takes place in the peritoneum in this
408
THE PERITONEUM
region as well as in the surrounding tissue. Because of tliese dif-
ferences, infections resulting from perforations may be divided
into those "vvhieh occur Avithout reaction, those with reaction in
which inflammation occurs in the gut Avail in the region of the
perforation, and those in Avhieli preliminary adhesive inflammation
takes place about the site of impending perforation which pro-
duces ijrotective adhesions.
Ulceration without Reaction. — In some instances the process is
so rapid that the continuity of the Avail is so quickly lost that there
Fig. 155. — Perforating ulcer of the duodenum. There are no adhesions about the opening.
is no reaction. Eapidity of the process must be due at least in
part to the environment, for this condition is noted chiefly Avhere
the ulcer is bathed in digestive juices, notably in duodenal, typhoid
and similar ulcerations. The gall bladder and cecum sometimes
perforate in a like manner. The occlusion of vessels in a limited
area seems to be the factor at fault in some instances. These are
thrombotic perhaps rather than ulcerous perforations.
A sharply defined ulcer results, the edge of Avhich presents Avith-
out reactive infiltration of any kind. These are well deserving the
PATHOGENESIS OF PERITONITIS
409
clinical designation of "pnnched out" ulcers (Figs. 155 and 156).
They are really perforations, lacking the attributes of ulcerous
processes. When perforations of this character exist there is an
unobstructed pouring out of the gut contents preventing any effec-
tive attempt at walling off. However, the absence of adhesions is
due not alone to the intensity of the bacterial invasion, but also
to the pouring out of the digestive ferments which prevent the
Fig. 156. — Acute perforation of the ai)pendix. The whole organ was black and the site of
perforation represented an area which first became liciuefied.
fibrin formation so that any attempt at the development of adhe-
sions is prevented. This is seen in a pronounced degree in per-
forations of the duodenum in which the gut contents pour out
unhindered.
Ulceration with Reaction. — This condition is typified by the "in-
durated" ulcers of the stomach and in some types of appendicitis
(Figs. 157 and 158). Here the solution of continuity is attended
with marked, often enormous thickening of the wall of the viscus.
410
THE PERITONEUM
Fig. 157. — [nflammatory t.'iickening of the appendix about an enterolith with a perforation
proximal to the foreign body.
Fig. 158. — Slight inflanmiatory thickening of the ai>i)cndix with ])crforation at the tip.
PATHOGENESIS OF PERITONITIS 411
This tliiekening is an expression of the attempt at healing. It is
in a large part made up of round-celled infiltration and fibrinoid
exudations, and to a lesser extent to the new formation of fibrous
tissue.
AVhen perforation occurs under these circumstances the attempts
at repair are exceeded by processes of dissolution until the entire
thickness of the wall is destroyed. While there has been no forma-
tion of adhesions, the reactive process on the part of the peritoneum
may be pronounced and in consequence walling off processes are
instituted more readily when therapeutic endeavors are instituted.
Since the visceral contents escape unhindered, the clinical results
are the same as the previous type of perforation unless aid is
offered by operative means. In this type the individual may have
been disturbed by preliminary manifestations absent in the other
type.
The majority of perforations belongs to this type. Aside from
the ulcers of the stomach already mentioned, it is noted in varying
degrees in typhoid ulcerations, in tuberculous and malignant proc-
esses as Avell as in appendiceal and gall-bladder infections, diver-
ticulitis and the like. In this type as in the "punched out" vari-
ety, there are no adhesions present, but the surrounding tissues
have already reacted and in response to additional irritation may
quickly do so.
Ulceration with Adhesion Formation. — In this variety as the ul-
cerous process approaches the surface the peritoneal tissues are set
into a state of reaction. By virtue of this reaction an exudate is
thrown out which attaches the threatened surface to its environ-
ment. In this way an artificial reinforcement is produced so that
when the peritoneum is finally destroyed some neighboring part is
attached firmly to the gut which prevents escape of the contents
(Fig. 159). This state is noted most frequently in appendiceal per-
forations and may exist about stomach ulcers, less often about duo-
denal ulcers, very occasionally about typhoid ulcerations. Not in-
frequently perforation of the gall bladder is prevented by the
attachment of the ubiquitous omentum. •
Often the protective adhesions are but partial. In that event a
local peritonitis or abscess may form, or the barrier may be passed
because the adhesion does not foi-m a perfect Avail, and the infection
412
THE PERITONEUM
may spread. When the adhesion formation becomes complete, the
infection forms a localized abscess and its contents may be con-
ducted to the pai'ietes and the infection may ultimately involve
this structure and a fistula result. This is sometimes noted in gall-
bladder infections, less often in perforations of the gut tract. More
often the localized abscess breaks into the lumen of the gut from
Fig. 159. — Ulcerating duodenum in which perforation was prevented bj' the formation of
omental adhesions.
which the infection originated or into some other hollow viscus.
Infection within the Wall of the Gut. — How often this may take
place in ulcerations can not be determined. Here the infection
gains access to the Avail of a viscus and by extension involves both
the mucous and serous surfaces. In this wav the entire thickness
PATHOGENESIS OF PERITONITIS
413
of the <iut -wall is destroyed and an unhindered passage for the
escape of contents is provided.
The consequences of this type of lesion are very varied. In many
the reaction produced in the surrounding peritoneum is so intense
that protective adhesions result (Fig. 160). The abscess may then
break vithin the lumen of the gut and the area is drained and in
due time only the scar in the gut wall and perchance an adhesion
is all that marks the previous existence of a menacing lesion.
The virulence of the infection may be such that the formation of
adhesions is repelled and the Avail is perforated permitting the
unhindered escape of the gut contents.
Fig. 160. — Small abscess within the gut wall covered with plastic exudate. A probe has
partly separated this exudate. From a case of irreducible inguinal hernia.
There may be a midstage between these two conditions and a
localized al^scess is formed, or the partial adhesions may serve as a
gubernaculum for the infection and an abscess may finally result.
This variety of aifection is most often demonstrated in the apin^n-
dix, but may occur anywhere in the gut tract. The infection takes
place in the lymph follicles of these organs and l)y extensioii af-
fects the nuicosa as \\ell as the muscularis and serosa. Sonictimes
several lesions may l)e found in the same gut. representing vary-
ing degrees of development, permitting tlie foniialidii of some
4U
THE PERITONEUM
opinion as to Iioav the process advances. It may also be found in
the bladder -wall, Avithin the tube or uterus, rarely in the Avail of
the stomach. Abscesses in the solid Adscus may reach the peri-
toneum in a like manner, as abscesses of the liver.
Infection by Stasis. — AVhen the circulation of the gut Avail
reaches a certain degree of embarrassment it becomes pervious to
bacteria. This may take place before the Avail is injured beyond
restitution if the disturbing process is removed, as is sometimes
observed in strangulated hernia (Fig. 161).
Fig. 161. — Xecrosis of a loop of ileum in a case of strangulated femoral hernia.
To determine Avhat character and extent of lesion must exist
before it is possible for bacteria to escape many studies have been
instituted. When there is an obvious solution of continuity or a
state of degeneration of the gut Avail Avhich precludes a return to
the normal, the problem seems simple enough, for an actual per-
foration results. In some instances, hoAvever, there is no solution
of continuity and the gut Avail is not so far diseased that it can
not become restored to the normal, yet bacteria pass. This factor
is most clearly observed in strangulated hernias in Avhich bacteria
PATHOGENESIS OF PERITONITIS 415
may be demonstrated in the exudate, but in which there is a com-
plete recovery after the release of the strangulation.
That a primary infection of the gut tract is not necessary to pro-
duce these changes which will permit the escape of bacteria is
probal)le from the fact that in degenerative ovarian cysts, which
come in contact with the gut wall, so irritate it that an infection
of the cyst takes place, due presumably to bacteria that have es-
caped from the gut canal. Even the blood clot from an extra-
uterine pregnancy that has ruptured may so act. Olshausen
ascribed the infection of ovarian cysts to direct extension from
the gut tract. Walthard attempted to prove that more than ad-
hesion of serosa to serosa was necessary before bacteria would
traverse the gut wall, a fact abundantly proved by clinical ex-
perience.
The means by which bacteria travel in such instances evidently
is that a fibrinous exudate foi-ms within the gut wall as well as
upon its surface. A like condition exists in the cyst Avail or blood
clot. These tAvo are connected l)y fil)rin masses. In this Avay a
homogeneous structure results Avhich permits bacteria to pass.
That bacteria may escape Avith the exudate into the peritoneal
cavity in intestinal obstruction has long been knoAvn. NepA^eu
AA'as the first to make this observation. Garre found a coccus non-
pathogenic to animals in only one of eight cases of intestinal ob-
struction examined. Naturally the likelihood of bacteria being
present is dependent upon the degree of injury to the gut Avail.
Clado found the colon bacillus in three out of five cases examined.
All three of these in Avhich the bacilli Avere found proved fatal.
That bacteria may escape early Avas proved by Blinnecken's case
in Avhich he found bacteria after strangulation Avas present only
4 hours. Lanz and Tavel in 21 cases of strangulated hernia found
bacilli in five. Kodella secured negative results by both aerobic
and anaerobic cultures in all of 5 cases. Dudgeon and Sargent ex-
amined 47 cases. In forty-tAvo of these the fluid obtained from the
sac AA-as sterile, in 5 bacteria Avere present. The colon bacillus Avas
found but once in pure culture, once Avith the staphylococcus albus,
and once Avith a Gram-positive staphylococcus. Anaerobic cul-
tures Avere made in eight Avithout demonstrating any anaerobes.
Numerous observers have attempted to soIa'c the problem of hoAv
416 THE PERITONEUM
bacteria escape by artifically induced intestinal obstruction.
Eeichel found that even after an ileus of several days' duration the
gut Avas not pervious to bacteria. Attempts at imitating the condi-
tion in strangulated hernia "were made by Zeigler and Tietze.
These experimenters placed a loop of gut in a condum and con-
stricted the base by a ligature. The former in 29 experiments
found bacteria 9 times in 17 cases. Wurtz and Hudelo found bac-
teria in the peritoneal exudate in one-half the cases in animals
killed during acute alcoholic coma. The presence of an extensive
peritonitis chemically induced is insufficient to insure the trans-
udation of bacteria. E. Fraenkel induced intense reactions with
iodine and chloride of iron and found that bacteria escaped from the
lumen of the gut only after destructive changes in the gut wall had
taken place. Tuffier allowed urine to escape into the peritoneal
cavity and found that bacteria did not escape from the gut until
profound changes had taken place.
The escape of bacteria into the general peritoneal cavity may oc-
cur either from the vessels or from the gut tract. The protecting liar-
rier is the Kittsubstanz betAveen the cells. At least I so conclude
because a precipitation of that substance with silver nitrate in-
creases the permeability of the tissue. For instance if a dilute so-
lution of silver nitrate is injected into the mesenteric vessels, bac-
teria-containing fluids will escape under relatively low pressure
into the peritoneal cavity, while if not preceded by the silver in-
jection much higher pressure is required. Binaglii concluded that
it was the peritoneum that protected the peritoneal cavity from the
infection from the intestinal cavity. From my own studies just noted
it would seem that these conclusions are sound but it does not fur-
nish the sole barrier, for intestinal walls devoid of peritoneum do
not become permeable without some change in the remaining
layers.
When a gut wall becomes so changed that an actual solution of
continuity takes place it goes without saying that an escape of
contents will take place. If an area of gut wall loses its vitality
through interference with its circulation or by cauterization with
a strong chemical sufficiently great to destroy the vitality of the tis-
sue, escape of bacteria will take place before the diseased portion of
the gut is cast oif. The protection the destroyed gut oifers seems
THE PERITONEUM 417
to be purely a mechanical one. If a hypertonic solution is placed
external to such destroyed gut, bacteria will escape sooner than
if the diseased gut is surrounded by an isotonic solution. In an
injured gut the escape of bacteria takes place in the zone of vi-
ability first, that is, in that area where the reaction of living tis-
sue is taking place against the dead. In a constricted gut the
greatest number of bacteria are found near the line of constriction
and in a stained section the greatest number of bacteria will be
found in the tissues of that region. Tissues which have undergone
changes to the degree that they are no longer acidophilic are most
likely to harbor bacteria, in fact it is the only living tissue in which
bacteria are found. In such tissue if the current is reversed by any
factor, bacteria escape. If a gauze pack is laid against the inflamed
gut the irritation from the foreign body will cause a current of
fluid to set in. This fluid will likely contain bacteria while the
fluid found on the surface of the gut at some distance from the
pack will contain none. Every surgeon knows hoAv prone a drain
placed against an inflamed organ is to produce a fistula from
that organ. The production of a fistula is but one step removed
from the reversed current which carries bacteria to the drain. Non-
irritative substances such as glass and rubber are less prone to pro-
duce fistulge than is gauze or other irritating substances.
From these studies it seems a safe hypothesis to assume that for
bacteria to escape from the gut lumen into the peritoneal cavity
two factors must be present: disturbance in the intercellular sub-
stance, the result of some reactive or chemical process, and the
action of some factor to reverse the current of absorption.
Reaction from other causes than interference with the circula-
tion may make the peritoneum permeable to microorganisms.
Gonococcic tubes permit the passage of infection after the fim-
briated end has been occluded. Tlie puerperal uterus presenting
septic throml)i within its walls likely does the same thing. In fact
any infection lying near the peritoneum may give off its infecting
material under certain conditions. It is, therefore, not entirely cor-
rect to class all these conditions under stasis since disturliance of
circulation is but one of the factors active. There seems to be no
more accurate term, however.
Infection by Necrosis. — As a corollary, sometimes as a sequence.
418 THE PERITONEUM
to the preceding there is a total solution of continuity from degen-
eration of the gut wall. This form is closely allied to perforation
by ulceration without reaction but dithers in involving a segment.
Gangrenous appendicitis and gall bladders properly belong here.
This variety of affection may show anywhere that a vessel may
be closed. Occlusion of the appendicular artery with total necrosis
of that organ is the most common example while perhaps the most
striking picture is seen in mesenteric thrombosis (Fig. 162). In
the former usually there is a primay infection of the wall of the
appendix which extends to the artery, producing within it a septic
thrombosis. In the case of the mesenteric thrombosis the occlud-
ing agent travels from afar and occludes the vessel but some more
local process may produce a septic thrombosis.
Fig. 162. — ^Kecrosis of the appendix from thrombosis of the appendicular artery.
Anywhere that the circulation may be destroyed this process
may take place. I have seen a segment of the transverse colon fall
out from necrosis produced by extension of infection from a gall
bladder. The small gut may suffer a similar fate Avhen it lies near
a tumor undergoing necrosis.
Perforation of Paraperitoneal Abscesses. — Any abscess arising
external to the peritoneum may escape into the abdominal cavity.
Abscesses of the abdominal Avail may perforate the peritoneum. I
once saw this accident occur in a child of four years.
These are among the rarer accidents in abdominal diseases.
They must be differentiated from walled-off abscesses within the
peritoneal cavity. Abscesses occurring within the parenchymatous
organs, liver, uterus, spleen, etc., are sometimes included imder
this head.
PATHOGENESIS OF PERITONITIS
419
Location of the Infection at a Distance from Its Source. — In
some instances the infection may escape at one point (Fig. 163) and
be conveyed to some distant point and there set up the chief reac-
tion. It is necessary in such instances, when there is not a suffi.-
Fig. 163. — Perforation of the duodenum showing how the contents of the gut are conveyed
into the pelvis laterally to the colon.
cient pathologic change in the region to account for tlie degree of
infection, to seek further for the source of the tr()ul)le. This con-
dition is encountered particularly^ in perforations above the attach-
ments of the great omentum.
420 THE PERITONEUM
Bibliography
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aigues, Gaz. d. hop., 1890, Ixiii, 1131.
AuBREE: Do I'erysipcle, These de Paiis, 1857, v, 598.
AuDiox: Contiilaition a 1 'etude de I'ombilic et des infections ombilicales chez
de nouvcau-ne, These de Paris, 1900.
Behier and Hardy: Traite elementaire de pathologic interne Paris, Labe,
1864, iii, 513.
BiGELOW: Eheumatie Peritonitis, Philadelphia Med. Times, 1872-3, iii, 554.
Binachi: Sull azione protettiva del peritoneo infezione d 'origin intestinale.
Eeforme med. 1899, 2(i2.
BONNECKINS: Ueber Baktorien des Bruchwassers eingeklemmter Hernicn und
deren Beziehung zur peritonealen sepsis, YirchoAvs Arch. f. path. Anat.,
1890, cxx, 7.
BoRMANN : Ueber das Yerhalten des Peritoneum gegeniiber dem Inhalte intra-
abdomiualer Tumoren, Diss, Berlin, 1887.
Breton: Essai sur la jjeritonite scarlatineuse, These de Paris, 1888.
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I'erysipele, These de Paris, 1879.
Clado: Sur le Ijacille de I'infection herniaire, Oong. Franq. de chir., Oct. 7-12,
1889; Ref. Rev. de chir., 1889, ix, 927.
Dudgeon and Sargent: The Bacteriology of Peritonitis, London, Constable &
Co., 1905.
Fehleisen: Die Aetiologie des Eiysipels, Berlin, Fischer, 1883.
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yii, 23.
Garre: Bacteriologische Untersuchungen des Bruehwassers eingeklemmter Her-
nicn, Fortsclir. d. med., 188fi, iv, 486.
Graavitz: Statistischcr und experimentell pathologischer Beitrag zur Kenntnis
der Peritonitis, Charite Ann., 1886, xi. 770.
Guttmann: Yerhandl. d. Yer. f. innere Med. zu Berl., 1883-1884, iii, 301.
Yeihandl. d. Yer. f. inneie Med. zu Bcrl., 1889, viii, 278.
Lanz and Tavel: Bacteriologie de 1 'appendicite. Rev. de chir., 1904, xxx,
43; 215.
V. Leyden : Uelier spontane Peritonitis, Deutsch. med. Wchnschr., 1884, x, 258.
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Meunier: Peritonite erysipelateusc par contagion: etat menstruel et infection,
Presse med., 1894," 312.
Milian and HAKREXSrH:\riDT : Peritonite a streptocoques, Presse med., 1900,
i, 141.
Moore : Scarlatina Avith Inflammation of Serous Membranes; Hydrops Cystides
Fellffi, Dublin Jour. Med. Sc, 1876, Ixii, 335.
Nepveu: Presence de bacteriens dans la serosite peritoncale des lierniee
etranglees, des occlusions intestinales, cas de fievre latent et de septicemia
latcnte, Compt. rend. Soc. de biol., 1883, 7. S, iv, 403.
Olshausen: Krankheiten der Ovarien, Stuttg., Enke, 1886.
Reiciiel: Zur 'Pathologie des Ileus und Pseudoileus, Deutsch. Ztschr. f. Chii.,
1893, XXXV, 495.
Eodella: Alcune considerazioni sui risultate dell 'esame batteriologico del
liquido erniario iuernie Strozzate, Riforma med., 1903, xix, 1265.
Tietze: Klinische und experimentelle Beitrage zur Lehre von der Darniincarccra-
tion, Arch. f. klin. chir., 1895, xlix. 111.
TuFFiER : Action d. 1 'urine asejitigne sur les tissus, Compt. rend. Soc. de biol.,
1890, pp. 153, 357, 432.
PATHOGENESIS OF PERITONITIS 421
Waltiiard: Experimenteller Beitrage z. Kenntniss der Aetiolooie der eitrigen
Peritonitis nach Laparotomie, Arch. f. exper. Path. u. Phaniiakol., 1891,
XXX, 275.
WURTZ AND HuDELO: De 1 'issue des bacteries intestiiiales dans e peritoine et
dans le sang pendant 1 'intoxication alcoolique aigue, Conipt. rend. Soe.
de biol., 1895, 10. s., ii, 50.
Zeigler: Studien iiber die intestinale Foim der Peritonitis, Miinchen, [Muhl-
haler], 1893.
CHAPTER XIII
GENERAL SYMPTOMATOLOGY OF PERITONITIS
NotAvithstanding- the great A^ariety of manifestations in the
various cases of peritonitis the fundamental phenomena have
much in common. It seems best, therefore, to give a somewhat de-
tailed account of the fundamental symptoms as observed in an
average case of acute diffuse peritonitis. It will be easier then to
consider the special forms Avhich present peculiarities in one way
or another because of the site of their origin.
Though the SA^mptoms about to be detailed may occur in varying
orders or more or less simultaneously, the presentation of each
group of symptoms as entities much facilitates the presentation of
a A^ery complicated disease. The most common order of the occur-
rence of the symptoms may be folloAved.
Pain. — The perception of unpleasant or distressing sensations
by the patient is the cardinal symptom in peritonitis from AA'hateA^er
cause. In the chapter on i^hysiology the question of sensibility of
the peritoneum AA'as considered. That the parietal peritoneum may
transmit painful impulses goes Avithout saying. That the visceral
peritoneum also may do so can hardly be denied.
Because of the tAA^o types of nerA'es Avhich supply these tissues
tAvo types of phenomena must be recognized. The initial pain in
peritonitis is usually that transmitted from the diseased organ to
the region of the semilunar ganglia. Distinct from this pain is that
produced at the site of the inflammation due to the irritation of the
sensory nerves by the reactiA^e process. AVe may speak of these
as the reflex and reactive respectively.
The Reflex Pain. — When the causative factor is AAdthin the Avail
of the gut tract the pain is apt to be felt in the region of the epi-
gastrium. This is true only so long as the disease process is con-
fined to the Avail of the viscus and does not reach the peritoneum.
The reason for the reflection toAvard the epigastric region is that
this is the region of splanchnic nerve couA^ergence. This is really
422
SYMPTOMATOLOGY OF PERITONITIS 423
understood Avheii the embryonal migration of tlie organ is remem-
bered. The character of this pain is similar to that elicited by
traction on a loop of gut or by distending a gut with fluid or
stretching its walls with forceps. In disease it is probably due to
the stretching of the Meissner and Auerbach plexuses by the in-
flammatory edema.
The Reactive Pain. — Why the pain later becomes localized in
the region of the lesion is a matter of controvers5^ At the sugges-
tion of my teacher, Professor H. Virchow, I made a series of dis-
sections seeking to locate the central termination of the nerve sup-
ply of the gut tract, and the relation of the sympathetic ganglia
to the root ganglia. About all that can be said is that the nerves
supplying the gut wall terminate in the semilunar ganglia and those
spinal nerves supplying the abdominal wall are connected with
these ganglia through the rami communicantes. There is no war-
ranty for supposing that any spinal root ganglion is continuous
with any particular division of the sympathetic. The fibers simply
can not be traced with anything like such accuracy.
The only reason we have for assuming that the primary pain is
recorded in these ganglia is that the pain is referred to their gen-
eral location, and that severe primary prostration may occur in
severe visceral disease which resembles closely primary injury to
these ganglia.
The popular explanation therefore which assumes that the
parietal pain is located Avhere the cerebrospinal nerve is distrib-
uted which is connected with the ramus communicans of the
sympathetic coming from the site of the lesion is without scientific
basis. The stock argument in favor of this view is that no matter
Avhere the appendix is located the pain and tenderness in the ab-
domen is felt at the same region corresponding to the termination
of the parietal nerve. This is a very pretty "library" theory but
there is little to substantiate it clinically. Splanchnic nerves go
from the region of the appendix to the semilunar ganglia. Fibers
go from these ganglia to the root of the twelfth intercostal gan-
glion or thereabouts. The theory is weak in at least two particulars.
It is impossible to trace fibers from the region of the appendix to
the twelfth spinal ganglion. That they go there is pure hypothe-
cation. The other error is that if pain were due to transmission
424 THE PERITONEUM
of impulses from the ganglion to the tAvelfth nerve the pain should
be felt in the nerve terminals instead of somewhere midAvay. "Why-
then is the pain felt at the same point ii-respeetive of the location
of the appendix ? The ansAver is simple ! It is not. Pain derived
from irritation of the parietal peritoneum, spontaneous or from
pressure, is felt at the point of irritation. The pain in appendi-
citis for instance, is usually at or near McBurney's point because
that is Avhere the appendix usually is. If the appendix is not here
the pain is where the lesion is. The same is true of other affec-
tions, as of the gall bladder. While the liase of the appendix, the
usual site of the inflammation, usually varies but little from a fixed
point, it does A'ary and sometimes greatly so, and Avhen there is a
deviation from the fixed point the site of pain varies also. I have
seen an appendicitis in the left inguinal canal in a case of cecum
mobile, the pain was all in the canal of the left side and the right
side was free from pain. The diagnosis of strangulated omental
hernia Avas Avrong, but justified; in another the appendix formed
an abscess betAveen the sigmoid and uterus, simulating sal-
pingitis, but the tubes Avere free. There Avas no pain in the normal
site of the appendix. I haA^e seA-eral times mistaken an appendi-
citis lateral to the ascending colon for a cholecystitis. In all of
these cases the pain and rigidity Avas Avhere the lesion Avas. The
same rule applies to jDeritonitis from any other cause, as in impend-
ing perforation. A A'ery long inflamed gall bladder may cause
pain at some distant point from that usual in inflammations of this
organ. I once saAv the late Professor Koenig operate for a sup-
posed appendicitis and find the fundus of the gall bladder at-
tached to the abdominal Avail in the ileocecal region.
Strangulated tumors cause pain Avhere they exert their irritating
effect upon the parietal peritoneum irrespectiA^e of the relation of
their ner\'es on the organ from Avliich they are deriA'ed, and irre-
spectiA^e of Avhere they obtain their pedicles.
Pain in its strict clinical considerations may be divided into tAvo
categories, that produced spontaneously by the action of the dis-
ease itself and that elicited by the pressure of the examining finger
or by the movements of the patient, as of the psoas in lifting the
thigh in appendicitis or the moA^ement of the diaphragm in
cholecystitis.
SYMPTOMATOLOGY OF PERITONITIS 425
Spontaneous Pain. — If a deeply lying process gradually ap-
proaches the surface pain may begin gradually and groAV in inten-
sity as the area involved increases. If, on the other hand, there
is a sudden escape of irritating substances, as in the perforation of
an organ, pain is sudden and intense and the most emphatic adjec-
tives in the language are employed by all nations in describing
it. Dreadful, awful, indescribable, are the common terms applied
by those who have experienced its pangs and have lived to recall
the experience in the calmer moments of restored health.
The pain does not remain in its fullest intensity but remissions
and exacerbations occur until the phenomena of inflammation be-
come established, then it tends to become more constant. The rea-
son for this variation in intensity is the succeeding contraction
and relaxation of an inflamed organ and the intermittent outpour-
ing of the irritating substance.
The intensity and character of the initial pain varies somewhat
according to the organ and pathologic conditions. Sudden occlu-
sion of the appendicular artery Avith subsequent complete necrosis
of the appendix is attended by sudden severe pain. The reason for
this is not clear. In the case of the appendix the early chemical
changes of impending grave nutritional changes probably exert
an instating effect upon the nerve terminals and it ceases when
the organ has undergone a degree of degeneration destructive of
all nerve conductivity. After this has occurred the appendix in
this state acts as a foreign body and may irritate the parietal peri-
toneum and a certain degree of pain remains, l)ut it may be absent
in the presence of complete necrosis. I have more than once hauled
a long black appendix from the depth of the pelvis from patients
who had been quite free from spontaneous pain for some days.
In duodenal or gastric perforation the cause of the intense pain
is yet more difficult to explain. In the very early cases, at the
very beginning of the intense pain there is as yet no evidence of
reaction on the part of the peritoneum and Ave must assume that
the pain is due to the direct irritation of the nerve endings in the
parietal nerves by the escaping fluid. I once placed a small drop
of this duodenal fluid on my e()njuncli\a and severe pain A\as ])i'()-
duced instantly. I once saw a perforated duodenal ulcer less than
an hour after the initial pain. There Avas an escape of a few clots
426 THE PERITONEUM
of milk and a considerable amount of gastric contents. There were
no visible inflammatory changes on the surface of the peritoneum.
The pain ceased largely after the hole was closed. I have been
able to determine, from the study of patients under local anesthe-
sia, that pain is produced by irritation of the parietal peritoneum
by dilute hydrochloric acid. In perforations which have existed
some hours the pain is often over and lateral to the ascending colon.
This distribution could be the result only of parietal nerve irritation.
On the other hand, large exudates sometimes are attended by little
or no pain though the abdomen is filled with pus. These patients
sometimes consult the surgeon in his office presenting other phe-
nomena of severe generalized peritonitis. I once had a young man
come to my hospital in a buggy. He had had soreness in his side
for a week but for two days had felt more comfortable and save for
weakness and an increasing dyspnea he believed himself better.
He presented extreme meteorism and as I reached to count his
pulse I was shocked at the clammy feel of death. The autopsy
done a few hours later showed a large amount of free purulent
fluid from a partly walled off appendiceal abscess which had
ruptured.
These exudates exert little irritation and there is little reaction
on the part of the peritoneum. They are analagous to large bouil-
lon cultures as it were of virulent bacteria. Toxicity evidently
has nothing to do with pain. Abscesses rupturing secondarily into
the peritoneal cavity are often attended by a distinct sense of well
being, until distention and creeping pulse awaken one to the dis-
illusionment.
AVhen pain is due to inflammatory reaction of the peritoneum
the onset is more gradual and constant and the pain increases in
intensity until the highest point is reached and then gradually les-
sens. The sources of pain in this common infiltrative variety of
peritoneal reaction most likely are several. The primary pain is
most certainly due to nerve irritation from the chemical exudate
into the tissues. It increases as the exudate increases. Contrac-
tion of hollow organs may add to this early in the disease. Very
soon, hoAvever, the gut Avail becomes paralytic, probably reflexly,
and this type of pain ceases. These cramp-like pains occur be-
fore the ordinary reactive phenomena of inflammation have had
SYMPTOMATOLOGY OF PERITONITIS 427
time to establish themselves. After inflammation has become estab-
lished the cellular exudation about the nerves no doubt plays the
same role as inflammation in other tissues, namely, irritation of,
or pressure on, the terminal end-organs.
Localized or localizing abscesses may be the site of great pain
due to pressure upon the tissues. At least this seems a fair infer-
ence since pain ceases Mhen such an abscess is relieved of its ten-
sion either by incision or spontaneous rupture. Sudden return
of pain spells perforation into the free peritoneal cavity in many
instances where a walled-off abscess had previously been
established.
Pressure Pain. — Under this head may be included all agencies
which change the mechanical relations of the different parts in-
volved in the inflammatory reaction. Compression from without
either accidental, as contact of bed clothes, or designed, as the
manipulations of the surgeon, may be contrasted with the volun-
tary or involuntary movements of diseased parts against each other
as in breathing or coughing.
It is not clear in just Avhat way pain is increased by these acts.
Mechanical pressure of the exudate is believed to be one of the
causes of the increased pain. The rubbing together of inflamed
surfaces as in pleurisy may be another source of pain. In assum-
ing that increased pressure may augment the pain, we must meet
the paradox that in local anesthesia pressure is supposed to be one
of the factors which produces anesthesia. The differences in the
character of the fluid and the state of the tissue doubtless are the
determining factors. There are so many factors present in inflamed
tissue which so change the argument that it is not necessary to
impeach the arguments of local anesthetists.
In the presence of inflammation of the peritoneum there some-
times is exquisite hypersensibility of the skin. This is due to irrita-
tion of the nerve trunks in continuity and consequent hyperirrita-
bility of the end-organs in the skin. That the nerve trunks are
affected as they course along the internal rectus and transversalis
may often be observed in operations when an extensive edema
affects all these layers. With the nerve shafts so buried in exu-
date, hypersensibility is easily explained. Deeper pressure may
affect the hydrostatics of the deeper tissues and thus increase the
428 THE PERITONEUM
pressure on the nerve shafts. Pressure Avhich depresses the entire
thickness of the belly wall irritates the end-organs of the parietal
peritoneum.
That frietion is an important factor is well illustrated by the
movements of the patient and by the movements of respiration and
even more violent movements of coughing and vomiting. The sur-
geon is able to use the spontaneous attempts at fixation in clinical
diagnosis. He groups these phenomena under the general head of
muscular rigidity.
That pain is produced by the mechanical contact of one diseased
surface against another is further attested to by the attitude of the
patient. He tends to limit its production by assuming a position
that will reduce the movements of the affected parts on one another,
and any pressure from without, to a minimum. Flexion of the
thigh in appendicitis or costal respiration in peritonitis having its
seat in the upper abdomen bears such mute witness. In this cate-
gory belongs the protective fixation of the abdominal muscles.
Though the patient is not aware of it he makes use of his volun-
tary abdominal muscles to protect the affected parts beneath.
These are quite as purposeful, if less voluntary, than is flexion of
the thigh. The extent of muscular rigidity is dependent on the
extent of the disease. Usually that segment of the abdominal wall
covering the lesion alone is set in spasmodic rigidity. This regional
fixation is possible by virtue of the inscriptiones tendenial. These
scar-like bands dividing the rectus muscles make it possible for the
abdominal wall to act in as many segments as there are segments
produced by these inscriptions.
The patient may complain of equal pain in all regions of the ab-
domen. By producing pressure alternately in various regions the
surgeon is often able to determine the seat of trouble by the facil-
ity with which he can increase the pain in some regions as compared
with others. The cause of this heightened pain by pressure has
already been explained as due to the pressure of one inflamed sur-
face against another. After the disease has existed some days fal-
lacies may creep in in certain cases. With increasing exudate the
pain at the site of greatest inflammation may lessen because the
fluid exuded keeps the affected surfaces apart. Analogous condi-
tions are produced when an exudate forms in pleurisy. Sometimes
sympto:matoi.ogy of peritonitis 429
Avheii there is abundant exudate there may be Init little pain and
consequently little rigidity. It is not uncommon to find exten-
sive acute inflammation at operation when there has been but little
pain and uncertain rigidity for some days before operation. In
these cases there is usually considerable exudate. The inflamed
parts float in an isotonic fluid, toxic though it may be.
The character of the inflammatory processes has much to do with
the signs of rigidity that may l^e elicited. In the beginning as
noted, there may be superficial hypersensibility Avith generalized
equal muscle rigidity. As the disease progresses this phase is more
marked and gradually becomes limited to the area involved. Be-
cause of this early in the disease it may not be possible to detect
the site of the lesion by physical examination but one must aAvait
the relaxation of tlio uninvolved areas before the offending area
can be detected by the persisting rigidity. When the limitation of
rigidity occurs the inflammation in the surrounding parts has re-
gressed as the tissues immediately around the infective focus shoAV
their ability to cope Avith the disease.
Unfortunately muscular rigidity spells extent of reaction, not
graA'ity of disease. When, for instance, complete necrosis exists
nerves may be lamed and physical examination may fail to elicit
premonitory evidence of impending separation of the devitalized
parts Avhich presage the opening of the lumen of the gut.
Very A'iolent infections Avhich repel reactive factors in equal pro-
portion fail to produce pain. In these conditions the patient may
die of toxic absorption Avithout there being either spontaneous or
elicitable pain. In these cases, hoAA'CA'er, the pinched look and the
glassy eye cause spontaneous contracture of the surgeon's oAvn
muscles as he involuntarily shriiiks from the scene of impending-
disaster.
Taken all togethei", this element of pain is the great signpost of
peritoneal inflammations. Spontaneous pain, its location, its man-
ner of onset indicates very closely the organ involved, to him Avho
understands how to secure a sequential story. Coupled with it the
trained finger by detecting the niceties of variation in muscle ten-
sion is al)le to outline the battle field no matter Avhat the source
or character of the offending agent.
The young surgeon must learn fully these tAvo elements of spon-
430 THE PERITONEUM
taneous and elicitable pain. By reading case reports of the masters
he may learn much of the manner of onset of these inflammations,
but it is only by careful palpation of inflamed al)domens that he
can educate his fingers to recognize the story the muscles tell.
The latter is the more important, for their veracity is unimpeach-
able. If these lessons are not learned, all the laboratory tests known
to science will not guide him past the pitfalls of error.
The Gastrointestinal Tract. — That the digestive tract should
share a heavy part of the atfections of the peritoneum is easily
understood when the topographic relations are remembered. To
this must be added the intimate relation of the nervous apparatus
of all parts of the gastrointestinal tract.
Involvement of one region of the peritoneum may reflexly set
in motion reflex contractions of remote parts at the onset of the
disease. This gives rise to one of the cardinal symptoms, vomiting.
Later reactive processes may limit the movements of the entire gut
tract, also reflexly, and we recognize paralytic distention. When
there is extensive involvement of the gut wall the nerve plexuses
become involved and the muscle coats are rendered incapable of
contraction. Finally when inflamed areas come in contact they
become agglutinated and movements may be mechanically hindered.
Vomiting. — Early emesis giA'es no evidence whatever of the lo-
cation of the disease. This most likely occurs reflexly through the
sympathetic system. The stomach nerves become sensitive, as is
evidenced by increased vomiting when fluid is taken into the stom-
ach. A direct irritation of the musculature may take place in some
instances. Vomiting is one of the early symptoms, following imme-
diately the advent of pain. Nothnagel says that vomiting may
precede pain. So it may in exceptional cases, though it may be
emphasized that this is not the rule. After the disease becomes lo-
calized, vomiting usually ceases. Vomiting at this stage is of
no great prognostic significance. Recurring later it is of the grav-
est moment for it frequently indicates spreading inflammation or
dynamic ileus.
Belonging to this phenomena is hiccough which appears most
often late in the disease when the diaphragm becomes involved.
This reflex irritation is sufficient to overcome the fixation of the
SYMPTOMATOLOGY OF PERITONITIS 431
voluntary muscle for the sudden contraction of the diaphragm is
often very painful to the patient.
Early vomiting is expulsive forcing from the stomach of what-
ever may have been taken into it. Later mucous or bile and in rare
instances blood is expelled. Later, particularly in the mori-
bund state, mouthfuls of fluid are expelled at frequent intervals
apparently without much effort. The mechanism of this late vomit-
ing is difficult to explain. Irritation of the phrenic terminals
probably is responsible.
Vomiting of blood is noted in rare instances. Gerassimowitsch
records eleven cases. In seven microscopic examination of the
stomach wall was made. There w^as round-celled infiltration about
the tips of the glands Avith enlargement and abscess of the lymph
follicles. The nuclei of the gland cells did not stain.
Meteorism. — Distention of the gut folloAvs the lesion of the gut
Avail. Disfunction of the muscle or nerves may be at fault. The
distention is sometimes reflex for not infrequently tympany is ol)-
served in regions not the site of inflammation at all. Similar phe-
nomena are noted in injuries of the back in Avhich great disten-
tion of the gut may occur Avhen there is no thought of a perito-
nitis. No lesion of the nerA^es can be demonstrated in such cases.
The changes that take place in the gut Avail have been detailed
in the section on general pathology. It may be repeated here
that usually more or less of the entire gut Avail is edematous and
infiltrated. In the lesser degree the muscle fibers may shoAV no
change, or at most, fine granular degeneration. In cases AA'here
there is a more extensiA^e degree of iiiA^olA^ement the muscle cells
may shoAV a distinct paleness in structure and in that type in w^hich
the gut Avail is much thickened and covered Avith a greyish exu-
date the muscle fibers may refuse all dyes. In this type of degen-
eration there is usually little or no distention, hoAvever.
The nerve ganglia, as noted in the section on pathology, may
shoAv but an increase of the perigangular fluid or there may be
a degeneration of the cell protoplasm and even of the nuclei.
This is the state in the cases of more extensive tympany.
Kader in his experiments found that Avascular disturbance, par-
ticularly venous hyperemia, AA^as the essential factor in tlic produc-
tion of distention in intestinal occlusion. For instance ligation
432 THE PERITONEUM
of a gut Avas attended by less distention above the occlusion than
another part of the gut not obstructed but Avhich had its venous
return cut off. It is possible therefore that circulatory disturbances
may play a irAi't in the distention of peritonitis. The edema which
followed the venous occlusion in Kader's experiments may be
absent in loops at a distance from the infection in distention from
perforation peritonitis. ScliAveninger weighed a segment of the
affected gut and compared this weight Avith an equal segment of
unaffected gut in order to determine the degree of edema. lie
found that the Aveight of a segment may be increased fourfold in
obstruction.
Late in peritonitis, distention may be intluenced by the edema
present but extreme distention may be present Avithout either edema
or vascular disturbance.
With more profoundly affected Avails and more extensive de-
generation there is less distention, the elasticity of the tissues evi-
dently being destroyed by the degeneratiA'e process. At least such
guts can not be artificially distended.
The degree of distention present may A'ary greatly. It is deter-
mined by several factors. When there is actual obstruction it is
naturally gi-eat. Distention in such instances seems to be purpo-
sive in that by so doing it attempts to Aviden its lumen. At least
there is no sign of a degeneratiA^e process. Early distention often
takes place OA'er the Avhole abdomen Avhen only a part of the gut
Avail is inA'oh^ed and in such areas structural changes can not be
invoked to explain it.
I have repeatedly noted that after sewing a AvindoAV into the
abdominal Avail the intestines distend and become motionless in
the absence of any infection. Distended loops of guts place them-
selves about the AvindoAV. That such a maneuver Avould be a most
effectiA'e one in limiting infection there can be no doubt, and Avhen
infection is added under the-.e conditions the distended loops
quickly form adhesions about it if Avithin their power to do so.
This obserA-ation causes me to question Avhether or not in those
cases in A\hich neiwe and muscle degeneration is present, as aboA'e
noted, the degenerative changes precede or folloAv the distention.
Experimental evidence leads me to believe that distention pre-
cedes and has a purpose just as vascular dilatation and rise of
SYMPTOMATOLOGY OF PERITONITIS 433
temperature has. and consequently may be salutary expressions
in the course of the disease and not things to he combated merely
because it exists.
The motive power for the expansion of the gut is furnished by
gases found in the intestine.
That the state of the intestinal contents at the time of the begin-
niug of the disease has much to do Avith its degree seems unlikely.
Bokai experimented by injecting various kinds of gases into the
lumen of the gut. Nitrogen had no et¥ect ; carbon dioxide, methane,
and hydrogen sulphide produce paralysis Avhile oxygen causes in-
testinal moveinents to increase. Paralysis may follow prolonged
distention in which instance it is probably due to exhaustion of the
muscle or it may be primarily due to reflex involvement of the
nerves. There seems to be no evidence available regarding the com-
position of intestinal gases and their effect on a normal gut. My
efforts in this line were expended by conducting gases from an
animal affected with distention from peritonitis to the gut of a
normal animal. The gut of the recipient distended of course but
the effect on the gut Avail if any could not be determined.
Late distention is ol)viously sometimes paralytic. With oi- Avith-
out degeneration of the elastic tissue the distention of the gut
exceeds the normal range of elasticity of the elastic tissue. In
these extreme degrees the elastic tissue refuses the specific dyes.
In these late cases there ai-e often degenerative changes in other or-
gans of the body and the changes in the gut Avail may be but an
expression of a generalized bacteremia. This condition is noted
more pai'ticularly in puerperal sepsis, a fact that lends color to this
hypothesis. The cause of this degeneration must be the toxicity
of the exudate, a lessening of the alkalinity, in some cases even an
actual acid reaction of the tissue may l)e noted.
In exti'eme degrees the distention causes embarrassment of rcs-
pii-ation by pressure on the dia]ihi'aiiiii. So extreme nniy be the
pressui'e that cyanosis and dyspnea gi-oAv apace A\i1h the distending'
gut. Hypostatic pneumonia and myocardial degeneration may
take part in the dyspnea bnl 1o (\r)]y thai i)ressui'e on the dia-
phragm lias anything to tlo with the dyspnea as \'an Sweringen tloes,
because a much less lung space is tolerated in tulierculosis, ignores
434 THE PERITONEUM
in part the truth because suddenness in the limitation of air space
is not taken into account.
Temperature. — In hyperacute cases, particularly those in chil-
dren, attended hy a chill, the initial temperature may be high, to
105° or even more. It soon descends. The characteristic tempera-
ture is one of moderate height subject to many A^ariations. "When
a large perforation initiates the peritonitis a primary fall in the
temperature to below normal may take place only to rise as the
disease becomes established. Not infrequently there is a terminal
rise of temperature, sometimes excessively high. I have seen it
exceed 107° a few hours before death. The characteristic tem-
perature in the acute forms ranges betAveen 100° and 103°. When
the affection tends to localize, the temperature is more apt to hover
around the latter rather than the former figure, only to approach
normal as the encapsulation becomes increasingly more perfect.
It is not uncommon to find a temperature at or near normal in
a very extensive process. As the skin cools Avith impending death
the temperature usually rises. Rectal measurement is the only
means of securing accurate determination. The axilla, as
noted by Lennander, is altogether untrustAvorthy and oral meas-
urement, because of the frequent demands for drink or ice, may be
A^ery unreliable.
Circulation. — AVith the advent of peritoneal irritation the en-
tire circulation is quickened, expressed at first in a fuller rather
than a rapid pulse. As the disease progresses, the pulse becomes
more and more rapid. This is quite uniform and is a most reliable
sign. It Avas called the abdominal pulse l)y the older AA^iters.
A rate of 120 to 140 is the ordinary, Avith an approach to the limit
of countability as the disease groAvs progressiA^ely Avorse. In qual-
ity it is often full and bounding in the beginning but the charac-
teristic peritonitis ]iulse, particulai-ly in the late stages, is small,
hard, and rapid. The cause of the rapidity is, in some eases at
least, due to irritation of the A'agi, reflexly at least at first. Later
in some instances there may be directly a nerve inA'olvement.
Later there is myocardial degeneration.
The Exudate. — In all cases of diffuse peritonitis there is more
or less exudate. Occasionally, particularly in those running a
sloAA^er course, the exudate is confined to a diphtheria-like mem-
SYMPTOMATOLOGY OF PERITONITIS 435
brane on the surface of the gut. Often the fluid is sufficient in
amount to be readily demonstrable by physical means. The amount
of fluid present gives little clue as to the outcome of the disease,
but its character may be exceedingly significant.
The physical character of the exudate is variable. In acute pro-
gressive cases it is pale milky, and in more localized processes the
puriform character is more marked. The odor may declare the
kind of organism present. The contained elements consist of leu-
cocytes in more or less imperfect state of preservation. In the most
acute cases the formed elements are composed largely of granular
debris. In the less acute cases polynuclear and endothelioid cells
occur in great abundance.
General Habitus. — Early in the disease the features may be ex-
pressive of acute pain even to the presence of cold perspiration.
The patient is apprehensive lest the surgeon's manipulations will
increase his pain. As the disease subsides the expression of the pa-
tient may exhibit tranquility. It is the sign of localized inflamma-
tion. If the disease progresses, the face may become flushed and
there is apt to be a yellowish or grayish tint of the skin about the
alfe of the nose. The eyes are Avide l)ut tend to l)e sunken. The
patient despite his attitude of resignation is apt to move his limbs
restlessly about while maintaining an immobile trunk. He often
inquires as to when he shall be given relief. In this stage the life
of the patient hangs in the balance. It is a sign of advancing
inflammation.
When the disease advances toward a fatal termination the char-
acteristic phenomena are pinched features, sunken eyes, pale skin,
white closely draAvn lips, a sharp pinched nose, and above all a
glaring, glassy eye. Delirium may take place in the terminal stages
but the mentality is often hyperacute, the demeanor hopeful or
indifferent. I recall the case of a young man in these final stages
who lay and discussed the prospects of the fall quail shooting as
his extremities gradually cooled in death. I recall a young man
who greeted my approach to his bedside Avith the remark that I
had saved his Avife, and I should noAv save him and he added ''but
you'll have to hurry." His further conversation indicated that
he had anticipated an operation in anxious hope.
I have often Avondered as to the mental content in these cases.
436 THE PERITONEUM
They lie apparently alert, yet usually uncommunicative, taking
little notice of their environment. Anxiety has given way to ap-
athy. I believe that the nerve cells are so at^ected by the circu-
lating toxins that tliey are incapalile of producing emotions of
hope or fear. The glai'e of the eyes most likely does not indicate
alertness as we are Avont to assume in the final stages. The
shrunken features retract from the eyes giving them an undue
prominence. They no longer follow the movements of those about
them. The pale skin and shrunken features but bespeak the con-
dition of the extremities. The peculiar cold clammy feel is not
imitated in any other condition and most closely resembles the
peculiar cold feel of a dog's nose.
AVith the cooling limbs, the eyes become more and more sunken,
the features more drawn. The ascending temperature fails to
change the cutaneous circulation. The patient responds to ques-
tions and Ave say he is conscious, but he is indifferent to his envi-
ronment. His children do not interest him, the surest sign of
departed comprehension. Of all the environment he suffers the
least.
In some instances an orientation Avitli his surroundings seems
to be retained to very near the last. This is true in those cases
where there is a paralytic ileus Avhich dominates the field, or some
other condition which hastens the final end, before intoxication has
had time to A'eil his comprehension.
Physical Characters of the Abdomen. — Examination of the
physical characters of the al^domen may reveal much. The scaph-
oid abdomen and its opposite, extreme tympany, tell the morst.
The one feature in common is immobility. The excursions of res-
piration are notably absent. In localized processes only a part of
the abdomen is immobile. AVhen an appendicitis has become lo-
calized the left half of the abdomen may not be fixed and in pelvic
peritonitis it is quite common for the upper abdomen to shai-e the
respiratory excursions. Sometimes certain areas may show dis-
tention not shoAvn in equal degree by contralateral regions. This
is particularly valuable in children. A localized abscess or an
agglutinated mass of intestines may produce a bulging of the ab-
dominal Avail. A localized abscess containing gas-producing bacilli
may shoAv distention beyond the unaffected side. AVhen such a
SYMPTOMATOLOGY OF PERITONITIS 437
state is attended by hypertympany it is a sign of great value. The
bulging of the navel may occur in children even "when there is no
fluid. Vascular dilatation may be noted Avhen tympany obscures
a paraperitonitis localized in one point. When in a child uniform
distention and tympany is attended by venous hyperemia it may
be very suggestive of local reaction.
The hand of the examiner usually follows his eye in the elicita-
tion of the phenomena and assists in their interpretation. Local
resistance in spite of tympany may indicate a reaction beneath.
The abdominal Avail over a pei'itonitic area may suggest the pres-
ence of a neoplasm. The presence of a localized abscess or omental
tumor is one of the most common signs. Battle noted edema of
the abdominal wall in the region of the anterior superior spine in
several cases of peritonitis. It is common enough to observe edema
of the deeper layers of the abdominal Avail during the course of an
operation, but its existence to a degree sufficient to cause
pitting must be unusual. I have seen this phenomena only A^ery
late Avhen a long neglected abscess presented beneath.
BibliogTaphy
Battle: Ah Uiulescrilied Svmiitoui in Peritonitis, Lancet, London, lSi)7. i,
871.
BOKAi: Experimentelle Beitriiye zur Kenntnis der Darndiewegmigen, Arcdi. f.
exper. Path. u. Pharniakol.. 1S87. xxiii, 414.
Gerassimoavitscii: [Hematemesis in Peritonitis], Russk. Vracli.. 190.3, ii, 1622;
Zentralbl. f. Cliir., 1904, xxxi, 104.
Kader: Zur Fraoe des localen Meteorismus bei innerer DarinociduHion, Arcli. f.
klin. Chir., 1S91, xlii, 851.
Xotiixagel: Die Erkrankunoen des Darnis und des Peritoneum. AVien, Holder,
1898.
Sciiavexixger: Experimentelle Studien liber Darm-Einklemmuno-. Arch. d.
Heilk.. 187;-;, xiv, .300.
Vax Swerixgex: The A'alue of Meteorism or T\nupanv in Peritonitis. Xew
York Med. Jour., 1912, xcvi, 107.5.
AValrai'M : Zur Histologie der acuten eitrigen Peritonitis, A'irfliows Arc-h. f.
path. Anat., 1900. elxii. 501.
CHAPTER XIV
DIAGNOSIS OF PERITONITIS
The simple abstract question as to the presence or absence of
peritonitis often perplexes the examiner. If peritonitis is present
the question whether it is irritative or suppurative needs to be
decided before treatment can be formulated. There are no signs
taken alone -which are pathognomonic of peritonitis and it is only
the association of several of these and particularly as to their
sequence and manner of onset that is significant. There seem to be
no fundamental facts in the minds of many practitioners as to the
relative importance of various signs. It seems Avorth while to at-
tempt to formulate general rules, based on my own errors and those
of others.
The general phenomena attending peritonitis have been enu-
merated in the chapter on symptomatology. The attempt here
will be to call attention to signs which may be observed in peri-
tonitis but which may likewise be observed in conditions not at-
tended by inflammation of the peritoneum.
The cardinal symptoms of peritonitis are pain and local reaction.
These bring with them muscular rigidity and constitutional re-
action. The statement is sometimes made that peritonitis may exist
without the presence of pain or fever. That is true, but it is not
true that peritonitis can exist without constitutional disturbance.
The thermometer is not the only measure of reaction. The eye of
the practitioner must supplement the thermometer just as the sense
of touch must check up the pulse rate as shown by the chart. Tem-
perature of 98.6° and a pulse rate of 75 when recorded on the
chart may indicate a normal patient but a look at the patient
and the feel of the pulse may indicate that grave things are pend-
ing. In order that the practitioner shall answer the question of
the presence or absence of peritonitis he must be able to evaluate
the symptoms by their presence or absence.
In order to analyze the various symptoms common in peritonitis
438
DIAGNOSIS OF PERITONITIS 439
it will be well to enumerate them and discuss their direct and dif-
ferentiating value in determining the question of the presence or
absence of peritonitis in the concrete case.
Pain. — This is the most constant sign in peritonitis. Abdominal
pain is also present in many other abdominal conditions. Diseases
that antedate the peritonitis may be caused by other factors. The
characteristic of the pain in peritonitis is that it is increased on
movement. It is a friction pain, and anything that increases the
rubbing together of the inflamed surfaces on each other increases
it. In this regard peritonitis closely parallels pleurisy and much
can be learned by watching the protective efforts of the patient in
this disease. The factors Avhich increase the pain may be either the
movement of some part of the body, as the iliopsoas in appendicitis
when the thigh is lifted, the movements of the diaphragm in res-
piration, the emptying and filling of the rectum, etc. In pleurisy
the necessary movements of respiration make it possible to note
the influence of movement on pain. In the case of the peritoneum
these movements may be Avanting and the surgeon imitates these
movements by manual pressure in the region of the supposed in-
flammation. Tavo axioms may be laid down for the pain in peri-
tonitis: (1) The pain produced by pressure is proportional to the
pressure or the range of the voluntary movement incited to produce
the pain. Pains relieved by pressure are not due to inflammation.
In neurotic conditions superficial pressure may cause pain, while
deep pressure causes none. (2) The pain of peritonitis is localized
at the site of the inflammation. Pains elsewhere are due to reflex
or referred pains or to hyperemia or edema. Visceral edema may
cause referred pain as in cholecystitis and appendicitis, but these
are splanchnic pains and have nothing to do with peritonitis, though
tliey are often followed by it. In violent inflammations the
area of pain may be Avidespread, because the area of hyperemia
and edema may spread beyond the actual site of infection. When
spontaneous pain and pain on pressure coexist, the limits of each
must be determined. For instance in the sudden perforation of an
organ there may be diffuse pain due to reaction of the sympathetic
nerA^ous system Avhile the pain due to actual inflammation may be
much more limited. The statement of the patient may be taken to
determine the referred pain while manual palpation Avill secure
440 THE PERITONEUM
information as to the limits of inflammation. In such instances the
tenderness is the guide to the degree, and not the area of spon-
taneous pain. Patients may complain of diffuse pain and the whole
abdomen may be rigid, but some area of this rigid abdomen shows
the greater sensitiveness. This area of tenderness is the guide to
the extent of the involvemerit. For instance, in a perforated duo-
denal ulcer, diffuse pain may be complained of and the Avhole
abdomen may be rigid, but the site of greatest tenderness will be
over the duodenum and over the ascending colon.
The site of the initial peritoneal pain is significant. It is Avhere
the infection starts, not necessarily the site of the source of infec-
tion. The site of the initial peritoneal pain is not parallel Avith the
initial pain of the disease. For instance appendicitis is often initi-
ated by an epigastric or diffuse pain. This pain is ditfuse, not
associated with local tenderness and is due to a splanchnic nerve
irritation Avithin the walls of the appendix. When the infection
escapes from the appendix the peritoneum is ii-ritated and the local
pain begins.
Pain in the abdomen may be the result of a variety of conditions
not associated with inflammation of the peritoneum. The most
common of these may be enumerated.
Colic. — Violent contractions of a hollow viscus may cause pain.
The more common of these are due to the attempts at the propulsion
of a foreign body, possibly in part l)y the irritation produced by
the foreign body itself. Familiar examples are renal, gall bladder
and intestinal colics due to the contraction of their walls. The es-
sential feature of these is sudden onset of great intensity, without
the signs of local reaction. The patient presses over the painful
area, rolls a])out and in general is indifferent to his position. There
is no rise in temperature and the pulse is responsive only Avhen
the pain is on. Infection may be associated Avith the colic and
then there may be fever and leucocytosis, and a measure of ten-
derness Avhen a diseased Avail can be directly pressed upon. It is
only Avhen the peritoneum is reached by the infection that the pain
on movement appears.
Thrombosis. — When an organ becomes ncci'otic from obstruction
of its 1)1 oud vessels, pain is produced. The pain in these cases is
due to the nerve irritation due to the dying tissues. This irrita-
DIAGNOSIS OF PERITONITIS 441
tioii may be due to chemical irritation, in part to the stretching
from the extravasation that always accompanies these conditions.
Gangrenous appendices, mesenteric thromboses, and cysts "with
twisted pedicles are familiar examples. These conditions are at-
tended by sequelae. Followino- the initial pains comes the secondary
pain of irritation. The necrotic oi'gan is an irritant to the sur-
rounding peritoneum and a violent peritonitis is set up. This peri-
tonitis is plastic in character, prone to form adhesions as is com-
monly seen about ovarian cysts, and is distinctly consecutive in
character inasmuch as it is able to give temporary nutrition to an
injured organ. This stage is attended by a considerable exudate,
sometimes enough even to admit of demonstration by physical
means. Absorption of these exudates may produce temporary leu-
cocytosis and rapid pulse. Necrosis of the organ alone is not
attended by local tenderness. ])ut when the reactive processes begin
all tlie signs of peritoneal inflammation appear. Perhaps thisj is
well, for, save in the case of the cysts with twisted pedicles, death
of the wall is apt to take place, followed by perforation and a
general septic peritonitis.
Probably the severe abdominal pain due to pancreatic necrosis
belongs here. Pain due to tearing of tissues, if there be hemor-
rhage, may be added. The distention of the guts and the rapid
heart are likely caused by the close proximity of the lesion to the
large ganglia. Exudate follows the initial lesion and peritoneal
irritation is produced.
Intraperitoneal Hemorrhage. — Coagulated, blood acts as a chem-
ical irritant. This may l)e frequently observed in the blood clot
from tubal abortion, hematoma of the ovary, etc. Tbe fibrin of the
blood clot excites exudation in the surrounding peritoneum and
with this comes pain. The normal course of a blood clot pain is
short, soon reaches its height, and gradually recedes. The pain is
due virtually to a chemical peritonitis. Blood not coagulated does
not produce pain. In cases therefore in which there is exti-avasa-
tion of blood the pain from the clot must be differentiated from
the pain attending the lesion from which the bleeding results, for
instance the cutting, tearing jtaiii of tubal abortion is veiy different
from the pain of blood-clot irritation. The pain due to the presence
of a blood clot produces a pain of moderate intensity and is equal
442 THE PERITONEUM
to the pain prodiiced by an infective process in the stage of fibrin
formation — less acute than in the primary infective processes. The
pain of a blood clot in the pelvis may be compared to the acute
pain of peritubal inflammation. In determining the different
causes the time element must be considered. A blood clot pro-
duces the kind of pain in a day Avhich attends peritubal infection
after a week. The same principles apply in any other region.
Pain Caused by Distention of Parenchymatous Organs. — When
an organ becomes suddenly distended pain is produced. Acute
hyperemia of the kidney due to multiple thrombi, septic or aseptic,
is attended by severe pain. The acutely distended liver from sud-
den failure of cardiac compensation may simulate an abdominal
infection very closely. Infective processes in the liver are seldom
large enough proportionate to the size of the organ to produce a
distention pain of any magnitude, and the kidneys are seldom mark-
edly painful in heart failure. The pain within the abdomen by
virtue of heart failure may entirely overshadow the heart lesion.
The rapid heart may erroneously be ascribed to an intraabdominal
infection. The big liver, and the diffuse apex beat which is nearly
always displaced outward should place the surgeon on his guard.
The lack of tenderness is distinctive.
Referred Pains. — The thoracic and abdominal walls serve as con-
duits for the same nerves and it can not be wondered at that irri-
tation in one part produces sensations experienced in other re-
gions. It is comparable to "listening in" on party telephone lines.
A pleural pain, it may be readily understood, may irritate the inter-
costal nerves and the sensation be transmitted to the abdominal
wall. The pain may be felt in the latter place and not be felt at
all in the pleura. There may be an absence of physical signs in-
dicative 01 pleural disease, particularly in children. Here rapid
respiration may be the first clue and a flaccid abdomen may give
further proof. When there is referred pain from the pleura the
abdominal wall may be rigid and painful to touch but the pain as
produced is greatest on superficial contact and lessens as the pres-
sure is increased, just the reverse from the relation in peritonitis.
The muscular rigidity may be marked but at just that moment
where inhalation passes to exhalation the tenseness of the muscle
lessens as it never does in peritonitis.
DIAGNOSIS OF PERITONITIS 443
Neuroses. — Neurotic persons commonly have abdominal tender-
ness. This is a superficial pain and is dispelled if the patient can
be engaged in the fascinating topic of her own ailments. If there
is muscular rigidity it applies to the recti alone and not to the
oblique muscles. Palpation may cause a violent contraction of the
muscles, a movement which would be very painful were a real
peritonitis present. Often these neurotics find the examination
exceedingly funny and respond with a giggle. There is no fear of
peritonitis in such cases.
Rig'idity. — Rigidity of the abdominal muscles is the most diffi-
cult sign to interpret. It may be due to a great variety of con-
ditions not associated Avith disease of the peritoneum. For in-
stance, rigid abdomens may accompany cerebral irritation, be this
due to meningitis or modesty. The various types may be very
difficult to differentiate and the practitioner must often call asso-
ciated conditions to his aid. Rigidity of central origin, whether
due to inflammation or mental obfuscation, is accompanied by fixed
retraction. The rigidity due to sensitiveness is spasmodic and is
accompanied by contraction of the adductors of the thighs and
often of the pectoralis and biceps. These may be described as
biological defensive movements. The diagnosis of a cerebral dis-
ease or of nervous hypersensibility does not end the problem, for
a typhoid patient or the overmodest maid may each suffer from a
peritonitis.
Once the reactive process is defined the rigidity of peritonitis
involves those segments of muscles only which cover the area of
inflammation. The sharpness of the border of the rigidity is de-
pendent on the degree of limitation of the inflammatory process.
In acute inflammation where the hyperemia is diffuse the rigidity
is usually more extensive than the actual site of infection, as al-
ready discussed, while when the process becomes limited the rigid-
ity may become so sharply circumscribed that a tumor is simu-
lated. In fact the peritonitis may wholly subside and but an
encapsulated mass remain.
Sometimes the peritoneal covering of an organ may be inflamed
and yet no muscle rigidity may be present. The inflamed area of
peritoneum may not be accessible to pressure and muscular rigidity
is absent. This is observed in lighter degrees of cholecystitis, sal-
444 THE PERITONEUM
piiigitis, or appendicitis Avhen that organ hangs deeply in the pel-
vis. In such instances wo Ining voluntary movements to our aid,
or seek by other means to subject the diseased organ to pressure,
or observe the effect of the movement of neighboring organs. For
instance in inflamed gall bladders ve press deeply over this organ
and ask the patient to breathe deeply; in salpingitis vaginal exami-
nation is made to aid alidominal palpation; and the effect of the
filling and emptying of the bladder and lectum on an inflamed ap-
pendix situated in the i?elvis is noted particularly in children.
Fever. — Fever is of little value in making a diagnosis of peri-
tonitis. It is usually present, particularly in the beginning, and
its absence if measured consistently in the beginning of the attack
is a presumptive sign against it, though no doul)t the peritoneum
may be inflamed when no fever is excited. The value of this sign
in peritonitis is lessened because there are so many diseases ac-
companied by fever.
The fever characteristic of peritonitis is not high. A tempera-
ture of 99.5° to 103° usually represents the limits of the tempera-
ture curve. If there is high fever the presumption is against the
presence of peritonitis. High fever may come later when there is
a walled off abscess, but high fever in the beginning is seldom ob-
served. The temperature may be subnormal. This indicates not
a reaction but an intoxication, and is not a measure of reaction
but of suppression of reactive forces. It is the severe case that
is accompanied ])y a subnormal temperature. The period of the
rise of temperature is not coextensive \\itli the inflammatoi-y
reaction.
Fever often subsides long before the reactive process ceases.
Fever is a measure of reaction against toxins absorbed and when
absorption ceases the fever subsides.
The Pulse Rate. — Tlie pulse rate, like the fever, is a measure of
general absorption and only in a general way runs parallel with
the local reaction. It is sometimes said that peritonitis may exist
in the presence of a normal pulse. This is not true. A pulse may
beat at the normal rate per minute yet be far from normal. Peri-
tonitis is not incompatil)le Avitli a slow pulse, but there are changes
in character that will not escape the careful observer. It may be
slow and quick, full, semidicrotic, etc. The characteristic pulse of
DIAGNOSIS OF PERITONITIS 445
peritonitis is a rapid one in proportion to the temperature. A slow-
ing pulse usually accompanies a receding area of tenderness.
Leucocytosis. — There is an increase in the number of leucocytes
in the blood Avhenever there is a considerable degree of reaction on
the part of the peritoneum. A proportionate increase in the poly-
nuclear leucocytes is particularly significant. This sign is of value
when other diseases of the abdomen are present which are accom-
panied by fever and intestinal disturbance, notably typhoid fever.
Generally speaking, the number of leucocytes runs parallel with
the extent of the infection, and is particularly likely to run high
when abscess formation begins. On the other hand the white count
may be below normal. This leucopenia is present when there is a
general intoxication, Avhether there is a peritonitis present or not.
Subsidence of leucocytosis is not a sign of a recession of the proc-
ess but of the absence of absorption of toxins. This may take
place when the abscess becomes encapsulated. If the capsule be-
comes broken by the surgeon or from increasing tension the in-
fection may spread again. The greatest delusion connected with
leucocytosis is that a recession necessarily indicates an absence of
infectivity.
Tympany. — ^Abdominal distention is a frequent accompaniment
of peritonitis, but is not a positive sign of appendicitis. At first
it is reflex in character and is purposive. Later it is due to direct
irritation of the infective material and serves the veiy valuable
purpose of exposing the greatest possible extent of surface toward
walling in the infection. It may later become paralytic and be-
come the most serious complication. Tympany Avithout local signs
of reaction is not a sign of peritonitis. On the other hand many
cases of tympany are associated with pain. These may be due to
reflex disturbances or to actual occlusion of the gut to such an
extent that fecal circulation is interfered with.
Intestinal obstruction is characterized by distention as an early
prominent symptom. There is lacking the localized tenderness
and rigidity, fever, and leucocytosis. Local pain may cause peri-
tonitis to be simulated if the cause of the obstruction is such that
a reaction is produced. In some cases a tumor may be produced,
as in intussusception, but there is no muscular rigidity surround-
ing it. Vomiting is common in acute obstruction, ])ut it comes on
446 THE PERITONEUM
after the distention develops, while in peritonitis vomiting is
early and if tympany occurs it follows the vomiting. Late vom-
iting may occur in peritonitis, due to mechanical or dynamic ileus.
At this stage the diagnosis can not be in doubt.
Severe contusions of the spine may be attended by pronounced
tympany. These usually begin early, sooner than tympany would
occur were there a peritonitis. This sign is distressing to the ob-
server for it may mask a peritonitis which may be set up by an
associated lesion, such as a traumatic rupture. The tympany may
be so great that the pulse rate may be increased, but there is no
tenderness or fever.
CHAPTER XV
PROGNOSIS OF PERITONITIS
The outcome of any given case of peritonitis is dependent on a
great number of factors. The cause in itself may be a determin-
ing factor. If an ulcer ruptures or the gut wall is injured so that
there is a free escape of gut contents, the patient will most surely
die. Here the dual elements of bacteria and foreign body reach
the unprotected peritoneum in amounts sufficient to overwhelm
the defensive forces. When there is not a complete perforation
and bacteria alone escape, then the problem becomes more com-
plicated for the type of bacteria that have escaped and the re-
sistance the body is offering can be determined in a general way
only from the symptoms or possibly from fluid obtained at the
time of operation. In the first group of cases, the perforative,
statistics are able to give reliable data as to the influence of op-
eration. In the group in which gradual escape of infection has
taken place statistics are quite valueless since classification is
wholly a matter of personal equation.
It may be profitable to view a few statistics of the infiuence of
time of operation on the cause of the acutely perforative cases.
The results obtained from the examination of fluid removed at
the time of operation have as yet given no reliable data, but
the possibilities of the future warrant the keeping of this line of
research in mind. When the surgeon is confronted with the prob-
lem of prognosticating the outcome of a concrete case he must
rely on the course the disease has taken to date and the symptoms
manifest at the time the summary is taken. The more prominent
of these guides may be detailed with the hope that they may be
of some use to the beginner.
Prognosis Dependent on Time of Operation in Perforating-
Ulcer. — INIiles (Observations on Perforating Gastric and Duodenal
Ulcers Based on a Personal Experience of Forty-six Cases Oper-
ated on, Edinburgh Med. Jour., 1906) : Cases operated on in the
447
448 THE PERITONEUM
first twelve hours give a mortality of 26 per cent, those operated
on between twelve and twenty-four hours give 45 per cent mor-
tality and 92 per cent in those operated on thirty-six or more
hours after perforation.
Fenwick's statistics (Ulcer of the Stomach and Duodenum, P.
Blakiston's Son & Co., Philadelphia, 1900) are as follows: Those
operated on in from one to twelve hours, 33 per cent; tAvelve to
twenty-four hours, 50 per cent and more than twenty-four hours,
86 per cent.
These statistics give a general idea of the importance of prompt
treatment, but none as to the outcome of a given case.
Prognostic Value of Examination of Peritoneal Fluid. — The
number and virulence of the bacteria in an exudate can be de-
termined in a general way by the examination of a smear at the
time of the operation. The number can be estimated per field
for usually early in the course of the disease the bacteria in the
field are within the range of mathematical estimation. Many ex-
tensive exudates are nearly bacteria-free. This is particularly
true of the odorless slightly floccular exudates. By constant ex-
amination one learns not facts but general impressions. The viru-
lence of an infection may be determined in a general way by the
action of the endothelial and polynuclear leucocytes. When the
bacteria are largely or wholly extracellular and particularly if
the leucocytes show evidence of disintegration the infection is
a severe one. If the leucocytes have englobed the bacteria, the
infection is a mild one. The time element must be considered.
Early in mild infections the bacteria may be extracellular. The
later the stage the bacteria are found extracellular, the graver
the prognosis.
Prog-nosis According' to Species of Organism. — In most cases
the type of l)acterium predominating can not be made out from a
slide examination. In some instances where the source of the in-
fection is known this may be a valuable clue. If a secondary
streptococcic abscess has been allowed to contaminate the general
peritoneal cavity, the prognosis is very grave. Even in slide ex-
aminations streptococci may be made out and when they dominate
the outlook is grave. The presence of B. pyocyaneus can not be
determined by the preliminary examination, but when identified by
PEOGNOSIS OF PERITONITIS 449
cnltiire or the appearance of blue green pus it indicates that
the course Avill be a very long and stormy one.
The foregoing remarks offer but little aid to the experienced
surgeon, valuable as they may be to the beginner. To the clinician
the general appearance of the patient is intuitively interpreted. The
result of this intuition is usually that he is very guarded in his opin-
ion and leaves a wide leeway for subsequent developments.
Prom what has been said in the chapter on pathogenesis and
pathology it is apparent that the discussion of the symptomatology
as an element in prognosis lends itself poorly to abstract consid-
eration. A careful observance of all the phenomena gives certain
definite clues as to what may be anticipated. For instance, by the
mode of onset of peritonitis associated Avith an appendicitis it can
be judged Avhether periappendiceal adhesions have formed or not.
A proper appreciation of such phenomena can be obtained only by
observing clinical and pathologic material. Certain signs may be
collected here, however, that may be of some service, as a chart to
the juvenile mariner sailing for the first time on the troubled sea
of abdominal surgery.
It must be appreciated that the fundamental problem in prog-
nosis resolves itself very largely into judging Avhether or not the
process Avill spread, and if so how much. The anatomic conditions
under Avhich spreading takes place have been discussed. When
all the data are at hand this admits of fairly accurate
consideration. Early in the course of the disease, however, when
only a portion of the data may be at hand, it may be extremely
difficult to determine this point, sometimes even after the abdomen
has been opened. If one can observe the patient for a period of
some days, or if clinical data have been recorded, one can deter-
mine how far the disease has spread during that time and deter-
mine from this what the effect will be on the welfare of the pa-
tient. To judge hoAV far an incipient disease will spread when ob-
served within the first hours, admits of judgment only Avithin the
Avidest ranges. It is under such circumstances as these that
statistical data are of A'alue.
When circumstances are siu-h that no definite knowledge can be
obtained as to the pathologic physiology, either because of the na-
ture of the case or because of the limited experience of the ob-
450 THE PERITONEUM
server certain data can be obtained by the statement of the patient
and by the general state of bodily reactions. The various cardinal
symptoms may be reviewed Avith this point of view in mind.
Pain. — The initial pain gives some idea as to the degree of se-
verity of the inflammatory process. A mild appendicitis may pre-
sent itself as a soreness in the region of the appendix, -with but
little general disturbance. A perforation of a duodenal ulcer on
the other hand begins Avith the most intense pain, pronounced
general disturbance, and early general abdominal tenderness and
rigidity. When the pain is slight and subsides early a mild lesion
is indicated, provided that no anodyne has been given. When an
anodyne has been given this sign is confused. Even when morphine
has been given the effect a single dose produces may be of some
aid in judging the intensity of the pain. If the patient goes into
a prolonged sleep on a sixth of a grain, one would hardly suspect
a perforating ulcer. Pain is the product of the reactive inflamma-
tion and in those cases Avhich are predominantly toxic, pain loses
its prognostic value. This is well marked late in the disease in
general peritonitis when euphonasia supplants suffering.
Ordinarily the pain of a well-localized lesion subsides in three
or four days. The diffuse pain lessens and only the immediate site
of the lesion is painful. The salutary cessation of pain from peri-
tonitis is gradual. Spontaneous pain first lessens, then pain on
movement and finally pain on pressure.
When the inflammation spreads there is an extension of the pain-
ful area, as is often seen when an appendiceal peritonitis spreads
across the pelvis to the left groin. The same is true when the sub-
diaphragmatic region becomes involved. Local pain is prolonged
if the reaction extends to a suppurative stage. When active ab-
scess formation begins renewed pain from distention of the tissue
from the increasing size of the abscess results. This increase in
pain must be distinguished from renewed pain from a spreading
of the inflammation.
A sudden cessation of pain on the other hand may be of the
gravest omen. Distinction here must be made betAveen a spasm pain,
pain from the inflammatory process itself, and pain from the me-
chanical distention of the tissue. Spasm of the gall bladder may
relax and the patient feels as Avell as ever within a very short time.
PROGNOSIS OF PERITONITIS 451
A pericholecystitis usually requires several days before any de-
gree of comfort is reached. The rupture of a distended gall blad-
der may give sudden temporary relief. The antecedent factors here
must be the guide. When a gall bladder ruptures the surcease
from pain does not bring the calm quietude of restored health. It
is rather an ecstatic state, a sort of ensthanesia, a salve of nature
to fortify against the trouble yet to come.
Sudden cessation of pain, after a considerable degree of reaction
pointing to abscess formation, spells disaster. Sudden cessation
of pain in a patient mIio has fever, increased pulse rate, and
leucocytosis means a spreading, and nearly always a spreading in an
unprepared field from which limitation without operative aid is not
to be anticipated. When an abscess breaks into the intestinal tract
the results may be salutary. Here the temperature and pulse ap-
proach the normal quickly after the cessation of pain.
Fever. — The initial fever in peritonitis is not high. A localized
peritonitis, if it is subsiding, should show a reduced temperature
at least by the third day. If it continues to ascend beyond this
period either the peritonitis is spreading or a localized suppurative
process is in progress. If the temperature suddenly drops an ac-
cumulation has ruptured, either within the free peritoneal cavity
or elsewhere. If in the free peritoneal cavity it drops to subnormal
and the pulse mounts, if elsewhere as an appendiceal abscess into
a gut, the temperature does not become subnormal, and the pulse
rate also drops. When fever and pulse rate part company, dis-
aster is impending. This rule applies to all diseases.
The Pulse Rate. — The rapidity of the pulse rate is dependent on
the general systemic reaction as measured by the suddenness of
the onset and the degree of toxicity. It is the most valuable single
prognostic sign. An increasing pulse rate implies an extension of
the process and the anxiety of the surgeon can not abate so long
as the pulse rate continues to mount, despite any sign of improve-
ment of other symptoms. As a matter of fact an ascending pulse
rate is made more grave if in the face of this the patient pro-
gresses toward a state of well beiug. If with an increased rate
the volume becomes smaller and more tense impending disaster
must be recognized.
Leucocytosis. — Very generally speaking leucocytosis bears a re-
452 THE PERITONEUM
lation to the state of the inflammatory process. When the infec-
tion is severe there may be a leucopenia. An experienced clinician
would hardly be fooled by a ''normal" eonnt, since infective proc-
esses severe enough to repel leucocytes bear unmistakable ear-
marks of gravity. Leucocytosis may fall as localized suppuration
develops, since the white count is an index of the toxin's reaching
the blood stream and not of what may be pent up somewhere in a
walled-off abscess. It is no evidence that the process is subsiding
without suppuration when a localizing process is attended by a
subsiding leucocytosis. If the white count begins to mount when
an abscess is known to exist even without increased pain, a spreading
of the infection is likely. This may be seen sometimes in a walled-
off appendiceal abscess. Spreading may take place toward the
pelvis without renewed pain ])ut Avitli an increased leucocytosis.
This is usually true in those cases in which agglutinating inflam-
mation has extended beyond the site of an abscess. When no such
agglutination has taken place the spreading infection causes
renewed pain corresponding to the area involved. Sometimes
when the ruptured abscess is excessively toxic renewed leucocytosis
and pain may be prevented by the extreme toxic absorption. The
patient may pass from the stage of freedom of pain caused by re-
lief of tension of the abscess, to the euphonasia of extreme toxemia.
I recall a man who had been writhing Avith pain from a periappen-
diceal abscess when the cot on which he lay broke, precipitating him
to the floor. Pain ceased at once, but the leucocytosis doubled.
Despite warning he refused operation until pain should indicate a
renewed inflammation. No pain appeared and a diffuse peritonitis
was revealed by the autopsy.
On the whole leucocyte determinations must be made at regu-
lar intervals to be of use. To the young surgeon the information
it gives is invaluable but the experienced surgeon becomes inde-
pendent of the information it gives.
Muscular Rigidity. — When the infection is becoming localized
the muscular rigidity gradually subsides. Thus a rupture of an
abscess into the peritoneal cavity may bring relief from pain but
the muscles become tense even in the diffuse toxic type. This is
a danger signal of the greatest importance.
Tympany. — Initial tympany may be expressive of a reflex aid
PROGNOSIS OF PERITONITIS 453
to the "walling in of the infection. Increasing tympany after the
process has once become established is of the greatest gravity.
Tympany is never so grave as retraction. A scaphoid abdomen
usually indicates a grave state. If attended by a leaky skin and
rapid pulse it means a wide extension of the exudate, often without
reaction on the part of the peritoneum, and consequently a speedy,
fatal termination.
Sordes. — A dry, brown furred tongue is a grave omen and when
associated with euphonasia spells impending dissolution. A widely
spread inflammation in the presence of a reaction may show a dry
tongue and yet recover. For this to come about there must be a
leueocytosis, some temperature and a hot skin. AVhen a dry tongue
begins to moisten it is a favorable sign.
Singultus. — Hiccough is a grave sign. It means irritation of the
diaphragm, either from pressure from distended guts, or the ex-
tension of the infection to the diaphragm itself. If due to dis-
tension recovery may follow; when due to spreading infection
death always follows.
Vomiting". — Vomiting in the beginning is common and is then
due to reflex irritation through the sympathetic. Late vomiting
is due to obstructive or paralytic ileus and spells early dissolution.
In rare instances an obstructive ileus may recover.
Complications. — The advent of associated lesions always adds
gravity. An infective pleurisy, lung abscess, venous thrombosis,
cerebral disturbance, joint infections, all add their quota to the
burden the patient has to bear. This influence must be evaluated
in each instance. Usually it may be said that when these compli-
cations appear the peritonitis has subsided beyond the danger
point. The prognosis then becomes the prognosis of the complica-
tion. The factor of importance is to i-ecognize the changed oi'
added phenomena as complications and not regard them as varia-
tions in the symptoms of the primary disease.
CHAPTER XVI
CAUSE OF DEATH IN PERITONITIS
In no chapter in the study of the peritoneum is the state of our
knowledge so unsatisfactory as that concerned Avith the cause of
death in peritonitis. Perhaps it may be admitted that, broadly
speaking, any fatal disease becomes so either through a failure of res-
piration or of the circulation. Be this as it may, the avenues which
lead up to either of such catastrophies remain unexplained in
the case of appendicitis. Obviously enough knowledge of the se-
quential development of deleterious phenomena would be of vast
importance in the formulation of a scheme of treatment if we pos-
sessed it. However, Ave have no such knowledge and once the
disease has passed the stage of its focal origin the surgeon is with-
out a fundamental scientific basis for subsequent procedure.
Generally speaking, tAvo main theories haA'e been adA^anced to
explain the cause of death in peritonitis: that it is due to a septic
intoxication, and that a shock to the nerA^ous system is the cause
of death.
Septic Theory. — This theory assumes that death from peritonitis
is due to the absorption of some sort of poison from the inflamed
peritoneum into the circulation AA'hence it is carried to some Antal
organ, there to exert its baneful influence. AVegner Avas the first
to emphasize the claims of this conception. Studying the results
of infection after abdominal operation, in consideration of the Avide
extent of the peritoneum and its capability of absorption, he con-
cludes that in these factors must be sought the explanation. He
bases his strongest argument on the fact that death may occur
before local changes have taken place. Kronlein and Bumm
supported this theory and Reichel also accepted it Avith qualifica-
tions, namely, that it be applied to the acute types Avhile the local-
ized pus-producing varieties presented additional factors Avhich
Avill be enumerated beloAv. Fraenkel and Kraft held the same
454
CAUSE OF DEATH IN PERITONITIS 455
views. Korte and Striimpell support Wegner in the main but ad-
mit the possibility of some reflex influence.
The main support for the septicemic theory is found in the con-
stant presence of a bacteriemia in this disease. Barbacci main-
tained that the bacteria appeared only in the agonal stages of the
disease. This contention is no longer possible since bacteria are
now Avith perfected technic regularly recovered from the blood
stream in the earlier stages, and from the parenchymatous organs
in experimental peritonitis in animals even in the earliest stages of
the disease. Tietze was one of the first to emphasize this point, and
Waterhouse also emphasized it.
Nerve Theory. — The basis for this theory is the observation of
Goltz that tapping the splanchnic area in frogs regularly produces
death. A full consideration of the possibilities of this theory
would involve a consideration of the theories of shock. The chief
modern contender for this theory was Ziegler. His chief reason
apparently for supporting it was the failure to secure positive blood
cultures. According to him death is due to reflex irritation due to
the action of bacteria on the peritoneum.
A number of unclassified theories have been advanced which
may be recorded with the hope that their further development may
bear fruitful results. Grawitz believed that it was the extensive
local suppuration which, by abstracting albumin from the circula
tion and by the high fever consequent to it, produced a paren-
chymatous degeneration of parenchymatous organs, notably the
liver and kidneys. Bauer believed it was the abstraction of water
from the tissues because of exudation and vomiting which exerted
the bad effects. He admitted also the possibility of a reflex influ-
ence on the nervous system.
A summary of the evidence is facilitated by considering sep-
arately those cases in Avhich death occurs before extensive changes
in the peritoneum develop and those where the local changes, sup-
puration, pseudoileus and the like take place.
In rapidly fatal cases death may ensue within a few hours, pos-
sibly even less. This is seen in puerperal infections and after per-
foration of ulcers. That these may cause death by a species of
shock can not be denied. The injection of chemical substances is
sometimes rapidly fatal in small amounts. I have experimented
456 THE PERITONEUM
particularly with turpentine, iodine and olive oil. In the first two
there is intense irritation of the peritonenm and death may ensue
before there is evidence of any injury to the parenchymatous or-
gans. Small amounts of silver nitrate injected into the peritoneum
are fatal, even in dose ranges which are avcU l)orne when injected
subcutaneously. In none of these can the chemical toxicity be ex-
cluded. Ice water injected into the free peritoneal cavity may
produce death in a few minutes in amounts not fatal when in-
jected intravenously. Death in this instance must be ascribed to
unknown influences, popularly called shock. That like results may
be caused by acute infections can not be denied or proved.
Nevertheless, in the majority of rapidly fatal cases an absorp-
tion of toxins, probably of bacteria themselves, is much more tan-
gible. How this acts is quite another problem. In experimental
injections of bacterial cultures in animals no lesion recognizable
by the microscope is discoverable. Possibly some potent factor
like anaphylaxis is operative. If this be true it is but substituting
a word of unknown meaning as a symbol for an unknown process.
In some cases small petechial hemorrhages are found in the cen-
tral nervous system. In less acute cases cloudy swelling of the
kidneys and liver is often observed. Generally speaking, it is only
in cases which have run a course of forty-eight hours or longer
that the above mentioned anatomic changes are noted. It is pos-
sible in the light of newer opinion that functional disturbance may
precede the organic lesion.
In the less acute cases, which are common ones, which run a
course of from 4 to 8 days the series of phenomena is far more com-
plicated. In such cases meteorism, vomiting, pseudo-obstruction
from kinking of the gut, are common observations. These serious
factors probably play a varying part in the different cases. I have
made the problem as to why the intestinal canal dilates a special
study in order to determine the cause of the meteorism. There is
no obvious change in the nerve plexuses surrounding the gut Avail.
These nerves and their fibers stain as in the normal gut. The mus-
cular coat of the gut shows definite changes, however. The muscle
cells show a fine granular change quite like the earlier changes in
cloudy swelling of the kidney. These shoAv in cases running a
course of twenty-four hours or more. In the hyperacute cases this
CAUSE OF DEATH IN PERITONITIS 4.57
change is not manifest. Whether this again represents a loss of
function antedating anatomic change is a matter of speculation.
The injurious effects of such dilatation likewise are not clear.
That great mechanical discomfort may ensue is obvious. Whether
the associated dyspnea is due to mechanical pressure on the dia-
phragm, degeneration of the diaphragmatic or other respiratory
muscles, or to some action of the nerve centers is difficult to answer
from anatomic evidence. Mere increase of intraabdominal tension
as by the return of large masses of intestine during operations for
large hernias may result in distressing even fatal dyspnea, I have
learned by experience. Dyspnea associated with great tj-mpany,
even in the most distressing cases, may be lessened temporarily by
puncture or drainage of a gut. I am disposed to believe, therefore,
that the problem is largely mechanical, despite the fact that degen-
erative changes may sometimes be noted in the diaphragmatic and
intercostal musculature. In fact this degeneration may make the
great distention possible.
Recent studies on intestinal obstruction make it seem possible that
absorption from the intestinal canal, particularly from its first por-
tion, may exert a deleterious effect. It can be easily demonstrated,
however, that Avlien such conditions exist absorption both from the
serous and mucous surfaces is very much slowed.
In the study of human material the picture is often much more
complex. Generalized cloudy swelling of and hemorrhages into the
parenchymatous organs is common. Secondary abscesses may form
in an endless number of situations.
That loss of fluid exerts any particular influence as Bauer thought
is unlikely, since the amount so lost is really small and may be much
exceeded in other diseases which are not fatal.
That the effect of local suppuration is other than salutary, com-
paratively speaking, is unlikely. The older authors were quite right
in their regard for pus. If one must have infection as they did, the
devolopment of pus is a laudable event. This fact is as true now
as ever. Suppuration merely means that an inflammatory reaction
has taken place and when such is the case absorption is markedly
lessened. When death follows suppurating processes the deleteri-
ous action is lessened in direct proportion to the encapsulation of
the mass. Death Avhen it follows such a state is due to the com-
458 THE PERITONEUM
plication of the process by the occurrence of a renewed infection in
the immediate vicinity or at some distant point in the form of a
metastatic abscess. Then the problem becomes the same as above
detailed for the nonsuppurative type.
The problem as to the cause of death apparently centers about the
absorption of toxins or bacteria, most likely both, and their action
on some vital organ or organs the identity of which is at present
unknown. How toxins may affect the organisms when absorbed has
been the object of numerous studies. One of the most careful of
these is by Heineke. In experiments upon animals he determined
that the blood pressure remains near normal until severe constitu-
tional effects had developed. The fall then was gradual. After con-
siderable fall had taken place by increasing the amount of blood in
the heart by pressure upon the abdomen or clamping of the aorta
the pressure again rose. He concludes that the loss in pressure is
due to lessened blood in the heart. This he ascribes to lessened
tonus in the vasomotor center. Since these changes are progressive,
death must be caused by progressive loss of the tonus of the vaso-
motor center.
The question has been raised as to why infection of the pleural
cavity differs in course and fatality from that of the peritoneum.
The answer is simple: it does not. The ordinary pleurisy runs a
different course from ordinary peritonitis because of the less extent
of the pleura and because the infective organism is usually of less
virulence. When equally virulent organisms are introduced into
the pleural cavity the course is quite as rapidly fatal as when the
peritoneum is affected.
Bibliography
Barbacci: Ueber Aetiologie iind Pathogenese der Peritonitis durch Perforation,
CentralV.l. f. allg. Path. u. path. Anat., 1893, iv, 7(59.
Bauer: Krankheiten des Peritoneums. In: Ziemssen's Handbuch der speeiellen
Pathologie und Therapie, Leipzig, Vogel, 1874, viii, 217.
BUMM: Zur Aetiologie der septischen Peritonitis, Miinehen. nied. AVehnschr.,
1889, xxxvi, 715.
Fraenkel: Ueber peritoneale Infection, Wieii. kliii. Wchnsehr., 1891, iv, L'41,
26.5, 285.
Grawitz : Statistischer und experinientell-pathologiseher Beitrag zur Kenntnis
der Peritonitis, Charite-Ann. 1884, Berlin, 1886, xi, 770.
Heineke: Experimentelle Uutersuchungen iiber die Todesursache bei Perfora-
tionsperitonitis, Deutsch. Arch. f. klin. Med., 1900-1901, Ixix, 429.
Korte: Weiterer Beiicht iil>er die ehirurgisehe Behandlung der diflfusen Baucli-
fellentziindung, Verhandl. d. deutsch. Gesellsch. f. Chir., 1897, xxvi, 15.
CAUSE OF DEATH IN PERITONITIS 459
Kraft: Experimental-pathologiske Studien over akut Peritonitis Kjbenhavii,
P. N. Laiigsted, 1891.
KrOnlein: Ueber die operative Behandlung der acuten diffusen jauchig-eiterigen
Peritonitis, Arch. f. klin. Chir., 1886, xxxiii, 507.
Reiciiel: Bcitrage ziir Aetiologie und chiriirgischen Therapie der septischen
Peritonitis, Deutsch. Ztsehr. f. Chir., 1889-90, xxx, 1.
Strumpell: Specielle Patliologie und Therapie der innereu Kraiikheiten, ed.
12, Leipzig, Vogel, 1899.
TiETZE: Beitrag zur Kenntnis des Eankenneuroms, Arch f. Chir., 1893, xlv,
326.
Die chirurgische Behandlung der akuten Peritonitis, Mitt. a. d. Grenzgeb.
d. Med. u. Chir., 1899, v, 15.
Waterhouse: Experinientelle Untersuehungen iiber Peritonitis, Virchows Arch.
f. path. Anat., 1890, cxix, 342.
Wegner: Chirurgische Bemerkungcn iiber die Peritonealhohle, mit besonderer
Beriicksichtigung der Ovariotomie, Arch. f. Chir., 1877, xx, 51.
Ziegler: Studien iiber die intestinale Form der Peritonitis, Miinchen,
E. Miihlthaler, 1893.
CHAPTER XVII
TREATMENT OF ACUTE GENERAL PERITONITIS
No other disease that falls to the lot of the surgeon places so heavy
a burden on his judgment as does the management of acute inflam-
mations of the peritoneum. In the progressive type it depends
largely on his judgment Avhether or not it shall be halted in its
course ; or, if tending to spontaneous limitations it may be set on
its way again by his injudicious manipulations. It is in this field
that fate exacts from the young surgeon its heaviest toll. He may
learn much from books, from experimentation and from the masters
of the art, but it is under his oAvn hands only that the minute de-
tails can be mastered. Hoav apt a pupil he shall be depends on the
inherent acuteness of his perception and the profundity of his
knowledge of the fundamental principles which underlie the genesis
and propagation of the inflammatory lesions of the peritoneum. If
he proceeds without the former he has not heard aright the call to
duty, if without the latter he commits a crime against his patient.
Historical. — The history of the literature bearing on the treat-
ment of peritonitis is a long one made up, as is the history of the
treatment of most diseases, of a vast deal of irrelevant papers,
many case reports of value in the final summation and a few path-
forming papers. It is the last group only which Avill receive atten-
tion here.
Accounts of incision of abscesses arising within the abdomen are
recorded in the earliest medical writings. It was only when per-
forations through the skin threatened, however, that this procedure
was undertaken. Only much later did surgeons open the abdomen
to drain purulent accumulations. Chomel Avas one of the first to
formulate rules for incision in walled-off intraperitoneal abscesses.
In this early period puncture was resorted to in order to remove
the pus without exposing the abdominal contents to the air. As late
as 1876 Kaiser reported sixteen cases collected from the literature
cured by puncture, paracentesis or incision. He advised such treat-
460
TREATMENT OF ACUTE GENERAL PERITONITIS 461
ment only after the acute symptoms had subsided. Schmidt advised
long incision -when the abscess was not well walled off in order to
avoid accessory accumulations.
Relaparotomy after infection during abdominal section Avas
advised by Tait. These papers were the first clearly to foresee the
modern operative treatment for peritonitis. Leyden first suggested
energetic irrigation in addition to drainage.
From this date the operative treatment of peritonitis forms a large
part of surgical literature. Two important papers appeared at this
time ; one by Mikulicz in which he practiced suture, irrigation and
immediate closure, albeit without success, and one by Kronlein in
which immediate suture was folloAved by recovery. In 1886
True presented a historic review of the treatment of peritonitis to
date. In this year our countryman Hall reported a case successfully
treated. Bull and Gaston are names to be remembered in connection
with the early treatment of this affection.
For early operation the first clear recommendation was by Bull.
Simultaneous with this Sands, McMurtry, and McBurney made
similar recommendations. Matter of fact as these suggestions now
seem to us, they were a veritable calling in the night. To appreciate
this, these papers must be read in their entirety. Following this
Senn raised his voice in favor of early operation. McBurney ad-
vanced the efficiency of treatment by clarifying the diagnostic side,
and first noted the point at which pain is most frequently found in
impending appendiceal peritonitis.
Reichel advancing far ahead of his time discussed on experi-
mental grounds the question of irrigation in septic peritonitis and
condemned the practice in the following words: "Die spiilerei der
Peritonealhohle ist eine Spielerei. "
About this time Schooler released adhesive bands which pro-
duced occlusion of the gut in acute perforative peritonitis and
saved his patient. Robinson in addition to incision and drainage
advised the use of saline laxatives to prevent adhesions. Renvers
called attention to the fact, still new to some, that operation in
these patients should be carried out with expedition. In line with
this Korte urged a simple procedure of incision and drainage. This
is perhaps the first clear, comprehensive statement of all that is
best in the treatment of peritonitis. Though the profession has
462 THE PERITONEUM
marelied forward since that paper was published the advance has
been in a circle.
From this time on the important literature may be discussed in
connection Avith the presentation of the problems which confront
the surgeon today and represent therefore in a way history in the
making.
Preventive Treatment, — The chief advance in the treatment of
peritonitis lies in the direction of prevention. Diseases which may
be complicated by peritonitis are so managed as to lead to their
cure before the disaster develops. Gastric ulcers are cured that
they shall not perforate, gall stones are removed in order to obviate
a suppuration of the gall bladder. Typhoid fever is so managed
that the least risk of perforation shall develop. Gonorrheal tubes
are allowed to cool off before being operated on in order that in-
fection shall not be spread by the manipulation of the surgeon.
Prophylaxis finds an even more important field in preventing the
extension of a localized peritonitis. In many instances the pres-
ence of a diseased state of an organ is not recognized until the
peritoneum becomes inflamed. The early recognition of such in-
flammation and the skillful removal of the disease causing it rep-
resents the chief field of projjhylaxis.
Medical Treatment. — The medical treatment of peritonitis has
brought out an astonishing array of drugs. Surgical treatment
has so overshadowed the medical treatment that few surgeons are
disposed to believe that medical treatment can have any place at
all. It is a mistake to be too sure aliout anything and it seems to
me that the literature of the medical treatment is well worth read-
ing. Sometime possibly a valuable drug will be discovered and a
knowledge of past efforts will aid in recognizing it when it is
found. At any rate historical knowledge always serves as a check
against overestimating our own importance. Omitting those drugs
of purely historical interest but two general groups remain for
consideration. The first, looking to elimination, consisted of ca-
thartics more or less drastic. Tait employed salts to prevent post-
operative peritonitis and for a time a like plan was followed to
prevent spreading in local forms of peritonitis. This method was
pernicious in practice and has been wholly abandoned as a method
of treatment. One still sees it in use in early peritonitis Avhen the
TREATMENT OF ACUTE GENERAL PERITONITIS 463
practitioner, under the general diagnosis of gastritis or ptomaine
poisoning, gives a cathartic to eliminate the toxin.
Opmm,. — The use of opium several generations ago was univer-
sal. It was supposed that it possessed a direct healing virtue.
Alonzo Clark first began its use about 1840. The essential feature
of the treatment is that the patient shall be completely narcotized
with opium. In his first case he gave 100 grains of opium in the
first four days of the treatment. He mentions a ease in which he
used 32 grains of morphine in twenty-four hours. In this case 208
grains of opium were given in twenty-six hours about the fifth
day of the disease and on the sixth day 221 grains, on the eighth
224 grains, on the ninth and tenth days the same amounts, on the
eleventh day 247 grains, and on the twelfth day 261 grains. After
this with the patient improving, the amount was gradually les-
sened. The patient recovered. Clark calls this heroic treatment;
none will oifer contradiction.
This treatment was quite generally followed, though be it said
mostly with less heroism. Wood, for instance, recommended that
75 grains of solid opium be given daily for five days. He notes
that as the disease Avears out the ability of the system to stand large
doses subsides, so that the quantity must be gradually reduced.
These heroic doses have long been abandoned and the use of
•this drug in any dose is generally condemned. Stockton still speaks
of the treatment with a measure of enthusiasm. He seconds Star-
ling in the belief that opium tends to lessen distention of the
intestines by its sedative action on the splanchnic nerves. Crile
recently advised the use of morphine to lessen exhaustion.
It can not be denied that the drug is capable of fulfilling two
of the offices ascribed to it by the old writers, namely, to prevent
exhaustion, and to cause quiet. The dose necessary to meet these
ends need be but a small fraction of those formerly advised. The
question arises Avhether or not opium does not have some direct
action in neutralizing the toxic effect of the toxins. The enor-
mous dose formerly employed would not be tolerated in any other
disease. Unfortunately no eifort was made in cases where huge
doses were given to recover the drug from the stools. The trutli
of the matter is likely that but a small amount of the drug was
absorbed. In my early practice, when available surgical skill did
464 THE PERITOXEUM
not seem to warrant operative treatment, I made use of the opium
treatment. I discovered to my discomfiture that patients receiving
large doses of opium by the mouth were proportionately A^astly
more susceptible to hypodermics of morphine. This difference is
not due to the substitution of the alkaloid for the crude drug, for
large doses of morphine may be given l)y the mouth without getting
this effect. Opium lessens absorption from the peritoneal cavity
in the normal animal and from my observation I feel certain that
the ability of the patient to stand such large amounts of opium is
due to the fact that the drug is not absorbed. In peritonitis absorp-
tion from the gut tract is lessened, as is evidenced by the accumula-
tion of fluid in the intestines, and Avhen the peritonitis subsides
absorption increases and the tolerance to the drug is lessened.
One curious phenomenon was noted in a number of instances.
Despite the continued exhibition of real respectable doses of opium
the patient had a spontaneous movement from the bowels. There
seems to be no ready explanation for this.
Modern surgery leaves but little room for the use of opium.
Once the real cause has been removed, the disease progresses to
recover.v. After the cause is removed, there seems to be no valid
objection to the use of the drug to alleviate suffering. I can not
suppress the feeling that the opium treatment has been too
completely abandoned.
In the extreme cases of acute diffuse peritonitis, with apprehen-
sive look, leaky, blanched or semicyanosed skin I believe opium
offers more than surgery. Opening the abdomen in such cases but
augments the already deadly rate of toxic absorption. Here I am
convinced opium is better than morphine hypodermically. Possibly
the local action of the opium on its way down the gut tract may
exert a beneficial influence. This whole question is so fraught
with uncertainties that its review in competent hands is much to
be desired.
EpinepJirin. — This drug was found to stimulate the circulation
by raising the blood pressure and having assumed that the pressure
falls in peritonitis it was assumed it would be desirable to raise it.
It was assumed also that if epinephrin Avould raise the pressure in
normal animals it would also do so in patients with peritonitis,
hence the use of epinephrin would be desirable in this disease.
TREATMENT OF ACUTE GENERAL PERITONITIS 465
Whether or not it might have some deleterious effect has not trou-
bled clinicians. Nevertheless, it is worth recalling that Josue found
that repeated injections of epinephrin in animals is followed by
the formation of distinct arteriosclerotic places in the intima of
the larger vessels. A considerable number of injections, as many
as eighteen, are required to produce these results and Loeb and
Githens did not find them to be constant. What is of much greater
importance is that Erb found extensive changes in the muscle cells,
consisting in the disappearance of elasticity of the elastic fibers.
These observations were in a large measure confirmed by Pearce
and Stanton. While inconclusive, these studies suggest the possi-
bility that the drug may produce mischief. Certainly a drug Avhich
produces degeneration of muscle cells should be used Avith caution
in the treatment of peritonitis. Holtzbach sought to establish a
scientific basis for its use. He found that the beat of a frog's heart,
poisoned by sodium arsenate, became stronger with the application
of a weak solution of adrenalin.
There is no doubt that, as Peiser showed, adrenalin added to the
salt solution introduced into the normal peritoneal cavity markedly
lessens the rate of absorption. It does this by its vasoconstrictor
action. If this drug is of any use in peritonitis the benefit from
this action would seem more plausible than from its capacity to
raise the blood pressure.
A number of surgeons speak enthusiastically of the value of epi-
nephrin in the treatment of peritonitis. Meissl, Rothschild, and
Heidenhain by means of experiments demonstrated that blood pres-
sure could be heightened and so maintained by a more or less con-
stant infusion of sodium-chloride-epinephrin solution. The last
named believes that this remedy is useful in severe cases. He de-
tails one case which at first seemed inoperable and became operable
after the use of this remedy. The patient subsequently recovered.
IMuch less enthusiastic is Mummery.
Whether or not epinephrin has a place in the bridging over of
a critical stage in peritonitis is difficult to say. That there is a
fall in blood pressure in tlie terminal stages there can be no doubt.
Whether this is due to a centi-al exhaustion, a vascular dilatation,
or a Aveakness of the heart muscle is difficult to say. Seelig's ex-
periments indicate that it is not a central exhaustion. That it is
466 THE PERITONEUM
often, late in the course of the disease, at least in part, an expression
of cardiac intoxication is likewise certain. It is possible, even prob-
able that in an earlier stage vascular dilatation plays a prominent
part. Even so it is still a question if such an ephemeral drug can
exert a lasting beneficial influence. Hunter Avas of the opinion
that a single abstraction of blood, by once lessening the load, ex-
tended its influence beyond the period of its activity. It may be
so with epinephrin. Heidenhain was of the opinion that its effect
lasted at least six or eight hours. On the other hand Crile and
Janeway found that the pressure when raised by adrenalin fell
again in a short time. My own experience in many cases, where this
drug was used in conjunction Avith local anesthesia, indicated that
the maximum pressure is maintained a very fcAV minutes only. The
conditions may be different in the peritonitic patient. Used as it
is in peritonitis in conjunction A\-ith a considerable amount of salt
solution it is impossible to judge to Avhich of these the good re-
sults, if any, may be due. Its A'alue AA'hen giA^en alone subcuta-
neously certainly is negligible.
Until further light is shed on the subject for me the folloAving
situation indicates a trial; Avhen there is distention of the intes-
tines, Avitli pallor or cyanosis and a large soft pulse. Then a pint
or two of adrenalin-sodium-chloride solution Avill at least bring
temporary improA'ement. I belieA'e Xeu is right Avhen he insists
that the solution must actually be put into a A^ein. He recommends
the use of a glass cannula tied into a slit in the vein so that the
solution may be conveniently introduced at short intervals.
Ether. — This drug is supposed to act as a general stimulant and
as a local antiseptic. The basis for such a belief is AA'holly unsat-
isfactorA\ The use of this drug seems to be largely, if not entirely,
empirical. Morton found that ether is first dissolved in the lymph
of the tissues, then enters the blood stream and is carried to the
lungs AA'here it is eliminated, beginning as quickly as 3 or 4 min-
utes after it is introduced. She quotes Park as saying that colon
bacilli are killed in one minute Avith a 75 per cent solution of ether
in oil and in 10 minutes Avith a 50 per cent solution. Jenanneret
believes it has an antiseptic action and is of peculiar Anrtue in that
it penetrates deeply. He does not reveal the source of his informa-
tion. He belieA'es also that it acts as a tonic. He does not state
TREATMENT OF ACUTE GENERAL PERITONITIS 467
the basis of his belief. Waterhouse quotes Tapley as saying that
ether is decidedly bactericidal. According to him it produces an
exudate in which the endothelial cells at first predominate while
later the polynuclears are the more numerous. My own studies
failed to disclose any action save that the cement substance be-
tween the endothelial cells is dissolved, and in prolonged action,
the cells are loosened and ecchymosis in the tissues takes place.
The same action is observed to a lesser degree in the lung epithe-
lium after prolonged inhalation anesthesia. Its action does not
seem to be in any way to abstract leucocytes or to excite other evi-
dence of reactive processes. In what way this drug might be believed
to be useful in peritonitis does not appear and clinical experience
seems to bear out this surmise.
Morestin's seems to be the first of a number of papers expressive
of satisfaction in its use, but the details of the case reports indi-
cate clearly that the optimistic attitude of the writers is Avholly un-
justified by the facts. For instance Saliba bases his belief on an
experience of 248 cases. He quotes five of these in detail. In one
of these the patient became suddenly pale, with thready pulse and
shallow respiration, followed by basal pneumonia on the third day.
Another became cyanosed fifteen minutes after leaving the operat-
ing table and remained unconscious for twelve hours. Another
suffered from diarrhea for a few days. Despite this experience he
regards ether as a safe and beneficial antiseptic. The amount used
varied from one to three ounces. Phelip and Tartois noted that
stupor often follows the use of ether. Santy found that 12 c.c. in
a 1900 gm. rabbit produced cyanosis, dilatation of the pupils and
death. Tansini used it in his two cases to wipe out feces that had
escaped into the peritoneal cavity. He also uses it to wipe the line
of suture after gastroenterostomy. Waterhouse regards three
ounces as the maximum. Auvray is said to have left a quart of
ether in the abdomen.
Pope in experiments on animals found that a dram of ether left
in the peritoneum of a rabbit profoundly shocked the animal. A
deep narcosis with fall in the blood pressure followed. He be-
lieves that the normal defenses of the peritoneum are broken down
by ether and warns against the use of this substance in the treat-
468 THE PERITONEUM
ment of peritonitis, a conclusion "which will be enthusiastically
endorsed l)y those who have experimented with this drug.
CampJiorated Oil. — This substance has been used for the double
purpose of limitino: infection bv local use and as a stimulant. As
a stimulant to the heart this drug no doubt has a place. There
is no evidence that it is of particular value in peritonitis. Its
local use in the peritoneal caA'ity has but slight evidence to sup-
port it. Glimm found that absorption of a sugar solution was
slowed if oil was injected into the peritoneal cavity before the
sugar solution Avas introduced. The slowing was supposed to be
due to the plugging up of the lymphatics by the oil globules, it
being assumed that a sloAving of absorption was desirable. Pfan-
nenstiel was the first to propose camphorated oil as a prophylac-
tic measure. He used 50 to 300 c.c. of olive oil in 20 cases and 25
to 50 c.c. of a 10 per cent camphor in olive oil in 22 cases, and a
preoperative intraperitoneal injection of olive oil in 120 cases.
He used 30 to 50 c.c. of 1 to 10 per cent of camphorated oil injected
into the peritoneal cavity four days before the operation. The re-
action so produced lasted from two to seven Aveeks. Burckhardt
used 50 to 100 g. as a prophylactic measure. Much greater pro-
portions of camphor have been used. Hoehne used 10 per cent.
Sven this did not prevent collapse from the oil, for Riibsamen had
a fatal collapse after the use of 170 g. of 10 per cent camphorated
oil. Schepelmann found that in experimental peritonitis the an-
imals died more quickly Avhen camphorated oil Avas used.
The danger of using oil in the peritoneal caAdty has already been
discussed in the chapter on the prevention of adhesions. The ad-
dition of camphor seems not to lessen the danger to more than a
A'ery slight extent. Animal experimentation and clinical experi-
ence are in accord in teaching that oil in any form should be
aA'oided in abdominal surgery.
External Application. — Heat. — Local application of heat, particu-
larly moist heat, has long been used for the relief of abdominal
pain. In the early stages of peritonitis it aids materially in relicA'-
ing such pain as may be due to the spasmodic contractions of hol-
loAv organs. It is the most harmless palliatiA^e means and can be
adA^antageously employed during the period the patient is observed
for the purpose of making a diagnosis.
TREATMENT OF ACUTE GENERAL PERITONITIS 469
Dry Heat. — The ubiquitous hot water bottle furnishes the most
convenient but the least eiTective means of applying heat. As a
direct means of controlling peritonitis its use is of quite recent
date. Gelinski was the first to employ it systematically as a meas-
ure of after-treatment in peritonitis. He employed dry heat in the
well-known Bier's oven. Danielsen warned against its general
application. Strumpel advised a temperature up to 550° C. Iselin
believes that drainage is promoted by the hot air bath.
Moist Heat. — Moist heat is much more efficacious in relieving pain
from inflammation or distention than dry heat. Pads as large as
the abdomen are made up of half a dozen or more layers of flan-
nel and after being wrung out of hot Avater are applied to the ab-
domen. These may be covered with dry blankets to retain the
heat. Moist heat is enhanced in etfectiveness if its stimulating
effect is augmented by irritating chemicals. Turpentine and can-
tharides are usually employed. Turpentine is most used, a dram
being sprinkled over a hot pack prepared as above noted. Hot
packs act on the general principle of counter-irritants and are often
very effective against distention of the abdomen.
Ice Pack. — In the beginning of an acute peritonitis the ice pack
often lessens the pain and is supposed to lessen the reactive proc-
esses. If the patient is required to balance an ice pack on his ab-
domen he is at least restricting his movements.
Operative Treatment
Once the diagnosis of peritonitis is made the question of its dis-
position to spread must be considered. Most cases tend to spread,
therefore tlie advisability of operative intervention must be
considered.
Indications for Operation. — This entire monograph is an attempt
to answer this question for one individual surgeon. It is a situ-
ation in which the surgeon must take stock of himself as well as of
the patient. My teacher of obstetrics, the late W. W. Jaggard,
was wont to say that before any operation is done the surgeon
should ask himself, "What harm may I do?" There is no depart-
ment of surgery in which this question is fraught with so much
responsibility as in acute peritonitis.
For the so-called occasional operator my advice is, don't do it.
470 THE PERITONEUM
Many cases of stormy beginning subside and localize. Then he
may operate. Those cases which have no tendency to localize, such
as perforating ulcers of any sort are seldom improved by unskilled
hands. In traumatic perforations, before inflammation begins, the
amateur may be of service. It is in inflammations which tend to
localize, such as most cases of appendicitis and all the gonorrheal
perisalpingitides, that injudicious operations do most harm. Op-
erations lasting two or more hours are still committed in acute
appendicitis. There can be no question but that the patient is
menaced by such prolonged manipulations. It was my privilege
to have practiced when it Avas the rule to await the interval for
operations for appendicitis. I have also lived in an environment
when everybody operated on appendicitis patients "as soon as the
diagnosis is made" and alas, often before. As a result of these
operations I have concluded that the chief indication for opera-
tion in acute peritonitis is the arrival of a surgeon. The requisite
skill being available, an acute spreading peritonitis is an indication
for operation in many instances. The offending lesion may permit
of removal and the mischief done then is capable of neutralization
in the shortest possible time. The old adage, too late for early
operation and too early for late operation, has lost its significance
in the development of our knowledge of the management of these
cases. There is no rule that can be written that can guide a trained
surgeon.
There comes a time in the spreading type Avhen operative pro-
cedures offer little or nothing. Pinched features, cold, clammy
skin, blue extremities, thready pulse, spell impending disaster and
incision can but hasten the end. Whether some such cases are
capable of spontaneous localization of the process with subsequent
recovery is a matter of study. That absorption in a distended
abdomen is hastened by incision there can be no doubt.
Preparatory. — The patient afflicted with acute peritonitis should
be prepared for his operation in the simplest manner possible. The
elaborate preparations permissible preliminary to operations on
noninfected patients are out of place here. Food and drink should
be withheld. If there is vomiting this may be controlled Avith mor-
phine while the preliminary steps of preparation are being com-
pleted. Some surgeons practice gastric lavage. In all conditions
TREATMENT OF ACUTE GENERAL PERITONITIS 471
except perforative lesions of the stomacli this is permissible and if
it can be accomiDlished without retching on the part of the patient
it is actually indicated, but too often the strength required to ac-
complish it does harm in spreading the infection. In such instances
it had best be deferred until the conclusion of the operation.
Preparation of the Skin. — Manipulation of the field of operation
is distressing to the patient and may do harm if rigorously em-
ployed when the patient is asleep. Dry shaving, when needed, fol-
lowed by the application of tincture of iodine is the work of but a
moment and meets every requirement in these cases. In the less
acute cases cleansing with soap and water before as Avell as after
shaving is the ideal method. The use of a sterile dressing after the
preliminary cleansing is not objectionable except as it tends to
continuously remind the patient of the coming operation. It is
quite useless, however, for no more infections occur without it than
with it. The use of a moist dressing, once in vogue, has now been
universally abandoned. Painting the skin with iodine before the
operation meets every requirement.
Anesthetic. — An acute peritonitis hypothecates a generalized
symptomatology but with local lesion. Because of the general state
of the patient the operation should be done in the least time pos-
sible. These requirements demand a general anesthetic since the
extent of the manipulation can not be foretold before the lesion
is exposed. Local anesthesia followed by gas may be employed
when a general anesthetic is contraindicated. Usually however
these patients are nervous and irritable and any attempt at infil-
tration anesthesia may disturb them. Gas alone Avhere the lesion
is simple may suffice, or if a more complicated lesion is encountered,
ether may follow. Ether is usually the ideal anesthetic, but its use
should be restricted to the smallest amount compatible with the
unhindered manipulations of the surgeon. Timid anesthetists often
seriously hinder the work of the surgeon by a failure to push the
point of relaxation. By so doing they prolong the time of the
operation so that in the aggregate more anesthetic is consumed than
if a bolder exhibition Avere practiced. Chloroform, because of the
danger at the time of the operation and particularly because of the
possibility of late yellow atrophy of the liver, whieli is apt to
follow its use in infected patients, is contraindicated.
472 THE PERITONEUM
Time of Operation. — In some cases immediate operation is de-
manded irrespective of the surroundings, and in a large measure
irrespective of the qualifications of the operator. This includes
those cases of acute peritonitis due to perforations of the gut where
there has been no anticipatory reaction on the part of the perito-
neum such as perforative gastric or duodenal and typhoid ulcers,
those incident to intestinal occlusion, etc. The rupture of encap-
sulated abscesses into the free peritoneal cavity may be included in
this list.
Those cases in which there is a gradual involvement of the peri-
toneum from disease arising in the wall of a viscus and gradually
approaching the surface do not ahvays demand immediate opera-
tion. In this group appendicitis is preeminent, followed by chole-
cystitis and salpingitis. In these cases there is a range of opinion
in selecting the time of operation. The average patient afflicted
with one of these diseases runs less risk from his disease than from
the operation by an inexperienced operator. Very unfavorable
surroundings may influence the experienced operator to elect to
operate at some other time.
Site of the Incision. — Two factors must be considered in selecting
the site for incision in the operation for acute peritonitis. The
first is accessibility to the site of the lesion and the other the pre-
vention of infection of the general peritoneal cavity. In acute
lesions in which Availing off is not to be expected accessibility,
generally speaking, is the dominating factor, while later when there
is partial or complete walling off the second factor is the more
important. For instance in perforation of a duodenal ulcer or in
the beginning of an acute appendiceal peritonitis the route Avhich
makes the site of the lesion most easily accessible may be selected,
keeping in mind of course the fundamental principles of operative
surgery; while in appendicitis partially or completely walled off
the incision would be made lateral to the focus of infection
in order to avoid disseminating the infection into the unaffected
portion of the peritoneal cavity. The more complete the walling off
and the more virulent the infection the more important does this
rule become. A localized pelvic peritonitis may demand drainage
through the rectum or vagina, and one situated below the diaphragm
may demand a transpleural drainage.
TREATMENT OF ACUTE GENERAL PERITONITIS 473
From the foregoing it is evident that the character of the in-
fection, its stage of development, and its topographic relations
must be taken into account in selecting the site of the incision.
Obviously therefore this question can be adequately discussed only
in consideration of specific groups of cases ; indeed in detail only
Avhen a concrete case is at hand in which all the questions in patho-
genesis can be determined.
Management of the Exudate. — When an infection has produced
a purulent exudate in any region of the peritoneal cavity the fun-
damental problem is to effect its removal. If an accumulation is
walled off the contents are under equal pressure from all sides
and if an opening is made at any point the fluid escapes because
of the elasticity of the walls. When there is no walling off no such
pressure exists and the force required to propel the fluid must be
manually supplied. This may be done by sponging or by irrita-
tion. Even in the diffuse variety the general intraabdominal ten-
sion tends to force fluid out of an opening, whether dependent
or not.
Sponging-. — Because of the capillarity of gauze pledgets fluid
is taken up by them and when saturated they may be discarded.
This act is repeated until all of the fluid is removed. The diffi-
culty met in employing this method is dependent entirely on the
amount of the exudate and the extent of the area involved. AVhen
gently done this method has the advantage of not disseminating
the infection.
Irrig-ation of the Peritoneal Cavity. — When one sees a deleterious
substance it is quite natural that one should desire to wash it off.
This natural desire has found expression in the treatment of peri-
tonitis. The central thought is to remove the toxic material by
means of irrigation and thus prevent its absorption into the circu-
lation. The logic is good, the result disastrous as is so often the
case when therapeutic problems are decided by abstract consid-
erations. The fallacy lies in tlie fact that the toxins being ab-
sorbed are not so much those contained in the fluid free in the
abdominal cavity as those in the tissues themselves, Avhich are not
reached by the ii-rigating stream. The chief mischief was done by
distributing toxic material over areas of peritoneum not previously
involved.
474 THE PERITONEUM
The general plan was to introdnee large amounts of normal sa-
line solution into the peritoneal cavity Avliich when it returned was
supposed to cari-y the infected material with it. Since the action
was largely mechanical it was but natural to suppose that the
larger the amount used the more efficacious the treatment.
The fundamental fault of irrigation lies in the fact that the in-
ditferent tiuid tends to carry the infective material to regions not
previously affected. ]\ruch harm also is done by removing the nat-
ural defensive forces of the tissues. The exudate covering the sur-
face of the peritoneum is composed of serum and cells and in just
the measure that irrigation is effective it is harmful by removing
this protective measure. The maximum of mischief Avas done by
adding manual friction to the irrigation.
In localized abscesses irrigation is sometimes employed for es-
thetic reasons. Offensive discharges may be deodorized by irriga-
tion with potassium permanganate. Irritative discharges may be
removed by irrigation in some instances.
Some weird theories were advanced to explain the hypothetic
benefit from iri'igation. For instance, salines Avere supposed to
mechanically remove the toxin-ladened pus and at the same time
Avere supposed to be absorbed, thereby stimulating the vital func-
tions and promoting elimination.
Though generally abandoned, irrigation has been recommended
from time to time by very able surgeons. Blake developed abdom-
inal lavage to the highest degree. He employed an irrigation tube
which by means of a syphon arrangement sucked the fluid out as
completely as possible. Crandon and Scannell also describe a spe-
cial apparatus. Mikulicz believed that the mechanical cleansing
was useful and that the fluid remaining produced a hyperleuco-
cytosis and acted as a stimulant as Avell.
There are still a few relatively recent papers which advocate its
use. Among those which may be mentioned are Schmidt, Propping
and Iselin.
Reichel Avas one of the first to oppose irrigation. He declared
that ''Spiilerei ist eine Spielerei." Many have opposed it, and since
Murphy excluded it from his method of treatment, it is but seldom
used. Robinson's excellent Avork along the same line has gone
unheeded.
TREATMENT OF ACUTE GENERAL PERITONITIS 475
While clinical experience was the chief factor in eliminating irri-
gation from the recognized means of treatment experimental evi-
dence added salve to the process of elimination. Clairmont and
Haberer in experiments on ra])bits found that irrigation did not
delay, on the contrary seemed actually to hasten death in experi-
mental peritonitis. Noetzel likewise failed to find any experimental
evidence that irrigation was useful. There is a question whether
or not irrigation may not be useful in the face of impending paraly-
sis of the bowel. Holtz showed that a gut that had almost ceased
to move by stimuli became active again after irrigation with saline
solution. This is capable of but momentary stimulation, however.
There is one condition in which irrigation seems rational. In
instances where large amounts of fluid have been poured into the
peritoneal cavity, as from a recently perforated ulcer or wound,
it seems that irrigation may be useful by removing mechanically
foreign bodies Avhich have escaped from the intestinal lumen.
There is no doubt that peritonitis is much enhanced when foreign
bodies enter along with bacteria present. If the manual force of
a stream of fluid can be made to remove them before inflammation
has been set up, the irrigation may be beneficial.
Drainag'e. — The term drainage in a general sense signifies the
institution of such relations that stagnant fluids shall be made to
escape by the force of gravity. As applied to the abdominal caA'-
ity this meaning of the word must receive distinct modification.
Here the hydrostatics are much modified by the intraabdominal
pressure and the agglutinations and adhesions of the abdominal
organs to each other Avhich commonly take place in conditions de-
manding drainage. In general hydrostatics drainage demands that
the cavity containing fluid shall be opened at its lowest point. This
requirement can rarely be met in abdominal drainage. We must,
therefore, utilize the intraabdominal pressure, and other forces
that will overcome the attraction of gravitation. The problems
in drainage have been nowhere so well stated as by Yates. He
states, "If drainage of the peritoneal cavity is possible it is limited
by — 1" the time requisite to the functional seclusion of the drain
through (a) the close application of serous surfaces to the drain
and (b) its subsequent encapsulation in adhesions; and 2nd by
the physical laws governing (a) the removal of the drainage
476 THE PERITONEUM
material from the tube, and (b) the restitution (absorption) of the
capillary action of the gauze." These may be discussed under the
respective headings.
• It is interesting to note that it was J. Marion Sims who first pro-
posed drainage after laparotomy. He advised particularly the vag-
inal drain. It is interesting also to note that he referred to the
drain as a plug the purpose of which Avas to hold the edges of the
wound apart. He therefore started at a point which we have not
yet reached.
Gravity. — The rule that fluid collections shall be opened at their
lowest point can but rarely be realized neither is it of importance.
It is only when the fluid is contained in a cavity with fixed walls
that this becomes of moment. When there is a collection of fluid
in the pelvis an opening at its lowest point facilitates the escape
of its contents. For the abdominal cavity drainage at the lowest
point is but seldom striven for.
Obviously there are anatomic difficulties in the way of draining
the abdominal cavity at its lowest point. Attempts have been
made to compensate for this by so placing the patient that the
wound area would become the most dependent part of the body.
In order to reach this end the patient has been set up, turned on
his side and even completely over, belly do^^^l.
The abdominal cavity is not a vat, but a cavity containing or-
gans. The laws of physiology and not the laws of hydrostatics
are those that must be studied in attempting to solve the problem
of drainage.
Viscosity of the Fluid. — One of the fundamental reasons that the
fluid within the peritoneal cavity does not respond to the force of
gravity is because the cohesion of its several particles exerts the
greater force. When in great mass of course the bulk of the fluid
may escape, but it leaves a thin layer lying next to the peritoneum.
Since the intoxication takes place in the region of the peritoneum,
the escape of the bulk of the fluid makes little difference. In some
instances the exudate is formed by a diphtheroid membrane the re-
moval of which is difficult by manual means and is wholly uninflu-
enced by gravity.
Duration of the Drainage. — The idea of drainage assumes that
the exudate to be conducted aw^ay is in a fluid state and that there
TREATMENT OF ACUTE GENERAL PERITONITIS 47/
shall be no ineelianieal hindrance to its outflow. At the time of the
operation those conditions are met in diffuse peritonitides of sudden
onset, such as perforating ulcers, and occasionally in appendicitis.
Once the fluid comes in contact Avith the air and the viscera come
in contact "with the drainage tubes all this quickly changes. The
course the drainage process then pursues varies Avith each case.
Experimental evidence on the duration of time a drain remains
effective is of general interest only, for the conditions obtaining
clinically can not be i-eproduced in the experimental animal. In
experiments the duration varies much with the material used for
drainage and the fluid experimented with. Gauze excites adhesions
in the abdomen of a normal animal, beginning in the coui-se of an
hour or two, they are quite well walled in Avithin eight hours, so
that the drainage ceases. Murphy places the extreme limit of
efficiency at 18 hours. This author conceived the clever idea of
placing a colored gelatin solution Avithin the peritoneal caA'ity.
This substance, fluid at the body temperature, becomes solid Avhen
cooled permitting the study at leisure of the portion remaining in
the abdomen. I employed an albumin solution, both Avith and
Avithout methylene blue, of the general specific gravity of thin pus.
This substance drains less than eight hours. Animals Avhose blood
has been made incoagulable drain a longer time. In recent studies
Petrot¥ obtained results corresponding A^ery closely to my OAvn.
lie placed tampons in the abdominal cavity of rabbits. After an
hour or Iavo a solution of methylene blue Avas injected into the
peritoneal cavity. Drainage diminished after 5 or 6 hours. In all
of these experiments the fluid escaped from the Avound around the
tampon and Avas not conducted out by the gauze. In other Avords
the gauze acted only as a plug to hold the edges of the Avound apart.
Ward and Robb found drainage to he effectiA^e for twenty-four
hours and JNIcOuire placed the time at forty-eight hours. Sanger
placed the time at a day longei'. V. Gubaroff found that the drain
l^ecame enclosed in tAventy-four hours and in less tini(> if infhimma-
tion was present. Delbet found that the drain was ('()iu])K'tely en-
closed in a neomembrane in forty-eight hours. Eul)ber protectiA'e
remains effective for a much loiigfn- period, usually a day or two.
It is interesting to note that the cigarette drain \\\\h the i)i'()trud-
in.'i' tuft of gauze becomes Availed in as (iuicl\ly as docs the gauze
478 THE PERITONEUM
drain. Murphy places the limit at three days. Glass tubes re-
main patent for a longer period, being occluded by a fibrin plug
sooner or later. The manner of walling off depends on the situa-
tion. When within the range of the great omentum, it is this or-
gan that walls in the foreign body. In other situations the neigh-
boring organs accomplish this act. When in contact with solid
parenchymatous organs there is much delay. Between the liver
and diaphragm, for instance, the drainage is effective several times
as long as in the region where the great omentum can act.
Under clinical conditions the duration of drainage varies under
wide limits. The moi'e fluid the exudate, the longer the drainage
will continue, and the less capable the tissue is of reacting the
longer the drainage. In virulent streptococcic and pyocyaneus infec-
tions where all efforts at adhesion formation are nullified drainage
may continue for a long period. In very toxic states of the patient
drainage may remain unhindered for several days. On the other
hand in conditions in Avhieh the Avalling-off processes are already far
advanced the duration may be very short for adhesions form in a
few hours. Fluids rich in fibrin quickly surround the drain and
impede further outflow. When both these factors are active drain-
age may cease in half an hour. In walled-off abscess foci also the
duration is dependent on the amount and character of the exudate.
On the whole the period of drainage is less than in diffuse inflam-
mations because the factors going to limit it are active, for it was
by virtue of these that the abscess became walled off.
Mechanism of the Drain. — A gauze drain acts by its capillarity.
This function ceases as soon as the meshes of the gauze become
filled with coagulated lymph. This period is measured by hours.
After this time the drain acts as a plug serving only to keep the
edges of the wound apart, allowing drainage to take place around
the gauze. The gauze tends further to limit its usefulness by irri-
tating the surrounding tissues to form adhesions. At the same time
by irritating the edge of the wound the gauze excites an exudate
about the tid)e Avhich tends to keep the Avound open.
The tubular drain allows the fluid to flow through its lumen.
The efficiency is dependent on the size and composition of the tube
and the character of the fluid to be conducted away. The forces
operative in causing fluid to flow from the tube are gravity and
TREATMENT OF ACUTE GENERAL PERITONITIS 479
the expansion of the intraabdominal tissue, reducing the space
available for the fluid. Mikulicz Avas the first to point out the de-
pendence of tube drainage on intraabdominal pressure. Because
fluid is escaping from the tube is no evidence, however, that fluid
from the general peritoneal cavity is being conducted away. The
tube by its presence may excite an exudate which may then escape
through the tube. This is merely a reaction of the tissues about
the wound against the foreign body.
Factors Which May Aid Flow. — Theoretically anything that would
prevent the coagulation of the exudate should increase the floAV.
Wright's solution has been proposed by Crandon for this purpose.
The calcium in this solution is supposed to prevent coagulation
wdiile the hypertonic salt solution (4 per cent) is supposed to in-
crease osmosis. Whether or not this works out in practice is dif-
ficult to say. Wet dressings of any sort may prevent the pasting in
of the tube in the wound and may perform some service. Hot
moist dressings applied over a recently drained Avound probably
are the most efficient means of promoting drainage.
Dangers of the Drain. — By causing adhesions between coils of
gut the drain may foster the development of an intestinal obstruc-
tion. Gauze is more apt than other drains to produce this result.
Because of this danger the drain should be placed about the periph-
ery of the abdominal cavity whenever possible so that a loop of
gut shall not become adherent to it. The presence of a drain tends
to aid the formation of permanent adhesions and thus to leave a per-
manent disability. Placed near a line of suture or ligation by
exciting a fiow of serum away from the stitches the healing is
interfered with and the establishment of a fistula is made more
liable.
By pressure on a vessel, either in the abdominal wall or in the
walls of the organ, erosion of its walls may result and a secondary
hemorrhage ensue. Turner advises that the drainage tube should
not be left in contact with a tissue bearing on an important vessel
more than two or three days. Aside from hemorrhage, pressure of
the tube may cause inflammation of the vessel wall with throm-
bosis. This may become the starting point for any one of a number
of disasters.
Pressure of the drain against a hollow viscus may result in per-
480 THE PERITONEUM
foration. A firm siil)staiice is more apt to act this way than a
pliable one. It is this danger that mitigates strongly against the
glass drain. The erosion of vessels is most apt to occur about
the tenth day. When these firm-Avalled drains are removed in the
course of a day or two this danger does not o])tain.
The loss of the drainage tube is one of its most serious dangers.
It may slip entirely within the wound and escape. It is only by the
most rigid care that these accidents can be reduced to a minimum.
Hie Removal of the Drain. — The time for the removal of a drain
is dependent on the material used, the purpose for which it is
employed and the qualitative character of the infection. The first
two factors admit of a measure of abstract consideration but the
last must be judged in the concrete case.
The time of removal is dependent also somewhat on the material
used.
A gauze drain after a day or two becomes firmly attached to the
edges of the wound by the formation of fibrin about the gauze.
Fine processes extend into its meshes firmly fixing it to the Avound.
During the succeeding days a forci])le removal produces a consid-
erable injury. By the eighth day the granulations have devel-
oped sufficiently to destroy these fibrin bundles and the gauze is
again loosened and the removal becomes easy. Those portions of
the wound most capable of producing granulations loosen the di'ain
earliest. It is advantageous sometimes to remove that portion only
which has become loosened. Rubber drains offer no attachment
to filn-in bundles and consequently are easily removed at any time.
When allowed to remain for some time granulation tissue may
grow into fenestra and thus fix the tube. When the openings
are large a segment of gut wall may extend into them and the for-
cible removal of the tube may produce serious mischief.
Material Used. — From the foregoing it is apparent that the
agent employed for drainage is dependent upon the fundamental
purpose in view. When a purely mechanical factor to remove exu-
date is desired, a smooth substance little calculated to excite ad-
hesions is indicated. Rubber tulnng is ordinarily employed,
though glass Avas formerly extensively used and is theoretically the
better because it irritates the tissues less. When adhesions are to
be invited in order to wall in the infected area and the drainage is
TREATMENT OF ACUTE GENERAL PERITONITIS 481
but incidental, an irritating substance sucli as gauze should be
employed.
Glass Drain. — This material was first introduced loy Koeberle.
The advantage of glass lies in the fact that it is readily sterilized,
readily introduced and does not collapse and shut off the lumen.
The great disadvantage lies in its inflexibility. Because of this it
may l)e uncomfortable to the patient and may endanger some struc-
ture upon which it presses and it may become broken. For these
reasons glass is now rarely employed in abdominal surgery.
Ruhher Drain. — Chassaignac first introduced rubber tubing to
avoid the disadvantages enumerated for the glass tubes. Eubber
drainage tubes or some modifications of them are now nearly imi-
versally used when a tubular drain is required. They have the ad-
vantage of retaining their lumen, if one suited to the case at hand
be selected, and yet present a degree of flexibility sufficient to pre-
vent injury to surrounding tissue by pressure. In using a rubber
drain a size commensurate with the amount and character of the
fluid to be removed must be selected. In deep exudates as in the
pelvis or under the liver, tubes Avith a lumen of a centimeter or
more should be selected. AVhen the exudate is widely distributed
several must be employed perhaps introduced through multiple in-
cisions. AVhen the focus is small, the infection but little virulent,
as about the stump of a subacute appendix, a small drain is suffi-
cient. It should be so placed that a vessel is not pressed upon and
the tip must not come to lie too near the site of suture if there be
one in the wall of the gut. Above all it must be securely fastened
in place in order that it may not escape. Its lumen may be kept
patent by producing suction with a syringe at intervals. So long
as this act is not done with violence it may be regarded as a harm-
less procedure. Usually the tube is quickly walled in and suction
produces little that is deleterious to the patient. Small fenestra
are usually cut into the sides of the tul)e so that fluid may enter
its lumen at several points, and that its efficiency shall not be
wholly destroyed should the terminal opening become occluded.
The ideal use for the rubber drain is Avhere the amount of fluid
to be removed is large and adhesions are absent or 1)ut imperfectly
formed, and the nature of the infection is such that effectual wall-
ing off is not to be expected. The ideal use of the 1ul)e is seen in
482 THE PERITONEUM
perforating duodenal ulcers, and to a less extent in infections from
the appendix "wlien it is spreading across the pelvis to the left
iliac fossa. The tubular drain is useful Avhen there are Avell walled-
off abscesses as about the appendix. The tube remains a ready exit
for the secretion of the pyogenic membrane while the walls are col-
lapsing.
The rubber drain in some of its forms is likewise advantageous
when drainage is desired a few hours only. The advantage lies in
its smooth nonpenetrable surface Avhich does not permit it to be-
come attached to the Avound. This finds most frequent use
where a noninfected exudate may become troublesome, as Avhere
there is much oozing after separation of adhesions, or Avhere there
is a mild infection and the operator is not sure whether or not the
tissue will be able to cope with it, as often occurs in very early or
subacute appendicitis.
Many modifications of the rubber drain have been suggested.
Applying it in a direct line or spirally has often been resorted to.
Half or a fourth of the circumference of the tube has been employed
whei'e temporary drainage is desired. Peple modifies the rubl:)er
drains by placing a plicated rul)ber dam within a split rul)ber
tube.
The Cifjarcffe Drain. — An attempt to retain the advantages of
the i'ul)ber tube and secure the advantage of a gauze drain led
Kehrer to combine the two. It Avas sought to accomplish this by
enclosing a Avick of gauze in sheet rubber, making the so-called cig-
arette drain. For reasons unexplained this combination has be-
come the most popular form of drain. This is surprising because
it possesses the disadvantages of both and the advantages of
neither. The idea of its construction Avas that the capillarity of the
gauze Avould conduct fluid Avhen there Avas insufficient pressure to
force the fluid out of the tube and gravity could not be brought
into play. As a matter of fact, as usually made this capillary ac-
tion is defeated by tying a string about each end to hold the rubljer
about the gauze. Properly made, a string of gauze is Avrapped in a
sheet of rubber protective Avithout the aid of a constricting string.
If it is desired to fasten the rubber it should be done by means of
sutures taking in only the rubber tissue, alloAving the gauze to re-
main free from pressure. The character of fluid to be drained is
TREATMENT OF ACUTE GENERAL PERITONITIS 483
usually such that when it gains the meshes of the gauze it rapidly
coagulates, producing a fibrinous plug thus occluding the drain.
As ordinarily employed the so-called cigarette drain is equal in
efficiency to a sterilized corn cob, serving the sole purpose of pre-
venting an agglutination of the wound edges. It serves only as a
plug whose sole advantage lies in its ease of removal. When a
tuft of gauze is allowed to protrude from beyond the rubber cov-
ering even this advantage is forfeited.
The Gauze Drain. — A strip of gauze in an abdominal wound has
for its primary effect the removal of fluids by virtue of its: capil-
larity. The length of time this action takes is dependent upon
the character of fluid involved. The time limit may be placed
anywhere between one-half and twelve hours, Avith an average
nearer the former than the latter limit as has already been dis-
cussed. Some surgeons seek to prolong the action of the drain by
changing it at intervals. Curtis for instance recommends this pro-
cedure and he invented an instrument to facilitate the reintroduc-
tion of the gauze. I regret to note that I also invented an instru-
ment for this same purpose, albeit in my early youth. The change
of gauze is a useless annoyance to the patient since it but serves to
keep open the canal that has been formed about it, and once re-
moved there can be no excuse for its reintroduction.
Its second and most important action is secured by virtue of its
irritating properties to the peritoneal surface with which it comes
in contact. An exudate is excited by virtue of Avhich adhesions
about the gauze are produced. This tends to wall off the area
about the tube. For this reason a gauze drain should be placed
near the border line between the infected area and the noninfected
area. Adhesions form in response to the irritation from the gauze
and by this walling-in process the infection is isolated. Once this
is accomplished there is danger of removing the drain too early.
The gauze may at this time form a part of the protecting wall and,
if removed, may permit the spreading of the infection through the
defect left after its removal. Even if the gauze does not partici-
pate in the formation of the wall, its forcible removal may lacer-
ate the protecting Avail and thus permit an escape of infection.
Therefore Avhen gauze is used for the deliberate purpose of has-
tening the formation of a retaining Avall, it should be alloAved to
484 THE PERITONEUM
remain until it has begnn to separate spontaneously in the manner
already mentioned. This occurs only after the fibrin l)ands are ab-
sorbed, usually requiring from six to ten days, ^vhen the gauze can
be removed Avithout violence. It is true that after the gauze drain
has. become saturated with fibrin-forming material it becomes
merely a plug and not a drain Init it still performs a function by
keeping the edges of the incision in the abdomen from closing too
soon. During this time the deeper jDortions of the gauze may be
performing valiant service in the forming of a protecting wall.
The ideal place, therefore, for a gauze drain is where there is an
infection with a moderate exudate and a poorly limited peritoni-
tis. It is sufficient in such cases to carry off the obnoxious fluid
and to aid in forming the barrier of adhesions. It is particularly
useful about a pericholecystitis or about a recently perforated ap-
pendix.
Where there is no limitation and abundant exudation gauze
and rubber drains may be combined, for instance, in an extending
peritonitis from a ruptured appendix with much exudate. Here
a large tube in the pelvis to carry off the free fluid and a gauze
drain at the border of the infection makes the ideal combination.
The ru])ber drain is i-emoved when the extensive exudate ceases,
while the gauze is allowed to remain until the Availing off is com-
plete.
Tampon Drainage. — The protecting effect of the gauze drain
finds its maximum development in this method. The primary ob-
ject here is to stimulate the complete Avail ing-off process so de-
sirable in infections. Mikulicz first treated this problem compre-
hensiA^ely. Lennander more recently has dilated on the advan-
tages of this method. The principle iuA^olved is that Avhen an in-
fected focus is not Availed off fi'om the general peritoneal cavity
the bari-ier is completed l)y means of some artificial substance.
Since an irritating substance is required gauze is usually
selected. Organs coming in contact Avith this foreign body
become adherent to the gauze and to each other. Miku-
licz i^laced a large piece of gauze in an infected area AAdiich
was made to serA^e as a sort of sac. This sac Avas then filled
Avith strips of gauze until the desired bulk Avas obtained. The ad-
vantages of this method lay in that the gauze strips Avithin the sac
TREATMENT OF ACUTE GENERAL PERITONITIS 485
could be removed without disturbing the surrounding tissues.
The removal of the sac was facilitated by attaching a string before
introducing it to what Avas to become its lowest point. By mak-
ing traction on this string the loAvest point was removed first.
This method is not used now, but the general principles underly-
ing it should not be forgotten. The same principles have been used
in appendiceal infection lying deep in the abdomen imperfectly
surrounded by adhesions. Van Hook has developed this plan with
ideal but unnecessary completeness. An infected gall bladder may
often be surrounded in the same way with advantage.
The same procedure may ])e applied in rare instances Avhen there
is bloody oozing with or without infection, as for instance when
pus tubes are forcibly torn fi'om the floor of the pelvis, as Coffey
has recently suggested, Lennander advises the use of this method
when large areas of serosa are so damaged that continued sup-
puration is likely and when there is necrotic tissue which must
separate before healing can be completed. Mikulicz advises
tampon drainage about suture lines so that should the line give
way they are very certain to have a barrier about the gauze which
Avill conduct the infection to the exterior. The disadvantage of
this procedure, as stated elsewhere, is that the healing of the
suture line is much jeopardized by the presence of gauze and
when so used fistula is almost certain to follow. If drainage is
used it must be placed away from the line of suture.
Once a tampon drainage is applied it should be allowed to re-
main until the fibrin begins to loosen, that is, the same laws gov-
erning the removal of gauze drains must be followed.
The use of this tampon drain should be restricted as much as
possible, for since it keeps a lai'ge part of the Avound open for a
long period, thus prolonging convalescence, it is very apt to result
in a scar hernia.
The After-treatment of a Dralnafje Woioid. — After the drain
is removed the edges of the avouiuI may be in part closed by suture
if the drainage tube is removed within a day or two. After that
time the approximation of the edges of the Avound by means of ad-
hesive sti-ips is adAHsable. While this method doos not equal the
suture in efficiencA" there is less risk of enclosing an undesirable
486 THE PERITONEUM
exudate. Another great advantage of the adhesive strips is that
they can be applied without discomfort to the patient.
Fate of tJie Scar Following a Drainage Wound. — In many in-
stances the abdominal wound may close by first intention through-
out its extent except where the edges are actually held apart by
the drain. That part of the Avound occupied by the drain closes
by secondary intention. If the area kept open by the drain is
small, usually sufficient firmness of scar will be produced to pre-
vent a hernia. If the wound is large, the scar tends to become
stretched after a time and a hernia is produced. One factor in the
production of hernia therefore is the extent of wound left open by
the drain. The other important factor is the length of time the
wound is kept open. A hernia is more apt to occur after a strepto-
coccic than after a staphylococcic infection. Old persons are more
apt to develop a hernia than children and young adults.
When a Avound stretches, it usually does so in from a month to
several years, usually in from three to six months. Once it begins
to stretch it usually continues to do so. Waiting for the scar to
contract is folly.
Posture of the Patient. — In harmony Avith the dictum that all
pus cavities should be drained at their loAvest point, surgeons haA^e
sought to make the available opening the loAvest point by A^arying
the position of the patient. Obviously the logical thing to do Avas
to place the patient up-side-doAA'n. Kehrer, in harmony Avith this,
proposed that the patient be placed in the A^entral position. Unfor-
tunately patients after lying on a fresh abdominal Avound for a
time, lose their respect for logic, and begin to express a desire for
a more comfortable position. Nevertheless from time to time
other surgeons have revived for a time this position. The latest
of these is Hill. As a modification of this position Coffey recom-
mended the lateral position A\'hen the infection occupied the flanks.
Dandy and Rountree likeAA'ise recommended this position.
FoAvler advised the elcA^ation of the head and trunk in order to
facilitate drainage. Bode suggested the elcA'ated head position
about the same time. It is Avorthy to note that FoAvler adAdsed an
eleA^ation of 12 to 15 inches. The "sitting position" Avas the prod-
uct of other minds, probably on the principle that if a little Avas
good, a lot more should be better. FoAvler Avas led to place his pa-
TREATMENT OF ACUTE GENERAL PERITONITIS 487
tients in this position because lie had observed that patients placed
in bed with elevated head to lessen postoperative nausea were
marked by especial freedom from complications. It was left for
other surgeons to unearth the fallacy that absorption took place
chiefly through the diaphragm, as a reason for placing patients in
this position. I wrote in 1909 as follows: "That there are special
openings in the diaphragm making absorption here more rapid,
and that there is a stream of fluid floAving toward the diaphragm,
is one of the curious fallacies perpetuated in modern surgical lit-
erature. The stomata have finally been accorded a much deserved
oblivion, and the notions quoted above will share an equal fate as
soon as surgeons shall take the trouble to make some very simple
studies in the anatomy of the peritoneum. When this occurs the
Fowler position will have lost one of its most important func-
tions." Time evidently has produced the result that I predicted
would be derived from a more extended knoAvledge of the peri-
toneum.
The argument underlying all postural methods is that fluids flow
down hill. This is opposed l)y the counterlaw that they do not
do so when opposed by forces which resist this tendency. The ab-
dominal cavity is divided off normally into a number of cavities.
The intestinal coils act as dams to the movements of fluids and it is
only when the amount of fluid becomes great enough to flow over
these obstructions that the fluid is able to floAV out by the aid of the
force of gravity. When this force has ceased to act there is still
much fluid retained in the abdominal cavity. This is true even
of drainage in the ventral position. Intraabdominal tension is at
all times a more powerful factor than gravity in expelling fluid
from the peritoneal cavity. All these points may easily be tested
out by animal experimentation. To attempt to do so by experi-
ments on the abdominal cavity of cadavers must lead to erroneous
conclusions for the rigid gut and abdominal Avails in no Avise re-
semble the conditions in the living patient.
In the presence of inflammation the problem is much compli-
cated. In addition to the complication presented by the holloAV
organs drainage is interfered A\itli l)y the presence of adhesions.
In this regard each case is a problem in itself. On the aaIioIc pos-
ture can aid but little. What little it can aid is confined to the first
488 THE PERITONEUM
feAv hours. After that time the drainage opening becomes walled
off and nothing can escape from a distance. It is useless, therefore,
to subject the patient for days to an uncomfortable position. Im-
mediately after the incision is made, posture may aid the escape of
an excess of fluid. There still remains much in contact Avith the
peritoneal surface where the actual conflict is going on. The pa-
tient may have his shoulders raised or he may be placed on his
side if this is more comfortable, but to keep the patient in an un-
comfortable position for days is without excuse.
Management of Complications. — After an operation for peri-
tonitis phenomena develop which are unpleasant for the patient,
sometimes dangerous.
After-pain. — By after-pain we understand any discomfort the
patient may suffer after an operation. The wound in the abdomen
gives rise to pain lasting 3 to 6 hours. AVhen drains are left in the
abdomen they may add to the pain. After-pain may be controlled
by the use of morphine — a dose or two on the day of the operation
in simple cases, while in the more diffuse or sjDreading varieties
+he repeated use of an opiate is needed. It is in the use of opium
here that much difference of opinion exists. I believe it may be
used to the point of securing comfort once the cause of peritonitis
is controlled. Food should be withheld as long as opiates are being
given.
Gas. — Pain from accumulation of gas within the gut tract fur-
nishes one of the most constant phenomena of the operation. Tur-
pentine stupes are often of use, the judicious use of laxatives may
do good, their injudicious use no doubt often does harm. The con-
trol of the formation of gas by a control of the diet is better than
to try to lessen the gas with laxatives. A rule to have the boAvels
move on the second day is often a cause for gas. If the patient
is doing well, the day on which the bowels are to move is quite im-
material. Enemas may succeed in removing some of the gas.
Soap suds or turpentine enemas are most apt to be effective in gas-
eous distention. Hypophyseal extract is used in gaseous disten-
tion. It sometimes works well, but it should not be used as a rou-
tine measure; for if the object to be overcome is too great for the
stimulated contraction of the gut, harm must result.
Management of Ileus. — One of the fundamental factors adopted
TREATMENT OF ACUTE GENERAL PERITONITIS 489
by nature in the localization of an infective process is the immobi-
lization of the bowels. Coincident with the immobilization is a de-
gree of distention. This distention aids very materially in form-
ing the barrier against the advance of infective exudates. This
state is purposive and there is no better example than this of adaptive
factors in pathology. It is a common error to combat this initial
distention by means of cathartics and enemas. This preliminary
distention usually lasts from one to seven days or even more, de-
pending on the time required for the inflammatory lesion to local-
ize. One of the hardest problems the young surgeon has to de-
termine is Avhen a pathologic state begins. When a pathologic
state is hypothecated it must be determined whether the disturb-
ance is dynamic or whether there is an intestinal obstruction pres-
ent. These types must be considered separately.
Dynamic Ileus. — The dividing line between this purposive state and
the deleterious paralysis is best determined by observing the expul-
sive efforts of the stomach. Postoperative vomiting may continue for
a day but if it continues beyond this time the patient must be care-
fully observed. If vomiting ceases once and then begins again it
is an omen of grave significance. Even early recurrent vomiting with
extreme distention undoubtedly places it in the category of impend-
ing ileus. This vomiting is due to reversed peristalsis and may
be distinguished from the reflex kind seen soon after the operation
by the larger amounts vomited, and by an increased pulse rate of
softer quality and usually Avith a pallor or beginning cyanosis.
Often there is an apprehensive look.
These symptoms are due to intraintestinal stagnation and may
be distinguished from those due to absorption from the peritoneal
surface by noting the site of maximum intestinal distention. The
reflex, pui-posive distention is most pronounced about the site of
the lesion and usually corresponds to the region of greatest pain.
Usually distention due to paralysis is progressive, and involves the
whole abdomen simultaneously leading to vomiting after it has at-
tained a certain degree of development. This distention is the re-
sult of the weakening of tlie gut Avail due to a degeneration of the
muscle coats while the purposive distention is reflex in character.
The constitutional intoxication may l)e due to absorption from the
peritoneum itself or from the contents of the ]);iralyzed gnt. That
490 THE PERITONEUM
it may be due to secondary changes in the gut contents is strongly
suggested by a similar condition in intestinal obstruction in the
absence of peritonitis. The studies of Draper suggest that the
site of the genesis of the toxins is in the duodenum.
The suffering of the patient may be much augmented by the
volume of the abdominal contents. So great may be the intra-
abdominal distention that the general function of respiration is in-
terfered with. This is usually abetted by lessened power of all the
respiratory muscles. I have seen patients, particularly in childbed
fever, who seemed to have their lives pressed out by the ever in-
creasing abdominal distention. The last scene resembles that of
mediastinal tumor.
It is instructive to watch the sufferers from dynamic ileus vomit
their lives out. They vomit a large amount and then lie quiet for
a time. Suddenly, apparently Avithout Avarning, they expel an-
other large amount. This vomiting seems to be an expression of
gastric overloadiiig from contents brought back from the small
gut below by a process of reversed peristalsis. It differs from the
primary reflex vomiting in that it appears as a Avelling up of large
quantities of fluid, expelled Avithout force. At this time peristal-
tic Ava\^es may be made out.
It may be differentiated from primai'v dilatation of the stomach
by the absence of marked distention of the stomach, and from ob-
structive ileus by the manner of its onset.
Being a mechanical problem it can be soh^ed only by mechanical
means, namely by bringing about a state in Avhich the gut can rid
itself of its poison-ladened contents Avith the least effort. This im-
plies an enterotomy and it must be done before peristalsis ceases.
Once the stage of reversed peristalsis is passed an opening in the
gut does not drain, for, once the power of peristalsis has been lost,
the gut collapses a short distance from the opening and prevents
fluid from a greater distance from reaching the opening. This
can be demonstrated in animals. The animal may breathe AA'hile
the gut tract is entirely dead. Drainage to be of avail, therefore,
must be made before the stage of paralysis is reached. Often the
impending paralysis is presaged by the changed general condi-
tions noted aboA^e, namely, the changes in the pulse and cutaneous
circulation. When these appear action is demanded, for they in-
TREATMENT OF ACUTE GENERAL PERITONITIS 491
dicate that the process is beginning. The first part of the gut to
suffer is usually the terminal ileum.
Fortunately the entire gut tract does not reach the same state
simultaneously. The ileum may he paralyzed and dilated while
the jejunum may retain its power of contraction. As a matter of
fact, reversed peristalsis is often an expression of ileal paralysis
with retained power of contraction in the jejunum. This reversed
peristalsis must in a measure be purposive. If an obstruction is
produced betAveen two ligatures in a segment of gut in the ileum,
reversed peristalsis may take place in the jejunum before the re-
tained contents in the obstructed portion are allowed to reach it.
The relation of jejunum and ileum is important in indicating the
site where the drainage should be made. The jejunum is the por-
tion of the gut which retains the motive power longest.
The reason the ileum is usually the portion of the gut first to
lose its motive power is that in the majority of cases the site of
most intense inflammation is in this region of the abdomen. This
is in harmony with the expressed belief that the gut paralysis is a
toxic degeneration of the muscle cells themselves.
Even in those conditions in wliich tlie site of infection is in tlie
upper l)olly, as in the perforation of ulcers, the great omentum act-
ing as a water-shed con-'/eys the infective material to the lower por-
tion of the abdomen.
The unburdening of the gut tract hy drainage may be accom-
plished by the formation of a permanent fistula or by incision with
closure after the contents of the gut have been allowed to escape.
McCosh advised drainage with immediate closure if after evacua-
tion there is any difficulty in returning the intestines to their nor-
mal habitat. His procedure was actuated more bj^ mechanical ex-
pediency for the convenience of the operator, than for relieving the
gut. Lund deliberately planned the procedure with the purpose
in mind of unburdening the intestines. He advises an incision at
the obviously most distended portion; complete evacuation of the
gut, then suture. This plan of incision, drainage and immediate
closure of the gut is suificient only in lesser degrees of paresis. At
all times it has the disadvantage of soiling the operative area
and if the gut is dropped back an infection and secondary fistula
formation is always a possibility. When prolonged drainage is
492 THE PERITONEUM
necessary he advises suturing the most distended loop of the gut to
the aponeurosis Avith the immediate introduction of a large cathe-
ter or ghiss tube. Heidenhain on the contrary failed to secure a
ready flow so long as there Avas a tube in the gut. I believe both
methods may be combined. In the first hours the tube serves to
convey the fluid aAvay from the abdominal Avound. When the in-
itial floAv ceases the tube may be removed.
Lund believes the small gut is a more favoral:)le site for the es-
tablishment of a permanent fistula than is the cecum, for in the
event of its subsequent closure being necessary the operation is
more simple here than if the fistula opens into the cecum. Len-
nander believes that Avlien a fistula is made in the small gut at
some distance from the cecum that portion of the gut lying be-
tween the fistula and the cecum collapses and becomes involved in
a mass of adhesions making separation impossible and leading to
an ileo-cecostomy. These opinions take into account only technical
expediency, OA^erlooking entirely the more Aveighty problems above
noted. An opening in the cecum is permissible only Avhen it is
the terminal ileum that has lost its function. This usually repre-
sents a type in Avhich a mechanical obstruction has resulted from
adhesion of the gut to the site of inflammation. This type Avill be
discussed under a separate heading.
Theoretically, of course, the best point for drainage is as near
the cecum as possible so that as great an extent as possible of the
gut Avill be emptied Avhen the gut assumes its peristaltic function.
A distended portion of the gut still active must be selected. If
the opening be made in completely inactive guts the drainage Avill
fail, for a collapsed area of gut lying betAveen the ostium and the
active gut Avill pi'event drainage. Whether or not a gut is still
capable of contraction is not easy to decide. Very often the ex-
travasation of red cells from the A'essels is marked by the presence
of dark lines transA^erse to the long axis of the gut. These do not
disappear on pressure and Avhen present indicate that the portion
of the gut is very seriously affected. Again Avhen the gut is so
distended that the Avail is Avell nigh transparent one may be as-
sured that it possessed but little poAver of contraction. In the pres-
ence of a deep red color Avhieh disappears on pressure, particularly
if one can note some contraction of the gut Avail between the fin-
TRKATMENT OF ACUTE GKNKKAL PERITONITIS 493
gers, one may feel sure tliat this segment is capable of peristaltic
action.
The portion of the gut in hand may l)e approximately judged
by the rules discussed in the chapter on anatomy.
When it is possible to drain at the cecum Lennander's recommen-
dations of the formation of a permanent fecal fistula at the cecum
may be folloAved. Allaben and Reed likewise recommend this
method. This site is selected by the last named author because it
is believed to permit the introduction of fluids in the region where
they will most readily be absorbed, ([uite overlooking the funda-
mental problem.
My experience has been that to be of value enterotomy must
be done at the time of the primary operation. Done after this,
there is an increase of the distention Avhich results in paralysis, after
this drainage has l)een uniformly useless in my hands.
As a prophylactic measure against impending paralytic ileus the
procedure recommended by Kanavel may be followed. He advo-
cates continuous gastric lavage coincident with continuous hypo-
dermoclysis. Here if anywhere adrenalin should have its place.
Ohsiructive Ileus. — In some instances an actual intestinal ob-
struction exists in association Avith a peritonitis at the time of op-
eration, or it may develop after the operation has been done. Not
infrequently loops of small gut are so attached to an inflamed
gut that an actual occlusion of the lumen occurs. After the ap-
pendix has been removed a loop of gut may l)ecome adherent in
such a manner as to produce an occlusion. These conditions do
occur, but they are diagnosticated more often than they occur. If
an adherent gut is widely distended above the point of attachment
and collapsed lielow, an ()l)struction exists. If distended above and
below the point of attachment an obstruction does not exist. The
recognition of an ileus is important, but meddlesome loosening of
loops engaged in the beneficent mission of limiting the spread of
infection is meddlesome surgery. Such adhesions are often loos-
ened with the idea that they will I'cmain and cause trouble later.
There is no sueli danger. These inflammatoi-y adhesions always
loosen.
The recognition of an obstructive ileus is dependent on the dem-
494
THE PERITONEUM
onstration of stercoraceous vomiting with the absence of clinical
symptoms that would accompany a dynamic ileus.
Wlien an obstructive ileus exists the lumen must be made pat-
ent. Sometimes it is easy to loosen an adhesion. If there is an in-
flammatory mass involving a convolution of guts, it is best to do
an enterotomy, awaiting the natural course of the disease to loosen
the adhesions. Possibly a resection may be necessary later but if
so a more favorable time can be selected.
Drainage of Extraperitoneal Abscesses. — Abscesses; strictly ex-
traperitoneal are those which lie outside the parietal peritoneum.
In a clinical sense walled-off abscesses may be considered as being
extraperitoneal since they are such so far as their relation to the
free peritoneal cavity goes.
Fig. 164. — Abscess within the broad ligament drained through the vagina.
Surgeons generally recognize the importance of avoiding the peri-
toneal cavity when draining the extraperitoneal spaces, except in
abscesses of the pelvis, particularly in those of the broad ligament.
Many operators seek to drain these abscesses by alxlominal section.
The difficulty is perhaps less the failure to comprehend the general
principle than one of mistaken diagnosis. Broad ligament abscesses
are mistaken for pus tubes.
Broad ligament abscesses are the result of infection of the lower
segment of the uterine tract, hence the abscess has its chief loca-
tion at the base of the broad ligament. These are best drained by
opening lateral to the cervix, care being taken not to penetrate the
overlying peritoneum. It is only the minority of broad ligament
TREATMENT OF ACUTE GENERAL PERITONITIS
495
indurations that break down to definite abscess formation hence
solid masses are often cut into. If pus is not readily found it is
best not to continue the search too long lest a gut be perforated.
4^
Abscess 111 broad lioamsat
Fig. 165. — Abscess situated far laterally in the broa/1 ligament drained by an incision above
Poupart's ligament. (Drawing modified by Cullen.)
An isolated pocket may find the opening or at least the incision
may deplete the indurated area, thus hastening the resolution.
When the infected area lies over the body of the ischium, it may
F g. 166. — I<arge broad ligament abscess pointing both in the vagina and over Poupart's liga-
ment. These are l)est drained above if the infection is mild.
be reached Avith difficulty from below. In such instances it may
be more readily reached 1)y making the incision over the medial
half of Poupart's ligament and l)y lifting the peritoneum approach
496
THE PERITONEUM
the infected area. AVhen these abscesses become Lii-ge they point
above Poupart's ligament (Fig. 166), and may then be easily
reached as indicated above. Sometimes low pelvic infections are
rm~»L
Large otrainagi
and Qauze pacK t
cess cav'ify-
Fig. 167. — Drainage oi siLxliaphragiriatic abscess below the costal margin.
Fig. Ki8. — Subdiaphragmatic abscess drained transijlenially after the pleural space had been
obliterated by jjacking it a week with gauze.
accompanied l)y snppnration of the upper group of inguinal lymph
glands. These must not be mistaken for the extention of infec-
tions continuous from the pelvis. Perirectal abscesses of course
TREATMENT OF ACUTE GENERAL PERITONITIS 497
are readied by perianal incision. Abscesses liigh in the sigmoid
form abscesses about the rectnm, sometimes of considerable mag-
nitude. When fluctuation from the rectum can be palpated, an
opening into the gut can l)e made. Sometimes a pararectal in-
cision Avill suffice. At any I'ate transperitoneal drainage should
be avoided.
Extraperitoneal abscesses may result from appendicitis. This
may occur when the appendix is anatomically extraperitoneal or
Avhen Availed in by previous adhesions. These are readily drained
by an incision along the edge of the quadratus from the twelfth
I'ib to the crest of the ileum. These abscesses are treacherous, for
they tend to extend upward to between the liver and diaphragm
in IMorris's pouch, or into the lung. When there is an extracolonic
infection and the patient has pain on deep breathing these spaces
should be investigated. Once the infection gains the space between the
liver and diaphragm it is little likely to become limited before the coro-
nary ligament is reached. The reason for the failure of limitation is
that there is no subperitoneal connective tissue, hence adhesion
forming reactions can not take place. In such cases free drainage
should be made betAveen the liver and diaphragm (Figs. 167, 168.)
Infections about the duodenum can be more safely drained from
the side than from the front. W^hen so approached at least one
wall of the drainage tract does not endanger the peritoneum.
When the pancreas requires drainage an opening from behind
is made, but unfortunately onl}" the knowledge gained from a
median laparotomy enables the surgeon to make a diagnosis. Ab-
scesses from sloAvly perforating gastric and duodenal ulcers must
be drained transperitoneally. When there is an adhesion to the
anterior abdominal Avail the abscess may be entered Avithout open-
ing the peritoneal cavity. When it is discovered after opening the
abdomen that the abscess is Availed off but that the peritoneal cav-
ity is free aboA-o, it is safest either to pack al)out Iho al)scess
and await until adhesions haA'c formed before opening into the abscess
or to seek to reach the al)scess from some route Avhich ^vill not traA'-
erse the peritoneal cavity.
In abscess of the solid parenchymatons organs the same plan
may be folloAved.
In all such instances an nl)undant packing off \\\{]\ gauze should
498 THE PERITONEUM
be practiced. The chief service of such a gauze pack is to excite a
rapid walling off of the region represented by the gauze.
Infections resulting from infections of the soft parts Avhich ap-
proach the peritoneum may menace it in more instances if the di-
agnosis is mistaken. Infective foci in bones or in muscles may sim-
ulate intraperitoneal abscess and the unwary surgeon may seek
to open in transperitoneally.
Drainage of Intraperitoneal Walled-off Abscesses. — An abscess
which has been formed by the common adhesion of abdominal vis-
cera must be drained by some route that does not traverse any
part of the free peritoneal cavity.
When, as in an appendicitis, the abscess is walled off, there are
commonly adhesions to the anterior parietal wall. Usually an in-
cision placed widely lateral will reach the abscess without trav-
ersing the free peritoneal cavity. When the abscess lies more me-
dial the peritoneum may be lifted from above Poupart's ligament
and the abscess approached extraperitoneally from behind.
When an abscess has formed in the pelvis the result of adhesion
of gut coils and omentum about the appendix, the peritoneum may
be pushed from the pubis until the bottom of the pelvis is reached
and then the abscess opened from below. When the abscess is
large it may be opened into the rectum. Unless the abscess is Avell
defined this procedure may result in inadvertently opening into
the gut. In parous females the drainage can be most conveniently
made, of course, through the vagina.
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to Enterolvsis and Drainage of the Rectum, Jour. Am. Med. Assn., 1910,
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Bode: Eine neue Methode der Peritonealbcliandlung und Drainage bei diffuser
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TREATMENT OF ACUTE GENERAL PERITONITIS 499
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Treatment, Namely, the Elevated Head and Trunk Posture, to Facilitate
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Vermiformis, Jour. Am. Med. Assn., 1887, ix, 262.
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Deutsch. Ztschr. f. Chir., 1906, Ixxxiii, 254.
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klinische Anwendung und Anwcndbarkeit, Arch. f. Gynak., 1895, xlix,
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1886, xliii, 662.
Heidenhain : Uelier Behandlung der peritonitischen B'lutdnicksenkung niit in-
travenosen Suprarenin-Kochsalzinfusionen nebst Bemerkungen iiber Peri-
tonitisches Erbrechen, Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1908, xviii,
837.
Hertzler: The Present Status of the Treatment of DiiYuse Peritonitis, Tr. "West.
Surg. Assn., 1909, xix, 87.
Hill: Posture in Abdominal Drainage, Tr. West. Surg. Assn., 1916, xxvi, 219.
HoEHNE : Die Anwendung des 1 prozentigcn Kamf erols bei Peritonitis und
die adhasionshemmende, Wirkung desselben, Zentralbl. f. Chir., 1911, xxx-
viii, 1115.
Die Technik der anteoperativen Reizbehaudlung des Peritoneums, Zentralbl. f.
Gynak., 1911, xxxv, 1145.
Zur Frage der intraperitonealen Kampferolanwendung, Miinchen. med.
Wchnschr., 1912, lix, 871.
HoLTZ : Beitriige zur Pathologie der Darmbewegungen, Jena, 1909.
500 THE PERITONEUM
HoLTZBACii: Die iiliarmakologischen Grim dla gen fiir eine intravenose Adrenalin-
therapie l)ci dor Peritonitis, Miinchen. med. Wclinschr., 1[)11, Iviii, 1122.
Hughes: Drainage in Abdominal Surgery, Jour. Am. Med. Assn., 1892, xix,
41.
Iselin: Die Beliandlung- der eitrigen Bauclifellentzvindung mit Kochsalzspiilung
und dauernder Erwarmung des Leibes, Deutsch. Ztschr. f. Chir., 1911,
ex, 573.
Janeway: Clinical Study of Blood-pressure, New York, Applet on, 1904.
JEANNERET: De 1 'emplol de 1 'ether dans les infections peritoneales, Rev. med.
de la Suisse, Rom., 1913, xxxiii, 909.
Josue: Atherome aortique experimental par injections repetees, d 'adrenaline
dans les veines, Prcsse med., 1903, xi, 798.
Kaiser: Ueber die operativ Beliandlung der Baucliempyeme, Deutseli. Arch. f.
klin. :\Ied., 1876, xrii, 74; Deutsch. Arch. f. klin. Med., 1876, xvii, 74.
Kanavel: Continual Stomach Lavage and Continuous Hypodermoclysis in Peri-
tonitis, Persistent Vomiting with Dehydration, and Dilated Stomach with
a Desciiption of a ]\rodified Stomach Tube, Surg. Gynec. and 01)st., 1916,
xxiii, 483.
Kehrer: Kapillardrainage der Bauchhohle, Ccntralbl. f. Gynjik., 1882, vi, 33.
Koeberle: Gaz. d. hop., 1879, 150, 191, 358.
KORTE: Erfalirungen iiber die chirurgische Behandlung der allgemeinen eiterigen
Bauchfell-Entziindung, Arch. f. klin. Chir., 1892, xliv, 612.
Kroxleix: Ueber die operative Behandlung der acuten diffusen jauchig-eiterigen
Peritonitis, Arch. f. klin. Chir., 1886, xxxiii, 507.
Lennaxder: Temporare Gastrostomie bei Magen-oder Duodenalgeschwiiren,
besonders bei perforierten Geschwiiren mit gleichzeitiger Retention,
Deutsch. Ztschr. f. Chir., 1908, xcii, 297.
Lexxaxder: Uelier Drainage und iilier Bauchschnitt, besonders in Fallen von
Peritonitis, Deutsch. Ztschi-. f. Chir., 1907, xei, 1.
Leydex^: LTel)er spontane Peritonitis, Deutsch. med. Wclinschr., 1884, x, 258.
LOEB AXD Githexs: The Effect of Experimental Conditions on tlie Vascular
Lesions Produced by Adrenalin, Am. Jour. Med. Sc, 1905, n. s., cxxx,
658.
Luxd: The Value of Enterostomy in Selected Cases of Peritonitis, Jour. Am.
Med. Assn., 1903, xli, 74.
McBurxey: Septic Peritonitis Following Perforation of the Vermiform Ap-
pendix, New York Med. Jour., 1888, xvii, 719.
The Indications for Early Laparotomv in Appendicitis, Ann. Suig., IsDl. xiii,
233.
McCosir: Tlie Treatment of General Septic Peritonitis, Ann. Surg., 1897, xxv,
687.
McGuire: Drainage After Abdominal Section, with Report of Case, Virginia
Med. Month., 1893-4, xx, 160.
McMtrtry: a Case of Typhlitis, witli Doulile Perforation of the Cecum, and
Peritonitis, in which Laparotomy and Suture of the Gut were Followed
by Recovery, Jour. Am. Med. Assn., 1888, xi, 9.
Meissl: t'ber den Wert der intraveuosen Adrenalin-Kochsalzinfusionen, Wien.
klin. Wclinschr., 1908, xxi, 835.
MIKT"L1CZ: 1'i)er Laparotomie l)ei Magen und Darmperfoiatinn. Sannnl. klin.
Vortr., 1885, No. 262. (Chir., No. 83, 2307.)
I'ber die Anwendung der Antisepsis bei Laparotomien, mit liosoiiderer
Riicksicht auf die Drainage der Peritonealliohle, Arch. f. klin. Chir.,
1881, xxvi, 111.
Morestix: L'eni]iloi de 1 'ether dans les infections peritoneales, Rennes med.,
1913-14, ix, 97.
Mortox : Oil Ether Colonic .\nesthesia, Woman's Med. Jour., 1916, xxvi, 3.
TREATMENT OF ACUTE GENERAL PERITONITIS 501
Mumjieey: Tho Physiology aiul Treatment of Surgical Shock and Collapse,
Lancet, 1905, i, 696; "776; 846.
Murphy: Observations on Experimental Drainage of the Peritoneal Cavity of
Cats, Boston Med. and Surg-. Jour., 1905, clii, 34.
Treatment of Perforative Peritonitis, Ann. Surg., 190S, xlvii, S70.
Neu: tJber Infusion von Suprarenin-Koehsalzlosung, Samml. klin. Vortr., n. f.,
1911, No. 622.
Noetzel: Die Principicn der Peritonitisbeliandlung, Beitr. z. klin. Chir., 1905,
xlvi, 514.
Pearce and Stanton: Experimental Arteriosclerosis, Jour. Exper. Med., 1906,
viii, 74.
Peiser: Zur Pathologic der bakteriellon Peritonitis, nebst einem Bcitrag zur
Kenntnis der "Wirkung des Adrenalin in der B^auchhohle, Beitr. z. klin.
Chir., 1905, xlv. 111.
Peple: a New Abdominal Drain, Jour. Am. Med. Assn., 1910, liv, 1499.
Petroff: Experimentclle Beitrage zur Frage der Bauchhohlondrainage, Chir.
arch. Yeliamiuova, 1913, xxix, 195.
Ppannenstiel: Klinisehe Versuche zur Prophylaxe der Peritonitis, Verhandlung
der Deutschen Gesellschaft. f, Gynak., 1909, 1272.
PiiELiP AND Tartois: Lc lavage du peritoine avec 1 'ether dans le traitement
des peritonites aigncs, Ann. de gynec. et d'obst., 1913, 2. s., x, 689.
Pope: Some Expeiimcntal Data on theMorcstin Treatment of Peritonitis, Cali-
fornia State Jour. Med., 1915, xiii, 226.
Propping: Die Relmsche Bchandlung der Peritonitis, Deutsch. nied. Wchnschr.,
1913, xxxix, 1096.
Reed: Cecostomv and Continuous Coloclysis in General Peritonitis and Other
Conditions" Jour. Am. Med. Assn., 1909, lii, 1659.
Reichel: Beitrage zur Aetiologie und chirurgischen Tlierapie der septischen
Peritonitis, Deutsch. Ztschr. f. Chir.. 1890, xxx, 1.
Renvers: Zur Pathologic und Tlierapie der Perityphlitis, Deutscli. med.
Wchnschr., 1891, xvii, 177.
Robb: The Management of the Drainage Tube in Abdominal Surgery, Johns
Hopkins Hosp. Rep., 1890, ii, 184."
Robinson : Treatment of General Septic Peritonitis, Tr. South Surg, ami Gynec.
Assn., 1890, iii, 190.
Rothschild: Ueber die lebeusrettende ^'V'irkung der Adrenalinkochsalzinfusionen
in einem Falle peritonealer Sepsis, Miinchen. med. Wchnschr., 1908, Iv, 624.
Rubsamen: Totliche Kamjifervergiftung nach Amvendung von oftizincllem
Kampferol zur postoperativen Peritonitisprophylaxe, Zentialbl. f. Gyniik.,
1912, xxxvi, 1009.
Saliba: The Antiseptic Action of Ether in Peritoneal Infections, Jour. Am.
Med. Assn., 1916, Ixvi, 1295.
Sands: An Account of a Case in Which Recovery Took Place After Laparotomy
Had Been Performed for Septic Peritonitis Due to a Perforation of the
Vermiform Appendix, with Remarks Upon This and Allied Diseases,
New York Med. Jour., 18S8, xlvii, 197.
Sanger: Uel)cr Resection des Peritoneum Piirietale, Cong, period internat. d. sc.
med., Compt. rend., 1884, Coperh. 1S,S(), ii, sec. d. obst. et d. gynei-., 154.
Santy: Le lavage du peritoine a I 'ether (recherches experimentales) Lyon
chir., 1914, xi, 313.
Schepeljiann : Das Oel in der P.auclicliirurgie, Arrh. f. klin. Chir., 1912, xcix,
879.
Schmidt: Gnoinii peritouiti: laparatomija, izliechenie, Vrach. St. Petersburg,
1881, ii, 861; 890; Ref. Zcntralbl. f. Chir., 1882, ix, 772.
Schooler: Appendicitis Perforans, ^Nied. News, 1890, Ivii, 421.
Seelig and Joseph: On the Condition of the Vasoconstiictor Center During the
Development of Shock, Tr. West. Surg. Assn., 1915, xxv, 135.
502 THE PERITONEUM
Senn: a Plea in. Favor of Early Laparotomy for Catarrhal and Ulcerative Ap-
pendicitis, with the Report of two Cases, Jour. Am. Med. Assn., 1889,
xiii, 630.
Sims: On Ovariotomy, New York Med. Jour., 1872, xvi, 561; 1873, xvii, 360.
Starling axd Tubby: On Absorption from and Secretion into the S€rouS' Cavity,
Jour. Physiol., 1894, xvi, 140.
Stockton: The Opium Treatment of Peritonitis, Buffalo Med. Jour., 1907-8,
Lxiii, 373.
Strumpel: Heisslufthehandlung naeh Laparotomien als peristaltikanreffeiides
Mittcl, zugleich ein Beitrag- zur Verhiitung postojwrativer Peritonitis,
Deutsch. Ztschr. f. Chir., 1910, ev, 527.
Tait: Treatment of Acute Peritonitis by Abdominal Section, Lancet, 1885, i,
1102.
Tansini: Disinfezione peritoneale eoll'alcool, Reforma med., 1912, xviii, 281.
Abstr. Brit. Med. Jour., 1912, ii, Epitomie, p. 8.
Truc: Traitement chirurgical de la peritonite, Paris, Alcan, 1886.
Turner: The Abuse and Dangers of Drainage Tubes, Brit. Jour. Surg., 1916,
iii, 552.
Van Hook: The Advantages and Technique of Capillary Abdominal Drainage,
Am. Gynec. and Obst. Jour., 1896, viii, 304.
Ward : Gauze as Drainage in Abdominal and Pelvic Surgerv, Jour. Am. Med.
Assn., 1896, xxvii, 199.
Waterhouse : A Report on the Employment of Ether in Surgical Tlierapeusis.
with Special R^eference to its Use in Septic Peritonitis, Pyogenic Arthritis
and Gunshot Wounds, Brit. Med. Jour., 1915, i, 237.
Wood: The Heroic Treatment of Idiopathic Peritonitis, Boston Med. and Surg.
Journ., 1878, xcviii, 555.
Yates: An Experimental Study of the Local Effects of Peritoneal Drainage,
Surg., Gynec. and Oljst., 1905, i, 473.
CHAPTER XVIII
OPERATIONS ON THE PERITONEUM
General Principles of Peritoneal Sutures. — The fundamental fac-
tors involved in the suture of the peritoneum were discussed in the
chapter on wound healing. It is necessary here only to consider
those factors directly involved in technic, and to consider such re-
finements only as are practicable in every-day surgery.
In the surfaces it is desired to unite sulftcient irritation is pro-
duced by the injury of the needle and from the pressure of the
suture to excite a plastic exudate. It is necessary that this coapta-
tion be maintained for a time sufficient for the formation of fibrous
tissue — at least two days. If the suture holds less than this, if trac-
tion of a sufficient degree is applied, the surfaces may separate.
When there is a question of ideal asepsis, as in making anastomoses,
this period should be lengthened fourfold. When in conjunction
with coaptation a sufficient pressure is produced to check or embar-
rass the circulation, or where vessels of some magnitude are acci-
dentally or designedly included in the suture additional disturb-
ances may be produced which may make a more permanent suture
desirable. When the peritoneum is severed as in most operations
the cut edge in addition furnishes an abundant plastic exudate.
Simple puncture and ordinary pressure is not sufficient in plications,
as in the shortening of the round ligaments to produce adhesion of
the deeper structures. Here the structures beneath must be exposed
to direct union or if the peritoneum is included pressure must be
made by a sufficiently permanent suture so that the peritoneum
will be destroyed and thus permit the supporting structure to come
in apposition secondarily.
The requirements of technic involving the peritoneum are con-
siderably more diversified than is required in the skin. In the lat-
ter simple coaptation is all that is required. In the peritoneum
the coaptation must be all that a skin suture needs to be and often
much more. In parietal incision the only requirement is a coapta-
503
504 THE PERITONEUM
tion sufficient to exclude adhesion to mobile intraabdominal organs
and resembles in principles a simple skin suture. In cases where
anastomoses of hollow organs are made the suture must be more
secure in order to prevent the escape of the contents of the viscus.
When adhesions are to be severed yet another factor enters.
Material Used. — Material suitable for suturing peritoneal surfaces
must be of sufficient durability to permit healing, as above indi-
cated, under the varying conditions found in the abdomen, and it
must be sterilizable. Two general classes only need be considered,
the absorbable and the permanent. Of the former catgut alone is to
be considered, while in the latter class silk and linen must receive
consideration.
Catgut. — As now prepared catgut is sterile. The question only
arises as to the best manner of preparation for the use in the peri-
toneum. Plain catgut is too ephemei-al to warrant its use in the
peritoneum. It lasts at most not more tlum two or three days and
even more quickly than this it becomes so attenuated that it no
longer acts as an efficient coapting agent. Of the various harden-
ing processes those giving the least irritant to the surrounding tissues
are j^referable. The pyoctanin guts are little initating aiul in situa-
tions where tlie wound receives other support as when fascia is
closed over it or where flaps as after adhesions are to be united,
is efficient. Chromic gut is more irritating but more durable and
in the smaller sizes 0 or 00 makes a desirable material for perito-
neal plastic operations. Iodized gut because of its irritating ac-
tion tends to produce wide adhesions and is not to be considered.
]\Iany surgeons use catgut throughout foi' anastomoses of hollow
viscera and if prepared so that it remains the necessary length of
time it no doubt is the ideal suture.
Linen. — Linen especially when impregnated with celluloid,
makes a desirable material. It is more pleasant to use than silk
but can not be had in sizes as fine as should be employed. It
should not lie rel)oiled l)ecause it tends to become fragile.
SilJi. — Sill< makes the most desirable material for routine use
and can be had in tine sizes. It is strong and is readily sterilized
if sufficient car-e is used. One ol)je('ti()n to sill\ is that it does not
slip readil>' llii'ougli the tissues. This ol)jection is overcome in
great measui'o by not using umuM'essai'ily long sti'ands and ])y pre-
OPEKATTOXS OX Till': i'i:i?i'roxKT":M nOf)
venting any kink in 12,-. Another objection to the general nse of silk
is the likelihood of its becoming infected. Kochev has well said
that to nse silk successfnlly one mnst be a master of asceptic tech-
nic. The chief objection is that it remains too long in the tissues.
When a silk sntnre is nsed it becomes covered by a plastic exudate.
This exudate forms the new peritoneum over the line of suture
and covers in the permanent suture. The tissue Avithin the grasp
of the ligature ])ecomes destroyed l)y a process of pressure ne-
crosis and gradually works its way into tlie lumen of the gut. This
means that an infected tract must extend to the suture. When a
running suture is employed this extrusion of the ligature requires
a considerable length of time, at least a number of Aveeks, and dur
ing this process healing can not be completed. This invites an ul-
timate extended cicatricial ring but chief of all is that an exten-
sive induration may take place about the line of suture which may
form a thick mass resembling a carcinoma in feel and may l)e so
extensive as to occlude the anastomotic ostium. I have lost two
patients from this cause. There is another objection hitherto not
recorded so far as I know. The minute abscesses about the silk ad-
mits bacteria to the general circulation and distressing arthri-
tides may begin at the time this process is active. These clear up
in time but are the subject of intense distress during this progress.
Though the classes above noted involve the same underlying
principle above discussed, the differences in technic are such that
they must receive separate consideration.
The Closure of Peritoneal Incisions. — The fundamental problem
in the closure in any incision through the peritoneum is to secure
coaptation of surfaces and prevent the severed edges from pre-
senting within the abdomen and thus to invite adhesions with the
omentum or other structures. This end is best assured by invert-
ing the edges so that the severed edge will present externally into
the wound and become buried between the muscle layers Avhen these
are coapted (Fig. 169). This may be accomplished by a Lembert
or mattress stitch done from the opposite surface fi-om that from
Avhich it is usually done. The suture must be firm enough to pre-
vent gapping when the elasticity of the elastic layer has been in
play for some time. The importance of this can be readily deter-
mined by opening the abdomen of animals after varying intervals
506
THE PERITONEUM
following the operation. One will be astonished at the imperfect
coaption revealed after a day or two. Because of the elasticity of
the subsera and the disposition of the catgut to elongate when
softened by the tissues the line of union relaxed and raw edges be-
A
Fig. 169. — The suture begins by including the recti muscles. A running suture coapts the
peritoneal surfaces, everting the edges between the muscle layers.
come inverted into the abdominal cavity inviting adhesions to
surrounding viscera.
In order to prevent this inversion tlie suture must be so placed
that the edge is held up by the entire line of suture. When so
OPERATIONS ON THE PERITONEUM 507
applied the cut edge can not become everted unless the suture gives
way. This result can not be secured when the usual over-and-
over running suture is employed.
The suture best employed is one that retains its tensile strength
for five or six days. Silk in small sizes would be the ideal suture
were it not that it remains permanently in the tissues and should
infection occur would be a source of great annoyance. The more
ephemeral forms of catgut are objectionable because they may dis-
appear too early. Midway between these two is pyoctanin or
chromic catgut. The smallest sizes are sufficiently strong and
cause less irritation than the larger ones. No. 0 pyoctanin or
No. 00 ten-day chromic are the most satisfactory sizes.
Because of the elasticity of the peritoneum in the loAver median
incision an uninterrupted (continuous) suture retracts the ends of
the incision producing a puckered rather than a linear one and if
this retraction continues after the suture is tied, relaxation of the su-
ture line takes place permitting the cut edges to reach the intraperi-
toneal cavity even though the Lembert suture has been used. Were
it not that the interrupted suture requires more time this would be
the ideal suture. Some of the advantages of the interrupted suture
may be obtained without undue loss of time by back-stitching,
which fixes the suture every few centimeters. Eelaxation may be
further prevented by fastening the suture to the overlying fascia
at either end of the incision. This may be accomplished by pass-
ing the suture through the muscle or fascia or l)y tying in with the
sutures of the overlying areas (Fig. 170). This maneuver has the
additional advantage of preventing the formation of a dead space
in the region of the pubes.
In those regions Avhere the peritoneum is A'ery intimately at-
tached to the fascia and there is much tension as in the upper ab-
domen of fat persons, a staple or mattress suture including both
fascia and peritoneum is often the best. A medium-sized chromic
gut of greater durability should be employed when this plan is
folloAved.
Suture in Hollow Viscera. — In the suture of hollow viscera
whether for the repair of wounds or for the formation of permanent
ostia between neighboring organs, the principles are the same. In
addition to the general principles laid down for parietal sutures
508
THE PERITONEUM
here several factors are added. While in pai'ietal sutures close
coaptation of the edges is desirable here it is imperative lest the
general peritoneal cavity become infected from material within
the organs sutured. Fortunately the environment is such that the
Fig. 170. — After the entire jieritoneum has been closed as in Fig. 169, the same suture con-
tinues baclc, coapting the muscles to the point of beginning.
more peimanent sutui-es may be used A\itliout objection. In addi-
tion a protective line of sutures is usually employed.
This preliminary line was first used by Czerny and bears his
name. It may include the cut edge of the mucosa only, the mucosa
OPERATIONS ON THE PERITONEUM 509
and muscularis or each of these layers may be united by a separate
line of sutures. Aside from protecting the peritoneal sutures from
infection they serve as hemostatic sutures as well.
The exact method of securing apposition of the peritoneal sur-
faces is immaterial. The classic method is that first employed by
Lembert. This and the mattress sutures introduced by Gushing
are those most generally employed.
While continuous sutures are noAv most generally used because
of convenience, the interrupted suture is theoretically most correct.
Running sutures all have the objection that as the tissues relax
the sutures become correspondingly less secure. Fortunately the
reactive infiltration of the tissues usually is sufficient to take up
this slack. If long lines of continuous sutures are employed the
line should be secured by interlocking sutures.
While the Lembert type of sutures is said to include only the
peritoneal layer, the peritoneal suture is too delicate to Avithstand
possible traction. For this reason the suture must be deep enough
to include the submucosa as "well, as practiced by Halsted, in order
to secure the firm attachment offered l)y this resistant tissue.
Because of the proximity of this suture line to the lumen of the
hollow viscera a neAv problem presents itself. The gut contents
may quickly al)sorb a catgut suture making the suture line inse-
cure in a surprisingly short time. The softer catgut will disappear
from the stomach or upper gut Avail in a day or two (in dogs)
exposing the deeper sutures to the action of the intestinal juices.
The harder varieties of gut withstand digestion for a number of
days, usually long enough to permit the peritoneal apposition to
advance well along to fibrous union.
The outer layer of sutures, that apposing the peritoneal sutures,
is the one depended on to prevent leakage while holding the ap-
posed surface in a position calculated to secure the most certain
union. If all goes well and there is no interference Avitli healing,
catgut will maintain this apposition for a sufficient length of time.
Should any factor develoi? Avhich delays this union the gut may
disappear before healing is sufficiently advanced to prevent leak-
age. Because of this possibility most operators prefer silk for this
layer. Nor is there any objection to the use of this material such
as was advanced against its employment in the parietal peritoneum.
510
THE PERITONEUM
The reason for this is that the silk does not remain permanently
imbedded in the tissues, but is extruded into the lumen of the gut
and is thrown off. This expulsion may take place in an astonish-
ingly short time, often as early as 10 days after the suture is placed.
Theoreticall}^ it should be possible for silk to become imbedded
'in the line of suture. This Avould demand that they be placed in
an aseptic field. This obviously is not possible in such close prox-
imity to the lumen of the gut. At any rate I have sectioned many
Fig. 171. — Adhesions between sigmoid and broad ligament and between rectum and uterus.
There is an intraligamentous cyst on the right side.
guts that were sutured and have never discovered any imbedded
silk. Even when two gut surfaces are united without making
opening into the gut the silk is expelled into the gut.
Suture of Adhesions. — The general principles here are the same as
those indicated for incision in the parietal peritoneum — the cut edges
must be everted from the general peritoneal cavity. Here the problem
is concerned chiefly with securing sufficient tissue to cover the denuded
area or to the gaining access to the region requiring suture. Where
OPERATIONS ON THE PERITONEUM
511
there are broad surfaces to unite frequently sufficient tissue is not
always available. As already noted in the section in the preven-
tion of adhesions, this difficulty may in a measure be anticipated
by cutting the adhesions with the same deliberate planning as is
exercised in making a skin flap in amputations (Figs. 171, 172, and
173). It is comparable to an amputation in which both proximal
and distal stumps are covered with skin. Such adhesions are
often seen about the gall bladder and particularly about the
ovaries and tubes.
l-'ig. 172. — The adhesions in Fig. 171 are so incised as to permit a covering of the denuded
area after the operation is completed.
The difficulty in such cases is that the peritoneum when cut tends
to retract so that difficulty is experienced in finding the edges one
wants to unite. This predicament may be obviated by fastening
these edges with forceps as they are cut. They can then be readily
identified when it comes time to apply tlie sutures.
When there is a single plane of tissue as when the omentum is
attached to some surface it is best managed by rolling the cut edge
512
THE PERITONEUM
in the folds of the peritoneum and fastening it there ^ith sutures.
If the adhesion contains large vessels, as in the omentum, they must
be first ligated.
Covering by Transplant. — AVhen two surfaces are broadly at-
tached there may not be sufficient peritoneum to cover either or
both surfaces. If it is possible to cover Ijut one surface, Avhen pos-
sible that surface is elected for repair Avhich demands the greatest
degree of mobility in performing its function. For instance, when
Fig. 173. — The adhesions severed in Fig. 172 have Ijcen united by Lenibcrt sutures.
a gut is attached to the parietal peritoneum sufficient parietal peri-
toneum is dissected off to cover the denuded area. The surface so
denuded on the parietal wall may be covered by mobilizing perito-
neum in the immediate vicinity, or from a distance. The same prob-
lem offers itself when there are gut adhesions to the broad liga-
ment. Sometimes there is not sufficient peritoneum available to
cover either denuded surface as when a loop of gut is broadly
attached to the uterus.
In such an event when the denuded area is too extensive to be
OPERATIONS ON THE PERITONEUM
513
closed by direct suture over the gut surface a flap may be formed
from one leaf of the mesentery according to a method developed by
Richardson. This same plan may be employed even more effec-
tively in case of the ascending or descending colon by mobilizing
the parietal peritoneum.
The most obvious tissue available for the repair of defects in
the peritoneum is the great omentum. Senn first employed this
structure for this purpose. His plan Avas to draw a convenient tip
Fig. 174. — The peritoneum is incised separately in order to secure the necessary tissue for
covering the denuded area.
of omentum to the re-iion involved ami fix it there Avith sutures.
The use of this method is made more or less hazardous by the fact
that organs may be unduly fixed or loops of gut may become en-
tangled in the loop of omentum so formed. This method is applica-
ble only Avhen the denuded ai'ca is somewhere near the root of the
omentum. One Mould hardly care to risk its use for instance on
the fundus of the uterus.
514
THE PERITONEUM
The use of the omentum in this manner is particularly desirable
Avhere there is disturbance of nutrition of the organ M'hose sur-
face is denuded. On the whole omental grafts have but a limited
use in the prevention of adhesions.
The use of detached omental gi-afts would seem to avoid the
objections above enumerated and yet make an ideal covering. But
a new difficulty arises: A detached lut of omentum partakes of
the reaction of the environment to which it is carried and bv add-
Fig. 175. — The flap planned in Fig. 174 on being closed.
ing to the exudate actually aids in inciting adhesions. It is only
when a denuded surface is likely to l)e particularly pernicious that
one is justified in making an omental transplant.
The Removal of Extraperitoneal Organs. — When organs lying
extraperitoneally are to be removed transperitoneally it is desir-
able to plan the flaps to cover all denuded areas before the opera-
tion is begiui. By so planning the entire operative field may be
comiDletely covered and adhesions most certainly avoided. The
OPERATIONS OX THE PERITONEUM 515
removal of tumors, and particularly of the uterus and liysterec-
tomy presents the most frequent opportunity^ to exercise this tech-
nic (Figs. 174 and 175).
The Suturing' of Solid Viscera. — The solid parenchymatous or-
gans require suturing when injured. Because of the delicacy of
the peritoneum in this situation it offers little resistance to the
suture lines. For this reason suture material of large diameter is
employed and often this is reinforced by placing some foreign
material on the surface of the organ in order to keep the suture from
cutting through. IMagnesium plates or gauze are most frequently used
for this purpose. Because of the density of the subperitoneal tissue
inversion of the edges of the peritoneum is never possible and the
surgeon must be satisfied with simple coaptation.
II
\
PART II
CHAPTER XIX
APPENDICITIS
APPENDICEAL PERITONITIS
Affections of the appendix serve as the most frequent starting
point of peritonitis. About this small organ the entire chapter of
etiology and pathology, if we knew enough, could be written. De-
spite the vast amount of literature that has been written, our knowl-
edge is still very elementary from both a theoretic and a practical
standpoint.
Historical. — BetAveen the time of IMelier and Fitz, a period of
some fifty years, a large number of papers appeared Avhich exhibit
a long series of side-stepping hardly paralleled in medicine. Nu-
merous papers appeared which seemed clearly demonstrative of
the truth, Init the rank and file of the profession remained obliv-
ious to their significance. A brief mention of a few of these may
be permitted.
Melier Avas the first man to make a general statement as to the
pi'obable frequency of disease arising in the appendix. His idea
of the pathogenesis was that the appendix became gradually dis-
tended with fecal matter until it became inflamed and gangrenous.
He records five cases. He correctly interpreted the recurring type,
and even suggested the possibility of operative treatment. It
seems that the clear presentation of this author would have led
to a ready acceptance of the facts. In this instance, as so often
happens in medicine, progress was blocked by one of the ablest
men of the time. Dupuytren would have nothing of the new idea.
He insisted that the peculiar conformation of the intestine in the
right iliac fossa, and the fact that the intestinal contents changed
in their character, accounted for the frequent abscesses in this
516
APPENDICITIS 517
region. Then followed a long period of floundering. Goldbeck
introduced the term periiyplditis, about which so much contention
followed. The clinical symptoms of localized tumor and abscess
were admirably Avorked out, but little appeared which shed light
on the true nature of the disease. Bright and Addison noted that
the appendix was often found in these abscesses, and that its ex-
tremity Avas often i^erforated; but because the cecum was itself
inflamed they concluded that the appendix had little to do -with the
origin of the disease. They correctly noted, however, the impor-
tance of fecal concretions in the appendix. These authors possessed
an astonishingly clear conception of the general principles of treat-
ment. He drew a parallel l)etween a broken leg and the inflamed
peritoneum. He notes that to compel the fracture patient to at-
tempt to walk Avould be as reasonable as to force a boAvel movement
in peritonitis. He insisted that perityphlitis was secondary to in-
flammations of the appendix. He was the flrst to note that the
disease may terminate without suppuration. Lewis tabulated forty-
seven cases. He notes the variation in size of the lumen, and the
possibility of an obliterating inflammation occurring. Ev^n so
early in the history of the disease appendiceal involvement was
already exaggerated. In 300 autopsies With found the appendix
diseased in 110. His paper emphasized the importance of the ap-
pendix as the etiologic factor in appendicitis. The papers already
quoted furnish a suitable background for the contribution that
finally awakened the profession. Fitz, in a series of papers, em-
phasized the fact that the cecum was intact while the appendix
was ulcerated and perforated. These statements shoAved clearly
that the old term ''perityphlitis" was misleading. But he did
more. He introduced the new name appendicitis, which, though a
hybrid, served to fix the attention upon the organ at fault by means
of two terms very easily eompi'chended by the profession. It must be
noted that the impression these papers made on the profession
v.'as due in part to the readiness of American surgeons to put
into practice the ideas of treatment suggested by Fitz. It was also
Fitz Avho first noted the true relation of the appendix to abdominal
infections, and presented the fundamental dictum that peritoneal
inflammations could be dealt Avith successfully only Avhen they
Avere localized. This made it imperatiA'e that the point of depar-
518 THE PERITONEUM
tore of such inflammations and the study of their cardinal symp-
toms be developed to the utmost.
Following Fitz came a stupendous mass of literature which
served gradually to clarify both the pathology and the symptom-
atology of appendicitis. The important part of this literature is
so recent that the proper place for its consideration is in the review
of our present clinical resources. History here merges into current
events.
The few milestones here indicated serve only as a starting point
for the student of history. More extended presentations will be
found in Kellj^ and Sprengel. The former contains a select, the
latter a complete bibliography.
Etiology
The etiology of appendicitis concerns ,us here only in so far
as it involves the peritoneum. Nearly all aifections of this
organ do involve its peritoneal covering ; and its inflammations at-
tain clinical dignit.y only because they cause gross changes about
it. The whole range of appendicitis falls almost entirely, there-
fore, within the realm of peritonitis. Certainly there is no other
process which so often gives rise to peritonitis. Therefore, from
the practical standpoint the appendix is the very center of interest
to the student of peritonitis. A somewhat careful study of the few
facts kno^\^l relative to etiology helps materially in comprehending
the pathogenesis.
Heredity. — Appendicitis like glandular diseases seems to have
a pi'edilection for certain families. Forsehheimer records a family
of fifty-two members, representing three generations, of whom 17
per cent had appendicitis, and another in which five out of twenty-
five members were affected. Giertz mentioned numerous instances
in which a parent and two ehiklren Avere affected. Albarran re-
ports four cases in one family, and Treves cites one family in which
there were five eases. I can duplicate in my own experience the
number of cases of each of the last two writers. I have had one
family in which a sister and four brothers were operated on by me
in the acute attack ; and another brother has had three attacks,
but has not been operated on. In another family, four were oper-
APPENDICITIS 519
ated on by me in the acute attack, and a fifth member was oper-
ated on by a colleague.
Families in Avhich tonsillar disease is prevalent are more apt to
be affected l)y appendicitis. Tuffier believed that a hereditary de-
formity of the appendix might play a part, and Delbert believed
that a general digestive predisposition might be a predisposing
factor.
Ag-e. — Nearly all authors are agreed that appendicitis most often
affects persons between the ages of ten and thirty years. Probably
more than 50 per cent of cases occur in this period. KrOgius, for
instance, presents the following percentages as to ages: 0 to 10
years, 2 per cent; 11 to 30 years, 36 per cent; 31 to 40 years, 16
per cent; 41 to 60 years, 16 per cent; above 60 years, 8 per cent.
These statistics give a greater percentage to middle and later life
than comes to the experience of most surgeons. Nearer the aver-
age experience are Gullstadt's figures: below 15 years, 15 per cent;
between 15 and 30 years, 57 per cent. Albu's statistics, on the
contrary, give too low a percentage to advanced life. He found
only 8 per cent after the age of 30 years. Nothnagel in the col-
lected statistics of 954 cases had 306 between 11 and 20 years, and
323 between 21 and 30 years. Giertz gives statistics that seem to
be representative. Of 533 cases, in 42 the patient was less than
10 years old; in 329 between 11 and 30 years; in 81 between 31
and 40 years ; in 33 between 41 and 50 years ; in 22 betAveen 51 and
60 years; and in 6 above 60 years old. This series is particularly
trustworthy because it includes only the cases in which suppura-
tion occurred. In ''interval" and "chronic" cases there is often
uncertainty about the diagnosis, even after a microscopic examina-
tion has been made.
The statistics above quoted are sufficient to indicate the great
preponderance in young adult life. Why young persons are most
frequently attacked is not known. The most plausible theory is
that at this age the entire lymphatic apparatus is more often in-
volved in inflammatory affections, and since the appendix is made
up largely of lymphoid tissue, it naturally shares the same fate.
To say that the appendix is longer and larger in young persons
proportionately is but restating the same thing.
Sex. — The general impression prevails that tlie male is more fre-
520 THE PERITONEUM
quently affected than the female. This is particularly true when
the suppurative type is considered. Krogius, hoAvever, gives 27 per
cent males to 28 per cent females. If careful histologic examination
is made of appendices coming to any laboratory, I dare say a
greater number removed from females will test the ingenuity of
the pathologist to confirm the diagnosis. In my own cases, in per-
sons over twelve years of age, 90 per cent of suppurating cases
have been in males. In children below 12 years of age there has
been a preponderance of girls. Many authors find a much less
marked discrepancy. Hansen had 156 males to 105 females. Riedel
had 955 males to 577 females. Of Albu's acute cases, 61 per cent
Avere males. Giertz had 321 males to 212 females in the suppura-
tive cases. In children, in his statistics, females predominated,—
54 per cent to 46 per cent males.
The cause of preponderance in males has had no explanation
save that in females a collateral circulation through the appen-
diculo-ovarian ligament exists. This is certainly an ingenuous ex-
planation, since the existence of such a vascular connection between
these organs is by no means certain in the vast majority of cases.
Occupation. — Giertz classifies his 533 cases according to employ-
ment. Of 311 patients Avho followed physical occupations 56 per
cent were males and 44 per cent females. Of those not engaged in
physical labor, 76.4 per cent were males and 24.6 per cent females.
Diet. — To meat diet has been ascribed an influence by many
writers, notably by Lucas-Championniere, Kiimmel, and Flesch.
As evidence of the influence of meat on the causation of appen-
dicitis its rarity among A'egetarian peoples is noted. Thus Naab
found this disease rare in the Turkish army, and Prolss found no
cases in the natives of East Africa.
Trauma. — The relation of trauma to appendicitis formerly had
but an academic interest. Since industrial accident insurance is
becoming constantly more widespread trauma assumes a very vital
practical interest, and it becomes necessary to form some general
plan by which the problems presenting themselves may be solved.
Trauma that may incite an acute appendicitis may be caused by
a bloAV from without; by striking the abdomen against some ol)-
ject; by a sudden jar, subjecting the al)dominal contents to sudden
violent movements, either by striking a remote part of the body,
APPENDICITIS 521
as in falling on the feet or buttocks, or by a sudden increase of
intraabdominal pressure, as in warding off a blow. Certain authors,
notably Watzold, include as traumatic causes those induced by the
irritation of foreign bodies that have been swallowed. These are
readily separated from the first class, since they obviously do not
readily involve responsibility in industrial insurance. Copland was
the first to report a case of appendicitis due to trauma. Whether
or not it is possible to produce an appendicitis in a normal appen-
dix by a blow is difficult to determine. Haist denies any influence.
Nothnagel, Sonnenburg and Sprengel do not believe that it can do
so, Avhile Cassanello and Neumann believed that it might do so.
In order that trauma shall be ascribed any etiologic importance
the symptoms must begin in the first 48 hours, according to Son-
nenburg, and Jeanbrau and Aglanda. Sonnenburg notes that there
is no relation between the severity' of the trauma and the extent of
the disease. In collected statistics Giertz notes that in 10,888
eases of appendicitis trauma was operative in 410 cases. In his
own statistics of 533 cases, trauma was assigned as the cause in
only 4 cases. In the recorded statistics there is a wide variation
between the estimate of Hawkins, with 54 per cent, and Ebner Avith
only 8 per cent. Here again Sonnenburg 's opinion is worth noting,
since he was dealing with the problem in a country where indus-
trial insurance had already long been in operation. Of 3,480 cases
he ascribes an etiologic influence to trauma in 1.5 per cent of the
cases.
It is necessary to differentiate cases in which the first symp-
toms of the disease immediately followed trauma from cases in
which an existent disease was aggravated by trauma or a renewed
attack apparently was precipitated. We may compare these cases
with those in which a sclerosed artery of the brain gives way after
a relatively slight traumatism.
In my own experience in only two cases was there an immedi-
ate onset of symptoms following ti-auma in patients previously
free from the disease. One of these was in a girl of nine years
struck by a thrown ball, the other in a boy of sixteen struck by a
comrade's knee in a game of football. I have had numerous cases
in which trauma was alleged to have been operative. The most
of these cases either carried liability insurance or desired to secure
522 THE PERITONEUM
indemnity from a corporation by which they were employed. In
most of these the very existence of trauma was not established.
These factors complicate the problem, for it is well known that
A^ery extensive visceral lacerations may be produced by injuries
that leave no external mark of injury. The manner of statement
and the alleged character of the injury are the only guide in such
instances. Among the more flagrant of the simulant cases are
those in which local pain is the only evidence of the existence of
appendicitis, with an absence of all the cardinal symptoms. If
joined to this the individual is overanxious for surgical treat-
ment he may safely be stamped as a malingerer.
The relation of trauma to recurrent attacks is problematic as a
general proposition. Fink looks on them as mere coincidences.
It is easy to conceive, however, that an appendix recently recov-
ered from an attack might be more readily set into renewed activ-
ity than would a normal appendix. The nature of the trauma and
the time of onset may throw some light on the probability, though
in general the surgeon will be obliged to accept the patient's state-
ment, at least as to the existence of trauma. In those instances in
which there is a fecal concretion in the appendix trauma may be
conceived as being more likely to stimulate mischief than one in
which there is no foreign body.
The question of the exaggeration of an existing appendicitis by
trauma is more clear. I have seen several such cases. In one case
a man, aged 46, who had successfully passed through the localiz-
ing process was thrown to the floor l)y the breaking of the cot on
which he lay. The effort to rescue himself was immediately fol-
lowed by a sharp pain in the abdomen. Laparotomy, undertaken
tAvelve hours later, failed to check a rapidly extending peritonitis.
In another instance the transportation of a patient a considerable
distance soon after apparent recovery, was followed by abscess
formation. This may have occurred under rest in bed, but renewed
pain set in during the journey. I have seen rapid extension follow
manipulation by a too enthusiastic osteopath in two cases.
Appendicitis in an irreducible hernia is not an uncommon occur-
rence. I saw one such case in Avhicli a suppurative appendix was
associated with volvulus of the cecum in an irreducible hernia.
In such cases the additional tax on the circulation produced by
APPENDICITIS 523
the displacement may well be considered as making the organ more
vulneral^le to injury.
Fecal Concretions. — No other factor in etiology presents so much
tangible evidence as inspissated fecal masses in the appendix. In
the perforative type particularly, it is common to find such a con-
cretion free in the peritoneal cavity or yet remaining in the lumen
of the appendix. A study of this condition gives us a lietter notion
of the genesis of general peritonitis than any other. In 400 autopsies
Kibbert found concretions in 10 per cent, and in only one of them
was there a perforation.
Concretions are found relatively with much greater frequency
in acute suppurative or perforative appendicitis than in the sim-
pler types. Sprengel has collected a large series of cases, and
fecal concretions were found in about 40 per cent of them. Among
these may be noted Fitz's 100 cases, in 47 of Avhich concretions
were found, and Murphy's 30 per cent in 141 cases. The associa-
tion is much more constant in the perforative than in the simple
cases. The conclusion draAvn by Sprengel is that those in which
there is a concretion are much more liable to perforation, and
it may be added, are much more apt to be followed by an unlimited
peritonitis. Whether or not previous simple attacks predispose
to the formation of fecal concretions is a question Avhich, it seems
to me, may receive an affirmative answer. In most cases in which
a fecal concretion is discovered a history of previous attacks may
be obtained. Since, according to Sprengel, in 85 per cent of the
perforative type a concretion is found, the conclusion would seem
warranted that the concretion was formed subsequent to a mild
attack of appendicitis. This may account for the relatively less
common occurrence of concretions at the present time, assuming
that not a sufficient number of attacks to develop a concretion
are allowed to take place before the organ is removed.
Foreig'n Bodies. — In the early period of the study of appendici-
tis foreign bodies were frequently described, due to mistaking fecal
concretions for cherry and grape or other seeds. Other foreign
bodies have repeatedly been noted, such as pins, fishbones, shot,
and small bullets. ]\Iitchell has made a collective report of such
cases, and Kelly has extended the list. Dawbarn and others have
reported a number of cases in ^'hich fishbones Avere found. In-
524 THE PERITONEUM
testinal parasites have been noted. Sprengel has published a list
of such reports.
General Infections. — The association of acute appendicitis and
other infections has often been observed by surgeons. A tonsillitis
followed in a few days by appendicitis is of relatively common
occurrence.
The relation of rheumatism and appendicitis is less generally
recognized. Finney reported three cases in which rheumatism was
associated with appendicitis. In the light of our present knowl-
edge it would probably be more nearly correct to speak of infec-
tive arthritis associated with appendicitis. I have seen a scar-
latiniform eruption follow appendicitis in which there was a septic
mesenteric thrombosis. The frequent association of gall-bladder
disease has been assumed in many cases but less often proved.
La grippe likcAHse may precede appendicitis. To accept merely
a clinical diagnosis, however, I believe is unwarranted, since not
infrequently in this disease many of the early symptoms correspond
to those of appendicitis, but the subsequent course makes such an
involvement unlikely. The demonstration of an actual disease of
the appendix during an attack of la grippe may be taken as an
indication of relationship, but of course the actual demonstration
of the influenza bacillus is required for final proof.
Pathogenesis
In view of what has already been said about the general patho-
genesis of peritonitis it is necessary in this place to call attention
to those points which have specific application to the appendix
only. We are here less concerned about the primary source of
the infective process in the appendix, since that has been discussed
in the section on etiology, than aliout the process by Avhich the in-
flammation reaches the surface of this organ, once it has begun.
The chief discussion centers about the processes involved in the ex-
tension of the infection to the surrounding peritoneum. In every
appendiceal inflammation recognizable clinically, this organ's own
peritoneal covering is involved in a reactive process by direct
extension, otherwise the condition could not l)e diagnosticated.
The problem involves the establishment of general laws from
a series of observations. From the determination of the stage of
APPENDICITIS ■ 525
the disease 'from the clinical history we obtain an idea of how long
a time was required for a certain anatomic state to be reached.
By comparing a large series a fair knowledge of the pathology as a
sequential process is arrived at.
In all cases there is more or less involvement of the various
coats of the organ which finds expression in round-celled infiltra
tion, edema, and fibrinous exudation. This fact gives little evidence
of the nature and extent of the primary infective process. All
coats of the entire appendix may be so affected, even in cases where
the bacteria are confined to small foci between the lymphoid nod-
ules in the submucosa. In such cases the peritonitis is strictly
speaking a bacteria free inflammation, and in a clinical sense an
aseptic peritonitis. That is to say, the exudate within and upon
the peritoneum is free from bacteria. Our concern here is to de-
termine the nature of the changes which must take place in the
organ before the infecting organisms can reach the surface of the
organ and become a menace to the general peritoneal cavity. The
appendix is such a serious menace, it may be insisted ou at the
outset, not because it is an organ made up so largely of lymph
tissue prone to infection, but because it has a precarious blood
supply. Being dependent on a single terminal vessel, Avhen this is
affected by thrombosis, destruction of the walls of the organ must
follo^r.
As has already been discussed in the general section of patho-
genesis, the degree of change in the Aval] of a gut necessary to
admit the passage of bacteria can not be definitely stated. Con-
fusion has arisen because clinicians have assumed the escape of
bacteria Avhen an aseptic floccular exudate Avas formed about the
appendix, or if an exudation existed in surrounding organs. We
haA'e been led to assume the escape of bacteria when no escape
has taken place. That bacteria escape through the Avails of the
appendix Avhen there is no macroscopic lesion there can be no
doubt, but that they do escape as readily as generally assumed
remains yet to l^e proved.
Sprengel noted such an extension in simple appendicitis in 3 of
15 cases, and Ivrogius saw such extension in 6 out of 46 cases.
Some obserA'ers l)elieA'e that sucli extension is possiljle even -wlien
the Avail of the appendix remains intact. An entirely intact A\all
526 THE PERITONEUM
is evidently not meant, since reference is made to a septic lymphan-
gitis, to Avhicli is ascribed the capacity of carrying organisms to
the peritoneal surface. So analyzed there is obvious agreement
that, in order that infective material shall escape from the appen-
dix to the surrounding tissues, the Avail must be organically or
functionally changed, for unless there is some physicochemical
alteration in the component structures of its Avail, bacteria can not
pass. I have sought to compare the histochemical structure of these
appendices, which have permitted the escape of bacteria, with
those, obviously inflamed, Avhich have not permitted bacteria to
pass. Obviously, in pursuing such an investigation ve have avail-
able for study only the state of the organ at the time of observation.
From a study of a large series of these Ave are enabled to form some
idea as to the extent of the process Avhich must precede the escape
of bacteria.
In general it may be said that so long as one or more coats re-
main unchanged, as indicated by their acceptance of specific dyes,
Avhen the cellular exudates in the interstices shoAv no nuclear de-
generation, and the fibrinous exudate is fibrillar, bacteria do not
pass. When the fibrills no longer take acid stains, and Avhen the
exudate consists of a granular fibrin Avith associated necrobiotic
leucocytes, bacteria may pass. They are likely to pass Avhen there
is an adjacent fibrinous exudate in sui-rounding organs; that is
to say, an appendix of the structure just noted surrounded by an
infiltrated omentum encourages the escape of serum toAvard this
omentum, and Avitli this escape of serum bacteria folloAv. When-
ever there is an adhesion, therefore, bacteria are more apt to es-
cape than Avhen there is no adhesion, though of course escape under
such conditions is less deleterious to the patient. This interchange
betAA'een diseased organ and a surrounding adhesion seems to haA'e
the tAvofold purpose of admitting defensive forces, leucocytes and
serum, to the suffering member and of encouraging the escape of
bacteria to the succoring organ Avhere, advancing in open ranks,
they can be more effectually dealt Avith. The effect of the omen-
tum on a diseased area may be imitated Avith a pledget of gauze
Avhich, Avhen it becomes infiltrated Avith leucocytes, has many of
the functions of the normal omentum. This admits of the study
of the bacterial flora at any stage of tissue change in the diseased
APPENDICITIS 527
area. The effect of filji'inous exudate on the miijration of infectiou
is a matter of daily observation. Surgeons employ this laAV in the
drainage of abscesses. They know that if an abscess is not actually
opened into by the incision in the course of time the abscess may
find the drain opening. This happens because the drain tract made
by the surgeon sets up an aseptic reactive process which sets up
an interchange of serum between this opening and the abscess.
Bacteria making use of this avenue of communication extend the
abscess in this direction and escape of pus through the previously
dry opening follows. It may be remarked that this is more apt
to occur if a gauze drain is used than if a rubber one has been
used, because the gauze produces a greater leucocytic and serous
infiltration about it.
Classification
It is pruljlematic Avhether an attempt at classification is worth
while in a disease showing such indefinite dividing lines as the
various "types" of appendicitis. As a concession to the clinician
such a classification Avill ])e adopted, though it must be insisted that
appendicitis, like the road to perdition, consists of a series of
changes which unchecked, by natural or artificial aid, leads finally
to destruction. ]\Iany classifications for appendicitis have been
proposed, some from the point of vicAV of the pathologist, and some
from thai of the clinician. Lennander applied the simple term
acute to all forms, provided the case under consideration is not
subacute or chronic. This classification does very Avell as a pre-
operative diagnostic classification, but once the abdomen is opened
the surgeon must apply a much more discriminating analysis.
Sprengel divides them into the simple and destructive types. This
classification has been commended by a number of surgeons and
is popular among physicians who sometimes advise operation and
sometimes do not. CTiertz augments Lennander by the addition of
the amplifying term perforatwe or (/(iiifjroioufi. as the case may
demand. Kelly divides them into catai-rhal, diffuse, ])urulent. gan-
grenous, and perforative. This classification from the patholo-
gist's point of view is excellent (if there is such a thing as a catar-
rlial type), but, in so far as it relates 1o the general peritoneal cav-
ity, it is too prolix. Since the chief interest in the appendix cen-
528 THE PERITONEUM
ters on the relation of its disease to the general peritoneal cavity,
that factor should be made the basis of classification. A simple
classification of the material Avhich comes to the surgeon's hands
may be suggested as follows: the diffuse exudative, the ulcerative,
and the gangrenous. AVhether these classes are final stages, or
whether the one merges into the other, depends on the aid received
from the defensive forces and the complications arising within the
appendix itself.
The Diffuse Exudative. — Beginning at one or at several points
in the Avail of the appendix, usually in depressions between the
lymph follicles, bacteria lodge and leucocytes collect about them.
It is interesting to note that, in many instances at least, while the
entire lymphatic apparatus of the appendix is in a state of reac-
tion there may be but a single focus actually harboring bacteria,
though of course the lumen of the aj^pendix harbors a great vari-
ety of bacteria, as it normally does. In response to this local in-
fected focus there is a general hyperemia of the entire organ, both
the service and the potential vessels being dilated markedly. If
the process does not go beyond this stage, regression may be prompt
and the peritoneal involvement v> ill not exceed an active hyperemia
(Fig. 176). If the process is more intense a general edema of the
organ results (Fig. 177) with the production of pain, due to the
stretching of the nerve plexus. In this state the surface of sur-
rounding organs, particularly the omentum, may respond Avith
hyperemia and exudation. The exudate may be sterile or it may
be infected Avith nonpathogenic bacteria or AA'ith such bacteria as
possess but little virulence. Regression may take place at this
stage Avithin a feAv days. This constitutes the so-called catarrhal
appendicitis, or appendicular colic, leaA'ing but little CA'idence of
the disease. This type might better be called the intermittent or re-
mittant form. After an incouA'enience or disalnlity of some hours
or days the patient proceeds about his business.
When the primary focus extends, all of the Avails of the gut
may become invoh-ed and the surface of the peritoneum may be
reached by the abscess. The omentum usually takes part (Fig. 178)
as above noted and in a Aveek or ten days a periappendiceal abscess
is formed (Fig. 179). Preceding this there is an intense change
in the tinctorial reaction of the tissues of the Avail of the appendix.
APPENDICITIS
529
Fig. 176. — Early acute appeiadicitis with edema of the walls. There is beginning disten-
tion of the vessels of the appendix and cecum. This was the second attack. T'here are abun-
dant adhesions from a previous attack.
"^a' T'
%
'-^m00
Fig. 177. — Farly acute appendicitis. There is edema of the walls, hyperemia of the peri-
toneal layer and some exudate. The patient had had a number of mild attacks. The organ
was hard to the touch and was erectile.
530
THE PERITONEUM
Fig. 178. — An acutely inflamed appendix entirely surrounded by the indurated omentum.
The pro.ximal portion of the omentum was severed allowing it to retract before the sketch
was made.
^^*^^ ■■" ^f
Fig. 179. — Appendi.K in which the wall is much increased in thickness due to several small
abscesses.
APPENDICITIS
531
possibly with occlusion of the lymph stream by coagulated lymph
or dead leucocytes (Fig. 180). Blood vessels may become occluded
in a like manner. Bacteria may now escape without there being
^
It-'r-
rrjf^ :-;. .
■\-~i'V>:'»-,-.^.~," ,*".-•-"
■pfeiJSsi
. «';^.MKr -
^ ■■-'v:
'
■•'v
m
j^^.;:
■.^
*-■-■
^,^.-^
n^; l''r*^?-i
Fig. 180. — Acute appendicitis showing lymph and blood vessels filled with clots.
Fig. 181. — Acute appendicitis in which a small gangrenous area about to perforate is seen
near the blackened and thickened extremity of the organ.
a macroscopic opening or thei-e may result a local necrosis of the
appendix wall Avith an escape of tlie baeteria-ladeiied contents of
the appendix upon the free poi-iloncal surface. A periappendiceal
532 THE PERITONEUM
abscess is the result provided adhesions with surrounding organs
have already developed. This process may take place so rapidly
that the valling-in process has not yet taken place and a diffuse
peritonitis may result. In such instances a gangrenous area vis-
ible to the naked eye is usually present (Fig. 181). In this con-
dition there is usually a thrombosis of one of the larger branches
of the appendiceal artery. In such cases there is no sharp distinc-
tion between this type and the frank gangrenous variety except
in extent of involvement. This process can be traced only by
studying the entire organ carefully. At a point remote from the
chief focus of destruction its supplying vessel will be found throm-
botic. As a result, Avhile the peritoneum of the appendix at some
distance from the necrotic area may be excited to plastic exudation
Avith adhesion to the environment, that portion of the organ pro-
ceeding to gangrenous change repels any familiarity on the part
of surrounding organs. These are the cases that apparently do
fairly well for a number of days when they suddenly ''go bad."
In such cases after the finger of the surgeon has separated omental
adhesions from the base of the appendix, its more degenerated
extremity pops into the field of vision.
The Ulcerative. — Those cases in which there is a local ulceration
with relative freedom of the remainder of the organ may be con-
sidered under this head. It may take place in the presence of a
foreign body or without such an exciting factor. In the latter
instance the wall surrounding the ulcerous area may resemble an
acute perforative peptic ulcer. The entire thickness of the wall is
destroyed because of deprivation of nutrition or by the destructive
infiltration of leucocytes (Fig. 182). It is as though a boil formed
within the Avail of the appendix subsequently breaking through the
peritoneal surface. To all these instances of course the Avliole ap-
pendix is somcAvhat changed but not enough to excite protective
adhesions. The result of a solution of continuity of the entire
thickness of the Avail is the escape of the entire flora of the appen-
diceal lumen. The surrounding peritoneum is not prepared for
the infection, adhesions have not taken place, and the exudate has
free passage among the intestinal coils or Avherever peristalsis,
capillary attraction, or gravity may lead it. This process takes
place most frequently at the base of the appendix or near its tip.
APPENDICITIS
533
111 this type there is an initial mass destruction of the entire wall,
producing, so to speak, a punched-out opening. The evidence of
this is to be found in the Avails of such ulcers. Necrosis of tissue
without the presence of large numbers of leucocytes is the char-
acteristic feature. This may be brought about either by occlusion
of vessels supplying this area or by the presence of bacteria which
have the power of liquefying tissues and at the same time acting
Fig. 182. — Section from the wall of an appendix near a perforating ulcer.
as repellent to the protective agents. The significant factor in this
type is that there results an open passage betAveen the lumen of the
gut to the peritoneal cavity Avithout the intervention of protec-
tive adhesions. Ea^cii Avhen the perforation is abrupt there may be
a secondary reaction of the surrounding peritoneum hoAvever Avhieh
may obscure the pathologic picture, but it is to be remembered that
bacteria and other contents of the appendix have escaped and
drainage is required.
534
THE PERITONEUM
When a foreign body exists there usnally is a necrosis coexten-
sive with the foreign body. In such cases the first evidence of a
peritoneal involvement may be an escape of the foreign body into
the peritoneal cavity. This perforation may take place so suddenly
that the vail is so little changed that it actually rolls as if incised.
It is interesting to note how tensely the muscle coats grasp such
foreign bodies. When incised in the little inflamed organ the for-
eign bod}^ may actually pop out (Fig. 183). Slight infection must
lead readily to perforation. Often however infiltration precedes
the final perforation, and not infi-equently complete walling off
takes place so that the foreign body is found in the abscess.
Fig. 183. — Large enterolith in an appendix. The appendix was removed a few hours after
the initial pain. When cut into, the muscle walls retracted forcing out the foreign body.
The Gangrenous. — In this type there is death of all or a large
part of the appendix occurring simultaneously. The entire organ
is black and shiny resembling the colored gentleman as he makes
doAvn the Pullman bunks on a July evening, and is generally but
moderately thickened. This type is the product of the occlusion of
one of the chief supplying vessels of the appendix (Fig. 184). In
structure such an appendix finds an exact counterpart in the intes-
tine in mesenteric thrombosis in the Avails of an ovarian cyst Avith
a tAvisted pedicle. In such cases the tinctorial reaction of the gut
Avails may be astonishingly little altered, and there may be slight
APPENDICITIS
535
cellular infiltration in the Avails of the organ, being confined usually
to rows of leucocytes arranged between the fibrils of the submu-
cosa or subserosa. The fibers usually suffer no tinctorial changes.
The extent of cellular exudation depends upon the suddenness and
extent of the thrombotic process in the supplying vessels. There is
in the beginning, at least, noAvhere a solution of continuity of
€^M:^m'^m.
Fig. 184. — Thrombosis of the mesenteric artery in a gangrenous appendix. There is marked
perivascular infiltration.
the Avail and hence no escape of its contents. "When the appendic-
ular artery becomes occluded the organ may l)e but little in-
creased in size and may feel soft, even semifluid to the touch. The
necrotic organ, coming into contact A\ith the surface of surround-
ing guts, excites them to exudation of a nonplastic fluid. Early in
536 THE PERITONEUM
the course of the disease this exudate may be sterile and so great
in amount that the blanched organ fairly floats in it. The subse-
quent course of this type can not be predicted Avith certainty. Sec-
ondary destruction of the walls may take place permitting of the
mass escape of the contents of the appendix. This state is reached
after the necrotic area is separated from the living part due to proc-
esses going on in the part of the organ not involved in the ne-
crotic process. Usually some days are required for this stage to
be reached. A considerable part of the organ may become ab-
sorbed, leaving little but the meson to indicate the site of the organ.
Whether or not such an organ once necrotic is capable of reestab-
lishing the circulation is difficult to say. I have examined several
such specimens which suggested that reestablishment of the cir-
culation was in progress. This seems possible. If the omentum or
other organs are adherent to it they may 1)e able to supply nutrition
durnig the period of stress, just as takes place when the pedicle of
an ovarian cyst becomes twisted. It attaches to the surrounding
peritoneum until its pedicle functions again when the adhesions are
released. HoAvever, because of the nature of the changes in the walls
of the appendix adhesions do not readily take place.
The significance of this type is that, notwithstanding the strik-
ing appearance of the appendix and the presence of the exudate,
in the early stage no intestinal contents or infection may have es-
caped, and the affection may really be an innocent one. The period
that must elapse before perforation takes place is considerably
greater than in the ulcerative types, and is compai'able with mesen-
teric thrombosis and mesenteric sti'angulation in hernia.
Pathology
In discussing the pathology of the appendix some of the points
discussed in pathogenesis must l)e repeated. The pathology is made
up merely of a series of observations from which the attempt was
made to chart the disease as a process.
It seemed expedient to divide the diseases of the appendix into
three categories Avhen discussing the pathogeneses. The division
is artificial, but it seems to typify certain general end-results as
the surgeon sees them in the operating room. In the laboratory it
at once becomes apparent that such a division is in a measure ar-
APPENDICITIS 537
tificial, because all inflammatory diseases of the appendix are iden-
tical in a general way in their pathology, and the clinical end-re-
sults depend upon what are sometimes very slight variations in de-
tail. Similar wide variations are observed in the diseases of the
tonsil ; follicular tonsillitis, peritonsillar abscess, malignant en-
docarditis, or polyarthritis, so wide in their significanee, are all
the products of similar changes in the tonsil.
The first thing that impresses one in the study of the pathology
of the appendix are the slight changes that remain after very
marked acute inflammation. I have repeatedly observed instances
where an appendiceal abscess had been drained and extensive in-
duration noted, the appendix when removed after some months
showed very slight changes when viewed under the microscope.
A few lingering plasma cells, or an increase in fibrous tissue may be
all that is observed. On the other hand, the most pronounced evi-
dence of necrosis may show but little under the miscroscope. It
seems best to discuss here the findings in certain types of appendi-
ces Avith but little speculation as to how they arrived at the state
they present.
Atrophy of the Appendix. — In some instances the various layers
of the appendix retain their normal relations but each is much re-
duced in volume. These are usually found in individuals with fat
mesenteries. The appendix lies in a groove in the fat meson. This
fat is usually very dense to the touch, without any evidence of in-
flammation. I believe the general atrophy is due to the gradual
narrowing of the lumen of the vessels from the ever increasing
pressure of the fat upon them (Fig. 185).
Fibrosis of the Appendix. — The external appearance of this form
may resemble the ati'ophic. In this type the typographic relation
of the various coats is lost, due to the partial or complete destruc-
tion of one or more of them. Usually the mucous coat has been
lost and a fibrous tissue has displaced it. In this Avay the lumen
becomes obliterated by fil)rous tissue, resembling scar tissue in the
cali])er of the fibers and the sparseness of the nuclei. Sometimes
but a part of the lumen is so obliterated and there results a dilata-
tion of the distal end, leading sometimes to the formation of large
mucous cysls. The muscular coats in this type may be much re-
538
THE PERITOXEITM
duced ill thickness and replacement liy fibrous tissue may he in evi-
dence.
In some instances the evidence of destruction may be much
greater. A part or all of the appendix may be represented by a thin
fibrous band lying along the edge of the meson. Usually there is
a segment of the appendix at the cecum and often the terminal
end remains. This remaining end may feel like a lymph gland
lying at the tip of the meson. These portions remaining may have
the appearance of a normal appendix.
Catarrhal Appendicitis. — This term implies that there is a dis-
Fig. 185. — Atrophic appendix imbedded in a fatty mesoappendix.
ease of the appendix characterized by an increase in the function
of the mucous glands. It is possilile that the appendix shares in the
activity of a mucous colitis. There is no evidence that there is an
isolated catarrhal lesion of the appendix. This term was hypothe-
cated to include those cases characterized by brief pain and sore-
ness in the region of the appendix. Specimens secured at this
time show that there is really a deep-seated inflammation present
and there is no evidence of a catarrhal state.
Diffuse Exudative. — The focal lesion in the appendix, as in the
tonsil, is an area of infection between the follicles. This is sit-
APPENDICITIS 539
iiated just below the surface mucous layer and involves it sec-
ondarily.
It is a question Avhetlier infection reaches this site by extension
from, the surface of the mucosa or through the blood stream. Both
theories have been championed.
In some instances no doubt bacteria reach this site by direct ex-
tension from the surface. The extension can be directly traced
when foreign bodies lie at the point of infection. There is increas-
ing evidence on the other hand that at least in many instances the
infection reaches the appendix through the blood stream. Not
infrequently appendicitis follows close on an attack of tonsillitis.
In such instances there is a distention of the lymph vessels, prob-
ably dependent on a general thrombotic process, since many fol-
licles are similarly and equally affected, which would likely not
be so if the condition were dependent on a local source of infec-
tion. In the majority of cases there is no such association with
a primary focus situated elsewhere in the body.
It is difficult to determine the number of primary foci because
a search of the entire organ involves immense labor. Aschoff is of the
opinion that there are many primary foci in all cases. I do not believe
that this is true. If those organs are examined in which but a
portion of the organ is diseased, one can find the primary focus at
the proximal end of the diseased area. In determining the point
of origin one must distinguish betAveen simple leucocytic infiltra-
tion and the primary bacterial focus. The leucocytic infiltration
and exudation of serum involve, more or less, the whole organ,
Avhile there may be an infection at one point only, just as a felon
causes swelling of the entire thumb while the actual infection in-
volves only the periosteum of the terminal j^halanx.
In early cases, areas of leucocytic increase about the lymi)li fol-
licles is all the change noted, aside from the general edema Avhich
gives rise to the symptoms which made the diagnosis of the lesion
possible. In mild cases the disease may regress at tliis point, giv-
mg rise to the mild eases referred to as catarrhal. These cases
find their counterpart in folliciilai- tonsillitis. When the process
lasts longer there is a further increase in tlie lencocytes al)()ut the
area of infection and its center may show some degeneration, while
the muscular coats show an infiltration of leucocvtes and there is
540 THE PERITONEUM
an exudate on the surface of the appendix. These changes occur
when there is local tenderness and muscular rigidity. In more ad-
vanced cases there are adhesions about the appendix Avith an in-
crease of all the changes above noted. There is often hemorrhage
into the walls of the appendix, particularly into the subserosa.
The mucosa is often exfoliated and there may be a distinct break-
ing down in the foci primarily involved. This may be considered
the height of the process in cases running their course in ten days
to three weeks. Wlien these cases have run their course all that
remains to indicate past trouble is some plasma cell infiltration,
possibly some increase in the germinal centers, and here and there
some scarring in the submucosa.
In the type where a periappendiceal abscess forms there is an
extensive exudation of granular fibrin, degenerated leucocytes,
and finally molecular disintegration of the muscular and serous
coats. In these cases there remains after recovery a scar extend-
ing through all the coats of the organ, and there is often evidence
of chronic vascular changes.
When the focus is more virulent, or thrombosis in a vessel oc-
curs, involvement of the entire thickness of the appendiceal wall
takes place. This area is wedge-shaped with the base of the wedge
away from the meson. The reason for this shape is that all gut
arteries are essentially end arteries, just as one sees them in the
kidney and spleen. The primary change is an anemic necrosis.
The area so involved becomes separated from the surrounding
viable tissue, and a perforation, "punched nut" in appearance, oc-
curs. This state can be observed by sectioning these openings, keep-
ing in mind the appearance of sections of like processes in the spleen
and kidney. When this occurs, the gut contents escape into the
surrounding peritoneum, if protective adhesions have not formed
before this disaster occurs.
Perforation may occur from the rupture of abscesses situated
in the wall of the appendix, in the absence of thrombotic proc-
esses. In such cases the perforation is not so precipitous, and pro-
tective adhesions usually occur with the result that a localized ab-
scess is formed.
Bacteria may escape in such conditions without actual perfora-
tion. Fibrin is deposited on the surface of the organ and the en-
APPENDICITIS 541
tire wall becomes infiltrated "vvith fibrin, and osmotic processes to-
Avard the peripherj^ are set up and bacteria are conducted beyond
the appendix. In this type bacteria are distributed over a wider
area than in any other type.
GangTenous. — The third type, the gangrenous, is dependent on
the occlusion of the chief supplying vessel. The changes here are
analogous to those which occur in the walls of an ovarian cyst
when the pedicle becomes twisted. The infection here may be
limited to the proximal region of the appendix, in which event the
entire appendix is involved, or may occur more distally, in which
event only a part of the organ is black. The blackness is due to
extravasation of blood and not to degeneration of the tissue. Such
appendices take all dyes clearly early in the disease, which indi-
cates that lytic processes are not active. Such organs, like the
cysts M'ith twisted pedicles, accept temporary aid from all organs
which come in contact with them. In such cases the organ shows
no changes on microscopic examination except the extravasation of
blood.
In these cases in which there is complete exclusion of nutrition
there is a disintegration of tissue, the cells no longer take any
stain, and the fibrous tissue loses its specificity or may take a basic
dye. In such cases there is no restoration, and if there are no ad-
hesions the lumen of the appendix comes to communicate with the
peritoneal cavity after the necrosed tissue becomes separated off.
The surface of a black appendix may be free from bacteria, until
a perforation occurs. After the first acute disturbance these or-
gans may hang free in the abdomen with but little disturbance at-
tending them.
Symptoms
The so-called cardinal symptoms of appendicitis are familiar to
every one. They consist of pain, vomiting, local tenderness, and
fever. The general characters of tliese phenomena l)olong to all
types of acute peritonitis, and they have already been considered,
l)ut their special chai'acteristics as obsei'ved in appendicitis remain
to be considered.
Pain. — The pain is genei-ally sudden in its onset, often emphati-
cally so, warranting the appellation "('()U]i de Pistolet." a toi-m
542 THE PERITONEUM
aijplied by several French writers. This is particularly true when
there is sudden perforation or complete occlusion of the artery
"vvith subsequent gangrenization of the entire appendix. In cases in
which perforation is sudden, the pain may be so acute as to cause
collapse, or, at least, collapse is associated though possibly it is
caused by the escape of gut contents. On the other hand the be-
ginning may be marked by but little pain. This is particularly
true when there is recrudescence of a slumbering lesion.
In the earlier stages the pain radiates over the abdomen, and is
very liable to l^e most intense in the region of the uml)ilicus or in
the epigastrium. This pain is reflex in character, and may be
caused in some instances by irritation of the mucosa with the asso-
ciated contraction of tlie muscle. In the majority of instances it
is caused by stretching of the nerve jjlexus from the developing
edema. AVhether this explanation is correct or not the fact re-
mains that if the appendix is cut into during appendectomy under
local anesthesia and a forceps put into the lumen of the appendix,
and the blades then separated, the patient experiences pain in the
epigastrium, and may be made to vomit. There is certainly no
longer any excuse for assuming that the diffused pains are caused
by an early diffused iri-itation of the peritoneum Avhich later be-
comes localized in the region of the appendix. Operations during
the period of the diffused pain have failed to disclose any diffuse
irritation. Possil)ly spasmodic contraction of its walls in an effort
to expel some of the contents may he an added factor in such in-
stances. That bowel contents may enter the lumen of the appendix
is abundantly proved by the bismuth test meal. Whether painful
contractions can be excited by these contents is less susceptible of
demonstration. The bismuth test meal indicates that the normal
appendix rids itself of such foreign matei'ial without attracting
the attention of the higher centers.
These preliminary pains are intermittent in character with peri-
ods of more or less complete remission. At their height, or even
in their incipiency, they may be attended by nausea and vomiting.
These initial pains are not referred to other parts of the body, and
they give no clue to the location of the organ Avhich excites them.
Sooner or later, usually in from six to tAventy-four hours, the
generalized pains lessen or cease, and the right iliac fossa becomes
APPENDICITIS 543
the site of the greatest distress. Often before spontaneous pain in
the region of the appendix is complained of, pain may be elicted
by pressure in this region even before muscular rigidity is ap-
parent.
The distinctive pain of appendicitis is due to the irritation of
its surface and of the surfaces Avith which it comes into contact.
When there is no escape of contents of the appendix the entire dis-
ease process tends to remain so localized. AYhen its contents es-
cape into the general peritoneal cavity the distinctive features of
periappendicitis are lost, and the whole picture merges into that
of a diffuse generalized peritonitis. Even then, certain features
may stand out distinctive of the source of origin, either of diag-
nostic or therapeutic importance. Among these may be men-
tioned a greater degree of tenderness, rigidity, or edema in the
right loAver quadrant. Usually, however, the history is the most
reliable guide to the origin of the infection.
With the advent of periappendicitis the spontaneous pain be-
comes localized at the site of the lesion. Since the organ usually
occupies the iliac fossa the pain is usually here. When the organ
is located in the pelvis and its tip is chiefly involved, vesical or
rectal tenesmus, particularly in children, may be the dominating
symptom.
When the appendix is turned upward laterally to the colon, the
pain may be in the region of the gall bladder. When the appendix
expatiates itself into a hernial sac and becomes diseased it ex-
presses its complaint in the language of its adopted land. I saw
one patient, a boy of four, in whom the pain was felt in a left in-
guinal hernia, the sac of which the inflamed appendix occupied.
There is on recoi'd a case of appendicitis occurring in the left
pleural cavity, the organ having gained access to this cavity via a
diaphragmatic hernia.
When the appendix lies retroperitoneally the peritonitic pains
are absent, and the picture becomes that of a retroperitoneal in-
fection. Usually a deep tenderness and edema are all that mark
the site of infection. The various types of appendicitis cause a
variable amount of pain. The large edematous appendices of the
nonperforative type cause the greatest degree of irritation to tlie sur-
rovmding peritoneum and, in consequence, the greatest pain. This
544 THE PERITONEUM
is apt to continue for a considerable time because tlie surrounding
tissue partalces of the tendency to serous infiltration.
"With this type the peritoneal irritation is associated with a se-
rous exudate in the general peritoneal cavity, as well as in the sub-
serous tissue. This fluid may be considered in the nature of a by-
product. It rarely becomes so great as to be readily demonstrated
clinically, neither does it exert any influence on the course of the
disease. If clear in character, it indicates the absence of diffuse
infection, though it may be so loaded with leucocytes and fibrin
flakes as to impart a cloudy appearance to it, and yet may be non-
infective in character. The type of cells is similar to the type of
those Avithin the Avails of the appendix, and, obviously, represents
the amount of fluid Avhich found no space within the meshes of the
tissue.
The amount of fluid is generally inversely proportional to the
amount of jDain. In some instances, particularly in children, the
fluid may be so abundant as to be of diagnostic significance. This
is especially true in young childi-en Avho do not reliably indicate
the site of greatest pain and in whom genei-al abdominal distention
tends to obscure muscle rigidity. By rolling these little patients
from side to side dullness may be demonstrated in the flanks, in
this Avay revealing the presence of this type of appendix.
When there is perforation Avithout prcAdous periappendiceal ad-
hesions the contents of the appendix escape. When abundant,
a direct foreign ])ody irritation may be added to that of the in-
fection. In such cases the pain may rival in intensity that of a
perforating duodenal ulcer, and like a perforating ulcer, may be
intermittent. In these cases a huge amount of semipurulent exu-
date may form in a A^ery short time.
The pain in the gangrenous type is characteristic. The initial
pain is A'ery intense and is continuous, but after persisting for
tAvelve hours or more, it subsides. The explanation seems to be
that as soon as the A^essel is shut off the tissue dies, and the pain is
that of acute necrosis, and as soon as the nerves die pain ceases.
When perforation folloAvs necrosis, rencAved pain, that of peri-
tonitis, supervenes and then continues as a primary perforative
peritonitis.
Those cases Avhich begin with intense initial pain are in general
APPENDICITIS 545
of serious character, l)iit not all of the serious cases are attended
by severe pain. Pain is a measure of irritation, "vvhile danger to
life is dependent on the toxicity. When intensely septic material
escapes from the appendix there may be little pain because the
character of the infection is such as to repel all reactive processes
and therefore may be quite pain-free. As a matter of fact the
moribund patient is usually free from pain and his distress comes
only from distention, vomiting, and like secondary phenomena.
Spontaneous pain is one of the most reliable symptoms in the
diagnosis of the disease, and while the severity of the initial pain
may give a general clue to the severity of the attack, once the ini-
tial pain subsides, the sensations of the patient are Avholly unreli-
able as an index to the course of the disease. When pain is re-
lied on as a guide to the time for operation disastrous errors will
be committed.
Pain on Movement. — Coexistent with the spontaneous pain is
pain engendered by movement imparted to the affected area. This
may be produced by movements of the body as a whole or by parts
of it. Jarring of the body, as in the movements imparted to the
bed or to the conveyance upon which the patient is being ti'ans-
ported, may excite it. This is caused by the change to its environ-
ment imparted to the inflamed organ by the sudden motion of the
body as a whole.
The most common source of increasing pain is movement of some
part of the body against the inflamed mass. This may be the move-
ments of the intestines transmitted from the diaphragm in respira-
tion, the contraction of the psoas in walking, or of the bladder or
rectum as they dilate and contract in the performance of their
functions.
The location of the pain so elicited gives a very accurate clue
to the location of the diseased organs. The most certain evidence
from these signs is obtained when they are produced by the pa-
tient's own volition. Tbe stooped gait with the body inclined
slightly to the right oi- tbe draAvn-uj^ right thigh as the ])atient
lies in bed declares elociuently 1hat the site of the lesion is over the
psoas muscle. The precautions that the patient takes to limit mo-
tion of the affected area may not 1)e particularly noticeable in the
respiratory movements. When the respiratoiy movement is en-
546 THE PERITONEUM
tirely costal it is at once apparent, but, on the other hand, the dia-
phragmatic movements may be carried out Avith caution so that its
excursions are regular and calculated, but limited. The right half
of the diaphragm, and with it the abdominal wall, may make
shorter excursions than the left. This phenomenon is best discov-
ered by alloAving the light to fall over the shoulder of the observer,
as he stands at the foot of the bed, upon the bared abdomen of the
patient. When not apparent at once it may become so if the pa-
tient is encouraged to breathe more deeply. This sign is of value
in children, particularly before the distention of the abdomen has
become very great.
After the disease has existed long enough for the adjacent parts
to become fixed to each othei-, the movements above noted do not
cause so much pain because movement of the entire mass results.
The presence of pain on movements imparted to the affected area
is quite as important in I'evealing complications as in the primai'y
disease. Subhepatic pain or subdiaphragmatic pain developing
in the course of the disease speaks for extension in that direction,
as does vesical or rectal irritation, not previously present, for ex-
tension into the pelvis.
Pain on Pressure. — Frequently as the surgeon approaches the
patient for the purpose of palpating the abdomen the patient ex-
presses his belief in the presence of local tenderness by involun-
tarily extending his hands in protection. Being possessed of this
advance knowledge it is often well to allow him to complete the
examination and indicate to the surgeon the point of greatest ten-
derness. A systematic perusal of this plan will soon convince the
observer that the initial point of greatest tenderness varies greatly
from McBurney's point. Like most great men Avho generalize a
great truth, McBurney himself stated that the point of maximum
tenderness may vary fi'om this point but. many of his followers, to
simplify the conception, have taught that the sensitive point must
be there, and they have entered into prolonged ptolematics to
prove that it is so. For this reason I believe Cordier's characteriza-
tion of the designation of this point as the location of maximum
pain as "most unfortunate" is not far from the truth. However,
the observation of ]\[cBurney called attention to a great truth, and
was a great factor in teaching the profession the early diagnosis
APPENDICITIS 547
of periappendiceal peritonitis. Having learned the fundamentals
from a dogmatic statement it is proper to proceed to a refinement
by recognizing the fact that the initial pain in appendicitis may-
be at a considerable distance from this point. The great variabil-
ity in the location of the appendix was noted in the chapter on anat-
omy. The portion of the appendix affected likewise may influence
the point of greatest pain. The tip of a long appendix may lie be-
side the rectum in the culdesac and give rise to vesical and rectal
tenseness while the usual site of appendicular pain is free from dis-
turbance.
It is well to remember the significance of a more or less localized
tenderness, usually somewhere in the right lower quadrant, but to
overlook the possibility of appendicitis when the initial pain is
elsewhere is to court frequent error. It is instructive to the sur-
geon to note the exact site of local tenderness on his clinical exami-
nation and then note the exact anatomic location during the opera-
tion.
Much discussion has arisen as to A^■hy the maximum pain is not
always located at the point of greatest pathologic change. The
reason is that it is the degree of irritation produced that governs
the amount of pain and not the extent of pathologic degeneration.
An omental mass adherent to a gut, or particularly to the abdomi-
nal wall, Avill very likely determine the point of greatest tender-
ness while the site of greatest pathologic change in the appendix
may lie at some distance. When a diseased appendix which has
excited the pain is examined histologically one can not wonder
that the location of the appendix does not always correspond to
the site of maximum pain for it may be wholly degenerated. Poets
tell us grief is sometimes too great for tears, and an appendix may
be too rotten to hurt, ^lorris. as usual, drives the tack with a
sledge hammer in these words, "The reason Avhy the appendix is
free from tenderness is, because it is dead, nerves and all." There
is no need to invoke special sensitiveness in certain regions. If
the site of greatest pain is determined with the aid of the patient,
and then at operation all the pathologic changes are carefully
noted, the location of abdoninal pain as relates to intraabdominal
changes will become much simplified and there will l)e no need to
invoke a complicated reflex process to explain its location.
548 THE PERITONEUM
The statement of ^Morris above quoted gives the clue to the cor-
rect understandino- of those cases, Avhich, in spite of extensive
changes, are painless both spontaneously and on pressure. In
very virulent infections the organ becomes necrotic without pre-
liminary reaction. In the gangrenous type there is intense initial
pain — then all is quiet. The reason is that the whole organ is to-
tally dead, and being dead it excites no painful impulses. Ap-
pendices, like dogs, Avhen once thoroughly dead, do not bark. Ap-
pendices, like canines, when dead for a certain length of time, may
become offensive again through the very fact that they are dead.
The degenerating appendix may in this state not irritate the sur-
rounding peritoneum until disintegration permits the escape of
its contents. I once saw a young man who was stricken with sud-
den excruciating pain Ioav in the groin which diffused over the
abdomen. In tAventy-four hours the pain had subsided. On tlie
fourth day a new pain gradually developed well above McBurney's
point. At operation a long black appendix was discovered. The
cecum at the base of the appendix had begun to separate, and
bowel contents were beginning to ooze out, exciting the surround-
ing peritoneum to reaction.
Superficial tenderness, emphasized by Dieulafoy, is an uncertain
sign. Early in the disease it may be caused by a reflex through
the sympathetic. It is a very unreliable sign because it is present
in so many neuroses. This type of pain will be discussed under
chronic appendicitis.
Muscular Rigidity. — This sign is l)ut a corollary to the preced-
ing. The careful respiration and flexed thigh are associated Avith
rigidity of the rectus muscles. As already indicated, the lessened
excursion of the abdominal muscles in respiration may be deter-
mined by the naked eye. The palpating fingei- of the surgeon em-
phasizes the impression gained by sight and detects the lesser de-
grees not apparent to the eye.
The rigidity of the muscle is a reflex designed to protect the dis-
eased area from pressure and from movement. The same phenom-
enon is noted in the free hand of a person affected with a felon on
his thumb when a solicitous friend inquires as to the cause for the
draping of the digit. Speculation as to the character of the nerv-
ous mechanism involved is not profitable.
APPENDICITIS 549
The rigidity is greatest over the area of maximum involvement
of the parietal peritoneum. This usually includes the lower seg-
ments of the recti and the lateral abdominal muscles. When the
appendix lies far lateralward the posterior group may show great
rigidity. When located high up under the liver the upper end of
the rectus alone may ]^e rigid. When the inflamed organs become
conglutinated, with or Avithout attachment to the abdominal wall,
so that movements of the abdominal muscles will not cause an in-
crease of pain, the rigidity relaxes. The relaxation begins in the
regions most remote from the site of maximum irritation. Because
of this a mass produced by the inflammation becomes easily pal-
pal)le Avhen the rigidity ceases.
It is interesting to note that as general muscular relaxation oc-
curs as the patient goes under an anesthetic, the parts of the mus-
cles which lie directly over the lesion relax last. Because of this
fact the surgeon, laying his hands gently over the abdomen of the
patient as he goes to sleep, may accurately judge the site of the
greatest intraabdominal irritation, Avhich in the early cases usually
means the site of the appendix.
Rigidity may be absent. If the condition of the appendix is such
that no irritation is imparted to the surrounding structures, the
muscles do not respond because they get their clue only from pain-
ful impulses.
When the patient is in extremis, especially when due to cerebral
irritation, the abdomen may be retracted and the muscles seem
rigid. This rigidity is uniform and does not characterize any par-
ticular kind or location of lesion.
Vomiting^. — Patients Avith appendicitis often suffer from disturb-
ances of the stomach, varying from an uncomfortable, burning
sensation to violent and protracted vomiting. Vomiting is a com-
mon symptom, but loses in importance because it is an accompani-
ment of so m.any other conditions. It is only when it is associated
with localized tenderness and muscular rigidity that it becomes of
value in diagnosis. Save in the violent hemorrhagic types, vomit-
ing gives little evidence as to the severity of the disease.
The cause of the vomiting is generally ascribed to inflammatory
irritation of the peritoneum. This view is held despite the fact
that vomiting usually occurs before such irritation begins and
550 THE PERITONEUM
ceases before the irritation is at its height. It seems to me clear
that the phenomenon is reflex. I have already stated that vomit-
ing may be produced by artificially distending the appendix.
Simple traction on the appendix, as in attempting to pull it into
a wound made for a gall-bladder operation, Avill uniformly produce
nausea and even vomiting if persisted in. The same is true of
traction on the gall bladder, colon, or jejunum, as I have repeat-
edly observed in doing gastroenterostomies under local anesthesia.
The amount and character of the vomiting varies. Usually a
little mucus or food is expelled. Bile is rarely produced, even
when retching continues for some time.
In rare instances blood is vomited. Sprengel saw it in no less
than nine cases. The cause of this condition has been discussed
here in the section on general symiDtomatology and in that on com-
plications after operation.
Recurrent vomiting sometimes takes place. This may be cere-
bral or obstructive. The former type is nearly always terminal,
and the latter usually is. In the former type the vomiting comes
on at frequent intervals, and is usually small in amount. The lat-
ter is often large in amount, and may become feculent. Both of
these types are general manifestations, and have no direct rela-
tion to the appendiceal region.
Tympany. — The contour of the abdomen in uncomplicated ap-
pendicitis is not much changed. Some distention in the region of
the head of the cecum may be present, l)ut the general contour is
not markedly aifected.
Sometimes in the beginning a more marked tympany may be
present and it follows closely the vomiting and generalized pain.
This early intestinal distention appears when the first reactive
hyperemia appears. It is reflex, and not paralytic, in origin.
Distended coils of intestine offer a greater surface for the forma-
tion of a barrier A\all about the point of maximum irritation. It
usually diminishes as the phenomenon regresses to the region of
the appendix. If alimentary indiscretions are permitted, a fermen-
tation distention may supervene.
In some instances tympany may develop from occlusion of some
portion of the gut as a direct local result of the peritonitis. I have
noted this once from adhesion of loops of the ileum to an appendix
APPENDICITIS 551
located in the pelvis, and three times from constricting adhesions
in the region of the appendix. The succeeding phenomena are
those characteristic of acute obstruction of the gut. These may be
confusing since vomiting and distention may be ascribed to a
spreading peritonitis. If peristalsis can be seen, felt, or heard, the
probability is that there is a mechanical obstruction. Stercora-
ceous vomiting and collapse should not be awaited.
If the infection spreads, a general diffused tympany may occur
in young adults, who usually have tense abdominal walls. Tym-
pany from spreading infection represents a phenomenon of
generalized peritonitis, and is considered under the section on
general symptomatology. A late tympanj^ may indicate a de-
generation of the muscle wall of the gut. Sometimes generalized
tympany may l)e prevented l)y the extensive plastic exudate which
covers the walls of the intestine. When this condition exists in but
a portion of the abdomen, tympany may be greatest in that part of
the abdomen least affected. In such eases the site of greatest dis-
tention may be in the epigastric and splenic region, and it thus may
resemble an acute distention of the stomach, when, in fact, the
tympany is due to distended coats of small gut which escape
around the left border of the great omentum and come to lie over
the left border of the stomach.
The border may be retracted instead of being distended, Avhen
there is an extreme toxemia or a cerebral complication. This is
the familiar scaphoid abdomen.
Fever. — The question of increase in temperature in appendi-
citis is important merely because of its presence. The extent of
the temperature increase is of little moment because of the great
variability of its range.
Theoretically, an appendicitis may exist without a rise of tem-
perature above normal. Its actual existence is assumed by many
writers. Tlerzog places these feverless cases at 26 per cent, and
Eotter at 19 per cent. In such cases it is questionable whether
fever did not exist before observation was begun. IMurphy em-
Ijha.sized the diagnostic importance of the initial fever, and it Avill
prevent many errors if one holds fast to a belief of its importance.
My experience has been that appendices removed under conditions
552 THE PERITONEUM
ill Avhicli there is no rise of temperature fail to show microscopic
evidence of acute inflammation.
Ordinarily the onset of the disease is characterized by moderate
fever, from 100" to 103° being the average range. An initial tem-
perature above this maximum speaks against appendicitis. Usu-
ally the height is reached soon after the beginning of the attack,
and runs its course in from three to fifteen days. Herzog classi-
fied 139 cases relative to their maximum temperatures. He found
a temperature of less than 39° C. in 69 cases, 39-39.5° in 40 cases,
39.6° to 40° in 14 cases, and 16 cases above 40°. Rostovtseff noted
that the highest temperature is observed betveen nine and ten
o'clock in the evening.
Some patients begin with an initial high temperature, accom-
panied, perchance, by a chill. This type quite regularh^ reaches
a temperature of 104° F. or more. Outside of this type, I have
rarely observed so high a temperature in uncomplicated cases of
periappendicitis. Usually the temperature ranges from 99.5 to
102. High initial temperatures should always excite suspicion that
the disease is not of the appendix. The development of a sec-
ondary abscess is often marked by a high temperature.
"When the disease does not extend beyond an involvement of the
peritoneum of the appendix, and the peritoneal surfaces coming
in contact with it, the temperature may recede to normal Avithin
one to five days. If there is considerable induration it may con-
tinue for a Aveek or more. It usually recedes by lysis, rarely by a
sudden drop ; yet many instances of a sudden recession are recorded
in the literature. In such cases it is likely that an abscess has
already formed which has drained spontaneously into the lumen
of the gut.
\\nien abscess formation begins the rise of temperature takes
on an indefinitely prolonged course. If the abscess formation
remains Avithin the confines of the original adhesions the temper-
ature is not prone to ascend to a great height, usually remaining
beloAv 103°. If, hoAVCA^er, an extension beyond the original con-
fines takes place, particularly if such extension takes place in extra-
peritoneal cellular tissue, a much greater height may be reached.
When the initial temperature recedes for a day or more and
then mounts again, the development of a periappendicular abscess
APPENDICITTS 553
ma.y confidently be predicted. The height of the temperatnre, due
to the formation of an al^scess, and its subsequent course depend
upon whether or not assistance is rendered. When the abscess is
drained a more or less sudden drop takes place. An even more
sudden drop follows the spontaneous rupture of an abscess into a
gut. This sudden drop may also occur when the abscess ruptures
into the free peritoneal cavity, attended by the symptoms of shock.
When the rupture takes place into the free peritoneal cavity the
temperature often goes below normal, but soon rises again. The
pulse, it is important to note, suffers in volume and increases in
rate.
An abscess left to itself, if of limited dimensions, may be taken
care of by the tissues, and ultimate complete absorption will ensue.
In such instances more or less uncertainty arises as to the exist-
ence of pus. After an abscess has attained a size to be certainly
diagnosable, regression will hardly occur until the pus, by some
means, gains its liberty. The mere presence of a palpable mass
with leucocytosis is not certain evidence of the presence of pus.
The mass is more likely due to agglutinated intestines and omentum.
Pulse Rate. — The pulse rate is usually increased parallel with
the rise of temperature. Early in the disease, when the pains are
yet diffuse, the rate may exceed the normal proportion. This is
particularly true when nausea and vomiting are present. At this
stage the rate is rather more a measure of the nervous state than of
the degree of intoxication. Later when the local reaction is in full
swing, the normal relations are restored. A pulse rate of from 80
to 120 is usually observed. Often the pulse rate reaches normal
before the temperature does.
The often discussed disproportionate increase of the pulse rate
is characteristic of a spreading peritonitis. When the infection
spreads without limitation the rate may exceed the ability of the
surgeon to count. A descending temperature with a rising pulse
rate is an omen of the greatest gravity.
The character of the pulse is one of moderate excitability. Early
it may be full, even presenting a suggestion of dicrotism. Later
it assumes a progressively quieter tone until normal is reached.
If it ascends in rate, or lessens in quality, once having regressed,
a spread of the disease is suggested. As abscess forms, too, the
554 THE PERITONEUM
rate increases, and may reach 120 oi' more, particularly if the ab-
scess has reached cellular tissue.
The extremely rapid and thready pulse is characteristic of gen-
eralized peritonitis and is observed in tei-minal stages only.
Leucocytosis. — The interest in the occurrence of leucocytosis in
appendiceal inflammations is heightened, for it was in relation to
this disease that Curschmann made his observations which resulted
in the general recognition of the relation of leucocytosis to acute
inflammatory lesions.
In a general vay the increase in leucocytes runs parallel with
the degree of infection and with the temperature. The usual range
is between fourteen and eighteen thousand, and with the forma-
tion of abscesses the increase may be double these figures. The
higher figures may be reached, as noted by French, when exten-
sive abscesses are formed. As localization takes place the count
falls, onh^, like the temperature, to rise again if abscess formation
spreads.
It was eai'ly noted that the polynuclears undergo a dispropor-
tionate increase. Kuttner and Federmann have studied this rela-
tionship carefully. The relative increase in the polynuclear leuco-
cytes may reach 90 per cent and more, and the count is apt to be
particularly high in cases in which there is extensive exudation
into the appendix and sui-rounding tissues. This disproportion be-
comes equalized as the intensity of the infection lessens. In some
very virulent infections the leucocytosis may not only be not in-
creased, but actually lessened. The polynuclears in such conditions
suffer actually and relatively. This leucopenia may be very pro-
nounced in the rapidly fatal types of spreading peritonitis. I have
seen the white count as low as 2,300, with 60 per cent polynuclears.
On the whole the leucocyte count is more apt to mislead than
to aid in so far as the determination of the severity of the attack
goes. It is of some value in differential diagnosis when typhoid fever
or tuberculosis is suspected.
Diag'nosis
Appendicitis is usually characterized by symptoms that are typ-
ical. When generalized abdominal pains, Avith or without nausea
present, followed by tenderness in the right flank and fever, the
APPENDICITIS 555
appendix probably is inflamed. Appendicitis is less often over-
looked than other diseases are mistaken for appendicitis. Taken
in the aggregate this organ is more often the subject of misdiagnosis
than any other abdominal organ. The diagnosis of appendicitis
involves not alone the site of the disease, but also its character.
This is important to remember in the diagnosis of the disease of
any organ so inconstant in its position. But, since the evidence
available is due only in part to the characteristics of the lesion
it produces, quite as much weight must be placed on the distinctive
characters of the diseases "which simulate it. After the positive
signs of the disease have been carefully considered, diagnosis by
exclusion should ahvays be carefully considered.
The variations from the typical cases are numerous. jMild forms
of the disease may be limited to colicky pains, at first diffuse, but
later localized, or the localization may be absent. Rise of tempera-
ture may not be detected, and muscle rigidity and tenderness will
not be noted unless searched for by a competent diagnostician.
In children the entire attack may be represented by generalized
pains with vomiting, possibly with an evanescent rise of tempera-
ture. The nature of these attacks may not seem clear until more
serious changes in the appendix precipitate peritoneal involvement.
In the community where I did general practice and have since
seen much of the graver diseases, I have observed that the young-
sters Avho were subject to bellyaches twenty years ago have most
of them developed appendicitis in late years.
The chief source of error in the diagnosis of appendicitis is the
attempt to reach conclusions without adequate evidence. This lack
of data may be due to failure to carefully study the patient, or
to the fact that the evidence has disappeared. The latter state may
be remedied in part by a carefully recorded history. The advent
of i^ain, its time relation to the taking of food, its intensity as
measured by the subsequent acts of the patient rather than by the
adjectives that are used in deseril)ing it is what counts. If fever
is said to have existed it must lie determined whether the opinion
is based on tliermometrie measuronuMit. If the patient's physician
states that muscle rigidity Avas present, his ability to determine
this point must be taken into account. Repeated examinations arc
556 THE PERITONEUM
desirable if this is possible, and wlieii the chronic type is in ques-
tion this is imperative.
When the probable diagnosis of appendicitis is arrived at, care-
ful consideration must be given the question as to "whether an
inflammation of the appendix could give rise to the symptoms
complained of. For instance a history of pain in the region of the
appendix associated with occipital headaches or right subscapular
pain should at once convince the examiner that an appendicitis
could not explain these phenomena. Every abdomen should have
painted across it the familiar railroad sign — stop, look, listen.
Differential Diagnosis. — In all Init the more typical cases the
diagnostician must consider the possibility of the existence of other
conditions "which simulate periappendiceal lesions. The range of
possibility is large, and each of these may require an analysis in
concrete cases. It is only by exercising every care that errors can
be prevented from creeping into the experience of even the most
careful diagnostician. With this idea in mind the various dis-
eases "which require consideration may be presented in order.
Kidney and Ureteral Colic. — Pain due to the passing of a foreign
body along the ureteral tract may be located in the region of the
appendix. It may be severe in character and radiate to the epi-
gastrium or umbilicus. Vomiting is often present ; slight fever and
rectus rigidity may be present. This picture resembles so closely
an attack of earlj- appendicitis that factors specific for the urinary
tract must be sought. Pain radiating to the bladder, perineum, or
testicle suggests a urinary lesion. Deep tenderness over the kid-
ney may be a bit of added evidence. A history of pain brought on
by jarring of the body, formerly much depended on, is uoav super-
seded by the more positive evidence supplied by the x-ray. The
kidney may be enlarged and palpal)le and sometimes tender. The
urine may shoAv blood, but this is sometimes present in appendicitis.
The leucocytes in the urine likewise may be increased both in kid-
ney stone and appendicitis, and only when abundant do they pre-
sent fairly reliable evidence in favor of stone. The x-ray may show
a stone, Avhich is quite conclusive, but an appendicitis may exist in
the presence of a quiescent stone, as I once observed to my chagrin.
The presence of a stone Avith associated lesions of the urinary or-
gans, the direction of the radiation of the pain may aid in preventing
APPENDICITIS 557
such an error. The muscular rigidity, when present in kidney colic,
is not so pronounced as the degree of pain would indicate Avere the
pain appendiceal in origin.
Diseases of the Gall Bladder. — Cxallstone colic and cholecystitis,
due to stone or other causes, sometimes produce symptoms Avhich
simulate appendicitis. "When the colic is typical, the subhepatic or
epigastric pain, radiating to the back or right shoulder, presents a
picture fairly typical, especially if the patient be "fat, fair, and
forty." The pulse is little affected, and the temperature but
slightly disturbed. When a cholecystitis supervenes, the muscle
rigidity is confined to the upper part of the right rectus. A tume-
faction just below the costal border, moving with respiration, when
present, is typical. When there is no tumor, a deep tenderness may
be present. The history of previous attacks is of importance par-
ticularity when attended b}^ jaundice. Sometimes the gall bladder
lies very low, and when inflamed may simulate an acute appendi-
citis. I once saw an abscess pointing in the ileocecal region which
when opened discharged many gall stones. Conversely, an appen-
dix lying lateral to the cecum and extending to the liver may
simulate a pericholecystitis. As an example may be mentioned
a case of a man of fifty years who had had several attacks of pain
situated just below the costal border. There was marked muscular
rigidity, and the pulse and temperature indicated an acute infec-
tion. He was seen in one of these attacks by a distinguished
internist. Avho confirmed the diagnosis of cholecystitis. At opera-
tion an appendix the size of the finger lay lateral to the colon,
reaching to a point just lateral to the gall bladder. There was
tenderness and rigidity of the anterior border of the quadratus lum-
borum muscle at its upper end. This point should have caused
me to suspect the appendix rather than the gall bladder.
Perforating Ulcers of the Stomach and Duodenum. — AVhen ulcers
of the pylorus or duodenum perforate, a severe pain is set up,
Avhich is sometimes mistaken for an acute appendicitis. The in-
itial pain in ulcer is epigastric, attended at once by rigidity. The
characteristic feature of an ulcei' is the great intensity of the jjain.
There is probably no pain moi'e severe. The most expressive ad-
jectives in tlie language are used in succession to make known the
feelings of these victims. The French have employed the word
558 THE PERITONEUM
"brutal" to characterize this pain, and Avere it tlie product of a
free will it might be so designated. Equally characteristic is the
definite time of onest. Patients state the exact time of the day
at which the pain began, and not infrequently indicate the very
act they were engaged in when the pain began. One patient men-
tioned the fact that it was just as he stooped to pick up a shovel;
another had reached over from his chair to pick up an object from
the floor; another had just arisen from the dinner table. Along the
same line, but less definite, was the assertion of a young student
that the pain ])egan while he was kissing his sweetheart good night.
In the early stage the tenderness is limited to the upper abdomen.
Later there may be pronounced tenderness lateral to the colon and
in the ileocecal region. This is readily understood Avhen it is
remembered how ciuickly the gut contents reach this region by
flowing over the great omentum. Sometimes the amount of fluid
collecting here may be so great as to be demonstrable by physical
means.
The history of epigastric disturbance is usually given as of im-
portance in diagnosing a perforated ulcer. Often unfortunately
the patient fails to recall any previous epigastric disturbance. The
pulse may become rapid early and the temperature may be sub-
normal.
Sometimes the region of the impending perforation is partly
walled ofl: before the disaster actually occurs. In that event a
localized abscess may form in the region of the ascending colon,
and it may then resemble an appendiceal abscess.
Gangrenous appendicitis also sometimes causes the most excru-
ciating pain. I have not seen this except in appendices which be-
came wholly gangrenous from thrombosis of the supplying arteries.
The pain is generally not located in any given point, as it is in ulcer,
and the pulse and temperature may be but little disturbed. When
some time has elapsed since the advent of the pain improvement
may have occurred in the appendicitis while in a perforated ulcer
the symptoms continue unabated.
When an appendix perforates with the escape of gut contents
the course may be as stormy as in perforated duodenal ulcers.
Here history of previous attacks and location of the initial pain
in the region of the appendix may aid.
APPENDICITIS 559
When the surgeon is confronted 1)y such a grave crisis as either
of these conditions presents, no time should be lost in diagnostic
niceties. A right rectus incision Avill reveal the presence of duo-
denal or stomach contents free in the peritoneal cavity or an
appendix obviously the source of the irritation. The more coura-
geous surgeon will make the incision over the most likely source
of trouble and if he is Avrong will abandon this incision and make
a new one in accordance witli the revised diagnosis. This leaves a
permanent record, written in scars, of the error of diagnosis, but it
gives the surgeon the better field Avhieh results from a correctly
placed incision.
Acute Pancreatitis. — Acute affections of the pancreas may simu-
late acute appendicitis because of the generalized pain and abdom-
inal distention. This pain, like perforating ulcer, is extremely
severe. It is situated in the epigastrium and may radiate straight
througli to the back. It usually occurs in males at or beyond
middle life. Distention, vomiting, and other symptoms of obstruc-
tion begin early. It is the epigastric fullness and the general evi-
dence of abdominal distention, in conjunction with the above symp-
toms, that points most to the diagnosis.
Diseases of the Urinary Bladder and Rectum. — AVhen the appen-
dix hangs over the l)rim of the pelvis it may produce a pelvic
peritonitis, but when the organ is long enough to reach the bottom
of the culdesac or to come in contact with some organ a localized
abscess may form. When the appendix lies entirely in the true
pelvis no symptoms may be produced in the iliac fossa. In some
instances all the symptoms are referable to the true pelvis and its
contained organs.
The symptoms produced in such cases are usually referable to
the bladder or the rectum. Sometimes vesical tenesmus or even
retention may initiate the complaint. A boy, aged 12, Avithout
other symptoms Avas unal)le to urinate. He was catheterized Avith-
out difficulty by his physician, and this proved the urethra free
and the urine normal. When examined, he had a temperature of
100° Avhich Avas not noted before A^esical distention became prom-
inent. The abdomen Avas soft and noAvhere sensitive. Bimanual
examination shoAved a mass behind and to the right of the ])ladder.
Operation shoAved an appendix adherent by its tip to the latero-
560 THE PERITONEUM
posterior surface of the ])ladder, imbedded in a mass of exudate.
This type is seen most frequently in young boys.
I have seen large abscesses form -with but little marked symp-
toms. The very paucity of symptoms associated Avith retention is
presumptive evidence of a pelvic appendicitis ; later, rise of temper-
ature always supervenes and usually there is physical evidence of
an abscess. The retention is usually due to ii'ritation of the sphinc-
ter, and not to direct pressure. I have never seen complete reten-
tion in an adult in the presence of large perivesical abscesses.
Abscesses in the pelvis by ii'i-itating the rectal wall excite a pro-
duction of mucus, often of pain and tenesmus. A sudden profuse
production of mucus, particularly if the mucus is streaked with
blood, presages a rupture of the abscess into the rectum.
Sometimes the chief symptom, aside from disturbance of the
bladder, is a diffuse tympany. This is most likely to be the case
when there is extensive involvement al)Out the rectum, or when
coils of small intestines are involved in the formation of the Avails
of a localized pelvic abscess. I once operated on a patient present-
ing the symptoms of intestinal obstruction without discernible
cause. Four coils of ileum dipped into the pelvis to surround an
inflamed appendix plastered in the floor of the culdesac.
Typhoid Fever. — Slowly l)eginning inflammations of the appen-
dix may simulate incipient typhoid fever. This is likely to be the
case Avhen the appendix lies lateral to or behind the cecum, and
particularly if it is primarily retrocecal. The explanation of the
absence of the cardinal symptoms of appendicitis is easily under-
stood Avhen we remember that this type represents essentially a
cellulitis of the retroperitoneal tissue, and not a peritonitis. Local
tenderness and the constitutional evidence of infection are all that
is apparent. Litten's method of determining the presence of this
deep edema was to pick up a large fold of skin, first on the affected
side then on the other. If edema is present the fold so picked up
Avill appear to be more voluminous. A deep edema of the lumbar
muscles, usually with tenderness, is the most reliable sign of im-
pending abscess in this region. The temperature early in the dis-
ease is often higher than is u.sual either in the intraperitoneal
location of the appendix or in typhoid fever. The pulse is apt
to be rapid and Aviry rather than dicrotic, as in typhoid. There
APPENDICITIS 561
is usually an absence of rigidity of the recti muscles in retrocecal
appendicitis. The leucocyte count is often distinctly increased. I
have seen it as high as thirty-five thousand. A case in point is
as follows:
A male, aged 35, complained of malaise and an uncomfortable
feeling in the right side with anorexia. AVhen first observed by
his physician on the fifth day he had a temperature of 103°. A
continued fever Mitli abdominal distention followed for the next
three weeks. Failing to develop the AVidal reaction or to show
distinctive clinical signs of typhoid he was brought to the hospital.
He had at that time a deep edema over the quadratus lumborum
muscle with deep tenderness. There was marked general disten-
tion. The blood count was as indicated above. Incision disclosed
an appendix with much thickened walls lateral to the ascending
colon and imbedded in cellular tissue Avhich was infiltrated Avith
pus. ]Massive drainage brought prompt improvement, but he died
of a pulmonary embolism thi'ee Aveeks after the drainage.
The recognized signs of typhoid rose spots and the Widal reac-
tion are absent in retrocecal appendicitis. ConA'ersely, typhoid
fever may resemble appendicitis. Sudden pain in the region of
the appendix with tenderness in the iliac fosa is sometimes ob-
served. The error may not be discovered until the definite signs
of typhoid fever develop, perhaps after the appendix has been re-
moved.
I Avell remember a lad of fourteen who, after a hearty meal, Avas
taken Avith acute pain in the ileocecal region. Within a fcAv hours
the temperature had reached 103°, and there Avas deep tenderness
over the cecum. There Avas some voluntary muscular rigidity.
The pulse Avas full, bounding, and not ovei- eighty. The folloAving
day it became dicrotic. The muscular rigidity disappeared, and
distinct ileocecal gurgling could be elicited. The Widal reaction
Avas not positive for ten days. Hemorrhages occurred repeatedly
during the third Avock, and lie died during the fourth Aveek Avitk
intestinal perforation.
This case illustrates the diicf diffcM'cntinting factors. The mus-
cular rigidity lessened Avhcn flic patient's attention Avas attracted
elscAvhere. The muscular rigidit\- had a swinging comeback, and not
the tense guarded hardness of acute peritoneal irritation. The
562 THE PERITONEUM
pulse was characteristically typhoidal. The leucocyte count in
this case was eight thousand a few hours after the onset. The leuco-
cyte count is very misleading early in the attack. Later it becomes
of more certain import. If distinctly pronounced, say fifteen or
twenty thousand, particularly if the polynuclear count is high, it
gives evidence in favor of the suppurative lesion. In the sudden
onset of typhoid I have seen white counts as high as twelve thou-
sand. In following up the count, however, the typhoid count vnW
decrease while the count in suppuration is more likely to increase.
Usually before the leucocyte count can be folloAved long enough
to give evidence of the cause, definite evidence Avill be available
from other sources.
Female Sexual Organs. — Numerous diseases arising from the
adnexa may simulate a periappendicitis. In some of these the
resemblance is so close that the most painstaking analysis may
fail to produce a positive diagnosis. In some rare instances, even
all the evidence obtained from the operation and the pathologic
laboratory put together may fail to make a positive differentiation.
It is desirable to consider all the physical evidence before the his-
tory is taken into account. This is desirable since appendicitis is
a thoroughly respectable disease, and young females in giving the
history may avoid factors that are not compatible with the most
exemplary social conduct.
I have found this the most difficult condition to differentiate
from appendicitis. Pain in the right groin in young women if
more or less persistent is likely not caused by an appendicitis. If
the pain radiates over the hip or down the thigh the pain most cer-
tainly is ovarian in origin. Unless a history of initial epigastric
pain, with or without nausea, preceding the groin pain is obtained,
the appendix is not involved.
The various diseases that may simulate appendicitis or its com-
plications will be considered separately.
Ectopic Pregnancy. — Tlie sudden pain of extrauterine preg-
nancy when located on the right side, may simulate appendicitis.
The pain is usually more severe than in appendicitis except in the
gangrenous types. The pain in tubal disease is usually situated
low in the pelvis often associated with vesical or rectal tenderness.
The pain is often described as bearing down. Collapse Avhen pres-
APPENDICITIS 563
ent indicates tubal trouble, while vomiting points to appendicitis.
Anemia when marked makes tubal trouble nearly certain. A leuco-
cytosis above fourteen thousand indicates appendicitis. An initial
rise in temiDcrature speaks for appendicitis while a temperature of
several degrees is usually present after a day or two when there
is a blood clot in the culdesac. An initial Ioav temperature and
rapid pulse operates for tubal disease. Physical examination in
the tubal disease shoAvs moderate rigidity of the lower segment of
both recti muscles, often with but moderately deep tenderness.
The vaginal examination may show a tubal lesion or a roundish,
fairly hard bloodclot palpable in the culdesac. If the social po-
sition is such that a careful history is permissible, the typical re-
lation of the attack to a missed period may be a great aid; but
when it is not, the statement of the patient is more apt to mis-
lead than to aid. In cases where there is doubt, delay may aid in
solving the problem.
A tubal pregnancy may cause pain and simulate an appendicitis
in the groin before rupture. Physical examination w411 demon-
strate a thickened tube and an absence of muscular rigidity.
Parametritis. — Infections of the parauterine connective tissue
resulting from abortion may give rise to sym^Dtoms of pelvic infec-
tion simulating inflammation of the appendix located in the pelvis.
The pain may be referred to the iliac fossa, and infection may ex-
tend over the pelvic brim, simulating a tumor mass originating
from the appendix in this region. If a history of abortion can be
obtained and a vaginal examination be made, the extraperitoneal
character of the exudate becomes apparent. The presence of a hard,
bone-like mass situated over the body of the ischium indicates un-
mistakably in favor of a parametritis. If one can separate such a
patient from her friends, and secure an examination under an
anesthetic, these facts can be determined with accuracy.
Ovarian Tumor with Twisted Pedicle. — AVhen the pedicle of an
ovarian tumor becomes twisted the wall suifers from lack of nu-
trition and becomes an irritant to the surrounding peritoneum
The symptoms are those of intense abdominal pain, usually lo-
cated in the pelvis and lower abdomen. When the previous exist-
ence of a tumor is known the diagnosis is easy. Even when not
knoAvn, if a vaginal examination is made, the rounded mass can be
e564 THE PERITONEUM
outlined, Avhieli is quite unlike the exudate from ai)pendieitis, par-
ticularly of a l)eginning appendicitis. After the disease has ex-
isted some da^'s the tumor may be obscured by the surrounding
exudation. Temperature and leucocytosis may closely simulate
the findings in appendicitis, save that the initial rise is apt to
be greater in case of the twisted pedicle. There may be a his-
tory of repeated attacks, -which simulates very much the course
of appendicitis. The muscular rigidity is usually bilateral even
though the cyst is small and lies in one side of the culdesac.
Gonorrheal Perisalpingitis. — The differentiation ])etween an acute
appendicitis and a gonorrheal infection of the tubes often presents
difficulties because of the position in which the consultant is placed.
Openly to suspect such an infection Avould excite sedition. In
such instances the manner in which the patient answers questions,
her disposition to observe carefully the movements of the examiner,
the general attitude of apprehension, much like one undergoing a
Bertillon measurement, should cause the examiner to exercise the
greatest caution in expressing an opinion.
The history may give additional aid. The first question may
bring forth a profusion of information, particularly as to the causa-
tion. A jDatient once told me the pain was caused by lifting a
bucket of Avater, and I believed it. Often the trouble is ascribed
to a fall, which perhaps conveys more truth than the patient in-
tended. An attempt is often made to mislead the examiner as to
the site of maximum pain. The region of the appendix is often in-
dicated in order to thi'ow the examiner off tlie track. I once met
such a situation by directing that the patient be alloAved to place
half a mustard plaster over the site of maximum pain. Returning
later I found the site of hyperemia following its use directly over
the pubes. After her sistei' had gone to the corner drug store and
her mother to the kitchen, the patient readily told all about her
trouble. When not hampered by the presence of fastidious rela-
tives the diagnosis is not so difficult.
When only the right tube is involved the pain may be referred
to the right groin and when sudden in onset, accompanied by vom-
iting, it may simulate appendicitis very closely even Avhen all the
factors are available. Though the tu])al infection be unilateral the
lower portion of both recti will be rigid because the entire pelvic
APPENDICITIS 565
peritoneum responds to the irritation. In appendicitis the right
rectus alone is rigid unless it lies in the pelvis and has caused a
generalized pelvic peritonitis, Avhen both recti may be rigid. In
such instances the right rectus Avill be found to be rigid for a
greater extent than the left.
The temperature is prone to be higher in the tubal infections.
Temperatures of 103° or 104° or more, are often reached
early in the attack. Such a degree of fever would be very unusual
in beginning appendicitis. Vesical and rectal tenesmus may be
pronounced in tubal disease. Leucocytosis is more apt to be high
early than in appendicitis, though this evidence should not be con-
sidered until after the diagnosis is made.
When a true history can be obtained the previous existence of a
leucorrhea, or vesical irritation, or a prolonged menstruation may
aid. When a physical examination is possible, and the microscopic
demonstration of the gonococci is made and palpation reveals a
pelvic mass or a thick tul)e, the diagnosis is easy. One must re-
member, however, that the diagnosis of a gonorrheal salpingitis
only is made by such evidence, and appendicitis is not excluded
thereby. I am led to emphasize this point because I once had a pa-
tient who Avas knoAvn to have chronic gonorrheal tubes. An acute
attack of pain in the right side was ascribed to a harmony meeting
among the organisms of the tube. A belated operation showed an
appendix perforated near its base. The versatility of modern
civilization must ever be kept in mind.
The site of pain in the normally located appendix is higher and
more lateral than that of tubal disease. Tubal pain is apt to be
greater just over the pelvic l)i'ini. Sometimes in aiipendicitis pain
may be elicited by pressing deeply over the anterior edge of the
quadratus lumborum muscle, while a painful tube is not ag-
gravated l)y this maneuver. In tubal disease the opposite side is
usually tender to deep pressure. Bilatei-al or left-sided tu])al
disease will seldom give rise to difficulty in diagnosis, but the pos-
sibility of an ujiusually located appendix should not be forgotten.
I once found an appendix in an inguinal hernia on the left side.
The difficulty in differential diagnosis is further increased be-
cause of the frequency Avith whicli llie tu])es and pelvic peritoneum
are involved in appendicitis. I have made it a point Avhen operating
566 THE PERITONEUM
on women for appendicitis so to place the incision that the pelvic
organs can be explored. In fully 10 per cent of cases the presence
of a distinct perisalpingitis is found. In some of these instances,
at first glance the primary focus of infection may not be apparent.
The point -which permits of a differentiation is chiefly that in
salpingitis secondary to appendicitis the mucosa of the tube is not
involved, while in gonorrheal salpingitis this is of course the pri-
mary seat. The occlusion of the tube is often stated to be a sign of en-
dosalpingitis. My studies lead me to believe otherwise. The inner
layer of the fimbria is the fixed point, and when a subserous edema,
from any cause, occurs, the end of the fimbria becomes turned in.
In appendiceal perisalpingitis the tube is not densely infiltrated,
nor is it so apt to be elongated as in the specific disease. Con-
versely, in primary tubal disease the appendix may be involved.
Fortunately, one need feel no compunction against the removal
of the appendix Avhen it is involved. Examination Avill shoAv foci
of infection if it is the primary source, and a diffuse periappendi-
citis if it is secondarily affected.
When a generalized pelvic peritonitis has resulted from a per-
forated appendix, the entire thickness of the tube may become in-
volved. In such a case the lumen of the tube itself may contain
pus. When the walls are thickened as the result of a perisalpingitis,
they are less edematous than in gonococcal infection. This is
due to the pronounced hyperemia of the submucosa. On section
there are fewer cells than in the gonorrheal tubes, and there are
proportionately more polynuclear leucocytes.
Ovarian Hemorrhage. — Hemorrhage within the substance of the
ovary may give rise to severe pain in the lower abdomen, but is un-
attended by fever of any considerable magnitude or by leuco-
cytosis. IMuscular rigidity is absent. The character and location
of the pain simulate tubal abortion rather than appendicitis, but
it lacks the constitutional disturbances of a ruptured ectopic preg-
nancy.
Dysmenorrhea. — (Noninflammatory pelvic complaints.) Many ap-
pendices are removed because of pelvic disturbances other than those
caused by frank inflammation. The source of these pelvic pains is not
known, and here it suffices to separate them from inflammations of the
appendix. The problem is simplified if it is remembered that dis-
APPENDICITIS 567
tiirbances from this organ are confined to those clue to reflex dis-
turbances, transmitted usually to the epigastric region, and those
due to periappendicitis which are local in nature. Constant pains
in the groin are almost certain not to be caused by any disease of
the appendix. The factors which point to their source in the pel-
vic organs is their dragging character, often associated with sacral
pain. Often they radiate over the hip or down the course of the
obturator nerve. They recur at frequent intervals, the patient
often declaring that they are constant. Not infrequently the pains
are aggravated by menstruation, less often they are relieved by
the monthly flux. In a previous publication I attempted to clarify
this problem by the use of French expressions. The one type, char-
acterized as "hyperovarie," is represented in the robust girl with
an abundance of animal vitality who does not complain of pain
when there is active physical exercise in prospect. The other type,
the "hypoovarie, " are generally frail and slender, and are pos-
sessed of limited physical ambition. They move, as George Ade
says, as if they were on casters. This type have small furrowed
ovaries, and time but confirms their complaints, while the first
mentioned type lose their pain as soon as they engage in the gentle
art of pushing a perambulator.
The hyperovarie type are not injured by a needless appendec-
tomy, -while the other type are apt to sufi'er a permanent nervous
upset. They complain of adhesions, and clamor for repeated op-
erations.
It has always been my rule not to remove the appendix from
a young woman unless there is physical evidence of a periap-
pendicitis or a distinct history of vomiting, fever, and localized
pain.
Pyelitis of Pregnancy. — Not infrequently there occurs an infec-
tion of the kidney in pregnant women attended by bacteremia, some-
times pyuria. Sometimes there exists merely an infection of the pelvis
of the kidney sometimes an infection of the kidney itself. The charac-
teristic symptoms are relatively high fever, often initiated by n chill,
sometimes attended l\v psychic disturbances. There may be ])aiii on
pressure in the appendiceal region. Since this complication occurs
usually in the later months of pregnancy, physical examinations
are rendered more difficult. The diagnostic features are the deep
568 THE PERITONEUM
tenderness over the kidney and the alienee of muscular rigidity
over the site of the appendix. I once had a patient with a suppurat-
ing appendix A^hich lay over the lower pole of the kidney. Since
appendicitis in pregnancy is of greater moment than in the nonpreg-
nant, exploration seems to be the only means of solution in such cases.
Genital Infections in the Male. — Epididymitis and diffuse infec-
tion may give rise to pain referred to the region of the appendix.
There is an absence of muscular rigidity, except possibly over the
lower abdomen just above the inguinal canal. The epididymis is
tender, and obviously the site of an infection. Leucocytosis and
rise of temperature may be as marked as in appendicitis. The
testicular lesion is sometimes so little obvious that its presence is
not suspected.
Hernias. — A beginning inguinal hei'mia may cause pain in the
groin, sometimes higher. These are particularly apt to confuse
when they split the muscle layers and extend upwards towards
the appendiceal region. These may become irreducible and in-
flamed, thus heightening the simulation. A bit of omentum may
become adherent, thrombotic, and inflamed, and thus produce a
tender tumor above Poupart's ligament.
A double difficulty is encountered if an appendix lying in a
hernial sac becomes inflamed. The correct diagnosis is seldom
made (just twice in sixty-two cases to be exact, — Wassiljew).
In one of the cases I observed, the diagnosis should have been made.
A large inguinal hernia A\hich had not l)een r-educed for many
5'ears suddenly became violently inflamed. There Avere no symp-
toms of strangulation. Fortunately, I made no attempt at repo-
sition, but proceeded at once to operation. A perforation at the
base of the appendix had already occui'red, and a prolonged sup-
puration in the sac lesulted. In my other case the symptoms of
strangulation were primary. The cecum and a loop of ileum
showed evidence of strangulation. I suspect the appendix be-
came inflamed because it suffered the vascular embarrassment of
strangulation of the gut higher up. There was a general peri-
vascular infiltration Avith no local foci.
Diseases of the Chest. — It is genei-ally recognized that in young
childi'cn pleural pains are fi-equently referred to the abdomen.
It is not so generally appreciated that the same condition may
APPENDICITIS 5G9
prevail in adults. In children the question as to the presence or
absence of muscular rigidity is ansAvered "with difficulty. The res-
piratory excursions are limited in both diseases, but in primary
pulmonary diseases they are more frequent. The diagnosis is de-
pendent largely on the demonstration of a pulmonary or, at least,
an intrathoracic lesion. This is often difficult, for some days may
elapse before definite physical signs develop. In such instances a
more tympanitic note on the right side may put the surgeon on his
guard even before there are any auscultatory changes. In adults
the physical signs are usually present, and found, if carefully
sought. Error here nearly ahvavs comes from lack of diligence,
though it must be added that all physical signs may be absent in
the first feiv hours. In the adult, muscular rigidity can be dem-
onstrated in all patients demanding immediate operation.
Possibly a too rigid attention to the pulmonary signs causes
many cases of associated infection of the peritoneal cavity by the
pneumococcus to be overlooked. This is a matter of small practical
moment, however, because a pneumococcic peritonitis is not a sub-
ject for early operation, while the removal of a normal appendix
in the presence of pneumonia is embarrassing to the operator,
and places a serious additional burden on the patient.
Chronic Appendicitis
The following interpretation of the term chronic appendicitis is
an attempt to correlate symptomatology and anatomic findings.
It is desirable that the surgeon know whether or not the oi'gan he
holds in his hand is responsible for the existence of the symptoms
for the relief of which he is operating. There are few more abused
terms in surgery. The vaguest local or general symptoms are too
often taken to warrant the removal of the appendix and the re-
covery of the patient from the operative traumatism is accepted
as vindication of the opinion. IVEuch has been written by surgeons
and by pathologists, and yet more by those who are neither. There
has been l)ut little attempt to correlate the histologic with the
clinical findings. This discussion is based on such a study. The
various conditions discussed under this head from time to time
do not admit of ready classification yet certain indefinite groups
niav be constructed.
570
THE PERITONEUM
The folloAviiig groups may be recognized: Those cases in Avhich
recovery is complete, those "which never come to an acute attack,
and finally, the vast group in which the api^endix is not diseased
at all.
Remittent Appendicitis (Postappendicitis, Fenger). — A designa
tion for this group is as difficult as forming a characteristic term
for tumors, Avhich it will be remembered Virchow stated could not
be made. It is meant to include under this head those cases only
in which, after an acute attack, recovery is not complete and a
Fig. 186. — Remittent appendicitis. Tliis patient had a sharp acute attack and was oper-
ated on in the free interval. An adhesion of the omentum with slight interstitial changes is all
that remains to indicate a past inflammation.
series of symptoms continue either as a continuance of reactive
processes or from conditions resulting therefrom. Fenger designated
the first group '^ postappendicitis" (Fig. 186). The second group
presents residual processes such as adhesions, etc. In very rare in-
stances these remain as anatomic structures, interfering mechan-
ically with the function of the gut (Fig. 187), or in sclerotic proc-
esses within the appendix itself the significance of which can
only be abstracted from the subjective manifestations of the pa-
tient before and after operation.
APPENDICITIS
571
From the first group must be excluded the ordinary everyday
appendicitis patients who suffer acute attacks, and recover, only
to be affected later by a renewed attack. Sonnenburg applied the
term chronic appendicitis to this group, obviously not Avithout jus-
tification, for it can not be determined with certainty whether or
not the recovery has been complete in the interval. Possibly re-
lapsing appendicitis Avould be a better term. Be this as it may, the
Fig. 187. — Adhesions of several loops of ileum about the cecum. There had been a per-
foration about the base of the appendix. Intermittent symptoms of intestinal obstructions
persisted.
diagnosis of these cases is usually easy from the history alone, and
appendices removed in the iiitcrxal may present no anatomic evi-
dence of past disease. An appendix which upon removal shows no
evidence of disease can not, in the light of present knowledge, be
said to be the cause of symptoms, though we must admit that, in
the light of studies in infections from other sources, such a rela-
572 THE PERITONEUM
tionship may exist. Therefore, it seems as justifiable to exclude
these from the group of chronic diseases, as in the case of the kid-
neys or tonsils in which acute attacks may present themselves from
time to time without their previous state being called into ques-
tion by the terminology.
Chronic Productive Appendicitis. — The elemental factor in the
determination of this group is the history of an acute attack. This
may be clear from the recounting of the cardinal symptoms, pos-
sibly confirmed by the attending physician who observed the pa-
tient at the time of the attack. More often the history is less
clear. Sometimes one must look back to the ])eriod of childhood
when attacks of indigestion and vomiting and general abdominal
pain occurred. It has been a source of unending astonishment
to many to observe with what regularity children seen many years
ago with these complaints, return in after years with unmistakable
appendicitis. So often has this observation been made that the
syndrome of acute abdominal pain with vomiting and fever has
come to mean to me only acute appendicitis. Green apples may
produce pain and vomiting, but not fever, nor does the encounter
with the first ''plug" or cigar. These early histories are impor-
tant, but must be elicited with skill, for a positive history may be
forced from most persons. When spontaneously presented such a
history gives a basis for the consideration of the possil)ility of the
existence of chronic changes within the appendix incident to an
acute attack.
Pathology. — The api)endix may appear thickened and in a state
of abnormal rigidity. The finger, in transporting the organ into
tlie wound, may note this more clearly than the eye. The organ
may present an aliuormal translucence, due to an absence of deep
capillary circulation (Fig. 188). Perhaps a few superficial vessels
may make up for this deficiency of the deep vessels by undue prom-
inence. More often the superficial vessels about the head of the
cecum and the mesentery of the terminal ileum show a marked
prominence. Sometimes an enterolith is palpable, and sometimes a
scar ; or a distention due to soft accumulations of feces and mucus
may be noted.
The microscopic changes are those of chronic reaction. Aschoft'
has well designated this state as "appendicitis cicitrans retardata. "
APPENDICITIS
573
Any of the changes l)eh)ng"ino- to tliis state may be noted. There may
be proliferation in the lymph follicles (Fig. 189) or round cells may
be scattered about in the connective tissue in the region of the fol-
licles. Round cells or leucocytes may be seen between the gland
Fig. 188. — Chronic induration of the wall of the appendix. The macroscopic appearance
was little altered but the organ was dense to the feel because of the increased amount of
librous tissue.
Fig. 189. — Chronic appendicitis in which the Iym|)li follicles remain prominent, simulating
hypertrophy of the tonsil. The vessels in the sulinnicosa show plasma cell infiltration.
cells. The gland cells may show a cicatiueial deformation. The
muscle layer may stain less intensely, and the muscle fibers may
be pressed apart by a myxedematous or pseudomucinous exudate (Fig.
190). The subserous and submucous connective tissue each may show
574
THE PERITONEUM
a lessened affinity for acid dyes, and the exudate between the fiber
bundles may press them apart. The subserous plexus of vessels may
show an intense endarteritis, even to the point of obliteration.
Any or all of the anatomic changes above recorded may be pres-
ent. Without careful examination Avith the use of various dyes
the changes may escape notice. Because of the difficulty of dis-
tinguishing nerve fibrils from elastic fi])ers any change in the for-
mer can not be determined with certainty. This is made more dif-
]r^m ^\^<%
^.
'/ \
v^oh'-M-T',
f^^V--:
ji I-
Fig. 190. — Section of a subacutely inflamed appendix. The submucosa is much thickened due
to a pseudomucinous exudate within the connective tissue spaces.
ficult by the fact that the elastic fibers are increased in number in
chronic appendicitis.
Symptoms. — AVhen acute exacerbations occur, reflexes may be
instituted. The lesser degrees of reaction may act the same way.
The reaction may be great enough to excite a local tenderness
without spontaneous local pain, or spontaneous local pain may be
caused without local tenderness. The latter align it Avith a re-
current acute appendicitis self-evident in character, and need not
APPENDICITIS 575
be cousidered here. The chronic reaction not sufficient to produce
spontaneous local pain may give rise to gastric disturbances. In
such instances reference to the appendix can be arrived at only
by exclusion. If local pain elicited by pressure is present a con-
nection may be inferred. An association is more likely if the his-
tor.y of an acute attack is obtained.
The manner of the production of the gastric disturbance is not
certain. It may be assumed that the ii-ritation of the splanchnic
nerve is transmitted to the semilunar ganglia. Any attempt to
say from the appearance of an appendix Avhether or not such re-
flexes were present is not possible. Deep tenderness to local
pressure exists only when the appendix is rigid, because of the
exudate above mentioned. This is constant. Superficial tender-
ness counts against any local changes. Spontaneous local pain is
caused l)y periappendicitis, as previously discussed in the section
on acute appendicitis.
Postappendiceal Cicatrization. — In this type of chronic cicatri-
zing appendicitis there are no signs of active organic processes.
All represent end processes.
Pathology. — Small cicatricial bands juxtaposed to masses of fat
%^ath the mesenteroleum are sometimes noted. It is a question
whether these are end results of reactive processes or merely atrophic
changes. Personally, I am inclined- to the latter view.
The changes undoubtedly produced by inflammation may be
grouped into those of the appendix itself and those of its environs.
In the appendix itself patches of scar tissue, including the whole
wall, including the mucosa, are tlie most frequent. The destruc-
tion may be so great as to produce an occlusion of the lumen for a
greater or less extent. Sometimes the destruction has been so com-
plete that a mere band of scar tissue may unite the terminal por-
tion of the appendix to the cecum. In none of these conditions is
there any trace of existent inflammatory processes.
The lesions in the environs of the appendix are represented by
adhesive bands. These may exist between different portions of the
appendix or between the appendix and cecum or ileum or between
the appendix and some foreign point, such as the parietal Avail,
tube, ovary, uterus, or a hernial sac. There is scarcely a region in
the abdomen to Avhieh the appendix may not become attached.
576 THE PERITONEUM
Bands may extend from one point to another in the region of the
appendix, and may limit the movement of some normally mov-
able point, or may, in rare instances, produce an actual constric-
tion of a hollow organ.
Symptomatology . — Scleroses within the appendix are often dis-
covered in patients who gave no evidence of their existence.
When no limitation of movement is exercised on any neighboring
organ there are no symptoms. Adhesions to adjacent organs like-
wise may exist without symptoms. Bands producing mechanical
constriction are productive of the usual symptoms of obstruction.
Differential Diagnosis. — A great variety of diseases may present
local discomfort and pain. Cecal carcinoma, before palpal)le tumor
formation, can only be suspected by its slowly progressive char-
acter and slowly developing stenosis. Actinomycosis is so rare
that the surgeon may consider himself fortunate if he thinks of
the possibility when the organ is exposed during an operation.
Tuberculosis likewise may cause a progressively advancing dis-
order. Stenosis and tumor formation may precede the develop-
ment of pain.
Masked Appendicitis. — In contradistinction to the recurrent ap-
pendicitis, by masked appendicitis is meant an affection of the ap-
pendix which never manifests itself in acute attacks or exacerba-
tions. This type includes those rather rare instances in which an
organ obviously diseased is associated Avith or simulates chronic
disturbances of one sort or another. The appendix does not mani-
fest disturbances of such a character as to direct attention to it-
self. In such instances the appendix when exposed at operation is
much thickened, and exhibits processes of a hyperplastic nature.
These have been well designated by Hiller as "masked appendi-
citis." Gussenbauer remarks that the term applies not to the na-
ture of the process, but to the possibilities of diagnosis.
Pathology. — In this type the entire picture is that of slowly ad-
vancing proliferation. The appendices are large, often as large
as the finger (Fig. 101). The organ is rigid on manipulation and
firm to the touch. The surface is deep red in color, numerous ves-
sels are visible, and the entire environment may show extensive
varicosities. On section the organ is firm to the touch, giving a
sensation to the knife more like that of cutting a carrot than of
APPENDICITIS
577
fibrous tissue. The cut surface is moist aud glistening and the
mueosa may point out of the lumen.
The microscopic section shoAvs a mucosa infiltrated with round
cells, and the germinal cells of the lymph follicles show activity of
proliferation in their endothelial elements. The submucosa is drop-
sical, and contains many round cells and a few leucocytes. The
muscular layer likewise is edematous. The subserosa presents the
greatest thickening. The fiber bundles making up this layer are
pressed far apart by a serous fluid exudate in which I'ound cells
are imbedded. The vessels are increased in number, and the walls
are much thickened and are infiltrated Avith round cells.
Fig. 191. — Large thickened appendix. The walls show pronounced fibrous thickening with
abundant round cell infiltration. Pseudotubercles are shown near the tip.
In many of these specimens an acute exacerbation has taken
place, and some point presents a proliferation or there are evi-
dences of a less localized acute exacerbation. In such cases large
numbers of iiolynucleai- leucocytes are intermingled in the tissue.
Symptoms. — The symptoms these cases present are those referred
to some distant point, such as indefinite pains in the gall bladder re-
gion or some chronic disturbance of the stomach. The former is
characterized by subcostal pains, sometimes slight attacks of jaun-
dice, and perhaps nausea and vomiting. The latter usually is rep-
resented by hyperacidity or hunger pains. The subjective symp-
toms are associated A\ith local tenderness in the region of the duo-
578 THE PERITONEUM
denum. Often there is a marked disturbance of the nervous sys-
tem, Avhieh much obscures the general picture.
This indefinite symptomatology is usually not cleared up until,
after failure to make a diagnosis, an exploratory operation is un-
dertaken. Search fails to disclose any disease of the upper ab-
dominal tract, and the appendix shoAvs changes of the character
already noted.
Sometimes, instead, after vainly searching for relief, the patient
develops an exacerbation of his trouble with pain on pressure over
the appendix, or possibly spontaneous pain Avhich leads to the cor-
rect diagnosis and operation. On the other hand, an acute inflam-
mation with periappendicitis may supervene, presenting the cardi-
nal symptoms of an acute appendicitis. Perforation may even take
place. The patient discovers after recovery from the operation
that his old symptoms have disappeared. He is then able to make
his own deductions.
If Ave seek the cause of the referred symptoms the explanation
must be sought in the reflex through the splanchnic system. The
irritation in the appendix affects the local plexus, as the periphery
of the appendix is not invoh^ed, none of the meduUated system is
affected, hence there are no local manifestations.
Pseudoappendicitis. — Aschoff suggests the term pscucloappcndi-
citis for conditions Avhich simulate appendicitis. I like the term
because it ridicules the limitations of our diagnostic skill. Litten,
speaking of pseudoleucemia, compared the term to that of pseudomil-
lionaire, the latter, according to Litten. being an impecunious in-
dividual Avith grandiose delusions of Avealth. So Ave, in speaking
of pseudodiseases, are deceiA^ing ourselves into belicAdng Ave have
diagnosed a disease Avhich does not exist.
Symptomatology. — In so-called pseudoappendicitis there is pain,
more or less constant, in the right iliac fossa, indefinite epi-
gastric distention, general malaise, the so-called ''dyspepsie ap-
pendiculaire" of Longuet. On the other hand the patient may
be ruddy and in the l)est of general health. More often the symp-
toms are more of a recalcitrant existent or imaginary loA^er. Con-
stipation or in extreme cases mucous colitis may be present. Fre-
quently scanty or abundant urine of Ioav specific gravity, or the
tAvo alternating, may be complained of. Associated Avitli the pains
APPENDICITIS 579
in the iliac fossa, sacral pains and pains radiating over the hip and
down the thigh may he complained of. Headache, sleeplessness,
globus, and any other nervous manifestations may complicate the
picture.
Physical examination reveals nothing except tenderness. Pain
on pressure over McBurney's point is usually the factor that stim-
ulates the diagnosis. In most patients a superficial tenderness ex-
ists, which may disappear on deep pressure, but sometimes deep pres-
sure is required to elicit it. Often a roll of muscle resembles in a
Avay a protective rigidity, but it is always as a roll, and not as a
broad protective reaction constantly fixed. When pressed deeply
doAvn this may give the sensation of a small oblong body, which,
because it occupies the position the appendix sometimes occupies,
has been interpreted as being that organ. Personally, I feel that
I am doing well to palpate these small organs after the abdomen
has been opened. The roll of muscle contracts under pressure of
the examining finger, and is evidentl}' reflexly stimulated from the
pressure beneath. This painful point may be over the usual site of
the appendix or just above Poupart's ligament, nearer the pelvic
brim, or near the lower pole of the kidney. In a considerable pro-
portion of cases an equal or less tenderness may be elicited at a
like point on the other side with like evidence of muscle con-
traction. Sometimes an additional point of tenderness is demon-
strable in the epigastrium, often over a pulsating aorta.
Differential Diagnosis. — With such an indefinite disease picture
the range of diseases which may need to be differentiated from it
is great. Only a few need be reviewed here.
Genital Disorders. — ]\Iany young Avomen complain of pain in the
groin, usually the right or the right predominatingly. This pain
is present more or less constantly, and is made Avorse by hard work,
especially housework, rarely by skating or dancing. It is often
worse a few days before the menstrual period. The pain is often
described as burning in character, and often radiates to the sacrum
or over the hip, occasionally down the region of distribution of
the obturator nerve. There is superficial as well as deep tender-
ness in the right lower abdomen, often in the epigastrium and the
left side, as above described. When palpation is undertaken the
abdomen may be humped up like a mustang about to receive the
580 THE PERITONEUM
saddle girth ; or the examination may elicit alternating giggles
and exclamations of pain. On the other hand, the patient may-
lie with perfectly flaccid muscles permitting deep palpation, evinc-
ing but little evidence of pain. These are usually noted in females,
single in fact as Avell as in name.
Another class is represented by women who have borne children.
They are devoid of the symptomatic frills above detailed, but usually
have backache, often leucorrhea, and frequently headache, par-
ticularly of the occipital region and of the vault. These patients
usually present obvious lesions of the genitals incident to child-
birth or to chronic disease of the uterus. Sometimes there is no
obvious genital lesion.
Sometimes a chronic salpingitis wrapped about an ovary may
produce such pains as are above noted. These changes may be so
slight as to escape the palpating finger. A little shortening of a
uterine ligament, pei'chance a tender ovary, may give the clue.
Sexual Neurasthenia. — Males form a large contingent of this class.
Their complaint is pain in the right lower abdomen, less often in
the left. They often complain of burning on urination, and often
get up at night. The whole train of phenomena coincident with
this state is usually more or less well pronounced. They have
deep tenderness, and, if the examiner shares the acute imagina-
tion, he may mistake the tense muscle bundles for a hardened
appendix. This type of individual has a peculiar psychology.
He works for forty dollars a month, his mustache droops, and he
does not play baseball on Sunday.
In females the genital bias of the complaint is usually more
pronounced, but in some instances the general features as noted
in the male only are noted.
Each of the classes above mentioned may perchance have had
his appendix removed. If so, he has adhesions at the site of the
operation, and his refrain is in nowise changed from that presented
before the removal of the appendix.
The elemental character of the neurosis is the factor Avhich guides
to the correct diagnosis. If the patient is neurotic or presents
neurotic manifestations during the examination, great caution is
necessary. In the solution of such problems errors are bound to
creep in. A neurotic may actually have a chronically affected
APPENDICITIS 581
appendix, and, on the other hand, the most demure may present
symptoms not dependent on organic lesions.
Treatment"
The literature on the treatment of appendicitis in all countries
shows a curiously parallel evolution. Medical treatment, open-
ing of abscesses, operation in the interval or Avhen diffuse peri-
tonitis is present represents the beginning, while the ultimate
stage is represented by early operation on all progressive cases.
Medical. — The expectant treatment may consist in the use of
an ice bag to control the local pain and vomiting. The withhold-
ing of everything by mouth according to the Ochsner plan is to
be commended. Laxatives are never permissible under any con-
dition. Once the diagnosis has been made and the patient is
headed for the hospital morphine may be given to control the pain,
not before.
The object of withholding anodynes until the diagnosis is made
is that after the pains have been controlled by artificial means
the chief of the cardinal signs is obliterated and the making of
the diagnosis is much more difficult. Furthermore, after the pain
has been controlled the patient is less likely to listen to arguments
in favor of an operation than when he is constantly being reminded
by intense abdominal pains.
Once an operation is agreed upon it would be permitting needless
suffering to Avithhold morphine until such, time as the operation
could be performed.
Time for Operation. — When a good surgeon arrives is the proper
time for the operation. This represents the fatal weakness in
this scheme of j)rocedure. The most variable tyro places himself
in the category of the competent. What competent surgeon does
not observe these Avith a degree of compassion ! Persons Avho op-
erate an hour or two on a patient afflicted Avith appendicitis are
a greater menace to the patient than the disease. Murphy's dic-
tum "in quick, out quicker" is of vast importance. Quickness
is not measured by the clock, but by the degree of traumatism
inflicted. Some operators are so sIoav that it takes them a long
*Those interested in the literature of the treatment nf appendicitis will find an excellent
resume in Sprengel, Appendicitis, Enke, Stuttgart, 1906.
582 THE PERITONEUM
time to inflict a little traumatism. An incompetent man, on the
other hand, can inflict more traumatism in a limited time in this
region than in any other region of the body.
Indications for Operation. — The requirements to justify the re-
moval of the appendix are the juxtaposition of a patient Avith a
diseased organ and a surgeon. An endless literature has been
written as to the time the organ should be removed.
In general two types may be distinguished: patients who have
had an attack and those who are having an attack.
Operation in the Interval. — Those who have once had an attack
are likely to have a recurrence. Among those whom I have seen
in an attack Avho were not operated on the vast majority of cases
have had a recurrence. The history of several previous attacks
makes the indication doul)ly emphatic. In adults after the age of
thirty-five and in children recurrences are particularly apt to be
severe.
In patients who have had severe attacks and have had abscesses,
particularly if there is evidence of perforation as the escape of
an enterolith or the formation of fistula, if the wovnid heals, the
patient is practically insured against future attacks. In these
subsequent operations are demanded because of scar hernia and
local disturbances of gut function. I have never seen such a
case suffer severe recurrences of appendicitis.
Operation in the Attack. — All acute cases are surgical from be-
ginning to the end. It was formerly advised that internist and
surgeon should work together. The internist has as little business
loitering about a patient with appendicitis as he has treating a
gunshot wound of the abdomen.
No one can tell particularly in the beginning of the attack what
type of lesion will ultimately develop. This is quite obvious from
a study of the pathology, for what is in the beginning an endo-
appendicitis may perforate and lead to the most virulent general
peritonitis. Once the diagnosis is made, the fate of the patient
depends very largely on the skill of his surgeon. Most surgeons
advise operation as early as possible because it is not possible to
distinguish between the mild and the potentially severe cases.
There are cases in which there may be some latitude. For in-
stance, when there is a falling pulse and temperature with a sub-
^
APPENDICITIS 583
sidence of the local symptoms of tenderness and rigidity it is per-
missible to await an opportune time. When there is a lessening
of the symptoms even if there is tumor formation it may be per-
missible to permit a spontaneous subsidence provided the patient
is where he can be observed. If some days are required for such
tumor formation and if rigidity persists, operation had best be
undertaken.
If the disease is on the ascendency, operation should be done
at once. It has been advised that in cases of excessively severe onset
a few hours should be awaited so that the patient may recover from
the primary shock. These are just the cases which demand
operation early.
Place of Operation. — There is often a question in acute appen-
dicitis whether the patient should be taken to the surgeon or the
surgeon brought to the patient. When within ambulance dis-
tance unquestionably the patient should be taken to the hospital.
Here only can the surgeon do his best work and the patient is
assured the best after care. When it is necessary to convey the
patient by train, the matter is somewhat different. There is no
doubt that the patient can be safely conveyed, but it is exceed-
ingly trying to both patient and friends. Save for the annoyance
it brings the surgeon, no doubt, the most convenient way is to call
the surgeon, but the safest way is to take the patient at once to
the surgeon. The chief danger the patient undergoes in being
treated in his home by those not familiar with the after care of
such cases is that he will l)e overtreated. Food and laxatives,
from the joint action of friends and anxious doctors, often spell
intestinal paresis.
Type of Operation. — The type of operation depends, in the first
place, on the capability of the surgeon, and, in the second place,
on the nature of the lesion. It is possible to individualize some-
what so far as the type of disease goes, but it is not possible to
classify the surgeons. In general, it may be said that the sur-
geon may be allowed to operate fifteen minutes. After this time
either he has finished or has lost his way.
Early Stage. — In the very beginning before there are any ad-
hesions the organ of course must be removed. Care must be ex-
ercised in ligating the meson. In the highly inflamed state there
584 THE PERITONEUM
may be no free bleeding yet prolonged oozing may follow if proper
ligation is not done. The method of treatment of the stump is
immaterial. If the cecum is not affected ligation and inversion is
preferable. If the cecum is infiltrated and friable inversion should
not be attempted, for the stitches but tear out and iuAite disaster.
Stage of Adhesions. — In this stage there is no abscess but the
organ is surrounded by adherent omentum or intestinal loops.
It is this type in Avhich the inexperienced plays his havoc. His
sense of touch does not guide him to the offending organ and
an endless amount of traumatism may result before the organ is
located. The gut wall may be torn or so injured that infection es-
capes after the operation is concluded. Experience only brings
facility in locating the organ. The operator can save time by locat-
ing the ascending colon, making sure of the anterior tenia and per-
sisting in following this until the inflamed organ is reached.
Stage of Abscess Formation. — Generally speaking unless the
operator is skilled and a walled-off abscess is formed he should
desist as soon as the pus pocket is opened. Usually there will be
less danger of extending the peritonitis and in the majority of
cases the patient Avill cure himself of his appendicitis. Should the
operator persist in finding the appendix the wall of the abscess
may be ruptured and the infection be permitted to spread. Some-
times there are multiple abscesses and the drainage of the first
may not drain all. This primary drainage may be supplemented
by later ones should this become necessary.
Diffuse Peritonitis. — When there is diffuse peritonitis and the
appendix floats free, it should be ligated and removed. When it
is buried in adhesions and the opei-ator requires more than a very
few minutes to locate it, he had best allow it to remain and con-
tent himself with the simple drainage of the abdomen. The method
of drainage is that common to general peritonitis. It need be
remarked that the drain, particularly a gauze drain, should not
be allowed to come in contact Avith the stump of the appendix, for
if it does, the formation of a fecal fistula would be very much
encouraged.
The drainage of late abscesses has been covered in the section
dealing with retroperitoneal abscesses.
APPENDICITIS 585
Prognosis
Nine-tenths of the eases of appendicitis recover from the attack
if left untreated. The conflict of therapeutics is waged against
the final ten per cent.
Interval Operations. — Operations done after the acute attack has
subsided should have no mortality. He who operates on a suffi-
ciently great number must likely sooner or later meet a surgical
disaster. There are no absolute certainties in surgery .
Acute Periappendicitis. — Operations in this stage likewise have
a very low mortality, but embolism, secondary abscess, and the
like will have a certain mortality — possibly one or two per cent.
Periappendiceal Abscess. — With a walled-oif abscess the mortal-
ity is about the same as in the group ju,st mentioned. Secondary
abscesses may form with a prognosis all their oavu, and must be
figured .for the individual case. Once a walled-off abscess is al-
lowed to break spontaneously, the prognosis becomes grave, par-
ticularly in those younger than pul^erty and beyond forty years
of age. Even secondary abscesses themselves walled off add mate-
rially to the gravity of the lesion.
Spreading- Peritonitis. — When the inflammation is not limited
by reactive inflammation, the prognosis depends on the time and
character of the treatment. If early drainage is secured ^Y\th. ab-
lation of the infecting area, the mortality should be not over five
per cent. If there is notable delay, beyond say twenty-four hours,
the mortality mounts rapidly. Attemj)ts have been made to cal-
culate the percentage. It is not possible to calculate the character
of the lesion and the degree of violence of the infection, hence a
mathematic calculation is not possible. The prognosis of the con-
crete case must be made on data given in the general chapter on
prognosis.
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586 THE PERITONEUM
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APPENDICITIS 587
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Sonnenburg: Neuere Erfahnnigen iiljer Appendicitis, Mitt. a. d. Grezgeb. d.
Med. u. Chir., 1898, iii, 1.
Pathologie und Therapie der Perityphlitis, ed. 6, Leipzig, Vogel, 1908.
Sprengel: Appendicitis, Stuttgart, Enke, 1906.
Treves: Peritvi)hlitis. In: Allbutt, System of Medicine, N. Y., Macmillan, 1S98,
v. 4, p. 89.1.
VOLZ: Die durch Kothsteinc bedingte Durcldiolirung des Wurmfortsatzes die
haufig verkannte Ursache einer gefiihrlichen Peritonitis und deren
Behandlung mit Opium, Carlsruhe, Miiller, 1846.
Wassjljew : uber A]ipendicitis in Inguiualliernien bei Mtinnern, Ari-li. f. klin.
Chir., 1904, Ixxiii, 179.
Watzold: Deutsch. MilitJiraztl. Ztsehr., Chir., Lief, 66, 1898.
With: Peritonitis appondicularis eller den ved. Ulceration og. Perforation af
appendixileo-cocalis fremkaldtc Peritonitis, Festskr. d. hugevidensk., Fak.
-,.' v..j^jobcnk., 1879, No. 5. p. 1.
CHAPTER XX
CHOLECYSTITIC PERITONITIS
Inflammation of the gaU bladder and the structures lying near
it is one of the most common phenomena observed in the abdomen.
In the simpler eases the peritoneal covering of the gall bladder
becomes hyperemic in sympathy with the circulatory phenomena
of the mucosa, less often the peritoneum is actually coactive in the
reactive process, without, however, this reaction being sufficiently
intense to affect the surrounding organs. Not infrequently the
surrounding organs do respond to the gall-bladder involvement,
either by simple inflammation or by adhesions limited only to the
area in contact Avith the gall bladder. These are toxic phenomena
only. In rarer instances bacteria escape through the wall of the
gall bladder and form a more or less spreading inflammation in
the peritoneal cavity. More rarely still the gall-bladder wall may
become perforated, permitting its contents to escape en masse into
the peritoneal cavity. This infection may be localized in the re-
gion of the gall bladder or it may extend uninterruptedly through-
out the abdominal cavity. These various exigencies may be consid-
ered seriatim.
Pericholecystitic Hyperemia. — In most cases of gallstone colic
when the organ is observed in the acute stage it shows more or
less hyperemia of the peritoneal coat. Even when much reddened
and edematous, it may show no real reactive process. This is the
state usually observed in the ordinary ei^hemeral gallstone colic.
On section the peritoneal vessels are dilated, here and there a few
leucocytes are seen, possibly some ecchymosis and fibi-inous exu-
date, but the state is hardly beyond that of simple hyperemia,
altogether analogous to that already described in the general sec-
tion on hyperemia of the peritoneum. AYhen the source of irrita-
tion ceases the hyperemia subsides if not too long continued so
that no permanent changes in the vessels take place. AVhen this does
occur a varicosity results. This state is more rare over the gall
588
CHOLECYSTITIC PERITONITIS
589
bladder than over any of the other hoUoAv organs. The surround-
ing peritoneal surfaces are much more apt to retain evidence of
passed irritation than is the peritoneum covering- the gall bladder
itself. In this respect it is entirely analogous to the conditions
existing about the appendix. The cholecystoduodenocolic ligament
often shows a permanent hyperemia when the gall bladder itself
shows none (Fig. 192). The peritoneum in the region of the colon
and beyond lilvewise may show an increased vascularization. This
Fig. 192. — Dilatation of the vessels in the hepatocolic ligament in a patient who had had
many attacks of cholecystitis, but at the time of operation was free from symptoms.
state of the surrounding peritoneum I believe is a more accurate
criterion for the removal of the gall ])ladder than is the appear-
ance of that organ itself. Like the appendix the wall of the gall
bladder may recover so completely that no exact evidence of dis-
ease can be pointed out, but it still is subject to recrudescence of
the inflammation.
The reaction of the peritoneum covering the gall bladder may give
590
fHE PERITONEUM
rise to local tenderness, )jut does not excite muscular rigidity un-
less the parietal peritoneum has become excited by contact. Rigid-
ity plus tenderness indicates a wider extent of reaction than
tenderness without rigidity.
Pericholecystitic Peritonitis. — AVhen the reaction witliin the gall
bladder is more intense, a reactive process on the part of the cover-
Fig. 193. — ^Pericholecystitis with adhesions which attach the gall bladder to the colon.
.The gall bladder was filled with jnis and a single large ball-valve stone occupied the begin-
ning of the cystic duct.
ing peritoneum takes place. The vessels dilate, abundant cellular
and fibrinous exudation takes place about the vessels and on the
surface of the peritoneum. The reaction is usually such that the
exudate irritates the peritoneum of the surrounding organs, setting
them into a state of hyperemia and corresponding exudation. The
CHOLECYSTITIC PERITONITIS
591
irritation of the surrounding organs is a cliemical one. In some
instances the fluid may be bile stained, and yet be free from bac-
teria. The abdominal wall is irritated as well and the recti mus-
cles respond by a defensive rigidity. The result of these opposed
exudates is an adhesion of the surrounding organs to the gall
bladder. This may be so extensive that Avhen the process is some
days old, particularly if previous similar attacks have occurred,
the gall bladder may be found Avith difficulty (Fig. 193).
Fig. 194. — beginning necrosis of the gall bladder. The outlined areas were made by
stones which had lain deejjly imbedded in the nuicosa. The peritoneum over these regions
was blue-black in color.
Usually the exudate on the gall bladder peritoneum is absorbed
and the adhesions are released. In exceptional cases the adhesions
to the surrounding organs are permanent. In extreme cases the
gall bladder may become imbedded in a mass of scar tissue.
Spreading Peritonitis Going Out from the Nonperforated Gall
Bladder. — In this condition bacteria escape through the wall of
the gall bladder because of the loss of its integrity. This occurs
in conditions more intense than in the preceding section, yet not
592 THE PERITONEUM
great eiiougli to be attended h\ aetiial perforation. In order tliat
bacteria may escape, the wall of the gall bladder must be more or
less necrotic (Fig. 194) and the contents must be under increased
pressure. This is usually brought about by a stone impacted in
the cystic duct or by an inflammatory occlusion of that channel.
When this occurs the infection may be localized either by adhesions
formed by some previous inflammation or in advance of the actual
suppuration in the attack under question. In the absence of this
the infection may extend unhindered. AYhen the infection is local-
ized the colon and great omentum usually form the prominent
barriers to the advance of the infection. Such infection may go
on to abscess formation with its consequences, or it may subside
with the subsequent absorption of the barrier adhesions, or they
may remain permanently, hieroglyiDhics of the past catastrophe.
The genesis of these nonperfoi-ative pericystitic infections has
been the subject of speculation. Schievelbein and Kehr believe
that infection travels by way of Luschka's canals. Clairmont and
Haberer were of the same opinion and report a fatal case. Riedel
reported three case^, one of which recovei'ed folloAving operation,
the others died untreated. Doberauer reported two cases, one of
which followed a trauma and the other followed a typhoid ulcer.
Hugel reports several cases. This author makes the interesting
observation that the reason peritonitis does not more frequently
follow cholecystitis as compared to appendicitis is because of the
free anastomosis the gall bladder receives from its peritoneal at-
tachment with the liver, in contradistinction to the lack of such
anastomosis in the appendix. Johansson reports a case of his own.
The changes in the gall bladder were so slight as to give rise to the
belief that the perforation may have been in some other part of the
biliary apparatus. The author explains its occurrence by exten-
sion along the lymphatics. Salager and Roques report a case
occurring in childbed. NeuAverck and Liibke doubt if peritonitis
can take place without perforation. They conceive it possible that
a rupture may have been present but has healed. This hardly seems
likely since a gall bladder that is in a state of reaction or degen-
eration such as these invariably are, would hardlj' heal during any
period of time, much less in the time these cases have been under
observation.
CHOLECYSTITIC PERITONITIS 593
This variety of pericholecystitic inflammation is not so rare as
the literature would indicate. Pericolic infections of this variety
are a common occurrence in the practices of those surgeons who
drain acutely inflamed gall bladders. In harmony with the law
of the formation of adhesions this type is less likely to be followed
l)y permanent adhesions than the simpler type just discussed. In
my earlier work I was often astonished to find at secondary opera-
tion made for the purpose of the removal of the gall bladder that
all vestige of adhesions had disappeared.
For the most part peritonitides following nonperforative inflamma-
tion of the gall bladder are mild in character and tend to regress.
Only in a limited number of cases, as indicated by the above cita-
tions, do they progress to the death of the patient.
The onlj' bacterial study recorded is that of Hugel. He found
coli in several cases, in one streptococci and in one typhoid bacilli.
The bacteriology of pericholecystitic inflammations has not been
adequately worked out. Gilbert and Lippmanu have studied the
anaerobes in the normal state. It is possible that these play a role
in the pericholecystitic infections. A number of the recorded
cases note that the patient had previously had typhoid. Hugel
found colon bacilli and typhoid bacilli in several cases and strep-
to<'occi in one.
Peritonitis Follovidng- Perforation of the Gall Bladder. — This con-
dition may result without pronounced infection. It is the product
of necrotic inflammation plus local pressure. Ulcers similar to
peptic ulcers have been reported as resulting in perforation. Fre-
quently perforation takes place over the site of a stone. In these
instances reactive phenomena accompany the pressure phenomena.
This may result in adhesions to a surrounding organ with perfora-
tion into this instead of into the free peritoneal cavity. This is
commonly observed in those cases in which huge stones which have
so ulcerated through call attention to their migrations by produc-
ing an intestinal obstruction. This type of disease is not rare.
McWilliams reports on 186 cases. This author records perforation
as dependent upon the virulence of the gall-bladder contents
and the presence or absence of anticipatory pericholecystitic ad-
hesions. When the escaping material is composed of unchanged
or slightly changed bile and mucus, the reaction may not be great.
594 THE PERITONEUM
In such instances the question is not far removed from that of the
absorption and local reaction from unchanged bile. Most authors
(Naunyn, Thomas) are agreed that no peritonitis is produced, or
at most a chemical peritonitis is produced when unchanged bile is
absorbed from the peritoneal cavity. My own observations on the
effect of bile in the free peritoneal cavity lead me to believe that
its presence is more deleterious than these authors indicate. That
an animal with a ligated common duct or a patient with an occluded
one may live for a long time is no argument for its innoxiousness
in the peritoneal cavity. By such occlusion the bile is forced into
the blood stream via the liver capillaries and may undergo some
change, while when alisorbed from the peritoneum no such change
takes place. At any rate an animal from which the fundus of the
gall bladder has been removed dies more quickly than one which
has had the common duet ligated. The general opinion is that
peritonitis following the rupture of the gall bladder is likely to run
a mild course.
When the perforation takes place slowly or previous attacks have
produced adhesions, a localization of the process may take place.
The process is then like that already described for localized non-
perforative peritonitis. Erhardt reported eleven recoveries in thir-
teen cases. Auvray reported a case dead after eighteen hours. I
observed a case in A\hich a Avoman of twenty-six after being sick
with extension to the environment, with the associated rectus rigidity
fever up to 104°, and a leucocyte count of 30,000, died in collapse
within three hours folloAving spontaneous rupture of the gall blad-
der without the clinical symptoms of a generalized peritonitis.
Noetzel and Korte regard gall-bladder perforation as a grave dis-
ease. If perforation erodes a large vessel hemorrhage may present
an added danger (Graff and Grube). AVhen the contents of the
gall bladder is purulent and there are no protecting adhesions the
result is a rapidly fatal peritonitis. If adhesions have formed, a
local abscess results.
Sijmjytouis. — Hyperemia and the milder inflammations hardly dis-
tinguish themselves from the symptoms of the gallstone colic. It
is only after definite inflammatory changes cause local tenderness,
with extension to the environment, with the associated rectus ri-
gidity that symptoms characteristic of peritonitis can be spoken of.
CHOLECYSTITIC PERITONITIS 595
In pericholecystitis Avith adhesions definite masses may form. The
infiltration ma}^ be so intense as to simulate malignancy. Diffuse
abdominal rigidity Avith symptoms of sepsis bespeaks perforation.
The symptoms of spreading peritonitis then ensue.
Diagnosis. — When the symptoms indicate a peritonitis localized
in the hepatic region the source can be determined only by the
antecedent history. If distinct cholecystitic attacks have preceded,
this source of the infection may confidently be diagnosticated. If
the gall bladder has become palpable folloAving pain in this region
and a peritonitis subsequently ensues, obliterating the palpable
gall bladder by the muscular rigidity, the diagnosis is certain. In
more obscure cases a diagnosis of peritonitis only can be made and
the surgeon must be prepared to find an appendix, lying high be-
side the colon, awaiting him. Perforating duodenal ulcers are usu-
ally attended by more intense pain at the onset Avith a rapid spread-
ing doAvn the right lateral portion of the peritoneal cavity. SloAvly
perforating ulcers and sudden bursting of infected gall bladders
can be distinguished by the history.
Prognosis. — In the simple associated peritonitis the prognosis is
altogether that of the disease upon Avhich it is dependent. When
an abscess has formed, if Avell encapsulated and no complications
exist, the prognosis is uniformly good if promptly drained. 'Even
when encapsulation seems complete, one can hardly be certain that
everything is favorable. Associated lesions or other abscesses may
exist. In one of my early patients, operated on by Dr. Dudley P.
Allen, death occurred on the tenth day from necrosis of the colon.
Neck and others collected 16 cases Avitli a mortality of 33 per cent
in the diffuse cases. Korte in his first four cases had a mortality
of 75 per cent. Harting reports 27 cases Avith 15 recoveries.
Hirschel recorded 7 cases all fatal. As in other cases of peritonitis,
the prognosis is dependent upon the time the disease has existed
since perforation AA'hen the operation is done. Kehr estimates that
nearly all should recover if operated in the first 24 or 48 hours. By
the third day the mortality Avill ])e fifty per cent, and ])y tlie sixth
day nearly a hundred per cent.
Treatment. — In simple inflammation the treatment is that of the
underlying disease. If caused by gallstones they had best be re-
596 THE PERITONEUM
moved. If evidence of pericholecystitic inflammation exists without
adhesions the gall bladder had best be removed.
When there are adhesions of the gall bladder with the surround-
ing organs, drainage without molesting the adhesions will relieve
the patient of his suffering, Avill add little danger of spreading the
infection, and will do much toward preventing the formation of a
localized abscess.
Kehr believes that it is correct to anticipate perforation in every
case of acute cholecystitis by the extirpation of the gall bladder
before it perforates. This does very well as a working plan for
the past master but for the common man there is room for thought.
Personally I prefer to drain and do a removal later unless, of
course, the gall bladder is free from adhesions as above indicated.
I am afraid to dig a gall bladder out of its adhesions and then
remove it. If there is an acute perforation with early signs of
generalized peritonitis, operation should be done at once. Drain-
age as employed in perforated duodenal ulcers is in order.
BibliogTaphy
AuvRAY : Perforation du col de lai vosieiile biliaire, peritonite purulente gen-
eraliseo; laparotomie: mort., Bull, et mem. Soc. Anat. de Paris, 1899,
Ixxiv, 771.
BOMPARD: Peritonites aignes d'origine vesicularie (sans perforation de la
vesicule) Lyon, 1903.
Clairmont and v. Haberer: Gallige Peritonitis olme Perforation der Gal-
lenwege, Mitt. a. d. Grenzgeb. d. Med. \i. Chir., 1911, xxii, 154.
DOBEBAUER: Ueber gallige Peritonitis ohne Perforation der Gallenwege, Mitt.
a. d. Grenzgeb. d. Med. u. Chir., 1912, xxiv, 305.
Erhardt: Beitrage zur pathologisehen Anatomie und Klinik des Gallenstein-
leidens. Arch. f. klin. Chir., 1907, Ixxxiii, 1118.
Gilbert and Lippmann: Le mierobisme biliaire normal, Compt. rend. Soc.
de biol., Paris. 190.3, Iv, 167.
Graff and Grube : Die Gallensteinkrankheit vom Standpunkt des inneren
Medizinors und Chirurgen, Jena, 1912.
Harting: Gallensteinerkrankungen, Miinchen. mod. "Wchnsehr., 1911, Iviii, 277.
HiRSCHEL: Die Behandlnng der diffusen eitrigen Peritonitis mit 1 proz. Kam-
pferol, Miinchen. med. Wchnsehr., 1910, Ivii, 779.
Jacob : Contiilnition a 1 'etude de 1 'appendicite, Paris, 1893.
Johansson: De la perihepatic hilieuse, avec epanchement biliaire dans le
peritoine sans perforation de 1 'appareil biliaire. Rev. de Chir., 1912,
xlvi, 892.
Kehr: Chirurgie der Gallenwege, Stuttgart, Enke, 1913.
Korte: Beitriige zur Chirurgie der Gallenwege, und der Leber, Berl., Hirsch-
wald, 1905.
McWiLLiAMS: Critical Analysis of 186 Operations upon the Liver and Gall
Passages and the After Results, Med. and Surg. Rep., Presbyterian
Hosp. N. Y., 1906, vii, 54.
CHOLECYSTITIC PERITONITIS 597
Nauntn: Zur Xatuigeschichte der Galleiisteiue unci zur Cholelithiasis, Mitt.
a. d. Grenzgeb. d. Med. u. Chir., 1905, xiv, 537.
Xeck: Ueber operativ behandelte Falle von Perforation der steinhaltigeu Gal-
leublase in die freie Bruchhohle, Deutsch. Ztschr. f. Chir., 1904. Ixxi. y^4.
Neuwerck and Lubke: Gilit es eine gallige Peritonitis ohne Peritonitis ohne
Perforation der Gallenwege, Berl. klin. Wchnschr., 1913, 1, 624.
jSToetzel: Die Ergebnisse von 241 Peritonitis-Operationen, Beitr. z. klin. chir.,
1905, xlvii, 241.
EiEDEL: Die Infektion der Bauchhohle per diapedesin von der Gallenblase aus,
Wien. med. Wchnschr., 1912, Ixii, 245.
Salageb and Roques : Une observation a propos des peritcnites biliaires, Mont-
pel, med., 1913, xxxvi, 67.
ScHiEVELEEix : Ueber gallige Peritonitis ohne Perforation der Gallenwege,
Beitr. f. klin. Chir., 1910, Ixxi, 570.
Thomas : An Address on Some Recent Experiences in the Surgery of the
Liver and Gall Bladder, Brit. Med. Jour., 1908, i, 17.
CHAPTER XXI
GONOCOCCIC PERITONITIS
Historical. — Affections of the peritoneum caused by the gon-
oeoccus involve chiefly that covering the tubes. The general peri-
toneum of the pelvis and the peritoneum covering the organs which
lie in the pelvis is commonly excited to inflammation when the
tubes are infected. The fact that these surfaces lie in contact with
the tubes makes it seem likely that the reaction is caused by ir-
ritating substances which extend by diffusion rather than by l)ac-
terial • growth. This reasoning is substantiated by bacteriologic
study of the extratubal exudates. Kelly made many investigations
calculated to clear up this point and failed to find the gonococcus
in the localized inflammation of the peritoneum. My own efforts
to demonstrate the coccus in the tubal serosa or subserosa were not
successful. "When the difficulty of demonstrating the coccus in the
tubal mucosa is recalled, such negative studies are not entirely con-
vincing. Some authors deny that a generalized inflammation is
possible. Bumm, for instance, did not believe the gonococcus could
multiply on a serous surface and McCann believed that gonorrheal
infection menaced the peritoneum chiefly because it provided a
chance for mixed infection. Wertheim attempted to solve this
problem by animal experimentation. By introducing culture
media into the peritoneal cavity of animals along Avith the gono-
coccic growth he was alile regularly to produce a peritonitis.
More recent studies have proved apparently beyond a doubt
that while in the very vast majority of cases the process remains
localized, in rare instances the gonococcus produces a peritonitis
which extends beyond the confines of the pelvis and becomes more
or less general. That spreading is most apt to occur at the time
of menstruation most surgeons Avill agree with Charrier. The
first to demonstrate the organism in such a case was Wertheim.
In such cases he was able to demonstrate the cocci in the endo-
thelial cells but not in the subsei'ous connective tissue. Gushing
598
GONOCOCCIC PERITONITIS 599
reports two cases in one of which the coccus was demonstrated in
the smear and in the other by culture. Young succeeded in culti-
vating the gonococcus from a case. In some cases of more or less
diffuse inflammation the gonococcus has not been found even where
the clinical evidence, together w4th the finding of the gonococcus
in the vaginal secretion, favored the diagnosis. Northrup reported
two such cases and reviews eight cases reported by Comby.
Dudgeon and Sargent also examined eight cases. -In five, cultures
were sterile. In one case diplococci Avere found Avhich were Gram
negative. In one case staphylococci were found, while the others
remained sterile. In such instances the coccus evidently has suc-
cumbed after producing the reaction.
Classification.- — From the foregoing it is evident that we can
distinguish two types of disease, depending on whether the re-
sponsible organism remains within the tube or escapes to the gen-
eral peritoneal cavity. Since in the first group the site of irrita-
tion is within the tube, it may be called a perisalpingitis. The
other being a spreading process naturally may be called such.
Gonorrheal Perisalpingitis. — By gonorrheal perisalpingitis is
meant the reaction imparted to the peritoneum covering the tubes,
and, secondary to this, the peritoneum of other viscera coming in
contact with them, when the interior of the tube becomes the hab-
itat of virulent gonococci. This term is preferable to the commonly
used one of "pelvic peritonitis" because it centralizes the atten-
tion on the focus of the disease.
Pathogenesis.- — The infective agents gaining access to the fe-
male genital tract ascend to the mucosa of the tube and there find
a suitable environment for their multiplication. This is the pri-
mary site of the infection, but does not concern us in this discus-
sion, for the mucosa may be affected without involving the peri-
toneum. In the general course of events the submucosa and the
muscle wall become infected and by extension finally infection
reaches the peritoneum. As the infiltration of the tu1)e Avail in-
creases, an abundant fi])rinous exudate forms extending to the
subperitoneal tissue, which results finally in an exudate upon the
serous surface. This exudate excites a reaction on the part of the
peritoneum covering the tube and in all surfaces which come into
contact with it. In some instances fluid bearing gonococci escapes
from the free fimbrial end of the tube and in this Avay infects the
600 THE PERITONEUM
peritoneum directly. In that event the chief site of reaction is
about the ovary and a periovaritis is the result. Even in instances
where the site of the greatest intensity of the inflammation indi-
cates that infection escaped from the free lumen of the tube,
cocci can not be demonstrated in the exudate. Even in such cases
the chief site of irritation remains about the tube and it remains
essentially a perisalpingitis.
Pathology. — The growth of the gonococcus within the tube ex-
cites an abundant exudate within the wall of the tube. This exu-
date is composed of fibrinous material and leucocytes. This be-
gins in the submucosa, extends to the muscle layer and finally
reaches the subserosa, and as the peritoneum is approached it re-
sponds with a marked dilatation of the vessels, swelling of the
endothelium and an abundant exudate upon its surface.
The fluid exudate coagulates into a fibrinoid material and the
connective tissue with which it comes in contact swells up and loses
its acidophilic properties. In the meshes of this tissue a very abun-
dant leucocytic infiltration occurs. The polynuclears predominate
in the early stage while later mononuclears become abundant. The
thickness of the tube wall is sometimes enormous, reaching some-
times the thickness of a centimeter or more. This increase in vol-
ume is due, chiefly, to the fibrinoid edema and to a lesser degree
only to the polynuclear infiltration.
When regression begins the polynuclears decrease and the mono-
nuclears increase in relative proportion. With the decrease of exu-
date the volume of the tube rapidly lessens. In pure infections the
height of the process is reached in 2 or 3 weeks, but Avhen there
are associated mixed infections the process may continue much
longer and in the case of the streptococcus even for years.
The advent of the peritoneal exudate about a gonorrheal tube is
followed by changes in the surrounding peritoneum that run a de-
finite course. This course is parallel with that followed by any
fibrin. It is closely simulated by the presence of a blood clot in the
pelvic cavity, as is seen in tubal abortion. A disposition to run
a course measured by the duration which results from any fibrin
irritation, raises the question whether or not the peritoneal irri-
tation is not chemical in nature as M^nge thought. As a result of
blood studies in pelvic peritonitis from pus tubes and pelvic irri-
(iONOCOCCIC PERITONITIS 601
tation from the presence of blood clot following tubal abortion, I
was struck by the parallelism. It is less intense in the latter con-
dition, but the duration is the same and in character the subperi-
toneal changes are parallel, though less intense in the case of the
blood clot.
In gonorrheal perisalpingitis a fibrinoid exudate forms on the
surface of the peritoneum, varying in degree according to the in-
tensity with which the peritoneum reacts. If the irritation is less
violent a fibrillar fibrin results which develops into fibrous tissue
and the familiar ' ' cob-web ' ' adhesion remains. It is the tube which
has been the subject of moderate repeated inflammation which is
most apt to present adhesions. If the endosalpingitis is very mild
no peritoneal exudate at all is formed and hence no adhesions.
In the more virulent inflammations a large amount of coagulable
material is exuded, granular for the most part, but on the sur-
face of which there is a layer of fibrinous material which may re-
sult in permanent organization. The granular substratum is ab-
sorbed while the surface organizes. There results, then, when the
process has been completed a free membrane spreading from tube
to ovary or to the gut. The actual thickening of the tubes may be
considera1)le but the bulk of the mass, felt in palpating a pelvis the
subject of this disease, is made up of the thickened neighboring or-
gans. The pelvic peritoneum, the small and large guts lying in the
pelvis all add to the mass (Fig. 195). The great bulk of the mass
is formed by subperitoneal exudations which are capable of com-
plete resorption.
The clinical manifestations of tubal infection by the gono-
coccus is directly dependent on the degree of irritation produced
in the wall and serosa. Pain is produced by distention of the wall
of the tube and by irritation of the serosa. The neighboring organs
are disturbed in their function both by the irritation of their peri-
toneal coverings and b,y the lessened room in which they lie. The
exudate, poisoning the general system, gives rise to leucocytosis
and fever and the train of general symptoms which commonly at-
tends such disturbances.
Pain. — In these cases it is difficult to separate the pain caused
hy distention from the subperitoneal exudate and that due to ir-
ritation of the tubal and particularly of the extratubal peritoneum.
602
THE PERITONEUM
Judging from the relative painlessness of the uterine endometrium
when the site of gonocoecic infection it is safe to say that the pain
exjjerienced is due to the irritation of the peritoneum itself or to
the stretching of the tubal nerve plexus. This assumption is sub-
stantiated by the vesical and rectal tenesmus so often associated.
The character of pain is always that characteristic of peritoneal
irritation — sharp and cutting. At first it may be localized in the
Fig. 195. — Gonorrheal perisalpingitis with adhesions to surrounding organs, subacute stage.
As these lesions further regress the adhesion bands lessen and finally "cob-web adhesions"
result.
region of the focus of origin, as at the ostium of one of the tubes,
and in mild cases it may not extend beyond this point. The initial
pain may be so intense as to suggest a tubal abortion. The spon-
taneous pain in tlic beginning may be diffused over an area Avider
than that actuallv invaded. This is due to reflex diffusion of sen-
GOXOCOCCIC PERITONITIS 603
sation and to the extensive and extended hyperemia Avhich re-
sults from the first irritation of the peritoneum from any cause.
Movement imparted by the voluntary acts of the patient, the
emptying of the bladder or rectum, because of the involvement of
their serosa, tends much to aggravate the pain. These means of ag-
gravation may be imitated by the manipulations of the surgeon
either by making pressure over the recti muscles or imparting
movements to the uterus or by l)oth as in making a bimanual ex-
amination. The pain early in the disease may be so intense as to
demand relief. This severe stage usually subsides in tvo or three
days. There remains a sensitiveness to pressure for a week or
more.
The diffuse character of the pain is often exaggerated by the pa-
tient, or the seat of its greatest intensity falsified. The reason for
this deceptive representation may l)e actuated by reasons of mod-
esty or caution. I have repeatedly- seen patients indicate the epi-
gastric region as the seat of the most intense pain. In instances
where I feel that the patient is willfully perturbing the scientific
accuracy of the clinical study I have made use of a little ruse that
has worked successfully in a number of instances. The following
is an instance: a young lady had been sick for some days with
some acute abdominal lesion the seat of which she declared to be
in tlie epigastric region. Because of the care with Avhich she fol-
lowed the movements of her environment I suspected she might
have been incautious in her social relations. The surroundings
were such a high plane of moral purity that I felt I would be tak-
ing my life in my hands if any reflecting interrogatory remarks
were directed elsewhere than to my cautious inner self. To get a
lead I directed the mother that she moisten a mustard plaster and
allow daughter to apply it to the seat of the greatest pain and to
alloAv it to remain to the limit of endurance. When I returned the
next day the tell-tale patch of hyperemia occupied the space just
over the pubis. A look at the patch, a quizzical look at the patient
with an apprehensive glance in response, caused me to make a diag-
nosis of acute gastritis to the mother. The relaxation of relief
manifested by the patient at hearing the diagnosis made me sure
of the diagnosis of gonorrhea. After recovery the mother was pro-
fuse in her thanks for having saved her daughter's life. "Not mv
604 THE PERITOXET'M
life but my reputation," is ^hat tlie young lady Avliispered as she
followed her mother from the room.
Muscular Rigidity. — Early in the attack the entire abdomen may
be distended and the entire wall rigid. This is true even in the
absence of diffuse pain. As the disease subsides the rigidity be-
comes limited to the loAver portions of both recti. Rarely, when
but one tube is affected, but one muscle may l)e rigid. Usually then
the rigidity is confined to a length of muscle of about three fingers.
Tumor. — A mass in the pelvis is the common accompaniment of
peritubal affections. Early in the disease there may be but slight
thickening of the tube, Avhich may be impalpable because of the
rigidity of the muscle above. There is early a sense of resistance
due to the edema. This becomes more and more marked until
within 48 hours or thereabouts the whole pelvis is as if filled with
a plaster cast. A mass appears to bulge in the culdesac and on
either side of the uterus. Sometimes only an indefinite resistance
is felt by the abdominal hand because of the rectus rigidity. As
the mass becomes more dense the sense of tumor is more pro-
nounced, and Avhen the process begins to subside and the muscle
rigidity disappears, definite tumor masses are made out so round
and distinct that many a surgeon has diagnosticated a myoma.
The density of the inflammatory tumor is astonishing and may ex-
ceed many of the myomata. It may in fact approach the density
of a carcinoma. The great bulk of the tumor is produced not by a
free exudate either in the tube or without, but by an extensive
edema of the subperitoneal connective tissue. This is especially
noteworthy since the beginner is apt to believe that an abscess is
present. It is only after the surrounding reaction subsides and
the edema and infiltration lessens that the tube itself becomes pal-
pable and pus within the tul)e becomes of a bulk sufScient to con-
tribute to any noteworthy degree to the size of the tumor. Only
rarely does the tubal contents form any considerable proportion
of the tumor.
Temperature. — The rise of temperature is usually marked —
higher than in other diseases producing the same degree of pain.
Often 103 degrees is exceeded early in the attack and temperatures
of 104 or more are not unusual. After remaining at this height for
GONOCOCCIC PERITONITIS 605
several days it begins to subside so that it reaches normal in about
ten days to two "weeks unless a mixed infection supervenes.
Blood. — A moderate leucocytosis is the rule though 20,000 is not
infrequently exceeded. I noted one patient vith 60,000. After re-
maining at the initial height for ten days it decreases and reaches
normal ten days or more after the temperature has become normal.
The leucocyte count reaches normal before there is any consider-
able lessening of the exudate. The blood count is not a guide to
the proper time to operate. A pronounced infection may be stirred
up in the presence of a normal white count.
Diagnosis. — The diagnosis of this condition may be made simple
if a history is obtainable. Those ignorant of their condition vill
tell the truth as Avill those Avho are lost to shame. The class who
know their condition and are sensitive to the opinion of society are
apt to fabricate and the surgeon must be on his guard lest he mis-
interpret the information oifered.
Extrauterine Pregnancy. — When disaster overtakes an extra-
uterine pregnancy the pain is sudden, but the general reaction is
one of collapse — rapid pulse, pallor, low temperature. In gonor-
rhea with sudden onset of pain these findings are reversed, full
pulse and fever. Rigidity and local tenderness are apt to lie present in
both. Later on the tubal abortion forms a mass, but it is less tender,
the temperature seldom is high and the leucocyte count rarely over
twelve thousand. The hemoglobin is not altered in perisalpingitis
but may be in tubal pregnancy.
Appendicitis. — With a low-lying appendix the general symptoms
of pelvic inflammation may be present. There may be a history of
previous attacks of appendicitis and the rigidity and tenderness
is usually marked lateral to the pelvic border. The rectus rigidity
is unilateral in appendicitis and a greater stretch of muscle is
rigid than in tubal infections. The markedly high temperature
may point to a tubal infection. Tliere may be tenderness on vag-
inal examination in appendicitis, but the cervix is not fixed. I
liave long studied the state of the pelvic organs in girls Avhen op-
erating for acute appendicitis. I have been struck with the fre-
quency in Mliich one or both tu1)es show marked reaction, which,
had the appendix itself not been inflamed, one miglit have regarded
as primarily an infection of the tubes.
606 THE PERITONEUM
Ovarian Cyst ivith Twisted Pedicle. — When the pedicle of a cyst
becomes sufficiently twisted upon itself to disturb the circulation
of the sac wall, degeneration begins and the exudate produced ex-
cites exactly the same irritating effect on the surrounding tissues
that takes place in the gonorrheal tube. Temperature and leuco-
cytosis may be equally marked. On examination a definite tumor
may be formed or the patient may have known of the previous ex-
istence of a tumor. Nearly always bimanual examination vnW
show a tumor better outlined than a "gonosalpinx" of the same
age. In rare instances, a small tumor may be so thoroughly
masked by exudate as to be indefinite. In such instances history
may be of some use. For instance one of my patients was quite
sure the trouble was brought on by lifting a wash boiler. I knew
then that it Avas an infection. A woman with a twisted pedicle
never knows Avhat started it. In medicine, as in life in general,
persons that are positive either lack discernment, or are bluffing
or lying. Of these, the lady Avith the saxophone tube is the queen.
Treatment. — When one allows his mind to travel the road that
the treatment of this affection has traveled he sees in his mind's
eye a picture like that from a recent battle field, hilly slope, ever-
green, little mounds, eternal granite. Scarcely in any other in-
stance has surgery added so much to the unfavorable prognosis as
in the precipitate operating on gonorrheal perisalpingitis. Unop-
erated on, the disease is rarely fatal; operated on in the acute stage
a mortality of about 10 per cent occurs, if one may judge from the
literature. Operating after the temperature and leucocytosis sub-
sides is less dangerous, Init the fragile tissue makes ideal technic
impossible.
Only recently, sad to relate, an eminent surgeon has found that
the foci can be handled early by placing in a semi-Mikulicz drain.
I have no doubt a sterile brick-bat could be successfully served in
the abdominal cavity- — why one should wish to do either is a dif-
ficult question.
The treatment of gonorrheal peritonitis is rest. Packs, hot or
cold, sedatives, coal tars, bromides, codeine or morphine may be
needed the first few days to secure rest.
After leucocytosis has been normal for a month or two the resi-
due of the disease may be treated surgically if anything remains.
GONOCOCCIC PERITONITIS 607
The operation consists of removing the tubes in most cases and
releasing adhesions. The removal of both ovaries is never justified.
Generalized Gonorrheal Peritonitis. — It is evident from clinical
experience that gonococci have no great affinity for serous sur-
faces, for not alone is the pelvic peritoneum exposed early in the
disease by way of the tubal ostia l)ut frequently in the course of
operation pus containing cocci has escaped without producing a
spreading.
Pathogenesis. — The greatest care is required in the interpreta-
tion of spreading infections following gonorrheal endosalpingitis.
Thus Menge in eight cases found gonococci in but three of them.
Even in one of these which ended fatally, streptococci were found
within one houi' after death. On the other hand the failure to
demonstrate cocci in a smear may not be sufficient evidence to ex-
clude a gonococcus infection. For instance in Gushing 's first case
cocci were obtained neither by smear nor culture. Kiefer in the
rupture of forty gonorrheal tubes saw no spreading of the gonorrheal
process and concludes that extension is not possible. Yet very
often after operations on acutely inflamed pus tubes a generalized
peritoneal irritation results, whether due to irritation or from
actual groAvth of bacteria is difficult to say.
My remarks relative to the pathogenesis of gonorrheal perisal-
pingitis Avere based on researches repeating the experiments of
AVertheim. My method was to implant a pus-soaked bit of gauze
into the peritoneal cavity, thus at once producing the irritation
by a foreign body and providing the organism Avith a favorable
environment for its development. Wertheim injected cultures into
the peritoneal cavity of animals and observed a nonfatal peri-
tonitis which reached its height on the third day. He found that
the cocci possessed the faculty of penetrating the endothelium for
he found them in the muscular layer of the guts. My studies indi-
cated that there was an early development of the gonococci. That
the cocci should develop after the introduction of a foreign body
is not surprising, for when the foreign body is introduced a serous
exudate forms about it producing a culture media of the proper
temperature, rivaling in perfection of appointment the most pains-
taking imitations in the test tube. The fact that these cultures
invariably die within 72 hours shows Iioav inimical is the environ-
608 THE PERITONEUM
nient. Nicolaysen found that mice died after injection \vitlioiit
the production of a peritonitis. This result likewise followed the
use of sterilized cultures.
The escape of pus from the end of the tube provides an irritant
which ordinarily acts only on the adjacent serous surfaces. Pos-
sibly the infection does not always travel by way of the tube.
Goodman reports one ease in which the generalized peritonitis de-
veloped on the third day after confinement and he concludes that
the infection traveled by way of the lymphatics. The frequency
with M'hich a pyosalpinx begins at the time of menstruation makes
it seem possible that the culture media furnished by the lochia may
have aided i]i the development of the gonococci. At any rate a
lymphatic transmission can not be proved. In most of the cases
reported the tube showed involvement or with care pus could be
pressed out of a tubal ostium.
Generalized infections are possil^le as the endocardial alTections
due to the gonococcus demonstrate. In a case of general peri-
tonitis Colombini found vegetations on the valves of the heart.
In one of Hunner and Harris' cases a diplococcus was recovered
from the blood stream. Metastatic septic emboli developed in
Frank's cases.
Why in rare instances the tul)al infection extends beyond the
confines of the pelvis and reaches the ultimate, region of the ab-
dominal cavity is not known. In some instances of generalized
abdominal inflammation careful search by competent men has
failed to demonstrate the gonococcus further than the lumen of
the tube. In other instances of like clinical pictures cocci are
demonstrated both in cover-slip preparations and in cultures from
the remote regions of the al)domen. The parallel clinical pictures
warrant us in assuming that those cases Avhich were bacteria-free
were due to the same bacterial cause. In some instances clini-
cians have no doubt gone too far in arguing from the minor premise
and have diagnosticated a ditfuse gonococcal peritonitis Avhen there
M'as no other evidence than the coincidence of a vulvovaginal Xeis-
serian infection and a generalized peritonitis. I once saw a per-
foration at the base of the appendix in a girl who had recently
acquired a gonorrheal infection.
Pathology. — The exudate in diffuse gonorrheal peritonitis is
GONOCOCCIC PERITONITIS 609
small ill amount, of a greenish color and usually clouded by floc-
culi of fibi-in. The intestinal coils are sometimes agglutinated by
the fibrinous exudate. The affection is often diffusely distributed
and the region about the liver is particularly involved. The sub-
peritoneal involvement is apparently not great. There is no evi-
dence available bearing on the question of adhesions in the dif-
fuse variety. The pathology is AvhoUy different than when the
disease is limited to the pelvis.
Frequency. — Diffuse gonorrheal peritonitis is one of the rarer
diseases of the abdomen. It is well to follow the plan of Hunner
and Harris who divided their cases into those in which there Avas
bacteriologic proof and those in which the diagnosis was made on
general grounds. Of the former class they Avere able to present
fifteen from the literature and added four more. Of the latter,
they gathered sixteen from the literature and added three more.
Since this paper a number have been reported. Goodman adds
three cases, all diagnosed on clinical grounds.
Age and Sex. — The majority of the cases, as would be expected,
occur in adult females. Seven, hoAvever, Avere girls under fifteen
years of age. A fcAV haA'e been reported in males. Information
relative to the conditions in the male is still more unsatisfactory.
V. Zeissl reports three cases. He, himself, expresses skepticism
Avhether or not the gonococci played any role in the peritoneal
process. In each of his cases there Avas an epididymitis and all
recoA^ered. Mermet reports a more plausible case in Avhich there
AA^as A^omiting and a temperature of 40° C, painful abdomen. The
symptoms in this case seem to have paralleled the testicular im-
provement. In a similar case in my experience the abdominal
symptoms disappeared Avithin a few hours after the epididymis
Avas drained. I have scA^eral times noted that I'ecurrent acute ab-
dominal symptoms coincided A\ith recurrent epididymitis both of
Avliich ceased to recur simultaneously with the relief of the latter
nffoction. The pain is due to inflammation of lymph glands along
the course of tlie A'as. I doul)t very much if a real inflammation of
the peritoneum due to the gonococcus has occni-red in the male.
Sywpfomii. — The onset may be relatively slow but usually it is
stormy. Chill, abdominal pain, vomiting, distention marked the
beginning in a number of the recorded cases.
610 THE PERITONEUM
In some instances pelvic infection preceded the more violent ab-
dominal symptoms, but in the majority the severe symptoms were
the initial complaints. In many tliere was a preceding vulvovagi-
nitis. The characteristic feature, according to Hunner and Harris,
is the sudden improvement after a few days of a stormy course.
The temperature is only moderate, varying from 100° to 102.5°.
In some instances it has been very high, even to 105° and over.
On the Avhole the temperature tends to range higher than in pus-
microbic peritonitis producing like symptoms.
Leucocytosis is usually moderate, varying from 15,000 to 20,000,
though Goodman reports one case Avith a leucocyte count of 60,000.
The polynuclears range Ioav, from 60 to 80 per cent.
Diagnosis. — The stormy onset may detract the attention from
the seat of its origin. Hunner and Harris believe that the surgeon
should be so familiar Avith the picture of peritonitis arising from
other sources that the symptomatology of gonococcal peritonitis
should excite his curiosity. The demonstration of a recent or more
remote genital infection makes such a diagnosis probable if the
history indicates the origin of the ])ain in the pelvis. This j^rob-
a])ility is much heightened ])y the discovery of salpingitis or peri-
salpingitis. If the general symptoms follow manipulation of the
tubes or during the menstrual period or puerperium with the
known presence of gonorrheal infection the diagnosis may be made
almost with certainty. There is little to add to the opinion of these
observers.
If the abdomen is opened before the diagnosis is made, the acute
di'y plastic peritonitis may give the operator his clue and excite
him to the proper investigations necessary to make a diagnosis
certain.
Profjnosis. — In the 39 cases reported on by Hunner and Harris,
of the 24 cases operated on, 10 recovered and 5 died, of the 15 not
operated on 8 recovered and 7 died.
Treatment. — In some of the cases operation was done before a
diagnosis had been made. During the period when it was consid-
ered proper to operate pus tubes in the acute stage naturally a gen-
eralized gonococcal peritonitis Avas regarded as a fit object of at-
tack. AVith the reaction against operating acutely inflamed
GONOCOCCIC PERITONITIS 611
tubes, doubt as to the correctness of operating on the generalized
type likcAvise arose. Most of the more recently recorded cases have
been managed by masterful inactivity.
BibliogTaphy
Bumm: Zur Aetiolooic der septischen Peritonitis, MUnchen. mod. Wchnschr.,
1890, xxxTii, 185.
Ciiarfjer: De la peiitonite lilennonliagique cliez la femme, Ann. de gjnec. et
d'obst., 1892, xxxviii, 217.
CoLOMBiNi: Bakteriolog'ische und cxperinientelle Unterstichungcn liber einen
merkwiirdigen Fall von allgenieineT gonorrhoiseher Infektion, Centralbl.
f. BakterioL, I Abt., 1898, xxiv, 955.
Gushing: Acute Diffuse Gonococcus Peritonitis, Bull. Johns Hopkins Hosp.,
1899, X, 75.
Dudgeon and Sakgent: The Bacteriology of Peritonitis, London, Constable &
Co., 1905.
Frank: Septic Peritonitis, Med. News, 1895, Ixvii, 421.
Goodman: Acute Diffuse Gonorrhoea! Peritonitis, Am. Jour. Dermat. & Genito-
Urin. Dis., 1911, xv. 511.
HuNNER and Harris: Acute General Gonorrhoea! Peritonitis, Bull. Johns Hop-
kins Hosp., 1902, xiii, 120.
Kelly : Operative Gynecology, New Yoi-k, D. Appleton & Co., 1898.
KiEFER : Consequeneen einei- liingeren Reihe von bakteriologischen Untersuch-
ungen. Verhandl. d. 68 Vers. Deutseher Naturforseher u. Aerztl. in
Frankfort, 1896, ii, 434.
McCann: Gonorrhceal Peritonitis, B'rit. Med. Jour. 1896, ii, 1774.
Menge: Ueber die gonorrhoische Erkrankung der Tuben und des Bauehfells,
Ztschr. f. Geburtsh. u. Gynak., 1891, xxi, 119.
Mermet: Pelvi-peritonite Idcnnorrhagigue ehez I'homme, consecuteve a une
orehi-epididymite, Gaz. nied. de Paris, 1893, 8. s., ii, 367.
Nicolaysen: Zur Pathogenitilt und Giftigkeit des Gonococcus, Centralbl. f.
BakterioL, 1 Abt., 1897, xxii, 305.
Northrup: Two Cases of General Gonococcal Peritonitis in Young Girls under
Pulierty, One Simulating Appendicitis, Tr. Assn. Am. Physicians, 1903,
xviii, 202.
Wertiieim : Die ascendirende Gonorrhoe beim Weibe ; bakteriologische und
klinisehe Studien zur Biologie des Gonococcus Neisser. Arch. f. Gynak.,
1892, xlii, 1.
Zur Lehre von der Gonorrhoe, Zentralbl. f. Gynak., 1891, xv, 484.
Young: The Gonococcus. A Report of Successful Cultivations from Cases of
Arthritis. Subcutaneous Al^scess, Acute and Chronic Cystitis, Pyonephrosis
and Peritonitis, Report Johns Hopkins Hosp., 1900, ix, 677.
V. Zeissl: Bauchfellentziindung in Folge des Harnrohrentrippers des Mannes.
Allg. wien. med. Ztg., 1892, xxxvii, 535; 547; 560.
CHAPTER XXII
PNEUMOCOCCIC PERITONITIS
A general infection of the peritoneal cavity by the pneumococ-
cus is not a freqnent malady if the paucity of reported cases be
accepted as a criterion. It is worthy of note that those who have
studied this type of peritonitis and have learned to recognize it
usually have several cases to report. From this one is led to sus-
pect that the majority of eases are overlooked. Aside from its
clinical importance it possesses an interest because of the fact that
it sheds some light on the genesis of cryptogenetic peritonitides in
general. Our knowledge of this malady is dependent very largely
on studies made by the French. English and particularly Amer-
ican literature has contributed but very little, aside from a few
case reports. The reason for the preponderance of the information
available from continual sources is not clear. Climatic or racial
conditions may be a factor which makes the disease more frequent
in continental Europe, but one can hardly repress the fear that so
little has found expression in English because minds employing this
language for the expression of their ideas have not given them-
selves to the necessary intensive study of the problem.
Historical. — Broussais records several cases of acute idiopathic
peritonitis which he regards as rheumatic which probably belong
to this class. Duparque under the head of "essential peritonitis
in young girls" presents the first complete account. Fereol em-
phasizes the disposition of this type to terminate in spontaneous
perforation at the umbilicus. Gauderon essays a collective report
and analyzes 25 cases.
The modern history begins witli Bozzolo. As the title of his
paper indicates (Ueber eine Form durcli Kapselkoken verursachter
multipler Serositis, eingeleitet durch Erscheinungen eines akuten
morbus Brightii) he was able by virtue of the then recent bacteri-
ologic investigations of Friinkel and Weichselbaum, to identify the
specific organism. Complete recent articles have appeared in the
612
PNEUMOCOCCIC PERITONITIS 613
Germau literature. V. Brunn reports 2 cases and collects 72 from
the literature. Kohr reports 9 cases< and gives a complete review
of the literature.
Pathog'enesis. — Brunn ^^•as able to produce a localized perito-
nitis by injecting pneumococcic sputum into the peritoneal
cavity. Boulay produced localized peritonitis by injecting some
insoluble substance like gelatin Avith the pneumococci. Jensen suc-
ceeded in producing a purulent peritonitis by the simple injection
of the pneumococcus into the peritoneal cavity. I Avas able to
produce a local peritonitis only by implanting a pledget of cotton
soaked in a bouillon culture of the pneumococcus. Cultures in-
jected directly into the peritoneal cavity either produced no marked
effect or killed the animal, apparently from toxic absorption.
As above noted the chief interest lies in the question as to the
possibility of hematogenous infection. Boulay by first introduc-
ing a foreign l)ody into the peritoneal cavity Avas able to produce
a peritonitis by injecting the pneumococci subcutaneously. My
OAvn attempt in this direction resulted in death by septicemia Avith
the usual inflammatory reactions about the foreign body.
In examining such a local irritation for bacteria in an animal
dead of general septicemia great care is required not to contami-
nate the local field from the blood sti-earn. This can best be avoided
by Avashing the animal's circulation free from blood Avith formalin
solution and then searching for cocci ])y tissue staining methods.
Desguin assumes the extreme position that all pneumonias are pri-
marily septicemias Avith later localization in special regions.
Opposed to this theory is that of Burckhardt Avho believes that
there is a direct transmission through the diaphragm. Bozzolo dem-
onstrated a transmission in 15 cases of pneumococcic pleurisy. A
possibility of the reverse must be kept in mind. Krogius reported
cases in Avhich pneumonia folloAved a general peritonitis. This
possibility is attested to b}^ our everyday experience of lung com-
plications fi'om the pus organism arising in the abdomen. In order
to establish the development of a pneumonia secondary to a pneu-
mococcic peritonitis it is necessary to demonstrate a local origin
for the primary pneumonic process in the peritoneum. Pus or-
ganisms metastatic in the lung may, l)y producing a reaction in llie
lung, stimulate the ubiquitous pneumococcus to development. A
614 THE PERITONEUM
frank pneumonia complicating a peritonitis is no evidence of tlie
pneumococcic nature of the peritonitis, nor even that the lung af-
fection is pneumococcic in origin. This is evidenced from the
fact that in such cases abscess frequently results from which pus
cocci may be recovered, indicating that the whole disease was due
to pus organisms.
The researches of Jensen sought to establish a hematogenous
pneumococcic peritonitis via the intestinal tract. He fed young
rabbits, without previous intestinal lesions, virulent bouillon cul-
tures of streptococci and secured a peritonitis and Geirswald got
the same result with pneumococci grown in milk. Jensen found
necroses in Peyer's patches. The source of the infection from the
mouth via the intestinal tract is easily hypothecated, but satisfac-
tory proof of its occurrence has not been provided. The fact that
the pneumococcus of the healthy sputum readily produces septi-
cemia in animals can hardly be entered as an argument. Dieulafoy,
discussing possible avenues of entrance, argued for the stomach and
Weichselbaum for the intestines. Flexner reported two cases in
which extension from the gut tract is likely. Lennander and
Nystrom report observations in the human subject in which there
was swelling and reddening of the gut wall with an associated peri-
tonitis. By microscopic examination they were able to trace the
infection directly through the wall of the intestine. Stoos reports
a case in a girl of five who died on the second day of the disease.
The solitary follicles and Peyer's patches were swollen and the
superficial surface necrotic. Microscopic examination showed dip-
lococci in all of the layers of the gut. Peritonitis going out from
an infection of the appendix from which the pneumococcus alone
was recovered, was reported by Canon, and a number of others.
A diplocoecus has been recovered in many cases of appendiceal
peritonitis. For instance Krogius in forty cases found such an or-
ganism in twenty-one of them. Neither the identity nor the etio-
logic relationship of these organisms was positively established.
There seems to be but little doubt but that such a route may be fol-
lowed by the infection, but there is no evidence that the gut wall
is more pervious to pneumococci than to other bacteria.
As yet no case has been proved to be of hematogenous origin.
Zesas makes the statement that experimentally no case of peri-
PNEUMOCOCCIC PERITONITIS 615
toneal infection has ever been produced by injecting organisms
into the blood stream. On the other hand Michaut believes that
the blood stream is the only avenue of infection and v. Brunn re-
gards this as the most obvious channel. Desguin regards peri-
tonitis as merely a local expression of a septicemia. CufE comes to
a similar conclusion. The existence of the disease in the meninges
and peritoneum in an infant three days old leads Netter to assume
a placental infection. A similar case is reported by Czemetschka.
Finally Rohr argues from analogy that since pneumococcic ab-
scesses in the thyroid, in the joints, and in the medulla of bone oc-
cur, it must be assumed that the infection gains entrance through
the blood stream.
Because the lungs are the natural field for the exercise of the
activities of the pneumococcus it is natural to suppose that the
primary lesion should be sought there. The hypothecated direct
communication betAveen the two great serous cavities would seem
to increase the probaliility. Notwithstanding these a priori argu-
ments, clinical experience does not seem to bear out this assump-
tion. Rohr in his nine cases found nothing more than a simple
cough preceding the peritonitis in two cases and no pulmonary
symptoms in the remainder. V. Brunn and Jensen regarded the
concurrence as rare. However, there are a number of instances
where a frank pneumonia seems to have preceded the peritonitis.
Burckhardt has reported such cases, as has Mathews. Bowen, An-
nand, and a number of others report cases equally as convincing.
Nevertheless, as a complication of pneumonia, peritonitis is not
a very frequent disease. Pawcett in 182 autopsies on bodies dead
of pneumonia noted that in only 5 was there an involvement of the
peritoneum. In this country Pearce found the association only 4
times in 121 bodies.
Because of the preponderance of females affected, at least in
children, it is quite natural that the genital portal should be inter-
rogated. Dudgeon and Sargent have reported a case of diplococ-
eic peritonitis in Avhich a pyometrium was the most pronounced
lesion. Notwithstanding the eminent qualifications of these in-
vestigators one can not help recalling that though the patient was
only eight years old there was an associated gonococcal infection.
616 THE PERITONEUM
Riedel reported a number of cases associated with inflamed tubes
from which pus could be squeezed.
In adults, likewise, a number of cases have been reported in
which pneumococcic peritonitis was associated with salpingitis.
Pearce reports one in Avhich a pneumococcic pyosalpinx ruptured
causing a peritonitis and tAvo in Avhich the pneumococcus could
be demonstrated in the endometrium. Jensen reports a similar
case. Canon saw a pneumococcic peritonitis associated Avith a car-
cinomatous uterus. Meyer saAV a case arising in the puerperium
and Pearce reports a similar case. Patellani Eosa found pneumo-
coccic salpingitis 13 times in 945 eases of tubal disease. Since
Netter was able to demonstrate pneumococci on cover slips in many
cases of pneumonia, v. Brunn's suggestion that since there never
has been I'eported a case of localized pelvic peritonitis due to the
pneumococcus, tul)a] disease due to this organism may be the
result of ])acteria, at first free in the peritoneal cavity, gaining en-
trance from tlie fimbriated end, deserves consideration.
A number of rarer foci have been reported. Netter believes the
middle ear is a frequent portal of entry in children. Stone reports
a case in which chronic otitis media folloAved a pneumonia and
after several years a peritonitis developed. Canon reports a case
developing from a pneumococcic infection of the gall bladder.
V. Brunn reports tAvo such cases. Bastianelli reports a case going
out from the urinary bladder.
Pathologic Anatomy. — The pus is thick, creamy in consistency
and of a greenish yelloAv color and usually odorless. Sometimes
there is an admixture of blood. The exudate is usually abundant.
In conformity Avith the usual action in the lung the production of
fibrin is abundant. Because of the abundant fibrinous exudate ad-
hesions are abundant and early. It is due to this abundant ad-
hesion formation that the disease is often localized. Once local-
ized the rapidly increasing exudate pushes the miaffected area to
one side. In this Avise the fact may be explained that even in cases
with enormous abscesses the greater area of peritoneal surface re-
mains unaffected. When AA'alling off does not take place the in-
dividual coils of gut are agglutinated so that the entire packet may
be lifted up together.
The usual site of the abscess is beloAv the umbilicus. This ac-
PNEUMOCOCCIC PERITONITIS 617
counts for the disposition of the navel to protrude as soon as the
accumulation has assumed large proportions.
Secondary or at least concomitant affections are often noted.
The lungs and middle ear are most often affected. These asso-
ciated lesions are regarded as etiologic factors by some writers
and as complications by others. Perhaps each view represents the
truth in individual instances. Abscesses in the kidneys and liver
may with better reason be regarded as complications.
In adults the pathologic anatomy is less typical. The fibrinous
exudate is less in amount and consequently the tendency to ad-
hesion formation is less marked.
Frequency. — The literature in general Avarrants the general
statement that the peritoneum is involved in one per cent or less
of all pneumonias. Netter found 2 cases in 140 cases of pneumonia.
Jensen was able to collect 86 cases out of the literature and to these
he was able to add 20 cases of his own. Since that time several
small groups of cases have been recorded, numbering in all now
about 160 cases. Many of these cases are not established beyond a
doubt. The finding of a diplococcus hardly rises to the dignity of
a scientific proof of fact. Among those cited by American authors
two were by Flexner, six by Pearce, one by Stone, three by Wool-
sey, and five by JNIatheAvs. This seems to represent about all the
authentic cases published in this country.
Cliildren are most frequently affected and among these girls are
most often affected. Thus in 52 cases under the age of 15 years,
45 were in females. In adults the sexes suffer in al^out equal
proportion.
Symptoms. — The pneumocoecus being like the gonocoecus, capa-
ble of iDroducing abundant fibrinous exudate, we may anticipate
that this form also will be characterized by a tendency to localiza-
tion. Our expectations are only partly realized for many of these
cases become diffuse quickly. In the main considering that there
is, so far as we know, no preliminary reaction on the part of the
pei-itoneum the course of the disease is relatively mild.
The disease, in conformity to custom, may be discussed under
the heading of localized and generalized forms.
Localized. — There is usually a history of sudden onset of pain
in the abdomen, resembling in this regard a perforation. The pa-
618 THE PERITONEUM
tients in many cases state the precise moment of the beginning of
the disease as they do in perforation. The pain is usually intense
and may be at first generalized. Vomiting seems to be more con-
stant than in many other forms of peritonitis. It is nearly always
present at an early period of the disease and usually lasts some
days. Diarrhea is emphasized by many authors as being a char-
acteristic feature, notably Stoos, Lenormant and Lecene, and Haw-
kins, while Rolir found this symptom in 4 out of 9 cases only.
Temioerature is usually high though there have been marked excep-
tions, as noted particularly by Annand and BoAven. Most of the
authors compare the temperature curve Avith that of croupous pneu-
monia which is in a measure justified by the sudden drop observed
in some cases. The possibility of different modes of onset may ac-
count for this discrepancy. A primary bacteremia may be asso-
ciated with the sudden rise while the lower temperatures may be
associated with a more localized conflict. Herpes has been noted
with considerable frequency and its importance is adjusted highly
by de Quervain. Koos noted one ease in which the lesion was
suppurative. Convulsions may occur in young children and chill
is a common preliminary symptom in older ones. Sleeplessness
and headache may be early symptoms. The headache may be so
intense as to suggest meningitis.
As occasional symptoms, epistaxis, vesical tenesmus, jaundice,
albuminuria and the diazo reaction may be mentioned.
There is usually a leucocytosis, there being an increase particu-
larly in the large polynuclear variety. In these, according to
Haim, there is a very marked fibrinous network and v. Brunn noted
an increase in the glycogen content.
The general course of the disease is milder than other varieties
of the disease of apparent equal initial intensity. Though the pulse
may be rapid and the abdomen distended, the general expression
is not that of a severe peritonitis. Muscular rigidity is less marked,
despite the intense pain, and it tends to subside earlier. The tem-
perature usually subsides gradually Ijut with greater rapidity than
in pus microbe peritonitis and may according to Comby and
Grancher end by crisis.
The exudate usually forms in the lower abdomen or near the
umbilicus projecting more or less to one side, but may extend up-
PXEUMOCOCCIC PERITONITIS 619
ward even to the diaphragm. The site of the abscess is sometimes
marked by edema of the abdominal wall or a dilatation of the
cutaneous veins. The exudate may be more evident from percus-
sion than by palpation since there is but little exudate in the sur-
rounding tissue. The abdominal wall may be soft and a little ten-
der over the site of the abscess, in fact the presence of abscess has
been repeatedly overlooked until threatening perforation or diag-
nostic aspiration has revealed its presence. When there is greater
induration the pyocyaneus may be associated, according to Desguin.
Because of the tlaccidity of the abdominal walls fluctuation may
be made out. Sometimes this is distinct and v. Brunn and Seves-
tre have resorted to exploratory puncture even early in the disease.
If the abscess is not drained the general condition becomes re-
duced, fever ascends, the abdomen becomes distended and accord-
ing to V. Brunn takes on the appearance of tuberculosis.
If relief is not provided the umbilicus may bulge, become edema-
tous, then reddened and finally perforate. Kohr regards this as
one of the most characteristic features of pneumococcic peritonitis.
It is Avorthy of note, however, that no more than five cases have
actually come to perforation.
While pneumococcic peritonitis is in general less stormy than
other varieties the likelihood of spontaneous regression is less,
though not impossible, even without spontaneous rupture. Such
cases have been reported by Broca and Brown.
Kupture in other regions as in a hernia, in Scarpa's triangle, and
the ])laddei' have been noted. Rupture into, the gut is rare.
Diffuse. — The diffuse variety may be regarded as typical for the
adult as the localized is for the child. It varies but little from
that of any other etiology. Chill, high fever, intense pain are less
usual introductory symptoms than in the circumscribed forms.
Early tympany is the rule, though the abdomen may remain flat
throughout the attack. The rigidity of the abdominal wall is usu-
ally relatively slightly marked. The course may proceed even
more violently and run its course in a few days under the picture
of a septico-ptemia as recorded by Schabad and Burckhardt. Even
more violent Avas the course of the disease in a patient reported by
Mace, in Avhom death occurred with the picture of a perforative
peritonitis, yet the autopsy by Ophuls revealed no perforation but
a pure culture of pneumococci.
G20 THE PERITONEUM
Predisposing- Causes. — That the time of the year should exert an
influence on the frequency of pneumococcic peritonitis is not sur-
prising Avhen the greater frequency of lung affections during the
winter months is remembered. General debilitating diseases such
as tuberculosis, cirrhosis of the liver, malignant growths and the
like also seem to invite the disease. Trauma to the abdomen has
been noted in two cases of circumscribed peritonitis, one by Dieu-
lafoy and one by Galliard. and two of difi'use, one l\y Hagenbach-
Burchardt and one by jMichaut.
Preliminary or associated pulmonary affections, such as bron-
chitis, pneumonia, bronchopneumonia, pleurisy and empyema are
the most common associated lesions.
A variety of commonly associated lesions has l)een noted. It
is often difficult to determine Avhether these exist as predisjDosing
factors, concomitant infections, or complications. Aside from the
lung conditions above noted may be mentioned meningitis, endo-
carditis, diseases of the middle ear, the parotid, thyroid, testicle,
and bone marroAV.
Diagnosis. — The paucity of literature in English-speaking coun-
tries may in part at least be ascribed to the fact that associated
lesions frequently dominate the picture, and the peritoneal factor
goes unsuspected. The inherent difficulty in diagnosis aside from
the associated lesion has frequently been emphasized. Duckworth
and Marsh, and Bowen believe the diagnosis is not possible with-
out incision. Dieulafoy on the contrary finds the clinical picture
very characteristic.
Because of the specific nature of the affection the demonstration
of the pneumocoecus must be considered essential to the establish-
ment of the diagnosis. Such a demonstration demands a high de-
gree of skill of the observer in bacteriologic investigation. The
morphologic, tinctorial, cultural and toxic characteristics all must
harmonize before a positive diagnosis is warranted. Because of
the faint cultural vitality of the organism even Avhen present it
can not always be identified by this means, as has been emphasized
by Krogius. The morphologic identification is sometimes made
difficult because of the fact that frequently they do not retain the
stain by Gram's method, as has been emphasized also by Krogius,
as well as Jensen. Still more confusing is the fact that in old ab-
scesses the morphology is modified. (Bozoolo, Bryant.) These dif-
PNEUMOCOCCIC PERITONITIS 621
ficulties are multiplied when other organisms, particularly the colon
bacillus, are present. When all these difficulties are taken into
account, it is easily understood that while the demonstration of
the cocci is the only scientific means of diagnosis, its recognition
is often fraught Avith difficulties.
In order to supplement the baeteriologic examination of pus the
blood has been studied by a number of investigators. Jensen, be-
cause pneumococcus can be recovered from the blood stream after
the injection of cultures into the peritoneal cavity, enthusiastically
recommended this means as a diagnostic measure in peritonitis
and reports two cases in Avhich the results were positive. Canon
has found this method of little use and explains the failure to re-
cover the cocci to the fact that the diseased peritoneum does not
absorb organisms as does the normal.
Because of the difficulty of bacterial demonstration diagnosis by
exclusion must receive more than ordinary consideration. The
usual varieties may be considered seratim. Unfortunately there
is l)ut little of more than uncertain value.
Appendicitis. — Rohr notes that diarrhea, because of the fre-
quently associated enteritis, is more apt to be present than in other
forms. This may be of some service in adults but does not obtain
in children, as pointed out by Jensen. The absence of a history of
previous attacks has been advanced as of positive value, but the
literature does not beai- this out, notably the statistics of de Quer-
vain and Rohr. The greater frequency of pneumococcic peritonitis
in girls and the pus A'arieties in boys is likewise quite useless Avhen
confronted by a concrete case. The difficulty finally is increased
by the cases of typical appendicitis due to the pneumococcus.
Tnl)e7'cvIous Pcriiouitifi. — Late in the disease the disposition of
tuberculous peritonitis to produce a bulging of the navel may sim-
ulate this same characteristic of pneumococcic peritonitis. The
history of the diplocoecic variety is usually more acute, though the
dispo-sition of the tuberculous affection is often to develop sud-
denly after some bronchial affection luit it is particularly 1o be
noted that these usually proceed without ])ain.
Gonococcic Peritonitis. — Broca states that a differentiation be-
tween the diplocoecic types can not be made early in the disease.
The same stormy beginning is present in both, vomiting, severe
pain, and often diarrhea. Dudgeon and Sargent note that meteor-
622 THE PERITONEUM
ism is more common in the pneumococeic variety. Rohr notes that
herpes of the lips points to the pneumococeic variety Avhile vulvo-
vaginitis points to the Neisserian type. When a pneumococeic peri-
tonitis is associated with a gonococcic vulvovaginitis, as has been
reported by Dudgeon and Sargent, and others, it is a problem for
the courageous bacteriologist.
Typhoid Peritonitis. — AValdo reported a case in which there was
roseola in pneumococeic jDeritonitis. The slow beginning of ty-
phoid and the increased leucocytosis in pneumonia usually suffice
to make the differentiation. Peritonitis in typhoid usually appears
in the second half after the diagnosis has been established. That
it is possible to become confused I know from experience. A boy
of eleven became quite sick with a temperature of 104°. There
were subcrepitant rales over the left lower lobe. On the second
day marked abdominal pains with vomiting and tympany set in.
Despite this beginning he settled down to a regular typhoid course.
It is worthy of note that he had a leucopenia from the beginning.
The essentials for making a diagnosis are oliviously that the sur-
geon thinks of the possibility of pneumococeic peritonitis and that
the necessary means of investigation be at hand to prove the point.
The rarity of this combination is sufficient to account for the pau-
city of American literature on this subject.
Treatment. — Because of the uncertainty of the clinical diagnosis
the deliberate planning of a line of treatment based on theoretic
grounds is of little value. Usually the surgeon will discover only
after the operation that he has been confronted by a pneumococeic
peritonitis. When presumptive diagnosis has been made from the
character of onset or by puncture of an abscess, or perchance from
a blood culture a planned operation may be possible.
It goes without saying that some have advised immediate opera-
tion, some delay — a discussion Avould not be orthodox that did not
recognize these two groups.
If there is a localized abscess, operation is indicated. All can
agree on that point l)ut that one should wait until fluctuation can
be demonstrated as advocated by Broea will hardly be assented
to by many. In the diffuse type an expectant treatment likely
would be advisable, but most operators likely will operate under
the general diagnosis of peritonitis and will proceed as is their
habit in this atfection. Fortunately this is a problem few of us
PNEUMOCOCCIC PERITONITIS 623
need worry about, for should we encounter such a condition it will
cause us no chagrin for Ave should never know it.
BibliogTaphy
Annand and Bowen: Pneumococcic Peritonitis in Children: A Study, Lancet,
London, 1906, i, 1591.
Bastianelli: Studio etiologico sulle infezioni delle vie urinarie. Bull. d. r.
Aecad. med. di Roma, 1895, xxi, 200; 394.
Boulay: Des affections a pneumocoques independantes de la pneumonie franche,
These de Paris, 1891.
Bowen: Two Cases of Pneumococcal Peritonitis in Children. Brit. Med. Jour.,
1908, ii, 916.
BozzOLO: IJeber eine Form durch Kapselkokken verursachter multipler Serositis,
eino-eleitet durch die Erscheinunoen eines akuten Morbus Brighti, Ceu-
tralbl. f. klin. Med., 1885, vi, 177.
Broca: Lecons cliniques de chirurgie infantile, These de Paris, 1905.
Peritonite suppuree probablement a pneumocoques; issue tardive d'un
ascaride lombaii-e par la plaie; laparotomie, Rev. mens. d. mal. de
I'enf., 1904, xxii, 385.
Broussais: History of Chronic Phlegmasiae or Inflammations, Philadelphia,
Carey & Lea^ 1831.
Brown: [Pneumococcal Peritonitis], Disc, Brit. Med. Jour., 1904, i, 135.
V. Brunn: Die Pneumokokken-Peritnnitis, Beitr. z. klin. Chir., 1903, xxxix, 57.
Bruns: Ueber die Fahigkeit des Pneumocoecus Frankel, locale Eiterungen zu
erzeugen, Berl. klin. AVchnschr., 1897, xxxiv, 357.
Bryant: Pneumocoecus Peritonitis, Brit. Med. Jour., 1901, ii, 767.
Burckiiardt: Ueber Kontinuitjits-infektion durch das Zwerchfell bei entziind-
liehen Processen der Pleura, Beitr. z. klin. Chir., 1901, xxx, 731.
Canon: Zur Aetiologie der Sepsis, Pyamie und Osteomyelitis, auf Grund bac-
teriologischer Untersuchungen des Blutes, Deutsch. Ztschr. f. Chir., 1893,
xxxvii, 571.
CoMBY AND Granciier : Traite des maladies de 1 'enf ance, Paris, Masson & Cie.,
1897, iii, 65. [Article "Peritonit-e."]
Cuff: Primary Pneumococcic peritonitis, Brit. Med. Jour., 1908, i, 918.
Czemetschka: Zur Kenntnis der Pathogenese der puerperalen Infection
(Metrolymphangitis post partum als Metastasis anderweitiger durch
Diplococcus pneumoniic bcdingter Erkrankungen), Prag. med. Wchnschr.,
1894, xix, 233.
Desguin: La pneumococcose gastro-intestinale epidemique. Bull. Acad. roy. de
med. de Beige, Biux, 1907, 4, S., xxi, 498.
La septicemie pneumococcique. Mem. couron. Acad. roy. de med. de Belg.,
Brux., 1906-7, xix, fasc. 9, 1.
Dieulafoy: Peritonite a pneumocoques, Clin. med. de 1' Hotel-Dieu, 1897, i, 396.
Duckworth and Marsh: Pneumococcal Peritonitis, Brit. Med. Jour., 1904,
i, 134.
Dudgeon and Sargent: The Bacteriology of Peritonitis, London, Constable &.
Co., 1905.
Duparcque: Dc la peritonite aigue essentielle ou spontanee. Gaz. d. hop., 1867,
xl, 436.
Faavcett: Pneumococcal Peritonitis, Disc, Brit. Med. Jour., 1904, i, 135.
Fereol: La perforation de la i)aroi abdominale anterieure dans les peritonites,
1859.
Flexner: Peritonitis Caused l)y tlie Invasion of the ^Microeocciis-Lanceolatus
from the Inte-stine, Bull. Johns Hopkins Hosp., 1895, vi, 64.
624 THE PERITONEUM
Fkankel: Ueber peritonealc Infckticn, Wicn. klin. Wcluisehr., 1891, iv, 241, 265,
286.
Galliard: Un eas do lujritonite a. pnouniocoqiies. Bull, et mem. Soe. med. d.
hop. de Par., 1890, 3. s., vii, 871.
Gauderon: De la peritoiiite idiopatliiquo aigaie des enfauts, de sa termiiiaison
liar suppuration et par evacuation du pus a travers I'omljilie, These de
Paris, 1876.
Hagenbach-Burckhardt: Ueher Diplnc-nreeiiperito7iitis Ijei Kiudern, Cor.-Bl.
f. schwciz. Aerztc, 1898, xxxviii, 577.
Haim: Die Epityphlitis in Wechselbeziehung zu iluen bakteriellen Erregern,
Arch. f. klin. Cliir., 1905, Ixxviii, 369.
Hawkins: A Case of Peritonitis Due to the Pneumococeus, Laneet, London,
1905, i, 568.
Jensen: Ueber Pncumokokkenperitonitis, Arch. f. klin. Chir, 1903, Ixix, 1134,
ibid., Ixx, 91.
Ko(')S: Pncumococcus-pcritonitis [im Kindesalter], Arch. f. Kindeih., 1907, xlvi,
228.
Krogit'S: Uelier die vom Processus verniiformis ausgehende ditfuse eiti'ige Peri-
tonitis und ihre chirurgische Behandlung, Jena, Fischer, 1901.
Lennander, and Ny STROM: [Kasuistische Beitrage zur Kenntnis der von
Enteritis ausgehenden Peritonitis, Uebers., Hft. 1-2], Upsala Liikaref.
Forh., 1900-7, n. f. xii, 57.
Lenormant and Lecene: Les Peritnnites a pneumocoques, Rev. de gynec. et
de chir. abd., 1905, ix, 225.
Mace: Primary Pneumococeus Peritonitis, willi Report of a Case, California
State Joiir. Med., 1909, vii, 64.
Mathews : Pneumococeus Peritonitis, Ann. Burg., 1904, xl, 698.
Meyer: Ueber die pvogene Wirkung des Pneumococeus, Mitt. a. d. Grenzgeb.
d. Med. u. Chir., 1903, xi, 140.
Miciiattt: Contribution a 1 'etude de la peritonite a pneum.oeoques chez 1 'enfant,
These de Paris, 1901.
Netter: Frequence relative des affections dues aux pneumocoques, Conipt. rend.
Soe. de l)iol., 1890, 9. s., ii, 491.
Patellani : Eziologia e cura cliiruigica delle salpingo-ooforiti, Alihnio,
F. Vallardi, 1898.
Pearce: Bacteriology of Lobar and Lobular Pneumonia, Boston Med. and
Surg. Jour., 1897, cxxxvii, 561.
de Quervain: Zur Aetiologie der Pneumococcenperitonitis, Cor.-Bl. f. schweiz.
Aerzte, 1902, xxxii, 457.
Riedel: Die Peritonitis der kleinen Madchen in Folge von acuter Salpingitis,
Arch. f. klin. Cliir., 190(), Ixxxi, 186.
Rohr: Ein Beitrag zur Kenntnis des typischen Krankheitsbildes der Pneu-
mokokkenperitonitis. Mitt. n. d. Grenzgeb. d. Med. u. Chir., 1911, xxiii,
659.
Schabad: Ein Fall von allgemeiner Pneumokokkeninfektion, Centralbl. f. Bak-
teriol., I Abt., 1896, xix, 991.
Sevestre: Observation de peritonite puiulente a pneumocoques. Bull, et mem.
Soe. med. d. hop. de Paris, 1890, 3. S., vii, 467.
Stone: Pneumococeus Peritonitis; with Report of a Case, Bull. Johns Hopkins
Hosp., 1911, xxii, 219.
Stoos: Die Pneumokokkenperitonitis im Kindesalter, Jahrb. f. Kinderh., 1902,
n. F., Ivi, 573.
Waldo: A Case of Pneumococcal Peritonitis, Brit. Med. Jour., 1904, i, 1254.
Weichselbaum : L^ebcr seltenere Lokalisationen des i^neumoniseheu Virus (Dip-
lococcus pneumoniae), Wien, klin. Wchnschr., 1888, i, 573; 595; 620;
642; 659.
Woolsey: Pneumocoeeus Peritonitis, xVm. Jour, r^led. Sc, 1911, cxli, 864.
Zesas: Ueber krA-ptogenetische Peritonitiden, Samml. klin. Vortr., 1912, (N.
F. No. 648), Chir. No. 180, p. 515.
CHAPTER XXIII
PUERPERAL PERITONITIS
The earliest accounts of diffuse peritonitis in the literature have
to do Avith those arising during the puerperium. The student who
wants to discover a real thrill in medical literature can obtain it
by reading the old accounts of childbed fever. Poe's most weird
tales are tame in comparison. These accounts are not without
their humorous aspects. The explanation the old observers gave
for the presence of the pus in the belly rivals some of the clinical
deductions of our own times. As an example it may be mentioned
that one theory Avas that the pus in the abdomen Avas milk due to
the exudation of this fluid into the abdomen rather than escape
through the breasts. To prove this casein Avas demonstrated and
one enthusiastic Avriter even churned butter from fluid obtained
from the peritoneal cavity.
Should a student find himself lacking in respect for his pro-
fession he can rencAV his faith by acquiring a knoAvledge of the
discoA^ery of the cause and the elimination of Avhat to me is the
most tragic disease to which flesh is heir. It is Avell to remember
that the infectious character of puerperal fcA^er Avas deduced by
the observation of epidemics. The first to formulate the infectious
theory Avas our oAvn 0. W. Holmes. Its elaboration and proof
by the ill-fated Semmehveis furnishes one of the most heroic and
inspiring accounts of achievements by medical men. That infection
came from Avithout Avas definitely established and only later devel-
opments Avere requii-ed to shoAv Avhat it Avas that came from Avithout.
It Avas my uncanny privilege to locate in a rural community
neighbor to an old school (or schoolless) practitioner A\-ho never
Avashed his hands before making digital examinations and l)ut sel-
dom afterAvards. Death and disaster followed his trail and noAV
more than a score of years after I can not contemplate the experi-
ence Avithout a slnulder. Through liis ministrations T was thus
enabled to see all too many patients presenting tlie clinical signs
about to be described. I want to say that no matter how many
625
626 THE PERITONEUM
patients an observer may have ol^served suffering from perfora-
tive peritonitis legitimate to the present day, the awfulness of the
disease can not be appreciated unless he has observed the diffuse
type that occurs in the recently delivered Avoman.
I can not refrain from recording here my first experience with
this disease. A woman in her eighth puerperium had been over-
come on the third day after labor by a violent chill and high fever.
When I saAv her on the fifth day she lay motionless, eyes sunken,
wide open, and fixed. Her respiration was labored and rapid and
despite this labor her color presented a mixture of waxy pallor
and cyanosis, as though some A'ulgar hand had soiled a marble
statue of Distress, or Nature herself was seeking to soften the
awful picture to spare the untried sensibilities of the embryo Aes-
culapian. The distended intestine found little resistance from the
lax abdominal muscles and ballooned out to an astonishing degree.
My first thought as I saw the patient lying in bed was that a can-
opy had been formed for her out of barrel hoops to prevent friction
from the bedclothes. ]\[y astonishment at finding that the whole
mass was belly knew no bounds. My eyes at this sight I am sure
rivaled the patient's in fixity and Avideness and my respiration
was equally labored. As I sought to feel her pulse the cold clammy
skin made me shrink and as I sought the pulse I could find but a
quivering string and because of the pounding of my own heart I
never knew its rate. As I turned from this scene, standing about
the room Avere the seven older children, the eldest a girl of tAvelve.
These, too, Avere Avild eyed and short of breath. Approaching the
cradle I sought to calm myself by vicAving the child. ]\rueh to my
consternation here lay a replica of the mother herself. The infant
vainly sought to emulate its mother in girth of abdomen but far
exceeded her in rate of respiration. In one particular only Avas
there essential difference. Instead of the Avaxy gray of the mother
it presented a peculiar ochre yelloAv, the result of cord infection.
In all that scene there Avas but one calm face — ^that of the fam-
ily doctor. Seeing my discomfiture he chuckled derisively and re-
marked. "Never saAv anything like that, did you, boy?" Glancing
at his dirty breeches Avhich long had done duty as a handkerchief
through an attack of coryza, and at the dirtier hands Avhich be-
cause of the inefficiencA^ of their natural cleaner had lost most of
PUERPERAL PERITONITIS 627
their flexibility, I replied, "No, yoii dirty old devil, and I swear
before the sliades of the lamented Jaggard that if scrubbing my
hands will prevent it, I shall never gaze on such a scene of my
OAvn making."
Etiology. — More than a century ago Gordon noted that puerperal
fever was due to an infection since it ''seized such women only as
were visited or delivered by a practitioner, or taken care of by a
nurse who had previously attended patients affected with the
disease."
We know now that this infective agent is some sort of organ-
ism. The streptococcus is the organism most often present.
MacDonald estimated that this is the causative organism in 40
per cent of the cases. Lloyd gives the statistics in 159 cases.
Streptococci were found in 35 cases, staphylococci in 30 cases,
pneumococci in 17 cases, gonococci in 21 cases, colon bacilli in 22
cases and the bacillus aerogenes capsulatus in 2 cases. The course
of puerperal peritonitis strongly suggests the presence of the strep-
tococcus, and when the ubiquitous staphylococcus or colon bacil-
lus is present the identification of the streptococcus is a very diffi-
cult matter. Even when present the pneumococcus or gonococcus
can with difficulty be conceived as the sole or even chief offending
organism. Confronted by such a stormy disease as puerperal peri-
tonitis it is as difficult to establish an alibi for the streptococcus
as for a small boy Avhen confronted with an empty jam jar and a
jam-besmeared face. Sister may be the culprit but there is the
prejudice born of experience.
The question as to the source of the infection can be discussed in
polite society only in the abstract. It usually comes from without
and since the attendant is usually an inhabitant of that indefinite
space called the environment of the patient the burden of disproof
rests on him. When confronted with a concrete case it is well to
remember that the infection may be supplied by the patient herself.
The patient may have a pneumonia as recorded by Baisch. A sup-
purating myoma has been a cause, as reported by Lepage and Mou-
chotte, and from suppurating cysts as recorded by Patton. An
appendicitis may produce the infection as emphasized by Findley.
It is evident from these few citations that puerperal peritonitis
mav be caused from some lesion Avithin the patient herself. At
628 THE PERITONEUM
the same time when a practitioner has the misfortune to have this
disease develop in a patient of his the verdict should ]je that ren-
dered by a trial board against a too amorous minister, "Not guilty,
but don't let it happen again."
Pathogenesis. — Bacteria gaining entrance through the genital
tract by tlie introduction of some unclean thing presents the com-
moner mode of introduction of the infection. Peritonitis, the prob-
lem A\iiicli concerns us here, represents l)ut one of the possible dis-
ease entities which might result. . Metritis, pelvic cellulitis, septic
thrombosis local and at a distance, and pure septicemia are but
some of the possibilities, aside from the infection of the peritoneum,
that may occur in the puerj^eral period. No student of genital in-
fections may consider himself possessed of a grasp on this problem
who has not read and reread the literature of two or more genera-
tions ago.
The infection gains entrance to the genital tract by way of the
uterus or lacerations of the vagina or perineum, and may reach
the peritoneum hy contiguity- without previous focal involvement
of structures, but usually arises secondarily to some lesion where
the invading organisms were momentarily halted.
How infections reach the peritoneal cavity is still not a matter
of certainty. Usually the endometrium is the first structure in-
vaded, but the infection rapidly spreads along the veins and
lymphatics. My own limited observation would lead me to believe
that the spreading infection along the lymph channels ultimately
reaches the peritoneum. The more frequent venous thrombosis
happily tends to remain localized. Even with all data at hand it is
difficult to reach a conclusion in a concrete case because of the
complexity of the picture. As an abstract problem one can scarcely
do better than hide his ignorance behind a mass of statistics, being
secure in the fact that the reader will see no clearer light than he
sees himself.
I believe that there is something in the strain of bacteria car-
ried from woman to Avoman in the old-time epidemics that made
them so frightful. Their pathogenicity must have exceeded the
ordinary one of virulent bacteria.
Diffusion through the lymphatics or escape through the tubes
are probably the common sources as they are the most obvious
PUERPERAL PERITONITIS 629
possibilities. Keaching the surface of the peritoneum the inflam-
mation is rapidly diffused over the whole surface of it. That the
dissemination of infection is rapid and diffuse is evident by the
overwhelming character of the invasion, an intensity rivaled only
by perforations of the duodenum.
Secondary invasion of the peritoneum is possible after the dis-
ease has become localized. Such secondary invasion occurs usually
from the tube or a walled-oif pelvic abscess, abscesses in the wall
of the uterus being apparently less often the cause of such second-
ary infection. In some of the recorded causes an intramural ab-
scess discharged through the umbilicus. It is conceivable that
more maj' have failed to reach such a distant part and have given
rise to a generalized peritonitis, but the literature is strangely
silent of record of such a catastrophe.
Septic thromboses may involve the peritoneum by extension
through the vessel wall and the overlying peritoneum. In several
cases which I have observed at autopsy a generalized gangrene
of the uterus and adnexa apparently preceded the generalized
infection.
Dr. J. X. Jackson once presented me with a uterus, broad liga-
ments and ovaries which he had removed from a puerperal woman
that were blue-black throughout. The patient recovered. A gen-
eralized peritoneal infection certainly would have resulted in a
short time had the necrosed organs not l)een removed.
Pathology. — The earliest recorded observations on the pathology
of peritonitis Avere made on the abdomens of women dead of
puerperal peritonitis and the accounts of the old writers may
be transposed to modern literature Avithout loss of meaning. The
thin flocculent exudate covering a reddened peritoneal surface, or
even in some instances a dry shineless surface Avithout exudate,
has been described. In other cases the exudate is more purulent,
supplying a more legitimate excuse for a comparison Avith lacteal
secretions. The angles betAveen the guts are often occupied by fi-
brinous flocculi which liold adjacent folds of gut in loose contact.
Such is al)out all that is seen in the i'a])idly fatal cases. In the less
acute. Availing off' may occur producing n localized nliscoss A\hich
is amenable to treatment oi' may Ix'conic the soni'ce of subsequent
mischief.
630 ' THE PERITONEUM
The older -writings abound in anatomic descriptions that make
the above description seem dull. The foUoAving from Hulme may
be quoted as an example: ''The belly was greatly swelled. The
skin of the whole body was of a taAvny or yelloAnsh hue. Upon
vicAving the abdominal contents, the omentum was found greatly
mortified. A yelloAV fetid Hqiior, ^ith a mixture of pus, tilled the
pelvis, and floated among the intestines. The Avhole intestinal
canal was distended with fetid air, but particularly the great flex-
ure of the colon. A general inflammation appeared, scattered in
various parts, over all the intestines. The stomach was not dis-
tended with flatus but lay concealed under the liver, which was of
an extraordinary magnitude. It had pushed itself , as it were, high
up into the cavity of the thorax and carried the diaphragm along
with it, to which it adhered so firmly, in its whole convex surface,
as not to be separated. In the right lobe was found a very exten-
sive abscess. The gall-bladder was pretty large, and full of bile.
The lungs were of remarkably small size, dense and livid ; they
did not adhere to the pleura." This description can easily be
duplicated hundreds of times in the older literature.
The pleural cavities are frequently infected in puerperal peri-
tonitis, and septic pneumonia or abscess often follows. Paren-
chymatous degeneration of the organs was very common. The
"black vomit" so often mentioned likely meant hemorrhage into
the stomach, the result of an infected gastric mucosa. Cerebral
edema and septic meningitis receive frequent mention. Metastasis
in the joints, particularly in the knees, I myself have observed in
several instances and many are recorded in the literature.
Clinical Signs. — The general symptoms of pueri^eral peritonitis
parallel those already discussed under the general head of symp-
tomatology— all magnified to the nth power. It remains here only
to discuss the A^ariations and peculiarities.
Chill. — An initial chill is more commonly observed than in other
forms of general peritonitis, obviously because the blood stream is
so often invaded. Usually Avithin one to three days after labor
the patient is seized by a chill lasting usually from thirty minutes
to three hours. The chills are usually decisiA^e, CA'en violent. There
may be but one initial chill or they may be repeated a number of
times during the course of the disease, particularly AA'hen pyemic
PUERPERAL PERITONITIS , 631
processes make up a large part of the picture. When chills are
recurrent Avith regularity, constant search must be made for com-
plicating foci of infection.
Temperature. — Preceding this chill or following it there is a rise
of temperature. The temperature usually ranges high throughout
the disease, but not infrequently is observed to fall at one or two
periods of the day. If there are distinct remissions Avith or without
chill localized foci should be anticipated.
Pain. — Early in the attack there is intense pain in the abdomen
rivaled only hy that observed in perforating ulcer. It usually be-
gins in the pelvis but rapidly spreads over the whole abdomen.
This pain is continuous but is increased by movement and by
external pressure, not alone by the palpating hands of the observer
but even by the weight of the bed clothes. The excessive sensitive-
ness represented in this type is not equaled by that due to any
other cause. Sometimes there is but slight pain or an entire ab-
sence of it. This is apt to occur Avhen there is preceding gangrene
of the pelvic structures. Sometimes the initial intoxication is so
overwhelming that there are no spontaneous complaints of pain,
but when the abdomen is palpated reflex manifestations of pain
are easily elicited.
Tympany. — If one has never seen a case of tympany in a puer-
peral woman he has no real conception as to how much the word
may mean. Because of the laxness of the abdominal walls due to
the pregnancy the distention is astonishingly extreme, exceeding
much that of the pregnant abdomen. It is most marked when there
is rapid diffusion of the infection. When there is deep involvement
of the gut wall, particularly when the peritoneum is involved sec-
ondary to gangrene of some of the pelvic organs, there may be
but slight if any tympany. I have never seen a scaphoid abdomen
as one sometimes sees after appendicitis.
Diag-nosis. — In a classical case the diagnosis is easy. The signs
already enumerated can leave no doubt in the mind of the observer.
It is only the milder, more slowly developing forms that can be
compared with other postpuerperal infections. However, venous
thrombosis may engender chill, rise of temperature and abdominal
distention. Muscle rigidity is not the aid that it is in other forms
of peritoneal infection. Because of the laxity of the muscles they
632 THE PERITONEUM
seem unable to lend the protective aid they do in other types of
peritonitis. Here tenderness is the sign on which greatest reliance
may be placed. When the initial signs above noted are associated
Avith upper abdominal tenderness a generalizing peritonitis may be
assumed. Tenderness over the pubic region is present in tubal and
broad ligament infections. Indurated masses within the pelvis may
be sometimes demonstrated and give the hope that the process may
be localized. In lieu of any localized manifestations the breasts
should be examined. The assumption on the part of the practitioner
that delayed bowel movements may be the cause of chill presages
an unstable state of his OAvn system when the I'eal truth dawns
upon him. I know of what I speak.
Prognosis. — The final outcome of puerperal peritonitis is much
more difficult to foretell than in other types of peritonitis because
the diagnosis is never so clear cut. Even if one observes at opera-
tion what degree of involvement exists he can not estimate the
influence of the possible complications which may exist or may
subsequently develop.
That really diffuse cases ever recover surpasses belief. AVhat
degree of extension is compatible Avith recoA^ery is impossible to
say. Involvement of the pelvic peritoneum only, no doubt is often
folloAved by recovery. The difficulty in forming an idea of the
outcome from recorded cases lies in the fact that operators differ
so AA'idely in their interpretations. That a really diffuse case ever
recovers I do not believe, no matter Avliat the treatment. The pro-
portion of cases of recovery folloAving treatment is difficult to de-
termine because the thromboses and extraperitoneal inflammations
are not sharply separated from diffuse peritonitis. This is indi-
cated by the Avritings of such masters as Leopold and Bumm. The
former had 13 recoveries out of 18 cases treated. With the latter in a
collected series of 177 cases 60 per cent recovered Avhile in distinctly
peritonitic cases 52 per cent recoA'cred.
When complications exist they may cause the death of the pa-
tient after the peritonitis has subsided. Joint suppurations are
particularly liable to exhaust the patient. Degeneration of the
heart and parenchymatous organs also must be taken into consid-
eration in estimating the outcome.
Treatment. — The results seem to be best if simple drainage Avith
PUERPERAL PERITONITIS 633
large tubes in one or more regions is instituted early. Attempts
to remove foci of infection seem unwise, though some good results
have come from hysterectomy performed early in the disease. If
localized abscesses occur they must be drained extraperitoneally.
This is important because a postpuerperal abscess may remain in-
fective many months, even years. I once lost a patient by trying
to remove a postpuerperal streptococcic pyosalpinx three years
after the infection. When the hyperacute type exists the human
race "will best be served if the attendant Avill go away and Avrap his
head in sackcloth and ashes.
BibliogTaphy
Baisch: Die operative Behaiulluiig- der diffuseii, speziell puerperalou-Perito-
iiitis, Miinehen. Med. Wehiisehr., 1911, Iviii, 1994.
B'UMM : Ueber die cMrurgisclic Behandliuii;' des Kiiidbettfiebers, Halle a. S.,
1902.
Findley: Appendicitis Complicating- Pregnancy, Jour. Am. Med. Assn., 1912,
ILx, 612.
Gordon: In Churchill, ed.. Essays on the Puerperal Fever, Philadelphia, Lea &
Blanchard, 1S50, p. 39.
Holmes: The Coutagionsuess of Puerperal Fever, New England Quart. Jour.
Med. and Surg., 1842-.3, i, 503.
Hulme: a Treatise on the Puerperal Fever, London, Cndell, Rolunson & Almon,
1772.
Leopold: Zur operativen Behandlung der puerperalen Peritonitis und Throm-
bophlebitis, Arch. f. Gynak., 1908, Ixxxv, 481.
Lepage and Mouchotte: Dp la torsion des tibromes au cours de la grossesse,
Ann. de gynec. et d'obst., 1906, 2, s., iii, 99.
Lloyd: Some ISTotes on the Bacteriology of Puerperal Infection. Intercolonial
Med. Jour. Australasia, 1906, x, 474.
MacDonald: Puerperal Infection: Report of Six Cases Illustrnting Its Va-
ried Character, Am. Med., 1906, xi, 231.
Patton: Ovarian Cysts Situated Above the Superior Pelvic Strait, Complicated
by Pregnancy, Surg., Gynec. and Obst., 1903, iii, 413.
Semmelweis: Die Aetiologie, der Begriff und die Proiihylaxis des Kindbett-
fiebers, Leipz. Hartlclicii, 1861.
CHAPTEE XXIV
TRAUMATIC PERITONITIS WITHOUT RUPTURE
External violence may so far injure an intestine that, while it
is not immediatel}' pervious to bacteria, it may become so after an
interval. The passage of bacteria may take place through a micro-
scopic opening, or they may pass thi'ough the injured wall without
a demonstra])le opening. In the interval between the receipt of
the trauma and the escape of bacteria reactive changes may occur
in the environs of the injured area, resulting in the formation of
protective adhesions. If changes do not occur a diffuse peritonitis
results. The perforation in such cases resembles the punched out
ulcers of the duodenum.
Pseudoperitonitis. — In the literature one finds a num])er of cases
reported in which there Avere acute abdominal symptoms but no
real peritonitis. Possibly a retroperitoneal mesenteric hemorrhage
or thrombosis of one or more vessels may account for such symp-
toms. Some of these cases present many of the symptoms of peri-
tonitis, notably pain, distention, and vomiting. In some of these
cases no pathologic lesion whatever can l)e found. I have ob-
served two such cases. One, a carpenter, was struck in the pit of
the stomach. He fell at once in a faint but soon recovered and
complained of pain and vomited several times. Within tAvo hours
an astonishing degree of distention took place. The temperature
did not change and the pulse, accelerated immediately after the
accident, gradually subsided. Operation disclosed nothing. I al-
ways felt somewhat chagrined at having operated on this patient.
Years later Fontoynont reported a case very similar to mine in
which he searched very carefully and found nothing. I appreciate
the feelings of the author just quoted when he states that as he
searched he found ahvays ''vein, toujours vein." The only thing
I found of note was a very Avide distention of all the veins of the
abdominal organs. My second case, resulting from the kick of a
horse, Avas A^erj^ similar. I decided to sit tight until some signs of
634
TRAUMATIC PERITONITIS WITHOUT RUPTURE 635
reaction appeared — increased temperature or pulse. None ap^
peared. Similar conditions are sometimes noted after injuries to
the back. The condition probably results from some sort of an
injury of the sympathetic system. At any rate it does not clarify
the problem any to force them into the class of inflammatory lesions.
The number of posttraumatic peritonitides without rupture is
not large but a number of cases have been reported. Guibal gives
a collective revicAV. In 26 cases he notes 16 diffuse and 10 local-
J
ized. Among these are a number, lunvever, in which no inflamma-
tion was found at operation.
Localized Peritonitis. — After a trauma the contused gut be-
comes adherent to its environment. Increasing degeneration of the
center of the lesion permits bacteria to escape into the area already
walled off. An abscess results. The extent of this abscess varies
greatly. It may rupture into the peritoneal cavity producing a
diffuse peritonitis. It may remain localized and permit drainage
or even drain spontaneously. I had such a case. A man was
kicked in the lower abdomen by a horse. He had pain at once, fol-
lowed by fever and distended abdomen. I saw him in 3 Aveeks
and opened into a tumefied mass and found much gas and colon
bacilli. A fecal fistula persisted for six months.
Diffuse Peritonitis. — In cases in which there is no reaction fol-
lowing the injury when the injured area becomes separated from
the surrounding tissue the intestinal material escapes and a diffuse
peritonitis results. This CA'cnt is most apt to occur in cases in
Avhich the violence of the injury was not extreme. The injured
area becomes necrotic, the result of thromboses, and drops out per-
mitting the contents of the gut to escape Avith the usual results.
These are very treacherous cases. I once saAV a man Avho had suf-
fered a moderate bloAv in the epigastrium. He had pain Avliich soon
subsided. He Avas attacked Avith acute abdominal pain a Aveek
later. An area the size of a dime had fallen out of the Avail of the
colon. The affected area Avhile undergoing necrosis may give no
symptoms before the lesion suddenly gives Avay. History of trauma
then is the only fact that may aid us in distinguishing such cases
from a peptic or other ulcer. When the escape of infection takes
place gradually through an opening jjartly Availed off. the onset
636 THE PERITONEUM
is less acute. The course of the disease is then similar to a non-
perforating appendicitis.
Diagnosis. — AVhen confronted ])y a questionable aljdominal in-
jury the patient should he placed in surroundings where immedi-
ate operation may be done should events demand it. The kind and
degree of violence executed may give some clue as to what com-
plication may be expected. The beginning symptoms may be those
of distention with little spontaneous pain or pain on pressure.
Superficial tenderness may be due to contusion of the abdominal
A\all. This should be at its height in 36 hours. Should it increase
after this time a graver lesion must be expected. Should muscular
rigidity increase an impending infection is probable. Iii such cases
the pulse and temperature usually keep pace with the increase in
the local reaction. If the progress is sIoav, one may be al)le to ap-
preciate a gradually A\alling-otf process.
The perforating type in Avhich there is no evidence until the
necrotic area separates presents no evidence Avhich enables one
to make a diagnosis until the perforation occurs. The occui'rence
of symptoms of acute perforation a A\eek or so aftei- an abdominal
trauma should be the signal for actioii.
Treatment. — AVhen there is evidence of internal injury of the
character above described an exploratory laparotomy may be the
safest course. One can not place his indications before the patient
too strongly, for he may refuse operation and go about his busi-
ness undisturbed. It is only the evidence of a progressive reactive
process that warrants unequivocal advice of operation. AVith a
sloAvly ascending inflammation with evidence of localization safety
may lie in procrastination until the process becomes Availed off.
The procedure then resolves itself into the simple opening into a
walled-off abscess, Avith the likelihood of producing a temporary
fecal fistula. These usually heal spontaneously if they are located
in the terminal ileum. Even if the fistula closes, the loop of gut
likely will remain attached to the abdominal Avail and these ad-
hesions remain as possible sources of further mischief.
AVhen there is a perforation through the gut Avail as a seeondar.A'
necrotic process the treatment usually accorded a perforating
duodenal ulcer is in oi-der. Usually the perforation a\ ill be be-
TRAUMATIC PERITONITIS WITHOUT RUPTURE 637
neath the great omentum and the drainage must be placed ac-
cordingly.
Peritonitis from Traumatic Rupture of the Gut. — Direct violence
may sever a loop of gut resulting in the immediate escape of fecal
contents with subsequent acute diffuse peritonitis. The nature of
the injury, such as being run over by a vehicle, or by a blunt ob-
ject as a wagon tongue, should excite the apprehension of the sur-
geon and if in a few hours the pulse should mount, exploration is
demanded. The disease is an uncommon one and is usually over-
looked until active inflammation has become advanced.
Laceration of solid parenchymatous organs with hemorrhage
may irritate the peritoneum and give the symptoms of a gener-
alized peritonitis. If the hemorrhage is extensive, early symptoms
of anemia may give a clue to the correct diagnosis, but a small
hemorrhage may cause a moderate rise of temperature, pain and
general tympany.
Rupture of the Mesentery. — A solution of continuity of the
mesentery as an isolated lesion is not common. Neumann reports
a case. Kudlek reports two cases. Autenrieth reports one case and
Erdman reports three cases. Hume reports one case as does Ogden.
The significant event in all these cases is hemorrhage. Pain and
collapse in proportion to the extent of the leak follows. When
there is traumatic rupture of the gut the mesentery is likely to be
involved to a greater or less extent. Bruising of the mesentery
may cause clotting within the vessels with subsequent gangrene
of the gut. This is likelj^ the etiology in many cases of late perfora-
tion of the gut already discussed.
POSTOPERATIVE PERITONITIS
General peritonitis following a "clean" abdominal operation is
to the surgeon Avhat puerperal fever is to the obstetrician — a
catastrophe. They rarely occur in the hands of skilled surgeons,
])ut they do occur now and then even under the most favorable
surroundings. AVben such tragedies do occur usually either the
operator or some one of his assistants has come in contact with
some virulent infective material. During the time I was an in-
nocent laboratorv worker I noted that when surgeons worked with
638 THE PERITONEUM
■erysipelatous patients and like infections there was likely to be a
call to do an autopsy on a patient dead of "paralytic ileus," what-
ever may be meant by that term.
Prophylaxis.- — ^Two general plans have been followed: the sys-
temic stimulation of the system to leucocyte formation, the leu-
cophytaxia of Jousse, and a local increase of leucocytes confined
to the peritoneum itself.
A number of substances have been employed to produce these
results. The nucleinic acid and nucleinate of soda have been most
studied. Von Mikulicz employed the former substance in normal
salt solution by injecting it directly into the peritoneal cavity.
He found that animals so treated resisted five times the lethal dose
of colon bacilli. These animals also resisted the introduction into
the peritoneal cavity of gastric or intestinal contents. Faucon in
repeating these experiments found that the animals were not pro-
tected Avhen virulent bacteria were added or the intestinal con-
tents which were allowed to escape. In employing this substance
clinically Mikulicz injected 50 c.c. of a 2 per cent solution.
Aschner and v. Graff: employed the solution subcutaneously.
They found that severe pain, requiring morphine, was caused as
well as fever and general depression. All these phenomena Avere
more intense in young subjects.
The clinical results of this practice are inconclusive. Jousse col-
lected 1047 cases in which it was used. The operative mortality
is alleged to have been lowered from 9.6 per cent to 4.6 per cent.
As one reads these case histories it is difficult to suppress the feel-
ing that the reputed inveracity of statistics here reaches the su-
perlative degree.
To Glimm belongs the doubtful credit of first employing olive
oil as a protective against postoperative peritonitis, though Bren-
nen seems to have suggested that it may prevent the development
of bacteria, this being his explanation of its alleged prevention of
adhesions. Assuming that the oil. as Avell as bacteria and their
toxins, are absorbed by way of the lymphatics, he proposed to
lessen the deleterious effects of peritonitis by plugging up the lymph
channels Avith oil globules. He found that rabbits in which 8 to
10 c.c. were injected into the peritoneal cavity were protected
from fatal doses of colon bacilli. Hoehne in repeating these ex-
TRAUMATIC PERITONITIS WITHOUT RUPTURE 639
periments found that the animals were not so protected. He found
that the oil is absorbed because he observed pulmouarj^ embolism.
Hoehne concluded that absorption of microbes was diminished if
the oil is injected 12 to 24 hours to 4 days before the injection of
the microbes. This slowing is due, he concludes, to reactive inflam-
mation. He employed it in 42 patients Avith satisfactory results.
Hirschel employed it in 3 cases of diffuse peritonitis and credits
this treatment with having saved one of them. He later reports 9
more cases with 4 recoveries. In these he used from 100 to 300 c.c.
of 1 per cent camphorated oil.
Petit used horse serum for the prevention of peritonitis. He
found that this substance made rabbits resistant to 5 times the lethal
dose of typhoid and colon bacilli. He reports good results in ex-
istent peritonitis. Schmidt found that the use of the serum pro-
duced a leucocytosis. Federmann employed it in 11 cases of gen-
eral peritonitis Avith 3 recoveries.
Numerous other substances have been used. Lardennois used
20 c.c. hydrocele ' fluid intraperitoneally. Doyen employed fibro-
lysin. Weiss and Sencert employed oxygen. Finally Miramond
de Laroquette employed ozone by means of the x-ray.
So far as concerns the value of the means aboA^e enumerated as a
postoperative prophylactic, tlie perfection of modern technic makes
them entirely superfluous. As therapeutic measures they illustrate
the fact so often noted in the discussions of treatment that an
author makes enthusiastic reports of the value of certain measures
then promptly ceases to emploj^ them in his own practice. Though
each of the substances discussed had its enthusiastic supporters,
none are used at the present time.
Bibliography
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voii Laparotoinien mil sulikutancr Injoktioii von Niikk'iiisaure, Mitt. a. d.
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Arch, de Doyen, Pa., 1910-11, i, ."'.5.").
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and One of Multijile Lacerations, Am. Jour. Med. Se., 190."), n. s., cx.xix,
980.
640 THE PERITONEUM
Faucox: De I'acide nucleinique dans Ics infections peritoneales. Pratique Jour.,
Lille, 1905-6, vi, 193.
Federiiaxx : Ueber Behamllung der akuten Peritonitis mit normalem Pf erde-
serum, Deutscli. med. Wchnschr., 1905, xxxi, 731.
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d'aueuu viscere, Bull, ct mem. Soc. de chir. de Paris, 1910, n. s., xxxvi,
402.
Glimm : Ueber Bauchf ellresorjition und ihre Beeintlussung bei Peritonitis, Deutseh.
Ztsclir. f. Chir., 1906, Ixxxiii, 254.
GuiBAL: Peritonite traumatique par contusion de 1 'abdomen sans ruptures
viscerales. Bull, et mem. Soc. de chir. de Paris, 1909, n. s., xxxv, 1272.
HiRSCHEL: Die Behandlung der diffusen eitrigen Peritonitis mit 1 proz. Kani-
pferol, Miinchen. med. Wchnschr., 1910, Ivii, 779.
HoEHXE: Zur Prophylaxe der postoperativen Peritonitis, Miinchen. med.
Wchnschr., 1909 Ivi, 2508.
Experimeutelle Untersuchungen iilier den Sehutz des Thiei-korpers gegen peri-
toncale Infection, Arch. f. Gynak., 1911, xciii, 562.
Hume : Torn IMesenterv : Eeseetion : Eecovery, Univ. Durham Coll. Med. Gaz.,
1905-6, vi, 112.
JousSE: La mise en etSt defense du peritoine dans la Laparotomie, These de
Montepelicr, 1912.
Kudlek: Isolierte Mesenterialabreissungen nach Bauchkontusionen, Deutseh.
Ztschr. f. Chir., 1908, xciv, 327.
Lardexxois: L'emjdoi du liquide d 'hydrocele en injections dans les infections
graves et les hemorrhagies. Union med. du nord-est, K«ims, 1912, xxxvi, 1.
Laubie: Rupture du mesentere i^ar chute d 'uu lieu eleve (rapport medico-legal),
Gaz. liebd. d. sc. Med. de Bordeaux, 1907, xxviii, 291.
V. Mikulicz: Versuche iiber Resist enzvermehrung des Peritoneums gegen In-
fection bei Magen- und Darmoperationen, Arch. f. klin. Chir., 1904, Ixxiii,
347.
MiRAMOXD DE Laroquette : Principes physiques et physiologiques du surchauf f -
age lumineux, Presse med., 1911, xix, 1038.
Xeumann: Ueber ausgedehnte Mesenterialabreissungen bei Kontusion des
Abdomens. Beitr. z. klin. Chir., 1904, xliii, 676.
Ogdex: Traumatic Rupture of the Mesentery, Jour. Am. Assn., 1910, liv, 1865.
Petit: Action du serum de cheval chauffe injecte dans le peritoine; son
utilisation en chirurgie abdominale, Ann. de I'Inst. Pasteur, 1904, xviii,
407.
SCHiiiDT: Intraperitoncale Serum- und Kochsalzliisunginjektionen zur Verliiitung
operativer Infektionen des Bauchfells, Deutseh. med. Wchnschr., 1904, xxx,
1807.
Weiss axd Sexcert: De I'emploi du courant continu d' oxygene en cMrurgie
abdominale, Med. d. accid. du travail, 1910, viii, 563; 863.
CHAPTER XXV
FETAL PERITONITIS
Under this heading a great variety of intraabdominal conditions
as observed in the fetus have been described. A few cases of real
peritonitis have been recorded, but most of the literature relates
to unusual developmental conditions either pertaining to unusual
union of peritoneal surfaces or to so-called adhesion formations.
Orthmann discusses particuhnrly the relation of fetal peritonitis
to double uterus and vagina duplex. Von Winckel also ascribes
many developmental anomalies to fetal peritonitis. Both these
authors discuss the literature.
Simpson through Bednar -was able to report on a collection of
186 cases. Theremin brings the records to the date of his paper
and muddies the waters by declaring that all gut occlusions of un-
known origin must be attributed to peritonitis, whether or not
there is evidence of the former existence of such a process. Ahl-
feld attempts to get away from this broad assumption by accusing
the prolonged persistence of the omphalomesenteric duct. Silber-
man brings the study to the date of his paper, reviewing fifty-seven
cases from the clinical viewpoint. He notes that twenty-four of
these occurred in the duodenum, i^ermitting us, in the light of re-
cent study, to bring the problem rather automatically to date and
to rid it of the confusing designation "inflammation" and remov-
ing it from the scope of this monograph.
The reason "peritonitis" is invoked as a cause of anomalies is
that adhesions, ascribed to previous inflammation, are supposed to
interpose between the developing organs. The fundamental error
in this assumption is that the term infUimmation is assumed to be
coextensive Avith pathologic process. "What the cause of these un-
usual conditions may be, we can not speak of with certainty, but
no one has ever demonstrated an inflammatory state in any of the
specimens recorded.
The conditions described as being due to adhesions are analo-
641
642 THE PERITONEUM
goiis, most likely identical, Avitli normal adhesions, that is to say the
normal obliteration of surfaces which takes place "when a surface
once intraperitoneal becomes extraperitoneal. Why normal ad-
hesions take place can not of course be definitely stated, but that the
abnormal is but an extension of the usual can not well be doubted,
because of their like histologic appearance and the fact that every
gradation from the normal can be observed.
Dalla Rose questioned the justification of ascribing these ad-
hesions to postinflammatory processes, preferring to refer to them
as developmental anomalies. As already noted none of the phe-
nomena of inflammation precedes their formation and the use of
this term merely confesses the paucity of our nomenclature. These
changes were noted as early as the fourth month in two cases and
between the sixth and seventh month in two other cases by Simp-
son. Orthmann j^laces them at the sixth to the eighth week, Gessner
at the third month, and ]\Iackenrodt at fi'om the third to the sixth
month. It seems Avorthy of note that in these young fetuses ad-
ventitious bands are vastly more common than at term. Conclu-
sions based on such observations are apt to be erroneous for in the
further development these "bands" must be used up by the ex-
panding organs. Many of the "bands" in these young fetuses
when sectioned fail to show an organic structure and they may
wholly disappear, judged by the standards we may say that they
Avould disappear.
In view of the available facts it seems impossible to define a limit
betAveen unusual dcA^elopment of normal processes and the patho-
logic. It seems safer in case of doubt to ascribe such occurrences as
an excess of the normal, being pathologic only AA'hen there is an inter-
ference Avith the proper performance of the function of the organs of
the abdomen. The term "peritonitis" had best be reserved for those
few instances in Avhicli there is evidence of a reactiA'e process. At the
same time it must not be lost sight of that membraniform agglutination
may occur in the adult as a result of irritation processes Avhich do not
lead to suppuration. Some of these Ave may ascribe to tuberculosis.
Possibly this organism may be active in the pelvis. These proc-
esses are in need of rencAved study.
It may be noted that the gut tract being free from bacteria, any
disturbance in the circulation capable of producing an exudate
FETAL PERITONITIS 643
might be followed by organization of the exudate. It still remains
for someone to advance the theory that the attachment of the
colon is due to circulatory disturbance due to the rotation of the gut.
The source of origin of the infection in these alleged peritonitides
has been hypothecated as being derived through the maternal cir-
culation as Peiser has pointed out. That such a transmission is
possible has been shown by Blumenthal and Hanne for the colon
bacillus and by Neuwerck and Flinzer for the paratyphoid bacil-
lus. Still it is a far cry from the finding of bacilli in the fetal blood
and to the cause of adhesion in the peritoneal cavity.
The anatomic findings usually described in cases of fetal peri-
tonitis are described as exudates in which fibrin flocculi are sus-
pended, or sometimes fibrinoid j^recipitates more or less intimately
attached to the peritoneal surface which may agglutinate peritoneal
surfaces together as in a ease recorded by Baumgarten.
It is not uncommon to note a coagulable exudate in the bellies
of fetuses. The agglutination is purely due to coagulable mate-
rial and there is no attempt at organization, neither is there any
reaction on the part of the peritoneum. Why this exudate forms
is not known. Whether it bears any relation to the equally mys-
terious hydrocephalus or hydramnios is a matter of great concern.
These exudates are sterile and occur independent of any infective
process of the mother. Possibly impending abortion interferes
with the placental circulation and the peritoneal exudate is but a
dropsy due to passive hyperemia, analogous to dropsy in liver
cirrhosis. The absence of a cellular content in both would make
such an explanation as logical as others that have been advanced.
Contrasted with the intangible conditions above noted are those
arising secondary to other conditions. Peiser has divided these
into those arising from congenital atresias and stenoses, torsion
of the gut, perforation of the gut and maldevelopment of the uro-
genital apparatus.
There is a group of cases in Avhich there is evidence of past
inflammation. In most of these a cause for the inflammation has
been demonstrated. The first group of causes is congenital anom-
alies, chiefly atresias, inflammation being in these cases the result,
not the cause of fetal peritonitis. The other most frequent cause
of fetal peritonitis is necrosis from inspissated gut contents.
644 THE PERITONEUM
111 most of the bona fide eases in Avhieli peritonitis was associated
Avith atresia there was evidence that stasis occurred behind the
constriction of the gut. Perforations may take place in the ab-
sence of atresia, however. Why these perforations take place is
not known. Paultauf believed they were due to stercoral necrosis.
Schlengel records a pea-sized perforation near the ileocecal valve.
Generisch reports a meconium abscess. Zillner believes rupture
of the gut may take place during birth. Thus Brandfoot records a
case in which there were organized adhesions in the right iliac
fossa of the small and large intestine. Ballentyne's case Avas a
child which died 32 hours after birth which showed extensive dry
adhesions. The oldest process seemed to be in the pelvis. Gener-
isch's case died 45 hours after bii-th. The abdominal wall was
thickened and was infiltrated with a tliin cloudy greenish serum.
The intestines were agglutinated with each other and with the
abdominal wall. There was an opening in the ileum 10 cm. from
the cecum which communicated with a cavity formed by adherent
gut and abdominal wall. Falkenheim and Askanazy reported a
case in which there was a perforation of a gut by calcified meconium.
Most of the cases reported, judging from the state of development
of the gut, seem to have arisen at the end of pregnancy. Gessner
believes his case originated in a peritonitis because the intestines
were enveloped l)y a thin membranous, adhesion ^^■hieh extended
over the liver.
I once studied a stillboi'ii child Avhieh had the intestines matted
together by a coagulated gelatiform mass. Near the sigmoid colon
the small intestines were matted together by membranous adhe-
sions. Near the pelvic brim the sigmoid made a high loop in which
was a mass of hard meconium which had much thinned the gut
wall. About this point the small intestines were adherent to the
sigmoid.
Owing to the sterile character of the intestinal contents its es-
cape into the peritoneal cavity produces only a chemical peri-
tonitis. As observed they are mostly end-products. One case of
suppurative peritonitis Avas reported by Hunt. This patient had
lived but an hour after birth. There Avere old adhesions and the
omentum and intestinal serosa Avere hyperemic and Avere coA^ered
FETAL PERITONITIS 645
■with pus. This seems to be the only case recorded in which "pus"
was noted.
As examples of the circumscribed type which has run its course
may be mentioned the following by Theremin. In this case all
that remained at autopsy was a contracted loop of ileum the mesen-
teric borders of Miiich were firmly adherent. Similarly Dorn re-
ports a case in which the duodenum Avas much contracted and there
were adhesions betAveen the duodenal Avail, colon, and neck of the
gall bladder to the right kidney. Peiser reports a case in Avhich
there Avere diffuse adhesions in a child six months old. There
AA'ere membrane-like adhesions oA^er all the A'iscera and the pehns
AA'as Avholly inaccessible because of them.
Despite the indefinite state of our anatomic knoAvledge Noetter-
brock discusses the possibility of a clinical diagnosis. He thinks
that there is a possibility of feeling the distended abdomen of the
fetus in cases Avhen the liquor amnii is small in amount, also in
breech presentation the absence of expulsion of meconium might
indicate a stenosis. It is Avorth noting that the proposal of making
a clinical diagnosis Avas made in a student's thesis.
Bibliography
Ahlfkld: Bostimmiingen dor Grosse uiul des Alters der Frueht vor der Gebiirt,
Arch. f. Gyuak., 1873, ii, 353.
Ballaxtyne: [A specimen showing peritonitis in the ncwliorn infant] Tr. Edinb.
Obst. Soc, 1889-90, xv, 56.
t'ber das Otfenbleibeu fotalcr Gefasse, Centralljl. f. d. mod. Wissensch., 1877,
XV, 721 ; 737.
Baumgartex: X'ircliows Arch. f. path. Anat., xci, 89.
Bedxae.: Die Kranklieiten der Neugebornen und Sauglinge vom clinischen und
pathologisch-anatoniischon Standpunkte, AVien, Gerold, 1850.
BrXMEXTHAL AXD Hajim : Bakteriokigischcs und Klinisches iiljer Coli- und Para-
coHinfektionon, Mitt. a. d. Gronzgeb. d. Med. u. Cliir., 1907, xviii, 642.
Braxfoot: Intrauterine Peritonitis, Brit. Med. Jour., 1886, ii, 169.
Dalla Rosa: Ein Fall von Uterus bicoruis niit Ligamontum rectovesicale, Ztsclir.
f. Heilk., 1883, iv, 155.
DoilRX: Falle von .Stenose des Darines und fotaler Peritonitis, Jahib. f. Kin-
derh., 1868, 1, 217.
Falkexiieiji AXD AsKAXAZ.Y: Perforationsperitonitis l)ci eineni Nengebornen
mit Verkalkung des ausgotretenen Meconiums, Jahrb. f. Kinderh., 1892.
n. F., xxxiv, 71.
Gexersich: Bauelifellentziiudung l)eim Xeugel)ornen in Folge von Perforation
des Ileums. Virchows Arch. f. path. Anat., 1891, cxxvi, 485.
Gessxeu: Ein Kind mit fotaler Peritonitis, Berl. klin. AVclinschr., 1896, xxxiii,
403.
Huxt: Foetal Peritonitis (in Utero), Obst. Soc. London, 1867, ix, 15.
646 . THE PERITONEUM
Mackeneodt: [Demonstration fijtaler Peritonitis], Zentralbl, f. Gynak., 1893,
xvii, 654.
Xautterck and Tlixzer: Paratvplms und ]\Ielaena des Neugebornen, Miinchen.
med. Wchnsclir., 1908, Iv, 1217.
Notterbeock: Zur Ivenntnis der fotalen Peritonitis, Giessen, Lange, 1904.
Orthmaxn: Fotale Peritonitis und Missbildung, Mouatschr. f. G^burtsch. u.
G.^aiak., 1907, xxv, 302.
Paltauf: Die spoutaue Dickdamiruptur der Xeugeboruen, A'irchows Arch. f.
path. Anat., 1888, cxl, 461.
Peiser: Die fotale Peritonitis, Beitr. z. klin. Chir., 1907, Ix, 168.
SCHLEGEL: Zur Casuistik des angeborenen Darmvei-sehlusses und der fotalen
Peritonitis, Diss. Bern, 1891.
SiLBERMAX: Uel)cr Bauchfelleutziindung Neugeborner, Jahrb. f. Kinderh., 1882,
n. F., xviii, 420.
SiMPSOX: Contriljutions to Intrauterine Pathology, Edinburgh Med. Jour., 1838,
XV, 390.
Theremix: Ueber congeuitale Occlusionen des Diirmdanns, Deutsch. Ztschr. f.
Chir., 1877, A-iii, 34.
V. WixCKEL: Ueber die Einteilung, Entstehung und Benennung der Bildungs-
hemmungen der weiblic-hcn Sexualorgane, Saniml. klin. A'ortr., n. F., 1899,
No. 231-252 (Graak. No. 90, 1523).
ZiLLXEK : Eupture flexura segmoid, Virchows Arch, f . path. Anat., 1884, xcvi, 307.
CHAPTER XXVI
TUBERCULOSIS OF THE PERITONEUM
Historical. — The foundation upon a\ liicli oui' conception of tuber-
culous peritonitis is builded was laid by Bicliat, who separated the
inflammations of the peritoneum from the diseases of the stomach
and intestines, and divided them into acute and chronic forms.
The chronic form, Avhich concerns us here, was not separated from
other chronic diseases, notably carcinosis. It is true, Morton,
Bonet, and Morgagni had previously written more or less accurate
descriptions of the disease, Init Bailie had not yet clearly defined
the tubercle as the specific lesion of tuberculosis. The recognition
of a distinct type for tuberculosis remained for Baron and, folloAv-
ing him, Louis. The latter noted the identity of the lesions existing
in the peritoneum with those in the pleura in pulmonary phthisis.
Broussais predicted its general recognition. It is interesting to
note that Hodgkin opposed this view.
Louis believed that peritonitis was always secondary to pleurisy.
Godart opposed this view, for he observed a case in which the
lungs were unaifected. Bright, Trousseau, and others noted similar
cases. Louis's observations were further limited by Cruveilhier,
who noted cases of chronic peritonitis in which there were no tuber-
cles. Since this occurred mostly in young women, he called this
type "Ascite des jeunes fiUes. " This conception was further de-
veloped by Aran, and this form Avas subsequently recognized as
idiopathic chronic peritonitis. For a time this idiopathic type pre-
vailed as the more common one. The relation of this type to the
tu])erculous form is pei'ha])s today not fully determined. Aran
observed tliat chronic peritonitis was noted chiefly in tuberculous
subjects and that in such cases tubercles Avere usually found, but
he observed cases in which chronic peritonitis occurred in those
not affected by pulmonary tuberculosis.
A new era in the history of tuberculous peritonitis began in
1884 when Konig recounted case histories in which the patients
647
648 THE PERITONEUM
recovered. With this announcement, the modern history of tuber-
culous peritonitis may be said to beg-in. The importance of this
announcement was not simply that a therapeutic measure of impor-
tance was introduced, but that it opened up a vast field for the
observation of the disease in its early stages and for the clearing
up of the diagnosis in many cases. From this time on the history
merges into the account of its pathologic anatomy.
Etiology. — The cause of tuberculous peritonitis is, of course, the
tubercle bacillus.
The determination of the specificity of tuberculosis is a matter
of interest. AVhile Louis recognized it as a local manifestation of
a general disease, it was Yilleman who first announced the theory
of the infectious character of pulmonary tuberculosis. Before, the
discovery of the tubercle bacillus by Koch, in 1882, many writers
had surmised the tuberculous nature of certain lesions of the peri-
toneum. The conclusions were based, of course, on the recogni-
tion of the unit lesion, the tubercle, reasoning by analogy from
similar lesions in the lung.
It is important to note that in the determination of clinical
problems we still employ the results of the observations made in
the period before the discovery of the bacillus. These conclusions
were based on the presence of tubercles, with infiltration and
caseation. Even with the aid of modern technic the demonstration
of the ])acillus in a given case of the disease is often difficult, even
impossible, either in the exudate or in the tissues, in cases in Avhich
the gross appearance of the lesion and the clinical course leave no
doubt as to the nature of the disease. There are cases of chronic
exudative peritonitis which lack the typical anatomic lesion of
tuberculosis, but Avhich. because of their chronicity, resemble tu-
berculosis. Prior to the discovery of the tubercle bacillus, these
cases were classified as idiopathic. Since the discovery of the ba-
cillus this group has been markedly reduced. INIany observers
even deny the occurrence of idiopathic cases. Be this as it may,
chronic peritoneal inflammations in wliich it is impossible to demon-
strate the bacillus, do occur. It would, perhaps, be better to clas-
sify such cases as idiopathic, and to be more rigid in our demands
for scientific proof of their tuberculous nature, than to categori-
cally force them into the specific group. The question is of
TUBERCULOSIS OF THE PERITONEUM 649
sufficient interest to warrant a separate discussion of idiopathic
peritonitis.
When the specific cause of a disease is known, the etiologic fac-
tors available for discussion are confined to a recounting of facts
pertaining to the conditions and circumstances under which the
disease develops.
Age. — No age is exempt. Monclair and Alglare have reported
a case of a baby which died on the sixth day after birth. The
autopsy shoAved an extensive tuberculosis of the peritoneum. The
mesenteric glands showed giant cells and tubercle bacilli. Bouardel
reported a case in an infant of ten weeks of age. Fletcher records
eight cases under one year of age. Cummins' statistics show a
variation in age from sixteen months to seventy-three years. In
Konig's series 30 per cent were below twenty years. Thoenes
found tAvo-thirds of the cases in young persons. Osier, however,
states that the disease occurs most frequently between the twen-
tieth and the forty-ninth years, and this corresponds to the statis-
tics of most authors. Thus Nothnagel had 83 out of 164 cases be-
tween the twentieth and fortieth years, and Shattuck had 52 out
of 98 cases during the same period. Schmalmack found the ages
most predisposed to be between one to ten and twenty-one to fifty
years.
Sex. — The sex incidence varies according to whether postmortem
or operative statistics are considered. In the former the male, in
the latter the female predominates. Thus Konig in 131 cases oper-
ated on found only 11 in men, while Rosthorn in 153 autopsies
found 122 in the male and 31 in the female. Fenwick in 46 cases
had 30 males and 16 females. Philipps in 107 postmortem cases
found the male affected 89 times, and the female 18 times; in oper-
ative cases, he found 120 females to 14 males. Miinstermann in
46 operative cases had 33 females and 13 males ; Cummins had in
92 autopsies 31 females and 61 males. Voigt had 29 females and
27 males in 56 cases. Taking this large series, we find that about
three times as many males are affected as females. Schmalmack
suggests that the reason for this discrepancy is due to the fact that
more males than females come to autopsy, and more females than
males to operation. This suggestion is a good one. Heintze sug-
gests, as the cause of greater frequency in males, that alcoholism
650 THE PERITONEUM
predisposes to tuberculous peritonitis. Alcoholism at least predis-
poses to death in a public hospital, with a subsequent autopsy
and a correct diagnosis. In either event the statistics are swelled
in favor of the male. Numerous writers, for instance, Rokitansky,
Forster, Weigert, and Grawitz, however, suggest that hepatic cir-
rhosis predisposes to peritoneal tuberculosis, and in this Avay al-
cohol might play an indirect part. On the other hand, it is pointed
out (Heintze) that the pelvic congestion of puberty, hematocele,
and pelvic peritonitis, predisposes the female to this disease. All-
port believes that the percentage of sex incidence would be equal-
ized "were we to add to the percentage of male operated patients
those who suffer from tuberculosis of those organs whose female
homologues are intraabdominal ; or Avere we to deduct from the
percentage of laparotomized women those who suffer from second-
ary or ascending tuberculosis of the intraabdominal genitals and
tuberculous peritonitis incident thereto." It is a general agree-
ment that the genital organs are the point of beginning in the
majority of cases in the female ; but whether this is true or not
is a question. That so few females, relatively, come to autopsy
may be explained on the ground that many recover spontaneously,
inasmuch as the discrepancy of sex at autopsy was noted before
the pelvic organs of the female were so often attacked by the sur-
geon. This fact should be remembered in considering treatment.
Heredity. — A family history of tuberculosis is obtained in but a
minority of the cases. Heintze obtained such a history in four out of
twenty-five cases. Hane found a positive history in 35 per cent of
cases. Delpeuch states that a hereditary history is exceptional.
General Physical State. — The general conditions under which
tuberculous peritonitis develops are parallel with those underlying
the disease in other organs. This is obviously true since in the
vast majority of cases, the disease first finds a nidus in some re-
mote organ, notably the lungs.
Maldevelopment, bad housing conditions, and insufficient nutri-
tion because of poverty and chronic disease of the digestive organs
are said to play a part. Maurange regards an alcoholic or syphi-
litic heredity as an important predisposing factor. Arullani con-
sidered drinking a great factor in the production of all forms of
tuberculosis. Vallin noted this disease most frequently among sol-
TUBERCULOSIS OF THE PERITONEUM 651
diers. My experience is in accord mth those observers who see
peritoneal tuberculosis attack those who have no tuberculous his-
tory and who were previously healthy.
Whether some preexisting affection of the peritoneum or its
immediate environs presages the advent of peritoneal tuberculosis
is still a matter of speculation. Thus Boulland believes that a scar
resulting from typhoid or other ulcerations may have an etiologic
importance. He also regards the congestion of menstruation and
the hypernutrition of pregnancy as factors which favor the de-
velopment of the disease in these organs. Steinln'iicke accuses
chlorosis of having a deleterious influence. Delpeuch sees in irri-
tation and preexisting inflammation an important predisposing
cause. That irritation does play some part, would seem to be indi-
cated by the repeated localization in hernial sacs, as already noted
by Cruveilhier.
Trauma. — In a number of instances a trauma has preceded the
development of the disease. Broussais regarded trauma as an im-
portant factor. O'Callaghan reports a case which developed in a
boy after an injury received during a football game. Plummer
reports a case following a kick by a horse. I had a case in a male,
aged forty-six, in whom a cystic mass developed in the umbilical
region, folloAving a violent injury. There was rapid emaciation,
and pancreatic cyst was diagnosed. Operation disclosed an en-
cysted tuberculosis. A number of like cases are reported in the
French literature.
Kelly believes there is a definite relation between pregnancy and
tuberculous peritonitis. In 28 per cent of his cases the disease
dated from childbirth, and Boulland believes the frequent con-
gestion due to menstruation and pregnancy favor the develoiDment
of tuberculosis.
Pathogenesis. — AVhile in rare instances, probably, the peritoneum
may be the site of the initial lesion, in the vast majority of cases
tliis organ becomes infected from a primary focus located else-
where in tlie l)()(ly. Such a focus can often ])e located in the lungs,
lymph glands. Fallopian tubes, etc. In other instances it can only
be suspected from llic ])revi()iis history. Even when the i)riinai'y
focus is known, the avcmic by which the tubercle bacilli reach the
peritoneum can not be demonstrated in the vast majority' of cases.
652 THE PERITONEUM
The results of autopsies are uncertain, because the lesion is then
advanced, obscuring all traces of the initial process. The evi-
dence obtained at laparotomy is often inconclusive, for investiga-
tion is necessarih^ limited. Even in cases in "wlnch conclusive e"sa-
dence of the existence of a primary focus can not be obtained,
thorough attempt to find such a focus should always be made. Al-
though a primary focus is known to exist, the avenue by which the
infection reached the peritoneum can not be demonstrated. There
is a huge literature on the subject, but there is still a great lack
of definite knowledge on this phase of the subject.
The investigator should always seek to answer the question
"whether the peritoneal infection is primary or is secondary to some
other focus. If secondary, the route traveled to reach the peri-
toneum should be determined, if possible.
Primary Form. — The limitations in our ability to satisfactorily
demonstrate the genesis of a tuberculous peritonitis are particu-
larly impressive when an attempt is made to answer the question
whether it is possible for tubercle bacilli to reach the peritoneum
without having previously involved some other organ. Eokitansky
commented on the extreme rarity of such an occurrence, and most
of the later Avriters have not committed themselves definitely. All-
port is quite certain that there is no such thing as an absolutelj^
primary tuberculosis of the peritoneum. He denies categorically
the transmission of bacteria across the normal intestinal wall.
With this opinion there can be no disagreement, but an associated
enteritis might produce a sufficient lesion of the gut wall to permit
the passage of bacilli, just as the ileum permits the passage of
colon bacilli through the damaged intestinal wall in strangulated
hernia. The possibility of transmission from a focal infection, such
as the tonsils or lung, by way of the blood stream can not be de-
nied. Primary peritoneal tuberculosis can be produced by the in-
jection of tubercle bacilli into the mesenteric arteries of animals,
and the possibility of the passage of bacilli direct to the jDeritoneum
after absorption from the tonsil can not be denied, for Lexer proved
this possibility in case of the pus organisms. HoAvever this may be,
primary peritoneal tuberculosis has not yet been proved. Children
affected Avith tuberculous lymph glands may develop tuberculous
peritonitis spontaneously or after some other disease. I have tAvice
TUBERCULOSIS OF THE PERITONEUM 653
observed a rapid development of tuberculous peritonitis in sucli
children who had recently suffered from measles. The diagnosis
was established by biopsy. Both of these recovered, and no sec-
ondary focus was ever discovered. Each had a tuberculous his-
tory, however, and presented general evidence of a substandard
physique. It is likely that the exanthematous affection lighted up
a dormant focus in some distant organ. To explain the advent of
the infection in the peritoneum, it is necessary to assume that it
was transported by the blood stream. The relative immunity of
the peritoneum to tuberculous infection, to which Weigert called
attention, would leave unexplained the escape of vulnerable or-
gans, if the bacilli traveled by way of the blood stream, unless we
assume that in certain instances, as from previous disease or other-
wise, the peritoneum in a given case was particularly susceptible.
In this regard the peritoneum bears much the same relation to the
tubercle bacillus as it does to the pneumococcus.
I have seen several cases of tuberculosis of the cecum in indi-
viduals otherwise clinically free. In these cases the subserosa
seemed to be the area chiefly involved. I had one patient, a boy
of fourteen, Avho became suddenly sick Avitli a moderate attack of
acute peritonitis. At operation a moderately inflamed cecum and
appendix were found. There was a solitary lymph ghuul in the
mesentery which was removed. On section it showed tlie typical
lesion of tuberculosis. The appendix showed only a general in-
filtration with acute necrosis in some of the lymph follicles. Since
the gland removed was the only one affected it seems probable that
it must have received its infection from the gut. Possibly the
cecum was the primary seat of disease, a condition the appendix
did not show.
I have seen a circumscribed peritonitis follow a trannia in a vig-
orous man of forty. While there was no obvious lesion, it is fair
to assume that there was one.
The cases that appear jirimary at the operating 1al)l(' ni'C most
likel.v intestinal in origin. It is generally recognized tluit the
retroperitoneal lymph glands are freciucntly infected. These must
receive their infection fi-oiii the gu1 mucosa. It is quite reasonable
to assume that a lesion liore will sometimes approacli tlie serous
surface. In the cases I have seen in children most of tlu'in were
654 THE PERITONEUM
under par in the year preceding the development of their peritoneal
affection. I believe if pot-bellied children were examined more
carefully for free fluid in the peritoneal cavity one Avould be led
to suspect peritoneal tuberculosis more often. Old adhesions and
vascular changes observed in later life may find an explanation in
such a past process. Herringham found lesions in 50 cases
in Avhich tuberculosis was suspected, but could not be proved. Many
such mild lesions could easily escape recognition. When the lesion
in the peritoneum is once established, it is difficult to say which
is primary when the lymph glands are also involved. While the
origin of the lymph gland tuberculosis from the intestinal mucosa
is largely hypothetical, the absorption from the intestine by these
glands seems most likely. On the other hand Borchgrevink believes
that the lymph glands in tuberculous peritonitis are usually free,
escaping infection apparently both before and after the peritoneal
involvement. The literature on this point is unsatisfactory.
Buszard reports a case in a man, aged 40, in which the supra-
renals were evidently the primary seat of the disease. At any rate,
the symptoms of Addison's disease preceded those in the perito-
neum. Tuberculosis of the adrenals is of course relatively com-
mon, but there seems to be little tendency to involve the perito-
neum.
The Fallopian tubes are apparently the most frequent primary
seat of tuberculosis, judging from operative results alone. Mayo
had 26 cases. Osier estimates that 30 to 40 per cent are primary
in the tube, and Konlich places it at 71 per cent. Hanot believes
that the tubes are secondarily affected from abdominal tuberculo-
sis. Pinner's experiments show that the open fimbria may admit
infection from the general peritoneal cavity.
At any rate, primary peritoneal tuberculosis is at least relatively
infrequent. Obviously a primary lesion could be proved only in
the rarest instances. Only complete autopsy could demonstrate
such a condition Avith any degree of certainty. Even then, the
preexistence of a focus elsewhere could not be denied, since be-
fore such an extensive study would be possible the process within
the peritoneum would likely have advanced to such a degree that
an origin by direct extension could not be excluded. Only in in-
stances in which the patient should die early in the disease from
TUBERCULOSIS OF THE PERITONEUM 655
some other affection wliilc the i3ei'itoiieal iiivolvenient was yet in
its incipiency, could such origin be demonstrated with satisfactory
certainty. The failure to find a primary focus at operation is no
evidence that none exists. McNutt, for instance, records four cases
as primary because they recovered, and no other focus was dis-
covered. Such a conclusion is obviously unwarranted; neverthe-
less, patients without previous ill health often develop a peritoneal
tuberculosis. I have been particularly impressed with the generally
accepted opinion as to the frequency with which tubercles are
found in the Fallopian tubes of otherwise healthy women who re-
main healthy after the offending tubes have been removed. A closer
study of such tubes has made me skeptical about their tuberculous
character in many of the reported cases. Tuberculosis is a virtu-
ous disease, and charity may cause us to form such a diagnosis in
some instances. The possibility of the tubercles being due to for-
eign bodies, from hemorrhage, or infection of the tubes, must be
seriously considered. Necrotic foci cause the formation of foreign
body giant cells which sometimes resemble tubercles ; small sub-
peritoneal cysts not infrequently are pointed out in the operating
room as evidence of tuberculosis. Unless the actual tuberculous
nature of the lesion is proved, either by demonstration of the
bacilli or by an animal culture, I should be extremely guarded in
the diagnosis.
Secondary Form (Extension from Other Organs). — ^Because of
the rarity of the primary form, it must be assumed that the ex-
istence of peritoneal tuberculosis presupposes, at least in nearly
every ease, the existence of a tuberculous lesion elsewhere in the
body. The problem to l)e solved is to find the focus and to deter-
mine how the infection travels from this point to the peritoneum.
In order to approach the problem Avith intelligence, it is neces-
sary to consider the relative frequency of peritoneal tul)erculosis
and the frequency of the disease in other organs. The most in-
structive statistics from the American point of view are given by
Cummins. In 3,405 autopsies collected from the Pennsylvania,
Philadelphia, and University Hospitals, he found some form of
tuberculosis in 835, or 24.5 per cent of cases observed. In addi-
tion 76 showed healed foci. Tul)erculous peritonitis was found in
92 autopsies, or 2.7 per ceii1 of the total inimber, or 11 per cent of
656 THE PERITONEUM
the tuberculous eases. Borsclike's statistics show a still greater
percentage of involvement. In 4,250 autopsies, 1,390 showed tuber-
culosis, and of these; 226 showed peritoneal involvement. Steiner
found the peritoneum involved 92 times in 800 autopsies. The
highest of all are the statistics of Nothnagel, who noted peritoneal
involvement in nearly a fourth of his autopsies. Sick, on the other
hand, noted a lesser proportion, and in 2,500 autopsies found no
ease of isolated tuberculous peritonitis, and in but 46 cases was
the peritoneum affected at all. Miinstermann in 2,837 autop-
sies found that 903 showed tuberculous lesions, and of these 46
cases showed involvement of the peritoneum, two of them appar-
ently primary.
It may be assumed, therefore, that the peritoneum is involved
in appi'oximately 10 per cent of cases when death is caused by
tuberculosis of some other organ of the body.
The lungs, naturally, are the organ most frequently affected.
Konig found them involved in 92 per cent, the gut in 74 per cent,
the kidney and spleen in 35 per cent each, the suprarenals and
liver in 5 per cent each, and a generalized involvement in 10 per
cent of cases of tuberculous peritonitis. Sick found the lungs in-
volved in 85 per cent, the gut in 65 per cent, the genitals and liver
in 26 per cent each, the pleura in 25 per cent, the mesentery in
20 per cent, and the kidneys in 19 per cent. Cummins found the
lungs involved in 84 per cent, the gut in 32 per cent, the tubes and
adnexa in 40 per cent, and the urinogenital organs in 8 per cent.
Borschke, as ali'eady noted, reporting on postmortems of 1,393
tuberculous patients, found the peritoneum involved in 226, or 16.2
per cent. This author makes a distinction between tuberculous
peritonitis and tuberculosis of the peritoneum. In the latter class
he puts cases in Avhich there is no reactive inflammation. Of this
group there were 16 cases. These were for the most part without
exudate, and but few showed any adhesions. In eight of these the
infection involved only limited areas of the peritoneum. In the
remainder of his autopsies the peritoneum Avas thickened with
fibrinous or hemorrhagic inflammation. Over the tubercles was
more or less fibrin. The great omentum was more or less involved,
being indurated or contracted and rolled up l)y the distended intes-
tines. Two of his cases were idiopathic. In 200 cases, the primary
TUBERCULOSTR OF THE PERITONEUM 657
affection A\as in the lungs. Tlie unsatisfactory state of the avail-
able data can be noted by contrasting the statistics of Borschke's
with those of Friedlander, above quoted.
Weigert notes in his paper that the relation of the peritoneum to
tuberculosis is the same as to any mycotic disease and to tumors.
Klebs believed that the intestinal tract in children is the com-
mon avenue of infection. The chief argument in favor of this view
is the relative frequency of mesenteric glandular tuberculosis in
children. He assumed that the bacilli could gain access to the lymph
stream or blood stream, and then gain a foothold in any part of the
body, escaping the lymph glands and involving the peritoneum pri-
marily. This Avould explain, but not prove, the origin of an isolated
peritoneal involvement. Some more recent writers look favorably
upon this possibility. Among these may ])e mentioned Tral)aud,
Straus, and Gamaleia, and particularly Levi-Sirgugue.
The frequency "vWth which intestinal tuberculosis is associated
Avith peritoneal tuberculosis is difficult to determine from available
statistics. The coexistence is frequent enough, but in most of the
instances there is likewise an advanced pulmonary lesion. Cruveil-
hier laid stress on the importance of gut ulcers, and more recently
Konig noted the coexistence in 80 of 107 cases. Spillman noted
this association in 70 of 100 cases examined by his student, Colman.
Schmalmack noted that in all of his 10 cases in the male there were
ulcerations of the gut and advanced lesions in the lymph glands.
Delpeuch believes that the intestinal lesion is usually secondary,
because the ulcers are often recent, while the peritoneal affection
is in the process of healing.
There can be no doubt that there are variations in the relative
frequency of peritoneal tuberculosis in different localities as com-
pared to the general morbidity of the population. Thus Dorfler in
collected statistics of 80,000 cases of tuberculosis treated, found
an involvement of the peritoneum in only 1.07 per cent of the cases.
Borschke, on the other hand, in statistics of 1,393 cases, found 16.5
per cent with peritoneal involvement among the tuberculous eases.
In the combined statistics collected by Bircher in 19,184 autopsies
the peritoneum was affected in 3.5 per cent of the cases.
I dare say that iu Ihc average American community there is no
such frequency as noted in the above statistics. In the community
658 THE PERITONEUM
about Ilalsteacl, Kansas, where I have been in close touch with the
great majority of the population for more than twenty years, but
few cases of tuberculous peritonitis have been noted. Conserva-
tively speaking, some 100,000 morbid conditions have been pre-
scribed for by me or one of my assistants, and Init, four cases of
this disease have been found. At the Halstead Hospital, in some
5,000 examinations, representing patients from central and west-
ern parts of Kansas, for the most part, but two additional cases
have been discovered. Tuberculosis in any form is a rare disease in
that community, however, representing not more than 1 or 2 per
cent of the patients examined.
The statistics above quoted are sufficient to indicate in which
organs the primary focus occui's. In some instances we can only
surmise the avenue of transportation. It can be easily proved ex-
perimentally that surface diffusion takes place, that is to say, bacilli
gaining the surface of the peritoneum are transported by the
movement of the fluids, aided no doubt by peristalsis, so that
simultaneously foci appear in the various parts of the abdominal
cavity. The same is true in the pleural cavity.
When the primary focus is known, the advent in the peritoneum
may be accounted for by one of the following paths; by the blood
stream, by contiguity, or l)y continuity (Allport.)
Hematogenous. — In instances in which the peritoneum becomes
involved as a part of a generalized miliary tuberculosis, as after
opei-ations on tuberculous joints or glands of the neck, hematog-
enous transportation can hardly be doubted, since the lesion be-
gins simultaneously in all parts of the body. In instances in which
the primary focus is located in some distant organ, as in the medi-
astinal or other lymph nodes, with no intervening foci, the evidence
is nearly as conclusive ; l)ut in the majority of instances the prob-
lem is not so simple, since intervening foci exist. In primary tuber-
culous peritonitis, if there is such a thing, transportation by way
of the blood stream must l)e assumed. This is the easier, because
the tubercles are often arranged along the course of blood vessels.
By Contiguity. — Hoa\' the iiifeetion travels by this method from
the primar}^ lesion to the peritoneum may be indicated by the ap-
proach of the infection from the lungs to the pleura. Here the ex-
tension may be traced along the lymph vessels from the lesion in
TUBERCULOSIS OF THE PERITONEUM 659
the lungs to the pleura. This extension in the lymphatics may-
take place by a direct extension from one lesion to another until
the pleura is reached, propelled more or less by retrograde
metastasis due to the central occlusion of the lymph vessels by the
central tuberculous lesion, as suggested by Ponfick. Friedlander
found in 88 autopsies a local lesion in the neighboring tissue, and
there was no occasion in any of them to hypothecate a hematog-
enous origin. These lesions, according to him, are most apt to
lie in the intestinal submucosa, the lymph glands, or lymphatics.
As these nodules approach the peritoneum, induration, possibly
the formation of adhesions, takes place. These observations show
plainly the likelihood of a combination of extension by contiguity
and continuity. Contiguous lesions may coalesce, and a continu-
ous lesion result. Konig compares the spread of the tuberculous
process from contiguous organs to the peritoneum with that of the
extension from the epiphyses of joints to the synovial surfaces.
By Continuity. — By this method is understood the direct exten-
sion from the primary focus to the peritoneum by continuity of
disease without the intervention of any uninfected tissue. The
most frequent example is the involvement of the peritoneum by
direct extension through the walls of the Fallopian tubes. Exten-
sion from intestinal ulceration occurs less frequently or at least
is less various. Whatever may be the truth as regards frequency,
there is no doubt that direct extension is extremely important in
a practical sense, because of the possibility of surgical removal of
the lesion.
In many instances, even when primary direct extension can not
be demonstrated because of the advanced state of the process, the
relative degree of localization makes origin from near that point
probable. The relative age of lesions also sometimes gives an idea
as to the source of the infection. This is true most frequently in
the ease of the Fallopian tubes. Here it is not unusual to find
an old caseated mass in the tube, surrounded by adhesions, and be-
yond this possi])ly a crop of young tubercles. Here the point of
origin is definite, but how the organism gained this point can not
usually be determined. After bacilli have gained access to the
peritoneal surface the dissemination takes place by diffusion and
by gravity. The lesions are most abundant in the dependent por-
660 THE PERITONEUM
tions of the abdominal cavity where inanimate bodies, such as lamp-
black, are wont to collect in experimental work on animals.
The extension from the pleura to the diaphragm may be by di-
rect extension or by way of the lymphatics. Levi-Siriigue found
lines of caseation extending across the diaphragm at autopsies.
Valemin states as Codelier's law, "When there is a tuberculosis of
the peritoneum, there is always a like affection of the pleura."
Maurange believes that the primary focus of ])oth of these condi-
tions is in the lymph nodes of the mediastinum, and that the dis-
semination is by way of the lymphatics.
The length of time required for a tuberculous peritonitis to de-
velop is i3rol)ably not very great. I have seen a diffuse involvement
within six weeks after stirring up a primary focus in an epididymis.
Holmes reports a case of operation for a distended gall Ijladder,
during which it was not noted that the peritoneum Avas free.
Autopsy five weeks later showed the peritoneum to be everywhere
involved.
Pathologic Anatomy. — General Consklemtions. — The genesis of
the unit lesion, the tubercle, does not differ Avhcn located in the
peritoneum from that situated elsewhere. The pathologic anatomy
of the tubercle has long been established and one must resort to the
older literature in order to find descriptions of it in the most
graphic types. More modern pathology has established the histo-
logic picture. More recently Smyth lias added another stage in a
study of the early stages of the tuberculous processes by observing
it in tissue cultures. His work materially supplements earlier ob-
servations. He found that when cultures Avere inoculated they
were at once surrounded by lymphocytes. Endothelial cells later
reached the scene, and by conglutination formed the giant cells.
His studies confirm therefore the conclusions arrived at by histopatho-
logic processes. Modern studies have added little to the older
vieAvs, but they haA^e done much to strengthen our faith in the cor-
rectness of the older opinions.
The Tiihercle. — The unit lesion of tuberculosis, the tubercle, re-
ceiA^ed its name before its cellular structure Avas understood. It
received extensive study by the naked eye. The frequency Avith
which experienced surgeons confuse disseminated carcinomata Avith
diffuse miliary tuberculosis makes me feel that the recognition of
TUBERCULOSIS OF THE PERITONEUM G61
the tubercle by the unaided eye is an art lost that may be deplored.
On the other hand, our conception of the disease must be based on
the finer changes which are revealed only by microscopic and cul-
tural methods. It behooves the surgeon, therefore, to study the
tubercle from both these points of view.
Macroscopic Appearance. — The name signifies a nodule. Bailli
seems to have been the first to apply this name to the unit lesion
of tuberculosis. He describes its appearance in the following
words: "They are small grayish granules, semitransparent, some-
times transparent and colorless, and of a consistency a little less
than that of cartilage ; their size varies from that of a millet seed
to that of a hemp seed; in form they are oblong at first glance but
are less regular Avhen examined with a magnifying glass, when they
sometimes appear to be angular ; they are intimately attached to
the underlying tissue and can not be separated from it without caus-
ing shreds of tissue to follow it."
It is desirable to remember that even these small lesions are not
coextensive with the tubercle in the microscopic sense, but are made
up of a number of these. Here is the clue to the irregularity Louis
noted. When secondary nodules form they appear "angular."
The cause of their oblong form is that the long axis is parallel with
the vessel supplying the area affected. This is readily explained
hy the fact that bacteria travel most readily along natural chan-
nels. This tendency is noted most strikingly in miliary tubercu-
losis of the pleura. Large nodules result when there is a limitation
of such extension by a process of beginning fibrosis. The larger
nodules represent therefore an older and generally a more benign
process.
The abdominal surgeon is able to distinguish t\\o general groups
on the l)asis of the size of the lesion. The very fine lesion, best des-
ignated submiliary, is seen in the more acute cases and the larger
one, tlie miliary, is commonly seen in the usual case of slowly de-
veloping disease. Not infrequently the two are associated. This
is evidence tliat au acute exacerbation has complicated the more
slowly developing process.
The submiliary lesions ai"e sometimes superficially siluatcd and
appear as though tliey might l)e scooped off Avithout injuring the
peritoneum. This type results from the development of the lesion
662 THE PERITONEUM
on the surface of the peritoneum and not in the subperitoneal ves-
sels.
The tendency of all tuberculous lesions is to undergo caseation,
as Yirchow first pointed out. When this occurs, they lose their
translucency and become opaque or cheesy. "When this occurs the
general contour is not changed, for, the center being dead, there
are no further changes. In this it differs, it may be here remarked,
from cancerous nodules. These, continuing the process of prolifera-
tion with subsequent contraction, produce a dimpling or umbilica-
tion of their summit. These, also being derived from a single focus,
retain a sphei'oidal outline. The outline of a tubercle may be ob-
literated by the recurrence of secondary reactive processes at its
periphery, producing an increased vascularization of its periphery.
In hyperacute lesions, the general appearance of the peritoneum
may be one of acute hyperemia with edema. Only on closer in-
spection can the fine tubercles be made out. The sense of touch
may emphasize the ocular impression. If this vascularization pro-
duces a sufficient defensive reaction, the entire tubercle may be
changed into connective tissue and the lesion healed. If, on the
other hand, the defensive forces are inadequate, neAv tubercles may
develop in the reactive zone. These, becoming confluent, encom-
pass a zone so large that the nutrition of the center reaches so low
an ebb that necrosis occurs. This necrosis differs from the casea-
tion ^^•ithin the lesion, as will be noted below. This necrosis is due
to vascular disturbances. When such a condition occurs destruction
of tissue may be rapid and extensive.
The tubercle bacillus is capable also of producing a more diffuse
infiltration Avithout the production of definitely circumscribed le-
sions. This is particularly liable to take place in the subperitoneal
tissue. I have seen a gut thickened to a centimeter for long dis-
tances mthout the macroscopic appearance of tubercles. It oc-
curs, apparently, when the virulence of the infection is mild. At
any rate, it occurs most extensively in animals when the inoculat-
ing material is heated to 60° before being injected into the animal.
These lesions have nothing to distinguish them from other hyper-
plastic processes other than the demonstration of the tubercle
bacillus. I have seen several specimens which were suspected of be-
TUBERCULOSIS OF THE PERITONEUM 663
ing tuberculous but definite proof could not be produced because
of the failure to demonstrate tubercle bacilli.
Microscopic Appearance. — In artificially produced tuberculous
lesions one is enabled to study to the greatest advantage the topo-
graphic relations of the disease in its various stages. The struc-
ture which enables us to determine by the topography the primary
source of the infection is the membrana limitans. In brief, it may
be stated that Avhen the bacteria reach the site of the lesion by
diffusion over the surface of the peritoneum, the lesion lies above
this membrane ; if by Avay of the blood vessels or Ij^niph vessels, it
lies beloAV it.
From Borchgrevink's description I take it that his early stage
represents a growth above this membrane, while his later stage
presents an origin below it. This seems true because Avhen bacilli
become deposited upon the surface of the peritoneum an exudate
furnishes the pabulum for their development. Cells gain access
to this exudate secondarily. In this manner a tubercle of consid-
erable size may be developing, and yet be quite clear and trans-
parent, like a pearl, as Borchgrevink says, with only slight evi-
dence of tissue reaction. In the second variety in which the bacilli
find a nidus in the lymph vessels or blood vessels, there is an early
dilatation of the A^essel and a more diffuse area of infiltration about
the developing tubercle. Sectioned at this stage, the elevation
above the surface will be found to be very slight, and the mem-
brana limitans goes uninterruptedly over it. As the disease pro-
gresses, the lesion enlarges and extends more prominently over
the surface, and the area of vascular reaction becomes greater.
It is to be noted that after a lesion has developed for some time
the specificity of the membrana limitans to dyes is lost, and its lo-
cation can no longer be traced. All the acid-staining tissues lose
their specific reaction and take on a reaction approaching tlie filiriii-
ous; or, adopting a tei'm used in the discussion of the develop-
ment of fibrous tissue, they are in a precollagenous state. There-
fore, in order to make use of the membrana limitans as a means of
determining the origin of the disease, only the earlier stages can
be studied. This method is adapted to experimental rather than
to clinical or postmortem study.
As observed in the peritoneum in the human subject, it seems
664 THE PERITONEUM
likely that the small fine protuberant tubercles are derived from
bacilli Avhich have been deposited upon the surface of the peri-
toneum. This seems true even in those cases in Avhich the mother
tubercles were derived from direct extension or from venous or
lymphatic transport.
What relation, if any, the means of transportation bear to the
type of lesion produced can not be stated. From the uniformity of
structure of the lesions and their superficial character it seems
quite possible that those characterized by purely exudative prod-
ucts into the peritoneal cavity are due to superficial dissemina-
tion, while the more indurative and localized processes are more
apt to arise more deeply in the tissues. The chief basis for this
argument must be found in animal experimentation.
In children in the early stages, when there is a diffuse dissemina-
tion of tubercles, the irritation produces a profuse exudation of
fluid, and ascites is the result. AVhether this shall remain a simple
fluid accumulation, or Avhether a fibrinous exudate shall result,
depends on the fibrin elements which the exudate contains, not on
the duration of the disease. If these are slight, either from too
limited an irritation or from the presence of too great toxicity, the
fibrin can not form, and the adhesive type does not result. On the
other hand, if excessive fibrin is deposited, adhesion results.
If the disease extends more deeply in the tissues and the toxicity
is greater, caseation and direct destruction of the tissue follows.
AVhether the tissue is better able to defend itself against bacilli
which lie above the membrana limitans than it is from those which
lie below it, is a matter of speculation. Animal experimentation
would indicate that it is. In animals, conclusions must be drawn
from histologic study, for all forms of the disease are fatal, sooner
or later. Tissue destruction is greater in areas in which the bacilli
are injected beneath the peritoneum than in lesions arising from
intraperitoneal injections, and therefore arising above the mem-
brana limitans. It is possible, however, that the subperitoneal in-
jections represent a more concentrated infection than takes place
on the surface.
The adhesive type is the least virulent of all. Instances in which
the site of origin of a tuberculous process lies deeply in the tissues
are more apt to be attended by caseation than are the more super-
TUBERCULOSIS OF THE PERITONEUM 665
ficial lesions. Of coiu'se there are wide individual variations.
These may be explained by lessened resistance of the individual or
greater virulence of the bacteria.
In the caseous type where intestinal loops are joined together,
the union is not a true fibrous one, but rather an agglutination pro-
duced by the coagulation of debris. On section, such material pre-
sents a homogeneous granular field, devoid of elements capable of
specific reaction to dyes. These deposits between the loops of gut
correspond more to the stage of caseous pneumonia, as observed in
lung tuberculosis, than to the fibrinous type.
That combinations of various forms occur is readily understood
when we remember that one type of process may take place about
an original lesion, Avhile quite another type takes place in some
other part of the abdomen. This is well shown in primary pelvic
tuberculosis in Avhich the tube itself is caseous with fibrinous ad-
hesions about it, and an abundant crop of newer tubei'cles occurs
over the remainder of the peritoneum, giving rise to an exudate.
The great omentum may be involved in a thick tumor mass be-
low the transverse colon. This mass contains caseated areas with
considerable increase of fibrous tissue. The remainder of the peri-
toneal surface may be covered more or less by discrete tubercles,
to the presence of Avhieh the peritoneum has responded by an
abundant exudate.
Classification. — An endless number of classifications has lieen
published. All recognize an exudative and a dry form. Charcot
recognized a miliary, ulcerous, and healing stage. Among the
more comprehensive classifications may be mentioned jNIunster-
mami's. He recognizes, from an anatomic view, a subacute miliary
form and a fibrous adhesive form. Galvini recognizes five types, —
a seromembranous, a serogranular, a purulent, a fibrous, and a
cheesy form. FeuAvick recognizes an ascitic, a fibrous-adhesive and
an uleeropurulent form. A number of writers have made, further
subdivisions. Roersch divides the ascitic type into the free and the
encapsulated. Thomas recognizes a dry and a purulent ulcerous
type, and Margarucci distinguislies 1)etAveen an exudalive typo
witli and Avithout adhesions.
To the pathologist the entire disease represents the same process
differing merely in small detail, (iiven the fact that tlie disease
666 THE PERITONEUM
exists, as is manifest by the presence of tubercles, the surgeon is
compelled to recognize that thei-e may be an exudate, that there
may be adhesions Avhicli he may ])e required to sever or let alone,
and finally there may be caseation, which may permit easy puncture
of the gut if he does not exercise great care. This simple classifica-
tion seems as good as any for the purpose of keeping clinical rec-
ords. At the operating table he can have no classification. Each
part of the diseased area must receive its OAvn interpretation in
terms of pathologic anatomy.
The pathologic types above mentioned are capable of endless
variation as to extent, rate of onset, and tendency to heal, de-
pendent, not only on the character of the process per sc, but also
on the resistance of the individual, due to, or influenced by, in-
herent or environmental conditions.
The MUiary Type, SithmUiarij Stage. — (Fig. 196). In the earlier
stages three characteristics may be recognized: superficial location,
small size, and the absence of reaction in the surrounding peri-
toneum. These lesions may be compared with the point of a pin,
if the ordinary tubercle is compared with the head. They are
more nearly spherical, smoother, and more glistening than the ordi-
nary tubercle. They are faintly translucent, and may have a
slightly bluish shade. They have a striking resemblance to a small
pearl. They may be more readily removed from the peritoneum
than an ordinary tubercle, and they cause no hemorrhage when
removed.
Weigert has emphasized characteristics of the lesions in cases
in which the bacilli are strewn into the free peritoneal cavity
from a primary focus. He believes that the peristaltic movements
tend to distribute the bacilli throughout the peritoneal cavity;
therefore the most numerous lesions exist in the places sheltered
from such movements. Experiments with lampblack tend to sub-
stantiate this assumption. As already noted in the chapter on
physiology, lampblack particles introduced into the abdominal cav-
ity collect in the recesses beyond the reach of peristaltic move-
ments. The distribution of tubercles is very similar.
This early stage is rarely observed in the human subject. It
is only when primary lesions rupture into the peritoneal cavity
that such a state can be observed. One sees them most frequently
TUBERCULOSIS OF THE PERITONEUM
667
in hernial sacs. In no instance should a clinical diagnosis of
tuberculosis be hazarded if such are the only lesions present. This
is particularly true -when applied to the Fallopian tubes, and here
often in response to some reactive process within the tube. These
Fig. 196. — Subniiliary tuberculosis of the omentum. The gastrocolic omentum is thickly
studded and the great omentum forms a solid mass along the lower border of the transverse
colon.
papules, so far as I have been able to determine, are due to an
exudate beneatli the membrana limitans Avhich coagulates and later
becomes infiltrated with endothelioid cells Avith tlie subsequent
formation of fibrous tissue. But at this point the process remains
stationary.
668
THE PERITONEUM
Miliary Stage. — (Fig. 197.) As compared Avith the preceding
stage the tubercles have become larger. In proportion to their
size they project less markedly from the surface, and are united
to the serosa by a broader base. The surrounding peritoneum
shows an inflammatory reaction, the degree of Avhich depends upon
Fig. 197. — Diffuse miliary tuberculosis of the peritoneum. These tubercles, contrasted with
those in the preceding picture, are much larger.
hoAV closely the lesions are situated together and perhaps upon the
virulence of the organism and the ability of the tissues to react.
The more deeply situated lesions produce more reaction than the
superficial; or, perhaps, a greater reaction tends to coA'er the tu-
TUBERCULOSIS OF THE PERITONEUM
6G9
X
'■'..^
(:
' ) I C> fX
^^^■\ A^
• h J
■i 1 .»
\ot». ■> )*>»»( ■>
Fig. 198. — Fibrinous tuberculosis of the peritoneum. The long strands were formed by
gently pulling apart coils of intestine which had' become agglutinated.
bercles the less they project from the surface. If the reaction is
great, the peritoneal vessels become prominent, the service ves-
sels dilate, and the potential vessels quickly spring into prominence.
670 THE PERITONEUM
There may be considerable proliferation in the subserosa with a
corresponding lessening of the mobility of the underlying organ.
This thickening may be so great as to make the organ they cover
palpable to the examining finger.
In the purely miliary form there is bnt little exudate, yet it is
rarely absent. Usually if the fluid is not demonstrable clinically the
case may be classed as purely miliary.
An exudate may form over the surface of the tubercle. When
this organizes the tul^ercles are still less prominent, and they be-
come less and less prominent as the exudate continues to form. If
they are situated closely together, the membrane becomes thick-
ened, often to an astonishing degree. When organization goes on
along with this process, enormous hypertrophies may result. Casea-
tion and hypertrophy may take place concomitantly in various
regions of the surface.
Fibrinous Type. — (Pig. 198.) The general anatomic picture of
this class may resemble the preceding closely, there being but the
addition of a more or less abundant serous exudate. The character
of this exudate varies in the different cases. If the fluid exuded
in response to the tissue irritation remains uninfluenced by sec-
ondary factors, fibrinous bundles may be deposited and membranes
and adhesions form. When the fluid remains in a free state, it
is usually because it is too poor in fibrin, being more closely re-
lated to a transudate than to a productive infiltration. If there
is great tissue reaction fibrin forms and the adhesive form devel-
ops. As a matter of fact there is usually more or less adhesion
formation. If great toxicity exists the exudate remains fluid
because coagulation is prevented because of toxicity. If only a
partial coagulation is possible, a granular fibrin fills the spaces
between the coils of gut and a false adhesion results. In this
type the fluid likely becomes absorbed and the dry type results.
At any rate in the dry forms there are usually some areas in which
there is still free exudate, and these appear to be the younger
lesions.
The character of the fluid varies in appearance, as well as in
chemical and microscopic characteristics. It is usually thin and
fluid, often lemon-yellow and sometimes greenish in color. Fibrin
flakes may be seen. After being withdraAVn it may either remain
TUBERCULOSIS OF THE PERITONEUM 671
fluid or coagulate spontaneously. In the latter instance a large
fibrin mass often forms. Sometimes the entire mass solidifies. In
some instances it may be jelly-like Avhile in the abdomen. This
is likely to occur "where a small amount of fluid becomes encap-
sulated while the remainder of the abdomen is free from disease.
The centrifugal specimen shows red blood cells, leucocytes, detri-
tis, and some epithelial-like cells with granular protoplasm. Von
Bauer states that the exudate is greenish or cloudy, or contains
more or less blood. It is much less often bloody than in
carcinomata.
The speciflc gravity at 18° C. is from 1.019 to 1.026. In one of
my cases, a child of three, it was 1.015 to 1.016 at body tempera-
ture. The albumin content is 4.17 to 7.37 per cent.
Maurange's opinion that tubercle bacilli can always be demon-
strated in the exudate has not been confirmed. Even in animal
experimentation most guinea pigs remain negative when injected
Avith peritoneal exudate. AVyssokowicz is of the opiniou that
guinea pigs can always be inoculated if enough of the exudate is
used. It is said the skin of a ])lack cat will cure whooping cough
if the skin is l)lack enough.
The amount of fluid varies greatly. It may 1)e so slight as to
escape detection during clinical examination, and its presence be
unsuspected until the abdomen is opened. This is particularly
likely to be the case in localized forms, particularly those involv-
ing the Fallopian tul)es only or those confined to hernial sacs. On
the other hand, the amount of fluid may be enormous, being rivaled
only by the exudates associated Avith adhesive pericarditis. In such
instances the life of the patient may be menaced by the increased
intraabdominal pressure.
Tuberculosis of the peritoneum may imitate all other diseases
that occur in the abdominal cavity. Dropsy, cysts, inflammation,
adhesion, tumors, intestinal obstruction, abscess, fistula, all come
Avithin its repertoire.
The Adhesive Type. — (Fig. 199.) As previously noted, the ques-
tion of the formation of adhesions is one of the degree and char-
acter of fibrin content in the exudate, and not a question of stages
or duration. It is only in the type characterized by reactive re-
sponse that adhesions can occur, that is, a substance which is capa-
672
THE PERITONEUM
ble of forming fibrin must be exuded. This takes place only when
the exudate is relatively slight in amount, just sufficient to fill in
Fig. 199. — Adhesive caseous tuberciilo.sis of the iieritoiicum. Contrasted with the preced-
ing cut the fil)rous bundles show a greater advancement toward organization, but even these
resorb vifheti the disease progresses to recovery.
the sulci between the intestinal layers. This exudate, coagulating,
forms a fibrin which undergoes some of the changes incident to
TUBERCULOSIS OF THE TERITONEUM 673
the formation of fibrous tissue. It is rare, however, that fully
developed fibrous tissue is formed. Usually the fibers, even in rela-
tively old adhesions, still take the picric acid, and refuse the fuch-
sin, in Van Gieson's stain. The formation of adhesions merely
means that the tissues are reacting and are capable of repairs.
Adhesions are but an expression of this state: they are not an
essential part of the healing process. Given the reaction in the
gut wall, healing Avould take place if no adhesions were present.
Usually, as the healing process progresses, the adhesions loosen and
are absorbed.
The relation of adhesions to exudate and caseation is only one
of association. Allport maintains that an exudate hinders healing.
At any rate, the formation of an abundant exudate of a low spe-
cific gravity indicates that the reactive poAver of the tissue from
Avhich the exudate comes is very low or they have not been stimu-
lated to full reaction. If exudate is present in such an amount as
to interfere Avith peristalsis and circulation, it is no doubt capable
of exerting an influence inimical to healing, and its removal may
aid in restoring equilibrium. The productive activities may con-
tinue operative in the subperitoneal tissue. There then results a
great thickening of the walls. This is particularly apt to take place
when the primary area of infection is limited, and it is noted most
often in the region of the appendix and cecum. Here the enlarge-
ment may be very marked without there being surface lesions of
tuberculosis. In many of these microscopic examination alone can
determine the tuberculous nature of the lesion.
The Caseous Type. — (Fig. 200.) When the destructive processes
continue, the tissue is destroyed. This process is the same here
as elsewhere. Toxins cause a liquefaction of the tissues, and an
ulceration results. Usually the ulcerative stage has been preceded
by a less destructive process, and adhesions have already formed.
The two degrees of involvement may be playing their respective
parts at contiguous or mure remote regions of the gut. In this way
adhesions and ulceration maj'- coexist. With ulceration an exudate
that is converted into a granular sul)stance may form. This, in a
measure, agglutinates adjoining coils of intestine, and protects the
environment somcAvhat should perforation take place. Usually,
the same sort of material has collected in the interstices of the
674
THE PERITONEUM
peritoneum, causing a thickened gut. This thickening is not com-
parable with the increase in the connective tissue in cases char-
acterized by marked reaction. When such ulcerated areas heal,
it is distinctly by secondary intention. The affected areas must
be pervaded by materials capable of fibrin formation. This is pos-
sible only after the virulence of the infection has somewhat abated.
Location. — The favorite locations for the tubercle eruption are
the cavities about the liver and spleen, the surface of the mesen-
tery, and in the pelvis. There can be but little doubt that grav-
itation plays an important part in the dissemination of the bacilli.
Experimentation and clinical observation both bespeak this fact.
Fig. 200. — Caseous tulierculosis of the appendix. The external appearance showed only uni-
form enlargement. On section the walls showed many areas of advanced caseation.
The anterior abdominal wall, being protected by the great omen-
tum from the sweeping action of the intestine in peristalsis, is
often the seat of conglomerations of tubercles. The great omen-
tum too is exposed to infection. If the process in the omentum
becomes extensive, adhesions with the abdominal wall are prone to
take place, or, as is micommon, it rolls up beneath the transverse
colon. The position of the omentum may be an index to the site
of origin.
The Relation of Cirrhosis of the Liver to Tuherculosis of the
Peritoneum. — As already noted, the liver is found to be cirrhotic
in a large number of cases of peritoneal tuberculosis. Cummins
TUBERCULOSIS OF THE PERITONEUM 675
found this to be the case 10 times in 82 cases; Miinstermann, 6 in
46 cases ; Friedlancler, 5 in 88 ; Nothnagel, 2 in 13 ; Heintze, 6 in
28; and Vierordt, 5 in 25, which, collectively, is about 12 per cent
of liver involvements. This frequent association indicates a causal
relationship. Whether the stagnation of the abdominal circu-
lation forms a favorable nidus for the infection (Weigert, Wagner,
GraAvitz), or whether the liver is secondarily involved from the
peritoneum, is not certain. The weight of opinion seems to favor
the latter assumption. Cases in which the pericardium is involved,
producing a hyperemia of the liver, are thought to be particularly
predisposed to liver sclerosis. Birner holds this vieAV, as do also
Grawitz, Weigert, and Rokitansky.
Woolley (quoted by Rolleston) collected 90 cases of cirrhosis of
the liver in patients under twenty-one. Ascites was present in 59;
and in 12 of these tuberculous peritonitis was diagnosed.
Tuberculous Cysts. — Unique in the pathology of tuberculous peri-
tonitis is the case of a cyst reported by Geipel. The patient Avas
a woman, age twenty-six, who had died of pulmonary tuberculosis.
Autopsy showed tuberculosis of the gut tract, but no ascites. At
the free border of the ileum five cysts were found. IMicroscopic ex-
amination showed the cysts to be formed between lamellae of the
hypertrophied peritoneum in the region of the tuberculous ulcers
of the gut. The cyst contents consisted of a granular, coagulated
mass. The author regards the cyst as having been formed in lymph
vessels, the outlet of which was constricted by the fibrous tissue in
the ulcer. He believes that the cyst wall proliferated in order to
keep pace with the developing cyst.
It has never been my fortune to observe a cyst of the magni-
tude reported, but I have seen several very small ones. It appeared
that these were formed extraperitoneally, independent of preexist-
ing lymph spaces. I have observed them most often on gonorrheal
pus tubes. Here they may resemble small, clear tubercles and are
no doubt often so diagnosticated. My opinion is that they belong
to the encysted spaces above mentioned. The author above men-
tioned noted that the weakness of his theory is found in the vary-
ing thickness of the cyst wall, a fact which would speak strongly
for the theory I have advanced.
As a corollary to this is the vastly more coiinnoii so-called
676 THE PERITONEUM
encysted tuberculosis. This condition is hi'onght abont hy tlie ad-
hesion of neighhorinii' structures imprisoning* a certain amount of
exudate. The condition is A^ery common Avheii the exudative and
fibrinous forms coexist.
Bovine Tuberculosis. — The relation of human to bovine tubercu-
losis has not been fully established. The occurrence of the bovine
type in the human subject has not been established Avith certainty.
Nevertheless, cases which resemble in their anatomic form the type
seen in cattle are occasionally met Avith in the human subject. An
attempt Avill be made here to present an outline based on the cases
recorded, Avithout an attempt to discuss the question of etiology.
Virchow reported the first case recorded, under the impression
that it Avas, a type of sarcoma. Bizzozero reported the first case
correctly diagnosed. He emphasized the fact that pedunculization
is the characteristic factor.
Creighton reports 12 cases, in four of Avhich, hoAA^ever, the peri-
toneum Avas not affected. Jurgens described a case in Avhich the
lesser omentum Avas the chief seat of trouble, though there Avas
thickening of the pleura and pericardium. The most perfect ex-
ample recorded is that of Ipsen. The omentum Avas adherent to
the abdominal Avail, and the sigmoid and small intestines Avere ag-
glutinated. There Avere many tubercles oA'er the peritoneum of
both the small and large intestines. Some of these tubercles Avere
flat, others sessilated, and others pedunculated. There Avas no
free fluid. The retroperitoneal lymph glands AA'ere large and
cheesy.
It is the large size of the tuljercles, and particularly the dispo-
sition to form a restricted base, that is characteristic. The large
lesions may dcA^elop from a single center, or scA^eral isolated cen-
ters may become confluent, producing a large lesion. Thus Uffen-
heimer reports a case in a child of one year in Avhich lesions the
size of a nickel Avere obserA^ed. MacCallum records a ease in Avhich
the indiAddual lesions A^aried from 2 mm. to 2 cm. in size. Some of
the nodules Avere imbedded, but others hung free. Some of them
hung by stalks up to 10 or 12 cm. in length. All of these pedicles
contained fluid.
The importance of the bovine type from a clinical point of
A'ie-w is that its lesions are copied l)y metastases from a papillary
TUBERCULOSIS OF THE PERITONEUM 677
cystadeiioma of the ovary, even to the grayish or reddish color.
According to Orth this form is sometimes seen in the human sub-
ject. According to Troja and Tangl it is possible to so attenuate
the human bacillus by means of iodoform that lesions resembling
the bovine type may be produced in rabbits.
Healing Process. — Bumm sums up the healing process as follows:
(1) cell infiltration of the tubercle and its environment; (2) degen-
eration of the giant cells and epithelioid elements of the tubercles;
(3) increase of surrounding connective tissue and encapsulation of
the tubercles; (4) formation of a scar nodule. Gatti, Nannotti, and
Baciocchi came to the same conclusions from experimental study.
Hermann has recently repeated these experiments, and illustrated
his paper with drawings of his work. According to him about
forty days are required in rabbits before vascularization and fibrous
tissue formation is at all advanced. That tubercles experimentally
produced may become vascularized and inclosed by fibrous tissue
is no doubt true ; but this does not assure a cure of the disease,
for at this time the lesion contains viable bacilli, as may be proved
by inoculation into fresh animals.
The disposition to the formation of fibrous tissue is likewise evi-
denced by the formation of pseudomembranes. Here, however, as
about the tubercles, the fibers are precollagenous, and do not form
a barrier to the spread of the infection.
Gatti, on the contrary, did not find healing by the formation of
fibrous tissue, but by hydropic degeneration, first of the cell proto-
plasm and then of the nuclei of the endothelioid cells.
Generally speaking, the process of healing is much the same as
that noted under the chapter on the formation of adhesions. Un-
der favorable conditions fibrous tissue is formed. The major part
of the exudate is absorbed without the formation of demonstrable
scar. The foreign material is removed by phagocytosis, and the
peritoneum may be left as smooth as formerly.
Formation of Fistulas. — Brichet was the first to describe a case
of tuberculous peritonitis in which pus escaped from the umbilicus,
but the first adequately described was by Dresch. Previous to this
Goebel had collected four cases. In the same year Gauderon re-
ported a case with recovery. A complete review of the literature
was made by Ziehl. He presented abstracts of 30 cases. Of his
678 THE PERITONEUM
eases 20 were in children and 10 in adults. Of the 20 cases in chil-
dren the opening lay in the umbilicus in 18. In 5 there "was a
direct communication between the gut and the abdominal wall.
This abscess then perforated the abdominal wall. The extent of
the opening varied. In 3 permanently, and in 2 intermittently, all
the feces escaped by the artificial opening, presenting, therefore,
fecal fistulas. Of the 10 adult cases, 5 perforated in the umbilicus.
In two the gut was directly attached to the abdominal wall. Very
recently Cullen presented an excellent review, together with a
presentation of the case histories of 19 cases.
The pathogenesis of these perforations may be as follows: the
gut may become adherent to the abdominal wall and the destruc-
tive process gradually perforates, producing a direct connection
between the gut lumen and the external world. On the other hand,
the opening in the gut may communicate first with a walled-off
space within the peritoneal cavity, a secondary ulcerative process
being necessary to perforate the abdominal wall, as in Borchgre-
vink's case. Obviously, in the latter instance perforation into
the peritoneal cavity is more liable to occur and lead to a fatal
general peritonitis.
The reason for the more frequent perforation at the umbilicus
is, obviously, the fact that this is the thinnest point in the abdom-
inal Avail. Possibly the round ligament or the urachus may act
as a gubernaeulum for the conduct of the process. The absence of
a muscular layer, a tissue always unfriendly to the tuberculous
process, furnishes an additional reason why ulceration extends to
this point. If distention of the abdomen has preceded, or accom-
panies, the tuberculous ulceration, the scar closing the umbilical
opening may become much attenuated, even to the point of bulg-
ing. Congenital weakness may contribute to the ease with Avhich
perforation may take place. Of more significance than this would
be the presence of an open ductus oraphalomesentericus or a
Meckel's diverticulum, along which the infection might extend
(MacSAviney).
In the majority of cases a mixed infection precedes the perfora-
tion. Thus Bertherand opened Avhat he thought to be a skin ab-
scess. At the autopsy the pus cavity was found to be surrounded
by tuberculous masses, and communicated with the transverse co-
TUBERCULOSIS OF THE PERITONEUM 679
Ion. It is possible that in some cases a peritoneal abscess perforates
the abdominal Avail, and, the pressure being relieved, the intestines
perforate into the abscess. At least that would be my interpretation
of Kjiecht's case.
Voigt reports a case in which an umbilical hernia developed
rapidly during the early stages of a peritoneal tuberculosis. If,
as in this case, an omental adhesion forms, the most favorable
conditions are provided for the perforation of the abdominal wall
at this point.
A consideration of the pathogenesis permits us to deduce that
the prognosis is very grave. One-third die within ten days after
the perforation takes place. If death is deferred, the prognosis
is then dependent upon the extent of the underlying process and
the effect the fistula may have upon the nutrition of the patient.
When such a fistula exists, a prolapse of the gut mucosa may
take place through the fistula. Pels-Leusden reports such a case,
occurring in a child aged three, which followed laparotomy for the
cure of tuberculous peritonitis. The condition was relieved by
incising the skin about the opening, and folding the edges together,
thus permitting the closure of the opening.
Maurange states that perforation of one intestinal loop into
another sometimes takes place. I have been unable to find a spe-
cific instance. The same may be said for perforations into the
vagina and uterus.
Communications betAveen the gut and the bladder are, fortu-
nately, of rare occurrence. Ulzmann and Schiitz each report a case.
Among the rare perforations, fortunately, is that into the blood
vessels. DeMussy and Tral)aud each mention such a case. Em-
bolism and hemorrhage must be the end in such cases.
Perforation into the Peritoneal Cavity. — Instead of perforating
through the abdominal wall with the formation of a fecal fistula
the perforation may occur into the general peritoneal cavity or
into as much of the cavity as may not be Availed off l)y adhesions.
If the site of perforation points into a pocket formed by the adhe-
sion of the intestine and omentum a fistula may result by perfora-
tion of the abdominal Avail, as previously described. If there are
no adhesions present, a general peritonitis is the result. This is
the type uoav under consideration. The cases reported in the liter-
680 THE PERITONEUM
atiire are not numerous. It is reported that Louis XIII died of
such a condition (Berard and Patel).
In several of the reported cases it is not clear whether a tuber-
culous ulcer of the gut or a peritoneal tuberculosis was the cause
of rupture. Thus Pasquet reports cases of perforation in patients
afflicted Avith pulmonary tuberculosis. Some of the cases published
under this head were clearly ulcers of the gut. Paulicki reported
a case belonging to this category. Cases reported by Labbi and
Beale probably belong to this class. The cases reported by Letulle
were probably cases of perforation in tuberculous peritonitis. Op-
penheim and Lanbry report two undoubted cases, and Lodure re-
ports three. The perforation ranges in size from 3 mm. to 4 mm.
in diameter to an opening involving half the circumference of the
bowel (Labbi). The perforations are usually solitary, but as many
as five have been reported. The most frequent site is in the ter-
minal ileum or at the ileocecal junction, but any region may be
involved. Barrier observed one near the duodenum. Corbin has
reported perforations of the appendix, and Simon and Chatin have
reported perforations of the large gut.
The accident is rare. This can be explained by the fact that
peritoneal tuberculosis is primarih' a productive inflammation, and
the disposition to form adhesions precludes the probability of per-
foration. Statistics bearing on this subject for the most part ante-
date the period of exact diagnosis in abdominal diseases. Eigen-
stedt in 566 autopsies on the tuberculous saw perforations 26 times.
The existence of a stenosis predisposes to the formation of ulcer
above the stenosis and a subsequent perforation.
"When perforation occurs in the absence of adhesions a diffuse
peritonitis develops. Because of the abnormal state of the peri-
toneum, a protective reaction of any great degree is not possible.
The symptoms and termination are those of an acute generalized
peritonitis.
Symptoms. — In no other disease is the onset more variable and
there is scarcely a disease of the abdomen that can not be mimicked
by tuberculous peritonitis. Errors of diagnosis arise most fre-
quently from failure to recognize its protean character and are
more common in regions where the disease is relatively uncommon.
The onset may be sudden as a perforation, brusque, even brutal,
TUBERCULOSIS OF THE PERITONEUM 681
as Dupre and Ribierre express it, or prodromal symptoms may ex-
tend over many years. These two extremes may be blended by
general ill health ■\\itli, exacerbations. Accordingly it is advanta-
geous to separate the acute and chronic types.
Acute Type. — Rolleston says the onset is acute in one-third of
the cases. Stone, Bottomly and Shattuck emphasize the importance
of the acute cases. According to these authors ascites in children
developing suddenly is usually due to tuberculous peritonitis. The
acute cases begin either as an acute infectious disease or as an
alnlominal crisis. Chill, fever, headache, vertigo, and malaise char-
acterize the former type, while vomiting, distention and pain mark the
onset of the latter. The conditions may be combined. When fever
and malaise predominate, typhoid fever may be simulated. This
resemblance is heightened bj' distention and general abdominal
tenderness and pain.
The acute, so-called typhoid form, is very rare. Reports of six
cases are presented by Vierordt ; one by Kyburz, one by Fenwick
and one by Schmallfuss. The chief symptom is the continuous high
fever, even to 105°, often with bronchitis and vomiting, sometimes
with roseola exanthema and swelling of the spleen. In all there
was an intense tuberculosis with thick pseudomembranes and
adhesions, with but slight affection of other organs. In two of
Vierordt 's cases the exudate was serous-hemorrhagic. It is not
uncommon for such cases to simulate acute perforative conditions.
Thus Halstead reports a case which began with chill and tempera-
ture of 103° and severe abdominal pain which localized in the re-
gion of the appendix. Bonet reports a similar case. Not all cases
of this type begin so brusquely, however. A case with rapidly
developing malaise may present no other symptom than an increase
of the girth. Bladder irritation may be the first symptom. A
hernia, long existent, may become more prominent and feel
uncomfortable.
When the peritoneal affection is only a part of a generalized
miliary tuberculosis, the peritoneal involvement may be overshad-
OAved by the severity of the general infection. Conversely, the
general infection may be dominated by the peritoneal involvement.
For instance, in a patient I once observed, following an injudicious
local resection of an epididymal tuberculosis, an acute abdominal
682 THE PERITONEUM
crisis developed. The autopsy disclosed an almost universal miliary
involvement without any apparent reason for the predominance of
abdominal symptoms.
Generally, however, the location of the predominant infection
may be determined from the symptoms. Pleural and pulmonary
involvement are recognized by the pain, exudate and respiratory
disturbance ; cerebrospinal, by the characteristic symptoms. How-
ever, the involvement of the abdominal surface of the diaphragm
may produce a rapid respiration, an extensive exudate may cause
dyspnea from pressure and a primary cerebrospinal involvement
may be characterized by early abdominal distention or retraction
and vomiting.
Unfortunately the differentiation of the predominant location
of these acute generalized infections is of academic interest only,
for the result in each is the same. Yet, if it be recognized that
the abdominal lesion is but a part of a generalized process much
embarrassment may be spared the surgeon.
Not infrequently an acute onset may involve a limited region
of the peritoneum only. The most frequent sites are the Fallopian
tubes in the female and the ileocecal region in the male. In the
former situation an acute salpingitis may be simulated and in the
latter an appendicitis. This latter type was first described by
Lejars; since by Guillemare and Eousseau. In this type the pain
may be sudden in its onset and confined to McBurney's point.
The first symptom may be the sudden appearance of hernia or
pronounced irritation in a previously existent one. The disten-
tion, due to the exudate, may open a patent sac. Operation for
the cure of the hernia may reveal the peritoneal tuberculosis (Rol-
leston and Wright).
Because of the rarity of the acute lesion in comparison with the
diseases it simulates, the diagnosis is usually made at operation.
It is only when there is obvious tuberculous disease elsewhere that
one is led to suspect a like condition in the local lesion.
Chronic. — The chronic type is characterized l)y an indefinite on-
set. Prodromal symjDtoms may exist for months or years. Lau-
per's cases varied from 18 months to 10 years Avith 50 per cent
lasting more than a year. There may be malaise, general weak-
ness, indefinite pain in the abdomen and possibly intestinal dis-
TUBERCULOSIS OF THE PERITONEUM 683
tui'bance. Local symptoms may predominate. Dysmenorrhea, sa-
cral pains, leucorrhea or referred pains common to irritation of the
pelvic organs may be present when the pelvic peritoneum is in-
volved. Periodic or persistent constipation mth localized pain in
some region, notably in the region of the umbilicus, less often in
the region of the ileocecal valve or transverse colon, may present
the first symptoms of the disease. A neoplasm may be simulated,
because of tumor, pain, obstruction and exudation. Fecal impac-
tion caused by overstretching of the part may simulate a tumor.
Classification of the clinical forms of chronic peritoneal tuber-
culosis presents difficulties equal to those already encountered in
the discussion of the pathology. Nevertheless, here as there, a
certain advantage comes of the consideration of the dominant types.
There is an advantage in adopting here the same classification fol-
lowed in the discussion of the pathologic anatomy.
Miliary Type. — In most of the cases where there is a sudden
onset, the disease presents the miliary stage. The same is true of
the localized lesions when pain is a dominant factor. In some of
the hyperacute types a preliminary stage may be said to exist
since the general symptoms of inflammation are predominant with
few or no tubercles.
On the other hand tubercles may be found in the course of opera-
tions for conditions in which it is not expected. Just how fre-
quently this occurs can not be determined from the literature, be-
cause in most cases the diagnosis depended on clinical observation
alone. A study of my own material shows that the most of the
cases presenting patches of small tubercle-like nodules in the neigh-
borhood of chronic irritations were not tuberculous at all. The
clinical diagnosis in such cases is not reliable.
From the foregoing it will be apparent that this type of the dis-
ease is the least characteristic of all. Sudden stormy onset on the
one hand, and vague indefinite pains on the other, is not sufficient
to warrant any diagnosis, and if the surgeon is confronted by such
a condition his first thought should be not chagrin, but a curiosity
to determine by microscopic examination whether or not it is really
tuberculosis.
Fibrinous Type.— In this type, usually following some of the
prodromal symptoms, fluid is present in the peritoneal cavity. The
684
THE PERITONEUM
increase in girth may be the first sign that convinces the patient
that he is ill. This phenomenon nsually excites the apprehension
of the most plethoric patient. Sometimes he expresses surprise
that, notwithstanding the progressive weakness, he is gaining in
weight. In nearly every exudative case the anamnesis Avill bear
record of some prodromal symptoms. Rolleston notes that in chil-
dren the intestines may be so filled with fluid that a pseudofluctua-
tion is imparted to the examining hand, which may be mistaken for
ascites. The outline of the abdomen is characteristic particularly
in children. There is a general abdominal enlargement (Fig. 201)
involving all regions of the abdomen alike. The more acute the
disease, the more marked is this fact.
Fluid is naturally detected in the flanks first. In purely serous
cases it will change its level with change of position. In extreme
H
^S^
Fig. 201. — Outline of extreme abdominal distention in a young girl with miliary tuberculosis
of the peritoneum.
cases nearly the entire abdomen may be filled with fluid. When
the process is at all extensive and adhesions are not present, the
characteristic signs of free fluid in the abdomen may be obtained.
It has seemed to me that in tuberculous peritonitis the wave ob-
tained by tapping is less distinct than in other exudates of like
magnitude, and that when the position of the patient is changed,
the line of the upper layer of the fluid changes less promptly than
in other affections attended by exudation. Attention to these
points has enabled me in several instances to correctly surmise the
tuberculous nature of the disease where sarcomatosis had previ-
ously been diagnosticated. Bulging in the pouch of Douglas may
be made out by vaginal palpation. Thomayer believes that the
presence of ascites predominantly in the left flank is particularly
TUBERCULOSIS OF THE PERITONEUM G85
characteristic of exudates due to tuberculosis. He explains this
by assuming that, when the great omentum retracts, it draws the
intestines with it, leaving the fluid to occupy the left portion of the
abdominal cavity. Numerous observers have confirmed this sign.
After a puncture, in some instances, a rubbing of the roughened
peritoneal surfaces upon each other can be heard or palpated dur-
ing respiration. If distention is not too great, this sign may be
elicited Avithout removal of any of the fluid, particularly if the pa-
tient can be taught to exhale suddenly.
In some instances the amount of fluid is not great, but may be
as much as two to six gallons. In rare instances in which acute
exacerbations occur, the pressure from the fluid may be so great
as to endanger life. In one of my patients 16 liters were removed.
Adhesive Type. —This type may be associated with or follow the
ascitic or may occur independently. Its general onset presents
much the same sequence of symptoms. When coils of intestines
become adherent to each other and to the omentum, pockets may
form Avhich become filled with fluid and present the physical char-
acteristics of cysts. These cysts are particularly apt to form in the
upper abdomen. The thickened gut may present palpatory evi-
dence of a solid tumor. On vaginal examination the thickened
tube may have anchored the uterus and the bulging fluid from
above may present a sacculated semifluid resistance on either side
of the tubal ridge. Disturbances due to lessened intestinal motility
often occur. The great omentum may be much thickened and at-
tached to coils of adherent gut, or it may form a tumor of itself.
Caseous {Ulcerous) Type.— In this type there is no free fluid,
but there are bossilated masses and great disturbances of intestinal
mobility. If the process ulcerates through the intestinal wall, as
not infrequently happens, a mixed infection takes place in the retro-
peritoneal spaces. The uterus is nearly always fixed, and usually
the omentum, much thickened and rolled upon itself, presents
somewhere in the abdomen as a palpable tumor. The surfaces of
the parenchymatous organs, liver, spleen, etc., are apt to be infil-
trated, complicating the picture.
Digestive disturbances are at their height in tliis type. Pain,
meteorism, and diarrhea occur. Fever increases as the disease pro-
gresses. The umbilicus may be distended, everted and reddened,
686 THE PERITONEUM
showing distended capillaries near its border and radiating veins
extending over the contiguous skin. This sign is of great value
when present, but it is rare. Thus Heintze noted it t-\\ace in 25
cases, and Hane not at all in 46 cases.
Localized Form. — Frequently the process is localized in one re-
gion of the abdominal cavity. The symptoms may be local, biit
the process diffuse. For instance, a chronic process may exist
about the cecum or tubes, while the whole peritoneal surface is
sprinkled with a younger crop of tubercles. The conditions here
considered are those in which the whole process is played in a
localized region of the abdomen.
Ileocecal Tuberculous Peritonitis. — Whether or not tuberculous
peritonitis is primary in this region is a matter of opinion. Con-
rath believes it is rarely so in the adult. Hartmann and Baum be-
lieve it is frequently primary. The latter out of seven cases found
no other lesion in four. Most convincing are the statistics of
Campiche. He collected 279 cases, in which more than one-half
were apparently free from the disease elsewhere. Weiner makes
the point that the existence of a slight pulmonary tuberculosis
does not demonstrate that the cecal lesion is secondary. From the
clinical point of view the important point is whether the lesion is
local or diffuse within the abdomen.
The general opinion is that the disease begins in the mucosa
and extends to the peritoneum. This must be true for most cases
because a true tuberculoma, palpable through the abdominal wall,
is often produced.
Ileocecal tuberculosis manifests itself either as an acute process,
simulating acute infection by pus organisms (Fig. 202), or as a
chronic fibrosing process simulating a i^eoplasm.
The former type is often mistaken for appendicitis and oper-
ated on as such. The acute onset with mass formation accounts for
the confusion. Andrews suggests as differentiating points the
greater density and greater motility of the tuberculous lesion.
Following this suggestion I made such a diagnosis in a young
woman who had a hard tumor in the ileocecal point which was
freely movable except downward. At operation a mass of indu-
rated omentum was found wrapped about the distal end of a long
appendix which harbored an enterolith which had given rise to a
TUBERCULOSIS OF THE PERITONEUM
687
suppurative pei'iappendicitis. Nevertheless, Andrews' point is well
conceived, and should work out as a rule. Localized tuberculosis
of the appendix is occasionally met with. It may be ulcerous,
giving rise to infection of the lymph glands of that region. The
chronic hypoplastic form is more common. In scrofulous persons
Fig. 202. — Acute iiiiliary tuberculosis of the ileocecal region, young man aged 19. The
great omentum is being drawn out of the wound. Save for a number of mesenteric lymph
glands, the entire disease is e-xposed to view.
with subacute inflammation in the appendicular region a tubercu-
lous lesion may be suspected, particularly if a mass is palpable.
This type must be differentiated from carcinoma. The presence of
tubercles in other regions of the peritoneum is often the best dif-
688
THE PERITONEUM
ferentiating sign, though one may conceive of the possibility of a
miliary carcinosis producing a similar picture.
The only other disease Avhich could be confused Avith tubercu-
losis of this region is actinomycosis. The differentiation likely must
be made at operation. Tendency to invade the retrocecal tissue
may suggest the possibility of actinomycosis (Teckener). It is
only the presence of the canary bodies that make a certain diagnosis
possible at the operating table.
This type resembles woody phlegmon of the neck. These con-
ditions are difficult enough to differentiate from hyperplastic tuber-
culosis in the laboratorv.
If
I-
.v\
Fig. 203. — Primary peritoneal tuberculosis of the Falloiiian tiilie. Kxcept for a few tubercles
on the ]ielvis peritoneum, no other lesion except in the tubes was to be seen.
On the whole the indurative diseases in the ileocecal region are
difficult to differentiate. Hill made a statement to the effect that
no one should undertake an operation for appendicitis unless he
is capable of resecting the cecum, should conditions demand it.
This is certainly true when tuberculosis or carcinoma is a possibility.
Therefore when there is a hard, more or less movable mass
present the operator should anticipate the possible need for a
resection of the cecum and the surgeon should be assured that
the necessarj' skill and instruments are at hand to cope with any
emergency.
TUBERCULOSIS OF THE PERITONEUM 689
The tumorous form is slow in onset and sometimes first gives
evidence of its jDresence by producing a constriction of the lumen
of the gut, simulating in this certain types of carcinoma.
Tnherculosis of the Pelvic Peritoneum. — Tuberculosis of the pel-
vic peritoneum is usually associated Avith involvement of the deeper
structures even to the lumen of the tubes. If Ave regard tubal
tuberculosis as primarily of two types as some authors do, endo-
salpingitis and perisalpingitis, it is the latter which is primarily
peritoneal (Fig. 203). The equivalent of this classification is that
commonly used, namely, the ascending and descending. The for-
mer classification is preferable since it implies pathologic rela-
tionship while the latter suggests the possible etiology. The eti-
ologic relations of this lesion have been sufficiently considered and
it remains only to discuss the pathologic features.
Peritoneal tuberculosis of the tubes may present any of the types
already discussed. Typical primary miliary tuberculosis of the
tubes is said to be uncommon. In fact Daurios denied its occur-
rence. I have observed several cases in which such condition ex-
isted. Many of the cases recorded seem to indicate that this type
is common. Evidence is sometimes lacking which would separate
these cases from pseudotuberculosis. Not uncommonly in septic
infections of the peritoneum of the tubes flakes of fibrin become
deposited on them. These organize, forming small granular eleva-
tions Avhich resemble tubercles very closely. Sometimes a positive
diagnosis is possible only after a careful microscopic examination.
Williams is of the opinion that the lesion is usually primarily sub-
mucous approaching the peritoneum secondarily. This is substan-
tiated by the fact that the common form is the caseous. Breaking
down of tissue is apt to be early, and once the lesion approaches
the surface early attachment to surrounding surfaces takes place.
In this way, a mass is produced formed by matted adnexa and
surrounding organs. Between these structures a granular mate-
rial, formed from the exudate, is found. The matting may be so
extensive that there may be no free surface presenting miliary
tubercles.
The important clinical factor is the differential diagnosis. Very
commonly where a chronic irritative process has existed for some
time small vesicle-like nodules are formed which in a very super-
690
THE PERITONEUM
ficial way resemble tubercles (Fig. 204). These cysts are in struc-
ture identical with the stalked hydatids so commonly observed hang-
ing from the fimbriated ends of the tubes. They are miliary cysts
filled Avith a clear fluid. The walls of the cysts are composed of
a very fine layer of connective tissue and are lined Avith a flat
endothelium and covered by the same kind of cells. When these
cysts are shrunk in alcohol these cells are nearly cubiform. They
owe their origin to the deposition upon the surface of the perito-
neum of any flocculcnt precipitate, the formation over these of a
pseudoperitoneum Avhich forms actual peritoneal cysts. Occasion-
Fig. 204. — Small subperitoneal cysts of the tube. These are often mistaken for tubercles.
There is no infiltration about them and they stand above the surface of the peritoneum.
ally, particularly over the fundus of the uterus, these cysts may
be as large as peas or even larger. The larger ones readily col-
lapse Avhen punctured, but the small ones can not be recognized.
The lack of any reactive process about them, either vascular or
indurative, and the semitransparent appearance are sufficient to
differentiate them from tubercles. Sometimes there are small gran-
ular nodules Avhich appear much like the cysts, but Avhich are made
up of granulation tissues covered by a ncAv endothelial layer (Figs.
205 and 206). These are less transparent than the cysts and may
TUBERCULOSIS OF THE PERITONEUM
691
Fig. 205. — Granulomatous nodules of the tube and ovary in an old infected tube in a
case of myoma of the uterus. The outline of the nodules is irregular, indicating growth by
deposition rather than by expansion as in tliel case of tubercles.
Fig. 206. — Granulomatous nodules on a chronic pus tube and ovary. These are formed
by the development of foreign body tubercles below the peritoneum and the deposition of
fibrin over the area so irritated or by the organization of such deposits.
692
THE PERITONEUM
. -■& ■, •■■.
Fig. 207. — Foreign body giant cells from specimen shown in Fig. 205. Plasma cell in-
filtration causes these areas to resemble tubercles but the giant cells have central nuclei and
the protoplasm has not undergone caseous degeneration.
■ • •• » *^ - - t ~ -' T'.^T "• • • ■
'-%C
Fig. 208. — Microscopic section of the specimen shown in Fig. 206, showing foreign body "tu-
bercle" developing on the surface of the tube.
TUBERCULOSIS OF THE PERITONEUM 693
attain a size varying from a pinhead to a split pea. Occasionally
foreign body giant cells are found in them (Figs. 207 and 208).
On the other hand a subperitoneal tuberculosis of so slight a
degree may exist that its nature is not suspected luitil the tube
is sectioned. In such tubes the involved area may be detected on
palpation when not discernible by inspection. WillianLS has called
attention to this type and has recorded several cases.
The indurative type, in which the subperitoneal tissue is exten-
sively hypoplastic, may resemble gonorrheal salpingitis very
closely. If caseated areas are discovered or if tubercles are seen
about the borders of the process the tuberculous nature of the
process may be recognized. If there are none such, perhaps a
section of the tissue will show find granulations suggestive of tu-
berculosis but miliary areas of necrosis are sometimes noted in
gonorrheal tubes. In such borderland cases microscopical examina-
tion may be necessary before the nature of the process can be
determined. Equally confusing are the chronic gonorrheal tubes
with small cysts or granulations on their surface (Fig. 208).
A localized thickening of the tube may be caused by tuberculosis,
presenting a veritable tuberculous salpingitis nodosa. The nature
of these can usually be detected by section with a knife when
caseated areas become apparent. These may resemble an ordinary
salpingitis nodosa. It is just possible that an ordinary salpingitis
nodosa may be due to healed tubercles.
It will be apparent from the foregoing that while generally
speaking tubal peritonitis is easily recognized at the operating
table, frequently cases will be encountered which must be followed
to the laboratory before the diagnosis can be made.
Sometimes the bottom of the culdesac is studded Avitli tul)ercles
-while the tubes are relatively free. This does not take place as an
isolated disease but Avhen other parts of the abdomen are involved
the most pronounced lesion may l)e found here. The thickening
may be so pronounced that it can l)e made out by vaginal palpation.
Tuberculosis of the Hernud Sac. — (Fig. 209). In a number of
instances cases have bcrii recorded in which the sac in hernias has
l)een the chief or exclusive portion of the peritoneum involved.
The first cases I'ccorded were by Cruveilhier, followed many years
after by the report of one case by Hayem. Collective papers have
694
THE PERITONEUM
been presented by Brunns and Haegier. Roth presents 22 cases,
supposedly all that "\rere reported to date. Finally Kohler collected
36 cases, and presented a careful analysis of them. The disease
evidently is not so rare as these statistics would indicate. I have
had a number of oral reports, and it seems unusual to find a sur-
geon of experience who has not observed a case.
When a hernia is present in cases of generalized tuberculous
peritonitis the sac is generally involved. The affection of the her-
nial sac presents merely a continuation of the main process. In
Fig. 209. — Tuberculosis of a hernial sac. No other area of disease could be discovered save
in the lungs.
fact there is no record of a case in which the sac was not involved.
The degree of involvement of the hernial sac is variable. In
some cases it is specifically stated that the sac was so thickened
that a tumor was produced, as in a case reported by Stauber. The
reason for the greater intensity of the disease in such situations
may be found in the irritation produced by the contents of the
hernial sac. If bacteria are free on the surface of the peritoneum
they tend to seek the lowest level.
In most instances recorded the hernia involved was inguinal.
TUBERCULOSIS OF THE PERITONEUM 695
Andrews reports a case in Avhicli the process was localized in a
femoral hernia. I once saw an umbilical sac that appeared to be
tuberciilons, but examination in the laboratory proved the case to
be a pseudotuberculosis.
To the list of genuine cases I can add one observation (Fig. 209).
This patient had long been the victim of pulmonary tuberculosis
and a right inguinal hernia. More recently the hernia became
painful and he desired to be rid of it. During the operation under
local anesthesia the sac was found studded with miliary tubercles.
There was but little thickening of the sac. The peritoneum inside
the abdomen as far as it could be palpated through the mouth of
the sac was free from tubercles and there was no free fluid or other
evidence of abdominal disease. The wound healed promptly and
all distress was relieved. No evidence of a general peritoneal
tuberculosis developed later.
"Why the affection is so localized is a matter of speculation. Wei-
gert was of the oi^inion that bacilli collected in this region by
gravity and the irritation produced by the hernial contents pro-
duced a favorable nidus for their development. This explanation
presupposes the presence of tubercle bacilli free in the peritoneal
cavity which are unable to secure a favorable field for development
except where the peritoneum was irritated by the hernia. There
is no knoAvledge that justifies this assumption. Jonneseo and Lejars
expressed the opinion that all cases reported began in the hernial
sac and spread to the surrounding peritoneum. They do not ex-
plain Avhy it should localize in the hernial sac in the first place.
In the case observed by me the idea of Weigert Avas substantiated
in so far as the lesions were superficial, but there is nothing in
this that would preclude a hematogenous origin, for lesions pro-
duced by injecting bacilli into the blood stream have this same
superficial location.
The recognition of this condition is easy after the sac is exposed.
But one case was diagnosed before operation, that reported by
von Braekel. Whether or not the general peritoneal cavity is
involved can be determined with a fair degree of certainty by
palpating the parietal peritoneum in the region of the hernial
opening. If there is an absence of tubercles about the opening
the affection is probably local.
696 THE PERITONEUM
Sometimes in irreducible hernias small nodules may be found
covering the sac, which in a way resemble tubercles. They may
be very small, nearly translucent, and give a grating feel to the
finger. On the other hand, they may be dense and scar-like. On
section they show a round-celled infiltration with a more or less
advanced stage of cicatrization. These nodules seem to ])e brought
about by floccular precipitates forming in the fluid exuded from
the irritated peritoneum. The nodules observed result from the
attempt at encapsulation of these floccular masses. The resem-
blance to tuberculosis may be heightened by the formation of giant
cells about these flocculi.
Diagnosis. — The clinical recognition of peritoneal tuberculosis
is difficult. Typical cases, it is true, may be diagnosticated with
considerable certainty, but a great number of cases are mistaken
for more common diseases, and mild cases are overlooked entirely.
Lohlein states that by carefully considering the history and phys
ical findings, the diagnosis can be made with considerable proba-
bility but never with certainty. My experience leads me to be-
lieve that some cases can be diagnosed with great probability and
some may be suspected, but many will suggest themselves for the
first time after the abdomen is opened. The difficulty of diagnosis
is well represented by the series of cases reported by Bonet. In
30 cases a correct diagnosis was made in 8. no diagnosis in 2,
ovarian cyst Avas suspected in 5, salpingitis in 2, peritoneal
hematocele in 1, uterine myoma in 1, and appendicitis in 1. Most
surgeons Avith an equal experience can duplicate this series of er-
rors, I dare say, perhaps some would even be disposed to regard
enviously the eight correct diagnoses.
Bacterial Examination. — To secure some of the peritoneal exudate
and demonstrate tubercle bacilli in it is of course the ideal method
of procedure. The fact that an exudate may be unsuspected, un-
procurable, or absent, lessens the value of this test. Even in those
cases in which exudate is available for examination, the bacilli
can not always be demonstrated. As a matter of fact in known
cases of i^eritoneal tuberculosis, the bacilli can be demonstrated in
not more than 50 per cent of the cases. The most certain method
of demonstrating the bacilli is by injecting the fluid into the peri-
toneal cavities of guinea pigs or rabbits (Maurange). Even this
TUBERCULOSIS OF THE PERITONEUM 697
test may be negative, probably because bacilli are not present in
the free fluid. Negative findings are most frequently in the purely
exudative, chronic type. Rubbing up a bit of excised tuberculous
tissue and implanting it directly into the tissues of a guinea pig may
secure a positive result when other methods fail. Thus Courmont
secured generalized tuberculosis in a guinea pig by implanting
caseous material of the tuberculous serosa when the injection of
the serous exudate was negative.
Tuberculin Reactions. — The reaction from the inoculation wdth
tuberculin is usually untrustworthy, because in the majority of
cases tuberculosis exists, or has recently existed, in some other re-
gion of the body. In instances where there is no other tuberculous
lesion the evidence secured by these tests may be regarded as sug-
gestive or confirmatory. Faludi recommends it, and reports a case
in which tuberculosis Avas excluded by this, test, autopsy showing
it to be a metastatic sarcoma. Nothnagel regards it as safe and
helpful. On the other hand, Henoch is skeptical of its value and
Herzfeld condemns it as dangerous, having seen miliar.y tubercu-
losis, which he ascribed to the test, follow its use.
Chemical Anahjsis. — The fact that the peritoneal exudate in this
disease is the product of a reactive process, makes it possible to dis-
tinguish this disease in some instances from ascites due to static
conditions. Tuberculous exudates may be higher in specific gravity
than the average, or a reactive process due to tuberculosis may be
complicated by a static exudate, when the changes in the perito-
neum are sufficient to produce an obstruction to some of the
mesenteric veins, and thus reduce the specific gravity. On the
whole differentiation by the specific gravity is as apt to confuse
as to clarify the problem.
The albumin content is greater in the tuberculous process than
in dropsies. Helmrich gives the average as 3 to 5 per cent. The
albumin content is subject to the same variations as the specific
gravity. In one of my patients it was 3 per cent.
A number of cases are reported in which the exudate is referred
to as purulent. Reyburn mentions a case in which a gallon of
purulent material was removed. Robinson records a case in which
a "large amount" of purulent fluid was removed. Koppen reports
a case, probably tuberculous, in which a purulent exudate was
698 THE PERITONEUM
noted. But in none of these eases was the diagnosis satisfactory.
The distinction between a peritoneal tuberculous exudate and
the contents of a parovarian cyst can likewise be differentiated with
but little certainty by chemical means.
The cell content of the peritoneal exudate in tuberculosis is apt
to be richer in small mononuclear leucocytes than that of the
static or carcinomatous exudate. The finding of large mononuclear
cells may indicate derivation from either tubercle or carcinoma
nodules.
Judd suggests a method of diiferentiation applicable at the
operating table worthy of trial. lie pours peroxide of hydrogen
into the peritoneal cavity, following it Avith saline solution. The
peroxide produces a frosted appearance of the surface, Avhich when
removed by the saline, leaves the unaffected portion a normal pink
color. Tlie tubercles stand out as pearly white on a pink back-
ground.
Tuberculous peritonitis must be distinguished from diseases at-
tended by the cardinal symptoms of this disease, notably, rise of
temperature, peritoneal exudation, and tumor formation.
The leucocyte count should aid in differentiating tuberculosis
from acute suppurative diseases. Hoav unreliable it is, a number
of instances in the literature will illustrate. Coves reports a case
diagnosed as an "acute a1)domen," having in mind a typical perfo-
ration, an appendix Avith diffuse peritonitis, or perforated gastric
or duodenal ulcer. There were 15,000 leucocytes. At operation the
intestinal coils were everywhere adherent, and the peiitoneum Avas
studded Avith tubercles. Schley reports a case simulating acute
appendicitis. Korte and Herzfeld operated on a ease of ascites fol-
loAving measles, and found the peritoneum studded Avith tubercles.
The patient's cervical lymph glands AA'ere breaking doAvn.
Fever may be present in tuberculous peritonitis. It is usually
highest in the CA'ening and often normal or subnormal in the morn-
ing. The fever is often slight as compared Avith the other evidence
of disease. It may run a course quite like typhoid, particularly if
the abdominal disease is but a part of a generalized tuberculosis.
The absence of the Widal reaction and rose spots aid in differentiat-
ing it from typhoid fever. Diarrhea usually attends the acute type
of tuberculous peritonitis, Init it lacks the pea-green color of ty-
TrBERCULOSiS OF THE PERITONEUM 699
phoid fever. This, together with the abdominal distention and
pain, invites confusion in tuberculous peritonitis. The history and
the presence of other tuberculous foci may furnish a clue. In a
case of my own in which this train of symptoms developed soon
after recovery from measles, in a delicate child, the presence of
tuberculous lymph glands in the neck gave the clue to the proper
diagnosis. Symptoms of a like character following a conservative
operation on a tuberculous epididymitis likewise once awoke me to
the impending disaster. Pneumonia and la grippe may produce
symptoms referable to the abdomen in children which may simu-
late tuberculous peritonitis. A slumbering retrocecal appendicitis
may do tlie same ; in fact, an appendicitis may be implanted upon
an ileocecal tuberculosis, as I once discovered postmortem.
A large collection of fluid in the abdomen suggests tuberculous
peritonitis in children and hepatic cirrhosis in the adult. Tubercu-
losis may complicate cirrhosis. Jaundice is more common in cir-
rhosis than in tuberculosis, but jaundice may be caused by pres-
sure of enlarged glands on the bile ducts in the latter disease.
Cases of this kind have been reported hj Florand. A ease of
obstruction due to constriction of the common duct by adhesions
has been reported l\v Dujon. In cirrhosis there should be an
enlarged spleen.
The primary hepatic lesion may be a syphilitic affection. Other
evidence of syphilis may lead to the correct diagnosis. Difficulty
in diagnosis is increased in^ cases in which the tuberculous lesion
is more extensive in the region of the liver, or the two diseases may
coexist. Five of Friedlander's 88 cases were complicated by liver
cirrhosis.
The subcutaneous veins are distended in 4.4 per cent (3 out of
69 cases), according to Eotch and are due to obstruction of the
inferior vena cava. The veins are situated about the umbilicus.
The distended veins in adhesive pericarditis are over the lower part
or the whole of the chest and are not particularly pronounced about
the umbilicus. There may he a history of or other evidence of a
cardiac affection. Rolleston states that the ascites is more per-
sistent in pericarditis and there is no fever. Gee, Fisher and Laz-
arus-Barlow report cases of ascites in primary obliteration of
700 THE PERITONEUM
hepatic veins. In such eases the site of the dilated vessels is the
same as in tuberculosis.
Tumors, particularly multiple carcinosis, may he confused with
tuberculous peritonitis. Exploratory incision may be required to
decide the question. Even then, the differentiation may not be
easy. Usvially in carcinoma there is greater tendency toward con-
fluence of lesions and the lesions are often umbilicated. History
suggestive of a primary malignant disease, particularly of the stom-
ach, is helpful. Peritoneal metastases from ovarian tumors, partic-
ularly papillary cystadenomata, are apt to simulate tuberculous
peritonitis. Tumors of the abdomen may resemble sacculated tu-
berculous peritonitis, or the thickened omentum may simulate a
solid tumor. The omental tumors are prone to lie in the region of
the colon, even between the colon and the stomach. These are
sometimes attended by gastric disturbances, such as vomiting and
pain. When associated with rapid loss of flesh, the presumptive
evidence seems to lean toward carcinoma. Twice in my experi-
ence an abdominal incision was required to settle the diagnosis.
In one instance a microscopic section was required to finally settle
the matter. The presence of an irregular fever would suggest the
possibility of tuberculosis, as would a white cell count below 10,000,
while one above that figure would speak for malignancy. Morris
reports two cases in which tuberculosis was mistaken for multiple
carcinosis.
In one case in my experience a cystic tmnor the size of a fetal
head developed above the umbilicus, following a violent trauma-
tism in this region. It was attended by a loss of 40 pounds in
weight. A pancreatic cyst was diagnosticated, but operation
proved it to be a localized tuberculous process. The patient had
always been well previous to his injury. There was no evidence
of tuberculosis elsewhere.
Hydatid cysts and cysts of the mesentery and omentum have
been reported in the literature as having been mistaken for saccu-
lated peritoneal tuberculosis.
Tumors going out from the pelvis may simulate tuberculous peri-
tonitis. Papillary cystadenomata, as already mentioned, may rup-
ture early and become disseminated over the peritoneum, produc-
ing an exudate with moderate pain. Pelvic examination shows a
TUBERCULOSIS OF THE PERITONEUM 701
diffuse infiltration of the culdesae, which can not he distinguished
from the infiltration of a primary peritoneal tuberculosis. Pat-
erson has recently reported a case in which a suppurating ovarian
cyst resembled a peritoneal tuberculosis. If the patient is young,
particularly if there is or has been a tuberculous process elsewhere,
tumor of the pelvis suggests tuberculosis. A cyst of the urachus
may be simulated by tuberculosis. Doran believes the allantoic
cysts reported by Lawson, Tait and B. Robinson are examples of
the residuum of earlier pelvic tuberculosis. In patients of more
advanced years, particularly if the cyst can be Avell outlined, the
diagnosis inclines toward malignancy. In a woman aged sixty-
two, presenting the usual symptoms of a malignant tumor of the
ovary, laparotomy disclosed a tuberculosis of the great omentum.
Parovarian cysts may simulate a peritoneal exudate. The pelvic
wall will be found free from induration, however, in these cases.
A localized peritoneal abscess in the pelvis or a dilated tube may
lead to the diagnosis of simple hydrosalpinx or gonorrheal salpin-
gitis. I once diagnosticated mj^oma, which proved to be caseated
tuberculous tubes.
After all factors have been considered, it is Avell to enter
these cases on the operating room bulletin board "Exploratory
laparotomy; possible tuberculous peritonitis."
Prognosis. — The prognosis of peritoneal tuberculosis has been
discussed by a vast number of writers. The augmentation of the
literature is due to the fact that the later reporters have had bet-
ter results to offer. That more persons recover now than formerly
is probable, broadly speaking, yet one needs to look further than
the superficial statements of the literature before a fair judgment
can be reached. Whether more recover or whether merely more
recoveries are recognized is the question that must be kept in mind.
The older wi'iters held the most melancholy views regarding the
probable outcome of a case of tuberculous peritonitis. Aran typifies
the view of the period graphically as follows: "la terminaison
constante des affections tuberculeuses de peritoine est le mort. "
The older authors emphasize with greater consistency than more re-
cent writers the importance of coexisting lesions in tlie question of
prognosis. Thus Gueneau de IMussy stated that if not complicated by
lesions incompatible with life the patient may recover. Louis noted
702 THE PERITONEUM
that the peritoneal affection may improve and the patient may
then succumb to the lung involvement. Likewise Siredey and Dan-
los believed cure was possible, at least for a time. Fernet believed
that the patient might recover from the subacute form and Hanot
believed that cure was the rule. On the whole, however, earlier
writers entertained the melancholy views of Aran above quoted.
A glance at the text books of a generation ago shows that the
prognosis was regarded with as much pessimism as by the early
writers above quoted. Thus Flint stated that all patients die, and
V. Bauer declared that the vast majority I'un a fatal course. Eich-
horst may be quoted as follows: "The course is nearly always
unfavorable from the increasing peritoneal exudates. Against
the disease itself we are altogether helpless." These pessimistic
statements could be multiplied a hundredfold.
Even after the possibility of recovery was proved by Konig
most internists were slow to admit the possibility of spontaneous
recovery. Kussmaul records the recovery of an extreme case, and
notes the recovery of others. Henoch denies spontaneous recov-
ery, and believes that when such takes place simple chronic peri-
tonitis, not tuberculous i)eritonitis, is present. Liebermeister and
Vierordt hold the same view. These melancholy statements filled
the literature up to the time Konig 's epoch-making paper appeared.
Since then the vast literature which has appeared breathes opti-
mism. At first thought it Avould seem that such a radical change
in viewpoint must have come because of the curative effect of
surgical treatment. A careful perusal of the literature casts much
doubt on the validity of such a conclusion. Operative treatment
has made possible a much closer study of the disease, particularly
in its earlier stages. Diagnosis is never certain without a direct
inspection of the field. When it became generally understood that
operative treatment was the correct procedure, the doubtful cases
were subjected to laparotomy. The opportunity offered to study
the disease by operative autopsy acquainted the profession with
the signs and symptoms, so that diagnosis without operation be-
came much more certain than it Avas in the preoperative days. The
result was that milder cases Avere recognized by the internist. He
observed I'ecoveries and h's results too l)ecame better than in the
days before Konig 's publications. So marked is this fact that man}'
TUBERCULOSIS OF THE PERITONEUM 703
writers now regard tuberculous peritonitis as a medical disease-
At any rate Avhether more patients recover now than formerly or
not, certainly more recoveries are recognized. No doubt the bet-
ter management of the primary lung involvement saves many pa-
tients the peritoneal complications. And no doubt, too, better un-
derstanding of the conditions and generally improved environment
have affected the outlook, so that a considerable prospect of cure
may be offered the patients afflicted with peritoneal tuberculosis.
After the appearance of Konig's paper, statistics had to do with
the results of surgical treatment. Some of the more carefully com-
piled statistics may be quoted. Konig secured a recovery of 65 per
cent in 131 cases. He regards persons as cured who have remained
free from the disease for two years. Roersch, in the collected
statistics of 359 laparotomies, found recovery in 70 per cent.
Margarucci in 250 cases, reported recovery in 85 per cent. Thomas
in 346 laparotomies reported 73 per cent cures in the exudative
type, 57 per ctnt in the dry, and 57 per cent in the encapsulated
type. V. Krencki in 266 laparotomies reported 71.65 per cent cures
in the encapsulated type. Baumgart in 54 cases had 17 per cent
recoveries and 8.5 per cent improvements. Frank in 63 personal
cases had 55 per cent recoveries in the exudative, and 21 per cent
in the dry type. In the ulcerative, suppurative form Frank lost
all of his three cases, while Thomas had a recovery of 70 per cent
of his cases of this type. Schramm in 45 cases, treated 25 ex-
pectantly Mith 36 per cent deaths, and operated upon 20 with 10
per cent deaths.
Konig places deaths from the operation itself at 3 per cent,
Schmitz at 10 per cent, and Meyer at 10.8 per cent. ]Meyer got bet-
ter results by laparotomy in males than in females. Shattuck re-
ported on 98 cases observed for periods of from 2 to 11 years. Of
these, 57 could be traced. Of the 57, 68 per cent of the medically
treated patients were dead at the time of the compilation of the re-
port, and but 47.3 per cent of those surgically treated.
Pic secured data by observing a considerable number of cases
untreated. Thus in 64 cases of young girls, 50 per cent died, Mhile
but 4 per cent recovered. Those readers who have a liking for
statistics Avill find them collected by Faludi, together with the lit-
erary citations.
704. THE PERITONEUM
Many of the papers presenting glowing prognostic possibilities
bear the earmarks of subjective enthusiasm.
Rose is obviously right when he contends that statistics have
been prejudiced in favor of operative treatment. The reported
cases are small series, and in many instances selected cases only
have been subjected toi operation. On the other hand, those who
report spontaneous recoveries have included cases which were not
tuberculous in nature at all. To obviate this difficulty, therefore,
it is necessary that those contending for spontaneous recovery
prove their diagnosis by demonstration of the bacteria. This has
been done for small series, notably by Borchgrevink.
In some of the series reports have been made too soon after op-
eration. Healing of the incision does not constitute a cure. As
long as two years after apparent cures relaparotomy has still showed
the presence of tubercles. In Konig's statistics of 65 per cent cures,
only 24 per cent had remained cured for two years or longer. In
Margarucci's compilation of 253 cases reported as cures, only 26
per cent had been operated on more than a year before. Roersch
reported on 358 cases with 70 per cent cures., Only 15 per cent,
however, had been operated on 2 years or more before. In Ados-
sides' 405 cases, 15 per cent had been cured more than 2 years.
The cures from expectant treatment furnish a no less imposing
series of statistics than those from operative treatment. Frank re-
ports 63 operative and 8 nonoperative cases in Czerny's clinic.
Those surgically treated showed 38 per cent recoveries; those ex-
pectantly treated, 50 per cent recoveries.
Rose reports on 71 cases medically treated, all in patients over
14 years of age. Of these 9 died while in the hospital. In 52 cases
which he traced, 34 died after leaving the hospital, one remained
sick, and 16 had recovered. In his series there were recoveries in
36 per cent in the tumorous form, 33 per cent in the ascitic, and
29 per cent in the mixed. He noted 50 per cent in the acute form,
31 per cent in the subacute, and 16 per cent in the "schleichende."
Frank had the best results in the exudative form, namely, 40
to 50 per cent recoveries. In the adhesive fonn 25 per cent re-
covered. The prognosis in the ulcerative and suppurative forms is
very grave. The best prognosis is seen in women in Avhom the dis-
ease began in the adnexa, and who were treated by removal of the I
TUBERCULOSIS OF THE PERITONEUM 705
adnexa, — 75 per cent recoveries in the exudative, and 50 per cent
in the adhesive. The fecal fistulas present a very bad prognosis.
Other statistics may be recorded as follows: Borchgrevink had 22
cases of "which 19 recovered; Monti 10 cases of which 6 recoA'-ered;
Schmitz 32 cases of which 30 recovered; and Sutherland 27 cases
of which 22 recovered.
Bonet explains the diversity of results reported by the various
writers as due in part to the difference in the classes of patients
treated. In the poorly nourished and those living under unfavor-
able hygienic conditions, recovery naturally is less likely than in
those whose constitutional and environmental conditions are more
favorable.
Wright makes the point which every observer must have noted,
that even when patients apparently recover from their peritoneal
affection, they are prone to die from tuberculosis of some other
organ.
The statistics above quoted will convey as much information as
a more extended series. The value of statistics has often been
questioned and nowhere is the occasion for this more warranted
than in the statistics relative to the results of any treatment, par-
ticularly a treatment that has not had the criticism of the profession
for at least 10 years.
Considering the late statistics only, it seems a fair estimate that
some 30 to 50 per cent of cases of tuberculous peritonitis recover
either after operative or expectant treatment. Cure could not be
spoken of in any instance, because the direct relation of the
therapeutic measures employed and the subsequent recovery of
the patient has not been determined in any case.
Conservative Treatment. — As in tuberculosis of other regions
of the body the chief agent to be directed against the disease
are the natural defensive forces of the ]K)dy. These may be
classed under conservative treatment. Not infrequently definite
conditions arise where active operative interference is warranted.
When abscesses form active intervention is imperative. Whenever
it is possible to remove the focus of infection operation offers a
prospect of relieving the patient of a part of his burden. These
various phases may be considered in detail.
Medical. — The exhibition of drugs for the cure of tuberculous
706 THE PERITONEUM
peritonitis is a trail which runs quite parallel Avith the medicinal
treatment of this disease located in other organs. The period in
which any paper or book was written can be quite accurately de-
termined by observing the measures recommended. For instance,
formerly codliver oil and the hypophosphites received the most
frequent mention, pressed closely by creosote and its congeners.
A few variations are recorded. Sandler gave mercury with chalk
and iodoform, and applied the same in the form of an ointment over
the whole abdomen. Schmidt used eacodylate of soda. Miihlberg
applied stupes of cinnamon oil, ten drops to a dram of olive oil.
Millard applied collodion to the entire surface of the abdomen.
Green soap was in quite general use, particularly in Germany, be-
fore laparotomy became the common mode of treatment. Soap may
be a good prophylactic, but it is difficult to understand hoAv it
could be curative. Wilcox used inunctions of iodoform in ether
and oil with success in two cases. Hofmann used iodine locally in
four cases, with success in all.
Climate. — Lalesque reports a cure in five cases by a prolonged
residence at the seashore ; and Leroux is of the opinion that sea air
is particularly useful after the acute symptoms have subsided.
X-raij. — Porter was the first to give this method a systematic trial.
Ausset and Bedart had previously reported the cure of a case by this
means. Bircher reported on 16 cases treated by x-rays after opera-
tion. Of these 7 were cured and 5 were improved. Of the 7 reported
as cured, only 4 had been well for a year or more. Twelve cases were
treated l\v the x-rays alone. Of these 6 were cured, and 2 were
improved. This investigator used hard or medium-hard tubes,
treating the patient daily for three or four weeks, the treatment
lasting from fifteen to thirty minutes at each sitting. If no results
were produced, an interval of two Aveeks Avas alloAved to elapse,
and then the treatment Avas repeated. Shober advises the use of
the x-rays in conjunction Avith laparotomy. The researches of
Falk made upon animals indicate that Avound healing is not in-
terfered Avith by radiation immediately after operation. This
combination of incision Avitli radiation under modern methods
Avould seem to be Avorthy of a trial. It must be remembered, hoAV-
ever, that theoretically x-rays are contraindicated, if the theory
of healing by fibrosis is correct. The x-rays cause a degeneration
TUBERCULOSIS OF THE PERITONEUM 707
of the connective tissue, and this might be expected to retard the
healing process.
The reports available fail to show any marked influence of the
x-rays on the course of the disease.
Ausset and Bedart report a case of cure after using x-rays for
eighteen months, after conservative treatment and laparotomy had
been used.
Sun baths, as suggested by Oppenheimer as a corollary to the
use of the x-rays, may be mentioned. He reports favorable results
in two cases. He believes that the action of the sun's rays produce
a hyperemia of the peritoneum, acting in this way like a lapa-
rotomy.
Tuberculin. — Varnek reports a cure from the use of tuberculin.
Anderson also records a case. Bumm reports on its use in con-
junction with laparotomy. McDonnell reports the use of Mar-
morek's serum, 5 c.c. each week for six weeks.
Paracentesis. — Von Mosetig-Moorhof recommends simple punc-
ture. IMader recommends puncture Avith a careful pressing out of
the fluid, and the subsequent use of abdominal compresses with
the idea of producing a slight inflammation. Seganti punctured
the abdomen at Uvo points, and irrigated the cavity through these
openings Avith salt solution. Mathis regards puncture with lavage
as the best treatment. Schomann recommends drainage Avith sub-
sequent iodoform injection. He begins Avith 1 to 2 c.c. of a 1 per
cent emulsion, and increases the dosage Avith each rencAved injec-
tion. The injections are repeated cA'ery four to eight days. He
treated seven cases, Avhich he regarded as cured after three to
ten Aveeks. Rendu injected naphthol camphor intraperitoneally
after draining off the fluid. He used five PraA'az syringefuls.
This treatment is evidently a liit heroic ; at any rate, it Avas fol-
loAved by nausea, pain, and vomiting. Von Helmrich reserA^es
puncture for cases in Avhich the distention is so great that digestion
is impaired, or edema of the lungs is threatened. GusseroAV sums
up the dangers of puncture as folloAvs: sepsis, folloAving puncture
of a gut and possible injury to blood vessels. He notes that com
plete emptying of the fluid is not possible l)y this means.
Air. — FolloAving the belief that it Avas the air that produced the
beneficial effect in laparotomies, numerous operators attempted to
708 THE PERITONEUM
secure these benefits by blowing air into the peritoneal cavity.
Among these may be mentioned Folet, Duran, and von Mosetig
Moorhof. Brial collected eleven cases treated by this method.
Nolen constructed a special apparatus for applying this kind of
treatment. Napoleone reports the recovery of a very grave case
after the injection of air into the peritoneal cavity. Floris reports
three successful cases ; and he advises the introduction of a volume
of air equal to that of the fluid removed. McGlinn inflates the ab-
domen with oxygen, alloAvs it to escape, and inflates it again. This
process is repeated a number of times.
Operative Treatment. — Danger of Operation. — Rolleston states
that an operation is not indicated in any case before a year from
the onset, and that it is unnecessary in the ascitic and fibrous forms
in the absence of symptoms of intestinal obstruction, but that it is
indicated in abscesses and intestinal obstruction. Thoenes em-
phasizes the danger of the operation per se because of collapse,
sepsis, fecal fistula?, etc.
Pic regards fever, lung tuberculosis of even moderate severity, and
intestinal ulcers as contraindications to operation; and Elmassian
agrees with this opinion.
Time for Operating. — Since Konig first reported cures in four
cases treated by laparotomy, this has been the favored method of
treatment. The question of the time at which laparotomy is most
effective, has engendered much dispute. Gelpke, on the basis of
animal experimentation on dogs, concludes that early laparotomy
is not followed by the best results. He regards the third or fourth
month as the best time for operation. He believes that the exudate
is at first beneficial, in that it contains a tubercle antitoxin which is
alone sufficient to produce a cure in mild cases. Bonet believes
that operation is contraindicated in acute cases. Friedlander
agrees with this opinion, and recommends operation only after the
acute symptoms have subsided. He believes that early operation is
useless, and is seconded by Gatti, who holds that at this stage the
bacilli are still too virulent to permit such a procedure, but that
later they undergo involution.
Technic. — Frank advises an incision twelve or fifteen centi-
meters long, reaching from the umbilicus to the pubis. Baumgart,
on the contrary, advises a short incision, and in females a vaginal
TUBERCULOSIS OF THE PERITONEUM 709
section. The advantages of the latter are that infection is less apt
to take place, there is less danger of scar hernia, and the tubes can
be removed by this means, and the pathologic tissues reached read-
ily, the involvement being usually the most pronounced in the fossa
of Douglas. Lohlein had previously advised posterior colporrhaphy
for better palpation of the pelvic peritoneum and for the excision
of a bit of peritoneum for the purposes of diagnosis, as well as to
establish drainage. Frank opposes this route, because it is useless
in the adhesive form, may endanger the bowel, and does not per-
mit an inspection of the entire peritoneal cavity.
Frank, in common Avith many others, advises tamponage and
drainage in cases in which there is much bleeding or pus, in which
cavities not obliterated by fluids exist after the escape of fluid, and
in the serous suppurative form.
Most operators regard drainage as dangerous because of the likeli-
hood of forming a fecal fistula. Many of the earlier operators used a
drain, for a longer or shorter period. Miller used a rubber tube
and an iodoform-gauze drain, allo-\Aang them to remain in for two
months. Briddon employed drainage and tamponage. A modi-
fied form of drainage Avas employed by Evler. He stitched the peri-
toneum over the edge of the recti muscles in an incision below the
umbilicus, and then closed the skin, hoping in this Avay to secure
drainage into the subcutaneous tissue.
Martens and Lindner regard drainage as superfluous. Gelpke
notes that fecal fistulas may arise after drainage.
Thoenes recommends an energetic rubbing of the peritoneal sur-
face during laparotomy in order to hasten the natural tendency to
encapsulation. Judd used peroxide of hydrogen. Frank advises
a thorough sponging out of the peritoneal cavity during lapa-
rotomy. Hofmanu treated four cases by painting the visceral and
parietal surfaces with iodine. All recovered. In none of these
cases Avas the disease severe, and too short a time had elapsed after
operation to permit an opinion. Experiments on animals have
proved that such a remedy must be used Avith great caution, for a
small amount of iodine in an animal's abdomen may produce death.
Eiva advises irrigation Avith eight to ten liters of salt solution.
Wilcox tried rubbing in iodoform. Jordan tried irrigating Avith
thymol, boric acid, etc. Von Marchthuru secured a recoA^ery of 21
710 THE PERITONEUM
out of 38 cases, or 55 per cent, by tliis means. Eccles advises the
use of dilute iodoform in oil. The patient recovered both from the
iodoform and from the disease.
Repeated operations have been recorded l)y many operators.
Galvini reports a case in which laparotomy was done five times,
with recovery.
Management of Adhesions. — Both Friedlander and Thoenes ad-
vise against the separation of adhesions because of the danger of
producing a fecal fistula. Porter advises the separation of slight
adhesions if necessary to let in light and air.
Removal of Tiihes. — Kaulich was the first to emphasize the im-
portance of thei removal of the primary focus. Veit recommends
the removal of the tubes in all cases, whether primarily or second-
arily involved. Runnels advises that the primary focus be searched
for diligently and if found, removed. Winter and von Kreneki
found that 66.1 per cent recovered without the removal of the
tubes, and 76.6 per cent Avith their removal. Mayo secured 25 re-
coveries in which the tubes were removed. In 7 of these simple
laparotomy had already been performed. Robson advises the re-
moval of not only the tubes, but also of the affected glands and
even of jjortions of the gut. Stone in 122 cases did not find the
tubes involved in any. In girls the tubes are seldom involved.
Maas, quoted by Murphy, could collect but 8 cases. Goodall be-
lieves that in 99 per cent of the cases in Avhich the tul)es are in-
volved removal is necessary, though in 30 to 50 per cent he could
not locate the primary focus. More recently a more conservative
note has been sounded. Stone believes that infected tubes do not
require removal any more than in infected omentum or intestine.
Tweedy reports a case in which conservative treatment Avas fol-
lowed by pregnancy. Heimann advises against the removal of the
tubes, and in his ease reports records good functional results by
conservative treatment. My own experience is in entire accord
with this more conservative vicAV. I had one patient AAdio con-
ceived after loosening adherent tubes. Where the tubes are deeply
imbedded their remoA^al may hazard a fecal fistula. In the exuda-
tive type, in Avhich the tubes are easily accessible, their removal
can not hasten the cure. In the primai'v and isolated lesions of the
tube, Avhere local thickening Avith caseation is present and Avhere
TUBERCULOSIS OF THE PERITONEUM 711
the remainder of the peritoneum is free, removal is in order. Fi-
nally, tubes are removed for tuberculosis when the disease does
not exist.
Removal of Tuherculomata. — Tuberculomata have been removed
ill three instances. Beatson removed a mesenteric tumor from a
child aged four ; and Kukula removed one in a man of thirty-eight.
Baum removed a mass from the omentum the size of the palm of
the hand over the pyloric region with the attached gut. A pocket
of glands and many small tumors remained in the region of the
main tumor.
Operation in the Dry Form. — Most authors advise against opera-
tion in the dry form. Von Helmrich sees in the tumorous form a
positive contraindication, because no good can come from it.
Gelpke also advises against it because of the danger of fecal fistula.
Gofert advises it only in cases of encapsulation and intestinal oc-
clusion. Schramm advises against operation in general in the dry
forms, but admits its use in such eases as begin in the tubes, since
in these instances the primary focus may be removed.
Objections Against Operation. — As in most methods of treatment,
the benefits claimed were, no doubt, much exaggerated. Soon the
results began to be questioned, and vehement opposers were not
lacking. Among these may be mentioned Comby and Grange.
Friedlander reports on 20 eases who died foUoAving operation,
and two had fistulas. Herzfeld in 11 fatal cases had 5 fistulas. Of
Borchgrevink's 12 cases 3 had fistulas. These statistics are suffi-
cient to show that operation promotes the formation of fistulas.
Regarding the question of the possibility of a secondaiy infection
of the abdominal Avail after laparotomy by the tuberculous process,
Parker Syms ansAvers in the negative. He belicA^es that tubercu-
lous infection of the avouikT does not take place. Braun, hoAvever,
records a case in Avliich such an infection reached the surface by
Avay of a stitch tract. Lindner is ])rol)al)ly correct in stating that
such an accident is very unlikely to happen, as the through-and-
thi'ough method of suture has been abandoned. In one of my cases,
a woman of tAventy-three, Avith a massive tuberculosis of the pelvic
organs, infection of the wound tract took ])lace in Avliich healing
Avas not secured for more lliaii a \ear. Healing of the sinus, as
712 THE PERITONEUM
well as cure of the original disease, finally occnrrecl, however, and
was complete five years later.
Lindner's collected statistics contain reports of operations in
205 cases, in which there was an operative mortality of 7.5 per cent.
How Operation Does Good. — About twenty theories have been
advanced to explain in what way operation does good; and this
in itself is enough to throw doubt on the value of the procedure.
Jaffe and Friedlander have advanced the theory that it is the ad-
hesions produced by operation that promotes recovery. Jaffe
made the important observation in five cases in Avhich he had oc-
casion to reopen the abdomen that, while there was a clinical cure,
the tubercles remained. Jordan reports a similar case. Fried-
lander makes the point that in the case in which improvement takes
place only after a long interval following operation the recovery
can hardly be ascribed to the operation. These cases, though small
in number, are sufficient to show that cure can not be ascribed to
the operation in all cases recovering after operation, and that some
cases that appear clinically to have recovered have not recovered
anatomically.
The most generally accepted explanation of the value of opera-
tion is that an active and passive hyperemia is produced. Gatti,
Nassauer and D ' Urso have particularly emphasized the validity of
this explanation.
Fritsch believed that laparotomy has the effect of restoring the
absorbing ability of the peritoneum ])y restoring the circulation.
As evidence he cited the increased diuresis following operation.
This restored circulation, according to Nassauer, increases the nu-
trition of the tissues.
Hildebrandt found from animal experimentation that the ar-
terial hyperemia disappears after a short time, but gives way to a
venous hyperemia lasting several days. Lohmann, besides a hy-
peremia following operation, hypothecated an increased diapedesis
of leucocytes. Pitfield believes that it is the blood that gets into
the peritoneal cavity that exerts the beneficial infiuence after opera-
tion. Sippel believes that air contact is the important factor, for
when the operation was done under a normal salt solution cure
did not result.
Schegoleff tried to arrive at a conclusion by means of animal ex-
TUBERCULOSIS OF THE PERITONEUM 713
perimentation. He produced tuberculous peritonitis in dogs, and
then studied the effect of laparotomy. He concluded that in the
early stages the disease is cured by this means, but in the later
stages it is not. He ascribes the cure chiefly to the reaction pro-
duced by the operation. More leucocytes and phagocytes, together
with an active proliferation of the connective tissue, result. Phys-
ical agents, too, have some influence, according to this author.
Among these he mentions heat, air, and perhaps light. These act
by increasing the irritation. Kishenski, from dog experiments,
concludes that laparotomy increases the proliferation of connective
tissue about the nodules. As a result of this ring the center
caseates, and later becomes calcareous.
Finally, it must be remembered that laparotomy may secure im-
provement in conditions when cure is out of the question, as in
cancerous peritonitis following ovarian carcinomata, as noted by
Freund.
Pseudotuberculosis
Under this caption may be included a heterogeneous group of
diseases which produce lesions or clinical manifestations resembling
those characteristic of tuberculosis.
These may be classified into (1) those due to organisms other
than tubercle bacilli, (2) those due to foreign bodies, and (3) those
characterized by a chronic reactive condition, nontuberculous in
nature, due to various or indeterminable causes.
1. Bacterial Pseudotuberculosis. — In this group are those caused
by the bacillus pseudotuberculosis rodentium (compare Ophlils),
and those caused by a related bacillus resembling the above, of
which two cases have been reported by Du Cazal and one by Wrede.
A diphtheroid bacillus has been the cause of lesions resembling tu-
bercles. Flexner reports an interesting condition under the name
"pseudotuberculosis hominis streptothrica." The patient was a
male, aged 70, who had died with symptoms of pulmonary tuber-
culosis. The autopsy showed the omentum rolled up beneath the
transverse colon. Translucent nodules of various sizes resembling
tubercles were irregularly scattered over the surfaces of the peri-
toneum. The liver and spleen showed similar nodules. A branch-
ing organism was discovered on microscopic examination. Mould
714 THE PERITONEUM
fimgi have been accused of playing a similar part. Finally, the
organism specific of blastomycotic dermatitis maj^ be classed in
this category.
2. Foreign Body Tiiierculosis. — First in this group may be men-
tioned those lesions developing about animal parasites and their
eggs. Helbing records a case in which, during an operation for the
removal of the appendix, tubercles were found on the cecum. Sec-
tion of these revealed eggs of the taenia, which had obviously es-
caped after perforation of the appendix. Deve repoi-ts four cases
in which pseudotubercles developed about hydatid booklets or
pieces of hydatid membranes. A number of interesting cases have
been recorded in which pseudotubercles formed about a variety of
foreign bodies. Meyer records a case in which pseudotubercles
developed about cholesterin crystals Avhich reached the peritoneal
cavity by the rupture of an ovarian cyst. Von Recklinghausen
(quoted by Meyer) reports a case in which bits of sponge furnished
the basis for a pseudotuberculosis. Hanau and Cooper report cases
in which pseudotubercles Avere found al)out an old gastric ulcer,
the basis of Avhieh Avas formed ])y food particles. I have seen a
similar case, in which bismuth, exhibited for the cure of the gas-
tric ulcer, furnished the basis for a small crop of tubercles about
the adhesions in a perforating ulcer.
3. Chronic Idiopathic Nontuherculous Peritonitis. — Those cases
which resem])le tul)ereulous peritonitis clinically may be placed in
this group. For the most part there is little anatomic resemblance
to tuberculosis, Init in some instances there may be a general
thickening of the peritoneum and subperitoneal tissue without the
production of tubercles.
Before laparotomy became the prevailing method of treatment
for peritoneal tuberculosis, many cases of chronic peritonitis were
assigned to the so-called idiopathic group. At one period this
variety was thought to exceed the tuberculous in frequency. The
increased opportunity Avhich laparotomy gave for observing chronic
peritonitis, on the other hand, reduced A^ery much the proportionate
number of the idiopathic variety. To such an extent is this true
that some recent observers deny the existence of an idiopathic
variety entirely. There is no doubt that the idiopathic form is
A'ery rare, but some cases have been observed AA'hich can be placed
TUBERCULOSIS OF THE PERITONEUM 715
under the tuberculous category only on negative evidence. The
safest Avay, therefore, is to recognize our limitations, and retain
this group for cases of chronic peritonitis in which it is impossible
to diagnosticate tuberculosis on positive evidence.
On the other hand, the older writers were unquestionably wrong
when they placed in the category of idiopathic peritonitis all cases
running a course identical Avith tuberculous peritonitis, but ter-
minating in recovery. It has of course been abundantly proved
that cases of tuberculous peritonitis may recover.
An analogue for idiopathic peritonitis has been sought in idio-
pathic pleurisy. Many observers hold that all exudative pleurisies
are tuberculous in nature. This has not been proved. Such broad
statements may be of great convenience, but they form a poor
basis for scientific investigation.
Bauer divides chronic nontu])erculous peritonitis into three
groups: (1) those which are terminal to an acute process; (2) those
in Avhich the peritoneum is placed in a reactive state as the result
of chronic circulatory disturbance, as is seen in obstruction to the
portal vein, nutmeg liver, or adherent pericarditis; and (3) those
in Avhich there is a gradual development of a peritonitis Avithout
a demonstrable etiology.
In cases of irritation of the peritoneum by the exudate from an
inflamed organ, a peritonitis may be produced which is essentially
chronic in character, tending to recovery as the causative factor
recovers. This may be seen about the gall bladder in cholecystitis.
It has been described as "gall-bladder peritonitis." The same proc-
ess may be instituted when a chronic or subacute gastric or
duodenal ulcer approaches the surface. An irritant exudate is
produced, and sets up a limited chronic peritonitis, which may
lead to peritoneal adhesions. Similar processes may lie excited
about the appendix. These jjrocesses may find expression in exu-
dation, in the formation of adhesions, or in a chronic hyperemia
of the peritoneum. I once operated on a patient who gave a typ-
ical history of appendicitis. An operation done after four months
shoAved an appendix the most of wliicli had disappeared. A mere
string extended from the cecum to a segment of appendix 3 cm.
long, representing the terminal end. Obviously, the remaining por-
tion had disappeared by a process of necrosis. Extending from
716 THK TKRITONEUM
the appendiceal region mesially and iipAvard were abundant web-
and band-like adhesions and much exudate. The peritoneum was
yet in a state of reactive hyperemia. No doubt this process was
instituted by bacteria, but it is equally certain that tubercle bacilli
were not responsible for its origin. Ruptured serous ovarian cysts
may likewise produce a chronic peritonitis at a time when the
papillary processes have not yet become malignant and capable
of primary metastasis.
Obstruction to the venous return ordinarily does not cause nota-
ble thickening of the peritoneum. Cases have been recorded in
which thickening has occurred about the site^ of puncture. How-
ever, it is likely that chronic obstruction may cause a reactive
hypertrophy of the peritoneum, particularly if the lymph return
is likewise interfered with. The process then becomes analogous
to elephantiasis in the extremities. At least this is my interpreta-
tion of a case of adhesive pericarditis in which laparotomy was
done to relieve the accompanying ascites. In this case the peri-
toneum, particularly the parietal in the region drained by the
mammary vein, Avas distinctly thickened, and mounted by small
granular elevations. These, however, were composed of lymphat-
ics, and the thickened peritoneum resembled in structure an
ordinary elephantiasis.
Cases are recorded in which there has been extensive hyper-
plasia of the subperitoneal tissue without any knoAvn cause. As
a clinical example of this may be mentioned the case reported by
Porter.
A similar case was reported by Henoch. This case Avas that of
a girl, aged ten, in Avhom, folloAving an injury, an exudate formed
and required puncture tAvice. After puncture a tumor the size
of the hand formed. At autopsy a simple peritonitis Avas rcA^ealed.
In many places the serosa Avas enormously thickened, the peri-
toneum measuring in some regions 0.5 to 1 cm. It is concei\^able
in this case that an injury to the gut Avail permitted the exit of a
mild form of infection.
I have seen such areas of thickened gut, and have been impressed
by the histologic resemblance of such tissue to the tissue of Avoody
phlegmon of the neck.
Cases in Avhich a chronic exudative or exudative-adhesive process
TUBERCULOSIS OF THE PERITONEUM 717
begins Avithout demonstrable exciting cause, and which in the main
resembles a mild tuberculous peritonitis, constitute the majority
of the idiopathic cases recorded in the literature.
The recorded cases present a great variety of conditions. Some
of them recorded as idiopathic were unquestionably tuberculous,
while others would better be classed in the group of polyseros-
itides. For example, Stitzer and Rochs report the following case:
a girl, aged fifteen, Avho had had abdominal disturbance since an
attack of measles seven years before, and had l^een punctured in
her eleventh, twelfth and thirteenth years. Each time a large
quantity of greenish yellow fluid was removed. Death finally oc-
curred with progressive edema, icterus, and cyanosis. At autopsy
the peritoneal cavity contained a large amount of colloidal fluid,
and yellowish exudate in part cloudy. The abdominal organs were
adherent into a convoluted mass, and Avere joined to the thickened
parietal peritoneum. A nutmeg liver was adherent to the organs
lying near it. Even more striking is Steinbriick's case in which
after terminal phenomena similar to the above, the lower part of
the abdominal cavity contained sacculated exudate, and the omen-
tum and transverse colon formed a cavity above. The intestines
were adherent to each other, and the liver was encased in a fibrous
capsule. In addition, the pleura were adherent, and there was a
synechia of the pericardium. A similar case is recorded by Riedel.
On the other hand, Heubner reports a, case the idiopathic nature
of which may well be questioned. A boy after some years of ab-
dominal complaint became ill with a pulmonary affection attended
by fever which terminated fatally. Autopsy showed adhesions of
the intestines without tubercles, and both old and recent tuber-
culosis of the lung. In the light of our present knoAvledge
there can be but little doubt that this represented a peritoneal
tuberculosis.
The vast majority of cases have to do Avith clinical records in
AA'hich the patient recovered. Such cases must of course be in-
volved in the greatest doubt, since Ave noAv knoAV that many cases
of tuberculosis recover. Thus five of Steinbriick's six cases re-
covered. Quincke noted that females near puberty Avcre the most
frequently affected, a fact Avhich Ave noAV k^lo^v to l)e true of
tuberculosis. Vierordt remarks on tlie difficulty of ascribing any
718 THE PERITONEUM
causative factors. Winge- likewise could suggest no etiologic fac-
tors. His fourteen cases, it is worth noting, were all clinical ob-
servations, in none of which was tuberculosis excluded. In fact,
he expressly noted the frequent coexistence of pleurisy. Frankel,
while not doubting the existence of this type of peritonitis, com-
ments on the difficulty of making a positive diagnosis in cases which
recover. Hagelstam and Delpeuch ascribe as etiologic factors such
general conditions as uremia, malarial poisoning, lead poisoning, and
alcoholism. Hagelstam believes that cases arising after acute in-
fectious diseases are due to the action of the toxin upon the peri-
toneum, but not to the action of the bacteria themselves. Other
reported eases in which material obtained at operation or autopsy
was examined for tubercle bacilli, offer greater difficulties for
judgment. Thus Spaeth and ProchoAvnick examined tissue and
declared against its tuberculous nature because of failure to dem-
onstrate tubercle bacilli. These cases clinically were tuberculous,
as the authors thought, and only the negative bacteriologic study
caused them to place their cases in the category of idiopathic peri-
tonitis. That these investigators failed to find the ]:)acilli can not
occasion surprise, since in many known tuberculous lesions this
is impossible, and it is only ])y the aid of animal inoculation that a
diagnosis can be made.
The clinical symptoms of the tuberculous and idiopathic types
as given by the older authors, are essentially the same. Henoch
does maintain that in the idiopathic type the exhaustion of the
patient is less. Vierordt gives the specific gravity of the exudate
as between 1.017 and 1.027, and the albumin content betAveen 4 and
7.5 per cent, figures Avhich correspond Avith those generally accepted
for tuberculous peritonitis.
After Konig's treatment by laparotomy Avas generally adopted
the report of idiopathic cases rapidly became less frequent. Re-
ports of specific cases practically ceased, and Avhat mention is found
in the more recent accounts, speaks of it in such general terms, as
"rare disease," etc. BorchgrcAnnk proA-ed by means of animal
inoculation that the simple forms are in fact tuberculous in char-
acter. This author advises the abandonment of the designation
"idiopathic peritonitis" entirely. At the same time, he admits
that there are other irritants, for example, chemical, AA'hich may
TUBERCULOSIS OF THE PERITONEUM 719
produce a serous exudate ; but these, he claims, have an altogether
different significance, and are not comparable to tuberculous peri-
tonitis. In this he is unquestionably^ right. However much one
might want to expurgate the literature of all the recorded cases
after reading them, it may, nevertheless, be well to retain a class
for cases in which a tuberculous nature is not capable of demonstra-
tion, which may now be "idiopathic," but after more careful study
may reveal their true nature.
Polyserositis. — A very remarkable condition of the peritoneum,
known as polyserositis, may be referred to here, because, so far as
is known, it may represent a corollary to the idiopathic peritonitides
above mentioned. In this condition the peritoneum, both parietal
and visceral, as Avell as the pleura and the pericardium, become
more or less thickened, and ascites is present in greater or less
degree. The onset is often brusque, affecting persons of previous
good health. The thickening of the peritoneum, which may be
massive, is made up of fibrous tissue without evidence of degenera-
tion. Gangitano has noted a distinct endarteritis. In the single
case I have been able to examine, there was an obliteration of many
vessels, and, judging from the character of the tissue, no doubt the
lymphatics likewise were disturbed. My judgment is that the
lymphatics are primarily affected. The cause is not known.
Huguenin thinks "it has something to do with tuberculosis," and
Pancet thinks that it is due to a tuberculotoxin. Von Creigern,
on the contrary, denies this for his patients were negative to both
Wassermann and tuberculin tests. Trauma has been blamed by
Gazette and Gangitano. Primary affections of the liver with sub-
sequent congestion have been suggested (Hiibsmann), but Esau
reports a ease in which the liver was not affected. This con-
dition is one, therefore, in Avhieh the serous membranes become
thickened, and in which there is an associated exudate for which
no cause can be ascribed.
Kieseritzky believes the condition may be due to either a pri-
mary serous inflammation with subsequent circulatory disturbance
or to a primary pericardial affection.
There are several conditions related to the hyperplastic processes
of the peritoneum. Among these may be mentioned linitis plas-
tica and sclerostenosis of the stomach. For literature see Krom-
pecher.
720 THE PERITONEUM
Chronic Hyperplasias of the Peritoneum
Either alone or in association with other serous surfaces the peri-
toneum, in rare instances, undergoes marked thickening. In yet rarer
instances other serous surfaces may undergo such thickening, and the
peritoneum remain unaffected. In conformity with the multiple char-
acter of the lesion it has been designated "multiple serositis."
The frequent predominance of the iDcricardium led Pick to call it
"pericarditic pseudocirrhosis of the liver." Curschmann empha-
sized the liver involvement designating the affection "Zuckerguss-
leber, " which is translated by Kelly as "iced liver." The French
call it "perivisceritis." American cases seem to be very limited.
Osier, Cabot, Herrick, and Kelly seem to mention about the only
recorded cases. The last-named author gives a resume of the liter-
ature, and tabulates all the knoAvn cases, 39 in all.
The essential nature of the lesion is a matter of question, as the
multiplicity of names employed by the various writers to designate
it indicates. We need be concerned here only with the change
within the abdominal cavity. Pick believed the changes in the peri-
toneum to be the result of long-continued congestion and the result-
ing persistent ascites. Weiss believed that there is an intervening
hepatic disease, in Avhich this organ and the peritoneum suffer
alike, though in varying degrees. The peritoneal changes, according
to one group of men, of whom Pick is the most prominent, are
of the opinion that the changes in the peritoneum are secondary to
the liver changes, and these, in turn, are due to long-standing con-
gestion. Others, of whom Weiss is the most conspicuous, believe
that there is an associated chronic i^eritonitis.
Etiology. — A history of repeated inflammations of one of the or-
gans, usually the heart, is about all that can be cited as of possible
etiologic significance. A number of cases have been found in which
tuberculous foci existed in some region of the body. In several
cases death was caused by an acute disseminated tuberculosis.
Cantu (cited by Hager) explained the peculiar course on the sup-
position that a peculiar form of tubercle bacillus, probably avian,
was active.
Pathology. — The most common lesion is the obliteration of the
pericardial sac. In some eases marked calcification existed, indi-
cating a postdegenerative process, as well as a proliferative one.
TUBERCULOSIS OF THE PERITONEUM
721
In most cases the pleura suffered a like change, though in a lesser
degree. In nearly all there was an associated perihepatitis, and
in many a marked increase of the intrahepatic connective tissue.
The peritoneum is generally described as being thickened and
opaque, with many adhesions. Kelly speaks of his case as pre-
senting recent hemorrhagic peritonitis. The upper abdomen in
the region of the liver is usually most intensely affected. Heide-
■■•,_•/ _ • -— -S* ' •
,••«■ • ■ -
Fig. 210. — Chronic liyperjilasia of the ijeritoneum. The upper three-fourths of the picture
represents newly formed tissue. The fiber bundles do not resjiond specifically to any stain.
mann speaks of involvement, particularly of Doviglas' pouch in his
case.
In Hiibeler's case, as well as in those of White, the peritoneum
alone was involved. Their cases had much in common with cer-
tain forms of tuberculous peritonitis, except that the perihepatic
peritoneimi was intensely involved.
Kelly explains the associated lesions by assuming that there is a
primary affection, of Avhatever nature it may be, beginning in the
722 THE PERITONEUM
peritoneal cavity, by virtue of the constant reaction of the cur-
rent toward the diaphragm, and exciting its reaction here, sub-
sequently extending to the pericardial and pleural caAdties.
I have observed one case in which there was extensive thickening
covering a large part of the area of the peritoneum. The pseudo-
membrane was several millimeters thick and Avas composed of
poorly staining connective tissue fibers (Fig. 210). It appeared as
if an exudate had formed which precipitated fibrillar fibrin and
then for some reason the change to fully developed fibers Avas held
up. I have seen the same thing in an imperfect state in very sloAvly
developing cases of diffuse peritonitis. In the latter instance the
development of the filnils Avas still more imperfect.
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TUBERCULOSIS OF THE PERITONEUM 723
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724 THE PERITONEUM
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TUBERCULOSIS OF THE PERITONEUM 725
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726 THE PERITONEUM
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TUBERCULOSIS OF THE PERITONEUM 727
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728 THE PERITONEUM
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TUBERCULOSIS OF THE PERITONEUM 729
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730 THE TERITONEUM
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la peritonite tuberculeuse. Arch, de med. exper. et d 'anat. path., 1894, vi,
649.
STEiNRui'CKE : f'ber idiopathisclie chronische Peritonitis, Diss. Tiibingen, 1876.
Stitzer and Rochs : Ein seltener Fall von allgemeiner chronischer Peritonitis
mit Prolapsus des Nabels, Berl. klin. Wchnschr., 1870, xiii, 295.
Stone: Tulierculous Peritonitis, Boston, Med. and Surg. Jour., 1908, clviii, 705.
Tuberculous Peritonitis, ibid., 1910, clxii, 813.
Straus and Gamaleiam: Recherches experimentales sur la tuberculose ; la tuber-
culose humaine; sa distinction de la tuberculose des oiseaux. Arch, de mod.,
exper. et d'anat. path., 1891, iii, 457.
Sutherland: The Prognosis of Tuberculous Peiitonitis in Children, Arch.
Pediat., 1903, xx, 8].
SymS: The Influence of Laparotomy upon Tuberculosis of the Peritoneum, New
York Med. Jour., 1891, liii, 141.
Thoenes: Zur Frage der operativen Behandlung der Bauchfelltuberkulose und
deren Dauerresultate, nebst 3 Fallen von Tuberculosis hemiosa, Deutsch.
Ztschr. f. Chir., 1903, Ixx, 505.
Thomas: Diss., Leyden, 1892.
TUBERCULOSIS OF THE PERITONEUM 731
Trabaud : Contribution a 1 'etude de la peritonite tuberculeuso chez 1 'adulte,
son etiolog^e ses terniiuaisons, These de Lyon, 1885.
Troja and Tangle: Aib. a. d. Geb. d. Path. Anat. Inst, zu Tiiliino-., liiOl-1902.
Trousseau: Lectures on Clinical Medicine, Trans., 4v., Philadelphia, Lindsay,
1867-71.
Tweedy: Female Sterility as a Sali.ent Feature of General Tuberculosis of the
Peritoneum, Jour. Obst. and Gynec. Brit. Emp., 1912, xxii, 342.
Ufpeniieimer: Echte })riniare Perlsueht des Bauchfells beim Kind©, Miinchen
med. Wchnschr., 190.3, lii, 1397.
Vallin: De 1 'intlammation periombilicale dans la tubereulisation du peiitoine,
Arch. gen. de med., 18G9, i, 558.
Varnek: Zur Frage von der Heilwirkuug der Laparotomie Ijei Peritonealtul)er-
kulose, Zentralbl f. Gyniik., 1893, xvii, 1159.
Veit: tJber Tuberkulose der weiblichen Sexualorgane und des Peritoueunv,
Monatschr. f. Gelnirtsh. u. Gynak., 1902, xvi, 525.
Vierordt: Die einfache chronische Exudation-Peritonitis, Tiibingcn, 1884.
Ueber die Tuberkulose der serosen Haute, Ztschr. f. klin. Med., 1887, xiii, 174:.
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Deutsches Arch. f. klin. Med., 1889-90, xlvi, 369.
Weitere Beitriige zur Kenntnis der elironischen, insbesonderc tulierkulosen
Peritonitis, ibid., 1893, lii, 144.
ViLLEMiN: De la propagation de la phthisic, France mod., 1869, xvi, 233; 244;
OK-i . 900 . 900
Etudes sur la tuberculose, Paris, Bailliere, 1868, p. 152.
ViRCHOW: Krankhafte Geschmilste, ii, 1863.
VoiGT: Zur Kasuistik der Bauchfelltubereulose, Diss., .Jena, 1896.
Wagner: Deutsch. Ztschr. f. klin. Med., 1883.
Weigert: Die Wege des Tuljerkelglftes zu den soroson HJiuten, Deutsch. med.
Wchnschr., 1883, ix, 471.
Wiener: Ileocecal Tuberculosis, Ann. Surg., 1914, lix, 69S.
Wright [et al] : Studies in Connexion with Therapeutic Inununisation, Lancet,
1907, ii, 1217.
Wilcox : Inunction of lodof oini in Tulicrculous Peritonitis, Med. Rec, 1908,
Ixxiii, 735.
WiLLL\MS: Tulierculosis of the Female Generative Organs, Johns Hopkins Hosp.
Rep., 1894, iii, 86.
Winter: Laparotomian aAiilla parannettu peritonitis tubereulosatapaus, Duo-
decim, Helsinki, 1897, xiii, 227.
Wyssokowicz: I'ber den Eiutluss der Inantitat der verimpfeen, Tuberkolbazillen
auf den verlauf der Tuberkulose, Verhandl. Internal, med. Kong., 1870, ii,
128.
Zieiil: tJber die BiWung von Darmfisteln aji der vorderen Bauchwand in Folge
von Peritonites tuberculosa. Diss., Heidelbeig, 1881.
Pseiidotiil)crculosis
Bauer: Krankheilen des Peritoi'.aeums, In Ziemssen 's Handl). der specielleii
Pathologic u. Therapie, Leipz., Vogel, 1874, viii, 315.
BORCHGREVINK : Klinische und exporimentelle Beitriige zur Lehre von der Baucli-
fell tuberkulose, E'iblioth. med., 1901, Abth. E, 1.
Cabot: Obliterative Pericarditis ns a Cause of Hepatic EnlargeuuMit and As-
cites: Boston M(m1. and Sury. .lour., 1898, cxxxviii, 463.
Cantu: (Cited by Hager.)
732 THE PERITONEUM
Coopek: Foreign Body Pseiulo-Tulieiculosis of the Peritoneum, Am. Surg. 1906,
xliii, 369.
V. Criegern: Ueber Polyserositis chronica, Miinchen. med. Wchnschr., 1910, Ivii,
1038.
CURSCiiMANN : Zur diiferential Diagiiostik der mit Ascites verbundenen Erkrank-
ugen der Leber und der Pfortadersystems, Ueutseh. med. Wchnschr.,
1884, X, 564.
Delpeucii: Des peritonites chroniques dites simples, Arch. gen. de med., 1884,
78.
Deve: Des cholerragies internes consecutives a la rupture des Kystes hydatiques
du foie et plus specialement de la cholerragie intrax)eritoneale,
(Choleperitoine hydatique), Rev. de Cliir., 1902, xxvi, 67.
Du Oazal: Peritonite tuberculeuse traitee par les injections de naphthol
camphre. Bull, ct mem. Soc. med. d hop. de Paris, 1897, 3 S., xiv, 702.
Esau: Ueber Polyserositis, Deutsch. Ztschr. f. Chir., 1913, exxiii, 155.
Flexner: Pseiulo-tuberculosis hoiuinis streptotricha. Bull. Johns Hopkins Hosp.,
1897, \T.ii, 128.
Frankel: Ueber idiopathi^clie, acut und chronisch verlaufende Peritonitis,
Charite-Ann., 1887, xii, 154.
Gangitano : Peritonitis und Phlebosclerosis abdominalis mit Endotheliosis des-
quamativa traumatischen Urspnmgs, Deutsch. Ztschr. f. Chir., 1910, cvl,
242.
Gazetti: Sulla cosi detta forma di fegato eaudito di Curschmann, Policlin., Eoma,
1909, xvi, sez. mod., 381.
Hagelstam : Om den subakuta oeh kroniska serosa peritoniten, Kinska
Lakaresallskapets Handlinger, 1896, xxxviii, 413.
Hager: Uber Polyserositis Festschr. z. Feier d. 50 Bestch. d. med. Gesellsch. zu.
Maddeb., 1898, p. 39.
Heidemann : tiber die Folgezustande von pericardialen Obliteration, Berl. klin.
Wchnschr., 1897, xxxiv, 92; 119.
Helbing: Pseuilotuberculose des Bauchfels durch Taenieneier, Berl. klin.
Wchnschr., 1899, xxxvi, 714.
Henoch: Ueber Peritonitis chronica, Berl. klin. Wchnschr., 1874, xi, 109.
Herrick: Pericarditic Pseudocirrhosis of tlie liver, Tr. Chicago Path. Soc, 1902,
V, 71.
Heubner: Ein Fall vo)i Meseuterialdriiseuveikasung mit chronischcr adhasiver
nicht tulx>rkuloser Peritonitis, vom Beginii der Erkrankung an beobachtet,
mit 2 jahrigem verlauf, Jahrb. f. Kinderh., 1880, n. F., xv, 465.
Hubler: Ein Fall von chronisclier Perioliepatitis hyperplactica Berl. klin.
Wchnschr., 1897, xxiv, 1118.
Huguenin : Etude anatomique des inflammations chroniques des sereuses et de
leur cffet sur les organes qu 'elles recouvrent, Geneve, 1903.
Kelly: On Multiple Serositis, Am. Jour. Med. Sc, 1903, cxxv, 116.
Krompegher : Zur Anatomie, Histologie und Pathogenese der gastrisehen und
gastrointestinalen Sklerostenose, Beitr. z. Path. anat. u. Allg. Path., 1910,
xlix, 384.
Meyer: Ueber einen Fall von Fremtdkor-peritonitis mit Bildung riesenzcUen-
haltiger, Knotclien durcli Einkapselung von Cholesterintafeln mit Bemerk-
ungen iiber die verschiedenen Riesenzellenarten, Beitr. z. path. Anat. u.
z. allg. Path., 1893, xiii, 76.
OSLER: Chronic Periphepatitis and ]\Iediastinopericarditis, Arch. Pediat., 1896,
xiii, 3.
Porter: Treatment of Tubercular Peritonitis, Jour. Am. Med. Assn., 1902, xxxix,
601.
Prochoaynick : Zur Frage des Bauchschnittes Ijci Peritonitis Chronica, Deutsch.
med. Wchnschr., 1889, xv, 475.
TTTBERCT'LOSIS OF THE PERITONEUM 733
Quincke: ttber Asc-ites, Deutsc-li, Ai(^'li. f. klia. nied., 1881-2, xxx, 569.
RiEDEL: Eiii Fall von chroiiisehev kli(>])Mtliischer exsudativer Pevitoiiitis, Miiiiehrn.
med. Welmpclu-., 18912, xxxix, 798.
Spaeth: Zuv eliiriirg-ischen Biehandlung der I5auelifelltul>erculose, Deutscli. nicd.
Wclmschr., 1889, xv, 395.
Steinbruck: Ueber idioiiatiiische clnoiiii^ehe Peiitoiiitis, Diss., Tubingen, Fiies,
1876.
Stitzer and Rochs: Ein seltenev Fall von allgeraeiner cluonischor Peritonitis
niit Prolapsus des Naliels, Berl. klin. Wclinschr., 1876, xiii, 295.
ViERORDT: Die einfat-lie chron. Exudation-Peritonitis, Tiibingeu, 1884.
Weiss: uber die Verwaelisuno- dor Herzens kit dem Ilerzbeutel, Med. Jahrljiiclier
(Wien), 1876, 1.
White: The Cause and Prognosis in Ascites, Guy's Hosp. Rep., 1893, xlix, 1.
WiNGE: Peritonitis bcliandlet med. Piu-acentese, Norsk. Mag. f. Lsegevidensk.,
1871, i, 211.
CHAPTER XXVII
THROMBOSIS AND EMBOLISM OF THE MESENTERIC
VESSELS
Under this caption may be classified those abdominal disturb-
ances which result from a primary occlusion of a mesenteric ves-
sel, either from local disturbance (thrombosis) or by a foreign
body transported from a distance (embolism). The essential
feature of this disease is a necrosis of the gut wall secondary to
occlusion of the mesenteric vessels. There has been a tendency,
particularly by American writers, to include those conditions in
which the mesenteric vessels become occluded secondary to some
disease of the gut itself. The extent to which this confusion may
lead can be appreciated when it is remembered that in most in-
stances when there is necrosis of the gut Avail there is some throm-
bosis of the vessels of the mesentery. Thus in the majority of
necrotic appendices the vessels in the mesentery will be found
thrombosed, if careful microscopic examination is made. Though
the gangrene may be the result of the occlusion of the vessel, the
vessel occlusion is the result of an inflammation of the appendix.
This condition is one of the rarer accidents of the abdomen.
Because of a failure to separate the various types above noted, it
is impossible to determine how many cases have been reportecL
Jackson, Porter and Quimby were able to collect 214 cases in 1904.
Etiology. — The causes which may lead to the closure of the
vessels differ in the arteries and veins. Emboli affecting the ar-
teries arise chiefly from endocarditis. This type is seen chiefly
in young persons with primary endocarditis, or in older persons
who develop clots after a period of incompensated myocardial dis-
ease, as in cases reported by Kiliani in which clots had formed on
the chorda tendinea, and Butlin in which a particle from a growth,
evidently an old clot, had occluded the vessel. Thromboses are
most often dependent on arteriosclerosis either as a part of a
general process or a localized process due to a change in the
734
THROMBOSIS AND EMBOLISM 735
mesenteric vessels alone. These atheromatous deposits not alone
destroy the elasticity of the vessels, but also narrow their lumen
and roughen their intima. In some instances an atheromatous deposit
may in itself be so great as to close the lumen of the vessel. Lorenz
reports a case in -which the finer branches of the superior mesenteric
artery were obliterated by intimal proliferation, the end result of a
multiple neuritis. When the obliteration from the endarteritis is not
complete spasmodic contracture of the vessel wall is thought by
some to be capable of completing the closure of the lumen.
In some cases a previous disease of the gut has existed. Gordon
and Elliot reported a case in which a hernia had been strangulated
some time previously. Hoster had a patient who had suffered from
diarrhea previous to the thrombosis.
Another group of cases followed operations involving large veins.
Delatour had a thrombosis of the superior mesenteric vein follow-
ing splenectomy, and Kiister a like accident folloAving pyloric
resection.
Still others have followed unrelated diseases. McWeeney saw a
patient in Avhom an abscess in the neck, followed by erysipelas,
preceded the mesenteric thrombosis.
Enteritis, surgical infections, puerperal thrombosis of the pam-
piniform plexus, milk leg, phlebitis of the legs following typhoid
fever and malaria have been noted as causes. Trauma, necessitat-
ing ligation of vessels, has been responsible and accidental ligation
during surgical operations has brought about the conditions.
Pathogenesis. — Notwithstanding the rich blood supply of the in-
testine the occlusion of a vessel acts like the occlusion of an end
artery. Many experiments have been made to determine the reason
for this. The very complexity of the anastomosis seems in part to
be responsible for the occurrence of blood stasis. Welch and Mall
showed that the blood producing the infarction reaches the af-
flicted area by Avay of the anastomosing arteries and that the
hemorrhage is the direct result of retardation of the blood floAV.
The ischemia they showed is due in part to spasmodic contrac-
tion of the muscle Avail of the gut. ]\Iall found that a gut 25 cm.
long Avhen quiescent shortens to 15 cm. during contraction and at
the same time becomes ischemic. Mall has also shoAvn that AA'here
the veins pass from the submucosa they have muscle Avails so thick
736
THE PERITONEUM
that they resemble the arteries. These likely contract when the
wall of the gut contracts.
I have sought to study this problem by injecting the mesenteric
«iihr4H««0>l
Fig. 211. — A gut, the vessels of which have been previously injected with a solution of sil-
ver nitrate, is treaded on a test tube and covered with another to facilitate the study of the
termination of the vessels. By revolving this under the objective of a binocular microscope
the vessels can be accurately followed.
THROMBOSIS AND EMBOLISM 737
artery Avith a solution of silver nitrate. By threading a segment
of gut over a test tube and covering it Avith a second tube, a cir-
cular slide is secured, (Fig. 211), the space between the Avails of the
tAvo tubes being tilled Avith glycerine. By placing a small electric
bulb Avithin the inner tube one can folloAv the vessels about the
circumference of the gut. From these studies it seems to me that
the chief factor is the failure of a collateral circulation to form,
in that the supplying vessels are too small to supply the needed
blood, just as if all the AA^ater for the inhabitants of a block had
to come from a single inch pipe. If each pipe Avere supplied from
a large main the supply Avould be adequate. The vessels are end
arteries in the sense that they anastomose AAdth their felloAvs coming
around the gut from the opposite side. Deckart and Neutra haA^e
studied the cause of the absence of a collateral circulation. Cohn-
heim explained the absence of a collateral circulation because of a
coincident closure of the anastomosing A^essels. In a case described
by Ponfick an actual occlusion of the smaller branches Avas demon-
strated. Litten's experiments seemed to demonstrate that the ves-
sels normally function as end arteries because a collateral circu-
lation could be produced only by a higher pressure than occurs
normally. Faber believed it Avas due to back pressure from the
portal circulation. It Avould seem that the constriction of the gut
by increasing the capillary resistance adds much toAvard making
the formation of a collateral circulation more difficult. Rosenbach
emphasizes the importance of this point.
That a collateral circulation to a degree is possible is shoAA^n by a
case reported by Karcher. A case in Avhich the superior mesenteric
artery Avas plugged did not proceed to gangrene. He assumed that
the area Avas supplied by the colica sinistra. In a case reported
by Chiene both mesenteric arteries Avere occluded and the circula-
tion Avas carried on by the superior hemorrhoidal and the colica
sinistra and dextra. Cohn describes a case in Avhich an area of
the transverse colon had been affected and Avas cured by the es-
tablishment of a collateral circulation. VirchoAV describes a case
in AA'hich the collateral circulation Avas established by branches of
the pancreaticoduodenalis and inferior mesenteric arteries. Kauf-
mann describes a case in Avhich there Avas a partly formed collateral
circulation. The ileocolic artery Avas occluded but the part of the
738 THE PERITONEUM
colon supplied by it Avas unaffected (because the colon is less capa-
ble than the small intestine of contracting spasmodically). Kobson
reports that in a case of injury by puncture, the abdomen Avas
opened and was found filled with Ijlood. The superior mesenteric
vein Avas found injured and Avas tied. RecoA^ery folloAA-ed. The
colon in general is less susceptible than the small intestine to
changes in the circulation. My notion of the reason for this is that
the colon is less capable of constricting its A'essels by A^iolent mus-
cular contraction. Roughton reported a case in AA'hich the arteria
intestini attenuis Avas ruptured close to its origin from the mesen-
teric A'essel and AA'as ligated. RecoA^ery folloAA'ed.
Pathology. — Broadly speaking thrombotic and embolic processes
in the mesentery may be diAnded into hemorrhagic infarction and
anemic necrosis. This scheme helps to a better understanding in
many cases both of the anatomic findings and the clinical manifes-
tations. In a fcAv cases pure forms are actually found in practice.
Kadei' in his experiments shoAved that Avhen the artery and A^ein
AA-ere compressed but not completely occluded hemorrhagic in-
farction took place, but Avhen complete occlusion Avas made anemic
necrosis folloAA'cd. This is quite in accord AA-ith the laAA's of the
occlusion of A'essels. Talke objects to the aboA-e theory on the basis
of a case in AAiiich AA'ith simultaneous closure of the artery and A-ein
hemorrhagic infarction took place. Similar cases Avere reported by
Taylor and Groskurth, Avliile in a case reported by C4raAvitz there
Avas an anemic necrosis though the artery alone Avas occluded.
The mesenteric A'essels do not make up the entire picture. If there
is an occlusion of the anastomosing plexus about the gut the fact
that there are not open A-essels aboA'e does not cause a hemorrhagic
infarction. Also a hemni'rhagic infarction, if the process is s1oaa%
may, after coagulation has taken place about the perii^hery, be-
come an anemic necrosis after the hemoglobin has disappeared. In
the localized forms, resulting from a local infectiA^e process, the
area of infarction does not become hemorrhagic because of the
filDrin throAvn out by the primary inflammation. An exudation on
the free surface of the peritoneum is produced by the same process
that brings about the edema of the gut Avall. The tissues even when
blue-black retain their tinctorial reactions notAvithstanding that
the functional activity of the gut is destroyed. The toxicity of the
THROMBOSIS AND EMBOLISM 739
fluid exudate seems in no wise to influence the tinctorial properties
of the tissues. The gut Avail may form adhesions to the parietal
peritoneum as a case reported by Watson showed. The process
here is like that commonly observed in various cysts Avith twisted
pedicles.
The end result of the occlusion is a necrobiosis of the gut Avail.
There is marked exudation into the Avails of the gut primarily of
serum, secondarily of ])lood cells. The process is really an ec-
chymosis as may sometimes be seen Avith the naked eye. The gut
Avail may be much thickened. A like process is seen in miniature
in necrosis of the appendix Avhen there is a thrombosis of the ap-
pendicular artery. When gangrene folloAvs an area of the Avail
separates and a perforation results. This requires from seven to
ten days.
Symptoms. — Pain. — Pain is the most common symptom. It is
usually sudden in onset, diffuse in distribution, constant and dull
in character Avith scA^ere colicky exacerbations. In some cases the
pain is sIoav in onset, due possibly to gradual closure of the lumen
of the vessel. This is not ahvays an adequate explanation, hoAvever,
for in a case reported by Litten in Avhich the pain Avas gradual in
onset but Avhich gave evidence postmortem of liaAdng become com-
pletely closed some days prcAdously. The pain is due to violent
colicky contractions. Borszekey and Kader think it is similar to
intestinal claudication. Later in the disease peritoneal irritation
comes in evidence. This course is particularly in evidence in those
cases in Avhich but a small segment of gut is invoh'ed. In such
cases after the diffuse generalized pains subside, local symptoms
dominate the field. In one case I observed after four days the
pains became localized in the right iliac fossa. Several loops of the
blackened gut, adherent to each other, occupied this region. The
parietal peritoneum covering this site Avas intensely infected.
Nausea and Vomiting. — These symptoms are present as frequently
as in other acute abdominal crises and bear nothing distinctive, ex-
cept that later in the disease the vomited matter may be blood
stained.
Diarrhea. — Diarrhea is the most distinctiAX sign and is present in
the majority of cases. It is particularly significant Avhen blood
stained, as it frequently is. Diarrhea may precede the pain by
some days as is shown by a case reported by Bradford. Jackson's
740 THE PERITONEUM
statistics show the presence of blood in the primary diarrhea in
19 per cent of the cases and at some time in the course of the dis-
ease in 41 per cent. Bloody stools are regarded as the most sig-
nificant sign.
Tenderness. — Tenderness is usually present to some degree. It
is usually generalized but later in the course of the disease when a
limited segment of the gut is involved may become localized.
Distention. — Distention is usually present to some degree. Evi-
dently the infiltration of the walls of the gut present the extreme
distention seen in general peritonitis.
Peritoneal Exndate. — In harmony with the pathology of the dis-
ease the escape of a moderate amount of bloody serum greets the
surgeon when the peritoneum is opened. The appearance of this
fluid indicates the character of the lesion.
General Symptoms. — Some cases show marked increase of the
leucocyte count. In some cases there was sugar in the urine. Tem-
perature is usually below normal but sometimes it is elevated, par-
ticularly Avhen there are complications, as endocarditis, peritonitis
or toxic absorption. Puerperic spots have been noted by Talke and
Osier.
Diagnosis. — Sudden abdominal pain, particularly in persons Avith
cardiac disease should suggest the pos-^ibility of mesenteric throm-
bosis. If a bloody diarrhea supervenes the diagnosis becomes a prob-
ability. Usually the diagnosis has been made after the abdomen
is opened. The escape of blood-tinged serum indicates the nature
of the trouble, and the surgeon has but to seek its source. Tis-
sues giving rise to such fluid have a peculiar odor, as is most often
observed in ovarian cysts Avith twisted pedicles. The blue-black
gut tells the tale once it is brought into vicAV.
Treatment. — Because of the extent of gut invoh^ed, treatment has
rarely been successful. The affected portion of the gut, if it is
not too extensive, may be draAvn out of the abdomen and an open-
ing made. The affected segment has been removed Avith success in
several cases.
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THROMBOSIS AND EMBOLISM 741
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XV, 145.
LOKENZ: Beitrag zur Kenntnis der multii)len. degenerativcn Neuritis, Ztschr.
f. klin. Med., 1890-91, xviii, 497.
]\[at,l: a Studv of the Intestinal Contraction, Johns Hopkins ITos])ital Rept.,
1896, i, 37.
McWeeney: a Case of TIinniilKisis of tlie Superior Mesenteric Vein, Lancet,
London, 1893, 1576.
Neutra: Ueber die Erkrankungen der Mesenterialgef Jisse und ilire Bedeutung
fiir die Chirurgie, Central!)!, f. d. Grenzge!*. d. Med. u. C!iir., 1902, v, 705,
737, 785, 830, 865.
PoxFiCK : Zur Casnistik der Em!)nlie der A. mesenterica su]icrior, Vircliows
Arch. f. path. Anat., 1870, 1. 623.
Robson: a Case of Perforating Wound of t!ie Abdomen, Brit. Med. Jour., 1897,
ii, 777.
742 THE PERITONEUM
EoSEXBACii : Zur S-s-mptomatologie unci Thorapie der Damiinsufficienz, Berl. klin.
Welmschr., 1889, xxvi, 269, 299.
Roughton: a Case of Ruptured Mesenteric Artery; Laparotomy; Recovery,
Lancet, London, 1899, i, 89.
Sprengel: Zur Patliologie der Cireiilationsstorungen im Gebiet der Meseuterial-
gefasse, Verhandl. der deutsch. Gesellseh. f. Chir., 1902, xxxi, 55.
Talke: Ueber Embolic und Thrombose der Mesenterialgef asse ; Yorkommen imd
diagnostisclie Bedeutung der Purpura haemorrhagica bei Embolic der Art.
mesenteriea, Beitr. z. klin. Chir., 190.3, xxxviii, 743.
Taylor: 01)struetion of the Mesenteric Artery and Vein, Followed by Intestinal
and Peritoneal HEemorrhage, with Rapidly Fatal Termination, Tr. Path.
Soc, London, 1881, xxxii, 61.
ViRCHOW: Yerstopfung der Gerkrosarterie durcli eiuen eingewanderten Propf.,
Yerhandl. d. phys.-med. Gesselseh. in Wiirzliurg, 1854, iv, 341.
Watsox: The Diagnosis and Surgical Treatment of Cases of Embolism and
Thrombosis of the Mesenteric Blood Ycssels, with Reports of Cases. Boston
Med. and Surg. Jour., 1894, cxxxi, 552.
Welch and Flexner: Obsei-^-ations Concerning the Bacillus Aerogenes Capsula-
tus, Jour. Exper. Med., 1896, i, 5.
Welch: Thrombosis and Embolism, In: Allljutt's System of Medicine, 1899, vii,
p. 155.
Welch and Mall: AUbutt's System, vi, 228.
CHAPTER XXVIII
DISEASES AND INJURIES OF THE GREAT OIVIENTUM
Inflammatory Tumors of the Omentum
Definition. — Under this heading are included those conditions of
chronic induration of a part of the omentum in which a tumor-like
mass is formed by cellular and fibrinoid infiltration of the tissues.
It has analogues in other regions of the body, notably in chronic
salpingitis, in the woody phlegmons of the neck, etc. In appearance
it represents a border line betAveen reactive processes and malig-
nant tumors. It is due to a peculiar low grade of infection and is
characterized by a fibrinoid degeneration of the connective tissues
and an infiltration of polynuclear and mononuclear cells. Hol-
lander suggested the descriptive name of epiploitis plastica.
The literature deals largely with those cases which follow re-
section of the omentum, particularly following hernia operations,
and no doubt the most typical eases have followed such operations.
Not infrequently, however, the omentum becomes inflamed because
of torsion or from strangulation in an irreducible hernia. When
the reaction is great pronounced disturbances result. Lesser degrees
most likely occur which are never recognized. In many cases in
which the patient does not recover normally after an operation in-
volving ligation of the great omentum, if careful search is made
some degree of this condition may be discovered. When the
omentum becomes attached to a variety of inflamed lesions it may
undergo similar but much less marked changes. This is not likely
to occur in low grades of infections of the appendix and cecum,
gall bladder, and Fallopian tubes. This condition must be dis-
tinguished from the usual thickening of the omentum common to
all infections.
History. — The literature bearing on this subject is all of rela-
tively recent date. Braun was the first to call specific attention to
this condition. He discusses his own cases and revieAvs thirty cases
743
744 THE PERITONEUM
from the literature. Zesas and Hollander bring the literature to
near the present date.
Pathogenesis. — The exciting factor is nearly always situated in
some neighboring organ, notably appendicitis, salpingitis, strangu-
lated hernias, and particularly following operations for hernia in
those cases in which portions of the great omentum were ligated
with silk. The essential factor is chronicit3^ Usually some time
after the infection the omentum begins to enlarge. This enlarge-
ment continues for a period usually from three to six months, then
regression begins. Roughly speaking, about nine months are re-
quired for the completion of the cycle. One case has been reported
(Boeckel) in which the induration did not begin until three years
after the operation that occasioned its development. On the other
hand, an acute development may take place, simulating a general
peritonitis, as in a case reported by Pantzer. When the onset is
acute there is normally an attendant venous thrombosis due to
trauma or torsion. There seems to be no specific organism. A
coccus is usually recovered. It is probable that the virulence
rather than the variety of the organism is the determining factor.
Two avenues of infection are possible: From direct contact
with an inflamed organ and by infection carried from a distance,
as Walther suggests. Prutz and Monnier doubt the existence of
the latter type. There is no case recorded that would require such
an explanation. It seems more plausible that bacteria free in the
peritoneal fluid may be taken up by the omentum or that owing to
some disaster, as torsion, a jjrimary affection of the organ in question
is produced because of the nutritive disturl^ance.
That form which follows operation usually follows some fault
of technic if the parts were healthy at the time of operation. An
astonishingly large number have followed the use of silk in the
ligation of the omentum. In these cases it is to be presumed that
the infection was carried with the silk.
The question as to Avhether the condition can arise witliout in-
fection is answered in the affirmative by Lucas-Championniere.
This vicAv seems tenable. Simon reports a condition arising
slowly during a hernia without evident infection. A hemorrhagic
exudate due to toxic or mechanical causes under certain conditions
seems capable of producing it. This condition may be produced by
DISEASES AND INJURIES OF THE GREAT OMENTUM 745
torsion m hen the torsion is not great enough to produce a gangrene.
I have been able to produce a very good imitation o£ this condi-
tion by placing within the folds of the great omentum a pledget of
cotton soaked in a culture of pus organisms, or in blood that had
been heated to 60°.
A condition very much like the one under discussion sometimes
occurs in the abdominal wall, particularly in the region of the in-
guinal canal, following an operation for hernia, and in the gut wall
in certain chronic conditions, as chronic appendicitis, or chole-
cystitis.
Pathology. — The essential factor is chronicity. The cellular
element is made up largely of polynuclear leucocytes in the more
acute cases, while in the more chronic forms there may be very few
polynuclears, and large round cells Avith ovoid vesicular nuclei
abound. The tumor mass may be made up largely of cells or the
bulk of it may consist of edematous fibrinous tissue. In either in-
stance the connective tissue loses its specific reaction to acid dyes
and approaches the fibrin reaction, staining a brownish yellow
with picrofuchsin. Within the meshes of this connective tissue may
be a granular fibrin and often red cells in a fair degree of preser-
vation. In the more cellular variety the groundwork is made up
of connective tissue of this kind and in its meshes cells of the varie-
ties above named find lodgment.
Variations from this type may occur in the direction of destruc-
tion of tissue, even to actual abscess formation, or on the contrary
an attempt at organization, characterized by the presence of spindle-
form cells simulating young connective tissue cells may l)e present.
These various conditions represent the different degrees of activity
of the irritative process. It seems likely that this condition repre-
sents a chemical rather than a bacterial process, being due to a
fermentative process. In some cases apparently there is an infec-
tion. This is particularly true in those arising from an acutely in-
flamed organ. In thrombosis following ligation the whole process
may run its course Avithout the intervention of bacteria.
Symptoms. — The onset may be relatively acute for a condition
destined to such a chronic course. Diarrhea, pain, and fever may be
present in the beginning. On the other hand general malaise may
be the only symptom until tlic tnnior is discovered. It is us-
746 THE PERITONEUM
ually more or less globular. The most common site is between
the umbilicus and the pubes, although sometimes, as in Hollander's
case, the tumor may be in the right groin. They vary in size from
a fist to an adult head. I once saw a case that filled the entire
abdomen below the umbilicus. The omentum formed a mass 10 cm.
thick and 25 cm. in diameter.
When a considerable portion of the omentum has been removed,
the tumor may be situated near the transverse colon. I observed
such a location where half the omentum had been removed with a
myoma to which it was adherent. On the other hand, the tumor may
be located low in the abdomen. In omenta little or none at all
of which has been resected, particularly those that have dwelt in
hernial sacs, the tumor is apt to be low in the tlank, even in the
pelvis.
The mobility varies within wide limits. Usually it is fixed in
position, often near the line of incision, if an operation has pre-
ceded the development of the tumor.
The density of these masses is usually marked, being in most in-
stances dense and elastic, and in some cases quite ec^ual to the den-
sity of carcinomata. Generally speaking the mass is uniform and
is free from the small bosselations which characterize carcinomata.
Diagnosis. — The presence of a tumor in the region of an opera-
tion which involved the great omentum may lead one to suspect
the presence of such a condition. The probability is heightened if
there are indefinite digestive symptoms, slight pain, a little fever,
and a moderate leucocytosis. In rare instances the leucocytosis
may be high. One of my eases had a white count of tAventy-five
thousand, 90 per cent of which were polynuclears. The difficulty
in some cases is in determining if the disturbance may not be due
to some other cause. The case just quoted followed resection of
the omentum with hysterectomy for myoma. There may have been
some trouble with the wound in the pelvis, though no disturbance
could be demonstrated. That it was due to the omental tumor is
rendered likely because the height of the disturbance was not
reached for six weeks following the operation. When the mass
is large enough to press on a segment of gut, symptoms of obstruc-
tion may appear. More pronounced disturbances may take place,
even to complete obstruction when the mass surrounds the gut.
DISEASES AND INJURIES OF THE GREAT OMENTUM 747
Enterostomy Avas required in Schmieden's case and in one of my
own cases. Colicky pains and vomiting do not always mean ob-
struction, however. Becker proved in his case by a bismuth meal
that no obstruction existed. The type that develops independently
of a surgical operation is usually mistaken for a malignant tumor.
Because of the relatively rapid onset and size of the mass, sarcoma
is most often diagnosed, while if small and they cause some con-
striction of the gut, carcinoma is most apt to be diagnosticated, par-
ticularly if the mass is in the epigastric region. I have twice made
this error. Not infrequently an exploratory operation is done and
the abdomen is closed and the patient recovers despite the grave
prognosis. If after exploratory operation a malignant condition
is diagnosticated which later recovers, this type of trouble most
likely was present. As a general rule if, when the abdomen is
opened, the mass is found adherent to the abdominal wall, it is
inflammatory and not neoplastic in character. If doubt exists and
the tumor is cut into, it M'ill be found to be pale pink in color and
exudes tluid. In some cases the final outcome must decide the
character of the tumor.
A microscopic differentiation may be possible. When a pre-
ponderance of polymorphic leucocytes is present a reactive proc-
ess may be diagnosticated without question. If the large mononu-
clears alone are present the resemblance to a sarcoma is sometimes
very close indeed. When the process involves a gut wall the dif-
ferentiation from sarcoma may sometimes be particularly difficult.
It seems more than likely that in some instances the process may
begin as a reactive one and end as a neoplastic one. When the proc-
ess takes place in the abdominal wall the resemblance to a desmoid
may be very close in the more chronic types. The presence of any
polynuclears at all speaks against desmoids. In fact it is likely that
the desmoids represent the end product of just such an inflamma-
tion. In all instances the clinical history must be taken into ac-
count.
Treatment. — ^Reynier advised the removal of the mass just as
though it were a malignant tumor. This is not such an innocent
procedure unless the mass is free from adhesions, except for its
omental attachments. Prutz had three deaths in 9 cases operated.
Braun removed a wedge of tissue to hasten regression. The gen-
748 THE PERITONEUM
eral tendency is one of regression, thongli many months may be
consumed in the process, and Enderlen is certainly right when he
advises a policy of waiting. This author advises the use of hot
air and wet packs. Simple incision into the tumor hastens resolu-
tion by alloAving serous drainage. Drainage of pus usually fol-
lows such a procedure and it is not certain whether it is caused by
bacteria existent within the tumor or introduced from without after
the incision has been made. Apparently bacteria Avithin the tissue,
securing more favorable conditions for development, set up the
suppurative process. This seems likely because in a goodly numl)er
of recorded cases in which incision had been made the extrusion
of silk ligatures followed.
Not infrequently suppuration takes place without incision, even
many months after the beginning of the disease, demanding in-
cision. Such cases may be detected because of the greater pain
and tenderness with the increase in leucocytosis which attends
them. The area breaking down is usually too deeply seated to ad-
mit the detection of fluctuation. Because some of them break down
Prutz recommends that all cases be treated as intraabdominal ab-
scesses. Abscesses must be found before they can l^e opened, how-
ever, and usually the foci of liquefaction ai-e small and numerous,
as in some lung infections, and the general area of maximum in-
volvement only can be drained. In large masses the site of the
trouble may not be located with certainty. In such instances the
center of the area may be boldly sought provided this does not lead
in the direction of a hollow viscus. Failure to recognize this cau-
tion cost Schmieden a gut fistula. This plan is too radical as a
general principle, for most of the m,asses resolve if allowed suffi-
cient time, and active interference is advisable only Avhen there is
evidence of suppuration.
Sometimes the fecal circulation may be interfered Avith, par-
ticularly in the transverse colon, and operatiA^e interference may
be demanded on that account. Partial removal of the mass may
meet this indication as recorded by Monad. Interference Avith the
fecal current is less likely to occur Avhen the omental hyperplasia
is primary than Avhen the infection reaches it A'ia a holloAV organ,
particularly the appendix. In some cases enterostomy^ or anastomo-
sis betAveen the obstructed loop and the colon may be required as
DISEASES AND INJURIES OF THE GREAT OMENTUM
749
in Schmieden's case. Such a procedure is better than to remove
the entire mass.
Defensive Reactions of the Omentum. — The general capacity of
the omentum to react to irritation has been considered in the chap-
ter on the formation of adhesions, and its specific action receives
Fig. 212. — Attachment of the oniciitum to a myoma that had sufTercd a disturbance of nutri-
tion. Note the pronounced dilatation of the veins.
mention in separate cha])tors in \\lii('li it performs its function.
Under this licndiug are ti:athered ;i iiuml)er of interesting condi-
tions Avhich do not lend themselves for a more specific discussion.
The Omentum as an Accessory Source of Nutrition. — AVhen an
750 THE PERITONEUM
organ l)econies distressed because of some accident to its blood
supplj' the omentum is able to attach itself and add to the sup-
ply, or what is equally as important, conduct away the stagnant
venous blood. This is best illustrated in those cases where a
pelvic tumor, because of some interference with its blood supply,
has its nutrition disturbed. Here the omentum often becomes at-
tached (Fig. 212) and aids in reestablishing an efficient circula-
tion. The great capacity of the omentum to render such aid has
been shown experimentally. If all the vessels of the spleen are
ligated the omentum may enveloiD and prevent gangrene.
This capacity of the omentum to aid venous return is made use
of in eases where the return circulation of the abdomen is hindered
by a cirrhotic liver. It was hoped that by attaching the omentum
to the abdominal wall a sufficient accessory circulation could be
established and thus circumvent the liver. The task is of course
too great, but it is paying a delicate compliment to a A^ery versatile
organ.
Fat Necrosis. — This condition represents chiefly a degeneration,
and only secondarily a necrosis. Whenever any lesion of the pan-
creas permits the escape of the fat-splitting ferments, areas of the
fat with which it comes in contact become necrotic. The omentum
being the organ most frequently attacked, it receives most attention.
The areas so affected appear as small mass areas of dull white set into
the surrounding omental fat. The line between the affected and non-
affected areas is very sharp. The necrotic areas vary in size from a
mere point to large patches (Fig. 213). On section these necrotic
areas show the fat cell to have undergone a granular degeneration
(Fig. 214). The nuclei as well as the protoplasm undergo this change.
After the condition exists for some days the unaffected area under-
goes a reactive round-celled infiltration.
t.
Torsion of the Great Omentum
Definition. — By this term we mean the rotation of the great
omentum on its longitudinal axis of sufficient degree to produce dis-
turbance of the circulation. Usually the entire omentum is in-
volved but a portion only may be affected. Occasionally instead of
twisting on its long axis some other axis is involved.
History. — Rudolf and Vignard and Giraudeau have presented
DISEASES AND INJURIES OF THE GREAT OMENTUM
751
Fig. 213. — Fat necrosis in the upper part of the omentum from a case of necrosis of the
pancreas. The white necrotic areas are set into the unchanged fat of the great omentum like
tiles in a floor.
* .-« ;.'
^^
%
'%}
--■^n-
Fig. 214. — Fat necrosis of the omentum in a case of acute pancreatitis. Note the opaque de-
generation of the fat cells. Some of these have moderate cellular infiltrations about them.
752 THE PERITONEUM
statistical papers. Hadcla collected 92 cases and v. Cackovie col-
lected 94 cases and added 4 ncAv ones. Prutz and Monnier bring the
total recorded cases to 134. The literature abounds in individual
case reports not included in this summary.
The possible types are manifold, as indicated by the classifica-
tion proposed by Prutz and Monnier. The practical requirements
are met by a more simple classification, however. The most fre-
quent A'ariety is that associated with a hernia, next in frequency
is the type in which the omentum lies free or at least Avholly Avithin
the abdominal cavity, and finally the small group Avhich is com-
plicated by the presence of some other disease either of the mem-
brane itself, such as a primary or metastatic tumor of the omentum
or the presence of some other disease to Avhich the omentum may
be attached, as an ovarian cyst.
Pathogenesis. — It is difficult to determine'in many instances Avhat
anatomic changes existed before torsion took place and what
changes followed the incarceration. That increases in bulk of the
omentum, particularly of an isolated segment of it, may act as a
predisposing factor may be assumed from the fact that other tumors
of like bulk undergo torsion. Torsion in a considerable proportion
of cases is found in corpulent persons Avhich in itself suggests a
primary bulky organ. An unduly fat omentum presents the same
mechanical problems that an ovarian cyst does. Gynecologists
have speculated much on the mechanics of torsion which is of in-
terest here, and avo are enabled to discourse learnedly at the ex-
pense of their labors. Aside from the bulk of the organ an uncommon
elongation of the organ or a segment of it has been observe ed. This
is true naturally of those cases in Avhich the omentum is found in a
hernial sac. It must have been unusually long originally or it could
not have become an inhabitant of a hernial sac extending into the
scrotum, but its sojourn in the sac no doubt tends to lengthen it still
more.
In order to determine the agent acti\'e in producing the rota-
tion the intraabdominal and the herniated A^arieties must be con-
sidered separately. The intraabdominal, as already indicated, may
be explained the same Avay as the torsion of oA^arian cysts. As the
body turns the upper border of the tumor tends to travel more rap-
idly than the loAver just as the upper segment of a AA'heel travels
DISEASES AND INJURIES OP THE GREAT OMENTUM 753
more rapidly than that segment m contact with the ground. The
action of the abdominal muscles and gravity both may act in ex-
aggerating the rapidity of the movement of the upper segment. The
action of the abdominal muscles may act directly on a segment of
the tumor, not only by increasing the intraabdominal pressure as
Hadda thought. The increase of intraabdominal pressure might
be a very potent force if it involved chiefly one portion of the ab-
domen, but if pressure is increased in all directions movement is
not imparted to the tumor. Bakes emphasized the influence of po-
sition on the movements of the omentum as observed during opera-
tions in the Trendelenburg position. As Prutz and Monnier point
out dislocation due to changes of position could explain rotations
to 180° only while the torsions as usually observed represent at
least 360°, sometimes much more, even to eight complete revolu-
tions. We might assume that torsion can be produced by succes-
sive turns of half a circle.
My own studies on the movements of the great omentum lead
me to believe that the omentum is not such a helpless structure as
might be supposed. Though immobile it does change its position;
of that there is no doubt. The cause of this movement will be more
fully gone into elsewhere. Here suffice it to say that when a for-
eign body causes a marked hyperemia with exudation in that por-
tion of the omentum in contact wilh the foreign body, cells are at-
tracted. There is a possibility that this attraction may carry with
it the web-like omentum. One might liken the omentum to a May
pole. The ribbons represent the tissues of the omentum and the
children the leucocytes. In their gyrations the children carry the
ribbons with them. I should not for a moment argue that the large
masses one sees after torsion has taken place are capable of move-
ment, but the omentum may roll about as one sees it do about a
pledget of gauze and subsequently acquire its bulk due to a disturb-
ance of the circulation consequent to the rotation. This would explain
those cases only in which there is torsion in a normally thin
omentum. Large fatty masses could hardly act so.
The most connnou varict\' of torsion is that affecting omenta tlie
inhabitants of hernial sacs. Steiner in 62 collected eases found only
7 not associated with hernia and Hedlev in 73 eases all but 13 were
754 THE PERITONEUM
associated with hernia. Three of my 4 cases were in association
with inguinal hernias.
The elongated omentum residing in the hernial sac becomes clubbed
and often there is a more or less sclerotic constriction of the
omentum near the inner abdominal ring. This may often be noted
in irreducible omental hernias without torsion. My first case sug-
gested to me that the curve of the inguinal canal carried the
clumped mass of the omentum like the 'Hands" of a riffle carry the
bullet. I once operated on a male aged 36 Avith a huge inguinal
hernia in which not only the omentum, but the cecum as well, which
also occupied the sac, had undergone torsion. Hadda has since
thought the same way. Quenue has called attention to the fact that in
proportion to the number of omental hernias, torsions are rarities.
Pressure of a truss or effort at reduction likewise fails to explain the
accident.
Pathology. — AYhen the torsion is complete gangrene of the parts
below the stricture must occur. HoAvever, obstruction usually is
not complete (Fig. 215) and the omentum obtains some nutriment
from the surfaces to Avhich it becomes attached. In this regard it
is exactly a parallel with the walls of ovarian cysts Avhich have be-
come tAvisted.
In the degree Avith Avhich reaction is possible cellular actiAdty
may be present. Usually many red cells have become extravasated
and but fcAV leucocytes are present Avhile the connective tissue loses
its specific staining reaction. When nutrition is reestablished
either through the natural channels or from secondary attachments
leucocytes and round cells may l)e present in abundance and the
connective tissue shoAv a fibrinoid rather than a narcotic change.
Symptoms. — There is usually a preexisting hernia, perhaps of
many years' duration. The actual torsion usually folloAvs some
violent effort or prolonged bodily actiAdty. Sometimes there are
slight attacks of pain. These may persist for some days or even
Aveeks. In a number of cases recorded lesser signs extended over a
period of many months. Then come the more pronounced symp-
toms of pain in the region of the torsioned omentum. Nauseas
and A^omiting and sometimes collapse folloAv. One of my patients
dropped in the road and lay Avrithing in pain until transported to
the hospital by passers-by. There may be radiating pains either to-
DISEASES AND INJURIES OF THE GREAT OMENTUM
755
Fig. 215. — ^Torsion of the great omentum. The ])ortion below the twist \va.s l)lack and dense
while that above was unchanged save for the marked dilatation of the veins.
756 THE PERITONEUM
ward tlie side or down the leg. If a hernia has been present it likely
becomes irreducible, much enlarged and invariably very sensitive
to manipulation. With this phenomenon prominently before him
the surgeon will hardly escape the diagnosis of a strangulated
hernia, if the onset is violeiit. or of irreducible hernia if the onset
is more gradual. I have made both errors. In my first case the
patient long carried a large irreducible left inguinal hernia. He
bore this affliction because of a chronic nephritis. He was suddenly
seized Mith a pain in the hernia after an unusual activity in in-
voicing a stock of clothing. He presented a large hernia which was
very tender to the touch and the skin over it was edematous. There
was an indurated mass extending upward and medially from the
inguinal region. This mass puzzled me but I did not grasp its sig-
nificance. The inguinal canal was laid bare under local anesthesia
and a black omental mass was disclosed. The hernia contained no
intestine. As the blackened mass was dislocated from the wound it
was found to extend upward into the abdomen and the ridge above
noted was found to be due to the black edematous omentum. Not
until this was ^Wthdrawn and a twisted area beloAV the transverse
colon was brought into view did the nature of the condition dawn
upon me. The torsion was from right to left and amounted to full
360 degrees. The mass was I'emoved just aboA^e the point of tor-
sion. The separation of the mass from the hernial sac caused pain
as did the traction necessary to bring the upper end of the mass
into view. The patient showed distinct exhaustion and vomited
several times during the first day following operation, but recovery
was uneventful. My second error was made in the case of a right-
sided hernia in a man of seventy-six. He had had a hernia for fifty
years, but until recent years was retained by a truss. "When the
truss refused to retain the mass he discarded it and allowed the
hernial mass to come down at Avill. I examined him several times
and a reducible omental mass could easily be made out, but could
be reduced at will, and it returned spontaneously into the abdomen
at night. As he became more feeble the mass became larger and
refused to retract into its normal habitat as of yore when the patient
assumed the recumbent position. The mass became tender from
time to time but a period of recumbency usually restored him to rel-
ative comfort though the mass did not return into the abdomen.
DISEASES AND INJURIES OF THE GREAT OMENTUM 757
Without known cause the pain continued to increase and caused a
constant pain down the anterior crural nerve. The hernial mass
increased in diameter and became more tender and the patient
vomited. There was an indefinite induration extending upward in
the direction of the deep epigastric vessels. Despite a similar ob-
servation in the case just mentioned the significance was not
grasped and a diagnosis of strangulated omental hernia was made.
Exposure of the inguinal canal showed a large club-shaped omental
mass which was blue-black in color. As it was drawTi downward a
twisted stalk Avas disclosed. Some of the gyrations seemed to be
old and were fixed by fibrous adhesions. In fact it seemed as
though all the turns antedated the onset of the acute symptoms.
It gave the impression as though the torsion had occurred without
producing marked symptoms and that it was only a later asso-
ciated thrombosis that caused disturbance sufficiently great to seri-
ously disturb the nutrition of the mass. The torsion in this case
was from left to right. The number of turns could not be definitely
made out.
The only sign of unusual character observed in these two cases
was the induration extending upward from the inguinal canal.
This might be of some service in diagnosis, but a like condition is
observed in mesenteric thrombosis without torsion.
I operated upon a colleague recently who had had an irreducible
inguinal hernia for many years. When the inguinal canal and
scrotum Avere opened a mass as large as a fist was dislocated from
its bed. At the lateral inguinal ring the omental stalk was less
than an inch in diameter. The vessels described a spiral about the
narrowed place. It was evident that they could have assumed this
position only by the twisting of the loAver extremity of the omental
mass. The clubbed portion occupying the scrotum Avas removed
only as a matter of mechanical convenience. This mass Avas firmly
adherent to the hernial sac beginning at the level of the pubic
spine and extending doAA^UAvard for 15 cm. Possibly the circula-
tion Avas disturbed at some time giving rise to these adhesions.
From these cases it seems there may not ahvays be a sharp diA'id-
ing line betAveen irreducible hernia and torsion of the omentum.
In the internal variety the general symptoms are those of some
pronounced abdominal crisis. The absence of a hernia makes the
758 THE PERITONEUM
nature of the disorder doubly hard to anticipate. It is only after
the abdomen is opened that the nature is likely to be suspected. I
once observed a condition of this sort associated with a more pro-
nounced lesion. The patient, 46 years of age, gave a history of sev-
eral severe abdominal crises. The most severe of these took place
15 months before she presented herself for examination. She had
a temperature for three weeks following that attack, her physician
said. When I saw her she had a renewed attack of the pain, though
less severe than the previous one. A rounded mass, tender to
touch, filled the pelvis and could be palpated above the pubes par-
ticularly to the left. A diagnosis of cyst with twisted pedicle was
made. At operation as the cyst was delivered the omentum fol-
lowed. The cyst was blue-black and the veins were filled with
thrombi. As the omentum was drawn down there appeared a twist
above which the omentum was normal though much congested (Fig.
215). The torsion was fresh and not over 180 degrees. The pedi-
cle of the cyst showed the remains of an old t-\vist and a new one.
It would seem that following a partial twist of the ovarian cyst a
year before, the omentum became attached and as the cyst under-
went a renewed gyration it Avas compelled to follow. It is doubt-
ful Avhether the degree of torsion the omentum suffered would have
been sufficient to disturb the circulation had it not been attached
to the seminecrotic cyst wall.
Diagnosis. — From the foregoing it is evident that when an
omental hernia produces marked symi^toms torsion of the omentum
must be thought of. From my own experience I would suggest that
torsion may be distinguished from simple omental strangulation by
the fact that the latter produces a tumefied mass extending up-
wards beyond the internal ring, while the latter produces its dis-
turbance within the confines of the inguinal canal.
In the variety contained entirely within the peritoneal cavity
the surgeon may be content if he diagnosticates a surgical lesion.
Prutz and Monnier note that a cursory examination during lapa-
rotomy may not be sufficient to discover a torsion and a nonoffend-
ing organ such as the appendix may be removed and the chief cause
of the trouble, the twisted omentum, may be overlooked. This is
merely another case in which if the surgeon does not know how
DISEASES AND INJURIES OF THE GREAT OMENTUM 759
miicli of a lesion is required to produce a given group of sj'mptoms,
he is likely to overlook the real pathologic condition.
The chief lesion that is likely to be confused with torsion of the
omentum is inflammatory tumors of the omentum. The chief dif-
ference lies in the fact that in the latter the onset is slow and grad-
ually progressive, and usually follows some operation on the
omentum, while in torsion the beginning is stormy and most often
associated with hernia. In the internal variety of torsion and the
omental inflammations not following operation the differentiation
may be aided by considering possible etiologic conditions but in
such cases direct inspection by laparotomy is better than hypotheca-
tion.
Prog-nosis. — Judging from the ability of an ovarian cyst to re-
cover after torsion of its pedicle it is more than likely that torsion
of the omentum is not incompatible with continued life of the pa-
tient. This is made probable because a careful examination of thick
omental masses sometimes shows evidence of such a catastrophy in
times past.
Treatment. — When a twisted omentum is discovered at opera-
tion, nothing remains ])ut to sever the diseased portion and remove
it. The appearance of the omentum above the twisted part is similar
to that observed Avhen it is attached to a pelvic tumor and the
treatment is the same: careful ligation in several segments Avith
ligatures large enough in diameter that they will not cut the thin-
walled veins.
Injuries to the Omentum and Mesentery
Generally speaking, traumatism of the omentum and mesentery
is overshadowed by perforation of the hollow organs and rupture
of the solid organs. It is usually only when injury of vessels oc-
curs that rupture of the omentum and mesentery assumes impor-
tance. Rupture of the nonvascular areas it is true may furnish
atria for subsequent hernias, but these are of very rare occurrence.
Tearing loose of the mesentery from the gut for great distances may
jeopardize the nutrition of the latter. This likewise is a rare
accident.
Etiology. — Two general classes of injury may be defined; those
due to blunt trauma and those due to penetrating wounds.
760 THE PERITONEUM
Blunt Trauma. — Thirty-four cases have been recorded. The most
common cause was being run over by a vehicle, with 9 cases ; next,
pinching betAveen two objects as between the bumpers of railway
cars, or other vehicles with four cases. Kicks from a horse were
responsible in tAvo cases. Injuries from contact Avith the ends of
objects such as a Avagon tongue Avere responsible for five cases, and,
finally, falls upon the abdomen Avere responsible for three cases.
Penetrating Wounds. — A bare half dozen cases have been re-
ported as such. The paucity of these may be accounted for by the
fact that generally other organs Avere injured at the same time and
these overshadoAved the mesenteric injury in importance. Ob-
A'iously many more cases occur than is apparent from a reading
of the literature. Severance of a mesenteric vessel, particularly
from gunshot Avounds, is not such a great rarity.
Pathogenesis. — The rupture of the mesentery in general may be
said to l)e due to a force acting on the organs to Avhich it is at-
tached. For instance when an intestine filled Avith fluid, in re-
sponse to pressure from above, travels doAvnAvard AAuth a greater
force than the mesentery can Avithstand, it leads to rupture. Like-
Avise if a force acts on the mesentery directly, if the range of its
elasticity is exceeded, rupture must occur.
Usually the history of recorded cases does not admit of such ac-
curate classification. Generally a trauma acts on the abdominal
AA'all and at autopsy or at operation a rupture of the mesentery is
found to haA^e taken place. Thus Neumann reports a case of Garre's
in which the mesentery Avas torn from the intestine for 150 cm. as
the result of a blunt trauma.
The mechanism of Avounds of penetrating objects requires no dis-
cussion.
Symptoms. — Usually there are surface indications of a blunt in-
jury such as excoriations and contusions. The history may sug-
gest the possibility of such injury if objectiA^e CA^dence is Avanting,
such as being run over by a vehicle or being struck by some object,
as reported by Riegner and Steinthal.
Pain is present in degree of associated injury of the abdominal
Avail, or of hemorrhage into the tissues of the abdomen. A hema-
toma in the root of the mesentery, or a blood clot may irritate the
peritoneum, as noted by Wilms.
DISEASES AND INJURIES OF THE GREAT OMENTUM 761
The most constant evidence of serious injury is manifest by pal-
lor, small and rapid pulse due to hemorrhage. This may be due to
the injury itself or to the associated hemorrhage. Primary shock
may be so great that the hemorrhage may be delayed, as shown by
the case reported by Matthes. In such cases hemorrhage may start
again as soon as the shock is recovered from.
Hemorrhage. — Aside from surface changes and character of the
pulse the local accumulation of blood can often be detected by per-
cussion.
Diagnosis. — The exact determination of an omental or mesen-
teric injury is hardly possible. The most that can be done is to de-
termine the presence of an intraabdominal injury (see rupture of
the intestines). In some evidence of pallor is present and the demon-
stration of ])lood in the abdominal cavity is possible.
Prognosis. — The prognosis is as varied as the type of injury.
Primary shock may cause death or death may come from hemor-
rhage. If the hemorrhage is moderate spontaneous recovery with
absorption of the blood is possible.
Treatment. — If evidence of grave abdominal injury is present
operation is indicated. In the presence of marked shock the ques-
tion arises, however, if operation should be undertaken at once or
if the passing of the depressed state should be awaited. In the
presence of profound shock with no evidence of intraabdominal
hemorrhage, the appearance of a reaction may apprehensively be
awaited. At best, procedure in all these cases is an exploratory
operation.
When a ruptured mesentery is found the question of the vascular
injury is the paramount one. If there is but an injury of the
mesentery without vascular injury the cleft is closed by suture as
a preventive against future intestinal obstruction. If a vessel of
any considerable size has been ruptured the extent of gut sup-
plied by this vessel must be accurately determined. If the detach-
ment of the mesentery from the gut is greater than four inches or
a vessel supplying a greater extent than this is injured intestinal
resection must be made. The circulatory disturbance in the gut
wall gives evidence of the extent of resection demanded as slio%vn
by the cases of Autenrieth and Reinicke. Too great a segment of
762 THE PERITONEUM
gut rather than too little had best be sacrificed iu case of doubt, as
shown by Lockwood's case.
Several experimental studies have been made to determine the value
of reinforcing portions of intestine, the circulation of which has been
jeopardized, by enveloping it in a fold of the great omentum. Benker
found that the gut can be notably reinforced by these means.
Scudder placed the omentum in the opening in the mesentery.
Rosenstein resected a portion of the omentum and stitched it about
the jeopardized segment of the gut. The result saved a gut freed
from its mesentery for 20 cm. This author overlooks the fact that
the mesentery can safely be severed for a greater extent from an
inflamed than from a normal gut.
Isolated injury of large vessels has been reported in a few in-
stances. Hagen reports the injury of the superior mesenteric vein;
Mayo-Robson (1897) reports a similar case. I saw one in which
the superior mesenteric artery was cut off by a rifle bullet.
Bibliography
Inflammatory Tumors of the Peritoneum
Beckek: tJber chronisch eiitziindliche Netzgescliwiilste, Berl. klin. Wchnschr.,
1913, 1, 1903.
BoECHEL: Sur uiie complication eloigiiee de la cure radicale des hernies, Rev.
de g\iiec. et de chir. abd., 1897, i, 479.
Braun: tJber entziindliche G-escluviilste des Netzes, Arch. f. klin. Cliix., 1901,
Lxiii, 378.
Enderlen: Entziindliche Xetztunioren, Miinchen. med. Wchnschr., 1914, Ixi, 337.
Hollander.: Zur Gcnese dor Netztumorcu, (Epiploitis plastica), Deutsch. mod.
Wchnschr., 1913, xxxLx, 706.
Lucas-Championniere : Presentation d 'une piece relative a itne epiploite chron-
ique ayant transforme tent le tablier epiploiqne en une masse indure oc-
cupant tout I'adbomen, 1 'inflammation chronique ayant une hernie inguinale
pour point de depart, Bull, et mem. Soc. de chir. de Paris, 1898, xxiv, 195.
MoNOD: Obstruction partielle de I'intestin (colon transA'erse) par brides d'origine
epiploique (epiploite plastique) chez un honime ayant subi la cure radicale
d'une heniie inguinale. Bull, et mem. Soc. de Clur. de Paris, 1899, xxv,
144.
Pantzer: Multiple Abscesses of the Omentum; Report of Two Cases, Jour. Am.
Med. Assn., 1904, xliii, 1529.
Prutz and Monnier: Die chinirgischen Krankheiton und die Verletzungen des
Darmgekroses und der Netze, Stuttgart, Enke, 1913.
Reynier: Du danger de la ligature a la sole dans la resection de I'eipiplooai
enflamme; traitement des accidents consecutifs, Assoc. fran§. de Chir.
Proc.-verb. [etc.] 1895, ix, 487.
Schmieden: tiber circumscripte entziindliche Tumorbildung in der BauchhohJe
ausgehend vom Netz, Berl. klin. Wiehnschr., 1913, 1, 908.
Simon : Intraabdominal Xetztorsionen, Miinchen. med. Wchnschr., 1905, lii, 1979.
DISEASES AND INJURIES OF THE GREAT OMENTUM 763
Walther: Epiploite, Bull, et mem. Soc. de cliir. de Paris, 1905, u. s., xxxi, 274,
356, 39G, 510.
Zesas: Ueber im Anschluss an Baucliopcrationcn und Entziindungen der Bauch-
organe vorkommcnde entziindliclie Geschwiilste des Netzes (Epiploitiden),
Deutsch. Ztschr. f. Chir., 1909, xc\'iiiy 503.
Torsion of the Omentum
Bakes: Zur Frage der nuH-hanisclK'n Netzverlaugerungen liei Trendelenburg 'seller
Position: Arch. f. klin. chir., 1903-4, Ixxii, 770.
V. Cackovie: Torsio omentis. Omentovolvulus, Zentrall). f. Chir., 1910, xxxv^ii,
1397.
Hadda: Die Torsion des grossen Netzes, Arch. f. klin. ohir., 1910, xcii, 843.
Hedley : Torsion of the Great Omentum : A Case Clinically Eescnibling Ovarian
Cyst mth Twisted Pedicle, Brit. Med. Jour., 1911, ii, 1246.
Steiner: Ueber Netztorsion, Deutsch. med. Wchnschr., 1910, xxx\d, 1322.
Prutz and Monnier: Die chirurgischen Krankheiten und die Verletzungen des
Darmgokroses und der Netze, Stuttgart, Enke, 1913.
Qui^nue: Torsion intraabdominale sus-herniaire de 1 'epiploon, Bull, et mem. Soc.
de chir. de Paris, 1903, n. s., xxix, 520.
EuDOLF: Demonstration zweier Falle von Netztorsion, Wien. klin. Wchnschr.
1903, xxi, 459.
ViGNARD AND GiRAUDEAU : Torsion intraabdominale du grand epiploon, Arch.
prov. de chir., 1903, xii, 206.
Injuries to the Omentum and Mesentery
AUTENEiETil: Ausgedehnte Mcscnterialabreissung bei Bauchkontusionen, Miin-
chen. med. Wchnschr., 1908, Iv, 513.
Matthes : Todliche Spatlduntuug aus einem latent verlauf enen Mesenterialriss.
nach Unfall, Ztschr. f. Med.— Beamte, 1904, xvii, 837.
Neumann : ttber ausgcdehnte Mesenterialabreissungen bei Kontusion des Abdo-
mens, Beitr. z. klin. Chir., 1904, xliii, 676.
Reinecke : Isolierte querc Mesenterialabreissung bei Kontusion des Abdomens,.
Miinchen. med. Wchnschr., 1908, Iv, 1885.
Eiegner: Uber einen Fall von Exstirpation der, traumatisch zerrissenen Milz,
Berl. klin. Wchnschr., 1893, xxx, 177.
Steinthal: Zur Kenntnis der Verletzung des Duodenums durch stumpfe Gewalt,
Miinchen. med. Wchnschr., 1908, Iv, 169.
Wilms: Zur Frage der Gefassverletzungcn, der Radix mesenteri Miinchen. med.
Wchnschr., 1901, xlviii, 1277.
CHAPTER XXIX
TUMORS OF THE PERITONEUM
The peritoneum itself is the source of origin of relatively few
true primary tumors. These of necessity must consist of endothe-
lial or fibrous tumors. However, there are many tumors so closely
associated with the peritoneum that practical considerations de-
mand their study. The more common are the retention and pro-
liferative cysts, usually within the layers of the mesentery or omen-
tum. Many of these arise in vestigial structures not directlv
related to the component parts of the peritoneum. Small ad
hesion cysts, the result of some ])ast inflammation, are common
but have no clinical significance. The blood, and particularly the
lymph vessels sometimes make distinct tumors. External to the
parietal pei'itoneum are many solid tumors, the product of the
retroperitoneal connective tissues, and teratoid tumors the result
of embryonal displacements. Parasitic diseases may find lodgment,
producing conditions closely simulating true tumors. The most
common tumors of the peritoneum are the metastatic ones, devel-
oping secondarily to malignancies in some abdominal viscus.
Classification. — Considered in its broad sense, therefore, the tu-
mor problem as it relates to the peritoneum must be approached in
a thoroughly comprehensive manner. Henschen has proposed a
classification possessed of many desirable features so far as it is
related to the cystic conditions. This outline will, with some mod-
ifications, be followed here. The solid tumors as well as the meta-
static ones may be arranged under the forms usually followed in
the discussion of tumors. The following outline, therefore, may be
suggested.
Cysts.
A. Proliferative (True cysts).
1. Cavernous lympliangiomata.
(a) with serous contents.
(b) with cliylous contei.ts.
2. Cystic endotheliomata.
3. Dermoid cysts.
764
TUMORS OF THE PERITONEUM 765
B. Foreign Body (Infective) Cysts.
1. Ecliinococeus.
2. Gas cysts due to bacteria.
3. Cysticercus cellulosiE.
C. Retention (Secondary) Cysts.
1. Blood cysts resulting from hemorrhages.
2. Adhesion cysts formed by the accumulation of
exudate in pockets.
3. Degeneration cysts.
4. Hydropic cysts.
Solid Tumors.
1. Lipomata.
2. Fibromata.
3. Endotheliomata.
4. Sarcomata.
Metastatic Tumors.
1. Cai'cinomata.
2. Sarcomata.
3. Pseudomyxomata.
Such a scheme must present some evidence of incompleteness.
This must of necessity be so since the genesis of some of the lesions
are as yet not definitely established. To make this less apparent
the tumors of the mesentery and omentum are discussed separately.
Lymphatic Cysts of the Mesentery
The justification for classifying these cysts as proliferative cysts
is found in the structure of their walls. They are composed of
connective tissue interspersed Avith many elastic fibers and usu-
ally an abundance of smooth muscle fibers in which are imbedded
masses of lymphatic tissue. In the wall are usuall.y found small
clefts or cysts. The cell content is variable. Usually numerous
cells surround the vessels. The free surface is covered with large
endothelial cells that may appear arranged in several layers. The
apparent stratification I believe is due to exfoliative processes.
Klemm believed that they represented foreign liody giant cells.
Frequency. — Berger collected 137 cases of these, three of which
were in the mesocolon.
Size. — The size varies between that of an egg or less to the case
reported by Weichselbaum, Avhich represented two enormous cysts
measuring 23x29x76 cm. each.
766 THE PERITONEUM
Multiple cysts have been reported, for instance one by Tuffier
and Bennecke.
Sex. — Gildermeister in collected statistics of 44 cases found 26
in females and 18 in males. Braquehaye found 4 females to 1 male.
Ag"e'. — Early adult life is most frequently affected. Gildermeister
found but three recorded cases over 50 years of age, Avhile 28 were
under 30.
Pathogenesis. — The structure of these tumors is altogether ho-
mologous Avith the lymph cysts of the neck and axilla, and I may
say also like the polycystic kidneys. It seems fair to assume that
they have a like genesis. The formation is obviously laid in a
congenital abnormality, l)ut the process is capable of neoplastic
development. This theory of genesis excludes the necessity of as-
suming that they are derivatives of degenerated lymph glands in
order to account for the presence of lymph nodules. The con-
genital character of the anlage is further attested to by the fact that
these cysts are usually observed in early life, as noted by Henschen
and Klemm. How these arise in early life is explained by Kostlivy
by assuming an abnormal dilatation of the primitive lymph spaces.
This would not account for the presence of the lymph nodules and
abundance of striated muscle fibers. Thei'c must be a pronounced
displacement of embryonic tissue. Dowd suggests their origin
from Wolffian bodies. This might be true in certain situations,
1;ut hardly in all regions in which these cysts are sometimes fouiul.
An attempt to account for them as retention cysts is not pos-
sible because of the structure of their walls. Winiwarter was the
first to advance this theory. Killian reported a large cyst which
he explained by the assumption of an obstruction of the thoracic
duct. Bramann believed that the cysterni chyle was the organ
obstructed. Kostlivy reported a case which he believed could be
accounted for on the assumption of the dilatation of a chyliferous
duct. He was unable to demonstrate any obstruction. Tilger's
case in which lymphectasis was observed about a healed gastric
ulcer is the only case reported in which a possible cause of obstruc-
tion could actually be demonstrated. Hlava assumes an obstruc-
tion of the afferent lymphatic ducts. This manner of formation
may be excluded, according to Prutz and Monnier, by the fact that
the abundant anastomosis of the lymph channels would permit
TUMORS OF THE PERITONEUM 767
escape through some other channel. Besides Dowd noted that cysts
do not develop after obliteration of the thoracic duct. According
to my own experiments all that can be accomplished by ligation of
the thoracic duct is the production of a peritoneal exudate. It
is worthy of note, however, that in elephantatic processes follow-
ing the total removal of groups of lymph glands areas may be
found in which the round cell groups resemble very closely those
seen in the walls of the lymph cysts in question. It seems pos-
sible therefore that simple stagnation may account for some of the
more complicated pictures above alluded to.
The cyst contents of these tumors vary considerably with the
structure of cyst wall. The contents may be clear, milky, "chylif-
erous," bloody, or a mixture of these. The bloody variety is easily
explained by the admixture of blood to some other variety of con-
tent. The chylous are most easily accounted for on the assumption
that they represent chylous ducts. This could only be assumed
after it is proved that a duet once functioning becomes obliterated.
Most likely this term must be used in a generic sense only as
indicating a cyst containing a milky fluid.
A numbei- of cases have been reported as blood cysts which Avere
obviously traumatic or spontaneous hematomata, for instance, one
by Brentano in which the cyst followed directly a trauma to the
abdomen. Secondary hemorrhage into a preexisting cyst is re-
ported by Wells in which a tumor of the ascending colon known to
have existed for 30 years suddenly enlarged. Blood clots Avere
found at operation.
They spring from the central layer of the mesentery but, like
myomata of the uterus, later shift their position. Prutz and Mon-
nier have represented these possibilities diagrammatically. It is easy
to understand by reference to these how by extension they may
compress the gut. Though usually ovoid in form, they are not
always so, as is indicated by a case reported b.y Vautrin. In this
case a polycystic mass spread over the entire mesentery like a
multilocular air cushion. A combination of the two types may
occur in that globulai' tumors made up of many separate cysts
may exist side by side, as I ()l)servo(l in one case.
No predilection as to site seems to exist. Metting in 18 cases
768 THE PERITONEUM
found 11 situated on the right side, while Hah.u found 8 on the left
side to three on the right.
Pathology. — The cyst contents are usually clear fluid. In some
instances it is mucinous, as in cases reported b}^ Tillaux and Werth.
In color these may be greenish, as in the case reported by Tillaux,
or yellow as in Thornton's case. Any of these forms may be com-
plicated by hemorrhagic exudates, particularly in those cases in
which blood stasis occurs from pressure of the tumor.
The walls are composed of fibrous tissue interlaced with elas-
tic fibers. Muscle fibers have been described. The cysts are lined
with flat or cuboidal epithelium. The latter form is likely to occur
in tissues hardened in alcohol and evidently is influenced by the
contraction of the surrounding tissue. In some places there is
apparent stratiflcation. It is difficult to distinguish between the
lining cells and round or endothelioid cells in the connective tissue
about them. In one of the specimens I examined the picture of
endothelioma arose in this way.
Symptoms. — In both my cases the tumor Avas discovered in the
course of operations for other conditions. They seemed to be of
no clinical significance. In most of the cases recorded the pres-
ence of a tumor Avas the first thing that the patient noted. Some-
times pain precedes the discovery of the tumor. Frentzel notes
that it is the sudden enlargement that leads to acute pain. This
pain is the moi'e severe the nearer the cysts lie to the root of the
mesenterj^, according to Carter. Kiister reported a case in which
symptoms of intestinal obstruction were the first manifestation.
When hemoi'rhage takes place into the cysts reactive phenomena
attended by sudden severe pain may follow and an inflammatory
condition be simulated, as in a case reported by Balfler. Many,
on the other hand, run their course quite painlessly. This is
particularly true of the ])eduncu]ated variety. Those situated
interstitially, particularly when near the intestinal border, may
produce an intestinal stenosis by direct compression. Sudden en-
largement of the cyst may lead to acute obstruction. Twisting of
the ileum about the cyst led to this disaster in Fertig's case, and
also in Briddon's.
Pressure on other organs may produce symptoms. When the
TUMORS OF THE PERITONEUM
769
cyst is situated in the pelvis tlie bladder ma,v be irritated. Gus-
seroAV aseri])ed dysmenorrhea to a cyst in one case.
Diagnosis. — The chief physical sign is the presence of a globular
tumor of great mobility. Usually it can be made out to be cystic.
This mobility distinguishes it from retroperitoneal cysts. Ovarian
tumors v\dth long i^edicles may simulate them. Usually mesenteric
cysts possess a greater mobility toward the diaphragm than ovarian
cysts and the manipulation of them does not impart movement to
the uterus. Cysts situated near the root of the mesentery may simu-
Fig. 21(). — Lymph cyst of the ileocecal region. This mass was accidentally discovered dnrinir
an operation for gallstones.
late a retroperitoneal cyst or an encysted peritonitis very closely.
Pain with cyst, particularly if evidence of obstruction is present,
speaks for mesenteric cyst.
Prog-nosis.— The c-olleeted stntislics of results following treatment
are wholly unreliable. This is in part due to the fact that many of
tlie recorded cases Mci-e treated before a dependaljle operative tech-
nic Avas developed. Here i1 is llie operator rather than the disease
that requires prognostication.
770
THE PERITONEUM
Areldon records 24 cases of cures to 2 deaths treated by mar-
supialization. Speckert records 8 recoveries in 22 cases treated
by the same method, and Braquehaye records 93 per cent recoveries
by resection. Begouin recorded 68 per cent recoveries and Friend
noted 12 recoveries and 6 deaths in cases treated by resection.
Gildermeister in 51 cases treated by various methods reports that
43 were cured.
Treatment. — If an inexperienced operator should unexpectedly
encounter a comjolicated mesenteric cyst it may be Avell for him
to remember that simple puncture has been advocated. Begouin
was a most enthusiastic advocate of this plan even in experienced
hands.
With modern technic marsupialization or extirpation is the
method of election. The cyst wall may be stitched to the incision
either Avith or without freeing the wall from its environment as
much as possible. Terrillon recommends the former procedure.
Speckert Avarns against incision of the cyst if fever is present for
fear of the spreading of the infection. In such instances the cyst
should be stitched into the incision and opened after adhesions
have formed. If the wall is too thin to admit of this, a tampon
may be placed over and al)ont the summit of the cyst until adhe-
sions have taken place. The advantage of this plan of treatment
lies in its simplicity. The danger of injury to the gut and of
hemorrhage is avoided.
As objection to this method of treatment Prutz and Monnier
have mentioned the folloAving: continued secretion from the cyst,
thus reducing the patient; the gut is fixed thereby inviting to toi'-
sion, malignant tissue may be allowed to remain ; existent com-
pression of the gut may not be fully relieved.
Eoscetion of the complete cyst is the ideal method of treatment.
This is easily carried out in small, simple cysts either with or without
resection of the gut. Terrillon and Hahn Avould limit resection
to the simple varieties. The chief factor to be determined before
deciding on this method of treatment is the relation of the cyst
wall to the larger vessels. Not only must the immediate results
be calculated on, but possible late disturbance of the circulation
threatening the integrity of the gut it supplies.
TUMORS OF THE PERITONEUM 771
Endotheliomata
There has never been a tumor described that could be said to have
sprung from the peritoneal endothelium. The endotheliomata of
the pleura most likely spring from the lymphatic endothelium.
There are many curious tumors observed in the peritoneum, the
source of which can not be' demonstrated. Some of these present^
large syncytial masses and are accepted as arising from the uterus,
notwithstanding that the history does not bear out the assumption
of relationship. Such things make an accurate historical account
of tumors of this tissue impossible. The earlier literature con-
tains isolated case reports of primary cancer of the mesentery,
but these accounts are not definite enough to exclude a primary
focus elsewhere. The diagnosis of a primary colloidal tumor taxes
our credulity, and from the nature of things makes us feel positive
that a primary tumor elsewhere was overlooked. Sprangenthal,
Corswell and Hodgkin Avere the first to present apparently authen-
tic cases of primary tumors of the peritoneum. Most of the cases
reported in the earlier literature are not based on careful post-
mortem studies and some even are without any autopsy at all.
Thus Lebert reports 10 cases observed in his own practice. Glock-
ner made a careful study of the literature and could collect but
16 cases.
It is perhaps assuming an unnecessary added burden by attempt-
ing to classify these tumors under this head, for no class of tumors
in recent years has been the subject of so much discussion as
endotheliomata. A great difference of opinion has prevailed re-
garding these tumors in general. Its greatest height is reached
in the discussion of the primary tumors of serous membranes, be-
cause here the problem is much complicated by the divided opinion
as to the nature of the cells covering the serous surfaces. The
histologic status of the covering cells has been discussed in the
section on histology and need not be repeated here. The opinion
was there expressed that so long at least as embryologists are
divided on the ])oiiit of origin of these cells it is useless to shift
the anatomic and pathologic classification to meet these changing
opinions. In pathologic as well as histologic discussions it seems
best to treat these cells and the tumors they produce in an objec-
772 THE PERITONEUM
tive way. How they look and what they do and not their origin
is what concerns us. It is but a name at most that is the subject
of the controversy. The final solution of the problem in tumor
genesis is better served by a study of facts than by the aligning
of observations behind one or the other of several hypotheses.
What efforts have been made to straddle the difficulty by means
of a comprehensive nomenclature is well seen by reference to the
literature. Schultz, as the title of his paper indicates (Das Endo-
thelcarcinom), -was uncertain as to the classification. He states,
hoAvever, that he uses the term "krebs" in a strictly clinical sense.
This author believed that the tumor cells Avere derived from the
endothelium of the lym])h vessels. Bostrom, Glockner and Teixeira
de Mattos adhere to this vieAv. Kolaczek applied a term well de-
scriptive of some types, namely, plexiform angiosarcoma. Boehnie
gets around the problem by using two terms tandem, as indicated
by the title of his pa])er (Primares Sarkocarcinoma der Pleura).
Hokmokl comes a little nearer committing himself. The title of
these papers and the descriptions they contain indicate that the^^
had to do with perivascular lymph endotheliomata. Therefore,
while they are tumors of the peritoneum, strictly speaking they
are not tumors derived from the peritoneal endothelium.
Another group of tumors were aligned with reactive processes
by a number of writers. Perls and Birsch-Hirsehfeld called them lym-
phangitis proliferans. Neelsen gave a more oncological ring to
his term, namely, lymphangitis carcinomatose, as did Schottelius
before him. I feel a deep personal sympathy for l)oth these terms.
Glockner evidently had a more pronounced specimen when he
conceived the ponderous term Endothelioma lymphangiomatosum
carcinomatodes. He recognized, it may be said, that this term Avas
applicable only to the less fully developed forms. Volkmann in
a very complete study expressed the opinion that the tumors were
derived from endothelial connective tissue cells. Hansemann sup-
plied terms enough for all contingencies, in carcinoma endothe-
liale, sarcoma endotheliale and even carcinoma sarcomatodes en-
dotheliale. Such terms as these no doubt Avould be pleasing to
dermatologists and obfuscated pathologists, but they are irksome
to surgeons Avho nuist think clearly.
We may start out \\ith an understanding that these tumors are
TUMORS OF THE PERITONEUM 773
derived from flat cells within the serosa. Since the lymph vessels
have been proved to be, like the blood vessels, closed channels, the ref-
erence to endothelial lined connective tissue spaces may be omitted.
No one has demonstrated the origin of the tumors from the surface
cells. Zeigier states that they do, but he does not attempt to prove
his statement, as do Jiirgens and Napp. Even though these may
finally be proved to have some genetic relationship with epiblastic
cells, this fact need not concern us here. The mere fact that these
tumors produce astonishingly variegated cell structures should
stimulate us to detennine the fundamental type rather than to
cover each variation Avith a ponderous designation. ^
Pathology. — The multitudinous nomenclature above noted gives
a clue to the variability of their structure. Schattelius noted that
the fundamental ditference between endotheliomata and carcino-
mata lies in the fact that the former springs from many areas
simultaneously, Avhile the latter begins in a circumscribed point
and extends to the surrounding tissues, or to the regional lymph
glands. Gephard reiterated this observation. Nevertheless Des-
plats and Harris believe that carcinoma may begin at many points
at the same time.
The majority of tumors of serous surfaces which have been de-
scribed were located on the pleura. Since there is an identity
of the anatomic structure between the pleura and the peritoneum,
the anatomic appearance of tumors of both regions may be expected
to be similar. This is the more justifiable since both pleura and
peritoneum are sometimes simultaneously affected by tumors of
the same histologic appearance.
In the simple form in hoih these regions there is but a piling up
of the endothelium lining the lymph vessels. In the pleura the
lymph plexus may l)e accurately outlined l)y the proliferating
endotheliomata. These sometimes seem to bear some relation to
acute irritative processes. I saw such a case in a patient dead
from a septic abortion in which a generalized endothelial prolif-
eration was present, most marked in the peritoneum of the broad
ligaments. This same condition may be observed in outlying dis-
tricts of moi'e marked neoplastic formations. This type gives the
impression of a generalized hyperplasia of the endothelium excited
by some irritant in the lymphatic circulation. This impression is
774 THE PERITONEUM
heightened ])y the fact that the transitory lymphangitis following
peripheral infections of the extremities shows a similar piling up.
The dividing line between the reactive and neoplastic does not
seem to he a sharp one.
In the pleura this hyperplasia is sufficient to outline the lym-
phatic network of the pleura as perfectly as can be done by in-
jecting methylene blue. Such lymph channels present a thick-
ened endothelium, usually two to four cell layers deep.
The tyi^e yet more pronounced presents small nodules to which
the term "miliary" has been applied with a measure of justification.
In these the nodular areas present a more pronounced piling up
of cells. The markedly tumorous type presents tumor masses of
varying size. These masses tend to displace the surrounding tis-
sue, rather than to invade it, thus grooving true to the usual type
of endotheliomata.
In the latter type the cell strands may cease to shoAV the hol-
lowed gland-like columns due to the proliferation of the endo-
thelium, but instead present solid cordons of cells. The picture
of carcinoma is then complete. This differs from carcinoma grow-
ing into a lymph vessel, as is sometimes seen in carcinoma of the
breast, by the fact 1liat in the latter the endothelium remains about
the cell columns. In such instances the cell columns lie closely
together with but sparse connective tissue between them. Such
specimens present a close duplicate of the ordinary carcinoma
simplex.
In another variety the cells do not form nests, but extend tan-
dem between connective tissue bundles. In such cases the cells
usually vary much in size but are often very large containing an
abundant jjrotoplasm with large spheroid nuclei in which lies a
deepl.v staining nucleolus. These cells resemble very much groggy
endothelioid cells as one sees sometimes in chronic reactive proc-
esses, notably in hyperplastic inflammations of the cecum and in
woody phlegmon of the neck. As before mentioned the amount of
protoplasm may be so great as to resemble syncytiums. The same
type of cell is observed in other conditions, however, notably in
the metastasis of an ovarian tumor.
According to Braude the elastic fibers about the tumor nodules
TUMORS OF THE PERITONEUM 775
are much increased. I have found this true likewise in chronic
reactive processes.
Symptoms. — The most constant manifestation is ascites, as
Spencer-Wells has pointed out, and next in importance is pain.
The ascites is particularly significant, according to Spencer-Wells,
if accompanied by rapid loss in Aveight. This ascites does not
differ from that present in secondary carcinomata but does differ
from hepatic or cardiac ascites in that it contains 4.5 to 6 per cent
albumin while only .3 per cent is found in the latter conditions.
Thomayer sought to differentiate between this and ordinary
ascites by noting that instead of the symmetrical dullness produced
by the ascites it extends up more pronouncedly on the left side.
This is supjDosed to he due to the thickened omentum. This is
probably true since the same phenomenon is observed in ascites
due to tuberculosis in which the omentum is regularly thickened.
Due to the same factor is the lessened cardiac dullness. According
to Gordon, however, the diminished cardiac dullness is due to the
loss of elasticity of the lung.
Pain is not as constant in this condition as in secondary carci-
nosis, since pain is not marked unless neighboring nerve plexuses
are invaded. In cases in which intense pain is associated Avith dif-
fuse infiltration it is often difficult to determine if there is a pri
mary epithelial tumor or not. This is even more emphatically
true of obstructive symptoms.
Treatment. — No treatment is of avail.
Enterocystomata
Under this caption are included cysts which ai'c derived from
some abiiormality of development of the gut tract. They are to
be distinguished from mesenteric cysts, which develop independent
of the gut tract. Moynihan confuses the prol)lem by classifying
mesenteric cysts according to their origin. Lewis and Thyng on
the other hand have sought to establish an anatomic basis for the
enterogenetic type. They are distinguished from diverticuli by
being without connection with the gut tract. Their structure may
differ so much from that of the gul Irad tliat according lo Xioso,
their nature is often overlooked even when examined microscop-
776 THE PERITONEUM
ically. In that event they may be mistaken for true mesenteric
cysts.
Location. — Owing to the extent through wliieh the omphalo-
mesenteric duct travels and the various changes it undergoes, a
variable site is easy to understand. In the abdominal portion but
four cases have been reported. The most frequent site corresponds
to the location of Meckel's diverticulum. There are nineteen of
these. Only three are reported on other portions of the ileum.
Five are reported at the ileocecal valve and seven near it.
Pathogenesis. — The least likely theory is that of Hedinger who
assumes that they are derived from the esophagus because they
are often lined Avith cubical epithelium. More plausible is the
theory that these cysts are derived from the fetal gut tract by
diverticulation of the gut tract from the fetal epithelium. Gfeller
and Sanger supported this \\qw. In some instances the close re-
lation to the gut epithelium substantiates this view. The most
probable source is from the ductus omphalomesentericus and
Meckel's diverticulum. The chief argument for this theory is the
seat of the tumor as above noted — either in the alxlominal wall
or at or near the usual site of the diverticulum. Eaesfeld was the
first to suggest this possibility. Hendee, Riml)aeh, and Colmers
support this view.
The occurrence of multiple cysts, Prutz and Monnier point out,
could hardly be explained by this view. Kostlivy's view that
these are due to diverticula is probably correct. Roth reports a
case interesting in this connection. In a ncAvborn child he found
a spherical enterocystoma which still communicated with the small
intestine. The upper portion was shut off from the loAver narrow
portion by numerous constrictions. True diverticula with their
own separate walls occur, as I have observed. Further proof of
their association with the gut wall is demonstrated by a specimen
I once studied in which small cysts located in the mesentery were
associated with multiple adenomata of the gut wall. That there
is a close relation to Meckel's diverticulum may be indicated by
the fact that these associated adenomata bore a very close resem-
blance to the gland tissue often found in the l)lind end of Meckel's
diverticulum. All this means that these structures represent early
TUMORS OF THE PERITONEUM 777
stages of gut epithelium, sometimes derived from the gut wall, and
sometimes from Meckel's diverticulum.
The fact that these cysts differ in structure within rather wide
limits indicates that they represent anlages derived from the gut
tract at varying stages of development. In the case reported by
Roth the type of epithelium in the part that communicated with
the gut showed a more mature epithelium than that portion which
had been constricted off. Perhaps the degree of deviation from
the normal gut epithelium furnishes some index as to the time
when the anlage was separated from the gut tract.
This variation is so great that in some instances the classifica-
tion of an enteromesenteric cyst may remain doubtful. In some
instances the anatomic relation of the cyst is as valuable a guide
in the identification of these cysts as the structure of their walls.
This is certainly true when the structure of the wall has been much
changed by inflammatory processes.
The explanation of the occurrence of ciliated cells is found in
the cases reported by v. Wyss and Dittrieh. In the early gut tract
ciliated cells have been described by a number of observers and
it is the suppositious persistence of these that accounts for the
existence of ciliated cells in the cysts.
Pathology. — Enterogenetic cysts have been confused Avith cysts
of other regions so that the literature is needlessly confused.
Lewis and Thyng have done much to clarify the problem and Miller
has recently presented an excellent summary. In the typical cases
it appeal's the relationship to the gut is at once apparent. The
form of the lining epithelium Miller suggests is dependent on the
intracystic pressure. In the typical cases the villi are retained,
Avhile in the other extreme even the distinctly columnar arrange-
ment of the cells is lost. In some even a stratified cuboidal epi-
thelium is found. The wall of the cyst may retain a double wall
of muscle fibers arranged at right angles to each other. In the
less typical cases irregular Ijundles of muscle fibers may be all that
remain to indicate the origin of the wall. In the latter instance
they may resemble the mesenteric cyst of extraenteric origin.
Symptomatology. — The symptoms produced by these tumors
have to do exclusively with iiilerferenee with the fecal circulation.
In none has a clinical diagnosis been made. In one case the tumor
778 THE PERITONEUM
^vas SO large that normal deliver.y was made impossible. Of the
reported eases fifteen were accidentally discovered at autopsy.
Prog'nosis. — In the thirty-five reported cases twelve died. Eleven
cases were operated, of these four died. Tavo of these Avere oper-
ated as movable tumors of the abdomen, notably those of Rimbach
and of Morton. One case was discovered accidentally while re-
moving an inflamed appendix from a hernial sac. (Hendee.)
Treatment. — Eesection of the gut together with the cyst seems
to be the logical treatment as was done in one case by Sudler
(Fig. 217). Should inflammation or intestinal obstruction exist,
drainage of the cyst with or Avithout enterostomy might be
indicated.
Lipoma of the Mesentery-
Mass accumulations of fat are not unusual in the mesenteries
in fat people. Their unusual enlargement has been reported as
lipomata. The mesosigmoid particularly is sometimes the site of
great masses of fat. The mesenteric attachments to the small gut
are sometimes so greatly distended Avith fat that the gut is parti}'
surrounded and at first sight may appear as a tumor.
True lipomata of the mesentery are very rare, if indeed a true
case is recorded. Alsberg's case grcAV betAveen the layers of the
gastrocolic omentum and became attached to the colon so firmlj'
that the gut Avail Avas lacerated Avhen removal Avas attempted. A
portion of the tumor extended retroperitoneally and Avas attached
in the region of the kidney. This portion was calcareous. This
fact strongly suggests that this Avas the oldest j^ortion of the tumor
and therefore represented the site of origin. This case therefore
should be grouped Avith the retroperitoneal lipomata. Waldeyer
reports an autopsy performed on a body in Avhich a huge lipo-
myxoma developed in the root of the mesentery. Since this huge
tumor englobed the right kidney, though declared to be mesenteric
in origin, it seems to belong Avhere Proust and TrcA^es place it,
namely, with the retroperitoneal tumors. These authors abstract
thirty-six cases under the heading of mesenteric lipomata. Many
of these certainly had their origin in the retroperitoneal connective
tissue as Avill be shoAvn in the consideration of retroperitoneal
lipomata. It may be argued that some of these tumors began in
TUMORS OF THE PERITONEUM
779
the mesentery and later extended to the retroperitoneal tissue.
This view is based on the erroneous vie^A- that the mesentery is
composed of two layers, and hence a tumor groAving between them
may separate them.
More authentic are the following cases: Roux reports a case of
fibroma and lipoma evidently in the mesosigmoid, and also one in
the mesentery of the small intestine about which a volvulus had
occurred. Heurtaux reports a myxolipoma in the mesentery of
the small intestines. Lennander reports a 15 kg. tumor arising
Fig. 217. — Mesenteric cyst. (Museum University of Kansas Medical School.) Note the
flattened gut passing over the summit of the tumor.
from the transverse mesocolon. Madelung reports a case in which
the mesentery of the small intestine A\as involved to such an cxIiMit
tliat resection of the gut a\ as necessary.
The few cases of true iiitrnjHM'itoneal lipomata reported presentctl
but little data th.at -would inal<e a clinical i)icture of distinction. At
operation the exclusion of rctroijei'itoneal tumoi-s is about all tliat is
required.
In several of the cases extirpation was successfully carried out.
780 THE PERITOXKUM
Before such an act is decided upon, its relation to the retroperi-
toneal tissue should be determined.
Secondary Peritoneal Cysts
In areas subject to irritation peritoneal cysts are occasionally
observed. These are seen most frequently on the broad ligaments
and on the fundus of the uterus after acute salpingitis, and in
hernial sacs.
In the former situation their genesis may be followed with ex-
actness. A fibrinous exudate forms over a granular mass, this
mass becoming absorbed, leaving a space formerly occupied by
the mass. Usually this process leaves but sheets of newly foi'med
peritoneum and cysts form only when the area is enclosed on all
sides.
In hernial sacs the opportunities for observation present them-
selves less frequently and their exact genesis is open to doubt.
Tiny cysts within hernial sacs are frequently observed, but larger
ones are not so common. They appear as sacculated hydroceles
within the wall of the hernial sac or project from its surface. I
have seen them within the sacs of hydroceles of the cord associ-
ated with hernias. Cantas reports a case in which a cyst the size
of a pigeon's egg and one the size of a cherry were found in the
inguinal hernial sac in a boy of sixteen who had had the hernia
since early youth. This author noted' that the portion of the sac
wall from which these cysts sprang was in a state of active
inflammation.
I have twice noted cysts associated with inguinal hernias in the
female. Each was the size of an orange and lay just within the
inguinal canal. They Avere alike in that both lay just within the
inguinal ring and had attachment along the course of the round
ligament. Opening into them caused me fright, fearing lest I had
inadvertently opened into the urinary bladder. Only careful search
convinced me that I had not made such a blunder. Resection of
the cyst wall apparently resulted in a cure in each case.
Tirket's case seems to have been of a different nature. His
patient was a male aged fifty-seven in whom a cyst was noted in
the hernial sac. During the following year the patient's abdomen
gradually enlarged. After incision the omentum mesentery and
TUMORS OP THE PERITONEUM 781
parietal peritoneum were found to be studded with innumerable
small cysts. A portion of the omentum was removed for examina-
tion and they were found to contain a clear fluid containing mucin
and a little albumin. The inner layer of the wall bore cilia.
Embryonal Cysts
Inclusional tumors in the abdomen are relatively rare. Taruffi
reports 71 cases. Braquehaye collected 104 cases, Moynihan col-
lected 113, and Dowd ])rouoht the number up to 136. Many more
have been reported in the literature, but a number of these are of
doubtful diagnosis, Avhile others obviously were derived from the
ovary.
Lexer divides these tumors into three groups: (1) True dermoids,
(2) those Avith undoubted fetal inclusions, and (3) true teratoid
tumors.
True Dermoids. — This group consists of simple epidermoidal sacs
usually placed retroperitoneal. I have observed one in the urachus,
this being an argument for the correctness of the view that holds
that these cysts are rests from the original body cleft. The argu-
ments applied to the explanation of the origin of mediastinal der-
moids may be applied here. In that situation tumors located both
above and below the sternum would indicate the origin from the
anlage of the cutaneous surface. The analogue between the
mediastinal and mesenteric situations is very apparent. Augag-
neur believes that they develop from the ectodermal rests of
Wolffian ducts.
Following Lexer it will avoid confusion to consider tentatively
the intraabdominal dermoids in four groujis, those intraperitoneal,
developing from inclusional defects of the abdominal Avail, Avhich
therefore are intraperitoneal.
About a dozen cases representing the first group have been re-
ported. These are reviewed briefly in Lexer's paper. The most
of these represent very incomplete reports, many of them being
mentioned incidentally only in autopsy reports.
The second group contains yet fewer representatives. These are
located in the retroperitoneal s]ia('e. Herrera's patient was a male,
aged eighteen, in whom the tumor extended from the diaphragm
to the pelvis. This Avas successfully extirpated. In Konig's pa-
782 THE PERITONEUM
tieiit, a female aped forty, tlie tumor lay heneath the liver aud was
operated on in the belief that it was an eehinococcic cyst. The
cyst was marsnpialized and the patient was dismissed with a
discharging fistula.
A third group was first suggested by de Quervain's ease in M'hich
tumors extended from the retrorectal space to as far as the level
of the umbilicus. I once observed a patient in whom three der-
moids occupied the retrorectal space, the upper being situated as
high as the sacral promontory. These were discovered by follow-
ing an ordinary sacral dermoid into the hollow of the sacrum.
jNrartiiii reports a case in which atresia of the anus and urethra
Avas present and the tumor filled out the entire pelvis and com-
municated with 1)oth the l)ladder and rectum.
The fourth gi'oup is less definitely defined, since they exist along
with similar tumors of the ovary. AVhether these arise from rup-
ture of the ovarian cysts and the dissemination of some of their
parts, or whether various parts of the body suffered simultaneous
embryonal displacement is not certain. Heinecke's case was a
Avoman of 31 in Avhom. besides a dermoid of the ovary, one the size
of an apple lay under the diaphragm. The only evidence of a
genetic relationship of the subdiaphragmatic tumor to that of the
ovary lay in the presence of small cysts extending from the
diaphragm to the broad ligament. Perhaps more convincing is
Kolaczek's case in Avhieh a large ovarian dermoid Avas complicated
by numerous yelloAv nodules, from one of Avhich a tuft of hair grcAV
into the free peritoneal caAdty. Frankel's case Avas a similar one
in Avhich numerous small cysts Avere distributed along the route
to the mesocolon, diaphi-agm and liver. Lexer reports a case Avith
the tiunor situated in the region of the cecum and of a more com-
plicated structui'e, in that it contained seA'eral teeth.
Fetal Inclusions. — Only those tumors containing a fetal organ
are included in this group. They are situated usually either in the
transA^erse mesocolon or in the epiploic bursa. These anomalies are
accounted for, it Avill be remembered, by Ahlfeld, by supposing the
simultaneous development of tAvo embryos. Marchand on the con-
trary believes that they are developed from a misplaced group of
cells, the misplacement taking place in the very earliest period.
About a dozen cases belonging to this group have been reported.
TUMORS OF THE PERITONEUM 783
One of the earliest and most complete was reported by Young, in
which a well formed fetus lay in the mesocolon of a newborn child.
This case is particularly interesting from the fact that the in-
clusion obtained its nutriment directly from the aorta of the host.
Pigni reports a case in which a cyst was similarly located and con-
tained a fetus representing about the fourth month. Ahlfeld also
quotes cases reported by Fattori in which the cysts were located in
the transverse colon. It is interesting to note that in all these in-
stances the aniage must have been situated at a definite point. In
one case an interesting slight variation is noted. Reiter and Stein-
iger cite a case in which the sac lay below the stomach, and ex-
tended downward and to the left. Obviously the aniage was sit-
uated somewhat differently than in the cases above quoted. The
point of origin obviously must be in that portion which later be-
comes the transverse mesocolon. Evidently slight displacements
of this aniage by the development of the spleen and pancreas de-
termine its subsequent topographic relations. In this way the in-
clusions may be covered by the developing cecum, as in Rizzoli's
case. Situated somewhat higher in the mesogastrium the aniage
would follow that portion of the mesogastrium which goes to form
the epiploic bursa. In such instances the tumor may he associated
with the duodenum, as in Highmor's case, or it may lie in the bursa
itself, as in Bernhuber's case. If the aniage lay at the point of
dorsal intersection of the mesogastrium its subsequent gro-wth might
lift the peritoneum above it and thus appear retroperitoneal, as in
Buhl's and also Phillip's case.
The fact of the definite location of these inclusions would seem
to speak for JMarchand's rather than Ahlfeld 's theory of origin.
No attempt has been made to determine the reason these inclusions
reach a certain size and then cease to grow. Perhaps a study of
their circulation would give some clue.
Teratoid Mixed Tumors.— These tumoi-s ai'e distinctly atypical
both as to their location and structure. They represent at times
all three of the embryonal layers, sometimes only one or two of
them, and sometimes they are wholly atypical in structure. It has
been established by Roux and others thai displaced embryonal tis-
sue is capable of continued growth in its new location. These
tumors are usually retroperitoneal. Their origin may be hypoth-
784 THE PERITONEUM
eeated from any of the sources discussed for fetal inclusions.
Gross and Baraban report one situated in the abdominal Avail, near
the anterior superior spine on the right side. In Dickinson's case
the tumor occupied a similar position in the right side. Marchaud's
case lay in the space between the kidney and aorta of a thirty-three-
year-old man. Fillaux's case lay in the iliac fossa of a twenty -tAvo-
year-old AA-oman, and extended to the renal region. Pilliet's case
lay oA'er the A^ertebral column, reaching from the promontory to
the epigastrium. Montgomery's case, a girl of tweh^e, presented a
tuimor Avhich lay about the cecum and extended lateral to it nearly
as high as the liA^er. Lexer's patient, a girl of elcA'en years of age,
presented a tumor beloAA' the liA^er.
Symptoms. — Tumor aa^s the single feature Avhich excited the at-
tention of tliese patients. It Avas only exploration or postmortem
that Avas al)le to giA^e a solution. The surgeon aa-III do Avell if he
recognizes the character of his tumor after he has it in hand.
Treatment. — In the case of the cysts marsupialization may be
done if the remoA^al of the cyst Avail is too difficult. In the tera-
tomata removal alone is permissible. ObA^ously in many of the
cases recorded any sort of treatment Avould liaA^e been Avithout
avail.
Tumors of the Retroperitoneal Space
Tumors beginning in the retroperitoneal tissue are compara-
tiA^ely rare so far as Ave may judge from the number of cases re-
corded in the literature. Whenever one is confronted AA'ith a con-
dition the diagnosis of Avhich is exceedingly uncertain and its treat-
ment is fraught Avith difficulty or disaster, it is more than jDrobable
that the number of cases reported bears a A^ery uncertain relation
to the number of cases that actually are obserA'ed. FeAV men take
any great pleasure in reporting a case in AA'hich the diagnosis Avas
Avrong and the treatment a failure. When one Avas AAa^ong and be-
comes right there may be some sense of satisfaction in proclaiming
it. But AA'hen one has made a blunder and never finds out just Avhat
happened it makes a poor text for a paper. One learns more of
this hy quiet listening in the smoking room than from the forum
or library.
From the foregoing it seems Avorth A\hile to take stock of the
TUMORS OF THE PERITONEUM 785
available knowledge on these tumors purely from its practical as-
pect. Quite aside from this they have a fundamental oncologic in-
terest in excess of their practical importance. Unfortunately most
of the cases recorded are lacking in detail to so great a degree that
the information conveyed aids hut little in enlightening the the-
oretic problems involved. It is only when the practical problems
are enlivened by their theoretic aspects that complete details be-
come available. The two fundamental factors of subsequent his-
tory and complete histologic examination are lacking in many of
the cases recorded.
Few clinicians understand what a careful histologic examina-
tion implies. To illustrate this point I w^ill mention an incident
that occurred during a lecture of the late Dr. Fenger. He was
demonstrating a large retroperitoneal sarcoma. He had removed
blocks for microscopic sections from no less than twelve separate
places. After describing slides from all these areas with a detail
Avith which only he Avas capable, he pointed his finger straight at
me and asked, ''Now we know what this tumor is made up of?"
I had been impressed with the unusual thoroughness and I unhesi-
tatingly gave him my assurance that we were noAv possessed of full
knoAvledge. "No," he fairly yelled, "we only knoAV what is in
those tAvelve places." It has taken me twenty years to learn the
significance of those remarks.
The series of tumors going out from this region because of the
names attached are taken to be Avidely separated in their clinical
behavior. Lipoma is the acme of innocence in tumor disposition
while sarcoma sounds the knell of despair. In this situation there
are often histological gradations. Lipomatous tissue is often in-
termingled with myxoid, and the latter is always closely related to
sarcoma. It is this tendency to admixture that removes them from
the usual class of histoid tumors. The size of the fatty tumors
often causes them to directly menace the patient. Because of these
factors the clinical aspect of tliese tumors must be considered from
a different viewpoint than is usually accorded tumors bearing such
designations.
Were it not for harmony in utilizing the recorded cases it Avould
seem best to discard the accepted nomenclature altogether and des-
ignate the entire group of tumors occurring in the retroperitoneal
786 THE PERITOXEUM
space as mixed tumors. This not only represents the state of our
knowleclfire regarding them l)iit also the structure of most of the
tumors. In oi'der to conform as much as possible with the literature
the terms lipoma and sarcoma Avill ])e retained. As occasion arises
an attempt will he made to point out their relation to the teratoid
tumors.
Retroperitoneal Lipomata. — Under this caption are included all
those tumors which are predominatingly lipoid in structure. For
the majority of the tumors recorded this is clearly a misnomer, for
a number \\\\\ he found in this list which were recurrent and a
number in Avhich sarcomatous areas Avere recognized. ^Myxoid or
"edematous" areas were almost the rule.
Etiology. — In five of the recorded cases, among which may be
mentioned Neumann's and Lauwers, tlie tumoi' began in early
childhood. None are recorded in the second decade of life. This
might suggest a congenital anlage, since this corresponds to the
age in tei-atoid tumors of this region and for mixed tumors of the
kidney. The fact that lipomata are most frequently observed at
the midperiod of life does not argue against an embryonal rela-
tionship since adrenal and other tumors of this region present a
similar age relationship. The proneness of lipomata to begin in the
pararenal region, the frequent site of teratomata, would lend ad-
ditional weight to this view.
In a few instances trauma has preceded the discovery of the
tumor. Tilmann records a case where trauma preceded the de-
velopment, oi' at least the discovery of the tumor. Vander Veer
records one in which disturbance began soon after conscious in-
jury from lifting, and Homans one following severe bodily exertion.
In the majority of instances the insidious onset precludes the pos-
sibilit.v of establishing a definite period of time for its beginning.
Because of this both age incidence and relation to trauma may be
much obscured.
In harmony with relative frequency in the sexes in other regions
of the body id i-operitoneal lipomas are o])served more frequently
in ANunieu than in men. Accoixling to the collected statistics of v.
Vegesack in 97 cases in which sex is given there were 72 females
to 25 males. This corr-esponds vei-y well to Grosch's, avIio found
in 665 superficial lipomas 441 were in females.
TUMORS OF THE PERITONEUM 787
Pathogenesis. — As the name implies these tumors develop from
the retroperitoneal tissue. 01)viously they attain their origin from
tissue which has been disturbed in its development for a consider-
able area. This is indicated not only because of their structure and
diffuse development but because many of them bear relation to
the intramesenteric connective tissue, as is manifest by their ten-
dency to insinuate themselves into the intraabdominal spaces. As
already noted tumors developing from the retroperitoneal connec-
tive tissue tend to grow into the fossfe in this region and into the
retrocecal and retrocolonic connective tissue and in some of the
mesenteries. The gut may be displaced far beyond its normal con-
fines, and by this displacement a primary mesenteric origin may be
erroneously assumed.
Pean was the first to emphasize the paravertebral connective tis-
sue as the most frequent site of origin. Gol)el described the area
bounded by the iliac and psoas muscles, which extends up to the
lower pole of the kidney, as the most frequent site. As unusual
sites the retrorectal space may be noted, as in the cases of Chiari
and Neupert. Yander Veer records a case which had a bulging
in the back and at autopsy the tumor was found to l)e attached to
the kidney capsule. Johnston reported a case in which the tumor
seemed to have sprung from the broad ligament. The vast majority,
however, seem to find their chief attachment in the paravertebral
space about the height of the kidney. The site of origin has like-
wise a genetic interest.
The site of the origin can be pretty certainly determined by not-
ing the site of the chief blood supply. Konig, on the Imsis of a case
in which a tumor weighing 22 pounds was removed and in -which
at autopsy a secondary isolated tumor Avas found in the region of
the kidney, Avas led to formulate the hypothesis that there is a pri-
mary diffuse anlage extending from the space of Retzius through
Douglas space along the uretei- to the kidney region. Lexer made
a similai' observation. In many of the case reports it is noted that
secondary tumors extend for some distance from the main tumor.
Homans noted that these lipomata Avere prone to ])c formed from
many lobulations. In one of his cases there Avas a secondary lobe
situated some distance from tlie main tumor, connected only by a
fil)rous band. Tn nine of tlie reported cases more oi- less extensiA'e
788 THE PERITONEUM
lobulation Avas noted. In Schiller's case the number of accessory
lobulations suggests a relation to the peripheral symmetrical fi-
brolipomata. This is further suggested by Roux's case in which
one of the accessory tumors Avas fibroid in character. It would not
seem that we should expect anything different since lipomata in
other situations likewise are prone to accessory lobulations. This
is particularly notcAvorthy in the case of the lipomata in the ab-
ductor muscles of the thigh. Here the accessory lobules often ex-
tend long distances betAA'een the muscle planes or even into the
muscle substance itself. These tumors are particularly interesting
in this connection, for, judging from their tendency to secondary
metaplasia, they stand very close to the retroperitoneal lipomata.
Neupert records a case of a characteristic lipoma of the thigh which
extended through the obturator foramen, establishing a continuity
Avith a tumor in the pelvis. In one case reported, lipoma of the
thigh AA'as folloAved by a like tumor in the retroperitoneal space of
the lumbar region. Siiice that folloAved AA'ithin six months of the
remoA^al of the primary tumor a relation is possible.
The more rapid groAAth of these tumors as compared AA^th
lipomata dcA'eloping on the surface can be explained by their close
relationship to the sarcomata. Ebner suggests that the lesser re-
sistance the tumors encounter in the retroperitoneal space might
account for their rapid groAAth. This might be assumed in the be-
ginning, l)iit Avhen they become large they no doubt encounter more
resistance from the abdominal AA-all than from the loose skin unrein-
forced by muscle. Their more rapid groAA'th can more consistently
be ascribed to their procliAdty to myxoid and sarcomatous degen-
eration. Their riotous rate of groAA'th AA'ould almost Avarrant the
reA'ival of the ancient term "malignant lipoma." According to
Vegesack 42 of the recorded cases shoAved myxoid change. In six
cases sarcomatous admixture has been recorded. AVhether the
occurrence of sarcoma takes place in the connectiA'e tissue, as sug-
gested by Yockler, or from metaplasia of the myxoid tissue is dif-
ficult to determine. From my observations of analogous condi-
tions in the thigh I should lean to the latter possibility.
All these facts point to the probability that these associated con-
ditions receiA^e their anlage from the beginning and that retroperi-
toneal lipomata represent a A^ery embryonal type of tissue, and
TUMORS OF THE PERITONEUM 789
that rapid growth, myxoid and sarcomatous admixture are but
manifestations of a primary impulse. The simultaneous occurrence
of these various tissues seems expressive of a compound tumor
rather than a degeneration of a lipoma. The inherent close relation
to malignancy is even more apparent when the retroperitoneal
sarcomas are considered.
A clear recognition of this fundamental problem is desirable.
The idea of lipoma makes surgeons bold. Experience has proved
that disaster attends action on this concept. If the close relation to
teratoid tumors were recognized, surgeons would hesitate more
before proceeding to radical operation in the more advanced cases
and thus save disappointment or disaster.
Pathology. — Lipoid tissue with more or less intermixture of fi-
brous tissue constitutes the usual structure. In this they diifer in
no wise from lipomata of other situations. Their chief claim to dis-
tinction lies in their disposition to be associated Avith myxoid tis-
sue. In half of the cases collected by Vegesack there was a com-
bination with some other tissue. It may be noted in passing that
in many of the cases where its presence was not noted an alto-
gether insufficient microscopic examination was made and in many
of the cases the diagnosis Avas made on clinical grounds entirely.
It seems difficult to determine in a given instance whether the as-
sociation with their tissues shall be regarded as a degeneration or
Avhether both classes of tissue exist from the beginning and grow
side by side. The latter is probably the case. They also differ from
the usual type of lipomata by the disposition to form long arms
which insinuate themselves into neighboring spaces. In this ten-
dency they differ from superficial lipomata. A similar tendency
is noted in the lipomata developing in the abductor group of mus-
cles of the thigh. For reasons already stated it is quite possible
that the relation of these to the retroperitoneal tumors is closer
genetically than those of the subcutaneous tissue.
The myxoid tissue complicating these tumors is likely to be-
come sarcomatous. In fact iu many of the rapidly growing
lipomata a hyphenated relationship to the more malignant tumors may
almost be assumed to exist as a matter of course. Neupert reported
a case that lends weight to this view. Other cases have been re-
corded by Yegesack, AValdeyer, Gerster and Vockler. Since the
790 THE PERITONEUM
malignant areas may be small, prolonged search may be required
to find them. This is particularly true of the myxoid areas. I
once used a tumor of this sort as a supply of material for the pur-
pose of demonstrating the structure of a pure myxoma to a class
of students. Finally an area was found distinctly sarcomatous in
character. Inquiry disclosed the fact that the tumor contained
sarcomatous areas, the patient having died of a recurrence.
Cyst formation sometimes noted is probably due to liquefaction
of myxoid areas, though in a few cases an association with caver-
nous lymphangiomata may be assumed. Borst reports a case in
which he ])elieved the cysts were due to retention of lymph. De-
generative changes have no doubt accounted for some of the cyst
formations. Von Yockler reports a case in which a smooth-Avalled
cyst resulted from myxoid degeneration. Secondary changes of
other characters are sometimes observed. Most notable is the de-
posit of calcareous material, as in ]\Iadelung's case. At least half
a dozen of the recorded cases have shown such calcareous deposits.
Vestberg (quoted by Ebner) found highly organized bone.
Symptoms. — In all the reported cases the onset was insidious.
It was only after the tumor had attained a considerable size that it
was recognized. Preceding the discovery of the tumor there were
usually symptoms of an indefinite character. Most frequently a
sense of fullness, often associated with progressive weakness, was
complained of. Symptoms even more indefinite, as sleeplessness,
eructions, and cardiac irregularity were occasionally noted. Later
more distinct pressure symptoms appear; obstinate constipation,
distiirbance of respiration, and urinary disturbance, all due to pres-
sure, represent the more definite symptoms. Vesical tenesmus has
been reported by a number of authors, notably Koux, Biittner,
Gardner, and Adami. These symptoms are due, according to
Vegesack, to a retention hydronephrosis.
More directly suggestive are the obstructive symptoms on the part
of the blood vessels. Edema of the legs, scrotum, and vulva on the
affected side are significant. Even more so is the dilatation of the
venous plexus over the loAver abdomen. Ascites is :^entioned by
many, among whom may he mentioned ^Nladcluii^- and Terrillon.
When the possibility of the existence of a tumor becomes appar-
ent ascites and the lesions that produce it are simulated. The soft-
TUMORS OF THE PERITONEUM 791
iiess of these tumors makes early recognition difficult, particularly
if in addition fluid is known to exist oi- associated lesions which are
known to be capable of producing ascites.
Diag'nosis. — Once the existence of a tumor is recognized the ques-
tion of differentiation arises. Chagrin should not overwhelm the
surgeon, for only Ten-illon and Schiller (cited by ITeinricius) were
able to make the correct diagnosis before operation. The general
topographic relation to the large bowel is the most important
diagnostic point. The gut is carried on the summit of the tumor
and usually displaced toAvard the median line. When this relation-
ship is demonstrated many tumoi's whose presence may be sug-
gested may be excluded, notal)ly tumors of the liver, spleen, ova-
ries, uterus, omentum, etc. The lateral location of the tumor tends
to exclude uterine and ovarian tumors. AVhen bulging backward,
as in Vander Veer's case, extraabdominal tumors may be suggested.
When a retroperitoneal location is demonstrated, there remains
only tlic differentiation from other retroperitoneal tumors, notably
its fellow group, the retroperitoneal sarcomata. From these it dif-
fers in its more diffuse growth, softer consistency, and less definite
tumor formation.
From kidney tumors, the absence of any urinary signs, less pro-
nounced bulging in the renal angle, and softer consistency may
give the right clue.
Lipomata are so soft that extensive studies relative to their
mobility are not possible. Garkische suggests the use of the cysto-
scope to exclude any renal affection. A definite notion of the ca-
pacity of the opposite kidney might be of comfort when in the midst
of an operation where one kidney was surrounded by the tumor.
In days gone l)}^ when exploratoiy incision was less safe than
now, exploratory aspirations were done — always, of course, Avith
negative results. Because of the inability to locate certainly the
holloAv viscera, this practice is to be condemned.
Prog-nosis. — "Without treatment the increasing size of the tumor
tends to destroy the life of the patient, usually within the period
of several years from the time of the initial symptoms and a period
of months fi-oni the time of the discovery of the tumor.
The I'esult of operation is dependent on the toi)ography and size
of the tumoi' ;iiid th{> ahilily of the surgeon to ]n-operly ])];iii his
792 THE PERITONEUM
procedure. So far as the environment goes, aside from the ves-
sels, the neighboring organs may suffer injni-y. The gut and kid-
neys are most likely to be injured. Gussenbauer and Chanazan
were obliged to remove the kidney because of the close association
of this organ with the tumor. Several other operators inadver-
tently removed or injured the kidney. The gut may be injured di-
rectly as in Madelung's case, or the mesenteric vessels may be in-
jured and the nutrition of the gut endangered, as in the case of
Alsberg and Roux. Biittner believes that death in one of Tillaux's
cases "was due to the compression of sympathetic ganglia in the
depth of the Avound.
According to Vegesack the operative mortality approaches 38
per cent. "What is the ultimate fate of those Avho recover from the
operation is in most instances quite unknown. In a number of
cases it is specifically stated that recurrence took place Avith the
subsequent death of the patient, either from the tumor itself or
from repeated attempts at relief by operation.
Treatment. — AVithout a specific knowledge of retroperitoneal
lipomata it is quite natural that the surgeon should approach the
removal of such a tumor of whatever size with a great degree of
confidence. The recognition of the close relationship of these tu-
mors to the teratoid tumors of this region greatly reduces this rosy
view and clinical experience substantiates it.
The smaller the tumor, the greater the prospects for easy re-
moval. The multiple lobulations, some of which may extend to an
inaccessible situation or in close j^roximity to great vessels, makes
any operation fraught with uncertainty. Operators regularly re-
port that the operation offered greater difficulties than were an-
ticipated. Homans particularly emphasizes this point. In his cases
extra lobulations made complete removal impossible. The diffi-
culties this surgeon encountered are so graphically set forth that
one can fairly hear his pantings as he labored valiantly with the
huge mass. In Madelung's case also, complete removal was not
possible because of the extensive interdigitations with the neigh-
boring structures. In many instances enucleations progressed satis-
factorily until the depth Avas reached Avhen vessels of unantici-
pated size Avere encountered. In one case the A'ena caA^a was in-
jured in the effort to separate the tumor from it, and one case
TUMORS OF THE PERITONEUM 793
is described by ]\reier in which the aorta and vena cava -were in-
advertently included in a ligature in the frantic attempt to arrest
the hemorrhage. In Neumann's ease the blood supply to the colon
was destroyed to such a degree that the resection of the gut was nec-
essary.
So far as the technic goes, most operators have selected the
transperitoneal route. Ligation of vessels as they are encountered
and tamponade of the remaining cavity to serve in the dual ca-
pacity of drainage and hemostasis was the usual procedure prac-
ticed. Lexer alone Avas able to close without drainage.
Retroperitoneal Sarcoma
Under this caption are included only those growths derived from
the connective tissue and fascia of the retroperitoneal tissues. This
excludes tumors groAving out from retroperitoneal organs, includ-
ing the lymph glands. It also excludes those from embryonic tera-
toid anlages, since those tumors belong to the group previously
discussed. Their uniform structure, to be discussed below, makes
it possible to recognize a very well-defined group. Their close re-
lation to the lipomata has been considered.
The first clear description of retroperitoneal sarcomata Avas Avrit-
ten by Lobstein. Not only did he correctly recognize their topo-
graphic relations, but also gave a good gross' description of them,
but he confused them AAith lymphadenomata and tuberculous
affections of the lymph glands. VirchoAV separated out the true
retroperitoneal sarcomata and defined their origin more precisely
as from the fascias. There is still a tendency bj^ some to confuse
these tumors Avith those arising from lymph tissue. This error is
not justified, for the retroperitoneal sarcomata are in topography,
mode of groAvth. and histology Avliolly different from the lymphatic
tumors.
Keresztszeghy and Steele have collected and discussed the litera-
ture pertaining to these tumors.
Etiology. — In considering the pathogenesis it is necessary to
remember the close topographic relation to teratoid tumors of this
region. The frequency Avitli Avhich myxomatous tissue is found in
the sarcomata is additional evidence that there is a close relation-
ship to embryonal rests.
794 THE PERITONEUM
The various types predominating at different ages is further
evidence of relationship to congenital tumors. In early life, be-
fore ten years of age, a A^ery cellular type predominates. Unfor-
tunately in a number of reported cases there seems to have been
no distinction betveen primary sarcoma and the more common
teratoid tumors Avell known to he predominant in this period of
life. Likely those tumors reported as retroperitoneal sarcomata
in children all belong to the teratoid group. The most frequent
occurrence of the typical retroperitoneal sarcomata is between
thirty and fifty years. After sixty they are rarities.
Males seem to be slightly more frequently affected than females.
The difference is too slight, hoAvever, to make it likely that sex is
other than a coincident factor.
Pathogenesis. — The origin of these tumors is confined to the
fascia aljout the spinal column, particularly at the height of the
renal arteries. AVhat has l^een said relative to the topography of
the lipomata of this region may be repeated here, as might be
inferred from their close structural relationship. Adami expressed
the opinion that all sarcomata are ingrafted on lipomata.
Pathology. — These tumors are usually spheroidal with numerous
prolongations and lobulations. They are usually soft, sometimes
semifluctuating, l)iit may lie quite firm if connective tissue predom-
inates. Usually the smaller ones are the most dense. On section
they are j^inkish Avhite and glistening. Areas of myxomatous de-
generation are often seen sometimes in more or less advanced states
of liquefaction. Not infrequently complete liquefaction with cyst
formation takes place. Sometimes hemorrhage takes place in these
softened areas and there result tlien lilood-filled cysts or hemor-
rhagic infiltration of solid areas.
The typical structure of retroperitoneal sarcomata is identical
Avith the predominant type in the OA'ary. They are uniform spindle-
celled tumors or mixed-celled tumors Avith loosely arranged con-
nectiA'e-tissue bundles. The nuclei are usually of many shapes and
sizes, often showing deeply staining clumps as though regressiA^e
processes Avere present. When more actiA'e groAvth takes place, as
often happens in an attempt at complete or incomplete removal,
the cells are much more numerous proportionately and assume the
picture of a round-celled or mixed-celled type.
TUMORS OF THE PERITONEUM 795
In the recorded cases many unusual cell types are reported.
From some of the reports it is evident that mixed tumors have been
included. It is possil)le that in some situations unstriped muscle
fibers may be included, as in the case of INIcGraw and Steele, but
if this tissue is present in abundance, the possibility of the exist-
ence of a mixed tumor must be considered.
Symptoms. — The onset as in the case of the lipomata is always
insidious, there 1)eino- a gradual onset of pressure symptoms ex-
pressed either as pain or edema of dependent parts, particularly
the legs or scrotum. Usually investigation instigated by the pres-
ence of one or other of these phenomena results in the discovery
of the tumor. Pain in the region of the distribution of the nerves
may be present. The lumliar region or down the legs are the
dominant sites. Sometimes unexplained areas .are involved. Ellis
reported a case in which in addition to edema of the scrotum the
left lung and left side of- the face Avere involved. Steele explains
the pain by pressure on the sympathetic system. In this connec-
tion it is well to remember that Elliott and Virchow reported cases
in which thrombosis of the femoral vein complicated the condition.
Pressure may, besides causing pain and edema, interfere Avith
the function of neighboring organs. The gut tract naturally re-
ceives the brunt of such offense. Osier reported a case in which
there was polyuria without sugar.
Diagnosis. — Retroperitoneal sarcomata must first be diagnosed
as a retroperitoneal tumor. This having been established, differ-
entiation from other retroperitoneal masses may be considered.
The chief point in determining the retroperitoneal character of
any tumor is. the determination of its relation to the colon. The
tumor arising behind the peritoneum either carries the colon on
its summit, particularly if, as is usually the case, the tumor grows
into the connective tissue l^ehind the colon and carries the gut
on its summit or displaces it to one side or the other. The trans-
verse colon usually describes an arch along its lower border. The
position of the colon may be located by inflation, or l)elter still
by means of barium and the x-ray.
The stomach is apt to suffer the same displacement as the trans-
verse colon, but is more likely to l)i» elevated than depressed, or
pushed to the left, or to the let'1 and dowuAvards.
796 THE PERITONEUM
Ketroperitoneal tumors present less mobility than intraperito-
neal tumors and move less with the respiratory excursion of the
diaphragm.
After all the data have been considered, the exploration by opera-
tion is the final deciding point. Fortunate is the observer who is
able readily to determine this point once the abdomen is opened.
Once the diagnosis of retroperitoneal tumor is made, retroperi-
toneal sarcomata must be differentiated from other tumors occur-
ring in this region. Tumors proper to retroperitoneal organs and
the teratoid must be excluded.
Tumors springing from the kidney when small and occupying
their place in the loin may be distinguished by bimanual palpation
with a high degree of certainty even in the absence of urinary
findings. The ability to cause the tumor to present to the examin-
ing finger at the lower border of the twelfth rib is particularly
characteristic. Larger tumors occupying a considerable portion of
the lateral half of the abdomen can not be so readily distinguished.
The general fixity of the tumor and the displacement of the colon
by the tumor may signify its location but its nature may be open
to doubt. Metastatic tumors may resemble both renal and retro-
peritoneal sarcomata. I once observed a striking illustration of
this difficulty in diagnosis. A man of twenty-three presented a
tumor extending from well under the costal margin above, full to
the spinal column medially, and beloAV it rode in the fossse of the
false pelvis. It was irregularly oblong, the lateral border repre-
senting the arch of a smaller circle than its median border. The
surface was marked by moderate undulations. The region near
the upper part was firm but slightly elastic. The lower portion
was softer but not fluctuating. One was unable to rock it inde-
pendently of the skeleton, but it evidently was attached to the
fascial structure of the paravertebral region. It presented less
mobility than even the large renal tumors usually do. Its exten-
sion well into the iliac fossa and its apparent fixation there made
it particularly resemble a retroperitoneal sarcoma. Its huge size
also indicated the same thing. Besides there were no urinary signs,
neither was there any history of there having been any. Notwith-
standing the fact that the diagnosis of hypernephroma was made
by exploratory incision by another surgeon, the diagnosis of retro-
TUMORS OP THE PERITONEUM 797
peritoneal sarcoma "was made, but operation obviously Avas not
possible. At autopsy many ai'eas of extensive hemorrhagic infil-
tration mingled with cellular areas were encountered. Further
search discovered the primary nodule in the left testicle. The pa-
tient had not mentioned the presence of this tumor and none of
the examiners discovered it.
The location of adrenal tumors suggests the differentiation.
When an adrenal tumor first appears it presents itself at the costal
border of the eighth rib, according to Israel. Sarcomata usually
present lower down and are usually attended by fewer symptoms
in proportion to their size. There is apt to be paresthesia of the
lumbar j^lexus, often a rise of temperature and in some instances
a bronzing of the skin. Israel "warns against mistaking compres-
sion of the common duct ])y some other kind of tumor Avith at-
tendant jaundice for the discoloration due to adrenal disturbance.
Tumors of the pancreas bear much the same relation to the colon
as sarcomata. Because of the location of the pancreas above the
transverse colon, its tumors tend to Inilge above it. The colon is
most likely, therefore, to lie along its lower border. Harris found
this to be the case in 95 per cent of 34 cases of pancreatic cysts
observed. Sarcomata usually lying loAver tend to carry the colon
on their upper border. This is not true, of course, when sarcomata
arise above the pancreas. The high location may bring even the
stomach below them. Cysts, the commonest tumors of the pan-
creas simulating sarcomata, are often accompanied by rapid ema
ciation, which is not the case in sarcoma. The exact median loca-
tion is less common in sarcoma than in pancreatic cysts. Solid
tumors of the pancreas are usually carcinoma. The dense nodos-
ities together with the general symptoms accompanying usually
make the diagnosis easy.
Teratoid tumors of the retroperitoneal tissue are usually ob-
served in children. They are round tumors, dense, oi- dense elastic,
and usually present just below the costal margin. AVhen these
tumors appear in later life they are more dense.
Prognosis. — Retroperitoneal sarcomata are ahvays fatal. Free-
dom for several years is sometimes obtained, Init recurrence follows.
Treatment. — AVhen globular, removal is not attended l)y unusual
difficulties since, being expansile in growth, they lend to i)i'ess the
798 THE PERITONEUM
large vessels aside. "When they present intercligitations "which
extend among the vessels removal is impossible. Recurrent retro-
peritoneal sarcomata are ahvays inoperable.
Tumors of the Omentum
The tumors of the omentum parallel those of the mesentery, as
might be expected, but the peculiarities of the function and topog-
raphy of the omentum give its new gro"\\i;hs a certain degree of
individuality.
The vast majority of tumors of the omentum are solid, and con-
sist of malignant deposits derived from some other source, but
many tumors have their beginning in the omentum. These tumors
are necessarily limited to the development of histologically normal
tissues, or those arising from the limitless growth of these tissues.
To these must be added congenital anomalies involving this struc-
ture itself or some organ morphologically moi'e or less closely re-
lated. These may be considered in order.
Lipomata. — Collections of fat within the omentum are not ex-
ceptional. These may assume the aspect of tumors, but so long as
they maintain dimensions proportionate to the general adiposity
of the individual, they can not be classed as tumors. Huge lipoma-
tous masses which can not be dignified by the name of tumor, may
be o])served in obese persons. For instance, I once operated on a
very obese woman with a huge abdomen. The abdominal enlarge-
ment had developed in a period of 18 months without any consider-
able increase in the general adiposity. An indefinite mass could
be felt in the pelvis which was resilient, if not fluctuating. Since
dyspnea was becoming progressively worse without evidence of
cardiac decompensation, the possibility of the presence of an ova-
rian cyst was accepted. If that were the case relief by operation
seemed a possibility. Since the patient could not lie down, opera-
tion was undertaken under local anesthesia with the patient sitting
on the edge of the table, the operator sitting between the spraddled
legs like the old time obstetricians seated themselves while aiding
a parturient woman. When the abdomen was opened I encoun-
tered a huge mass of fat which filled the whole abdomen and was
at least 6 inches in thickness. It seemed to be the uniformly
enlarged omentum. If such a tumor Avere discovered in a sparse
TUMORS OF THE PERITONEUM 799
individual 1 might well have regarded it as a tumor. Since such
accumulations are often seen in lesser degrees and nearly always
diffusely distributed over the entire omentum, these had best be
excluded from the present consideration.
Minor local accumulations are often noted. Most notable in
this category are the hypertrophied appendices epiploiese. These
not infrequently are as large as walnuts and sometimes as large
as moderate-sized oranges. Such conditions also are observed only
in obese persons, and therefore can not properly be regarded as
tumors. Sometimes these masses are associated with excessive
lipomatous accumulations in other parts of the body. I recently
noted epiploic tags as large as small oranges in a woman who bore
masses as large as a quart cup situated about the shoulder and
hips and on the medial side of both knees. The subcutaneous tu-
mors bore all the landmarks of true lipomata and possibly the
epiploic hypertrophies deserved such an appellation. At any rate
the patient was gratified to learn that the external accumulations
were lipomata and not "just fat." Malifert (cited by Ebner) re-
ports a case in which a twelve-pound lipoma sprang from an ap-
pendix epiploica of the sigmoid flexure.
Much confusion exists in the literature relative to what should
be regarded as mesenteric lipomata. Thus Prutz and Monnier
discuss under the heading of lipoma of the mesentery many tumors
that are unquestionably retroperitoneal in origin. Lower includes
Homan's cases in this category. These were chiefly retroperitoneal.
He also includes Mendeth's case as well as J. Cooper Foster's. In
some of the reported cases retroperitoneal lipomata in their devel-
opment carry the colon with them and become attached to the
omentum, and in this way in a measure insinuate themselves be-
tween its layers but in doing so do not, as pointed out by IMunro,
thereby repudiate the land of their nativity.
Other lipomatous masses become developed within the omentum
as the result of accidents. It is not unusual to find huge masses in
the omentum in umbilical hernias. I once removed a mass weigh-
ing eight pounds from this location. The same condition may be
observed in hernias of other locations. For instance, I once re-
moved a mass of fat the size and shape of a cocoanut from an
irreducible scrotal hernia in an old man. It had received attach-
800 THE PERITONEUM
ment to the base of the sac and the omental attachment was no
larger than a lead pencil. It was dependent quite as much on its
secondary attachment for its nutrition as upon its original omental
connection. Partial torsion of the omentum may be followed by
more or less massive accumulations in the distal part. These may
appear as tumors in the vulgar sense, but they bear none of the ear-
marks of true neoplastic growths and their consideration may be
deferred to their proper section. Edebohls reports a case in which
an omental mass was adherent to a degenerated fibroid, and an-
other in which such a mass surrounded a recalcitrant tube and
ovary.
A case is reported by Legiardi-Laura, in which a tumor the size
of a goose egg lay on the anterior aspect of the great omentum
which was connected with the omentum by a thin vascular pedicle.
Lower's case pi-esented three lol)ulati()ns in the lower left termina-
tion of the omentum.
When all these facts are considered it becomes clear that greater
accuracy in reporting this class of tumors is needed.
Sarcomata of the Omentum. — Primary sarcomata of the omen-
tum are less common than m the retroperitoneal tissues. The litera-
ture is very much confused. Many of thef cases reported as such
are distinctly endothelial in character. In general two classes may
be distinguished, the diffuse, in '\\hieh the entire omentum is thick-
ened, and the localized, in Avliich a distinct tumor nodule occupies
some part of the great omentum. The former is very closely
related to the endothelial tumors, the latter to the mesenteric
sarcomata.
The attempt to form a definite picture is made much more dif-
ficult by the attempt of authors to escape the difficulty by using a
straddle term. Thus Miller employs the term "endothelial sar-
coma." Happily here, in spite of the misleading title, a cut and an
excellent word picture by D. S. Lamb show the tumor to be an
endothelioma.
The diffuse variety forms a thickened mass which covers the
entire al)dominal contents. Cobb reports a case in Avhich the omen-
tum resembled a bath towel, forming a mass an inch thick, cover-
ing the intestinal mass. Matas compares his case to a sponge, and
notes that it was friable and presented a trabeculated stroma in
TUMORS OF THE PERITONEUM 801
meshes of which was a translucent gelatinous stroma. The mass
is made up of nodules varying in size from a pinhead to a hazel-
nut or larger. It is reddish gray in color, friable for the most part,
and necrotic in some places.
I confess an antipathy for this group. The whole picture is
contrary to that presented l)y all kinds of sarcoma in any other
part of the body. Sarcomata tend in general to develop in an
expansile manner. On the other hand endotheliomata in serous
surfaces tend to cover wide areas. Before a diagnosis of sarcoma
of the diffuse variety is made it should be subjected to the closest
scrutiny. Probably more often than has been suspected, they rep-
resent secondary tumors, as Boormann has contended. Probably
some of the diffuse examples were nothing more than chronic
reactive processes. Those which are friable and show degenerated
areas are always open to suspicion. Unfortunately the after his-
tory of such cases is generally lacking. AVithout this he must be
a brave man who ventures a positive opinion as to their nature.
The typical sarcomata form rounded bosselated tumoi-s, piiddsli
gray in color, showing a til)rous network on section. Anders re-
ports a typical case of this type in the following Avords, "large
whitish pink, nonvascular, markedly lobulated and fun-owed tumor
mass. ' '
Pathog-enesis. — Little can be said about the factors which ante-
date the development of these tumors. Tate reports a case in
which at pi'imary operation an omental mass extended into a scrotal
hernia and enveloped the cord and testicle. The thickened mass
extended somewhat into the abdomen. This was diagnosticated
round-celled sarcoma. This was evidently correct, for in sixteen
months the patient presented himself with a large mass in the
abdomen. The interesting feature is that this patient had pre-
viously had his hernia treated by paraffin injections and at opera-
hoii lariie masses of this substance were found al)<>ut the lu'rnial
ring. It is well known that paraffin oil has the property of stimu-
lating cell proliferation and there may have heen some connection
in this instance.
Pathology. — The tumors reported have usually presented spindle
cells with rather abundani fibious tissue or interspersed A\ith
myxoid tissue. AVoolsey reports a case in A\hi('h the first tumor
802 THE PERITONEUM
removed was reported by the pathologist as a fibroma. A recur-
rence was recognized as fibrosarcoma. Eound-celled tumors occa-
sionally occur. Segond reports a case in Avhich a melanotic tumor
in an omentum was attached to a uterine myoma. The presence
of melanin is explained by the fact that the patient had had an
eye removed four years before, therefore it obviously was a sec-
ondary tumor. Capelle reports a case of lymphosarcoma. There
was an ulcer in the region of the pylorus. The author thinks this
was the primary lesion. This would be unusual since sarcomata
in that situation are not prone to ulceration. Goldenstein reports
a case in which a cystic sarcoma was discovered in the pelvis four
years after a sarcoma of the uterus had been removed. The ques-
tion here, the author thinks, is whether this tumor was primary or
secondary to the uterine tumor. He would be quite safe in assum-
ing that it Avas secondary. It is always precarious business to diag-
nosticate a tumor as primary when a representative of the class has
existed elsewhere in the body.
The gross appearance of the nodular type is that of a lobulated
mass, light gray or pinkish in color. The blood vessels traverse
the constricted region. On section they are semilucent and in
areas may be cystic.
The diffuse variety is composed of lobulations usually described
as varying from pinhead to grape size or larger. In some instances
they have been pedunculated. The tissue is mottled grayish red,
sometimes hemorrhagic.
Symptoms. — ^Gradually increasing Aveakness, nausea, vomiting,
loss of flesh and strength are the phenomena that usually antedate
the discovery of the tumor. Swelling of the feet is sometimes
noted but much less constantly than in retroperitoneal tumors.
These tumors differ but little therefore from similar tumors aris-
ing elsewhere within the abdomen. Cobb made a clinical diagnosis
of malignant disease of the large gut. In a case reported by Cabot
the first symptom noted was a hematuria, a phenomenon easily
explained by the fact that the tumor had invaded the bladder wall.
The tumor is often obscured by a coexistent ascites. When the
tumor is diffuse, its demonstration by palpation is more difficult
than Avhen localized and nodular.
The onset may be acute, simulating peritonitis. Capelle reports
TUMORS OF THE PERITONEUM
803
a ease diagnosed as an acute peritonitis. The acute symptoms in
this case may be exphiined by the fact that a recent hemorrhage
into the peritoneal cavity had taken place. Such an error would
be invited if in addition to pain a leucocytosis should exist.
Cobb records a case in which there Avere twenty-three thousand
leucocytes.
The degree of pain varies. Usually it is vague and indefinite.
In a ease reported by McLean there was pain severe enough four
years before to require morphine for its relief. This case is further
remarkable by the fact that throughout the source of the disease
severe pain was caused by a sudden twist of the body.
Diagnosis. — As intimated, the surgeon will do a creditable act,
and incidentally confer a favor to oncologists, if he will make a
satisfactory diagnosis after operation with all the aids available
in such cases.
Treatment. — A few have l^een followed by relief for a period
following operation. Cabot, notAvithstanding the involvement of
the top of the bladder and a loop of the terminal ileum, necessitat-
ing the resection of these, secured relief for his patient for at
least three years. Bonamy and Bonamy secured a recovery from
operation from a large spindle-celled sarcoma. IMeLean also se-
cured relief for at least three years following a resection of the
transverse colon. Woolsey operated three times and at last
accounts his patient was free.
Usually, however, the treatment has consisted in exploratory
laparotomy with more or less satisfactory exploration. It is very
difficult in such cases to determine the point of departure of the
tumor.
Douglas lost his case from secondary gastric hemorrhage.
Fibromyoma of the Omentum. — The fcAV tumors that might pos-
sibly belong under this caption have stirred up considerable dis-
cussion as to their genesis. They must needs come either from a
gut wall, then not omental in origin, or they must arise from some
muscle source in the omentum. Obviously only the vessel walls
could be the source. Klebs advanced the theory that myomata of
the uterus arose from the vessel Avails of the uterus. Lubarsch
assumes a similar source of origin in sarcomata of the stomach.
Cohen could find evidence of vascular genetic origin in only three
804 THE PERITONEUM
out of fifteen eases. Aiiitsehkow in tlie examination of myomata
of the coi'dia found evidence for origin about vessel walls. Orloff
failed to find any relation lietween the vessels and the tumors.
My own observations in seedling myomata of the uterus have been
in accord with this.
Sarcoma of the Omental Bursa. — The tumors described in the
literature as l)eing native to the lesser peritoneal cavity form a col-
lection from which no definite picture can be formed. Obviously
a tumor growing out from any of the contiguous structures and
developing into this region may retain little evidence as to its
nativity. This is particularly true of the malignant types. A
number have been reported, the origin of which has been laid in
this region. Gross and Sencert report a case in which the tumor
arising from the lesser omentum spread to the greater. Kaufmann
described a tumor, the size of a man's head, in the lesser omentum.
Secondary masses resembling hydatidiform moles covered the wall
of the stomach and great omentum. Walcker reports a large cystic
tumor witli t^\"o distinct cavities the one of which was infected due
to ulceration of the mass into the lumen of the stomach. Miodowski
reports a case of a solid spheroid tumor going out from this region.
Lohfeldt reports three cases. In the first case there Avas a tumor
the size of a swan's egg Avell encapsulated. On section it was yel-
lowish, translucent for the most part with darker areas. Fibrous
bundles divided it into large lobules. It contained a number of
small cysts. The cjipsule Avas intimately adherent to the stomach
and colon. A small opening in the stomach Avail communicated
with one of the cysts. Two openings united the lumen of the colon
Avith other cysts. It Avas formed by round cells intermixed Avith
spindle cells. His second case presented a massiA'e tumor of soft
consistency and grayish red color Avliich took in all of the left
half of the abdomen. Whitish grape-like tumors hung from the
diaphragm. One of these smaller tumors Avas examined and found
to be made up of round cells Avitli large dark nuclei. In some
regions a limited number of spindle cells Avas obserA^ed. The
third case a tumor the size of two fists was situated l)ehind the
colon and stomach. The great curvature Avas united Avith a tumor,
the interior of ANiiicli coiumunieated through a perforation the size
of a finger. The tumor Avas composed of spindle cells.
TUMORS OF THE PERITONEUM
805
From the foregoing it is apparent that these tumors do not differ
from other omental and mesenteric tumors and their interest is
purely a topographic one.
Tumors of the Gastrocolic Omentum. — New growths in this lim-
ited field are not numerous. Clarke reported a case in a woman
aged fifty, who had an ahdominal tumor of four years' standing.
A large tumor occupying the space between the layers of the small
omentum was found. It was fibroid in structure. Gould reports
* • . • ' . - • • , ■- -Jfy •*■■ -^ V; ^ i^
t '
//^
■>;^V •',^.- .^ V- J
Fig. 218. — Wandeiing tumor of the alxiomiiial cavity. The lower left picture shows the
tumor somewhat reduced in size in its normal state. The upper picture shows the same in
section about the natural size. The right i)icture shows a moderate magnilication. The cen-
tral area is degenerated fat, while the upper border shows the capsule of newly developed
librous tissue.
a ease in a nude aged thirty-eight, in whom a tense, firm, roundish
tumor extended from the tenth costal cartilage along the left semi-
lunar line ti> the pubis, filled out the right groin to the eleventh
rib on the right side. The tumor i)ushed the stomach and intestines
into the pelvis. It was successfully removed. ^lurphy reports a
case in which a liaid mass extended from the tij) of the sternum to
four linuers below llie umbilicus and laterallv into llie riglit and
806
THE PERITONEUM
left hypochondria. It could be moved both laterally and hori-
zontally. The tumor had caused no symptoms. At operation it
Avas noted that the tumor developed from the posterior portion of
the gastrocolic omentum and extended downward on the posterior
wall of the stomach, elevating the posterior peritoneal layer. Veins
as large as the index finger lay on the posterior surface of the
tumor. On section it proved to be a fibroma Avith areas of myxoid
degeneration.
Fig. 219. — ^Wandering tumor which has secured secondary attachments to the omentum.
The structure of this nodule was the same as the preceding but the connecting fibers sug-
gested a recent origin.
Wandering- Tumors of the Peritoneal Cavity
I have seen a number of tumors floating free in the abdominal
cavity which resemble very closely similar bodies in the knee
joint. It seems likely to me that they are derived from the pinch-
ing off of fat tags. When entirely free (Fig. 218) they are covered
by a thick fibrous membrane resembling that covering corn pith
that has been placed in the abdominal cavity. The interior is made
up of fat cells in varying degrees of preservation and sometimes
crystals are intermingled. I had one specimen (Fig. 219) in Avhich
TUMORS OF THE PERITONEUM
807
the mass was attached to the edge of the omentum by fibrous bands.
This attachment obviously was secondary. Many tlieories have been
advanced as to tlie origin of these bodies. Emmert has recently col-
lected them, together with an abstract of the cases reported, 38
in all.
Fig. 220. — Carcinomatous mass in gastrocolic omentum in a case of carcinoma of the pylorus.
Advancement was by direct extension. The great omentum was not involved.
Secondary Tumors of the Peritoneum
The commonest tumors of the peritoneum are those occurring
in conjunction with tumors of other organs. The most common
primary seat in such instances is in the stomach, and next most
common is the ovaries.
808
THE PERITONEUM
'' ^M
/■J
rUne/
^A\
^K*-*'- ' ■'^***!i^^^i^l
.-, .;^Ai. «M!^.,-.!<,-^
l-'ig. 221. — In contrast with the preceding the great omentum was converted into a huge mass
by secondary invasion of carcinoma secondary to carcinoma of the stomach.
Pathogenesis. — In general four varieties may be distinguished
according to the manner in which they spread from the primary
seat to the secondary deposits in the peritoneum ; namely, by direct
TUMORS OF THE PERITONEUM
809
extension as in most colloid tnmors, by superficial dissemination
as in papillary cysts of the ovary by hematogenous dissemination
as in diffuse sarcomatosis, and by dissemination with reaction as in
pseudomyxoma peritonei.
B}) Direct Extension. — In a great many tumors of the gut tract
there is a direct extension to the peritoneum from the affected part
(Fig. 220). Few carcinomata of the gut it may be said run their
Fig. 112. — Secondary tumor of the mesentery. A newly developed fibrous capsule covers in
the implanted tumor nests.
course A\ithuut some iuvohcment of the omentum and mesentery
and often late in the disease the secondaiy disease far overshadows
the primary growth in pathologic dignity. This extension at first
often involves the lymph glands only, but later many nodules may
be scattered throughout Avhere no lymph glands norinally exist.
These secondary implantations may extend by direct growth
810
THE PERITONEUM
V c ^f~^. * ■'. - ;
'y ■'■■^-
Fig. 223. — Secondary glandular carcinoma of the omentum. The mother type of tumor struc-
ure is accurately preserved.
through the connective tissue spaces, or along the lymph and blood
vessels. In some instances the entire omentum or mesentery, may
be changed into a solid mass (Fig. 221). Very often in carcinoma
of the stomach large masses are formed in the upper abdominal
region which when exposed are found to be tumors in the gastro-
TUMORS OF THE PERITONEUM
811
Fig. 224. — Secondary carcinoma of the omentum from a papillary cystoma of the ovary.
Cysts containing fluid as well as small papules are formed in tissue otherwise thickened by
diffuse carcinomatous infiltration.
Fig. 225 — Secondary carcinoma of the ueritoneuni of the anterior abdominal wall. In this
case the entire surface was covered with nodules causing it to resemble tuberculosis.
812 THE PERITOXEUM
eolie onientuin. This extension may travel somewhat circuitous
routes. In a case of hypernephroma I found large masses in the
omentum. There was no direct attachment and the possibility of
extension througli the l)lood stream must be considered, for in this
case the tumor mass extended from the kidney to far up the cava.
Extension hy Dissemination. — In papillary serous ovarian cysts,
often the cyst Avail has ruptured allowing the tumor mass to be-
■'M0
A ,'
'/ - .
t"
'^
M
,#>!
S*'.
^ ^-.M^'^C ■[-'■ ^ ^' ,.^
=^?.
Xi
i^fij
Fig. 226. — Colloid metastasis in the omentum. In most alveoli all cells are degenerated. In
others a single layer has been preserved.
come exjDosed, particles break off and scatter over the peritoneum
and there become implanted. These "heal in" just as a foreign
l)ody does (Fig. 222). Their presence excites a reaction on the
part of the jicritoneum which in turn exudes its plastic material
and a fibrin network covers the tumor tissue. Growth then
continues.
This type is of interest because the mother tissue may be re-
TUMORS OF THE PERITONEUM
813
produced in the peritoneum, the glandular (Fig. 223) papillary or
even cyst (Fig. 224) formation may be continued in great perfec-
tion. Curiously enough these daughters are sometimes dependent
on the mother tumors for continued existence, for when the pri-
mary tumor is removed the secondary ones maj^ disappear.
Unfortunately this takes place only rarely.
Hematogenous Dissemination. — In those instances where the en-
-jf »
''^'rjM:-
Fig. 227. — Syncytial masses of the omentum secondary to papillary cystoma of the ovary.
Some of these nodules closely resemble true syncytioma. There were no sucji areas in the
primary tumor.
tire body becomes studded l)y secondary tumors, the peritoneum
obtains its share (Fig. 225). I recall one case in Avhieli a cai'ciiKMn;!
became diffusely disseminated. An industrious intei-ne counted
more than a thousand in the skin, but when the peritoneum was
exposed he gave u]) his mathematical task in despair. I saw a
similar case in Avhich a melanoma of the temple which had been
814 THE PERITONEUM
"cured" bv a plaster gave rise to a similar Avidelv distributed
tumor formation. Among the curious things in medical literature
are those cases of melanotic tumors which are recorded as being
primary in the peritoneum. I recall one case in which a mela-
notic tumor of the eye had been removed three years before, yet
the tumors in the peritoneum were declared to be primary.
Dissemination with Reaction. — In a small group of tumors the
peritoneum reacts against the intrusion of the tumor mass. This
condition is called pseudomyxoma peritonei and because of the
great interest attached to this condition it is treated as a corollary
to this chapter.
Pathology. — Secondary tumors of the peritoneum are interesting
because of their structure, because they may retain very closely the
structure of the mother tumor or may depart astonishingly widely
from it. As an example may l)e mentioned the small epithelial-
lined cysts seen secondary to ovarian cystomata. Little less re-
markaljle is the glandular fidelity often seen in tumors of the
colloid cells of the gut tract. Here the simple colloid gland cell
may be retained with the production of huge masses of colloid
material rivaling in mass the pseudomucinous material in pseudo-
myxoma peritonei. This colloid material may destroy the cells
which produced it, at any rate alveoli filled with colloid material
but without a trace of a cell, or any del)ris of them, are found
(Fig. 226).
As an example of wide deviation those cases may be cited in
w^hich large syncytial masses containing several nuclei are found
(Fig. 227). These are called syncytiums by some writers, but where
there is no primary source there is no reason for hypothecating
them. Personally it does not seem to me unreasonable to assume
that these syncytial masses are the product of the endothelial cells
due to irritation by tumor cells of other genesis. I have seen sev-
eral instances of this kind occurring in association Avith papillary
cystomata of the ovary.
In some instances there seems to ])c no structural relation be-
tween the primary tumor and the secondary tumor in the mesentery
and omentum and such relation can only be hypothecated on gen-
eral grounds. For instance in a case of hypernephroma with asso-
ciated tumors in the mesentery it is only ordinary caution, based on
TUMORS OF THE PERITONEUM 815
a knowledge of the variety of multiple tumors of pi-imary origin
that causes us to accept such a relationship despite the fact that
there is no structural similarity.
Symptoms. — "When a malignant tumor secures a secondary es-
tablishment in the peritoneum it manifests itself either as a mass
or by exudation. The appearance of the mass is usually superim-
posed on the symptoms produced by the primary malignancy. This
is not ahvays the case, however, particularly in carcinoma of the
stomach. A mass in the gastrocolic omentum may appear before
there is any evidence of gastric distress. Exudate may appear as
the first symptom, particularly Avhen secondary to papillary tumors
of the ovary.
Diagnosis. — Secondary tumor masses are dense even in the col-
loidal type and are usually so typical that their discovery clears up
the diagnosis, if any existed before. In the case of a dominating
exudation there may be some difficulty even after the peritoneum
is exposed. This is true only in the case of miliary dissemination
because of the close resemblance of these nodules to tubercles
(Fig. 228). If the primary tumor is recognized, the differentiation
may be easy, Init even the recognition of the primary tumor may
not be easy. A localized tuberculosis of the gut may be surrounded
by tubercles which closely resembles a carcinoma with local dis-
semination. I have seen a number of instances in Avhich a
laboratorj;- examination Avas necessary. Age is no criterion for I
saw a carcinoma of the transverse colon in a boy aged eighteen
with dissemination that resembled a tuberculosis very closely. In
some of these cases a degree of care needs to be exercised even in
the examination of the section, for in tuberculosis the endothelial
elements may so dominate the field that a malignancy may be sus-
pected, and on the other hand a malignant cell nest may be so pro-
fusely surrounded by round cells that a very young tubercle may
be diagnosticated. The most helpful sign at the operating table
is the shape of the nodules. Tubercles are often oblong and may
show tiny bosselatioiis while the cancer nodule growing expansilely
does not have these nodules and may show some tendency to uml)ili-
cation. Usually, too, in carcinoina there Avill Ije some nodules too
large to classify as tubercles.
Sometimes fluid obtained at operation or by aspiration may show
816
THE PERITONEUM
large epithelial cells which may aid in the diagnosis of malignancy.
The tluid from tuberculosis of the peritoneum shows a predom-
inance of lymphocytes.
Fig. 228. — Miliary carcinosis of the peritoneum. Some of the nodules show dimpling. There
is less tissue reaction than in tulierculosis.
Prognosis. — Save in case of carcinomata following papillomata
of the ovary, the prognosis is al)solutely bad. In the case
of these if the primary tumors can be removed and the secondary
tumors are young, the removal of the primary tumors is advisable.
TUMORS OF THE PERITONEUM 817
Carcinoma of the peritoneum in conjunction with solid tumors
of the ovaries does not admit of any treatment. These tumors are
often associated with carcinomata of the stomach, and death usu-
ally follows within a few weeks if any treatment is undertaken.
Treatment. — In addition to the remarks just made, in extensive
exudation temporary relief may be obtained by Avithdrawing some
of the fluid.
Pseudomyxoma Peritonei
Under this title is described a condition of the peritoneum in
which masses of gelatinous material are diffusely distributed over
wide areas of the peritoneum, either as a homogeneous layer or as
cyst-like masses. This condition follows bursting of ovarian cysts
or cystic appendices, and possibly other tumors. The relation of
this material to the peritoneum may be purely a passive one ; or
it may be responded to by the usual reactive processes, or real
secondary tumor proliferation may occur, or a combination of
these.
It is more questionable whether the term employed fits all these
conditions or any of them. On the contrary, the term should be
regarded as purely symbolical and in no Avise be regarded as preju-
dicing the pathogenesis. In the first place a negative attribute
furnishes a poor basis for a designation. In the second place the
name given the condition is based on an erroneous conception in
that the substance under discussion is mucoid and not myxoid.
If we were sure that that substance was identical with the product
of the cysts the condition arises from, we might employ the term
pseudomucinoma peritonei. Until such a time, however, as Ave
shall have a proper term for iiseudomuein Ave may as Avell employ
the couA'entional term above accepted.
In a number of instances in the older literature cases have been
described Avhich set forth more or less clearly the condition noAV
being considered, as for instance, Atlee describes a ease that may
belong here. Schroeder ami Pean eacli report several prol)able
cases. IMore clear are the cases reported by Beinlich. It is Avorthy
of note that SalkoAvski i-ecovered mucin from one of the cases.
Menning noted its association witli ruptured ovarian cysts and
studied the reaction produced on the part of the peritoneum, and
818 THE PERITONEUM
expressed the opinion tliat this membrane became active in the
production of the substance. Menuing was the first to present a
microscopic study. Though Werth gave no better description than
those above noted, he is generally accredited with having first
adequately described this disease. His chief distinction lies in
having mistaken its pathogenesis and assisted in perpetuating an
erroneous appellation. He did emphasize the fact that the existing
factor is the bursting of an ovarian cyst with the resulting pour-
ing out of the contents of the cyst, though Virchow had previously
expressed the same opinion. His term was regarded as an im-
provement on that employed by Virchow, namely, "myxomatous
degeneration of the peritoneum." Olshausen contributed to the
pathologic conception of the disease in that he expressed the
opinion that it was a metastatic and not a degenerative process.
Pfannenstiel confirmed this opinion, basing his opinion on the
studv of four cases.
The collective literature may be found in Strassmann's article
which presents a collection of 36 cases, and Schumann's who col-
lected 20 more. This last paper presents the best recent collection
of literature.
Pathogenesis. — The disease under consideration folloAvs the rup-
ture of a pseudomucinous cyst and the escape of its contents into
the peritoneal cavity. Whether by its presence this material sets
up a reaction on the part of the peritoneum, producing the com-
pleted picture of the disease as Virchow (quoted by Beinlich) was
the first to advance, or AA'hether cells from the cyst, finding a neAv
nidus in the peritoneal cavity, continue to perform a nefarious
function, constitute the two theories of the genesis of this disease.
Olshausen was the first to advance the theory that the condition
does not represent a simple reaction of the peritoneum to irritation,
but that it actually represents a neoplastic process.
It is not easy to select between these two theories. Olshausen 's
theory unquestionably is correct for a part of the cases, for in some
of them true pseudomucinous tumors are scattered over the peri-
toneum. It is equally true that in others no trace of epithelium
can be found and such cells as are found can not be identified with
certainty.
When an attempt is made to align the analogous conditions aris-
TUMORS OF THE PERITONEUM 819
ing from the appendix the difficulty is heightened or clarified ac-
cording to the leanings of the observer. The appendiceal type
seems incapable of producing the cysts such as follow the rupture
of ovarian cysts. Lejars,, with much show of reason, argues that
the condition is due to a pouring out of the goblet cell secretions
into the peritoneal cavity. GoldscliAvend believes that the cells ex-
truded when the appendix ruptures are dead and incapable of
further development.
In some cases columnar epithelium is found in the lining of cysts
secondary to pseudomucinous cysts of the ovary. This may occur
as well when there is no escape of cyst contents. Baumgarten
records a case in which many cysts filled with colloidal material
were found in the peritoneum after the removal of a cystoma of the
ovary. These cysts were lined with columnar epithelium. This
may take place a long time after the removal of the cyst. In
Olshausen's case the removal of the original cyst preceded the
peritoneal complication by 17 years and Elizabeth Lewis records
a case the interval in which was 22 years. I once observed a pa-
tient from whom I removed bilateral pseudomucinous cysts in
which there was no rupture and no reason evident at the operating
table to cause me to be apprehensive of a recurrence. Examina-
tion of the Avails after the completion of the operation showed
malignancy in both tumors. In two years many small pseudo-
mucinous tumors covered the pelvic and abdominal peritoneum.
These were clearly metastatic tumors just as one sees them follow-
ing papillary tumors of the ovary, but they were of course morpho-
logically different. It is obvious that peritoneal metastasis may
follow pseudomucinous cysts either Avith or Avithout rupture.
Whether this represents merely a complete deA'elopment Avherein
the more typical pseudomyxoma of the peritoneum represents a
less fully developed form is open to question. Netzel (quoted by
Strassmann) is of the opinion that the OA'arian tumors AA'hich
give rise to pseudomyxoma peritonei differ from the usual pseudo-
mucinous ovarian tumors. He Avould call them ovarian myxomata.
The evidence of proliferative activity of the cells Avhich escape
Avith the cyst contents is not great but positiA'e. In case of the
appendix (xoldschAvend is of the opinion that the cells AA'hich es-
cape Avith the colloidal masses are dead and incapable of develop-
820 THE PERITONEUM
ment. Experience seems to hear out this assertion, for in none of
the reported cases has proliferation of the epithelium been demon-
strated. McConnell's case may be an exception. Here granular
proliferation of the Avail of the appendix at least seems to have
been present.
In case of; the ruptured cyst contents there are undoubted evi-
dences of proliferation. Friinkel particularly emphasizes this point,
though the areas he demonstrated are small and none too plain and
he prejudices his case by saying had he searched more thoroughly
he undoubtedly would have found other areas. The use of the
subjunctive mode always jars in the description of scientific ob-
servations. However, Olshausen and Gebhard both attest to the
fact that epithelial proliferation takes place.
While observations of these authors may be accepted, there are
a number of directions in which the conclusions may by far over-
reach the minor premise. Because some of the material shows evi-
dence of proliferation the conclusion is not warranted that all do
so, nor does the mere presence of cells, even Avith evidence of
active proliferation, Avarrant the conclusion that the pathologic
process is all or even in part due to such activity. Their presence
is far too sparse to Avarrant the assertion that the process is to be
regarded as a simple metastatic process. Frankel even goes so
far as to advise the abandonment of the title Avhich implies activ-
ity on the part of the peritoneum. In none of the four cases from
Avhich I Avas privileged to examine material could any evidence of
columnar celled activity be found. Perhaps I labored under the
ban of the subjunctive mode as set forth by Frankel, but energy
and credulity often run parallel. Another source of error is in
classing frank metastatic tu,mors of the peritoneum with the dis-
ease under discussion. In this condition there are real cysts Avhich
may burst, it must be added, and thus they may simulate pseudo-
myxoma peritonei. This phase of the question can best be stud-
ied in the section dealing Avith peritoneal metastasis of colloidal
tumors in general.
The source of the abundant material is not explained by the
small number of cells present in the extruded material. Perhaps
Lejars has the correct notion in that he expresses the belief that
in the case of the appendix the cells continue active, and produce
TUMORS OF THE PERITONEUM 821
material Avhich from time to time is added to that already extruded.
This might be assumed in the case of ovarian cysts likewise when
the cyst Avith a patent opening is still present, but in those cases
in which the cyst has been removed this view fails. In those vast
areas in which fibrinoid septa unite masses of homogeneous mate-
rial to the peritoneum one must assume that the cells that pro-
duced it have degenerated and their carcasses have become blended
with the homogeneous substance, or that some of the mass is the
product of local tissues. The use of strong solutions of formalin-
glycerine applied to the peritoneum may produce a material mac-
roscopically very much like that in pseudomyxoma peritonei. It
is true that the more thorough the investigations the fewer cases
in which epithelial cells are not found. There are instances in
which known carcinoma of the stomach is followed by the produc-
tion of colloidal masses in the omentum and peritoneum, which
on section give very small evidence of cell activity. Ewing reports
a case in which the association with the gut tract was discovered
only after careful search.
Even in the most carefully investigated cases, however, the num-
ber of cells seems ridiculously small compared to the amount of
myxoid tissue. Often in large masses of material no cells are
found. If cells produced this, their complete disintegration fol-
lowed. The formation of web-like strands of fibrous tissue with-
out cells and without full development of fibrous tissue resembles
very much the changes that take place in the hemorrhagic exu-
dates in myomata. That a considerable reaction on the part of
the peritoneum does take place is well attested to by the fact that it
led Virchow to believe that the reaction was the source of the mate-
rial. This phase may more properly be considered in the para-
graphs on pathology. It may be mentioned here, however, that we
have become so thoroughly imbued with " oynnes celliila e cellula"
that we can scarce think in other terms. Wlien a tumor grows in
a tissue it compels the tissue to give up the material necessary for
the elaboration of its kind. It seems to me that in this instance
the mucinous material coming in contact with a serous membrane
compels this membrane to give up a like material. The mucinous
material acts in this instance as a ferment in that it perpetuates
its influence. In the large colloid myomata we must depend on
822 THE PERITONEUM
some such process. It is possible to find every stage of change
from small vascular degenerations to large cysts. Columnar epi-
thelium is never found here. There is no use sticking to the fetish
of cell secretion in this case, for we know nothing of the chemical
methods in any cell secretion.
That such is possible is in line with the opinion of Eichwold who
compared the cement substance between endothelial cells with the
mucin of ovarian cysts, and Schaffer regarded this substance as
mucin. If we regard the opinion of these authors as correct, a
source for the substance in question is present.
In accounting for the presence of the colloidal material in this
connection, it is worth noting that in primary colloidal carcino-
mata of the peritoneum Zeigler (1895) believes that the colloidal
material is derived from the endothelium of the blood and lymph
vessels. Glockner also believes that it is derived from this source.
Miller and Wyss believe mucin found in this condition is a spe-
cific fluid, being like joint fluid. The term colloid is morpholog-
ically and macroscopically descriptive of several products of cell
activity or degeneration that have nothing in common except their
gelatinous character. So long as we have no trustworthy knowl-
edge of the chemical composition of substances, the product of
endothelial and epithelial activity, we can but hypothecate its
origin from its association Avith one or the other of these types of
cells.
If we possessed reliable chemical knowledge of the peritoneal
material here considered some aid could be expected. Beinlich re-
ports that Salkowski found mucin in one of his cases. In all the
cases in which chemical analysis has been made, all except that
reported by Neubaur contained mucin. If these analyses withstand
the tests of modern chemistry, the presence of this substance might
serve as a guide in comparing this substance Avith that' developed
in ovarian cysts. The fact that ovarian cysts contain no mucin,
hence called pseudomucinous (Pfannenstiel), some differentiation
might be possible.' It would be interesting to know also if those
cases following rupture of the appendix are of the same composi-
tion as those derived from ovarian cysts. McCrae and Coplin re-
port a case that according to them proba1)ly had its source from the
gall bladder. I have in several instances removed gall bladders
TUMORS OF THE PERITONEUM 823
filled with mucin. These showed no change in the epithelial lining,
but did show changes in the Avail of the gall bladder that would
admit the thought of colloidal degeneration. McCrae and Coplin
state that in their case the morphologic and chemical reactions of
the columnar cells were identical with those of ovarian cysts. The
gelatinoid material from the peritoneal cavity was examined by
Hawk and pronounced ^'mueh like the material knoAvn as serosa
mucin. ' '
It is Avorthy of note that the appendix may be iuA^olved secondarily
to the ovary. Eden^ reports a case in Avhich tAvo years and four
months after operating for pseudomyxoma peritonei going out from
the right ovary, a rencAval of the disease Avas found to affect the
left oA^arA*, Avhich Avas healthy at the time of the first operation.
More important is the notation that the appendix Avas distended
Avith colloidal material.
It is Avorthy of note, also, that the necessary condition for the
production of a pseudomucinous appendix is the occlusion of the
lumen in the proximal portion of the appendix. Chavannaz records
a case in Avhieh repeated attacks of appendicitis Avere folloAved by
a pseudomucinous appendix. This is so thoroughly in accord Avith
gall-bladder occlusions Avitli subsequent distention that further ar-
gument is unnecessary. These facts at least point to some relation
of reactive processes to the production of the condition under
discussion.
The next problem is Avhether or not those ovarian cysts Avhich
give rise to pseudomyxoma peritonei differ in structure from the
usual pseudomucinous cysts.
The cysts Avhich antedate the peritoneal condition are universally
stated to have friable Avails. Rupture is most apt to occur, as
Spiegelberg pointed out, in those in Avhich there are many daugh-
ter cysts AA'hich groAv to a size to press on the Avails of the mother
cyst. It may possil^ly be A\orth noting that it is in .just these
cases that the most active cellular proliferation is present. These,
therefore, stand closest to the papillary serous ovarian tumors in
Avhich secondary implantation is the regular thing.
In many of the case reports it is impossible to gather from the
description of the microscopic specimen Avhat the character of the
cells may be Avhieh are found in these tumors.
824 THE PERITONEUM
Attempts to solve the problem by experimentation were abor-
tive. Donati introduced some of the material obtained from a case,
into the peritoneal cavity of a rabbit. He had previously placed
this material in a solution of carbolic acid. The animal died 5
days later. He noted that the mass was surrounded by a "pus
celled" membrane and the peritoneum surrounding it was similarly
covered. Beyond this the peritoneum was hypertonic. IMy own
experiments in this line gave quite similar results save that the
"pus membrane" was seen to be a fibrinous layer in which were
many polynuclear cells. The pseudomucin may be regarded, there-
fore, as an irritant producing a greater degree of reaction than
for instance a bit of corn pith.
When all has been said, there is still a lamentable lack of definite
knowledge. The outstanding fact is that in some of these cases
there is a definite metastasis. In other instances small islets of
columnar cells only are found, ^hile in others cells of uncertain
genealogy are found. These facts warrant the general opinion that
the condition is the product of cell growth derived from the cyst.
Those arising from the appendix fit less kindly into this scheme.
The instances in Avhich cell proliferation was demonstrated are few
and unsatisfactory. Chemical knowledge which would enable a
comparison is lacking. That reaction on the part of the connec-
tive tissue is marked will be seen in the discussion on pathology.
Whether this reaction is merely a protest against the growth, or
whether it contributes to the mass of mucoid material Avhich irri-
tated it to reaction, only more definite knowledge can decide.
Pathology. — The structure of the tissues produced by this dis-
ease presents a number of perplexities all of which are not yet
solved. The essential factors to be determined are to what degree
the peritoneum suffers changes, and to what extent the cells ex-
truded from the cyst are capable of autogenic activity.
Testimony is in accord on the point that when the abdomen is
opened large quantities of colloidal material roll out (Fig. 229).
This material is usually widely distributed, l)eing usually insinu-
ated even l)etween the livei- and diaphragm. It is usually described
as being yellowish, honey-like in color, though it may be, as I have
observed, nearly ])('ai'ly Avhite. If any unusual activity or trauma-
tism has occurred, it may l)e tinged M'ith blood in certain places,
TUMORS OP THE PERITONEUM
825
which may appear as l:)right red streaks of recent liemorrhage or
in diffused chocolate colorations of more ancient extravasations.
The colloidal material may be diffusely distributed in homogeneous
layers, but usually, at least in some areas, tends to assume globular
Fig. 229. — Pseudomy.xoma of the iieritoneum. Large masses were scooped out with the haiuls
before tlie intestines were exjjosed.
forms, either in response to physical laws or to developmental proc-
esses. These globular masses may be covered with fine vascular
pellicle-like membi-anes. The pliysical character of this material
is well expressed by Virchow wlieu lie states tliat strings of it may
826 THE PERITONEUM
be clraAvn out Avitli forceps and cut off with the scissors. What he
fails to state, however, is that the pieces so cut off tend to assume
a globular form. This physical property may best be demonstrated
by causing it to flow from the abdomen or from a container, or
by forcing some of the material through the clefts between the
fingers of the closed hand. Like molasses, when the volume is not
too large, a globular form is attempted by the isolated masses.
The difficulty of removing this material from the abdominal cavity
at autopsy or at operation is due in part to its viscosity, and in
part to its adherence to the surface of the peritoneum. In virtue
of these same characteristics the intestines and omentum are often
agglutinated. This cohesion may be so intimate that forcible sepa-
ration may threaten the integrity of one or the other of the gut
walls.
The material may amount to many liters, distending the abdo-
men to an extreme degree. It may surround all of the viscera, even
filling the space between the liver, spleen, and diaphragm. In
this tendency to even distribution it resembles the peritoneal ex-
udates and is unlike any neoplastic process.
The masses and nodules often described are sometimes true
metastatic neoplastic processes, but sometimes represent amorphous
mucinous masses. McCrea and Coplin describe these nodules in
their case as composed of a capsule 1 to 3 mm. in thickness, en-
closing a soft gelatinous substance. Running in from this capsule
M'ere fine trabecula formed of imperfectly developed fibrous tissue.
There was no epithelium, round cells and leucocytes being the sole
cell representatives.
The Avail of the mother cyst is grayer than that usually found
in pseudomucinous cysts and is more easily torn. In this they
resemble the serous cystadenomata of the ovaries. In this, per-
haps, as in their clinical habit, they lean toward the more malig-
nant types of ovarian c.ysts.
The microscopic appearance may best be considered from the
viewpoint of the theories of the nature of the disease, namely, the
changes in tlie peritoneum itself and the cyst contents.
VirchoAV Avns the first to note that there Avere distinct changes
in the peritoneum. These consist in the usual reactions to irritation,
fibrinoid degeneration of the connective tissue bundles and, as
TUMORS OF THE PERITONEUM 827
Friinkel pointed out, in the disappearance of the elastic fibers.
At a distance from the direct contact Avith the foreign material the
peritoneum responds only by an increased vascularity.
Over the masses a fine pellicle of fibrin takes place. That this
is a product of the peritoneal exudate can be shoAvn experimen-
tallv. It is the organization of this which produces the fine vascu-
4
0
Li
Fig. 230. — ■Pseudomyxoma of the peritoneum. Alveolar formation is suggested but all cells
have undergone degeneration. Xote the resemblance to colloid carcinoma in Fig. 226.
lar membi-ane Avith which some of the globular masses are covered.
Beneath the masses the peritoneum responds l)y the production of
fibrous septa (Fig. 230) Avliich oxteiul between the lobulations of
the masses. The presence of colloidal material between these fiber
bundles together with stellate cells may be regarded as products
828 THE PERITONEUM
of myxoid degeneration, or as Westplial tliinks, may be due to
the plugging of lymphatics by colloid masses in the process of ab-
sorption. Though this idea has the stamp of Virchow on it,
modern tinctorial chemistry makes it difficult to uphold. These
account for the difficulty of removing the material from the peri-
toneal surfaces. These septa may branch like a tree, or the various
branches may coalesce, forming cavities in -which the material lies.
These may be free from cells or may carry on their surface endo-
thelial-like cells and polynuclears near the peritoneal surface.
The colloidal material is homogeneous at most, palely staining
but may show laminations, the various layers of Avhich may show
variations in coloration. The peritoneal base may show hypertro-
phy and as in the case of the appendix the reaction may be suf-
ficient to cause attachments to surrounding structures, sufficiently
great to wall off the organ in a measure.
In these instances in which a distinct columnar epithelium has
been described the basement tissue is edematous and the cells in
a state of beginning disintegration (cf. McCrea and Coplin). These
changes presage the early destruction of the cell and may account
for many areas containing no cells.
Evidence of deeper invasion of the tissue is not lacking. The
most marked example of this is recorded by Myer in which cystic
processes penetrated the spleen and produced openings into the
colon. In Polano's case they followed along the portal vein into
the liver. In following along the tract made by the trocar as in
the cases of Baumgarten, Sanger and Peiser, one is reminded of
the late metastases in papillary cystadenomata.
Symptoms. — Tlie symptomatology of the appendiceal and ova-
rian type is sufficiently divergent to warrant a separate considera-
tion of the two types. The symptoms in neither lead to more than
a suspicion of the nature of the disease.
Ovarian Type. — Uneasiness amounting to actual pain with al)-
dominal distention are the usual complaints the patient brings to
the practitioner. Chills and sweating are mentioned by Smith.
Sometimes a history of an acute pain is presented, as in Lewitzky's
case, in which two attacks simulating a generalized peritonitis pre-
ceded the discovery of the tumor. The cause of these pains can
not be determined. That it may hei-ald the rupture of the cyst is
TUMORS OF THE PERITONEUM 829
clear. I once operated on a patient stricken with severe abdom-
inal pain. The discovery of an ovarian tumor seemed to warrant
the diagnosis of a twisted pedicle. At operation the pedicle was
not twisted, bnt one compartment of a multilocular pseudomucin-
ous cyst had ruptured, producing a marked reaction on the part of
the peritoneum. Whether such pains are due to rupture of the cyst
or some other accident can not be stated. The distention is gener-
ally symmetrical, though sometimes one side presents the greater
enlargement. The degree of distention varies greatly. The dia-
phragm may be pressed upward, making respiration difficult. In
one of Atlee's cases this was the symptom that demanded inter-
ference. Sometimes the mother cyst can be palpated more or less
definitely. Percussion waves across the mass may be elicited.
Wendler made the observation that this wave traveled more slowly
than in ascites. Myer finds the fluctuation uncertain and sees
in the indefiniteness a symptom of value. In some instances, on
the other hand, ascites of a simpler character may long precede the
development of gelatinous material, as in the case of McCrea and
Coplin. It is possible that ascites is always the first response on
the part of the peritoneum. In my case in which rupture pre-
ceded operation by two weeks, a serous exudate was present.
The percussion note may be dull over the entire abdomen, but
usually there is tympany in some region, usually asymmetrically
distributed. There is always tympany in the epigastrium.
Vaginal examination gives evidence of a varying character. In
some cases the uterus is high, barely palpable, as in Myer's case,
or it may be deep in the pelvis and massed in by colloidal material,
or any degree of variation between these extremes may exist. The
high location of the uterus is often noted.
Appendiceal Type. — In many of the appendix cases one or more
attacks of acute pain precede the discovery of the disease. Since
a proximal occlusion is essential, an inflammatory attack likely
always precedes, save in one case in which a carcinoma caused the
occlusion, namely, that reported by Hiiter. Sometimes the discov-
ery of the gelatinous mass is brought about because of the sudden
onset of severe pain as in INIorris's case. Goldschwend had a sim-
ilar case. Neumann's case had had two typical attacks of peri-
tonitis as did also that of Chavannez.
830 THE PERITOXEU:SI
The repeated attacks of pain may in some instances be due to
successive ruptures of the appendix with escape of its mucinous
contents. Cysts remaining after the appendix has iDeen removed
then present the same symptoms as the rupturing appendicitis.
I\IacLean observed one case in which the intermittent discharge
took place twelve times.
Aside from the history of previous pain the discovery of an in-
definite tumor is about all that has been recorded that might aid
in the diagnosis.
Diagnosis. — A positive clinical diagnosis has been made only
when the trocar was employed. Wendler succeeded in securing a
few drops of the material through a large trocar, as did Atlee.
Spiegelberg demonstrated the danger of this manner of obtaining
evidence in that a fatal peritonitis followed one of his attempts.
Negative results following puncture are of importance. Explora-
tory incision is safer. jMeyer believes that a differentiation should
be made, and presents a table designed to aid in diiferentiating
this condition from ovarian cyst. The abdominal disturbance and
rate of growth, according to him, are greater than in the case of
ovarian cysts and fluctuation is less pronounced. In a cyst with
a twisted pedicle, on the other hand, the pain may be greater, and
there may also be a moi-e pronounced febrile reaction and a rapid
increase in size. In pseudomyxoma from the appendix there is
greater difficulty in demonstrating the tumor by palpation by vag-
inal examination than in the case of cyst origin.
In contrast to retroperitoneal tumors edema is rare. In only one
case, Geyl's. Avas edema of the feet a marked symptom.
The previous removal of an ovarian cyst should always excite
suspicion when a renewed abdominal enlargement begins. IMany
cases recorded bear this out. Polano had a patient with a free
interval of more than two years. Eden also had a patient who
showed ?>. renewal of the disease in the other ovary after two years
of freedom.
The type developing from the appendix can be suspected only
in cases in which there have been previous attacks of appendicitis
and they present an indefinite mass in the region of the appendix.
After the available symptoms have been employed for the pur-
pose of forming a diagnosis, curiosity will excite the average
TUMORS OF THE PERITONEUM 831
individual into an exploratory incision. Examination for ovarian
tumor, or cystic disease of the appendix rcA^eals the site of origin.
In McCrea and Coplin's case incision did not reveal the source of
the disease.
Prog'nosis. — In some instances the removal of the primary of-
fender seems to check the disease. This is particularly true of the
appendiceal type. In ruptured cysts the chances for recovery are
less, thouo'h it is possible even after considerable extension on the
peritoneum. "We recognize here again an analogy to the papillary
cystadenomata. "When the disease has once become fully estab-
lished, recurrent development of the material takes place with an
invariably fatal result. This may be deferred even to a numlier of
years, however.
Statistics avail luit little in arriving at a conclusion, for late
recurrence is common. Giinzberger in 44 cases collected from the
literature found 17 recoveries. Bettmann reports 18 recoveries in
35 cases. Sehurmann found 39 recoveries and 16 deaths. As is
usual with statistics in malignant disease the results sound better
than is borne out by clinical experience. Sehurmann after stating
the figures above quoted begins the next paragraph Avith the state-
ment "Recurrence is almost universal." Sometimes secondary
operations achieve results. Pfannenstiel quotes a case in Fritsch's
experience in which the patient remained well eleven years. Gott-
schalk reports one still well after four and a half years.
Death takes place in a surprisingly large number of cases be-
cause of sepsis or embolism. This was true in eight out of eighteen
cases reported by Honecker.
Treatment. — The treatment consists in removing the offending
lesion and the removal of as much of the gelatinous material as
possible. The appendix usually is easily removed and the remains
of ovarian cysts are usually removed by simple ligation of the
pedicle. It was formerly the practice to remove the colloidal mate-
rial by irrigation, but the more recent practice has been to remove
as much as possible by manual means. The former practice of
placing a drain has also most properly been given up.
It is a question whether actinic rays exert a favorable influence
or not. In a recent case in Avhich metastatic colloidal tumors of
the peritoneum appeared, temporary improvement Avas coincident
with the use of x-ravs.
832 THE PERITONEUM
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TUMORS OF THE PERITONEUM 833
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834 THE PERITONEUM
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TUMORS OF THE PERITONEUM 835
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^36 THE PERITONEUM
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TUMORS OF THE PERITONEUM 837
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838 THE PERITONEUM
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Taruffi: Storia della teralologie, Bologna, 1886, iv.
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Terrillon : Liponies des mesenteres. Arch. gen. de med., Paids, 1886, i, 257; 434.
Tumeurs du mesentere, kystes et liponies. In Lemons de clin. chir., Paris, 1889,
p. 456.
Teixeira de Mattos: Zur Casuistik des primjiien Pleura-endothelioms und diag-
nose des Pleura-krcbses, Diss., Freiburg, Leiden, E. Ijdo, 1894.
Thomayer: Beitrag zur Diagnose der tuberculosen und careinomatosem Erkrank-
rmgen des Bauchfells, Ztschr. f. Idin. Mod., 1883-4, vii, 378.
Thornton : Removal of Hydatids of the Omentum and from the Pehds, Med.
Times and Gaz., London, 1878, ii, 565.
Tillaux: Kyste du mesentere chez un honune, ablation par la gastrotomie;
g-uerison. Rev. de therap. med.-chir., Paris, 1880, xlvii, 479.
Tumeur de I'arriere-cavite des epijiloons; diagnostic des tumeurs abdomiiiales,
Gaz. d. hop., 1886, ILx, 757.
Tilmann: Exstirpation af en fran venstra ujurkapseln utgaende 10 kg. vagande
tumor, Hygrea, 1892, i, 277.
Tuffier: Kyste chyleux du mesentere. Bull, et mem.. Soc. de chir. de Paris,
1892, n. s., x\-iii, 582.
Vander Veer: Retro-peritoneal Tumors: Their Anatomical Relations, Pathology,
Diagno^s, and Treatment, Am. Jour. Med. Sc., 1892, ciii, 17.
TUMORS OF THE PERITONEUM 839
Vautrin: Lo l^niipliangiome cavoiiieux du mesentere, au point dc vno clururgical
Assn. FraJiQ. de Cliir., Proees-veibal, 1808, xii, 625.
V. Veges.VCK: tJber retropeiitoiiealc Lipoma, Bcitr. z. kliu. cliir., 1010, Ixix, 578i
Yestbeiig : Cited by Ebncr.
ViKCHOW-HiRSCii : Jahresbericlit, 1880, ii, 207.
ViRCHOW: Die krankhaften, Geschwiilste Berlin, Hirsclnvald, ISfi.*?-?, i, 383.
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1009, xcviii, 110.
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Wexdeler: t'ber einen Fall von Peritonitis cdironiea produetiva myxomatosa
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Klinische und anatomische Untersuehungen zur Lehre von den Bauch-
geschwiilsten und der Laparotomie (Pseudomyxoma peritonei), Arch. f.
Gynak., 1884, xxiv, 100.
Winiwarter : Chvlangioma cavernosa, Jaliresber. des Eudolphs-Spitals in "Wien.,
1877, ii, 321.
Woolsey: Sarcoma of the Omentum and Mesenteiy, Am. Surg., 1911, liii, 139.
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Anat., 1870, Ii, 143.
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Zeigler: Spezielle pathologische Anatomie, Jena, Fischer, 1895.
INDEX
Al)domen, development of, in embr\o,
i, 84
external topograpliy of the, i, 228
pliysieal characters of the, ii, 436
Al)doniinal cavity, integrity of, de-
pendent on peritoneum and
fil)rons tissue of gut wall, i,
238.
distention in miliary tuberculosis, ii,
684
fascia, i, 114
muscles, rigidity of, ii, 443
organs, topography of, in develoii-
ment, i, 88
region, lowei', i, 134
wall, omentum adherent to, i, 282
parietal peritoneum of the, i, 148
penetrating wounds of the, in rela-
tion to peritonitis, ii, 403
perforation of, in jieritoneal tu-
berculosis, ii, 678
Abscess, encapsulated, i, 302
formation stage of appendicitis, type
of operation in, ii, 584
subdiaphragmatic, drainage of, ii,
496
within gut wall covered with plas-
tic exudate, ii, 413
Abscesses accompanying pneumococcic
I)eritonitis, ii, 617
as cause of spontaneous pain, ii, 427
deep in p)elvis, perivesical si^ace af-
fords easy access to, i, 127
extraperitoneal drainage of, ii, 494
forming about silk sutures, ii, 505
in rectal wall simulating symi)toms
of appendicitis, ii, 5()0
intraperitoneal, Avalled-off, drainage
of, ii, 498
paraperitoneal, perforation of, ii,
418
Absence of appendix, i, 189
Al)Sorption, avenues of, i, 8
factors whicli delay, i, 18
factors which hasten, i, 17
glycerine and formalin delay, i, 19
influence of hydremia upon, i, 19
meclianism of, i, 6
Al)sorption — Cont 'd.
of blood from peritoneal cavity, i, 20
of blood in peritoneal cavity by way
of lymphatics, i, 22
of solid particles, i, 12-17
of the omentum, i, 33
of toxins as cause of death in peri-
tonitis, ii, 456
rate of, effect of inflammation on,
i, 23
effect of massage on, i, 17
effect of osmotic pressure upon, i,
11
from peritoneal cavitv, i, 11
site of, i, 22
slowing of, by lessened peristalsis, i,
18
Aecunuilations in pelvis, extension of,
to diaphragm, i, 128
Acidophilic properties in liasement
membrane, i, 67
Actinomycosis, simulating ileocecal tu-
berculous peritonitis, ii, 688
Active hyperemia, i, 330
Acute appendicitis, ii, 529
hyperemia, i, 333
pancreatitis, differentiation from ap-
]3endicitis, ii, 559
peritonitis, hemorrhagic exudate in,
i, 377
type of peritoneal tuberculosis, symp-
toms of, ii, 681
Adhesion exerting pernicious influ-
ence, operation only manage-
ment, i, 301
formation, and fibrous tissue, melli-
ods of studying, i, 245
fornmtion, ulceration with, ii, 411
nmss, i, 300
of colon to parietal peritoneum due
to foreign body, i, 281
stage of appendicitis, type of oper-
ation in, ii, 584
Adhesions, attenuation due to tiaction,
i, 297, 29S
l)etween gall l)ladder and iieritoneum
due to gallstones, i, 282
between omentum and parietal wall,
i, 2S7
841
842
INDEX
Adhesions — Cont 'd.
breaking up, stimulates greater for-
mation, i, 295
deleterious effects of temporary, i,
314
destroying functions of hollow or-
gans, i, 295
due to chemical irritation, i, 280
due to disease processes, i, 281
due to external violence, i, 291
due to injuries during operations, i,
291
fetal, i, 279
fetal, in fetal peritonitis, ii, 641-642
following gonorrheal infections in, i,
290
formation of, about gauze drain, ii,
483
in gonorrheal perisalpingitis, ii, 601
influence of species of bacteria on
character of the, i, 313
interference with, unnecessary, may
permit spread to unaffected
areas, i, 315
limitation of infections by, i, 302
management of, in operation for
peritoneal tuljerculosis, ii,
710
may exist without detriment, i, 318
normal variations regarded as, i, 318
of a loop of gut to an inflamed focus,
i, 296
of several loops of ileum about ce-
cum, ii, 571
pericholecystitis with, ii, 590
peritoneal, nature and genesis of, i,
276
permanent, i, 280
deleterious effects of, i, 295
late changes in, i, 297
management of, i, 301
relation of, to more intense in-
fections, i, 285
prenatal, i, 279
j)ressure in production of, i, 294
preventing perforations, ii, 411, 412
prevention of, i, 317
by drugs, i, 321
by oil, 321
in closing peritoneal incisions, ii,
505
primary, prevention of, i, 317
relation of, in gut perforations, i,
286
remaining after an attack of ap-
pendicitis, i, 284
secondary, i)rcvention of, i, 318
suture of, ii, 510
Adhesions — Cont 'd.
sutured by Leml)ert sutures, ii, 512
temporary, i, 302
late changes in, i, 314
management, of, i, 315
pathogenesis of, i, 302
variations in capacity to form, i,
294
Adhesive caseous tuberculosis of the
peritoneum, ii, 672
peritoneal tuberculosis, ii, 671
symptoms of, ii, 685
type of tuberculosis least virulent,
ii, 664
Adrenalin lessens rate of abfiorption,
ii, 465
Adrenals, tulierculosis of, ii, 654
Adventitious bands frequent cause of
real mischief, i, 296
in the fetus, ii, 642
After-jiain in operation for perito-
nitis, ii, 488
After-treatment of a drainage wound,
ii, 485
Age and sex in gonorrheal peritonitis,
ii, 609
in relation to appendicitis, ii, 519
in relation to lymphatic cysts of the
mesentery, ii, 766
in relation to tubeiculosis of the
peritoneum, ii, 649
Agglutination of the sigmoid witli
parietal peritoneum, i, 175
peritoneal, i, 277
Agglutinations and adhesions, different,
i, 278
causes of, i, 277
Air, exposure of peritoneum to, as
cause of iuflamnmtion, i, 353
exposure to, in formation of adhe-
sions, i, 294
in treatment of peritoneal tubercu-
losis, ii, 707
Albumin content in tuberculous proc-
ess, ii, 697
Albuminous fluids, changes undergone
])y, in peritoneal cavity, i,
7*
Anaerobic Ijacteiia in peritonitis, ii,
398
Anesthetic, in operation in peritonitis,
ii, 471
Anatomic clianges in static varicosities,
i, 339
Anatomy of the ileocecal region, i, 175
of the omentum, i, 216
of the iieritoneum, i, 112
of tlie peritoneum in pelvic region,
i, 138
INDEX
843
Anemia of the pciitoocum, i, 328
Aiilage, i, 92
Animal nienibranes placed in peritoneal
cavity as means of prevent-
ing adhesions, i, 322
Appendiceal peritonitis, ii, 516 {see
Appendicitis)
type of pseudomyxoma peritonei,
symptoms of, ii, 829
Appendicitis, ii, 51(5
adhesions remaining after an attack,
i, 284
age in, ii, 519
catarrhal, ii, 538
changes in endothelial cells in, i,
361
chronic, ii, 569
productive, ii, 572 (see Chronic
productive appendicitis)
cicitrans retardata, ii, 572
classification, ii, 527
diagnosis in, ii, 554
diet in relation to, ii, 520
differential diagnosis, ii, 556, 579
differentiation from gonorrheal peri-
salpingitis, ii, 605
from pncunioeoccic peritonitis, ii,
621
of gall bladder diseases f.rom, ii,
557
diffuse exudative, ii, 528, 538
early stage, ii, 583
etiolog_y, ii, 518
exaggerated by trauma, ii, 522
fecal concretions in, ii, 523
fever in, ii, 551
foreign boclies in, ii, 523
gangrenous, ii, 534, 541
general infections in relation to, ii
524
genital disorders simuhiting, ii, 579
heredity in, ii, 518
historical, ii, 516
kidney and ureteral colic, differenti-
ating from, ii, 556
leucocytosis in, ii, 554
nmsked, ii, 576
medical treatment, ii, 581
nuiscular rigidity in, ii, 548
occupation in relation t(), ii, 520
operation in the interval, ii, 582
indications for, ii, 582
])lace of, ii, 583
time of, ii, 581
type of, ii, 583
pain in, ii, 541
on movement, ii, 545
on pressure, ii, 546
Appendicitis — Cont 'd.
])athogenesis, ii, 524
pathology of, ii, 536
postappendiceal cicatrization, ii, 575
prognosis in, ii, 585
pseudoappendicitis, ii, 578
pulse rate in, ii, 553
relation of trauma to, ii, 522
remittent, ii, 570
sex in, ii, 519
spreading type of peritonitis seen in,
ii, "383
symptoms, ii, 541
trauma in relation to, ii, 520
treatment, ii, 581
tympany, ii, 550
ulcerative, ii, 532
vomiting in, ii, 549
Appendicular artery, sudden occlu-
sion of, with subsecpient
necrosis, cause of sponta-
neous pain, ii, 425
colic, ii, 528
Appendix, absence of, i, 188
acute perforation of the, ii, 409
and meson, cross section of, i, 308
atrophy of the, ii, 537
blood vessels in region of, i, 183
caseous tuberculosis of, ii, 674
cause of absence of, i, 189
defining location of, i, 233
escape of bacteria through walls of,
ii, 525
fibrosis of the, ii, 537
indurated wall of an, ii, 573
infective process about, walling-off
of, i, 306
inflamed, surrounded by indurated
■ omentum, ii, 530
localized tuberculosis in, ii, 687
perforation of, ii, 410
position variable when meson is
fused, i, 183
vascular changes in, i, 345
Arch of Treitz, i, 201
Area involved in peritonitis, ii, 382
Aseptic wounds, healing of, i, 244
Atresia, peritonitis associated with, ii,
644
Atrophy of the appendix, ii, 537
Avenues of absorption, i, 8
B
Bacillus coli comnuinis, in peritonitis,
ii, 396
r.arillns ]i\(u-yan('us. in peritonitis, li.
'398
844
INDEX
Bacteria, absorption of, as cause of
death, ii, 458
as cause of iutlannnation, i, 352
causing peritonitis, ii, 387
cultures and body cell cultures com-
pared, i, 258
escape of, from gut wall, ii, 415,
416
through walls of appendix, ii, 525
through walls of gall bladder, as
cause of spreading perito-
nitis, ii, 591
in wound healing, i, 239
iiitlammatory reactions due to, i,
356
influence of species of, on character
of adhesions, i, 313
introduced into peritoneal cavity,
experiments with, i, 391
raiaidly absorbed from peritoneal
cavity, ii, 391
transmission of, in j)eritoneal tuber-
culosis, ii, 652
varieties found in peritonitis, ii,
394
Bacterial examination in diagnosis of
peritoneal tuliercuUi.sis, ii,
696
peritonitis, ii, 391
pseudotulierculosis, ii, 713
Bacteriologic study of peritonitis, i,
359
Bacteriology of pneumococcic jierito-
nitis, ii, 620
of puerperal peritonitis, ii, 627
Basement cement substance, i, 68
Basenrent membi'ane, i, 67
acidophilic properties in, i, 67
composition of, i, 69
development of, embryologic, i, 99
exudate above in acute inflamma-
tion, i, 372
exudate below in chronic inflamma-
tion, i, 374
preparing specimen of, i, 67
removal of, destroys adhesion-
forming power, i, 293
Batrachians, cell structure in, i, 52
Bile, effect of, in peritoneal eavitv, ii,
594
Blackness of gangrenous appendix, ii,
541
Bladder, distended, ])eritoneum in re-
lation to, i, 139
distended, relation of pubovesical
fold to, i, 124
l^erivesical space as avenue of ap-
proach to, i, 126
Blood, alisorption of, from peritoneal
cavity, i, 20
hastened by reduction of, i, 17
cells passing through preformed
openings, first observation
of, i, 55
clot, organizing, i, 254
organization of, study of, i, 246
in gonorrlieal perisal2)ingitis, ii,
605
l)ressure, omentum as a regulator of,
i, 32
stream as avenue of absorption of
Idood in peritoneal eavitv,
i, 22
tulierele bacilli transmitted by, ii,
652
supply of the parietal peritoneum of
the posterior al)dominal
wall, i, 148
vessels and lymphatics, connection
between, i, 78
as avenues of absorjitiou, i, 9
in region of appendix, i, 183
in region of duodenal folds, i, 201
occlusion of, in appendicitis, ii,
531
of the gall Idadder, i, 76
of the intestine, i, 170
of -the omentum, i, 221
of the peritoneum, i, 71
potential, i, 72
service, i, 71
stigmata and stomata in the, i, 54
Bloodless fold of Treves, i, 178
Blunt trauma of omentum and mesen-
tery, ii, 760
Bovine tuberculosis, occurrence in
human beings, ii, (>76
Breaking up adhesions stimulates
greater formation, i, 295
Broad ligament abscess drained tlirough
vagina, ii, 494
in relation to periuterine spaces,
i, 127
of the uterus, i, 141, 142
ligaments and uterus, peritoneum of
the, i, 140
Bundle, fibrin, formation of, i, 246
Bursa omentalis, anlage of, in em-
Inyo, i, 94
Camphorated oil in treatment of peri-
tonitis, ii, 4()S
Canalization of the cell protoplasm,
Klein's idea of, i, 47
INDEX
845
Capillary i-osistaiu-e, dccreaSL'd, tliooiy
of, i, 6
Carcinoma, secoiularv glandular, of the
oniontiim, ii, 810
Caseatii)ii, tendency of all tuberculosis
lesions to undergo, ii, (i(i2
Caseous peritoneal tuberculosis, symp-
toms of, ii, 685
type of peritoneal tuberculosis, ii,
673
type of tubercle, microscopic ap-
pearance of, ii, 665
Cautery, in removal and prevention of
adhesion, i, 320
Catarrhal appendicitis, ii, 528
pathology of, ii, 538
Catgut as peritoneal suture, ii, 504
Cecal fossfP, i, 196
Cecum, adhesions about, causing ob-
struction, i, 319
Cecum becomes retroperitoneal, i, 106
beginning development of the, i,
87
descent of, carrying peritoneum, i, 91
in relation to external parietoeolic
fold, i, 190
location of, i, 106
tuberculosis of, ii, 653
vessels of, direction of, i, 340, 341
Celiac axis, i, 86
Cell activity renewed l>y transplanting
to new media, i, 261
lining of potential vessels, i, 75
outline, development of, i, 42
protoplasm, canalization of the, i,
47
staining of, i, 46
structure in batrachians, i, 52
Cells, absence of openings Ijetween,
method of demonstrating, i,
60
action of, in infection, i, 304
action of various, in li(|uid portions
of media and against a
surface, i, 260
cause of changes in, iiroldenuitic, i,
2(;i
cement substance between, i, 49
chemical iclation to fibrin bundles, i,
262
coiinocti\e tissue, i, 70
containing 7io nuclei, theoiies regard-
ing, i, 44
embryonal development of, i, 42
endothelial, i, 39
changes in in(lammati<ui, i, 3()1
cross section of, i, 40
Cells, endothelial— Cont M.
disposition of, to form a stellate
group around a central
opening, i, 45
nuclei in, tending to form stel-
late groups, i, 45
outline of, i, 42
protoplasm of, i, 46
size of, i, 42
groups of, resemt)ling cells in em-
bryonic state, found in some
adult animals, i, 44
in relation to fibrin formation, i, 257
in relation to transfer of fibers from
fibrin, i, 264
in subperitoneal exudates, i, 376
in their final resting stage in newly
formed i^eritoneum, i, 266
in wound healing of the simplest
form, i, 260
located below the endothelial cells
mistaken for stomata, i, 62
lying in the subserosa, i, 361
nomenclature, i, 40
of endothelium lining peritoneum,
differentiation from those
of blood vessels, i, 43
peritoneal, outline diffeis in various
species of animals, i, 43
present in healing tissue depends
upon reactions undergone by
tissue in early stage, i, 260
ladiating from a central point, re-
garded by some writers as
the only true stomata, i, 61
red, increase of, after injection of
blood into peritoneal cav-
ity, i, 21
relation of, to formation of filnous
tissue, i, 25i)
single, do not grow, i, 258
snuUl, between large, discoveiy of, i,
61
Cellular ti^'sue of broad ligament, i,
128
Cement substance removed from fibrous
tissue by means of pancre-
atin, i, 68
l)etween cells, fiist description, i,
49
Changes in llie circulation, i, 325
in jiermaiuMit adhesions, i, 297
Chemical analysis of ]>eritoneal tuber-
culosis, ii, 697
irritation, adhesions due to, i, 280
peritonitis, ii, 389
relation of cells to fibrin bundles, i,
262
846
INDEX
Chemicals capable of iiijuiiiii^- endo-
thelium sufficient to cause
adhesions, i, 294
Chills in puerperal peritonitis, ii, (JoO
Cholecystitic peritonitis, ii, 588
diagnosis of, ii, 595
prognosis of, ii, 595
symptoms of, ii, 594
treatment of, ii, 595
Cholecystoduodenocolie ligament, per-
manent hyperemia in, ii,
589
Chromie eatgut as peritoneal suture, ii,
504
Clironic ajipendicitis, ii, 569
hyperplasias of the peritoneum, ii,
720
peritoneal tuberculosis, symptoms of,
ii, 682
productive appendicitis, pathology
of, ii, 572
sj'mptonis, ii, 574
Cicatricial adhesions as result of in-
fection of retrorcnal space,
i, 132
Cicatrization, postappendical, ii, 575
Cigarette drain, ii, 482
Cilia, iu peritoneal endothelium, noth-
ing more than fibrin, i, 48
presence of, on peritoneal endotlie-
lium, i, 47
Circulation, changes in inflammatory
reactions in the pieiitoneum,
i, 364
in the peiitoneum, i, 325
changes in the, i, 325
rate quickened in peritonitis, ii, 434
Cirrliosis of the liyer, relatio;i of, to
tuberculosis of the perito-
neum, ii, 674
Classification, of appendicitis, ii, 527
of gouococcic peritonitis, ii, 599
of peritonitis, ii, 381
area involyed, ii, 382
based on extent of involvement, ii,
382
diffuse type, ii, 384
organ from whicli infection origi-
nates, ii, 385
specific causative organism, ii, 386
spreading type, ii, 383
of tuljerculosis, ii, 665
of tumors of the peritoneum, ii, 764
Climate in treatment of peritoneal tu-
berculosis, ii, 706
Clinical signs of pueiperal peritonitis,
ii, 630
Clinical symjitoms of tuberculous and
idiopathic types of perito-
nitis, ii, 718
Closure of peritoneal incisions, ii, 505
Clot contraction, effect of temperature
upon, i, 263
CoagTilable exudate in the bellies of fe-
tuses, ii, 643
Coagulated Ijlood acts as a chemical ir-
ritant, ii, 441
Coagulation of exudate in infective
process, i, 303
Cob-web adhesions accompanying gon-
orrheal perisalpingitis, ii,
602
Colic, ii, 440
kidney and ureteral, differentiating
from appendicitis, ii, 556
Colloid metastasis in the omentum, ii,
812
Colon, attached to pylorus, i, 101
bacillus in peritonitis, ii, 396
displacement of, by retroperitoneal
hernia, i, 213
embryologic development of the, i,
87
meson of the, i, 158
migration of, in fetus, i, 94
relation of, to peritoneum, i, 115
Complications following operation foi'
peritonitis, management of,
ii, 488
prognosis of peritonitis in presence
of, ii, 453
Concretions, fecal, in appendicitis, ii,
523
Congenital absence of ajijiendix, i, 189
anomalies causing fetal peritonitis,
ii, 643
Connective tissue abundant wlieie mo-
bility of extraperitoneal or-
gans is demanded, i, 121
amount present in peritoneum, i,
69
Connective-tissue cells, i, 70
in relation to fibrin formation, i,
256, 257
formation, theory of, i, 238
perivascular, changes of, i, 368
suliperitoneal, i, 69
theories of the development of, i,
241
Conservative treatment of peritoneal
tuberculosis, ii. 705
Constitutional diseases reduce adhesion
formation, i, 294
INDEX
847
Contiguity, tuberculosis travels from
jirimary lesion to perito-
neum by, ii, 65S
Continuity, extension of tuberculosis
by, ii, 659
Contraction of a scar, i, 297
Corn pith j^laeed in peritoueum to test
rate of movement of omen-
tum, i, 312
Cyst formation in retroperitoneal li-
pomata, ii, 790
Cystic tumor simulating: tuberculous
peritonitis, ii, 700
Cysts associated with hernia, ii, 780
bursting of, as cause of peritonitis,
ii, 390
embryonal, ii, 781 {sec Embryonal
cysts)
of the mesentery, lyni])liatic, ii, 765
secondary peritoneal, ii, 780
subperitoneal, of the tube, ii, 690
tuberculous, of the peritoneum, ii,
675
D
Death, causes of, in jieritouitis, ii,
454-459
Defensive reactions of the onvcutum, ii,
749
Defibrinated blood, al^soiption of, in
peritoneal cavity, i, 20
Degeneration, fibrinoid, in inflannna-
tory reactions, i, 375
Dentated borders of cells, i, 51
Dermoids, ii, 781
Desiccation, inflammatory reaction due
to, i, 353, 354
Deleterious effects of permanent adlie-
sions, i, 295
Development of connective tissue, tl;e-
ories of, i, 241
of hepatoduodenal region, i, 100
of ileocecal region, i, 105
of omentiun, i, 217
of peritoneum, i, 84
of sigmoid region, i, 110
of special region, i, 92
of splenic region, i, 108
Diagnosis of appendicitis, ii, 554
of cholecystitic peritonitis, ii, 595
of gonorrheal perisaljiingitis, ii, 605
of gonori'heal ]ieritonitis, ii, (ilO
of inflammatory tumor of the oiiieii-
tuni, ii, 746
of injury to tlie (inieutum and mes-
entery, ii, 761
of lyiniiluitic cvsts of the inesenter\',
ii, 769
Diagnosis — Cont 'd.
of peritoneal tuberculosis, ii, 696
of jjeritonitis, ii, 438
of postap])endiceal cicatrization, ii,
576
of pneumococcic peritonitis, ii, 620
of pseudomyxoma jieritonei, ii, 830
of i^uerperal peritonitis, ii, 631
of retroperitoneal lipomata, ii, 791
of retroperitoneal sarcoma, ii, i795
of sarcomata of the omentum, ii,
803
of secondary tumor of the perito-
neum, ii, 815
of thrombosis and embolism of mes-
enteric vessels, ii, 740
of torsion of the omentum, ii, 758
of traumatic peritonitis, ii, 636
of tuberculosis of the jielvic i:)erito-
neum, ii, 689
Diaphragm, absorption of solid par-
ticles, resistance to, i, 67
endothelium and lymphatic vessels
identical with that of other
parts of peritoneum, i, 67
lymphatics of, i, 78
Diaphragma secundarium, i, 148
secundarium of Henle, i, 152
special opening in the, theories re-
garding, i, Qi(i
Diaphragmatic peritoneum, i, 153
Diarrhea symptom of thrombosis of
mesenteric vessels, ii, 739
followed hj generalized ])eritonitis,
ii,"406
in pneumococcic peritonitis, ii, 618
Diet in relation to appendicitis, ii,
520
Differential diagnosis of appendicitis
ii, 556
Diffuse exudative appendicitis, ii, 528
pathology of, ii, 538
miliary tuberculosis of peritoueum,
ii. 668
peritonitis, ii, 384
following traumn, ii, 635
type of operation in, ii, 584
type of pneumococcic peritonitis, ii,
619
Digestive disturbances as symptom of
ulcerous peritoneal tuber-
culosis, ii, 685
Dihitntion of mesenteric vessels, i, 331,
."■32
of vessels in hepatocolic ligament
due to cholecystitis, ii, 589
of vessels in peritoneum, i, 326
848
INDEX
Disease as cause of hyperemia, i, 3oG
processes, adhesions due to, i, 2S1
Diseases of the chest, differentiation
from appendicitis, ii, 568
of the great omentum, ii, 749
of the urinary lihidder and rectum,
differentiation from api)en-
dicitis, ii, 559
Displacements, normal, of intestines, i,
168
Dissemination, extension of tumors by,
ii, 812
Distention as symptom of thrombosis
of mesenteric vessels, ii, 7-40
effect of, upon cell outline, i, 59
of gut, causing em1>arrassment of
respiration, ii, 433
in peritonitis, ii, 431, 432
late, sometimes paralytic, ii, 433
postoperative, ii, 489
of gut Avail in absence of infection, ii,
432
Division of surface of alidomen into
triangles, i, 229
Double mosoappendix, i, 184
Douglas' pouch, peritoneum in, i, 139
Drain, cigarette, ii, 482
dangers of the, ii, 479
gauze, ii, 483
and rubber, combined, ii, 484
glass, ii, 481
material used, ii, 480
mechanism of, ii, 478
removal of the, ii, 480
rubber, ii, 481
Drainage in puerperal peritonitis, ii,
632, 633
of extraperitoneal abscesses, ii, 494
of the gut tract, accomplishing, ii,
491
of intraperitoneal walled-off ab-
scesses, ii, 498
of the ])eritoneal cavity, ii, 475 (see
also Drain)
duration of, ii, 476
factors which may aid flow, ii, 479
gravity as factor in, ii, 476
material used for, ii, 480
posture of patient in, ii, 486
of subdiaphragmatic abscess, ii, 496
tampon, ii, 484
wound, after-treatment of, ii, 485
fate of scar following, ii, 486
Drugs believed to act specifically on
adhesions, i, 321
retard wound liealing, i, 255
Dry heat, application of, in treatment
of peritonitis, ii, 469
Dry pack as protective against s]iread-
ing fluid, i, 355.
fluid, i, 355
influence of, on peritoneum, i, 354
Drying, inflammatorj- reaction due to,
i, 353
Duodenal folds, i, 201
and fossa?, i, 202
fossa, inferior, i, 205
posterior, i, 206
superior, i, 204
liernias, i, 212
or gastric perforation may cause
spontaneous pain, ii, 425
Duodenocolonic folds, i, 157
Duodenojejunal angle, fixity of, i, 95
Duodenum, fusion of, to posterior wall
during fifth and sixth
months in the embryo, i, 97
only seginent of small g-ut not pos-
sessed of a meson, i, 163
perforation of the, i, 289 ; ii, 419
perforating ulcer of the, ii, 408
Dynamic ileus, ii, 489
Dysmenorrliea, differentiation from ap-
pendicitis, ii, 566
E
Ectopic pregnancy, differentiation from
appendicitis, ii, 562
Edema influencing distention of the gut
late in peritonitis, ii, 432
of walls in acute appendicitis, ii,
529
Elasticity of peritoneum, i, 113
Embolism and thrombosis of the mes-
enteric vessels, ii, 734
Rml)ryo, al>dominal development, i, 84
Embryonal cysts, ii, 781
fetal inclusions, ii, 782
symptoms, ii, 784
teratoid mixed tumors, ii, 781
treatment of, ii, 784
true dermoids, ii, 781
Emesis in peritonitis, ii, 430
Encapsulated abscess, formation of, i,
302
end-organs, i, 226
Endoabdominal fascia, i, 114
End-organs, encapsulated, i, 22(5
medullated fibers terminating in, i,
227
nonencapsulated, i, 227
size of, i, 226
Endothelial cell, i, 39
cells, (sec Cells, endothelial)
changes in, in inflammation, i, 361
I
INDEX
849
Eiidotlu'liiil cells — Coiit M.
in malignant infection of the peii-
toneuni, i, 364
laver in advanced infiamniation, i,
393
Endothelioniata, ii, 771
pathology of, ii, 772
Endothelium, as protective covering, i,
355
covering diaphragm identical with
that of otlier parts of peri-
toneal cavity, i, 67
of a newly formed peritoneum, i, 266
of peritoneum, normal, in young rab-
l)it, i, 43
of potential vessels, i, 75
of service vessel of the mesentery, i,
72
regeneration of the, i, 264
thickening of, near site of subacute
inflammation, i, 363
Enterocystomata, ii, 775
location of, ii, 776
pathogenesis of, ii, 776
pathology of, ii, 777
prognosis of, ii, 778
symptomatology of, ii, 777
sj'mptoms of, ii, 775
treatment of, ii, 778
Enterogenetic cysts, ii, 777
Enteiolith in an- apfiendix, ii, 5."'>4
Enterotomv for relief of dynamic ileus,
'ii, 490
Epididymitis, differentiation from ap-
]icndicitis, ii, 568
Epinephrin, as stimulant to circulation,
ii, 464
in treatment of peritonitis, ii, 464
Epithelial leucocytes, i, 259
Epitlielium, definition of, i, 40, 42
Etlier in ti-eatment of peritonitis, ii.
466
Etiology of appendicitis, ii, 518
of chronic hypei])hisias of the peri-
toneum, ii, 720
of inflammatory proces.ses, i, 352
of injuiies of the omentum and
mesentery, ii, 759
of peritonitis, ii, 389
of pueiperal ])eritonitis, ii, 627
of retro])eritoneal lipomata, ii, 786
of retroperitoneal sarcoma, ii, 793
of thrombosis of the mesenteric ves-
sels, ii, 734
of tuberculosis, ii, 648
Excavatioparicovesicalis, i, 1.39
Excavatiorectovesicalis, i, 139
Exeavatiopuliovesicalis, i, 139
Experimenl.-il work on ])i'ritonitis, i,
357
External aiiplications in treatment of
peritonitis, ii, 468
Extraperitoneal abscesses, drainage of,
ii, 494
drainage, i, 125, 126
by way of perivesical space, i, 127
organs, removal of, ii, 514
Extrauterine pregnancy, differentiation
from gonorrheal persalpin-
gitis, ii, 605
Exudate, coagulable, in bellies of fe-
tuses, ii, 643
formation of, as barrier to advanc-
ing infection, i, 302
in gonorrheal perisalpingitis, ii,
601
over surface of a tubercle, ii, 670
granular, i, 305
in caseous peritoneal tuberculosis, ii,
673
in peritonitis, ii, 434
in ]ineumocoeeic peritonitis, ii, 618
management of, ii, 473
plastic, covering silk suture, ii, 505
Exudate-produeing substances, study
of, i, 359
Exudates causing little or no pain, ii,
426
in 'acute inflammation, i, 371, 372
serous, formation of, in inflam-
nmtion, i, 370
subperitoneal, cells in, i, 376
Exudative, diffuse, ap]>endieitis, ii, 528
Fallopian tul)e, jirimary ]ieritoneal tu-
])erculosis of the, ii, 688
tulies, tuliercuhjsis of, ii, 654
Fascia, endoabdominal, i, 114
lining structures of abdominal wall,
i, 114
Falciform band, i, 157
Fan-like arrangement of mesentery of
smiill intestine, i, 164
Fat lictwcen fascia and peritoneum, i,
123
in mesentery of ileocecsil jniiction, i,
193
in file mesentery, ii, 778
in the mesoapi)endix, i, 187
necrosis of tlie omentum, ii, 750, 751
Fate of fibrin bundles, i, 253
Fecal concretions in ajijiendicitis, ii,
523
850
INDEX
Female sexual organs, diseases of the,
diiferentiation from aj'-
pcndicitis, ii, 562
Femoral fovea, i, 138
hernia, i, 138
Fenestration, cause of, in great omen-
tum, i, 220
Feiments, irritation by, i, 271
Fetal adhesions, i, 279
inclusions in tumors, ii, 782
2)eritonitis, i, 279; ii, 611-645
Fever, as a svmptom of api^endicitis, ii,
551
in diagnosis of peritoneal tuljercu-
losis, ii, 698
in diagnosis of peritonitis, ii, 414
in prognosis of peritonitis, ii, 451
Fiber bundles extending between two
peritoneal surfaces, i, 250
Fibei's forming in intercellular sul)-
stance to form connective
tissue, theory of, i, 241
forming within protoplasm of cell to
foim connective tissue, the-
ory of, i, 241
transfer of, from fibrin, cell contri-
bution not clear, i, 264
Fibrils removed from center of disc of
corn pith, i, 250
Fibrin bridges which appear when ag-
glutinated surfaces have
been pulled apart, i, 277
bundles after anastomosis, i, 247
experiments preventing, i, 251
fate of, i, 253
formation of, i, 246
initial factor in wound healing,
i, 255
over surface of foreign body, i,
219
staining of, i, 250
exudation, i, 372
fibrils forming in an amorphous ex-
udate to pi'oduce connective
tissue, i, 241
formation in temporary adhesions, i,
303
in jieritoneal cavity mistaken for
cilia, i, 48
mononuclear cells covering a layer of,
i, 265
Fil)rinoid cliaracter of connectise tis-
sues in chronic inflamma-
tion, i, 374
degeneration in inlhimniatdry reac-
tions, i, 375
state of connective tissue, i, 369
Fil)rinous exudate in acute api)endi-
citis, i, 304
2)eritoueal tuberculosis, symptoms of,
ii, 683
tuberculosis of peritoneum, ii, 669,
670
P''ibromyoma of tlie omentum, ii, 803
Filirosis of the appendix, ii, 537
Fil)rous tissue, formation of, i, 238
regeneration, effect of trauma on,
i, 265
relation of cells to formation of, i,
259
Filtration theory of escape of fluid
from lymphatics, i, 4
First intention, liealing by, i, 244
Fistula, fornmtion of, i, 285
in peritoneal tuberculosis, ii, 677
permanent, estaldishment of, in cases
of dynamic ileus, ii, 491
Fluid in abdomen in tulierculous peri-
tonitis, ii, 699
in appendicitis, in relation to pain,
ii, 544
in exudation, lessens pain by keep-
ing surfaces apart, ii, 428
in filninous type of peritoneal tu-
berculosis, ii, 670
in peritoneal cavity, viscosity of, ii,
476
of the peritoneum, i, 353
Fkiids, cliaracter of, influence duration
of drainage, ii, 477-478
Foci of infection in appendicitis, ii,
539
Folds, duodenal, i, 201
external parietocolic, i, 190
mesentericoparietal, i, 193
parietocolic, internal, i, 193
retrocolic, i, 189
retroduodenal, i, 200
Foreign bodies, absorjition of, in peri-
toneum, i, 12
in aiipendicitis, ii, 523
in peritoneal cavity, i, 321
l)ody as cause of adhesion formation,
i, 285
filirin l)undles forming aljout, in
peritoneum, i, 249
placed in peritoneum to test mi-
gration of omentum, i, 312
tulierculosis, ii, 714
Foramen of Winslow, i, 155, 211
hernia into, i, 214
Formalin, effect of, on peritoneal
cells, i, 19
Formation of lymph, i, 3
INDEX
851
Fossa, diKxU'iial, iiitViior, i, 205
posterior, i, 20G
superior, i, 204
ileocecal, i, 197
ileiicolic, i, ISK!
intennesocolic, i, 207
intersiginoid, i, 210, 211
meseiiteroparietal, i, 209
paiadiuxlenal, i, 208
parajejuiial, i, 209
retroappendicularis, i, 197
retrocecal, i, 197
retrodnodenal, i, 207
Fossa>, cecal, i, 196
Fovea femoralis, i, 138
iiiguiiialis lateralis, i, 136
medialis, i, 136
siipravesicalis, i, 136
Fowler position, use of, in drainage, ii,
487
Frequency of gonorrheal peritonitis, ii,
609
of pneumococcic peritonitis, ii, 617
Friction, as cause of pain, ii, 428
Function of the peritoneum, i, 2
Fusion of sigmoid mesentery al)out
seventh month in embryo, i,
92
G
Gall bladder, udiiesion of, to perito-
neum, i, 282
l)lood vessels of the, i, 76
diseases, differentiating from ap-
pendicitis, ii, 557
inllammation causing peritonitis, ii,
588
necrosis of, ii, 591
nonperforateil, spreading peritoni-
tis from, ii, 591
peritonitis, ii, 715
following perforation of the, ii,
593
relation of tlie omentum to, i, 219
vessels in region of, direction of, i,
341
(Jallstone colic, hyperemia seen in, ii,
5SS
Gallstones causing adlicsions of gall
bladder and peritoneum, i,
282
Gangrenous appendicitis, ii, 534
patliology of, ii, 541
Gas, following operation for perito-
nitis, ii, 488
in tlie gut in relation to distcnliim.
ii, 433
Gastric hemorrhage, relation of resec-
tion of omentum to, i, 32
Gastrocolic omentum, i, 89
tumors of the, ii, 805
Gastrointestinal tract in peritonitis, ii,
430
Gastrohepatic region, i, 154
Gastrophrenosplenic region, i, 161, ]()2
Gauze drain, ii, 483
General habitus of patient with peri-
tonitis, ii, 435
General infections in relation to np-
pendieitis, ii, 524
Genital disorders simulating appendi-
citis, ii, 579
infections in. the male, differentiation
from appendicitis, ii, 568
Genitoenteric fold, i, 144
Genitoenteric folds, i, 180
Genitomesenteric fold, i, 107
Genesis of ileocecal folds and fossa, i,
198
of peritoneal adhesions, i, 276
of peritonitis, ii, 389
of retroperitoneal hernia, i, 214
Germinal layer, uncertain knowledge
of, i, 40
Gerota 's capsule, i, 130
Glass drain, ii, 481
Gonoeoceie peritonitis, ii, 598
classification of, ii, 599
differentiation from pneumococcic
peritonitis, ii, 621
generalized, ii, 607
gonorrheal perisalpingitis, ii, 599
history of, ii, 598
Gonococcus a pronounced filjrin pro-
ducer, i, 290
Gonorrheal infections, adhesions fol-
lowing, i, 290
perisalpingitis, blood in, ii, 605
diagnosis of, ii, 605
differentiation from appendicitis,
ii, 564, 605
differentiation from extiaulerine
pregnancy, ii, 605
differentiation from ovarian cyst
with twisted pedicle, ii, 606
juuscular rigidity in, ii, 604
|)ain in, ii, 601
liatiiogenesis, ii, 599
patliohigy of, ii, 600
tenij>eratuie in, ii, 604
treatment, ii, 606
tumor, ii, 604
])eritonitis, ii, 607
age and sex in, ii, 609
diagnosis in, ii, 610
852
INDEX
Gonorrheal poritoiiitis — Cout "d.
frequency, ii, 609
pathogenesis of, ii, fi07
patholo|ijy of, ii, 608
prognosis, ii, 610
symptoms, ii, 609
treatment of, ii, 610
salpingitis, adhesions following, i,
2S9
Grafts, omental, ii, 514
peritoneal, influence of availal>ility
of, on operation, i, 319
Granular exudate, i, 305
material in limitation of infection,
i, 303
Granulation, healing by, i, 273
Granulonuitous nodules of the tul)e and
ovary, ii, 691
Gravitation in dissemination of tu-
l)ercle bacilli, ii, 674
Gravity in diainagc, ii, 476
Great omentum, i, 29
embryologic development of, i, 87
fused to ascending colon and right
parietal wall, i, 104
Grippe preceding appendicitis, ii, 524
Gross anatomy of the peritoneum, i,
112
Ground sul)stance, i, 49
Gut and its mesentery, beginning de-
velopment of the, i, 86
development of, i, 87
healing by suppuration about, i, 273
infection within the wall of the, ii,
412
perforations, relation of adhesions
in, i, 286
peritonitis from traumatic rupture
of the, ii, 637
resection of affected portion to pre-
vent re-formation of adhe-
sions, i, 320
small, mesentery of the, i, 163
suturing of, not attended 1)V pain, i,
28
wall, perforation of, by mechanical
injury, ii, 407
wall, sensitiveness of, to mechani-
cal trtiiniia, i, 27
H
Habitus, general, of patient with peri-
tonitis, ii, 4;'>5
Healing by first intention, i, 244
by inflammation, i, 269
by second intention, i, 267
by granulations, i, 273
by suppuration, i, 272
Healing — Cont 'd.
failure of proper, due to waste prod-
ucts in area of wound, i,
262
of aseptic wounds, i, 244
of infected wounds, i, 267
process in peritoneal tuberculosis, ii,
677
Heat, application of, in treatment of
peritonitis, ii, 468
Heidenhain 's theory of lymph fornm-
tion, i, 4
Hematogenous dissemination of second-
ary tumors of the perito-
neum, ii, 813
infection, ii, 404
theory of, in pneumococcic peri-
tonitis, ii, 613
transportation of tuberculosis, ii, 638
Hemoglobinuria, i, 21
Hemorrhage as symptom of injuries to
the omentum and mesentery,
ii, 761
in perforation of the gall bladder, ii,
594
intraperitoneal, in diagnosis of peri-
tonitis, ii, 441
Hemorrhagic exudate in acute perito-
nitis, i, 377
peritonitis, acute, i, 368
Hepatic flexure of the colon, i, 156
omentum influenced bv, i, 106
Hepatocolonic folds, i, 157
Hepatoduodenal ligament in embryo, i,
157
region, development of the, i, 100
Hepatogastric ligament, i, 88
Hepatorenal fold, i, 106
Hereditv in relation to peritonitis, ii,
518
in relation to tuberculosis, ii, 650
Heinia, beginning, differentiating pain
from tliat of appendicitis,
ii, 568
duodenal, i, 212
in retroduodenal region, i, 200
inguinal, i, 137
into foramen of Winslow, i, 214
into retroperitoneal spaces, i, 211
into sigmoid fossa, i, 214
femoral, i, 138
of ileocecal region, i, 211
pain in, due to occupation l)y in-
flamed appendix, ii, 543
peritoneum in relation to, i, 121
production of, not facilitated by
looseness of attachment of
peritoneum, i, 121
INDEX
853
Hernia — Coiit 'd.
retioporitoneal, genesis of, i, 214
strangulated femoral, necrosis of a
loop of ileum in a case of,
ii, 414
strangulated omental, ii, 757
Hernial sac, cysts in, ii, 780
torsion of the great omentum in, ii,
753
tuberculosis of the, ii, 693-696
Hiccough in peritonitis, ii, 4.')0
in prognosis of peritonitis, ii, 453
Histogenesis of omentum, i, 99
Histologic appearance of endothelio-
mata, ii, 773
Histology of the peritoneum, i, 39 (see
Peritoneum, histology of
the)
of vessels of the peritoneum, vari-
cose, i, 341
Historical study of peritonitis, i, 357
History of appendicitis, ii, 516
of gonococfic peritonitis, ii, 598
of iuflanunatoiy tumors of the omen-
tum, ii, 743
of pneumococcic peritonitis, ii, 612
of retroperitoneal tumors, ii, 785
of torsion of the great omentum, ii,
750
of treatment of peritonitis, ii, 460
of tuberculosis of the peritoneum, ii,
647
Hollow viscera, suture in, ii, 507
Hydremia, production ofj to test in-
fluence on absorption, i, 19
Hyperemia, active, i, 330
due to functional activity of the peri-
toneum, i, 330
due to inflammation, i, 333
due to iriitation, i, 331
in diffuse exudative type of apiiendi-
citis, ii, 528
in tlie peritoneum and (iinriitum, i,
311
of peritoneal layer, ii, 529
observed in niyoniatous uterus, i,
'J '} I •> •} ~
of the peritoneum, i, 329
passive, i, 3."!5
pericholecystitic, ii, 588
types of, i, 330
Hyperplasia with hyaline degeneration
of the media of vessels, i,
341
Hyperplasias, (dinniic, of the perito-
neum, ii, 720
Ice pack, application of, in treatment
of peritonitis, ii, 469
Ideal wound healing, i, 240
Idiopathic peritonitis, ii, 405
Ileocecal fold, i, 178
and fossa, genesis of, i, 198
of Waldeyer, 1, 181
superior, of Waldeyer, i, 176
fossa, i, 197
region, anatomy of, i, 175
development of the, i, 105
hernias of the, i, 211
tuberculous jjcritonitis, ii, 686
Ileocolic fold, i, 176
and fossa, i, 177
fossa, i, 196
Ileoparietal fold, i, ISO
Ileum, formation of fold about, at
point where cecum is
reached, i, 107
mesenteric vessels in the, i, 172
retrocolonic position of a portion of,
• i, 215
Ileus, dynamic, ii, 489
management of, ii, 488
obstructive, ii, 493
Indurated ulcers of the stomach, ii, 409
Incision, site of, in ojieration for peri-
tonitis, ii, 472
peritoneal, closure of, ii, 505
Indication for operation in appendi-
citis, ii, 582
for operation in peritonitis, ii, 469
Indurated ulcers of the stomach, ii,
409
Infected tube and ovary, adhesions fol-
lowing, i, 289, 290
Infected wounds, healing of, i, 267
Infection by necrosis, ii, 417
by stasis, ii, 414
change in virulence during, i, 304
location of, at a tiistance from its
source, ii, 419
irritation from, i, 270
hematogenous, ii, 404
of appendix by extension from pii-
mary focus, ii, 539
of pleural cavity wilh tiial of the
peritoneum, ii, 458
omentum seeks site of, i, 309
within the wall of the gut, ii, 412
Infections, adhesions me(dianicallv lim-
iting, i, 302
general, in relation to iieritonitis, ii,
524
ill retrorenal space as cause of cica-
tricial adhesions, i, 132
854
INDEX
Infections — Cont 'd.
lying at a distance as source of peri-
tonitis, ii, 40i
inierperal, ii, 625
relation of permanent adhesions to, i,
285
spread of, in pelvis, i, 128
violent, which repel reactive factors
in proportion fail to pro-
duce pain, ii, 429
Infective process, continuous, masses of
scar tissue in, i, 299
Inferior duodenal fossa, i, 205
Infiltration of jiosterior parietal perito-
neum in appendicitis, i, 307
perivascular, in gangrenous ai^pendix,
ii, 535
Inflammation (see Inflammatory reac-
tion)
acute^ exudates in, i, 371, 372
and wound healing, i, 239
Cohnheim's theory of, upheld the-
ory of special openings be-
tween cells, i, 54
effects of, on absorption rate, i,^ 23
hyperemia due to, 1, 333
in relation to healing, i, 351, 352
increases sensitiveness of gut, i, 2S
of the gall bladder, causing perito-
nitis, ii, 588
peritoneum frequent site of, i, 350
presence of, complicates drainage,
ii, 487
spread of, increased area of pain as
indication of, ii, 450
stigmata and stonmta in relation to,
i, 54
wound healing Ijy, i, 269
Inflammatory infection, extension of,
in diaphragm, i, 80
jirocesses, etiology of, i, 352
milder ones most apt to l)e fol-
lowed hj permanent dilata-
tion of the vessels, i, 345
reaction, i, 350
changes in circulation in, i, 364
changes in endothelial cells in, i,
361
degree dependent ujion destiuctidii
of tissue, i, 352
due to bacteria, i, 356
due to drying i, 353
due to mechanical injury, i, 355
due to variations in temperature,
i, 356
formation of serous exudates in,
i, 370
Inflammatory Reaction — Cont 'd.
formerlv only means of diagnosis,
i", 350'
pain due to, ii, 426
varicosities in relation to, i, 340
tumors of the omentum, ii, 743 (see
Omentum, tumors)
Inguinal hernia, i, 137; ii, 757
Injuries during operations, adhesions
due to, i, 291
of the omentum, ii, 743
and mesentery, ii, 759
Intercellular bridges, i, 51
question of existence of, i, 40
cement substance, i, 49
lines, broadened, in inflammation, i,
362
processes, i, 50
determining the ]»resenee of, i, 50
staining for, i, 50
Intercostal nerves, i, 223
Interference with adhesions, unneces-
sary, may permit spread to
unaffected regions, i, 315
Intermesocolic fossa, i, 206, 207
Internal parietocolic fold, i, 193
Interrupted suture in peritoneal inci-
sion, ii, 507
Intersigrnoid fossa, i, 210, 211
Interstitial fibrinoid fibrin compared
with fibrillar fibrin of
wound healing, i, 375
Intestinal contents, character of, in-
dicating site of fistula, i,
173
dilatation, as factor in cause of
death, ii, 457
loops, i, 167
common arrangement of, i, 166
determining arrangement of, i, 169
localization of isolated, i, 169
seek former site when disjilaced, i,
168
obstruction caused by drain, ii, 479
in peritonitis, ii, 445
tract as avenue of infection in peri-
toneal tul)erculosis, ii, 657
tulxnculosis in relation to peritoneal
tuberculosis, ii, 652
Intestine, small, arrangement of, i, 165
arrangement of the coils of the, i,
163
topography of, i, 165
vascular arrangement in, i, 170
Intima, change in, can not be demon-
strated, i, 367
Intiaabdominal pressure, increase of,
hastens absorjition, i, 17
I
I
INDEX
855
Intiaalxlominal — Cont 'd.
type of torsion of the omcntiini, ii,
752
Intraperitoneal hemorrhage in diag-
nosis of peritonitis, ii, HI
walled-off abscesses, ii, 498
Iodine, painting skin with, prepara-
tory for operation, ii, 471
Irrigation of the peritoneal cavity, ii,
473
Irritating substances, sudden escape of,
as cause of spontaneous
pain, ii, 425
Irritation by ferments, i, 271
from infection, i, 270
from necrosis, i, 272
hyperemia due to, i, 332
Jejunum, mesenteric vessels in, i, 171
Kidney and ureteral colic, differenti-
ation from appendicitis, ii,
556
Kidneys, relation of meson to, i, 150
Kittsubstanz, i, 51
Lamplilack in testing absorption of
solids in peritoneum, i, 14
Lanz 's jioint, i, 232
Lemljert suture for suturing adhesions,
ii, 512
in peritoneal incisions, ii, 505
Lesser omentum, beginning develop-
ment of, i, 85
peritoneal cavity, i, 154
formation of, i, 119
Leucocyte count in diagnosis of ]ieri-
toneal tuliercuhisis, ii, (598
Leucocytes, escape of, from potential
vessels in beginning inllam-
niation, i, 3()6
in formation of stomata, theories of
i, 58
in intiaiumatory reaction, i, 365
nidHiiiuu-lear, appearance of, when
infective forces have been
overcome, ii, .">70
in infections, i, 305
polynuclear, action of, in infec-
tions, i, 303
reparative agents, i, 31
Leucocytic infiltration into omentum,
influences movement in in-
fections, i, 311
Leueoeytosis in appendicitis, ii, 554
in diagnosis of peritonitis, ii, 445
in prognosis of peritonitis, ii, 451
Leucopenia, i, 13
Ligamenta lata, i, 141
Ligaments, parietocolie, i, 191
peritoneum in relation to some, i, 115
uterolumbalis of Valliu, i, 148
nterosacral, i, 146
Ligamentum infundil)ulocolicum, i, 146
Light, effect of, on peritoneal tissue, i,
59
Linen, as ])eritoneal suture, ii, 504
Lining cells as active factors in for-
mation of lymph, i, 5
Lipoma of the mesentery, ii, 778
of omentum, ii, 798
Lipomata, retroperitoneal, ii, 786
diagnosis of, ii, 791
etiology of, ii, 786
pathogenesis of, ii, 787
pathology of, ii, 789
prognosis of, ii, 791
site of origin, ii, 787
symptoms of, ii, 790
treatment of, ii, 792
Liver, beginning development of, i,
85
cirrhosis of, relation to tuljerculosis
of the peritoneum, ii, 674
Localized peritoneal tuberculosis, symjj-
tonis of, ii, 686
peritonitis, ii, 382
following trauma, ii, 635
pneumococcic peritonitis, ii, 617
Location of enterocystomata, ii, 776
of tubercle in peritoneal tuljerculosis,
ii, 674
Loops, intestinal, localization of iso-
lated, i, 167, 169
common arrangement of, i, 166
Lower abdominal region, i, 134
Lowered resistance as factor in perito-
neal infection, i, 313
liudwig's theory of lymph formation, i,
4
Lymph, i, 3
-canalicular system, i, 78
clianiiels, i, 79
cyst of the ileocecal region, ii, 7()9
follicles, prominence of, in chronic
appendicitis, ii, 57.'>
formation of, i, 3
Heideidiain 's theory of, i, 4
Ludwig's tlieory of, i, 4
856
INDEX
Lymph f oimation — Coiit 'd.
theory of decreased capillary re-
sistance, i, 6
glands, involvement of, in peritoneal
tuberculosis, ii, 654
-occlusion giving rise to subperitoneal
edema, i, 347
vessels, distribution, i, 79
in the omentum, i, 221
occlusion of, in ap])endicitis, ii,
531
Lymphagogues, i, 5
Lymphatic cysts, mesenteric, age in re-
lation to, ii, 7(56
diagnosis of, ii, 769
frequency of, ii, 765
l>athogenesis of, ii, 766
pathology of, ii, 7()S
prognosis of, ii, 769
sex in relation to, ii, 766
size, ii, 765
symptoms of, ii, 768
treatment of, ii, 770
plexus, of mesentery, i, 77
Lymphatics and blood vessels, connec-
tion between, i, 78
as avenues of absorption, i, 8
of the diaphragm, i, 78
of the peritoneum, i, 77
dilatation of, i, 346
part played in transmission of tu-
berculosis to peritoneum, ii,
659
thoracic, and abdominal serosa, con-
nection between, i, 80
M
McBurney's point compared to Lanz's
point, i, 232
Macroscopic appearance of tuljcrcle, ii,
661
^fanagement of temporary adhesions, i,
315
^Manipulations causing formation of
adhesions, i, 293
Masked appendicitis, ii, 576
Mass adhesion, i, 300
Massage, hastens absorption, i, 17
^lechanical injury, inHammatory reac-
tion due to, i, 355
perforation of gut wall liy, ii, 407
limitation of infections, i, 302
physiology of the omentum, i, 34
Mechanism of absorption, i, 6
of the drain, ii, 478
Medical treatment of appendicitis, ii.
581
Medical treatment — Cont 'd.
of peritoneal tuberculosis, ii, 705
of peritonitis, ii, 462
Medullated fillers terminating in end-
organs, i, 227
Membrana limitaus, i, 67
^Membrana propria, i, 70
Membrane, basement, i, 67
new, formed around foreign body in
peritoneum, i, 253
pericolic, i, 347
Mesenchymal tissues, fusion between,
i, 90
Mesenteric cyst, ii, 779
thrombosis, ii, 418
vessels in beginning and termination
of jejunum, i, 171
in the ileum, i, 172
occlusion of, in gangrenous appen-
dicitis, ii, 535
thrombosis and embolism of the,
ii, 734
Mesentericoparietal fold, i, 193
Mesenteries of the uterus, i, 141
Mesenteroparietal fossa, i, 209
Mesentery, attachment of root of the,
i, 174
cross section of, i, 70
dilated vessels of the, i, 346
importance of, in orientation in sur-
gery, i, 174
injuries to, ii, 759
lipoma of the, ii, 778
lym]iliatic cysts of, ii, 765
lympliatic plexus of the, i, 77
of small intestine, fan-like arrange-
ment of the, i, 163, 164
rupture of the, ii, 637
secondary tumor of the, ii, 809
supporting small intestines, i, 119
theories regarding the, i, 90
traction on, as cause of pain, i, 27
vascularity of, i, 170
Mcsoappendix, i, 181
anatomy of, importance of, in sur-
gery, i, 187
double, i, 184
fat in the, i, 187
Mesocolon, relation of omentum to, i.
94
Mesogastrium, posterior, important
changes in, in development,
i, 95
Meson of the colon, i, 158
relation of attachments to the kidneys
and pancreas, i, 150
Mesosalpinx, i, 144
Mesosigmoid, attachment of the, i, 175
INDEX
857
Metcorism in peritonitis, ii, 431
IMitToscopic api)oaranee of tlie tubercle,
ii, G63-665
Migration of the omentum, causes of
the, i, 309
rate of, i, 312
]\[iliary carcinosis of the peritoneum,
ii, 816
peritoneal tuberculosis, symptoms of,
ii, 683
stage of peritoneal tuberculosis, ii,
668
type of peritoneal tuberculosis, ii,
666
Mixed infection in peritonitis, ii, 398
!Moist heat, application of, in treat-
ment of peritonitis, ii, -469
pack, exposure of peritoneum to, in-
fluence of, i, 354
Mononuclear cells about fibrin bundles,
i, 265
leucocytes, appearance of, when in-
fective forces have been
overcome, i, 370
in infections, i, 305
!Mor]ihology of the omentum, i, 99
Morris ' pouch, i, 159
Movement, pain on, in appendicitis, ii,
545
]\rovements of the omentum, ij 35; ii,
753
]\rnscle laxity associated with varicosi-
ties of the peritoneum, i, 338
sensitiveness in peritoneum, i, 26
Muscles, abdominal, rigidity of, ii, 443
of gut wall, varicosities in relation
to, i, 344
of peritoneum in relation to nerve
su]i]dy, i, 224
Muscular rigidity as symptom of ap-
pendicitis, ii, p48
in gonorrheal perisalpingitis, ii,
604
in prognosis of peritonitis, ii, 452
^[vxoid tissue complicating lipomata.
ii, 789
N
Nausea and vomiting in thrombosis of
mesenteric vessels, ii, 739
Necrobiosis of gut Avail, ii, 739
Necrosis as a cause of pain, ii, 441
fat, of the omentum, ii, 750, 751
in presence of foreign body, ii, 534
infection by, ii, 417
irritation from, i, 272
of appendix from thrombosis of the
appendicular artery, ii, 418
Necrosis — Cont 'd.
of gall bladder, ii, 591
of loop of ileum in a case of strangu-
lated femoral hernia, ii, 414
of tissue in ulcerative appendicitis, ii,
533
Nephrocolic ligament, i, 192
Nephroduodenal region, relation of vis-
cera, 1, 133
Nerve, phrenic, i, 227
supply of i^eritoneum, i, 222
theory of death from peritonitis, ii,
455
Nerves, intercostal, i, 223
of peritoneum, sensitiveness of, i, 26
terminals of, in peritoneum, i, 225
Neurasthenia, sexual, simulating ap-
pendicitis, ii, 580
Neural anatomy of the peritoneum, i,
o ■; o o o
Neuroses, abdominal tenderness accom-
panying, ii, 443
Nodules covering hernial sac, ii, 696
Nodules of tuberculosis, macroscopic
appearance, ii, 661
Nonencapsulated end-organs, i, 227
Normal variations regarded as adhe-
sions, i, 318
Nuclei in endothelial cells tending to
form stellate groups, i, 45
Nucleus of endothelial cell, axis of, i,
46
on cross section, i, 47
shape of, i, 45
size of, i, 45
staining, i, 46
Nutrition, omentum as an accessory
source of, ii, 749
O
01)structlve ileum, ii, 493
Occuiiation in relation to appendicitis,
ii, 520
Oil, introduction into peritoneal cavity
as preventive of adhesions,
i, 321
Onu^ntal bursa, sarcoma of the, ii, 804
Omentum, absorption of the, i, 33
adherent to abdominal Avail, i, 282
agglutination of the tAvo layers soon
after liirth, i, 97
anatomy of, i, 216
and mesentery, blunt traunm of, ii,
760
diagnosis of injuries of the, ii, 761
]iathogenesis of injuries of the, ii,
760
858
INDEX
Omentum and mesentery — Cont 'd.
penetrating wounds of the, ii, 760
prognosis of the injuries of the, ii,
761
symptoms of injuries of the, ii,
760
treatment of injuries to the, ii, 761
as a regulator of blood pressure, i, 32
as accessory source of nutrition, ii,
749
attachment of, to ascending colon,
pathologic, i, 192
to colon, i, 217
causes of migration of the, i, 309
chief organ in -walling-off process, in
infections, i, 307
defensive reactions of, ii, 749
diseases and injuries of the, ii, 743
development of the, i, 92, 217
embryology of, i, 96
extent and position of, i, 217
fat necrosis of the, ii, 750, 751
fibromyoma of the, ii, 803
functions of the, i, 30-32
gastrocolic, tumors of the, ii, 805
grafts, ii, 514
great, i, 29
fenestration in, i, 220
normal, i, 218
physiology of the, i, 30
union of, with mesocolon and colon,
i, 97
cause of, i, 98
in lower animals remains as two
layers, i, 93
injuries to, ii, 759
"intelligence" of the, i, 30
lipomata of, ii, 798
lymph vessels in, i, 221
mechanical physiology of the, i, 34
minus, development of, i, 97
morphology of the, i, 99
movements of the, i, 35 ; ii, 753
peristalsis in relation to, i, 309
plasticity and capacity for fusion, i,
■'92
position of the, i, 217
rate of migration of the, i, 312
relation to duodenum and transverse
colon, i, 103
relation of, to gall bladder, i, 219
relation of, to mesocolon, i, 94
sarcomata of the, ii, 800
secondary glandular carcinoma of, ii,
"810
submiliary tuberculosis of, ii, 667
thickness of, i, 221
torsion of, definition of, ii, 750
Omentum, torsion of — Cont 'd.
diagnosis of, ii, 758
history of, ii, 750
pathogenesis of, ii, 752
pathology of, ii, 754
prognosis of, ii, 759
symptoms of, ii, 754
treatment of, ii, 759
tumors of the, ii, 798 (.lec Tumors
of omentum)
definition of, ii, 743
diagnosis of, ii, 746
history of, ii, 743
pathogenesis of, ii, 744
pathology of, ii, 745
symptoms of, ii, 745
treatment of, ii, 747
two layers still free at birth, i, 97
Openings in the diaphragm, theories re-
garding, i, 66
Operative treatment of appendicitis, ii,
581
of peritoneal tuberculosis, ii, 708
of peritonitis, ii, 469 (see Treat-
ment of peritonitis, opera-
tive)
Operation for adhesion exerting per-
nicious influence, i, 301
for appendicitis, in the attack, ii,
582
in the interval, ii, 582
indications for, ii, 582
place of, ii, 583
time for, ii, 581
type of, ii, 583
for peritoneal tuberculosis, danger
of, ii, 708
good done by, ii, 712
in dry form, ii, 711
management of adhesions, ii, 710
objections against, ii, 711
removal of tuberculomata, ii,
711
removal of tubes, ii, 710
technic, ii, 708
time, ii, 708
for peritonitis, time of, ii, 472
Operations, peritoneal, ii, 503
closure of peritoneal incisions, ii,
505
covering raw surfaces by trans-
plant, ii, 512
removal of extraperitoneal organs,
ii, 514
suture in hollow viscera, ii, 507
suture of adhesions, ii, 510
sutures in, ii, 503
suturing of solid viscera, ii, 515
INDEX
859
opium ill tlio treatment of peritonitis,
ii, 463
Organ from whifli infection orifjinates,
classification of peritonitis
according to, ii, 385
Organism causing peritonitis, determi-
nation of, ii, 386, 387
causing puerperal peritonitis, ii, -627
prognosis of peritonitis according to
species of, ii, 448
Organogenesis of peritonitis, ii, 385
Organs, hollow, adhesions destroying
functions of, i, 295
Osmie acid, effect of, upon cement sub-
stance in absence of cells, i,
50
Osmotic pressure, increase of, hastens
absorption, i, 17
induence of, on absorption, i, 11
of normal lymph, i, 5
Ovarian cyst with twisted pedicle, dif-
ferentiation from gonor-
rheal perisalpingitis, ii, 606
hemorrhage, differentiation from ap-
pendicitis, ii, 566
tumor, with twisted pedicle, differen-
tiation from appendicitis, ii,
563
type of pseudomyxoma peritonei,
symptoms of, ii, 828
Ovary and tul)e, infected, adhesions
following, i, 289, 290
Pack, dry, i, 354
moist, i, 354
Pain as symi)toin of peritonitis, ii, 422
area of, in appendicitis, ii, 542
as a diagnostic sign of peritonitis, ii,
439
as symptom of thronil)osis of mesen-
teric vessels, ii, 739
caused by adhesions, unusual, i, 295
caused by distention of parenchyma-
tous organs, ii, 442
caused by friction, ii, 428
caused by inllammatory reaction, ii,
426
caused by necrosis, ii, 441
caused by perforation of duodenum,
ii, 425
caused l)v pressure in appendicitis ii,
'546
caused l)y thrombosis, ii, 440
in appendicitis, ii, 541
in gangrenous appendicitis, charac-
teristic, ii, 544
Pain — Cont 'd.
in gonorrheal perisalpingitis, ii, 601,
602
in prognosis of peritonitis, ii, 450
in puerperal peritonitis, ii, 631
on movement in appendicitis, ii, 545
pressure, ii, 427
produced by mechanical contact of
one diseased surface against
another, ii, 428
reactive, ii, 423
referred, ii, 442
reflex, in peritonitis, ii, 422
spontaneous, ii, 425
sudden cessation of, may be grave
omen, ii, 450
Pancreas, development of, i, 87
relation of, meson to, i, 150
Pancreatin extract, fresh, prevents
formation of filjrin, i, 252
to remove cement substance from
fibrin tissue, i, 68
Pancreatitis, acute, differentiation
from appendicitis, ii, 559
fat necrosis of the omentum in a case
of, ii, 751
Paracentesis in treatment of peritoneal
tuberculosis, ii, 707
Paraduodenal fossa, i, 208
Para.ie.iunal fossa, i, 209
Paralysis of the gut tract, ii, 490, 491
Parametritis, differentiation from ap-
pendicitis, ii, 563
Paraperitoneal abscesses, perforation
of, ii, 418
Periappendiceal abscess, prognosis of,
ii, 585
Parenchymatous organs, pain caused by
distention of, ii, 442
Parietal peritoneum, i, 95, 133
elevations and dejiressions in, i, 115
of the posterior abdominal wall, i,
148
relation of, to endoalidoniinal fas-
cia, i, 114
sensitiveness of, i, 25, 26
Parietocolic fold, external, i, 190
internal, i, 193
ligament, i, 158, 191, 192
Pars inf racolica duodeni, i, 152
I'assive liyperemia, i, 335
Pathogenesis of appendicitis, ii, 524
of enteroeystomata, ii, 776
of gonorrheal perisaljiingitis, ii, 599
of gonorrheal peritonitis, ii, 607
of inflammatory tumors of the omen-
tum, ii, 744
860
INDEX
Pathogenesis — Cont Vl.
of injuries of the omentum and mes-
entery, ii, 760
of lymphatic cysts of the mesentery,
ii, 766
of perforations in peritoneal tuber-
culosis, ii, 678
of peritoneal tuberculosis, ii, 651
of peritonitis, ii, 401
of pneumococcic peritonitis, ii, 613
of pseudomyxoma peritonei, ii, 818-
824
of puerperal peritonitis, ii, 628
of retroperitoneal lipomata, ii, 787
of retroperitoneal sarcoma, ii, 794
of sarcomata of the omentum, ii, 801
of secondary peritoneal tumors, ii,
808
of temporary adhesions, i, 302
of thrombosis of mesenteric vessels,
ii, 73.J
of torsion of the omentum, ii, 752
Pathologic anatomy of appendicitis, ii,
5o6
of chronic hyperplasias of the per-
itoneum, ii, 720
of chronic productive appendicitis,
ii, 572
of endotheliomata, ii, 773
of enterocystomata, ii, 777
of gonorrheal peritonitis, ii, 600,
608
of inflammatory tumors of the
omentum, ii, 745
of lymphatic cysts of the mesen-
tery, ii, 768
of masked appendicitis, ii, 576
of peritoneal tuberculosis, ii, 660
of pneumococcic peritonitis, ii, 616
of puerperal peritonitis, ii, 629
of postappendiceal cicatrization,
ii, 575
of pseudomyxoma peritonei, ii,
824
of retroperitoneal lipomata, ii, 789
of retroperitoneal sarcoma, ii, 794
of sarcomata of the omentum, ii,
801
of secondary tumors of the peri-
toneum, ii, 814
of thrombosis of mesenteric ves-
sels, ii, 738
of torsion of the great omentum,
ii, 754
Pedicles remaining after ligation of
peritoneal-covered organs,
adhesions in relation to, i,
292
Pelvic peritoneum, i, 138
tuberculosis of, ii, 689
region, i, 138
Pelvis, retroperitoneal spaces of the,
i, 122
Penetrating Avounds of the abdominal
Avail, in relation to perito-
nitis, ii, 403
of the omentum and mesentery, ii,
760
Peptone acts as repellaut to leucocytes,
i, 252
as a preventive of fibrin formation,
i, 251
Perforating ulcer of appendix, effect
of, on peritoneum, ii, 533
of the stomach and duodenum,
differentiation from appen-
dicitis, ii, 557
prognosis of, dei^endent on time of
operation, ii, 447
Perforation at umbilicus in peritoneal
tuberculosis, ii, 677
by ulceration, ii, 407
into i:)eritoneal cavity in peritoneal
tuberculosis, ii, 679
of duodenum, i, 289; ii, 419
of gall bladder, causing peritonitis,
ii, 593
of gut wall, by mechanical injury, ii,
407
of paraperitoneal abscesses, ii, 418
of the terminal ileum and colon, ba-
cillus coli communis in, ii,
396
Perforative peritonitis, ii, 407
Periappendiceal abscess, ii, 528
Pericholecystitic hyperemia, ii, 588
peritonitis, ii, 590
Pericholecystitis Avith adhesions, ii, 590
Pericolic membrane, i, 347
Perirectal space, i, 128
Perisalpingitis, gonorrheal, ii, 599 (see
Gonorrheal perisalpingitis)
differentiation from appendicitis,
ii, 564
Peristalsis in relation to the move-
ments of the omentum, i,
309
reversed, in dynamic ileus, ii, 490
Peritoneal adhesions, nature and gene-
sis of, i, 276
agglutination, i, 277
cavity, i, 154
irrigation of, ii, 473
lesser, i, 119
perforation into, ii, 679
rate of absorption from, i, 11
INDEX
861
I'l'iitoiR'al cavity — Cont 'd.
waiuloring tumors of the, ii, 806
conglutination, i, i;^7
cells, outline of, differs in various
species of animals, i, 43
cysts, secondary, ii, 780
exudate, as symptom of thrombosis of
mesenteric vessels, ii, 740
flexure, degree of separation of, from
pubis, i, 123
fold, in relation to distended bladder,
i, 127)
fluid, jirogiiostic value of examina-
tion of, ii, 448
viscosity of, ii, 476
grafts, operation when not available,
i, 319
incisions, closure of, ii, 505
surfaces, raw, covering by transplant,
ii, 512
sutures, general principles of, ii, 503
tuberculosis, tumors simulating, ii,
700
tumors, ii, 764
elassifieation of, ii, 764
vessels, analogous to those of the
skin, i, 326, 327
Peritoneum, absorption in the, i, 6
anatomy, gross, of the, i, 112-237
anemia of the, i, 328
arrangement of, i, 112
cells of the, i, 40
changes in the j^erivascular connec-
tive tissue, i, 368
chronic hyperjilasias of the, ii, 720
circulation in the, i, 325
covering ligaments and folds, i, 148
development of the, i, 84
general considerations, i, 84
hepatoduodenal region, i, 100
ileocecal region, i, lOq
omentum, i, 92
sigmoid region, i, 110
special regions, i, 90
splenic region, i, 108
exposure of, to moist pack, influence
of, i, 354
to air, as cause of inflamnuitory re-
actions, i, 353
lluid of the, i, 353
frequent site of inflammation, i, 350
function of the, i, 2
general relations of the, i, 116
histology of the, i, 39
basement membrane, i, 67
blood vessels, i, 71
cells on cross section, i, 46
cell outline, i, 42
Peritoneum, iiistology of — Cont 'd.
cell protoplasm, i, 46
cilia, i, 47
endothelial cell, i, 39
intercellular cement substance, i,
49
intercellular processes, i, 50
lymphatics, i, 77
nucleus, of cell, i, 45
scope of, i, 39
stigmata and stonmta, i, 53
subperitoneal connective tissue, i,
69
hyperemia of the, i, 329
in Douglas' pouch, i, 139
in the phrenohepatic region, nature
of, i, 161
in relation to hernia, i, 121
incised separately to secure tissue
for covering denuded area,
ii, 513
inflammatory reaction of the, i, 350
influence of dry pack upon, i, 354
lymphatics, dilatation of, i, 346
membrane lining abdominal cavity, i,
112
nature of the, i, 1
neural anatomy of, i, 222
normally free from visilde vessels, i,
007
operations on the, ii, 503 (see Opera-
tions, peritoneal)
of posterior abdominal wall, i, 148
of small intestine, acute inflamma-
tion of the, i, 362
of the uterus and broad ligaments, i,
140
parietal, i, 133
and visceral, i, 112
elevations and depressions in, i,
115
infiltration of, in appendicitis, i,
307
nerves of the, i, 223
pelvic, i, 138
physiology of the, i, 1
absorjition, avenues of, i, 8
factors which delay, i, 6
factors which hasten, i, 17
mechanism of, i, 6
of blood from peritoneal cavity,
i, 20
of solid particles, i, 12
rate of, from peritoneal cavity,
i, 11
site of, i, 22
formation of lymph, i, 3
nature of the peritoneum, i, 1
862
INDEX
Peritoneum — Cont 'd.
plastic exudation excited in, as re-
sult of appendicitis, ii, o32
protective membrane, i, 1
relations of, general, i, 112
to appendix, i, 185
to its environment, i, 114
to parietocolic fold, i, 190
secondary tumors of, ii, 807
sensibility of, i, 21
surface of, extent of, i, 113
tensile strength and elasticity of, i,
113
topography of, 1, 118
translucency of, i, 325
varicosity of the, i, 337
veins of the, i, 76
visceral, i, 162
vulnerable to jihysical agents that in-
jure other tissue, i, 352
wound healing in, i, 238, 245
Peritonitis, after-pain from operation
for, ii, 488
amorphous exudate in, i, 376
anaerobic bacteria in, ii, 398
appendiceal, ii, 516 (see Appendici-
tis)
area involved, ii, 382
Itacillus coli communis in, ii, 396
bacillus pyocyaneus in, ii, 398
bacteria found in, ii, 394
bacterial, ii, 391
camphorated oil, in treatment, ii, 468
causes of death in, ii, 454-459
chemical, ii, 389
cliolecystitie, ii, 588
chronic idiopathic nontuberculous, ii,
714
chronica mesenterialis, i, 175
circulation in, ii, 434
classification of, ii, 381
according to organ from which in-
fection originates, ii, 385
diagnosis of, ii, 438
diffuse, ii, 384
following trauma, ii, 635
due to invasion of peritoneal cavity
by pathogenic organisms,
ii, 401
epinei^hrin in treatment of, ii, 464
escape of fluids from hollow organs
as cause of, ii, 390
ether in treatment of, ii, 466
etiology of, i, 352; ii, 389
external application in treatment of,
ii, 468
exudate in, ii, 434
fetal, ii, 641-645
Peritonitis — Cont 'd.
fever in diagnosis of, ii, 444
fever in prognosis of, ii, 451
following perforation of the gall
bladder, ii, 593
gas following operation for, ii, 488
gastrointestinal tract, ii, 430
general habitus in, ii, 435
generalized, symptoms of, Avhen ap-
pendix ruptures, ii, 543
genesis of, ii, 389
gonococcic, ii, 598 (see Gonoeoccic
peritonitis)
gonorrheal, ii, 607 (see Gonorrheal
peritonitis)
hemorrhagic, i, 368
historical study of, i, 357
idiopathic, ii, 405
leucocytosis in diagnosis of, ii, 445
leucocytosis in prognosis of, ii, 451
localized, ii, 382
following trauma, ii, 635
medical treatment in, ii, 462
meteorism in, ii, 431
mixed infections, ii, 398
muscular rigidity in, ii, 452
tympany in prognosis of, ii, 452
operative treatment of, ii, 469
opium in treatment of, ii, 463
pain a symptom of, ii, 422
as a diagnostic sign, ii, 439
in prognosis of, ii, 450
penetrating wounds of the aljdominal
wall in relation to, ii, 403
pathogenesis of, ii, 401
perforative, ii, 407
pericholecystitic, ii, 590
pneumococcic, ii, 612 (sec Pncumo-
coccic peritonitis)
postoperative, ii, 637
preventive treatment of, ii, 462
prognosis of, ii, 447
puerperal, ii, 625 (see Puerperal
peritonitis)
pulse rate in diagnosis of, ii, 444
in prognosis of, ii, 451
singiiltus in prognosis of, ii, 453
specific forms of, ii, 398
spreading, ii, 383
going out from the nonperforating
gall bladder, ii, 591
sordes in prognosis of, ii, 453
staphylococcus in, ii, 397
streptococcus pyogenes in, ii, 395
symptomatology of, ii, 422
temperature in, ii, 434
traumatic rupture of the gut as
cause of, ii, 637
INDEX
863
Peritonitis — Cont M.
traumatic Avitliout rupture^ ii, 634
(see Traumatie peritonitis)
treatment of acute general, ii, 460
(see Treatment of peritoni-
tis)
tuberculosis of the, ii, 647 (see Tu-
berculosis, peritoneal)
tympany in diagnosis of, ii, 445
symptoms of, (see Symptoms of peri-
tonitis)
virulent, in relation to varicosities, i,
345
vomiting in, ii, 430
in prognosis of, ii, 453
Perityplilitis, ii, 517
Periuterine spaces, i, 127
Perivascular connective tissue, changes
of, i, 368
endothelium thickened as result of
irritation in beginning ap-
pendicitis, i, 369
Perivesical space, i, 126
affords easy access to abscesses
deep in pelvis, i, 127
as an avenue of approach to the
terminal ureter, i, 127
available route for attack of the
seminal vesicles, i, 127
Permanent adhesions, i, 276, 280
management of, i, 301
Phrenic nerve, i, 227
Phrenocolic ligament, i, 108
Phrenohepatic region, i, 160
Physical characters of the abdomen, ii,
436
Physical state, genei-al, in tuberculosis,
ii, 650
Physiology of the peritoneum, i, 1 (see
Peritoneum, phvsiology of
the)
Planes of retrorenal space, i, 132
Plethoric individuals, vessel changes
in, i, 339
vascular changes in, i, 330
Plexus formation of nerves in perito-
neum, i, 224
Plexuses of gut tract, i, 27
Plica epigastrica, 1, 136
gastropancreatica, 1, 95
parajejunalis, i, 209
Plica\ production of, i, 106
umbilicales, i, 134
Pneumococeic peritonitis, ii, 612
diagnosis of, ii, 620
differentiation from appendicitis,
ii, 621
differentiation from gonococcic, ii,
621
Pneumococeic peritonitis — Cont 'd.
differentiation from tuberculous, ii,
621
differentiation from typhoid peri-
tonitis, ii, 622
diffuse, ii, 619
frequency, ii, 617
history of, ii, 612
localized, ii, 617
pathogenesis of, ii, 613
pathologic anatomy of, ii, 616
predisposing causes, ii, 620
symptoms, ii, 617
treatment of, ii, 622
pyosalpinx, rupture of, causing peri-
tonitis, ii, 616
Pneumonia in relation to peritonitis, ii,
613
Polyuuclear leucocytes, action of, in in-
fection, i, 303
Polyserositis, ii, 719
Position of appendix, i, 184
Postappendiceal cicatrization, ii, 575
differential diagnosis, ii, 576
pathology of, ii, 575
symptomatology of, ii, 576
Postappendicitis, ii, 570
Posterior duodenal fossa, i, 206
Postoperative peritonitis, ii, 637
prophylaxis of, ii, 638
vomiting, ii, 489
Postural measures in prevention of ad-
hesions, i, 320
Posture of patient in cases requiring
drainage, ii, 486
Potential vessels, i, 72, 73, 75
in beginning inflammation, begin-
ning of escape of leucocytes,
i, 366
Predisposing causes of peritoneal tu-
berculosis, ii, 651
to pneumococeic peritonitis, ii, 620
Pregnancy, ectopic, dift'crentiation from
appendicitis, ii, 562
pyelitis of, ii, 567
relation bet^veen peritoneal tuberculo-
sis, ii, 651
Preparation of patient for operation, ii,
470
of skin for operation, ii, 471
Prenatal adhesions, i, 279
I^ressure as cause of obliteration of
peritoneal surfaces, i, 137
caused by drain, danger of, ii, 479
in production of adliesions, i, 294
pain, ii, 427
pain produced bv, in appendicitis, ii,
546
864
INDEX
Pressure — Cont M.
use of, in deti'riiiiiiiiit>' areas of great-
est pain, ii, 428
Prevention of adhesions, i, .317
Preventive treatment of peritonitis, ii,
462
Prevesical space, i, 123
Primary adhesions, jinnention of, i, .".17
Primary form of peritoneal tuberculo-
sis, ii, 6.52
Prognosis of appendicitis, ii, 58.5
interval operations, ii, 595
of cholecystitic peritonitis, ii, 595
of enterocystomata, ii, 778
of gonorrheal peritonitis, ii, 610
of injury of the omentum and mes-
entery, ii, 761
of lymphatic cysts of the nu senterv,
ii, 769
of periappendiceal abscess, ii, 585
of peritoneal tuberculosis, ii, 701-70.5
of peritonitis, ii, 447
according to species of organism
causing, ii, 448
of pseudomyxoma ]ieritonei, ii, 831
of puerperal peritonitis, ii, 632
of retroperitoneal lipomata, ii, 791
of retroperitoneal sarcoma, ii, 797
of secoudarv tumor of the peritoneum^
ii," 816
of spreading peritonitis, ii, 585
of torsion of the omentum, ii, 759
Prognostic value of examination of
peritoneal fluid, ii, 448
Proliferation of fibers with thickening
of fibrinous layer, i, 377
Prophylactic measure against paralytic
ileus, ii, 493
Prophylaxis in postoperative peritonitis,
ii, 638
Protective adhesions, formation of, ii,
411, 413
Protoplasm, cell, i, 46
of endothelial cell, cross section, i, 47
Pseudoappendicitis, ii, 578
symptomatology of, ij, 578
Pseudonuicinous exudate in appendici-
tis, ii, 574
Pseudomyxoma peritonei, ii, 817
appendiceal type, symptoms of, ii,
829
diagnosis of, ii, 830
ovarian type, symptoms of, ii, 829
pathogenesis of, ii, 818-824
pathologj' of, ii, 824
prognosis of, ii, 831
symptoius of, ii, 828
treatment of, ii, 831
Pseudoperitoneal formation, i, 290
Pseudoperitonitis, ii, 634
Pseudostomata, i, 54
Pseud6tuberculosis, ii, 713
Pubis, space between peritoneum and
fascia at, i, 123
Pubovcscial fold in relation to dis-
tended bladder, i, 124
Puerperal infections, ii, 625
peritonitis, ii, 625
chill in, ii, 630
clinical signs, ii, 630
diagnosis of, ii, 631
etiology of, ii, 627
])ain in, ii, 631
]iathogenesis of, ii, 628
pathology of, ii, 629
prognosis of, ii, 632
temperature in, ii, 631
treatment of, ii, 632
tympany in, ii, 631
Pulmonary affections associated with
pneumocoeeic peritonitis, ii,
620
tuberculosis, perforation of peri-
toneal cavity in cases of, ii,
680
Pulse rate in appendicitis, ii, 553
in diagnosis of peritonitis, ii, 444
in prognosis of peritonitis, ii, 451
Puncture by suture, as a factor in pro-
ducing adhesions, i, 292
Pus formation in wound healing, i, 269
in pneumocoeeic peritonitis, ii, 616
Pyelitis of pregnancy, differentiation
from appendicitis, ii, 567
B
Raw surfaces left by removal of ad-
hesions in inaccessible
places, i, 319, 320
Rectum and urinary bladder, diseases
of the, differentiation from
appendicitis, ii, 559
Recurrent vomiting, ii, 550
Reaction, inflammatory, of the peri-
toneum, i, 350
Reactive pain, ii, 423
Reactive type of varicosities of the
peritoneum, i, 339
Referred pains in peritonitis, ii, 442
Reflex iiahi in peritonitis, ii, 422
Regeneration of the endotlielium, i, 264
Remittent appendicitis, ii, 570
INDEX
865
Removal of tin- drain, ii, 480
of extraperitoneal organs, ii, 514
of tubes affected with tuberculosis,
ii, 710
Renal retroperitoneal space, i, 128
Respiration, embarrassment of, by dis-
tention, ii, 433
Retroappendicularis fossa, i, 197
Retrocolic folds, i, 189
Retrocecal fossa, 1, 197
Retrocolouic position of portion of the
ileum, i, 215
Retroduodenal folds and fossa?, i, 200
Retroduodenal fossa, i, 207
Retroperitoneal appendices, direction
traveled by pus in cases of,
i, 131
appendix, i, 195
hernia dis])lacing colon, i, 213
genesis of, i, 214
lipomata, ii, 786 (sec Lipomata, re-
troperitoneal)
sarcoma, ii, 793 (see Sarcoma, re-
troperitoneal)
space of renal region, i, 128
spaces of the pelvis, i, 122
tissue, i, 120
relation of, to parietal peritoneum,
i, 120
variation in amount and structure
in different locations, i, 120
tumors, ii, 784
histology of, ii, 785
Retrorenal si)ace of upper alxlomen, i,
131
Ret/.ius. space of, i, 123
Rlieumatism in relation to ajipendi-
citis, ii, 524
Rigidity of abdominal muscles, ii, 443
Root of mesenterv, attachment of, i,
174 ■
Round ligaments, i, 143
Rul)l)er drain, ii, 481
Ruliber ])rotective in i)reventi(in of ad-
hesions, i, 320
Rupture of the mesenterj', ii, ();;7
S
Sacculati'd hydroceles, ii, 7S0
Sac-like characteristic of peritoneum,
i, 112
Sarcoma of the omental bursa, ii, 804
retiopeiitoneal. ii, 79,'!
etiology of, ii, 7!t.")
pathogenesis of, ii, 794
symptoms of, ii, 795
treatment of, ii, 797
Sarconuita, onu'utal, ii, SOO
diagnosis of, ii, 803
pathogenesis of, ii, 801
patiiology of, ii, 801
symptoms of, ii, 802
treatment of, ii, 803
retro]ieritoneal, diagnosis of, ii, 795
pathology of, ii, 794
prognosis of, ii, 797
Scar contraction, i, 297
following a drainage wound, fate of,
ii, 486
relation of changes in permanent ad-
hesions to, i, 297
Secondary adhesions, prevention of, i,
318
form of tulierculosis of the perito-
neum, ii, 655
peritoneal cysts, ii, 780
tumors of the peritoneum, ii, 807
(see Tumors, secondary)
Scnsiljility of the peritoneum, i, 24
Sensitiveness of peritoneum, i, 24
Sensory nerves of pleural surface, i,
225
Septic theory of death in peritonitis, ii,
454
thromboses involving the peritoneum,
ii, 629
Serous exudates, formation of, in in-
flammations, i, 370
Service vessels, i, 71
Sex in relation to appendicitis, ii, 519
in relation to lymphatic cysts of the
mesentery, ii, 766
in relation to tuberculosis of the
peritoneum, ii, 649
Sexual neurasthenia simulating a]^i)endi-
citis, ii, 580
Shock as cause of death in ])eritonitis,
ii, 456
Sigmoid, fixation of, i, 109
fossa, hernia into, i, 214
mesentery, fusion of, i, 92
region, development of, i, 110
Silk as peritoneal suture, ii, 504
Silver albuminate, unknown, i, 66
chloride theory of formation of sfig-
mata and stoinata, testing
of, i, 64
solution, eifect of, on serous mem-
lirane, i, 79
injected into peritoneum in pres-
ence of light, i, 59
u.se of, in staining for cells, i, 50
use of, in staining for intercellular
processes, i, 53
866
INDEX
Singultus in proguosis of peritonitis,
ii, 453
Site of ansorption, i, 22
of incision in operation for perito-
nitis, ii, 472
Size of Ij-mphatie cysts of the mesen-
tery, ii, 705
Sliin, preparation of, for operation, ii,
471
Small intestine, arrangement of coils
of the, i, 163
Sordes in prognosis of peritonitis, ii,
453
Space, perirectal, i, 128
periuterine, i, 127
perivesical, i, 12(5
prevesical, i, 123
retroperitoneal, of lenal region, i,
128
retrorenal, of upper alidonien, i, 131
Specific causative organism, classifica-
tion of peritonitis based
upon, ii, 386
forms of peritonitis, ii, 398
Specificity of tuberculosis, ii, 648
Spine, severe contusions of, may l)e at-
tended by tympany, ii, 446
Splanchnogenesis, si)ecial problems in,
1, 90
Spleen, attachment of peritoneum to, i,
161
development of, i, 87
Splenic region, development of, i, 108
Sponging in operation for peritonitis,
ii, 473
Spontaneous pain, ii, 425
symptom of appendicitis, ii, 545
Spreading of infectious process, prog-
nosis of peritonitis largely
dependent upon, ii, 449
peritonitis, ii, 383
going out from the nonperforat-
ing gall liladder, ii, 591
Streptococcus in liematogenous infec-
tion, ii, 405
Staining cells, i, 50, 52
filirin Imndles, i, 250, 253
])erivaseular eouTicctix'e tissue, i, 368
stomata, methods of, i, 57
Staphylococcus in peritonitis, ii, 397
Stasis, infection by, ii, 414
Static type of varicosity of the peri-
toneum, i, 337
Stigmata, i, 53
and stomata, description of, i, 57
discovery of, i, 53
in the blood vessels, i, 54
Stignuita — Cont 'd.
produced by mixing egg albumin
with silver nitrate solu-
tion on a cover glass, i, 64
theories regarding, i, 53
Stomach, development of, i, 87
embryologic development of, i, 86
Stomata, i, 53
at present not considered so impor-
tant in relation to phys-
iologic and pathologic proc-
esses, i, 55
cells located below the endothelial
cells, mistaken foi', i, 62
description of, i, 57
figure resembling, produced by silver
nitrate, i, 65
functions of, disputed, i, 54
influence of form of cell upon [»ro-
duction of, 1, 60
methods for staining, i, 57
not real openings, i, 56, 57
number lessened by preliminary rins-
ing in distilled water before
api^lication of silver nitrate,
i, 58, 59
similar objects described elsewhere
than in the intercellular
line, i, 61
spurious products formed by a pre-
cipitation of silver, i, 63
theories regarding genesis of, i, 57
vera, i, 54
Strangulated omental hcniia, ii, 757
Streptococcus pyogenes in peritonitis,
ii, 395
Sul)hep:itic region, i, 155
Submiliary lesions of tulierculosis,
macroscopic appearance of,
ii, 661
stage of peritoneal tuberculosis, ii, 666
tuberculosis of the omentum, ii, 667
Subperitoneal connective tissue, i, 69
reticular in character, i, 70
exudate in acute peritonitis, i, 310
layer infiltrated with red cells, i, 368
tissue, abundance of, permits free
m()l)iiity of peritoneum over
underlying structures, i, 121
Subserous exudate immediately around
varicose vessels, i, 342
Superior duodenal fossa, i, 204
Superior ileocecal fold of Waldeyer, i,
175, 178
Suppuration, healing by, i, 272
Sux)racolonic region, i, 152
Supravesical folds and fosss, i, 135
Surface of j)eritoneum, extent of, i, 113
INDEX
867
Suture ill lioUow viscera, ii, 507
Lembert, in peritoneal incisions, ii,
505
of adhesions, ii, 510
Sutures as a factor in the fonnation
of adhesions, i, 29'2
peritoneal, catgut as, ii, 504
general principles of, ii, 503
linen as, ii, 504
silk as, ii, 504
Suturing gut not attended 1)V pain, i,
28
of solid viscera, ii, 515
Sympathetic fibers, pain transmitted
by, i, 26
Symptomatology of enterocystomata, ii,
777
of peritonitis, ii, 422
of pseudoappen(iicitis, ii, 578
Symjitoms of appendicitis, ii, 541
fever, ii, 551
leucoeytosis, ii, 554
nmscular rigidity as, ii, 548
pain, ii, 541
pulse rate, ii, 553
tympany, ii, 550
vomiting, ii, 549
of cholecystitic peritonitis, ii, 594
of clironic productive appendicitis,
ii, 574
of embryonal cysts, ii, 784
of endotheliomata, ii, 775
of gonorrlical peritonitis, ii, (309
of inflammatory tumors of the omen-
tum, ii, 745
of injuries of the omentum and mes-
entery, ii, 760
of lym^jhatic evsts of the mesenterv,
ii, 768
of marked appendicitis, ii, 577
of peritoneal tuljcrculosis, ii, 680
of peritonitis, circulatory changes,
ii, 4;!4
meteorism, ii, 431
Jiain, ii, 422
physical characters of the alidu-
mcn, ii, 436
temperature, ii, 434
vomiting, ii, 430
of juuMimococcic peritonitis, ii, 617
of postapjiendiceal cicatrization, ii,
576
of pseudomyxoma peritonei, ii, S2S
of retroperitoneal lipomata, ii, 790
sarcoma, ii, 795
of sarcomata of tlie omeutuni. ii, 802
of secondary tumor of the ]ierito-
neum, ii, 815
Symptoms — Cont 'd.
of thrombosis of the mesenteric ves-
sels, ii, 739
of torsion of the great omentum, ii,
754
Sypliilitic affections of the peritoneum,
differentiating from tuber-
culous affection, ii, 699
Tampon drainage, ii, 484
Technic of operation for peritoneal tu-
berculosis, ii, 708
Temperature, effect of, on contraction
of clot, i, 263
in appendicitis, ii, 552
in gonorrheal perisalpingitis, ii, 604
in peritonitis, ii, 434
in puerperal peritonitis, ii, 631
inflammatory reactions due to vari-
ations in, i, 356
influence of, on absorption, i, 11
of packs, i, 354
Temi^orary adhesions, i, 276, 302
deleterious ett'ects of, i, 314
late changes in, i, 314
management of, i, 315
Tenderness as symptom of thro7nbosis
of mesenteric vessels, ii, 740
localized, in appendicitis, ii, 546
Tenesmus, vesical or rectal, as symp-
tom of appendicitis, ii, 543
Teratoid mixed tumors, ii, 783
Terminals of nerves of the peritoneum,
i, 225
Tensile strength of peritoneum, i, 113
Testicle, descent of, through fovea in-
guinalis lateralis, i, 136
Theories of the development of con-
nective tissue, i, 241
Thrombosis, ii, 440
and emljolism of the mesenteric ves-
sels, ii, 734
necrosis due to, ii, 418
of appendiceal vessel in ajipendicitis,
ii, 540
of mesenteric artery in a gangie-
nous appendix, ii, 535
of mesenteric vessels, diagnosis of,
ii, 740
etiology of, ii, 734
pathogenesis of, ii, 735
pathology of, ii, 738
symptoms, ii, 739
treatment of, ii, 740
Time of operation in peritonitis, ii,
472
868
INDEX
Tonsillitis, appiMidic-itis following
closely an attack, ii, 539
Topography of abdomen, i, 228
of alKloniiiial organs in development,
i, 88
of intestinal loops, determining, i,
170
of the |)eritonenm, i, 118
of small intestine, i, 165
Torsion of the great omentnm, ii, 750
{•see Omentum, torsion of)
Trabecular material in mechanical lim-
itation of infections, i, ?.0r>
Traction causing attenuation of adhe-
sions, i, 298
Transplant, covering raw surface l)y,
ii, 512
Trauma, effect of, on fibrous tissue
regeneration, i, 265
in relation to appendicitis, ii, 520
in relation to peritoneal tulerculosis,
ii, 651
Traumatic jicritonitis, diagnosis of, ii,
636
treatment of, ii, 636
without rupture, ii, 634
rupture of the gut, peritonitis from,
ii, 637
Treatment of appendicitis, ii, 581
medical, ii, 581
of cholecystitic peritonitis, ii, 595
of embryonal cysts, ii, 78-1
of enterocystomata, ii, 778
of gonorrheal perisalpingitis, ii, 606
of gonorrheal peritonitis, ii, 610
of inflammatory tumors of the omen-
tum, ii, 747
of injury of the omentum and mes-
entery, ii, 761
of Ivmphatic cysts of the mesentery,
ii, 770
of peritoneal tuberculosis, conserv-
ative, ii, 705
of peritonitis, ii, 460
camphorated oil in, ii, 468
epinephrin in, ii, 464
ether in, ii, 466
external apjdication, ii, 468
history of, ii, 460
medical, ii, 462
operative, ii, 469
after-pain, ii, 488
anesthetic, ii, 471
drainage, ii, 475
gas, ii, 488
indications, ii, 469
irrigation of the ])eritoneal cav-
ity, ii, 473
Treatment of jjeritonitis, operative —
Cont'd,
management of complications,
ii, 488
management of the exudate, ii,
473
management of ileus, ii, 488
posture of patient, ii, 486
preparatory, ii, 470
site of incision, ii, 472
sponging, ii, 473
time, ii, 472
opium in, ii, 463
preventive, ii, 462
of pneumococeic peritonitis, ii, 622
of pseudomyxoma peritonei, ii, 831
of puerperal peritonitis, ii, 632
of retroperitoneal lipomata, ii, 792
of retroperitoneal sarcoma, ii, 797
of sarcomata of the omentum, ii, 803
of secondary tumor of the perito-
neum, ii, 817
of thrombosis and embolism of mes-
enteric vessels, ii, 740
of torsion of the omentum, ii, 759
of traumatic peritonitis, ii, 636
Tulial gonorihea, ii, 599
infections simulating appendicitis,
ii, 564, 565
Talje and ovary, granulomatous nod-
ules in, ii, 691
infected, adhesions following, i,
288, 290 •
peritoneal tuliereulosis of, ii, 689
removal of tul)erculous, ii, 710
Tul)ercle bacilli, determination of how
peritoneum is reached by,
ii, 652
bacillus, cajiable of producing a more
diffuse infiltration without
production of definitely cir-
cumscribed lesions, ii, 662
microscopic appearance of, ii, 661,
663-665
of bovine tuberculosis in the human
being, ii, 676
pathologic anatomy of the, ii, 660
Tuberculin in treatment of peritoneal
tuberculosis, ii, 707
reactions in diagnosis of peritoneal
tubercidosis, ii, 697
Tuberculomata, removal of, ii, 711
Tuberculosis of the cecum, ii, 653
of the hernial sac, ii, 693-696
peritoneal, ii, 642
acute type, symptoms of, ii, 681^
adhesive type, yiathology of, ii, 671
symptoms of, ii, 685
age, ii, 649
I
INDEX
869
Tiilicrculosis, pcritonenl — C'oiit M.
air in treatmoiit, ii. 707
bacterial cxaniination, ii, (liUi
bovine, ii, 676
by eontiii^uity, ii, 658
by continuity, ii, 659
caseous type, patholoay of, ii, G7;3
symptoms of, ii, 685
elicmical analysis of, ii, ()07
clironic type, symptoms, ii, 6S2
classification, ii, 665
climate in treatment, ii, 706
conservative treatment, ii, 705
cysts, ii, 675
diagnosis, ii, G^6
etiology, ii, 648
extension from other organs, ii,
655
fibrinous type, pathology of, ii,
670 "
symptoms of, ii, 683
foreign body, ii, 714
formation of fistulas, ii, 677
frequency of, ii, 655
general physical state, ii, 650
healing process, ii, 677
hematogenous, ii, 658
heiedity, ii, 650
history of, ii, 647
ileocecal, symptoms of, ii, 686
location, ii, 674
symptoms of, ii, 686
macioscopic appearance of, ii, 6(il
medical treatment of, ii, 705
microscopic appearance of, ii, 663
niiliary stage, ii, 668
military type, pathology of, ii, 666
symptoms of, ii, 683
objections against operation, ii,
711
operative treatment of, ii, 70S
paracentesis in treatment, ii, 707
pathogenesis, ii, 651
pathologic anatomy, ii, 660
pelvic, symptoms of, ii, 689
perfoiation, ii, 679
primary form, ii, 652
prognosis, ii, 701
pseudotuberculosis, ii, 713
relation of cirrhosis of the liver to,
ii, 674
reuu)val of tul)ereulumata, ii, 711
removal of tubes in, ii, 710
secondary form, extension fiom
oilier organs, ii, ()55
sex, ii, 649
symptoms, ii, 680
the tubercle, ii, 660
Tulierculosis, peritoneal — Cont M.
tuberculin reactions, ii, 697
tuberculin treatment, ii, 707
trauma, ii, 651
ulcerous type, symptoms of, ii, 685
x-ray in treatment, ii, 706
Tuberculous cysts of the ]ieritoneum, ii,
675
peritonitis, differentiation from pneu-
mococeic peritonitis^ ii, 621
Tumors of gastrocolic omentum, ii, 805
of omentum, ii, 798
inflammatory, ii, 743
of retroperitoneal space, ii, 784
peritoneal, ii, 764
secondary, by direct extension, ii,
809
diagnosis of, ii, 815
dissemination with reaction, ii,
814
extension by dissemination, ii,
812
hematogenous, ii, 813
patliogenesis of, ii, 808
pathology of, ii, 814
prognosis of, ii, 816
symptoms of, ii, 815
treatment of, ii, 817
simulating tuberculous peritonitis, ii,
700
strangulated, as cause of pain, ii, 424
teratoid, mixed, ii, 783
tulial, ii, 604
wandering, of the peritoneal cavity,
ii, 806
Tvmpany as a result of peritonitis, ii,
550
as symptom of appendicitis, ii, 550
in diagnosis of ])eritonitis, ii, 445
in jjeritonitis, ii, 431
in prognosis of peritonitis, ii, 452
puerperal peritonitis, ii, 631
Typhoid fever, differentiation from ap-
pendicitis, ii, 560
form of peritoneal tuberculosis,
symptoms of, ii, 681
peiitonitis, differentiation from pneu-
mococcic peritonitis, ii, 622
wluch ])er-
u
L'lce rating duodenum
f oration was i>revented liy
formation of omental adhe-
sions, ii, 412
Uh'eration, perforation by, ii. 4(i7
with adhesion formation, ii, 411
with reaction, ii, 409
without reaction, ii, 408
870
INDEX
Ulcerative appendicitis, ii, 532
Ulcerous peritoneal tultereulosis, symp-
toms of, ii, 685
Ulcers, chronic, adhesion formation in
cases of, i, 286
perforating, of the stomach and duo-
denum, differentiation from
appendicitis, ii, 557
Ureter, perivesical space as an avenue
of approach, importance of,
i, 127
Ureteral and kidney colic, differenti-
ation from appendicitis, ii,
556
Urinary bladder and rectum, diseases
of the, differentiation from
appendicitis, ii, 559
Uterolumbar fold, i, 148
Utcroovarian ligament, i, 143
Uterosacral ligaments, i, 146
Uterus and l)road ligaments, perito-
neum of the, i, 140
Valvula eonniventes, landmark in intes-
tine, i, 173
Varicosities in relation to inflammatory
reactions, i, 340
most apt to follow mild inflamma-
tory processes, i, 345
muscles of gait in relation to, i, 344
of the j)eritoneum, reactive tvpe, i,
339
static type, anatomic changes, i,
339
representing end processes, i, 340
types of, i, 337
Varicosity of the peritoneum, i, 337
visceroptosis associated -witii, i, 338
Varieties of bacteria found in perito-
nitis, ii, 394
Vascular arrangement in intestine, i,
170
changes in the appendix, i, 345
dilatation, permanent, i, 339
fold, anterior, of Moynihan, i, 1^6
posterior, i, 181
Vascularization of new tissue forma-
tion, i, 252
Veins of peritoneum, i, 76
Vesical or rectal tenesnuis as SATiiptom
of appendicitis, ii, 543
Vessels, degree of distention of, in-
fluenced by irritation and
changes in intravascular
pressure, i, 326
dilatation of, in jjeritoneum, i, 326
Vessels — Cent 'd.
direction of, i, 340, 341
in the apparently avascular areas of
the peritoneum, i, 340
invisible, in normal peritoneum, i,
mesenteric, thrombosis of, ii, 734
of cecum, direction of, i, 340, 341
of gut, visibility of, on operation, i,
326
of mesentery and intestinal wall, di-
latation of, i, 331
of peritoneum, varicose, histologic
picture of^ i, 341
of organs seen through peritoneum
in operation, i, 325
Violence, external, adhesions due to, i,
291
necessary to produce degree of
al>rasion sufficient to cause
adhesion, i, 293
Virulence of infection, change of, i,
304
Viscera, hollow, suture in, ii, 507
solid, suturing of, ii, 515
Visceral peritoneum, i, 162
Visceroptosis, general, associated with
varicosity, i, 338
Viscosity of fluid in peritoneal cavity,
ii, 476
Vomiting and nausea, in thrombosis of
mesenteric vessels, ii, 739
as symptom of appendicitis, ii, 549
in dynamic ileus, ii, 489, 490
in iieritonitis, ii, 430
in prognosis of peritonitis, ii, 453
W
Wandering tumors of the peritoneal
cavity, ii, 806
Wet pack tends to conduct infective
mateiial to sterile parts of
abdomen, i, 355
Wound healing, i, 238
bacteria in, i, 239
in inflammation, i, 269
ideal and slightly disturbed, i, 240
inflammation in relation to, i, 351,
352
irritation by ferments, i, 271
irritation from infection, i, 270
irritation from necrosis, i, 272
Wounds, aseptic, healing of, i, 244
X-ray in treatment of peritoneal tu-
berculosis, ii, 706
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