Polyserositis

POLYSEROSITIS (polyserositis), synonym panserositis, systemic lesion of serous membranes by acute or chronic inflammation. The serous coverings of the pleural cavities, cardiac cavity, and abdominal cavity are simultaneously affected, and rarely the joints. Combinations of lesions of serous membranes can be diverse. Cases of transition of the inflammatory process from one serous cavity to another are not considered as P. P. was first described by Bamberger in 1862. P. does not represent, in terms of etiology, any separate disease. More often it is a local manifestation of a general infection of the body or, less frequently, its intoxication. In etiological terms, acute rheumatism (rheumatic infection) occupies first place, for which the acute form of P. is more characteristic; second place is occupied by tuberculosis, which more often causes chronic P. A number of cases of P. have been described, which authors associate with past scarlet fever, measles, malaria, typhoids, syphilis, erysipelas, as well as with anaphylactic conditions. The etiology of P. is diverse, and Aschoff considers it unclear. Adhesive P. occurs in 0.1% of all autopsies; more often affects individuals up to 30 years of age and especially children; more often affects men (Gerke). In the literature, up to 150 cases of polyserositis have been described. Gofferje developed 40 cases of P., of which in 39 the liver capsule was affected, in 34 the spleen capsule, in 8 two serous cavities, in 8 three serous cavities, and in 24 four serous cavities.--From a pathoanatomical point of view, exudative P. and adhesive-sclerosing (adhesive-productive) can be distinguished. Exudative P. manifests less frequently in fibrinous (dry) inflammation, as occurs for example in uremic P., and more frequently in serous inflammation with accumulation of serous or serofibrinous exudate in the cavities. Usually exudative P., which initially has an acute character, subsequently takes a chronic course, with the formation of adhesions and thickening of the serous membranes (deposition of fibrin, formation of scars, proliferation of connective tissue). For adhesive-sclerosing P., thickening of the serous coverings, formation of synechiae and obliterations in many serous cavities is characteristic. P. is a collective concept and from the pathogenetic point of view, Curschmann (1884) includes in P. the peculiar disease of the liver described by him-Zuckergussleber (see Glazed organs)-with marked fibrous thickening of Glisson's capsule and proliferation of connective tissue deep into the organ. This progressive penetration of connective tissue into the liver, followed by its shrinkage, leads to stagnation in the portal vein, ascites and enlargement of the spleen. In 1896, Pick described under the name pericarditic pseudoliver-cirrhosis (pericardial pseudocirrhosis of the liver) a special disease, which, starting with a slowly progressing adhesive pericarditis, leads to impaired blood circulation in the liver; venous stagnation in the latter promotes proliferation of connective tissue in it with thickening of the capsule and interstitium. Subsequent stagnation in the portal vein system leads to ascites, fibrous thickening of the peritoneum and enlargement of the spleen. Pick's data were confirmed by a number of authors and finally experimentally it was possible, by causing adhesive pericarditis, to obtain stagnation in the inferior vena cava and in the liver with subsequent cirrhotic changes and ascites (Hess, Rosenbach, Weiss). Hess believes that in most cases the process begins in the liver or spleen, since these organs play an important role in infectious diseases; subsequently it spreads along lymphatic pathways toward the pleura and pericardium. Others believe that the process begins with the peritoneum and finally still others consider the pericardium or pleura as the starting point. The clinical classification of P. according to the sequence of anatomical lesions of serous membranes distinguishes ascending P. (from the abdominal cavity), descending P. (from the pericardium and pleura) and transverse P. (lesions of the pleura and pericardium). This division is rather artificial and clinically not always easy to carry out. According to the course, P. is divided into acute and chronic and finally according to the nature of the inflammatory process into adhesive-productive P., exudative-serous P. and mixed P. (Gurevich et al.). The given classifications show the diversity and variety of the clinical picture of P.-Most often against the background of the main, benign disease (rheumatism, tuberculosis) with relatively good general condition of patients, complaints of a general nature appear, there is slight general weakness, indistinct pains in the sides, in the heart area, localized or diffuse pains in the abdomen, rarely pains in the joints; dry cough; sometimes slowly progressive emaciation, depending on the underlying disease (tuberculosis); temperature is usually subfebrile or normal, during exacerbations with a rise to 38° and above. Subsequently, complaints dependent on insufficiency of the cardiovascular system appear-dyspnea, palpitations, interruptions. The clinical picture of P. consists of symptoms of primary order, directly depending on the lesion of one or another serous cavities and organs, and symptoms of secondary order, depending on compression and displacement of organs, insufficiency of the cardiovascular system, etc. In adhesive-productive P. with pleural involvement, a rather rough and constant pleural friction rub can sometimes be heard; vocal fremitus is often preserved, often slightly weakened; dullness of percussion sound over scars. At the same time, friction rub of the pericardium, liver, spleen can be detected. The abdomen on palpation is sensitive or painful, more often in the area of the liver. In the abdominal cavity, dense strands and nodes can often be palpated. With involvement of the serous membrane of the intestine in the process, various stenoses, pseudoileus, etc. may occur on this basis. Sometimes it is possible to palpate a dense, painful edge of the liver. In exudative-serous P., exudates in the abdominal, pericardial and pleural cavities come to the fore. In the picture of the disease, in addition to the symptoms listed above, the phenomena of ascites predominate, in most cases relatively slowly progressive. Symptoms of secondary order are diverse and do not require special description. In differential diagnostic terms, P. with predominance of exudative-serous phenomena present particular difficulties. Progressive emaciation, ascites, dense, sometimes slightly nodular liver force one to suspect cirrhosis of the liver, tumor in the abdominal cavity. Detailed examination, X-ray examination and further observation usually lead to the correct diagnosis.-The course of P. is slowly progressive and relatively benign. Usually patients consult a doctor in later stages of the disease, but even then in some cases recovery is not excluded. However, most patients die from the underlying disease (tuberculosis) or from the consequences of P. (sharp displacement and compression of organs, insufficiency of cardiac activity). Thus, the prognosis of P. is not favorable. The working capacity of patients with P. depends on the degree of development of the disease.-Treatment of patients with P. is almost exclusively conservative. Treatment of the underlying disease is necessary. Treatment of P. proper amounts to symptomatic therapy. Auto-serotherapy was applied without particular success. Local resorptive (mustard plasters, warming compresses, cups) sometimes have a good effect. Cautious use of mountain sun (quartz) in the presence of ascites or exudate in the pleural cavity can give good results. Pharmacotherapy is very limited and amounts to preparations of iodine, used with doubtful success; in the presence of initial signs of cardiac insufficiency-use of preparations of foxglove. Some effect from diuretics is possible. In the presence of exudate in the cavities (especially ascites), worsening the patient's condition and leading to cardiac insufficiency, evacuation of the fluid is indicated. In adhesive pericarditis or mediastino-pericarditis, in some cases, cardiolysis operation according to Brauer is indicated.-The limitation of therapeutic measures forces special attention to be paid to the prevention of diseases, the consequence of which is P. (tuberculosis, rheumatism, etc.).