PERITONEUM, DISEASES OF THE.
Acute General Peritonitis.
Symptoms.—Acute general peritonitis is usually of sudden onset and is ush ered in by rigor, chill, and high fever. There is intense pain in the abdomen, which is sometimes localized, but usu ally soon becomes general. The pain, when localized, is often in the region of the disorder acting as primary cause. When due to a ruptured gall-bladder, it is located in the right hypochon drium; when a ruptured gastric ulcer is the cause, it occupies the region of the left hypochondrium or the back be tween the shoulder-blades. A ruptured appendix vermiformis or a peritonitis caused by disease of the appendix causes intense pain, which, when localized, is in the right iliac fossa. The pain, how ever, is frequently at the umbilicus and not seldom in the left iliac region. (See APPENDICITIS.) The pain of an acute general peri tonitis, if at first localized, soon becomes general. It is aggravated by movements and by pressure. The patient lies on the back or the side with the legs drawn up. The face is blanched and haggard and the expression anxious. These are the symptoms at the beginning, during, and shortly after, the chill. The tem perature at this time may not be much elevated. Occasionally, if the shock is very great, it may even be subnormal. The pulse is thready and rapid. Vomit ing is an early and very painful symptom.
Acute diseases of the abdominal vis cera and, in particular, perforation of the stomach are often accompanied by thoracic pain, either dorsal, scapular, or intrascapular. In general peritonitis this symptom is of great importance. J.
L. Faure (La Semaine Med., Jan. 23, 1901).
Soon, however, the symptoms of acute septic poisoning begin, and we have an entirely different clinical picture. The face, while still drawn and pinched, is less pale; the expression is of great suf fering and absolute helplessness; the pulse is fuller, though weak and more rapid, 120 to 140; the temperature is high, 102 to 104 or over; the skin is dry; the abdomen is distended and tym panitic. The area of liver-dullness is generally obliterated in the mammary and middle lines, and there is intestinal paresis. The urine is scanty and the bowels constipated; the skin may be dry or bathed in sweat. An effusion of fluid
is usually present at some stage of the disease and can be demonstrated in the flanks, which are dull on percussion. The patient presents all the symptoms of septimmia, and is gradually over whelmed by the toxins of the organisms which are the cause of the inflammatory process.
Diagnosis. — The diagnosis of acute general peritonitis is not always clear at first, but, as a rule, it is made from the history and the sudden onset of the symptoms. The primary source of the infection determines the treatment, and must be diligently searched for. This disease simulates several other condi tions. The more common of these con ditions are: enterocolitis, obstruction of the bowel, hysterical peritonitis, rheu matism of the abdominal walls, local circumscribed peritonitis, and tubercular peritonitis. In enterocolitis the pain is less severe and more spasmodic in char acter, the distension of the abdominal walls is not so great as in acute peri tonitis, and the dyspncea is less severe. In enterocolitis there is usually diar rhoea, whereas constipation is common in peritonitis.
Acute peritonitis is to be distinguished from INTESTINAL OBSTRUCTION by the absence of stercoraceous vomiting and tumefaction above the seat of obstruc tion.
The differential diagnosis between acute septic peritonitis and acute me chanical obstruction is always difficult, and oftentimes impossible, without an operation. But perhaps the following slight differences may help in making the diagnosis: 1. The intestinal obstruc tion is more often absolute in mechan ical obstruction. 2. The vermicular movements persist for some time, and may be increased in mechanical obstruc tion. 3. The pulse has a good volume, and is not markedly accelerated in me chanical obstruction. 4. Fluid does not collect in the pelvis in mechanical ob struction, and evidences of inflammation of the appendix, Fallopian tubes, gall bladder, and so forth are wanting. 5. Elevations of temperature are less corn mon in mechanical obstruction. 6. Ftccal vomiting occurs earlier in acute mechan ical obstruction.
Laparotomy may have to be done as a final step in the diagnosis C. B. Lock wood (Clin. Jour., Apr. 1, '96).