DISEASES OF THE PERITONEUM - in speaking in general terms of the diseases of the peritoneum we might include all those occasions on which it bears a part in disease of the viscera which it incloses. It seems better, how ever, to limit our attention to those conditions in which the mem brane is principally or alone involved—the acute and chronic; forms of inflammation; along with the latter the non-inflamma tory exudations must be noticed, and the occasional association of ascites: a few remarks must also be made upon those tumors which, as they are unconnected with any particular organ, will not find a place in the succeeding pages of this volume.
§ 1. Acute Peritonitia.—The extent of the serous membmne lining the abdominal cavity is such that, when the inflammation pervades its whole surface, the symptoms are more severe than are met with in any other organ of the body ; and at the same time its folds are so numerous that the spread of the inflamma tory action is liable to be checked by the adhesion of two con tiguous portions in a way that is not met with in other serous membranes. We might, therefore, divide the cases into general and partial peritonitis ; but, for the purposes of diagnosis, the for mer must be again subdivided, as the history, the progress, and the symptoms are so dissimilar in the different forms, that they might almost be regarded as distinct diseases.
a. Traumatic peritonitis.—I can find no better name for that which arises suddenly, after rupture of some organ and escape of its contents into the abdomen; and this, whether occurring from external violence or not : it differs in no respect from the inflam motion excited by a penetrating wound of the abdomen. It generally results from previous thinning of the membrane by dis ease; but on this point the history of the case is perhaps silent, Sometimes, inde4., we may learn that the individual has had ha3matemesis, or other symptoms of ulceration of the stomach, or the persistence of diarrhcea in phthisis, or in convalescence from fever, points to a similar condition of the small intestine. With out any previous warning, the patient is suddenly seized with severe pain on making some unusual strain ; we find great ten derness and tension over the abdomen, extreme prostration, pro bably sickness and painful efforts at vomiting ; the pulse is fee ble, quick, and laboring; the skin becomes cold, and covered with perspiration; and he sinks rapidly. The state of collapse resembles cholera, but there is no evacuation from the bowels; the mental faculties are clear, and therefore narcotic poisoning is excluded, while both suppositions are opposed by the existence of extreme pain all over the abdomen ; and, on the other hand, there is no irritation about the mouth and fauces to suggest the possibility of irritant poisoning.
Perhaps we may obtain a history of a blow or a fall which may have ruptured the stomach or the liver, &c.; death has been even known to result from a blow on the stomach without rupture, in which, from its suddenness, peritonitis can have had no share. Occasionally we meet with suppression of urine ; and when the catheter is introduced, only a few drops of blood are evacuated, and then it is probable that the bladder has been ruptured by the accident.
The symptoms are occasionally not quite so severe, because the effusion of the visceral contents has been, to a certain extent, limited by adhesions, and then the attack cannot be distinguished from idiopathic general, or partial peritonitis.
b. Puerperal peritonitis presents the same features as the third form, of which we have yet to speak; it is only distinguished by its history in connection with childbirth, and demands separate notice, from the peculiar condition of the blood with which it is associated, and the different treatment which it consequently de mands.
On this point practical medicine has made great advances in late years : inflammation, which post-mortem examination reveals to have been of great extent and intensity, does not of necessity suggest the use of the lancet ; the correlative symptoms must be taken into account, both with reference to the previous exhaustion of labor, and the special characteristics of the disease in the individual case. It seems highly probable that two forms of puerperal peri tonitis exist, of which the one corresponds to ordinary inflammation, being only modified by the previous exhaustion of a labor perhaps unusually severe ; the other, by far the most common, is the result of suppurative changes in the blood, and presents analogies to erysipelas. It is worth remembering that, as erysipelas and its allied diseases occasionally put on an epidemic character, BO also does puerperal fever ; and its frequent occurrence at any given time would tend to confirm a diagnosis drawn from the character of the symptoms, which are asthenic, and approximate those of suppurative fever. The pulse is very and feeble, there is often diarrhoea, the tongue is not much coated, and more frequently raw and chapped, and even an aphthons state of the Month and of the anus are recorded. The question of its propagation by contagion, which is now pretty generally acknowledged, may also serve to guide our opinion, because, if in the hands of the same practitioner another case of puerperal fever have recently occurred, there is good ground for sus pecting that, through some means or other, the same blood-poison has been Introduced.