In a few cases the inflammation becomes limited to the uterus and its appendages, when the disease does not differ from cases occurring in the non-parturient state, which we class as local peri tonitis.
c. Idiopathic peritonitis will give a very different history, ac cording to the circumstances in which it occurs, and the causes on which it depends. It may arise in a stout, healthy person, from exposure, or from injury ; or, in the very opposite condi tion, in one worn by fever or phthisis, when excited by extensive ulceration of the coats of the bowel, even when no rupture oc curs. Its close connection with enteritis has been already men tioned ; it is similarly allied to inflammation on the upper side of the diaphragm, sometimes preceding, sometimes following diaphragmatic pleurisy ; it is often met with in uterine derange ments apart from pregnancy, although then it is more generally local and limited.
The best examples of its pure type will be found in cases which are believed to have been excited by exposure, when at least no other cause can be assigned, or those which have followed some mechanical violence, without rupture of any viscus. The leading symptom is pain and tenderness, which we know to be characteristic of inflammation of all serous membranes. Enough has been already said to show the necessity for caution in taking this symptom as our chief indication ; but with due care we cannot be deceived in a case of general peritonitis. There is not only the complaint of pain, but the position of pain ; the patient shrinks from pressure, and we learn more from the expression of pain byefeature than by exclamation ; but the evidence is still more trustworthy which is obtained from the bending of the limbs, the motionless diaphragm, and the fixedness of the body. We must not rudely press on the abdomen ; but its distended out line and its tympanitio tension and tenderness show clearly that inflammation is going on beneath the surface. Besides this, there is the presence of fever, a quick pulse, a coated tongue, and a hot skin ; often sickness, sometimes dysuria, and, if the mucous mem brane be affected, the bowels may be relaxed ; but more commonly there is constipation from a sort of paralysis of the muscular fibre, which also produces the tympanitic distension : even if the stools be watery, there is always a certain impediment to the free action of the bowels.
Such may be regarded perhaps as an extreme case, and it mity be alleged that there are others of a much milder form : at all events, in common par lance many cases are spoken of as " inflammation" which do not come up to this type. The majority of these, when inflammation really exists, belong to the next division; in a few, perhaps, from constitutional apathy, the evidence of suffering is less distinct ; but in a large number I think we must admit that errors in diagnosis are committed from taking a contracted view of the symp toms, being contented with the observation of one or two, while the rest are forgotten or overlooked. Genuine cases of idiopathic peritonitis are certainly rare; and when there has beed no injury, when there is no evidence of ante cedent affection of the intestines, and the case does not belong to the puer peral form, the practitioner ought not hastily to come to the conclusion that he has so formidable a disease to deal with ; at the same time, when the tient is in fair health, the error of over-activity is perhaps the least dangerous.
d. Partial peritonitis.—During the incursion of an ordinary attack of peritonitis, the pain is frequently confined to one spot, where it may linger for a considerable period ; and this is very generally the lower part of the abdomen : for a time the pulse is not particularly accelerated. These are ca.ses in which it is due to some local cause, and from thence it may spread to the whole membrane, or may remain fixed at the spot where it originated, putting on a subacute type, and preserving a local character. Partial peritonitis is no doubt very often overlooked, and leaves traces of its existence in bands of adhesion, when no account of its history is obtained. The chief indication upon which we must rely is the existence of tenderness on pressure, accompanied by slight pyrexia. This serves to distinguish it from cohc, and from the passage of a calculus, whether biliary or renal, the latter more especially imitating it in site : in them the pain greatly ex ceeds the tenderness, and, indeed, is often relieved by pressure, while the pulse is slower than natural—slower at all events than we could imagine possible if the same amount of pain were due to inflammatory action.