Partial peritonitis may be excited by ulceration of the bowels which does not proceed to an extreme degree, and has a conser vative tendency to prevent perforation ; this constantly happens in phthisis, when it may pass alogether unobserved. 'It is very often produced by some unusual irritation within the bowel, such, for example, as the lodgment of undigested substances about the mecum ; and these cases very frequently pass into sup puration. Sometimes the puerperal inflammation is thus limited to the neighborhood of the uterus, and pus may be ultimately discharged by the rectum or vagina, or the uterus and its appen dages may become matted together and adherent to surrounding parts. It is not uncommon in women who are subject to irregu lar menstruation, especially when attended by uterine irritation ; but with them the disease seldom terminates in suppuration.
When the inflammation is of any notable extent, or when the rest of the membrane is in any degree irritated by the persistence of the local action, we generally find some expre,ssion of tender ness in the posture of the patient besides what is observed on pressure; dysuria, too, is a very common symptom in those attacks which are seated in the pelvis. As the disease advances, considerable infiltration of the surrounding tissues takes place, and local swelling may be observed, at first deep-seated, but very soon involving the parietes, which become hard and painful over the seat of inflammation, in preparation, as it were, for the occur rence of suppuration.
In enteritis we have a set of symptoms which, without reaching the same intensity as general peritonitis, have a character very similar to those of partial peritonitis, only with more decided constipation, more constant vomit ing; and it is really of no consequence whether we can discriminate between the two, or can say, when both exist together, which is the more prominent.
In fever, again, it is of importance that the existence of the blood-disease should not be lost sight of in regard to treatment, and if in the early stage there be pain of the bowels, with tympanites and tenderness, the diagnosis re quires care. Two facts we may remember, first, that in fever the symptoms which are called febrile, the hot skin, quick pulse, &c., predominate, and are out of proportion to the local sign of tenderness; second, that the bowels are relaxed, with borborygmi or meteorismus in fever, while such a circum stance is much less common in peritonitis, and is always attended with aggra vation of the pain ; fever spots on the abdomen would of course remove any doubt. In advanced fever genuine peritonitis very often comes on either with
or without rupture of the intestine ; in its treatment regard must be had to the previous existence of blood-disease.
§ 2. Chronic Peritonitis.—Two forms of this disease are recog nized. a. The acute attack runs on into a chronic form. b. An insidious disease arises without acute symptoms, which is most commonly associated with a tubercular or a cancerous diathesis.
a. The suppurative stage of partial peritonitis, as it may con tinue for a lengthened period, might be regarded as an instance of chronic disease : the condition, however, which we wish to dis tinguish by this name, is one in which the acute symptoms have entirely subsided. The patient, perhaps, continues liable to uneasi ness in some particular part of the abdomen, which, on examina tion, is found to be harder than natural; occasional exacerbations occur, and after a long interval, during one of these accessions of fever, the case terminates in suppuration, the matter either finding vent outwards, or exciting general peritonitis and blood-poisoning. In other cases the inflammation has been more general, the bowels have contracted adhesions, and the patient is subject to constant irritation, both in the interior of the canal and in the peritoneum itself; there is almost constant tenderness, and at length suppu rative inflammation supervenes, or ascites is developed, or the action of the bowels is so seriously interrupted that the patient sinks from mere inanition.
If the history of such cases be sufficiently distinct, the difficulty of diagnosis is not great; but there is generally little trustworthy information to be obtained beyond the fact that there has been at no very great distance of time a severe illness with much pain in the abdomen ; and-when with this there is abiding tenderness, with some acceleration of pulse, and some tendency to constipa tion; when the general outline of the abdomen is full and rather tense and tympanitic; if there be, on the one hand, hardness felt in a particular spot, or, on the other, serous effusion found in the cavity of the peritoneum—the diagnosis may be regarded as pretty certain. The greatest chance of error is when hardness is felt, because such a circumstance might be caused by fecal awn znnlation. But when neither hardness is felt nor fluid detected, there will be a considerable resemblance to cases of ulceration of the bowels : in them, however, diarrhoea is generally present, while in chronic peritonitis the bowels are irregular, and rather incline to constipation.