In speaking of wiles, reference was made to its occasionally resulting from chronic peritonitis ; but it was then observed that really this is not by any means its common cause. It is true that along with the thickened cap. sule of the liver there is often found a certain thickening of the peritoneal membrane, and possibly this condition may have a clinical history of inflam mation which we have overlooked ; but, except there be the evidence of adhe (dons, it seems a misappropriation of language to call this pathological state by a name which implies the existence of a disease of which during life we have no proof whatever. Chronic peritonitis, in so far as it can be traced at the bed side, always gives rise to adhesions ; and for this reason the mites which occasionally supervenes very generally presents characters of much interest, which tend more or less to obscure its diagnosis. The relations of the fluid to the intestine are changed, they no longer obey the laws of gravitation, but either a portion of intestine, which is specifically lighter, is tied down, so that it cannot rise to the surface of the fluid, or the whole of the fluid is so hemmed in by adhesions that it cannot reach the most depending situation, although itself specifically heavier. In using the term ascites in this way it must be understood that such an accumulation of fluid is meant as really becomes of itself a source of inconvenience or of danger to the patient : for, though the peritoneal membrane in its inflammations contrasts very remarkably with the pleura in regard to effusion, yet a small quantity of turbid serum, mixed with flakes of lymph, or of fluid closely resembling pus, may be found in most cases both of acute and chronic peritonitis. Ascites never occurs as the immediate effect of acute peritonitis.
b. In the second form the symptoms come on so insidiously that there is generally no complaint of illness till the disease is fully developed ; and were it otherwise, the indications of what is going on are not sufficiently distinct to be relied on. When the patient is first seen there is generally a persistent acceleration of the pulse, with a certain amount of emaciation and loss of strength; the bowels act irregularly, and the motions are often unhealthy and offensive : sometimes, however, this symptom is wanting; he complains of deep-seated pain or uneasiness, with a feeling of ten sion of fulness of the abdomen. Placed on his back in the abdomen is still full ; and though the extreme tension and tender ness of acute peritonitis be wanting, yet pressure causes uneasi ness, and the parietes have a feeling of hardness which is extremely different from the elasticity of health : when the disease is much advanced, the fulness of the belly contrasts very strikingly with the emaciation over the ribs and pelvis. This fulness, it must be remembered, is not like that produced by ascites, for it scarcely exceeds in the erect posture that which is constantly found in health, and it is only when the patient is lying down that the difference strikes the eye : any doubt as to whether it be depend ent on an accumulation of fluid is immediately set at rest by per cussion; the abdomen is universally resonant., and any indications
of fluid are scanty and limited. The pathological condition in these cases sufficiently accounts for the symptoms to which we have just referred. The peritoneal membrane is studded with morbid grovrths, tubercular, scrofulous, or cancerous, and the intestines are glued together by adhesions; they are consequently distended with gas which they are unable to expel, and they can not glide on each other in change of position, so that the parietes do not retract as the patient lies on his back.
In further attempting to analyze these forms of peritonitis, we may be gnided by the follovnng general considerations. The tubercular occurs espe cially in the period of youth, it is associated with a particular diathesis, and, like tubercular attacks in general, is apt to supervene upon measles or other diseases of infancy,.as wen as upon exposure, bad living, Bic. It is attended with emaciation, quick pulse, irregular bowels, and the signs of hectic rather than of inflammatory fever : the skin of the abdomen has a remarkably harsh, dry feeling, and some reliance may be placed upon a sensation as if the mug clee could be moved over the hardened peritoneum beneath. But, however distinct in its full development, its earlier stages can only be guessed at.
The cancerous form, again, occurs chiefly after middle age. Perhaps the face has acquired the sallow hue of malignant disease, and there is generally considerable emaciation : with care, some indication of fluid may be found. The tenderness is not so great as in other cases, and the distinctive character of the disease may sometimes be made out, when, by gentle and yet firm pressure, the rounded nodules of cancer are felt under the muscles of the parietes.
§ 3. Morbid Growths in the Cavity of the Peritonetnn.—In the two forms of chronic peritonitis just detailed, the peritoneum itself is the seat of the tubercle and the cancer: we have now to speak of the same morbid material when deposited in the glands, the mesentery, and the omentum. Early diagnosis seems almost impossible : until the tumor has become sensible to the touch, or has excited. inflammation, we are in great measure ignorant of ita existence ; we have not even the indication of uneasiness or tenderness to guide us, before the appearance of the concomitant inflammation. It is true that they occasionally interfere with, or press upon, some nervous trunk, and anomalous neuralgic pains may be complained of in the scrotum or.in the leg; but this can hardly rank as a symptom.