P A T H O 
the ill fuccefs which has attended this plan may be re¬ 
ferred to the difficulty we have to make patients perfevere 
in this very abftemious regimen, and the prejudice's we 
hdve to encounter againll the innumerable bleedings 
which it is neceflary to perform. 
We cannot difrnifs the fubjeft of cardiac difeafe with¬ 
out reminding the praftitioner of the occafional fimilar- 
ity Which nervoits irritations difplay to organic difeafes 
Of the heart. We refer the reader, for one fource of this 
irritation, to Dyfpepfia; but nervous excitement in other 
organs befides the ftomach gives rife to fyncope and 
palpitation ; as for inftance, in hyfteria, pregnancy, pul- 
fation in the epigaftrium, See. The diagnofis is founded 
on the permanency of organic malady, in contradiftinc- 
tion to the paroxyfmal attack of irritative palpitation ; 
for though, in the former cafe, the patient is better and 
worfe, he is feldom wholly free from difeafe. The in¬ 
creafe in-the fymptomsof organic difeafe when mufCular 
exercife (particularly running up ftairs) is uled, furniflies 
another point of difference between this and nervous 
diforder. Some further and obvious indications of diag¬ 
nofis are drawn from the appearance of the tongue, fkin, 
general date of the pulfe, &c. 
9. Emprefma peritonitis, inflammation of the perito¬ 
neum: pain and tendernefs of the abdomen, efpecially 
in an ereft pofture ; with little affeftion of the fubjacent 
vifcera, or abdominal walls. Dr. Good gives three va¬ 
rieties. 
' a.. P. propria: the inflammation taking the general 
range of the peritoneum; pain extreme, often pungent, 
with little or no relief from ftools. 
| 3 . P. omentalis: with a more fenfible fwelling in the 
region of the omentum. 
7. P. mefenterica: pain deeper feated, and more im¬ 
mediately in the mefenteric region ; external tendernefs 
lefs than in the preceding varieties. 
Inftead of thefe diftinftions, we ffiail adopt the more 
Cornrhon ones'of acute and chronic peritonitis. 
Acute Peritonitis generally commences, like other vif- 
ce’ral inflammations, with chills and fliiverings, though 
thefe are forrietimes flight, and occafionally abfent alto¬ 
gether. This cold ftage has been known to continue 
two or three days before the re-aftion took place. After 
this, the pulfe becomes quick and frequent ; there is 
confiderable third; and the general affedfion, called 
fever, enfues. Thefe fymptoms are attended from the 
very beginning witli a fenfe of heat and pain in the ab¬ 
domen, at firft generally confined to fomeone part, though 
fometimes diffufed over the whole of its furface. This 
pain is much increafed by preffure; or, in other words, 
there is a great tendernefs or forenefs of the belly, and 
moft invincible coftivenefs. The pulfe is at leaff one 
hundred in a minute, and fmall; yet the tongue is not 
much altered at firft from its natural appearance. 
As it is of much importance to diftinguiflr the tender¬ 
nefs on preffure, we flrould carefully watch the counte¬ 
nance of the patient while we prefs on the belly. In 
doing this, we ihould put both hands on the fides of the 
beliy, and draw them as it were to the centre ; this mode 
of preffure producing more pain than that which is made 
direftly downwards. In the courfe of twenty-four 
hours the pain and tendernefs on preffure increafe, fo 
that even the weight of the bed-clothes fometimes be¬ 
comes intolerable, and the pulfe riies to a hundred and 
twenty or thirty in a minute: at this time the tongue be¬ 
gins to be covered with a cream-coloured mucus, and, 
though it is moift, there is great thirft. A confiderable 
degree of tenfion and fwelling now takes place over the 
■whole abdomen ; and the patient finds moft relief from 
ain by remaining motionlefs upon the back, with the 
nees in a fmall degree elevated. This pofition, while 
it throws the weight of the inteftines to the fpine, and 
therefore removes the preffure of them from the inflamed 
membrane, at the fame time relaxes the abdominal muf¬ 
cles, and prevents any ftrifture over the outer furface of 
L O G Ye 253 
the inflamed part. As thefe mufcles are called into ac¬ 
tion by any attempt to rife or even to turn, fo fuch a 
motion neceffarily aggravates the acute pain ; whence 
abfolute reft, as juft ftated, is moft eafy to the patient. 
The patient, for the fame reafon, generally breathes by 
the intercoftals, and very littie by the diaphragm. The 
tenfion of the belly continues to increafe to the fixth, 
feventh, or tenth, day ; on one of which days, unldfs 
proper meafures have been taken to remove the difeafe, 
the patient moft commonly expires. Previous to death, 
the pain often fuddenly ceafes, and the inexperienced 
may conceive that this is an indication of amendment in 
the difeafe: but, if the fymptoms be minutely examined, 
it is found that, at the fame time, the pulfe is finking 
in ftrength and increafing in rapidity, that the ftrength 
of the patient is alfo fenfibly diminiftted ; the counte¬ 
nance collapfes, cold clammy fweats break out, the ex¬ 
tremities lofe their vital warmth, and at length a labo¬ 
rious refpiration manifefts the concluding llruggle of 
life. 
But the fymptoms above enumerated are often modi¬ 
fied by age, conftitution, feafon, and other circumftances. 
Thus, in fome fubjefts, of feeble conftitution and advan¬ 
ced age, peritonitis will creep on without fever, or even 
local pain—and yet the diforder will go on to complete 
diforganization of the peritonaeum, or fuch an effufion 
of ferous fluid as gives the complaint the character of af- 
cites. In fome fubjefts, the thicknefs of the mufcles and 
parietes of the abdomen renders the pain of preffure 
icarcely perceptible. A favourable prognofis, however, 
is to be deduced from a gradual ceffation of the pain, ef¬ 
pecially when it is accompanied by a diminution of ten¬ 
fion and forenefs, and when at the fame time the pulfe 
becomes fuller and lefs frequent, the fkin lefs parched, 
foft, and moift, the refpiration lefs laborious, and the 
countenance more open and expreffive of eafe. 
Inflammation of the peritoneum may be diftinguifhed 
from colic by the permanency of the pain, and the frei 
quency of the pulfe, as well as by the tendernefs on 
preffure, even before any tenfion of the abdomen has 
taken place ; and by the abfence of any inclination to go 
to ftool when the pain is fevere, as well as by the undi- 
miniftied fuffering when an evacuation of the bowels is 
eft'efted, either fpontaneoufly or by medicine. It is not 
fo eafily diftinguifhed from inflammation of the bowels, 
or .enteritis. In this latter difeafe, however, there is ob- 
ftinate conftipation, and the pain is more acute, and not 
fo much aggravated by external preffure ; the ftomach is 
alfo commonly affefted with vomiting. 
But thefe diftinftions are by no means to be depended 
on; for, though we have the authority of Hunter for 
confideringperitonitis a diftinft affeftion, (Hunteron the 
Blood, 244.) yet it cannot be difputed that many cafes 
do occur in which the organs in veiled by the peritonaeum 
become implicated in its inflammatory difeafe ; and, ac¬ 
cording as the peritonaeum is inflamed, over the ftomach 
or over the bowels, fo enteritis or gaftritis will enfue. 
The predifpofing caufes of peritoneal inflammation are 
involved in obfeurity. The exciting caufes are various: 
compreffion of the abdominal vifcera ; blows or falls on 
that region ; internal friftion or preffure, as of the gra¬ 
vid uterus, extra-uterine conceptions, enlarged ovaries, 
or other morbid growths within the abdomen; violent 
and long-continued corporeal exertions, violent and re¬ 
peated contraftions of the abdominal mufcles in vomit¬ 
ing ; irregular circulations of the blood in the cold ftages 
of intermittents, and ftriftures of the colon or reftum 
producing unnatural contortions and friftion of the in¬ 
teftines on one another, are all caufes of peritoneal in¬ 
flammation. 
But the grand caufes are to be fought in the aftion of 
a cold atmofphere on the furface of the body ; the appli¬ 
cation of wet or cold, efpecially to the feet, when the 
perfon is in a ftate of corporeal inaftion ; the negleft of 
changing wet clothes, the drinking of cold liquids when 
1 the 
