1756 HUMAN ANATOMY. 



a case of injury to the abdominal wall, therefore, the impression is barely made upon 

 the skin before the muscles contract and an attempt at protection is made. In a case 

 of visceral lesion or of beginning peritonitis the rigid contraction of the muscles in 

 closest nerve relation to the area involved will constitute a \'aluable diagnostic symp- 

 tom. In general peritonitis the board-like, tender abdomen, the fixed diaphragm, 

 and the thoracic breathing (to lessen movement of the abdominal viscera) are all 

 phenomena to be understood only by recalling the correlation of the nerves involved. 

 The flexion of the thighs (to remove pressure from the tender surface and to relax 

 the muscles as much as possible ) is a secondary symptom due to the same cause. 

 The condition is in strong contrast with that seen in intestinal spasm {co/ic), in 

 which, although the patient may be doubled up with pain, pressure gives relief and 

 the loose, relaxed abdominal muscles may be moved easily and freely over the un- 

 derlying viscera. The intestinal distention and paresis of peritonitis are due partly 

 to the involvement of the nerve-plexuses of the gut and partly to the extension of in- 

 flammation to its muscular walls. They are increased by later vasomotor paralysis 

 and by fermentative decomposition of intestinal contents. 



Other phenomena common to many abdominal lesions, but especially to those 

 affecting the peritoneum, are due to the relation of the nerves of the latter to the 

 great abdominal nerve- plexuses. They have been grouped by Giibler under the 

 X.QXvs\ peritonism , are independent of toxaemia, and are essentially the symptoms of 

 " shock," — subnormal temperature, a running pulse, pallor or lividity, quick, shallow 

 breathing, and great mental and physical depression. The more distinctive peritoneal 

 symptoms are vomiting (although that is not uncommon in many forms of shock) 

 and generalized abdominal pain becoming epigastric or umbilical, and later — if peri- 

 tonitis develops — associated with tenderness. In illustration of this relation of nerves 

 and nerve-centres, Treves says, very truly, that almost all acute troubles within the 

 abdomen begin with the same group of symptoms, and that until some hours have 

 elapsed it is often impossible to say whether a violent abdominal crisis is due to the 

 perforation of an appendix or other portion of the intestine, the bursting of a pyo- 

 salpinx, the strangulation of a loop of gut, the passage of a gall-stone, the rupture of 

 a hydatid cyst, an acute infection of the pancreas, the twisting of the pedicle of an 

 ovarian tumor, or a sudden intraperitoneal hemorrhage. 



The later symptoms of peritonitis — the board-like rigidity of the abdominal mus- 

 cles, the tenderness, the meteorism, the intestinal paresis or paralysis, and the ascitic 

 dulness in the flanks — require no further anatomical explanation. The factors already 

 described, plus the existence of profound toxaemia, sufficiently account for them. 



Chronic peritonitis of the proliferative type (said to be found frequently in the 

 subjects of chronic alcoholism) is attended by great thickening followed by fibroid 

 contraction, which, in accordance with the locality chiefly involved, may cause (a) 

 constriction of the gastro-hepatic omentum with pressure on the portal vein and re- 

 sulting serous effusion ; (^b~) diminution in the volume of the liver from perihepatitis ; 

 (<:) thickening of the omentum, which forms a hardened roll lying transversely 

 between the colon and the stomach ; {d') shortening of the mesentery so that the 

 intestines are drawn into a rounded mass, situated in the mid-line and feeling like a 

 solid tumor ; {e) thickening and contraction of the intestinal walls, the mucous mem- 

 brane being thrown into folds like the valvulae conniventes ; (^f) the formation of 

 cicatricial bands attached at their ends to intestine and parietes or to two portions of 

 the gut, and under which other coils of intestine may pass and become strangulated. 



Tuberxnloiis pcritojiitis is the most common chronic form of the disease. The 

 infection — especially in children and males — usually proceeds from the digestive tract 

 through the retroperitoneal lymphatics ; or from the lung or pleura and bronchial 

 lymph-nodes by the same route ; or, less frequently, directly from ulcers within the 

 intestine ; in women it often enters through the Fallopian tubes. It may be con- 

 veyed by the blood. 



Of the conditions described as due to chronic peritonitis, the omental thickening 

 and the retraction and thickening of intestinal coils are frequently present. Agglu- 

 tination of these coils is apt to occur and to contribute to the sense of resistance which 

 may be erroneously interpreted as indicating the presence of a tumor. In addition 

 there are apt to be (a) a sacculated exudation in which the effusion is limited and 



