CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAt. 595 



do not toss around on the bed, like those above described, but lie still 

 on their back, carefully avoiding all movement, because it increases 

 their pain. The pulse is very frequent, the temperature very high 

 the diaphragm, pressed upward, compresses the lungs, and the respira- 

 tion is hastened ; the obstructed flow of blood from the right side of 

 the heart gives the patient a cyanotic look. In comparison with the 

 symptoms above mentioned, which even now continue, those of peri- 

 tonitis are so prominent that the former are not sufficiently noticed, 

 and, while the peritonitis is recognized, the internal strangulation, or 

 other obstruction of the intestine causing it, escapes observation. We 

 should make it a rule to consider " rheumatic peritonitis " a very rare 

 disease, and, when peritonitis occurs in a non-puerperal patient, to think 

 of perforation, particularly of perforation of the stomach by an ulcer, 

 or of acute obstruction of the intestine. If the disease has occurred 

 quite suddenly, and is not accompanied by vomiting, the chances are 

 hi favor of perforation. If it has come on gradually, and there was 

 vomiting at the very first, which continues obstinately, or if fecal 

 vomiting occurs, there is, most probably, obstruction of the intestine. 

 In the latter case, the course is usually much more rapid ; even after a 

 few days, there is usually great collapse, general paralysis, and almost 

 always a fatal termination. 



During life it can hardly be said, in any case, whether the group 

 of symptoms that we have described depends on a rotation, internal 

 strangulation, intussusception, or an obstruction of the intestine by 

 hardened faeces or stony concretions. We have the least certainty in 

 diagnosticating rotation of the intestine on its axis. The suspicion of 

 internal strangulation is somewhat supported, if the patient has had a 

 previous attack of peritonitis, as the bands, which are the most fre- 

 quent cause of the strangulation, are almost always remains of former 

 peritonitis. Intussusception occasionally shows peculiarities of symp- 

 toms by which it may readily be distinguished from other forms of ob- 

 struction of the intestine. Among these is a sausage-shaped tumor, 

 usually of only moderate resistance, which may sometimes be felt in 

 the abdomen, particularly when the walls are not very tense. This 

 tumor cannot be moved much ; it is painful, and, on percussion, gives a 

 pound not quite dull. In intussusception, moreover, the calibre of the 

 intestine is often not closed so completely as in other forms, so that, 

 occasionally, small quantities of faeces, or intestinal gases, are evacu- 

 ated. Moreover, from the compression of the veins of the mesentery, 

 which is likewise invaginated, there is great congestion of the invagi- 

 nated portion of intestine, which may readily induce rupture of vessels 

 in the mucous membrane, and bloody or bloody-mucous passages. This 

 symptom is peculiarly important in the diagnosis of intussusception in 



