DISEASES OF THE PERITONAEUM. 



is most apt to occur where there is haemorrhagic exudation. Thirdly, 

 and lastly, there is very frequently a partial chronic peritonitis, which 

 we know better in its results than in its first stages. It occurs in 

 chronic inflammations and degenerations of the abdominal viscera, and 

 causes partial cloudiness and thickening of the peritonaeum, adhesions 

 of neighboring organs to each other, and distortions and folds of the 

 intestines. 



SYMPTOMS AXD COUESE. The symptoms of acute diffuse perito- 

 nitis at its commencement vary with the causes which induce it. 

 Traumatic peritonitis usually begins with severe pain at the seat of 

 the injury, which quickly spreads over the entire abdomen. In peri- 

 tonitis from perforation also, excessive pain over the whole abdomen 

 is the first symptom, if the perforation has occurred suddenly, and 

 foreign substances have entered the peritonaeum. At first, along with 

 the pain there are symptoms of great general depression, and subse- 

 quently there is severe fever. If the perforation occurs gradually, and 

 only a slight amount of foreign substances enters the peritonaeum, the 

 symptoms of general peritonitis are preceded by those of partial peri- 

 tonitis. The commencement of an acute diffuse peritonitis, where the 

 inflammation is propagated from neighboring organs, is far less strik- 

 ing. The pain already existing gradually increases ; it is at first re- 

 strioted to the seat of the affected organ, and thence spreads gradually 

 over the entire abdomen. It is only in rheumatic peritonitis, and 

 those cases resulting from infections, that we have a severe chill and 

 intense fever at the onset of the disease, as in other severe inflamma- 

 tions. 



No matter how the disease begins, whether there is fever at first, 

 or it does not come on till late, pain is always the most troublesome 

 and the most characteristic symptom. Any slight pressure on the ab- 

 domen increases it ; even the pressure of the bed-clothes may become 

 unbearable. The patient does not toss about the bed, as he does 

 in colic, but lies on his back with the knees drawn up, and dreads 

 every change of position. The slightest cough causes a distortion of 

 the countenance, from pain ; the patient speaks low and carefully, and 

 does not breathe deep, fearing the pressure of the descending dia- 

 phragm. The abdomen soon becomes tense and puffed up. At first 

 the distention depends but little on filling of the abdomen with exuda- 

 tion, and is mostly caused by distention of the intestines, which are 

 filled with gas. This tympanitis is not easily explained ; it is proba- 

 ble that it is not due to an increased formation of gas, for we can find 

 no cause for a more rapid decomposition of the contents of the intes- 

 tines ; and it is just as unlikely that air should be exhaled from the 

 'vail of the intestine in peritonitis. Hence the meteorismus seems to 



