INFLAMMATION OF THE PERITONAEUM, PERITONITIS. 643 



depend, to a small degree, on the expansion of the gases due to relax- 

 ation of the intestinal walls ; to a greater degree on obstructed escape 

 of the gases due to paralysis of the muscular coat. The belly may 

 soon become very much distended. But of course the exudation and 

 the inflated intestines press upward against the diaphragm in the same 

 way that they press against the abdominal walls, and so cause symp- 

 toms which, next to the pain, are the most distressing and most dan- 

 gerous. The compression of the lower lobes of the lung by the up- 

 ward pressure of the diaphragm, as well as the excessive hyperaemia 

 of the non-compressed portions of lung (resulting from the disturbance 

 of circulation in the compressed portions), induces excessive dyspnoea 

 and a frequency of respiration of 40 to 60 inspirations in a minute. The 

 effect of the disturbance of the circulation of the lungs may extend be- 

 yond the right side of the heart to the veins of the general circulation, 

 and give the patient a cyanotic look. In most cases of acute diffuse 

 peritonitis the patient is obstinately constipated ; this symptom is ex- 

 plained by paralysis of the muscular coat of the intestines by collateral 

 oedema. In puerperal peritonitis alone there is usually watery diar- 

 rhoea ; for in this form the oedema extends to the mucous coat, and 

 causes copious transudation into the intestines, and, it they become 

 somewhat full, it flows away in spite of the paralysis of the muscular coat. 

 If we set such patients up in bed, or if we press strongly on the abdomen, 

 watery, slightly-colored masses pass from the anus. Besides the above 

 symptoms, there is often vomiting, provided the peritonitis has not 

 been caused by the perforation of a chronic ulcer of the stomach. At 

 first the vomited masses are mucous and colorless, later they are more 

 watery, greenish, or even intensely green. The causes of the vomit- 

 ing, and the circumstances under which it is absent, are obscure. This 

 difference is not explained by the participation of the covering of the 

 stomach in the inflammation, or by its freedom from it. If the inflam- 

 mation extend to the peritoneal covering of the bladder, there arises 

 an incessant desire to urinate, and a feeling of fulness in the bladder. 

 If an inexperienced physician be deceived by this, and be induced, by 

 the patient's desire to urinate, to introduce a catheter, only a few drops 

 of concentrated urine will be withdrawn. Fever is one of the symp- 

 toms of acute diffuse peritonitis, and, where this does not begin with 

 the disease, it occurs very early. The pulse is very frequent and small ; 

 the temperature rises to 105 or more. As in any severe fever, the 

 general state of the patient is much affected the mind is unusually 

 clear. 



In severe cases the above symptoms become very decided in a few 

 days. But the pain is usually worse at first, and subsequently dimin- 

 ishes. The belly is inflated like a drum ; the li ver and the point of the 



