044 DISEASES OF THE PERITONEUM. 



heart are often pressed up as high as the third rib. While at the com- 

 mencement of the disease percussion gave a full tympanitic sound, after 

 the exudation has become abundant, there is a distinct but rarely ab- 

 solute dulness. The anxiety of the patient is pitiful ; he beseeches 

 aid, and looks perfectly desperate. If a quantity of blood be not ab- 

 stracted, or the volume of blood be not diminished by extensive exuda- 

 tions, the countenance may become excessively cyanotic. Finally, the 

 mind becomes cloudy, the patient grows apathetic and delirious, the 

 pulse is smaller and more frequent, the body covered with cold sweat, 

 and occasionally on the third or fourth day after the commencement of 

 the affection, or more frequently at the end of the first week, the patient 

 succumbs to his disease. 



If the malady take a favorable course, which usually occurs only 

 when we succeed in removing the exciting causes, or when these are 

 not very grave, the pain, tympanites, and fever gradually subside, the 

 respiration becomes freer, and the patient may recover rapidly. But 

 very often, as a result of the adhesions and flexions of the intestines, 

 habitual constipation, and occasionally colicky pains before stool, re- 

 main for life. 



If the patient does not die during the first week, and if there be 

 no decided improvement during this time, the character of the disease 

 usually changes : it takes on a more chronic course. The pain moder- 

 ates, the abdomen is only sensitive on hard pressure, the tympanitis 

 decreases without disappearing entirely. If, up to this time, the pa- 

 tient has suffered from constipation, he now has movements from the 

 bowels ; if, on the contrary, there was diarrhoea as a result of the ex- 

 cessive transudation into the bowels, this disappears, or constipation 

 and diarrhoea alternate. The pulse and temperature also sink some- 

 what, without, however, becoming normal. As the tympanites sub- 

 sides, the dulness at the dependent parts of the abdomen usually be- 

 comes more distinct, and at the dull spots we perceive a gradually 

 increasing resistance ; by degrees the abdomen becomes unsymmetrical 

 and nodular, and the capsulated exudations appear like irregular tu- 

 mors. The fever, although moderated, continues and exacerbates from 

 time to time, and it consumes not only the strength of the patient, but 

 his blood and tissues. The fat disappears, the muscles become flabby 

 and relaxed, the skin dry and scaly ; not unfrequently there is oedema 

 of the legs, and in the fourth, fifth, or sixth week, the patient dies of 

 exhaustion. If^ contrary to our expectation, there be reabsorption of 

 the fluid, convalescence is very slow, and the symptoms of contraction 

 and distortions of the intestines, which remain more constantly after 

 these cases, are the sources of long and severe sufferings. If there be 

 ulceration and perforation of the peritonaeum, the fever increases, and, 





