(J.|.(J DISEASES OF THE PERITONAEUM. 



and gradually assumes a spherical shape. Finally, the abdominal walls 

 become tense, even shining, and are often traversed by enlarged veins. 

 By pressure on the abdomen, which is still painful for the child, we 

 find an elastic resistance. The results from percussion of the abdomen 

 vary. Only in rare cases can a free exudation be recognized by dulness 

 in the dependent portions of the abdomen, which changes its locality 

 with the change hi position of the patient. More frequently the entire 

 abdomen gives a dull sound, as the intestines are drawn back against 

 the spine by the atrophying mesentery, and the exudation lies on the 

 abdominal wall. In most cases the percussion is tympanitic at some 

 places (where the intestines He), and dull at others (where the fluid is). 

 If we bear in mind this description, we shall rarely mistake this disease, 

 which does not often occur, and which alone, or by its complications, 

 always causes death. 



Chronic partial peritonitis, whose remains, in the shape of thick- 

 enings, adhesions, and cicatricial contractions of the peritonaeum, are 

 found in the cadaver just as often as thickenings and adhesions of the 

 pleura, develops just as latently as the pleuritis does, from which the 

 pleuritic adhesions arise, and we cannot give any description of it. 



DIAGNOSIS. Peritonitis is not readily mistaken for any other dis- 

 ease, as the great sensitiveness of the abdomen to the slightest pres- 

 sure, the tympanites, and, in the acute form, the fever, give almost 

 certain points for the diagnosis. Those cases dependent on perforation 

 of ulcers of the stomach or intestines, that have not been recognized, 

 present some difficulties of diagnosis. The sunken countenance, cool 

 skin, small pulse, retracted abdomen, and other symptoms of severe 

 general depression, remind us more of colic than of a severe inflam- 

 mation. But if we bear in mind how insignificant the symptoms of 

 gastric and duodenal ulcers may be, and if we observe how sensitive 

 the abdomen is to pressure from the commencement, we shall avoid error. 



On the other hand, colic, and the impaction of bilious and urinary 

 calculi, may be erroneously considered as peritonitis; but the diag- 

 nosis is only difficult in those cases where, in hysterical women, mesen- 

 teric neuralgia is complicated with hypersesthesia of the skin of the 

 abdomen, in the so-called rheumatic colic, and in that from gall-stones, 

 when the right hypochondrium is very sensitive to pressure. In these 

 cases it may be necessary to wait for further developments before form- 

 ing a diagnosis. In all other cases, the insensibility of the abdomen 

 to pressure, or even the relief afforded by this, renders the diagnosis 

 certain very early in the disease. 



PROGNOSIS. Although most of the patients attacked with perito- 

 nitis die of the disease, it is not because this affection is particularly 

 ill borne by the organism, but because it almost always depends 011 



