Peritonitis 3 1 5 



may pass forwards between the peritoneum and transversalis fascia 

 to the middle line or even across it. 



Except in the female, where the Fallopian tubes pierce it, the 

 peritoneum is a shut sac. It is lined by squamous endothelium, which 

 secretes a serous exudation so as to allow the coils of intestine to roll 

 freely over each other. In intestinal wounds and ulcerations plastic 

 peritonitis often prevents leakage of the contents of the bowel into the 

 general cavity. Thus, gall-stones may escape into the colon ; spinal 

 abscess may be discharged into small or large intestine, and peri- 

 caecal suppuration may be relieved through the groin with the occur- 

 rence of no more than a limited and conservative inflammation. By 

 the theory of inflammatory adhesions encysted peritoneal collections 

 are explained. 



In peritonitis, on account of the swelling and tenderness, the 

 patient lies supine with his shoulders raised and his knees drawn up, 

 so as to relax the abdominal muscles and to ward off the weight of the 

 bed-clothes. As the inflammation extends to the muscular wall of 

 the intestine it paralyses it, and thus constipation sets in. Decom- 

 position of the contents of the bowel occurs, gas being evolved, 

 and tympanites resulting. To ensure complete rest for the inflamed 

 bowel, opium is administered. As the descent of the diaphragm in 

 respiration disturbs the inflamed membrane, respiration is carried on 

 entirely by the ribs and the intercostal muscles. The arms are often 

 thrown up and the hands placed behind the head, so as to give the 

 pectoral muscles a greater command over the ribs. 



Inflammation of the peritoneum is accompanied by the deposit of 

 plastic material upon its surface, and when two areas of inflamed 

 membrane lie in quiet apposition the effusion may glue them perma- 

 nently together. But it often happens that before the effusion can be 

 thus organised the movements of the bowel itself, or of the abdominal 

 walls, gently drag the sticky surfaces apart, false bands and lengthened 

 fibrous adhesions being thus spun out. These bands offer a dangerous 

 snare to the neighbouring coils of bowel, and are a common cause 

 of intestinal obstruction, especially in the neighbourhood of the 

 uterus. 



In the course of acute peritonitis the muscular coat becomes 

 implicated in due course ; the exudation into it and into the nerve 

 plexuses throws them out of working order, and the symptoms of 

 acute obstruction arise. It has happened to surgeons (besides my- 

 self) to open the abdomen for the relief of acute obstruction and to 

 find no other cause for it than acute peritonitis. 



When a patient has intestinal muscular cramps colic it may be 

 at first a question whether his distress is due to peritonitis or not. If 

 the surgeon can move the flaccid abdominal wall freely over the bowel 

 there is no peritonitis. The peritoneal cavity is like a joint when 

 the latter moves easily there is no synovitis. 



