PERITONITIS 303 tions so as to resemble the spasms of colic. The respiration is hurried, and is almost en- tirely carried on by the movement of the ribs, contraction of the diaphragm and abdominal muscles producing acute pain. There is great tenderness on pressure over the abdomen, con- tinuing during the course of the disease. The patient generally lies upon the back with the knees raised, to relax the abdominal muscles and take oft' the weight of bed clothing. The abdomen is often greatly distended, the intes- tines containing considerable gas, and the peri- toneal cavity serous effusion, which post-mor- tem examinations show to contain coagulated products of inflammation. Vomiting is a fre- quent and often a prominent symptom, attend- ed by great pain. In the later stages regur- gitation of the contents of the stomach is apt to take the place of active vomiting. The pulse is frequent, hard and wiry, beating from 120 to 150 per minute. There is great pros- tration, and the countenance is haggard and anxious. In some cases the upper lip is raised and tightly drawn across the teeth, and this when present is a characteristic symptom. There is great difficulty in voiding the urine, partly owing to paralysis of the muscular coat of the bladder, and partly to the pain caused by any effort to contract the abdominal mus- cles, which induces the patient to postpone the act ; the use of the catheter is therefore fre- quently necessary. The intellect is usually lit- tle disordered, but slight delirium is common toward the close of fatal cases. The disease is distinguished from acute enteritis by the greater degree of pain, especially on pressure, and of tympanitis, more frequent pulse, and as a rule the absence of diarrhoea, although this sometimes occurs. From colic it may be dis- tinguished by the fact that although the pain may have exacerbations, yet it is continuous, and is always aggravated by pressure, while colic pains are often somewhat relieved by it. Acute general peritonitis is a grave dis- ease, recovery depending more than in most simply inflammatory diseases on management. Judiciously treated cases of idiopathic perito- nitis have a good prospect of recovery. When connected with gastric or intestinal ulceration or Bright's disease, the prognosis is always unfavorable, death often taking place in a few hours in cases of perforation, although recov- ery here sometimes occurs. The average du- ration of fatal cases of peritonitis is from four to six days. In regard to treatment authori- ties are somewhat divided. Bloodletting was almost invariably resorted to by the older phy- sicians, and is still used by some; but since about 1852 an important change has taken place, more particularly in the city of New York. Cathartics also used to be employed, but their action is now regarded as injurious. Arrest or retardation of the peristaltic move- ments of the intestine is one of the principal requirements, and is imperatively demanded in cases of perforation ; and this is obtained by 650 VOL. XIIL 20 full doses of morphine or some opiate. The use of opium in conjunction with other reme- dies was recommended by Armstrong more than 40, and by Watson more than 30 years ago ; but what is known as the opium treat- ment, upon which almost exclusive reliance is now placed, is due to Prof. Alonzo Clark, who first called attention to it in connection with some cases of puerperal peritonitis in the lying- in wards of Bellevue hospital in 1851-'2. The dose is to be governed by the effect, which should be nearly perfect relief from pain and diminution of the pulse. From half a grain to a grain of some salt of morphia may be given, when in the course of two or three hours the size of the repeated doses may be estimated. In addition to the opiate, warm fomentations over the abdomen, with applica- tion of rubefacients to the legs and feet, will be of service. The use of calomel in small doses was formerly practised, and by many is not yet discarded, although when given the doses are greatly reduced, not being more than from one eighth to a quarter of a grain every four hours. Its efficacy is doubtful. Peritoni- tis is decidedly an asthenic disease, and great caution should be exercised in guarding the patient against depressing agencies. Bice-water drinks and beef tea, in quantities as great as may be borne without increasing the nausea or loading the intestines, are advisable. Ton- ics and alcoholic stimulants are for the same reason recommended. Partial peritonitis, or that which is limited to a circumscribed por- tion of the peritoneum, is the result of inflam- mation of parts lying beneath the membrane. In ulceration or abscess of some organ, as the 'liver, that portion of the peritoneum covering the part becomes inflamed, and the conserva- tive tendency in the system is to cause the adjacent fold of the membrane to become at- tached to it by organized exudation. In cases of wounds of the abdomen, a similar glueing together of the two layers of peritoneum tends to take place, either accompanied with a clo- sing of the orifice or its remaining open. The treatment should be palliative. Chronic peri- tonitis is rarely the result of acute, the latter affection generally passing away completely. It is commonly developed as an accompaniment of tuberculosis, when it is known as tubercu- lous peritonitis. Tuberculous deposits in the mesenteric and intestinal mucous glands are generally present, but the peritonitis may oc- cur without such lesions, or other affection than the tuberculous cachexia. In some cases chronic peritonitis occurs in connection with carcinoma, either seated in the membrane or originating in adjacent structures, and is called cancerous peritonitis. The prognosis in all cases of chronic peritonitis is unfavorable. A fatal termination, even when the affection is not connected with either tubercle or cancer, is the rule; but in this case the duration of the disease may be extended several years. When it is tuberculous or cancerous, the period is
