we can generally, by making pressure in the spaces between the leech-bites, satisfy ourselves of the actual degree of tenderness of the internal parts. As regards the state of the bowels, if not moved by the combination of calomel recommended above, it is perhaps better to abstain altogether from the internal administration of cathartics until the violence of the disease has been greatly subdued, and until the milder operation of glysters has afterwards failed. At this later period the senna and salts may be given in divided doses until it operates, provided the stomach will retain it. In some cases, half an ounce or six drachms of castor oil will have the desired effect.

In addition to these remedies, a strictly antiphlogistic regimen must be observed, the patient confined to bed, and almost entirely deprived of food for two or three days, or only the blandest and least nutritious fluids allowed in small quantity. If the disease be much protracted in consequence of the extent of effusion as indicated by fluctuation, by the doughy feel, and soft tumefaction of the belly, and by obscure symptoms of hectic fever, a more nutritious diet must of course be allowed, consisting of such articles as arrowroot, sago, beef-tea, and animal jellies; employing, at the same time, mild diuretics, such as the tincture or infusion of digitalis with nitre; or the compound infusion of roses, as a refrigerant; or, unless the perspiration be in excess, the liq. ammon. acet. mixture may be substituted, with digitalis and the spt. æther, nitric and acetate of potash. Of course, it will often be necessary, in the progress of convalescence, to administer a gentle laxative from time to time, as well as anodynes, to procure repose at night. The absorption of the effused fluid, and the entire removal of inflammatory action, will also be materially promoted by the repeated application of a blister, or of the turpentine, or other stimulating liniment, to the parietes of the abdomen.

When acute peritonitis occurs in the aged or cachectic, and when it assumes much of the asthenic or typhoid type, general depletion must be used very sparingly; an attempt being made, by placing the patient upright, to induce faintness by as small a loss of blood as possible. It will seldom admit of repetition; instead of which, we must substitute leeches, blisters, and calomel and opium in moderate doses; together with a somewhat liberal allowance of nutriment.

When the disease arises from extravasation, the prostration is so sudden and extreme, that depletion is for the most part out of the question; but although the case is all but hopeless, it will be right to attempt to lessen the frightful and overwhelming irritation by the free administration of solid opium; and if the stomach will retain it, to support the strength by means of mild, nutritious food.

CHRONIC PERITONITIS.

Chronic, or, perhaps, more properly speaking, subacute peritonitis, may be a mere result or sequel of the acute form of the complaint, when its existence and progress are for the most part sufficiently manifest. In a majority of instances, however, it is an original disease, when both its commencement and its subsequent progress are apt to be involved in considerable obscurity. It is highly probable, if the patient were in every case of sufficiently mature age, and attentive to his feelings, that we should find the ordinary forms of chronic peritonitis commencing with rigors, shivering, pain, and other general and local symptoms, corresponding in kind, though not in degree, with those of the acute disease. It most frequently happens, however, either from the youth and inattention of the patient, or from the inconsiderable degree of inconvenience which often results from this form of perito

nitis at its commencement, that we do not succeed in obtaining a very satisfactory history of the case; and hence it is, that we not unfrequently have some difficulty in satisfying ourselves whether we are called upon to treat a new, or only an incidental aggravation of an old disease. In either case, we for the most part find symptoms which, as already observed, differ rather in degree than in kind from those of acute peritonitis. The patient has probably experienced rigors, chilliness, or shivering, with a general feeling of indisposition, weakness, and loss of appetite, accompanied or presently followed by pain in some part of the abdomen: this pain is seldom complained of over so large an extent of surface as in acute peritonitis; but, like the pains of the latter, it is aggravated by pressure or motion, and is sometimes observed to dart or shoot in various directions; the belly is usually more or less tympanitic; but whatever may be the degree of distention, the abdominal muscles generally, and particularly those situated over the tender part, are commonly somewhat rigid, or contracted to the feel. Unless the patient be naturally of a very florid complexion, the countenance is generally pale, with an expression of distress-the latter being rendered much more obvious on any attempt being made to press the abdomen. The patient complains of thirst, perhaps with nausea, or even vomiting; the matter vomited consisting either of the ingesta, or of a mucous or green, bilious-looking matter; the pulse is frequent, and perhaps small, but nevertheless hard and resisting; the tongue, at its centre and base, is covered with a whitish fur; the skin is hot and dry; the urine scanty and high-coloured; and the bowels generally costive. As the disease advances, considerable effusion occasionally takes place, rendering the belly tumid and soft, or doughy; but whether in this state, or highly tympanitic, a distinct fluctuation may now and then be felt. The symptoms enu

merated, and, if there be much effusion, probably an irregular form of hectic, will often continue, with variable intensity, for several weeks, or even months, then prove fatal; or, though neglected, gradually subside. When properly and successfully treated, they usually disappear in a period varying from ten days to six weeks.

After recovery from such an attack, the patient is usually left pale, weak, and more or less emaciated, but without any very observable alteration either in the form, size, or feel of the abdomen. Occasionally, however, the abdominal muscles are found to have become permanently somewhat rigid and less moveable beneath the integuments, or the abdomen itself presents some irregularity of shape, or even an obvious hardness is felt in a particular spot, as if from a deposit or thickening in the interior. The disease may never return; but, in a considerable proportion of cases, sometimes from an assignable cause, and sometimes not, the patient experiences a second attack, probably after the lapse of several weeks, or as many months, when nearly the same assemblage and succession of symptoms are observed. It generally happens, however, that each succeeding attack displays a less degree of activity than that which preceded, whilst the tendency to a return seems to be increased; so that at length the patient can hardly be said to be at any time altogether free from complaint, but rather suffers from occasional aggravations of a now permanent disease of his peritoneum; the febrile symptoms assume a hectic character, probably with evening exacerbations and irregular sweats; the pain is either fixed, or it only subsides in one part to attack another; the abdomen is sometimes rigid, sometimes flaccid, but pretty uniformly more or less tympanitic; or, when the disease has been of long standing, we may have it somewhat rounded and prominent, and at the same time hard and rigid to the feel, as if there existed

a general contraction of the whole parietes; the body wastes, the countenance gets remarkably pale, often with a strongly-marked expression of distress; the bowels are probably relaxed or extremely irregular, being sometimes costive, at other times loose: there is occasionally vomiting, especially after taking food; the tongue is covered with a whitish fur, or is unusually red at the tip and edges, and towards the close, often remarkably clean, tender, and aphthous; the pulse is small and quick; the appetite is gradually lost; the patient lingers, and at length, after months, or even years, dies completely exhausted by repeated or long-protracted suffering. In other cases, whilst the disease is pursuing its usual tardy and tedious course, a sudden and rapid increase of emaciation takes place, which soon terminates in death; or the patient is somewhat unexpectedly cut off by a severe accession of inflammation or diarrhoea.

Morbid appearances. On inspecting the body after death, the morbid appearances are observed to vary, not only in degree and extent in different cases, but also in kind, accordingly as there is present, or not, a tuberculated condition of the peritoneum. In both forms of the disease we find the membrane opake, and apparently thickened over a greater or less extent of surface; and in both we discover adhesions, either between the different folds of the intestines, or between the intestines and parietes, or between the intestines and the rest of the viscera. These adhesions of course vary in extent according to the activity, duration, and frequency of previous attacks of inflammation. Associated with these adhesions, there are occasionally considerable deposits of albuminous matter, which having undergone organization, produce hard and thick masses, most commonly found in the omentum, or between the folds of the intestines. In some instances these adhesions are so