Pneumoperitoneum cannot be diagnosticated from its physical signs, since any one of these may be present in tympanites. These signs, apparently first recognized by Barth and Roger, are:
A high-pitched, tympanitic, often metallic, percussion note, uniform in quality over the entire abdomen.
A diminished or absent area of liver flatness.
A distended, tense abdominal wall.
Embarrassment of the respiratory movements and the heart action.
In clinical work the only sign much regarded is the obliteration of liver flatness, and against its reliability there is an increasing array of evidence. Osler1 has spoken of the probability of its occurrence in tympanites; T. C. Janeway2 of the proof of this at operation. Sprengel3 considers it a sign of early spreading peritonitis. McCrae4 says that if there is any degree of distention no dependence should be placed on it in the diagnosis
HERRICK WW. A STUDY OF PNEUMOPERITONEUM: WITH A MEANS FOR ITS DIAGNOSIS. Arch Intern Med (Chic). 1910;V(3):246–251. doi:10.1001/archinte.1910.00050250031003
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