LECTURE XXXVIII.

PERITONITIS-Sometimes occurs during foetal existence, or in very early infancy-is then possibly dependent on syphilitic taint-when epidemic in large institutions, is often connected with infantile erysipelas.

Peritonitis in after childhood—a rare occurrence-generally secondary to some febrile attack-case illustrative of its symptoms, which are much the same as in the adult-occasional escape of the fluids effused, through the abdominal walls, and recovery of the patient.-Inflammation sometimes circumscribed, especially in connection with disease about the appendix cæci-illustrative cases.-Treatment of peritonitis. Chronic peritonitis-almost always a tubercular disease.-Morbid appearancessymptoms-their vagueness-pauses in the advance of the disease-various and often obscure forms which it assumes-close analogy between its symptoms and those referred to tubercular disease of the mesenteric glands.

TABES MESENTERICA-rarity of extensive disease of the glands-slightness of its symptoms when uncomplicated-Treatment of it, and of tubercular peritonitis.

FROM the study of the affections of the mucous lining of the intestinal canal, we pass by a natural transition to that of the diseases of its serous investment. Peritonitis, however, which is not very common as an idiopathic affection at any period of life, is still more rare during the greater number of the years of childhood; while its symptoms do not deviate in any important respect from those which characterise it in the adult. It would be idle to spend our time in speculating on the reasons for the rarity of inflammation of the peritoneum in early life. Some connection may perhaps be thought to subsist between the great irritability of the intestinal mucous membrane, and its proneness to disease during the greater part of childhood on the one hand, and the immunity from disease which the peritoneum exhibits during the same period. At any rate, it is certain that in the new-born infant, in whom the former peculiarity has not yet become developed, inflammation of the peritoneum is of more common occurrence than in subsequent childhood.

Inflammation of the peritoneum, giving rise to adhesions between the intestines, and to the effusion of lymph and serum into the cavity of the abdomen, occurs sometimes even during intrauterine life, and occasions the death of the foetus. It is not possible

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PERITONITIS IN EARLY LIFE.

to say with certainty to what cause the disease should be attributed at a time when the being is sheltered from all those influences from without which may excite inflammation after birth; but it is worthy of notice that in many instances of peritonitis in the fœtus, traces of syphilitic disease are observed upon it; or there is clear evidence of the existence of venereal taint in the mother. In such cases, the inflammation of the serous lining of the abdomen is probably due to the altered state of the circulating fluid—a cause to which, in after life, inflammation of the serous membranes is frequently owing. In the only instance of non-congenital peritoneal inflammation that has come under my notice in early infancy, there was no other cause than this to which it could be attributed.

In this case, a little boy, five weeks old (whose mother had twice. before been confined prematurely with still-born children), began to have snuffles at the age of three weeks. In the course of the next week a few copper-coloured spots appeared about his face; his scrotum next grew sore, then his voice became hoarse and his lips cracked; and at the end of the fourth week he grew sick and his abdomen enlarged and became tender. When brought to me, the child was extremely small; he was greatly emaciated; the skin of his face wrinkled; his appearance distressed; his chin covered with copper-coloured blotches; the angles of his mouth were ulcerated; his lips cracked; and small sores beset his scrotum. His abdomen likewise was very large: it was remarkably prominent about the umbilicus, and its superficial veins were much enlarged. It was extremely tense; somewhat tympanitic; and though dull in places, it yet did not yield the impression of distinct fluctuation anywhere. The abdomen was exceedingly tender to the touch, but the child seemed in pain also at other times; he had been very sick for nearly a week, and vomited almost immediately after sucking, besides which he threw up a yellow fluid at other times. His bowels were purged several times a day. His mother, who did not suffer at that time from any syphilitic symptom, was put upon a mild mercurial course, with iodide of potassium and sarsaparilla; and the mercury with chalk was likewise administered to the child. By degrees, as the syphilitic spots faded, the abdomen grew less tender and less swollen-it became soft; and in the course of time the infant regained perfect health. The symptoms in this case ran a chronic course; but peritonitis of an acute character, and tending to a rapidly fatal termination, is sometimes observed to occur among very young infants when

PERITONITIS-SOMETIMES EPIDEMIC IN HOSPITALS.

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collected together in large numbers, and under conditions unfavourable to health. A French physician, M. Thore,* during a year's observation at the Hospice des Enfants Trouvés at Paris, found that acute peritonitis existed in about six per cent. of the infants who died at that institution. The disease, such as he observed it, seems to be exclusively an affection of early infancy, since, though the hospice contains children of all ages, yet no child above the age of ten weeks was attacked by it, while thirtyfive out of fifty-nine were less than a fortnight old. The previous health of the children had in some instances been good, but in many cases the peritonitis appeared as a consequence or complication of some other affection. A sudden tympanitic swelling of the abdomen was often the first symptom of the disease, and was soon associated with vomiting of a greenish matter; which phenomenon, however, was seldom of long continuance. The bowels were generally constipated throughout, the respiration and pulse soon became accelerated, and the heat of the skin increased, while the child evidently suffered pain in the abdomen. With the advance of the disease the countenance altered, the skin grew cold, and the pulse feeble; and in the majority of cases the child died within twenty-four hours, while life was not in any instance prolonged beyond the third day.

The appearances found after death were much the same as those which characterise peritonitis in the foetus. In none of the sixty-three cases which were examined was there any puriform matter in the abdominal cavity, but only a dirty serous fluid, in which flocculi of lymph were often floating; while the intestines were more or less coated with false membrane, which was especially abundant about the spleen and liver. Pleurisy was found associated with the peritonitis in a third of the cases; and the frequency of this complication is another point of resemblance between the disease as it occurs during foetal life and in early infancy. Its causes, too, appear to be such as act through the medium of the circulating fluid; for in seventeen out of sixtythree cases the peritonitis followed upon erysipelas, and in four upon phlebitis of the umbilical vein,-affections which, it is known, are immediately dependent on epidemic causes, and are excited by the same atmospheric conditions as induce puerperal fever in lying-in women. The influence of such agencies is still further shown by the fact that forty-two per cent. of the cases of

* De la Péritonite chez les Nouveau-nés, in the Archives Gén. de Méd. for August and September 1846.

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SYMPTOMS OF ACUTE PERITONITIS IN CHILDHOOD.

peritonitis recorded by M. Thore occurred during the months of April and May, while the others were somewhat unequally distributed over the remainder of the year.

When the child grows older it is no longer so susceptible of noxious influences as before; and when they come into play, the mucous membrane of the bowels suffers, rather than their serous investment. Hence, acute idiopathic peritonitis becomes a very rare disease in childhood; and peritoneal inflammation usually occurs as a sequela of some affection which has been attended with considerable alteration in the circulating fluid. It sometimes succeeds to an attack of scarlatina; and the possibility of its occurrence should lead us to look with great suspicion upon any complaint of pain in the abdomen made by children during their convalescence from that disease; while, though the danger of its supervention after other febrile affections is less considerable, the risk is by no means to be forgotten.

The symptoms and course of the disease appear to be much the same whether it occurs as a primary or as a secondary affection; but there is a great difference between the severity of the symptoms and the amount of danger to which the patient is exposed, in different cases.

I do not recollect ever to have witnessed more intense suffering than was endured by a little boy, nine years old, who, after recovering from fever, yet seemed to regain his health by but slow degrees, and had almost habitual constipation. He came under my notice on May 25, and was much benefited by alterative and slightly aperient medicines; when he was suddenly, and without any known cause, seized on the 3rd of June with profuse diarrhoea, and severe pain in the abdomen. On the following day, when I saw him, his face was haggard and anxious, and his abdomen excessively tender; while the diarrhoea continued even more profusely than before. Some leeches were applied to the abdomen, and calomel and Dover's powder were given every four hours; but the leeches drew but little blood, and though the purging ceased, the pain in the abdomen increased in severity. On the 5th of June I found the boy lying on his back, with his legs stretched straight out; while the slightest movement, or any attempt to sit up, produced excruciating pain. The abdomen was tympanitic, very tender to the touch, and especially so just below the umbilicus. The pulse was frequent and sharp; the tongue moist, and uniformly coated with yellow fur. Leeches were again applied, in greater numbers than before; and the

CASE OF ACUTE PERITONITIS.

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mercurial was given every three instead of every four hours. Towards evening he was rather better, but the pain, which was referred especially to the neighbourhood of the umbilicus, came on severely during the night, and was aggravated in paroxysms. He had passed no urine for many hours; but only half a pint was drawn off by the catheter, and this was dark-coloured, and had a very strong smell. The bowels had acted only once, and then scantily. The same remedies were continued, but the child's condition continued to grow worse; and during the night he was in such pain that he frequently shrieked aloud, so as to alarm the neighbourhood. On the morning of the 7th he had turned round upon his right side, and lay with his knees drawn up towards his abdomen, his head supported in his mother's lap; his face expressed the most intense suffering, and he shrieked frequently with pain. The abdomen was much distended, and so tender that it could not endure the slightest touch. The pulse had become frequent and thready. He had made water twice of his own accord. The abdomen was now covered with a large blister beef-tea and brandy were given to support the vital powers; and while the mercurial was continued, an endeavour was made, by a full dose of opium, to procure a temporary abatement of the child's sufferings. When seen at 6 P.M. he had vomited frequently a dark-green fluid, and had passed three natural liquid evacuations. He was lying in the same attitude as before, dozing with half-closed eyes, his forehead wrinkled, the corners of his mouth drawn down, terror and pain stamped on his countenance, -seeming as if dying, till roused by a return of pain, when he called with loud and piteous cries on his mother for help. His pulse was now smaller, and more thready. During the night his sufferings were unceasing; towards morning he became quieter, and died quietly at 9 A.M. on June the 8th.

On opening the abdomen, thin pus, unmixed with lymph, poured forth in great abundance. It quite concealed the intestines from view, and must have amounted to at least a quart. The peritoneum lining the abdominal walls was highly vascular, especially in the hypogastric region; that covering the intestines had lost its natural transparency, was softer, and seemed thicker, but was not much injected. There was no lymph effused on any part of the parietal peritoneum, nor were there any adhesions between the intestines; but the spleen and liver, the latter especially on its convex surface, were coated with lymph. The whole tract of the intestines was examined with great care, and