If the distention of the abdomen become great, it may cause serious distress by lungs and displacing the heart. In such cases there is clyspncea, with some lividity of the face, and hurry of breathing. The tongue is furred on the dorsum, red at the tip and edges. The pulse is small, hard and frequent. The urine is high coloured, but not espe cially acid, and its passage causes no pain. The bowels are confined or re laxed. Constipation is the rule in adults, but in children it is common to find looseness of the bowels with watery and offensive stools. Still, even in the child, if the muscular coat of the bowel be involved, and there be no sub-mucous oedema to cause effusion into the intestinal tube, the bowels may be obstinately confined.
As the illness progresses the vomiting usually ceases, but the other symptoms become more and more severe. The tympanitis increases ; the tongue becomes dry and brown ; the eyes are sunken . the face is haggard and pale, often cyanotic. The child lies with his eyes half closed in a dreamy state. His pulse is excessively small and rapid; and death usually occurs by the end of the week.
In exceptional cases the disease ends in recovery, the fluid being ab sorbed or discharged through the navel or abdominal wall. I have met with one case in which purulent matter escaped in large quantity through the umbilicus, and the child recovered. If the pus be evacuated by this channel, the relief experienced by the patient is usually extreme. The vol ume of the belly is diminished ; vomiting, if it had persisted, ceases ; the tongue begins to clean, and some signs of returning appetite are manifested.
Gauderon has referred to ten such cases, in eight of which recovery took place. The fistula left after the discharge of the purulent matter closes in about a month, sometimes at an earlier date. The disease is said some times to pass into a chronic state. Such a termination would excite sus picions of a tubercular origin for the peritonitis. There are few recorded cases of chronic peritonitis in the child, where an opportunity of examining the body was aftbrded, which do not make mention of tubercle in the ab dominal cavity or in the lungs.
When the peritonitis is the result of perforatiOn of the bowel, the oc currence of this serious accident is indicated by sudden severe pain in the belly, which becomes distended with gas and excessively tender. At the same time the child is reduced by the shock to a state of collapse. His face is haggard and ghastly looking ; his eyes are deeply sunken ; his pulse becomes very quick and small ; his breathing is thoracic ; his hands and feet are cold, but the temperature of the body, if taken in the rectum, is found to be 103°, 104°, or even higher. Sometimes he vomits, and the secretion of urine is suppressed. On examination of the belly it is found
that the liver dulness has disappeared. Niemeyer gives this as a certain sign that peritonitis resulting from perforation of the bowel has taken place.
The above is the typical form ; but often the symptoms are much less characteristic. Pain and tenderness may be little complained of, and, as Andral has pointed out, sudden increase of the prostration and the ghastly look of the face may be the only symptoms drawing attention to this new complication. Even when the pain has been it often ceases com pletely for some hours before death. In most cases the child survives perforation but a very few days. Sometimes, if adhesion have previously taken place in the neighbourhood of the ulcer, so as to confine the extra vasated matters to the immediate vicinity of the rupture, the peritonitis may be localised. An abscess then forms, which after a time makes its way to some point of the surface, and discharges its contents externally. Under these more favourable conditions the child may recover, but it is needless to say that such cases are exceptional.
Sometimes peritonitis in the child is entirely latent, and is only dis covered on post-mortem examination of the body. In such cases the belly may be swollen, and the child may look ill and colourless ; but pain may not be complained of ; there may be no tenderness of the abdomen, no tension of the parietes, no fluctuation, or other sign to indicate the presence of this serious lesion. I have only observed this latent form in cases of secondary peritonitis. In the little boy, whose case has been be fore referred to, where peritonitis resulted from extension of the purulent inflammation to the belly from the chest, the abdomen was swollen, and a., watery diarrhcea began which resisted all treatment ; but there appeared to be no pain or tenderness ; the parietes were soft and flaccid ; no fluc tuation could be detected ; and although on account of its fulness the ab domen was repeatedly examined, nothing was discovered to lead to the suspicion of the existence of peritonitis. On examination of the body some purulent fluid was discovered in the peritoneal cavity, and the bowels were more or less adherent from exuded lymph. It is important to be aware of the occasional latency of the inflammation, so that we may not exclude peritonitis, because the symptoms and signs are ill marked and little characteristic of the lesion. If in such a case the delirium, restless ness, and tendency to stupor are unusually prominent, the most experienced physician may misapprehend the nature of the illness and be disposed to suspect the onset of a meningitis. Dupareque relates a case in w.hich this mistake was actually made, and the error was only discovered on examina tion of the body.