Diagnosis.—When the symptoms are well marked the diagnosis of the disease is easy. Swelling of the belly, which takes no part in the respiratory movement and is intensely painful and tender ; vomiting ; a pale haggard face, and a quick wiry pulse—these, together with the position of the child in his bed, with the thighs flexed,. and his dread of movement or even of a touch, form a very characteristic group of symptoms.
When the inflammation is a consequence of perforation of the, bowel, the complication is sufficiently clear. Even if the pain and tenderness are inconsiderable, the sudden occurrence of collapse with tympanitis suffi ciently indicates what has occurred.
From tuberculous peritonitis the acute simple form may be readily distinguished by the more violent character of the symptoms and the more rapid course of the disease. In the tuberculous variety vomiting is rare, and the illness runs, as a rule, a very slow and chronic course.
In colic there is often constipation and vomiting, with severe par oxysmal pain in the belly ; but between the attacks of pain there is no tenderness ; the pulse is less rapid, small, and wiry, and there is none of the fear of movement which is so characteristic of peritonitis.
Rheumatism of the abdominal wall may be mistaken for inflammation of the peritoneum. The distinctive characters are given elsewhere (see page 159).
It is important to remember the occasional latency of the symptoms in peritonitis. Tension of the abdominal parietes on palpation, especially if partial, in a child above the age of infancy, must not be disregarded. It may, of course, be voluntary, and the belly be quite healthy ; but if the abdomen is full, and the child looks ill, with a haggard, pinched face, we should consider the possibility of peritonitis, and make a very careful ex amination. In cases of chronic empyema we should be always on the watch for the occurrence of peritonitis. If the child, after a period of im provement, cease all at once to gain ground and begin to look pale and distressed, with an elevated temperature, a more or less distended belly, and a rapid, wiry pulse, we are justified in suspecting peritonitis although there be no tension, tenderness, or other sign connected with the abdo-. men to give support to this opinion.
It is well in all cases where a feverish child looks ill and has a dis tended belly, to make trial of Duparcque's plan of placing the patient for a minute or two on his side, so as to allow all the peritoneal fluid to collect in the depending flank. Turning him, then, quickly upon his back, evidences;
of fluid, if peritonitis be present, will be found at the site of accumulation!.
Had this been done in the case of the little boy already twice referred to, the cause of the distention of the abdomen would not have escaped re cognition.
When the inflammation affects exclusively the visceral peritoneum, the muscular coat of the bowel is usually implicated. There is then often obstinate constipation from paralysis of the affected portion of the intes tine ; there may be vomiting ; and excessive tenderness of the belly is combined with paroxysms of colicky pain of agonizing severity. Such cases may simulate very closely obstruction of the bowels, and may be mistaken for intussusception. Some time ago I saw, with Mr. Izod, of Esher, a young lady, aged ten years, who had got up in her usual health on the morning of the previous Sunday. In the afternoon of that day, after running about in the garden (the day was very damp) she complained suddenly of pain in the belly. That night she slept fairly well, but complained of pain again on the next (Monday) morning. A pill was given to her, followed by a saline.
This acted on the bowels, but the pain was not relieved. She slept badly that night. On the Tuesday morning she was seen by Mr. Izod, who found a temperature of 102°. There was some tenderness of the belly, with frequent paroxysms of colicky pain. She had had no vomiting. Opium was given, but the pains continued, becoming more and more fre quent and more and more severe. The bowels were confined all the week except on the Thursday, when they acted spontaneously twice, the stools beimg copious and lumpy, light coloured and rather offensive. I saw the child, with Mr. Izod, on the following Sunday—the eighth day. She was lying in bed hollow-eyed and livid. Every ten minutes a paroxysm of pain came on, during which she raised herself up in an agony and tried to get on to the floor. The belly was swollen and excessively tender, the slightest touch appearing to induce a fresh access of pain. The child had been kept for some time under the influence of chloroform, but when the anaesthetic was remitted the pain instantly returned. Hypodermic in jections of morphia and atropine were given repeatedly ; but large quan tities of these narcotics appeared to dull the pain but slightly. The child died on the following day.