On examination of the body the small intestine was found healthy, ex cept for a reddened and ulcerated patch in the middle of the jejunum. The large bowel was distended with liquid faeces. Its parietal coat was very red and inflamed, but there was no injection of its mucous lining. 'The parietal peritoneum was not inflamed. Its cavity contained much dirty serum, but no lymph.
If the inflammation, instead of being confined to the visceral perito neum, spreads through the muscular coat to the mucous membrane (phleg monous enteritis) there is, in addition to the above symptoms, a profuse wa tery diarrhoea. The diagnosis is then easy. If the mucous membrane is not implicated, there is constipation which may be obstinate. In such a case intussusception may be excluded by noticing the early occurrence of ten derness, of abnormal tension of the abdominal wall, and in most cases of fever. Moreover, there is no tenesmus ; and the passage of blood and bloody mucus from the bowel, which is such a characteristic feature of intussusception, is absent. If, as in the case just narrated, an action of the bowels, spontaneous or otherwise, occurs some days after the be ginning of the illness, there is evidently no complete obstruction of the intestinal channel ; but unless the iuvaginatecl portion of gut be tightly constricted, secondary peritonitis is very unlikely to arise.
Prognosis.—The disease is fatal in the large majority of cases. In primary peritonitis from cold the chances are perhaps a trifle less unfa vourable than in the other varieties. Restlessness and inability to sleep are bad signs. In partial peritonitis, if the inflammation remain localised, the child will sometimes recover.
Treatment.—Directly the existence of peritonitis is ascertained no time should be lost in resorting to energetic measures for its removal. The most perfect quiet in bed should be enforced, and the presence of too many attendants should be strictly forbidden. One good nurse can do all that is required. Turpentine stapes should be applied to the belly, and opium should be given by the mouth or by hypodermic injection. For a child ten years of age six or eight drops of laudanum may be given in a teaspoonful of water every four hours, or one-twelfth of a grain of morphia may be injected under the skin, and the operation can be repeated as re quired. It is best to produce drowsiness, with some contraction of the pupil. Children vary greatly in their susceptibility to this form of nar cotic ; but inflammation of the peritoneum, if the pain is great, may require larger quantities of the drug than one would be disposed to anticipate to produce a sufficiently sedative effect upon the patient. Thus, I have known a little infant of four months old, who was suffering from agonising colic, owing to inflammation of the peritoneal coat of the bowels, take three minims and a quarter of laudanum in the space of two hours, with but little remission of his suffering. The same infant some hours afterwards had a hypodermic injection of one-twelfth of a grain of morphia ; and this powerful dose, although it contracted the pupils to the size of a pin's point, did not completely suppress all signs of pain. Energetic counter-irri
tation is of great value in these. cases, and when the turpentine can no longer be endured upon the abdomen, it may be applied to the front of the chest or to the back. Cold applications are well borne in many cases, and seem sometimes to comfort more than hot flannels. Cold is employed by means of cloths wrung out of ice-cold water and frequently changed.
All purgatives are to be avoided. If it be considered necessary to re lieve the bowels, this can be done by enema. If the peritoneal coat of the intestine is involved, constipation is often absolute ; but it is best to make no attempt to excite a movement. Our object is to quiet peristaltic action and insure rest. Probably the chief value of opium consists in its in fluence in this direction. Any attempt, therefore, to oppose its action will be hurtful. If in these cases the paroxysms of pain are frequent and agonising, it is advisable in a robust subject to apply leeches freely to the abdomen. I believe this form of disease to be one in which the abstrac tion of blood is a distinctly valuable therapeutic means ; and should not hesitate to employ ten or twelve leeches, or even more, if the attacks of colicky pain resisted the action of morphia. Even when the inflammation is limited to the parietal peritoneum, leeches may be employed in the case of a sturdy child, when the disease is primary, especially if the pain and tenderness can be referred to any particular spot. • In many severe cases of peritoneal enteritis, where the pain is excessive, and morphia, even fol lowing the application of leeches, proves impotent to control the paroxysms of suffering, it is advisable to keep the child under the influence of chloro form.
If thirst be much complained of, it is best allayed by sucking ice ; and the same measure is also useful in checking the tendency to vomit. The food should be concentrated. Strong beef-essence, milk in small quantities at a time, and yolk of egg can be given ; and as the patient becomes weaker, a teaspoonful of sound brandy in milk or water should be administered every few hours.
Tympanitis is a symptom which it is difficult to treat successfully. I have never seen benefit result from enemata of assafcetida or the passage of a long tube into the bowel. It is best relieved by free stimulation, and the external application of turpentine. If the child survive, and the abdominal distention continue after the inflammation has begun to sub side, as a consequence of loss of tone in the bowel, gentle frictions to the belly, compression with a flannel bandage, and quinine and strychnia by the mouth are of service.
Men peritonitis is the result of perforation of the bowel, warmth to the abdomen and the feet, the free use of opium, concentrated food, and energetic stimulation offer the best chances of success.
In every case where collections of matter can be discovered under the skin, either at the umbilicus or elsewhere, no time should be lost in aiding the escape of the pus by the puncture of a lancet.