In an ordinary case, the first sign noticed by the mother is that the child's belly looks large, and the next, that it is a little tender. The child_ is unusually listless and dull. He looks ill. He avoids exercises which cause a jolt or jar to his body, and shows a caution iu all his movements which soon attracts attention.
A boy between ten and eleven years old was brought to me at the hos pital. The lad had always been healthy and active, although there was a tendency to consumption in his family. For some weeks it had been noticed that he looked pale, often complained of nausea after food, was languid, lay about instead of playing, and cried if he was scolded. Then he began to suffer from pains in his abdomen, and excused himself on this account from running errands as he had been accustomed to do. Pressure on the belly, as in leaning against a chair or table, had not been noticed to be painful ; but the boy said that if he leaned forward his "food " rose at once. After some days the abdomen began to be tender and painful. The child complained of feeling cold, and slept badly at night. He was thirsty, but cared little for food. The bowels were relaxed.
The above is a very good illustration of the mildness of the early symptoms, and the stealthy way in which the disease creeps on. The ab dominal pains appear to be at first intermittent and of a griping character. The bowels are relaxed or confined. Often the disease is said to have begun with diarrhoea, and the attacks of looseness are sometimes separated by periods of more or less marked constipatiOn. Nausea and vomiting are not such common symptoms in this form of peritonitis as they are in the simple variety, and the appetite may be preserved for a considerable time.
After some weeks the tenderness of the abdomen and its sensitiveness to the slightest jar or shock, as well as the increasing weakness of the patient, obliges him to keep his bed. But he will sometimes go about as usual, if allowed to do so, for a long time—long after the disease is fully established. IIe may then be noticed to take very characteristic precau tions to avoid jolting his belly when he moves. Thus, he will steady it with his hand as he walks ; and go backwards down-stairs, so that he may more conveniently pass from step to step upon his toes. If the tempera
ture be taken at this time, it will be found to be higher than normal ; but the mercury seldom rises above•101° in the In the morning it may be at the natural level.
If the belly is examined, it will be found to be distended and oval in shape, the projection being more marked about the umbilicus and epigastrium than below the navel. The skin has often a shiny look ; the veins ramify ing over the surface may be noticed to be full ; and the natural markings of the belly have disappeared. On palpation there is often increased ten sion of the recti muscles, which contract instinctively to protect the tender peritoneum, and the resistance offered by the contents of the abdomen is very unequal. In some parts the parietes are easily depressed ; in others a certain feeling of solidity is conveyed to the finger, and distinct, firm masses may be often detected here and there. These are usually tender, and frequently pressure upon any part of the belly causes pain. In some eases free fluctuation can be detected. If there be pressure upon the por tal vein by enlarged glands or caseous masses, the amount of ascites may be large. It is then often accompanied by cedema of the lower extremities and abdominal wall, with dilatation of the superficial veins of the belly. It is seldom, however, that these symptoms are noticed. Usually the amount of effused fluid is small, and there is merely an imperfect sense of impulse conveyed from one side of the abdomen to the other ; not a dis tinct tap of the wave of fluid, such as we feel in the ascites accompanying cirrhosis of the liver. If the amount of fluid be small, or its consistence thick, no fluctuation may be discovered ; but in these cases it will be noticed that on percussing the belly the tympanitic note which prevails over the greater part of the abdominal wall changes in the flanks to dulness from the presence of fluid ; and that if the child be laid on one side, so that the fluid may gravitate downwards, the note on the flank turned upper most becomes clear.