A boy, aged four years, was under the care of my colleague, Dr. Donkin, in the East London Children's Hospital. The child was said to have been ill for two weeks. He had first complained of pain in the belly, which was full and distended, and his bowels were relaxed. The pain was attrib uted by the mother to wind, for it was relieved by hot grog. The loose ness of the bowels ceased after a day or two, but the boy remained weak and listless ; his feet swelled a little when he sat up, and his face was noticed to be puffy in the mornings. For two or three days before admis sion he had had a slight cough.
When the boy came into the hospital his face was a little puffy about the eyelids and bridge of the nose. The heart and lungs appeared to be normal. His belly was distended, but there were no dilated superficial veins ; no dulness was noted on percussion in either flank ; no enlarged glands or fluctuation could be detected ; no pain or tenderness was com plained of ; and the liver and spleen were of normal size. There was a little oedema of the scrotum, but none of the lower limbs. His urine was scanty, but there was no albumen. Pulse, 88, regular ; temperature, 98° ; respirations normal. After a few days, as the temperature was natural, and the boy was up and about and seemed convalescent, there was a question of sending him home. Before this could be done, however, a sudden change took place in his condition. He became very drowsy, and was forced to return to his bed. He then began to vomit ; his pulse was 80 and intermittent : his temperature rose again, and he seemed at times to be only half conscious. Three days after his return to his bed, the boy had an attack of convulsions ; his temperature went up to 108°, and he died. On examination of the body, there was found a basic meningitis with many gray granulations in the cranium. Similar granulations were seen on the pleurae. The peritoneum, both parietal and visceral, was pro fusely studded over with gray and yellow granulations, varying in size from a pin's head to a pea; and there was much recent lymph, which had matted together the coils of intestine, and fixed them with the omen tum to the abdominal wall. There was no excess of fluid in the peritoneal cavity.
Such a case is very perplexing. The only symptoms pointing to the abdomen are the abdominal swelling and pain ; but these alone, in the absence of tension and tenderness of the parietes, or other equally charac teristic symptom, are insufficient to establish the diagnosis of peritonitis. Pain in the belly is a symptom so frequently met with in the child that its occurrence excites little remark ; and a large belly in young subjects is not sufficiently uncommon to attract special attention. Still, if we are
aware that -the illness may run this rapid course, such symptoms, taken in connection with the general weakness, the slight oedema without albumi nuria, and the terminal manifestations of cranial disease, may justify us in at least suspecting the existence of the abdominal complication.
Diagnosis.—In ordinary cases, the diagnosis of tubercular peritonitis is easy. Inflammation of the peritoneum developing slowly and insidiously, accompanied by rapid wasting and a very variable temperature, and pre ceded by general impairment of nutrition and abdominal pain, is very suspicious of tubercle. We must remember that tenderness and tension of the abdominal wall may be little pronounced, and that fluctuation is often absent, or, if present, is usually imperfect and indistinct. A definite tap readily transmitted through the fluid from one side of the abdomen to the other, although met with in rare cases of tubercular peritonitis, is yet not at all characteristic of this disease. Indeed, if such free fluctuation be present in a child who is lively and fairly active, it tells rather against than in favour of the diagnosis. In doubtful cases, it is desirable to test the effect of a sudden jar upon the child. If he be made to jump down to the ground from a low chair, and experience no uneasiness from the little shock, it is improbable that the peritoneum is inflamed. A child with abdominal tubercular disease is invariably dull and listless from the earliest period of the disease. He looks ill from the first ; and although he may be fairly stout, there are usually signs that his nutrition is already impaired. These symptoms are of great importance when combined with abdominal pain, swelling, and tenderness. Chronic digestive derange ments are common in early life, and I have known children who have been habitually overfed with farinaceous food, to be subject for months together to attacks of abdominal pain, often of great severity. But such children are lively and active enough ; although pale and often flabby, they do not look ill ; they have not the careworn, haggard expression which is almost inseparable from serious disease at every period of life ; and although the abdomen may be full and sometimes painful, the fulness is variable, often subsiding completely ; tyre is no tenderness or involuntary tension of the parietes, and the temperature is that of health. Such cases are easily cured. Limiting the consumption of farinaceous matters, a gentle aperient, and an alkaline aromatic mixture, will soon put an end to the indisposi tion.