529 Girl Meur

with a most acute pain. The fæcal matters on that day were slightly tinged with blood.

From this period, at each stool, the child is seized with very acute pain during the efforts of defæcation, and each time a small portion of very pure blood tinges the Cured

fæces without mixing with them.

On examining the anus, a slight erythema is observed, mixed with eczema nearly 89.

well, and the existence between two folds of the anus of a fissure about one-eighth of an inch broad, and less than one-sixteenth of an inch in length, not very deep, of a reddish colour, and which becomes perfectly developed when the child makes

days by

an effort of defecation. The anus is also the seat of a considerable constriction. patiens In these two little patients, M. Trousseau prescribed:

This treatment had wonderful success, and effected the cure in the little girl at the end of eight or nine days, and in the little boy, at the end of three days only.

Phatary again

BOOK XI.

ON DISEASES OF THE PERITONÆUM. ON PERITONITIS.

Peritonitis, or inflammation of the peritoneum, is a very common disease amongst newly-born children. It has been described by Billard, Dugès, and more recently by M. Thore, in a work of which I have a very high opinion.

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Peritonitis is sometimes developed in the foetus whilst still enclosed in the womb of the mother, and it constitutes congenital peritonitis. Billard, Dugès, and Simpson have related numerous examples of it. Peritonitis most usually manifests itself after birth, and during the first month of existence. It is more rare amongst children of a more sustine advanced age. Its appearance often coincides with the existence of epidemics of puerperal fever. It is sometimes developed in a primary tasud manner without any appreciable cause, and without any anatomical lesion in the neighbourhood of the peritonæum accounting for its presence. Most usually the peritonitis is secondary, and results from risk Est the erysipelas of infants, and from the umbilical phlebitis which follows

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SPECIAL PATHOLOGY OF INFANCY.

[Part III.

Any ligature of the cord; from an obstacle to the progress of the faecal air matters in the intestine by constipation, imperforation of the anus, intestinal invagination or inflammation of a hernial sac; from rupture of the bladder, laceration of the liver, perforation of the stomach, general eczema, &c. In all these cases we may admit that the inflammation has been communicated to the peritoneum by the lesions of the surrounding parts above alluded to.

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Peritonitis is nearly as frequent amongst boys as amongst girls, and is developed in all seasons, especially in spring and summer, but without any well-marked influence of the external temperature.

ANATOMICAL ALTERATIONS.

Under the influence of the various causes above enumerated, the peritonæum becomes at first the seat of a more or less decided capillary injection, at the situation of the abdominal walls, and at the inferior surface of the liver, in the case of umbilical phlebitis, or in the whither parts of the peritoneum near to the cause of its inflammation. Sometimes this redness is general, and exists alone without any other lesion of the peritonæum. False membranes, of a variable consistence and thickness, often accompany this tinting, and this effusion of plastic lymph serves to establish more or less numerous adhesions between the different intestinal folds. The peritoneum is, moreover, sticky and glutinous. It encloses a viscous sanguinolent or purulent serosity, in a quantity varying from one to seven ounces. At a later period these adhesions are more compact, more resisting, and, after the cure of the peritonitis, have the same appearance as that of other old serous inflammations, that of vascular filaments converted into cellular bands. Billard has observed this in two newly-born infants who were attacked with peritonitis in their mother's womb.

According to M. Thore, peritonitis often exists with pneumonia, sometimes with pleurisy without effusion, and with pericarditis; but these lesions are consecutive to the peritoneal inflammation.

SYMPTOMS.

The peritonitis of infants is usually observed in the acute, and very rarely in the chronic form. In both cases its symptoms are very obscure, and the diagnosis is often only established on the table of the amphitheatre, that is to say, after death. This is readily understood, for peritonitis is very often a secondary disease, and is developed as a consequence in the course of other diseases which mask its commencement by their proper symptoms.

When, however, the patients are narrowly watched, and when, on daily examination, the abdomen is felt, in order to appreciate its state of suppleness, it is discovered to be the seat of a very acute pain

on pressure, and to be greatly stretched and swollen; this is sufficient to give warning, and to lead us to search if there are not other phenomena of peritoneal inflammation. ́ Dugès and Thore have alluded to the considerable projection of the umbilicus in the infant, but this characteristic is no longer observed in the peritonitis developed a month after birth. The children often vomit, and are usually constipated. However, both these symptoms may be wanting, the skin is cold, the pulse small, frequent, often inappreciable. The face does not present the marked alteration similar to the modifications which the features of an adult, labouring under peritonitis, undergo. There is, however, a very apparent alteration of the respiratory movements which seems to indicate their obstruction and the pain which they cause. This characteristic appears to me to be one of great importance. The respiration is short, incomplete, and irregular; each inspiration, suddenly arrested, appears painful; occasionally a slow and deep respiratory movement takes place in order to make amends for the insufficiency of the preceding respirations.

To recapitulate: pulse small, frequent, often not to be felt; tension of Fr. the abdomen, projection of the umbilicus, pain of the abdomen on pressure; sometimes vomiting and constipation; decided change in

the external characteristics of the respiration, which becomes painful, ours short, incomplete, jerking, irregular; these are the most important symptoms of the acute peritonitis of young children.

Case 1. Acute peritonitis. Billard relates that Alexis Sonnecourt, fourteen days old, strong and vigorous, has had oedema for two days, has vomited all that has been given him, and has become very pale.

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The appearance is anxious, the child continually restless. The abdomen is swollen and forms a projection towards the navel; it is hard and very painful to C the touch, for as soon as pressure is exercised, the child utters a cry, becomes flushed, and breathes with the greatest difficulty. The chest is resonant throughout; the skin is dry and burning, the pulse cannot be felt at the wrist, and the pulsations of the heart under the stethoscope are deep and obscure; the cry is small, feeble, sharp, and scarcely to be heard; there is no alvine evacuation. Diet, sugared water, poultice to the abdomen; baths.

The child died three days after the commencement of the symptoms. On the examination the next day, the mouth, oesophagus, and stomach were observed to be healthy. The intestines were distended by a large quantity of gas; the peritonæum did not present any redness in the different points of its surface, but recent and yet rather firm adhesions existed between the intestinal convolutions and a rather thick pseudo-membranous layer on the mesentery, and about two ounces of a sero-purulent liquid were effused into the peritoneal cavity. The organs of bitte d circulation and the brain were healthy.

Case 2. Acute peritonitis. A boy, four months old, born of a mother infected with syphilis, having itself coryza and general syphilitic eczema, was admitted into the Necker Hospital.

This child was treated by topical applications, and it was nearly cured when it was seized with pulmonary catarrh with considerable dyspnoea, and a very peculiar

obstruction in the external movements of respiration. These movements were short, incomplete, jerking, and appeared painful; they regularly succeeded each other, and at the end of eight or ten inspirations, a slow and deep inspiration came on, capable of supplying the insufficiency of the preceding respirations. The abdomen was very tense and swollen; the skin very hot, the pulse very small and very frequent, 160 pulsations in the minute. There were no vomitings, and the stools were regular.

The child died; it had an acute peritonitis with sero-purulent effusion and false membranes on the intestines. There were several nuclei of lobular pneumonia. Case 3. Acute peritonitis. At the Necker Hospital, in a boy six weeks old, following one of those cases of erratic erysipelas so serious at this age, peritonitis appeared with swelling and pain of the abdomen; smallness and frequency of the pulse, 170 to 180 a minute; an obstruction to the respiration exactly similar to that just described, and there was in addition a plaintive groan very evident at each expiration.

There was neither nausea, vomiting, nor constipation. The face, although changed, did not present the sharp appearance observed in the peritonitis of adults.

The child died; there was a considerable serous effusion in the abdomen, some false membranes on the intestine, and a great number of these products on the superior and inferior surface of the liver.

Such are the symptoms of acute peritonitis; as to the symptoms of chronic peritonitis, they are very difficult to make out; indeed I have never met with it in young children, and there is only one case of it published. It is related by Billard. It is a case of chronic peritonitis consecutive to inflammation of the intestine which resembles al analogous cases well known at a more advanced age.

The swelling of the abdomen, diarrhoea, efforts to vomit, obstruction to the respiration, smallness of the pulse, marasmus, and feebleness of the cry, were the symptoms observed during life.

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The peritoneum was the seat of numerous adhesions and contained more than two ounces of a yellow and turbid serosity. The small intestine was injected, and in the colon numerous slaty streaks were observed, the traces of an old inflammation of this intestine. The acute peritonitis of young children usually makes very rapid progress and terminates fatally in twelve, twenty-four, or hours. It is the exception when it lasts a longer time. The prognosis of the peritonitis of infants is extremely unfavourable. In the town as in the hospital, nearly all the children die. Some however recover, as is proved by the fact that in some autopsies, bands are observed round the intestinal folds which are evidently the result of old inflammations of the peritoneum terminating in recovery. For my part, I am of opinion, that in these cases, these adhesions are the result of latent inflammation of the peritoneum developed around a deceased viscus, for I cannot believe in the cure of a true acute peritonitis of any intensity.

TREATMENT.

Notwithstanding the unfavourableness of the prognosis, the practitioner should not remain inactive in a case of acute peritonitis. It is a disease which must be treated as if we were sure of curing it, or at least in the hope of bringing about the recovery.

Lactation should be suspended, and nothing given to drink except gum water slightly opiated. One or two leeches should be applied on the abdomen around the umbilicus, the child should be put into baths of bran and marshmallow, and poultices applied on the walls

of the abdomen. If the child is so weak as to lead to hesitation about the application of leeches, they should be immediately replaced by a thick layer of mercurial ointment, or what is better still, by a Art Sod. large flying blister on the abdominal wall; it is even the best means to be employed. If the child does not pass any motion, a few grains of calomel may be given, or the syrup of chicory, or slightly purgative enemata. These means are not suitable when diarrhoea leads to the suspicion of the existence of enteritis.

ASCITES.

121

[Dr. Wolff (Analek über Kinderkrank; 1837) has met with above one hundred cases of dropsy in his own practice during six years; the children attacked with it were, in most instances, between the second and fifth year. It is usually ushered in by general indisposition with loss of appetite, and an irregular state of the bowels. The tongue is slightly furred, and the patient suffers from occasional pain in the abdomen, with some degree of fever and acceleration of IL & pulse. After the lapse of from five to fourteen days, during which it often

happens that drastic purgatives are given to the child under the supposition that 272

it is suffering from worms, the pains become constant, the febrile symptoms more strongly marked, the loss of appetite is complete, the abdomen grows tumid and on a careful examination yields a distinct sense of fluctuation. Among the symptoms of the disease Dr. Wolff attaches considerable importance to a peculiarZAAA tumidity about the root of the nose, and the value of this sign is confirmed by Professor Nasse. This form of abdominal dropsy does not reach so great a degree as is often attained by ascites in the adult, and it is never associated with oedema of the extremities. Hence its real nature may be overlooked. however, the disease be left to itself, the extremities of the child grow emaciated by degrees, till at length the skin hangs around them in folds; fluctuation becomes gradually more obscure without any diminution occurring in the size of the abdomen, the patient's strength fails, universal emaciation takes place; the bowelsh go are now purged, now constipated, irregular accessions of fever come on, and the.. little sufferer pines away into its grave.

If,

In the early stage, leeches are to be applied and small doses of calomel given;

as it assumes a more chronic form, calomel and digitalis, and digitalis and cream b of tartar are to be carefully administered.

Acute ascites: M. Trousseau (Gazette des Hôpitaux; No. 100) has recently called attention to a form of acute ascites in children, which, according to his experience, is by no means rare. In a case referred to, only four days before ea in the child was brought to the hospital, it was in complete health. After only