THE LANCET, JANUARY 1, 1881.

more or less tympanites, sometimes associated with a little ascites. The tympanites usually remains moderate, but in Clinical Lecture some children it becomes excessive, so much so as to cause permanent dyspnoea. The ascites of the onset is small in TUBERCULAR PERITONITIS IN CHILDREN. quantity, and mostly goes away in a few weeks. After- wards the indurations which I spoke of begin to appear. Delivered at St. Bartholomew’s Hospital, Nov. 5th, 1880, 2. The onset is sometimes sudden, and attended by very great tympanites. The tympanites is sometimes the only BY SAMUEL GEE, M.D., F.R.C.P. LOND., abdominal symptom. Sometimes it is associated with PHYSICIAN TO THE HOSPITAL. vomiting. And sometimes there are also all the signs of acute gastro-enteritis. In my lecture on tympanites last are three kinds of tubercular abdo- session I narrated a case of this kind-a child suddenly GENTLEMEN,—There attacked infantile violent minal disease occurring in children: chronic peritonitis, by cholera; vomiting and purging, with collapse, algidity, and tympanites. This was the be- decay of the mesenteric glands, and ulceration of the in- ginning of chronic tubercular peritonitis. testines. These diseases are sometimes associated in dif- III. COURSE OF THE DISEASE. ferent ways, sometimes they happen each alone by itself. the chronic will most They constitute a condition which the common people call Suppose peritonitis established, you " be able to detect one or other of the of the bowels," this term also likely pathognomonic consumption although which I at the I will now includes the chronic enteritis which is not tubercular. signs spoke of beginning. speak of the symptoms which are attendant upon the confirmed My topic to-day is tubercular peritonitis, or, what in the disease. Emaciation from the first ; appetite bad ; vomiting case of children is almost the same thing, chronic peritonitis. now and then. Action of the bowels uncertain. Diarrloea, occasional or even more continual, is no proof by itself of I. PATHOGNOMONIC SIGNS. the co-existence of intestinal ulceration. Constipation is They are discovered by physical examination of the common, and it goes on in a few uncommon cases to abso- abdomen, and are of two kinds : indurations and suppura- lute obstruction of the bowels. This obstruction is either tions. temporary, giving way at length to the remedies employed, 1. Indurations are detected by palpation. They have the or it is permanent, and causes the death of the patient. form of bands and patches, or of lumps and knots. They The latter course is well illustrated by a case published by certainly are present in most cases at some period or other Dr. Wolston in the 10th vol. of the Clinical Society’s Trans- of the disease. They begin to appear within a few weeks of actions. Obstruction of the bowels, although it may have the onset of the illness. They are more or less obscured by been relieved, is apt to recur. Pain in the belly is some- co-existing tympanites ; and for this, or some other reason, times severe, and is sometimes felt on heavy pressure only. they are not felt equally well at all times in the same The movements of the bowels are sometimes visible, whether patient. When the abdomen is very tender or resisting, I there be much tympanites or not. Fever is present at first, usually administer chloroform to the child before proceeding but is seldom high; it often ceases altogether after a week to the examination ; and I strongly advise you to do the. or two; sometimes a low degree of fever is constant through- same thing in a doubtful case. The bands which I spoke offout the whole course of the disease. So that, at the time are commonly transverse, stretching right across the belly, you see your patient, it may happen that there are no fever or confined to one side of it. They are felt above the navel, or other symptoms of disease, except the emaciation and the on a level with the navel, or below it-for instance, parallel. abdominal signs already spoken of. to Poupart’s are sometimes ligament. They remarkably IV. TERMINATION OF THE DISEASE. hard. They are mostly about the breadth of the finger, orr rather more. The patches of induration, like the bands, 1. Recovery from tubercular peritonitis is common. In may be met with anywhere ; in a boy, now in the hospital,, the course of months, or a year or two, the tympanites disap- they are felt in the hypogastrium. The lumps and knots! pears, and the indurations cease to be palpable. The patient are sometimes very numerous, sometimes there are only one! is left pale and weak, and may continue so for the rest of or two. Their size is very different, they often feel like nutsslife. On the other hand, he may regain his original state of or pips. They differ very much in situation ; there is nohealth. The most positive proof of recovery from tubercular rule in these matters. The distinction (not always possible)I peritonitis is afforded by Mr. Spencer Wells’ case, in which between peritoneal and glandular lumps is to be found inL the ascites of that disease resembled an ovarian cyst. the fact that the former are as a rule more superficial, lessabdominal section was performed ; the peritoneum was seen deeply seated than the latter. to swarm with tubercles ; the intestines, for the most part, 2. Suappuration.-Discharge of pus from the navel, due to) were adherent together. Acute peritonitis followed the a local peritoneal abscess, is likewise characteristic. Some-- operation, but the patient recovered, and six years after- more an times there is nothing than appearance of pointing,, wards she was stout, hearty, and well. which afterwards subsides, and never goes on to discharge.. 2. Death from tubercular peritonitis occurs in several ways. The navel looks red and swollen, not merely protruded, butt A slow exhaustion is common, especially when other forms its tissues swollen,. This sign I believe to be no less cha-- of tubercular disease come to complicate the case. Increas- racteristic. The pus is sometimes mixed with fseces. Thiss ing and.great ascites may be the cause of death. You re- a of a is condition which indicates ulceration the intestine,, member girl who died in Mary ward after paracentesis for and is a very much more dangerous affair than the discharge3 ascites ? In her, tubercular peritonitis was associated with of pus alone. highly-marked cirrhosis of the liver, and this is a combina- Physical examination will also discover signs of either orr tion of lesions which I have seen before. Obstruction of both of two other abdominal lesions in most cases of tuber-- the bowels is an uncommon cause of death. cular peritonitis. Tympanites to a less or greater degree iss When suppuration has occurred there is an additional a symptom almost always present at some period or other off danger. Mere pointing sometimes goes away without any the disease. Ascites is less common. In one case of thiss manifest discharge of pus from the navel or any other part. kind a diagnosis was made possible by the co-existence off When actual discharge of pus from the navel has occurred phlegmonous scrofulides on the leg, otherwise there wass recovery is still possible. But when there are signs of a nothing but ascites. fistulous opening into the bowel the case is hopeless, as I II. ONSET OF THE DISEASE. said before. V. THERAPEUTICS. Tubercular peritonitis is usually idiopathic, that is to say, it constitutes the disease in and by itself. This is the only’ The first thing to mind, in the treatment of tubercular is to the abdomen at rest. This can be done case which I consider on the present occasion. I pass by peritonitis, keep the chronic peritonitis which is secondary to manifestt;t only by keeping the patient in bed. I have known a boy, who was whilst he was in a tubercular disease of the lungs, intestines, or other parts. slowly recovering bed, undergo 1. The onset of protopathic tubercular peritonitis is mostlyfatal relapse of his disease by being taken up and dressed The becomes tender, and attagainst orders. gmdual. belly painful, large Another - of the treatment a flannel the same time the health of the child fails; there are emacia- part consists in putting loss of and in cases fever. At the 1 tion, appetite, many slight Quoted by Dr. Fagge, Guy’s Hospital Reports, third series, vol. sx., beginning examination of the abdomen discovers nothing but ,J p. 203. 1BJ No."00’) 2992. A 2

bandage round the belly, so as to reach from the hips to the vhich we apply ourselves at the hospital, we give the ribs. Much pain in the abdomen is alleviated by hot and patients weaker solutions to use at home as lotions. The moist fomentations, as hot as the patient can bear ; linseed atropia lotion which we give is of the strength of one grain meal poultices, flannel fomentations, or, what is usually ;o eight ounces. We never give a nitrate of silver lotion. best, a flannel bag full of bran or camomile flowers, which IV, e give a weak solution of some other irritant, such as the can be heated in hot water or an oven as often as needful. bichloride of mercury of the strength of one grain to eight You may sprinkle the fomentation with laudanum ; or you ounces, or alum, sixteen grains to eight ounces. The reason may smear the abdomen with a liniment composed of equal we do not entrust the patient with a nitrate of silver solu- parts of extract of belladonna and glycerine. tion is that when its use is injudiciously prolonged, as I need not say much about the necessity of allowing none it is liable to be under the circumstances, the con- but the most easily-digestible kinds of food ; in short, to junctiva becomes dyed by it of a dirty-olive hue. feed the patient very much as you would feed a baby. Though you will see the nitrate of silver or other Cod-liver oil, if it can be taken, is sure to do good. irritating solution dropped into the eye in cases of inflamma- For the ascites you may try copaiba resin cautiously, be- tion of the conjunctiva, you will never see it dropped into ginning with three or four grains, made into an emulsion, the eye in cases of iritis or other internal inflammations of with an equal quantity of compound tragacanth or almond the eyeball, for in such cases irritating collyria do more ill powder, and some water. If this mixture disagree with the than good. In cases of iritis you will see the solution of stomach you must discontinue it. the sulphate of atropia dropped into the eye, not, however, When suppuration has set in the proper treatment is assi- with the expectation of subduing the inflammation of the duous poulticing. iris, such as we have of subduing the inflammation of the conjunctiva when we drop the nitrate of silver solution into the eye in a case of catarrhal conjunctivitis. The principal object we have in view, when we drop the atropia solution Introductory Lecture into the eye in a case of iritis, is to counteract, as far as ON THE possible, the strong tendency which the pupil has, in the OF THE DISEASES course of that inflammation, to become contracted. CLINICAL STUDY But how are we to distinguish between conjunctivitis and OF THE EYE. iritis, you may perhaps desire to ask, in order to know when to drop in the nitrate of silver solution and when to abstain, Delivered at University College Hospital on Thursday, but to drop in the atropia solution ? My answer to such a October 7th, 1880, question would be in the words with which I commenced this lecture, viz. :—" If take the to examine for BY WHARTON you pains JONES, F.R.C.S., F.R.S., yourselves the cases which come under treatment in the PROFESSOR OF OPHTHALMIC MEDICINE AND SURGERY IN UNIVERSITY department of the hospital and watch their AND OPHTHALMIC SURGEON TO THE HOSPITAL. ophthalmic COLLEGE, progress, you will soon learn to recognise the principal forms of disease and the remedies employed for them." take the to examine for eye GENTLEMEN,-If you pains your- If you will but study clinically the nature and treatment of selves the cases which come under treatment in the Oph- the purulent ophthalmia of new-born infants, catarrhal con- thalmic Department of the hospital, and watch their progress, junctivitis, scrofulous ophthalmia, and iritis, you will find in the of these forms of you will soon learn to recognise the principal forms of eye knowledge you thereby acquire eye disease a on which at leisure success- disease and the remedies for them. The of foundation you may employed study fully erect the superstructure of whatever else the exigencies the diseases of the the observation of cases eye by practical of practice may render it necessary for you to know respect- is comparatively an easy task, soon comes to be interesting, ing ophthalmic medicine and surgery. and is sure to prove successful. But without the aid of such At the Eye Infirmary you will have the opportunity of on But let means of study, the attempt to become acquainted with the seeing performed the various operations the eye. me observe that it is of that nature and treatment of eye diseases is and laborious, though great importance you painful should witness the operations, it is also of great importance and in the end unsuccessful. what I now be an May say to watch the progress of the case after the operation; encouragement and inducement to you to bestow some atten- forand youof equally great importance, moreover, it is to have tion to the clinical study of the diseases of the eye, while examined the case before operation, and made yourselves you have the opportunity of frequenting the ophthalmic acquainted with its pathology and the reasons for operating, now and then themselves with department of the hospital. If, however, you do not accept Every patients present injury of the eye of various degrees of ranging from the it as hint sufficient to incline to do let what I am severity, you so, case in which there is merely complaint that something has be as a going to say taken warning against the neglect of it. got into the eye to cases in which there is an actual wound, You are not likely to be long engaged in practice before even smash of the eyeball. In the case in which something meeting with a case of the purulent ophthalmia of new-born is in the eye, the foreign particle you will usually see dis- infants. Now, this disease, if seen in time and properly covered adhering to or embedded in the cornea; and if not treated, may, in the large majority of cases, be completely there, you will most probably see it discovered on everting cured ; whereas, if it is not properly treated, it is liable to the upper eyelid adhering to the palpebral conjunctiva. In run on to the damage of the cornea, if not destruction of that a case in which there is a wound or smash of the it ’ eyeball, important part of the eye, with irremediable blindness. may be that you will see us cut out the whole damaged The proper treatment is simple; nothing, indeed, more organ at once. One principal reason for performing this simple. But picture to yourselves the position of a young operation of enucleating the eyeball is to guard the other practitioner who helplessly witnesses the eyes of his infant eyeball as far as possible from the risk of becoming affected patient running on to destruction, and remembers that he with destructive sympathetic ophthalmitis, to which there is- - never took the trouble when a student of the hospital to a great liability under the circumstances. prepare himself for such an emergency by lending a hand By even a short attendance at the Eye Infirmary the vari- in the manipulations necessary in the treatment of cases of ous points I have now touched on will become familiar in ophthalmia neonatorum. your mouths as household words, so that you will be able You will observe that the diagnosis is obvious, and that, to understand what I may have to say more in detail in. as regards treatment, it depends merely on the practical tact subsequent clinical lectures. Until a few years ago crowds you can bring to bear in the application of the local remedies of ear patients used to invade the ophthalmic department whether you shall be successful or unsuccessful in curing of the hospital. In commiseration I did not turn them your case. away, though they necessarily cost me much additional Of the liquids which you will see dropped into the eyes labour. Of late, however, Mr. Barker has undertaken the of our patients, a solution of the nitrate of silver and atask of looking after such cases. But the truth is, we solution of the sulphate of atropia are those in most commoncannot altogether exclude cases of disease of the ear from use. The nitrate of silver solution-five or ten grains to the our attention at the Eye Infirmary, even if we would, be- ounce-is one of the most efficacious applications in inflam- cause ophthalmic patients are often found to be at the same mations of the conjunctiva, though, let me remark, it is’nottime labouring under some affection of the ears-for ex- the sole remedy at our command, for other irritating sub- ample, in children with scrofulous ophthalmia there is often stances do nearly, if not quite, as well. Besides the drops, chronic inflammation of the membrana tympani, with dis-