CASEOUS PERITONITIS If the organism is not strong enough to overcome the affection in the beginning, caseous peritonitis will develop from the exudative form. In other cases there is from the first only a minimai effusion or none at all, in which case the adhesive form will at once develop. In the latter case the affection is a particularly insidious one with initial vague digestive disturbances and chronic distention of the abdomen. In the first case the exudate will lose its character of a free effusion.
The abdomen is distended with gas and rather tense. On percus sion there are irregularly distributed circumscribed dull places, alter nating with tympanitic areas.
When there is a large exudate, the sound is often more tympanitic in the right abdominal half than in the left, which is explained by the fact that the tuberculously affected mesentery is contracted and the intestines are drawn over into the right abdominal half (Thomay-er's symptom).
A peculiar resistance of the abdomen is experienced on palpation. It is impossible for the palpating hand to make deep pressure except by overcoming a certain sensation of resistance. Susceptibility to pres sure may be entirely absent.
Often there is an elongated cord, susceptible to pressure, which runs above the umbilicus transversely or obliquely through the abdomen and emanates from the thickened omen tum; or there may be tumor-like masses of various sizes in the umbilical region, lying closely' at the abdominal wall; or, after the exudate has partly receded, tumor-like masses may appear in other parts of the abdomen which are simulated by adherent intestinal coils.
Lastly, it is a noteworthy fact that sometimes in the presence of a large, non suppurative exudate the skin around the umbilicus shows an indolent hypemmia which will disappear spontaneously.
Encapsulated suppurative exudates may perforate through the umbilicus as periumbilical phlegmons. (Fig. 73.) Abdominal pains and colic are hardly ever quite absent.
Fever is nearly always present in the course of caseous peritonitis, but it is quite irregular, and it may here be mentioned that afebrile periods may alternate with periods of hectic fever, the latter form of attack being more acute.
The character of the fecal evacuations varies, inclination to diarrlicea alternating with constipation. If intestinal tubercu losis is associated with peritonitis, obstinate diarrhma will usually be present. Discolored fatty stools are not infre quently observed, but are by no means characteristic in tuberculous peritonitis.
The indican content of the urine is not abnormally large, nor does the blood examination disclose anything noteworthy. An increase of lymphocytes cannot be observed, so that ascitic lymphocytosis appears to be but a local manifestation (Naegeli).
The development of the abdominal knots is accompanied by- an exacerbation of the general condition. There is anorexia, and the child becomes pale and considerably emaciated. There may also be phlyc tenular manifestations of the ocular conjunctiva and glandular swellings of the neck. Dry, pleurisy or an insidious pleuritic exudate may also occur and the lungs may show symptoms of tuberculous infection. The course is chiefly dependent upon the reactive power of the general organism. If there is tuberculosis in other organs, the course of the disease will be very unfavorably influenced.
If it takes an unfavorable course, it may end fatally owing to gradual exhaustion, or there may be an eruption of a general miliary tuberculosis. In other cases local complications may accelerate the unfavorable result; suppuration may collect and perforate into the intestine, or outwardly through the umbilicus, or through the diaphragm, causing septic pro cesses. Furthermore, there may be chronic or aeute manifestations of intestinal occlusion, kinking of agglutinated loops or compression of tumor masses.
If there be improvement and a cure, the fever will abate and gradu ally subside altogether. The exudate, the thickened walls, and the hard knots will gradually disappear. Progressive improvement may take place rapidly, but usually it is very- slow and gradual. A complete cure may be the result.