The diagnosis of caseous peritonitis is, generally speaking, not likely to cause many difficulties. The multiple, fixed, or less often movable abdominal knots should be demonstrated by palpation; these and the thickened omentum are very characteristic.
Sarcoma and lymphosarcoma are rare, but have to be taken into consideration. Carcinoma need hardly be considered. Its origin, the febrile conditions, the demonstration of possible tuberculosis in other organs and the tuberculin reaction, will usually afford a sufficient basis for the diagnosis.
Tuberculous effusions may be taken for abdominal cysts (ovarian, omental and mesenterial cysts).
In connection with caseous peritonitis another form of localized peritonitis should be mentioned which is prone to occur between the age of twelve and fifteen years. It is periceeal tuberculous peritonitis, which has an acute onset under the picture of appendicitis.
The violent attacks, the severe pains in the ileocecal region, accom panied by vomiting and fever, quite coincide with the sympt OITIS of acute appendicitis.
The disease may take an entirely acute course, leading to death with in a few days, or it may pass into the chronic state.
In the treatment of tuberculous ascites, *operative interference occupies the foreground. Opinions as to indications still vary consider ably among internal practitioners, pediatrists and surgeons. While Heubner, for instance, regards laparotomy as indicated in every form of ascites, the Norwegian surgeon, Borchgrevink, advocates the opposite extreme, saying that operation will only do harm.
There is no doubt that tuberculous peritonitis may undergo spon taneous cure, particularly so in children, and the tendency toward such a cure is distinctly marked at the age in which it occurs most frequently, about the fifth year and onward. (Fig. 75.) Serous peritonitis should be regarded as a local affection and may be compared to serous pleuritis or eireumstribed lympharlenitis. In the first year of life, however, tuberculosis generally attacks other organs and the child succumbs to general tuberculosis.
Considering now that every operative interference, including the necessary antesthesia and after-treatment, involves some temporary weakening of the organism, it should not be resorted to unnecessarily.
On the other hand, there is equally little doubt that many cases of tuberculous ascites which were not benefited by medical treatment or suffered relapses, have rapidly and permanently been cured by lapa rotorny.
On the ground of this experience I cannot agree with either Heubner or Borchgrevink: the indications for the opening of the abdomen should be separately- considered in each ease.
If a patient can be removed to favorable environments, and if the effusion is not a particularly large one, conservative treatment should be tried first and operation only resorted to if the effusion, in spite of hygienic anti medicinal treatment, does not permanently recede.
If, however, it should not be feasible to remove the patient to fa vorable surroundings, I would, in accordance with Heubner, advise laparotomy without compunction, because the chances of a rapid cure are thereby increased.
My methods of procedure have become more conservative in the first class of cases, and more radical in the second.
Comparative statistical figures showing results of operative and internal treatment have no value, as long as the external conditions under which patients are treated are different, and I therefore abstain from giving them.
According to my experience, the opening of the abdominal cavity is distinctly advisable if, aside from free ascites, there are hard tuber culous masses and knots. After evacuation of the exudate, tumefaction often rapidly recedes. The tumors themselves should, as a general rule, never be touched.
On the other band, and contrary to Faludi, I do not advise opening of the abdominal cavity in dry peritonitis, the results I have seen there from _being unsatisfactory, owing to fecal fistufir, which easily form in spite of good healing of the wound as long as there are obstacles in the way of free passage.
The most plausible theory which has been brought forward to ex plain the effect of laparotomy is in my opinion the assumption that the.