Caseous peritonitis may develop from the exudative type, if the organism has not the power to overcome the disease in the beginning. Afore exceptionally, there is no demonstrable fluid in the peritoneal cavity at any time in the disease. We can no longer demonstrate the presence of movable fluid; and the areas of percussion dulness are little, if any, changed by alterations in the position of the patients. The abdom inal walls lose their elasticity and give to the palpating fingers a sense of doughy-resistance of irregular distribution. We can often feel an elongated tumor, painful on pressure, which runs above the navel, straight or transversely across the abdomen, and consists of thickened omentum; or we feel, in the neighborhood of the umbilicus, tumor like masses of varying size, close to the abdominal wall. When the exudate has to a great extent been reabsorbed, we find in other parts of the abdomen tumor-like formations clue to adhesions of the intestinal coils. The general appearance of the patients has changed for the worse; and their pallor and emaciation have become marked, the results of the continued fever that is usually associated with the development of cheesy changes in the tubercles.
Abdominal pain is rarely absent, but varies in intensity. Sensi bility to pressure is usually present, but may be scarcely noticeable. Fever is present in all cases at some period, but varies according to the course of the disease. Constipation alternates with diarrhma.
Thomayer's symptom may be of diagnostic importance; namely, the finding of dulness on percussion of the left side of the abdomen, with a tympanitic note on the right side. I have found these conditions present on several occasions.
I must also mention a physical sign associated chiefly with large exudations; namely, indolent and transitory reddening of the skin above the umbilicus. The sign may also be found when pus is present. Localized, encapsulated abscesses may perforate through the umbilicus (periumbilical phlegmon).
When improvement sets in, the fever disappears or lessens, and the exudation nodes and thickenings of the peritoneum become less and less. Sometimes rather quickly, but more commonly gradually and slowly, improvement sets in; and convalescence is followed by complete cure. Should the disease take an unfavorable turn, death may follow through gradual exhaustion; or as the result of intestinal perforation (suppurative peritonitis), or from intestinal occlusion (formation of bands or shutting off of adherent loops of intestine).
When nodular tumors are present, differential diagnosis from sarcomatous and lymphosarcomatous new growths may offer some difficulties. The demonstration of tuberculosis in other organs may
furnish a clue, or we may give tuberculin injections.
The paths by which injection reaches the peritoneum are by no means always evident, but vary much in individual cases. In the first place, we are inclined to consider the intestine as a likely port of entry. Con sidering the infrequency of diffuse tuberculous peritonitis, in spite of the existence of extensive tuberculous ulcers in the intestine, such an assumption is hardly justified in the majority of cases. Peritonitis may proceed from the lymph-nodes of the mesentery, the retroperitoneal, and the inguinal lymph-nodes (coxitiO ; but usually remains circumscribed.
The female genitalia assume considerable importance in the etiology of this disease, and their examination must not be overlooked. I recently saw, at the autopsy of a two and a half year old child that had suffered from caseous peritonitis and died of miliary tuberculosis, advanced tuberculous disease of the tubes, and found the corpus uteri trans formed into a cheesy mass. Brfining has reported two similar cases, and Borehgrevink found four children under twelve years of age among ten patients affected with tuberculosis of the Fallopian tubes. In other cases, peritonitis is only a part of a general tuberculous " poly serositis." Peritonitis seldom occurs in connection with tuberculosis of the lungs. In quite a few cases we cannot discover the mode of infection. As yet, we are not in a position to decide whether we are justified in assuming for these cases hamatogenous infection.
The prognosis of tuberculous peritonitis used to be considered unfavorable. This is by no means our present standpoint, when every year brings reports of recoveries and marked improvement in these cases, with or without operation. Naturally the prognosis depends on the extent of tuberculous involvement of the other organs. In childhood, peritonitis constitutes apparently the primary disease in a comparatively large number of cases.
Treatment. —The great question in the therapeutics of tuberculous peritonitis is, Shall we operate or limit ourselves to medical treatment? Whereas, a few years ago, the results of abdominal section were lauded to the skies; nowadays, the views, even of many surgeons, have changed. The Norwegian surgeon, Borchgrevink, has even made the statement that operative interference never helps, and only does harm. This change of view has come about from our observation of the frequency with which peritonitis (both the ascitic and the dry form) heals without operation. Our task must, then, be to place the patients in the most favorable conditions for recovery.