Of these signs the most characteristic are : The enlargement of the belly, with its smooth, shining surface ; the tenderness, the unequal resist ance at different parts of the abdominal parietes, and the indistinct fluc tuation. In some cases, however, many of these symptoms may be absent. The tenderness may be insignificant and the parietes perfectly flaccid ; fluctuation may be completely absent ; and nowhere may any sense of resistance be experienced by the hand pressing the abdomen. Thus, in a little boy of four years old, after three weeks of illness it was noted : " Abdomen large and smooth, with loss of natural markings ; superficial veins of chest and epigastrium dilated ; abdominal wall perfectly flaccid ; no fluctuation to be detected ; edge of liver felt one finger's-breadth below the ribs ; edge of spleen not felt ; several lumps about the size of a walnut can be perceived in different parts of the abdomen, but not very deeply placed. One of them is immediately below the edge of the liver. They seem tender on pressure, but there is no general tenderness of the belly. Chest healthy. Tongue dry and glazed-looking." The temperature that evening was 98.6°. The child died about a week after this note, of ary tubercular meningitis. If, in such a case, the liver be much enlarged from fatty infiltration, a very incorrect opinion is likely to be formed of the nature of the illness.
As the disease progresses, the skin often gets very harsh and rough. The child looks haggard and distressed ; he rapidly wastes, and his temples and cheeks grow hollow. He lies on his back, or turned partly on to his side, with his knees drawn up, and every movement is painful. The tongue is dry, and is either thickly furred or is clean and shining, as if de nuded of epithelium. The appetite is lost ; the thirst is great, and the bowels are generallfrelaxecl. Often, the .motions consist of dark, watery, offensive matter, with a flaky deposit containing black clots of blood. Such a stool is very characteristic of ulceration of the bowels. Instead of diar rhoea, there may be constipation which may prove obstinate. Fatal ob struction, even, may ensue. Sometimes at this period the distention of the abdomen becomes very great, and the child is tormented with spasms of colicky pain. In other cases, the size of the belly diminishes, and hard, tender lumps are felt, apparently in firm contact with the under surface of the abdominal parietes. The temperature, which before was variable and often little raised above the normal level, now becomes higher, and in the evening may reach to between 103° and 104°. The emaciation of the child is great, and his weakness extreme.
When the disease reaches this stage, improvement rarely takes place ; but at an earlier period of the illness it is not uncommon for the malady to take a favourable turn. The tenderness and tension of the belly then
diminish and disappear ; the appetite returns ; the diarrhoea ceases ; the nutrition of the child improves, and he begins to regain flesh. The fa vourable change may go on in fortunate cases to complete recovery, and although the belly for a long time remains large, there is no return of the serious symptoms. Often, however, after a longer or shorter interval, the child begins to fail once more ; inflammation is lighted up again in his peritoneum, and this time the illness goes on uninterruptedly to the end.
In some cases, the course of the disease is very variable, and is broken by occasional periods of remission in which hopes of amendment are raised only to be disappointed by an early return of the worst symptoms. Often, the end of the disease is preceded by purpuric spots on the body, and by cedema of the legs, with no albumen, or with only a trace of it, in the urine. Death may be hastened by tubercular disease of other organs, especially of the lungs, and sometimes, as in the case referred to, the pa tient dies with all the symptoms of tubercular meningitis. In rare cases, perforation of the bowel takes place, or an abscess forms at the umbilicus or some other part of the abdominal wall.
This chronic or sub-acute form of the disease is always slow in its course, and usually lasts several months. It is the form the disease as sumes in the large majority of cases. Occasionally, however, the periton itis is acute. In all the cases of acute tubercular peritonitis which have come under my notice, the abdominal disease has formed part of a general tuberculosis. The child complains of pain in the belly, but an exam ination of the abdomen gives entirely negative signs. There is no ten derness of the parietes, or pseudo-fluctuation ; no caseous lumps can be felt ; and the belly, although full, may not exhibit any remarkable swell ing. The child looks ill, and is languid ; his appetite is poor, and his evening temperature is higher than natural. Often, his bowels are relaxed. These symptoms, as in all forms of acute tuberculosis, succeed to a period more or less prolonged, of general but indefinite malaise. After an illness lasting a few days or a week or two, the child dies, with or without the symptoms of meningitis. After death, his bowels are found matted to gether with recent lymph ; there is, perhaps, a little thin purulent fluid in the peritoneal cavity, and the signs of general tuberculosis are cliscoveref over the body. In most cases, the existence of the peritonitis is only re vealed by post-mortem examination.