CIIRONIC TUBERCULOUS ASCITES This disease often attacks children that are apparently healthy. An insidious onset is by no means the rule. More frequently, vague abdominal pains, with moderate fever, nausea, and vomiting, usher in the disease. Marfan has drawn our attention to the frequency of pleu ritic friction at the base of the lungs, associated sometimes with exuda tion into the pleura. These symptoms soon vanish, and a considerable free exudate accumulates in the abdomen, which may be the only sign of the disease for weeks or et-en months. Since the initial symptoms last only a short time, and are not very severe, the physician usually first observes the cases after the marked distention of the abdomen has attracted the attention of the child's caretakers, when the exudate has reached considerable dimensions.
The general health is not seriously affected. Wasting, which is so marked in the later stages of the disease, in contrast to the distended abdomen, is slight or absent; and the investigxtion of the other organs shows no signs of tuberculous disease. The exudate may remain sta tionary for months together, or at times disappear, only- to reappear again. When it is 011 the increase, nausea and vomiting, with slight. febrile disturbances, show the reaction of the organism. The evacua tions are at times somewhat loose and diarrhccal; sometimes clay colored. Again, they may be constipated. The appetite is variable. The exudation may entirely and permanently disappear, as well as all signs of illness; and the health be completely- restored. In other eases, tuberculosis develops subsequently in some other part of the body.
I found, in a child that had been operated upon for intestinal occlu sion due to a traumatic hoematoma of the intestinal wall, unsuspected tuberculous nodes on the peritoneum. \\lien I saw this patient again, many years later, I learned that there had been no further symptoms of abdominal tuberculosis. On the other hand, she then sufTered with tuberculous spondylitis.
The physical signs are those of every free fluid exudate in the abdomen. The exudate may be so large that the abdominal wall becomes
tense and the navel protrudes. The demonstration of any considerable amount of ascites offers no difficulties, but it may be more difficult to determine the primary causal factor in the disease. Besides tuberculous peritonitis, we must consider as possible causes of the aseites, general circulatory disturbances due to heart dis ease, Bright's disease, cirrhosis of the liver, abdominal tumors, general cachexia, and chronic serous peritonitis.
Aseites of cardiac origin is associated with other signs of passive congestion; also aseites flue to nephritis. The differen tiation from atrophic cirrhosis of the liver may, now and then, offer a difficulty; but the cirr hoses are comparatively seldom encountered in childhood, and the diminution in the size of the liver can be demonstrated objec tively after abdominal puncture.
In doubtful cases, the investigation of the exudate may aid the diagnosis. A large number of lymphocytes always speaks in favor of ft tuberculous process.
Abdominal tumors must be considered in making our diagnosis, when nodular tumors are present in addition to the exudate. The mode of development of the disease and the consideration of the symp toms as a whole will help us to decide. In addition, the character of the exudate must be determined by bacteriological and cytological examination.
Chronic Exudative (IV ontubereuloas) Peritonitis is certainly a very rare disease. Not a single ease has been confirmed by autopsy. Still, we cannot deny that there occur at the time of puberty cases that have only a small abdominal exudate and can hardly be considered tuber culous (Quincke). Possibly they depend on functional disturbances of the heart and alterations in the composition of the blood. Explora tory puncture, injections of tuberculin, and inoculation experiments in the laboratory will throw light on the case. In general, the practi tioner should consider all cases of chronic peritonitis with exudate for which no definite cause can be found as most probably tuberculous.