TUBERCULOUS PERITONITIS Tuberculosis of the abdominal peritoneum, with a few exceptions, runs a chronic course. However, we have recently been reminded that tuberculous peritonitis may- begin under the guise of acute perityphlitis (appendicitis). Such cases have also been described in children.
The view has long been held that the great majority of chronic inflammations of the peritonetun are of tuberculous nature. As early as 1850, Aran declared in his clinic that, one would find tubercles in the peritoneal cavity in most cases of chronic peritonitis. It was not until the tubercle bacillus was discovered and until after Honig, in 1884, had introduced laparotomy in the treatment of tuberculous peritonitis, that it beeame possible to determine definitely the etiology and course of this disease, as well as to differentiate it from other diseases of the peritoneum. Even to-day, we have not reached complete accord; especially con cerning the existence of a nontubcreulaus chronic serous peritonitis.
Tuberculosis of the peritoneum occurs comparatively often in child hood, and deserves special mention from the pathological standpoint.
Laparotomies on patients that have suffered for only a compara tively short time with serous exudation in the abdominal cavity have enabled us to study the early stage of tubercle development in the peritoneum. In these cases, we find the same crop of minute tubercle nodes that we find oecasionallv in acute miliarv tuberculosis; the serous coat shows almost no change. The tuberculous process may remain stationary or may completely retrograde, with disappearance of the tubercles, leaving the serosa uniformly smooth ancl shining.
In a more advanced stage, conditions are essentially altered. The tubercles become larger and caseated centrally, and the serous coat is thickened as the result of the reactive inflammation. The ordinary anatomical form of tuberculous peritonitis gradually develops, with pseudomembranous formation and with adhesions between the abdominal viscera and the peritoneum. The plastic fibrinous exudation leads to adhesions, and the tubercles become confluent and form larger cheesy nodes. Around these easeous foci, we always find a crop of gray miliary tubercles, partly caseated centrally. The onientum usually show-s marked evidences of tuberculous disease. The tubercles become con fluent, forming very large nodes. Adhesions are formed with the coat of the intestines and of the abdominal wall, giving rise to the well-known tumor-like band, which runs transversely or directly across the navel gateau abdominal.).
The exudate may never be large, but sekioni fails completely. Out of forty-two cases, Borehgrevink found not a single one without some exudation. Strictly speaking, dry, fibrinous peritonitis nuist be exceptional. The exudate is usually clear and thin; at times, greenish and turbid, front the admixture of fibrin-flakes.
thrmorrhagie peritonitis is rare, especially in childhood. Bacilli are not plentiful in the exudate. Encapsulation usually results after the disease has existed for some time, with the formation of intestinal adhesions. Even in this stage. the process may undergo retrograde changes. The granulation-tissue undergoes fibrous transformation; cheesy deposits that are not absorbed may be encapsulated in the connective tissue. We then find peritoneal thickening and adhesions as the sole residue of the tuberculous process, which has run its course. The very marked tendency of peritoneal tuberculosis to get well has been espeeiallv emphasized bv the investigation,: of Borchgrevink.
Infection of the exudate, especially from the intestines, may give rise to suppurative, walled-off abscesses, which may make their way through t'ne abdominal wall (especially the umbilicus) or may involve the contiguous organs. Exceptionally, they may heal without perforation or operation. In the abdominal organs, we see a diffuse crop of gray or cheesy tubercles. The intestines are rarely affected; exceptionally, fistulas follow perforation of a suppurative focus in the intestines. In childhood, tuberculous ulcers of the intestines, which might be con sidered the starting-point of tuberculous peritonitis, are decidedly rare. Perforation of the bladder-wall rarely oceurs. An extensive cheesy tuberculosis of the tubes, and also of the body of the uterus is by no means rare in girls, analogous to the conditions in the adult.
Symptomatology. --The French authors have differentiated several varieties of this disease. From the pathological and clinical standpoint, T shall attempt to differentiate only the conunon types of the disease and that known as chronic serous peritonitis. Chronic aseites is very fre quently the earliest and the most important sign of tuberculosis of the peritoneum in childhood, and gives us a well-defined type of the disease.