inflammation of the peritoneum which results from abdominal tuber culosis usually runs a subacute or chronic course. The disease is rarely acute ; but it is important to be aware that an acute form is occasionally met with, and is very difficult to detect. Tubercular peritonitis may be the only indication of the tubercular disease to be discovered in the body, or may be accompanied by signs of distress from other parts of the system. It is rarely seen in young children, perhaps never in infants, and does not begin to be a common affection before the seventh or eighth year of life. After that age, however, it is frequently met with. The earliest age at which the disease has come under my notice has been three years.
Norbid Anatonty.—On opening the abdomen in a case of tubercular peritonitis we find the bowels covered more or less completely with yellow ish, greenish, or gray coloured lymph. The consistence of this varies. It may be loose and soft in texture, or tough. Usually it is mixed up with thick cheesy matter. The lymph often lines the parietal peritoneum, and penetrates between the coils of intestine, which it glues firmly together. Sometimes the whole bowel is so matted together into a confused mass that it is quite impossible to follow out the course of the canal. More or less greenish or yellow purulent matter is held in the meshes of the exuded lymph, and more is seen to have gravitated to the deeper parts of the abdominal cavity. On clearing away the lymph from the surface of the peritoneum and contained organs, we find gray and yellow granulations studding the surface more or less thickly. With these are larger masses and even broad plates of cheesy matter, probably also tubercular in their nature. These are yellow or fawn coloured, and may be dotted with black points of pigment. Similar cheesy masses may be discovered lying in the adhesions formed by one organ with another—between the liver or the stomach and the diaphragm, and between the coils of intestine. The more chronic the case the larger and thicker are the caseous masses. When the case is acute, these are usually absent ; but the serous surface is covered with lymph in the substance of which are scattered gray and yellow granulations varying in size from a pin's head to a pea.
The larger tubercular cheesy masses may cause the intestinal wall to give way, perforated from without. Extravasation of the contents of the intestine rarely takes place into the peritoneal cavity, owing to the existence of the firm adheSions ; but in this way a new and unnatural communication may be formed either between two different parts of the intestinal tube, as was noticed by Messrs. Millet and Barthez, or between the bowel and the umbilicus, as happened in a case recorded by Henoch.
In the most chronic cases the adhesions may be very tough and fibrous, and even the lymph on the peritoneal. surface may resemble connective tissue. The omentum, itself unusually firm in its texture, may be ad herent to the abdominal wall ; and the mesentery may be tough and con tracted.
Tubercular peritonitis is not always general. Sometimes it is partial, and is then usually confined to the upper parts of the abdominal cavity— the neighbourhood of the diaphragm, the liver, and the spleen. The liver itself is often enlarged from amyloid or fatty change, and has been found by some observers to be cirrhotic. The bowels are often the seat of tuber cular ulceration, and the mesenteric glands are enlarged and cheesy.
Besides the peritoneum, tubercle is often found in other organs. In the more chronic cases it may be limited to the abdomen ; but in the acute form the abdominal disease is almost invariably a part of a general development of tubercle over the body.
Symptoms.—Tubercular peritonitis always begins insidiously, and its symptoms may be far from being well marked. In some cases attention is diverted from the belly by the more striking phenomena arising from tubercle, and the consequences it involves, in other organs ; but even if the tubercular granulations are limited to the abdomen, the early symp toms are often curiously insignificant when we consider the serious nature of the disease. In these cases of local tuberculosis the general nutrition may be good at first, and the appearance of the patient fairly robust ; but as the illness progresses the child rapidly loses flesh, colour, and strength, and before death occurs may reach an extreme degree of emaciation.