Tuberculosis of the serous membranes within the body is an insidious disease, occurring usually secondary to local tubercular conditions elsewhere in the system. It is commonly believed that the condition occurs as a primary infection, but, if so, such an occurrence is rare. It may occur as an acute sero-fibrinous manifestation, or it may occur as the result of general tubercular infection in the form of an acute miliary serositis. These two conditions may occur coincidently or separately, or the disease may develop slowly in a strictly chronic form. The latter form occurs usually from infection of the serous membrane from some tuberculous organ adjacent, in which the process of development has been slow.
This condition may occur both in an acute and in a chronic form. In the acute form the initial symptoms are in every way similar to those of acute pleurisy, or to an attack of acute lobar pneumonia, in which the pleura is involved.
There is a chill, which may be quite severe, but the temperature does not reach a high point, but will be irregular and perhaps hectic in character. The sharp acute pain occurs among the first indications, and there is painful inspiration, a catching of the breath with rapid breathing, irregular and shallow, and a short hacking, very painful cough. Effusion also occurs early and is serous, serofibrinous or seropurulent in character. The effusion rarely contains the bacillus. This must be taken from the pleural membrane direct:
In the chronic form of this disease, which occurs more frequently than the acute form, the invasion is insidious and may be overlooked until fully developed. It is evident that the visceral layer of the pleura must be immediately involved whenever the periphery of the lung is infected. This results in the occurrence of pain, which will slowly increase, interfering to a corresponding extent with the respiration. This pleuritis may develop from the advancement of the inflammatory processes before the membrane is invaded with the bacillus. The effusion is similar to that of the acute form, but is apt to be sero-fibrinous and is more likely to be streaked with blood. It is scanty at first, but increases slowly in quantity. The cough and other symptoms of pulmonary disease are attributed to that condition which has pre-existed. When the effusion is absorbed, adhesion occurs, and there is thickening of the pleura of a permanent character. When the pulmonary disease advances toward a fatal issue and the tubercular mass softens and becomes disintegrated perforation of the pleura may occur and a portion of the contents of the cavity may escape into the pleural sac, resulting in greatly increased pain, profound depression and extreme dyspnoea, with all the phenomena of pyo-pneumo-thorax.
In tubercular invasion of the percardium the conditions are similar to those of tubercular pleuritis. It is usually a secondary infection, and presents but few symptoms, and these are so similar to those of non-tubercular pericarditis that they cannot be distinguished. The knowledge of a pre-existing tubercular condition is almost positively confirmatory of the diagnosis, when the disease is fully established. In a few cases there are no clinical evidences by which the disease may be positively diagnosed, and its existence is only determined post mortem. Most frequently there is but little effusion, and adhesion takes place slowly. This leads ultimately to hypertrophy and dilatation with the usual symptoms. Where effusion is present in any quantity the evidences of dilatation are apparent earlier.
Invasion of the peritoneum by tubercular bacilli is an exceedingly frequent and important disease. The condition occurs most frequently in females and in adults. In nearly three thousand autopsies performed on patients who had died from tuberculosis more than twenty per cent were found to have tubercular peritonitis. It occurs as secondary infection in most of the cases, although primary invasion is not impossible. It is necessary that it should be recognized early, as it is a curable condition if so recognized, being more amenable to treatment than any of the other tubercular infections, except perhaps that of the lymphatic glands. It occurs in the development of acute miliary tuberculosis, with the characteristic phenomena, or in the form of a chronic invasion where the nodules are large and firm, and although there is but little exudation, there may be widely diffused adhesions. In still another form, which is designated as the fibroid form, the fibroid degeneration occurs slowly.
In the acute miliary form ascites occurs early, the serous effusion is profuse in many cases, and often this dropsical condition is the first manifestation of the disease. In the second form, which is sometimes called the ulcerative type, the nodules, which contain caseous matter, ulcerate and adhesion occurs, usually with but little effusion. The effusion, however, may be purulent and of considerable quantity, but walled off by adhesions.
In the fibroid form adhesion between the intestines and omentum occur slowly, interfering materially with the functional action of the intestinal canal. The abdominal wall is hard and board-like, and the nodular condition of the peritoneum is very perceptible to the feeling. The abdominal muscles can also be readily outlined through the skin. While this condition is not uncommon before puberty, it is much more apt to occur in women between the ages of eighteen and thirty-five years, and occurs more frequently in negroes than in whites. It is thought that the invasion of the peritoneum in females occurs from tuberculous invasion of the fallopian tubes.
Symptomatology:—The acute cases develop with a chill and a temperature which quickly becomes high, perhaps 104° F., and which may remain quite steady, with but little remission for many days. The effusion occurs early and with it typhoid symptoms, emaciation, prostration, anemia and some delirium may also occur. If the effusion is purulent or sero-purulent in character the fever quickly assumes a hectic type, and the pulse becomes rapid, small and feeble. A distinction must be made between abdominal distention, from ascites and from tympanites. It is not uncommon from intestinal peresis for the intestines to become distended with gas. In another class of cases the development is very insidious. The patient is distinctly out of health, but the local manifestations are not marked, gradually pigmentation occurs and a slight nodular feeling is apparent in cases where the abdominal walls are not too thick. There may be but little effusion, but this, if it persists, as it usually does, induces a slight fever, with anemia, progressive debility, persistent malaise, gradual emaciation and ultimate decline.
Diagnosis:—The diagnosis may be rendered difficult by the absence of any characteristic symptoms. The close resemblance of the acute or sub-acute manifestations to typhoid, results in the real character of the disease being overlooked in some cases. These manifestations, where tuberculosis elsewhere is known to exist, will point directly to infection of the peritoneum.
Treatment:—Apart from the treatment of tuberculosis of the lungs which, in part, applies to all forms, this condition must have special attention. The condition of the blood must be corrected with active alteratives, and the stomach must be treated with reference to obtaining a rapid appropriation of nutrition, with the least possible irritation. The nutritive material must be in a concentrated form, free from extraneous matter and of ready appropriation.
The results of inflammatory action in the peritoneum must be persistently combated with aconite and bryonia. Iron tonics for the anemia, and cod liver oil for the general nutrition of the patient, are important accessory measures.
With the medicinal treatment the opening of the peritoneum is important. Any serous or sero-purulent exudate must be evacuated, and any sac containing fluid must be opened and thoroughly drained. Immediate benefit is often observed from this operation in cases where there is ascites, and much good is observed in other cases, but the benefit is not more immediate nor apparent in any other case than in tubercular peritonitis.