There are three chief forms in which abdominal tuberculosis is manifested in early life. First, there may be tuberculous enteritis, an ulcerative form of inflammation affecting chiefly the lower part of the small intestine, the caecum and the colon; secondly, there may be tuberculous mesenteric glands, a condition which is known clinically as tabes mesenterica; and thirdly, there may be tuberculous peritonitis. It is possible that any one of these types may occur alone, but as an isolated condition tuberculous enteritis or tabes mesenterica is distinctly rare in childhood. The commonest form met with clinically is tuberculous peritonitis. At the same time, while tuberculous peritonitis overshadows the others by its frequency and by the prominence of its symptoms, it is to be viewed as a result of tuberculous infection of the bowel. In some cases it may be that infection comes from the thoracic glands along the lymphatic channels, or from other tuberculous deposits via the blood stream, but such are not examples of abdominal tuberculosis, pure and simple.
Abdominal tuberculosis as a primary disease is not often met with during the first two years of life. Tabes mesenterica is not a common disease of infancy. "Consumption of the bowels," which is such a popular diagnosis, is most frequently a misnomer for chronic intestinal indigestion and diarrhoea the results of improper food and overfeeding. At the same time, from the age of six months one may meet with typical and severe cases of abdominal tuberculosis. The majority of the cases occur after the age of two years. The symptoms of tuberculous enteritis may be very slight, or there may be severe and persistent diarrhoea, with the passage of blood and mucus, and with a considerable degree of irregular pyrexia. The symptoms of tabes mesenterica may be wasting only, and unless one can make out definitely a mass of enlarged glands about the mesentery, the diagnosis must remain uncertain. Tuberculous peritonitis, on the other hand, is usually a well marked affection, and as it is usually accompanied by the other two conditions, we shall in the following remarks discuss abdominal tuberculosis under the name of tuberculous peritonitis.
The preventive treatment of tuberculous peritonitis consists in the use of wholesome fresh food as the diet, and of the maintenance of a healthy condition in the alimentary canal. The dread of tubercle-laden cows' milk has affected the profession and the public for some years, and elaborate methods of sterilization were introduced to destroy not only every tubercle bacillus, but also every spore. This was probably effected, but at the same time the nutritive value of the milk was destroyed. For practical purposes it has been found that boiling the milk for one or two minutes will destroy the bacilli, which as a rule are not abundant in cows' milk, unless the cow's udder is the seat of active disease. As a matter of clinical experience, it has been found that tuberculous peritonitis may occur later in children who have been fed entirely at the breast for nine or ten months. While it is most important that children should have tubercle-free food as far as possible, there is no evidence to show that the subjects of tuberculous peritonitis have been swallowing more tubercle bacilli than their neighbours who have escaped. It may be assumed that in town life and in crowded areas every child consumes in the food a considerable number of tubercle bacilli, both living and dead. The real risk lies in an unhealthy condition of the alimentary canal, which may allow of the penetration of the bacilli. Consequently the troubles of infancy and childhood - flatulence, diarrhoea, chronic intestinal catarrh, and other disturbances of the gastro-intestinal tract - in so far as they weaken the self-protecting and resisting power of the bowel, may predispose to abdominal tuberculosis. With a history of a stormy period from the above disturbances in early life, and also a family predisposition to tuberculosis, one has to regard the danger to the child of tuberculous peritonitis as a real one. So far as the preventive treatment of tuberculous peritonitis is concerned, we shall probably do more by the regulation of the diet, so as to avoid gastro-intestinal disturbance, than by the attempt to destroy tubercle bacilli in the milk. If the mucous membrane of the stomach and bowel is in a healthy condition, it will be able to protect itself from the invasion and penetration of any tubercle bacilli.
In all acute cases, and in all cases with pyrexia, rest in bed should be maintained for a time. The natural tendency is to put such cases on a "sloppy" diet - milk, bread and milk, and pudding. Experience has shown that this is the worst possible form of treatment. The abdominal swelling which is present is largely due to the intestinal catarrh or ulceration, with consequent flatulent distension and atony of the bowel. These conditions are increased on a diet of farinaceous foods and milk, which ferment in the bowel. The first part of the treatment is to clear out the bowel thoroughly, and the next to put the patient on a non-fermentable diet. A drachm of castor oil may be given twice daily until four doses have been taken, or some other simple evacuant may be used. The diet selected should be one which will allay intestinal catarrh, which will not decompose readily in the bowel, which will be easily digested and absorbed, and which will supply the system with the important constituents calculated to combat the affection. These conditions are best fulfilled by a protein diet. At the outset, if pyrexia and loss of appetite are present one can order a diet of mutton, beef, veal, or chicken soup. Small quantities of these should be given at frequent intervals during the day. For children, these soups should never be made strong, as concentrated soups are apt to produce indigestion. They may, however, be made more nourishing by the addition of raw meat juice, 1-2 oz. daily in divided doses, or plasmon powder, or somatose. It is to be noted that diarrhoea is no contra-indica-tion to this diet. Diarrhoea in these cases is usually due either to the fermentation of food or to the presence of ulceration in the bowel, and the protein diet will be found suitable in both conditions. The important point is to give only small quantities of food at first. As soon as possible, that is to say, when the patient will take it, more solid food is to be ordered in the form of pounded fish or chicken, or mutton, with some breadcrumb and white of egg to make it more savoury and appetizing. This is to be given quite irrespective of the condition of the temperature chart, provided the patient's appetite is good. In some cases one will find that during the morning apyrexial stage the patient is ready for solid food, while during the evening pyrexia he is feeling ill and is disinclined for anything but fluids. Advantage should be taken of the fluctuations of the temperature chart to feed accordingly. Often one will find that although pyrexia continues, the patient's tongue is clean and the appetite is rapidly improving. Advantage is taken of this to put him on to a meat diet, which he can chew thoroughly. It must be recognized that in children over three years of age a diet of plainly cooked food is more digestible and more nourishing than any forms of invalid cookery. The following dietary therefore may be ordered as suitable both for the later stages of an acute case, and for those chronic cases in which the temperature has never risen above 100° F.
Fresh fish; tongue, freshly boiled or tinned; white of egg, raw or lightly boiled; two small pieces of crisp toast; one teacup of weak cocoa, with 1 oz. of milk.
Fish, chicken, sweetbread, tripe, hot or cold boiled or roast mutton or beef; chops and steaks. These must be plainly cooked, and served without any fat and without any sauce or gravy. A small quantity of breakfast or dinner biscuits (one tablespoonful), or two plasmon biscuits. Half a glass of claret.
If the appetite is good, as it usually is, three meals a day are better than frequent small meals. If, on the other hand, the patient is not inclined for a good meal, then the same materials should be given more frequently in smaller quantity. Raw meat sandwiches, made of scraped beefsteak and thin slices of stale bread, are usually readily taken by children, and may be given between meals. The amount of carbohydrate material is to be strictly limited, but a small quantity is probably not injurious and is much appreciated. Only a small amount of fluid is to be allowed at meals, as a dry diet is more digestible, but water may be given freely between meals. Claret acts as a tonic, and as an astringent when diarrhoea is present.
The benefit derived from one or other form of this protein diet is usually striking. The patients take it with relish and without discomfort. The abdominal distension usually subsides markedly within a week or ten days. The motions become more healthy in character, and if diarrhoea has been present it usually passes off. If there is no improvement under this treatment, one is led to suspect that there may be some grave lesion present, such as extensive ulceration of the bowel, or a mass of caseous and suppurating glands, or a rupture of some intestinal ulcer, with leakage and abscess formation in the surrounding tissues. It is plain one cannot expect improvement from dietetic treatment under such conditions.
The above diet, while it is strengthening and tends to maintain the vital powers of the patient, is not fattening. As soon as possible, one goes on to add some fatty food in the form of cream or cod-liver oil to increase the nutrition. This is a much more severe test of the digestive powers, and the fatty food must be commenced tentatively and in small quantities at first. I have frequently found digestive disturbances follow at once, so that one had to fall back on the protein diet. One drachm of cream or the same amount of cod-liver oil and malt may be ordered three times a day. Some children will take by preference a sardine with some of the accompanying oil, and this, or the yolk of an egg, may be substituted. The amount may be gradually increased, and some beef or mutton fat may also be allowed as the convalescent stage is reached. At this period also one may allow a return to milk and farinaceous foods, care being taken that the quantity given is small at first.
I do not say that a protein diet is a cure for tuberculous peritonitis, but I believe that it places the patient in a better position to resist and conquer the attack of the tubercle bacilli. As fresh air tends to check pulmonary catarrh, and thus allows of pure air entering the pulmonary blood vessels, so a protein diet tends to check intestinal catarrh and allows the pure products of digestion to enter the blood stream. These are all the advantages that are claimed for it, but if the disease is not too advanced the result is usually satisfactory.