INTESTINAL TUBERCULOSIS 
1, Etiology, Pathology and Diagnosis, 
2, Surgical Treatment. 
BY N. SENN, M.D., Ph.D„ LL.D. 
PROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE; ATTENDING SURGEON PRESBYTERIAN HOSPITAL; PROFESSOR 
OF SURGERY CHICAGO POLICLINIC; SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL. 
-CHICAGO, ILL. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
MAY 21 and JUNE 4, 1898. 
CHICAGO: 
American Medical Association Press. 
1898. INTESTINAL TUBERCULOSIS 
1, Etiology, Pathology and Diagnosis. 
2, Surgical Treatment. 
N. SENN, M.D., Ph.D., LL.D. 
PROFESSOR OF SURGERY, RUSH MEDICAL COLLEGE; ATTENDING SURGEON PRESBYTERIAN HOSPITAL; PROFESSOR 
OF SURGERY CHICAGO POLICLINIC; SURGEON-IN-CHIEF ST. JOSEPH’S HOSPITAL. 
CHICAGO, ILL. 
REPRINTED FROM 
THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
MAY 21 and JUNE 4, 1898. 
CHICAGO: 
American Medical Association Press. 
1898. INTESTINAL TUBERCULOSIS. 
Etiology, Pathology and Diagnosis. 
Address in Surgery delivered at the Meeting of the Ohio State Medical Society, May 5, 1898. 
Renewed interest has been awakened in the subject 
of intestinal tuberculosis since recent experience in 
modern aggressive surgery has taught the profession 
that some of the cases in which the disease occurs as 
a primary affection are amenable to successful surgi- 
cal intervention. Intestinal tuberculosis appears under 
so many different pathologic forms and presents such 
various clinical aspects, that it becomes necessary to 
inquire carefully into its etiology and pathology, in 
order to enable the surgeon to exercise the necessary 
care in the selection of cases for operative treatment. 
The field of abdominal surgery is rapidly increasing 
in extent and usefulness, and one of its most recent 
acquisitions is the successful treatment of certain 
forms of intestinal tuberculosis. 
It is my intention on this occasion to discuss as 
briefly as possible the etiology, pathology, symptoms 
and diagnosis of this affection of the intestinal canal, 
with special reference to the indications which dictate 
and warrant surgical interference. 
Frequency of intestinal tuberculosis. — Intestinal 
tuberculosis is a very common complication of pul- 
monary and miliary tuberculosis. It is not often met 
with as a primary affection. In one thousand tuber- 
cular subjects examined postmortem in the Patholog- 
ical Institute at Munich between the years 1886 and 
1890, only one case of primary intestinal tuberculosis 
was noted, while in 566 cases secondary intestinal 
tuberculosis was seen. 
That the disease occasionally occurs as a primary 
affection can no longer be doubted; the results of an 
enormous clinical exyierience and thousands of necrop- 
sies furnish a substantial verification of this fact. 
There can, however, be but little doubt that in many 
cases of tuberculosis of the intestine in which the 
clinical features point only to this organ as the sole 
seat of disease, careful search would reveal old, per- 
haps latent tubercular foci in some other part of the 
body. The prudent surgeon selects for his operative 
work only the cases in which he has reason to believe, 
from the clinical history and the signs and symptoms 
presented, that the disease is limited and confined 
largely if not entirely to the intestinal canal. 
Tuberculosis of the stomach.—As primary intestinal 
tuberculosis is for the most part a feeding disease, it 
is interesting to know whether or not the stomach is 
ever the seat of tubercular infection. For good reasons 
we have for a long time assigned to the gastric juice a 
destructive, or at least an inhibitory effect on patho- 
genic bacteria, but the results of experimentation and 
clinical observations seem to combine in proving'that 
the virulence of the bacillus of tuberculosis is little 
if any impaired on its way through the stomach. It 
is natural to assume that in cases in which the physi- 
ologic activity of the glandular appendages of the 
stomach is lessened, the antiseptic properties of the 
gastric secretions would be correspondingly dimin- 
ished. The correctness of this statement is borne out 
by the experience of many reliable clinicians and by 
the results of experimentation on the lower animals. 
Blumer (Albany Medical Annals, March, 1898) re- 
ports a case of tuberculosis of the stomach in which 
he found postmortem an old caseous area at the apex 
of the right lung which had softened at the lower 
part, general miliary tuberculosis, tuberculous ulcers 
of the stomach and ileum, tuberculosis of the kidneys 
and of the aorta. The stomach lesion consisted of 
three or four small, shallow, circular ulcerations, and 
near them, numerous miliary tubercles. Blumer has 
studied the literature of the subject and finds but 
thirty cases on record, in all of which the gastric 
lesion was secondary to tuberculosis elsewhere. He 
divides the reported cases into miliary tuberculosis, 
and single and multiple ulcerations. Four were cases 
of pure miliary tuberculosis of the stomach wall; 
about eight were single and the remainder multiple 
ulcers. 
Tuberculosis of the stomach usually occurs only in 
connection with similar affections of other organs, 
especially the intestinal and lymphatic glands. The 
ulcers are pale and have thickened edematous edges. 
The inflammatory product presents the usual evi- 
dences of the nature of the disease—giant cells, bacilli 
and perhaps cheesy material. The disease in this 
locality presents no characteristic symptoms. Perfor- 
ation and hemorrhage may occur under the same cir- 
cumstances as in intestinal tuberculosis. The ulcer 
presents a sharp contrast to its dark-colored surround- 
ings. In a few cases the serous coat over the floor of 
the ulcer is studded with miliary tubercles. In Lit- 
ten’s case the tuberculosis of the digestive tract was 
limited to the stomach. Similar cases have been 
described by Talamon-Balzer, Gilles and Eppinger. 
Musser (“Tubercular Ulcer of the Stomach,” Phila- 
delphia Hospital Reports, Vol. i, p. 117) found a 
tubercular ulcer of the stomach one and one-half by 
three and one-half inches on postmortem examination 
of a patient who had died of pulmonary tuberculosis. 
Tubercle bacilli were found in the cheesy material. 
Most of the cases of tubercular ulcer of the stomach 
have been observed in children. The disease presents 
no characteristic symptoms. Musser claims that death 
in these cases often results from hemorrhage. 
Tuberculosis of the stomach is a very rare affection, 
as is shown by the researches of Letorey (These de 
Paris, 1895), who was able to find an account of only 4 
twenty-one cases. This rarity is explained, to a cer- 
tain extent, by the well known action of the gastric 
juice on the bacillus tuberculosis, which either dies 
or loses its virulence in an acid medium. Absence or 
diminution of hydrochloric acid would therefore favor 
the development of tubercular lesions, as would also 
other affections which impaired the digestive func- 
tions of the stomach. Letorey believes that the bacil- 
lus reaches the stomach more frequently by the way 
of the circulation than by entrance with infected food. 
The disease is more frequently demonstrated in the 
autopsy room than at the bedside. The usual site of 
the ulceration is near the pylorus and on the larger 
curvature. In only six cases out of the twenty-one 
was more than one tubercular ulcer noted, so that the 
lesion may be said to be generally single, the ulcer 
round or oval, with ragged and bleeding edges and a 
grayish-yellow floor. The ulcer occasionally reaches 
a diameter of from three to five centimeters. The 
prognosis in these cases is grave, since the patient < 
usually dies from the effects of the primary pulmo- 1 
nary affection or tuberculosis of other organs, the 
gastric complication perhaps hastening the fatal ter- < 
mination. The occasional occurrence of tubercular 1 
gastritis is the best possible proof that the bacillus of i 
tuberculosis may pass through the stomach, subjected : 
to the action of the gastric juice, and still retain suffi- : 
cient virulence on its entrance into the intestinal 
canal to exercise its specific pathogenic action upon < 
the tissues prepared for its reception and multiplica- : 
tion by hereditary or acquired predisposing causes. i 
Etiology.—Primary tuberculosis of the intestinal 1 
canal is the result of infection from without by the 
ingestion of food contaminated with the essential cause < 
of the disease, the bacillus of tuberculosis, usually in i 
the form of tubercular milk and meat. The secon- i 
dary form is caused by auto-infection by the entrance i 
of tubercular sputa into the intestinal canal. The < 
lymph follicles and Peyer’s patches furnish the most i 
favorable anatomic conditions for the localization and 1 
growth of the tubercle bacillus. Klebs believes that 1 
the introduction into the intestinal canal by the swal- 1 
lowing of sputa in phthisical patients is a frequent i 
cause of intestinal tuberculosis. He discovered two 
tubercular ulcers in the stomach of a patient who had i 
died of pulmonary tuberculosis. The supposition that i 
intestinal tuberculosis is often caused by the ingestion i 
of tubercular food or sputa is supported by the exper- 
iments of Maiin, Parrot and Bonley, who found that i 
animals fed with the expectorations of consumptives 1 
died of tuberculosis; while Chauveau, Bollinger and < 
others succeeded in producing intestinal tuberculosis 1 
by feeding animals susceptible to the disease with i 
fragments of tubercular lungs or with raw tubercular i 
meat. The experiments of Gerlach, Ziirn and Klebs < 
demonstrated the dangers attending the use of milk < 
from tubercular cows. In these experiments it was 1 
noted that the disease commenced in the form of an i 
intestinal catarrh, and that the extension of the tuber- t 
cular infection began through the mesenteric glands 
before the development of diffuse miliary tuberculosis. < 
W. Zinn (“Ein Fall von Futterungstuberculose bei 1 
einem erwachsenen Menschen, mit Ausgang in Miliar- i 
tuberculose,” Munch. Med. Wochenschrift, 1895, No. < 
37) observed a man 29 years of age who in the course i 
of nine weeks died of acute miliary tuberculosis. The i 
autopsy showed that the miliary tuberculosis had its 
origin in a mass of caseous tubercular mesenteric < 
glands. No other old tubercular deposit could be 1 
found. In the intestine, at a point corresponding to 
the diseased glands, was found the scar which followed 
the healing of a tubercular ulcer. The ulcer was evi- 
dently the primary lesion which led to tubercular 
lymphadenitis, and finally death followed from rein- 
fection of the body from the tubercular glands, long 
after the intestinal ulcer had healed. General infec- 
tion in this case took place through the thoracic duct. 
Wyss (“Zur Kasuistik der primaren Darmtuberku- 
lose im Kindesalter,” Correspondenzblcitt f. Schweiz- 
erarzte, 1893, No. 22) found in seventy-one postmor- 
tems on children three instances of undoubted primary 
intestinal tuberculosis. In one case, a girl 5£ years 
old who had died of diphtheria, a solitary tubercular 
ulcer was found in the ileum with extensive tubercu- 
losis of the mesenteric glands. No trace of tuber- 
culosis could be detected in any other organ. Upon 
inquiry it was ascertained that the child had been fed 
on milk almost exclusively for some time before she 
contracted diphtheria. In the other two cases the 
disease could be traced to the same cause. 
Intestinal tuberculosis is found most frequently in 
children and young adults, although no age is entirely 
exempt. In the language of Virchow: “the predispo- 
sition to tuberculosis, the hereditary vulnerability 
resides in the tissues, and that the younger and more 
incompletely developed these are, the more readily 
will the vulnerability manifest itself in the presence 
of exciting causes.” This may explain the special 
frequency of intestinal tuberculosis in children and in 
subjects affected by antecedent inflammatory affec- 
tions of the intestinal mucous membrane. 
Baumers (“Recherches sur la maladie propre aux 
enfants”) first called attention to intestinal tuberculosis 
in children, which has been known as tabes S., phthisis 
mesaraica, febris mesaraica, febris xanthus infantum 
and intestinal scrofula. Intestinal tuberculosis in 
children results in early and extensive infection of the 
mesenteric glands, from which reinfection usually 
terminates life by miliary tuberculosis. Secondary 
tuberculosis appears to be more frequent in adults 
than in children. In children intestinal tuberculosis 
is not within 30 to 40 per cent., in the adult in 60 to 
70 per cent. The local predisposing lesion, although 
important in determining localization, is not essential, 
as the tubercle bacilli can penetrate the intact mucous 
membrane. 
In six of Czerny’s cases subjected to operative inter- 
ference the patients were between 25 and 50 years of age, 
the average age being 39. In four of the cases tuber- 
culosis was hereditary, in two cases the disease fol- 
lowed typhoid fever, and in one it was preceded by an 
acute attack of parametritis. In three of the cases the 
intestinal disease was complicated by pulmonary tuber- 
culosis, and in one by diffuse miliary tuberculosis. In 
one case the infection occurred by the rupture of a 
tubercular adnexal abscess into the intestine, and in 
another the intestinal tuberculosis was complicated by 
actinomycosis. 
Clinical experience has shown that intestinal tuber- 
culosis pursues a more benign and chronic course in 
the adult than in children, and consequently the pri- 
mary form of intestinal tuberculosis amenable to suc- 
cessful surgical treatment is met with most frequently 
in young adults and persons of advanced age, seldom 
in the case of infants and young children. 
Infection from the blood is undoubtedly of quite 
common occurrence in primary and secondary intes- 
tinal tuberculosis. The most favorable cases for suc- 5 
cessful surgical intervention are those in which a 
localized predisposing lesion furnishes an infection 
atrium for the entrance of tubercle bacilli into the 
tissues. These are the cases in which characteristic 
solitary or multiple tubercular ulcers develop which 
manifest an intrinsic tendency to heal, and in which 
an operation finally becomes a necessity after symp- 
toms of obstruction indicate the existence of a cica- 
tricial stenosis. 
Pathology.—Intestinal tuberculosis presents itself 
clinically and pathologically in the form of a chronic 
catarrhal or ulcerative enteritis. The inflammation 
which follows the tubercular infection is characterized 
by a series of pathologic processes common to all 
tubercular affections, influenced and modified, how- 
ever, by the structure and function of the tissues in- 
volved. The primary seats of infection are the gland- 
ular appendages of the mucous membrane, the lymph 
follicles and Peyer’s agminated glands. The mode of 
infection resembles typhoid fever in many respects. 
The lower portion of the ileum and the ileo-cecal 
region are the most frequently infected, although any 
portion of the intestinal canal may be involved pri- 
marily or by extension. Of six cases of intestinal 
tuberculosis reported by Schiller (“Ueber die Darm 
Operationen an der Heidelberger Chirurgisclien Klinik 
aus den letzten vier Jahren.” Dissertation, 1896), 
which were operated upon by Czerny during a period 
of four years, the disease involved the ileo-cecal region 
four times, and the descending colon twice. In all 
cases of cecal tuberculosis operated upon by Czerny, 
the ulceration was limited on one side by the ileo- 
cecal valve; the mucous membrane of the cecum was 
extensively ulcerated, presenting elevations and depres- 
sions and polypoid excrescences between the ulcers; 
the cecal wall was much thickened and indurated. 
The lumen of the cecum was usually found contracted, 
the stenosis being the direct cause of the intestinal 
obstruction. In one case the mechanical impediment 
was found to be a sharp flexion at the insertion of the 
ileum into the cecum. In one case the contracted 
lumen of the cecum was divided by a band of cicatri- 
cial tissue. The bowel below the obstruction was, as 
is always the case, nearly empty, reduced in size and 
anemic, while on the proximal side reverse conditions 
existed, which facilitated circular suturing after excis- 
ion. In acute cases, such as are observed in children, 
and which seldom come to the notice of the surgeon, 
the disease is usually diffuse and often implicates a 
large section of the intestinal canal above the ileo- 
cecal valve. Tuberculosis is apt to attack a portion 
of the intestinal canal subjected to mechanical irrita- 
tion, as is the case in hernia. 
A number of cases of tuberculosis of hernia have 
been reported. Bruns (“Beitrage zur Klin. Chirurgie,” 
B. ix, p. 206) adds one new case to those previously 
published. In these thirteen cases the hernial sac was 
attacked ten times, and in seven it was alone the seat 
of disease. This, together with other conclusions, 
substantiate the belief, that “tuberculosis of hernia” 
may occur as a primary disease; generally, however, 
it is associated with peritoneal tuberculosis. 
It appears from the present literature on the sub- 
ject that tuberculosis in the ileo-cecal region and the 
colon is usually a disease of adults, although there 
are a few cases on record in which the intestinal 
canal at and below the ileo-cecal region was affected in 
children not more than 10 years of age. 
Reclus (Le Bulletin Midicale, June 25, 1893) has 
called attention to the rapidly increasing number of 
cecal tuberculosis cases which have been operated upon. 
The cases of Bouilly, Terrier, Hartmann, Reynier, 
Broca, Roux, Salzer, Billroth and Hochenegg, the 
anatomical researches of Duguet, Spillmann, Herard, 
Cornil and Hanot, and the more recent descriptions 
of Pilliet and of Le Bayou have thrown some light 
upon this hitherto but little recognized affection. 
This affection may manifest itself as a localized tuber- 
culosis without infiltration and as a purely local dis- 
ease. This suffices to place this intestinal lesion 
among the surgical tuberculoses. From the moment 
it is a limited focus and this focus is accessible, in 
such favorable circumstances intervention is legiti- 
mate. The greatest number of cases of cecal tuber- 
culosis so far reported have been over 25 years of age. 
It seems that two distinct anatomo-pathologic forms 
may be described, associated with different symptoms; 
the one a fibrous and the other an ulcerating variety; 
moreover, these may be combined, or there may be 
noticed many intermediate stages between the varie- 
ties. The majority of cases thus far reported have 
been characterized by an abundant tissue proliferation, 
which imparted to the swelling much of the aspects 
of carcinoma. The inflammatory mass is almost 
always found freely imbedded in plastic adhesions, 
and it is difficult if not impossible to outline the ana- 
tomic landmarks of the parts involved. Ordinarily 
the lesions are most marked around the ileo-cecal 
valve. The appendix is generally affected and con- 
stitutes a portion of the inflammatory mass. 
The second or ulcerated form may present thicken- 
ing of the peritoneum and adhesions around the 
intestinal loops, but these have not the remarkable 
hypertrophy of the other form; on the contrary the 
ulcerative process predominates, the mucosa has 
often completely disappeared, especially at the site of 
the ileo-cecal valve. Ulceration often leads to abscess 
and fistula formations. The fistulous openings are 
often multiple. 
Cornil believes that in such cases the primary 
infection takes place in the appendix vermiform is, 
more especially when it is the seat of a fecal concre- 
tion or foreign body. 
The tubercular infection may take place in the 
upper portion of the intestinal canal. Claude (“Ul- 
cerations tuberculeuses du duodenum,” Bulletin de 
la Soci6t6 anatomique de Paris, No. 8, 1896) made 
a postmortem on a man 33 years of age who had died 
of pulmonary tuberculosis. He found tubercular 
ulcers in the upper portion of the duodenum; four 
other ulcers were found in the ileum. He attributed 
the intestinal disease to infection from the blood. 
During life this patient never showed any symptoms 
referrable to the intestinal canal. The tubercular 
nature of the intestinal affection was established by 
histologic and bacteriologic examinations. 
The entire length of the intestinal canal is seldom 
affected by tuberculosis, and in the exceptional 
instances when this is the case the disease pursues a 
rapidly fatal course. It has already been stated that 
intestinal tuberculosis always begins in the lymph 
follicles'or Peyer’s patches. The tubercular process 
is at first submucous, and reaches the surface only 
after degeneration and ulceration have taken place. 
The glands become swollen, can be felt under the 
epithelial lining as small hard nodules, which present 
a grayish color before caseation sets in. With the 
onset of caseation the swelling increases in size and 6 
assumes a yellowish color. As soon as the overlying 
epithelial lining is destroyed softening of the inflam- 
matory product and ulceration set in. The primary 
ulcer is small and round with yellowish margins. 
At the time the crater-like defect takes place the 
mass is not larger than a hemp-seed. Such small 
ulcers may heal, but more frequently progressive 
extension takes place in the direction of the blood 
vessels. In Peyer’s patches the appearance of sieve- 
like defects can be seen during the early stages of the 
disease, which Rokitansky described as primitive 
tubercular ulcerations. They constitute the prepar- 
ing stage or secondary tubercular ulcers. Even in 
superficial ulcers tubercles can constantly be found 
between the muscular fibers. By confluence and 
progressive infection the surface defects increase in 
size. Not infrequently remnants of intact mucous 
membrane remain between the different points of 
ulceration. The shape of the ulcer is variously 
modified by the confluence of several ulcers. The 
most extensive ulcers are found in the cecum, colon 
and terminal portion of the ileum. 
The intrinsic tendency of intestinal tubercular 
ulcers is to increase in size in the direction of the 
blood vessels; that is, transversely to the long axis 
of the bowel, a pathologic feature which wras first 
pointed out by Rokitansky (Lehrbuch der path. 
Gewebelehre,” 1871, p. 327). The tubercular infec- 
tion follows the lymph sheath of the blood vessels. 
Through the lymphatics the infection extends to the 
serosa, upon the surface of which miliary tubercles 
are often found over an area corresponding in 
extent to the base of the ulcer. The mesenteric 
glands are infected through the same channels. In 
children the mesenteric glands are often affected 
without an antecedent intestinal lesion. In such 
cases the tubercle bacilli penetrate through the 
mucous membrane and enter the lymphatic system 
without producing a demonstrable surface lesion, or 
infection takes place by the way of the general circu- 
lation. Infection through the mucous membrane 
undoubtedly is often determined by catarrhal enteri- 
tis, which damages the epithelial lining and prepares 
the way for invasion from the intestinal canal. 
Extension of the ulcer in the muscular coat takes 
place by progressive extension of the ulcerating 
process and by diffusion of the infection through the 
lymph channels (Figs. 1 and 2). As soon as the 
serous coat is reached secondary plastic peritonitis is 
almost the constant result. Usually the peritonitis 
is limited to the affected portion of the bowel, 
between which and the adjacent viscera firm adhes- 
ions are formed. In exceptional cases the peritonitis 
becomes profuse without perforation. More fre- 
quently, however, the diffuse tubercular peritonitis is 
caused by the rupture of a peri-intestinal tubercular 
abscess. Perforation of a tubercular ulcer is often 
prevented by early and firm adhesions. In one of the 
cases reported by Rindfleisch the intestine was found 
perforated at five different points without causing 
diffuse peritonitis, owing to the existence of firm 
adhesions. Perforative peritonitis is so rare in intes- 
tinal tuberculosis that Leube saw only two cases dur- 
ing his service in the clinic at Erlangen. Leudet 
reports six cases that occurred in his practice, which 
were due to tubercular affection of the appendix. 
Eisenhardt (“Ueber die Haufigkeit und Vorkommen 
der Darmtuberculose,” Dissertation, Munich, 1891) 
found perforation in 28 out of 566 cases of intestinal 
tuberculosis examined postmortem. Extension of 
the disease to other parts and organs frequently takes 
place through the lymphatic system. 
Tubercular lymphadenitis is a frequent and, in 
Figure 1.—Tubercular ulcer of ileum. [Pathological Museum Rush 
Medical College.] a, round tubercular ulcer of ileum; b, narrow circu- 
lar annular tubercular ulcer of ileum. 
long-standing cases, a constant concomitant patho- 
logic condition, as was first pointed out by Schiippel 
and Rindfleisch. The observations occurring during 
operations made for intestinal tuberculosis and the 
Figure 2.—Diffuse annular tubercular ulcer of ileum. [Pathological 
Museum Rush Medical College.] 
results of postmortem examinations combine to show 
that retrograde metamorphosis of the inflammatory 
product of the tubercular glands takes place very 
slowly. The writer has seen repeatedly tubercular 7 
mesenteric glands as large as a hazel-nut which had 
not undergone any decided cheesy degeneration. 
Coagulation and caseous degeneration, however, occur 
in the course of time, but liquefaction and abscess 
formation in and around tubercular mesenteric 
glands are of rare occurrence. Infiltration and thick- 
ening of the intestinal wall occur most frequently 
and reach the maximum height in cases in which the 
tuberculosis is located in the ileo-cecal region or 
colon. In these localities the disease is most fre- 
quently primary, a fact which would explain its 
chronicity and comparatively benign nature. When 
the tubercular process affects this part of the intes- 
tinal canal the resultant swelling is often of larger 
size and has frequently been mistaken for malig- 
nant disease. In such instances the intestinal wall 
has been found several centimeters in thickness. 
In acute cases of intestinal tuberculosis the ulcers 
manifest little or no tendency to repair. In chronic 
cases attempts at healing or complete healing is the 
rule. Eisenhardt (op. cit.) in examining the post- 
mortem records of 566 cases of intestinal tuberculosis, 
found that healing was completed in only 10, while 
in 25 instances the ulcers were only partly healed. 
Attempts at cicatrization are frequently seen, but 
very often while healing is going on in one part of 
the ulcer progressive infection and destruction are 
witnessed in another portion. The healing of a tuber- 
cular ulcer of large size requires an enormous quan- 
tity of new material, which is composed largely of 
new connective tissue. The scar tissue always evinces 
a tendency to contraction, which leads to stenosis 
and flexion. If the ulcer is circular, healing is 
attended by contraction of the lumen of the bowel, 
which finally leads to intestinal obstruction. If only 
one side of the circumference of the bowel is ulcer- 
ated, healing will result in contraction and flexion. 
The healing of several tubercular ulcers gives rise to 
the development of multiple strictures, which have 
been found by several surgeons in operations for 
intestinal obstructions. Progressive cicatricial con- 
traction may eventually result in almost complete 
obliteration of the lumen of the bowel. In one of 
Scheuer’s cases the stricture at the time the intestinal 
resection was performed for obstruction was so nar- 
row that it admitted only a probe three millimeters in 
size. The healing of intestinal tubercular ulcers is 
seldom followed by complete recovery, as all such 
patients are liable later to intestinal obstructions and 
reinfection from the tubercular mesenteric and retro- 
peritoneal glands. 
Symptoms.—Intestinal tuberculosis may run its en- 
tire course from beginning to end without any symp- 
toms which would point to the intestinal canal as the 
principal seat of the disease. Tubercular ulcers of 
the intestines are often found at autopsies without 
the slightest evidence of their existence during life. 
That an isolated tubercular ulcer of the intestine may 
exist without causing symptoms before perforation 
occurs, is shown by a case reported by Baumgarten 
(“Ueber latente Tuberculose,” Volkmann’s Klinische 
Vortrdge, No. 218). A young soldier, in almost per- 
fect health, died suddenly of perforative peritonitis. 
The postmortem revealed, as the cause of the peri- 
tonitis, a solitary perforated ulcer, the size of a penny, 
in the lower portion of the ileum. Microscopic exam- 
ination of the tissues demonstrated the tubercular 
nature of the ulcer. No evidence of tuberculosis was 
found in any other organ of the body. 
In other cases the symptoms are misleading. Thus 
Leonhardi-Aster (Ueber einen unter dem Bilde per- 
nicioser Ansemie verlaufenden Fall von Darmtuber- 
culose,” Deutsche Zeitsch.f. prakt. Med., 1878, Nos. 8 
and 9) recorded a case of intestinal tuberculosis which 
presented all the clinical features of pernicious anemia, 
the intestinal symptoms being masked by the pro- 
gressive anemia for which no cause could be assigned 
until the necropsy revealed the characteristic patho- 
logic lesions of intestinal tuberculosis. In cases of 
diffuse acute intestinal tuberculosis the most important 
and prominent symptoms point to the existence of an 
intestinal catarrh. Profuse diarrhea is seldom absent, 
the stools being copious and liquid. Colicky pains 
referred to the umbilicus, slight tenderness on deep 
pressure, progressive emaciation and more or less rise 
in temperature, especially toward evening and during 
the night are symptoms well calculated to arouse sus- 
picion in regard to the probable tubercular nature of 
the intestinal disease. Enlarged mesenteric glands 
can often be palpated through the thin and relaxed ab- 
dominal wall. In some cases enlarged mesenteric and 
retroperitoneal glands can be detected by vaginal or 
rectal examination. The severity of the diarrhea is 
attributable more to the existence of the complicating 
intestinal catarrh and increased peristalsis than to the 
ulcers themselves. Pulmonary tuberculosis, as well 
as tuberculosis of any other important organ, often 
overshadows and masks the intestinal complication. 
In all cases of pulmonary tuberculosis attended by 
diarrhea, which does not yield to the ordinary treat- 
ment, we have reason to assume the existence of intes- 
tinal tuberculosis. In primary intestinal tuberculosis 
the early symptoms set in insidiously, the disease is 
usually mistaken for an ordinary intestinal catarrh 
and is regarded as such until the negative results 
obtained from the treatment induces the physician to 
make a more thorough investigation of the case. 
The suspicions of the tubercular nature of the intes- 
tinal disease are materially strengthened if it can be 
ascertained that the patient has made unsterilized 
milk a staple article of diet. 
The frequent presence of traces of blood in the 
stools is decidedly suspicious. If the ulcers are 
located in the small intestine the blood is intimately 
mixed with the stools; if in the large intestine the 
extravasated blood often forms a coating for the other- 
wise well formed fecal masses. Pus in the stools is 
found, as a rule, only when the tubercular process in- 
volves the lower portion of the large intestine. In the 
small intestine the pus that forms on the surface of 
the ulcers is speedily washed away with the intestinal 
discharges and, on the other hand, pus formation is 
checked by the peptic action of the intestinal juice, 
which acts as an efficient antiseptic. Bamberger has 
called attention to the character of the stools in intes- 
tinal tuberculosis, which according to this authority 
frequently contain transparent particles of mucus 
resembling frog spawn or boiled sago grains. These 
masses of mucus are probably formed in and are dis- 
charged from the lymph follicles of the intestinal 
mucous membrane, the structures primarily affected 
by the tubercular process. 
Virchow places less diagnostic importance on the 
presence of this pathologic product, which he believes 
has often been mistaken for partially digested starch. 
The partial or complete healing of a tubercular ulcer 
of considerable size is usually announced clinically by 
the appearance of a complexus of symptoms which indicates the existence of chronic intestinal obstruc- 
tion, caused by the cicatricial stenosis which so con- 
stantly attends and follows the healing of a tubercular 
ulcer. Intermittent colicky iiains in the umbilical 
region, diarrhea alternated with constipation, and 
perhaps occasional attacks of vomiting, are the most 
prominent clinical manifestations in such cases. 
Chronic intestinal obstruction from this, as well as 
other causes, often terminates in an acute attack. In 
rare cases, the chronic obstruction presents few or no 
symptoms until symptoms of acute obstruction set in, 
when operation or autopsy reveal the presence of an 
old cicatricial stenosis, which was never suspected 
before the abdomen was opened. 
The formation of a chronic abscess in the ileo-cecal 
region, or any part of the abdominal wall, in connec- 
tion with intestinal symptoms of long standing, always 
suggests the probable existence of a tubercular intes- 
tinal ulcer. The writer has always observed these in 
the ileo-cecal region, over the ascending colon, and in 
one case in the umbilical region. These are the cases 
in which, prior to the perforation of the ulcer, adhesion 
takes place, excluding the peritoneal cavity, followed 
by the formation of a mural tubercular abscess. In 
more than one case the tubercular nature of the abscess 
and its intestinal origin were predicted before the 
abscess was opened. A fecal fistula is sure to follow 
the opening of such an abscess. The granulations 
8 
ileo-cecal region and the presence of a swelling, which 
on percussion yielded a dull tympanitic resonance, 
and which was movable and only slightly tender on 
pressure, and the periodic abdominal pains caused by 
exaggerated intestinal peristalsis, as described by 
Czerny, Konig and Benoit. 
The anatomic location of the stricture is indicated 
by clinical phenomena which deserve a careful study 
and analysis. Stenosis of the duodenum above the 
entrance of the bile duct, gives rise to the same 
symptoms as stenosis of the pylorus, but below this 
point it is attended by symptoms which not only 
simulate the latter affection, but also obstruct the 
entrance of bile into the intestinal canal. 
The most important condition which characterizes 
duodenal stenosis below the bile duct, is the constant 
presence of bile in the chyme and repeated ejections 
of the fluid by vomiting. On the other hand, of three 
clinical observations Boas (“Ueber die Stenose des 
Duodenum,” Deutsche med. Wochenschrift, 1891, 
No. 28), sliowTs that fluid taken from the stomach 
Peritoneal tubercle showing bacilli. A, visceral peritoneum. Eye 
piece 4, obj. 1/12. 
Tubercular intestine. A, necrotic mucosa; B, tubercle in sub- 
mucosa: C. vessels. High power. 
lining the abscess cavity may for a time prevent the 
escape of intestinal contents, but in the course of a 
few days or weeks the granulations give way and the 
fecal fistula appears. If the disease is attended by 
plastic peritonitis to any considerable extent the 
inflammatory exudate may often be distinctly outlined 
by palpation. 
Voehts calls attention to a condition of diagnostic 
value, often met with in such cases, in the form of 
indurated plates in the peritoneum of almost cartil- 
aginous hardness. 
Such areas of induration are not only found in the 
ileo-cecal region, along the course of the colon accord- 
ing to the seat of the disease, but also in Douglas’ 
fossa. In the pelvis these indurations may grow to 
actual exudates of considerable size, which in women 
might be mistaken for diseased adherent ovaries or 
tubercular Fallopian tubes. 
In four out of six cases operated upon by Czerny a 
diagnosis of probable intestinal tuberculosis was made 
before the operation was performed. The diagnosis 
was based largely upon the clinical history which 
indicated the existence of a cicatricial stenosis in the 
contains not only bile but also pancreatic juice. The 
contents of the stomach possessed all of the cliemic 
properties of duodenal chyme. 
Duodenal differs from pyloric obstruction also by 
the absence of a corresponding dilatation of the 
. stomach, by the absence of the products of fermenta- 
tion of the stomach contents and by the absence of 
s sarcinse and yeast cells. No distinction can be made 
: between obstruction in the lower portion of the duo- 
■ denum and the upper part of the jejunum. Vomit- 
ing of large quantities of bile indicate duodenal 
) obstruction, while the ejected material assumes 
- more and more the character of feces, the lower the 
’ location of the obstruction. In eight out of twelve 
) cases of duodenal obstruction, collected by Gerhardi 
i and Hagenbach, the disease was due to carcinoma, 
r cysts or hemorrhage of the pancreas. The search for 
the pancreatic juice in the stomach contents is im- 
i portant. The number of well authenticated cases of 
3 tuberculosis of the duodenum have been placed on 
3 record, and there is no reason to doubt that in isolated 
1 cases the ulceration might heal with the usual remote 
3 conditions following cicatricial stenosis and intestinal 9 
obstruction. If the cicatricial stenosis involves the 
ileo cecal region, or any part of the colon, the usual 
symptoms indicative of intestinal obstruction in these 
portions of the intestinal tract, will develop. Diarrhea 
is the most constant symptom in such cases. In far 
advanced cases extensive tympanites, fecal vomiting 
and complete interruption of the fecal circulation at 
the point of obstruction complete the clinical picture 
of intestinal obstruction. 
Diagnosis.—The diagnosis of secondary tuberculo- 
sis of the intestines presents few difficulties if the 
primary disease is well marked, and affects an organ 
readily accessible to examination. Pulmonary phthisis 
generally precedes and attends secondary intestinal 
tuberculosis. In women, tuberculosis of the internal 
genital organs occasionally constitutes the primary 
affection, and extension takes place to the intestinal 
canal, either through the lymphatic channels or, as in 
one of Czerny’s cases, by rupture of a tubercular i 
abscess into the intestinal canal. In cases of primary ' 
intestinal tuberculosis, an early correct diagnosis is < 
seldom made. There are other ulcerative affections 
of the intestines which in many respects resemble i 
produced the chronic intestinal catarrh. Examina- 
tion of the lungs and other important organs failed to 
locate a tubercular focus. The mesenteric glands 
could not be felt on palliation and rectal examination. 
The stools were frequent and liquid. The pain slight 
and referred to the umbilical and hypogastric regions. 
Intestinal tuberculosis was suspected. Carbonate 
of guaiacol and salicylate of bismuth were adminis- 
tered internally and the colon was washed out daily 
with a copious enema of warm salt solution. On 
many different occasions the stools were examined for 
tubercle bacilli, but none could be found. Myriads 
of colon bacilli and micrococci were invariably found. 
The absence of tubercle bacilli in the stools and the 
marked improvement which followed the treatment, 
leave but little doubt that this was a case of intestinal 
ulceration, caused by infection with the colon bacillus. 
Bacteriologic examination of the feces in suspected 
cases of intestinal tuberculosis should never be neg- 
lected, as it often furnishes positive proof of the tuber- 
cular nature of the disease. Tubercle bacilli, when 
present in the feces, in which they may be demon- 
strated by the same methods as in sputum, are indica- 
Tubercular intestine. Low power. Cross section of ulcer. A, necrotic mucosa; B, tubercles in 
submucosa; C, invasion of muscular layers; D. peritoneal tubercle with giant cells. 
intestinal tuberculosis. Councilman (“Johns Hop- 
kins Hospital Reports,” March, 1892) reports a case 
of extensive and deep ulceration of the lower portion 
of the ileum complicated by stricture of the rectum, 
which terminated in death from perforation and gan- 
grenous periproctitis, and in which typhoid fever and 
tuberculosis could be safely excluded as causes. At 
the postmortem, ulceration of the ileum was found, 
with invasion of the tissues by colon bacilli. Some 
of the ulcers presented the appearance of an acute 
process, others were of a chronic nature. Numerous 
bacteria, both short rods and micrococci, were found 
in the superficial necrosed tissue, in some places ex- 
tending into the cellular infiltration in the submucosa. 
These microbes did not seem to stand in any direct 
etiologic connection with the pathologic changes. 
The writer recently had under his observation for sev- 
eral months a case of chronic diarrhea, which had 
resisted all remedial measures. The patient was a 
man about 30 years of age, very anemic and greatly 
emaciated. No hereditary tendency to tuberculosis, 
and no cause could be ascertained, which might have 
tive of intestinal tuberculosis, providing that they are 
observed upon repeated examination, and that clinical 
symptoms are present which point to the intestines as 
the seat of disease, as otherwise they may be referable 
to swallowed sputa. 
The best way to find the bacillus is to dilute the 
feces with distilled water and to prepare and strain 
the deposit after centrifugation. Sawyer (Medical 
News, May 23, 1896) urges the importance, in cases 
of suspected intestinal tuberculosis, of examining the 
mucus collected from the rectum, just above the 
sphincter ani, for bacilli. When found, particularly 
on the surface of fissured stools, these clusters of 
bacilli are of diagnostic value, and may be relied on 
to indicate tubercular processes in the intestinal tract. 
He has thus found them in several cases when they 
could not be found in the sputum, or when sputum 
could not be obtained. 
If the tubercular enteritis has progressed to the 
formation of cicatricial strictures, the differential 
diagnosis between intestinal obstruction from this 
cause and other inflammatory affections which result 10 
in ulceration and cicatricial stenosis, is always diffi- 
cult and sometimes impossible. In such cases a prob- 
able diagnosis must rest on a careful study of the 
clinical history and search for tubercular foci in other 
organs. 
Congenital stricture.—Congenital stenosis of the 
intestinal canal may appear as a single or multiple 
congenital defect, may affect any portion of the intes- 
tinal canal and may cause no symptoms until long 
after birth Intestinal stricture occurring in infants, 
children and young adults, without any history of the 
existence of an antecedent ulcerative lesion, is quite 
frequently of a congenital origin. 
Traumatic stricture.—If in cases of intestinal ob- 
struction from a stricture the clinical history shows 
that the patient has been for some time in the past, 
the subject of an injury to the abdomen it should be 
borne in mind that the stricture may be the direct re- 
sult of the trauma. Such strictures are occasionally 
caused by a blow on the abdomen. Mygiud reports 
such a case. Intestinal resection was performed six 
months after the accident for symptoms of obstruction, 
and the patient recovered. 
Traumatic strictures may result from laceration of 
the mucosa or from plastic peritonitis. In the former 
variety the lesion of the mucous membrane would be 
likely to simulate more closely tubercular enteritis 
than the peritonitis form. In both instances, how- 
ever, the catarrhal enteritis complicating the chronic 
obstruction would present some clinical features in 
common with tubercular enteritis. 
Stricture following strangulated hernia.—It has 
been known for a number of years that intestinal stric- 
ture occasionally develops after the reduction of a 
hernia by taxis or operation. The stricture in such 
cases is caused by a circular necrosis of the mucous 
membrane, resulting from the pressure by the strang- 
ulation. The elimination of the necrosed tissue is 
followed by ulceration, and the healing of the circu- 
lar ulcer finally leads to cicatricial contraction and 
intestinal stenosis. Garre first described intestinal 
stricture as one of the remote results of a strangulated 
hernia. (“Ueber eine eigenartige Form von Darm- 
stenose nach Brucheinklemmung.” Beitrdge zur klin. 
Chirurgie, B. ix.) He made the observation that in 
some cases of strangulated hernia the mucous mem- 
brane of the bowel at the point of constriction be- 
comes necrotic and is cast off as a slough. The cir- 
cular defect heals by granulation, and the resulting 
scar leads to circular constriction. 
In his first case the symptoms of obstruction neces- 
sitated a laparotomy, which was performed nine weeks 
after the herniotomy. The patient was 27 years old, 
and the subject of a preperitoneal inguinal hernia. 
Intestinal resection to the extent of forty-one centi- 
meters was made, and the continuity of the bowel 
restored by circular enterorrhapliy. The patient 
recovered. Examination of the specimen removed 
showed that the ulcerated surface had not entirely 
healed. At one point the ulceration extended as far 
as the peritoneum. 
Ravult (“Retrecissement cicatriciel de l’intestin au 
niveau des 2 points de lAtranglement d’une ancienne 
hernie,” Bidl. de la Soc. anat. de Paris, 5, Serie iv) 
reports a case of double cicatricial stricture of the small 
intestine which caused death from acute intestinal ob- 
struction. Several years before the last illness the patient 
was operated upon successfully for strangulated hernia. 
The acute attack of intestinal obstruction resulted 
fatally in a few days. The necropsy revealed two 
strictures eight centimeters apart; the segment of 
bowel between them was distended by gas. Above the 
stricture on the proximal side the bowel was greatly 
distended and vascular, while the intestine below the 
second siricture was contracted, empty and pale. The 
strictures were undoubtedly the result of sloughing, 
uiceration and scar formation, consecutive pathologic 
conditions caused by harmful circular constriction by 
the neck of the hernial sac. 
The time of the appearance of symptoms of obstruc- 
tion in this form of intestinal stenosis varies from a 
few days to a year or more. Pitt records a case of fem- 
oral hernia in which symptoms of obstruction appeared 
five days after the reduction of the strangulated her- 
nia, while in Garre’s case the symptoms of obstruc- 
tion did not set in until nine weeks after the relief of 
the strangulation by taxis. 
The possibility of the existence of a cicatricial 
stricture due to such a cause must be remembered in 
cases of intestinal obstruction in which the clinical 
history refers to strangulated hernia relieved either 
by taxis or operation. 
Stricture following healing of typhoid ulcer.—The 
healing of typhoid ulcers is very rarely followed by 
cicatricial stenosis. Treves made a very careful 
search for stricture of the intestine caused by typhoid 
ulcer and was able to find only one well authenticated 
case. Typhoid ulcers, as a rule, heal rapidly and 
much of the tissue destroyed is reproduced by the 
reparative process, leaving only a minimum quantity 
of connective tissue, while the healing of a tubercular 
ulcer is attended by the formation of an abundance of 
connective tissue, which subsequently undergoes pro- 
gressive cicatricial contraction. The locations for 
the stricture are the same in typhoid and tubercular 
ulcers. 
Syphilitic stricture.—Among the multiform visceral 
lesions caused by tertiary syphilis are to be noted 
intestinal strictures. According to Rieder (“Annual 
of Universal Medical Sciences,” Vol. 1, D. 31) the 
lesions causing the obstruction are most frequently 
met with in the upper part of the small intestine. 
Syphilitic stricture is not caused by ulceration but by 
the production of new connective tissue in the sub- 
mucosa and later in the other coats. The symptoms 
attending syphilitic intestinal stricture indicate the 
existence of a mechanical obstruction without the 
existence of a previous ulceration, as is the case in 
tubercular stricture. 
Ovarian tumor.—The differential diagnosis between 
a tubercular stricture and intestinal obstruction caused 
by certain anatomico-pathologic forms of ovarian 
tumor is attended by many difficulties. In one of 
Czerny’s cases of ileo-cecal tuberculosis, the swelling 
was mistaken for an ovarian tumor by the attending 
physician. Veit has shown that in women the differ- 
ential dignosis between tuberculosis of the ileo-cecal 
portion of the intestinal tract and ovarian tumor 
which has extended to the meso-cecum and meso- 
colon is always extremely difficult and often impos- 
sible. 
Malignant stricture.—The two causes which give 
rise to intestinal obstructions most likely to be mis- 
taken for each other, are cicatricial stenosis following 
tubercular ulcer and malignant stricture. The ileo- 
cecal region is the favorite locality for both of these 
affections. In intestinal obstruction due to either of 
these causes the clinical history is characterized by a 11 
complexus of symptoms pointing to chronic obstruc- 
tion, and in either case involvement of the mesenteric 
and retroperitoneal lymphatic glands is sure to occur 
sooner or later. Tubercular strictures are found most 
frequently in persons below middle age, while carci- 
noma is more likely to occur in persons of advanced 
age. The reverse may, however, be the case, as intes- 
tinal tuberculosis may attack the aged and intestinal 
carcinoma may occur in young adults. The detection 
of a tubercular focus in another organ, and the dis- 
covery of tubercle bacilli in the stools will furnish 
evidences of the tubercular nature of the obstructive 
lesion and will exclude the probability of the exist- 
ence of malignant disease. 
Surgical Treatment. 
Address delivered at the Meeting of the Illinois State Medical Society, at Galesburg, May 17, 1898. 
The title of this paper will probably appear some- 
what strange and out of place to the general practi- 
tioner and the surgeons who have not kept fully abreast 
with the great advancements that have been made 
during the last decade in the diagnosis and surgical 
treatment of localized lesions of the intestinal tract. 
Our increased knowledge of the location, nature and 
clinical tendencies of accessible tubercular affections 
has opened a wide and fertile field for successful 
surgical intervention. There is hardly an organ in 
the body which when the seat of a localized tubercular 
process has not been exposed and subjected to direct 
treatment with a fair expectation of removing or lim- 
iting the further extension of the disease. The med- 
ical treatment of tuberculosis in its various forms at 
the present time is not much in advance of that of 
fifty years ago. The numerous specifics invented and 
vaunted in different parts of the world have all fallen 
by the wayside and the old-fashioned remedies are 
again taking their place. Leaving out the local 
measures we have to rely in the treatment of such 
cases largely on diet, change of climate and occupa- 
tion, outdoor air and the administration of those 
remedies known to exercise a favorable influence in 
improving digestion, nutrition and assimilation, 
and thus indirectly antagonize the ravages of the 
disease. 
Powerless as we remain today in the successful 
systemic treatment of tuberculosis, it is a source of 
gratification to know that great improvements have 
been made in the local treatment of accessible tuber- 
cular lesions. The intestinal canal is one of the last 
territories opened up for successful surgical invasion. 
All the work done in this department of surgery dates 
back but a few years. The results obtained by the 
surgical treatment of localized intestinal tuberculosis 
are such as to encourage further effort in this direc- 
tion. The number of cases operated upon so far 
remains a small one, and it is my intention on this 
occasion to bring them to the attention of the profes- 
sion of this country and to describe the different oper- 
ative procedures which have been employed by dif- 
ferent operators with the same aim in view, either to 
remove the diseased tissue, or to render the affected 
portion of the bowel accessible to direct treatment, or 
to place it in a more favorable condition for spon- 
taneous healing of the tubercular ulcers. 
This paper will deal largely with localized primary 
tuberculosis of the intestinal canal, with cases amen- 
able to successful surgical treatment. Diffuse pri- 
mary tuberculosis of the intestines remains, for the 
present, a surgical noli me tangere. Surgical inter- 
vention is also contraindicated in secondary intestinal 
tuberculosis in all cases in which the primary disease, 
usually pulmonary tuberculosis, is far advanced and con- 
stitutes in itself an imminent source of danger to life. 
There are, however, cases of primary intestinal tuber- 
culosis in which timely radical measures prove suc- 
cessful in eliminating the disease permanently and in 
restoring normal intestinal digestion and absorption. 
The attention of the mass of the profession must be 
called to the necessity of a more careful and thorough 
examination of chronic inflammatory affections of the 
intestinal tract, for the purpose of making an early 
and correct diagnosis and with a view of selecting 
appropriate cases for timely surgical treatment. The 
internist and the surgeon must co-operate with each 
other in the future development of this, one of the 
most recent departments of the healing art. 
I shall quote and describe the cases operated upon 
for intestinal tuberculosis under the headings of the 
different operative procedures: 
1. Abdominal section and iodofumigation.—Every 
surgeon is familiar with the curative effects of abdom- 
inal section and drainage, with or without iodofumi- 
gation, in cases of peritoneal tuberculosis. The modus 
operandi of this method of treatment has never been 
fully and satisfactorily explained, but the fact remains 
that it has proved eminently successful in the majority 
of such cases. There is no doubt in my mind that 
the local application of iodoform adds to the thera- 
peutic value of this method of treatment. In one of 
the cases which has recently come under the observa- 
tion of the writer abdominal section and drainage were 
resorted to on two different occasions, but the tubercular 
hydrops returned. Tapping and the injection of from 
7.4 to 15 c.c. of a 3 per cent, of iodoform-glycerin 
emulsion repeated six or eight times at intervals of from 
one to two weeks finally succeeded in effecting a cure, 
and the patient remains in perfect health, more than 
a year after the last tapping. Future observations will 
undoubtedly prove that peritoneal tuberculosis is more 
frequently caused by infection from primary intestinal 
lesions than has been heretofore supposed. 
It is not strange that the same treatment should 
occasionally prove equally useful and efficient in cer- 
tain cases of intestinal as in peritoneal tuberculosis. 
Nove-Josseraud (“ Tuberculose localises du caecum 
trait6e par la simple laparotomie,” Societedes Sciences 
M6dicales de Lyon. Lyon MSdicale, 1896, No. 22) 
made a laparotomy on a child 12 years old for a swelling 
the size of an adult’s fist in the region of the cecum. 
The incision demonstrated the existence of extensive 
tuberculosis of the cecum and adjacent portions of the 
ileum and ascending colon. The affected parts were 
not interfered with, except that they were wiped gently 12 
with iodoform gauze and dusted with a thin film of 
iodoform, and yet the operation was followed by a 
speedy and permanent recovery. 
This method of treatment has a limited application 
in the treatment of intestinal tuberculosis when the 
disease is too extensive for more radical measures and 
no obstructive lesion is indicated by the symptoms or 
discovered at the time of operation. Iodofumigation 
and capillary drainage with iodoform gauze for a few 
days would seem to be indicated in such cases. 
2. Enteroplasty.—Plastic operations are indicated 
in solitary circular strictures following the healing of 
a tubercular ulcer and constituting the cause of intes- 
tinal obstruction. In narrow circular strictures an 
operation similar to that devised by Heineke-Mikulicz 
for pyloric cicatricial stenosis will yield the most sat- 
isfactory operative and functional results. The stric- 
ture is divided on the convex side of the bowel and 
the incision carried sufficiently far into healthy tis- 
sues on each side of the stricture, in a direction parallel 
to the long axis of the bowel, and the visceral wound 
closed transversely by two rows of sutures of fine 
braided silk, thus restoring the lumen of the bowel 
to its normal size. 
P6an (Bulletin de VAcad6mie de M6decin, Dec. 30, 
1890) performed such an operation for cicatricial 
stenosis of the ileo cecal valve, following the healing 
of a tubercular ulcer. He made the abdominal inci- 
sion above and parallel to Poupart’s ligament. The 
bowel was tied above and below the constriction with 
a rubber cord passed through a slit in the mesentery. 
The intestinal wall was incised at the level of and at 
each side of the strictured valve for a distance of 
three inches. After washing out the opened segment 
of the bowel with a 1 per cent, solution of carbolic 
acid, the cicatricial tissue was excised. This being 
done, the two extremities of the intestinal wound 
were brought together by means of forceps. The 
incision, which was first longitudinal, soon took the 
form of a lozenge, two sides of which were represented 
by the lips of the small intestine and the other two by 
those of the large intestine. Bringing the forceps 
nearer together the incision became transverse, and 
in this position the edges were sutured in the usual 
way. Catgut was used for the inner and silk for the 
outer row of suturing. The patient recovered and re- 
mained in good health at the time the report was made. 
3. Enterectomy.—The most radical treatment of 
intestinal tuberculosis, in appropriate cases, is resec- 
tion followed by circular suturing. Resection is indi- 
cated in isolated intestinal tuberculosis as long as the 
swelling is movable and the disease gives rise to symp- 
toms of obstruction; if, however, the disease is no 
longer limited to the organ primarily affected, or if it 
is complicated by advanced pulmonary or general 
tuberculosis entero-anastomosis should take the place 
of a radical operation. Experience has shown that it 
is neither essential or even necessary to add to the 
gravity of the operation by attempts to remove the 
products of regional infection. After removal of the 
primary focus of infection the lymphatic tuberculosis 
usually comes to a standstill, although cases have been 
recorded in which later reinfections occurred from this 
source. 
Diffuse glandular tuberculosis in such cases is 
beyond the reach of safe surgery. Caseous glands in 
the mesentery, corresponding with the portion of the 
intestine excised, should be removed by including 
the mesentery in the excision. So far excision has 
only been performed in eases in which the tubercular 
lesion gave rise to intestinal obstruction. The results 
of this operation will be greatly improved in the future 
when intestinal resection will be performed as soon 
as a localized tubercular lesion can be diagnosticated, 
and before the patient’s general condition has been 
seriously impaired by the mechanical obstruction. 
Intestinal resection has been most frequently per- 
formed for tuberculosis in the ileo-cecal region. A 
number of cases, however, have been recorded in 
which the seat of the disease was the small intestine. 
Dr. Rudolph Matas made a successful enterectomy 
for intestinal stricture, following the healing of a 
tubercular ulcer involving the upper portion of the 
jejunum. The patient made a rapid and permanent 
recovery. (Personal communication.) 
Konig (“Die stricturirende TuberculosedesDarmes 
und ihre Behandlung,” Deutsche Zeitschvift f. Chi- 
rurgie, 1892, B. xxxiv, p. 62) reports five cases of 
stricture of the intestine caused by cicatricial contrac- 
tion of tubercular ulceration, all treated by laparotomy 
and resection of the intestine with circular enteror- 
rhaphy. Two of the patients died; one from exhaus- 
tion, the other from the giving way of a suture, an 
accident which resulted in leakage and diffuse peri- 
tonitis. He believes that this pathologic form of 
cicatricial stenosis is much more frequent and more 
easily recognized than has hitherto been thought. He 
has met with this affection most frequently in persons 
between 20 and 30 years of age, and especially in those 
suffering from other tubercular lesions. He has made 
a careful investigation of such cases and found that 
the clinical history usually reveals a chronic cause, 
frequent attacks of colic with constipation, tympa- 
nites, visible peristalsis and peculiar splashing and 
musical sounds, ending with a sound which resembles 
that of fluid driven forcibly from a syringe. The dis- 
ease invariably produces great emaciation and anemia 
In spite of the feebleness of the patients, Konig 
thinks surgical interference advisable, especially as 
the ulceration is probably still progressing in part of 
the cicatricial contraction and often the tubercular 
disease elsewhere is not far advanced. 
Treves (“Resection of Intestine,” The Lancet, Jan. 
4, 1896) made a resection of the intestine for tuber- 
cular stricture and united the bowel ends by the use 
of Murphy’s button. The patient made a satisfactory 
recovery. 
Sachs (Archiv fur klin. Chirurgie, 1892, B. 43), 
reports the following case of resection for intestinal 
tuberculosis: A woman, aged 41, had suffered for a 
Ions: time from constipation, and for two years had 
had loss of appetite and gradually increasing maras- 
mus and debility. On examination a hydronephrosis 
of the right kidney was discovered, and also a swelling 
in the right iliac fossa, which was supposed to be of a 
malignant nature. Laparotomy was performed when 
the right iliac fossa was found to be filled up by a hard 
swelling, which was the size of an adult’s fist. Sur- 
rounding the ileum was a band of contracted fibrous 
tissue with tubercular granulations in some places. 
The diseased parts were resected and the two ends of 
the intestine joined together by circular enterorrhapliy. 
The patient recovered and was in a satisfactory condi- 
tion several weeks after the operation. On examina- 
tion of the specimen removed the ileum was seen to 
be surrounded by a band of scar tissue and granula- 
tions. At the junction of the ileum with the cecum 
there was a large tubercular mass, which extended to 13 
the mesenteric glands. The mucous membrane of the 
cecum was replaced by tubercular granulations, which 
extended into the muscular coat, and on microscopic 
examination were seen to consist of epithelioid and 
giant cells. He collected thirteen cases of resection 
of the ileo-cecal portion of the intestinal canal for 
tuberculosis, of which eleven recovered. 
Zahlmann (Hospitals Tidende 1892, No 36) re- 
ports a case of tubercular stricture of the intestines 
removed by Tage Hansen of Denmark. The patient, 
a girl, aged 17 years, had been previously treated for 
tuberculosis of the phalanges of the fingers and toes. 
For one and a half years she had exhibited signs of 
stricture of the intestines, and at the laparotomy the 
entire cecum, with the adjacent parts of the ascending 
colon and ileum, was found to be the seat of an inflam- 
matory mass which had produced a stricture an inch 
and a half in length, of a diameter corresponding to 
that of a lead pencil, while the walls were nearly an 
inch in thickness. Six inches of the ileum, the entire 
cecum and four inches of the ascending colon were 
removed. The healthy ends of the ileum and colon 
were united by means of Lembert’s sutures, the diffi- 
culty in adapting the different lumina to each other 
being overcome by dividing the ileum by an oblique 
section at the expense of the convex side. The patient 
recovered and remained in good health at the time the 
report was made six months after the operation. 
Of five cases of intestinal tuberculosis in which the 
cecum and colon were the seat of disease, and in which 
Czerny resorted to resection and circular suturing, 
two died of peritonitis and one of hemoptysis after 
complete recovery from the operation. In one case 
the peritonitis was caused by leakage through one of 
the needle punctures, and in the second the perfora- 
ture occurred in consequence of abscess formation in 
the line of suturing. The patient died from the effects 
of peritonitis, septic pyemia and metastasis, five weeks 
after the operation. In one case the operation proved 
successful, but was followed by rapid generalization 
of the tubercular process, an observation fully corrob- 
orated by Wahllander and Wolff, who have called 
special attention to the diffusion of tubercular pro- 
cesses after intervention for what appeared as localized 
processes. In one case of secondary tuberculosis, 
following rupture of a tubercular adnexal abscess into 
the intestine, circular suturing after excision was 
found impossible and consequently an artificial anus 
was established with an excellent functional result. 
Among the cases operated upon by Czerny, and re- 
ported by Kindfleisch (“Ueber die an der Heidelberger 
Chir. Klinik ausgefiihrten Operation am Magen und 
Darme.” Beitrage zur Klin. Chirurgie B. ix, p. 661), 
are several in which the remote results of operations 
for intestinal tuberculosis have since been ascertained. 
In the case of a woman, 34 years of age, operated upon 
in 1886, nothing definite could be learned as to the 
subsequent history. In the case of an ileocecal resec- 
tion performed in 1888, on a man 30 years of age, 
death resulted three years later from pulmonary tuber- 
culosis. The postmortem revealed tubercular ulcers 
in the colon and small intestines, with miliary tuber- 
cles on the peritoneal surface and cheesy mesenteric 
glands. No information could be had in the case of 
a man, 54 years of age, subjected to ileo-cecal resec- 
tion, but the operation appeared to have exerted no 
influence in checking the progress of the pulmonary 
affection. A man, 26 years old, died of pulmonary 
tuberculosis two years after the operation. A woman, 
22 years of age, was in good health four years after 
the operation. A man, 31 years old, was found in 
excellent health four years after the operation, having 
gained during this time twenty-three pounds in weight. 
This patient suffered only occasionally from catarrh 
of the colon, the attacks being of short duration. 
These cases go to prove that resection for intestinal 
tuberculosis in well selected cases yields satisfac- 
tory remote results, wThile the reverse is true if the 
operation is performed under adverse conditions. 
Rentier (“Caecum provenant d’une resection ileo- 
sacrale pour tuberculose.” Bulletins et Memoires 
de la Soci6t6 de Chirurgie, 1896, No. 7) resected the 
entire cecum for tuberculosis and united the bowel 
ends by means of Murphy’s button. Death occurred 
on the sixth day after the operation. The lumen of 
the button, which remained in situ, was completely 
blocked by feces. Additional tubercular ulcers were 
found in the jejunum. 
Caminiti-Vinci (Riforma Medicinia, July 11, 1896) 
reports the case of a man, aged 24, without any tuber- 
cular family history, who for the last nine months had 
suffered from severe pain in the left superior quadrant 
of the abdomen, aggravated after meals; no diarrhea 
or vomiting. In the affected region an ill defined 
swelling could be felt, descending slightly with inspir- 
ation, rather painful on palpation. The patient, not 
improving under medical treatment, was operated 
upon March 8, 1896. The omentum was found thick- 
ened, hard and adherent to the small intestine for 
about ten centimeters; this was excised, and also about 
thirty centimeters of the intestine itself, with its mes- 
entery and glands. The bowel was united by circular 
suturing. The patient recovered and remained in 
good health four months after the operation. Macro- 
scopic and microscopic examination proved the tuber- 
cular nature of the disease in the parts removed. 
Courtillier (“Tuberculose clironiaue de Tangle ileo- 
caecal. Resection, Enterorrhapliie, GuG'ison, Fistule 
pyo- stercorale, Operation, Mort, Autopsie.” Bulletin 
de la Society Anatomique de Paris, 1896, No. 13) 
reports the case of a boy, 12 years old, operated upon 
by Broca for tuberculosis of the cecum. The entire 
cecum was resected and the ileum united with the 
ascending colon by circular suturing. The patient 
recovered from the operation and remained in perfect 
health for three years, when a fecal fistula appeared 
at the site of operation. Operation for closure of the 
fistula was followed by death. The autopsy showed 
the small intestine in a perfectly healthy condition, 
but the disease had reached the ascending colon and 
was complicated by tuberculosis of the left lung. 
Durante (“Resezioni intestinali per tuberculosi del 
cicco.” R. Acad. Medica di Roma, No. 4, 1895) has 
resected the cecum for tuberculosis five times. He 
calls attention to the difficulties presented relative to 
making an early diagnosis. Intermittent diarrhea for 
two to six years is a conspicuous and almost constant 
symptom. For a long time the general health is not 
much impaired. Symptoms of progressive cicatricial 
stenosis finally appear. In one case he was able to 
ascertain from examination of the specimen that the 
tubercular process had its primary starting point in 
the appendix. Of the five cases four lived and were 
in good health five to seven years after the operation. 
In one case relapse was due to incomplete removal of 
the infected tissues. He regards the prognosis as 
favorable after a complete extirpation of the affected 
portion of the intestine. 14 
Emil Muller (“ Extra - abdominal Tarmresection 
mid fortsatz; Extra-abdominal Behandling, Hospitals 
Tidende No. 3, 1896) resorted to resection in two 
cases of tubercular stricture of the intestine. In the 
first case the disease extended over the lower part of 
the ileum, cecum and ascending colon to within an inch 
of the right colic flexure. In the second case, the 
operation was performed extra-peritoneally. After 
opening the abdomen by lateral incision the colon was 
made movable by incising the external layer of the 
meso-colon, when the diseased portion of the intestine 
was brought forward into the wound. The inner layer 
of the meso-colon was sutured to the inner margin of 
the incision and the peritoneal cavity on the outer 
side of the bowel was shut out with an iodoform gauze 
tampon. After six days the affected portion of the 
intestine was extirpated extra-peritoneally. The con- 
tinuity of the intestinal canal was restored by circu- 
lar suturing, which could be done without invading 
the excluded peritoneal cavity. The external wound 
was sutured and drained. The patient recovered rap- 
idly, without any untoward symptoms and was dis- 
charged from the hospital with his health restored. 
To what extent operative procedure can be carried 
in true cases of intestinal tuberculosis with ultimate 
recovery is well shown by a case reported by Korte 
(Verhandlungen der Deutschen Gesellschaft fur 
Chirurgie, 1894.) The patient, a man, 25 years old, 
was operated upon in 1891 for acute suppurative peri- 
tonitis. The following year, March 16, the appendix 
was removed. In August, of the same year, a swell- 
ing developed along the course of the cecum and 
ascending colon. August 27, the cecum and ascend- 
ing colon, nearly as far as the hepatic flexure, were 
excised. Healthy tissue was not reached. An arti- 
ficial anus was established. The microscope dem- 
onstrated the tubercular nature of the intestinal affec- 
tion. The enterotome was used without any benefit. 
In November, twenty-one centimeters of the colon 
was resected. The end of the colon was invaginated 
and sutured and an entero-anastomosis established 
between the colon and the lower portion of the ileum. 
A fecal fistula followed the operation. In February, 
1893, Diffenbach’s enteroplasty was performed, but 
proved unsuccessful. In May, a loop of the small 
intestine was implanted into the sigmoid flexure. For 
two weeks there were normal evacuations per rectum, 
then a fecal fistula formed. July 3, what was left of 
the colon was permanently and completely excluded 
by closing both ends. Regular evacuatiousby rectum 
followed. July 23, the excluded colon was resected. 
Patient recovered. Subsequent treatment was with 
iodoform gauze packing. The fecal discharge from 
the fistula was always liquid, but as soon as it passed 
through what remained of the colon the stools became 
natural. Only one case of resection for intestinal 
tuberculosis has come under my own observation. 
Tuberculosis of the cecum and ileum; resection of cecum 
and eighteen inches of the ileum with corresponding portion 
of mesentery. Restoration of continuity of intestinal canal 
by lateral anastomosis with the aid of decalcified bone plates. 
Recovery; return of the intestinal affection and death six 
months after operation.—The patient was a spare man of 
medium height, 37 years of age, and a farmer by occupation. 
He is unaware of the existence of any hereditary taint or pre- 
disposition to tuberculosis or malignant disease in the family. 
His health was excellent prior to Aug. 16, 1887. On that day 
he was taken suddenly ill with an attack of vomiting, without 
any obvious cause, which lasted for six hours. The patient 
insists that toward the last he vomited fecal matter. He recov- 
ered rapidly and remained in comparatively good health until 
the following October, when he suffered from a similar attack 
of four hours duration. This time he experienced a sharp 
pain in the ileo cecal region, and soon after felt a distinct swell- 
ing in that locality. From this time on until March, 1889, the 
pain recurred periodically, the intervals becoming shorter 
until pain became almost continuous with few and incomplete 
remissions. During this time he suffered also a great deal from 
flatulence. The bowels were inclined to be loose, but the gen- 
eral health was not seriously impaired. Since March, 1889, 
diarrhea became a prominent symptom, the stools being liquid, 
but showing no trace of blood or mucus. Pain increasing in 
severity and more constant, and always partially relieved by 
the free escape of gas per rectum. A t the time he entered the 
hospital (Oct. 9, 1889), he had lost forty-five pounds in weight. 
Examination at this time revealed the existence of a hard, nod- 
ulated, fixed swelling in the ileo cecal region, and tympanites 
in the hypogastric and umbilical regions. Distention of the 
colon by rectal insufflation of hydrogen gas made the swelling 
more prominent and defined. Not much tenderness on pres- 
sure. Digital exploration of the rectum yielded a negative 
result. Marasmus and anemia were well marked. For the 
last seven months the patient has had daily from four to six 
liquid discharges from the bowels. Appetite is impaired, slight 
rise in the evening temperature, pulse from 80 to 90 per min- 
ute. From the history of the case, and more especially from 
the character and location of the swelling, a probable diagno- 
sis of tuberculosis of the cecum was made. As the usual 
medical treatment, which had been pursued for months, 
afforded but temporary relief, the consent of the patient and 
his friends to an operation was readily obtained. Laparotomy 
was performed on the day of his admission into the hospital. 
The abdomen was opened by an incision from near the middle 
of Poupart’s ligament to a point half way between the ante- 
rior superior spinous process of the ileum and umbilicus. On 
opening the abdomen the swelling at once came within easy 
reach. Examination showed that the swelling involved the 
entire circumference of the cecum, and its immobility sugges- 
ted that it was intimately connected with the retroperitoneal 
tissues by inflammatory adhesions. The lower portions of the 
ileum and cecum were emptied by displacing their contents, 
and each part was entrusted to an assistant, who was instructed 
to prevent fecal extravasation by digital compression, until the 
completion of the anastomosis. The ascending colon was 
divided about two inches below the margin of the swelling and 
the ileum near its junction with the cecum; both sections 
showed that the visceral incisions had been made through 
healthy tissue. The bleeding vessels were tied with'fine silk 
ligatures. Several large partially caseous glands were found 
in the retroperitoneal space behind the cecum and enucleated 
in one large mass with the cecum and a portion of peritoneum, 
which was adherent to the glands. After the removal of the 
cecum it was noticed that the mesentery of the lower portion 
of the ileum contained several enlarged glands, consequently, 
after preliminary ligation, it was excised with eighteen inches 
of the ileum. During the whole operation a small compress 
was kept in the abdominal cavity to prevent prolapse of the 
small intestines, and to guard against infection. After all 
hemorrhage had been carefully arrested, both ends of the 
bowel were closed by invagination and a few stitches of the 
continuous suture; the first stitch was made to transfix the 
mesentery at the point where it was invaginated into the bowel. 
Medium sized perforated decalcified bone-plates were used in 
making the ileo-colostomy, by lateral approximations. An 
incision about two inches in length near the closed ends of 
both intestines was made at a point opposite the mesenteric 
attachment, and into each opening a bone plate was inserted, 
and the lateral sutures, armed with a needle, were passed 
about an eighth of an inch from the margin of the visceral 
wound, from within outward and in such a way as not to 
include the peritoneum, at a point half way between the angles 
of the wound. The surfaces of the bowel corresponding to the 
part covering the plates were freely scarified with an ordinary 
sewing needle. The visceral wounds were now brought vis a 
vis in such a manner that both closed ends were directed 
downward, bringing in this way the free surface of the colon and 
ileum together. Before any of the plate sutures were tied, a 
number of Lembert sutures were applied posteriorly, so as to 
approximate the serous surfaces along the margin of the plates, 
thus affording additional security in maintaining coaptation. 
The posterior pair of approximation sutures was now tied with 
sufficient firmness to hold the parts in contact without suffi- 
cient pressure to cause gangrene, after which both pairs of 
sutures not armed with needles were tied. During the tying 
of these sutures it is of the greatest importance that an assist- 
ant should keep the plates accurately and closely pressed to- 
gether. The last to tie was the second anterior pair of trans- 15 
fixion sutures, and as this was being done the bowel on each 
side was carefully pushed in between the plates with a probe. 
After all the approximation sutures were tied, it only remained 
to apply on the anterior side a few Lembert sutures. After 
the exposed parts were disinfected and dried, the bowel was 
returned into the abdominal cavity and anchored near the 
wound with a silk suture, which was made to embrace the 
parietal peritoneum on one side and the mesentery on the other, 
at a point opposite the anastomotic opening. The abdominal 
incision was sutured throughout, no provision was made for 
drainage. The subsequent history of the case was uneventful. 
The highest temperature registered was on the third day when 
it reached 101.5 degrees F., but returned to normal on the 
fourth day. During the first two days liquid food was admin- 
istered by rectum. After that time the patient was allowed 
milk, beef tea and raw eggs, and after another week he was 
given the ordinary hospital .diet, which he relished. The 
bowels moved several times a day, the passages gradually 
becoming normal in color and consistence. The external 
wound healed by primary intention with the exception of a 
small place where a stitch abscess formed at the end of the first 
week. At the ninth day half of the plate in the colon passed 
per rectum, and the following day the remaining half, with the 
plate from the ileum with the sutures attached, were found in 
one of the stools. The patient left his bed on the twenty - 
eighth day after the operation, and three days later he returned 
to his home. At the time he left the hospital nothing abnor- 
mal could be felt in the right iliac fossa, no pain and no ten- 
derness on pressure. He gained rapidly in flesh and strength, 
and when I saw him again, during the latter part of January, 
1890, he weighed nearly as much as before he was taken ill. 
Since the operation he has had no pain, no diarrhea, and the 
discharges from the bowels once or twice a day were normal in 
every respect. At this time, however, I was able to detect a 
small hard swelling behind the colon at a point above where 
the ileum had been attached, which I regarded as a recurrence 
of the disease along the chain of lymphatics behind the peri- 
toneum, but no evidence of a return of the disease in the 
bowel could be found. In the course of a few months the 
patient died from the effects of the recurrent disease without 
any symptoms of obstruction. 
I have had reason to regret that I did not resort to 
a second operation as repeated operations in similar 
cases have finally succeeded in eliminating the dis- 
ease. The specimen removed represents the entire 
cecum, a number of cheesy mesenteric and retroperi- 
toneal glands, eighteen inches of the ileum with the 
corresponding mesentery. A few small tubercular 
ulcers were found in the lower portion of the section 
of the ileum removed. The tubercular process had 
evidently started in the cecum which it involved in 
its entire circumference. The walls of the cecum had 
become greatly thickened by the infiltrations. The 
lumen of the ileo-cecal valve was not larger than an 
ordinary lead pencil, and the interior of the cecum, 
near the valve, presented a number of deep excava- 
tions resulting from the breaking down and ulceration 
of the tubercular mass. The ileum for a consider- 
able distance was the seat of a well marked compen- 
satory hypertrophy, the thickening of its walls being 
due to an increase in muscular fibers, a result which 
so constantly follows progressive intestinal stenosis. 
The presence of numerous caseous mesenteric and 
retroperitoneal lymphatic glands, the character of the 
ulcers and microscopic examination of the diseased 
tissues removed, proved the tubercular nature of the 
inflammatory process. Although in this and some 
other cases the use of decalcified bone plates proved 
satisfactory in establishing a lateral anastomosis, I 
have discarded largely this and similar mechanical 
aids in. intestinal surgery and have learned to rely on 
suturing in all cases in which there are no contra- 
indications presented to this method of dealing with 
intestinal wounds. 
From the accumulated experience of the past in the 
treatment of intestinal tuberculosis by resection, it 
becomes evident that this operation is indicated in all 
cases in which the disease is sufficiently circumscribed 
to admit of complete removal, and the general condi- 
tion of the patient is such as to entitle us to the hope 
that the operation will not prove fatal by its immedi- 
ate effects. It is in such well selected cases that enter- 
ectomy will find far better results than any other 
operative procedure, as it has for its object the com- 
plete eradication of the disease, thus protecting the 
patient against reinfection from this source. 
Partial physiologic exclusion of affected portion 
of intestinal canal by entero-anastomosis.—Ten years 
ago I made a series of experiments on the lower ani- 
mals for the purpose of demonstrating Ihe value of 
partial physiologic exclusion of the intestine by 
entero-anastomosis in the treatment of certain local- 
ized affections not amenable to resection. The results 
of the experiments proved that the excluded portion 
undergoes atrophy and is placed in a condition 
approaching physiologic rest. In none of the experi- 
ments did the excluded portion became the seat of 
fecal accumulation. 
In the introduction to this part of the paper on 
“Experimental Intestinal Surgery,” I said: “As ex- 
tensive resections of the intestine are always attended 
by great risks to life from trauma, I concluded to 
study the subject of sudden deprivation of the system 
of a more or less extensive surface for digestion and 
absorption, by eliminating or diminishing the cause 
of death from this source, by leaving the intestine, 
but by excluding permanently a certain portion from 
participating in the functions of digestion and absorp- 
tion; in other words, by resorting to physiologic 
exclusion. These experiments were also made to 
determine the tissue changes which would take place 
in the bowel thus excluded, and to learn if under such 
circumstances accumulation of intestinal contents 
would take place and constitute a source of danger, as 
had been feared by the older surgeons.” 
The results of the experiments, as well as clinical 
experience since that time, have shown conclusively 
that this fear is unfounded. In speaking of the 
results of the experimental work and its application 
in intestinal surgery, the following statements were 
made in the same paper: “The exclusion was com- 
plete, or nearly so, hence we must conclude from the 
postmortem appearances, that in nearly every instance 
the excluded portion presented an absorptic, contracted 
condition, and was only sparingly supplied with blood 
vessels. From a practical standpoint these experi- 
ments teach us that a limited portion of the intes- 
tinal canal can be permanently excluded from the 
processes of digestion and absorption in proper cases, 
by operative measures without incurring any risk of 
fecal accumulation in the excluded part. These ex- 
periments demonstrate also that physiologic exclusion 
of a certain portion of the intestinal tract is a less 
dangerous operation than excision, and that in certain 
cases of intestinal obstruction where excision has 
heretofore been practiced, it can be resorted to as a 
substitute for this operation in cases where excision 
is impracticable or where the pathologic conditions 
which have caused the obstruction do not, in them- 
selves, constitute an intrinsic source of immediate or 
remote danger to life. The postmortem appearances 
of the specimens of these experiments tend to prove 
that as long as any of the contents of the intestines 
reach the excluded portion, the peristaltic or anti- 
peristaltic action in that part is effective in forcing 
it back into the active current of the fecal circulation.” 16 
Since that time entero-anastomosis has become a 
well established operation, and has proved of signal 
success in the treatment of limited intestinal tubercu- 
losis complicated, as it so often is, by cicatricial steno- 
sis. The operation effects two desirable objects in 
the treatment of such cases. 1, it relieves the symp- 
toms of intestinal obstruction; 2, it secures rest for 
the part affected. I have had an opportunity to 
perform entero-anastomosis in two cases of intestinal 
tuberculosis. 
Intestinal tuberculosis complicated by acute intestinal 
obstruction caused by cicatricial stenosis; ileo-ileostomy; 
recovery; patient in almost perfect health two years after the 
operation.-— The patient was a boy 16 years of age, member of 
a healthy family, free from any predisposition to tuberculosis 
or malignant disease. He had never been seriously ill and 
was in the best of health, weight 140 pounds when he was 
attacked with colicky pain, which he referred to the umbilical 
region, December, 1895, which continued for two days. He 
recovered from this attack and remained in fair health until 
Dec. 18, 1896, when he was again seized with fever pains in the 
abdomen of a colicky nature, which continued until he entered 
the hospital. Bowels had not moved for two days prior to his 
present illness. Vomiting which soon became fecal, and abso- 
lute constipation followed by great tympanites came on in rapid 
succession. The attending physician made a diagnosis of 
intestinal obstruction and resorted to the usual treatment 
including the use of high rectal enemata with little or no 
relief. When he was admitted into the St. Joseph’s Hospital, 
March 1, 1896, he had lost forty pounds in weight. He was 
very anemic and the emaciation was pronounced. The abdo- 
men was enormously distended, visible intestinal coils could 
be distinctly outlined. Temperature was normal, pulse small, 
100 per minute. There had been no free movements from the 
bowels since the attack; frequent attacks of vomiting, at times 
fecal in character. Rectal examination yielded no information 
regarding the anatomic location or nature of the obstruction. 
The day after his admission into the hospital, after thorough 
preparatory treatment, laparotomy was performed. The abdo 
men was opened in the median line, half way between the 
umbilicus and pubes. Intestinal coils, enormously distended 
and exceedingly vascular, protruded at once from the wound 
and were carefully protected with compress wrung out of a hot 
physiologic solution of salt. One of the first things noticed 
was the existence of numerous enlarged mesenteric glands. 
Some of them were the size of a hazel nut and presented dis- 
tinct evidences of beginning caseation. The visceral as well as 
the parietal peritoneum was studded with innumerable tuber- 
cle nodules. The existenee of peritoneal and glandular tuber 
culosis was at once made evident. In searching for the seat 
of the obstruction the distended intestine was traced in a 
downward direction, the intestinal loops being replaced as 
soon as examined so as to prevent extensive eventration. In 
reaching the lower part of the ileum, the obstruction was 
found about twelve inches above the ileo-cecal junction, in the 
form of a tight circular stricture. Above this point the intes- 
tine was uniformly distended, very vascular, while below the 
obstruction the intestine was empty, contracted and pale. An 
ileo-ileostomy was made by establishing an anastomotic open- 
ing between the lower part of the distended ileum and that 
part of the ileum between the obstruction and the cecum. 
Before the visceral incisions were made the serous surfaces of 
the convex side of the intestinal loops, which were to be united, 
were sutured together with a row of Lembert stitches, extend- 
ing a little beyond the intended limits of the incisions. On 
incising the proximal, distended loop the bowel was drawn 
well forward, the patient placed on his right side and as much 
of the intestinal contents as could be poured out was evacuated 
through the incision. After incising the empty loop to the 
same extent the mucous membrane was sutured all around 
and finally a row of anterior serous stitches completed the 
operation. The parts exposed were thoroughly cleansed, dried 
and lightly dusted with iodoform, after which the intestines 
were returned and the external incision closed in the usual 
manner. The patient recovered promptly from the immediate 
effects of the operation. The incision healed by primary inten- 
tion throughout. The bowels moved freely the day after the 
operation. The tympanites diminished rapidly and disap- 
peared entirely in the course of a week. For a few days the 
stools were copious and liquid, later once a day and normal in 
color and consistence. Rectal feeding was continued for four 
days, later liquid food by the stomach, followed by solid food 
at the end of the first week. The patient left the hospital in 
excellent condition, March 30, 1896. A letter from his physi- 
cian received recently, states that he is in perfect health, hav- 
ing gained twenty-seven pounds in weight two years after the 
operation. 
Careful search for tuberculosis in other organs was 
made but proved negative. The tubercular nature of 
the intestinal affection in this case was obvious from 
the simultaneous existence of peritoneal and lymph- 
atic tuberculosis. The entero-anastomosis relieved 
the obstruction promptly and placed the affected 
organs in a condition for spontaneous healing of the 
tubercular lesions. The patient was placed upon the 
prolonged internal use of guaiacol, which may have 
contributed to the remarkable result of the operation. 
Tuberculosis of the cecum, and ascending colon, compli- 
cated by tuberculosis of the urinary organs; ileo sigmoidos- 
tomy; death forty eight hours after operation from exhaus- 
tion.—The patient was a man 38 years old, who was admitted 
into the Presbyterian Hospital Nov. 6.1897. His health began 
to decline four years ago, when symptoms of chronic cystitis 
developed. For a long time the urine contained pus and at 
times blood. In February, 1896, he had a chill followed by 
fever and pain in the region of the right kidney. A swelling 
developed below the costal arch on the same side and soon 
reached as far as the crest of the ilium, and to within an inch 
or two of the median line on the left. The temperature ranged 
between 102 and 101F. for five days. A second chill occurred 
a few days later followed by slight jaundice, which continued 
for a few days. The swelling was diagnosticated as an abscess, 
which was incised in front at a point half way between the last 
rib and crest of the ilium. On cutting through the abdominal 
wall the distended kidney presented itself and was incised, 
and about a pint of pus escaped. The cavity was washed out 
and drained. For some time urine escaped through the drain- 
age opening. Three weeks after the operation feces escaped 
through the opening and the fecal fistula has remained since 
that time. At the time the patient entered the hospital he 
was very anemic and greatly emaciated. Examination of the 
bladder and prostate left no doubt that both of these organs 
were the seat of a tubercular affection. Through the fistulous 
opening a probe could be inserted into the ascending colon. 
Gas and fecal material escaped through the opening daily. 
Action of bowels irregular, diarrhea and constipation alter- 
nated with each other. From the cecum in the course of the 
colon a resistant swelling could be felt, which extended some- 
what above the fistulous opening. Examination of the lungs 
revealed a limited infiltration in the left apex. A slight rise in 
the evening temperature was almost a constant feature. The 
fistulous opening externally was enlarged and a large cavity 
found between the skin and abdominal muscles, which was 
lined with fungous granulations. These were scraped out 
with a sharp spoon and the cavity thoroughly disinfected and 
packed with iodoform gauze. This and the subsequent 
operations were performed in the clinic of Rush Medical Col- 
lege. The scraping out of the cavity was followed by increased 
fecal discharge and in a short time the fistulous opening in the 
colon was large enough to insert the tips of two fingers. Car- 
bonate of guaiacol and tonics were admintered internally, but 
the patient continued to lose strength and flesh. Owing to 
the existence of formidable complications and the extent of 
of the intestinal affection I decided to exclude the cecum and 
colon, as far as the sigmoid flexure, from the fecal circulation, 
by performing ileo sigmoidostomy. 
After making careful preparation the operation was per- 
formed Dec. 20, 1897. The abdomen was opened in the median 
line. The cecum and ascending colon, nearly as far as the 
hepatic flexure, were found imbedded in an extensive exudate. 
Numerous enlarged lymphatic glands especially in the meso- 
cecum and mesentery of the ascending colon. The anasto- 
motic opening was established between the ileum, about 
eighteen inches above the cecum and the sigmoid flexure. 
The operation was performed in a similar manner as in the case 
of lateral anastomosis after excision with the exception that no 
bone plates were used, the visceral wounds being united by 
two rows of sutures. The operation was completed in less than 
an hour. Very little shock followed. The next day, however, 
vomiting and symptoms of prostration set in, the pulse became 
more rapid and feeble, but the temperature never exceeded 
100 F. Death occurred forty-nine hours after the operation. 
The clinical history in this case points to primary 
tuberculosis of the urinary organs followed by intes- 
tinal and, later, pulmonary tuberculosis. A number 17 
of cases have been reported in which entero-anasto- 
mosis was performed for intestinal tuberculosis. 
Hofmeister (“On Multiple Stenosis of the Intestine 
of Tubercular Origin,” Beitrage zur Klinischen Chir- 
urgie, B. xvii, No. 8) reports a case of multiple tuber- 
cular strictures of the intestine treated by establish- 
ing an entero-anastomosis. The patient, a man aged 
32, had suffered for four years with attacks of colic 
accompanied by vomiting and constipation, recurring 
at intervals of greater or less length, the last seizures 
had been particularly severe. Finally the patient was 
taken to the surgical clinic of Bruns, at Tubingen, 
with all the symptoms of a marked intestinal obstruc- 
tion. The operation, which was undertaken without 
delay, revealed ten annular strictures of the small 
intestine, f6r the most part, very narrow and distrib- 
uted over two meters of the bowel. The large intes- 
tine was absolutely empty and contracted. Resection 
being out of the question on account of the debili- 
tated general condition of the patient an anastomosis 
was made between the intestines above and below the 
seat of obstruction. At the very outset the distended 
intestine was punctured with a small trocar, to evac- 
uate its contents The puncture was closed with two 
rows of sutures. The patient was temporarily im- 
proved by the operation, but died the following day 
in sudden collapse. The autopsy revealed the fact 
that death had been caused by a general peritonitis. 
Inspection showed that the sutures inserted for the 
purpose of closing the puncture-opening were insuffi- 
cient to resist the intra-intestinal pressure by gas, and 
had given way, followed by fecal extravasation. 
Besides the ten discovered at the operation, two addi- 
tional strictures were found, one near the ileo-cecal 
valve and the other a little higher up. When the 
strictures are multiple the disease usually involves the 
ileum. Hofmeister found records of eighteen cases 
of multiple strictures of the intestines of a tubercular 
nature. 
Murwedel (“Ueber Entero-anastomosis,” etc. Beit- 
rage zur Chirurgie, B. xiii, Heft 3) reports a case of 
tuberculosis of the cecum treated by entero-anasto- 
mosis from Czerny’s clinic. The patient was a man, 
43 years of age. No hereditary predisposition to 
tuberculosis in the family. He suffered from two 
attacks of localized peritonitis, probably caused by 
appendicitis, the first in 1870, the second in 1887. 
Since last attack pain and tenderness in the right iliac 
fossa remained. In 1891, the pain increased, attended 
by colicky pains in the abdomen, the latter disap- 
peared after two or three minutes under a loud pour- 
ing sound. Bowel movements were irregular! A few 
weeks before his admittance into the clinic eructa- 
tions and transient vomiting returned. He was 
treated for some time in the medical clinic, by high 
enemata without any benefit. He was admitted into 
the surgical clinic, August 17, 1893. At this time 
with the exception of a chronic conjunctivitis, rhinitis 
and pharyngitis and a slight pulmonary emphysema, 
the general health of the patient did not appear to be 
much impaired. Cecal region was prominent, and to 
the right of the cecum and ascending colon, particu- 
larly the latter, a hard cylindrical swelling could be 
felt, extending from the iliac spine to the tip of the 
eleventh rib. The swelling was fixed and tender on 
pressure, there was visible peristalsis of small intes- 
tines near cecum. 
Clinical diagnosis: Stenosis and tumor formation in 
the region of the cecum and ascending colon, chronic 
inflammatory (perhaps tubercular) process. First 
operation, Aug. 20, 1893. Vertical incision in the 
linea Spigelii showed infiltration of pre-peritoneal 
tissues and firm adhesions between anterior abdom- 
inal wall and ascending colon. In separating the 
adhesions an ulcerated portion of the colon near its 
middle was torn and a quantity of pus but no fecal 
material escaped. From this opening digital explora- 
tion showed that the colon was ulcerated as far as the 
ileo-cecal valve, which induced the operator to aban- 
don all thoughts of performing a resection. The 
tear in the bowel was sutured and an entero-anasto- 
mosis made. The lower portion of the ileum was dis- 
tended and hypertrophied, on the other hand the 
transverse colon contracted and atrophied. These 
two parts of the intestinal canal were then brought 
into communication by establishing, by incision and 
suturing a free anastomotic opening. The sutured 
wound of the colon was fastened to the abdominal 
wall with two peritoneal sutures. External incision 
was closed with the exception of a space over the 
cecum to secure drainage, which was effected by using 
the iodoform gauze tampon. The diagnosis made at 
this time confirmed the previous suspicion of the 
tubercular nature of the affections. Bowels moved 
on the second day after the use of an enema. A week 
after the operation some fecal matter was mixed with 
the discharge from the wound. When the patient 
was discharged, four weeks after the operation, the 
wound was healed, with the exception of a fistula, 
which discharged a small quantity of pus, but no 
fecal material. Bowels moved without the aid of 
cathartics or enemata. General conditions much 
improved. During the fall of the same year, he was 
attacked with influenza and at the termination of the 
illness the parts around the fistula became inflamed 
and soon after, a more copious flow of pus ensued, 
which became mixed with feces. He re-entered the 
clinic Nov. 31,1893. The swelling in the cecal region 
was smaller but firmer than at the time of operation. 
There was constipation, which when relieved by 
cathartics, was followed by diarrhea, some of the fecal 
material escaping through the fistula. At this time 
the fistulous tract was enlarged with the knife suffi- 
ciently to enable exploration of the abscess cavity 
with the finger. The cavity was about the size of a 
walnut, partly filled with hard fecal masses and lined 
with tubercular granulations. Curettage and iodoform 
gauze tamponade were used. After operation nearly all 
of the feces escaped through the fistula. Third opera- 
tion was performed December 7 of the same year. 
The old scar was incised and the adherent ascending 
colon separated. During this step of the operation a 
small subcutaneous abscess was opened. The fistulous 
opening was next exposed and was found near the lower 
end of the ascending colon, where a defect was found 
large enough to admit the tip of the index finger. Ex- 
ploration of the interior of the cecum revealed a large 
cicatrized surface. The margins of the intestinal 
fistula were vivified and the opening closed with two 
rows of sutures, the operation being entirely extra- 
peritoneal. The external incision was closed with the 
exception of a space large enough to bring out the 
iodoform gauze tampon. No unfavorable symptoms 
followed the operation. Normal stool after injection 
on the eighth day. Patient left the hospital with a 
small fistula on the last day of the same month, 
almost in perfect health and with normal bowel 
movements. One year later the fistula still remained 18 
and at times small quantities of feces escaped, otherwise 
the patient was in good health and had gained twenty- 
three pounds in weight. Czerny attributes the heal- 
ing of the extensive tubercular ulcerations to the 
elimination of the affected part of the bowel from 
the fecal circulation by the ileo-colostomy. Schiller 
reports three cases of intestinal tuberculosis treated 
by physiologic exclusion of the affected part, operated 
upon in Czerny’s clinic during a period of four years. 
(“Ueber Darmoperationen an der Heidelberger Chi- 
rurgischen Klinik, etc.” Dissertation, 1896.) In all 
cases the disease was located in the cecum and had 
given rise to chronic obstruction. In two cases the 
anastomotic opening was made between the ileum and 
transverse colon, and one between the ileum and 
the ascending colon. In two cases the cecum was 
incised and the tubercular ulcers curetted. The vis- 
ceral incision was closed by suturing parallel with 
the long axis of the bowel. In one case the diseased 
appendix was excised in addition. In one the gall 
bladder was extirpated at the same time for lithiasis 
and chronic inflammation. In all of the cases the 
contraindications to resection were well defined. In 
one case the operation was done by the use of the 
Murphy button, which was removed from the ampulla 
of the rectum on the fifteenth day after a severe hem- 
orrhage three days previously. The pulmonary symp- 
toms became seriously aggravated after the hemor- 
rhage. All these cases recovered and the patients left 
the hospital improved. In one case (reported in 
extenso above), a fecal fistula developed, which was 
sutured on two occasions wdth partial success. 
The exclusion of the affected part of the intestine 
although not complete, led to speedy healing of the 
ulceration, as was shown in one case at the second 
operation, four and one-half months later. The heal- 
ing of the ulcers was undoubtedly favored by the atro- 
phy and diminished peristaltic action, conditions 
which are always established in the excluded part 
soon after the operation. 
James Israel (“Ueber Chirurgische Heilung von 
Peritoneal und Darmtuberkulose,” Ceniralblatt fur 
Chirurgie, 1896, No. 4) reported to the Surgical 
Society of Berlin a case of tuberculosis of the cecum 
and ascending colon in a woman 20 years of age, 
greatly improved by establishing a communication 
between the ileum and the ascending colon. The 
disease was attended by symptoms indicative of 
chronic intestinal tuberculosis. Exploratory laparot- 
omy was performed and a probable diagnosis of sar- 
coma was made. The mesenteric glands were found 
enlarged. Later a second operation was performed, 
when a swelling the size of an apple was found pro- 
jecting into the ascending colon, complicated by dis- 
seminated peritoneal tuberculosis. The patient made 
a good recovery, gained in weight, and after seven 
months, the swelling was reduced in size to that of a 
walnut. 
Gessner (“ Entero-anastomose bei tuberculoser 
Darmstriktur,” Centralblatt f. Chirurgie, 1896, No. 
6) made a laparotomy on a case in which the cecum 
was tubercular and had attained the size of a goose- 
egg. The swelling was nodulated and the serous coat 
studded with miliary tubercles. The obstruction 
caused by cicatricial stricture in the region of the 
ileo-cecal valve was relieved by an anastomosis be- 
tween the ileum and the ascending colon, which was 
made by the aid of the Murphy button. The button 
was discharged per rectum on the thirteenth day. 
The operation was followed by manifest improve- 
ment. 
A very interesting case of intestinal tuberculosis 
complicated by invagination came under the observa- 
tion of Czerny and is reported in detail by Murwe- 
del (“Ueber Entero-anastomose, etc.” Beitrage zur 
Klinischen Chirurgie, B. xiii, Heft 3). The patient 
was a boy 14 years of age who, two months prior to 
Ins admission into Czerny’s clinic, was suddenly taken 
ill with vomiting and severe pain in the abdomen, 
attended with the appearance of a swelling in the 
upper and right side of the abdomen. In a few days 
the pain subsided and the vomiting occurred less fre- 
quently. A sausage-shaped tender swelling, above the 
umbilicus, remained. Bowels could only be moved by 
the use of injections. For a few days during the early 
part of the attack the stools contained traces of blood. 
On his admission into the clinic, June 2, 1894, the 
patient presented an anemic appearance and was con- 
siderably emaciated. There was no fever, lungs and 
heart normal. Inspection and palpation revealed the 
existence of a cylindric swelling, ten centimeters in 
length, in the region of the transverse colon. The 
swelling was slightly movable and tender on deep pres- 
sure. Liver, spleen and kidneys were normal in size 
and function. Under rectal insufflation the swelling 
increased in size, and dulness on percussion gave way 
to tympanitic resonance. Capacity of colon was only 
three pints. The rectal injection did not increase the 
dulness on percussion over the swelling and was fol- 
lowed by the escape of hard fecal masses. Chronic 
invagination of ascending and transverse colon was 
diagnosticated. Operation was performed June 6. 
Median incision was made from xiphoid cartilage to 
umbilicus, which later had to be extended two inches 
to bring the invaginated colon forward into the wound. 
The swelling, the size of two fists, was composed of 
the cecum and ascending colon, into which the lower 
portion of the ileum had become invaginated. The 
intussusception could be traced as far as the right 
flexure of the colon. Reduction, owing to the pres- 
ence of extensive adhesions, was found impossible, 
and resection was contraindicated by the debilitated 
condition of the patient. An entero anastomosis be- 
tween the ileum above the invagination and the middle 
third of the transverse colon, was established by incis- 
ing the previously approximated ileum and colon and 
suturing the visceral wounds with two rows of sutures 
in the usual manner. Abdominal incision was closed 
throughout. 
The existence of a tubercular lesion of the invagi- 
nated bowel was suspected from the presence of a 
plastic caseous perityphlitis. Recovery was without 
any untoward symptoms. Patient left the hospital 
August 9, swelling much diminished in size, bowel 
movements normal. A year later the patient remained 
in good health and examination showed that the invag- 
ination swelling had nearly disappeared. The tuber- 
cular complication presented itself in the form of 
caseous adhesions found at the time the operation was 
performed. The infection probably occurred from the 
intestinal canal. Whether the tuberculosis occurred 
as a primary affection or whether it appeared after the 
invagination had taken place, would be difficult to 
determine. Flenier describes two other cases of intes- 
tinal tuberculosis from Czerny’s clinic in which the 
pathologic conditions produced by the disease gave 
rise to invagination (Virchow’s Archiv, B. 101). 
The cases reported above furnish conclusive proof 19 
of the therapeutic value of entero-anastomosis in the 
treatment of intestinal tuberculosis, sufficiently lim- 
ited to warrant surgical interference and beyond the 
reach of successful treatment by more radical measures. 
Complete physiologic exclusion.—Practical experi- 
ence has demonstrated the value of partial physiologic 
exclusion in the treatment of certain forms of local- 
ized intestinal tuberculosis. It would be natural to 
assume that the therapeutic value of entero-anasto- 
mosis would be enhanced if the affected part of the 
bowel could be completely excluded from the fecal 
circulation, thus securing for the diseased tissue a 
condition of absolute rest. At the time the writer 
made his experiments on physiologic exclusion of 
parts of the intestinal canal, he had this object in 
view and made a number of experiments to demon- 
strate the possibility and practicability of the proce- 
dure. The exclusion was made by isolating a section 
of the intestine and closing its ends by invagination 
and a few Lembert sutures. The continuity of the 
intestinal canal was restored by circular suturing or 
lateral anastomosis. The results of these experiments 
proved unsatisfactory, as it was found that the retained 
intestinal secretions constituted a source of danger. 
A few years later, Salzer modified the operation by 
establishing a fistula in connection with the excluded 
portion. This method of effecting complete physio- 
logic exclusion has been resorted to only in a very few 
cases in the surgical treatment of intestinal tubercu- 
losis. I will limit myself to a detailed reference to v. 
Eiselberg’s case. 
In a case of tuberculosis of the cecum, ascending 
colon and hepatic flexure, this surgeon (“Zur Casu- 
istik der Resectionen und Entero-anastomosen am 
Magen und Darmcanal,” Arch. f. Klin. Chirurgie, B. 
54, Heft 8), resorted to complete physiologic exclu- 
sion, with temporary benefit. The patient was a man 
85 years old, who was in good health until five years 
ago, when a tubercular affection of the foot developed, 
followed soon by symptoms of acute pulmonary tuber- 
culosis. Three years ago, the head of the tibia was 
operated upon by curettage, for tubercular caries. 
During the healing of the wound the patient suffered 
from an attack of perityphlitis, from which he recov- 
ered, but the disease was followed by periodic pains 
in the ileo-cecal region, at short intervals. During 
the last few months the pulmonary symptoms became 
aggravated and an obstinate diarrhea set in. On 
admission into the hospital, examination revealed 
extensive tubercular infiltration of left apex of lung 
and a cylindric swelling in the region of the cecum; 
the swelling was somewhat movable and tender on 
pressure. Operation was commenced, by making an 
oblique incision directly over the cecum. The cecum 
was found smaller than normal and not adherent. The 
infiltration extended from the ileo-cecal valve to the 
middle of the transverse colon. The affected portion 
of the bowel was completely excluded and the conti- 
nuity of the intestinal canal restored by circular sutur- 
ing, the resected end of the ileum had to be joined 
with the transverse colon. The mucous membrane, at 
the points of section, appeared to be healthy. The ends 
of the excluded portion were fixed in the upper and 
lower angles of the wound, respectively, and the bal- 
ance of the abdominal incision was closed in the usual 
manner. From the excluded portion of the intestine 
mucus and pus escaped in considerable quantities. 
The patient improved temporarily. On the seventh 
day the affected part of the bowel was washed out 
carefully, from both ends, with a warm physiologic 
solution of salt. These irrigations proved the com- 
petency of the ileo-cecal valve. The flushings were 
found useful in diminishing the amount of the inflam- 
matory product. The patient left his bed in three weeks. 
A few days later the pulmonary symptoms became 
more marked and when the patient left the hospital, 
a week later, he was attacked with pulmonary hemor- 
rhage, which recurred several times and from the 
effects of which he died two months after the opera- 
tion. Diarrhea reappeared soon after the operation 
and continued to the end. The persistence with which 
the diarrhea continued soon after the operation tends 
to establish the existence of the tubercular lesion of the 
mucous membrane beyond the limits of the operation. 
Complete physiologic exclusion will, in all proba- 
bility, have a very limited scope in the surgical treat- 
ment of intestinal tuberculosis, as the immediate dan- 
gers to life are almost equivalent to the risks incident 
to resection and the advantages over those of partial 
exclusion are not sufficient to warrant a more general 
recourse to this procedure.' There can be but very 
little doubt that with an increased knowledge of the 
etiology and pathology of intestinal tuberculosis sur- 
geons will be induced to resort to operative treatment 
more frequently in the future, and that with further 
improvements in the technic of intestinal operations, 
the surgical treatment will yield more encouraging 
results.