On Tubercular and Suppurative Peritonitis. BY GAEL BECK, M.D., NEW YORK. REPRINTED FROM THE Neto ¥orfc J&eUtcal journal for April SI, 1894. Reprinted from the New York Medical Journal for April 189 f ON TUBERCULAR AND SUPPURATIVE PERITONITIS* By CARL BECK, M. D., NEW YORK. It is only within a few years that surgery has become a rival of internal medicine in the field of the different forms of peritonitis-just as the kidney was regarded to be the domain of internal medicine only until Gustav Simon, by performing the first successful nephrectomy, showed this to be an error-while before treatment of the different forms of peritonitis seemed forever to be condemned to consist of opium or calomel and the ice bag or the flaxseed poultice. It is a characteristic sign of our period that now the physician and the surgeon are in entire accord in these cases, and are mutually dependent one on the other. The first step in that direction was undertaken when in this country the indications for and the limits of the operation for appendicitis were outlined. The gratifying results which are obtained in this affection have shown that this direction was the right one. * Read in part before the Surgical Section of the Academy of Medi- cine, November 13, 1893. Conclusions read in absentia before the Eleventh International Medical Congress, Rome, March 30, 1894. Copyright, 1894 i:y I). Attleto.n axi> Company. 2 TUBERCULAR AND SUPPURATIVE PERITONITIS. But not alone this-they encouraged surgeons to ap- proach the surgical treatment of peritonitis, heretofore a noli me tangere for the scalpel. We are not, however, so far advanced as the statistics of Stiihlen show,* where in seventy-eight cases of suppura- tive peritonitis fifty recoveries are reported. These apparently splendid results have to be taken cum grano sails. There can be no doubt that the author knows of fifty successful cases, but he did not know of many hundreds of fatal cases besides the twenty-eight which he published. It is quite natural that brilliant cases are made known, while the fatal ones, with few exceptions, are passed over; therefore only such statistics can be valued scien- tifically where all the cases of their kind are reported to- gether. So far as my knowledge goes, these postulates in reference to suppurative general peritonitis have been ful- filled only by Miculicz,f Kronlein, J and Korte.* These reports are much less favorable, but if the fact is considered that a cure obtained in even one desperate case, which was formerly thought to be impossible, it is a vic- tory ; they certainly present a new phase in the history of surgery. Statistics, of course, will appear in a different light if the cases are selected, or if such cases are only operated which seem to give a better prognosis than others. But what we demand is that a series of operations inclusive of those without any prospects should be reported as well. * Stiihlen. Drainage des Peritonaum bei Peritonitis. Strassburger Klinik, 1890. f Miculicz, one recovery among fourteen cases. (Paper read at the Eighth Congress of the German Surgical Society at Berlin.) | Kronlein, two recoveries among seven cases. * Korte, Chirurgische Mit'.heilungen von Bruns, 1890, Bd. vi. W. Korte, Archiv fur klinische Chirurgie, Heft 3, Jahrgang 1892. TUBERCULAR AND SUPPURATIVE PERITONITIS. 3 Experience has shown that recovery has taken place even when the surgeon proceeded to the operation without the slightest hope, and where the pulse has not been percept- ible, and, vice versa, cases ended fatally where the prospects were comparatively good. As a patient suffering from general suppurative perito- nitis has, indeed, nothing to lose, he should be operated upon at all hazards. The permission of the patient can be obtained almost always on account of his great suffering and his cognizance of the unfavorable outcome. The trouble in getting the permission comes-at least this is my experience-in such cases, from the objection of the attending physicians, and not from the patient or his friends. Consultation and consideration usually consume most valuable time. Laparotomy always enables us to evacuate the pus from the many pockets and crevices of the abdominal cavity, and to destroy adhesions, which follow the inflammatory pro- cess and are generally a great impediment to the thorough evacuation of the pus. But even in the most complicated or extensive cases we would only leave a trifle, thereby at least reducing the quantity of the dangerous germs consid- erably. Furthermore, the intra-abdominal pressure will be necessarily lessened to a great extent, so that respiration may become free at once, and, again, a perforated organ eventually may be occluded or necrotic tissue (gangrenous appendix, for instance) may be removed. A thorough disinfection of the abdominal cavity is still a desideratum, but much can be done by extensive drainage with rubber drainage tubes surrounded by iodoform gauze. Strong antiseptics are not borne by the peritonaeum on ac- count of its great tendency toward absorption and of its irritability. Weak antiseptic or sterilized solutions are useless in such cases. But even if strong antiseptics, like 4 TUBERCULAR AND SUPPURATIVE PERITONITIS. bichloride, for instance, could be borne, neither the stream of irrigation nor wiping off with sponges could on account of the anatomical condition of the abdomen reach every cor- ner of the cavity. Especially in hernias, where gangrene is suspected, I have employed bichloride of mercury repeat- edly, to the terror of many colleagues, but with apparent success, and have never perceived any symptoms, that could be traced to its use. T employed without fear a l-to-2,000 solution for disin- fecting the intestine, taking the precaution, of course, to occlude the abdominal cavity with sterilized compresses so as to irrigate only the part of the intestine lying outside the abdominal cavity, and to wash immediately after with sterilized water.* Induced by the great ease with which iodoform pow- der as well as iodoform mixtures were borne by patients suffering from tubercular peritonitis, I thought of using this ideal drug in general peritonitis also. During the past nine months I have done so by infusing one ounce of a ten- per-cent. mixture of iodoform and glycerin in five cases of general peritonitis and in two other cases where septic pus had escaped into the abdominal cavity during operation. Though not claiming any specific results for this treat- ment, which certainly would be useless in acute septic peri- tonitis, it is remarkable that in five cases in which the chances of recovery on account of their nature were very poor, all with the exception of one, which was operated on at a very late stage, terminated favorably. It is conceivable that the virulence of the pus may be weakened by the coabsorption of the iodoform. I do not refer to a localized accumulation of pus-that is, to a cavity, no matter how large it may be, which by adhesions is well * Compare Resection of the Intestine in Gangrenous Hernia, by Carl Beck. Medical Record, April 8, 1893. TUBERCULAR AND SUPPURATIVE PERITONITIS. 5 separated from the cavum abdominis. Such extraperito- neal and extremely favorable cases should not be called or treated the same way. I would suggest the same name as for other similar abscesses, characterized by their seclusion -that is, empyema. The most frequent abdominal abscess of this kind is the one depending upon appendicitis. This should be called " typhlo empyema." The best chances for the operation naturally offer at the earliest stage of suppurative and in tubercular perito- nitis. It is often difficult to make an exact diagnosis before laparotomy is done. I can safely say that in the greater number of cases of extensive appendicitis in which I have been called by the attending physician, it was to operate for "internal obstruction." Any kind of peritonitis, on ac- count of sudden paralysis of the intestines, can produce the symptoms of obstruction-namely, stercoraceous vomit- ing and retention of faeces and flatus. On the other hand, peritonitis, caused by perforation, may follow obstruction, so that a deflnite discrimination is very difficult, if not impossible. The character of the pulse, as some maintain, should show if perforation had occurred already or not. I do not think this to be reliable, as to my surprise I once found a good pulse although, as laparotomy later on showed us, perforation had taken place quite a time previous. The exploratory needle may be used in doubtful cases, but it very often fails to yield pus, which then is no proof that there is none. If by microscopical or bacteriological examination we could demonstrate the coccus characterizing the infection at the time of the operation, we could be more positive still. I have repeatedly been able to affirm that, when the axillary and rectal temperature differed for more than two 6 TUBERCULAR AND SUPPURATIVE PERITONITIS. degrees, pus in the peritoneal cavity was always present. In one case of a young married woman, who died from general peritonitis following appendicitis, I found the temperature to be 99° in the axilla and 103-5° in the rectum. Here, as the symptoms of appendicitis were only very slight for the first four days, a prominent surgeon had advised expectant treatment. Suddenly perforation took place, the patient collapsed, and then an operation was declined. If the intestines are very much distended, the explora tory needle might be fatal, as the hole in the paralyzed in- testine may remain open. All these facts show that lapa- rotomy in all doubtful cases is the lesser risk. In the cases of tubercular peritonitis I do not hesitate to confess that I have never been able to make the diag- nosis before the laparotomy. As I understand it, the diagnosis of a tubercular pro- cess can only be made by seeing the tubercular nodules or by demonstrating the bacillus of Koch under the micro scope. The latter proof can easily be furnished in the sputa of a consumptive, but in tubercular urine, in tuber- culosis of joints, glands, or of the peritonaeum, it is only exceptionally that such evidence can be secured, and then only if serous or purulent fluid in the abdominal cavity is present, which usually is found only at an advanced stage. Our aspiratory technique is not so far developed as to entice the bacilli into an exploratory needle; and, if the symptoms are developed beyond any doubt, then local treatment offers hardly any chance. The cures which I have effected after having performed laparotomy have now, a year and a half after the opera- tion, remained perfect. How this was achieved I fail to understand, but nevertheless it is a fact. If this is only due to the exposure of the abdominal organs to the at- mosphere, as is probable, it seems to me that the repeated TUBERCULAR AND SUPPURATIVE PERITONITIS. 7 infusion of an iodoform mixture is a great help and will make the cure more permanent. The idea of inflating air was quite obvious regarding the theory of the influence of the atmosphere, but the diffi- culty of diagnosis will always be the weak point for its in- dication. The iodoform infusion on the other hand will be useful in doubtful cases, be it for exudatory processes de- manding absorption or for its specific antitubercular effect. I generally infused one ounce of a ten-per-cent, mixture of iodoform and glycerin. Iodoform, subt. pulveris 50 parts. Mucil. gummi arab 23 " Glycerin 83 " Aq. destil q. s. ad 500 " This was done in intervals of one week, altogether be- tween three and eight times. No after-effect ever fol- lowed. Generally I used my own irrigation trocar, which I have devised for the treatment especially of tubercular abscesses. The difference of its construction from other trocars consists of the fact that we can introduce another cannula after the stilette has been withdrawn. This second can- nula presents a double barreled tube. Through the small tube, which can be brought into connection with an irri- gator, a sterilized liquid can be infused. Through the 8 TUBERCULAR AND SUPPURATIVE PERITONITIS. large tube, solid particles, which generally have to be ex- pected in the pus, can be washed out. Afterward, through the large tube, iodoform and glycerin or oil can be infused either by an irrigator or by a piston syringe. The advan- tage I claim for this instrument is that the force of the irrigation will cause solid fragments to dislodge and take them away with the recurrent flow. At the same time the force of the water can easily regulated. Patients who had had opium administered before the operation seemed to stand the laparotomy better, as the peristalsis was suppressed, thereby favoring adhesions. As in all other inflammatory processes every surgeon is looking for immobilization as a conditio sine qua non, and he should look out for this " splint principle " in the abdomen also. Patients who have had calomel given to them are generally much weaker and seem to have poorer chances for recovery. They especially require stimulants before the operation (camphor, or preferably injections of hot wine or cognac into the rectum). If the patient's condition will allow it, the stomach should be washed out before the operation. Ether anaesthesia was only induced superficially and only at the beginning, as the pulse was generally very weak. It is less cruel to bother the patient and save his life than to give him the so-called benefit of a full anaesthesia and kill him under the pretext of humanity. If necessary, the operation should be done under a simple cocaine anaes- thesia. In such cases where marked swelling at the right iliac fossa was present I incised there. The best view I gener- ally have had by making a vertical incision at least four inches in length in a line uniting the anterior axillary line with the spina anterior superior ossis ilii. Whenever this was not satisfactory, I added a cross incision (T shaped) TUBERCULAR AND SUPPURATIVE PERITONITIS. 9 toward the lumbar region, rectangular to the longitudinal one. Otherwise I prefer to open the abdomen through the linea alba. Here a large, bloodless, and quick incision can be made. Then with hot sterilized water the pus is evacuated. Wherever small cavities were formed, from adhesions, drainage-tubes, surrounded by iodoform gauze, were intro- duced-once seven in number, all discharging through the abdominal opening. Fibrinous exudations were always wiped off with steril- ized gauze, except when they extended over too large a portion of the intestine so that bleeding was excessive or too much time wasted. When the seat of a perforation is found it should be pulled outside, and by separating it from the abdominal cavity by sterilized compresses, it should be irrigated with a 1-to-2,000 bichloride solution and then washed with sterilized water. After this, if the condition of the patient allows it, the perforation (or open- ing) should be closed. If not-that is, if it should ap- pear that he can not stand any such manipulations, which may require fifteen to twenty minutes' time-that portion of the viscera should remain outside enveloped in iodo- form gauze until the patient's condition allows closure and replacement. In the larger proportion of cases the vermiform appen- dix causes perforation. Following common surgical prin- ciples, it is, of course, advisable to remove the appendix. But if this can only be done at the expense of destroying adhesions, which sometimes may save the patient's life, or, if long searching is necessary, it is better to pack iodoform gauze around this portion, hoping for a later removal or separation. Iodoform gauze adapts itself tightly to the serosa, and becomes loosened only when suppuration becomes copious. 10 TUBERCULAR AND'SUPPURATIVE PERITONITIS. Sometimes I kept it in the abdomen for two weeks. It then (ten per cent.) still contained plenty of iodoform, and cultures showed it to be still sterile. If there are symptoms of retention afterward, the fin- ger must be introduced, not the probe. Hereby valuable information can be obtained, as Case III shows, where 1 am quite sure that it was only through extensive counter- opening and drainage that I saved the patient's life. So far, however, as the removal of the appendix is con- cerned, I do not remove it simply because it may be at- tached to the tube or ovary by previous inflammatory pro- cesses, in case it is of normal appearance. In one case where I performed oophorectomy, I found a very long and wide appendix of normal appearance Touching it accidentally, I felt some hard substances in its distal end, which I could easily press out into the caecum. Assuming that there was enough room a.s well as contractile elements to let faecal matter circulate in the appendix, 1 did not remove it. The patient did not show any symptoms in this direction later on. I have repeatedly felt the appendix in women, but never in a male patient, in whom I often have tried to find it, through the rectum. But a distinct impression of its condition we are proba- bly never able to get by palpation. In this particular case, if I had tried to palpate the appendix I should, on account of its contents, probably have assumed a pathological con- dition of its structure. And, vice versa, as one case below shows, even its expos- ure after laparotomy sometimes may leave a doubt, if there is such a change as would justify its removal. IIistories. Tuberculosis.-Case I.-Gerdic K. (case presented to the surgical section of the Academy of Medicine, Decem- TUBERCULAR AND SUPPURATIVE PERITONITIS. 11 ber, 1892, and December, 1893), who at the present writ- ing is fifteen years old, came under my observation in Oc- tober, 1892. Since about October, 1891, she had had pain and tenderness in the hypogastric region. Physicians whom she had consulted diagnosticated dyspepsia, chlorosis, en- docarditis rheumatica, etc. In May, 1892, after having swallowed some seeds of a lemon, she claims that the pain suddenly assumed an acute character. Soon afterward the pains became permanent and local- ized in the right iliac fossa. Dr. George W. Rachel, who had her at this time under his charge, reported to me that she had suffered from ap pendicitis. Two weeks after the onset of the pains in the right iliac region she was free from fever and was able to go about, but held the body in a slightly bent position. The pain remained the same as before. Dr. A. II. Stiebeling, who saw her then, discovered a hard, well-defined tumor of the size of a man's fist appar- ently attached to the os ilii, on account of which he ad- vised surgical interference. I did not consider a laparotomy justifiable at this time, as I was in doubt about the character of the swelling, which I thought might be the residual product of a peri- typhlitic process, and which eventually might undergo absorption. I therefore put the patient in bed and kept her under observation. Hot and cold applications were made, elec- tricity and massage were tried, but all without avail. Opium gave but temporary relief. Aspiration of the swelling yielded blood. After having injected a saturated solution of iodoform- 12 TUBERCULAR AND SUPPURATIVE PERITONITIS ether into the tumor four times at intervals of five days, the swelling subsided almost entirely. But the pain re- mained the same as before, so that the patient herself urged me to an operation. When I performed an exploratory laparotomy, Novem- ber 3, 1892, I found about three tablespoonfuls of a light serous fluid in the abdominal cavity. The appendix ap- peared to be normal, and was attached to the right ovary and to the mesocolon. The extensive adhesions were divided at once. At the same time a condition was found which pre viously had been unsuspected-that is, the peritonaeum and mesentery were covered with innumerable tubercular nodules, varying in size from a pin's head to a pea. The intestines were apparently untrammeled. Following the principle which I have adopted in the treatment of tubercular glands and joints, I rubbed the affected portions with iodoform, using about five grammes of the powder. There was no trouble after the operation, except that, on the fifth day following, an eczema appeared (probably due to iodoform), extending over the entire abdominal wall. The patient could not resist the temptation to scratch, so that the skin sutures partially sloughed. On account of this, union was not perfect till three weeks after. On the fourteenth, twentieth, and twenty-seventh days after the operation, an ounce of'a ten per-cent, mixture of iodoform-glycerin was injected into the cavum peritonei without causing any trouble. The pain in the right iliac region disappeared at once, so that I feel quite confident in saying that it was due to the adhesions. At the present time, nearly a year and a half after the operation, she is perfectly well. TUBERCULAR AND SUPPURATIVE PERITONITIS. 13 During the winter cod-liver oil was given, while in sum- mer guaiacol was substituted. . Case II.-Mrs. G., twenty four years of age, married since November, 1892, gives a history of personal tuber- culosis. She had always been well until two weeks after her wedding, when she took sick with chills and sharp pains in the sacral regions. Every afternoon for five weeks follow- ing her temperature reached 104'5°. Dr. Volkenberg, who has been her family physician, diagnosticated peritonitis. When, on January 11th, I first saw the patient in con- sultation, I found a temperature of 104'5°, a weak pulse of 140, and a respiration of 31. The abdomen was dis- tended, and immediately above the symphysis pubis quite sensitive to pressure. Tympanites was but slight. The legs were drawn up and the thighs flexed upon the abdomen. Constipation had been present during the first week. There was also disturbance in urinating. Menstruation had been absent for two months. By a vaginal examination under ether we found the left ovary enlarged to the size of a hen's egg. The uterus was drawn toward the left side, fluctuation was well developed in the posterior cul-de-sac, and the neighboring tissues were indurated. As there was a history of gonorrbcea, I was quite posi tive in diagnosticating an ovarian abscess. A prominent gynaecologist of this city, who kindly ex- amined the patient under anaesthesia with me, concurred in this opinion. Laparotomy on the following day revealed the presence of about a pint of sero-fibrinous fluid in the abdominal cavity and of innumerable miliary tubercles, 14 TUBERCULAR AND SUPPURATIVE PERITONITIS. which studded the peritonaeum, mesentery, and intes- tines. The left ovary was enlarged, but no evidence of suppu- ration was found in it or in the tube. About six grammes of iodoform powder were dusted over the tubercular field, and the abdomen was then closed. Uninterrupted recovery followed. The temperature remained normal, with the exception of on the tenth day, when it went up to 104° F. An explanation for this phenomenon could not be found. On the thirteenth, twentieth, and twenty seventh days after the operation, an ounce of a ten-per-cent, mixture of iodoform glycerin was injected into the peritoneal cavity. Three weeks after the operation the patient was dis- charged from St. Mark's Hospital, and until to-day has re- mained well. A slight cough, which was present before the operation, has, curiously enough, disappeared. Case III.-Anna R., aged fifteen years, with good family history, had measles, scarlet fever, and diphtheria several years ago. For two months she complained about a dull sensation around the umbilicus, and at the same time her abdomen became distended. The ap- petite was poor and in the evening an exacerbation of temperature. On May 4, 1893, on physical examination, I found a thin, slimly-built patient, having a temperature of 102-5°, a pulse of 140, respiration of 23. Ascites was present, so that an exploratory puncture was made. A microscopical examination of the fluid which was drawn shed no light on the nature of the disease. The microscopist suggested cirrhosis of the liver. An exploratory laparotomy revealed the presence of tubercular nodules, the greater number be- ing of the size of a pin's head and extending over the peri- TUBERCULAR AND SUPPURATIVE PERITONITIS. 15 tonaeum, intestines, and mesentery. The other abdominal organs appeared to be free. Two quarts of a Lght serous fluid was discharged. About six grammes of iodoform powder were dusted over the tubercular area. The abdominal walls were united with the exception of a space to allow the introduction of a rubber drainage-tube, surrounded by iodoform gauze, which was removed two weeks later, when the serous dis- charge, which during the first few days was quite copious, stopped entirely. Recovery has remained perfect. General Peritonitis. Case I.-Jacob W., aged seven years, who had always been in good health, was taken sick suddenly with chills and sharp pains in the region of the umbilicus. Vomiting set in a few hours later. Dr. Sandberg was called, and, as laxatives and enemata were of no avail, he was suspicious of ileus, and advised laparotomy at once. When I saw the case in consultation (May 17, 1893) I found the following state present: The patient, well nourished, showed the typical facies Hippocratica. The pulse was 131 and weak, temperature 101°, and respiration 32. The abdomen was tympanitic and very painful to the touch. Resistance or particular tenderness at the right iliac fossa was not present. After having washed the stomach and the bowel opium was administered, but only slight improvement followed, so that on the following morning 1 made a large incision at the usual point. About three tablespoonfuls of gray pus, which had an offensive odor, was discharged. When I pulled the intestines out they were seen to be of a dark- red color and loops were attached to each other by fibrin- ous exudations. I opened a second pus cavity above the 16 TUBERCULAR AND SUPPURATIVE PERITONITIS. right synchondrosis sacro-iliaca. Looking for the vermi- form process, I found the caicum tightly adherent to the right sacro-iliac synchondrosis, from which I was afraid to loosen it. A cross incision reaching nearly as far as the umbilicus was added, to give a better view. About two yards of in- testine, covered with fibrin and purulent exudations, could now be brought into view. With hot sterilized water the abdomen was irrigated and the exudations dissolved off with peroxide of hydrogen. Being fearful for the fate of the appendix in the depth of the iliac fossa and of the dark-red caecum, I united the edges of the cross incision only after having dusted iodo- form powder over those portions of the intestine which had been covered with exudations. One loop of about twelve inches in length I kept out- side the abdominal cavity by enveloping it in iodoform gauze, thereby being able to pack some gauze around the caecum down in the fossa. Into the other corner 1 intro- duced a few iodoform wicks. The patient's condition was satisfactory after this, until five days later an elevation of temperature induced me to examine the cavity by introducing my index finger, whereon I discovered a retention of pus in the lumbar region. I therefore made a counter-incision above the crista ilii, introducing a large drainage-tube surrounded by iodoform gauze. Great improvement followed. Ten days after the operation I replaced the enveloped intestine and at the same time tried in vain to find the appendix. As the patient made rapid and satisfactory improvement I refrained from further attempts to remove the appendix. But three weeks after the first operation the patient complained of sharp pains around the bladder; frequent TUBERCULAR AND SUPPURATIVE PERITONITIS. 17 micturition troubled him, and his general condition became impaired. No retention of pus could be detected by intro- ducing a grooved director all around. Examination through the rectum as well as of the urine revealed nothing particular. The patient became gradually weaker, had several at- tacks of syncope each day, and had incontinence of faeces, so that we were fearful lest all our previous proceedings were useless. After much opposition on the part of the parents of the unfortunate child, I succeeded in pushing my finger toward the bladder and evacuating about two tablespoonfuls of creamy pus, which settled in a cavity extending from the posterior wall of the bladder to the rectum. Forcing my index finger as far as possible toward the opposite side, I incised on its tip so as to enable me to pull through a drainage-tube nearly a foot in length. Great improvement followed. Two weeks later I drained this " post-vesical " cavity from the right side only, so that the counter-opening on the left side became obliterated. The patient was allowed to get up contrary to my instructions, and was taken sick again with chills and convulsions. When I was called I was able to discover retention of pus in the same dependent cavity. Drainage was again made on the left side, as before, this time having the rubber drain off at the right side first. Two weeks later the canal was packed with iodoform wicks for one week, whereafter recovery became perfect. The patient now is as strong and healthy as he ever was. Tn the right iliac region a very large ventral hernia, undoubtedly due to the weakening of the abdominal walls caused by the long-continued drainage, is present. 18 TUBERCULAR AND SUPPURATIVE PERITONITIS. Although this docs not disturb him, I have suggested an operation, which, under the present circumstances, could not be dangerous. Here, then, is another case which shows that after a successful laparotomy of this kind a good many dangers may arise from the retention of pus. These dangers can readily be counteracted by prompt and energetic interfer- ence. Great stress must be laid on the introduction of the finger as a diagnostic aid which can never be supplied by a probe. Case II.-Abraham T., of Brooklyn, aged forty-three years, had always been well until four days ago, when he took sick with chills, nausea, and sharp pains in the right iliac region. Castor oil was administered, but without re- sults. When I was called in consultation with Dr. Sachs (June 12, 1893) I found the abdomen moderately distended and tender. The pulse was 104 and weak; temperature, 102°, and respiration, 26. After I had made a T-shaped incision at the usual place, a dark serous fluid discharged. The intestines, as well as the mesentery, were of a dark- red color. After having pulled out a loop of the bowels the index finger involuntarily opened an abscess cavity. About four tablespoonfuls of offensive pus were discharged. As the patient's pulse became so feeble that it could not be felt, the ether was left off and the operation finished without an anaesthetic. In the depths of the cavity the gangrenous appendix was found and secured by a forceps. When ligated, it broke off. All attempts to close the opening by sutures were TUBERCULAR AND SUPPURATIVE PERITONITIS. 19 useless on account of the brittle condition of the tis- sues. While this portion of the intestine was temporarily left outside of the cavity enveloped in sterilized gauze the other portion of the intestines was inspected. Fibrinous exuda- tions covered them to the extent of about a yard, so that they were all pulled outside. The abdominal cavity was then secluded by packing numerous sterilized compresses around the opening and a bichloride solution (1 to 2,000) irrigated for about ten sec- onds. It was then washed with hot sterilized water for about two minutes, thereby trying to remove fibrinous exu- dations. A ten-per-cent.- mixture of iodoform glycerin was infused after the intestine was replaced. Only three sutures were used to occlude the cross incision, but the long incision was left wide open so as to allow the packing of iodoform gauze around the brittle portion of the caecum. Perfect recovery followed. The gauze was entirely removed on the tenth day. Case III.-Valentine R., a strong man of thirty-seven years, with a good family record, was always well until December 27, 1893, when he was suddenly taken sick with intense abdominal pains. On the following day frequent vomiting set in, and the abdomen became distended. Laxa- tives, enemata, and injections with the Seltzer-water siphon were administered without producing a movement of the bowels. With the trial of other useless therapeutics two days were wasted, so that on December 30th, when I first saw the patient, the chances seemed almost hopeless. The scarcely perceptible pulse was 160, the temperature 99'5°, and the respiration 34. In the right iliac region well-defined dullness could be demonstrated, indicating a large purulent exudation which was found after incision. 20 TURERCULAR AND SUPPURATIVE PERITONITIS. An aspiratory puncture yielded yellow pus. After caffeine per os and hot wine per rectum were ad- ministered, a large incision under an ether spray was made at the usual place. About three quarts of pus, having a feculent odor, was discharged. The gangrenous vermiform process, which was adherent laterally to the caecum, was removed without any difficulty. To the original incision a second one, extending toward the umbilicus, was added. Now three more cavities, formed by adhesions between the intestines, could be detected and were emptied. Sterilized water was used only for cleaning the abdomi- nal cavity. Wherever fibrinous exudations had been pres- ent, they were wiped off with sponges dipped into peroxide of hydrogen. That portion to which the appendix had been attached was rubbed with iodoform powder. Then one ounce of iodoform glycerin was infused into the abdomen, the cavities as well as the smaller edges were drained with iodoform wicks, and the pocket adjoining the caecum was packed with iodoform gauze. The original in- cision was kept open while the cross incision was united firmly. The patient was stimulated after the operation, which fortunately had lasted only twenty-two minutes, and after four hours the pulse became distinctly perceptible. Slow but uninterrupted recovery followed. The last tampons were removed eighteen days after the operation. No evidences of ventral hernia have as yet appeared. Case IV.-Mrs. Rosa F., twenty-six years of age, had always been well until shortly after being married she showed the symptoms of pyosalpinx. TUBERCULAR AND SUPPURATIVE PERITONITIS. 21 A prominent gynaecologist performed laparotomy suc- cessfully in the summer of 1891. Union had taken place two months after the operation by second intention. For several months the patient had been doing well. Then she became more and more constipated and her stomach was repeatedly so much distended that respiration was impaired. On August 17, 1893, after having been constipated for five days, intense abdominal pains and repeated vomiting set in. The patient herself diagnosticated coprostasis and tried her own therapy, consisting of castor oil and hot poultices for twenty four hours. On August 19th Dr. Talmey found the symptoms of ileus, which he pronounced to be due to constringent bands, the consequence of the inflammatory process following the removal of the ovary. As irri- gations of stomach and rectum were of no avail, lapa- rotomy was performed August 20th at the Post-graduate Hospital. The emaciated and weak patient had a comparatively good pulse of 120, a temperature of 103°, and a respira- tion of 24. Tympanites was present. Vomiting was al- most constant. A long incision in the linea alba exposed the incarcer- ated portion at once. After having loosened a few thin adhesions, about a quart of a green sero-fibrinous fluid was discharged. Above the right synchondrosis sacro-iliaca a bundle of intestinal loops, belonging to the small gut, was discovered. They were tightly attached to each other by fibrous adhesions and appeared like an M, so that the intestine was obstructed in four portions. On its left side the intestine was attached to the stump of the left tube, where the oophorectomy had been per- 22 TUBERCULAR AND SUPPURATIVE PERITONITIS. formed previously. On its right side it was adherent to the vermiform process, which, being of unusual length (five inches), was of normal appearance; T then loosened it from its adhesions, which was possible only after resection of a considerable portion of mesentery adhering to it. When the bands between the intestines were loosened three perforations appeared. A fourth occurred when I tried perhaps too forcibly to separate the attachments. Faecal matter was present in the pelvis, which was quite small. The perforations, after having been cleaned with bichloride sponges, were trimmed and adjusted. Czerny's sutures with thin iodoform silk were applied, and the serosa was rubbed with iodoform powder and covered with small strips of iodoform gauze. One ounce of iodoform glycerin was then infused. Through the abdominal wall, which was united so far as to allow the introduction of my hand, iodoform gauze was freely applied. Uninterrupted recovery without elevation of tempera- ture followed. The gauze was removed partially on the third, and en- tirely on the eleventh day. This is another case showing the great danger of the formation of adhesions after laparotomy. Only six months before this I had a similar (fatal) case (Dr. Dorfmann) where two years after oophorectomy in a patient twenty-two years old constriction of the intestine, under exactly the same cir- cumstances, had resulted. Perforation had not, however, occurred. (Iodoform was not used in this case.) I know of about half a dozen similar cases, and there fore lay great stress upon the necessity of massage treat- ment after laparotomy, especially if inflammatory or even suppurative processes have followed. A very cheap and practical way to carry this out and TUBERCULAR AND SUPPURATIVE PERITONITIS. 23 induce peristalsis is the frequent use of a cannon ball, to be rolled around the abdomen every morning for five to ten minutes. Case V.-Fred D., aged six years (tubercular family history), had scarlet fever four years ago; was always well until, on November 9th, he suddenly took sick with sharp pains around the sixth and seventh ribs at the right anterior axillary line. Vomiting was present. Obstruc- tion was successfully removed by the administration of calomel. The attending physician was in doubt about the char- acter of the disease, until six days after its onset the pain became permanent at the right iliac region, associated with well marked dullness. Tympanites became more developed and the patient showed signs of collapse. When I saw the patient for the first lime the pulse could hardly be felt, and was so rapid that counting was im- possible. The temperature was 99° in the mouth and 102° in the rectum. The respiration was 30. Vomiting during the last twenty-four hours had been noticed but five times. An incision at the usual site was made without delay. A similar condition was found as in Case III, except that no single cavities were noticed besides the large one around the appendix. Ether had been given for a few minutes when cyanosis appeared, so that I finished the operation, as in Case III, without giving more anaesthetic. The patient bore this without any sign of excitement. Great improvement fol- lowed. An hour after the operation the pulse was weak and frequent, but could easily be perceived. Vomiting stopped entirely, but on the following day he succumbed in col- lapse. Case VI.-Miss Carrie li., aged twenty-six years, suffer- 24 TUBERCULAR AND SUPPURATIVE PERITONITIS. ing from pyosalpinx (gonorrhoea), was operated at the Post- graduate Hospital September 24, 1893. In loosening the adhesions from the tumor, which was of the size of a new-born child's head, it happened in spite of all the precautions taken before that the sac burst and a considerable amount of yellow, badly smelling pus es- caped into the peritoneal cavity. Cultures afterward showed streptococci. A piece of the mesentery as large as an adult's hand was so tightly attached to the sac that I had to remove it with the sac after having ligated it with iodoform silk. The appen- dix, normal in appearance, was adherent too, but could be separated without any difficulty. An ounce of iodoform glycerin was infused and the stump then surrounded by iodoform gauze, which was re- moved four days after. The temperature was normal on the following day and recovery was perfect three weeks afterward. Since this article was written I have operated in two other cases of general peritonitis. Tn one case, that of a child, where the peritonitis was due to trauma, considerable improvement followed the operation. The patient died on the third day. In the other case perfect recovery was obtained. Mrs. W., twenty-nine years of age, mother of two healthy children, was taken sick with high fever, frequent vomiting, and pain in the right iliac region. Soon after the whole abdomen swelled. When I saw her in consulta- tion with Dr. M. P. Jacobi at St. Mark's Hospital, I found the abdomen so much distended that localization was im- possible. The pulse was 140 and weak, the temperature 101°, and the respiration 48. After having opened the abdominal cavity, general peritonitis was found. Fibrinous exudations were discovered to a great extent, and especially TUBERCULAR AND SUPPURATIVE PERITONITIS. 25 in the vicinity of the appendix. They were all wiped off. As the appendix itself only looked hyperaemic, I was in doubt if it was the source of the peritonitis, but, as I found no other, I removed it. Tt was only then, on splitting it open, that two gangrenous portions could be detected. The respiration went down to 30 immediately after the operation, and the gauze was removed on the ninth day without any difficulty. Wl East Thirty-first Street. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. EDITED BY FRANK P. FOSTER, M.D. THE PHYSICIAN who would keep abreast with the advances in medical science must read a live weekly medical journal, in which scientific facts are presented in a clear manner; one for which the articles are written by men of learning, and by those who are good and accurate observers ; a journal that is stripped of every feature irrelevant to medical science, and gives evidence of being carefully and conscien- tiously edited ; one that bears upon every page the stamp of desire to elevate the standard of the profession of medicine. Such a journal fulfills its mission-that of educator-to the highest degree, for not only does it inform its readers of all that is new in theory and practice, but, by means of its correct editing, instructs them in the very important yet much-neglected art of expressing their thoughts and ideas in a clear and correct manner. Too much stress can not be laid upon this feature, so utterly ignored by the " average " medical periodical. Without making invidious comparisons, it can be truthfully stated that no medical journal in this country occupies the place, in these par- ticulars, that is held by The New York Medical Journal. No other journal is edited with the care that is bestowed on this ; none contains articles of such high scientific value, coming as they do from the pens of the brightest and most learned medical men of America. A glance at the list of contributors to any volume, or an examination of any issue of the Journal, will attest the truth of these statements. It is a journal for the masses of the profession, for the country as well as for the city practitioner; it covers the entire range of medicine and surgery. A very important feature of the JOURNAL is the number and character of its illustrations, which are unequaled by those of any other journal in the world. They appear in frequent issues, whenever called for by the article which they accompany, and no expense is spared to make them of superior excellence. Subscription price, $5.00 per annum. Volumes begin in January and July. PUBLISHED BY D. APPLETON & CO., 1, 3, & 5 Bond Street, 2YETT YORK.