Tubercular Peritonitis.* BY 7 A. VANDER VEER, M- D., ALBANY, N. Y., [Reprinted from Virginia Medical Monthly, October, 1891J One of the good results following the development of ab- dominal surgery is the treatment of tubercular peritonitis. All of us call to mind our early knowledge of this disease, how helpless we seemed in the presence of a patient where once this diagnosis had been made. Again, notwithstanding all our pathological studies given to the subject, holding autopsy after autopsy, yet nothing in the line of a curative treatment was evolved. The line of treatment that now offers so much encourage- ment has had a peculiar ushering in. The attention of the profession seems first to have been called to this method by Sir Spencer Wells, who, in 1862, in operating for what he believed to be an ovarian tumor, found a condition of en- cysted peritoneal effusion-the peritoneum being studded with tubercles. He simply emptied the cavity of the peri- toneum of its fluid, and was surprised to have his patient recover. Abdominal section for the relief of tubercular peritonitis seems to have had its conception, as it were, by chance, but *This paper was prepared for the meeting of the Medical Society of Virginia, Session of October, 1891, but the author found it impossible to attend. 2 it was not long in receiving the endorsement of the profes- sion. I remember to have listened with much astonish- ment and earnestness to Mr. Tait in 1884, when, in operat- ing on a case of this kind he said, " By simple incision and drainage, I have seen these cases get well." As in all surgical conditions, much has been gained by careful comparisons of early investigators-their views as to pathology, and, what is of so great importance to the prac- tical surgeon, operative procedure. In this brief paper it is not my intention to enter much the field of pathology. Since the discovery of the tubercle bacillus, the pathology of tuberculosis has become exceed- ingly simple. But why the therapeutic value of so simple a surgical procedure should be so great, is far from being satisfactorily solved. Of this, and the most approved method of treat- ing these cases at the present time, I desire to speak later. I wish to report the following cases, which are far- from ideal ones, and then to draw some conclusions as to the necessity of early and prompt diagnosis. For, after all, if these cases are to be a success by the treatment of peritoneal incision, the rate of mortality will be far less if they are reached early and before the tubercular diathesis has become estab- lished. By this I mean that the tubercular bacilli must be confined to the peritoneum, and not already infiltrated into other organs. Case I.-Miss E. B., set. 18, admitted to Albany Hospital November 17,1886; discharged December 1,1886, improved. Patient says that she has always been healthy until last April, when she noticed an elargement of the abdomen. Had some pain in back of dull heavy character; lost appe- tite, but bowels were regular. No trouble passing urine. Menstruated at fourteen, and has been regular ever since, except one time the past summer when she went two months over her time. Last two periods have been regular. Tumor seemed to enlarge for a time, and then diminish, but for the last two months increased very rapidly. Abdominal section was performed Nov. 18, 1886, believing the case to be a par-ovarian cyst. The abdominal cavity was com- pletely filled with an ascitic fluid, the left ovary, the omen- 3 turn and peritoneum were covered with tubercular points or conns. Her mother died of phthisis while patient was in the hospital. After thorough exploration of abdominal cavity, with my hand, the incision was closed, and patient recovered rapidly. She was not told as to no tumor having been removed until six months later, when she was greatly surprised. There was no return of the dropsy, and for two years she continued in excellent health in every respect. Later, I was told that in an adjoining city, she died of ab- scess within the abdomen. Although making earnest efforts, I have been unable to learn the diagnosis in her last illness. Case II.-Miss M. L., set 10, admitted to Albany Hospi- tal February 3d, 1887. Diagnosis, general tuberculosis. Patient always well and strong until August, 1886, when lower part of abdomen began to enlarge. Enlargement slowly increased upward until respiration was embarrassed and heart's action disturbed. When admitted, circumfer- ence of body at lower end of sternum was thirty inches, and at umbilicus thirty-one inches. Family, history con- sumption. Physical examination showed symmetrical enlargement of abdomen, dullness on percussion and well-marked fluctua- tion. It was thought best to aspirate for comfort of the pa- tient and to clear up diagnosis. Three pounds of pale, straw-colored fluid was drawn off, alkaline in reaction and albuminous, solidifying on boiling. This treatment gave her much comfort. February 17th, an exploratory incision was made. Abdominal section was done, and nine and three-fourths pounds of fluid (as above) was removed. Peritoneum and mesentery were studded with tubercular masses. It was thought best to close wound, which was done without drainage Patient rallied nicely. Bowels moved on fourth day after operation; temperature oscilla- ted between 98 and 101|° for six days when it was normal for three days, wound having healed with stitch abscesses. All symptoms seemed pointing towards a rapid recovery when tubercular pneumonia developed, and she died on tenth day after operation. Post-mortem showed tuberculo- sis of lungs extensive ; also of peritoneum. Case III.-Miss M. G., set. 18, native of United States, and by occupation a housewife. Entered Albany Hospital June 17th, 1890. Had had pneumonia, and was still confined to bed when she came in. Prominent symptoms were hacking cough and dyspnoea, and intense pain in lungs. Patient re- mained in hospital for seven weeks, and left feeling ill and 4 weak. Soon after, abdomen began to enlarge, for which she consulted a physician and obtained some relief. Again en- tered hospital September 4, 1890-enlargement of abdomen returning. Diagnosis-general tuberculosis, abdominal fullness due to tubercular.peritonitis. She was tapped October 19th, November 1st and 13th, and December 17th-each time about twenty-four ounces of fluid being removed. On ex- amination, fluid faintly yeMow and curdy; no pus; no tu- bercle bacilli. Owing to her great weakness, her medicines consisted largely of spirits of ammonia and tincture of dig- italis. Changed September 8th to muriate of ammonia, etc., and September 15th added morphia in consequence of her severe cough. December 26th, laparotomy was per- formed, and drainage tube introduced. In consequence of severe pain of pleurisy, drainage tube was removed on the fourth day ; wound granulated from below. The peritoneum was found studded with tubercular masses, confirmed by microscopical examination. On second day had a severe attack of pleurodynia; right plefira filled with fluid, probably the result of an old pleu- risy. January 17th, abdomen having again filled, old wound was re-opened by incision and abdomen washed out; drain- age tube re-introduced. Patient was very comfortable for a few days, but gradually failed in strength, and died Janua- ry 23rd, 1891. No autopsy. Case IV.-Miss G. M., set. 20, native of United States. Family history good, with one exception, that of an uncle, who is supposed to have died of phthisis. Personal health good up to two years ago, when patient had an attack of anaemia, but recovered almost wholly from this: First men- struated at the age of twelve; advent always painful, but regular. Noted an enlargement of abdomen, which felt hard, about one year ago. Enlargement at first slow; soon became more rapid, and during last two months exceeding- ly so. General health remained fair. Diagnosis-tubercular peritonitis. Physical examination revealed abdomen enlarged; no solid mass; uterus normal in size; movable; left ovary enlarged. Urine normal in quantity and constituents. Appetite exceedingly good; di- gestion unimpaired. No pulmonary lesions; heart normal in action; no symptoms of nervous derangement. Opera- tion at Albany Hospital January 14th, 1891. Usual incis- ion for oophorectomy, accompanied with profuse discharge 5 of fluid. Peritoneum studded with what, under microscope, proved to be tubercles. Left ovary enlarged, cystic, an ! studded with tubercles. Ovary removed, wound closed, and glass drainage tube used. Glass tube removed January 27, rubber substituted. At the end of a week, tract expelled drainage tube, and it could not be re-inserted. Gauze iodo- form packing then used. Patient made a speedy and un- eventful recovery. There was no ascites, and she was discharged February 25th, fistula almost closed. For five months following the operation; this patient was troubled with a continuous diarrhoea, apparently catarrhal in its character, which seemed to yield to the use of salol and bismuth, and the continuous use of iron. Her men- struation was regular, greatly improved in character, be- coming somewhat more free, and in July, August, and Sep- tember, was the most natural she had ever had. She had gained in flesh, has a good color, and feels stronger now, September 6th, than she has for two years. She looks well. Physical bi-manual examination shows a slight enlarge- ment on the left side of the uterus in the neighborhood of what would seem to be the stump of the broad ligament. From these, it will be gathered that Nos. 1 and 4 were typical cases of the disease; that the treatment and result were all that could be expected or desired. Cases 2 and 3 were undoubtedly general tuberculosis, and too far ad- vanced to recover from any form of therapeutics. They also illustrate the danger there is, in operating in these cases, of developing that formidable complication, tubercular pneu- monia or inflammatory phthisis. Such results have been observed by other operators; and I would say here, that in such cases as we suspect or know tubercular deposits to be present in the lungs, that a simple peritoneal incision with- out drainage is all that we ought to undertake at first; that it should be done under cocaine, and not an anaesthetic. The washing out with hot water of the peritoneal cavity is not so very painful, and the patient will bear it. The concensus of opinion, I take it to be, is this: That in the pathology of tubercular peritonitis we are far from a satisfactory understanding. Cabot, in his report of cases, refers to the pathology which has been advanced by Hirsch- 6 field, and which is exceedingly meagre, but undoubtedly of value. There can be no doubt that the nidus or bed for the development of tuberculosis in the lungs and from the peritoneum present very different conditions. One would suppose that the former gives a much greater opportunity for the bacilli to increase and invade the tissues than in that of the peritoneum. In the latter, the tubercles form from the surface from which they project. They are in con- tact with the healthy tissues on but one side. They are bathed in the serum which favors rather than hinders their growth. They often become pedunculated and hang off into the serum, almost detaching themselves from the mem- branes from which they originate. Is it not possible, in our explorations of the peritoneal cavity, in these cases of tubercular peritonitis, that we de- tach sufficient of the tubercular tissues, and by continuous washing and drainage eventually do that which has been aimed at by Koch, and spoken of by Keetley, as "Conceiv- able that the human being or other animal may cultivate and attenuate a protective bacillus in his own peritoneal cavity, and profit by the culture himself?" Undoubtedly there have been many cases of tubercular peritonitis which were not strictly such in their character, and still it may not always be easy for us to determine be- fore as to the presence of tubercles. Tapping has certainly failed in removing fluid in which bacilli were to be found, and yet they were present in operating afterwards. There can be no doubt that in primary tubercular peritonitis, ab- dominal section and drainage, is the proper line of treat- ment, but that we should classify our cases with great care, and, when making a diagnosis, a careful bacteriological ex- amination should be made, so that cases of simple lympho- ma of the peritoneum are to be excluded. In general tu- berculosis, where other organs are implicated, where the in- guinal glands show evidence of lymphatic infiltration, or if there is evidence of tubercular enteritis, then the operation can only be, of necessity, palliative in its results. We must, in the study of these cases, keep constantly in. 7 mind, such as occur particularly among children, and who, for some reason, recover without operatton. I have now under observation two cases, one a girl aged eight, and a boy aged twelve years, whom I have seen with their family physicians at different times during the year, and upon each of whom I advised exploratory incision for relief of what certainly seemed to be a condition of tubercular peritonitis. The operation was declined by their parents, and yet for the past two months there is certainly an improvement taking place in the little ones. They have ascitic fluid, have no constitutional symptoms, but seem rather to be growing less in size and more in their general strength. It is not possible that the mere fact of doing an operation can have its effect upon the patient in the way of a mental impression that tends to the cure of tubercular peritonitis. White, in his very able article upon the-supposed curative effect of operation, per se, in reference to tubercular peritonitis, says: " Finally, as to the rationale of the cure of tuberculosis of the peritoneum :-Peritoneal tuberculosis is dependent upon ex- tension of tubercular inflammation from adjacent organs, or to direct infection by means of bacilli circulating with the blood. Phillips' pathological studies showed that of 107 cases of tubercular peritonitis, the lungs were involved in 99, the pleura also in 60, and the bowel in 80. The fre- quency of intestinal invasion by tubercle is well known. The serosa becomes quickly involved, but this involvement may remain strictly localized, and may undergo spontaneous reso- lution, if the original source of infection, the intestinal lesion, cicatrizes, as autopsy findings show that it frequently does. When, however, the peritoneal involvement comes from a large organ and is extensive, it is as difficult to conceive the rationale of spontaneous resolution as it is to explain in what way operative procedure, except absolute ablation of the disease, can possibly be of the slightest avail. Yet the fact remains, that a gratifying percentage of success follows simple opening and intra-abdominal manipulations in cases of tubercular peritonitis." to treatment, simple incision seems to have been at- 8 tended with better results than the more elaborate applica- tion of the various germicides. In fact, the statistics thus far are in favor, where no disinfectants or germicides were used. As to the use of iodoform, in solution or otherwise, there is yet certainly a wide difference of opinion. When we consider the success given by Koeing of 140 cases in Germany, with 131 recoveries, we are strongly impressed with the belief that the treatment there mentioned is cer- tainly the simplest, if not the best. This method consists of flushing or injecting into the peritoneal cavity hot water, followed by continuous drainage. In a recent article on the subject in the report of three cases (Archives of Pediatrics, Vol. VIII, p. 717,) Dr. Keetley remarks, that " he does not consider the relationship of cause and effect between operation and the cure to be proven yet. We have no sufficient standard of comparison by means of which we can compare the operated with the non- operated; and also those we have, are open to the objections which lessen the value of all heterogenous collections culled from the journals." To take away dropsical fluid, may be to strike a blow-to let in air and light; even mechanical disturbances of the tubercles by the passage of the opera- tor's finger over them, or by flooding them with water, and even by the action of opposing surfaces rubbing against each other, when the peritoneal cavity has been deprived of fluid, and adhesions separated, may be injurious to the vi- tality of the bacilli, although it is generally regarded as favorable to infection." We must distinguish between infection and culture. The c.onditions favorable to one, may not be so to the other. Moreover, the mere fact of being inoculated with a bacillus may be a protection to the'sufferer against the ravages of the inoculated organism. One looks in vain through the medical journals for the successful treatment of these cases by means of Koch's lymph, and yet it seems to be a very good opportunity for the employment of tuberculin, were it the treatment for tu- berculosis.