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tuberculosis are not apparent. Previ-
ously impaired health is exceptional,
the majority of cases having no ill
health prior to this particular illness.
In many instances the disease is most
insidious, and the patient requires no
special treatment until they seek relief
from the peritoneal effusion which re-
mains as a sequel after the disease has
practically become limited in its course.

Age may to a certain extent be re-
garded a predisposing factor. In 346
cases analyzed by Osier, the largest
number (87) occurred between the age
of 20 and 30 years; between 10 and
20 the next largest number (75) oc-
curred ; between 30 and 40 almost the
same number (71) occurred. This
form of tuberculosis is rare in the very
young and very old — more frequent in
the former. It is doubtful if race
wields a marked influence in predispo-
sition, the disease occurring both in the
white and black races.

The symptoms of peritoneal tubercu-
losis are very variable. The disease
may exist for a considerable period of
time without producing any distinctive
symptoms, or any symptoms whatever.



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The common forma usually show, be-
sides loss of flesh aud strength, local
indications of the disease. The abdo-
men is swollen, hard and tender; and
by careful palpation irregular masses
may often be felt. Often the thickened
and rolled over omentum, with adhe-
sions, may be felt as a long sausage-
shaped mass lying across the upper
abdomen. In another class of cases
there may be no local symptoms, only
•a gradual loss of health with evening
rise of temperature and rapid pulse.
In another class the disease may appear
like an acute peritonitis or intestinal
obstruction, with distension, vomiting,
high temperature and rapid pulse. In
women the disease often starts in the
pelvis, and may first indicate its pres-
ence by pelvic pain, slight fever, and a
mass posterior to or to one side of the
utertis. Tuberculosis of the perito-
neum is often associated with neo-
plasms and other diseases of the pelvic
organs in women. In many instances
the healthy appearance of the patient,
the mild character of local symptoms,
or their entire absence, render a diag-
nosis through ordinary diagnostic re-
sources impossible.

The prognosis in peritoneal tubercu-
losis differs from that of tuberculosis of
other vital organs. In a considerable
proportion of these cases we have a
slow, rather chronic, pathological pro-
cess which may be localized in the
peritoneum alone, and which does not
send into the circulation a large amount
of toxic material.

There can be no doubt that some per-
sons affected with tubercular peritonitis
recover spontaneously, without any
treatment whatever. In the gynecolog-
ical cases, where the pathological pro-
cess originates in the tubes, uterus or
ovaries, complete removal of the in-
volved structures is usually followed by
permanent cure. In another class of
cases the disease persists and spreads
throughout the entire peritoneum with
encysted dropsical accumulations.
These patients become chronic invalids,
and in a good proportion of them, when



the abdomen is opened and the fluid
evacuated, permanent inhibition of the
disease obtains. In another cla£s the
disease is from the beginning acute;
invades progressively the general peri-
toneum, the peritoneal surfaces become
adherent, no effusion obtains; there are
fever, rapid pulse, emaciation and per-
sistent progress to a fatal termination.
In still another class of cases, less acute
than the last, the disease seems to be
stayed for a time, then resumes its ac-
tivity, the effusion persists, after a
time becomes purulent and terminates
fatally. Oftentimes, however, the most
hopeless cases apparently, if given the
benefit of abdominal section, make sur-
prising recoveries.

In 1881 Sir Spencer Wells called at^
tention to the now generally accepted
clinical fact that section of the abdomen
in tuberculosis of the peritoneum will
often arrest the progress of the disease
and the health will be restored and per-
manently maintained. Sir Spencer op-
erated upon a young girl with diffuse
tuberculosis of the peritoneum and eu-
cysted dropsy, which he supposed be-
fore the operation to be an ovarian cys-
toma. The girl recovered and regained
her health. Ten years later, in the last
edition of his book, he states that this
patient remains in good health. Similar
observations were made by other sur-
geons, and soon it became a generally
recognized clinical fact that a certain
proportion of cases are cured by abdom-
inal section. Medical literature now
abounds with tabulated reports of cases.

It was soon apparent that the results
of operation varied with the different
grade and character of pathological
manifestation. For example, it is gen-
erally conceded that operation in cases
of tubercular peritonitis, with effusion
(the so-called wet cases), is more effect-
ive in the arrest and inhibition of the
pathological process than in the class of
cases unaccompanied with effusion (the
so-called dry cases).

In my own work I have had consid-
erable experience with tubercular dis-
ease within the peritoneum. In a good^



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327



ly number of cases of effusion, where
the disease was not diagnosticated prior
to operation, I have been gratified in
the apparent permanent care of the pa-
tients}. Some of these patients I have
kept np with, and they are now in good
health from six to ten years after oper-
ation. In a considerable proportion of
apparently favorable cases there was
no improvement after operation, the
disease progressing to a fatal termina-
tion.

In cases of marked acateness, char-
acterized by high temperature and
rapid palse, both with and without ef-
fusion, it is my experience that opera-
tion fails to arrest the active progress
of the disease. But the hopeless char-
acter of the disease under any other
treatment, and the harmlessness of sec-
tion under aseptic precautions, justifies
resort to operation in all cases — espec-
ially if accompanied with effusion and
diagnosis is not absolutely positive.

A careful examination of neoplasms
of the uterus and its appendages, also
of specimens of inflammatory disease
of the Fallopian tubes and ovaries, con-
vinced me long since that tubercular
invasions of these structures through
the Fallopian tubes and intestinal tract
is much more common than is generally
understood. A thorough removal of
the invaded structures is usually fol-
lowed by permanent cure.

It was formerly deemed important in
the operative procedure — abdominal
section for tubercular peritonitis — to
separate adhesions after evacuating ef-
fused serum, and irrigate and drain the
peritoneum. The injection into the
peritoneum of antiseptic solutions and
dusting the exposed membrane with
iodoform were practiced by some.
It is now generally conceded that
the best results follow simple in-
cision and evacuation of fluid, with
no more manipulation and treatment
than is necessary to accomplish this
end. Intestinal and other visceral ad-
hesions should not be disturbed, and
both irrigation and drainage had best
be omitted.



The modus operandi of abdominal
section in the treatment of peritoneal
tuberculosis is not known. Various
explanations have been offered. Some
have attributed the good results to ad-
mission of light and air; some to other
influences. The clinical fact as yet has
not been satisfactorily explained.



SOME CLINICAL OBSERVATIONS
IN INTESTINAL SURGERY.*

BY AP MORGAN VANC3B. M.D.,

LOUISTILLB, KT.

In this section of country we meet
with more than the average num-
ber of intestinal injuries. This may
be explained by the fact that the
ubiquitous '^forty-four" and the ''festive
Bowie" are a part of the apparel of the
average man, and oftentimes that of the
woman also.

A number of years ago I did consid-
erable experimental work in this line.
This was undertaken more to practice
with the needle and thread than any-
thing else. It proved very valuable to
me in other ways; in determining to
my satisfaction the best thread to use,
the best needle, and the best kind of
stitch; and, as practice makes perfect,
I learned on the dog how better to han-
dle the human intestine.

I once attended a meeting of a lit-
erary club where the subject for discus-
sion was vivisection; the essayist, a
doctor, was rather on the fence. As a
guest, I was asked for my ideas. I
asked the simple question, in case any
of the gentlemen present should acci-
dentally or otherwise get a perforating
belly wound, which he would rather
have do the repair work, one who had
killed a hundred dogs learning h(Tw to
sew guts, or one whose practice had
only been on an occasional human?
This was bringing it home so closely
that the "anti" fellows were at once
converted, and the discussion closed.

It is just as important for a surgeon
to have learned to sew intestines as it

*Read before the LooisviUe Sorgical Society, De-
cember 7, 1004. For dlscnsdon see page 864.



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is for a tailor to learn to make button-
holes, or a lady to have practice before
^he can do embroidery well.

I report the following cases with a
conclasion or two;

Case I. Abdominal gunshot wound;
one mesenteric and four intestinal per-
forations; operation; recovery. On
February 7, 1893, 1 was called to see
H. F., aged 29, who half an hour be-
fore had received a pistol-shot wound
of the abdomen, the ball entering in a
line with and five inches to the left of
the umbilicus. The man was found
where he had fallen after running two
squares, with marked evidences of
shock, face pallid, pulse barely percept-
ible at the wrist; temperature not
taken.

A hypodermic injection of nitrogly-
cerine, 1-lOOth of a grain was given,
and the patient removed carefully and
rapidly fully a mile to the infirmary,
and, after as careful preparation as the
circumstances of the case would allow,
the cavity was opened in the median
line between the umbilicus and pubes,
no attention being given to the bullet
wound. The ileum was brought out
and carefully read, no more than six
inches being exposed at a time during
this process.

Four perforations — two of entrance
and two of exit — were closed with fine
catgut, as was also a large wound of
the mesenteric border, which exposed
the mucosa. Careful search was made
for any other injuries, but none were
discovered. The cavity was then thor-
oughly irrigated and cleansed of the
extravasated blood and fecal matter,
the wound being closed with silkworm
gut, a glass drainage tube being carried
weU into the pelvis at the lower angle
of the wound. The method of suturing
was by the continued Lambert suture,
which was rendered doubly secure by a
resuturing with the same piece of cat-
gut, the two ends being then tied to-
gether.

Ether was the anesthetic used, and
the patient vomited large quantities of
undigested food, this necessarily pro-



longed the operation, which lasted fifty
minutes.

The drainage tube was removed at
the end of forty-eight hours, it having
been demonstrated, from the amount
of bloody serum aspirated, that its use
was a wise precaution.

At the end of three weeks the patient
was up and walking about the ward in
exC'Cllent condition, appetite and diges-
tion normal, giving evidence of having
lost very little of his strength. The
bowels did not seem to have been dis-
turbed in their function, castor oil hav-
ing been administered at the end of
fourteen days, evacuation each alter-
nate day having been maintained prior
to this by enemata.

The favorable outcome in this case
was due to the fact that the bullet
ranged transversely and evidently en-
tered the abdominal wall on the oppo-
site side at a point nearly correspond-
ing to the point of entrance. This was
not demonstrated, however, by its lo-
cation. The direction of the bullet was
changed by its having struck a trousers
button in its passage through the cloth-
ing, thus being deflected from its pri-
mary course, which was directly back-
ward.

Case II. Gunshot wound of stomach
and duodenum; operation; recovery.
Dr. G., aged 45 years, was shot in the
abdomen by a drunken negro, October
30, 1898, with a 32-caliber Smith &
Wesson revolver, the bullet entering 2^
inches above the umbilicus, and 1^
inches to the left of the median line,
the pistol being only a few feet away at
the time. The patient did not fall, but
walked 100 feet into the house. He
was immediately removed to the hos-
pital and within forty minutes the ab-
domen was opened by an incision to the
left of the median line, the bullet
wound being at its center; the wound
extended up to the ensiform cartilage
and down to a point on a line with the
umbilicus. A large wound in the an-
terior aspect of the stomach was discov-
ered at once, and closed with fine cat-
gut, interrupted Lembert sutures, and



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329



then a continaed Lembert sutare being
used in addition. No wound of exit in
the stomach could be found. There
was a wound of the lower border of the
duodenum three inches below the pylo-
rus, the bullet evidently getting out of
the stomach at the poloric opening,
making the extensive wound of the in-
testine, the peritoneal covering of
which was lost for quite an extent.
This wound was closed with catgut, and
a flap of the lesser omentum was sutured
over in place of the lost serosa. The
jejunum was much distended with blood
and the bullet had evidently barked it
in its passage, one point* showing loss
of peritoneum and slight bleeding. No
other wounds were found. Irrigation
with saline solution soon removed re-
maining clots, with some pieces of
clothing which came from back of the
liver.

The abdomen was closed with inter-
rupted silkworm gut sutures, a glass as
well as gauze drain having been intro-
duced between the stomach and liver
back to the posterior abdominal wall,
the gauze being covered with rubber
tissue. The glass tube was removed at
the end of fourteen hours, the gauze
after twenty.

On the fifteenth day the patient re-
turned to his home without having
taken a single dose of medicine after
leaving the operating room, and at the
end of four weeks he returned to his
practice as well as ever.

Case III. Gunshot wound of stom-
ach, liver, ileum and mesentery; op-
eration; recovery. Just one week
after the last case, I was called to In-
diana to see a boy aged 13 years, who
six hours before had received a wound
of the abdomen, the bullet was a 22-
caliber from a Flobert rifle loaded with
a long cartridge. The gun was in his
own hands, and he had been looking
into the muzzle above his head; it was
discharged just as he lowered it. The
bullet entered the abdomen midway be-
tween the ensiform cartilage and the
umbilicns, a little to the left of the
median line. He immediately vomited



the extensive breakfast he had just
eaten, along with a great deal of blood.
Six hours afterward I found him with
great evidence of shock and loss of
blood, pale, lips blue, pulse 130, hands
and feet cold, large beads of perspira-
tion on face and forehead.

The mother consented to an opera-
tion, though the desperate chances were
fully explained. Without loss of time,
with the cottage kitchen as an operating
room, the abdomen was opened from
the tip of the sternum to the umbilicus.
As the peritoneum was opened fluid
blood escaped in quantities, and the
cavity seemed filled with clots. The
history of his having vomited blood
made me seek the stomach first.
A large wound was found about the
middle of the anterior wall, evidently
the bullet having bitten out a piece,
continuing on downward. This wound
was closed with plain catgut. No other
wound of the stomach could be found.
There was a button-hole through the
edge of the left lobe of the liver which
was not bleeding. Reading of the ileum
was then done, the blood clots being
removed as we progressed. Hot water
from a pitcher was constantly poured
into the cavity, and also over the boy's
body. About three feet above the
cecum three wounds of entrance and
three of exit were found and carefully
sutured as they appeared. The wounds
of the exit were large and ragged.
Two wounds of the mesentery near the
gut were also cared for. One of these
had severed a large artery, which was
bleeding actively and evidently had
supplied most of the blood found in the
cavity. The great omentum had three
or four hematomas, produced by the
small bullet having grazed or passed
through its meshes.

By this time the boy was in pretty
bad shape, and the abdommal wound
was closed rapidly with a large gauze
drain wrapped in rubber tissue inserted
at the lower angle. The drain was re-
moved at the end of twenty-four hours.
After starving for three days this boy
did well, and at the end of sixteen



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days bad recovered, the only mishap
being that the night after the stitches
were removed he tore the wound open ;
being a rather unruly chap I think he
undertook to scratch too vigorously.

I had no idea when I finished this
work but that this boy would die
promptly. The result in this case
should encourage us to operate in al-
most any case that presents itself within
a reasonable time after the injury.

This is my seventh operation and
third recovery after extensive gunshot
injuries of the stomach and intestines,
the last three getting well.

The first patient had eight wounds of
the ileum, living four days, the post-
mortem showing that, death occurred
from a wound oi the ureter.

The second patient had eight wounds
of the ileum and one of the fundus of the
bladder, living three days, dying of
sepsis due to infiltration of urine from
the wound of exit in the bladder, which
was undiscovered and must have been
near the neck, as an abscess appeared
in Scarpa's space before death.

The third had four wounds of the
ileum, death at the end of thirty hours,
the post-mortem proving death to have
occurred from hemorrhage into the
bowel.

The fourth occurred in the country,
the operation was done under unfavor-
able conditions, as a forlorn hope, and
the patient died of shock.

The experience of the writer proves
that success is due to the early period
in which the patient is seen after the
receipt of the injury, and from the fact
that the bullet fails to injure the extra-
peritoneal and other abdominal viscera.
After the patient has stood the neces-
sary work to repair the intestines, ad-
ditional exploration adds so greatly to
the shock and to the time of the opera-
tion that a fatal outcome is almost cer-
tain.

The possibility of forestalling sepsis
from the absorption of fecal matter is
just in proportion to the time elapsing
between the injury and the operation.
This fact alone should admonish the



surgeon to be always ready for such
emergencies, that no time be lost- An-
other momentous factor in this connec-
tion is the necessity of the careful
handling of the patient, that no un-
necessary movement on his part shall
increase fecal extravasation.

Case IV. Strangulated Femoral Her-
nia; Resection of Gut at End of Eleven
Days; End to End Anastomosis; Wolfs
Method Modified; Recovery. On Jan-
uary 30, 1893, I was called by her
physician to see K. G., aged 33, do-
mestic, who gave the following history:

Eleven days previously she was taken
sick suddenly- with vomiting followed
by purging. Purging ceased early on
the first day; the vomiting continued
until seen by the writer.

It was evident that the extreme mod-
esty of the patient had prevented the
physician attending from discovering
the cause of the trouble, which upon
closer investigation proved to be a stran-
gulated femoral hernia of the left side.

The patient gave evidence of extreme
exhaustion, the pulse being 150; the
temperature, according to the physi-
cian, subnormal. No history of the
hernia antedating the present illness
could be obtained, and tlie patient had
never been seriously sick before, hav-
ing suffered occasionally from "bilious
attacks" of short duration.

Nitroglycerine 1-100 of a grain was
administered hypodermically at once,
and the patient removed in a rolling
chair to the infirmary, only a short dis-
tance from her residence, and after
slight preparation at 11:30 p.m. the
operation for relief of her conditiop was
begun.

Upon exposure and fihaving of the
pudendum the tumor was found to be
about the size of a hen's egg. The sac
was exposed and opened and about half
an ounce of a very dark colored fluid
evacuated, and the blackened intestine
lifted out of the sac. The. sac was
much thicker than is ordinarily found
in a recent hernia, so it is probable that
the hernia had existed without the pa-
tient's knowledge.



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The very tight constriction was re-
lieved, and after thqrongh irrigation
with sterilized filtered water the intes-
tine was carefully drawn out, when one
large perforation discharging fecal mat-
ter was drawn into view, the intestine
being sphacelus in the line of constric-
tion, which included a large portion of
the convexity, the mesenteric border not
being involved.

This line of slough was fully four
inches in length. Resection was im-
mediately determined upon, and an
end-to-end anastomosis decided to be
the best suited to the condition. The
assistants each making digital com-
pression well on either side of the
strangulated portion, nine inches were
quickly removed with scissors, the
incisions being extended between the
vessels down into the mesentery, a
silk ligature being applied and the
whole removed. These incisions ap-
proached each other so nearly that the
part controlled by the ligature was not
more than an inch in width.

There was no hemorrhage, and the
suturing was rapidly done as follows:

By a continued fine cdtgut suture the
mesenteric borders were closely ap-
proximated ; with the same size catgut,
which was a* No. 0, an interrupted
suture was passed from the inside
through the entire thickness of the in-
testinal wall, coming out at a cor-
responding point of the opposing gut
to be approximated.

The part of the intestine above the
constriction being greatly dilated, and
that below being collapsed, made the
approximation more difficult, but the
result obtained was good.

The first stitch was taken through the
mesenteric junctions. • This method of
suturing was continued on either side
of this point just as far as could be
accomplished from the inside, the re-
maining third of the circumference was
carefully closed by interrupted Lem-
bert sutures. To make the closure
doubly sure, a continued Lembert
suture was commenced on one side at
the apex of the mesenteric angle, and



continued from this point around the
gut to a corresponding point on the
other side. By this means there was
no fresh surface left uncovered by peri-
toneum.

During the whole procedure the parts
were frequently douched, and every
care taken to prevent infection of the
cavity.

With some little difficulty the sutured
part was returned to the abdomen, the
sac being removed high up, and deep
approximation sutures applied to the
canal. The wound was closed with
silkworm gut, with a gauze drain in the
lower angle.

The patient's condition at this time
was better than when first seen, the
pulse being 135 when the operation was
commenced, falling to 120 before its
completion. The operation was begun
two hours after the patient was first
seen, arfd there was certainly a very
decided eflFect from the nitroglycerine,
the operation occupying fifty-three min-
utes.

The fact that the patient had con-
tinued so long without nourishment
rendered her chances of recovery much
less, as an element of exhauston had to
be considered and com batted. After
rather a slow convalescence, however,
she made a complete recovery, and is
well to-day, never suffering with any
sequelae whatever.

In every case of emergency of this
kind a rapid decision is necessary as to
what is best, and this depends entirely
upon the condition of the patient. To



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