Vol. XIV

No. 11

Tuberculous

Peritonitis.

Hamman (Bulletin of the Johns Hopkins Hospital, September, 1908), has reviewed the statistics of 150 cases of this disease which have occurred at the Johns Hopkins Hospital.

The symptom which first attracted the patient's attention to his illness is of interest. In 146 cases the history is detailed enough to give us this information:

Sixty, or 41 per cent., first noted pain in the abdomen.

Twenty-two, or 15 per cent., came complaining of swelling of the abdomen.

Twenty-seven, or 18 per cent., first noted general constitutional symptoms.

Two cases complained of a lump in the abdomen.

Seven of the gynæcological cases entered the hospital on account of menstrual disorders.

Two cases noted first shortness of breath, nine cough, four pain in the side, three diarrhoea, one constipation, two painful micturition, three a feeling of weight in the abdomen, one vomiting.

One case came for a hernia operation and tuberculous peritonitis was diagnosed at operation.

One case was admitted with a tuberculous knee and one case for a severe Pott's disease.

While in most instances the disease came on rather abruptly with well defined symptoms, it is interesting to note in how

many it was well advanced before attracting the patient's attention. Twenty-two cases were unconscious of their illness until abdominal swelling was well marked; two sought aid because they felt a tumor; and in a number of cases, particularly among those in the gynecological division, the condition was not suspected until an operation was performed. Some of the cases presented more special features of onset:

Four of the cases simulated appendicitis and at least three of these went to operation with this diagnosis.

Two cases simulated gall-bladder disease and one of these, after being seen by Dr. Osler and Dr. Halsted, was operated upon by Dr. Halsted for acute cholecystitis.

Six cases had symptoms of intestinal obstruction. Three of these had symptoms of acute obstruction when admitted to the hospital, and in two the symptoms of obstruction, coming on with great abruptness, were the first evidence of disease.

Three cases were diagnosed ovarian tumor before operation—a repetition of Spencer Wells' classical mistake.

Eighteen cases went to operation with a diagnosis of pyosalpinx.

The most important symptoms and clinical findings during the course of the disease are as follows:

One hundred and four cases com

plained at some time of abdominal pain. This is the most constant and most important of all the symptoms.

them special emphasis in his article in the Johns Hopkins Hospital Reports. Spencer Wells' error was the beginning of the

nausea.

Forty-eight cases were constipated, 33 had diarrhoea and four alternating constipation and diarrhoea.

Six had blood in the stools. In one of these, tubercle bacilli were found in the fæces; two more came to autopsy and both showed tuberculous ulcers in the intestine.

Eleven cases complained of pain in the chest; four of these had pleurisy, three pulmonary tuberculosis, three both pleurisy and pulmonary tuberculosis, and one probably pulmonary tuberculosis.

Forty-seven cases had cough; in 34 there was clinically evidence of pulmonary disease; three more of the 47 came to autopsy and all showed pulmonary tuberculosis.

Thirty cases complained of dyspnoea; 24 of these had definite pulmonary lesions.

Less common symptoms are loss of flesh in 61 cases; night sweats in 27; chills in eight, headache in 10; and painful micturition in seven.

Fluid was present in the abdomen in 62 cases, or 42 per cent. In the cases in which the amount of fluid is stated either at operation or autopsy, in 56 cases, there was a large amount in 27, moderate in 15, and small in 14-over four litres being considered a large amount, under one litre a small.

There is no more interesting feature of tuberculous peritonitis than the tumor masses it frequently gives rise to-interesting because they are such stumblingblocks to diagnosis. Koenig was the first to call attention to their importance and to classify them and Dr. Osler has given

Enlarged spleen...... 3
Nine cases showed intestinal
peristalsis; four of these had
intestinal obstruction.

The study shows that primary peritonaal tuberculosis is very rare and that usually there is accompanying involvement of either pleura or pericardium, sometimes of both.

The results of the treatment of these cases were as follows: Discharged from the hospital as well. . . . . Discharged improved.....71 Discharged unimproved...15 Died....

16 cases.

66

66

.48

Tuberculous peritonitis is then a very fatal disease; and even when there is improvement, the after-results are not very brilliant. Still one can never say what the outcome will be in a given case and

some of the least promising turn out the best.

The Treatment of Pul- Forlanini (Gazzetta monary Phthisis With Artificial Medica Italiana, No. Pneumothorax. 1-5, 1908). The two chief principles of the method advocated by the author are as follows: (1) The pneumothorax cures the destructive process of pulmonary phthisis by absolutely immobilizing the lung. (2) The solutions of continuity which are already established, including cavities, are made to disappear as the result of compression, and in this way the agglutination of their walls is obtained.

Therapeutic pneumothorax has its clearest indication in cases of unilateral phthisis, without advanced tuberculosis of the larynx, and with adhesions weak enough to be relieved by the pressure of the pneumothorax itself. A bilateral distribution of the phthisis does not prevent the treatment. After recovery the pneumothorax should be maintained for a certain time, the period varying according to the conditions present. This method of treatment is not indicated in cases having a rapid course, and of bilateral distribution from the start; these do not leave time, as it were, for the pneumothorax to act. In a similar way the method is contraindicated in case of associated disease, especially circulatory disturbances, and in patients with an extra

thoracic distribution of the tuberculous process, such as tuberculous pleurisy or intestinal adhesions.

The author reports his observations on eight patients who were treated in this manner. In one case, in which an autopsy could be obtained, the affected (left) lung was found to have been transformed into a solid cicatricial mass, without any remaining function, consisting for the better part of strands of very dense connective tissue. The cause of death was pneumonia of the right lung.

In another case of advanced unilateral phthisis, with a rapid course and a beginning lesion on the other side, a clinical cure was obtained within about a month. This having persisted for over five years at the time of the report, it is justifiable to assume a permanent anatomical cure as well.

The remaining observations concerned patients suffering from advanced unilateral phthisis, with cavities and pleuritic adhesions, or patients having very severe bilateral phthisis. In all these cases the pneumothorax was followed within a few months by the clinical recovery of the patients.

The application of this method is very easy, and it is readily tolerated by the patients, especially in the cases of unilateral lesion, with intact pleuræ. It is warmly recommended for more general adoption. F. R.

New-Born.

the teachings of brain pressure to the foetal skull and its changes during birth, arriving at the following results, which possess a certain practical importance:

1. Large intracranial hæmorrhages cause distinct symptoms of brain pres

sure, which, as a rule, permit not only the general diagnosis of intracranial hæmorrhage, but also the recognition of the seat of the hæmorrhage (above or below the tentorium, right or left side of the cerebrum).

2. Hæmorrhages over the cerebral hemisphere (the purely supra-tentorial hæmorrhages) are almost without exception unilateral. Children with these hæmorrhages may survive for several days, but finally perish under increasing symptoms of brain pressure. Upon the basis of this experience the author suggests for those cases in which the symptoms of brain pressure have a progressive character the performance of trephining, with evacuation of the hæmatoma.

Illustrative case: Easy spontaneous labor of a primapara, with a barely asphyctic full-term child, which breathed regularly, nursed and slept on the first day, but subsequently developed attacks of cyanosis, respiratory spasms, clonic convulsions in the right upper and lower extremity and other alternating spasms. Death ensued 48 hours after birth under increasing cyanosis and a peculiar grayish-blue discoloration of the skin. Cause of death: Infra-tentorial hæmorrhage over the cerebellum and medulla oblongata; secondary passage of a very small amount of blood into the left cerebral hemisphere.

Another child was unsuccessfully operated upon by the author's method, but this case was peculiarly complicated and unfavorable. The symptoms of brain. pressure were constantly on the increase, the comatose condition became worse and the heart action diminished. Nothing remained but an attempt at operative removal of the pressure symptoms, although the prospects were gloomy in view of the bad general condition. The seat of the hæmorrhage was located presumptively

over the right cerebral hemisphere. The presence of an infra-tentorial hæmatoma was assumed on account of the marked alteration of the respiration. (Symptoms: Left-sided lagophthalmos; rightsided mydriasis; head held toward right side; rigidity of left arm; increased tendon reflexes and periosteal reflexes on left side.)

Operation: Curved skin incision on right side coinciding anteriorly approximately with the coronary suture; in the middle, with the sagittal suture, and posteriorly with the lambda suture. Division of periosteum, with detachment of entire piece, about 1 cm. in width, from the bone. Exposure of bony margin with the scalpel anteriorly at the outermost lateral margin of the large fontanel to a distance of about 3 cm. Detachment of dura from bone, and division (with scissors with blunt inner shank) of bony margin, in part directly, the soft friable bone being divided at first parallel to the coronary suture, then along the sagittal and lambda suture. The latter were incised only to about half the suture. It was now an easy matter to evert the entire right parietal bone to the outside. The dura was at maximum tension to its entire extent, presenting a transparent blue color. It was nicked with the knife rather low down toward the base, the blood gushing out in a thick spurt. The incision was enlarged to about 4 cm. backwards and forwards; the coagula were removed, and an attempt was made to remove the blood with gauze from the posterior and anterior portions of the hemisphere. The entire hemisphere was then flushed with physiological salt solution, the dura was reunited with four catgut sutures, the parietal bone with the skin flap attached to it was turned back again, and the skin was united with continued catgut sutures. Iodoform gauze

was put over the wound, and over it sterile cotton, the whole being fixed with a circular strip of adhesive plaster, other strips passing over the dome of the head for fixation.

The infant, who had been comatose and had hardly reacted during the operation (no anesthesia), began to breathe a little more freely after the incision of the dura, and was evidently a little improved by the relief of the brain pressure. It had been rendered very anæmic, however, through the loss of blood, and was given a subcutaneous injection of 50 c. cm. of physiological salt solution. Time of operation, 25 minutes. The comatose condition, etc., became worse again in the next few hours, the child was cold to the touch, refused food, and died 10 hours after the interference without having presented further noteworthy phenomena.

The author is convinced that in purely supra-tentorial hæmorrhages, in which the hæmorrhage is limited to one cerebral hemisphere, it will prove possible to save children with progressive symptoms of brain pressure, provided the interference is undertaken at a time when general symptoms of paralysis are as yet absent. The time for the operation is as soon as the symptoms of brain pressure are found to increase instead of improve. Simple puncture is not sufficient in these cases, in the author's opinion. This simply serves to remove the fluid blood, and probably not all of it, while the clotted blood, which compresses the cerebral cortex and interferes with the circulation, is left behind. The clotted blood also may be readily removed through a transverse incision across the dura and applied in the middle of the parietal bone, thus reestablishing the regular blood supply of the brain. This alone is of importance,

The patient was operated on at 4.30 P. M., February 21, 1907. Pathologic examination showed that on right side. one whole parathyroid and parts of two others had been removed. On left side part of one parathyroid was found.

An uninterrupted recovery until 88 hours after operation, when teeth became clinched and shortly after general muscular rigidity.

February 25 0.192 gm. of thyroid extract was given every three hours, and 0.0648 gm. of parathyroid extract every four hours, but with no results.

February 26 and 27 beef parathyroids were given by mouth. February 27 five fresh beef parathyroids were placed in a 1.1000 solution of bichloride of mercury and allowed to soak 10 minutes. These glands were emulsified and given as a transfusion with normal salt solution into patient's breast at 10 P. M. Within 31⁄2 hours contractions were less violent; they had disappeared by noon, February 28. Parathyroids were not given by mouth after morning of 28th.

March 3 patient experienced attack lasting 20 minutes. Two parathyroids were given subcutaneously, and attacks almost immediately ceased. No more attacks up to present time.

The important fact that this case has remained permanently well is probably due to the fact that the parathyroids were not all removed. The parts left were undoubtedly so damaged by the traumatism