localized, where the primary infection is apparently in the appendix, Fallopian tubes or the peritoneum itself.

Many different forms of surgical procedures have been advocated in the treatment of this disease. Morse in the treatment of cases in children does not believe in laporatomy, saying that he has better results from tapping. Ochsner, after laporatomy, inserts a glass drainage tube, wound with iodoform gauze, into the cul-de-sac of Douglas, to be withdrawn as soon as drainage ceases. In the Massachusetts General Hospital, the abdomen is flushed with normal salt solution and some cases are drained and some are not. Treves says that the best results are obtained where there is neither flushing nor draining done. And so the literature teems with an endless "do this" or "do that" and "don't do so and so"; until one who is looking for guidance in the treatment of this disease selects a course which seems most reasonable and the one most generally accepted, and this I believe is for the medical man to treat his case with rest; fresh air, preferably in the open air; nutritious food; medicine if necessary to help the emunctories, and all that goes with good nursing. If after six or eight weeks there is no improvement, and the case is one of the ascitic form, or where the Fallopian tubes or the appendix appear to be the location of the mass, then a laporatomy should be advised. Simple incision and the evacuation of the fluid, with a removal of the primary seat if possible, close without drainage and again begin with the hygienic treatment.

BIBLIOGRAPHY.

Osler's Modern Medicine, Vol. III, Baldwin.

Forscheimer.

Morse, Case Histories in Pediatrics.

Cabot, Clinical Diagnosis.

Judd, Annals of Surgery, Vol. LII, Dec., 1910.

Matthews, Annals of Surgery, Vol. LII, Dec., 1910.

Shook, Am. Med., Feb., 1910.

Noble, Illinois Medical Journal, Jan., 1910.

Bryan, Journal of Tenn. State Med. Assoc., Oct., 1908.

Yates, Texas State Journal of Med., April, 1909.

Douglas, Surgical Diseases of the Abdomen.

Moynahan.

Osler's Practice.

Rotche, Diseases of Children.

Holt, Diseases of Children.

A. K. Stone, Tubercular Peritonitis, Boston Med. & Surg. Journal, Jan. 9th, 1910.

Klebs, McArthur's Tuberculosis, Chap. 7.

DISCUSSION.

DR. JOHN B. BOUCHER (Hartford): Mr. Chairman and Gentlemen of the State Medical Society—I wish to congratulate Dr. Sullivan on his very excellent paper on tuberculous peritonitis. He has covered the ground thoroughly in the time allotted to him, and has left very little new material for me to bring up. There are, however, a few points that he has referred to which I should like to emphasize.

In the first place, we must classify our cases, separating those of miliary tuberculosis from those in which the whole peritoneum is involved. In the second, we have contraction of the mesentery in which the bowel is the size of a cord. The cases of ulcerative tuberculosis with sinuses are not surgical; so I shall not discuss them, but confine my remarks to serous exudative peritonitis.

Dr. Sullivan has mentioned tuberculous peritonitis as being caused by infection from distant organs. While I am aware of the fact that modern text-books name this as a cause, I believe this view to be erroneous. The surgeon has proved it, in the first place. We operate on tuberculous peritonitis, and find the whole abdomen studded with nodes the size of a walnut. We remove the appendix, and the child gets well. The peritoneum has taken care of the infection. In other cases, the abdomen is opened and the pelvis is found to be one conglomerate mass, so that it is impossible to recognize a single structure in the pelvis. The bowels are studded with tubercles, and the anterior abdominal wall also. We have seen this condition five times. In dissecting out these tuberculous tubes and glands, the abdomen is closed without drainage, and the patients recover. If a peritoneum like that is capable of taking care of itself after the focus of infection has been removed, how is it possible for it to take infection from a distant organ, unless it is being constantly reinfected? I believe, like septic peritonitis, that tuberculous peritonitis is due to a local infection in every case. Surgeons are finding that to be a fact. In men, it is caused by a tuberculous cecum or appendix. The latter is found to be tuberculous in one per cent. of the cases. Tuberculosis of the genital tract is also a cause. In women, there may be tuberculosis of the tubes. How often does it occur in men and in women? It is

three or four times more common in women than in men. This tube, in women, next to the tonsils and the lungs, is the most susceptible organ to tuberculous infection. It is lined with a spiral, saccular membrane, which makes a fine incubator for tuberculosis. The tuberculous material is stored here, and vomited out constantly into the peritoneum, until the latter is not able to overcome the infection. When Koenig published his first operation for peritonitis, in which he opened the abdomen, wiped out the fluid, and then closed the wound, the surgeons who followed this procedure reported fifty to seventy-five per cent. of recoveries. They did not know why this result was obtained; it was the mystery of medicine. It was not until the brilliant mind of Murphy conceived that it might be due to a local focus in every case, that a better method was introduced. He communicated his findings to the Mayos, who had had twenty-six cases; of these seven had been operated on, one from one to four times previously. In their next twenty-six cases, they had twenty-five recoveries by applying Murphy's method. We have had twelve cases, eleven being followed by recovery. The twelfth patient would have probably recovered also had we not employed abdominal drainage. This was done before we knew better. It should not be used, because we should avoid mixed infection in such cases. If we get this, we get death. The surgeon to-day would not open a tuberculous joint or a psoas abscess that is not infected. We must bear in mind that tuberculosis is a comparatively harmless disease, if we prevent mixed infection. In conclusion, I would say that these cases are surgical; and that if the surgery is done aseptically, the abdomen being afterwards closed, nothing will give more brilliant results.

DR. SELDOM B. OVERLOCK (Pomfret): When the practice was first evolved of the man who wrote a paper sending it to the men who were to discuss it, it seemed to me that it would avoid the difficulties that the men discussing a paper meet with. This is not the case in this instance, however, because I have read the paper, but not the discussion, and Dr. Boucher has said everything that I had intended to say.

Dr. Sullivan's paper raises the point whether the peritoneum is ever primarily infected with tuberculosis. This is often a question with us, when we seem to have before operation undoubted evidence one way or the other; and the most of the statistics showing, that it is found more often in females than in males are due to the avenues of infection found in the female, but not in the male. I have no doubt that Dr. Sullivan's statistics are reliable in that respect. Frequently a case of tuberculous peritonitis is found when the abdomen is opened in a patient in whom we have not suspected it, and have thought that there must be some other lesion. This illustrates the difficulty in operative diagnosis. I remember a case in point. A colored boy came into the hospital with

apparently a straight attack of acute peritonitis. As he came of a tuberculous family and had been associated with tuberculous people, I had him gone over by a competent man; but nothing was found. There was no cough or anything else to draw attention to the lung. A tuberculous appendix was found at operation, and a localized area of tuberculosis in the peritoneum. The patient went along for two weeks after this, and the incision healed up and everything seemed normal. Then he began to have a cough, the temperature came up, and disastrous lesion was found in both lungs. He had galloping phthisis. He has now, after two months, two large cavities in the lung. This is a case in which we have reason to suppose that there was already a tuberculous focus in the lungs; and that, owing to the lowered vitality produced by the operation, he developed pulmonary tuberculosis, while the seat of the operation apparently recovered.

The diagnosis is very important; but it is very difficult, on account of the fact that tuberculous peritonitis simulates so many other things. If the patient has a tuberculous lesion elsewhere than in the peritoneum, and is seized with sudden pain and symptoms referable to the abdominal cavity, we should not jump to the conclusion that he has tuberculous peritonitis. A patient with tuberculosis elsewhere may have an acute process in the peritoneum. We are not justified in jumping to the conclusion that the condition is tuberculous peritonitis, and in telling the family so. It is best to keep up their courage. We should tell them so after the operation, if we must; but should not bury them under the discouragement of thinking that it is tuberculous peritonitis, when it may turn out to be something else. In the majority of cases, it will be tuberculous peritonitis; but it may not be.

Several years ago, at a meeting of this Society, Dr. Bacon called attention to the fact that in some cases of tuberculous peritonitis there is present a friction sound similar to that heard and felt in pleurisy. I have seen one case in which Dr. Bacon's sign was present. In this particular case it is worthy of note, that early in the history of the attack, before much if any effusion was present, the sound could be recognized with the patient on her back, while later it could only be elicited when she was in the reverse Trendelenburg position.

The medical treatment of peritoneal tuberculosis consists in putting the patient in the best condition to resist the disease. This may be done principally by care, using drugs, if they are needed. I have a patient taking cacodylate of sodium who is improving markedly. It encourages her, and she is much better than she was two or three months ago.

The surgical treatment can be of service in eliminating the foci and covering them up, so as to get rid of as much tuberculous material as possible, letting nature pour out an effusion to help bury what are left behind.

DR. DAVID RUSSELL LYMAN (Wallingford): There are very few words that I can say, as it is a subject that I do not know much about. My experience has usually been that the surgeon has shown me the existence of tuberculous peritonitis, when I had not recognized it. I have usually referred these patients to the surgeon because of acute appendicitis, but back of this there has been the tuberculous peritonitis.

In regard to operating in any tuberculous cases, there is one thing that I do not think has been sufficiently emphasized; and that is the danger of ether anesthesia in tuberculosis. I have had eight tuberculous patients operated on under ether, and six of them developed pneumonia. In one case, it had to be a prolonged anæsthesia. In this case, there was acute appendicitis, with a leucocyte count of twenty-eight thousand. The patient was operated on as soon as we could get her to the hospital. We discovered tuberculous peritonitis, and the whole ascending colon, appendix and cecum were involved by an acute ileo-colitis, and adherent down into the pelvis. It had to be a long dissection. In several other cases I have seen bad effects from ether anesthesia. When I have mentioned this, the surgeon has not thought that there was much danger from it; but with my experience of six acute pneumonias produced in eight cases operated on, I am inclined to be very cautious. If an operation in such cases can be done under gas, so much the better, for time means everything.

One other point that has been brought out is that the medical part of the treatment of peritoneal tuberculosis is a great factor in conjunction with the surgical. In fact, it is in tuberculosis anywhere. The rest, fresh air, good food, and control of the patient will often bring results that one does not expect. I had one patient in Wallingford who developed what was thought to be acute appendicitis. He had an abscess, and the surgeon could not get to the appendix on account of the tangled adhesions of a tuberculous peritonitis. The abscess was drained, and the wound closed up. Then the patient was treated hygienically, with plenty of fresh air. That was three years ago, and he is now playing on a ball team. At our sanatorium at Wallingford, we have just completed a tuberculosis ward for children that will accommodate fifteen patients. We will take children whose ages range from three or four to fourteen years. I want to say especially to the surgeons and orthopedists that it is intended for any case of tuberculosis that we have a fair chance of being able to do something for. We shall be glad to take the peritoneal cases in children, after the appendix or the primary focus has been removed; and not only these, but also the bone and joint cases and the orthopedic cases. I am father a poor orthopedist; but we shall be glad to take these cases from the surgeon with their casts or appliances on, and send them back to him as often as he pleases for readjustment, or do the readjusting ourselves, if he prefers. We think that we can