344 SURGERY 



opexy. Cases of extirpation of a movable spleen have been collected 

 by Stierlin, who shows that the mortality is now only 6.25 %. Splen- 

 ectomy in echinococcus of the spleen, according to Bessel-Hagen , 

 previous to 1890, was attended with a mortality of 60 %, and from 

 1891 to 1900 the mortality was reduced to 10%. 



Tuberculous peritonitis has been taken out of the realm of internal 

 medicine and transferred to clinical surgery. It has now become an 

 established routine of practice that laparotomy is justifiable in 

 cases of ascites in which the etiology does not depend upon disease 

 of the liver, kidney, or heart. The method of invasion of the bacilli 

 in their attack upon the peritoneum varies in different cases. The 

 bacilli in rare instances may gain entrance through a perforation 

 from a tuberculous intestinal ulcer, or from a purulent tuberculous 

 vaginitis. Again, the peritoneum may become infected through a 

 perforating tuberculous appendicitis, or from a tuberculous ovary, 

 or fallopian tube. Williams, of the Johns Hopkins University, has 

 shown that from 40 % to 50 % of the cases of tuberculous peritonitis 

 can be traced to this origin. Abbe has demonstrated that about 66 % 

 of the cases of tuberculous peritonitis are due to infection of the 

 thoracic lymph-nodes, and in only 16% is entrance gained by the 

 mesenteric glands. It is thus evident that, while 16 % of the cases 

 of tuberculous peritonitis can be explained by infection through 

 the alimentary canal from milk or other kinds of infected food, the 

 great proportion is due to infection from the thoracic lymph-nodes. 

 There is little doubt but tuberculous peritonitis may arise as a sec- 

 ondary affection following tuberculosis of the intestinal canal. Here 

 again inhibition of infected milk and meats play an important role. 

 The entrance of tuberculous sputum into the stomach in those 

 affected with pulmonary tuberculosis explains intestinal and peri- 

 toneal infection. The latter method of invasion is considered a fre- 

 quent cause of peritoneal tuberculosis. The presence of tuberculous 

 ulcers in the stomach in phthisical patients who subsequently suffered 

 from intestinal tuberculosis has been thus explained by the investi- 

 gation of Klebs. Many experiments upon lower animals which were 

 fed by food containing tuberculous sputum and fragments of tuber- 

 culous lung have proved beyond doubt that intestinal and peri- 

 toneal tuberculosis can arise hi this way. It is a strange clinical fact 

 that laparotomy for the cure of this disease has become established 

 as a recognized procedure through errors of diagnosis. Sir Spencer 

 Wells cured a case of tuberculous peritonitis by a laparotomy per- 

 formed under the supposition that it was ovarian disease. Lapa- 

 rotomy, however, as a curative measure, was first introduced by 

 Dr. Van de Warker, of Syracuse, N. Y. He blundered upon a case 

 of tuberculosis of the peritoneum, under the supposition that he was 

 operating for the cure of a case of hydrops of the peritoneum. Dr. 



