190 CLINICAL FORMS OF SURGICAL TUBERCULOSIS. 



same tendency to limitation of the infective process as in joints, by 

 the formation of an impenetrable wall of connective tissue, which 

 imparts so often to this form of peritonitis its circumscribed char- 

 acter. 



Kiimmell (" Ueber Laparotomie bei Bauchfelltuberculose," Ver- 

 handl. der Deutschen Gresettschaft f. Chirurgie, 1887, p. 323) looks 

 upon this form of peritoneal turberculosis as a purely local affection 

 amenable to surgical treatment in the same sense as a tuberculosis 

 of joints. That some of these cases can be permanently cured by 

 local treatment is well shown by a case treated by Sir Spencer 

 Wells twenty-six years ago by abdominal section, the patient hav- 

 ing remained up to this time in perfect health. 



In a recent paper on this subject Fettling (" Beitrage zur Lapa- 

 rotomie bei Peritonealtuberculose," Correspondenzblatt /. Schweizer 

 drzte, 1 887) reports four cases of his own, and gives an account of 

 all the operations which have been done up to that time, 21 in 

 number. Of this number, 15 recovered, and the patients are known 

 to have been well from 1 year to 23 years, and in a number of cases 

 their condition was learned 4 to 5 years after the operation. 6 of the 

 patients died ; 2 of sepsis, 1 of pyaemia several months after the opera- 

 tion, and 3 of the continuance of the disease for which the operation 

 was done. In 5 of the cases ascites attended the tuberculosis, and 

 in 3 the swelling was not due to effusion but to adhesions between 

 the intestinal loops, which were covered with miliary nodules. 



Of fifty- four cases of laparotomy (Medical News, July J4, 1888) 

 in tubercular patients, collected by Trzebicky, four died from the 

 immediate consequences of the operation, while in a fifth, death 

 occurred after the operation from acute tuberculosis, though the 

 fluid had not re-accumulated. One case died in four months of 

 general tuberculosis without the peritonitis disappearing ; cures 

 resulted in forty cases, though here and there evidence of pulmo- 

 nary tuberculosis was reported. The majority of cases were females, 

 which may find its explanation in the fact that most were operated 

 upon under an error in the diagnosis of ovarian cyst. The statistics 

 are yet too meagre, the correctness of diagnosis not entirely above 

 doubt, and the period of observation after operation not long 

 enough; but, in view of the results, there is no longer any justifica- 

 tion for expectant treatment. Even though in some cases recovery 

 was not permanent, the fluid did not re-accumulate, and the patients 

 were relieved of their distress. Spontaneous recovery from tuber- 

 cular peritonitis is exceptional, and operative interference is indi- 

 cated the more, as it would seem that, in many cases, tuberculosis 

 of the peritoneum is a primary affection, and the source of general 

 infection. 



As all other therapeutical measures are futile in such cases, and 



