[Reprinted from the Transactions of the Philadelphia County Medical Society, 1894.] A PATIENT CURED FIVE AND A HALF YEARS AFTER CCELIOTOMY FOR TUBERCULAR PERITONITIS. GEORGE ERETY SHOEMAKER, M.D. [Read May 23, 1894.] This patient is exhibited to show a late result. Five years ago she was reported' as an operation recovery before the Obstetrical Society, but her after-history has been so peculiar as to be of interest aside from her present condition of good health, the record of which after such an interval of time is not without value. You will notice that she looks the picture of health, is very strong, and weighs 160 pounds, without having any redundant fat. She works six days in the week at washing, ironing, and house-cleaning; has remarried and leads a happy, vigorous life. Has no evidence of pulmonary tuberculosis and none of abdominal disease. She has no ascites and no pain. She is twenty-nine years old. Briefly, her condition at the time of operation was as follows :1 Moderate emaciation, very tense abdominal distention from ascites of five months’ duration, a little cough, no definite lung lesions. The peritoneum was everywhere thickened, vascular grayish-red, and roughened universally by nodules about the size of a mustard- seed. No point either on bowel or outer wall could be touched by the finger-tip without encountering numbers of these tiny elevations. Some of them seemed partially detached and hung by little pedicles. The intestines were slightly adherent everywhere by curdy web-like adhesions which felt rough like the peritoneum, and were easily broken up by the hand. Tubes and ovaries were not enlarged, but with the uterus felt rough like everything else. Flushing, glass drainage for two days. Good recovery. 1 See “Laparotomy for Tubercular Peritonitis,” Medical and Surgical Reporter, April, 1889, p. 447. 2 CCELIOTOMY FOR TUBERCULAR PERITONITIS. You will notice that she has a large hernia at the site of the wound, which is one of the points of greatest interest, as its history is peculiar. Its presence is partly my fault and partly her own. My responsibility comes in from my having allowed her to get up and walk half a block two weeks after the operation. I know better now, and have no sympathy with the week-and-a-half confinement in bed which one enthusiastic operator has recently advocated after appendicitis operations, for example. Every abdominal section should be followed by at least three weeks in bed. Her responsi- bility for the hernia began when she got out of bed and dressed herself twice on the eleventh day. She has always been extremely careless and unwilling to take the slightest precautions; has not now, and never has had, an abdominal belt. She disappeared soon after the operation and has from time to time been seen with some com- plication for which she never would submit to proper treatment. It was subsequently learned that three months after the operation a little leakage of serum began at the former site of the drainage-tube, but soon ceased. She was seen six months after it with no hernia and well, except a little ascites. Some time within the following year a hernia developed which grew' as large as two fists, then became inflamed, and four openings appeared which, she says, discharged pus at first, and then serum. These openings failing to close after several weeks, she sought advice. I found her in very unfavor- able surroundings, with four sinuses penetrating deeply a hard non- reducible hernial mass of the size of the fist and discharging a watery fluid abundantly, but no pus. As she absolutely refused to enter a hospital or receive other treatment, she was ordered to syringe the sinuses with a weak corrosive sublimate solution and to keep the hernia dressed with muslin wet with the same. It was supposed that the sinuses led to tubercular masses and that she had no outlook for a permanent recovery. She disappeared for a year or more after that one visit, but reported afterward that she continued the wash and that after nine months the discharge ceased. You may see the scars where the sinuses were. When next she sent for me I thought her time had really come. She had been vomiting severely for hours, was unable to move the bowels, had a thin red tongue and a poor pulse, and had in the left side a large resonant tender tumor about which on palpation distinct crackling could be felt. Evidently a loop of bowel had become twisted or confined by an adhesion. The hernia was not involved. She did not procure the calomel ordered, but fortunately did use CCELIOTOMY FOR TUBERCULAR PERITONITIS. 3 the enema advised containing Epsom salt and spirit of turpentine. This produced a sharp pain, disappearance of the tumor, immediate relief of the vomiting and pain ; was followed by a stool with blood and mucus, after which the patient considered herself well and insisted on getting out of bed in a few hours. You see her now in good condition, I having but recently again discovered her whereabouts. She is unwilling to have the hernia operated upon, as it gives her little trouble, even though she wears only a strip of muslin in an attempt to retain it. Should she con- clude to have this operation done it will be of interest to note the condition of the peritoneum. No nodules can now be felt through the thin walls of the hernia. The writer has recently reported two other cases of tubercular disease of the abdomen ; in one, now living and well, the fluid had become purulent; in the other, large sessile multiple masses were pres- ent which could not be removed, consequently drainage did not arrest the disease. She died a year and a half later, of another disorder. Cure by operation is only to be looked for in the ascitic form where no deep involvement of organs has taken place, or else where the whole infected area can be removed, as in some cases of tuberculosis of the tubes, ovaries, and uterus. Frederick Treves (Annals of Surgery, May, 1894) has recently summarized the statistics collected by furChirurg., 1890) in relation to the results of operation. Among 308 cases of all varieties treated by coeliotomy the mortality due to operation was 2.5 per cent,; 33.4 per cent, may be regarded as complete recoveries from the disease. It has been estimated, says Treves, that under medical treatment 9.5 per cent, are cured, 19 per cent, die, and 71.5 per cent, are unimproved. There is much difficulty in obtaining reports of cases which extend over more than a few months, which makes all statistics somewhat misleading.