ably less severe. Both the pain and tenderness are localized, while the vomiting is less frequent and sometimes of but short duration. The fever may be quite as high as in general peritonitis, but the cases run a much longer course, sometimes ending in apparent recovery after a prolonged convalescence. The physical examination, exclusive of the determination of tenderness or rigidity, relates to the detection of fluid and the recognition of definitely circumscribed masses. In cases characterized by excessive exudation, dulness is obtained upon percussion. This is early recognized in the flanks, and is found to vary in location with a corresponding change in the position of the patient. As the fluid increases the dulness in some cases becomes general and fluctuation is detected. Rising of the diaphragm, acceleration of the respiration, and alteration in the position of the cardiac apex is possible in severe cases. Circumscribed collections of fluid are recognized by palpation, chiefly in the form of rounded, fluctuating tumors. Sometimes, however, on account of the extreme tension of the contained fluid they appear as resisting masses. Hard, unyielding tumors may be present, which strongly simulate solid neoplasms of various organs. These masses, either solid or apparently so, may occur in almost any portion of the abdominal cavity and resemble almost any conceivable new-growth. They may occur in the right or left epigastric region, in either hypochondrium, above the pubis, in the right or left iliac fossa, and in the neighborhood of the umbilicus. The location of the induration and the simulation of solid growth are often sufficient to confound the most experienced examiner. It is possible at times to appreciate a distinct peritoneal friction or crepitation, which affords quite definite information as to the character of the involvement. Diagnosis. The diagnosis may be comparatively simple in many cases, but in others it is often exceedingly difficult. Acute perforative cases exhibiting a sudden and violent onset are seldom regarded in the beginning as instances of tuberculous peritonitis. Such cases are likely to be confused with appendicitis, strangulated hernia, and the common form of acute peritonitis, a positive diagnosis often not being established until the abdominal cavity has been opened. In internal hernia and acute intestinal obstruction from other cause the pain, as a rule, is localized and paroxysmal. In such cases the abdominal distention is due to gas rather than to fluid, and constipation is common. The early vomiting soon becomes fecal in character. In appendicitis the onset is usually acute, but the rigidity, pain, and tenderness are localized in a definite area in the immediate region of the appendix. While tumor-like masses are often present in tuberculous peritonitis, they are exceedingly rare in the acute fulminating type, exhibiting a violent onset. cases of appendicitis despite the history of chill, rapid pulse, and vomiting, there may be elicited by physical examination not the slightest external evidence of its presence. Per contra there may be found a sharply localized area of resistance and tenderness over the region of the appendix, without associated subjective symptoms. This will be considered more fully in connection with tuberculosis of the appendix and simple. appendicitis among pulmonary invalids. In some Difficulties of diagnosis also attend the chronic forms of general tuberculous peritonitis. In these cases the condition at times may be essentially latent, and give rise to no symptoms whatever. The diagno sis is often made at the time of an operation for some other condition among individuals in excellent nutrition. There may be absence of fever or of previous suspicion of tuberculous involvement. Peritoneal infection is undoubtedly present more frequently among pulmonary invalids than is commonly supposed. Many consumptives with quiescent pulmonary infection, display abdominal tenderness, moderate distention, and continuous slight elevations of temperature without explainable cause other than the hypothesis of a mild peritoneal infection. This group of symptoms in the presence of a known tuberculous lesion in the lung capable of producing temperature elevation, is often attributed to disturbances of digestion. Many of these cases exhibit recurring attacks of slight colicky pain, which is more or less vague and indefinite in localization. The persistence of such manifestations among consumptives is sufficient to suggest the possible existence of a chronic peritoneal tuberculosis. Especial confusion is likely to be experienced in the differentiation of the circumscribed exudations and tumor-like masses from the solid neoplasms or fluctuating tumors peculiar to certain organs. It is hardly appropriate to infringe upon the domain of surgery and enter upon a necessarily detailed consideration of technical diagnostic features pertaining to the simulation of cysts of the pancreas, pyonephrosis, empyema of the gall-bladder, hydatid cysts, ovarian tumors, pustubes, pelvic disease, and new-growths in the stomach or intestine. precise diagnosis is often out of the question without an exploratory operation. A tuberculous omental tumor, however, presents somewhat fewer difficulties than the more definitely circumscribed masses, because of its characteristic elongated shape. When the omentum is the seat of tuberculous infection, it is sometimes stretched across the abdomen in a firm mass which is attached to the transverse colon a little above the region of the umbilicus. This hard, band-like mass may be similarly situated in cases of carcinoma, though less often than in tuberculous processes. In doubtful cases the existence of tuberculosis elsewhere should afford a reasonable assumption as to the nature of a local peritoneal involvement. In the event of an undiscoverable tuberculous focus in other parts of the body a distinct family history of this disease is of undoubted significance, as is also the admission of an idiopathic pleurisy, glandular enlargements, or caries of bone. It has been shown quite conclusively that the tuberculin reaction in obscure cases is of unmistakable value. If this is absent, a reasonable doubt may be entertained as to the tuberculous nature of the affection, while a positive result is strong prima facie evidence of such condition. In doubtful cases recourse to the ophthalmotuberculin test is worthy of trial. As indicated previously the age is often an important determining factor. I have in mind the case of an intimate friend, thirty-five years old, of tuberculous family history. He was well nourished and unusually robust, but in the midst of apparent health experienced a severe rigor with sharp pain in the left lower abdomen, followed by vomiting and abrupt elevation of temperature. Upon examination tenderness and resistance were at once detected. Had the physical signs existed upon the right side, instead of the left, the conclusion would have been unavoidable that the condition was acute appendicitis demanding imme diate operative interference, and in this connection the possibility of transposition of the viscera was entertained. Drs. Powers and Bagot concurred in the non-advisability of immediate exploratory laparotomy and counseled for the time being a policy of delay. After weeks of recurring pain and nausea, with progressive emaciation and physical debility. following the subsidence of the initial violent symptoms, an exploratory operation disclosed extensive tuberculous involvement of the peritoneum with multiple adhesions of intestinal coils. There had previously been recognized upon examination a firm, hard, linear mass extending from the left iliac fossa upward into the flank for a distance of five to six inches. This mass was found to be due to a localized proliferative and adhesive peritonitis, the fibrous tissue growth being especially marked. The patient survived but a few days following the operation. The acute onset of abdominal symptoms took place less than two weeks following an accident while riding horseback through an almost impenetrable region in the mountains, the horse in falling having pressed upon the abdomen with great force. The thought is, therefore, suggested that the tuberculous involvement may have been of traumatic origin. Prognosis. The prognosis of tuberculous peritonitis varies in accordance with the age, the severity of the infection, the extent and character of the involvement, and the general condition of the patient. In young children, particularly if of tuberculous parentage, the outlook is less favorable than in adults. Acute cases of suppurative peritonitis following perforation are almost invariably fatal. Localized tuberculous involvement, even if acute, is not necessarily hopeless, though uniformly of grave significance. Exudative cases possess a much more favorable prognostic import than the adhesive and proliferative forms. Many cases are amenable to cure, as the result of either medical or surgical management. Of Shattuck's 25 cases subjected to medical treatment alone, the mortality was 68 per cent., which is accounted for in part by the fact that in all but 6 of these cases there were present other important complications. Among his 57 cases submitting to surgical operation the mortality was 47.3 per cent. An analysis of Shattuck's report disclosed the fact that the most favorable results were obtained in the non-exudative cases, while the mortality was high in ascitic cases irrespective of the nature of the fluid. These results are at variance with the usual conception of the prognostic import attaching to the exudative type as compared with cases exhibiting well-defined masses. As a rule, the subacute or chronic exudative forms furnish the best results, particularly if subjected to operative interference. Modern opinion regarding the manner in which improvement is secured in such cases as a result of opening the abdomen, inclines toward an increased phagocyting power of the white blood-cells by virtue of the direct entrance of air into the abdominal cavity, or, in accordance with the theory of Wright, the presence of a new exudate rich in opsonins. Cameron calls attention to the highly favorable influence resulting from the stimulation given to the lymphatic and vascular circulations on account of the trauma and the reduced intra-abdominal pressure. It is apparent that operation offers but little to patients exhibiting the fibrous obliterative type or ulcerous form. The existence of advanced tuberculous infection in other parts of the body adds to the gravity of the prognosis. The same is true of suppurative processes, persisting fever, diarrhea, and progressive loss of weight. Generally speaking, about 50 per cent. of all cases may reasonably be expected to improve, if not absolutely recover. Treatment.-There is no general method of treatment for tuberculous peritonitis which may be considered justly applicable to all cases. Quite a proportion are known to recover under purely medical management, while some do well after tapping the abdomen and removing as much as possible of the ascitic fluid. Others demand, on the merits of the case, an exploratory operation, which determines at once the nature of the subsequent management. At such a time many cases are discovered to be entirely inoperable. The general medical treatment is chiefly that of superalimentation, with due regard for possible digestive disturbances, rest, hygienic surroundings, and attention to special symptoms. A suitable environment with cheerful surroundings, good food, and outdoor facilities is of prime importance. Symptoms should be relieved, if possible, as they arise. It is proper to resort to occasional tapping if demanded for the comfort of the patient. My experience with this condition has been somewhat limited, but sufficient to afford satisfying proof as to the efficacy of rest, improved nutrition, and absence of worry in the effort to establish convalescence. I have in mind a young lady in whom the diagnosis of peritoneal tuberculosis was established at the time of operation for appendicitis in 1900, previous to which there had been no symptoms suggestive of abdominal disease. For several years following the operation there were no clinical evidences of peritoneal infection, but there developed a slight pulmonary involvement with laryngeal complications which constituted the basis for her coming to Colorado. In the midst of a most excellent nutrition, absence of cough, expectoration, and fever, there took place, five years following her initial peritoneal involvement, a severe rigor and sharp elevation of temperature, associated with intense abdominal pain and vomiting. Examination of the abdomen was entirely negative, save for a very slight distention and general stiffening of the abdominal wall, without localized tenderness. With recurring chills and continued high elevation of temperature, increasing abdominal distention, and beginning general tenderness, the abdomen was opened by Dr. Powers, and an extensive adhesive tuberculous peritonitis was found. The serous membrane was studded throughout both its parietal and visceral layers with small tubercle deposits, and there were multiple adhesions between the intestinal coils, adjacent organs, and the abdominal wall. The case is of especial interest in view of the knowledge that during a period of many years, despite an extensive pathologic change involving the wall of the peritoneal cavity and its contents, she exhibited no symptoms whatever of general or abdominal disturbance. The operation was indicated as an exploratory procedure, but was recognized to be unavailing as a therapeutic measure, on account of the character and extent of peritoneal infection. It is often difficult to determine satisfactorily when the indications point conclusively toward the expediency of operative interference. An exploratory laparotomy is often justified after failure to secure improvement under four to six weeks' medical management, and earlier if the patient is rapidly declining. In acute miliary tuberculosis the patient often dies before the symptoms of peritoneal infection are apparent, but if detected, operation is clearly contraindicated in the majority of cases. All cases presenting evidence of acute intestinal obstruction should be accorded the possible benefit to be derived from abdominal section, although unusual difficulties for successful results are presented by the existence of the numerous adhesions. Surgical interference avails practically nothing in cases associated with great prostration and emaciation. The coëxistence of tuberculous infection in other parts of the body does not necessarily contraindicate operation, providing the general condition is not that of extreme prostration. The nature of the operative interference must vary in individual cases. A simple incision is sometimes sufficient and often highly satisfactory. The opening of the abdominal cavity must be performed with special care, on account of the possibility of intestinal and peritoneal adhesions immediately beneath the site of the incision. It is important to remove as much of the contained fluid as possible in order to diminish the likelihood of reaccumulation. It is rarely advisable to resort to drainage or flushing of the abdominal cavity. In general, the less meddlesome the interference, the more satisfactory the results. It is unwise to attempt to break up adhesions unless to relieve intestinal obstruction or to provide opportunity for the removal of the contained fluid. It is important to remove, when possible, local foci of infection. This applies particularly to the Fallopian tubes, the appendix, or large cheesy masses in the omentum. It is under such circumstances that drainage is at all permissible, and even then but for a short period. The danger of fecal fistula is much enhanced in those cases in which drainage is employed. A reaccumulation of fluid does not in itself contraindicate the performance of a second or a third operation. SECTION IV GLANDULAR TUBERCULOSIS CHAPTER LIX PATHOGENESIS OF GLANDULAR INFECTION THE relation of the lymphatic system to the development and spread of tuberculosis is of exceeding interest. The distribution of bacilli from a primary focus of infection is effected in very many instances along the lymphatic and circulatory channels. In the light of comparatively recent investigation it is known that tuberculosis of the lymph-nodes, i. e., the cervical, tracheobronchial, mesenteric, and retroperitoneal glands, often represent primary foci of infection. An initial tubercle deposit having taken place, the infection is conveyed subsequently by way of the lymphatics much more frequently than by the bloodvessels. When the vascular system is the sole carrier of bacilli, the |