OXYGENATION CAVITY
IN
OF THE
TUBERCULOSIS OF
THE
PERITONEAL TREATMENT OF THE ABDOMEN*
By NANDLAL BORDIA,
m.b., b.s.
District Medical Officer, Indore District, Indore, and Medical Officer in charge, Rao Sanatorium
In this article I propose to deal with the treatment of abdominal tuberculosis by oxygenation of the peritoneal cavity without making so as to any reference to general treatment, make the article reasonably brief and concise. *
Rearranged by the Editor.
234
THE INDIAN MEDICAL GAZETTE
In Central India tuberculosis of the abdomen is often found without being associated with pulmonary tuberculosis. It is the commonest form of tuberculosis met with in this part of the country and lung infection is usually secondary to abdominal disease. For some years the treatment adopted has been exploration of the abdomen and again closing the peritoneal cavity without doing anything inside. This It was believed that was found to be useful. it is the exposure to the atmospheric air, or probably oxygen contained in the air, that inhibited the growth of the tubercle bacilli. On this assumption Lieut.-Col. Tyrrell introduced intraperitoneal administration of oxygen, about the In all cases of abdominal tuberyear 1920. culosis a preliminary exploration of the abdomen was first performed to confirm the diagnosis and to ascertain if there were any adhesion of the gut to the peritoneum forming the part of the anterior abdominal wall. The abdomen was opened by a one-and-a-half-inch-long incision in the middle line, the contents were examined visually and by introducing a finger to feel any glands, adhesion, matting of the gut, or thickening of the peritoneum. If there was any evidence of tuberculosis the abdomen was closed and a small cannula of 1 mm. bore was introduced inside near the last knot in the peritoneum. The wall was sutured, the outer end of the cannula being kept.out and the inner end inside the cavity. Now oxygen was introduced in the following way :? Two flasks (wash bottles) of 500 c.cm. capaone of which is graduated, with the necesThe sary rubber connections are required. graduated flask is filled with perchloride lotion (1 in 1,000). Oxygen is passed from the cylinder into the graduated flask displacing the The graduated lotion into the second flask. flask is now connected with the cannula and by raising the second flask the oxygen is forced into the peritoneal cavity. The level of the lotion in the graduated flask indicates the amount of oxygen introduced.
city,
Nowadays preliminary exploration is tried only in doubtful cases. If there is a tumour or suspected adhesion, exploration is done first, otherwise in every straightforward case oxygen is introduced by the following way:? The skin and the abdominal wall are anaesthetized by 1 c.cm. of 2 per cent novocaine solution. The site chosen is about 1 inch below and lateral to the umbilicus. A sharp-pointed Graefe's knife is plunged perpendicularly through the skin, subcutaneous tissue and muscle at the anaesthetized spot. The trocar with the cannula attached is introduced into the knife puncture and gentle pressure applied. As soon as the peritoneum is punctured the patient experiences Now the trocar can be pulled a sharp pain. out leaving the cannula in situ, which then is freely movable up and down if it is inside the
[April, 1937
There is no danger in this procedure as of the cannula is blunt. Now the adaptor is fitted to the outer end of the cannula and gas allowed to flow in. The lotion in the flask rises freely if the gas is escaping into the
cavity.
the
end
peritoneal cavity.
Difficulties during operation (1) It may be difficult to judge when the peritoneum is reached, but free movement of the cannula by manipulation and free escape of are enough to show that the cannula is inside,
otherwise the trocar must be introduced into the cannula and further bored down to penetrate the peritoneum. In a short time after doing a few oxygenations the operator can easily judge when it is inside. (2) Even if the peritoneal cavity is reached the omentum may block the end of the cannula, but it can be easily cleared by moving the cannula up and down and allowing gas to flow under pressure by raising the flask. (3) The gut may be punctured if it is adherent to the abdominal wall and a faecal fistula may result. But in such doubtful cases exploration of the peritoneal cavity must always be tried first. of the blood vessels may be (4)
Any
large
introduced injudiI have never met with the last two accidents yet, and have seen and done the little operation hundreds of times. How much gas to introduce.?After exploration about 200 c.cm. of gas is sufficient on the first occasion, but the quantity on later occasions varies according to the size of the
punctured if the trocar is
ciously.
abdominal cavity. Formerly, when oxygen was introduced without measuring, the hollow note produced by percussing was a sufficient indica-
tion that the abdomen was full of gas. The obliteration of liver dullness is another good indication that enough gas has been introduced, provided there are no adhesions. Every week the quantity is increased till about 350 to 400 c.cm. and, rarely, even 500 c.cmof oxygen are introduced at each operation. I* there are adhesions it may be impossible to introduce more than 100 c.cm. without causing severe pain afterwards. Therefore, it is always wise to start with a small dose and then increase it gradually watching the condition of the
patient.
Post-operative complications a common complaint when the quantity of gas introduced is a large one( i.e., after 500 c.cm. at the first sitting or if there (1) Pain.?This is
adhesions inside. (2) Temperature.?In the majority of case=
are
the
uncomplicated
temperature tends to fall in cases, but if associated with extensive pulmonary tuberculosis the temperature may shoot up n a large amount of gas is introduced.
April, 1937] (3)
TREATMENT OF TUBERCULOSIS OF THE ABDOMEN: BORDIA
Dysentery-like
account of
Rarely, vessels, there
on
condition.
is
a
of the exudation inside the intestine and mild attack of a dysentery-like condition may result, which subsides as soon as the gas gets absorbed, usually in 4 or 5 days. (4) Surgical emphysema.?If the gas is allowed to escape into the abdominal wall ns complication occurs, but is not troublesome.
congestion
blood-stained
Results In the early stages when there
!?
are minute the peritoneum this form of treatment is at its best. There are records of a very large number oif cases, but it will be sufficient to quote only a
tubercles
on
few here:?
Case /.?A Mohammedan Bohra .female, aged years, was admitted to the M. T. Hospital for abdominal pain and the temperature high continued fever, rangmg from i03?F. to 104?F. She was very weak and Weighed 68 pounds. She was delivered of a child Wo months ago, following which she started getting 'gh temperature and was treated as a case of puerpera !tPils' but to no effect. There was history of diarrhea, abdominal pain and fever for five months before her
Pregnancy.
days ioSVe?ty she was
after her admission on the 8th March, given 150 c.cm. of oxygen without exploiathe abdomen. The temperature came down to F. next morning but rose to 103?F. in the evening, ?nd varied from 100?F. to 102'F. afterwards, bhe was oxygenated on the 15th March. our days her no morning temperature became fmal but the evening rise persisted. After the fourth ygenation she was completely afebrile. Her pam vl ded gradually. She put on eight pounds in weigh, ohRn sh? left the hospital. The patient is still under ^ervation with no complaints whatsoever. ,,.i a.Se II.?A Baniva was 16 years, emitted to the M.'T. female, aged Hospital, Indore, on the 16th siJ>a 1?33, complaining of pain in the abdomen, occandiarrhoea, loss of appetite and nausea for the last, Her temperature was 104.4?F. in the cvnn- months. ,nm?Liver and spleen were not enlarged. Abdomjn, Was th iUa" slightly rigid. She was operated on on all u Jul>v The abdomen was opened by a one-anda"-mch-long incision. The peritoneum was thickened 1(i? studded with minute tubercles. There were no Tl. CS',ons- Glands were enlarged in both iliac fossa?. .
?
?
abdomen was closed and aftr>ln; Every week 300 c.cm.
5,
200 c.cm. of oxygen were of oxygen were given and
,Ur oxygenations her temperature was completely Her Pain subsided partly after the second W^atum and completely after the fourth. Hei anri i lncreased by six pounds in one and a half months she was "a? uiscilai discharged on the 28th August. At S^e *s ^nite well and has no complaints, aged 18 years, married, was udtintfp i on ?"Female, l?th October, 1931, complaining of abdominal p. 111
nn
ovv
-
w
C'a&PreT/nt ?
and
distension for two years, and had no appetite. She several dispensaries in the Her temperature was 100?F. in the eVenin
IN
OF THE
TUBERCULOSIS OF
THE
PERITONEAL TREATMENT OF THE ABDOMEN*
By NANDLAL BORDIA,
m.b., b.s.
District Medical Officer, Indore District, Indore, and Medical Officer in charge, Rao Sanatorium
In this article I propose to deal with the treatment of abdominal tuberculosis by oxygenation of the peritoneal cavity without making so as to any reference to general treatment, make the article reasonably brief and concise. *
Rearranged by the Editor.
234
THE INDIAN MEDICAL GAZETTE
In Central India tuberculosis of the abdomen is often found without being associated with pulmonary tuberculosis. It is the commonest form of tuberculosis met with in this part of the country and lung infection is usually secondary to abdominal disease. For some years the treatment adopted has been exploration of the abdomen and again closing the peritoneal cavity without doing anything inside. This It was believed that was found to be useful. it is the exposure to the atmospheric air, or probably oxygen contained in the air, that inhibited the growth of the tubercle bacilli. On this assumption Lieut.-Col. Tyrrell introduced intraperitoneal administration of oxygen, about the In all cases of abdominal tuberyear 1920. culosis a preliminary exploration of the abdomen was first performed to confirm the diagnosis and to ascertain if there were any adhesion of the gut to the peritoneum forming the part of the anterior abdominal wall. The abdomen was opened by a one-and-a-half-inch-long incision in the middle line, the contents were examined visually and by introducing a finger to feel any glands, adhesion, matting of the gut, or thickening of the peritoneum. If there was any evidence of tuberculosis the abdomen was closed and a small cannula of 1 mm. bore was introduced inside near the last knot in the peritoneum. The wall was sutured, the outer end of the cannula being kept.out and the inner end inside the cavity. Now oxygen was introduced in the following way :? Two flasks (wash bottles) of 500 c.cm. capaone of which is graduated, with the necesThe sary rubber connections are required. graduated flask is filled with perchloride lotion (1 in 1,000). Oxygen is passed from the cylinder into the graduated flask displacing the The graduated lotion into the second flask. flask is now connected with the cannula and by raising the second flask the oxygen is forced into the peritoneal cavity. The level of the lotion in the graduated flask indicates the amount of oxygen introduced.
city,
Nowadays preliminary exploration is tried only in doubtful cases. If there is a tumour or suspected adhesion, exploration is done first, otherwise in every straightforward case oxygen is introduced by the following way:? The skin and the abdominal wall are anaesthetized by 1 c.cm. of 2 per cent novocaine solution. The site chosen is about 1 inch below and lateral to the umbilicus. A sharp-pointed Graefe's knife is plunged perpendicularly through the skin, subcutaneous tissue and muscle at the anaesthetized spot. The trocar with the cannula attached is introduced into the knife puncture and gentle pressure applied. As soon as the peritoneum is punctured the patient experiences Now the trocar can be pulled a sharp pain. out leaving the cannula in situ, which then is freely movable up and down if it is inside the
[April, 1937
There is no danger in this procedure as of the cannula is blunt. Now the adaptor is fitted to the outer end of the cannula and gas allowed to flow in. The lotion in the flask rises freely if the gas is escaping into the
cavity.
the
end
peritoneal cavity.
Difficulties during operation (1) It may be difficult to judge when the peritoneum is reached, but free movement of the cannula by manipulation and free escape of are enough to show that the cannula is inside,
otherwise the trocar must be introduced into the cannula and further bored down to penetrate the peritoneum. In a short time after doing a few oxygenations the operator can easily judge when it is inside. (2) Even if the peritoneal cavity is reached the omentum may block the end of the cannula, but it can be easily cleared by moving the cannula up and down and allowing gas to flow under pressure by raising the flask. (3) The gut may be punctured if it is adherent to the abdominal wall and a faecal fistula may result. But in such doubtful cases exploration of the peritoneal cavity must always be tried first. of the blood vessels may be (4)
Any
large
introduced injudiI have never met with the last two accidents yet, and have seen and done the little operation hundreds of times. How much gas to introduce.?After exploration about 200 c.cm. of gas is sufficient on the first occasion, but the quantity on later occasions varies according to the size of the
punctured if the trocar is
ciously.
abdominal cavity. Formerly, when oxygen was introduced without measuring, the hollow note produced by percussing was a sufficient indica-
tion that the abdomen was full of gas. The obliteration of liver dullness is another good indication that enough gas has been introduced, provided there are no adhesions. Every week the quantity is increased till about 350 to 400 c.cm. and, rarely, even 500 c.cmof oxygen are introduced at each operation. I* there are adhesions it may be impossible to introduce more than 100 c.cm. without causing severe pain afterwards. Therefore, it is always wise to start with a small dose and then increase it gradually watching the condition of the
patient.
Post-operative complications a common complaint when the quantity of gas introduced is a large one( i.e., after 500 c.cm. at the first sitting or if there (1) Pain.?This is
adhesions inside. (2) Temperature.?In the majority of case=
are
the
uncomplicated
temperature tends to fall in cases, but if associated with extensive pulmonary tuberculosis the temperature may shoot up n a large amount of gas is introduced.
April, 1937] (3)
TREATMENT OF TUBERCULOSIS OF THE ABDOMEN: BORDIA
Dysentery-like
account of
Rarely, vessels, there
on
condition.
is
a
of the exudation inside the intestine and mild attack of a dysentery-like condition may result, which subsides as soon as the gas gets absorbed, usually in 4 or 5 days. (4) Surgical emphysema.?If the gas is allowed to escape into the abdominal wall ns complication occurs, but is not troublesome.
congestion
blood-stained
Results In the early stages when there
!?
are minute the peritoneum this form of treatment is at its best. There are records of a very large number oif cases, but it will be sufficient to quote only a
tubercles
on
few here:?
Case /.?A Mohammedan Bohra .female, aged years, was admitted to the M. T. Hospital for abdominal pain and the temperature high continued fever, rangmg from i03?F. to 104?F. She was very weak and Weighed 68 pounds. She was delivered of a child Wo months ago, following which she started getting 'gh temperature and was treated as a case of puerpera !tPils' but to no effect. There was history of diarrhea, abdominal pain and fever for five months before her
Pregnancy.
days ioSVe?ty she was
after her admission on the 8th March, given 150 c.cm. of oxygen without exploiathe abdomen. The temperature came down to F. next morning but rose to 103?F. in the evening, ?nd varied from 100?F. to 102'F. afterwards, bhe was oxygenated on the 15th March. our days her no morning temperature became fmal but the evening rise persisted. After the fourth ygenation she was completely afebrile. Her pam vl ded gradually. She put on eight pounds in weigh, ohRn sh? left the hospital. The patient is still under ^ervation with no complaints whatsoever. ,,.i a.Se II.?A Baniva was 16 years, emitted to the M.'T. female, aged Hospital, Indore, on the 16th siJ>a 1?33, complaining of pain in the abdomen, occandiarrhoea, loss of appetite and nausea for the last, Her temperature was 104.4?F. in the cvnn- months. ,nm?Liver and spleen were not enlarged. Abdomjn, Was th iUa" slightly rigid. She was operated on on all u Jul>v The abdomen was opened by a one-anda"-mch-long incision. The peritoneum was thickened 1(i? studded with minute tubercles. There were no Tl. CS',ons- Glands were enlarged in both iliac fossa?. .
?
?
abdomen was closed and aftr>ln; Every week 300 c.cm.
5,
200 c.cm. of oxygen were of oxygen were given and
,Ur oxygenations her temperature was completely Her Pain subsided partly after the second W^atum and completely after the fourth. Hei anri i lncreased by six pounds in one and a half months she was "a? uiscilai discharged on the 28th August. At S^e *s ^nite well and has no complaints, aged 18 years, married, was udtintfp i on ?"Female, l?th October, 1931, complaining of abdominal p. 111
nn
ovv
-
w
C'a&PreT/nt ?
and
distension for two years, and had no appetite. She several dispensaries in the Her temperature was 100?F. in the eVenin
