PERITONEAL TUBERCULOSIS. JOHN MCHALE DEAN, M. D. ST. LOUIS, MO. IN treating the subject of tubercular peritonitis, one is necessarily confronted with the different varieties as well as the various advanced degree of involvement of the peritoneum in given cases. We may crudely divide tuberculosis of the peritoneum into two classes-primary and secondary. Primary, that is beginning in the peritoneum itself, is an extremely rare disease. Secondary, the more common, is due to the infection of the peritoneum from a neighboring organ diseased with tuberculosis, or through the lymphatic system from a distant organ. In the former case we may have a spread of the disease from the tubes, ovaries, appendix, kidney, bladder, intestines, or mesenteric glands. In the latter case the lymphatics may carry the infection from the lungs, bronchial glands, brain, pharynx, tonsil or the cervical glands. In one of my cases it followed intestinal tuberculosis, in another I obtained a history of the removal of enlarged tonsils and adenoids, and in another it followed tabes mesenterica. The types of peritoneal tuberculosis may be divided as follows: (a) Exudative, moist, either general or encysted. (b) Dry or adhesive. (c) Ulcerative. The exudative type is marked by a small or very copious amount of fluid free or encapsulated in the abdominal cavity. The fluid has some characteristics, it is alkaline, slightly viscid, of a yellowish-green color, and contains a small or large amount of blood. On standing a large sediment forms composed of blood, fibrin and coagulum. The sediment when centrifuged, digested with pancreatin and thereby concentrated, sometimes reveals the tubercular bacilli upon staining. It has been my experience seldom to find the bacilli in this way. Injection of the serum intraperitoneally and subcutaneously into guinea-pigs will often produce tuberculosis in these animals. When the tubercular process is not ulcerating we often get negative results from inoculations. The dry or adhesive type is marked by the absence of fluid and the presence of more or less adhesions between the intestines themselves and the parietal peritoneum, the liver, tubes, ovaries, bladder and uterus. In some cases of this type the adhesions may be so extensive as to almost obliterate the abdominal cavity and any attempt to disturb same would cause injury to the intestines. The ulcerative type does not differ materially from a lupus of the skin. The primary foci will almost invariably be found undergoing this ulcerative process. From this ulcerative nucleus the entire peritoneum is infected, and frequently this form is only an early stage of the other types. The organs in the abdomen most commonly selected for the primary foci are the fallopian tubes in the female and the appendix in the male. Why this fact so often confirmed on the operating-table is true is a point to be explained by conjecture. Possibly the anatomical relations coupled with the absence of an abundant supply of air or the poor natural drainage of the parts may be predisposing factors. Whatever the explanation may be the surgeon would be guilty of gross neglect if he failed to examine these parts in his search for the primary foci, and if found to be the starting points they should, if possible, be removed. That the chance for recovery is greatly enhanced if the primary foci are removed is borne out by Mayo in his remarks on this subject. It does seem only rational that were we to leave the fountain or source of the tuberculosis undisturbed, that it should subsequently become active. It is a common experience of the surgical pathologist connected with large hospitals to find many an apparently innocent appendix removed for chronic inflammation to show tuberculosis. Further, how many of us have operated on pus-tubes and been surprised to find them studded with miliary tubercles? Symptoms.-The symptoms are as peculiar as they are variable. The disease may begin as a case of acute appendicitis, or as a case of acute salpingitis. It may continue as an acute affection for weeks when the symptoms disappear almost entirely, but the patient complains of some discomfiture and vague pains. Anemia and emaciation continue in spite of internal medication, when gradually an exudate begins to form in the abdomen. The physician first suspects tuberculosis when this is detected. Noting the temperature we may find it normal, subnormal, or evening rise. The respiration is accelerated and the pulse is invariably rapid. Should examination disclose pulmonary tuberculosis the diagnosis becomes clear. Pain. This may be a prominent symptom in some cases, and then again it may be almost absent in other cases. In the dry or adhesive types we find it constantly present, and is often described as excruciating. The degree of seve ity in this type is laregly dependent on the distension of the intestines with gas, and when the same is expelled relief is obtained. In the exudative type the pain is slight, or may surprisingly be absent. In the ulcerative type the pain is of moderate intensity. I have seen cases of this type where the pain was not complained of, but by deep palpitation painful zones could be made out. Cases of tabes mesenterica are seldom accompanied by pain, unless some other complication is present. An exudative type I operated showed pain only on deep palpation. Temperature.-In the beginning of the disease temperature is noted, but after weeks duration, the temperature may disappear, or only show evening exacerbations. Some cases are accompanied by no temperature, only evening rises, or by subnormal temperature. The most extensive exudative type I have had the opportunity to closely observe never showed an elevation of temperature, but occasionally showed subnormal temperature. A case of tabes mesenterica under my care at the present time constantly shows a perfectly normal temperature. A dry or adhesive type I have observed constantly showed temperature with evening rises. We must conclude, that though temperature may be present, it is nevertheless a strikingly inconstant symp tom. Pulse. The pulse is invariably rapid, and and does not differ from other tubercular affections in this respect. Should temperature be present, the rapidity is out of proportion to its elevation. It may be described as a rapid, small, weak pulse. The pressure is generally low. Irregularity is noted towards the decline of the disease. As an index as to the condition of the patient I have found it the most reliable symptom. Fre Bowels.-There may be no disturbance in regard to the bowels, and then again, the symptoms may be prominent. The dry or adhesive type of cases generally show marked constipation, or if the intestines are involved, diarrhea is a prominent symptom. The pure exudative or ulcerative types frequently show a perfectly normal intestinal action. quently the dry type gives marked symptoms of intestinal obstruction due probably to adhesive bands or paresis. This type has often been discovered by the surgeons when called to operate on cases of intestinal obstruction. In cases of persistent diarrhea we must strongly suspect intestinal involvement by tubercular ulceration. Examination of the stools macroscopically or microscopically will reveal the presence of blood, when ulcers of the intestines are present. Examinations of the stools in pure uncomplicated types shows nothing abnormal. Stomach.-A curious fact about these cases is the appetite. It is invariably good; or I may add, in some cases abnormally good. Vomiting, except at the onset, when the case is considered appendicitis or salpingitis, is not generally present. At the onset vomiting is present with fever, pain and rapid pulse. Seldom is a case diagnosed until it has reached the chronic stage. Blood. The hemoglobin is diminished, the white blood corpuscles are increased, and the red blood corpuscles are generally decreased. Should intestinal ulceration result in perforation (as occurred in one of my cases) the white cells are very markedly in. creased in number. Urine. If the patient is febrile, then naturally the quantity is diminished, otherwise there is no alteration in quantity. Traces of albumen, with possibly a few hyaline casts, may be present, due to the accompanying anemia. Indican is present in large quantities. Should there be tuberculosis in the urinary tract, then serious alterations in the urine would be noted. The diazo-reaction is present in severe ulcerative types, and absent in other types, and as a diagnostic point is of little value. Diagnosis.-It seems impossible, clinically, to differentiate tuberculosis at the onset from acute appendicitis or acute salpingi. tis, and when such an achievement is made is generally on the operating-table. In any chronic peritonitis where no definite cause can be found we must not fail to consider tuberculosis in the etiology. Tuberculosis of the peritoneum is then essentially a chronic disease, and, therefore we must differentiate it from similar chronic disient symptoms, and careful examination of Attention should be paid to its salthe patient should be made. eases. Examination of the abdomen will reveal an exudate, and probably some enlarged mesenteric glands. Rectal and vaginal examination may reveal the presence of an enlarged appendix, fallopian tube or ovary, the probable foci of the disease. The rectal examination in the male may further disclose some prostatic tuberculosis. In one of my patients, a young girl, it was possible to detect tuberculosis in the tubes as the focal point of tubercular peritonitis by rectal examination. The dry type may closely resemble intestinal obstruction, but by persistent efforts we can succeed in getting the bowels to move. From cirrhosis of the liver tubercular peritonitis can be plainly and clearly distinguished by tapping. Localized tubercular exudate could only be confused with ovarian cystomata. A freely movable tumor, without pain, fever or constitutional disturbances whatever, marks ovarian cystomata as a condition not difficult to diagnose. Further, the history of slow growth, proceeding from one or the other side, aided by vaginal examination makes clear the diagnosis. It has been my experience sometimes with ovarian cystomata to have the patient tell me that the growth was discovered accidentally. Such would not be the case with tubercular peritonitis. Nevertheless, after all the symptoms have been considered, and still the diagnosis is doubtful we should draw off the fluid and inject same intraperitoneally and subcutaneously into guinea-pigs, and observe the symptoms produced in these animals. The prodromal period may vary from ten days to six weeks, and therefore the animals should not be too hastily killed. The autopsy of the animals may reveal tuberculosis has been inoculated in these animals. Microscopic examination of the new tubercular tissue, thus produced should be made and a sectional stain for the tubercular bacilli. If we are successful in these experiments we can make our diagnosis without doubt. Still it often happens when the tubercular process is not ulcerating that these experiments are negative, we are then forced to rely on the tuberculin test, i.e., the injection of tuberculin in patients with the view of getting a reaction like the veterinarians obtain in cattle. This is noted within twenty-four to forty-eight hours by chill, fever and marked constitutional disturbances. Should all tests and examinations still shroud the case in mystery we should for the benefit of the patient, and incidentally for ourselves, perform laparotomy. Prognosis.-This naturally depends on the advanced stage of the disease, and whether other organs are involved. In cases accom panied by pulmonary tuberculosis the prognosis is bad. In cases operated on the percentage of recoveries may be roughly placed at 50 per cent. Some report cases of spontaneous cure. This must be admitted as a possibility, but certainly it appeals to me as not only an unscientific, but also as an inhuman method of procedure to allow these patients to go without operation. Treatment. The treatment is easy of adoption. Open the abdomen, allow all the fluid to escape, dry the abdominal cavity with gauze, remove the focus or starting point, sew up the abdomen without drainage are the condensed steps of procedure in operating on cases of tubercular peritonitis. If expedient never neglect to remove the foci of the disease. Never drain these cases, for you are almost certain to get a fecal fistula following. It is not necessary to irrigate with salt solution, while it does no harm, and it accomplishes little good. MEDICINAL USE OF EGGS.-For burns and scalds there is nothing more soothing than the white of an egg, which may be poured over the wound. It is softer as a varnish for a burn than collodion, and being always at hand, can be applied immediately. It is also more cooling than the "sweet oil and cotton" application to allay the smarting pain. It is which was formerly supposed to be the surest the contact with the air which gives the extreme discomfort experienced from ordinary accidents of the kind, and anything which excludes air and prevents inflammation is the best thing to be at once applied. The egg is also considered one of the very best remedies for dysentery. Beaten up lightly, with or without sugar, and swallowed at a gulp, it tends by its emollient qualities to lessen the inflammation of the stomach and intestines, and by forming a transient coating on these ful sway over the diseased body. organs to enable Nature to assume her healthAn egg taken like an oyster, with pepper and vinegar, has been known to be retained on the stomach when everything else has failed. So THE VALUE OF SPINACH.-The French call this homely vegetable the scavenger of the stomach, and now our own medical men are awakening to its wonderful medicinal properties. It contains salts of potassium, iron, and other things which conduce to a good complexion, long life, and cheerful disposition. The man with a disordered liver, and the woman with a bad complexion, should contract the spinach habit, and these things will be rectified. This article of food contains more iron to the square inch than the most renowned ferruginous remedies. convinced has the medical profession become of the value of the once despised spinach that it is said to be an important factor in several new and popular tonics. The iron in spinach is easily assimilated, and the vegetable is eas. ily digested. The fact that spinach has such a remarkable effect upon the complexion will recommend it to the girls, and its benefi cial effects on the liver will recommend it to the men. In short, the virtues of the vegetable are so numerous that it would take a long time to tell them, but if the spinach habit grows to anything like proportion reached by the breakfast-food fad, we shall shortly turn into a strong, iron built, fresh complexioned, antibilious nation.- Bealth. THE MEDICAL FORTNIGHTLY Issued Tenth and Twenty-Fifth of Every Month. THOMAS A. HOPKINS, Editorial Staff: O. E. LADEMANN, Internal Medicine. JOHN MCHALE DEAN, Surgery. F. P. NORBURY, Nervous and Mental Diseases. R. B. H. GRADWOHL. Pathology and Bacteriology. WALDEMAR FISCHER, Ophthalmology. A. LEVY, Pediatrics. W. T. HIRSCHI, Therapeutics. A. F. KOETTER, Otology. HERMAN STOLTE, Laryngology and Rhinology. Editorial Rooms, Suite 319-321 Century Building, St. Louis. EDITORIAL CONTINUING the very effective work inaugurated some months since against quackery and oriminal phases of medicine the St. Louis Med. The Movement Against Criminal ical Society devoted the Abortion. evening of October 13th to a further discussion of abortion. Dr. Nicholson presented a resume of the work accomplished by the society through his committee and the plan of campaign for the future. Dr. Funkhouser spoke on the Present Legal Status of Criminal Abortion in Missouri and indicated legal enactments necessary to a proper handling of the subject. Rev. J. W. Day, Judge Shepard Barclay, Rev. W. C. Bitting and others spoke on the subject. The following proposed amendments to the laws relative to this question were presented, and after discussion it was decided to refer them to the Legislative Committee of the State Association, and to interest every medical body in the State in an endeavor to secure their enactment: PROPOSED DRAFT OF AMENDMENT OF LAW TOUCHING CRIMINAL ABORTION. Amended Sec. 1825. Any person who with intent to produce or to promote a miscarriage or abortion, prescribes, advises, gives, sells or administers to a woman (whether actually pregnant or not) or who with such intent procures or causes her to take any drug, medicine, or article or uses upon her, or advises to or for her the use of, any instrument or other method or device to produce a miscarriage or abortion (unless the same is necessary to preserve her life or that of an unborn child, or, if such person is not a duly licensed physician, unless the said act has been advised by a duly li censed physician to be necessary for such a purpose) shall in the event of the death of said woman or any quick child whereof she may be pregnant being thereby occasioned, upon conviction be adjudged guilty of manslaughter in the second degree and punished accordingly; and in case no such death ensue such person shall be guilty of the fel ony of abortion, and upon conviction be punished by imprisonment in the penitentiary not less than three nor more than five years, or by imprisonment in jail not exceeding one year or by fine not to exceed $1,000 00, or by both such fine and imprisonment; and any practitioner of medicine or surgery, upon final conviction of any such offense as is above defined, shall also be subject to have his license or authority to practice his profession as physician or surgeon in the State of Missouri revoked by the State Board of Health in its discretion, upon satisfactory proof of such final conviction. PROPOSED AMENDMENT OF LAW TOUCHING CRIMINAL ABORTION IN RELATION TO THE ADMISSION OF EVIDENCE. Sec. 2635-A. In prosecutions for abortion or for manslaughter occasioned by an abortion or miscarriage, or by an attempt to produce either, or attempted abortion, cr for any crime of which abortion or miscarriage may be part of the essential facts to be proven, the dying declarations of the woman whose death is charged to have been caused thereby shall be competent evidence on the trial of any person charged with such crime, with like effect and under like limitations as apply to dying declarations in cases of felonious homicide, provided, that the party offering such declarations shall first satisfy the court by competent testimony that such woman was of sound mind when said declarations were made; and provided further, that no conviction shall be based alone upon such declarations unless corroborated as to the fact that an abortion or miscarriage has taken place and in all such prosecutions aforesaid any physician or medical practitioner who may have attended or prescribed for such woman shall be a competent witness in said cause to testify concerning any facts relevant to the issue therein, and shall not be disqualified or held incompetent by reason of his relation to such woman as an attending physician or surgeon. SOME weeks since we announced the establishment in connection with the City Dispensary of a Contagious Diseases Clinic which purposed working principally with the victims tuberculosis, The St. Louis Society for the Relief of Consumptives. of this clinic is demonstrating itself a tremendous success; already better than three hundred patients have presented themselves for diagnosis and treatment, and the work promises to speedily assume proportions exceeding the most extravagant hopes. The development of the situation has accentuated many needs, and to meet some of these it seemed best to those in charge of the movement that other physicians and influential laymen be interested in it. To this end steps were taken to form a society to be known under the above title, a meeting was called at the auditorium of the St. Louis Medical Society on the evening of October 12, and the preliminary steps in organization were taken. Dr. H.J. Scherck was made temporary chair man, and Dr. L. M. Warfield temporary secretary; a temporary board was also appointed which is composed in equal numbers of physicians, clergymen and laymen, which shall arrange for the next meeting and the election of officers for the ensuing year. The objects of the organization are the maintaining of a large nonsectarian society to minister, without charge, to needy consumptives and their families; to maintain a system of visiting nurses for that class of afflicted; to aid tuberculosis victims who are too poor to move into better quarters, in obtaining more healthful abodes; to furnish special diet for those who cannot afford such; to institute home treatment under the supervision of trained nurses; to watch especially incipient cases and to combine them into classes under the charge of physicians; to aid any movement for the purpose of establishing or making use of hospital for advanced cases of consumption, which will effectually segregate the poor consumptives for the protection of the general community; to devise plans to assist and relieve those with surgical tubercuJosis, such as hip and spine disease, and in general to foster and carry further the international humanitarian movement to stamp out the white plague. The following are charter members: Drs. Louis M. Warfield, W E. Fischel, Frank L. Henderson, Wm. W. Graves, J. W. Charles, Geo. M. Tuttle, Robert Barclay, Jchn Green, Jr., H. J. Scherck, F.J. Lutz, J. R. Lemen, W. G. Moore, Geo. Homan, Kenneth W. Millican, Justin Steer, Albert E. Taussig, Greenfield Sluder, Nathaniel Allison, G. Baumgarten, W. A Hardaway, W. C. Sauer, Hanau W. Loeb, Henry Schwarz, Hugo Summa, Jesse Myer, E. W. Saunders, Harvey G. Mudd. Thos. A. Hopkins, D. L. Harris, Ralph L. Thompson; the Reverends Samuel Sale, Leon Harrison, Carroll M. Davis, Naphtali Luccock, Daniel S. Tuttle, L. H. Dorchester, John W. Day, William J. Williamson, Charles S. Mills, W. J. McKittrick, W. C. Bitting, John F. Cannon, S H. Wainwright, Robert A. Holland, John T. M. Johnston, James Thomas Coffey, J. C. Addie, John J. Glennon, Samuel J. Niccolls, J. H. Young, H. S. Bradley, W. T. Foster, J. N. Fitzgerald, B. T. Kemerer and Messrs. Hanford Crawford, A. D. Brown, Jos. R. Barroll, Lambert E. Walther, Selden P. Spencer, R. J. Newton, W. M. Powelson, N. O. Nelson, Irvin W. Barth, J. Hal Lynch, W. Daviess Pitman, Robert Rutledge, Moses Fraley, Lewis Rosenbaum, Edward F. Goltra, Marcus Bernheimer, H. M. Blossom, Chas. Neidringhaus, Murray Carleton, Homer P. Knapp, Thos. H. McKittrick, D. R. Cal houn, Forrest Ferguson, Clarence N. Jones, A. L. Shapleigh, Francis A. Drew, G. Geitz, John F. Shepley. IN a recent issue a reader appeared in our pages in which it was stated that the title The Term "Doctor." "doctor" was first used as such in the twelfth century. The editor of the Medical Review kindly calls our attention to the fact that the term was used centuries earlier by Horace and Cicero, and by other Latin writers, with a meaning of master or teacher. Our reader was somewhat clumsily worded; we had not thought that the word originated at the time mentioned, but rather that the academic title was then originated. Speaking of this Dr. Millican says: "As a university appellation, it was first formally established, it is true, at the University of Bologna, at the instigation of this same Irnerius, or Wernerus, the universities themselves being an evolution from the "schools" of previous ages. We must not lose sight of the fact that, common usage to the contrary notwithstanding, the term "Doctor" has nothing whatever to do with medicine as such, which is only one out of many faculties that have their acknowledged professors or teachers "the masters." Some time ago, if we remember correctly, American Medicine deplored the vulgarization of the erm "Doctor," whereby the doctorate of medicine was in danger of being swamped by the number of those styling themselves "Doctor" in virtue of degrees in laws, music, divinity, and other faculties We fancy that the shoe is really on the other foot. It is the vast numbers of Doctors in Medicine who have reversed the ancient position, wherein they formed but a small portion of the doctors in all university faculties. A doctorate really and essentially, in any faculty is a license to teach, and not necessarily carry with it a license to practise. That is why the distinction is still maintained in Great Britain between those who obtain their diplomas from medical colleges, which can grant only a license to practice-not a doctor ate in medicine-and university graduates. modern supplementary registration of diplomas and licensing system is directly in the line of evolution. The MISSOURI GRADUATE NURSES' ASSOCIATION. A movement is being inaugurated by the Missouri Graduate Nurses Association, of which Mrs. G. M. Gibson, superintendent of the Jewish Hospital is president, to elevate the nurses' calling and improve the status of those who have undertaken its responsibili ties. The organization purposes the registra tion and regulation of trained nurses and the placing of this profession in much the same position relative to the law as that now occupied by physicians. |