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lowing patients to die of

large the subject of tuberculosis is at the clots following injury following present time uppermost in the minds of fractures of the base of the skull. the laity, as well as of the medical profesEven if these clots cannot be located, they sion, and every effort is being made to find cannot often escape detection at the opera- some means of stamping out the great tion; and if not complicated by multiple white plague, it ought not to be out of place lacerations and multiple small hemor- for the Brooklyn Gynecological Society to rhages, recovery will usually follow their spend a little time in considering the ravremoval. The same thing is true in large ages of the disease on the women who measure of cysts, abscesses and tumors. come under the notice and care of the Further experience may show us that many gynecologist. insanities and epilepsies and certain types Can we not find some way of recognizing of meningitis may be cured by cerebral these cases sufficiently early to enable us surgery. Certainly it would seem that to use the proper remedy for radical cure, purulent meningitis, not benefited by or in inoperable cases, give the kind of atserum, spinal puncture or other means tention which will arrest the progress of now in use, should be directly drained the disease and prolong the life of the pathrough the skull; and it is not impossible tient? Up to the present time the majority that some cases of tubercular meningitis of these cases have been rec gnized only may be cured by simple opening and at autopsy or when operating for some draining as are some peritoneal infections other form of pelvic trouble, or on exof the same kind. With more knowledge ploratory incision for diagnostic purposes ; much may be done that is now considered some few having been recognized as such impossible and even now I think explora- previous to section. Many cases even aftory craniotomy by competent operators is ter opening the abdomen have in the past as justifiable as exploratory laparotomy in been overlooked,—as in some stages of many obscure cases.

miliary tuberculosis where the tubercles

are all microscopic in size, or in the early TUBERCULOSIS OF THE PERITONE- stage of the chronic diffuse tuberculosis in UM, UTERUS AND ADNEXA.1

which

the gross appearance presents

nothing striking to the naked eye which FREDERIC J. SHOOP, M, D.,

would differentiate it from inflammation Chief Gynecologist of the Samaritan Hospital,

from other causes.

But by more careful Brooklyn.

observation and with the aid of the microTuberculosis of the female organs of scope in examining for tubercular tissue or generation, associated often with the same

for the tubercle bacillus, several observers affection of the peritoneum, occurs with

have shown by their statistics that in sufficient frequency to call the attention of

salpingitis alone, out of all cases in which the profession generally to it as an im

the tubes have been removed for all kinds portant factor in the causation of the vari

of diseases, 8 to 18% of the tubes proved ous symptoms for which women seek their family doctor for relief. Inasmuch as

to be tubercular, an average of about one

in seven, surely a statement which should * Read before the Brooklyn Gynecological Society, Dec. 3rd, 1909.

cause us to pause and consider! Again, in

BY

500 autopsies at a consumptive hospital 8% portia vaginalis to the peritoneal cavity, had tuberculosis of the genital organs. most frequently passing through the lower

The disease may attack any individual at portions and infecting the endometrium any age but more frequently between the

without infecting the other parts in transit ages of twenty and forty, the period of rarely extending as far as the isthmus of the height of sexual activity, and more fre- the tube without infecting the uterus, frequently in married women. As to the rela

quently the invasion stops at the cervix. tive frequency of the organs attacked, 90% From within, and most cases are from are tubal either alone or combined with one within, the infection of the generative oror another of the organs. In 40% the gans may be from the peritoneum, or from uterus is affected alone or in combination. infected lymphatics, from tubercular ulcer They stand in about this order :

of the intestine which either allows the 1. Tubes.

bacillus to float down to be picked up by 2. Corpus uteri.

the tube without infecting the peritoneum 3. Peritoneum.

in transit or becomes agglutinated to one or 4. Cervix uteri.

another of the organs and involves it in the 5. Ovary.

inflammatory exudate, or the organs may 6. Vagina.

be involved as a part of a general miliary 7. Kidneys.

tuberculosis. All authors speak of the 8. Bladder.

probability of the bacillus being carried to This disease of the bladder is very in- different organs or other secondary foci frequent and most usually secondary to a through the medium of the blood, but I focus far advanced elsewhere.

cannot conceive how this can be done exEtiology.- I shall confine the scope of cept in advanced stages of the disease at this paper to the progress and treatment some point where the degeneration or of the disease as it appears in the peri- ulceration has literally eaten its way toneum, uterus and adnexa. Tuberculosis

through the wall of a good sized vein, of these tissues may be primary or second- pours the bacilli into the blood current and ary, most frequently secondary, and of sends them on to principally the liver and the peritoneum it is always secondary kidneys. either preceded or followed by the in

One observer, Lasker, examined the blood fection of the generative organs. The of 68 cases of advanced tuberculosis and invasion may be from within or from with- found the blood free from contamination out; if from within it is usually if not al

except in one case and that one died in 19 ways secondary; if from without, nearly

hours after his observation. Nearly all always primary. It may be introduced

agree in saying that infection from within from without by unclean instruments, is usually secondary but may occur as a douche tube, or examining finger, or in

primary invasion, yet do not explain how coitus with a tubercular male consort, or by it may happen as a primary. The only way perverted sexual gratification with a tuber

I can see is that the bacillus may be ingested culous lesbian tribadist or cunnilinguist. with the food in an individual who is free The disease introduced by any of these from tubercular infection, pass through a means may fasten itself at any point from

typhoid ulcer or a benign ulceration, float

2.

name

or

down into the cul de sac and be picked up those which can only be seen with the microby the tubes without infecting the peri- scope to those of the size of a split pea scattoneum.

tered over the mucosa or serosa, usually sitAny infection from the blood and the uated superficially just beneath the epithelymphatics must be secondary to a focus lium. At first the tubercles are all invisible situated elsewhere from which such chan- to the naked eye, gradually they increase in nels pass it on.

size as the disease advances, become more All authors speak of at least three forms elevated and now assume a spheroidal of the disease.

shape of grey translucent color with yel1. Miliary.

lowish white to yellow center and finally Chronic Diffuse or Caseous.

becoming opaque. Some of these tuber3. Chronic Fibroid, and some cles contain amorphous granular material, seven varieties of tubercular peritonitis some contain epithelial cells, some pus and alone, an entirely unnecessary confusion of others a mixture of all; and frequently distinctions; they are all one and the same numerous tubercular bacilli are found. As disease and the different appearances are

the disease advances into the caseous merely different stages of the disease in chronic diffuse condition it invades the advancement or arrest of its progress, and membrane, the nodules enlarge and bethat condition known as chronic fibroid or come flattened, irregular ulcers may form the cicatrized or calcified condition is only with elevated edges which are undermined nature's attempt to block out or seal up by the advancing tubercular disease, many the disease as arrested, which if success- nodules break down and coalesce into ful, constitutes a spontaneous cure.

I find larger masses and then invade the muscuor two recent authors holding this lar tissue finally replacing all the physical view as instanced in Klebb's work on Tuber- elements of the organ affected. Or the disculosis, in speaking of the classifications: ease may be arrested at any point in any “It is safest to regard it as a widely varying of these stages of the disease and calmanifestation of one process whose severity careous or chronic fibroid degeneration set and extent are dependent on many factors.” in, calcifying the affected areas or infiltraAnd II. W. Longyear, in an article written ting or replacing the tissue with a fibrous in 1904, made this statement, “All the connective tissue, thus bringing about the varieties are simply different stages, one spontaneous cure before referred to.

The following the other with greater or less cheesy masses in the actively degenerative rapidity depending on the power of re

condition contain a tubercular tissue comsistance of the individual. In some the dis- posed of a reticulated, delicate and transcase may not pass the first stage, etc.” In parent basement membrane which becomes fact, in operating we frequently see both opaque and denser as the disease advances. miliary and chronic diffuse in the same case This membrane contains nodules of inand occasionally all three varieties have different nucleated round cells with occabeen found. I will not enter into the path- sional multinuclear giant cells and usually ology more than to say that at first the in- numerous tubercular bacilli scattered vasion is in the form of minute rounded throughout ---but occasionally the bacillus pearl-like tubercles varying in size from cannot be demonstrated. If the disease is

one

der

active on a mucous surface, the membrane tissue or of the secretion will help out, pours out a great amount of cheesy ma- and also the fact that the ulcer is less likely terial which later becomes muco-purulent to bleed, the odor not so foul, and little or and we have a pyosalpinx or a pyometra no pain localized near the cervix. The paaccording to the cavity affected. If tient may come to you because of sterility, it is the peritoneum which is attacked scanty menstruation, frigidity with referwe may not have an accumulation of clear, ence to the marriage relations, for some turbid, sanguineous or sanguino-purulent discharge, a vague uneasiness in and fluid.

around the ovarian region, a tenderness on Diagnosis.- Here comes our trouble.

the right side making her think of appenThe patient does not walk into the office dicitis, or for ascites. Most all of these with a diagnosis ready made for corrobora- are symptoms of any form of inflammation. tion, nor with the signs and symptoms If the patient is unmarried and a virgin sticking out-in fact, the early invasion is the chances are 90% in favor of a tubal seldom if ever brought to our notice. Pain enlargement being tubercular, provided that which is a most prominent factor in send- gonorrhoeal infection can be excluded esing the patient to us for other difficulties, pecially if the pain is not markedly severe; is tardy in making its appearance and sel

and under the same conditions, the chances dom becomes prominent enough to compel are nearly the same for an endometritis bethe tubercular patient to ask for relief un- ing tubercular. til much advance has already been made, In the married women we will have to and may even then be passed over as of

depend more upon (1) a family history of no great importance,—but a painful men- tuberculosis; (2) consort with a tubercular struation in any woman with associated in- husband; (3) tuberculosis in some other ter-menstrual pelvic pain, pain when the part of the body; (4) the use of the mibowels move, and with progressive increas- croscope to examine secretions and scraping constipation ought to cause the physi

ings from the uterus to help out in the diagcian to look into matters with the possibility nosis; and these are available mostly only of tuberculosis in his mind, and a thorough

in the more advanced diseases. One or two examination to be made. In the early of the more recent authors on general tu

berculosis mention the use of the tuberculin stages nothing can be felt by the examining finger, later enlarged tubes, enlarged or

test as a confirmatory diagnostic agent. This irritable ovary may be outlined, yet these

agent may therefore be of value to us in are not necessarily indicative of tuberculo

determining an early invasion where we sis. The cornutubal shoulder like thicken

have only a suspicion that trouble of that

nature is developing. There are several ing can sometimes be made out in the as

preparations on the market supplied by the cending tuberculosis and helps in making

drug houses for this purpose, sealed in a diagnosis especially if the cervix has

tubes in the proper dosage ready to use been infected on the way up and shows the and with full directions-one made after tubercular infiltration or an erosion. This the formula of Morro to be rubbed into the erosion may be mistaken for cancer but clean sound skin, covering with a gauze microscopic examination of a piece of the and oil silk dressing. Another which is

more

probably more practical and easy of application is made after the formula of Von Pirquet (old tuberculin i part, a 5% solution of carbolic acid i part, and normal salt solution 2 parts), two or three drops are placed on a scarified surface such as is usually made for an ordinary vaccination, let stand for a minute or two and then wiped off and a protective covering placed over it. The preparation for the eye test may be more reliable in its accuracy but is

severe in its reaction and would arouse opposition to its general use. While an occasional test may show in a patient having an especially irritable skin, a reactionary rash somewhat simulating the regulation one in which presence of the disease cannot ultimately be demonstrated, yet the absence of a reaction may be taken as a pretty sure evidence that no tuberculosis exists. An occasional failure should not cause us to throw aside so valuable an aid. Of course the tuberculin test only indicates the presence of a focus somewhere indefinitely located, but given a positive reaction in a case with some vague pelvic trouble, we are pretty sure to know what that trouble is.

Treatment.-Being assured that there is tubercular disease in the intrapelvic tissues or organs, or knowing there is some disease there and only strongly suspecting it to be tubercular, exploratory incision should be made to complete the diagnosis with the understanding that removal of the diseased organs shall be done if warrantable. If the trouble is in the endometrium only, and so determined, abdominal section need not be done but merely give the uterus a thorough curettage, swab with iodine or an iodoform emulsion and establish free drainage; often this is sufficient to bring about a cure and does not

militate against a subsequent hysterectomy in case the disease is not conquered. The mere opening of the abdomen, airing the cavity and instituting drainage is often sufficient to bring about a cure of miliary tuberculosis of the peritoneum.

In salpingitis both tubes are as a rule affected and both should be removed; often only one ovary is diseased and should be removed, the other one may be left, if apparently healthy, unless the patient is at or near the menopause when in my judgment both should be removed together with the tubes. Some think a panhysterectomy should always be done if both tubes are affected, but if the uterus is only slightly infected or apparently normal it may be safely left and curetted and swabbed as before described. These are matters for individual judgment.

The presence of an advanced focus elsewhere is usually contra-indicative to operative procedures, and only palliative and general tubercular treatment can be used together with the usual hygienic, climatic and nutritive measures which should be employed in all cases whether operative or not. However, in these advanced cases, if the local process is causing more irritation and weakening the patient more than would be caused by removal, such removal might be considered as a part of palliative treatment—as curettage or amputation of the cervix, etc.

Medicinally, Ferrier claims to be getting excellent results by limiting the ingestion of acids with the foods and using a powder three times a day composed of calcium carbonate gr. viii, tribasic calcium phosphate gr. iii, and magnesium calcined gr. i, to promote calcification.

Prognosis.- The prognosis of intrapelvic tuberculosis is bad especially in ad

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