lowing patients to die of large clots following injury or following fractures of the base of the skull. Even if these clots cannot be located, they cannot often escape detection at the operation; and if not complicated by multiple lacerations and multiple small hemorrhages, recovery will usually follow their removal. The same thing is true in large measure of cysts, abscesses and tumors. Further experience may show us that many insanities and epilepsies and certain types of meningitis may be cured by cerebral surgery. Certainly it would seem that purulent meningitis, not benefited by serum, spinal puncture or other means now in use, should be directly drained through the skull; and it is not impossible

cases of tubercular meningitis may be cured by simple opening and draining as are some peritoneal infections. of the same kind. With more knowledge much may be done that is now considered impossible and even now I think exploratory craniotomy by competent operators is as justifiable as exploratory laparotomy in many obscure cases.

TUBERCULOSIS OF THE PERITONEUM, UTERUS AND ADNEXA.1

BY

FREDERIC J. SHOOP, M. D.,

Chief Gynecologist of the Samaritan Hospital, Brooklyn.

Tuberculosis of the female organs of generation, associated often with the same. affection of the peritoneum, occurs with sufficient frequency to call the attention of the profession generally to it as an important factor in the causation of the various symptoms for which women seek their family doctor for relief. Inasmuch as

Read before the Brooklyn Gynecological Society, Dec. 3rd, 1909.

the subject of tuberculosis is at the present time uppermost in the minds of the laity, as well as of the medical profession, and every effort is being made to find some means of stamping out the great white plague, it ought not to be out of place for the Brooklyn Gynecological Society to spend a little time in considering the ravages of the disease on the women who come under the notice and care of the gynecologist.

Can we not find some way of recognizing these cases sufficiently early to enable us to use the proper remedy for radical cure, or in inoperable cases, give the kind of attention which will arrest the progress of the disease and prolong the life of the patient? Up to the present time the majority of these cases have been recognized only at autopsy or when operating for some other form of pelvic trouble, or on exploratory incision for diagnostic purposes; some few having been recognized as such previous to section. Many cases even after opening the abdomen have in the past been overlooked, as in some stages of miliary tuberculosis where the tubercles are all microscopic in size, or in the early stage of the chronic diffuse tuberculosis in which the gross appearance presents nothing striking to the naked eye which would differentiate it from inflammation from other causes. But by more careful observation and with the aid of the microscope in examining for tubercular tissue or for the tubercle bacillus, several observers have shown by their statistics that in salpingitis alone, out of all cases in which the tubes have been removed for all kinds of diseases, 8 to 18% of the tubes proved to be tubercular, an average of about one. in seven, surely a statement which should cause us to pause and consider! Again, in

Etiology. I shall confine the scope of this paper to the progress and treatment of the disease as it appears in the peritoneum, uterus and adnexa. Tuberculosis of these tissues may be primary or secondary, most frequently secondary, and of the peritoneum it is always secondary either preceded or followed by the infection of the generative organs. The invasion may be from within or from without; if from within it is usually if not always secondary; if from without, nearly always primary. It may be introduced. from without by unclean instruments, douche tube, or examining finger, or in coitus with a tubercular male consort, or by perverted sexual gratification with a tuberculous lesbian tribadist or cunnilinguist. The disease introduced by any of these means may fasten itself at any point from

portia vaginalis to the peritoneal cavity, most frequently passing through the lower portions and infecting the endometrium without infecting the other parts in transit rarely extending as far as the isthmus of the tube without infecting the uterus, frequently the invasion stops at the cervix.

From within, and most cases are from within, the infection of the generative organs may be from the peritoneum, or from infected lymphatics, from tubercular ulcer of the intestine which either allows the bacillus to float down to be picked up by the tube without infecting the peritoneum in transit or becomes agglutinated to one or another of the organs and involves it in the inflammatory exudate, or the organs may be involved as a part of a general miliary tuberculosis. All authors speak of the probability of the bacillus being carried to different organs or other secondary foci through the medium of the blood, but I cannot conceive how this can be done except in advanced stages of the disease at some point where the degeneration or ulceration has literally eaten its way through the wall of a good sized vein, pours the bacilli into the blood current and sends them on to principally the liver and kidneys.

One observer, Lasker, examined the blood of 68 cases of advanced tuberculosis and found the blood free from contamination except in one case and that one died in 19 hours after his observation. Nearly all agree in saying that infection from within. is usually secondary but may occur as a primary invasion, yet do not explain how it may happen as a primary. The only way I can see is that the bacillus may be ingested with the food in an individual who is free from tubercular infection, pass through a typhoid ulcer or a benign ulceration, float

down into the cul de sac and be picked up by the tubes without infecting the peritoneum.

Any infection from the blood and the lymphatics must be secondary to a focus situated elsewhere from which such channels pass it on.

All authors speak of at least three forms of the disease.

1.

I.

2.

Miliary.

Chronic Diffuse or Caseous.

3. Chronic Fibroid, and some name seven varieties of tubercular peritonitis alone, an entirely unnecessary confusion of distinctions; they are all one and the same disease and the different appearances are merely different stages of the disease in advancement or arrest of its progress, and that condition known as chronic fibroid or the cicatrized or calcified condition is only nature's attempt to block out or seal up the disease as arrested, which if successful, constitutes a spontaneous cure. I find one or two recent authors holding this view as instanced in Klebb's work on Tuberculosis, in speaking of the classifications: "It is safest to regard it as a widely varying manifestation of one process whose severity and extent are dependent on many factors." And H. W. Longyear, in an article written in 1904, made this statement, "All the varieties are simply different stages, one following the other with greater or less. rapidity depending on the power of resistance of the individual. In some the disease may not pass the first stage, etc." In fact, in operating we frequently see both miliary and chronic diffuse in the same case and occasionally all three varieties have been found. I will not enter into the pathology more than to say that at first the invasion is in the form of minute rounded pearl-like tubercles varying in size from

those which can only be seen with the microscope to those of the size of a split pea scattered over the mucosa or serosa, usually situated superficially just beneath the epithelium. At first the tubercles are all invisible to the naked eye, gradually they increase in size as the disease advances, become more elevated and now assume a spheroidal shape of grey translucent color with yellowish white to yellow center and finally becoming opaque. Some of these tubercles contain amorphous granular material, some contain epithelial cells, some pus and others a mixture of all; and frequently numerous tubercular bacilli are found. As the disease advances into the caseous or chronic diffuse condition it invades the membrane, the nodules enlarge and become flattened, irregular ulcers may form with elevated edges which are undermined by the advancing tubercular disease, many nodules break down and coalesce into larger masses and then invade the muscular tissue finally replacing all the physical elements of the organ affected. Or the disease may be arrested at any point in any of these stages of the disease and calcareous or chronic fibroid degeneration set in, calcifying the affected areas or infiltrating or replacing the tissue with a fibrous connective tissue, thus bringing about the spontaneous cure before referred to. The cheesy masses in the actively degenerative condition contain a tubercular tissue composed of a reticulated, delicate and transparent basement membrane which becomes opaque and denser as the disease advances. This membrane contains nodules of indifferent nucleated round cells with occasional multinuclear giant cells and usually numerous tubercular bacilli scattered throughout, but occasionally the bacillus cannot be demonstrated. If the disease is

it is the peritoneum which is attacked we may not have an accumulation of clear, turbid, sanguineous or sanguino-purulent fluid.

Diagnosis. Here comes our trouble. The patient does not walk into the office with a diagnosis ready made for corroboration, nor with the signs and symptoms sticking out-in fact, the early invasion is seldom if ever brought to our notice. Pain which is a most prominent factor in sending the patient to us for other difficulties, is tardy in making its appearance and seldom becomes prominent enough to compel the tubercular patient to ask for relief until much advance has already been made, and may even then be passed over as of no great importance, but a painful menstruation in any woman with associated inter-menstrual pelvic pain, pain when the bowels move, and with progressive increasing constipation ought to cause the physician to look into matters with the possibility of tuberculosis in his mind, and a thorough examination to be made. In the early stages nothing can be felt by the examining finger, later enlarged tubes, enlarged or irritable ovary may be outlined, yet these are not necessarily indicative of tuberculosis. The cornutubal shoulder like thickening can sometimes be made out in the ascending tuberculosis and helps in making a diagnosis especially if the cervix has been infected on the way up and shows the tubercular infiltration or an erosion. This erosion may be mistaken for cancer but microscopic examination of a piece of the

tissue or of the secretion will help out, and also the fact that the ulcer is less likely to bleed, the odor not so foul, and little or no pain localized near the cervix. The patient may come to you because of sterility, scanty menstruation, frigidity with reference to the marriage relations, for some discharge, a vague uneasiness in and around the ovarian region, a tenderness on the right side making her think of appendicitis, or for ascites. Most all of these are symptoms of any form of inflammation. If the patient is unmarried and a virgin the chances are 90% in favor of a tubal enlargement being tubercular, provided that gonorrhoeal infection can be excluded especially if the pain is not markedly severe; and under the same conditions, the chances are nearly the same for an endometritis being tubercular.

In the married women we will have to depend more upon (1) a family history of tuberculosis; (2) consort with a tubercular husband; (3) tuberculosis in some other part of the body; (4) the use of the microscope to examine secretions and scrapings from the uterus to help out in the diagnosis; and these are available mostly only in the more advanced diseases. One or two of the more recent authors on general tuberculosis mention the use of the tuberculin test as a confirmatory diagnostic agent. This agent may therefore be of value to us in determining an early invasion where we have only a suspicion that trouble of that nature is developing. There are several preparations on the market supplied by the drug houses for this purpose, sealed in tubes in the proper dosage ready to use and with full directions-one made after the formula of Morro to be rubbed into the clean sound skin, covering with a gauze and oil silk dressing. Another which is

probably more practical and easy of application is made after the formula of Von Pirquet (old tuberculin 1 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 more 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 iodo form 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