i^a; O, o3AT.^. IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 [if IB 1^ 1^0 1.8 1.4 11.6 V] <^ /a ^/,. m, '/ M Photographic Sdences Corporation 23 WEST MAIN STREST WEBSTER, N.Y. 14580 (716) 872-4503 CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian Institute for Historical Microreproductions / Institut canadien de microreproductions historiques ;\ Technical and Bibliographic Notes/Notes tachniques at bibliographiquas The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, or which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de couleur □ D D D D D D D Covers damaged/ Couverture endommagt&e □ Covers restored and/or laminated/ Couverture restaurde et/ou pelliculie Cover title missing/ Le titre de couverture manque I I Coloured n aps/ Cartes gdographiques en couleur Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noiral Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relii avec d'autres documents Tight binding .^/'v^ T.G. TUBERCULAR PERiTONiTiS BT F. G. FINLEY, M.D., Assistant Professor of Medicine, and Associate Professor of Clinical Medicine, McGill University ; Attending Pliysician. Montreal General Hospital. (Reprinted from the Monlreal Medical Journal, Ajiril, 1898.) TUBERCULAR TERITONITIS, BY F. G. FiNLEY, M.I)., Assistant Profussor of Medicine, and Associate Professor of Clinical Medicine McGill University; Attending Pliysician, Montrca' General Hospital. Tubercular Peritonitis— Abrupt onset— Latent Pulmonary Tu- berculosis -Laparotomy. Tlie patient, a man of 42, was admitted to tlie hospital on Fel)ruary 7tli, 1«9H, for pain and swelling in the abdomen. He stated tliat his health was always good up to last July, when he sulFered witli shortness of Ineath for two weeks. Toward the end of December he felt tired and unable to work. After a lon^ drive on January 2nd, the following day he was feverish, and sull'ered irom severe pain in the back. There was also pain in the right inguinal region, and pain and ililHculty, bit not undue frequency, of micturition. Tlie abdomen became swollen on Jaimary (ith. I'ain has been present in tlie left side of th'' al)domeu for al)oul an hour when- ever he takes much solid food, at times sharp arl startling in character. He has lost 30 lbs. since July. Neitlier cougli nor expectoration have ever lieen present. Tile fuiniUi history is negative as regards tuberculosis and cancer. E'.irimi)i(ition. — lle is a rather poorly nuurished man, slightly anicmic, the tem- perature varying between W and It)!', the tongue coated, and the pulse 80. The abdomen slightly distended and the muscles rather tense. There is increased full- ness on the left side below the ribs, and a gurgling sensation, but no clearly defined tumor. The note is dull in both Hanks, especially the left, unaltered by change of position, and there is slight ductnation over the tumor. At the right apex tliere is dullness both front and back, with tine crackling iid sibilant rales ; no cough or expectoration. The other organs are normal, and tiie urine is alkaline, contains a trace of albumen, and a heavy deposit of phosphates, but no pus. The condition remained unchanged, slight fever being present, and on tlie 24th he was transferred to Dr. Armstrong's ward for laparotomy. The operation was performed. on February 25th, when the intestinal coils were found much matted together by mcjderately firm adhesions. Numerous tubercles were scattered over the peritoneum, and small pockets of fluid were present on the left side. A good recovery from the operation ensued, the stitches being removed on the tenth day, and the patient was ui on the IStli. The temperature continued elevated in the evening, but showed a rather lower average than 'before the operation, but witli occasional rises to between 102 and 1())5. He left the hospital on March !)th, feeling in better health, free from alidominal pain, and his general condition somewhat im- proved. In this case the diagnosis of tubercuhir peritonitis rested on an indetinite tumor in the abdomen, witli fever, and on tlie presence of physical signs of tuberculosis at the apex of the lung. Miliary tuberculosis of peritoneum — Laparotomy— Subsequent involvement of pleurae and pericardium. The patient, a woman about 21, domestic servant, was admitted to the hospital for abdominal swelling. She came to the city last fall, and had been gradually losing (le.sli from the previous Hiiniinrr, Koiiiu; down from 121 to KMl lbs. between tliese periods. On .laiiiiiu-y 2:ir(i, IHDS, she iioliceil slight iibdoiiiiiml swelliiiK in the morniiiKi ii"d by evcnlpn she was iiiiiil)le to button her elollics. About the same time she bcKiin to sutler from nifjht sweats, and was ar(!ath on exertion. There was at the lime of Iku- admission evidence of ascites and fever. A diHK"u«'H of tubercular peritonitis was made, and I)i. Armstrong performed laparotomy and emptied the abdominal cavity of lliiid on February Ulh. The peritoneum was then Htiidded thickly with tubercles. .She continued, however, to have hi^h temperatures, with evening exacerbations; the loss of tiesh continued, and on February ii-ltli she was tran^ ferred to the niediciil ward. The note nuide on this date states that the patient is much emaciated, the cheek bones are prominent, the face Hushed, the muscles smiill, the subcutaneous f.it scanty, and the skin normal. The abdomen is slightly disii nded, measuring 27j inches, there is dullness in both Hanks, chan^^iuK with alteration of ))osition, but no liuctuation. Th- bi'eathing is slightly hurried, 24 to 2H per minute, no cough or expectoration. Fxpiinsion is deticlenton the leftside; there is dullness in the lower axilla and l)ase behind to the fifth dorsal spine. The dullness in the axilla disappears on lying on the other side. There is distant blow- ing breathing over the dull area. Owing to the feeble voice, resonance and fremitus show no alteration. A loud grating pleural friction which had been heard a few days previously has disappeared. On the right side there was dulness and a few crackling rales for a hand s breadth at the base posteriorly. The apex impulse was felt in the fourth space, somewhat feeble in spite of the thin chest wall. The cardiac dulness was triangular in form, beginning above at the third rib, its right border extending obliquely downwards and outwards to join the hepatic dulness at the fifth right rib, the lower part of the sternum and the fourth and fifth intercostal spaces to the right of the sternum being dull. The left border of the triangular area of dulness extended down from the third left rib to the apex and then blended with the dullness of the fluid in the pleural cavity. On sitting up in bed the line of cardiac dulness fell about a finger's breadth ; the other or{!;ans are normal. March 13th. The patient has gained somewhat in strength, but continues emaciated. The temperature ranged from i)7 to 1(W, being higher at night. The fluid in the left pleura has diminished, and a pleuro-pericardial friction is present along the left border of the heart. March 25th. The patient is gaining flesh and strength, and is able to sit up daily in a chair. The fluid in the pleurie has much diminished. This case is clearly one of tuberculosis involving the serous sacs and without obvious disease of the viscera. On her admission the pre.sence of tluid in the abdomen, hicrh temperatures, and gradual loss of flesh preceding any local symptoms, and strong hereditary tenden- cies to tuberculosis, rendered the diagnosis clear. The later involve- ment of the three great thoracic serous mernV^ranes is undoubtedly of the same character. The physical examination indicates very clearly the signs produced by small quantities of Huid in the pericardial sac. Percussion gives us the earliest and most certain indications. Dul- ness of a roughly triangular form, extending obliquely down and out to the right of the sternum, and especially to the fifth right space (Rotch's sign) is the earliest sign of pericardial effusion. The presence of movable dulness can often be demonstrated as in this case, and is a further sign of much value. In this case the percussion dulness was readily made out owing to the thin chest wall. It is in stout I 8 I people that a pericardial effusion ia most likely to be mistaken for cardiac erdargeniont. The proj^nosis in this case is extremely un- favorable. With such extensive disease an unfavorable proj^uosis iinist be j^iven, and althouj^h a gain in strength has occurred, the continued fever shows the process to be still active. The improvement which is going on seems remarkable in the presence of the general involvement of the serous sacs. It seems highly improbable that laparotomy should inHuence the process in the pleura) and pericardium, and it seems more rational to attribute the improvement to the natural tendency to arrest of the pathological process seen in many cases of tuberculosis.