LUETIC PERITONITIS

Syphilis of the peritoneum is not mentioned as a possibility in the great majority of our textbooks in which diseases of the peritoneum are discussed. Even in the most recent textbooks on special pathology, as Aschoff's for instance, the section on the pathology of the peritoneum does not hint at the existence of a luetic peritonitis; and tuberculosis of the peritoneum is the only specific peritoneal infection discussed. In Nothnagel's system peritoneal syphilis is noted as one of the greatest rarities. Practically the only references to it are in the French literature. Lancereaux's case is the best known; it showed a dense white pseudomembranous adhesive peritonitis between the anterior abdominal wall and the small intestine associated with severe syphilis of the liver and other abdominal organs. Nevertheless, suspicions of the existence of such a clinical and pathological entity are beginning to creep into the literature; and with our rapidly increasing knowledge of the general pathology of syphilis, it is not at all unlikely that syphilis of the peritoneum may soon become definitely established as one of the especial, although perhaps not common, localizations of generalized syphilis. Korach of Hamburg, in the Deutsche medizinische Wochenschrift, October 10, 1924, contributes an article on "Ueber visceral Lues (luische Peritonitis) und luisches Leberfieber." He reports a case which he believes to be an undoubted example of syphilitic peritonitis uncomplicated by active syphilitic disease of the other abdominal viscera. The patient was a woman of thirty-nine, who had been perfectly well until 1920, when she suddenly developed pains in right arm and leg, head and back, with insomnia, which, in the neurological division were diagnosed as purely functional ("hysteria

gravis"). During four weeks stay in the hospital there developed a slight, irregular intermittent fever not influenced by antipyretics. The Wassermann was found to be XXX: a latent lues was diagnosed, and a mercury-cure was instituted, with the result that the fever disappeared, and the patient left the hospital. Six months later she again had fever with frequent chills, and on account of increasing weakness, returned to the hospital, entering the Medical Clinic on December 11, 1922, with complaints of increasing weakness, insomnia, loss of appetite, marked loss of weight, frequent chills, and persistent abdominal pain. Inspection showed a medium-sized woman moderately well-nourished with pale face and subicteric conjunctivae, and many scars on the forehead and back. The pupillary reflexes were slightly increased, pupils normal, ankle clonus was present, and there was no Babinski. Examination of heart and lungs negative. Wassermann +++. Intermittent fever with evening exacerbation, falling during the night with profuse sweating. Inspection of the abdomen showed an irregular tumor in the right upper quadrant 5 cm. below the rib-margin, about the size of a child's fist, 9 cm. broad in its upper portion, narrowing below to a breadth of 3.5 cm. It moved but slightly with respiration and was very sensitive to pressure. On palpation the tumor could be easily separated from the lower edge of the liver, and the lower pole of the right kidney could be easily palpated laterally from the tumor. Percussion over the tumor gave a dull tympanitic sound. The spleen, both by palpation and percussion, was found to be slightly enlarged. Blood examination showed haemoglobin 75 per cent; leucocytes 8-12,000, chiefly polynuclears; polychromatophilia; no polychromatophilia; no parasites. The temperature curve was that of a long, hectic, intermittent fever with profuse night-sweats and occasional chills. Re

peated Röntgen-ray examination of the intestines showed only a pushing of the ascending colon to the right, which could be corrected by pressing the palpable tumor towards the median line. Since the character of the fever suggested that of visceral syphilis, liver-syphilis in particular, a diagnosis of "syphilitic fever" was made, and borne out by the response to treatment with potassium iodide. After some delay resulting from an intercurrent thrombosis of the saphenous vein the tumor became much smaller and the fever ceased. Since a residuum of the tumor remained as a cord 3 cm. broad along the course of the ascending colon, accompanied by severe pain, and as the Röntgen examination threw no further light upon the condition an exploratory operation was carried out. The peritoneal cavity contained no fluid; the peritoneal surface was cloudy, and covered with a delicate membranous deposit; firm, cord-like and flat adhesions were present between the folds. A thickened strand of omentum adherent in the pelvis ran parallel with the ascending colon forming a firm tumorlike structure. This was removed. No pathological changes were found in the abdominal and pelvic viscera. Healing followed by first intention. Microscopic examination showed a diffuse, adhesive, indurative peritonitis which was regarded as "syphilitic" in the absence of any other etiological condition in the abdomen, and because of its association with the characteristic syphilitic fever, the positive Wassermann, and the therapeutic action of potassium iodide upon the peritoneal tumor and the symptoms. No histological findings characteristic of syphilis are mentioned, and no spirochaete examination carried out. The diagnosis, therefore, while very probable, is purely a clinical one. The author discusses the

genesis of syphilitic fever. Degenerative changes in gummatous nodules with resorption of the products of disintegration have been regarded as the cause of the fever not infrequently seen in association with syphilis. However, fever occurs also in cases of syphilis in which there are no degenerating gummas. In individual cases secondary infection of gummas has been regarded as the cause of the associated fever, but in other cases such secondary infection is not present. In the case under consideration there were no degenerating or infected gummas, and Korach would explain the fever in this case, as in others also, as due to the formation of endotoxins by the spirochaetes. He regards his case as important in throwing light upon the nature and etiology of the by no means rare cases of chronic adhesive and contracting peritoneal inflammations in which neither the anamnesis, operation or autopsy shows any associated lesions in the abdominal organs to explain the peritonitis. Many surgeons have reported the occurrence of scirrhous forms of adhesive peritonitis with formation of tumor-like masses in omentum and mesentery, particularly in the upper abdomen without coincident visceral pathology. Matthes has already advanced the view that such adhesive forms of peritonitis in children, when not tuberculous, are probably of syphilitic origin. Korach thinks that the same may be true of some of the adult forms of chronic adhesive peritonitis, and suggests that in such cases the surgeon should have a Wassermann reaction made, and if this is positive, apply the therapeutic test. After the clinical demonstration of syphilitic peritonitis it will still be the work of the pathologist to demonstrate the presence of spirochaeta pallida in the peritoneal lesions, and to fix the microscopical nature of the lesion.

Practical Lectures, Delivered under the Auspices of The Medical Society of the County of Kings, Brooklyn, New York, 1923-1924 Series. 484 pages, 132 illustrations and 3 color-plates. Paul B. Hoeber, Inc., New York, 1925. Cloth, Price $5.50.

This volume consists of twenty-five lectures given before the Medical Society of of the County of Kings during 1922-1923 by such well-known men as Blake, Bray, Brooks, Campbell, Deaver, Dickinson, Ewing, Fordyce, Fowler, Gant, Jennings, Johnson, Libman, MacAusland, McCrae, Mosenthal, Oliver, Polak, Regan, Tilney, Truslow, Walsh and Warren. It was a course of practical lectures dealing with common problems of medical practice and designed especially for practitioners, and proved so successful that the publication of the lectures was urged as constituting a valuable addition to the practitioner's working library. There is a broad scope and variety of subjects covered, each one of which is given a "practical" treatment; and the lecturers were selected either for their ability as teachers of medicine or because of outstanding accomplishment in some special line. Among the subjects treated are the surgical abdomen, appendicitis, abdominal tumors, ectopic gestation, common rectocolonic diseases, diabetes and insulin, endocarditis, renal function, chronic joint diseases, treatment of pneumonia, backache, epidemic encephalitis, common skin diseases, physical signs of incipient tuberculosis, common diseases of the breast, surgical diagnosis, rational pathology, everyday bacteriology, etc. While varying in interest and value, all of these articles are good and practical, and will be very helpful to the progressive practitioner. The book is well-printed and illustrated. It will serve as a good post graduate course, and can be especially recommended for this function.

Infantile Paralysis in Vermont (1894-1922). A Memorial to Charles S. Calverly, M.D., State Department of Public Health, Burlington, Vermont, 1924. 375 pages with numerous charts and maps.

This volume prepared as a memorial to Dr. Charles S. Calverly contains the latter's observations on the epidemics of anterior poliomyelitis occurring in Vermont during the years 1894, 1910, 1911, 1912, 1914-1915 and 1916-1917, preceded by a short biographical sketch of Dr. Calverly by Dr. Robert W. Lovett. Dr. Calverly became a member of the Vermont State Board of Health in 1890, and its President and animating spirit in 1891, which office he held until the time of his death in 1918. He was also Professor of Hygiene and Preventive Medicine in the University of Vermont. His article describing the epidemic in Vermont during the summer of 1894, published in the New York Medical Record in December of that year, stands out as the best American Contribution to our knowledge of this disease up to that time. He recognized the abortive cases, which were not so named until many years later, and gave an advanced account of the behavior of the disease. His biennial reports on the incidence of infantile paralysis in Vermont have been of great value to the medical profession. The volume also contains valuable articles by R. W. Lovett and E. G. Martin and Bertha E. Weisbrad on the treatment and after-care of poliomyelitis, and contributions from the Research Department by W. L. Aycock, Harold L. Amoss and Edward Taylor. The volume is of especial value in the study of the epidemiology of infantile paralysis, and of the treatment and after-care of cases of this disease.

International Clinics, Volume IV, Thirtyfourth Series, 1924. Edited by Henry W. Cattell, A.M., M.D., Philadelphia, with numerous collaborators. 308 pages and

101 plates and figures. J. B. Lippincott Company. Philadelphia and London, 1924. Price in cloth.

This volume contains 22 articles by competent writers on a variety of subjects: Blastomycosis, granuloma inguinale, pellagra, Vincent's angina, bacillary dysentery, administration of quinine in malaria, prophylaxis of yellow fever, intestinal obstruction, eczema, periodic health examinations, clinical use of X-ray and radium, insulin, acute pancreatitis, syphilis of the thyroid, calcification of the pericardium,

congenital cardiac disease, effects of tonsillectomy on existing visceral disease, mental disease in infancy and childhood, internal fixation in fractures, ethylene, fractures of the lumbar spine, and the practical application of industrial medicine. Of especial interest to the internist are the papers on "Congenital Cardiac Disease" by Maude E. Abbott and W. T. Dawson, on "Mental Disease in Infancy and Childhood" by James Burnet, and the one on "Insulin" by F. G. Banting.