Medical Association, and my home is as pleasant as it is, you can put me down as a contract doctor, I am proud of it. I devote all my time to my camp, but if I have to open up a practice I assure you I will have friends among those in the camp.

TUBERCULOSIS OF THE PERITONEUM AND
PLEURA.

BY NATHANIEL GUIDO CLARK, M. D., OF ENSLEY.

Member of The Medical Association of the State of Alabama.

In choosing the above subject, I have done so because of the fact that, while the morbid anatomy of tuberculosis of these two sites is practically the same, and a form of treatment for tuberculosis of the peritoneum has been instituted which has given fairly good results, the same line of treatment cannot be carried out in tuberculosis of the pleura, for obvious anatomical reasons.

I will consider these conditions from the standpoints of treatment solely, and will only enter in such discussion of their pathology, etc., as would modify the treatment, prognosis and cause of cure.

I am basing my paper on ten cases each of peritoneal and pleural tuberculosis created in the Prison Hospital, at Pratt City, Ala.. These latter cases were all treated as set forth in this paper. I will only consider those cases which can be benefited by treatment; i. e., chronic tubercular peritonitis, and pleurisy with effusion. These patients were all negro convicts, the class of patients for whom it is hardest to do anything, if tuberculous. I do not doubt that a better class of patients treated by the same methods would yield better results.

The treatment of chronic tuberculosis of the peritoneum with effusion has been to open the abdomen, let out the fluid and sew up the cavity again; this has been modified by different operators, by washing out the abdomen, sponging off the

intestines with mild antiseptics, inserting drainage &c. I have washed out some abdomens, but could see no advantage to be derived, so I discontinued this form of treatment, and simply opened the abdomen, drained, and closed without permanent drainage.

Now, let us compare the differences noted at autopsy between those cases aspirated for the effusion, and those which were opened, drained, and closed. In those aspirated, the abdomen between loops of the bowels. The tubercles on the peritoneum stood out plainly. In those cases which were opened and drained, the intestines were matted together by a layer of fibrin, and in nearly all cases there was no fluid. The individual tubercle could not be made out in cases of long standing after the operation. This may possibly throw some light on the method and cause of cure in the cases which do get well,, but this will have to be worked out by those skilled in autopsy and laboratory work. I have only one suggestion to make as to the technique of this operation, and that is not to use sutures of cat-gut; for, by its capillarity, it is liable to infect the wound from the abdominal cavity with tuberculosis as happened in two of my cases.

Of the ten cases under observation, two were not operated upon. One died and the other had made a symtomatic recovery. Of course, in this case a mistake in diagnosis might have been possible, but the clinical picture was perfect.

Of the eight cases operated on, three were discharged cured as far as could be discovered; one, after a period of years, is living and improving slowly. This is one of the cases in which the incision became infected with tuberculosis from the cat gut; the other four died within two months after operation. One of the cases which recovered was operated upon by Dr. B. G. Copeland at the prison in 1898, and is to-day wel! and hearty. As far as a careful physical examination could reveal, these three men are cured of tuberculous peritonitis. No doubt some have tubercular lesions elsewhere.

Thre is a great diversity of opinion as to how this opening, draining and closing effects a cure, but all agree that it does so in favorable cases.

The morbid anatomy of tuberculous peritonitis and pleurisy with effusion is necessarily the same, except that in pleurisy the constant movement of the lung and rubbing together of the pleural surfaces. cause more fibrin to be deposited on the surface of the

pleura than occurs on the peritoneum. For tuberculous pleurisy with effusion the ordinary method of treatment by aspiration is not successful. The lung is forced from its compressed piace in the apex and inner wall of the pleural cavity, thus distending the inflamed pulmonary pleura, disturbing, and possibly rupturing and tearing, infiltrated and caseous areas in the parenchyma of the lung. My observation in cases treated in this manner, at the prison, the period of observation is since 1897, and must include not less than fifty cases-is that they nearly all die in two or three months, and of general miliary tuberculosis. This I believe to be the result of tearing and stretching tuberculous areas in the pleura and lung, giving a direct systemic infection. Aspiration by the old method rarely removes more than half the fluid, induces coughing, sets up the pain again, and is a general shock, so much so, that I have seen syncope result in several cases. I have seen three cases treated by resection of a rib, and drainage. These cases required dressing daily, all became infected by pus germs and all died.

For a year I have been treating these cases, as near as possible, in line with the accepted treatment of tuberculous peritonitis with effusion, i. e. by the withdrawal of the fluid and the introduction of air into the pleural cavity. I do not know that this is original, nor do I claim originality for the method. There is practically little danger in an aseptic pneumothorax, as is proven by the numerous cases of stab, pick and gun-shot wounds that recover without any trouble. The air is removed by absorption in from one to three weeks, and no bad results occur. There is practically no shock in removing fluid from the pleural cavity and introducing air, as a condition of equilibrium of internal and external pressure is brought about.

In cases of large effusion, when an aspirating needle or canula is introduced, the fluid will flow for a time from internal pressure. This is due to the retractility of the chest walls, and the expansion of a compressed lung. As soon as the internal and external pressure is equalized, this flow stops and on examination the patient is found easier, but at least twothirds of the fluid remaining. Now if an aspirator is attached and the pressure in the bottle removed, the air rushes in a retracted lung, forcing it out to fill the pleural cavity, and the bad results of stretching diseased areas in the pleura and lung commence.

If the disease of the pleura has been severe, and compression of the lung has existed for some time, with as thorough work as can be done with the aspirator, the lung refuses to fill its normal space, and from one-third to one-half of the remaining fluid is left behind to reinfect all abraded, stretched and torn places in the pleura; consequently we have a systemic infection, and general miliary tuberculosis follows.

If, instead of attaching the aspirator to the canula, a rubber tobe, filled with water is attached, and a small aspirating needle is introduced about one space above the first one, this improvised syphon will start the flow again, air pressing into the cavity through the second needle, and in this way all fluid can be removed which that can be reached by the end of the canula. This removes nearly all the fluid, leaves the lung at rest, and gets what benefit is derived from the introduction of air into a tuberculous serous cavity; it also allows the diseased pleura and lung to be gradually drawn back into its normal relation in from two to four weeks instead of in two minutes.

This is a rational procedure, and I will append the results in ten cases:

Symtomatic recoveries, 2.

Improved and returned to work, 2.

Recent cases improving,2.

Lost sight of-discharged, 2.

Dead, 2.

There is a possibility of a mistake in diagnosis in some of these cases, and the number is not as large as I had hoped to be able to present, but from my previous experience with pleurisy with effusion, at the prison and in the negro convict, I am convinced that 90 per cent. of all cases are tuberculous, if not

more.

In conclusion, there is this to say for this procedure:-it lessons the liability of general infection; does not produce cough; gives the therapeutic benefit of the introduction of air into a tuberculous serous cavity; does not produce enough shock to prevent the patient from walking away from the operating table, and is not dangerous.

I wish to thank Dr. H. M. Martin, of Wetumpka, Alabama, for help given me in collecting data.

ALCOHOL AS A MEDICINE.

BY EDWARD HENRY SHOLL, M. D., OF BIRMINGHAM. Grand Senior Life Counsellor of the Medical Association of the State of Alabama.

The tragedy of the sick room with its sombre shadows and baffling problems requires the focal light of all past experiences to solve its perplexities. Towards the furtherance of the desired end it is my purpose to bring briefly to your attention some of the practical observations of forty-nine years of professional work.

In my early career prior to the Civil War much of this was on large plantations where every care was bestowed upon the sick, both the humanitarian and material side demanding and obtaining it. For those of the present day, too remote from the ideal patriarchal life of that generation, to even conceive of its careful surroundings, it would be difficult to realize how solicitous and to how great an extent this was carried; thus giving the physician of that day the best opportunities to secure the desired results. It did not take long to learn that in the case of the negro, because of his predisposition to pneumonia, owing to his markedly diminished vital lung capacity as compared with the white man, care, quiet and early stimulation were needed. Good nursing, Dover's powder and alcohol in some form,-whiskey generally-and in such quantity as the case demanded, became our steady reliance and with largely favorable results. I may say in passing that during all my plantation practice I never knew a negro to die with consumption. The record of the present day makes it their greatest scourge and in all of our Southern Cities it increases largely the death percentage. It will be understood that this subject is being treated from a pathological and not from a physiological standpoint. It has been asserted that four ounces of alcohol pure can only be utilized by any system during 24 hours.

I wish to show by practical illustration in two cases of tvphoid fever how much can be safely utilized to furnish the necessary fuel to keep the machinery moving in desperate cases.

The first case was that of a young lady of this city, who, in 1885, had an attack of typhoid fever. Late in the third