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From the detailed reports and tabulated results of all cases on record, it seems to be a matter of indifference

The advantages of these processes mercury 1 to 5,000, and others by dustover all others are easily seen. It ing iodoform over the surface of the possesses the most important property peritoneum. which the others enjoy, but in part, it disinfects with certainty. If in comparison to this all other advantages are insignificant, still it must be brought out that we have convinced ourselves that this procedure is not injurious to the instruments, that it is easy, not costly, not a time robber, and lastly, that for instruments of ordinary size it may be readily turned to, in every dwelling by the use of any kettle.

how the peritoneum is treated, so it be opened, evacuated, and cleansed. Mr. Greig Smith, in the second edition of

his valuable work on Abdominal

ORIGINAL COMMUNICATIONS. fact.

TREATMENT OF PERITONITIS
BY ABDOMINAL SECTION AND

DRAINAGE.

An Abstract of a paper read before the Kentucky
State Medical Society July 12, 1888.

BY L. S. MCMURTRY, A. M., M. D., OF DAN-
VILLE, KY,

Formerly Professor of Anatomy in the Kentucky
School of Medicine, etc.

THE

surgical treatment of peritonitis has recently grown to be a subject of great interest and of the highest practical importance. I will first consider the subject of tubercular peritonitis, which, in the progress of abdominal surgery, has come to be a curable disease. At the Congress of German Surgeons, held in Berlin last fall, Dr. Kummel reported thirty cases of tubercular peritonitis treated by abdominal section. Other surgeons present in discussing the report added six more cases, making thirty-six cases with thirty recoveries. In some of these cases the peritoneum was treated with tincture of iodine in hot water; some by a solution of bichloride of

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Surgery, says of the successful results following abdominal section in tubercular peritonitis: "It must be conceded that this is an exceedingly surprising It may be, and has been said of these results, that the disease in these cases was, probably, not tubercular at all; but more than one case has been shown not only the true structure of miliary tubercle, but the tubercle. bacillus itself was present."

The case of Sir Spencer Wells is an historic one, since it has opened the way for these remarkable results, and has confirmed the hopes of surgeons as to of cure. In Sir the permanency Diseases of the Spencer's work on

Ovaries, published in 1865, he records a case of tuberculous peritonitis, which, with the encysted effusion, was diagnosed as an ovarian tumor. An exploratory incision, removal of effusion, and cleansing of the peritoneun resulted in recovery.

Reverting to this case in his treatise on the Diagnosis and Surgical Treatment of Abdominal Tumors, published in 1885, (page 210) he says: "That patient is still quite well twenty-three (23) years after the operation, although the whole of the peritoneum was seen to be studded with myriads of tubercles, and the colon and omentum with

coils of small intestines were bound with tubercles. The intestines and

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symptoms characteristic of ovarian cystoma. The peritonum was found when opened to be studded with tubercles. The intestines and puriental peritoneum were everywhere covered with them, varying from the size of millet seed to that of buck shot. The fluid was removed, the peritoneum cleaned and the abdomen closed. The operation was done on June 11, 1886, and writing of the case one year afterward, Dr. Van de Walker says: "Before the sutures were removed there was a great change in her appearance; her demand for food increased and color returned to her cheeks. In three months she was a strong, robust woman and at this time remains so."

In September of last year (1887) I saw in consultation with my friend, Dr. D. C. Tucker, of Danville, Kentucky, a lady from Spencer county, this State, who some months previously had noticed a gradual and progressive enlargement of the abdomen and failure of the general health. The history, the physical signs, and the entire array of symptoms were those of ovarian tumor. Several physicians saw her and concurred in the diagnosis of ovarian cystoma. On September 29th, 1887, Drs. Tucker and Dunlap, of Danville, and Dr. Schoolfield, of Covington, being present, I opened the abdomen and found an encysted dropsy with the entire peritoneum thickened and studded throughout its entire extent

pelvic viscera were matted together everywhere by adhesions. Separating the adhesions, I evacuated the encysted accumulations of serous fluid, irrigated and cleansed the peritoneum with scrupulous care, and closed the incision. The patient made a rapid recovery from the operation. Neither pulse nor temperature ever reached 100 after the operation; no preparation of opium or other anodyne was required, and the catheter was not needed. The sutures were removed from a dry wound on the seventh day; the patient sat up on the tenth day, and returned to her home in another county at the end of three weeks. This lady was sixty years of age, and was already confined to bed the greater part of the time, failing rapidly in strength, and suffering with nausea and vomiting daily. Her appetite returned at once after the operation, she rapidly regained her flesh and strength, and from a letter received from her daughter three days ago, I learn that she continues well, rides about the neighborhood, and has had no return of her former troubles.

I have recently done an exploratory laparotomy in the case of a young woman aged twenty-six, in the care of Dr. R. W. Keene, of Versailles, Ky., which we found to be a case of tubercular peritonitis. The disease was quite acute, and accompanied by high fever, with constant pain and rapid emaciation. The operation, which consisted of opening the abdomen and thoroughly irrigating the peritoneum with warm water and putting in a drainage-tube, was done on June 14th, now a month ago. This woman was in an extreme condition, and no one could doubt that the end was very near. She improved at

once; has improved so that she goes about her room, and under date of July 7th, Dr. Keene writes me that she continues to improve, and is bright and hopeful. The cachexia was so marked and the disease so active in this case that nothing more than an arrest of the disease for a period could reasonably be expected. The establishment of the diagnosis, the relief of pain and freedom from opium, with improved nutrition, are advantages which scarcely can be estimated in a desperate, painful and hopeless illness.

Abdominal section, irrigation and drainage are of supreme value in the treatment of supperative peritonitis. In the case of a lady, aged forty years, I had proposed, some months before, to remove the uterine appendages for longstanding oophoritis and salpingitis, when I was called to treat her with severe general septic peritonitis. On On opening the abdomen, a large, disorganized blood clot was found to occupy Douglas' space, and the intestines and pelvic viscera were matted together by the deposits of former attacks of peritonitis. After removing the clot and thoroughly cleansing the peritoneum, I closed the abdomen without a drainage tube. Three weeks afterward, when convalescence seemed about complete, she was again attacked by septic peritonitis.

I placed her on the operating-table, and again opened the abdomen. After cleansing the peritoneum by irrigation, I put in a glass drainage tube. Drs. Tucker, of Danville, and Purdon, of Mitchellsburg, were present at both operations. On the tenth day I removed the glass tube, aud inserted in its place a soft rubber tube. The tube was kept in twenty-eight days. For two weeks

after the operation I administered a Seidlitz powder every morning, to supplement peritoneal drainage, and depletion. This lady has made a complete recovery, and is now restored to good health. This case is an illustration of the important clinical fact that suppurative peritonitis can only be successfully treated upon the same surgical principles that an abscess in other parts of the body is treated, viz.: by incision evacuation, cleansing and drainage.

CONDITIONS RENDERING DIAGNOSIS DIFFICULT IN PELVIC AND ABDOMINAL DISEASES.

BY T. B. HARVEY, M. D., LL. D., Professor of Clinical and Surgical Diseases of Women in the Medical College of Indiana.

THE subject assigned to me by the

judicial council of the Marion County Medical Society, of Indianapolis, that of "Conditions which Complicate and Render Diagnosis Difficult in Pelvic and Abdominal Diseases," should really be divided, as there is enough for two or three papers for one who loves the pen.

In the first place, the title of the paper would very naturally include the various reflex disturbances, a vast, and as yet a field not fully explored; and in the second place, in would include conditions which are evidently of pelvic or abdominal origin, but in which unusual symptoms are present which point to other diseases in the same locality or region than those which are upon examination found to exist; and third, the old question as to whether the conditions and symptoms, which are so common and are treated by some as pelvic or abdominal, are primary or secondary; or, in other words, are not simply results or symptoms of some

general or constitutional condition. Each one of these points should claim the serious consideration of the rational physician, and he alone who looks at all the surroundings of a case can justly claim to be a physician.

I can therefore only hope to present a few cases in each class in the time allotted me.

In the reflex pains we are very often perplexed with manifestations in one region when the real origin of the disease is in another and distant organ. So intimately is the uterus connected by the sympathetic and cerebro-spinal systems of nerves with all other parts of the body as to often present cases simulating serious affections of these parts when at the same time they are merely the points of manifestation.

It may be said that this statement is true in regard to other organs, as the brain, stomach, heart, kidneys, and so on, and to some extent it is true; but when the physiological requirements of the uterus and ovaries are considered it will be found that they are so highly endowed with nerve connections that little wonder need be expressed at the numerous cases in which the symptoms are totally at variance with the real

disease.

A few cases of this character will serve to establish the statement.

Case 1. Mrs. R.; æt, 32; mother ef one boy nine years old, apparently enjoying good health, presented herself to me about seven years ago, complaining of nothing but severe pain in the left eye, which was not periodic, but the eye was red, and looked as though it was badly inflamed. No symptoms whatever could be elicited from her of diseases in any other locality by careful questioning. Accordingly, she was ad

vised to consult an occulist. She said she had been treated by one for weeks without benefit and declined to try him again, but consented to see another. After three weeks of ineffectual treatment, with careful examination, she returned to me with the statement that Dr. S. L. Thompson had failed to find any disease of the eye, and urged the view that it was of reflex origin. In the absence of any rational or subjective symptoms of pelvic disease, except disturbed menstruation, I decided to examine for some objective sign. The uterus was found in complete retroversion, with bilateral cervical inflammation. Treatment be

laceration and

ing addressed to this condition, all symptoms of disease of the eye rapidly disappeared.

Case 2. Mrs. M., wife of a physician, fifth para, the last about two years. Had pains in left supraorbital nerve, periodic, coming on about five o'clock every evening, and requiring hypodermic use of morphine to relieve it. No symptoms of other disease. Had tried an occulist and neurologist separately and in conference, when, after the exhibition of all the remedies suggested no relief was obtained, I was requested to see her, although no symptoms of uterine disease had ever been known. It was found upon examination that the uterus was large, measuring internally five and one-half inches, bleeding on touch, and when explored with noncutting curette was found to have numerous fungosities attached to the endometrium. Through curretting and application of equal parts tincture iodine and carbolic acid with three grains of ergotine daily, gave relief to pain in the eye, and by subsequent treatment once or twice a month the

uterus was freed from fungosities and reduced to three inches in measurement, with rapid improvement. Case still under observation. In this case if the patient was free from pain in the eye and supuraorbital nerve when treatment was commenced, it was invariably produced at once by treatment.

Many other cases could be given in detail to show the truth of the state

ment that very many cases of diseased action simulating the neurotic diseases

are reflex in character, and only to be properly treated by recognizing their origin, for example:

Two cases of insanity, with laceration of cervix uteri, one with and one with out displacement, entirely cured. Four cases of epilepsy caused by laceration of cervix uteri, with displacement and inflammation, relieved from the start, and finally entirely cured by appropriate treatment of the uterus. case of catalepsy, of nine years' duration with invalidism, completely and rapidly cured after operation on unilateral laceration with retroversion.

One

As no two cases of any disease present uniformly the same symptoms it will not be expected that any definite rule can be adopted for our guidance; that is, it will not be expected that in a given case of uterine disease the attendant can at once foretell the point or character of the reflex symptoms; neither will it be possible, in the present state of our knowledge of the brain and nervous system, to predict what may be found as a cause upon a thorough examination. It will be well for the patient if the physician properly recognizes the probability of a reflex.

There is one symptom, however, which is so nearly invariable that it is

worthy of being mentioned. It is the occipital pain which is generally connected with laceration of the cervix uteri, although it is not strongly marked in some cases and is found in other The diseases occasionally. numerous instances of pain in the solar to the plexus, generally referred stomach or heart, and those other cases of hystero-epilepsy, which are generally often of assigned to hysteria and neglected as to cause and treatment, are uterine or ovarian origin, and might, if properly observed, be saved from years of suffering or from ridicule by the ignorant.

It is in the second division of the

subject that often great difficulty is presented to the physician in determining the correct condition, as in this large variety of cases there is great demand made for relief. The intimate connection through the nerves, and by contiguity of the uterus and appendages with the bladder and rectum, often cause symptoms of disease in one organ when careful examination proves that a neighboring organ is the offending member.

of

In this way a case presenting marked symptoms of cystitis, calculi or polypi may be diagnosticated and subjected to various treatments, when upon careful exploration it may be ascertained that a large anteverted uterus is pressing on the neck of the bladder, producing obstruction to micturition; or that a retroverted uterus is drawing the bladder out of shape and by its neck making direct pressure, impairing its action and in time laying the foundation for cystitis.

There may occasionally be met with a case of fissure of the anus, or of ulcer in the rectum, which the pudic nerve

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