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think it is well to exercise light pressure in the neighborhood of the gall-bladder, which is moreover very accessible, the patient being slightly inclined forward.

We recommend above all things: First. To inquire in to the state of the organs near the large intestine, and to be sure that no contra-indication exists from the presence of tumors, inflammations, pregnancy, etc. Second. To have the patient urinate before the sitting, to aid the deep pressure. Third. To find if any biliary calculi exist. If an examination shows the existence of hepatic calculi one ought to avoid pressing on the portion of the transverse colon near the gall-bladder, for the sharp contact of the calculi may cause lesions of the mucous membrane of this organ, which, lying back of the short ribs, may affect also the corresponding part of the colon. There is no doubt that in practicing the massage of the colon the fingers should press on the gall-bladder, and aid the expulsion of the bile into the duodenum. Beside the mechanical action produced by the pressure of the hand, the vesicle is perhaps indirectly excited to contractility, for we may consider the presence of muscular fibre in the walls of the gall-bladder to be demonstrated to-day. Haller, Zimmerman, Magendie, Brücke, and others, have established experimentally the contractility of the reservoir of bile. It should be remembered, too, that the stimulation of the intestine in the neighborhood of the bile-duct provokes by reflex means the contraction of the vesicle. Now when we practice massage of the large intestine we cannot give our action to the colon alone, but a simultaneous stimulation of the small intestine is produced by these maneuvres. This difference we introduced, is to knead not only the large intestine but the whole intestinal mass in all our patients. Saying nothing of the favorable action that the bile may exercise by its presence, on the contractions of the intestine, we think it is rational to aid its passage in the duodenum where it should flow toward the large intestine. We think this practice perfects the usual maneuvres of massage.

Massage ought also to stimulate the intra-abdominal circulation. Now we know that arterial blood is stimulating by the oxygen it contains; carbonic acid, on the contrary, depresses the excitability of muscular tissue (this may be observed in venous stasis and in local obstructions of the circulation.-Schiff). may say, with Ch. Richet, "that the mechanical stimulants. cause the cells to react, and that the rapidity of the circulation is augumented in the muscle which is contracting." Though

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the stimulation of the large intestine provokes, in experiments on animals, less intense movements than those of the small intestine, they have all the essential characters of them (Bertin). Among the divers parts of the large intestine, the ascending colon seems to contract with the greatest energy. It is, indeed, at this point that the muscular fibres have the most considerable obstacle to overcome, the intestine being vertical and ascending. At this point the massage should be the most active.

In the case of hard fæcal matters, massage is the best means to employ for the trituration of these matters, and to favor mechanically their expulsion. This means ought to be recommended before all others in the case of occlusion of the intestine due to the accumulation of these matters.

The nerves of the large intestine coming from the great sympathetic system both by the superior mesenteric plexus (coming from the solar plexus), and by the inferior mesenteric (coming from the lumbo-aortic plexus), it is rational to think that the stimulation produced by massage directly to the nerve-centres, and indirectly by the nerves of the intestinal wall, awaken reflexes that aid both the secretion and the contraction of the intestine. We know indeed that, though the stimulation of the pneumo-gastric nerve arrests the peristaltic movements of the intestine, the stimulation of the solar plexus, on the contrary, provokes contractions of the muscular coat.

En résumé: (1) Abdominal massage is an always inoffensive. and salutary means in the treatment of constipation which does not give way to ordinary therapeutic means.

(2) The duration of each sitting should be from fifteen to twenty minutes. The sittings should be daily in the first part of the treatment.

(3) The natural evacuations should take place after the sixth sitting. The effect of the treatment lasts after the cessation of the massage.

(4) We recommend gentle pressure on a level with the base of the gall-bladder, to excite the contractions of this reservoir, then the assistance to the passage of the bile toward the large intestine.

(5) Massage, in provoking the more abundant secretion of the intestinal juices, stimulates the contractility of the large intestine by the action on the intravisceral diastaltic system.

(6) Besides the reflex phenomena, massage assists mechanically the passage of the contents of the large intestine.-By Berne in the Journal de Medicine de Paris.

M.

TREATMENT OF DIPHTHERIA.

Dr. O. Brondel has obtained, in the last five years, truly extraordinary results. He has not lost a patient in two hundred cases, save some children, afflicted at the same time with croup, and still he has not as yet rigorously employed his mode of treatment.

It is as follows: In the first place, to administer every two hours a tablespoonful of a potion of one hundred and fifty grammes containing four to five grammes of benzoate of soda, according to the age of the child; to give at the same time the sulphide of calcium in pills of a centigram, or in the form of a syrup; finally to practice every half hour, regularly, night and day, in grave cases, spraying with a ten per cent. solution of the benzoate of soda; to nourish the patients with beef tea, eggs, and tender meats, and to administer tonics and combat the fever with quinine, aconite and antipyrine.-Bulletin de Therapeutique.

CLINICS.

CHICAGO MERCY HOSPITAL.

SURGICAL CASES.

SERVICE OF EDMUND ANDREWS. M. D.,

M.

Professor of the Principles and Practice of Surgery and of Clinical Surgery, Chicago Medical College; Surgeon to the Mercy Hospital.

REPORTED FOR THE PHYSICIAN AND SURGEON BY SPECIAL STENOGRAPHER.

TWO OVARIOTOMIES.

Case I.-Mrs. J. C., aged thirty-four, came to the Hospital on October 13, 1887, for the removal of a large tumor in the abdomen, which had been slowly growing until it attained the size of a uterus at full term. The growth had been noticed for about eighteen months. Patient had had one miscarriage at the fifth month; is the mother of two children, aged respectively five and seven. She enjoyed fairly good health, although she was quite thin, of even temperament, medium height, menstruates regularly, no pains or aches, and claims never to have been sick. prior to the time the abdominal growth was first recognized. Patient was duly prepared for operation on the 18th. On the 19th, at 3 P. M., Dr. Frank Andrews performed the operation of ovariotomy, assisted by Professor Edmund Andrews. Patient being etherized, an abdominal incision was made three and a

half inches in length, in the median line. The cyst was found non-adherent; a trochar was introduced and a considerable quantity of dark fluid resembling molasses drawn off. Two more apartments were found in the cyst, which were tapped, Dr. Andrews drawing off about two gallons or more of fluid. Each part of the cyst had a different colored fluid, and of different specific gravity. The cyst was then drawn out; a large pedicle was found attached to and involving the left Fallopian tube, along which were observed several small cysts. A ligature of heavy silk was passed through the center of the pedicle, and so tied that the two halves, and then the whole, were included in the ligature. A little hæmorrhage followed, which was speedily arrested, and the whole pedicle again secured against a repetition. The "toilet of the peritoneum" was carefully attended to, and the abdominal wound closed with silk sutures, after which an antiseptic dressing was applied and the patient put to bed.

After-treatment.-October 19, 8 P. M.: Pulse, 126; temperature, 99°; one-quarter grain of morphia sulphate was given hypodermically. At 9 P. M. gave a quinine suppository, five grains; also eight minims tincture digitalis hypodermically. 11 P. M.: Pulse, 120; temperature, 99°.

October 20, 1 A. M.: Pulse, 106; temperature, 99.6°; patient feeling comfortable. 3 A. M.: Pulse, 100; temperature, 99.2°. 6 A. M.: Pulse, 105; temperature, 99.3°. Patient asks for a little nourishment and is given a little toast and tea. 11 P. M.: Pulse, 100; temperature, 99°; patient sleeping. 12:30 P. M.: After considerable retching, vomited about one ounce of mucus, stained with bile; felt much better after it. 2 P. M.: Pulse, 105; temperature, 100.1°; gave antifebrin suppository, five grains. 4 P. M. : Pulse, 104; temperature, 100.1°; patient resting well. 7 P. M.: Temperature, 100°; passed catheter.

October 21, 9 A. M.: Pulse, 105; temperature, 98.8°; gave quinine suppository, five grains; coughed up some phlegm; gave one-fifth grain morphia sulphate hypodermically. 10 A. M.: Pulse, 99; temperature, 99°. She complains of pain in her sides.

October 22, 1 P. M.: Pulse, 102; temperature, 99.2°; gave antifebrin suppository, five grains. 3 P. M.: Temperature, 99°; patient taking oatmeal tea and beef tea, tablespoonful every hour. 6 P. M.: Pulse, 101; temperature, 99°. 9 P. M.: Temperature, 99.1°; gave quinine suppository, five grains. 1 P. M.: Temperature, 99°.

October 23, 8 A. M.: Pulse, 86; temperature, 99.2°; patient drank a small cup of milk, one-third aquæ calcis. 11 A. M.: Temperature, 99.8°; patient has a headache. Gave antifebrin suppository, five grains. 7 P. M.: Temperature, 99.8°; patient seems a little restless and uneasy, but takes nourishment well. 11 P. M.: Pulse, 94; temperature, 99.2°; patient has a slight headache and pain in the abdomen.

October 24, 8 A. M.: Temperature, 99.5°; took a small piece of dried toast and tea for breakfast. 10:30 A. M.: Temperature, 99°. 1 P. M.: Temperature, 99.6°; took a small piece of toast and a cup of tea for dinner. 7 P. M.: She complains of headache; then gave a five-grain antifebrin suppository. 11 P. M.: Pulse, 7; temperature, 98.4°; resting well.

October 25, 3:30 A. M.: Temperature, 97.8°; gave seven minims of tincture digitalis. 6 A. M.: Pulse, 98; patient complains of sharp, lancinating pains in the abdomen. 8 A. M.: She has no appetite. 12 P. M: Ate small piece of cracker with some tea. 9 P. M.: Gave an antifebrin suppository, five grains.

October 26, 2 A. M.: Patient complains of pain in abdomen. 7 A. M.: Ate a little toast, drank some milk and tea, and feels good. 1 P. M.: Pulse, 88; temperature, 99.6°; gave antifebrin suppository, five grains. 10 P. M.: Pulse, 87; temperature, 98.8°.

October 27, 7 A. M.: Patient taking solid food. 8 A. M.: Temperature, 99°. 8 P. M.: Temperature, 99°; patient feels about as usual.

October 28, 7 A. M.: Temperature, 98.5°.

NOTE.-Patient has had catheter passed twice a day since. the operation. She made water naturally to-day. 12:30 P. M.: Wound re-dressed. 4 P. M.: Temperature, 99°; patient eats well. October 29, 7 P. M.: Temperature, 98.8°; bowels moved by

enema.

October 30: Patient moved from ovariotomy room.

October 31, 5 P. M.: Temperature, 98.8°; patient feels nervous; gave one-fourth grain morphia sulphate hypodermically. November 1, 7 A. M.: Patient vomited some thick, yellowish matter, after which she felt a little better.

November 2, 7 P. M.: Temperature, 98.8°; wound dressed and two stitches removed, one remaining. Sat up to-day to have her bed made.

After this date the patient's improvement was so rapid that she shortly afterwards left the hospital.

Case II.-Mrs. D. S., aged forty-two, was brought to the

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