fibro-purulent, which shuts off the infected from the intact peritoneum by adhesions. The inflamed portion is continuously separated from the healthy peritoneum, but the limits of the process steadily extend, thus encapsulating, between the agglutinated viscera, pus in greater or less amounts-a progressive fibropurulent peritonitis." In the first form Mikulicz considers a thorough operation rational. He would freely open the peritoneal cavity, find and close the perforation, disinfect, as far as possible, the whole peritoneal surface. In the fibro-purulent form this is contra-indicated, and the adhesions should in his opinion be carefully preserved. He thinks that the fresh infection from the freed contents of these encapsulated foci of purulent exudation has been the active cause of many failures to save life. In this form not the peritoneal cavity as a whole but each intra-peritoneal ab-cess should be evacuated separately. His action in two cases corroborates this view. In one, six intraperitoneal abscesses were evacuated through three incisions at four successive operations. In the second three different operations were necessary to relieve the patient. Here three separate abscesses were opened as the separate foci became evident at three different points, namely, the rectum, the right and left groin. The diagnostic indications for locating such abscesses are increased resistance, tenderness, dullness, and an elevation of temperature; in doubtful cases an exploratory puncture. A free incision should divide the abdominal wall where the abscess is most prominent. This form of peritonitis does not extend so erratically as has been supposed. The cavities should be carefully irrigated-drained by packing with iodoform gauze and not closed by suture. The patient should be carefully watched till the abdomen is uniformly soft, all tenderness is absent, and the temperature has been normal for several days.-Boston Medical and Surgical Journal. THE SECONDARY INFECTIONS IN SCARLATINA. (Rev. Mens, des Mal. de l' Enf., September, 1889). Guinon says: The idea of a possible secondary infection has become too prevalent to allow it to pass without conisderation. Chanin says that it results from the penetration into the organism of a second microbe, which is added to and is distinct from the first. Before the idea of microbic infection was applied to the eruptive fevers, the question had been raised whether the abnormal phenomena appearing in the course of the-e di-eases was of the same nature as the primary disease, and whether they resulted from external or internal conditions; whether, in a word, they constitute a function of the primary disease or were the manifestations of another disease engrafted upon the first. The discussion of this subject has, of course, a practical as well as a theoretical side. Bouchard, after studying the local manifestations in general diseases of the character under discussion, has demonstrated that the accidents and complications in these diseases are almost always new diseases, which are distinct from the original ones. The number and gravity of the complications occurring with scarlatina render it most suitable for the application of this theory. As a matter of fact, we do not as yet know the characters of the microbe of scarlatina, but we do know those of the micro-organisms which produce secondary infections in that di-ease. Klein, Crookshank, and others have discovered micro-organisms which were supposed to be peculiar to scarlet fever, but their results are not entirely har monious, and have not been entirely convincing. Levhartz, Marie Ra-kin, and Babés, on the other hand, have studied the blood, the viscera, and the organs especially involved in the complications of scarlatina. In suppurative adenitis, Raskin found in seven cases, with or without diphtheria, a streptococcus which was constantly present. With tonsillar and pharyngeal ulcerations, Lenhartz found a thick layer of chains of streptococci, without the presence of gangrene-that is, the streptococcus was evidently a secondary manifestations. In septicemia, occurring as a complication, absolute conclusions were not drawn. Raskin found a streptococcus and a small and oval micrococcus, but did not determine their nature nor their virulence. In the blood the streptococcus was rarely found. Raskin found it in only six cases out of twenty-three. Raskin and Babés found the streptococcus, with other microbes, in connection with complicating pleurisy, pneumonia, pericarditis, and endocarditis. It was believed that the bacteriology of the pericardium was identical with that of the pleura. In scarlatinal pyemia, investigators are agreed that the streptococcus, is the most frequent cause, but other microbes are found at the same time in the same organ, or in other viscera. In nephritis an important point to be decided is, whether the microbe acts upon the kidney by itself or by the products which it secretes, and recent investigations tend to show that the former supposition is the correct one. Raskin has found aud isolated in the kidney the streptococcus alone or united with a micrococcus, a diplococcus, or a bacillus, and they were also found in other organs. Babés studied fourteen cases, in which there were albuminuria and edema, and in thirteen the streptococcus, alone or associated Both with the pneumococcus of Talamon-Fraenkel, was found. In scarlatinal rheumatism, three forms or varieties must be distinguished, a serous non suppurative form, a serous suppurative form, and a form in which suppuration occurs at the outset. In the non-suppurative fluid of the synovial membrane Raskin found the streptococcus; in purulent arthritis the streptococcus may be found in great numbers. In the pus of otitis Raskin constantly found the streptococcus, and in the later stages of the disease it was associated with the staphylococcus aureus et staphylococcus albus. In diphtheria. Raskin found streptococci, diplococci, micrococci, and Loeffler, in addition to the streptococci, found also the Klebs-Loeffler bacilli. From the foregoing, it would appear that most of the complications in scarlatina are due, in all probability, to the action of a streptococcus, either isolated or associated with other microbes, and it has always presented the same character, with the exception that it varies in virulence. It is probably identical with the streptococcus pyog nes of Rosenbach, and Lenhartz thinks that it is modified in scarlatina by the primary infection. It is probably this organism which causes death in scarlatina, either directly by septicemia or indirectly by nephritis. Secondary infection in this disease most frequently occurs by way of the pharynx, and the penetration of the microbes is favored by the loss of epithelium, by the dilatation of the lymphatic channels, and by the recumbent position which the sick child assumes. The foregoing indicates anti-epsis of the throat in all the pyrexias of childhood, but especially in scarlet fever, and before any complications occur; but caustic or irritant applications must always be avoided because of their destructive action upon epithelium.-Archives Pediatrics. IN STUBBORN CONSTIPATION IN WOMEN Dr. Lutand (Revue de Therap. Med. Chri.) has found the following most efficacious: Ferri et ammonia citrat......gr. xxxj; Aquæ destillat INTRA-MUSCULAR INJECTIONS OF MERCURY IN THE TREATMENTOF SYPHILIS.-In the last part for 1889 of the Archiv für Dermatologie und Syphilis, Dr. Watraszewski discusses the effect of the injection of insoluble mercurial preparations into the muscles. The mercurial salts, recommended for their parasitiside effect on theoretical grounds, have not shown any advantage, and practically the question of advantage lies between calomel, the yellow oxide, and the gray oil of mercury. With respect to calomel, while it is undoubtedly very effectual in the treatment of syphilis, it has proved dangerous to the patient, Runeberg having collected seven fatal cases; but the author found that dangerous symptoms could to a great extent be avoided by reducing the dose originally suggested by Smirnoff from three grains to not more than two thirds of a grain, and this, too, without sacrificing its therapeutic efficacy. He regards the gray oil as recommended by Lang and Neisser as still more dangerous, instancing Kaposi's fatal case and Hallopeau's case of severe stomatitis and several cases of fat embolisms in the lungs which are on record. The author expresses, therefore, a decided preference for the yellow oxide of mercury, but in the reduced dose of two thirds to one grain. These doses he has given thousands of times without ill effect, while the doses originally recommended, of from two grains to two grains and a half, have produced serious symptoms, such as adynamia, diarrhea, stomatitis, etc. The choice of the vehicle for injection is not unimportant. Those hitherto used have been generally glycerine, olive, almond, or paraffin oils, or gum Arabic mucilage. The author made experiments on this point, injecting these vehicles alone into the jugular veins of cats, and found that serious embolic pneumonia was excited by the oily fluids, while the mucilage only produced scattered embolic foci of small size, which were absorbed without subsequent reaction of any importance. These experiments have a practical bearing, for in intra-muscular injections a vein is occasionally pierced, and serious pneumonia has ensued. Glycerine excites local irritation, and is therefore unsuitable. Dr. Watraszewski therefore finally decides that mucilage (gum Arabic 1 part, water 120 parts) is the best, as it combines all the essentials of a vehicle, viz: (1) It can be made of the proper consistence to hold the powder in suspension. (2) It has no local irritating effect. (3) It does not decompose the mercurial salt. (4) It excites no general disturbance. In the same number Touton relates a case in which, a few hours after the third injection of salicylate of mercury into the left gluteus muscle, that muscle seemed paralyzed, and then tenderness and pain were felt radiating up to the sacrum and lower lumbar vertebra, but abruptly terminating at the middle line. The pain lasted two days, but twenty-four hours after its commencement there appeared an abortive herpetic eruption; that is, the eruption consisted in papules, which did not develop into vesicles. It was distributed in three groups of firm papules in the course of the left posterior femoral cutaneous nerve; and as this takes its origin from the lumbar plexus, while the injection was in the domain of the sacral plexus, Touton argues that it was reflexly, and not directly, produced by the injection.-London Lancet. USE OF STATIC ELECTRICITY IN GENERAL PRACTICE. In a paper on this subject, read recently before the Philadelphia County Medical Society, Dr. Andrew Graydon reached the following conclusions: 1. Static electricity is a safe and reliable agent in the general practice of medicine. I do not mean to say that its reliability is of such a nature that its environments are to be neglected. For example, the office in which the instrument stands must not have any dampness about it. 2. This treatment can be applied pleasantly and with benefit to patients, and at times when the galvanic and faradie can not be used. 3. In "static insulation" we get results only attainable from "general galvanization" and "general faradization," without the expense of time, trouble, and exposure--and frequently, too, after both those forms have failed. 4. In many forms of pain, prompt and permanent relief follows its application, such as is unequaled by other agents. 5. As a tonic in systems overwrought, overdrawn, mental grip slipping away, it performs a very important part. The readiness with which it can be applied, and the good results obtainable, prompt me to make use of its properties frequently. 6. In various forms of headaches its effects are uniformly good. It is a common remark to hear from patients, "I can feel the pain being lifted, the heaviness going," or similar expressions indicative of appreciable relief. 7. In the treatment of insomnia the use of the douche is effective, a feeling of drowsiness making itself felt during its application. 8. In treatment about the head I have found a difference in the effect between the positive and negative poles, not elsewhere. 9. The benefit of the faradic current is obtained from the static inducer. 10. Growth of hair, I have observed. has been promoted, and the falling out of it stopped in some of my cases of head pain.—Boston Medical and Surgical Journal. SALINE INJECTIONS INTO VEINS IN DIABETIC COMA.—The striking case related by Dr. Dickinson at the last meeting of the Clinical Society is somewhat encouraging as to the value of intravenous injection of saline fluids in cases of diabetic coma, although, unfortunately, a fatal issue eventually ensued, for after the first injection (of 106 ounces) the patient regained consciousness to a very complete extent. The importance of such a respite may occasionally be very great; for instance, in the case of one who is attacked with diabetic coma without having made his will. It is something to know that by this method the coma can, temporarily at least, be made to pass away. The subsequent course of Dr. Dickinson's case is equally instructive. The patient relapsed into coma, and resort was again had to the procedure which had already proved of service. But this time the amount of saline fluid received into the circulation was actually more than the estimated average total amount of blood in the adult body. In spite of the state of plethora which so heroic a case must have produced, the patient once more regained consciousness. Dr. Dickinson's conclusions that one hundred or even two hundred ounces of saline fluid may in such cases be introduced into the circulation with advantage, but that the benefit to be gained thereby can only be temporary, were doubtless justified by the experience in this case. Perhaps the same end might be obtained more rapidly if the injection were preceded by venesection, so as to secure a greater degree of dilution of the blood with a comparatively small amount of the diluent. The practice of saline injections in diabetic coma has, as Dr. S. Mackenzie remarked, been frequently employed, but, so far as we know, in no case with permanent good results. Indeed, few patients submitted to this treatment have, as in Dr. Dickinson's case, regained consciousness even for a short time.London Lancet. THROMBOSIS IN THE CHLOROTIC STATE.M. Vergely, in a thesis (summarized in Centralbl. f. Allg. Path., No. 5) upon Venous and Arterial Thrombosis in the Course of Chlorosis, points out that this complication often arises early in the disease. He reports fourteen cases of venous thrombosis-in nine spontaneous, in three after overexertion, and in one iliac thrombosis was attributable to distension of the sigmoid flexure. In eight cases the thrombus was symmetrical; in four cases the thigh was the seat of the plugged vein; in seven the calf. But arterial thrombosis also occurs in this disease; at least, it has been noted in the pulmonary and Sylvian arteries. It does not appear that mention is made of thrombosis of the cerebral sinuses, which is also well known to occur in the chlorotic. The cause of such spontaneous thrombosis is referable to an increased tendency of the blood to coagulate, and also, perhaps, to the altered nutrition of the vessel walls. The latter factor is supported by Virchow's discovery of fatty degeneration in the intima of the aorta in chlorosis. But in the two cases related by Vergely, where the middle cerebral artery was thrombosed, no histological changes could be detected in the blood-vessel, although it is thought that slight endothelial lesions might have passed undetected. Certainly there is much yet to learn concerning the etiology of spontaneous thrombosis.-London Lancet. MASSAGE IN PAINFUL FLAT-FOOT.-In a paper on this mode of treatment by Dr. A. Landerer, the writer says that his observations go to show that the muscular system is necessary for the preservation of the bodily form. He believes the normal tension and activity of the muscles to be the great cause in preventing alteration in structure. Bandages alone without the help of muscles can not avert deformparalytic club-foot. The appliances may be ity. This is seen in the case of the origin of accurately adjusted, while at the same time the whole cause of the mischief may lie in the deficient tensions of the muscles not counteracting the weight of the body. In flat-foot one must seek to strengthen by massage all those muscles which are concerned in the support and preservation of the arch of the foot. These are in the first place the tibialis posticus, triceps suræ, and small muscles of the sole, which, by their contraction, hold the piers of the arch. The method of massage is as follows: To begin with, the region of the tibialis posticus is forcibly tapped, then the triceps suræ and the sole muscles. Thereafter the same parts are powerfully kneaded with pliant grasp, and finally the foot and leg are rubbed centripetally. The painful points are at first gently and then gently and then more strongly pressed and rubbed. Landerer has, in accordance with his view of the mechanism of flat-foot, treated the muscles alone, and quotes eight cases of excellent result. In some the form of the foot altered, a certain arching taking place, resem bling closely the natural shape.--Berlin. klin. Wochensch. CULTURE OF VACCINE VIRUS.-A Russian physician has succeeded in cultivating vaccine virus, and finds that the virus, artificially cultivated, is as effective as the genuine, and has the advantage of absolute purity, so that its use involves no danger from scrofula, tuberculosis or other constitutional diseases.-The Pacific Record. INJURIES OF THE BLADDER DURING LAPAROTOMY.-A. Reeves Jackson, M. D., of Chicago, has collected sixty-seven cases of injury of the bladder during the performance of laparotomy among forty-one operators, and thinks that this list is sufficiently large to show that the accident is by no means infrequent. Considering the conditions under which bladder injuries may happen during laparotomy, it is not discreditable to any surgeon to meet with them, for they may not be due to any carelessness or lack of skill on his part. In many of the foregoing cases no possible degree of diligence could have averted the accident. Adhesions of the peritoneal surface of the elongated bladder to that of the anterior abdominal wall frequently can not be known in advance, and their existence is only demonstrable after the viscus has been opened. The use of the catheter as a diagnostic means is not always available, because the compression of the bladder against the pubis may prevent the introduction of the instrument beyond that point. Certainly, however, this should always be attempt ed in any case of suspected difficulty, and would seem to be even a proper and unobjectionable routine method. Another useful precaution is, to avoid prolonging the abdominal incision far down toward the pubic bone until the opening into the peritoneum has permitted the relations of the bladder to be ascertained. The mortality of the cases in which the bladder has been wounded is large, namely, about thirty per cent; but this is due to the complicated and serious character of the cases in which the accident has occurred, the consequently increased length of the operation, and the greater danger from shock, rather than to the mere vesical injury. Inasmuch as the bladder is recognizable with more difficulty when empty than when full, it would be better, in cases presenting doubtful features, to commence the operation with the viscus wholly or partly distended. When its position has become known, after the completion of the abdominal incision, it may be emptied by an assistant. Treatment: When it is known at the time of operation that the bladder has been cut or torn, the opening should be at once closed with a continuous suture of catgut or fine silk, applied so as to invert the edges of the wound and bring together the peritoneal surfaces. A permanent catheter ought to be used during the first two days. After the expiration of that time its constant use is usually unnecessary; and if the wound has been small--less than one inch in length--the instrument may be subsequently dispensed with. If, however, the wound has been large-exceeding two or three inches→→ the bladder ought to be artificially emptied as often as every three hours during three or four days additional. The catheter should be used so long as the urine contains blood. In the cases in which urine appears through the abdominal wound subsequently to the operation, at a time and under circumstances which might make it dangerous or inexpedient to reach the seat of the vesical injury, the catheter ought to be used either continuously or at short intervals, for the purpose of lessening the amount of urine which escapes through the fistula, and thus aid in the closure of the latter. If, however, the fistulous opening should show no disposition to close after two or three months, the edges ought to be freshened to the depth of half an inch or more and stitched together. In exceptional instances it may be expedient to affix the edges of the wounded bladder within those of the abdominal incision, in the manner detailed by Thomas and others; but as this method must interfere, to some extent, with the subsequent contractility of the bladder, it is not to be commended as a u-ual practice. The suturing and "dropping " of the vesical wound is the better method.--Journ. Americ. Medic. Associat., February 22, 1890. RADICAL CURE OF VARICOSE VEINS BY MULTIPLE LIGATION.--Dr. Phelps applies subcutaneously a large number of ligations to a single vein, by means of a Keyes-Reverdin needle. The operation is indicated in the following cases: 1. When this condition constitutes disability in physical examination--as for admission to the army or navy, or for appointment in a municipal department. 2. When the size of the veins, the formation of venous tumors, or the attenuation of the coats or tegumentary covering threaten hemorrhage. 3. When chronic ulceration or eczema exists. 4. When the circulation has been so far impaired as to occasion swelling of the feet or loss of power in the limb.--New York Medical Journal. GONORRHEAL INFLAMMATION OF THE EYE.— Kemény (Centr. Bl. für Bak. und Parasitenkunde) reports a case of accidental auto-infection of the right eye with gonorrheal virus in the person of a soldier, who was suffering at the time from acute gonorrhea. Actual proof of the character of the conjunctival inflammation was furnished by the discovery of gonococci in the secretion. The gonococci were found, as in urethral gonorrhea, in the protoplasm of the pus corpuscles. |