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In the one case we have to get rid of the products of adhesions is certainly distinctive of a desirable process a limited inflammation; in the other, we have to rid the of repair. Still, when it is indicated that the cause of cavity of a poison which has already done much harm peritonitis has to be searched for and imprisoned exuda. and is causing a progressive poisoning.

In cases of localized purulent peritonitis an incision should be made into the collection by the most direct route. When the pus has escaped, a drainage tube is passed to the bottom of the cavity and a dressing of some absorbent material applied.

Treves says that he has seen no advantage attend either the fuller evacuation of the pus by squeezing or immediate irrigation of the cavity; that he is confident harm may be done by scraping the wall of the inclosure, by persistent searching for a diseased appendix or other cause of trouble, and by stuffing the exposed space with gauze. At the end of twenty-four and thirty-six hours, irrigation of the cavity may be commenced and contin ued twice daily, and now and then a little iodoform emulsion introduced.

tion between the intestinal coils to be set free this freeing of adhesions must to a certain limited extent be carried out. A stump of adherent intestine will often cover and protect a perforation and the lymph close it with much more speed and security than sutures. Treves says, "As the surgeon reaches what appears to be the starting-point of peritonitis (plastic), he must proceed with the utmost caution, and be not only prepared but inclined to have the actual fons et origo mali undemonstrated."

The main purpose of the operation is to allow a noxious exudation to escape, and, if possible, free the peritoneum of the cause of trouble. Some of the best results in perforated peritonitis have been obtained in instances in which the exact site of the perforation was never ascertained. Kaiser gives six examples with five

Gilbert Barling, of Philadelphia, in the British Med-recoveries. ical Journal of last January, reports eleven operations In this class of peritonitis neither drainage nor irriga. with four deaths. In summing up, he says, "Incision tion seems to be regarded. The peritoneum is dried in the middle line, irrigation and drainage is a simple with gauze sponges and iodoform dusted over the serous procedure, and carries with it little risk, and it is a membrane most affected. question whether it is resorted to as often as it should be. The profession is, perhaps, fully alive to its advantages, when a very acute onset such as perforation can be recognized; but when the commencement is less acute and the symptoms less alarming in the early days then it is doubtful if drainage is adopted as often as it is called for. When the inflammatory collection is localized, it is well not to do too much. Simple incision and drainage suffices; anything like forcible irrigation or searching about with the fingers, by disturbing lim ited adhesions, is likely to do harm." He says that if a perforative focus is discovered, it should be dealt with directly, and even if an incision has been made over the appendix, at the same time median section should be performed for irrigation and drainage of the general cavity.

In cases of generalized peritonitis the procedure adopted must depend upon the cause and degree of the trouble. If the exudation be serous, Treves says it will suffice if the fluid be evacuated, the peritoneum dried in the most dependent parts with gauze sponge, and the abdomen closed without drainage.

When the exudation is sero-purulent or purulent, it is in most cases desirable that the cavity be irrigated after washing the depths of the peritoneal cavity, and dried, as far as possible, with sponges, iodoform powder dusted over the portion of the serous membrane most involved, a long drainage tube introduced, and the ab. dominal wound closed. Any treatment directed against the cause of the peritonitis will be independent of these

measures.

There are cases in which the peritonitis is more plastic in character. The intestines are found matted to gether with grayish lymph, which may be present in considerable quantity. The breaking down of these

The subject of irrigation in peritonitis has received much attention. So many questions come into playsuch as the nature of the exudation, serous or purulent or fecal, whether it is well localized or diffuse, and the condition of the patient, whether able to stand a prolonged operation or not-that it is not surprising that opinions are divided as to its advisability. Treves said last March that the bias of opinion was against irriga tion. Pearce Gould, last October, in a paper on "Operative Treatment of Perforated Ulcer of Stomach and Intestine," said cleansing of the peritoneum was the important step in the operation. No time or care must be spared to make this flushing absolutely thorough, as upon it chiefly hangs success or failure. Roderick Maclaren, on the same subject, at the British Medical Association meeting last October, said, "Cleansing of the abdominal cavity is all important. Success depends almost entirely on how this is done."

Gilbert Barling believes in a very thorough flushing. Ford Cousens says the cavity must be cleansed at all risk, but prolonged irrigation must be avoided. Knowl. sley Thornton, in speaking of diffuse septic peritonitis, at the Royal Medical and Clinical Society last October, said "that septic material spread over the surface of the gut rendered thorough irrigation absolutely necessary;" and at this meeting there was not one opposed to this method of treatment. Once having septic material in the peritoneal cavity, it seems that, if we care to stop the spread of the peritonitis, it must be got rid of. In Germany it has been done by wiping the surface with aseptic gauze. In England flushing is preferred. The former method is rough, tends to do more damage, and cannot be as effective as irrigation. Certainly it might be used when there was a septic deposit; but for a thin layer of septic serum, or sero-pus, spread over a large

part of the peritoneal surface, it would be ineffective press the chest-wall very quickly and strongly (at about and possibly harmful, both to the tender peritoneum the rate of 120 to the minute), and in a short time was itself and to any occlusive adhesions formed by Nature, agreeably surprised to observe the pupils contract and should a perforation be the starting point. The danger to detect faint attempts at respiration. Although the in irrigation seems to be that the septic material may boy's life hung in the balance for fully an hour, during be washed to distant portions of the peritoneum; but is which time this quick compression had to be continued, not this spreading of the peritonitis one of the bug in the end he recovered. bears, in fact, our chief danger? and should the poison be got rid of, the trouble ceases, or rather, we have a simple localized inflammation to deal with. Should the patient be in a condition of collapse, and not able to stand prolonged and thorough irrigation, then more speedy but less effective measures would have to be adopted.

Since that time the quick compression of the precordium has invariably been used in the Gottingen clinic and with the best results. While acting there as assistant to Professor Koenig, Leedham Green had several opportunities of testing its value, and was much struck with its efficacy in case of heart-failure. But the most striking instance of its efficacy that he has met with As to the fluids used, they are many: carbolic acid was one in which he had occasion to use it a few weeks solution, boric acid, corrosive sublimate, and salicylic ago. The circumstances of the case were these: A acid solutions. Many use boiled water, and some a healthy child, four months old, was under operation for weak preparation of alcohol. But whatever solution circumcision in the out-patient room of the Queen's fluid is used, it can not be used as a germicide, and all that can be aimed at is a solution that is sterile and non-irritating. Perhaps the choice is between a sterile .6 per cent salt solution and boiled water at 110° F.

This fluid is introduced at low pressure, and in a wide stream, with a soft rubber tube, regulated with a clip; the peritoneal cavity to be gently flooded out, and by a movement of the hand pressure here and there the fluid overflows by the wound.-Therapeutic Gazette.

Hospital. The child took the chloroform at first very well, and, the operation being almost concluded, the lint on which the chloroform had been given had been laid aside for a moment or two. Suddenly the child became deathly pale, the pupils dilated, and the respira. tion and the heast's action ceased. The operation was instantly stopped, the head was lowered, and the tongue was pulled well forward. As the child made no attempt to breathe, artificial respiration (Sylvester's method) was energetically used. This proving ineffectual, the A Method of Restoring Persons Appar- child was completely inverted for a few seconds, being ently Dead from Chloroform.-Leedham-Green, held up by the heels. Sylvester's method was again in the Birmingham Medical Review, under this title, tried, but without producing the slightest effect either writes of what is often called Mass' method, which was on the breathing or on the heart. At this point Green described in the Berliner Klinische Wochenschrift for happened to come into the room, just as the anesthetist 1892, in an article by Dr. Mass., of Gottingen. Little declared the child to be dead. He at once examined notice was taken of it at the time. It was, however, the child and could not find any trace of life whatever. again brought prominently forward by Professor Koenig There was no impulse of the heart to be felt, nor was at the Surgical Congress at Berlin in 1893. The method there the slightest effort to breathe; the surface of the advocated was a slight but important modification of body was pale and cold; the eyes were shrunken and the well known one suggested by Professor Koenig the pupils widely dilated; at the mouth and nostrils a himself. As originally practiced by that Professor, the collection of froth appeared, together with some stomoperator, standing on the left side of the patient and ach contents, which has been forced up during the artifacing him, placed the ball of the thumb of the opened ficial respiration. right hand upon the patient's chest, between the place of the apex-beat of the heart and the sternum. He then repeatedly pressed in the thoracic wall with a quick, strong movement, at the rate of thirty times to the

minute.

Although Green did not for a moment doubt that the child was dead, yet, in desperation, he at once com. menced the rapid compression of the precordium, as de scribed above. For fully three minutes he worked away, apparently without result, during which time his Dr. Mass was led, through the following incident, to colleague and he discussed the painful questions of inmodify the procedure in one particular, and thereby forming the waiting mother and the unpleasantness of greatly to enhance its value: A boy, aged nine years, an inquest. Suddenly they were surprised and delighted while under chloroform for cleft palate, suddenly ceased to hear a faint gasp, followed in a few seconds by anto breathe; the pupils dilated and the face became other. A little later they felt a weak heart-throb, and cyanotic. He was at once treated by Professor Koenig's in a minute or two more the child began to cry, and all method; but both pulse and respiration became gradu danger was passed. ally weaker, until at length they stopped altogether, and The points of special interest to be noted in this case the boy was considered to be dead. Dr. Mass, who had are (1) the length of time (seven minutes) during which been compressing the thorax at the usual rate, on learn neither heart beat nor respiratory effort could be deing that the respiration and the heart's action had en- tected; (2) the inadequacy of Sylvester's method, invertirely ceased, became excited, and commenced to comsion, or ether to re-establish the circulation and respira

tion, none of them producing the slightest apparent ef fect; (3) the complete recovery of the patient under the rapid and forciple heart compression.

There can be no doubt that the efficacy of KoenigMaas' method lies in its direct action on the heart, restoring not the respiration only, but the circulation also. If, on a fresh cadaver, the precordium be quickly and forcibly compressed, it is easy to detect a distinctive pulse-wave in the carotid arteries, and the pupils will be found to contract as the blood fills the capillaries of the iris.

Although this method is naturally easier of applica tion upon the flexible chest of a child than on the rigid thorax of an adult, yet age does not preclude its use. It need hardly be mentioned that provision must be made for the free entry and exit of the air to and from the chest.

A method so simple and rational, and withal so effective, Green feels sure only requires to be better known in order to be more generally adopted.-Therapeutic Gazette.

of a member is a very important sign and calls for a prompt determination.

Finally, the pulse, under the influence of chloroform, by its irregularity, intermittence and arrhythmia, indicates, even better than auscultation of the heart, that the valvular lesions are badly conpensated for, and that there is danger in the administration of chloroform. Med. and Surg. Rep.

Operative Methods in the Sacral Region. -Borelius has studied the anatomy of the sacral region from a practical and operative standpoint on twenty-nine cadavers-twenty males and nine females. In order to gain access to the upper part of the rectum the method of Rehn-Rydygier is recommended; for the uterus and the upper vagina, that recently proposed by Hochenegg. The author operated once by the former method, but vesical paralysis followed the operation and lasted for two weeks. In order to avoid this Borelius has invented a method of sacral resection so as to reach the upper part of the rectum and at the same time avoid the sacral plexus, so important for innervating the blad. der and anus.

1. Incision of the skin and soft parts in the median line from the posterior inferior spinous process of the ilium to the lower end of the coccyx down to the bone; from the coccyx the line deviates to the right, following the lower border of the gluteus maximus; denudation of the right border of the coccyx and sacrum to the right sacrosciatic ligament.

The Pulse in Clinical Surgery.-The Revue Internationale de Medicine et de Chirurgie Practiques The method is as follows and has been tried in four contains a review of a work by M. Francois Bertonnier cases without any bladder trouble or any other inconon this subject. In this interesting work, says the venience: writer, the author first recalls Marey's statement as follows: "The pulse is the sensation of sudden swelling felt by the finger which palpates an artery. The blood vessel that allows itself to be depressed becomes sud denly hard each time that a systole of the heart in creases the arterial tension." Bertonnier then considers this physiological phenomenon with regard to its frequency, its power and its rhythm. In two chapters he explains the connection between the pulse and the temperature, also the usefulness of examining the pulse in cases of severe hemorrhage. His principal conclusions are the following:

1. The discordance of the two curves, that of the temperature and that of the pulse, is often an indication of a serious condition.

2. In grave hemorrhage the great depression of the pulse that accompanies it has sufficed occasionally to in dicate the true diagnosis.

8. In traumatic shock, or that following an operation, the degree of slenderness, of frequency and of irregu larity of the pulse will be the most exact measure of the violence of the shock and of the patient's vital resist

ance.

2. Section of the bone in an oblique line touching the lower border of the fourth posterior sacral foramen on the right, and the third on the left; during the operation the bony flap is held toward the left and replaced when done.

The advantages of this over the Rehn-Rydygier method are:

1. The incision in the skin and soft parts is more simple and more favorable to healing.

2. The sacro-sciatic ligaments on each side are left intact, also the fourth sacral nerve.

and the lower end of the coccyx is also untouched.
3. The muscular connection between the anal region

fers the method proposed by Hochenegg in 1892, with
To reach the uterus through the sacrum, Borelius pre-
a slight modification. In order to preserve the connec.
tion of the anal region with the bone, instead of extir.

4. In traumatic cranio-cerebral lesions extreme slow-pating the coccyx like Hochenegg he makes a tempo. ness of the pulse is a never-varying sign of concussion, rary resection of the bone and when the operation is of contusion, or cerebral compression. Eventually, its finished replaces the coccyx. In two cases operated on acceleration with elevation of temperature is a sign of by this method recovery was complete.-Nord. Med. meningo-encephalitis. Arkiv., in Rev. Int. de Med. et Chir. Prat.; Jour. Amer. Med. Ass'n.

5. The pulse should often be a guide in surgical in terference in traumatic or inflammatory affections of the abdomen.

Now is the time to subscribe for the MEDICAL

6. The absence of arterial pulsation at the extremity | REVIEW.

OBSTETRICS AND GYNECOLOGY.

Are the Uterine Ends of the Fallopian Tubes Ever Pervious When the Tubes Contain Pus?—Notwithstanding the recent empha tic declaration of one of our most noted gynecologists to the contrary, numerous cases in which tubes are pervious are being reported. Dr. T. J. Watkins, of Chi cago, says that while separating the adhesions of a pus tube on the left side he noticed that the tumor suddenly decreased in size without rupture. Fully four drams of pus were forced out through the uterus into the vagina, over the vulva, and onto the operating table. He thinks that this case, however, could not have been relived by curettement, drainage, massage or galvanism, because, first, the patient had an abscess of the opposite tube and ovary, and, second, because the walls of the left tube were so distended, adherent and thickened as to be incurable by any operation short of an abdominal

section.

that infection may occur through the examining finger, though the latter is easily disinfected, since the rectum does not contain specific microbes. The author considers rectal examination of great value to midwives, enabling them to determine if the presence of an obstetrician will be necessary. Zweifel's experience in the Leipzig obstetrical clinic showed that students instructed in this method of examination could determine all the necessary details without recourse to vaginal examination. Ries believes that midwives should be forbidden to make examinations through the vagina, a8 their duty is only to assist at normal births. Kroenig is inclined to permit vaginal examinations only (1) when it is difficult to determine through the rectum what part of the fetus is presenting, (2) when the midwife is not able to bring about relaxation of the cervix, and (3) when the pains last more than two hours.-Med. and Surg. Rep.

The Hysterical Breast.-In the Nouvelle iconographie de la Salpetriere for March and April there is a long and interesting article on this subject by Prefessor Dr. F. A. Glasgow, of St. Louis, practices dilating Gilles de la Tourette, who remarks that this affection the cervix with sterilized elm tents in these cases say should be ranked among the trophic troubles allied to ing, "We can gradually slip in tent after tent, first dip-hysteria and closely connected with edema. It constiping them in glycerine or water for a moment, until tutes, he says, one of the most interesting manifestathe cervix is full. I now place a wad of cotton tied tions of the neurosis, especially from a surgical point of with a string just against the cervix; the tents are cut view. The hysterical breast has led to many errors in off to a length which will just permit them to entirely diagnosis, followed occasionally by the ablation of an enter the os externum without pressing on the fundus; organ which, under the circumstances, was amenable they have each a short, string attached to them. This only to medical intervention. is kept up for a number of days, the patient being kept in bed. Sometimes the dilation causes pain; often none. If, when the uterine canal is large enough to admit the finger, there is no discharge of pus with relief of the symptoms, I anesthetize and curette. I now pack with gauze and repeat for a number of days. I can not at present recall a case of tubal distention where I did not get some discharge after packing with gauze or dilating with tents for some time. Very often there is a very offensive watery discharge comes through the packing, even soaking into the bed. Every case is not permanently relieved."-Med. and Surg. Rep.

Rectal Examination of Pregnant Women. -W. H. Beckman (Shurnal akuocherstwa i Shenskich bolesnej) has tried this method with great success in 100 parturient women, the details of pelvis and cervix being easily made out. The length of the pregnancy and state of the bladder could not be determined in 7 per cent of the cases, and the fontanelles and sutures could not be felt in 28 per cent, but this was less important, since the position of the fetus could easily be detected by external examination and especially by auscultation. It was always possible to distinguish the occipital from the frontal portion of the head. The advantage of rectal examination is that infection through the genitals is avoided, the only objection being that sometimes exam. ination through the vagina may become necessary, and

Willis, at the end of the seventeenth century, seemed to be the first to observe this manifestation. A young woman was attacked with very violent hysterical symp toms following a blow on the breast. The swelling of the organ and the pain were coincident with the convulsions. After pregnancy, however, the hysteria, with the swelling and the pain, disappeared. Frederic Hoff. man, in 1748, reported two cases of painful swelling of both breasts coincident with hysterical attacks. At the end of the last century M. P. Pomme said: "The breast swells occasionally from the effects of the reflux of menstruation, and often this swelling has been mistaken for a true tumor. It is painful, and is a source of great alarm to the patient. Too much air in the cellular tissue of the breasts and the engorgement of the mammary veins from the reflux of the hypogastric region give rise to this error. The application of a wet cloth usually arrests the symptoms." Watson said that surgeons were well acquainted with the hysterical breast. The breast becomes painful and sensitive, and increases somewhat in size. In 1837 Brodie made a distinction between the cases of hysteria and those of tumor. though his opinion on this point is erroneous, says the author, his description of the hysterical breast is not without importance, and is remarkable for its clearness. "Some young women," he says, "are subject to an affection of the breast which shows a great resemblance to the articular affections of an hysterical nature. The

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patient complains of a pain in the breast, and the least that are transformed then into hyscerogenic zones. pressure causes her to cry out. Sometimes simply pal- Direct pressure and acute emotions may cause the zone pating the organ produces movements of the entire of the breast to become active in the same way that it body, which resemble very much those of chorea; how feels the influence of the excitation of the neighboring ever, if the patient's attention can be completely turned zones or of those which, situated near the vagina or the from herself, not only will the movements cease, but uterus, become excited during menstruation. At the she will scarcely feel any pain. This hyperesthesia is moment when, under the action of these various causes, not limited to the breast; it extends to the aqilla and to the zone of the mammary region becomes excited, it or the arm. No tumor is found in the organ, but when the breasts become spontaneously the seat of a pricking the affection is somewhat advanced the breast becomes sensation and of darting pains which are very severe and swollen, probably in consequence of a secondary hyper- of a neuralgic character. The breast becomes tumefied, emia. Nevertheless, there is no redness of the skin, the nipple is erect, and the entire organ increases to alrather, on the contrary, a slight pallor, with a generally most double its size. Frequently the pain does not reshiny aspect. These cases must not be confounded with main localized, but radiates to the axilla, to the spine, those of painful tumors of the breast, of which Astley Cooper gives illustrated examples in his work. It is also necessary to distinguish them from all kinds of tumors presenting themselves in women who are not in any way predisposed to hysteria. In these cases the pain tumefaction and other symptoms are not always limited and the sensitiveness are much less than in those of true hysteria." Brodie's description is excellent, says the author, with the exception of a few points, particu larly in regard to the fact that hysteria may produce veritable tumors in the breast that may lead to errors in diagnosiz.

etc. The skin at this period, according to Brodie, is not red, and tense. Fere held the same opinion, The aspect of the skin may be variable, according to the cases, during the paroxysms or in the intervals. The

to the duration of the paroxysm itself. In simple cases, or when the affection is just beginning, the swelling disappears with the painful attack, but more frequently, especially if the attacks follow each other closely, the tumefaction persists in variable degrees during the intervals between the paroxysms, and the attacks are Hysterical breast, says M. de la Tourette, like arthral always accompanied by this exquisite cutaneous hypergia, is a type of local hysteria. In its etiology, contu-esthesia, which is excited under the influence of various sion of the organ will often be observed. The local causes. In these cases palpation reveals interesting traumatism influences the mental state of the patient, peculiarities. During the attack it is almost impossible who is only too ready to favor this localization. Apart to palpate the breast. The pain is much too acute to from these cases where the occasional cause may be recognized, there are others in which we have only the common etiology of hysteria. The symptoms often ex ist in women who suffer with painful menstruation, who present hyperesthetic or hysterogenic zones of the vagina or of the neck of the uterus. It is certain that disturbances of the latter may singularly influenec the organs of lactation and produce there hysteria. Nearly always one breast alone is attacked, although Frederic Hoffman and Liouville have observed cases where the two breasts were involved at the same time.

The hysterical breast consists of a temporary or permanent increase in the size of the organ with considerable hyperesthesia of the skin. It is a question of a hyperesthetic, hysterogenic zone the excitation of which leads, in the majority of cases, to convulsive paroxysms. At the moment of the attack a series of vaso motor symptoms are produced locally whiah begin with sim ple congestion and lead to edema, sometimes, perhaps, to gangrene of the skin. Hyperesthesia of the skin of the breast does not differ from that of the skin of other parts of the body. It is much more marked when a slight, superficial friction is applied; sometimes it is so exquisite that the patients can not bear their clothing to touch them, although in certain cases the pressure of the corset seems to give relief.

admit of a reliable examination. But it is not so in the intervals between the paroxysms, especially if care is taken to palpate the gland deeply and not superficially, as the cutaneous irritation is likely to produce excitation of the hysterogenic zone.

Hysteria of the breast, says M. de la Tourette, is very tenacious, and its duration may be very long. It is known, moreover, how difficult it is sometimes to remove a mark of the nature of a hyperesthetic zone, and the hysterical breast is nothing else than the reaction of a special organ under the influence of a zone of this kind.

This affection 18 perfectly characterized and depends on the hyperesthetic and hysterogenic zone of the skin of the mammary region and on an edema of the connective tissue of the gland, which may assume a white, a red, or the violet color of hysterical edema. Apart from this form, where the swelling of the breast is uniform, there is another form susceptible of the same in. terpretation. In this the edema is hard and is localized more particularly in certain points under the form of tumors which are not accompanied by ganglionic en. gorgement unless there is ulceration.

If these peculiarities are considered, says the author, the diagnosis should scarcely be doubtful, although amputation has been practiced several times, and it is The hyperesthesia is permanent, but it is more marked still advised at the present day. M. Pean, he says, at certain times under the influence of causes which practiced partial amputation of the breast in a young usually control the excitation of the hyperesthetic zones hysterical girl in whom palpation had revealed some

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