I

point, it was my pleasure to read quite a lengthy discussion upon the matter. It was pointed out by an anatomist that the base of the appendix rotates upon two or three planes and never upon one point. Although I believe it does nothing more, McBurney's point will serve a purpose in attracting attention. to the region more than has been done heretofore. think the teaching of older medical men had a good deal to do with the mortality in these cases, for the very reason that they were thoroughly imbued with the idea that when you have disease of the intestine you are to place the intestine in a splint with opium, and while the patient is relieved from pain the mischief is going on there in spite of the opium. While laxatives may be abused, I think that very frequently, especially by the use of calomel, good could be done with them at the outset, and very many cases are cured with the use of purgatives and hot applications and rest in bed, while if the opium treatment is continued to any excess, just what you want to avoid, that is the accumulation of fecal matter in and around the parts, will result disastrously.

Dr. Buchanan: One or two points I think might be dwelt on a little more at length than has been done this evening. I suppose it would be right to confine the discussion to the matter which has been presented by the gentleman who opened the discusssion—the subject of appendicitis and pelvic peritonitis. These two subjects illustrate the advances which the gynæcologist has made in medicine. On the subject of appendicitis all medical men are pretty well versed; they do not require the services of a specialist to give them any information; whereas, when they come to examine the ovaries and tubes, many otherwise wellinformed practitioners are all at sea; it is because they are not accustomed to the bimanual method of examination; they are not in the habit of taking these parts between their fingers and finding out what they hold. In most cases of pericæcal abscess operation is readily acceded to, while in many ovarian and tubal abscesses they frequently object to the opening of the abdomen for the removal of these abscesses, because they have no familiarity with the examinations necessary to demonstrate the condition.

In inflammation of the appendix I believe that wherever there is a tumor to be demonstrated, there is always localized peritonitis and the cases can be grouped into three classes:

First, those in which the inflammatory collection is such as to give rise to a tumor which can be felt, and which goes on to resolution. These are the great majority of cases, and for that reason alone I think it would be unwise to treat all cases by abdominal section.

Statistics given are to the effect that a very large percentage of cases get well with merely palliative treatment.

The second class of cases includes those in which the peritonitis goes on to the formation of a localized abscess. This abscess sometimes opens spontaneously, occasionally through the bowels; when an incision is required, it is often merely the opening of an abscess, the peritoneal cavity not being invaded.

The third class of cases comprises those where no local abscess is formed, but where the first peritonitis is a general peritonitis, and these are the unfortunate or fatal cases that Dr. Werder has spoken of, and he gives a reason for the difference: for one being localized and the other generalized peritonitis. The per

itonitis has not had time to shut off the disturbing element and encapsulate it in an abscess.

It is not

I will make a suggestion in these cases. the element of time that makes the difference, but the nature of the material that excites the peritonitis. A perforation may be made and no streptococci or other virulent germs may have entered. In this case it is a nonseptic peritonitis, therefore a local peritonitis ; for the same reason that, in cases of gonorrheal salpingitis, attacks of local peritonitis are common. The gonococcus may enter the peritoneal cavity, and it has been pretty well established that when it does enter that cavity it is not an extremely dangerous visitor. It sets up a localized peritonitis, and these are the attacks of localized peritonitis that prostitutes have. Entirely different is the course of the peritonitis which arises from the bursting of an abscess, the result of infection at the time of confinement. Here the most virulent germs enter the cavity and give rise to a general peritonitis which may result fatally in a few days, possibly in a few hours. As I said before, the different course of the peritonitis in the second and third classes of cases of appendicitis, may not be due to the element of time but it may be in the nature of the exciting cause of the peritonitis.

Now the subject of inflammation of the Fallopian tubes which frequently gives rise to what is commonly recognized as pelvic peritonitis, is a subject which I believe in this part of the country has not received sufficient attention. I have seen within the last couple of years a good many cases where abscesses of the ovaries and tubes could be demonstrated easily, and where the operation has not been recommended to the patient by the attending physician, even though attention was strongly called to it. I recall one case where a patient with an ovarian abscess was treated for malaria by a gentleman who is considered in the front rank of the profession in this city, until the abscess broke through the vagina. Now that could only have come through lack of examination. Another case was one of gonorrhoeal salpingitis, followed by very severe local peritonitis, in which a mass could be distinguished very easily after the peritonitis had subsided. This patient is now under electric treatment. Her doctor comes every day, or second day, and applies the battery. This woman has been about one and one-half years undergoing this and similar treatment and has not had a well day. Another case was treated by a most excellent physician in this city, one who stands very, high, which I never saw but once and then at his request. This patient had probably an abscess, certainly as large as my fist. This woman had been carrying this abscess, according to accounts, for about three years. She was an invalid as most of these cases are. It was pitiable to see her turn in bed. This gentleman had not advised or apparently thought of an operation. He was much pleased at her being a little better than she was a month before.

Another case I saw about a year ago in a neighboring town. She had an abscess that could be distinctly felt by any person who put his hand on the abdomen. this patient had been constantly in bed for two years, and in that time had not touched her feet on the floor. She has since died. I mention these cases because I believe that many others of similar character now exist in this and neighboring communities, and that this matter is not sufficiently talked of by the profession here.

DR. LANGE: The subject of peritonitis has been limited to pelvic peritonitis and appendicitis.

at work at the present time upon a paper reporting a series of twelve cases of typhlitis, part of the number that I have treated during my professional life and of which I have accurate and full notes. I will publish these cases as I complete them. I must state I have never lost a case of typhlitis I stand with the Germans in this respect, if as the reader of this paper stated, the mortality in Germany is very much lighter than in America. Of these twelve cases of which I have notes, one only received surgical treatment, and that was a simple incision through the belly wall for the evacuation of pus. Dr. Werder seems to support the statement that after a duration of three days, the inflammation-typhlitis-not showing any apparent improvement, a section would be indicated. It strikes me that this is entirely too energetic, that it is to say the least unwarranted. This is all right when pus has been demonstrated. Otherwise it is not warranted, because we still sometimes have septic peritonitis after abdominal section with the most careful precaution by the most careful operator. In other words, antisepsis is not yet thoroughly understood nor mastered. As long as this is true, it is unwarranted to advocate incision in typhlitis because it does not improve after an existence of three days. The reason is not sufficient. It must still be the demonstration of pus. It is justifiable, however to dilate the sphincters, enter the hand into the rectum and search for pus, because it forms frequently behind the cæcum, and when so, cannot be found by examination through the belly-wall.

Among the twelve cases I shall report, is one in which the tumor was as large as a melon, whereupon careful and repeated examinations, no pus could ever be found. A deformity lasting almost two months. after recovery existed by reason of extreme flexion of the thigh upon the abdomen during the inflammation, and the whole limb was infiltrated and oedematous from vein pressure, and before the leg could be brought down and the tumor disappeared, had a duration of between three and four months. The recovery is perfect. I think I have a right to assume that no pus existed in that case, and I would, with all due regard for the opinion of the authority quoted by Dr. Werder and of Dr. Werder himself, insist that this rule is unjustifiable. The criterion, I think must be the demonstration of the existence of pus.

The treatment of general peritonitis has undergone some change. The change advocated in the last few years is the administration of purgatives, particularly the sulphate of magnesium instead of opium. I believe that general septic peritonitis is always fatal, and I believe we often speak of general septic peritonitis where it does not exist, as for instance: I was recently concerned in a case where an abdominal section was done, and on the third day it was concluded that the patient had general septic peritonitis. She was given at my earnest solicitation morphine. The sulphate of magnesium treatment was ruled out by my insistence, and she recovered. I was doubtful of it at the time, and now I do not believe she had septic peritonitis. One case of septic peritonitis I remember very distinctly, occurred five or six years ago. A patient came to my office in the middle of the night out of breath, said his neighbor was very sick, and took me to his bedside. I went with this man for a distance of three blocks and found the pa

tient with an extremely bad case of cholera morbus. I gave him morphine, remained with him about half an hour, and when he was better, the wife of the messenger came to me and said: "Doctor, my husband has the same thing." I went into the adjoining house and found this patient with apparently a very severe attack of cholera morbus; but it was septic general peritonitis, and killed him in forty-eight hours. Here were two cases occurring at the same time and side by side, and though I may lack special acuteness, I could see no difference between them. It was impossible for me to say that one had a certainly fatal affection and the other a temporary slight illness without any mortality. This was true until the effects of the morphine decided one to be cholera morbus. Both were chilled, both were shocked, both were very tender and tympanitic, both drew up their legs, both were cold and blue and almost pulseless, and both had death in their faces. Both also vomited and purged, and both were evidently in unutterable anguish. I could appreciate no difference between them. From this and like evidence, I believe a diagnosis of general septic peritonitis is not always correct; and further, that when such a patient has recovered under the magnesium treatment no general peritonitis existed. I am told by a laparotomist of large experience, that most of his women on the third or fourth day have such an attack; that he gives them magnesium and they get well. But this is certainly not general septic peritonitis. I believe it is a colic with meteorism from handling or exposing the bowels; a condition analogous to that frequently seen after hard protracted labor, and in such cases the magnesium treatment is excellent. But in my opinion a patient with septic peritonitis dies. There are two ways, generally, by which septic inflammatory agents reach the peritoneum: by ulceration through the stomach or intestinal tract, and in women from the genitalia. genitalia The messenger for the cholera morbus man probably had some ulcer of the bowels, perhaps painless, with a perforation which happened through his violent run to my office that night. No post-mortem was had.

One thing that appears from Dr. Werder's paper and the discussion, is that no one mentioned idiopathic peritonitis. pathic peritonitis. I believe there is no such peritonitis. The messenger of whom I spoke was seen by other physicians, and the conclusion was that he died of idiopathic peritonitis. But this was many years ago, and barring puerperal and traumatic inflammations of the peritoneum, all others were idiopathic. We know better now. As to the treatment of this septic inflammation of the peritoneum, if there be a chance to benefit patients, I believe it to be by opium, and very slight. Dr. Andrew Clark, as all the world knows, was a very eminent physician, and he reported a number of cases of acute general peritonitis cured by the opium treatment. I do not know whether that is correct. It possibly is, but from what I have seen, I must doubt it. As to what I have seen of magnesium treatment in cases where the diagnosis was certain, I must condemn it. Can you do anything else when you think of typhoid or duodinal or gastric ulcer perforation? I believe the prognosis to be always extremely bad, and the only forlorn hope to be opening the belly and washing it out.

Dr. Macfarlane also objects to the opium treatment; to "putting the bowels in splints" in perityphlitis. I have here twelve cases of such peritoneal inflamma

tion, all of which recovered and all of which were so treated. I have had additional cases of which I have no record, which were treated and which ended in the same manner. Therefore I shall continue so to treat them. But I do not use morphine alone; I do not trust to morphine alone. I use also calomel, we were wont to say for its alterative effects, now we give it for its antiseptic and antiplastic effects.

Dr. Koenig: It seems to me Dr. Lange must have misunderstood Dr. Werder in regard to at least one assertion. He said Dr. Werder had not mentioned idiopathic peritonitis. If I am not mistaken, Dr. Werder declared that peritonitis might be produced as a result of "catching cold" at the time of the catamenial period. If that means anything else than idiopathic peritonitis, I fail to understand it. The term, catching cold," to my mind, is simply an admission of ignorance. I wish also to add the weight of my testimony in favor of the opium treatment. We want

to relieve the nervous system of the irritation that the disease produces, and we can do it better by opium than by any other remedy.

The late Prof. Austin Flint was sometimes jestingly accused of having reduced his medication to the use of two drugs, whisky and opium, and I well remember his remarks regarding opium. In serious diseases, he admitted, it was not curative under the ordinary acceptation of that term, but he declared that it was curative nevertheless, for the reason that it established a tolerance of the disease for the time being, allowing nature to repair the trouble under the reduced sensibility of the nervous system.

Dr. Grube: I can recall two cases which I think illustrate the fact that no one line of treatment can be laid down. Each case must be treated on its own merits. One case was of peritonitis which went along for some two weeks or more, until I was satisfied there was pus present. I demonstrated the presence of pus by the hypodermic needle and then I operated. It was a very simple operation. I merely cut down through the muscles of the abdominal wall and met the abscess cavity, and instead of cutting into it, I took the forceps and stretched it and the pus came out, and that was the extent of the operation. Any physician can do that.

The next case was very much like it, and I thought I would have another opportunity for operation, for I had some of the surgical enthusiasm. I watched the case, and in about a week the whole thing disappeared without any pus at all. My idea of the treatment of all these cases is as Dr. Lange said. The time for operation is when you can demonstrate the presence of pus, and not until such time, with the exception of the cases where you have collapse, and if they are not operated on quickly, you have no chance of saving your patient. My own experience has been that each case has to be watched carefully. What is necessary in the case is simply opening the abscess, or else we will kill our patients very quickly.

Dr. McKibbon: The gentleman on my left has stated the history of two cases that he had. Dr. Senn, of Milwaukee, has given the history of the cases he treated. He claims the operation done in this condition is practically of very slight importance, and on the other hand that by waiting for these cases to become bad, is the worse treatment that can be pursued. He says the operation is not of sufficient magnitude to wait until there is something turning up.

DR. BUCHANAN: I would like to express myself against making a fixed time for operation. I think with Dr. Lange that to fix absolutely on the third day as the time to operate if the patient is not improving, is rather arbitrary. I could submit a number of cases that got well without an operation. I have seen many cases that did badly for three days and eventually recovered without early interference. I think Dr. Lange has been wonderfully fortunate in the class of cases he has had, if he has had twelve consecutive recoveries. One of his cases would have been much better with an operation. I think very few of us would be willing to let such a mass go on, even to the size of a small melon, without opening it up and endeavoring to do away with the origin of this immense inflammatory exudate. I think there was pus in this case. According to the history given, this patient did not make a very pleasing recovery. I think Dr. Grube has very well stated the two classes of cases that should be submitted to operation, those in which pus can be demonstrated and those in which the perforation is through the appendix, and is setting up general peritonitis. If you can catch such cases in time, it is proper to remove the appendix and wash out the cavity. Usually they die.

Now in regard to septic peritonitis. As I understand Dr. Lange, he makes the test of septic peritonitis the death of the patient. If he dies it was septic peritonitis, and if he recovers it was not septic peritonitis. I do not think this a fair way to test the method of treatment for that disease. If I had septic peritonitis, I would like to have some very vigorous treatment with epsom salts at first, and if that did not succeed very soon, I would be willing to take very large doses of opium.

The case which has been cited, in which marked improvement took place, which was supposed at first to be septic peritonitis and recovery occurred in three days, it seems to me from the description of the symptoms, was one of beginning septic peritonitis. I think very likely if the operations of this gentleman were all followed on the third or fourth day by the symptoms described by Dr. Lange, it was the result of septic conditions. It has been remarked that Dr. Sands always advocated the removal of the appendix. This is certainly proper in case you can find it, but you cannot always get it. It is a nice thing to remove and a safe thing to remove; at the same time I do not think it is a very good thing to hunt for it. There is a great deal of change taking place in the surrounding parts which render it difficult to find. The rule that operations should be made parallel with and a short distance above Poupart's ligament is a very good rule, except in those cases where the abscess does not approach the ligament. There is a class of cases where the localized peritonitis occurs opposite the umbilicus or a little lower.

DR. LANGE: I do not set myself up as a judge concerning the case Dr. Buchanan has reference to, but merely submit my opinion. I think the doctor will agree with me, that if my associate in the case was correct when he said that nearly all his patients had such symptoms on the third or fourth day, that it was not septic peritonitis, because if all his patients had septic peritonitis and all got well, that gives a grand and new aspect to the whole matter. I did not believe at the time that it was septic peritonitis; recovery confirms that belief. I

am entirely willing to put myself on record that when this inflammation does not kill, it is not septic and not general; in other words, that septic general peritonitis is fatal despite opium, calomel, magnesium, or any drug that may be given; that when such a case ends in recovery it involves an error of diagnosis. Another point, the operation of opening an abscess, which I did in one of my twelve cases, is quite a different thing from opening the cavity on the third day of perityphiltis. There may be no pus sac, no pus cavity; if not you will get into the general peritoneal cavity, easy enough in any event; if you do not, if you content yourself with cutting down to the tumor adherent all around and do not free it, and palpate and examine it, you have accomplished nothing. Doing this thoroughly all the chances

are you will get in; and if you do not and there is no pus what have you accomplished? Nothing. The criterion still must be, pus or no pus.

DR. GREEN: I want to say one word in regard to trying to make the distinction between septic and nonseptic peritonitis. It seems to me in nearly all cases it can be detected by the general symptoms of the patient. I think the best guide is the condition. of the patient. That is the general condition, and the general aspect of the patient. If the disease is of a bad nature, the patient will readily succumb. These are the symptoms I have allowed to guide me in all such cases, and I think no physician ought to find any trouble in distinguishing after twenty-four hours what kind of a case of peritonitis he is dealing with. I think twenty-four hours will determine the case, thirty-six hours at the utmost.

DR. WERDER: I am thankful for your kind consideration of my paper and also for the discussion of the subject. I have very few remarks to make, because the matter has been discussed so thoroughly that there is not much to be said. Only a few points I would mention. The first is in regard to McBurney's point. I have very little experience with it. Of course the appendix is a very movable organ, but Dr. Macfarlane claims that if you put the end of your finger at the point he claims as diagnostic, that that point touches the base of the vermiform appendix, and the base of it is always located in the same place unless the cæcum is displaced. It may be so, but if so the displacement is very common. I know Dr. Clark claimed great results for the opium treatment. He gave opium simply according to effect only. If I am not mistaken he gave what are usually considered enormous doses, reducing the respirations in some cases to ten or twelve per minute. Of course these are enormous doses. I think no one to-day gives those enormous doses, and I know our results are no worse than Dr. Clark's were. I prefer the calomel treatment.

If I had peritonitis I would not want to suffer very much pain, I would want a dose of morphine, but as a routine treatment I think I would prefer the purgative treatment. When opium is given the bowels confine the fecal matter which contains septic germs, and some of these cannot help getting into the general abdominal cavity. Septic peritonitis has often been produced by an accumulation of fecal matter which could not be passed. Often cases of peritonitis are due to germs getting into the abdominal cavity through the bowels. Now purgation will carry that off.

An Army Medical Board will meet in this city during February to examine candidates for appointment to the Medical Corps of the U. S. Army. The Surgeon-General's notice will be found in another column. Candidates must be between the ages of 21 and 28 years, graduates of regular medical schools, and of good moral character. The examination will be physical as well as mental. The latter will cover subjects of preliminary education, general literature and general science and medicines. The examination will be oral, written and practical. There are twelve vacancies in the staff to be filled by the successful candidates. As the pay of an assistant surgeon is $1,600 a year and his rank is first lieutenant, the position is a most desirable one.

Interleaved Advertisements.

Doctors are proverbially good natured and long suffering and bear with equanimity impositions that would move any other class of men to rebellion. This is exemplified in the fact that they continue to subscribe for and read medical journals which insult. them with interleaved advertisements. Publishers find interleaving profitable and will continue the habit till the subscribers to their publications express their disapprobation in no uncertain manner.

Cannot the reform idea be extended so as to include this improvement in journals? Readers want the advertisements and the best men read them carefully and find in them many and valuable hints as to new medicaments and instruments, but no man, when reading of an interesting obstetrical operation, wants to be interrupted by a flame-colored leaf telling him of the advantage to be derived from a kidney cure or rheumatic specific. The publishers must live or journals will not exist. It is desirable that they should live and make money, but they can attain both ends without marring the beauty of their productions by the interleaved advertisement.

Keeley and the Washingtonian Home.

The Washingtonian Home, at Madison Street and Ogden Avenue, is the city inebriate asylum. While not under city control it receives a bonus of $25,000.00 a year from the municipal government in consideration of which it furnishes free treatment to all inebriates consigned to it by the police magistrates. It is one of the best known institutions of Chicago.

Dr. Leslie E. Keeley, of Dwight fame, has offered to take charge of the institution, conduct it on the terms upon which it is now managed and in addition use his secret methods of treatment on the patients. In this proposition Dr. Keeley's friends see magna

nimity and a yearning to make all men, who drink, sharers in the benefits of his discovery and laud him freely for his goodness.

The Washingtonian Home loses no money by its contract with the city and its income from private patients is not inconsiderable. These facts Dr.

Keeley knows and his proposition is a thinly veiled scheme to secure the official endorsement by the city of Chicago of his method of treating inebriety. He will not be satisfied with the endorsement but wants as a bonus the privilege of treating city patients at a profit and a free hospital for his private patients, all of which he will get if his proposition is accepted. The endorsement by this city of him and his remedies would be worth many times $25,000.00, for it would be used as an advertisement to attract patients all over the world. Dr. Keeley could take the Washingtonian Home, conduct it as a private charity of his own with no remuneration save the endorsement of the city and from the private patients attracted by that endorsement, derive a princely income.

This city will not accept the proposition. It is not ready to yield the control of its public institutions to men who deal in secret remedies even though it is claimed those remedies are the result of revelations.

Label the Doctors.

Since the imperial government has given physicians' carriages the right of way in Berlin the drivers of these vehicles are required to wear a regulation hat that they may be recognized at once. A number of physicians in this country have been impressed by this and have advocated the adoption by all doctors, when not incog, of a distinguishing badge or mark. No concerted action has been taken as every man had his own ideas as to what the badge should be and how it should be worn. Many and valid reasons were given for having medical men marked "doctor" indelibly and it is to be regretted that the plan resulted in nothing tangible. If any one doubts the desirability of having physicians labelled, let him read the following: On the West Side there lives a young couple who have recently come to the city. They have few acquaintainces and know no physician. The wife developed a furuncle of large size on the buttock near the genital fissures. Domestic remedies had no effect and after a sleepless night during which she suffered greatly, her husband suggested that a doctor be called in. She agreed but asked if he knew a doctor. He did, he did not know his name but every morning as he went to work he met, near the house, a man whom he knew to be a doctor because he had a full beard, wore a silk hat and carried an instrument bag. He would send him over that morning. On his way down town he met the supposed doctor, but being in a hurry he asked no questions but told him to go to No. his wife wanted to see him.

on

street as

When the "doctor" arrived at the house the lady led him into the parlor and began moving the things off the center table, remarking as she did so that she had been suffering for several days with a boil which prevented her setting down. Leaning over the table she raised her skirts till the troublesome member was visible and requested that it be examined. The man was in a cold sweat, but he succeeded in saying that he was a piano tuner and the instrument exposed was not the kind he played upon. He made his escape

before the woman recovered sufficiently to scream. The husband swears he will never call another doctor till after he has examined his diploma. Now is it not desirable that doctors should be marked.

Notice.

An Army Medical Board will be in session in Chicago, Illinois, during February, 1892, for the examination of candidates for appointment in the Medical Corps of the United States Army, to fill existing vacancies.

Persons desiring to present themselves for examination by the Board will make application to the Secretary of War, before January 15, 1892, for the necessary invitation, stating the date and place of birth, the place and State of permanent residence, the fact of American citizenship, the name of the medical college from whence they were graduated, and a record of service in hospital, if any, from the authorities thereof. The application should be accompanied by cirtificates based on personal knowledge, from at least two physicians of repute, as to professional standing, character, and moral habits. The candidates must be between 21 and 28 years of age, and a graduate from a Regular Medical College, as evidence of which, his Diploma must be submitted to the Board.

Further information regarding the examinations may be obtained by addressing the Surgeon General U. S. Army, Washington, D. C. C. SUTHERLAND, Surgeon General U. S. Army.

ABSTRACTS.

Surgery.

DRAINAGE AFTER LAPAROTOMY.-Dr. Rufus B. Hall, Med. Record, Dec. 12, 1891, advocates drainage after all cases of abdominal section. He believes drainage as now used is a comparatively harmless procedure. He uses only the small perforated tube suggested by Dr. Price and has never seen harm result from it. The two cases in which hernia resulted in the line of the cicatrix, it was at some distance from the point of drainage.

ACTINOMYCOSIS HOMINIS.--John B. Murphy, M. D. -The North American Practitioner. A young woman twenty-eight years of age, had a severe toothache in the left side of the lower jaw, and shortly afterward a swelling appeared in the throat. It was impossible to open the mouth, and great pain was felt when swallowing. The face was poulticed for several days and the symptoms disappeared. Some days after this, she was again attacked with severe pain in the tooth, ringing in the ears, and a swelling appeared in the mouth and on the outside of the jaw, the pain increasing and the swelling enlarging.

At the time of examination, about one week after, there was found a swelling behind the angle of the left jaw, and the mouth could not be opened more than three-quarters of an inch. The left tonsil was much enlarged, filling most of the pharynx. A lancet was introduced into a spot on the skin, which indicated an abscess was about to break, and a considerable amount of pus evacuated. This gave relief and the patient made a rapid recovery, but failed to re