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LYONS, Dr. FREDERICK A., New PRENTICE, Dr. Charles, Chicago, Ill. VALK, Dr. FRANCIS, New York.
York.

PUTNAM, Dr. HELEN C., Providence, VAN DER POEL, Dr. John, New York.
R 1.

VAN ZANDT, Dr. I. 1., Fort Worth,
MCBURNEY,
McBurney, Dr. Charles, New York. PUTNAM, Dr. William E., Whiting, Tex.
McCourt, Dr. P. J., New York.

Ind.

VINEBERG, Dr. HIRAM N., New York. McCreery, Dr. FORBES R., New

Virden, Dr. J. E., Cochranton, O. York.

RACHFORD, Dr. B. K., Cincinnati, O. McCully, Dr. S. E.

RANSOM, Dr. G. MANLEY, New York. WAECHTER, Dr. C., New York. McIlhenny, Dr. R. A., Conway Ray, Dr. C. A., Winifrede, W. Va. WALKER, Dr. D. E., New York. Springs, Kan.

RECTOR, Dr. Joseph M., Jersey City, WARE, Dr. EDWARD J., New York. MCINTOSH, Dr, Perry A., Thomas

WARNER, Dr. FREDERIC M., New ville, Ga.

RICHARDSON, Dr. John B., Louis- York. MCKINNON, Dr. John A., Selma, Ala. ville, Ky.

WATERS, Dr. W. E., U. S. Army. McLAURY, Dr. WILLIAM M., New RING, Dr. FRANK W., New York. WATKINS, Dr. Royal P., Worcester, York,

RINGNELL, Dr. CHARLES J., Minne- Mass MACLEISH, Dr. A. L., Los Angeles, apolis, Minn.

WAUGELIN, Dr. Hugo E., Belleville, Cal.

Roberts, Dr. E. G., Fair Haven, Vt. Ill. Mailly, Dr. HAMILTON, Bridgeton, Roberts, Dr. N. S, New York. ,

WEBER, Dr. W. C., Cleveland, O.
N. J.

ROBINSON, Dr. BYRON, Chicago, Ill. Weir, Dr. James, Jr., Owensboro',
MAINE, Dr. FRANK E., Auburn, N. Y. ROCKWELL, Dr. A. D., New York.
RockweLL

Ky.
MANCHESTER, Dr. H. L., Pawlet, Vt. Roeth, Dr. A. Gaston, Boston, Mass. Wells, Dr. H. M., U. S. Navy.
MANGES, Dr. Morris, New York. Roosa, Dr. D. B. St. John, New Wendt, Dr. EDMUND C., New York.
MARCY, Dr. Henry O., Boston, Mass. York.

WERDER, Dr. X, O., Pittsburg, Pa.
MARPLE, Dr. WILBUR B., New York. Rose, Dr. Achilles, New York.

WESTBROOK,
Dr. BENJAMIN

F.
May, Dr. CHARLES H., New York. v. Ruck, Dr. CARL, Asheville, N. C. Brooklyn, N. Y.
MENDELSON,

Dr. WALTER, New Rugh, Dr. J. TORRANCE, Philadel- White, Dr. GEORGE R., New York.
York.

phia, Pa.

White, Dr. J. WILLIAM, PhiladelMETCALFE, Dr. ORRICK, New York. Rupp, Dr. ADOLPH, New York.

phia, Pa. METTLER, Dr. L. HARRISON, New RyERSON, Dr. G. STERLING, Toronto, WhitFIELD, Dr. G. W. York.

Canada,

WHITNEY, Dr. H. B., Denver, Col.
MICHAELIS, Dr. L. M., New York.

WIENER, Dr. ALFRED, New York.
MILLIGAN, Dr. E. T. Detroit, Mich. SABETTI, Mr. A., Woodstock, MD, Wiggin, Dr. FREDERICK HOLME,
Moor, Dr. William, New York, SAVAGE, Dr. William B., East Islip, New York.
MORGENSTERN, Dr. JULIUS, New N. Y.

Wilcox, Dr. REYNOLD W., New
York.

SCHAPPS, Dr. JOHN C., Brooklyn, York.
MORRISSEY, Dr. John J., Hartford, N. Y.

Williams, Dr. HERBERT UPHAM,
SCHWARTZ Dr. MARTIN, New York. Buffalo, N. Y.
MoschCOWITZ, Dr. Alexis V., New Seibert, Dr. A., New York.

WISE, Dr. John C., U. S. Army.
York.
Senn, Dr. N., Chicago, Ill.

WOOLSEY, Dr. GEORGF, New York.
MOSHER, Dr. J. M., Odgensburg, Shively, Dr. HENRY L., New York.

SHIVELY, Dr. HENRY L., New York. Wright, Dr. John DUTTON, New
N. Y.

SHRADY, Dr. George F., New York. York.
MUNDÉ, Dr. PAUL F., New York. SILK, Dr. J. FREDERICK W., London, WRIGHT, Dr. JONATHAN, Brooklyn,
MYNTER, Dr. HERMAN, Buffalo, N. Y. England.

N. Y.
Skeel, Dr. FRANK D., New York.
NAMMACK, Dr. Chas. E., New York. Smith, Dr. Homer E., Norwich, Zwisohn, Dr. L. W., New York.
NELSON, Dr. JAY O., New York,

N. Y.
NEUMANN, Dr. William F., New SOUTHARD, Dr. W. F., San Francis-
York.

Societies from which Reports have
NORTH, Dr. N. L., Brooklyn, N. Y. SPRATLING, Dr. EDGAR J., Fishkill

been received.
Landing, N. Y.
OHLMACHER, Dr. A. P., Cleveland, O. STEDMAN, Dr. Thomas L., New York. AMERICAN GYNECOLOGICAL SOCIETY.
OSTRAN, Dr. Homer I., New York. STEIN, Dr. ALEXANDER W., New AMERICAN MEDICAL ASSOCIATION.
Otis, Dr. W. K., New York.

York.

AMERICAN SURGICAL ASSOCIATION. STEWART, Dr. William W., Colum- AssocIATION OF AMERICAN PHYSI. PARK, Dr. Roswell, Buffalo, N. Y. bus, Ga.

CIANS.
PARK, Dr. William HalloCK, New St. John, Dr. D., Hacken ack, N. J.
York.

STOKES, Dr. CHARLES F., U. S. N. MEDICAL AND CHIRURGICAL FACULPARKER, Dr. W. THORNTON, Grove. Stowell, Dr. William L., New TY OF MARYLAND. land, Mass.

York.

MEDICAL SOCIETY OF THE COUNTY
PARSONS, Dr. Ralph Wait, Sing STUBBERT, Dr. J. EDWARD, Nica- OF NEW YORK.
Sing, N. Y.

ragua, Central America.

MEDICAL SOCIETY OF THE STATE OF PEASE, Dr. CHARLES G., New York.

New YORK.
Peck, Dr. GEORGE A., New York. THOMAS, Dr. Allen M., New York.
PHENIX, Dr. N. J., Alvin, Tex. THOMPSON, Dr. W. Gilman, New New YORK ACADEMY OF Medicine.
PHILLIMORE, Dr. R. H., Cookshire, York.

NEW YORK COUNTY MEDICAL AssoCanada.

TINGLEY, Dr. WITTER K., Norwich, CIATION.
Piercy, Dr. A. T., Placerville, Cal. Conn.

NEW YORK PATHOLOGICAL Society.
PIFFARD, Dr. HENRY G., New York. TOMPKINS, Dr. J. EDWARD, Freder-
Pipino, Dr. W. C., Des Moines, Ia. icksburg, Va.

PRACTITIONERS' SOCIETY OF NEW
POTTER, Dr. THEODORE, Indianapo. Tucker, Dr. Willis G., Albany, N. Y. York.

lis, Ind.
Powers, Dr. CHARLES A., Denver, VALENTINE, Dr. R. K., Brooklyn, Society MEDICAL JURISPRU-
Col.
N. Y.

DENCE.

Conn.

Co, Cal.

OF

New York. rt Worth,

A Weekly Fournal of Medicine and Surgery

ew York

ton, 0.

Vol. 47, No. 1.
Whole No. 1261.

NEW YORK, JANUARY 5, 1895.

$5.00 Per Annum. Single Copies, 10c.

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peræmia. One such inflamed Peyer's patch showed a Original Articles.

gangrenous perforation a quarter of an inch in diameter, from which intestinal contents were seen to pump out.

This was promptly closed by interrupted silk sutures, PERFORATING TYPHOID ULCER-PERITO

over which two layers of Halsted mattress stitches were NITIS-OPERATION-RECOVERY.

placed, these being found to be the only suture that BY ROBERT ABBE, M.D.,

would hold in the tender and inflamed intestinal coat. A large abdominal tamponade of iodoform gauze was

placed within the abdomen and pelvis, and no attempt LATE on Saturday afternoon, November 3d, I was asked made to close the wound. A hot black coffee and by Dr. J. H. Bache, of this city, to see with him a whiskey enema assisted greatly in preventing shock ; young married woman, twenty-one years of age, whom the patient was put back to bed in three-quarters of an he had been attending with typhoid fever for three hour from the beginning of etherization. weeks. Every characteristic symptom had been pres- She passed a good night and had a stronger pulse ent: rather free diarrhea, evening temperature rang- next morning. Pulse, 132 ; temperature, 102%2° F.; ing about 102° F., and delirium every night during the tympanites less. At the end of forty-eight hours afsecond week. On Monday, October 29th, the patient ter operation, as she was in good condition, except seemed to be beginning convalescence, all the symp- for tympanites, I removed the tamponade, reapplied a toms abating. Wednesday night she was seized with loose one, and gave five grains of calomel. This progreat pain, as if something had suddenly given way in duced numerous loose movements and she felt much her abdomen below her navel. She vomited, and was better Temperature, 101%2° F.; pulse, 120. A little much collapsed. Her temperature rose promptly to fluid fæces leaked from the wound after the calomel ac102° F., with great pain and tympanites.

tion, showing that the perforation had slightly opened. Dr. Bache at once suspected perforation, kept the This continued for two weeks, when it ceased, and the patient absolutely quiet, and treated her by poultices abdominal wound pursued the usual course, closing in over the abdomen, and enough morphine to allay her rapidly by granulations, and has left a narrow and firm great pain. The temperature fell somewhat, but for scar. two days varied from 102° to 102%2° F. Her vomiting After the third day her appetite improved and a was less, but her tympanites continued. At the end of rapid convalescence ensued. the second day her condition became suddenly worse ; Remarks.—The recording of this one case is not an the pulse became weaker ; the abdomen greatly dis- occasion for a long paper on the subject, which would tended, with skin stretched and shining.

be superfluous in view of the three excellent ones by As she had survived two and a half days, Dr. Bache Mears,' Fitz, and Van Hook,' written in 1888 and 1891. thought, despite her low state, surgery might help her. But it is an opportunity to express a surgical view of On examination I found her with mind clear, but heart the subject ore mature than would have been possible and respiration oppressed by her distended state ;

since. For, while but few cases of this emertongue dry and moderately coated; pulse, 140 ; tem- gency have as yet been operated on, corresponding perature, 104° F. The distended abdomen was dull in conditions of perforating gastric, duodenal, and appenthe hypogastrium half-way to the navel, and the dul- dical ulcers have been relatively common in the hands ness extended along the right Poupart ligament. I con- of the general surgeon. Excepting for the exhausted firmed the diagnosis and advised the earliest possible condition of the patient during typhoid fever, there is operation.

practically no difference, as far as I can discern, beThe patient was in too low a state to be removed to tween the conduct of perforations in various parts of a hospital, so the most complete arrangements possi- the alimentary tract. The same sudden onset of sympble were made to do a thorough operation at the house. toms is witnessed, acute tearing pain, shock, vomiting In this I was assisted by Drs. A. L. Fisk and Nelson followed by tympany and peritonitis.

The same seH. Henry, of Trinity Hospital.

quel pertains as to the peritoneal exudation. In one A median incision below the navel exposed distended case, shock or non-reparative inflammation will succeed coils of deeply congested and greatly inflamed intestine, and be fatal before operation, or in spite of operation ; smeared with sticky lymph. The pelvis and lower ab- in another, a fine quality of plastic lymph'will repair domen were filled with a collection of foul, purulent, the damaged part, or hold the extravasation in check and fetid intestinal extravasation. This was feebly con- until the surgeon can operate. No doubts exist in my fined by matted coils of intestines, loosely glued together, own mind that recovery without operation can follow that broke apart on being touched, but which, being perforation anywhere—and in typhoid also. But this is recognized, enabled me to introduce clean laparotomy certainly infinitely rarer here than in other diseases, besponges under the upper abdominal wall, where a few cause the parts are centrally located where the explosion coils were seen which showed more recent inflamma- occurs and a natural outlet through the abdominal wall tion. Two pints of foul, purulent Auid and thick does not easily take place. The case narrated later, lymph were cleaned out, and the abdomen irrigated where a typhoid ulcer perforated and a resulting abscess with warm and weak sublimate solution, i to 20,000, was opened in the perineum, is consistent with much of followed by plain warm-water irrigation.

nature's good work.
Search now revealed the cause. The lower part of
the ileum showed many thick oval patches in its wall-

J. Ewing Mears : Transactions of the American Surgical Associ

ation, 1888. their long axes parallel to that of the gut, and easily 2 Fitz: Transactions of the Association of American Physicians, identified by touch as the gut was passed through the

1891, vol. vi., p. 200.

3 Philadelphia Medical News, 1891, vol. ix., p. 591. Chicago Medifingers, and shown also by increased subperitoneal hy- cal Record, 1891, vol. ii., pp. 229-270.

a

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Fitz says: “ The similarity of the symptoms of typhoid case of supposed perforation with collapse and reperforations of the bowel and those of the appendix, is covery, in a female, which I am strongly inclined to restriking. Cases of perforating appendix have repeat- gard as one of high intestinal hemorrhage in the fourth edly been regarded as typhoid fever, and, as a rule, the week, indicated by a drop in temperature to 95°, rapid symptoms of typhoid which suggest perforation of the thready pulse, cold extremities and extreme pallor, and bowels are those which in the absence of typhoid would fulness of the umbilical region and tenderness in the be regarded as diagnostic of appendicitis. The symp- right hypochondrium. No pain existed and the patient toms are not merely similar, they are actually identical. made a slow recovery with a very thin pulse. No operaEven to the usual localization of the consequent peri- tion was performed. tonitis to the right iliac fossa."

In August, 1893, Dr. Newton, of Chicago,' treated a This lucid statement by Fitz must appeal to every case of supposed perforation by morphine ; as the parobserver of appendicitis cases, as true to the letter. ents objected to the operation. The case seems unWhy one class of cases should be left to die, while we doubted, and the boy recovered, an abscess of the operate on all appendicitis cases when perforation can pelvis being opened a fortnight later in the perineum. be recognized, does not appear. The typhoid statistics Netschagaw, of St. Petersburg, records a case this are improving, and as it was in the other, we may here year of resection of a portion of perforated bowel in also soon record as much gain in the near future. typhoid, with recovery.

Van Hook operated on a desperate case at two o'clock Since Van Hook's successful case in 1891, there have in the afternoon, where perforation had taken place at been reported the following operations : The extravasation was wide of the ulcer. The

1894. Cayley and Bland Sutton, one case, fatal. patient was washed out with plain boiled water, sewed 1894. H. Allingham, one case, fatal. up tight, rescued from collapse, and saved.

1894. Netschagaw, Medical News, December 1, 1894, p. 609, one Now, we have not yet learned enough about the sur- case, recovery.

1894. Abbe, one case, recovery: gical procedure to do exactly right in all cases, and it

1894. Alexandroff," one case, death. gives me some satisfaction to state in a few words what I regard of growing importance in the work. The If we accept all the nineteen laparotomies for sotechnical points are known to every surgeon, but very called typhoid perforations with four recoveries, colessential do I consider it, that the surgeon should never lected by Van Hook, and add the five new ones, we be so hasty in getting at his work that he enters upon have 24 cases and 6 recoveries. it handicapped by poor assistance, poor light, poor ar- If we throw out doubtful cases—which I agree with rangements for irrigation and sponging, or inadequate Van Hook should be done—and accept only 12 of the plans for restoration from shock.

19 with i recovery--to which the above five are added I regard the rescue of these cases from collapse as --then the correct statistics revised up to date, stand, most important. I always give a restorative enema at 17 cases with 3 recoveries. the end of operation (often on the table) composed of a cup of hot black coffee and one or two ounces of whiskey, followed later by hypodermics of strychnine CASES OF PERFORATION OF THE STOMand digitalis, abundant heat about the body, and eleva- ACH FROM ULCER, WITH SUCCESSFUL tion of the foot of the bed for twelve hours. Very OPERATION. warm saline infusion into the vein, of at least one pint,

BY A. V. ATHERTON, M.D., must always be tried as a valuable resort.

SURGEON TO ST. JOHN'S HOSPITAL, TORONTO, CANADA. To quote from Dr. Van Hook's article, the statistics up to October, 1891, of operation for typhoid perfora- CASE I. February 5, 1884.—R. O'B

-, aged about tion were :

fifty, night watchman in gas-house. For three years

has been much troubled by dyspepsia, giving rise to “ 1884. Mikulicz, four cases, one recovery, though, unfortunately, the diagnosis is doubtful.

pain in the stomach, flatulence, and more or less vom1885. Lücke, one case, resection, death.

iting. Fifteen months ago had a severe attack of hæma1886. Escher, one case, recovery, but the case is regarded by

tomosis with melana, and accompanied by syncope. Louis as one of appendicitis.

For the three following months he suffered from great 1886. Greig Smith, one case, doubtful diagnosis, death.

anæmia and general anasarca. After this length of 1886. Bartlett, one case, death. 1887. Bontecou, one case, death.

time he began to resume his customary duties, but his 1887. Morton, one case, death.

old dyspepsia persisted. 1889. Bontecou, one case, death.

One morning, after his usual night-watch, he was 1889. Senn, volvulus and perforation, one case, death.

suddenly seized with a most excruciating pain in the 1889. Hahn, two cases, death. 1890. Kimura, one case, death.

epigastrium, causing him to drop on the floor where he 1890. Taylor, one case, recovered.

stood. He also vomited, and great drops of sweat 1891. Van Hook, three cases, two dead, one recovered.

came out on his face. He was carried in the arms of

his fellow-workmen to his home, which was close by. Making in all, nineteen laparotomies and four recover- I visited him about two hours afterward, and found ies.

him lying on his back with knees drawn up, complain“ " Mikulicz's case was said by the author to be of ing bitterly of pain in upper abdomen, increased by long doubtful origin. That of Escher was probably a per- breath or movement of body ; countenance anxious ; forative appendicitis. Taylor's case should not be extremities and nose cold and clammy, and a feeble counted, as it was operated on ten days after onset of pulse of 60. He reported having eaten only a light symptoms, and is not demonstrated to have been ty- lunch in the night, nothing since. He described the phoid perforation.

pain with which he was seized as feeling “just as if a “If we include all the doubtful cases, the present re- spike were being driven through " him. covery (Van Hook's case), as appears from the liter- Vomiting of a little gruel-like fluid occurred during ature at command, is the nineteenth case and fourth recovery. If we include only closely diagnosticated I at once gave one-fourth of a grain of morphine cases, it is the twelfth case and first recovery."

hypodermically, and ordered the same dose pr. n. by In 1894, Cayley' and H. Allingham ? each reported

2

the mouth. To have only small bits of ice to quench a fatal case after early operation, stitching the gut to thirst. Hot things to be applied to body till reaction the abdominal wound.

occurred. In The Lancet, 1894, vol. i., p. 1615, is recorded a 12 M.-Has had one dose of morphine since visit, i British Medical Journal, 1894, vol. i., p. 578.

my visit.

1

i Chicago Medical Recorder, 1893, vol. v., p. 409.
· Clinical and Therapeutical Journal, vol. ii., p. 735. Paris, 1894-

2 Ibid.

nd re

to refourth rapid

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atient Ppera.

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and feels much easier. No more vomiting. Extrem- piration, 33. A hypodermic injection of 1 grain mor-
ities are still somewhat cold. Abdomen much dis- phine given.
tended, tense, rather hard, and tympanitic. Liver dul- II P.M.-Had three or four doses of morphine since
ness entirely obscured.

morning. Raises wind occasionally. Pulse, 138; tem-
More comfortable. Extremities warmer. perature, 101.6° F.
Pulse, 88 ; temperature, 99° F.

February 6th, 9 A.M.— Three doses of morphine in January 6th, 10 A.M.-Had another one-fourth grain night. Pulse, 140; temperature, 101.5° F. of morphine last evening, and rested fairly well. Pulse, II P.M.-Menstruation began this afternoon, two 92 ; temperature, 99.6° F. Abdomen still much dis- weeks before time. Has had more than a grain of tended and tympanitic, but not quite so tense and morphine to-day. Tympanites is getting more marked. hard.

Gas passes freely downward. Pulse, 140; temperature,
8 P.M.-Countenance better. Had one-fourth grain 102° F.
morphine during day. Pulse, 96 ; temperature, 100° F. February 7th, 9 A.M.-Rested well. Three half-

January 8th, 10 A.M.-Takes two or three doses of grain morphine suppositories used in night. Says she
one-eighth grain morphine every twenty-four hours, feels better. Pulse, 130 ; temperature, 101° F.
which keeps him comfortable. Abdomen still suffi- February 8th, 9 A.M.--Had five suppositories of mor-
ciently tympanitic to obscure liver dulness, but less phine since yesterday morning. Rather restless night.
tense.

Pulse, 140 ; temperature, 102° F. Epigastrium very
Has had a nutrient enema or two, but does not re- prominent and tympanitic. A hypodermic needle
tain them. May have two drachms of milk and lime- thrust in and much foul gas escaped with relief.
water every
half-hour.

7 P.M.-A pretty comfortable day. No opiate. January 10th.—Abdomen now quite soft, but still Pulse, 124; temperature, 101.6° F. ; respiration, 26. tympanitic. Pulse, 80 ; temperature, normal. May .

February 9th, 9 A.M.-Had restless night, some dehave half an ounce of milk and lime-water every half- lirium. Took one-half grain of morphine by mouth. hour.

Complains of pain in top of left shoulder. Feels January 15th.-Doing well, abdomen quite flat, com- hungry. Pulse, 138 ; temperature, 102.2° F. May have plains a little of fatulence after milk. Relieved by a teaspoonful of milk and lime-water every half-hour. maltopepsin.

Epigastrium again punctured with good effect. January 23d.—Going about the house, but has more Patient grew worse during the day, the pulse runor less dyspepsia.

ning up to 144. At 8.30 P.M. I made a small opening in In 1886 I saw him at his old employment, still prominent epigastrium and let out about two quarts of complaining of his stomach.

sour greenish fluid from the peritoneal cavity. DrainIn 1889 the patient died with symptoms of perfora- age-tube inserted. Dr. J. H. Burns gave chloroform tion after a day or two's illness. I did not see him, as and rendered other assistance. I had removed to Toronto.

February 10th.—Patient sank during the night, with CASE II. February 4, 1892, 12.15 A.M.-M. H-, constant delirium, and died at 6.30 A.M., being the aged twenty-two, female. General servant, always seventh day of illness. No autopsy. healthy till three years ago, when she had an attack of CASE III. September 18, 1894.-I. D-, aged severe dyspepsia, which kept her in bed for three twenty. Female servant. Usually well, with the exmonths. Became very pale and thin at this time. ception of dyspeptic symptoms on and off during the Has suffered every year since, for a few weeks, with last three or four years. Never laid up by them. pain after eating and sometimes with vomiting ; never never eat meat without suffering.

Has frequently raised blood.

vomited after meals. During the past month, and esA week ago had quite a severe attack one day of pecially for a week back, has been troubled very much pain in left epigastrium, accompanied with eructations with her stomach, although not enough to prevent her of wind.

performing the customary duties of a general servant. The present illness began just as she was retiring At her dinner, at 2 P.M., and at 6.45 P.M., was sudto rest after her usual household duties, with an ago

denly seized with very severe pains in left epigastrium nizing pain in epigastrium and left hypochondriac and left hypochondriac region. This was accompanregion, and was accompanied with vomiting of her ied with pain in the top of left shoulder ; and she vomevening meal, which consisted of hard-boiled eggs and ited about a pint of thin sour fluid. bread with raisins in it.

I saw her within an hour, and found her moaning When I visited her, about an hour after the seizure, with pain ; extremities somewhat cold and clammy ; she was suffering acutely with pain in upper abdomen left upper abdomen somewhat hard, tender, and and on left side, running through to back. Extremi- slightly increased in resonance, without noticeable disties were cold ; abdomen hard and tender, especially tention; and with decubitus on back, knees being in left upper part, but not much distention nor tym- straight. Pulse, 88, of fair strength; temperature, 99.4 panites; breathing thoracic; pulse, 90 ; temperature F. ; respiration, 28. 98° F.

After two hypodermics of one-fourth of a grain of After two hypodermics of i grain morphine each, morphine I left her fairly comfortable. To have only she became easy. Ordered 1 grain morphine p.r.n.,

drachm doses of cold water, and 74 grain morphine and a teaspoonful of cold water occasionally to relieve P.r. n. To keep perfectly quiet, and use bed-pan if thirst

necessary. 9.30 A.M.-Slept fairly well without further opiate. At 10 P.M. she was quite easy, two doses of morphine The attendant, contrary to instructions, gave a few tea- having been taken by the mouth.

No more vomiting. spoonfuls of milk a short time ago, which caused some Pulse, 116 ; temperature, 100°F. ; respiration, 30. pain ; } grain morphine given hypodermically. To September 19th, 7 A.M.-Had a quiet night, sleeping adhere strictly to the drachm doses of water. A bed- at intervals, no further opiate required. Breathing pan to be used for urine.

continues to be thoracic. No further distention. Left 8.30 P.M.-Had one dose of morphine two hours ago upper abdomen still tender on motion or pressure. for pain. Dozing. Abdomen rather less tender and Pulse, 92 ; temperature, 100.2° F. ; respiration, 28. hard. Pulse, 122 ; temperature, 100° F.; respiration, Considering an operation advisable I had her re35.

moved in an ambulance to St. John's Hospital at 8 A.M. February 5th, 9 A.M.-One-fourth grain morphine 10 A.M. Operation.-Chloroform by Dr. G. B. Smith, at midnight. After that rested well. Abdomen more assisted by Dr. J. H. Burns. The usual antiseptic distended and tympanitic than yesterday, but less ten- precautions having been taken, I made an incision from der and softer. Pulse, 132 ; temperature, 100° F.; res

four to five inches long in the middle line of the epi.

Can

!

gastrium. On getting into the peritoneal cavity, a few case reported was an instance of recovery from perfora-
ounces of turbid serous fluid escaped, and the some- tion by a gastric ulcer. Unfortunately, however, it is
what distended stomach presented. This I carefully more than probable that the same ulcer or another one
drew up into the wound. While doing so, I felt some brought about a fatal issue by a subsequent perfora-
adhesions giving away in the direction of the pylorus, tion.
and then that part came into view. Its peritoneal cov- In the second case we have the patient living till the
ering was red and much thickened, having several seventh day after this occurrence. My experience in
shreds of the same character hanging from it and partly the first case led me to hope for a possible recovery in
surrounding an opening of the size of a quill in the the following one, especially as the symptoms.of shock,
stomach-wall. The perforation was situated near the distention, etc., were not nearly as marked as in the
gastro-hepatic omentum and not far from the pylorus. patient who recovered. After losing this patient I
A probe passed readily into it, and a drop or two of determined that I never would trust to the powers of
fluid escaped.

nature in a similar case again, but do an early laparot-
I now introduced two sutures of fine silk with a com- omy and suture the opening in the stomach.
mon sewing-needle close to the margin of the opening, As it was after dark when I first visited the third
and tied them, thus snugly closing it. Outside of these case, I thought it advisable to wait till morning before
I placed five or six Lembert sutures of the same ma- operating. When morning came, and I found the pa-
terial. Several times the thread cut through the soft tient had passed such a comfortable night and was
thickened peritoneal coat, but finally I succeeded in then feeling and looking so well, with little or no
getting a sufficient number to hold, my assistant keep- abdominal distention, I had half a mind to postpone
ing the folds of the indurated coats of the stomach-wall surgical interference. But the remembrance of my
close together until all the sutures were tied.

preceding case, with her apparent improvement after I then gently cleaned the surface of the stomach with morphine and rest, warned me that too much reliance a soft sponge, and closed the abdominal wound with could not be placed upon any such temporary lull in silkworm gut sutures. No washing out of either the the symptoms, and I therefore had her at once restomach nor peritoneal cavity, and no drainage. Iodo- moved to hospital for operation. form gauze dressing.

As there was so little of the stomach-contents or of During the operation the patient vomited about a inflammatory material in the abdominal cavity, I did pint of greenish fluid.

not deem it necessary to wash it out. Neither did I 5 P.M.- Vomited once since operation. This caused attempt to clear out the stomach itself, because it considerable pain. Two hypodermics of $ grain mor- would have been impossible to have done so via the phine have been given. Has had an enema of beef-tea perforation without the escape of some of its fluid into and brandy. Temperature rose to 102.4° F.at 2.30 P.M. the peritoneum, and I did not think it of sufficient imIs now 101.8° F.; pulse, 104. Gets a teaspoonful of portance to demand the use of the esophageal tube cold water occasionally.

for that purpose.

Possibly, by emptying this viscus, September 20th, 10.30 A.M.--Had a third dose of less strain would be put upon the sutures in its wall, $ grain morphine at midnight. Has vomited several but in the present instance they must have borne that times, and then complained of considerable pain in strain well, although the patient vomited a number of neighborhood of wound. Slept three or four hours times after the operation. during night; nutritious enemata are given every six In view of the fact that a very small per cent. of hours and are retained. Pulse, 82 ; temperature, 99° F. cases of gastric perforation from ulcer recover, and

September 21st, II No further opiate re- some of these after long and continued suppuration quired. No vomiting since yesterday afternoon. Had and discharge, we think that most medical men will four hours sleep during night. Pulse, 88; temperature, agree that when the diagnosis is reasonably certain, a 98.8° F.

laparotomy should be done, and that with the least September 22d, 10.30 A.M.-Slept four or five hours. possible delay. As far as I have been able to glean Pulse, 88; temperature, 99.2° F. Rectum was washed from the reported cases, none has made a good recovout with warm water last evening. Bowels moved well. ery when twenty-four hours or more have elapsed beAs nausea had ceased, may have 3j. of cold water tween the onset of the symptoms and the operation of every half-hour.

gastrorrhaphy. September 23d.-Doing well. Pulse, 76 ; tempera- In conclusion, let me draw attention to the pain ture, 99° F.; to have two drachms of milk and lime- that was complained of in the top of the shoulder in water every half-hour.

two of the cases reported. Mr. Gilford reports, in the September 24th.-Menses appeared last evening. London Lancet of June 2d, another in which pain, in They were due about the time perforation occurred. the top of both shoulders, was a prominent symptom. Pulse, 76 ; temperature, 98.6° F.

Pain in this locality is not, however, necessarily diSeptember 25th.-Doing well. Has a little flatu

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agnostic of gastric perforation only, for I recently operlence at times. Pulse, 76 ; temperature, normal. Or- ated on a ruptured tubal pregnancy, where there was dered five grains bismuth subnitrate four times a day. acute pain in both shoulders the day before operation.

September 28th.-Patient takes a considerable quantity of milk and junket now. Pulse and temperature as before. Omit nutritive enemata, which had been Transplantation of the Human Cornea.- At a recent given only twice a day of late. Sutures all removed meeting of the Vienna Society of Physicians, Professor yesterday. Transferred to the general ward to-day. Fuchs exhibited a case of transplantation of the human October ist. Patient takes about thirty ounces of

It is well known that Professor Hippel has milk and a pint or more of junket every day. Has no succeeded in transplanting pieces of the cornea in four dyspeptic symptoms whatever. Bowels are moved

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cases ; but the pieces of cornea that he transplanted every other day by enema.

were small, while Professor Fuchs used flaps of from October 8th.-Doing well. Has a quart of milk, a four to five millimetres in diameter. Large pieces of pint of junket, a few soda biscuits, and the white of the cornea, when transplanted, do not become opaque one or two eggs per day. May get out on couch. so soon as small ones. The pieces for transplantation

October 17th.-Has been going about the ward for used by Professor Fuchs in this case were taken from a several days, and left for home by train to-day. To human eye. Four weeks had elapsed at the time of continue present diet, chiefly, for several months. Has exhibition since the operation had been performed, not felt any discomfort at all from food for two or three and the piece implanted was perfectly transparent, weeks.

while in previous cases the opacity had commenced Remarks. I think no one can doubt that the first after the tenth day.

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A.M.

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cornea.

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