RACHFORD, Dr. B. K., Cincinnati, O. MCILHENNY, Dr. R. A., Conway RAY, Dr. C. A., Winifrede, W. Va. Springs, Kan. MCINTOSH, Dr. PERRY A., Thomas ville, Ga. MCKINNON, Dr. JOHN A., Selma, Ala. MACLEISH, Dr. A. L., Los Angeles, MAILLY, Dr. HAMILTON, Bridgeton, MAINE, Dr. FRANK E., Auburn, N. Y. METCALFE, Dr. ORRICK, New York. MICHAELIS, Dr. L. M., New York. RECTOR, Dr. JOSEPH M., Jersey City, RICHARDSON, Dr. JOHN B., Louis- RING, Dr. FRANK W., New York. ROBERTS, Dr. E. G., Fair Haven, Vt. ROSE, Dr. ACHILLES, New York. RUPP, Dr. ADOLPH, New York. SABETTI, Mr. A., Woodstock, Md. SCHAPPS, Dr. JOHN C., Brooklyn, MORRISSEY, Dr. JOHN J., Hartford, SENN, Dr. N., Chicago, Ill. VALK, Dr. FRANCIS, New York. Tex. VINEBERG, Dr. HIRAM N., New York. WAECHTER, Dr. C., New York. WATERS, Dr. W. E., U. S. Army. WAUGELIN, Dr. HUGO E., Belleville, WEBER, Dr. W. C., Cleveland, O. WELLS, Dr. H. M., U. S. Navy. F., Brooklyn, N. Y. WHITFIELD, Dr. G. W. WHITNEY, Dr. H. B., Denver, Col. WILCOX, Dr. REYNOLD W., New WILLIAMS, Dr. HERBERT UPHAM, WISE, Dr. JOHN C., U. S. Army. WRIGHT, Dr. JONATHAN, Brooklyn, SKEEL, Dr. FRANK D., New York. SOUTHARD, Dr. W. F., San Francis- SPRATLING, Dr. EDGAR J., Fishkill Landing, N. Y. STEWART, Dr. WILLIAM W., Colum- ST. JOHN, Dr. D., Hacken ack, N. J. STOKES, Dr. CHARLES F., U. S. N. PARKER, Dr. W. THORNTON, Grove. STOWELL, Dr. WILLIAM L., New land, Mass. York. PARSONS, Dr. RALPH WAIT, Sing STUBBERT, Dr. J. EDWARD, Nica- PEASE, Dr. CHARLES G., New York. Canada. PIERCY, Dr. A. T., Placerville, Cal. POWERS, Dr. CHARLES A., Denver, ragua, Central America. THOMAS, Dr. ALLEN M., New York. TINGLEY, Dr. WITTER K., Norwich, TOMPKINS, Dr. J. EDWARD, Freder- TUCKER, Dr. WILLIS G., Albany, N. Y. Societies from which Reports have been received. AMERICAN GYNECOLOgical Society. CIANS. MEDICAL AND CHIRURGICAL FACUL- NEW YORK ACADEMY OF Medicine. NEW YORK PATHOLOGICAL SOCIETY. PRACTITIONERS' SOCIETY OF NEW Vol. 47, No. I. Whole No. 1261. A Weekly Journal of Medicine and Surgery NEW YORK, JANUARY 5, 1895. Original Articles. PERFORATING TYPHOID ULCER-PERITONITIS-OPERATION-RECOVERY. BY ROBERT ABBE, M.D., NEW YORK. LATE on Saturday afternoon, November 3d, I was asked by Dr. J. H. Bache, of this city, to see with him a young married woman, twenty-one years of age, whom he had been attending with typhoid fever for three weeks. Every characteristic symptom had been present rather free diarrhoea, evening temperature ranging about 102° F., and delirium every night during the second week. On Monday, October 29th, the patient seemed to be beginning convalescence, all the symptoms abating. Wednesday night she was seized with great pain, as if something had suddenly given way in her abdomen below her navel. She vomited, and was much collapsed. Her temperature rose promptly to 102° F., with great pain and tympanites. Dr. Bache at once suspected perforation, kept the patient absolutely quiet, and treated her by poultices over the abdomen, and enough morphine to allay her great pain. The temperature fell somewhat, but for two days varied from 102° to 1021⁄2° F. Her vomiting was less, but her tympanites continued. At the end of the second day her condition became suddenly worse; the pulse became weaker; the abdomen greatly distended, with skin stretched and shining. As she had survived two and a half days, Dr. Bache thought, despite her low state, surgery might help her. On examination I found her with mind clear, but heart and respiration oppressed by her distended state; tongue dry and moderately coated; pulse, 140; temperature, 104° F. The distended abdomen was dull in the hypogastrium half-way to the navel, and the dulness extended along the right Poupart ligament. I confirmed the diagnosis and advised the earliest possible operation. The patient was in too low a state to be removed to a hospital, so the most complete arrangements possible were made to do a thorough operation at the house. In this I was assisted by Drs. A. L. Fisk and Nelson H. Henry, of Trinity Hospital. A median incision below the navel exposed distended coils of deeply congested and greatly inflamed intestine, smeared with sticky lymph. The pelvis and lower abdomen were filled with a collection of foul, purulent, and fetid intestinal extravasation. This was feebly confined by matted coils of intestines, loosely glued together, that broke apart on being touched, but which, being recognized, enabled me to introduce clean laparotomy sponges under the upper abdominal wall, where a few coils were seen which showed more recent inflammation. Two pints of foul, purulent fluid and thick lymph were cleaned out, and the abdomen irrigated with warm and weak sublimate solution, I to 20,000, followed by plain warm-water irrigation. Search now revealed the cause. The lower part of the ileum showed many thick oval patches in its walltheir long axes parallel to that of the gut, and easily identified by touch as the gut was passed through the fingers, and shown also by increased subperitoneal hy $5.00 Per Annum. Single Copies, 10c. peræmia. One such inflamed Peyer's patch showed a 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, over which two layers of Halsted mattress stitches were placed, these being found to be the only suture that 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 made to close the wound. A hot black coffee and whiskey enema assisted greatly in preventing shock; the patient was put back to bed in three-quarters of an hour from the beginning of etherization. She passed a good night and had a stronger pulse next morning. Pulse, 132; temperature, 1022° F.; tympanites less. At the end of forty-eight hours after operation, as she was in good condition, except for tympanites, I removed the tamponade, reapplied a loose one, and gave five grains of calomel. This produced numerous loose movements and she felt much better. Temperature, 1011⁄2° F.; pulse, 120. A little fluid fæces leaked from the wound after the calomel action, showing that the perforation had slightly opened. This continued for two weeks, when it ceased, and the abdominal wound pursued the usual course, closing in rapidly by granulations, and has left a narrow and firm scar. After the third day her appetite improved and a rapid convalescence ensued. Remarks.-The recording of this one case is not an occasion for a long paper on the subject, which would be superfluous in view of the three excellent ones by Mears, Fitz, and Van Hook, written in 1888 and 1891. But it is an opportunity to express a surgical view of the subject more mature than would have been possible a few years since. For, while but few cases of this emergency have as yet been operated on, corresponding conditions of perforating gastric, duodenal, and appendical ulcers have been relatively common in the hands of the general surgeon. Excepting for the exhausted condition of the patient during typhoid fever, there is practically no difference, as far as I can discern, between the conduct of perforations in various parts of the alimentary tract. The same sudden onset of symptoms is witnessed, acute tearing pain, shock, vomiting followed by tympany and peritonitis. The same sequel pertains as to the peritoneal exudation. In one case, shock or non-reparative inflammation will succeed and be fatal before operation, or in spite of operation; in another, a fine quality of plastic lymph will repair the damaged part, or hold the extravasation in check until the surgeon can operate. No doubts exist in my own mind that recovery without operation can follow perforation anywhere-and in typhoid also. But this is certainly infinitely rarer here than in other diseases, because the parts are centrally located where the explosion occurs and a natural outlet through the abdominal wall does not easily take place. The case narrated later, where a typhoid ulcer perforated and a resulting abscess was opened in the perineum, is consistent with much of nature's good work. 1 J. Ewing Mears: Transactions of the American Surgical Associ ation, 1888. 2 Fitz: Transactions of the Association of American Physicians, 1891, vol. vi., p. 200. 3 Philadelphia Medical News, 1891, vol. ix., p. 591. Chicago Medical Record, 1891, vol. ii., pp. 229–270. Fitz says: "The similarity of the symptoms of typhoid perforations of the bowel and those of the appendix, is striking. Cases of perforating appendix have repeatedly been regarded as typhoid fever, and, as a rule, the symptoms of typhoid which suggest perforation of the bowels are those which in the absence of typhoid would be regarded as diagnostic of appendicitis. The symptoms are not merely similar, they are actually identical. Even to the usual localization of the consequent peritonitis to the right iliac fossa." This lucid statement by Fitz must appeal to every observer of appendicitis cases, as true to the letter. Why one class of cases should be left to die, while we operate on all appendicitis cases when perforation can be recognized, does not appear. The typhoid statistics are improving, and as it was in the other, we may here also soon record as much gain in the near future. Van Hook operated on a desperate case at two o'clock in the afternoon, where perforation had taken place at 5 A.M. The extravasation was wide of the ulcer. The patient was washed out with plain boiled water, sewed up tight, rescued from collapse, and saved. Now, we have not yet learned enough about the surgical procedure to do exactly right in all cases, and it gives me some satisfaction to state in a few words what I regard of growing importance in the work. The technical points are known to every surgeon, but very essential do I consider it, that the surgeon should never be so hasty in getting at his work that he enters upon it handicapped by poor assistance, poor light, poor arrangements for irrigation and sponging, or inadequate plans for restoration from shock. I regard the rescue of these cases from collapse as most important. I always give a restorative enema at 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 and digitalis, abundant heat about the body, and elevation of the foot of the bed for twelve hours. Very warm saline infusion into the vein, of at least one pint, must always be tried as a valuable resort. To quote from Dr. Van Hook's article, the statistics up to October, 1891, of operation for typhoid perfora Making in all, nineteen laparotomies and four recoveries. "Mikulicz's case was said by the author to be of doubtful origin. That of Escher was probably a perforative appendicitis. Taylor's case should not be counted, as it was operated on ten days after onset of symptoms, and is not demonstrated to have been typhoid perforation. "If we include all the doubtful cases, the present recovery (Van Hook's case), as appears from the literature at command, is the nineteenth case and fourth recovery. If we include only closely diagnosticated cases, it is the twelfth case and first recovery." In 1894, Cayley1 and H. Allingham each reported a fatal case after early operation, stitching the gut to the abdominal wound. In The Lancet, 1894, vol. i., p. 1615, is recorded a 1 British Medical Journal, 1894, vol. i., case of supposed perforation with collapse and recovery, in a female, which I am strongly inclined to regard as one of high intestinal hemorrhage in the fourth week, indicated by a drop in temperature to 95°, rapid thready pulse, cold extremities and extreme pallor, and fulness of the umbilical region and tenderness in the right hypochondrium. No pain existed and the patient made a slow recovery with a very thin pulse. No operation was performed. In August, 1893, Dr. Newton, of Chicago,1 treated a case of supposed perforation by morphine; as the parents objected to the operation. The case seems undoubted, and the boy recovered, an abscess of the pelvis being opened a fortnight later in the perineum. Netschagaw, of St. Petersburg, records a case this year of resection of a portion of perforated bowel in typhoid, with recovery. Since Van Hook's successful case in 1891, there have been reported the following operations : 1894. Cayley and Bland Sutton, one case, fatal. 1894. Netschagaw, Medical News, December 1, 1894, p. 609, one case, recovery. 1894. Abbe, one case, recovery. If we accept all the nineteen laparotomies for so called typhoid perforations with four recoveries, collected by Van Hook, and add the five new ones, we have 24 cases and 6 recoveries. If we throw out doubtful cases-which I agree with Van Hook should be done-and accept only 12 of the 19 with 1 recovery-to which the above five are added -then the correct statistics revised up to date, stand, 17 cases with 3 recoveries. CASES OF PERFORATION OF THE STOM- BY A. V. ATHERTON, M.D., SURGEON TO ST. JOHN'S HOSPITAL, TORONTO, CANADA. CASE I. One morning, after his usual night-watch, he was suddenly seized with a most excruciating pain in the epigastrium, causing him to drop on the floor where he stood. He also vomited, and great drops of sweat came out on his face. He was carried in the arms of his fellow-workmen to his home, which was close by. I visited him about two hours afterward, and found him lying on his back with knees drawn up, complaining bitterly of pain in upper abdomen, increased by long breath or movement of body; countenance anxious; extremities and nose cold and clammy, and a feeble pulse of 60. He reported having eaten only a light lunch in the night, nothing since. He described the pain with which he was seized as feeling "just as if a spike were being driven through" him. Vomiting of a little gruel-like fluid occurred during my visit. I at once gave one-fourth of a grain of morphine hypodermically, and ordered the same dose p. r. n. by the mouth. To have only small bits of ice to quench thirst. Hot things to be applied to body till reaction. occurred. 12 M. Has had one dose of morphine since visit, 1 Chicago Medical Recorder, 1893, vol. v., p. 409. 2 Clinical and Therapeutical Journal, vol. ii., p. 735. Paris, 1894. and feels much easier. No more vomiting. Extremities are still somewhat cold. Abdomen much distended, tense, rather hard, and tympanitic. Liver dulness entirely obscured. 3 P.M. More comfortable. Extremities warmer. Pulse, 88; temperature, 99° F. January 6th, 10 A.M.-Had another one-fourth grain of morphine last evening, and rested fairly well. Pulse, 92; temperature, 99.6° F. Abdomen still much distended and tympanitic, but not quite so tense and hard. 8 P.M.-Countenance better. Had one-fourth grain morphine during day. Pulse, 96; temperature, 100° F. January 8th, 10 A.M.-Takes two or three doses of one-eighth grain morphine every twenty-four hours, which keeps him comfortable. Abdomen still sufficiently tympanitic to obscure liver dulness, but less tense. Has had a nutrient enema or two, but does not retain them. May have two drachms of milk and limewater every half-hour. January 10th. Abdomen now quite soft, but still tympanitic. Pulse, 80; temperature, normal. May have half an ounce of milk and lime-water every halfhour. January 15th.-Doing well, abdomen quite flat, complains a little of flatulence after milk. Relieved by maltopepsin. January 23d.-Going about the house, but has more or less dyspepsia. In 1886 I saw him at his old employment, still complaining of his stomach. In 1889 the patient died with tion after a day or two's illness. I had removed to Toronto. symptoms of perforaI did not see him, as CASE II. February 4, 1892, 12.15 A.M.-M. H—, aged twenty-two, female. General servant, always healthy till three years ago, when she had an attack of severe dyspepsia, which kept her in bed for three months. Became very pale and thin at this time. Has suffered every year since, for a few weeks, with pain after eating and sometimes with vomiting; never raised blood. A week ago had quite a severe attack one day of pain in left epigastrium, accompanied with eructations of wind. The present illness began just as she was retiring to rest after her usual household duties, with an agonizing pain in epigastrium and left hypochondriac region, and was accompanied with vomiting of her evening meal, which consisted of hard-boiled eggs and bread with raisins in it. When I visited her, about an hour after the seizure, she was suffering acutely with pain in upper abdomen and on left side, running through to back. Extremities were cold; abdomen hard and tender, especially in left upper part, but not much distention nor tympanites; breathing thoracic; pulse, 90; temperature 98° F. After two hypodermics of grain morphine each, she became easy. Ordered grain morphine p.r.n., and a teaspoonful of cold water occasionally to relieve thirst 9.30 A.M.-Slept fairly well without further opiate. The attendant, contrary to instructions, gave a few teaspoonfuls of milk a short time ago, which caused some pain; grain morphine given hypodermically. Το adhere strictly to the drachm doses of water. A bedpan to be used for urine. 8.30 P.M.-Had one dose of morphine two hours ago for pain. Dozing. Abdomen rather less tender and hard. Pulse, 122; temperature, 100° F.; respiration, 35. February 5th, 9 A.M.-One-fourth grain morphine at midnight. After that rested well. Abdomen more distended and tympanitic than yesterday, but less tender and softer. Pulse, 132; temperature, 100° F.; res piration, 33. A hypodermic injection of grain morphine given. II P.M.-Had three or four doses of morphine since morning. Raises wind occasionally. Pulse, 138; temperature, 101.6° F. February 6th, 9 A.M.-Three doses of morphine in night. Pulse, 140; temperature, 101.5° F. II P.M.-Menstruation began this afternoon, two weeks before time. Has had more than a grain of morphine to-day. Tympanites is getting more marked. Gas passes freely downward. Pulse, 140; temperature, 102° F. February 7th, 9 A.M.-Rested well. Three halfgrain morphine suppositories used in night. Says she feels better. Pulse, 130; temperature, 101° F. February 8th, 9 A.M.-Had five suppositories of morphine since yesterday morning. Rather restless night. Pulse, 140; temperature, 102° F. Epigastrium very prominent and tympanitic. A hypodermic needle thrust in and much foul gas escaped with relief. 7 P.M.-A pretty comfortable day. No opiate. Pulse, 124; temperature, 101.6° F.; respiration, 26. February 9th, 9 A.M.-Had restless night, some delirium. Took one-half grain of morphine by mouth. Complains of pain in top of left shoulder. Feels hungry. Pulse, 138; temperature, 102.2° F. May have a teaspoonful of milk and lime-water every half-hour. Epigastrium again punctured with good effect. Patient grew worse during the day, the pulse running up to 144. At 8.30 P.M. I made a small opening in prominent epigastrium and let out about two quarts of sour greenish fluid from the peritoneal cavity. Drainage-tube inserted. Dr. J. H. Burns gave chloroform and rendered other assistance. February 10th.-Patient sank during the night, with constant delirium, and died at 6.30 A.M., being the seventh day of illness. No autopsy. aged CASE III. September 18, 1894.-I. D twenty. Female servant. Usually well, with the exception of dyspeptic symptoms on and off during the last three or four years. Never laid up by them. Can never eat meat without suffering. Has frequently vomited after meals. During the past month, and especially for a week back, has been troubled very much with her stomach, although not enough to prevent her performing the customary duties of a general servant. At her dinner, at 2 P.M., and at 6.45 P.M., was suddenly seized with very severe pains in left epigastrium and left hypochondriac region. This was accompanied with pain in the top of left shoulder; and she vomited about a pint of thin sour fluid. I saw her within an hour, and found her moaning with pain; extremities somewhat cold and clammy; left upper abdomen somewhat hard, tender, and slightly increased in resonance, without noticeable distention; and with decubitus on back, knees being straight. Pulse, 88, of fair strength; temperature, 99.4 F.; respiration, 28. After two hypodermics of one-fourth of a grain of morphine I left her fairly comfortable. To have only drachm doses of cold water, and 4 grain morphine p. r. n. To keep perfectly quiet, and use bed-pan if necessary. At 10 P.M. she was quite easy, two doses of morphine having been taken by the mouth. No more vomiting. Pulse, 116; temperature, 100° F.; respiration, 30. September 19th, 7 A.M.-Had a quiet night, sleeping at intervals, no further opiate required. Breathing continues to be thoracic. No further distention. Left upper abdomen still tender on motion or pressure. Pulse, 92; temperature, 100.2° F.; respiration, 28. Considering an operation advisable I had her removed in an ambulance to St. John's Hospital at 8 A.M. IO A.M. Operation.-Chloroform by Dr. G. B. Smith, assisted by Dr. J. H. Burns. The usual antiseptic precautions having been taken, I made an incision from four to five inches long in the middle line of the epi gastrium. On getting into the peritoneal cavity, a few ounces of turbid serous fluid escaped, and the somewhat distended stomach presented. This I carefully drew up into the wound. While doing so, I felt some adhesions giving away in the direction of the pylorus, and then that part came into view. Its peritoneal covering was red and much thickened, having several shreds of the same character hanging from it and partly surrounding an opening of the size of a quill in the stomach-wall. The perforation was situated near the gastro-hepatic omentum and not far from the pylorus. A probe passed readily into it, and a drop or two of fluid escaped. I now introduced two sutures of fine silk with a common sewing-needle close to the margin of the opening, and tied them, thus snugly closing it. Outside of these I placed five or six Lembert sutures of the same material. Several times the thread cut through the soft thickened peritoneal coat, but finally I succeeded in getting a sufficient number to hold, my assistant keeping the folds of the indurated coats of the stomach-wall close together until all the sutures were tied. I then gently cleaned the surface of the stomach with a soft sponge, and closed the abdominal wound with silkworm gut sutures. No washing out of either the stomach nor peritoneal cavity, and no drainage. Iodoform gauze dressing. During the operation the patient vomited about a pint of greenish fluid. 5 P.M. Vomited once since operation. This caused considerable pain. Two hypodermics of grain morphine have been given. Has had an enema of beef-tea and brandy. Temperature rose to 102.4° F. at 2.30 P.M. Is now 101.8° F.; pulse, 104. Gets a teaspoonful of cold water occasionally. September 20th, 10.30 A.M.-Had a third dose of grain morphine at midnight. Has vomited several Has vomited several times, and then complained of considerable pain in neighborhood of wound. Slept three or four hours during night; nutritious enemata are given every six hours and are retained. Pulse, 82; temperature, 99° F. September 21st, II A.M.- No further opiate required. No vomiting since yesterday afternoon. Had four hours sleep during night. Pulse, 88; temperature, 98.8° F. September 22d, 10.30 A.M.-Slept four or five hours. Pulse, 88; temperature, 99.2° F. Rectum was washed out with warm water last evening. Bowels moved well. As nausea had ceased, may have 3j. of cold water every half-hour. September 23d.-Doing well. Pulse, 76; temperature, 99° F.; to have two drachms of milk and limewater every half-hour. September 24th.-Menses appeared last evening. They were due about the time perforation occurred. Pulse, 76; temperature, 98.6° F. September 25th.-Doing well. Has a little flatuHas a little flatulence at times. Pulse, 76; temperature, normal. Ordered five grains bismuth subnitrate four times a day. September 28th.-Patient takes a considerable quantity of milk and junket now. Pulse and temperature as before. Omit nutritive enemata, which had been given only twice a day of late. Sutures all removed yesterday. Transferred to the general ward to-day. October 1st.-Patient takes about thirty ounces of milk and a pint or more of junket every day. Has no dyspeptic symptoms whatever. Bowels are moved every other day by enema. October 8th.-Doing well. Has a quart of milk, a pint of junket, a few soda biscuits, and the white of one or two eggs per day. May get out on couch. October 17th.-Has been going about the ward for several days, and left for home by train to-day. To continue present diet, chiefly, for several months. Has not felt any discomfort at all from food for two or three weeks. Remarks. I think no one can doubt that the first case reported was an instance of recovery from perforation by a gastric ulcer. Unfortunately, however, it is more than probable that the same ulcer or another one brought about a fatal issue by a subsequent perforation. In the second case we have the patient living till the seventh day after this occurrence. My experience in the first case led me to hope for a possible recovery in the following one, especially as the symptoms of shock, distention, etc., were not nearly as marked as in the patient who recovered. After losing this patient I determined that I never would trust to the powers of nature in a similar case again, but do an early laparotomy and suture the opening in the stomach. As it was after dark when I first visited the third case, I thought it advisable to wait till morning before operating. When morning came, and I found the patient had passed such a comfortable night and was then feeling and looking so well, with little or no abdominal distention, I had half a mind to postpone surgical interference. But the remembrance of my preceding case, with her apparent improvement after morphine and rest, warned me that too much reliance could not be placed upon any such temporary lull in the symptoms, and I therefore had her at once removed to hospital for operation. As there was so little of the stomach-contents or of inflammatory material in the abdominal cavity, I did not deem it necessary to wash it out. Neither did I attempt to clear out the stomach itself, because it would have been impossible to have done so via the perforation without the escape of some of its fluid into the peritoneum, and I did not think it of sufficient importance to demand the use of the œsophageal tube for that purpose. Possibly, by emptying this viscus, less strain would be put upon the sutures in its wall, but in the present instance they must have borne that strain well, although the patient vomited a number of times after the operation. In view of the fact that a very small per cent. of cases of gastric perforation from ulcer recover, and some of these after long and continued suppuration and discharge, we think that most medical men will agree that when the diagnosis is reasonably certain, a laparotomy should be done, and that with the least possible delay. As far as I have been able to glean from the reported cases, none has made a good recovery when twenty-four hours or more have elapsed between the onset of the symptoms and the operation of gastrorrhaphy. In conclusion, let me draw attention to the pain. that was complained of in the top of the shoulder in two of the cases reported. Mr. Gilford reports, in the London Lancet of June 2d, another in which pain, in the top of both shoulders, was a prominent symptom. Pain in this locality is not, however, necessarily diagnostic of gastric perforation only, for I recently operated on a ruptured tubal pregnancy, where there was acute pain in both shoulders the day before operation. Transplantation of the Human Cornea.-At a recent meeting of the Vienna Society of Physicians, Professor Fuchs exhibited a case of transplantation of the human cornea. It is well known that Professor Hippel has succeeded in transplanting pieces of the cornea in four cases; but the pieces of cornea that he transplanted were small, while Professor Fuchs used flaps of from four to five millimetres in diameter. Large pieces of the cornea, when transplanted, do not become opaque so soon as small ones. The pieces for transplantation used by Professor Fuchs in this case were taken from a human eye. Four weeks had elapsed at the time of exhibition since the operation had been performed, and the piece implanted was perfectly transparent, while in previous cases the opacity had commenced after the tenth day. |