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ligament. March 29th. At times complains of spasms of pain under right ribs. March 31st A small painful spot is seen and felt in the right hypochondrium, which is slightly swollen.
April 5th. Service of Dr. Arnold. Pain more marked, paroxysms occurring every six hours. Epigastrium and right hypochondrium very tender. Hepatic dullness not increased, as far as can be ascertained, owing to tenderness of part. No pain or tenderness in lower abdomen. Tumefaction in hypochondrium quite marked. April 6th. Intense pain, paroxysmal in character, at eight P. M. Tumefaction, with sense of fluctuation, centres over cartilages of eighth, ninth, and tenth ribs. Abdomen normal. April 8th. Abscess opened with bistoury; a free discharge of glairy pus without offensive odor. Probe passed inwards and downwards two and a half inches, backwards and outwards in direction of liver two and a quarter inches. At this time the walls of the abscess seemed to be continuous, and hence it was considered to be confined to the abdominal wall. Whenever the opening became more or less occluded, pain and swelling would increase, and the patient would show constitutional disturbances, which ceased when the pus was allowed again to escape. April 24th. Two other openings were made in the abscess. May 9th. A month after the first incision, when the abscess was probed, there was a slight serous discharge. This raised the question whether the cavity of the abscess did not somewhere reach the peritoneum. In probing the abscess at different times the probe entered downwards, dipping, as it seemed, below the ribs to the distance of four or five inches. The greatest extent of the abscess was always downwards from the site of first incision, never to any length upwards. May 31st. Discharge much less. Seton introduced superficially and horizontally in course of abscess about five inches. June 13th. Uterus now in normal position. On the left side is a hard, distinct mass commencing at upper fourth of cervix, very painful on pressure, and movable with uterus ; external os very patulous. June 25th. Catamenia commenced ten days ago and still continue, but diminished. No tenderness whatever throughout vagina; that spoken of on the 13th has entirely disappeared. Sound passes two and three quarters inches. Os patulous from right lateral laceration of cervix depending on last confinement, three years ago. Complains of pain in left iliac region. Abscess in hypochondrium and umbilical region still discharging. June 26th. Seton removed. On the 29th the sinus had healed, and she was discharged, well, on the 30th. Dr. E. O. Otis, house physician, to whom I am indebted for the above notes, saw patient some three weeks later. She was then in very good health. and had gained a great deal of flesh.
Dr. Curtis stated further that the peritoneal effusion did not extend up to where the opening took place. There were no hepatic symptoms. The fistulous opening in the rectum was detected by the finger. There was a question whether there existed a sinuous tract extending upwards from the pelvic abscess, so as to point in the high position in the hypochondrium. - DR. SINCLAIR recalled a case reported to the Boston Society for Medical Observation by Dr. Ellis, many years ago, in which an abscess formed in the lumbar region posteriorly, and the question arose whether it had any direct connection with an abscess in the pelvis. On post-mortem examination a fistulous tract was clearly traced from one to the other. Proof of similar communication in Dr. Curtis's case could be obtained only by following the sinus. · Dr. HOSMER, touching this question, gave the outline of a case which came under his observation ten years ago. The patient was ill conditioned, and the result was pelvic cellulitis appearing soon after labor. There was tumor in the right inguinal region, which became the starting-point of a free and extensive suppuration As the case went on an opening was made two or three inches above the umbilicus to the right of the median line, and pus was discharged abundantly. The communication in this case was unmistakable; it was actually traced. Dr. Fifield remarked that in abscess of the ischio-rectal space, pelvi-rectal, above the levator ani, pus diffused there can and sometimes does pass forward underneath the pelvic fascia, and become located in the broad ligament.
Examination by the Rectum. — DR. FIFIELD stated that Daniel Molière, a writer on the rectum, has asserted that under favorable positions of the patient, and with the use of an anal speculum, one can see to the sigmoid flexure. Dr. Fifield did not himself think that, with a Sims vaginal speculum, which is the best also for the rectum, it was possible to get a good view of more than the first three or four inches of the bowel. – DR. CHADWICK said he had introduced his hand into the recta of five patients in the wards of the late Professor Simon, at Heidelberg. The practice was to wash out the rectum thoroughly with water ; at first, four fingers of the left hand were oiled and introduced into the rectum, distention of the sphincter ani being effected by steady pressure and constant rotation of the hand. Ten or fifteen minutes were occupied in the process. When the hand had finally passed the sphincter all the pelvic organs could be distinctly felt. None of the patients whom he had examined had incontinence for more than a day or two. So harmless did Professor Simon consider this act that he did not hesitate to improve the very first opportunity to instruct the speaker by demonstrating the procedure upon a man who chanced to be upon the table at the time, under the influence of chloroform, with a view to the reduction of a dislocated thumb. — DR. Ellis asked if it were considered right to introduced any hand into any rectum. DR. CHADWICK said that Professor Simon had fixed the limit to the size of a hand which could be introduced into the rectum with safety at twenty-five centimetres (ten inches) at its largest circumference. DR. SULLIVAN said that he had been frequently called upon to operate for hæmorrhoids, and that, following the plan of Professor Van Buren, of New York, it was his invariable practice to stretch the sphincter ani by forcible distention with the fingers as a preliminary to the operation. This process, far from resulting in harm to the patient, is a positive advantage both to the patient and to the operator.
DR. FIFIELD spoke of a method of extracting the kidneys post mortem by passing the hand up the rectum. After dilatation a knife is carried up to divide the bowel, and the hand is then enabled easily to reach the abdominal cavity. — DR. Sullivan mentioned that he had seen Dr. Spiegelberg, of Breslau, introduce the whole hand into the rectum, in order to examine more thoroughly than he could per vaginam an abdominal tumor. No injury resulted.
THE PATHOLOGICAL SOCIETY OF PHILADELPHIA. Upon the title-page of this volume a change may be noticed which is indeed hardly unexpected, yet still somewhat unwelcome. It relates to the transfer of the editorship from Dr. Tyson, who has so long and ably held this office, to Dr. Simes. The task of collecting and preparing the material for an annual publication is one demanding much patience, persistence, and endurance. With these qualifications a large quantity of critical acumen should be combined, and the possession of this implies a wide and varied training. It is needless to remind the reader that the previous editor was everywhere recog.
1 Transactions of the Pathological Society of Philadelphia. Volume Seventh. Edited by J. HENRY C. Simes, M. D. Philadelphia : Printed for the Society by J. B. Lippincott & Co. 1878. Pp. 175.
nized as filling his part to more than the satisfaction of those concerned, and all must admit that he has earned a deserved rest, or rather the opportunity for undertaking such new work as may present a stronger claim for his energies.
The labors of the society during the year 1876–77, as represented in the Transactions, are hardly up to the standard held by it during the previous years. There are fewer comprehensive papers, reports of cases are less thoroughly and carefully prepared, and critical remarks, though sometimes prominent, are occasionally found lacking.
For instance, the cause of intestinal obstruction (?) in a case of peritonitis appears to be a last resort to explain the occurrence of the fatal disease. It is difficult to conceive that fat tissue surrounding the sigmoid flexure should produce serious constriction, and that an obstruction at a limited part of the colon, of two weeks' duration, should not be followed by a distention of the rest of this tube. The case seems rather one of peritonitis from unknown cause, accompanied by constipation. Another case of equally doubtful character is reported as one of death from embolism in diphtheria. Unfortunately there is no mention of an embolus. A white, hard, and large clot was found to extend from the right ventricle into the venæ cavæ, and “ throughout the whole venous system” (?). A similar clot, though smaller, was found in the left heart and its communicating vessels. To regard these clots as rapidly formed thrombi is wholly in harmonious with our knowledge of the appearance of such, their method of origin, and their effects.
In general, the necessity for criticism is not urgent when volumes of transactions of learned societies are considered. The task of the critic properly be gins when he has found in the contents matter which he desires to utilize for such purposes as the society may comprehend.
This volume, like its fellows, is offered to the profession as a collection from which various needs may be satisfied, and should not be passed by where the study of special forms of disease is being carried on. The new editor has seen fit to retain the form and arrangement adopted by his predecessor, and has accomplished his work satisfactorily.
R. H. F.
WILSON'S NAVAL HYGIENE.1 This second edition is an improvement on the first. The author, however, still adheres to his original plan, by which much questionable matter is interspersed with some valuable observations. Under Recruiting, strange to say, no mention is made of our admirable training system, whereby boys are made thorough, intelligent, and reliable seamen. The general consideration of Water is good, but the methods given for its examination are very unsatisfactory. The small part allotted to Ventilation simply embraces the author's own views, which are in many instances at variance with the more modern and effective systems now in use. Monitors are notoriously difficult to ventilate, especially
1 Naval Hygiene: Human Health and the Means of Preventing Disease. With Illustrative Incidents principally derived from Naval Experience. By JOSEPH Wilson, M. D., Medical Director, U. S. Navy. Second edition. With Colored Lithographs, etc. Philadelphia : Lindsay and Blakiston. 1879.
at sea, when the hatches are battened down, yet they are hardly given a passing notice. Nothing is said of the exact means for the estimation of carbon dioxide, or the important use of the psychrometer in determining positive humidity. The botanical compilation appears out of place. In the chapter on discipline and punishment, some good ideas have been collected, and are well worth reviewing. It is with pleasure that we see the author strongly recommends the use of the metric system in the navy. The work is designed to meet the requirements of the mercantile marine as well as the navy, but fails to do either.
LEBLOND'S ELEMENTARY GYNÆCOLOGY.1
We have been much interested in reading this volume, the subject matter of which the author divides broadly into three parts, namely, Exploration of the Genital Organs, Minor Surgery, and Operations. We naturally expect so large a book, devoted solely to these three subjects, to be exhaustive, and while it proves so in many of its subdivisions, we are in a measure disappointed, in its perusal, to find no mention made of some of the well-recognized and important operations which have now for a long time been performed in this country, and reference to which we have seen in foreign journals. Noticeable among these is Emmet's operation for laceration of the cervix uteri.
About one half the book is taken up with the description of different instruments used in gynæcology, the tarious methods of exploring the genital organs, and minor surgery, as it is termed, by which is meant the ordinary everyday treatment of the patient, such as the vaginal douche, uterine and vaginal dressings, depletion, adjustment of pessaries, etc.
The remaining half is devoted to operative gynæcology, as, for example, operations on the vulva and perinæum, the urethra and bladder, the vagina, the uterus, and ovaries. Here the author does not attempt to give all the different methods of operating on the parts, but only those which seem most simple and valuable.
In Chapter I. of this part of the book, Article X. on Perineorrhaphy is exceedingly good, and from the numerous illustrations and clear description we do not see how one can fail to understand every step of the operation. Where the tear has extended through the sphincter, the operations of both Emmet and Demarquay are fully described, and Bantock's method mentioned, preference being given to Emmet's, which we do not remember having seen anywhere else so fully illustrated and distinctly described.
Chapter V., also, is quite as good, and even more exhaustive. After giving the honor of first prescribing the rules for amputation of the cervix uteri to Lisfranc, the author proves, from the experience of many surgeons who have frequently done the operation, that it is but rarely accompanied or followed by dangerous symptoms. He considers carefully the anatomy of the parts, particularly the relation of the peritonæum to the uterus, vagina, bladder, etc., also the cellular attachment of the uterus to the adjoining viscera, and deduces
1 Traité élémentaire de Chirurgie gynécologique. Par LE DOCTEUR A. LEBLOND. Sro, pp. 659. Paris : H. Lanwereyns. 1878.
from this his reasons for advocating the operation in place rather than at or near the vulva, the principal reason being the great liability of opening the peritoneal cavity. The experiments on the cadaver, under direction of Gallard, for amputation of the cervix, when this lesion occurred with only very slight traction of the cervix to the vulva, show the importance of operating in situ.
We see no mention made of taking advantage of the knee-chest position, whereby the exact vaginal attachment to the cervix may be determined and marked prior to an operation. In many cases the advantages of traction during such amputation might thus be had without the danger of opening the peritoneal cavity. In this operation the author advises the use of the galvanocautery, particularly in cases of uterine cancer.
We have mentioned but few of the many subjects of which the book treats so fully and so well. It is furnished with nearly two hundred illustrations, which are exceedingly clear and good. We can heartily commend it to the profession, and only wish it might be translated and published in our own country, and its usefulness thereby extended to many who will now be debarred from reading it. We think American gynæcologists should feel highly complimented at the frequent references made in it to them and their methods of treatment and operation.
BARNES ON DISEASES OF WOMEN.1
The first edition of this work was extremely satisfactory, and showed small room for improvement; but with the careful revision and additions of the experienced writer and the increased number of illustrations, the second edition is even better than the first, and we gladly admit for it a degree of perfection inferior to none attained by any work in the special department of which it treats.
Chapter I., on the Anatomy of the Pelvic Organs, is particularly instructive. For definiteness of description it is unequaled in any work on general gynæcology with which we are acquainted. We would refer to the author's remarks upon Douglas's pouch, a part of great importance to the surgeon, and one to which Dr. Barnes seems to have given careful attention by observation, on the cadaver as well as clinically, the result of which shows that this pouch“ reaches its greatest depth quite on the left of the uterine neck and vagina; so that it lies not only behind these organs, but partly on the left upper fourth of the vagina," descending to this point obliquely from the right side.
We are pleased to find the new chapter on Diseases of the Bladder and Rectum and their relations to uterine disease, matters which have been much neglected in gynæcological works. The subjects of chief interest in the chapter are Retention of Urine, Cystitis, Irritable Bladder, Incontinence of Urine, Primary and Secondary Malignant Disease of the Bladder, and Retention of Fæces. We suppose that the limited space necessarily given to this subject led the author to pass over some points of interest in the local treatment of
1 A Clinical History of the Medical and Surgical Diseases of Women. By ROBERT BARNES, M. D., London. Second American from the second and revised London edition. 850, pp. 784. Philadelphia : Henry C. Lea. 1878.