Ether may be

champagne may be given if the pulse be failing. injected hypodermically in conditions of collapse. Small doses of morphia, given hypodermically, diminish the restlessness. The patient must be kept warm and wrapped up in blankets. In very severe cases I have seen excellent results from the injection into the rectum of a quart of a warm solution of common salt (one drachm to the pint). To assist the patient in retaining it, the rectum should be firmly plugged. If necessary, the injection may be repeated in three or four hours' time. It is quite as efficacious as intravenous injection, and not nearly so troublesome.

(To be continued.)




ON April 27th, 1893, I saw a case with Mr, Sainthill Pearse, upon which I subsequently operated with success, which since the publication of Mr. Barling's paper on Typhlitis and Appendicitis has seemed to me worthy of publication. The patient is an unmarried maidservant of 23 years of age, with a good family history, and no special previous ailments beyond anæmia and amenorrhoea for which she was treated two years ago. Since then she has had some pain at each menstrual period and sometimes has felt tired and short of breath. The last few menstrual flows were scanty. About the beginning of April she suffered from abdominal pain and general illness and had to lay up. The symptoms did not abate and severe gastric catarrh with quick pulse and a septic appearance followed. It was found that there was a firm mass dull on percussion spreading from the

right iliac fossa into the pelvis and reaching the middle line in front. Per rectum a fluctuating swelling behind the uterus could be felt. It was thought best to make a complete examination under anæsthesia. This was done on April 27th. A very free discharge of bloody fluid from the uterus was taking place. The vaginal introitus was narrow, admitting one finger; the hymen was present but of small extent. Cervix was firm and conical, the uterine sound passed to a normal distance. The uterus was anterior and to the left. The posterior and right lateral fornices bulged into the vagina and gave a fluctuating cystic impression to the finger. Bimanually no definite structure could be made out, as the parts felt by the external hand seemed hard, firm, and irregular, and suggested matting of omentum and bowels together. The right inguinal and hypogastric regions were seen to be prominent. The mass extended half-way to the umbilicus in the right lateral line and was dull on percussion. The pulse was 120 per minute, and the tongue glazed, cracked, and very bright red. The temperature was 99° F. There was practically no bladder trouble. There was some obstinacy of the bowels but easily overcome, and nothing had been noticed in the fæces.

Seeing that medical treatment had not improved the condition of the patient, and deciding that whatever might be the pathology of the case there could be no doubt but that septic mischief existed in the abdominal cavity, I determined to make an exploratory incision and do what was indicated afterwards. The incision was median, and the parietal peritoneum was inflamed and so adherent to omentum that I went through the omentum at one point thus exposing the abdominal portion of the peritoneal cavity to infection. Grumous foul-smelling pus welled out. There was great matting with adhesions, and these had to be separated before the pelvic floor was reached. The uterus was perhaps enlarged. The condition still was doubtful. There was free oozing from the right broad ligament and the tube was enlarged and swollen. I removed the right tube and ovary and as much broad ligament as I could draw into the

ligatures. This secured the bleeding points, which seemed to be due to tearing of adhesions and not to be the vascular internal surface of a cyst or pregnancy sac. The left tube and ovary were normal. The cavity was washed out with warm water and a drainage tube inserted to the bottom of the pouch of Douglas. The after history has been uneventful, the temperature not going above 100° F., and although there is still some slight discharge the patient is able to sit up and is taking a general diet with avidity. The abdomen is flat, no mass can be felt above the pelvis or in the right inguinal region, and on percussion it is not dull, so that all exudation has disappeared. On examining the removed appendages the tube was found to be swollen and inflamed; it contained a few drops of pus. The ovary contained a few small follicular cysts but nothing abnormal was discovered.

Here then we have a collection of pus which was chiefly broken down and disorganised blood, so that the term suppurating hæmatocele would apply to it. There was no distinct history of appendicitis, and there was no history as to where the swelling or mass was first felt. There was no fæcal odour from the pus and no escape of fæces, so that if the mischief arose in the iliac fossa it was more probably perityphlitis than perforation or appendicitis. Against its being an early extra-uterine pregnancy, there was no history of amenorrhoea; the vaginal introitus, if not virginal, certainly was as near that condition as one finds in many virgins, and so far as a character for piety and virtue go these were present in this case. Such a condition may follow gonorrhoea, and virginity is no bar to this, as many patients confess to men having attempted copulation with them. without success, and this would be quite sufficient to infect the woman. There was no account of this here and everything against it. I am grieved to say that I did not examine for gonococci.

I may submit that the treatment of incising and draining the lowest part of the pus area was correct in any case. My reason for removal of the right appendages was the hæmorrhage, and

because, during the operation, I was of opinion that I had to deal with a case of ectopic pregnancy which had escaped through the dilated internal mouth of the tube, in fact a tubal abortion followed by suppuration.

If the case is gonorrhoeal there will be trouble in the left appendages, as this generally follows unilateral operation in gonorrhoeal disease of the appendages when the seemingly healthy appendages of one side are left behind.

In the operation it was impossible to get an idea of the condition of the cæcum and appendix without separating dense adhesions, but from the rapidity with which all dulness and resistance has disappeared in their region it seems as likely that the suppuration extended to it from the pelvis as that the inflammatory mischief originated about the cæcum or appendix and descended into the pelvis.




C. S., æt. 46, admitted November 14th, 1892, with a swelling in the abdomen, which she had first noticed four months ago. Ten children and one miscarriage; last child twelve years ago. Menstruation regular, but more painful and less in quantity lately. Has had slight pain in abdomen and has lost flesh recently.

On Admission.-Abdomen is distended by a tumour reaching up to midway between umbilicus and ensiform, extending at little more to right of median line than to left. There is distinct thrill, and fluctuation is more marked on right side, whilst on the left side of the tumour there is a solid mass. The greatest measurement, which is one inch below umbilicus, is 36 inches. On vaginal examination, a tense swelling can be felt in front of

the cervix. Patient is a spare woman, and all the other organs appear to be sound.

Operation.-November 19th. Patient anesthetised by chloroform, and abdomen opened in median line by three-inch incision. Tumour, which lay immediately under incision, tapped by trocar, and contents of larger cyst evacuated. Trocar then pushed on to break up smaller cysts, and mass drawn from abdomen. Pedicle, which was about one inch in diameter, tied by Staffordshire knot, and wound closed by six silk


As no fluid appeared to have escaped into peritoneal cavity, no flushing or drainage-tube was used. The fluid, which was of mucilaginous consistence, measured 169 ounces, and the solid matter weighed 31 ounces. Patient made an uninterrupted recovery. She had little pain and no vomiting, Temperature never rose above 100° F. The stitches were removed on December 7th, she got up on December 12th, and left the hospital well on December 28th.

A. L., æt. 32, sent to the Queen's Hospital by Mr. Hawley, Coventry. Admitted February 20th, 1893, complaining of a large swelling in the abdomen, which she had first noticed four months previously, after her confinement, since which time it had rapidly increased in size.

On Admission.—The abdomen is greatly distended and skin very tense; umbilicus protruded. Dulness, with distinct thrill all over abdomen, with exception of extreme flank, Circumference at umbilicus, 4334 inches. On the left side there is a small hard mass.

Operation.-February 25th. Abdomen opened in middle line by four inch incision. On opening peritoneum, the cyst wall was seen to be adherent to the serous lining of the anterior abdominal wall. These adhesions were separated by the finger, and there were then found to be extensive adhesions to the omentum. Some of these were separated with the finger, and others, containing vessels of some size, were tied with silk in two places and divided by scissors. The cyst was tapped with

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