370

12th.-Has slept well, and is without pain. Tempe-rature normal. Allowed two teaspoonfuls of milk everyhalf-hour.14th.-Did not sleep so well last night. Complains of

slight aching pains in the back and limbs, but has nonein the abdomen. Temperature at midnight 992°; now98’4°. Was allowed as much milk as he wished, and alsohalf a pint of tea.

16th.-Slept without morphia. Still complains of generalaching pains. Pulse 80.17th.--Complains of slight discomfort about the wound,

but of no pain. Takes about three or four pints of liquidfood daily. Bowels acted after the injection of two tea-spoonfuls of glycerine as an enema. In the afternoon thewound was dressed under the spray; it was perfectly healed,and all the sutures were removed, the wound being supportedby long strips of strapping. Allowed solid food.21st.-Progress entirely satisfactory. Bowels acted again

after a glycerine enema. He is allowed full diet.24th.-Patient feels well, though somewhat weak. Tem-

perature 96-G° this morning. Dressing again changed;wound in perfect apposition; covered with dry salicylic wool,and flannel roller applied.

’

Aug. lst.-The man is now gradually recovering strength,and gets up during the day. The bowels act naturally. Thewound is still covered with a pad, and supported by a flannelroller. This was replaced by an abdominal belt before thepatient went home on Aug. 7th.

LIVERPOOL ROYAL INFIRMARY.SOME ABDOMINAL OPERATIONS ; REMARKS.

(Under the care of Professor WALLACE.)WE are indebted to Dr. Gemmell for the notes of the

following cases :—

CASE 1. Pitritlent ascites fi-ona ruptured m’arian cyst; "ovariotomy.-Mrs. E. 11I aged fifty-seven, was admittedon June 22nd, with urgent dyspnoea dependent upon greatascites, with an ovarian tumour occupying the left iliac,lumbar, and hypochondriac regions. Abdominal section was

performed, and two gallons of purulent ascitic fluid drawn off:The tumour was partially cystic and solid, and was removed,the pedicle being ligatured in three pieces. The intestineswere adherent to the tumour, matted together, and coveredwith plastic lymph. The abdomen was washed out anddrained. The patient was discharged on July 8th, quitewell, and went to a convalescent home.CASE 2. Disease of appendages adhesionsfrom old pelvic

peritonitis " abdomina! section and excision of diseasedorgans " cure. -L. A, aged twenty-nine, when ad-mitted, complained of constant pain in the right side,dysuria, pain on walking, and total unfitness for work.She had an attack of pelvic inflammation six years ago;has never been well since. On vaginal examination, theright ovary and tube, matted together, were felt in theright fornix, and were very tender. The left ovary,enlarged, was easily felt through the left fornix, andwas also tender. Abdominal section was performedon June 28th. The left ovary was enlarged and cystic,and was removed. The right ovary and tube were

firmly bound down to the plane of the ischium by old in-flammatory bands, and, on being freed, the right Fallopiantube was found to be nothing more than a fibrous cord.The tube being quite obliterated and hard, it was removed.The abdomen was drained, and the patient did well, thewound having healed up in fourteen days.CASE 3. Abdominal section for adhesions and fixation oj

appendceges; cure.-A. lB1, aged twenty-four, on ad-mission, complained of great pain in the left side andbearing-down feeling, the pain being much worse at themenstrual period. She had been suffering for five years.The first attack commenced with pelvic peritonitis. On

vaginal examination, the uterus was found to be retro-verted and to the riglxt side, and fixed. A round hardmass, the size of a small orange, was felt in the left lateralfornix ; it was not movable. Abdominal section was per-formed on July 3rd. The left ovary was completely sur-rounded by inflammatory tissue and fixed ; it was separatedfrom its adhesions and found to be healthy. The rightovary, which was fixed to the pelvic wall, was loosened, andthe uterine adhesions were broken down. The abdomen was

washed out and drained. The wound healed, and the patientgot quite well.CASE 4. Ovariotomy ; recovcry.-C. McG—, aged sixty,

when seen, complained of distension of the abdomen, whichhad only been noticed nine weeks previously. On exaniina-tion an ovarian tumour was found. Abdominal section wasperformed on July 4th. On being exposed, the cyst wastapped, and half a gallon of ovarian fluid withdrawn. Thecyst was multilocular, was adherent to the peritoneum, andwas dissected free. The pedicle was very broad, and, con-taining large vessels, was ligatured in three pieces, and theabdomen washed and drained. The patient had greattrouble with the bowels, which became distended and hadno movement for eight days, when they were movednaturally, and she has gone on well; wound healed.CASE 5. Ventral hernia following ovariotomy ; eure.-

J. W—, aged twenty-six, was operated on in October,1887, and an ovarian tumour was removed. The patient wenthome in two weeks, and four weeks later, whilst lifting aheavy coal-box felt something give way, and came to thehospital again with a small ventral hernia through thecicatrix. The cicatrix was re-divided, and the abdominalwall brought together with deep sutures of relaxation andsuperficial sutures. The incision has almost healed up, andall the stitches are out. The patient has not been out ofbed yet.

Remarks.—Dr. Wallace pointed out that these five caseshave been all convalescent in the Thornton ward at the sametime. In Case 1 the washing out of the abdomen with warmwater-a practice followed out by him for twelve years-was the chief feature of importance. A drainage-tube wasemployed, and the patient put in the prone position for anhour, by which speedy drainage was secured. Cases 2 and 3exemplify the principles taught and practised in this clinique :only to remove diseased organs, and to break down adhesionsand restore mobility to healthy organs. Both cases are

cured. The operation in Case 5 was quite justifiable whenthe course of increasing ventral hernia is remembered, andthe cure has been accomplished with a strong cicatrix notlikely to give way again.

Notices of Books.The Treatment of Acute Rheumatism, with special refer-

ence to the 2zse of the Salicylates. By DONALD W. C. HOOD,M.D. Cantab. London: Harrison and Sons. 1888.-Thisis a reprint of a paper read during last session before theMedical Society of London, and published in abstract form inTHE LANCET of April 14th last. It is based upon records ofmore than 2000 cases treated at Guy’s and St. Bartholomew’sHospitals, 850 being cases treated at the first-named hospii/a.1before the introduction of salicylates. The analysis of solarge a group of cases must have involved great labour andpatience, but whether the result can be said to have thrownany material light upon either the nature of acute rheu-matism or the modus operandi of the salicylates is doubtful.The main contention of the writer is that these drugs haveno specific action, and that their prescription should beguided by the type of case before the practitioner; never-

theless, throughout, in speaking of them, he uses freelythe terms "specific" and "anti-rheumatic." He especiallywarns against their too ready employment in cases where thereis a neurotic tendency, and in the presence of hyperpyrexia(which he shows to occur notwithstanding the administrationof salicylates) he counsels their immediate abandonment.Whatever may be the true explanation of the action of thesalicyl compounds in this disease, their efficacy can no longeradmit of any doubt. At the same time Dr. Hood has donesome service in pointing out the class of cases in which theyare most suitable-although, to our thinking, he ratherneedlessly restricts their employment,-and deserves com-mendation for his industry in the accumulation of facts.The brochure is disfigured by certain clerical errors-e.g.," Wunderlick," "Zielnsenn," "Bristow," "prodroma aresic) very slight," " hyperpyrexic"; and it is surely by over-