We have all probably seen many similar cases. When a patient is having recurring attacks of peritonitis in the region of the cæcum, the only safe method of cure is to cut down and remove the diseased appendix, which will most always be found. That diseased and adherent appendix, pus or no pus, stands as a constant menace to the life of the patient, and should not be allowed to remain one minute longer than would be a Fallopian tube in the same condition, as almost surely an attack of peritonitis will eventually end the life of the individual.

When there is pus in or near the peritoneal cavity and it is causing inflammatory trouble, it is simply folly to ever attempt any method of treatment other than surgical. The moment there is good reason to suppose that pus is at the bottom of the attack, or has subsequently complicated it, we have an absolute and imperative indication to operate, it matters little whether this arises from a pus tube, an abscess of the liver, an appendicitis, a suppurating ectopic gestation, or abscess from any other

source.

It would seem hardly necessary to even suggest that an operation was strongly indicated where a perforation of the intestine had taken place. And yet even within the past few months I know of several cases, with gunshot wounds, allowed to die from subsequent peritonitis, without an effort to save them. When extravasation of the contents of any of the hollow viscera has taken place, it matters little if it is fæces, urine or bile, a violent peritonitis is the rule, and we can only be safe by acting on the supposition that it is inevitable. With perforation in typhoid ulcers our ground is not so sure. The results have so far been anything but encouraging, and yet it is entirely too premature to come to any such conclusions as are arrived at by Mears, in his paper on the subject, in 1888. It must be remembered that laparotomy is almost absolutely the only chance for the patient under these circumstances, and much more general trial should be made of this virtues of this treatment before condemning it. Perforating ulcers of the cæcum must necessarily be treated by surgical means. Only last year, McMurtry of Kentucky demonstrated the soundness of this procedure in such a case occurring in a young physician whom he saved by an early and timely operation. always easy to say whether or no, in perforating wounds of the parietes, the viscera are injured; not even is Senn's injection of gas sure to tell the tale correctly. But where such a wound has taken place and a peritoneal inflammation has followed, there is no room for hesitation or

It is not

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for medical treatment. In these cases we should always turn to the surgeon and to surgical methods. All cases arising from traumatisms, such as blows, falls, etc., should properly come under surgical management, for the reason that one can never be sure that some of the viscera are not ruptured or otherwise badly injured. It is true that even without this direct injury to the internal organs the peritoneal inflammation may be excited, but the supposition is, or always should be, where the symptoms are of such a character as to make it probable that rupture or laceration has taken place, and the patient should, by an operation, be given the benefit of the doubt.

With a given ovarian tumor or a tumor from any other source, an attack of peritonitis is most decidedly a positive indication for laparotomy. It is perfectly true that such cases have time and again recovered, and subsequently gone through a second and even a third attack safely. But that argues nothing in favor of waiting or allowing the disease to remain. Each and every inflammatory attack means more extended and dense adhesions, and each one means immediate, imminent risk to the patient's life.

In cases of intestinal obstruction it is generally extremely hard to tell when peritonitis has developed, but fortunately the disease here is of such a character as to demand early surgical interference, peritonitis or no peritonitis, and noone need hesitate to operate on a case of intestinal obstruction at any time, if he can be reasonably sure it be not one of fæcal impaction. He will, by so acting, save⚫ twenty cases out of twenty-five, where otherwise he would probably lose twenty out of twenty-five.

Cases of chronic peritonitis are best treated by the surgeon. As a rule, some well defined disease is at the bottom of the inflammation and it can be best cured by the removal of this cause. If no cause be found, then as in the acute form irrigation and drainage follow as a matter of course. The tubercular form of the disease is no exception to this rule, and daily experience is showing that many of these cases live on for years in comfort after an operative procedure.

We are all of us frequently called to see patients suffering from peritonitis, and after an incomplete examination, which the individual's condition renders necessary, are unable to find any disease to which the attack may be attributed. In a case such as this one would, a few years ago, naturally have hesitated to propose surgical interference. And so it is today. An effort should first be made to relieve

the trouble by medical means, and this will probably in many cases prove successful. But if medical means are going to do any good, they should do so very quickly. The records contain cases of recovery where the treatment has been kept up for a week or weeks, and the result has been in extreme doubt the whole time. But for one such case of recovery, there are many deaths. Such a prolonged uncertainty could only have existed in the old days of opium. With our present treatment by purgatives, twenty-four or at most forty-eight hours must, in the majority of cases, tell the tale; by this time the patient is or is not convalescent, this depending to a great extent on whether purgation has been produced or not. If purgation is properly produced and the individual is not beginning convalescence, then is the time for the bold use of the knife; every moment after this is lost time, and the attendant can only excuse himself for neglect to turn to surgical mean; on the ground that he is afraid of surgical procedures. The results of peritonitis have been too terrible and its mortality too great for any false sentiment to stand in the way of an operation. Where we can control the situation, we have no right to temporize on account of our own feelings, or to humor the fanciful and ever-varying whims of the patient and her friends. This always reluctant consent of friends is too often used as an excuse for our own hesitancy and lack of decision. In this, as in all other abdominal troubles, the ideal physician should have no feelings, or if he has them, should keep them down with a strong and relentless hand. The patient should be a mere machine to him; that machine is out of order and the only question should be, how may it be best and most surely repaired? In the great majority of cases, some well defined disease will be found to be present and causing the inflammation. This should always be removed if it can safely be done, and the resolution of the inflammatory attack will in the natural order of events follow the removal of the cause.

The time was when a peritoneal inflammation was a positive contra-indication to an operation. Even to-day there are many who will refuse to operate until the inflammatory attack has subsided. From the principles of treatment laid down in this essay (drainage and depletion), it must be self-evident that the very details of the operation accomplish one of the desired results. If much of an enucleation be necessary and many adhesions are broken, there will be free bleeding directly from the parts, and much good will be accomplished by

this alone. Then again the operation gives the opportunity of applying the best of all treatment of any trouble whatsoever, viz.: Removal of the cause. But if the cause cannot be found, we are in a position to adopt a line of treatment at once both rational and necessary. As long ago as 1881, Flint wrote that "these measures of course are applicable only to cases in which the presence of septic, infective, morbid products may be inferred. In many instances these products probably constitute the chief source of danger. The time may come when paracentesis abdominalis will have been proven to be as applicable to certain cases of peritonitis, as are thoracentesis, injections into the pleural cavity, and a permanent opening in the chest, in cases of suppurative pleurisy." The time has come, as Flint predicted, and if he simply means by his "septic, infective morbid products," pus, then we are far beyond the time, and it is already an old and settled affair. Where the peritonitis is purulent no one will dispute for an instant that the only possible chance for life is operation. But the inflammatory products thrown out from the peritoneum in every inflammatory attack are just as septic; it is simply a matter of quantity and that is to a great extent a matter of luck. If the quantity is too great for successful elimination, then the patient is lost. It not only is being absorbed and poisoning the blood, but is continuing by its irritant action to excite the inflammation, and more and more is constantly poured out into the cavity, until the patient is finally overcome.

After every abdominal section for peritonitis, whether the case is found or not, the necessary complements of the operation are free irrigation and drainage. The irrigation washes away all the irritating septic materials, leaves the membrane in a clear, soothed condition, and the drainage tube stands ready to remove all new formations of these liquids. The tube not only gives the surgeon an opportunity to draw away the fluids, but also allows of free and frequent irrigations, when they are considered necessary.

In treating any given case of peritonitis, unless it is decided to operate at once, the safest and most effectual treatment is by saline purges. When these fail, operation becomes necessary.

The abdomen being opened, the cause must be removed when found, if it is possible.

Whether removed or not, in the words of Price, “douching and flooding of the abdomen are absolutely necessary, and drainage is the bulwark of the whole procedure."

1

THE recent meeting of the Mississippi Valley Medical Association was the most successful in its history. With a large attendance, and a programme embracing ninety-eight papers with over eighty of the authors present, it is no exaggeration to say that the meeting looked at from a scientific point of view was the ablest representation of medical talent which has been gathered together this year outside the National Association.

The marvelous growth of this association in numbers and influence we attribute to two factors; first, the absolute severance of politics from the deliberations of the society. All matters relating to the business of the association are delegated to committees whose action is final; second, the thorough working spirit manifested in the scientific sections. Within fifteen minutes of the opening of the association all preliminaries had been disposed of, and the reader of the first paper was engaging the attention of the audience. The rapid disposition of papers, by grouping them under appropriate heads, that discussion of several may occur at the same time, is productive of great good in preventing tedious repetitions. The methods of work adopted by the Mississippi Valley Medical Association have been the means of gaining for the society the name of "a working body," and could with profit substitute some of the more cumbrous machinery in use in our State and National associations.

ONE hundred and fifty-four deaths, according to the "Bulletin-Medical" have thus far resulted from the "preventive inoculation" of Pasteur. It is exceedingly astonishing to find so-called scientific men ("Medical and Surgical Reporter") "accept without question the assertions in regard to rabies and hydrophobia of a man who is known never to have studied either subject ; who knows nothing of the work of other investigators, who gets credit as a humanitarian while neglecting the method he long ago said would eradicate rabies in dogs (and consequently in men) and the method which has almost eradicated hydrophobia in Germany, and while practicing a clap trap method without analogy in theory or practice in the whole round of medical experience, and which results in an absolute increase of deaths from hydrophobia!" The "Medical and Surgical Reporter" regrets to find that an attempt is to be made to put the Pasteur method in operation in Chicago. It hopes that

'this will not go on, for fear that Chicago may share the fate of Paris, and have a rapid multiplication of cases of so-called hydrophobia, and that the United States will no longer enjoy the immunity which goes with skepticism, but fall into the condition of every town where Pasteur's theories are believed and practiced." A Hahnemanniac pervert, who is the ready took of the most disreputable members of the county board, and who leads the cheap medical politicians who compose the majority of the county hospital medical staff, did make an attempt to establish a Pasteur institute, but through the influence of the MEDICAL STANDARD, and the Chicago "Daily News" the project was killed for the present year.

NEW YORK took the initiative in a legal requirement of preliminary education for medical students, when it passed the following act:

Before the Regents of the University of the State of New York, or the trustees of any medical school or college within this State, shall confer the degree of doctor of medicine on any person who has not received a baccalaureate degree in course from a college or university duly authorized to confer the same, they shall require him to file with the secretary or recording officer of their university or college a certificate showing that, prior to entering upon the prescribed three years' study of medicine, he passed an examination conducted under the authority and in accordance with the rules of the Regents of the University of the State of New York, in arithmetic, grammar, geography, orthography, American history, English composition, and the elements of natural philosophy, and such certificate shall be signed by the secretary of the regents and countersigned by the principal or commissioner conducting said examination. This act shall not apply to persons who have already entered upon the prescribed three years' study of medicine, nor shall it alter the time of study or the courses of medical instruction required to be pursued in the medical colleges of this State by existing statutes.

It should, however, be remembered that in but few States is there a body endowed with the legal powers of the Board of Regents of the University of New York. In the eye of the law this body exercises some supervision over every educational institution in the State. The public spirit which many of the New York county medical societies have shown, indicates that the law will be properly executed, and badly educated students will therefore, henceforth avoid New York like a pestilence.

THE MEDICAL STANDARD some years ago in discussing the statement of Dr. G. Frank Lydston that "marriage is a cure for most of the sexual defects and complaints of young men," said:

"These opinions would express bad morality and worse sociology, even were they therapeutically well based. That they are not, every neurologist and surgeon who has followed up his cases can bear witness. Every insane hospital contains dozens of masturbatory_lunatics for whom marriage has been prescribed as a remedy resulting in complete failure, and the prolonged unhappiness of two human beings. The error of Dr. Lydston lies in mistaking the desire for sexual intercourse for an entity, furnishing an indication for treatment. Desire for sexual intercourse is merely a symptom and can be treated only by the removal of its causes. This is the true treatment, not the satisfaction of the desire nor its repression. In the great majority of cases sexual desire, which cannot be healthily controlled by the will, is due either to constipation, improper food, improper clothing, improper literature, ascarides or leucorrhoea or analagous causes. Satisfaction of sexual desire will not remove these causes. Until they are removed the satisfaction of it in any way is but adding fuel to the flame. The results of so-called 'sexual starvation' are due to partial sexual gratification in an abnormal, albeit unconscious, way, not to abstinence from sexual intercourse and are never cured by it. Cold sponging, proper diet, proper clothing, proper literature and proper attention to the rectum will cure all cases of 'sexual starvation' except such as are reversions to the savage type of unrestrained debauchery, or depend on cerebral or spinal disease or malformation. In the first case training is indicated, and in the last hospital treatment, not marriage nor sexual intercourse. Christianity teaches restraint of the 'old man Adam.' Evolutionary ethics teach that the higher the organism the better developed and the greater the checks on the primitive instincts of the race. Where theology, the dominant philosophy, and clinical experience join in condemning a procedure of doubtful morality intended to benefit one individual at the possible expense of another, the physician incurs a great responsibility who prescribes it."

The "Medical Record" criticised this position at the time as that of an ascetic. It is with some amusement that the MEDICAL STANDARD finds the "Medical Record" lately quoting substantially the same view from Forel, the Swiss alienist, and strongly indorsing it.

THE "Medical and Surgical Reporter" says with equal force and truth that "there are exceedingly few diseases which are treated better, or more successfully, because of the application of knowledge gained in the bacteriological laboratory. In nothing is this disappointing fact more apparent than in the case of tuberculosis and cholera. The most striking discoveries of many

years have been those of the tubercle bacillus, and the cholera bacillus; and what have they done to improve the methods of treatment for or prophylaxis against tuberculosis or cholera? In regard to tuberculosis, the only valuable application of a faith in the etiological relation of the bacillus to the disease, is made in surgical practice; and this valuable as it is-simply confirms principles practically applied long before the bacillus was heard of; while in the treatment of tuberculosis of the viscera nothing whatever has been gained. As before, so now, attention to general hygiene, good air, good food, and roborants are the only means of treating tuberculosis successfully. As to its prophylaxis, the same is true. At present there is evidence accumulating which indicates that pulmonary phthisis may be infectious; but this is a discovery entirely independent of bacteriological studies, and one which-if true-will be met by measures which have nothing to do directly with the germ theory of disease. Roux calls attention to the sensation caused by the discovery of the comma bacillus and the announcement that it is the cause of cholera. What effect, he asks, has this had upon the treatment or prevention of cholera? The imitative genius of Gamaleia has brought forth the suggestion that previous inoculation with attenuated virus of cholera may protect an individual against an attack of the disease. But this suggestion only shows the lack of the logical faculty which seems to possess the disciples of Pasteur. Cholera is not a disease analogous to any in which there is respectable claim for the usefulness of preventive inoculations; and there is no reason—and, of course, no experience to support the notion that preventive inoculations would have any influence on the development of cholera."

Dr.

The lack of a logical faculty has affected other bacterio-maniacs besides the victim of the Pasteur "fake." Those with whom "secondary mixed infection" is a fad, set aside or distort physiological facts with an airy lightness which often suggests a previous infection with Hahnemania.

"LIFE" partially redeems the jonrnalistic profession from its disgrace when it denounces in strong language the brutality with which Dr. D. Tilden Brown was hounded to suicide by the "crank" sensationalist now editing the New York "World." "Life" says:

And what is the name for this piece of wanton wickedness? Can we call it murder, or in what grade of homicide can we class it? Here is a life that pious devotion had protected and preserved, suddenly trampled out by a ruffian. But

no grand jury will investigate the case or send the "World" to trial. The particular villainy of which it seems to be guilty is not one that the courts regard or the law punishes, but only "newspaper enterprise."

It is said of the New York "World" that no man can be so faithless, so base, or so great a liar, but what that journal is willing to employ him, and able to find for him congenial work. We suspect that that saying is true.

The Chicago "Inter Ocean" and the "Times", are local examples of journals described in the last paragraph by "Life." Both have been guilty of newspaper "fakes" concerning physicians as vile as any of the "World." The editor of the "Times" is meeting the deserved punishment of his crimes. The editors of the "World" and "Inter Ocean" should profit by his fate.

UNDER the legal principle that no man is compelled to criminate himself, the privilege of examining patients under anesthesia without their consent, has been repeatedly refused by American courts. The "Northwestern Lancet" inclines to an opposite position, for it says: "Anæsthetics have sometimes been administered for the sole purpose of determining whether certain symptoms were realized or not, and in the hysterical, diagnosis is often much aided by this plan. In medico-legal cases where there is reason to doubt the reality of the disability claimed, the matter could often be settled by putting the claimant of injury under an anæsthetic. This has sometimes been done, but in a recent case in France, where it was proposed, the injured person refused to submit to anæsthetization, and, when the matter was argued before the court, his attorney took the ground that the procedure was objectionable because it involved a certain degree of risk to life, which his client was in no way called upon to undergo for the mere purposes of an examination which would be of no benefit to himself. The attorney further argued that the only situation in which the court would be justified in ordering anæsthesia for diagnostic purposes, would be in a criminal case where it was done for the benefit of the accused. The court fully sustained this position."

DR. W. A. HAMMOND in 1881 called attention ("Chicago Medical Review," Vol. III) to the possibility of an hypnotized individual being used for purposes of crime. Liegeois, at the recent Hypnotic Congress, said:

"This is probable, and furthermore the real criminal might, and probably would, suggest to the subject whom he wished to make an instrument of his vengeance or cupidity to not recall any of the circumstances preceding the crime, and to believe that he alone had the idea of it,

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etc. The amnesia thus aroused would be a serious obstacle against the best directed efforts. Those who can be put into a profound state of hypnotism are irresponsible; their automatism being absolute, they are not free, and therefore irresponsible. There are certain indications by means of which it can be shown that the author of the felonious act is hypnotizable, and to such a point that he could be irresistibly made to realize the suggestions. Automatism can be combated by forcing it to produce effects contrary to those that the real culprit had supposed. In other words, as the accused would never, by virtue of the order received, directly denounce the author of the suggestion, he must be made to do so indirectly by acts whose significance he would not comprehend, or even by measures that would have the appearance of being for the protection or defense of the criminal himself. An experimenter can thus make to the hypnotized subject, relative to the author of the criminal suggestion, all the suggestions that would not be directly and expressly contrary to the amnesia already suggested. The true criminal would thereby fall into the hands of justice, because it would have been impossible for him to foresee everything."

WHEN Madame de Sevigne, in one of her letters, hoped that the expressions "poisoner," and "Frenchman" would not become synonymous, she was moved by the almost epidemic form of this crime in France. But every country has at some time been plagued with the secret poisoner. The interest aroused in England and America by the Maybrick case recalls to mind some of the more prominent of female poisoners in English history. poisoners in English history. It is remarkable, looked at from a medical point of view, with what unanimity poisoners have chosen arsenic as their favorite drug. The "popular" poison has always been arsenic. It was a compound of arsenical salts that Hieronyama Spara supplied to her clients, the secret society of Young

Roman matrons.

This "wonderful elixir," as

she termed it, was "a slow poison, clear, tasteless and limpid, and of sufficient strength to destroy life in the course of a day, week, month or number of months, as the purchaser preferred." It appears to have been similar in its action and properties to the acquelta sold in Naples by Tofana for similar purposes.

The case of Amy Hutchinson is the first noted female poisoner on record in English history. She was a native of the Isle of Ely, married a man to spite her sweetheart. Repentance came, and after a quarrel she administered arsenic in her husband's ale. He died the same day, and the young widow was burnt for "petit treason," in 1750. Ann Williams, another poisoner, was burnt three years later, after which this barbarous punishment was repealed by an act passed by George the Third.