blood pressure and maintains it as long as it is given, and the reverse is true of chloroform. The blood pressure is well maintained during major operations in children in spite of the opinion to the contrary, provided hemorrhage is not great and that the length of time is proportional to the age. The blood pressure inold age may be termed as irregular, going quickly up and down, and is not to be depended upon. Shock in an operation or an injury is equal to the sum of the mechanical insults to the peripheral nerves, which so excite the vasomotor centers that they become exhausted.

Our task, then, to prevent shock, is to prevent either the sending of the message or the receiving of it. The first problem has been solved in injuries or operations on the extremities. By the injection of a 4 per cent solution of cocain into the main nerve trunks, we may absolutely prevent the nerves from sending any messages, and by its use shock in operations on the extremities is prevented. The nerves to be cocainized in the lower extremity are the sciatic and crural, and the brachial plexus in the upper. At first thought we might think that spinal cocainization would meet all these requirements in the treatment of shock, but, unfortunately, it paralyzes the vasomotor centers, and is one way to produce it. In abdominal work we cannot block the impulses, but we can limit the excitement of receiving these messages. The best drug so far found for this purpose is morphine, used just before and just after the operation. It also quiets that mental fear of an operation that often itself produces shock. The other therapeutic remedies are ergot, given hypodermically, which acts in a few minutes, contracts the dilating arterioles, and maintains blood pressure; and adrenalin which will keep the blood pressure up only for a few minutes, and therefore must be given constantly and very slowly intravenously in about 1-50,000 solution. In giving normal salt solution Crile has shown that after about a pint of normal salt solution to every hundred pounds of body weight has been given, the fluid will leave the vessels as quickly as it is given. For orlinary cases the best way is by the rectum, and as slowly as possible. Of course, in hemorrhage. it should be given intravenously, and as quickly as possible. The most important mechanical

means for the prevention of shock is to keep the body warm. The operating table should have a hot-water or electrical attachment. As the splanchnic vessels are congested in abdominal shock pressure on the abdomen by the hands or by a tight abdominal binder will aid in driving the blood to where it is needed. Elevate the foot of the bed at least a foot. The last mechanical means to be mentioned is any method that will press the blood out of its peripheral vessels. A bath of a fluid of a heavy specific gravity would do it. Crile uses a rubber suit of two layers to be inflated with air and the right amount of pressure maintained with an air pump.

We have mentioned the fact that after the vasomotor centers had failed to keep up the blood pressure, the heart was called on for increased work and increased speed. There is nothing the matter with the heart; its rapidity is only secondary to the low blood pressure. This is where the older therapeutists failed, and treated shock with heart stimulants. We may say positively that in the treatment of shock strychnine, digitalis, alcohol, and nitroglycerine are either inert or harmful. Crile found that the easiest way to produce shock was by big doses of strychnine, and that the control dog that received no digitalis lived as long as the one that did.

I can, in closing, only sugest one other idea in the treatment of shock, and that is the value of time. Any one will do well to read M. H. Richardson's article in the St. Paul Medical Journal for June, 1905, on the value of time in operating. Every operation over an hour and a quarter long tends to produce shock. It is better to put our patient to bed without shock than to be too careful over the little niceties of technic. It is better to do two operations than to subject a patient to this dangerous condition.

If a patient begins to vomit long after a radical operation for carcinoma of the stomach, do not jump to the conclusion that the cause is a local recurrence. It may be a metastasis in the brain.-American Journal of Surgery.

ST. BARNABAS HOSPITAL

MINNEAPOLIS

A CASE OF DEFORMITY OF THIGH RESULTING FROM AN OBLIQUE FRACTURE OF THE FEMUR

IN THE SERVICE OF DR. W. E. ROCHFORD

Frank P, aged 9, farmer boy, Bohemian. The patient entered the hospital March 19, 1905. While playing in the hay-loft in the barn, he fell to the floor and sustained a fracture of the right femur, a little about the center. He was attended by the local physician.

cision on the outer surface of the thigh and about six inches long was made over the center of the fracture, exposing clearly the fractured ends. The fracture was found to be oblique, with great displacement and over-riding of bones. There was ligamentous union. The connective tissue and callus around the fractured surfaces were removed with a knife and sharp curette. An attempt was then made by manipulation and strong extension to put the fragments into normal position. The powerful muscles of the thigh had contracted so much, producing about four inches shortening, that it was difficult to overcome it. A strong assistant making continuous extension for about twenty minutes enabled me to secure perfect co-aptation,

Fig. 1.

This retouched skiagraph shows the position of the bones before the operation.

Five weeks after the accident, he was brought to St. Barnabas Hospital, and placed in my charge by the physician then attending him. There was a four-inch shortening of the injured limb, and a bulging and bowing out of the thigh, causing marked deformity and swelling at the seat of the fracture. The patient had been confined to his bed, all of the time, and was very nervous and timid. General nutrition was only fairly good.

On March 20, two days after entering the hospital, an operation to correct the deformity and to secure bony union was performed. An in

Fig. 2. Skiagraph showing the position of the bandaged limb. and then an effort was made to wire the bones, but it proved useless. The bones could be held in place only by the assistant continuing the powerful extension on the leg. With the fractured ends held in normal position, I gripped them with a Ferguson lion-jaw forceps, and when the assistant released his hold on the limb, there was not the slightest displacement of the fracture. The forceps held the fracture so securely it was impossible to disturb them. I then decided to dress the fracture with the forceps left on. The handles of the forceps were secured together by wire and adhesive plaster. A strip of iodoform gauze was placed in the wound for drainage. The wound

was closed with sutures close around the forceps. A copious dressing of sterile gauze was placed over the wound, and a plaster-of-Paris cast was applied to the limb, extending from the toes up. around the thigh and pelvis, the plaster embracing the handles of the forceps. No extension was necessary, the forceps holding the bones in place, and the fracture was maintained in place by the cast when the forceps were removed. The treatment otherwise was practically the same as for any other ordinary compound fracture, care being taken that asepsis was perfect.

The forceps were left on about fifteen days. A window cut in the cast allowed the wound to be dressed when necessary. There was very little reaction in the wound following the operation. When the forceps were removed the wound closed without any difficulty.

The patient was discharged from the hospital on May 29. He was then able to walk on the injured limb, but the cast was not removed until three weeks later. There was no shortening or deformity, and the contour was perfect as measured with the other leg.

The method here used and the excellent result obtained have encouraged me to devise a forceps especially for this purpose. Fig. 1., which is a retouched skiagraph shows, though imperfectly, the condition of the fracture just before operation, and Fig. 2 shows the position of the bone with the forceps attached, and was taken on the day the dressing was removed, fifteen days after the operation.

The result was perfect.

CASE OF TUBERCULAR PERITONITIS, PULMUNARY TUBERCULOSIS, CYSTIC OVARIES, AND APPENDICITIS

IN THE SERVICE OF DR. A. E. BENJAMIN

. Miss S., aged 22, very tall, usual weight, 156 lbs., had ordinary appearance of good health.

Family History.-Father died at 55 years of some kidney disease, probably tubercular; grandfather and uncle died also of tuberculosis; mother perfectly well; one sister has tubercular spine.

Personal History.-Has had usual diseases of childhood. She was unable to participate as a child in the ordinary sports, as she tired easily. She gave a history of having had dysmenorrhea, and a great deal of tenderness at all times over the lower abdomen. At 19 she had an attack of peritonitis, which was quite severe; and two subsequent attacks, closely following, which were also quite bad. The first atacks came on very suddenly and with severe pain. She had a great deal of vomiting, distention of the abdomen, bowels constipated. Her subsequent attacks were similar in character and about two months apart.

I first saw the patient in October, 1902. She was just recovering from an attack of peritonitis. A period of rest and careful selection of diet prepared the patient for operation.

Physical examination revealed a fixed condition of the pelvic organs, with possible cysts of the ovaries and pelvic adhesions. At the time. of the operation all of the organs in the pelvis were found firmly adherent; multilocular cysts, ranging in size from 3 to 8 cm. in diameter, arose from the ovaries. The cecum and small intestines

were firmly united by adhesions, and loops of intestines were adherent to the diseased tubes and ovaries. Tubercular nodules were present over the cecum, and covered numerous small areas of the small intestines. The adhesions were so extensive and so firm that it was impossible to get at the appendix without stripping the serous membrane from the bowel, and causing a severe hemorrhage. Owing to this condition the appendix could not be seen, and was not removed. A number of cystic cavities of the ovaries were evacuated, and the cysts removed where possible. Because of the firmness and extent of the adhesions, as well as the unfavorable condition of the patient, nothing more was done. The abdomen was then closed. The patient steadily improved after the operation, and was apparently well for a time, but had a few mild attacks of peritonitis of short duration. An attack, lasting three weeks, occurred about six months after the operation. After this attack she was well for two years.

In January, 1905, severe and sudden acute symptoms of peritonitis with possible appendiceal involvement occurred, lasting seven weeks.

The temperature ranged between 99° and 105°. The soreness and chief involvement appeared to be of the left abdominal and pelvic organs. She also coughed a great deal at times. Mucous râles were present in both lungs; and tubercle bacilli were found in abundance in the sputum. The patient, however, gradually improved, the cough ceased, appetite became normal, and the weight increased, but she complained of abdominal tenderness. Tubercle baccili were absent from the sputum.

A second operation was determined upon to remove the offending organs. This was done in April, 1905. The omentum was found adherent in a number of places along the site of the former incision. The appendix was considerably enlarged at the outer four-fifths, while the proximal end was narrowed to a very small cord, and that was removed. The meso-appendix was very small. The ovaries were both cystic; the cysts ranged from 2 to 7 cm. in diameter. They were thin-walled and contained clear serum. Both tubes were adherent and enlarged. The peritoneum completely enveloped the fimbriated extremities. No signs of the former tubercular condition were present. The left ovary was resected, and the cysts removed. Both tubes were removed. The broad ligaments were brought up to the horns of the uterus, and all raw surfaces covered and the abdomen closed. The patient made an uninterrupted recovery, and has been well since. She has no cough, has gained greatly in flesh and looks well.

The important points in connection with this

Showing the position of the Ureter, just over the Peritoneum, after being freed from inflamed tissue. structures below the internal oblique were found so matted and adherent that the cecum was reached before any definite landmarks could be made out. After freeing the median side of the cecum what seemed to be the appendix was found lying parallel with the median line of the body, one and one-half inches below the anterior superior spinous process of the ilium, but above the cecum and to its outer side. This supposed appendix was laid bare, and when brought well into view looked more like a ureter than an appendix. This it proved to be after further careful dissection downward nearly to the bladder. It lay really in the anterior abdominal

wall, just under the peritoneum. When within about one inch of the bladder it turned sharply downward and to the right, and so under the peritoneum to the bladder. The upward course of the ureter was not traced for fear of tearing the very fragile bowel, but on making traction' it seemed to dip down to nearly its usual position, but more to the outside.

CASE 2. Mrs. H. miscarried several years ago and then flowed irregularly for two weeks. She was taken with sudden colicky pain in the right side with faintness. There was a tender mass the size of a lemon in the right pelvis. The uterus was rather large. There were frequent pains with nausea, but no temperature. The family physician made a diagnosis of appendicitis, but in view of the very typical history and physical findings I was inclined to the diagnosis of tubal pregnancy or perhaps a combined appendicitis and tubal gestation.

The incision was made in the median line, and the following conditions found:

1. A Meckel's diverticulum arising from the ilium three inches above the ileocecal valve. This was about three inches long, and was curved upward and then around to the base of the appendix, where it had been attached, but had sloughed off, leaving its end open.

2. An appendix five inches long and perforated at its base. The appendix was traced downward, and its tip found attached to the right horn of the uterus. The appendix was adherent to the right tube for its whole length. 3. The right tube, iying under the appendix

OCCULT BLOOD IN FECES

In the January 1st (1905) number of THe LANCET the writer gave a resumé of work done by various observers upon the so-called occult blood test in feces. This is a test devised by Boas to detect the presence of small quantities of blood in feces, which heretofore have escaped detection either by macroscopical or microscopical examination.

In the July (1905) number of the American Journal of Medical Science, Steel and Butt give the results of the examination of 720 stools from 100 patients for occult blood. The writers aloin-turpentine test of Klunge and Schaer. used the guaiac-turpentine test of Weber and the

The technic of the test found most reliable is as follows:

Take 5 grams of fecal matter, soften with a little water, and mix with its own bulk of ether