Hæmatemesis wanting.

Melæna more frequently.

Pain at end of three hours on right side.
Icterus.

More common in men.

More like acute perforating appendicitis. 2. Rupture or perforation of gall bladder. 3. Perforation of typhoid fever.

4. Appendicular perforation.

5. Rupture of ovarian tumours, pyosalpinx, tubal gestation.

6. A series of affections without rupture, as

(a) Gastralgia.

(b) Hepatic, renal, or lead colic.

(c) Intestinal obstruction, occurring suddenly.

(d) Hæmorrhage or inflammation of pancreas embolus or thrombosis of mesenteric vessels; torsion of abdominal tumours, ingestion of certain toxic substances, as arsenical poisoning.

There are many recorded cases in which, in spite of every care, a diagnosis of perforation has been made, and laparotomy has disclosed no perforation and no peritonitis. Brunner recalls twelve by English surgeons :-Seven had ulcer, but not perforated; one had preceding hæmatemesis, but no ulcer post mortem; one had previous laparotomy, showed nothing abnormal, second laparotomy perigastritis; two had hysterical gastric crises; one had ruptured abdominal

aneurysm.

Prognosis. Total mortality, 95 to 97 per cent. Death supervenes rapidly, ordinarily in first twenty-four hours, by septic peritonitis. Of thirty-three cases collected by Chopin and Leblanc-eight in first twelve hours; ten in twelve to twenty-four hours; seven in twenty-four to forty-eight hours ; five in three days; three later.

Causes. Some say general intoxication from the organism; others say from profound reflex nervous depression acting on cardiac and respiratory centres. Heinicke thinks that the vasomotor and respiratory paralysis is due to direct intoxi

cation of the centres from the absorbed poison. He admits the possibility of reflex phenomena in man, but cannot produce it experimentally in animals.

Spontaneous cure infinitely rare. Pansier collected fifteen cases; F. Brunner collected eighteen others; but on closer examination reduces them to eleven and fourteen respectively. Leube declares he has never seen one. Still autopsy has sometimes shown that it is possible. Several cases are recorded in which dense adhesions round stomach, stomach to interior abdominal wall, have been disclosed in a laparotomy for some stomach trouble. The conditions necessary would be a nearly empty stomach, a very small perforation, and gastric fluid sterile or nearly so.

Treatment.-Exclusively surgical-i.e., laparotomy-and at once, except where condition of patient is too grave. Mitchell goes so far as to say: Do not wait for antiseptic precautions; success depends upon rapidity of operation. Pearce Gould and Leube say wait for shock to pass; but, on the other hand, Mickulicz and others say that the best way to combat shock is to open the peritoneum. Mitchell has in two cases seen the pulse rapidly improve on doing this, and therefore suggests making a small incision, under cocaine, to allow gas to escape, and believes this would make a laparotomy possible in some cases. Le Dentu, while believing it prudent to allow stage of initial shock to pass over, recommends combating it by injections of ether, caffeine, saline fluid, inhalations of oxygen, and considers that after the first three or four hours the patient ought to be considered in a fit state for operation. Note here the inconvenience caused by injections of morphia, which, by creating a deceitful calm, often robs the surgeon of a precious guide whereby to recognise the lesion, and exposes the patient to a loss of time which may be fatal, besides favouring the worst sequel to the operation, viz., post-operative paralysis of intestine. For this reason, then, in doubtful cases a laparotomy is always indicated.

Then follows description of operation itself, with methods of treating posterior perforations with fluid enclosed in lesser

sac.

REVIEWS.

Diagnosis of Kidney Disease.

By CASPER and RICHTER. Translated by DRS. R. C. BRYAN and HENRY L. SANFORD. London Rebman, Limited.

THIS work, now appearing in English, was written by Drs. Casper and Richter with a view to showing the importance of examining the secretion of each kidney separately. The bearing of careful estimation of the sufficiency of the second kidney when disease-calculus or otherwise is known to be present in one, is of obvious importance when the question of operation arises. The number of catastrophes now on record is sufficient apology for any contribution to our knowledge and technique of urinary analysis. It is now known that only one kidney may be present; that certain pathological processes may cause the damaged or discarded kidney to fuse with the sound one to the detriment of the latter; or, lastly, that disease of the kidney may spread via the bladder to the other. It is ever a problem of difficult solution-what is the state of the kidneys individually?

It is pointed out in this book that surgical exploration of the presumably sound kidney for purposes of verification is neither justifiable nor reliable. Resort must then be had to catheterisation of each ureter, and analysis of the urine so obtained. The results of urine analysis may settle the question of disease at once. There are, however, other considerations. It is necessary to know if the second kidney is able to perform its function under altered circumstances. Further, the second kidney may secrete albuminous urine as the result of amyloid disease due to suppuration in the other. It follows that removal of the damaged kidney is the best means of dealing with such a case. The mere presence, therefore, of albumen may, under certain circumstances, be an indication for operation. The elimination by the kidneys of certain substances introduced into the system may be a means

of estimating the integrity of the renal function. Methylene blue, as suggested by Achard, the formation of hippuric acid, and renal glycosuria, are instances of the system employed by the writers. To describe the methods of determining the secretory power would take up too much space, and therefore we must refer the reader directly to the work. There is much that is of practical value in the book, and many questions of importance and interest are opened up. That some of the matter is redundant there is no doubt, but the pith of the book is sound.

The Sterilisation of the Hands: A Bacteriological Enquiry into the Relative Value of Various Agents used in the Disinfection of the Hands. By C. LEEDHAM-GREEN, F.R.C.S. Birmingham: Cornish Brothers. 1904. So various have been the results obtained by the numerous bacteriologists who have investigated the subject of the sterilisation of the hands that it has been perfectly clear that there must in many of the investigations have been some source or sources of error. In all probability it has been in the actual testing of the cleansed hand that an error has crept in. Thus Kümmel was satisfied with dipping the fingertips into fluid or solid media. This is manifestly not so severe a test as the hand is subjected to in a prolonged surgical operation. Mr. Leedham-Green has adopted the plan of scraping the skin with a sterilised ivory strip: he has performed the necessary control experiments, and has taken the precaution of neutralising any of the antiseptic agents that may be present. So far as we can judge from reading his book, his technique is open to no objection whatever, and so we can accept his results as being quite reliable.

Looking at the question from the point of view of the surgeon, we notice that the author makes one remark which is of the greatest importance, viz. :-" Any method which causes the hands of an individual to become rough and cracked stands at once condemned for habitual use by him, no matter how efficient the method may have proved to be on the bands

of other persons." This is an all-important point, which makes it necessary that every operator should find out what method suits his own hands best. Mr. Leedham-Green has laboriously tested every one of the well-known methods of cleansing the hands, and has come to the conclusion that the alcohol-and-sublimate method is by far the most reliable, though he clearly shows that, even by the use of this method, it is quite impossible to be at all sure of sterilising the hands. The reader of this book must be careful not to think that, because no method of cleansing the hands is perfectly reliable, therefore the elaborate precautions generally taken are useless. It is true that absolute sterility is difficult to obtain, but it is not therefore to be taken that any one of our precautions are to be relaxed. Rather are they to be redoubled, for it is quite clear, from the results detailed in this book, that, if the hands cannot be rendered perfectly sterile, yet the number of micro-organisms on them can be reduced to a minimum.

Mr. Leedham-Green's work has been done so carefully, so thoroughly, and with such an obvious absence of preconceived ideas, that his book, which is a concise and readable record of his work, must be taken to embody the opinions of an authority on the subject. It is a book which should be read by everyone engaged in the practice of operative surgery or of midwifery.

The General Pathology of Inflammation, Infection, and Fever. By E. W. AINLEY WALKER, M.A., M.D. Oxon. London: H. K. Lewis. 1904.

THIS little book, which consists of a series of twelve papers, constituting the first series of Gordon Lectures delivered at Guy's Hospital, and which were originally published in the Clinical Journal, meets a distinct want. The ordinary textbook of pathology usually has not the space to devote to a full discussion of the above subjects, and yet they are questions of fundamental importance both in relation to the science of pathology and in its application to medicine and surgery.