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immobilised. This contraction of muscles is not only voluntary, but also reflex. Roux holds that the retraction of the abdominal wall is particularly pronounced where the stomach is concerned, since this organ is more intimately connected with the diaphragm. The degree of retraction is augmented by the fact that the diaphragm is held in forced expiration by the same reflex which contracts the abdominal muscles ; the stomach is thus held fixed between the two planes. It is to be noted, however, that of this fixation there are varieties; thus one rectus may be more fixed than another, or the upper half only may be fixed, and in some cases it is wanting altogether. There may also be a certain amount of ballooning, which disappears at the end of twenty-four hours. F. Brunner states that in one half it goes at the end of ten hours. This ballooning is not accompanied by distension of the bowel, as in general peritonitis, but is caused by first escapes of gas into the peritoneum.

Prehepatic Resonance.-The importance of the disappearance of the liver dulness is not to be over-estimated, since it can be easily imitated by the transmitted resonance of distended gut under a tense abdominal wall, and its ease of elicitation depends upon the amount of escaped gas, while it may be altogether absent. Liver dulness may also be wanting, and there be no perforation, as cited by Barker. F. Brunner estimates liver dulness persisting in one quarter of the cases ; liver dulness diminished in one quarter; and liver dulness disappeared in one half the cases; but in this he does not count the time after perforation when signs of peritonitis may cause its absence.

Abnormal dulness in flanks in first twenty-four hours and in dependent parts ; thus it may appear at Poupart's ligament, but this sign is more than that of general peritonitis.

Respiration is costal in type, superficial and accelerated, while there is a certain amount of what may be termed phrenic dyspnoea.

Pulse is generally good, in spite of the gravity of the situation—a fact which is not generally recognised. D-Arcy Power shows that it augments in frequency every half-hour.

Temperature. Nothing constant. In the first few hours after perforation a subnormal temperature has frequently been recorded, or one nearly normal; more often the commencement of a febrile rise. With the onset of peritonitis, the temperature rapidly rises.

The general state is at first that of great shock, determined by the amount of pain and the effect of the gastric contents on the peritoneum and sympathetic ganglia ; also by the air in the peritoneal cavity. It seems to depend upon the intensity of the irritation, its rapidity and extent, and therefore depends somewhat upon the amount of the escaped gastric contents. As a matter of fact, severe shock is by no means constant, for some patients may remain after the first pain in a fairly satisfactory state; may even continue their work, whilst others show extreme collapse, with cold extremities ; rapid, small, feeble pulse; subnormal temperature; cold sweat all over body, the legs flexed on abdomen and avoiding the least movement. Complications and Sequela :

1. General peritonitis, with classical symptoms.

2. Local peritonitis, i.e., localised abscess. The shorter the time after perforation that these local abscesses form, the more dangerous the condition. Symptoms may be quite similar to general peritonitis at first, and the distinction is not easy. When, however, the general peritonitis manifestations lose their hyperacute characterthe tenderness, ballooning, pulse, etc.—but the fever persists with remissions, one must think of a localised abscess, needing careful search to find it, since there are often no local manifestations, no sensibility to pressure, or, as in the case of subphrenic abscess sometimes, no recognisable dulness.

Diagnosis :-Perforated ulcer of duodenum. This is almost impossible to distinguish from perforation of pyloric end of stomach, but the following are peculiar features : Previous history more often wanting.

F. Brunner says 24 per cent., occur in apparently healthy persons, instead of 8 per cent., or even 47 per cent., as in case of stomach perforation.

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 gesta

tion.
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 em-

bolus or thrombosis of mesenteric vessels; tor-
sion 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 ; 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

one

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

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