dial activity a friction accompanying the heart's excursion is clearly palpable. The friction is not palpable anywhere else over the precordial area. Percussion shows the right lung to be free from any involvement. The left apex and infraclavicular regions are dull-tympanitic. The dull-tympanitic note gradually merges into a dull note at the second interspace in the left parasternal line. The dullness in the left axillary line begins high in the axilla and extends to the base of the lung. The semilunar space of Traube is dull and resistant as far externally as the nipple line, but external to this point it is clearly tympanitic and nonresistant. (Pericarditis and not pleurisy with effusion). Percussion over the sternum shows the upper portion of the manubrium to be nonresistant, but a finger's breadth above Louis' angle resistance begins which persists along the entire lower portion of the sternum. Over an area on the sternum extending only from a finger's breadth above Louis' angle to a finger's breadth below the angle, percussion gives a distinct tracheal tone (Wintrich's or Williams' tracheal tone change). This tracheal tone can be brought out only when percussion is done during a forced inspiration. This tone was due to the percussion vibration being communicated to the trachea at its bifurcation by the distended pericardial sac. Beginning at the right of the sternum with deep palpable percussion we can demonstrate a deep resistance marked by a line reaching from the third rib a little to the right of the sternum and reaching down to three finfiers' breadth to the right of the sternum in the fifth interspace. Superficial percussion and mediate percussion over this area give a tympanitic note, due to a thin tongue of lung being fixed between the thoracic wall and the distended pericardial sac. As later observations will show, there was marked mediastinitis; with the deep palpable percussion we were able to penetrate this tongue of lung and perceive the resistant body beneath it. Posteriorly there is diminished resonance over the left supra and interscapular areas, but marked dullness begins at the angle of the scapula. The infrascapular area is very dull and resistant. The base of the lung in the left paravertebral region is also very dull and resistant. There are some distinguishing features, however, between the infrascapular area of dullness and the paravertebral area of dullness. If an assistant percusses gently over the infrascapular area and we listen at the patient's mouth, we can perceive a distinct tone change when a patient opens his mouth. (The Williams' tracheal tone over the compressed portion of the lung). The tracheal tone is not perceptible from percussion over the paravertebral area of dullness. If the patient be instructed to turn on his right side the flatness over the paravertebral area changes to a dull tympanitic percussion note. The infrascapular area of dullness is unaffected by a change in position. This paravertebral area of dullness is due to the displacement of the liver by the pericardial effusion. The liver is rotated downward on its transverse axis, at the same time being pushed backward against the thoracic wall, thus displacing the lower thin portion of the lung. If the patient lie on his right side, thus permitting the liver by its weight to fall forward and to the right, the lung again extends in this location and gives a tympanitic note instead of the flatness. The infrascapular dullness is due to compressed lung. The paravertebral flatness is hepatic. Palpation over the left thorax shows marked diminution in vocal fremitus over all areas excepting in the infrascapular area where the fremitus is marked. Auscultation over the heart's apex gives nothing but loud friction sounds, which obscure the tones, both systolic and diastolic. Over the aortic area the frictions are audible though not so loud as to obscure entirely the aortic closure. Over the pulmonic area the frictions are loud, though the diastolic tone is heard. Over the entire preventricular area as far to the right as the area of dullness extends there are loud friction sounds The same patient shown in Fig. 2 after disappearance of the pericarditis. He now has aortic insufficiency. The curved right border was determined by palpable percussion, the left border by both palpable and mediate percussion accompanying both the systolic and diastolic phases. Over the infrascapular area of dullness there is distinct broncophony. An aspirating needle was inserted in the fifth intercostal space at the right of the sternum over a line marking the junction of the rib with its cartilage. After passing through the thoracic wall the needle could be felt to be passing through a medium of less resistance (lung) and then a resistant body was encountered (the thickened pericardial sac).This was penetrated and onehalf pint of bloody serum aspirated. The specific gravity of the fluid was 1027, measured by the Hammerschlag method. Directly the patient's breathing improved. The resistance in the cardiohepatic angle diminished. The left border of the heart's dullness receded slightly. On the following day the Williams' tracheal tone was no longer demonstrable over the sternum nor over the infrascapular area. The friction disappeared within a few days. The entire clinical picture now changed. The pulse changed from a dicrotic character to that of a pulsus celer; all the signs over the heart and vessels pointed to an aortic insufficiency. The accompanying figure 3 shows the present precordial area of dullness. Note how the right border of the dullness curves towards the median line at the fifth rib, whereas in figure 2 the right line of dullness extends downward and outward to meet the hepatic line of dullness. In this case we had the displacement of the liver, the Williams' tracheal tone over the manubrium and gladiolus, the dullness of the internal portion of Traube's space, the tracheal tone and broncophony over the infrascapular area and the paravertebral flatness to assist in diagnosing pericarditis with effusion. Though with all these signs had there not been the deep palpable resistance to the right of the sternum I should not have had the courage to aspirate the pericardial cavity. I' INFECTION AFTER ABDOMINAL OPERATIONS, AND ITS TREATMENT BY HUNTER ROBB, M. D. Professor of Gynecology, Western Reserve University, Gynecologist to Lakeside T is a well-recognized fact that the honest student in any subject often learns less from his successes than from his mistakes. Among the many benefits which the science of bacteriology has given to us is to be reckoned the power of determining definitely the true nature of certain processes which, during the life of the patient, were hidden from, and mistaken by, the clinician, and which formerly escaped the notice even of the most painstaking and careful pathologist. Among these conditions are those which are the result of a septic infection which has not given rise to the characteristic symptoms of septicemia and in which death has often been regarded as having been due to shock, pneumonia, heart-failure, suppression of urine or some more or less intangible cause. This vagueness is now, thanks to the bacteriologist, becoming rarer every day; and if his decisions are not always conducive to the maintenance of the self-satisfaction of the operator, nevertheless they are to be received with submission, and the lessons taught by them should be taken. to heart, in order that no avenue of danger may remain unguarded, and no time may be lost in rectifying, as far as possible, any untoward condition which directly or indirectly may have resulted from some perhaps unavoidable imperfection in our operative procedures. Read before the Cleveland Medical Society June 10, 1898 Autopsies are on record at which none of the local lesions which attend septic inflammation were demonstrable to the naked eye. The examination of coverslips, however, made from a small amount of fluid in the pelvic cavity, has shown that organisms were present in large numbers, and culture tubes inoculated with the same fluid gave the characteristic growths. Experiments have shown that the poisoning resulting from a peritoneal infection is sometimes so intense as to cause death before the appearance of any marked local reaction in the peritoneum itself. In the fatal cases in which it has been impossible to secure a complete autopsy, even in which during life the ordinary symptoms of such a condition were absent, we have not the right to state positively that death was not due to septic infection. One frequently reads in the literature reports of patients dying of intestinal obstruction or intestinal paresis following abdominal operations. The obstruction in the great majority of cases was not present before the operation, and if such a condition follows immediately afterwards or within several weeks of the operation, we cannot feel sure that the condition has not occurred as the result of an infective agent, introduced or set free at the time of operation, without having excluded this by a careful microscopic examination of the exudate. But, besides serving as a means of correcting our errors and making us even more careful in our operative technic, it seems to me that the fact that such untoward symptoms are not infrequently associated with the presence of septic infection affords us valuable indications for treatment. My recent experience certainly has led me to the opinion that in many cases, in which the patient, after operation, does not progress satisfactorily, the abdomen should be reopened and irrigation should be freely employed. Occasionally we can accomplish all that is necessary by opening the vagina behind the cervix, separating adhesions and washing out the lower portion of the pelvis with salt-solution and afterwards employing a gauze drain. In most cases I prefer, however, to employ the abdominal route, since I believe that in this way it is possible to separate adhesions to much better advantage, while at the same time one can sponge out any fluid or other material that may have accumulated in the pelvis and carry out irrigation to better advantage. It has therefore become my custom whenever a patient complains of frequent attacks of pain in the abdomen or of pain that is more or less persistent, with or without marked distention, throughout convalescence, or even when these symptoms begin after the patient seems to all practical purposes to have recovered from the operation, to try for a short time the measures that are ordinarily carried out for the relief of such conditions, and then if improvement does not speedily take place, to reopen the lower angle of the incision, gently separate adhesions, freely irrigate the pelvis with sterile normal salt solution and finally introduce a piece of gauze for drainage. Even in some instances in which the temperature is practically normal and the pulse not over 90 and no vomiting is present, but in which the abdominal pain persists or is so marked that it requires the use of morphin to relieve it, I believe that we should irrigate and drain as soon as possible, particularly in the case of those patients who cause us anxiety by seeming better one day and worse on the next. When the abdomen becomes distended from the very first and when the bowels are not relieved by the usual methods, and the patient is surely getting weak or not improving, I do not think that we should waste any time before reopening the incision and washing out the pelvis thoroughly. Even in those cases which have already been drained, if the temperature and pulse become much increased, even though we may not have vomiting and distention to contend with, I believe we should wash out and establish our drainage afresh. The drainage-tube or the gauze drain may not suceed in carrying off the material which is producing the symptoms and yet in such cases we may succeed in washing it away by irrigation. Even in the most desperate cases thorough irrigation and drainage can never do harm and the good results which may follow the procedure are sometimes simply astonishing. The secondary operation will not, in the majority of cases, shock the patient to any extent as all the necessary measures can be carried out while she is in bed. The lower angle of the wound should be reopened, a two-way catheter carried down to the lower portion of the pelvis and irrigation with sterile normal salt-solution can then be carried out. In cases in which the symptoms are not so urgent, that is, when the pulse is not over 120, I do not hesitate to give the patient a small amount of ether in the operating-room, and then thoroughly explore the pelvic cavity through the line of incision, in order to let out any fluid that may have accumlated. At the same time any adhesions that may be binding down some portion of the intestine are generally separated. After this I irrigate with large quantities of sterile salt-solution and introduce gauze drainage. The following cases will be of interest in demonstrating the conditions met with and the treatment that was carried out in the individual cases. Case I-Porro-Cesarean Operation for Large Interstitial Myoma Obstructing the Pelvic Canal On the third day the pulse rose to 125 to the minute and the temperature to 102° F. There was at the same time some slight abdominal distention. The bowels were thoroughly well opened. The pulse increased in frequency to 140 and ranged between this and 160. The temperature by the mouth was 102.5° F. Seeing that the patient was assuredly getting worse, I determined to open the lower angle of the incision and to irrigate the pelvis and institute drainage. This I did on the evening of the fourth day without anesthesia while the patient was in bed. On opening the lower angle of the wound a |