860 HOSPITAL MEDICINE AND SURGERY.

than lupoid. In the case of cancerous or sarcomatousulceration, the destruction of the soft parts can beregulated. and determined very accurately. Unlike theescharotics in common use, it has practically no effect onhealthy cutaneous or mucous surfaces, but requires the actionof a granulating or raw surface to determine the formation ofsulphurous and sulphuric acids, which are apparently theagents which influence the vitality of the organisms andtissues with which they come in contact. I have also found

sulphur most useful in the foul ulcerative stomatitis which isso common among the children of the poor, and which resistsso obstinately such local treatment as is usually adopted. Insuch cases, if gauze or wool be dusted abundantly with thefinely powdered drug, and this be retained in firm contactwith the foul ulcerated surface for an hour or two, sufficientdestruction results to clear the surface of its infectiveorganisms, and it then heals rapidly. Should one applicationnot produce a sufficient result, a second or even more maybe required, the number depending on the extent andlocality of the ulceration, the facility with which the

plug can be retained in position, &c. Also in the foulimpetiginous ulcers in children, the application of sulphuris similarly most effectual in the destruction of the micro-organisms producing these conditions. I might multiplyvery largely similar examples of the good results thatmay be obtained by the action of sulphur used in thismanner, but I think that I have given enough to induce othersurgeons to give it a good trial. Sulphur, like iodoform,becomes active as a germicide, and is very considerably morepowerful in its action than iodoform only when in immediatecontact with a raw surface, the living tissues causing it toform certain combinations with hydrogen and oxygen, 3

St. Thoma,s’a-street, S. E.

HYDATID OF LIVER ; OPERATION ; RECOVERY.BY ROBERT JONES, F.R.C.S. EDIN.,

HONORARY SURGEON, ROYAL SOUTHERN HOSPITAL, LIVERPOOL.

THE patient, a woman aged twenty-one, was sent to me byDr. Evans of Festiniog through Dr. Carter, who had diagnosedhydatid of liver. I first saw her on May 8th, 1893. She then

gave the following history. About six months previouslyshe noticed DJ swelling below the lower border of the ribs onthe right side. It caused no pain or inconvenience, andseemed to her about the size of a hen’s egg. The tumour

developed rapidly, but she was able to go on with her work,paying but little attention to it. She took her food well, andup to five weeks before my examination of her she was in

absolutely good health and suffered no local disturbance.She then had rheumatic fever, from which she made a rapidrecovery. Her family history was good. It should be notedthat three dogs were kept where she was a servant, two ofthem living in the house.On examination the patient looked healthy, with rosy

cheeks and bright eyes. The abdominal swelling was dull onpercussion, and extended about four inches in every direction,taking its centre to the left of the right hypochondrium. Itwas uniform in contour and moved up and down duringrespiration, the skin not being affected beyond being tense.The mass conveyed a thrill to the hand on palpation, but wasnon-pulsatile and no bruit could be heard on auscultation.

I transferred her for operation into the Royal SouthernHospital. An incision was made on May 17th in the middleline of the abdomen about three inches in length, from aboutone inch and a half below the ensiform cartilage. All bleed-ing was stopped and the peritoneum was opened to the extentof about one inch. The tumour presented itself at the

wound, could be moved freely, and had formed no adhesions.It was found to have occupied the liver. Some of the con-tents, which were of the usual hydatid character, were re-moved by aspiration. An incision, about three-quarters of aninch, was then made into the cyst and the finger introducedfor the dual purpose of preventing leakage into the abdo-men and of introducing the cyst wall into the abdominalwound. One hundred and twenty ounces of fluid then escaped,and even then the cavity was not emptied. The incision intothe cyst was then enlarged and attached to the abdominal

2 Dr. Ray-Pa.ilhade, from experiments on the action of sulphur inye!tst &c., concluded that there exists in living tissues a substancewhich he culls philothion, which can combine with sulphur. Particularsas to his experiments will be found in his R<Jchethes Exp6rimentalessur le Philothloll.

parieties by a double set of sutures, the inner set being com-posed of a continuous stitch and serving to fix the hepaticincision to the parietal peritoneum. By the guidance of thefinger placed within the cyst a few outside interruptedsutures were so placed as not to perforate the whole thick-ness of the cyst wall, these serving both to lessen the dragupon the abdominal wound and to extend the area of opposedperitoneum. The stitching being completed large portions ofthe cyst wall were removed by forceps, and the cavity wellwashed out by quantities of mild warm boracic lotion. Alarge-sized drainage-tube was inserted and the wound wasdressed in the usual way. With the exception of an occa-sional elevation of temperature the subsequent progress ofthe case was in every way satisfactory. The cavity was regu-larly washed out, and for some four or five months continuedto discharge, and for the first six weeks portions of the cystwall were found in the dressings.On Sept. 2nd the patient was discharged, cured.Liverpool.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

LONDON HOSPITAL.A CASE OF LOCALISED SUPPURATIVE PERITONITIS WITH

GASEOUS DECOMPOSITION.

(Under the care of Mr. MCCARTHY.)

Nulla autem est elia pro certo noscendi via, nisi quamplurimas et mor.borum et dissectionum historias, tum aliorum turn proprias collectashabere, et inter se comja.ra.re.&mdash;Mo&GA&Nl De Sed. et Caus. Morb.,lib. iv. Proaemium.

-

THIS is an example of an acute form of abdominal abscessto which the term "tympanitic " is sometimes applied. The

operation did not throw any light on the causation of thedisease, and that must remain obscure, especially as thevermiform appendix could not be felt. We occasionallymeet with somewhat similar cases in younger people in whichthe appendix is also probably the cause of the trouble, butwhich close satisfactorily, and nothing further occurs to

help in the diagnosis. The other cases mentioned byMr. MacCarthy render the series of considerable interest.

In December, 1893, Mr. McCarthy was requested to see aman who had been admitted on the medical side of theLondon Hospital three days previously with abdominaltrouble. The patient, a man aged thirty-two, with an

excellent family and personal history, had been suddenlyseized with severe abdominal pain followed by vomiting.For this he was admitted into the hospital. His bowels actedwith purgatives and enemata, but the pain and vomitingpersisted. The vomited matters consisted of food and bile-stained fluid. His temperature was normal. When seen byMr. McCarthy he was in great pain and writhed aboutin bed, so as to render examination difficult. When he wasinduced to lie still for a few seconds the appearance ofthe abdomen was remarkable. Above the umbilicus theabdomen was slightly retracted, and below the umbilicusit was distended, especially in the centre, which from theumbilicus to the symphysis pubis presented an ovoid pro-minence, such as would be caused by a greatly distendedbladder. Percussion was impossible, as the slightest touchcaused great pain, but the appearance and history of thepatient suggested localised suppuration, with gaseous decom-position. The patient having assented to an operation if itshould be thought requisite was anaesthetised. The percus-sion note over the central prominence was then found to bevery tympanitic. A catheter was passed but the bladderwas empty. The abdomen having been shaved and washedwith carbolic lotion (1 in 20) a vertical incision for about twoinches was made through the skin in the middle line midwaybetween the umbilicus and symphysis pubis. This wascarried down layer by layer until the peritoneum was exposed.When this was punctured a quantity of fetid gas escaped.When the opening was enlarged about a pint of putrid pus

861HOSPITAL MEDICINE AND SURGERY.

came away. Mr. McCarthy especially explored with his

finger the right iliac fossa, so as if possible to ascertainthe condition of the vermiform appendix, but it could notbe felt. The bowels had been pressed upwards and to theside so as to leave a large cavity, which had smooth wallsand extended into the true pelvis as far as the fingercould reach. No further exploration was made from fearof breaking down adhesions and generalising the peri-tonitis. The cavity was copiously irrigated with warmboracic lotion, a large rubber drainage-tube was inserted,and the wound was sutured and dressed antiseptically.The next day the patient was very comfortable ; the painand vomiting had ceased and he had slept well. For thefirst two days the discharge through the drainage-tubehad a putrid odour notwithstanding daily irrigation withboracic lotions. On the third.day after irrigation about twodrachms of iodoform emulsion were injected and the putridityceased. For the first week the temperature varied from990 to 101&deg; F., and then became normal. The patient’srecovery was rapid and uninterrupted, and by the middle ofJanuary, 1894, he was practically cured, but was kept underobservation for another month and then discharged, withdirections to return at once if any untoward symptom shouldoccur.

In commenting on this case Mr. McCarthy mentioned avery similar one which had some years before been underthe care of Mr. Couper. The following particulars havebeen extracted from the Hospital Register and are publishedwith Mr. Couper’s permission. In December, 1886, a managed forty-eight was admitted with intense abdominal pain,vomiting, and diarrhoea. He stated that he had beenlosing flesh for two years, but could give no explanation ofthe cause of his then condition. As he did not improve,Mr. McCarthy saw him in consultation with Messrs. Couperand Tay on Dec. 23rd. He was in a state of extreme pro-stration. At the lower part of the abdomen there was anovoid prominence simulating a distended bladder and verytympanitic on percussion. Localised suppuration with

gaseous decomposition was diagnosed. The patient wasaneasthetised and the abdomen opened in the middle line.A quantity of gas and putrid pus escaped. Convalescencewas tedious, and the temperature charts indicate that thepatient was in a hectic condition for several weeks, but heultimately recovered, and was discharged cured on May 5th,1887.A third and somewhat similar case was mentioned which

occurred in private practice. In May, 1877, a man agedseventy was under the care of the late Mr. Coward of

Bromley-by-Bow for what was diagnosed as typhoid fever.The chief symptoms were abdominal pain, vomiting, anddiarrhoea. The late Dr. Sutton, being consulted, thought asurgical opinion desirable. On May 22nd Mr. McCarthy sawthe patient in consultation with Dr. Sutton and Mr. Coward.The patient seemed to be dying. His face was livid, histongue dry and brown, and his pulse scarcely perceptible.The abdomen was uniformly distended; but in the righthypochondrium the skin was livid and oedematous, and overa limited area the percussion note was very tympanitic. As thepatient’s condition prevented any anaesthetic being employeda scalpel was thrust in as in opening an ordinary abscess.Gas and about ten ounces of very fetid pus came away.By digital exploration a large cavity was found with irregularprojections on its median wall, but no abdominal viscus couldbe recognised. The cavity was washed out with warmwater, and ordinary dressings were applied. No special anti-septics were used. The next day the patient was much better,and pain and vomiting had ceased. The cavity was washed outwith warm very dilute Condy’s fluid, and during the processtwo small bodies floated up, which proved to be grape pips.The patient then stated that for several weeks before hisillness he had eaten large quantities of grapes daily. Hisrecovery was rapid, but a sinus persisted for several weeks.On Aug. 27th he called on Mr. McCarthy, and the woundwas then soundly healed. He stated that twenty-seven moregrape pips had come away from time to time in the discharge.In this case Mr. McCarthy thought that the suppurationwas extra-peritoneal. He conjectured that the grape pipshad accumulated in the vermiform appendix, and that this,having become adherent to the parietal peritoneum, hadulcerated through into the subperitoneal tissue. The result-ing suppuration had pointed upwards, possibly guided bythe peristaltic contraction of the ascending colon. In theother cases the suppuration was certainly intra-peritoneal,but there was nothing to indicate the exciting cause.

HULL ROYAL INFIRMARY,COMPLETE ATRESIA VAGIN&AElig; (ACQUIRED).

(Under the care of Mr. HENRY THOMPSON.)THE usual cause for such a condition as that described in

this case is difficult labour followed by irregular sloughing ofpart of the vaginal wall. In the absence of a history ofunusual difficulty during any of the confinements which

occurred before the one during which the occlusion was firstnoticed it is difficult to assign the cause with any certainty ;it is not, however, improbable that it may have been theresult of syphilitic infection, for the husband is stated tohave suffered severely from the disease. The other causes foracquired atresia are excluded. There is no account of injuryfrom a foreign body or cauterisation, and none of gangrenefrom infectious disease, of lupus of the vagina, of suppura-tion in the true pelvis, or of vaginitis. The occlusion wascomplete, leading to retention of menstrual fluid and render-ing operation imperative. Dr. Skene writes of operation inacquired atresia vaginse: ,The difficulty in the operation andultimate success depend upon whether the atresia is partialor complete. If the portion of the vagina which is closed islimited to one-third of the whole canal, reasonable hopes ofsuccess may be entertained, but I doubt if the vagina wasever fully restored and maintained when complete atresiaexisted." Schantz has described two cases in which he was

compelled to perform Porro’s operation for pregnancy com-plicated by atresia vaginas. The treatment after operation ofthese cases is very troublesome. For the notes of this casewe are indebted to Mr. Sutcliffe, house surgeon.A woman thirty-one years of age was admitted into the

Hull Royal Infirmary on Sept. 9th, 1893. The patient was amarried woman and has had five children. The first fonr ofthese were born without difficulty, the first being stillborn,but the other four living and healthy. Nothing abnormalwas noticed until she was in labour with the fifth child,when the medical attendant, Mr. Baron, found that thevagina was occluded by cicatrisation. Whilst under chloro-form a powerful labour pain came and drove the child throughthe occluded passage, tearing open the adhesions. Nothingfurther was done, and the woman nursed the child for sixteenmonths, at which age it died from bronchitis. Shortly afterthe death of the child the woman went through all the

subjective symptoms of a menstrual period, but there wasno escape of fluid. She was accordingly examined byMr. Baron, who sent her under the care of Mr. Thompsonat the Hull Royal Infirmary. So far as could be madeout there was no history of injury, but the husband wasknown to have had severe syphilis. In spite of thecondition described below, regular sexual interecurse badtaken place up to the time of admission to the hospital.On admission, the patient was a stout, well-developedwoman. Vaginal examination revealed a complete occlusionby cicatrices up to within an inch of the external orifice.Per rectum a fluctuating swelling could be felt occupyingthe vagina above the atresia. The abdomen was ratherdistended, but the fundus uteri could not be distinctly madeout above the pubes. On introducing one finger into therectum and another into the remains of the vagina the twoopposing surfaces could be felt to glide over one another ;accordingly, under ether an incision was made at this point,and a large quantity of black treacly fluid escaped. Theincision was extended in various directions, the vaginastretched so as to admit three finger?, and then the vaginaand uterus were well washed out with hot solution of per-chloride of mercury (1 in 5000). After the fluid had been allwashed away examination showed that the os uteri andneck had apparently disappeared, and that the upper part ofthe vagina and the whole of the uterus formed one hugecavity. The douching being finished, the vagina was lightlyplugged with iodoform gauze and an external antisepticpad and T bandage applied. The patient never bad a badsymptom, and she menstruated naturally on Sept. 20th. Onexamination on the 23rd the vagina was found to be re-

closing ; the cicatrices were accordingly again freely divided,and the vagina was stretched and plngged. On the 28th aBarnes’ dilating bag was given to the patient with instruc-tions to use it regularly, and she was discharged.Remarks by Mr. TnoMPsoN.-Such complete acquired

atresia I personally never saw before. I could find no aper-ture that would admit even a probe. The woman herselfwas utterly unconscious that anything was or had been the