At 12.40 gave hypodermic of same strength as the first night, after which there were no more convulsions, and he slept. On the 27th of June he got three compound cathartic pills, but had no dejection during the day. At 5 P. M. the convulsions recurred, and in the next two hours he had fifteen. Then got an enema of glycerin and water, followed by a slight dejection; after which there were no more spasms. During this day his respiration had been labored, but what was the exact condition of his lungs I did not know, having myself a temporary deafness which prevented auscultation. He had no cough nor expectoration, but there was forced expiration, a rapid and feeble pulse, and a temperature of 99°. At 8 P. M., Dr. John C. Shaw him in consultation, and found on auscultation a rather coarse crepitus over whole of both lungs posteriorly, and to a less extent in front. He found no cardiac signs. He suspected the convulsions were uræmic. The urine had not then been examined; there was, however, no oedema anywhere, no vomiting, nausea or headache-only entire want of appetite. We increased his stimulants, giving whiskey or champagne, alternating with carbonate of ammonia every two hours. June 28th.-Had two dejections in the night. No convulsions. Slept uneasily. Passed xij of acid urine during the night, which showed the merest trace of albumen, but no casts, nor any other peculiarity. Seidlitz powder now. B Tinct. Strophanthi, gtt. x, every three hours. June 29th.-Slept fairly well. Two dejections. Temperature normal all the time. Pulse small and rapid. Expiration still forced. Moderate pain still in cardiac region. Urine has hardly any perceptible albumen; no casts. June 30th.-One dejection yesterday. Pulse 102. Temperature 981. Setting him up to auscultate him, his pulse fell to 90, and became irregular. Has some desire for food, but only liquid. Takes about three pints of milk, a cup of cocoa, one of beef tea, and the juice of three or four oranges, daily. Evening.-Pulse 102. Temperature 98°. July 1st.-Yesterday got strophanthus only every six hours; since last evening every three hours. Now, pulse somewhat increased in volume, regular, 102. Temperature normal. Temperature normal. No forced expiration. Pain in cardiac region slight and not constant. Tongue nearly clean. No dejection. Urine freer-3 xvj during night; no albumen. Seidlitz powder. July 2d.-Slept more. afternoon. Feels as well. One dejection yesterday Eight ounces of normal urine in night. Pulse 101. Temperature 99% July 3d. Evening. -Has had a comfortable day. Says he feels a little better every day. Has not been able to lie on left side, but lies on back or right side. Breathing only occasionally labored. Has little pain. Does not sit up at all. Pulse still feeble, but has more volume than several days ago, and is regular. Tongue about clean. Takes his liquid food with some relish. Is in good spirits. Sleeps well. At my request Dr. G. R. Westbrook examined his chest carefully this evening. Found coarse crepitus at the base of chest in the rear, most marked on the right side, where the respiration was somewhat bronchial; elsewhere nothing abnormal, front or back. Heart sounds faint; no souffle; no impulse. He sat up two or three minutes for examination without any lowering of the pulse, which was 100. July 4th.-Passed 3 xvj of urine in the night. Sleep somewhat disturbed by street noises, but feels well this morning. Temperature in the last two nights has been 99. Pulse as it has been. Substitute tinct. ferri chloridi and acidum phosph. dilutum for the carbonate of ammonia. 2 P. M.-Found dead, his nurse having sat in the next room for an hour, supposing him to be asleep. Face and hands cold where exposed. inclined. Blood has settled on left side of face, to which his head is Pupils very little dilated. No rigor of arms, but jaws stiff, and a little froth between the lips. To recapitulate: An elderly man with a weak heart had an indi-` gestion, followed by complete loss of appetite and sluggish bowels for three days. Forty-eight hours from attack, convulsions, checked by hypodermic of morphia and atropia. On the third day dyspnoea began, which proved to be due to pulmonary congestion, resulting from cardiac weakness. On that day recurrence of the spasms, finally arrested by action of the bowels. The only symptom of any consequence after this was the dyspnoea, which began to lessen on the sixth day; and his improvement in every way was continued without interruption to the time of his sudden death on the eleventh day. For the last three days of his life his temperature was 99%, but his appetite was good, his digestion normal, bowels free; and his urine, which had at one time a trace of albumen, was normal in quantity and quality; and not a symptom indicating peritoneal inflammation or any new morbid condition, except an elevation of one degree in temperature. The symptoms of acute peritonitis are a dorsal decubitus, with knees drawn up; pain and extreme tenderness over the abdomen, which is distended; a general aspect of collapse; constipation and vomiting; scanty urine; cold sweats; pulse rapid and small; an elevated temperature; thirst; respiration shallow and rapid; voice weak -all wanting in this case. Indeed, he was feeling better every day. It is difficult to state with any degree of positiveness the mutual relations of the various symptoms in his case. The cardiac dilatation and adipose deposits had not manifested themselves previously to this fatal illness by any symptoms. But they were probably the original cause of the pulmonary congestion and the spasms. The spasms correspond to the pseudo-apoplectic attacks which Stokes describes in some cases of fatty degeneration of the heart. But the spasms and the pulmonary congestion might never have occurred had active purgation been procured on the first day. During the first two days, the patient. presented no marked symptoms; he seemed to be simply weak and without appetite, as might be natural after an attack of gastric indigestion; and rest, with a saline cathartic, appeared to be all the treatment required. The saline was repeated on the second day, and rhubarb pills added; and on the third day, after the first convulsions and the commencement of dyspnoea, more powerful cathartics were administered, and when free catharsis was established, general improvement soon began. Active stimulation with whiskey, ammonia, and strophanthus were continued with good effect during the life of the patient. Was death due to a convulsion, produced possibly by his inclining to his left side during sleep, which had always during this illness brought on dyspnoea? What part did the peritonitis play? It gave no sign whatever during life. The autopsy revealed the existence of an old affection of the peritoneum, in the cicatrices in the peritoneal surface of the ileum, and the roughness of the surface of the liver, without any adhesions; but there was no history of anything that would account for these lesions. MEANS FOR THE MORE PERFECT STERILIZATION OF SURGICAL INSTRUMENTS AND DRESSINGS. BY H. BEECKMAN DELATOUR, M. D., Read before the Brooklyn Surgical Society, Oct. 17, 1889. So much has been written upon the preparation of surgical dressings since the advent of antiseptic surgery that there seems hardly room for more to be said. Yet, with all this literature, opinion is still divided as regards the best means of sterilization, and, as a consequence, the subject appears to be very complicated. With this state existing, is it not well to look about us and see what means are being employed at our general hospitals? Having this idea. in view, I visited some of our hospitals, and to-night will present you with a summary of what was found. Let us, while reviewing the sterilization of dressings and instruments, also look at the means used to render aseptic the parts immediately about the field of operation and also the cleansing of the surgeon's hands. That the seat of operation should be sterile does not admit of question. Too little attention has, as a rule, been given to this subject, for of how much avail can completely aseptic instruments and dressings be if the parts immediately about the wound are not first rendered aseptic? The methods of cleansing the parts, now practised, vary with different surgeons. With some the preparations are very extensive, notably in Germany. Von Bergmann (Centralblatt f. Chir.), for instance, orders the patient a general warm bath, in which he is thoroughly scrubbed with soap and brush, and from this bath is immediately taken to the operating-table. Here the parts are rinsed with alcohol and afterward rubbed with ether and washed again with 1.2000 bichloride solution. At the Presbyterian Hospital, New York, the routine is to give the patient, the night before operation, a general warm full bath, and on the morning of the operation the parts are shaved and scrubbed and another warm bath given. Then, for the few hours preceding the operation, the parts are covered with cloths wet with a one-per-cent. mixture of creolin. Immediately before the incision is made the parts are scrubbed with sapo viridis, irrigated with bichloride, 1. 2000, then a solution of iodoform in ether is scrubbed over the surface. At the majority of the metropolitan hospitals the preparations are not so elaborate; the general rule being to have the parts about the wound shaved, well scrubbed, and covered by an antiseptic solution for a few hours before operation. As to the means used by the surgeon to render aseptic the hands: The majority thoroughly scrub the hands with soap and warm water and then dip them in a solution of either bichloride or biniodide of mercury just previous to beginning the operation. Others use green soap in place of the ordinary soap, dip the hands first in alcohol and then in some antiseptic solution, and from time to time during the operation rinse off the blood in the solution. The general plan of sterilizing the instruments is to have them thoroughly washed with soap and hot water and well dried after each operation. Before being again used they are placed in an antiseptic solution, either three-per-cent. carbolic or 1.4000 hydronaphthol. In some of the hospitals for the more important operations, as laparoto mies, the instruments are either boiled or submitted to dry or moist heat. The usual method of treating the dressings is to subject them to the action of some chemical germicide. The chemical most used for this purpose is the mercuric chloride in solution of the strength of 1.1000 or I. 20CO. Besides chemicals, the well-known sterilizing properties of heat are taken advantage of for rendering sterile both instruments and dressings. The common gas oven, in which dry heat is obtained, the use of superheated steam, and ordinary boiling are examples of this method. It is the object of this paper to more particularly direct attention to this means of sterilization and the facility with which it can be carried out. Heat has always been considered, by the bacteriologists, as the most efficient of sterilizers. Many varieties of bacteria, in fluids, are killed by a temperature of 100° C., if it be continued long enough. When dry they resist somewhat higher temperatures; the spores being more resistant than the bacteria. Even these may be destroyed by repeating the application of the heat after they have had time to develop. From this it follows that all germs existing in dressings or on instruments can be destroyed without the use of chemicals, provided the exposure to heat is made long enough and the temperature sufficiently high. Burrell and Tucker (Boston Med. and Surgical Journal, Oct. 3, 1889) have made some very interesting experiments testing the efficiency of heat and chemicals to sterilize instruments and dressings. They took a number of instruments from a glass case in the hospital, and found that they were always covered with bacteria. They then exposed some of these to the action of 1.40 solution of carbolic, and on examination bacteria were found on all but two. The same was true of 1.500 alcoholic solution of hydronaphthol. Next they boiled the instruments for two hours, all sterile; some were simply steamed, and were found to be not entirely sterile. Another lot of instruments were baked, part at a temperature of 130° C. and the remainder at 160° C. These instruments were all sterile and had not been harmed by the tempera ture. From these experiments we learn that instruments can be more certainly sterilized by heat than by any of the chemical antiseptics, which will not destroy them. The only objection to the use of dry heat is that the danger of an excessive temperature damaging the instruments makes very careful watching of the heating-apparatus necessary. That this objection can be easily overcome, I will demonstrate later on. All dressings can be readily freed of germs by the use of either dry |