an estimation outside influences must always be considered and avoided when possible. Arteriosclerosis plays an important role in blood tension estimation; the greater the sclerosis, the higher the tension estimation, probably because of the inelasticity of the artery walls. These general facts must be borne in mind. when using such an instrument for purposes of diagnosis. I want to call your attention to three diseases or conditions in which blood pressure observations, taken by means of one of the above described instruments are of value. I refer to uremia, intracranial hemorrhage and typhoid fever with its complications. No one now thinks that it is sufficient to note that a patient has a fever, but the degree of temperature is always taken with a thermometer and stated in terms of a known standard. Why, then, should we be satisfied with noting that the pulse tension is high when an accurate and definite statement can be made regarding it? In uremia, pulse tension is always high and in a doubtful case seen for the first time in a comatose condition the tension of the pulse is recognised as an important factor. The course of the disease can usually be foretold with considerable accuracy and when the tension falls in a case of uremia which is still showing such grave symptoms as headache, nausea or convulsions a favorable prognosis may be made, although all other clinical symptoms remain unchanged. And this lowering of pulse tension may be quite imperceptible to the unaided finger of even the most skilled observer. In like manner therapeutic measures may be commenced before such active signals as convulsions have manifested themselves and the severity of the attack undoubtedly shortened by beginning treatment earlier than otherwise would be possible. These facts apply as well in puerperal eclampsia as in uremia. Intracranial hemorrhage.-The brain is the only organ of the body which has not its own vasomotor mechanism. It is believed that when the brain needs more blood the vessels of the body are constricted through the central nervous system, thus sending more blood to the brain as less is allowed to pass through the general systemic circulation. After an intracranial hemorrhage the brain becomes anemic from pressure of the clot and the vasomotor centers contract the arteries of the body in an endeavor to send more blood to the brain. The pulse tension becomes high and again, as in uremia, an accurate estimation of this is of value. In this case in deciding whether or not trephining is necessary. Another point to be taken into consideration as an indication of intracranial hemorrhage is a pressure which shows from moment to moment great alterations in level. A case in point being one operated upon by Dr. Finney, of Baltimore. A young man received a blow on the head and, as I recall the case, there was no indication other than the history; the fact that the patient on the second day complained of more headache than on the first, and that the blood pressure showed great variation, changing in a moment over level of 30 or 40 m.m., but at no time remaining uniformly high. Dr. Finney operated and removed a small extradural clot, the patient making a good recovery. I feel some hesitancy about mentioning this case, as I report it entirely from memory and the operation took place two years ago, but I wish to bring out the importance of oscillation in blood pressure. Dr. Harvey Cushing, of Baltimore, who was one of the pioneers in the use of blood pressure estimations, in speaking of their value in cranial trauma says: "In conjunction with other symptoms a progressive increase in arterial pressure or a high degree of the same which has been already reached or a pressure which exhibits from moment to moment great alterations in level may be taken as a certain indication of the advisability of early operative intervention." Typhoid fever.-The blood pressure in typhoid fever is uniformly low except in complications. In 115 cases which Geo. W. Crile, of Cleveland, reports, the highest pressure noted of any uncomplicated case was 138 m.m.,-the lowest, 74 m.m. The average pressure for first week, 115 m.m.; second week, 106 m.m.; third week, 102 m.m.; fourth week, 96 m.m.; fifth week, 98 m.m. This low tension is evident in the dicrotic pulse, so commonly seen in typhoid. If in a patient suspected of having typhoid fever, with soft arteries and no kidney complications, we find a blood pressure of 140 m.m. of mercury, it is very strong evidence that the patient is not suffering from that diseaseand such an accurate estimate cannot be made with the unaided finger. The pressure is remarkably uniform in typhoid and a sudden fall of 20 to 30 m.m. in a patient under constant observation may be taken as a strong indication of hemorrhage and steps taken accordingly. Its value here, however, is not as great as in perforation where a correct diagnosis and a prompt operation often means life to a patient who would otherwise have a surely fatal termination of his illness. In peritonitis the blood pressure is always high except just before death, or after great shock. In a series of twenty cases reported by Dr. Crile, made with the same instrument and by the same observer as the typhoid series just mentioned, the highest pressure was 208, the lowest 156 m.m.,-the average of all the cases being 166 m.m. Whereas the average of the typhoid cases was Among these twenty cases, there were five typhoid 104 m.m. perforations, the blood pressure before and after perforation being as follows: Before 84 116 116 After 110 180 165 165 208 All of these figures are reported by Dr. Crile in the Journal of the American Medical Association, May 9, 1903. For more than a year I have been estimating with the Riva Rocci instrument the blood pressure of nearly all typhoid patients in the wards of the Buffalo General Hospital and can corroborate Dr. Crile's figures. The highest pressure of uncomplicated cases with soft arteries, coming under my notice, has been 132 m.m. Dr. J. B. Briggs reported in the Boston Medical and Surgical Journal, September 24, 1903, two cases from the wards of the Johns Hopkins Hospital which are such striking illustrations of the value of blood pressure estimations in typhoid perforation that I will give them in some detail, as the second one came under my own observation: Case I.-A young man entered the hospital in the third week of an attack of typhoid. On entrance he was very toxic though not in stupor. Blood pressure for ten days after entrance ranged from 98 to 110. At eight o'clock on the night in which perforation occurred, his blood pressure was 104; at midnight it was 144. At that time he complained of no pain and his abdomen was everywhere soft and natural, deep pressure causing no distress. His leukocyte count below 6,000. At 4 a. m., when being taken from a tub, he gave a cry of pain, the pain being located below the umbilicus. When seen at that time his knees were drawn up and there was extreme tenderness in the right iliac fossa, rigid lower right rectus, and a suggestion of muscle spasm. Blood pressure 150, leukocytes still below 6,000. He was operated upon at 8 a. m. There were two perforations with rapidly spreading peritonitis which the surgeons estimated to have been present eight or ten hours, certainly more than four hours, which was the time which had elapsed since the first sudden starting of pain. It was suggested that in this case perforation had occurred before twelve o'clock, the time at which the high arterial tension was first noted, but that it had been confined within coils of the intestine touching only the visceral peritoneum and that not until four o'clock, the time of the pain, did the peritonitis spread to the parietal walls. Case II. That of a woman who had been in the hospital fifty-seven days. She had had two relapses and five hemorrhages, but no complications for three weeks prior to the date of operation. She had marked toxemia, slight delirium, and slight abdominal pain, never well localised, for several weeks. The leukocyte counts had remained constantly low, the abdomen was somewhat full; but there was no tympanites until three days before operation, when this developed with slightly increased tenderness of the abdomen, never localised. Liver dulness was obliterated the day before operation and there was considerable increase of pain, though never very severe; not enough so that the thighs were flexed. Her facial expression was quite drawn. On the day of operation the leukocytes rose rapidly to 17,000, never before in many counts having been above 8,000. There was no muscle spasm, but tenderness was increased and respiratory movements more limited so that an operation was decided upon, in spite of the fact that blood pressure remained constantly between 115 and 122 and that peripheral stimulation of the skin and central stimulation with strychnia caused a rise in pressure, showing that the vasomotor mechanism was active. Operation revealed no peritonitis or perforation, although over the base of two ulcers there was a slight amount of fibrin. In this case hemorrhage was considered but excluded because the temperature and blood pressure had not fallen. I do not wish to intimate from the history of these cases that estimation of the blood pressure is the one and only thing to be taken into consideration in making a diagnosis of typhoid perforation, but I consider that it should take its place as an important factor in forming an opinion and believe that conclusions drawn from it are of more import than from leukocytosis or distension, and that it should be ranked with muscle spasm, muscle rigidity, general expression and sudden pain. 185 SUMMER STREET. Intestinal Surgery. A Study of the Treatment of a General Spreading Peritonitis. BY MARSHALL CLINTON, M. D., Buffalo, N. Y., Attending Surgeon, Sisters of Charity, and Erie County Hospitals, Buffalo, N. Y.; Instructor in Surgery in the University of Buffalo. T HERE is probably no subject on which a wider difference of opinion will be found among leading operators of today than in their treatment of a spreading peritonitis following perforation of a septic appendix. Individual opinion is generally based on clinical experience, but many men of equal experience hold opposite views of the proper treatment of this condition. Until this subject is settled one way or the other, every case which may shed light on the value or uselessness of each type of procedure should be added to the side where it belongs. The following case offers some interesting features: On January 28, W. H., aged 20, felt a sudden, sharp pain in the right lower quadrant of his abdomen while lifting some timber. He left work, went home and was confined to his bed and under medical advice. The pain increased, his abdomen became distended on the following day and he began to vomit. There was a slight raise in temperature and a pulse running from 100 to 120. There was constipation and enemas were without result. I was called to see the patient January 29, in the evening, and expressed the opinion that he would die unless an operation was performed at once. This was refused until twelve hours later when the condition of the patient became so serious that operation was accepted as the only chance for him. The patient entered the hospital with a pulse of 140, temperature 96°, vomiting continued and he was extremely prostrated. He was prepared for immediate operation. An incision over the appendix revealed a quantity of creamy, foul-smelling pus that seemed to fill the entire abdominal cavity. There were few adhesions and pus was found in every part. Õpenings were made in the middle line, on opposite side and in both flanks. Over ten gallons of hot salt solution were used to flush out his belly, and at the end of that irrigation his general condition seemed slightly improved and the abdominal cavity apparently clean. Large drainage tubes wrapped with gauze were introduced into each incision, draining most of the peritoneal cavity. Twelve hours later while lying in bed with the head of the bed raised to drain the abdomen by gravity he was again irrigated with a large amount of salt solution and a considerable quantity of the same creamy, foul pus was washed out of the tubes as found at the first irrigation. The next day, or twenty-four hours later, the abdominal cavity was found clean on irrigation and the tubes all adherent. The patient convalesced rapidly and recovered completely except for a fecal fistula which had to be closed by a second operation on March 9. He was discharged from the hospital with instructions to watch for a possible obstruction developing and explicitly cautioned to watch for the point of obstruction should it occur. On April 8, at 6 in the morning, the patient telephoned that he was in pain and wanted me at once. He had begun to vomit and said he had felt obstructed since 3 o'clock the previous afternoon. He designated the point of obstruction and wished to go to the hospital immediately. He was entered and prepared for operation. An incision over the point he had indicated along the outer border of the right rectus muscle showed the upper portion of the ileum constricted by an adhesion band. This was easily released with the finger and, milking the contents of the intestine into the empty lower bowel, the incision was closed |