The Psychic Factor in Disease

symptoms of severe shock, local pressure, tenderness and rigidity.When extravasation and hemorrhage occur, the pulse begins to rise and we have then im- perative indications for interference; a few hours' de- lay tips the scales unfavorably.The call for surgical consultation is imperative in ¡ill eases of gastric perforation, for operations to be successful must, according to Lund, be performed within twelve hours of the accident, 7!l% recovering of these early operative cases.The general conditions, according to Warren, under which surgery may become necessary in gastric and duodenal ulcers are perforativo hemorrhage, persistent spasm of the pylorus with pain and dilatation, and, finally, perigastritis with the formation of adhesions and abscesses, the causis of death in these cases be- ing septic peritonitis, retrogostrio and subphrenic ab- scess.In all perforativo cases where pain is continuous, or when it revives after a period of freedom from if, the call for aid must, be heeded immediately, Nature showing that she cannot resist the.invasion.General abdominal distention and immobility are the two other most important, allied signs calling for Outside aid.If the general distention does not'pass away after the use of rectal tube, turpentine enema, etc., by tlie second day, if indicates a progressive ease and a surgical oiks.In perforativo appendicitis general distention with pain and pressure tenderness, but without localized tumor, is a grave condition ; if in such a case the temperature constantly rises, the prognosis becomes worse and death is imminent within lour days, unless surgically treated.Leiicoeyfosis, as you know, increases and is marked before this perforation of ¡m appendix or ulcer, but afterward suddenly drops, und when general peritonitis supervenes, if may disappear entirely.Its presence serves to differen- tiate appendicitis from typhoid, aneurism, simple ob- struction, Moating kidney, uncomplicated renal or he- patic colic, functional colic, fecal accumulation and ataxia.A steadily increasing leiicoeyfosis in appen- dicitis is always a bad sign though Other signs i in- prove.Typhoid perforations, -As from 10% to 20% of typhoid fatalities are caused by perforation, the major-'ty of them occurring hi the region of the cecum, a peceilt list of I O.'l operative cases, including Dr. Keen's, 18 of some interest, showing finit 21 were saved when done within twenty-four hours.Scnn writes, relative to his experiences in the Santiago campaign, that a bullet may penetrate the abdominal cavity at or above the umbilicus without causing lesions which demand s,"'gical attention, but that if if pénétrâtes below the ¡ j ftvel , one to fourteen perforations will occur.Did ''"'le allow if would be profitable to discuss Professor Mauley's aphorism : " When in doubt don't operate."y o would raiher say, first consult, then if in doubt, ''•'-patient being in fairly good condition but with symp- oiiis growing progressively worse, give him the bene- '* "Ithe only plausible course and operate.Of these °ases of perforation if may justly be stated that the ^perience of Professor Si-un at Santiago, and of Sir '"• MaoCormac in South Africa, points to the advisa- ""¡y of non-interference in visceral wounds below the j !"' 1"1' 1' -!!« made, by the modern bullet, while in civic ' !' the traumatic cases of abdominal blows and crushes , ter ;i much less successful surgical lield than the Vm'h pathologic.When the terni peritonitis can be relegated to the same oblivion as luis the term bedridden in connec-