nightshade

1065NIGHTSHADE.-SURGICAL DRAINAGE

Nightshade.THE series of cases of belladonna poisoning, notes of

which have been appearing in our correspondencecolumns, brings before us two striking points in thetoxic action of this drug. First, the capricious wayin which it selects its victim ; and, secondly, the wayit spares its victim when it has brought him todeath’s door. Many of us have had experience at

any rate of minor cases of poisoning such as that ofa patient who, after the application of a belladonnaplaster or of the liniment, has a widespread erythe-matous rash, or loses the power of accommodation socompletely that he or she-it is generally, of course,a female patient-avers blindness. Dr. D. FiRTHand Dr. J. R. BENTLEY, in the case related in THELANCET of Oct. 29th (p. 901), gave a more unusualmethod of absorption, a method which may well havebeen the cause of some of the unclassified cases ofrabbit poisoning in the past. Atropine is rapidlyabsorbed and rapidly secreted, mainly by the urine,so that in this case the rabbit had probably taken theherb recently. On the other hand, patients, deliriousfrom atropine, and even those who have reached thestage of the somnolence which follows delirium,frequently recover. The poison works itself off in

sleep, and the patient who has seemed in dangerwakes as from a dream. While the opium case

frequently does badly, the patient who seems tohave a corresponding depth of poisoning from bella-donna does better than the medical attendant mightexpect. Of course, there are a certain number ofdeaths. In the Registrar-General’s causes of deathin England and Wales for the nine years 1911-19102 deaths are recorded (accidental and suicidal) inwhich belladonna and hyoscyamus apparently playedsome part. Of recent years pharmacology hascleared up the active principles of the belladonnaseries, so that now we have little to consider but theisomers atropine and hyoscyamine, and the closelyallied hyoscine or scopolamine. The two first stimu-late the brain centres and paralyse nerve terminals,the last depresses both centres and terminals. Thevarious species of datura are now recognised to owetheir active properties to these alkaloids. Poisoningby any species of datura must be very rare in Britain,but ISHMAEL states, in the Practitioner of July, 1915,that in Cairo datura poisoning is so common that itoccurs in frequency next only to acute alcoholism,and the symptoms are those of belladonna poisoningas regards the dilated pupil, the joking delirium, andthe rapid recovery. He further writes, " I have notseen a fatal case, though many on admission wereand remained for some hours on the verge of death."

BRITISH ORTHOPÆDIC ASSOCIATION.-The annualmeeting will be held on Dec. 2nd and 3rd, at Liverpool, underthe presidency of Sir Robert Jones. On Dec. 2nd, the morningsession will be held at the Liverpool Medical Institution,where, at 10.30 A.l’tL, a discussion on " The Late Results ofthe Treatment of Congenital Dislocation of the Hip " willbe opened by Mr. H. A. T. Fairbank, followed by Mr. E.Laming Evans. Mr. C. Thurstan Holland will give a

demonstration of radiograms of bone and joint affections.The afternoon session will be held at the Royal SouthernHospital, where Mr. T. R. W. Armour will give a demonstra-tion of operations and cases at 2 P.M. On Dec. 3rd, at9.30 A.M., a short paper on a series of endosteal tumours willbe read by Mr. Harry Platt. A demonstration of endostealtumours and bone cysts will be given by Mr. R. C. Elmslie,and a paper on Function in Relation to Repair in Bone willbe read by Mr. D. McCrae Aitken. In the afternoon visitswill be paid to Heswall and Leasowe Hospitals.

Annotations.

SURGICAL DRAINAGE.

" Ne quid nimis."

THOSE who have followed surgical practice duringthe last 20 years have observed varying fashions inthe methods of drainage, and even now there is nofixed rule of teaching. In our issue of Oct. 29thMr. F. D. Saner judiciously discussed the firstprinciples involved in the treatment of acute suppura-tion and recalled the fact that drainage benefits largelyby relieving tension. On the general question ofdrainage Mr. Saner suggested that the prominencegiven to several very attractive but accessory lines oftreatment such as antiseptics, tissue solvents, serums,artificial hyperæmia, has tended to divert us fromconsideration of the main principles. All surgeonsof wide clinical experience will agree that rest andrelief of tension are the most important points toattend to in a case of spreading inflammation. Indealing with large serous cavities, such as theperitoneum and pleura, other factors intervene.The main principles must be fulfilled, yet opinionsas to the technique of abdominal drainage still differgreatly. It is not so long since any patient sufferingfrom spreading peritonitis would leave the theatrewith many rubber tubes projecting from the abdomen,like quills upon the fretful porpentine. This was thetime when futile attempts were made to flush theperitoneal cavity free from infection by copiousstreams of saline solution.Such methods, since they involved the neglect of

the natural reparative processes of the peritoneum,were scientifically unsound and practically unsatis-factory. Later there arose the school which taughtthat the peritoneum could take care of itself in thepresence of infection, so long as the main part of thegross exudate was removed by operation ; thisassertion was backed by experimental proof, whichshowed that drainage-tubes inserted into the abdo-minal cavity did not drain the main cavity for morethan 12 to 24 hours owing to the formation ofadhesions. Clinically it was found that the peritoneumcould cause absorption of large masses of blood-clotin cases of ruptured tubal gestation. L. S. Dudgeonand P. W. Sargent showed that such clot was frequentlyinfected by staphylococei. Further it was shownthat even gross contamination of the peritonealcavity, as evidenced by turbid fluid or lymph oreven pus, could sometimes be successfully absorbedwithout drainage. But the question of closing theabdomen in the presence of infection is still sub judice.Mr. Saner voices a common view when he regardsit as largely a matter of judgment whether theabdomen should be closed and the patient asked todeal with the remainder of the inflammatory process.If tubes are inserted, he says, it must be on theunderstanding that their purpose is not drainage,but an attempt to create a temporary track or lineof least resistance. Possibly it is too great an assump-tion that the insertion of a tube merely relievestension. There are cases of peritonitis in whichmuch fluid is secreted and few adhesions form.Following perforation of a gastric ulcer there isoften such free drainage from a pelvic tube forseveral days that no one can believe the fluid to comemerely from the track of the tube. Experimentsupon the formation of adhesions made upon normaldogs need to be checked from the experience ofdisease and surgery upon human beings. Peritonealexudates vary greatly in their lymph-forming powers ;ascitic fluid and some forms of inflammatory exudatedo not tend to form limiting adhesions so quickly,and will continue to drain through a tube for a longerperiod than the prescribed 48 hours.In judging how and when to drain the abdomen

one must therefore consider the intensity of theinfection, and the fibrin-forming or clotting power of