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tended, though with somewhat impaired pronation and, supination.

The Knee. In speaking of the knee I shall confine myself to sprains, of which I have recorded six cases, two of them being physicians. One chronic case was much benefited by four months' use of a plaster cast. In another (a physician) the injury to the joint structures had been very severe, and a month after injury he was unable either to step upon the limb or to extend it within an angle of thirty degrees of straight. I put him in bed with a weight and pulley attached to leg. In five days the leg was straight and protected by a snugly fitting cast he resumed practice. One week later the cast was removed at night and a month later entirely discarded. My method of treating an injury of this kind, if seen early, is complete rest in bed, evaporating anodyne lotions for pain and firm compression by means of a Martin's rubber bandage. When the swelling has been thus reduced a well-fitting cast is applied and the patient allowed to get up, dưe care being taken that resumption of the use of the leg is gradual.

The Ankle. The same treatment applies, in the main, to sprains of the ankle-joint. I keep the patient quiet a few days until the pain is lessened, and swelling reduced by Martin's bandage; then apply firm compression from the toes well up the leg by strapping with adhesive plaster, and encourage the patient to use the joint. The five cases which I have treated in this way gave uniformly prompt and gratifying results. The method of strapping is as follows. First protect the skin by a layer of gauze, adding cotton over the prominent bony points. Then begin at the toes, using strips one to one and one-half inches wide and fifteen to eighteen inches long, and cover the whole foot to the lower third of the leg with overlapping strips firmly applied. In this way, better than any other, we get firm support, at the same time allowing limited use of the joint.

III. VARICOSE ULCERS.

The same method of strapping I have found useful in seven cases of varicose ulcer, applicable when the ulcer can be kept dry enough not to require too frequent dressing. The successful treatment of varicose ulcer requires three things-time, patience and rest of the affected leg. The wide range of expedients recommended proves the obstinacy of the condition. I think rest and firm support in aid of the return circulation are primary factors to which local treatment is secondary. Two of my cases have been unsatisfactory, because I could not enforce the most essential featurerest. One seen only in consultation drifted away from the attending physician. The other is now progressing nicely, with rest, in a hospital. The local treatment which has seemed

to me most beneficial is scarification of the edges, or occasional stimulation with silver nitrate stick applied lightly also to the ulcer, cleanliness, dressing as infrequently as possible with iodoform or other antiseptic powder, meanwhile keeping the limb elevated and well bandaged. In two of these cases the ulcers were very large, three inches square at least, but were completely healed in less than six months. In one case I elicited a syphilitic history and by giving large doses of potassium iodide and indifferent local treatment soon healed two varicose sores which had resisted four years of treatment at the hands of a fellow practitioner. I trust the wide range of my paper will offer free scope for discussion.

Traumatic Rupture of the Spleen.

At a recent meeting of the Society of Alumni of Bellevue Hospital, Dr. Samuel Pierson of Stamford presented a report of such

a case.

The patient, a boy of ten years, had been seen in consultation with Dr. Treadway on the morning of January 16, 1896. While coasting on the previous evening, the boy had been thrown from his sled against a post and had struck upon his head and shoulder, and had then fallen on his side. When seen by his physican a few minutes later, he had been pulseless, but conscious, and had located his worst pain under the left axilla in a line with the nipple. After careful examination no evidence of fracture of the ribs or of any other injury could be discovered. During the night the boy had vomited almost constantly. When first seen by Dr. Pierson in the morning he had been lying with his knees drawn up, the face pinched, the abdomen very much distended and exquisitely tender. Pulse, 145; temperature, 103.5 degrees; respiration, 40. It was apparent that the boy had sustained some serious abdominal injury, and his removal to the hospital for possible operation had been advised. On arrival there he had been given an enema of warm water, which had relieved the distention and tenderness to a considerable degree. Temperature, 102.5 degrees; pulse, 130; respiration, 30. Had the boy been seen for the first time in this condition he would probably not have been operated upon, but having fortunately been under observation from the first, there could be no doubt that he had sustained a serious injury. At six o'clock, twenty hours after the injury had been received, an operation had been done, with the assistance of Dr. Parker Syms of New York (to whose valuable advice the success of the operation was largely due), Dr. L. R. Hurlbutt, Dr. A. M. Hurlbutt, Dr. Sherrill and Dr. Gibbs. A small incision had been made in the median line below the umbilicus.

When the peritonæum had been reached, liquid blood had been plainly seen underneath, and on cutting through the membrane the blood had gushed forth in large quantity. The opening had been enlarged, and the cavity deluged with a saline solution. Besides the liquid blood a large quantity of clots had been washed out from among the coils of intestines, which had been carefully searched for rupture. As no rupture had been found, and as the fresh blood had seemed to come from the upper part of the abdomen, the incision had been enlarged upward almost to the ensiform cartilage. The liver had been first examined carefully, with a negative result. More clots and liquid blood had been found covering the intestines on the left side under the border of the ribs. After these had been washed away, the ribs had been held up by an assistant, and, on depressing the intestines, the bleeding point had been plainly seen in a transverse laceration of the hilum of the spleen. Fresh blood had been oozing from the rent. As it had been impossible, owing to the depth of the cavity and the nature of the tissue, to ligate the bleeding point, a long piece of iodoform gauze had been packed tightly in the rent, and brought out of the upper end of the abdominal wound. The abdominal cavity had been filled with saline solution and the wound closed with silkworm-gut sutures. Profound shock had followed the operation, and three high saline enemata had been given during the night with very happy results. At midnight the pulse had been 148, temperature 102.5 degrees, respiration 26. Oozing had been free during the night, but the general condition had improved steadily. On January 17, a. m., temperature, 102 degrees; pulse, 130; respiration, 28; p. m., temperature, 10 degrees; pulse, 120. He had passed a fair day, and had retained some milk and limewater. The bowels had been moved freely by calomel on the 18th. For the next three days the temperature had ranged from 101 degrees to 103 degrees; and the pulse from 96 to 120.

On January 21, five days after the operation, the wound had been dressed under chloroform. The gauze had been removed with some difficulty, and replaced with a much. smaller packing. There had been no hemorrhage. Notwithstanding the absence of suppuration at the first dressing, for the next four days the temperature and pulse had still ranged high. On January 25 several stitch abscesses had been opened, and the cause of the disturbance was thought to have been reached. The next day the temperature had been higher than ever, and a careful examination of the chest had shown fluid in the lower part, and a beginning broncho-pneumonia in the middle lobe of the left lung. The discharge from the wound had nearly ceased,

and, except for the stitch abscesses, the wound had been entirely healed. For the next five days the temperature had ranged from 100 degrees to 104.5 degrees; pulse from 100 to 130; respiration from 28 to 45. The pneumonia had then begun to resolve, but the fluid had increased, and there had been great tenderness and a fulness over the seat of the laceration in the spleen. The wound had been discharging a moderate amount of serous fluid daily. Fearing that the fluid in the chest might have become purulent, on February 2 an aspirating needle had been inserted and a drachm of pure blood withdrawn. This would, of course, not account for the temperature, and a purulent collection at the seat of the original injury had been feared. At three o'clock of the same day about a pint of thin, chocolate-colored, absolutely nonodorous fluid had been discharged from the original opening. The temperature had immediately dropped to normal, where it had remained until February 13, when it had again reached 100 degrees without any apparent cause. From this time convalescence had been uneventful, by March 1 the fluid in the chest had been entirely absorbed, and, with the exception of a small sinus, the boy had been entirely well.

So far as he had been able to find, there was no recorded history of such an injury to the spleen, treated by packing only for the stoppage of hemorrhage. In this case the child's condition had been so bad that no time could be taken in attempts at suturing the rent or in removing the organ. The hæmothorax had evidently been due to the original injury. That the injury would have been fatal without operation, even had the bleeding ceased, seemed hardly open to question, owing to the very large quantity of blood and clots in the abdominal cavity.

Dr. Robert T. Morris said that, assuming that the patient's bad condition had been due to loss of blood, it would seem to him that the case might have been easily and successfully treated by first giving a large intravenous saline infusion, and then extirpating the spleen, but one must know particulars of any given case.

Dr. J. Blair Gibbs said that when the case had been first seen, the patient's condition had been very serious, and the symptoms only those of grave shock. On making an exploratory incision the whole abdominal cavity had been found filled with clots and bloody serum. The removal of this large quantity of blood clot had necessarily consumed considerable time, and when this had been accomplished, the boy's condition had been extremely bad. The spleen had been found to be covered with very adherent blood clots, and with a very well-defined laceration on its anterior border.

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Dr. E. Le Fevre asked if the fluid in the pleural cavity was thought to have been due to the original injury.

The president said that he had only seen the patient once after the operation, the next day, and that then there had been no indication of such a condition. His own impression was that the fluid had been retained blood, of the nature of a subphrenic abscess. He would doubt very much the wisdom of treating most cases of hemorrhage from the spleen by this method, although it was undoubtedly a very proper procedure in this particular instance. In most cases of rupture of the spleen there was some penetrating wound of the abdomen, or else the spleen had been previously diseased-e. g., from malarial infection. In one case which he recalled there had been a similar rent in such a diseased spleen. The spleen had been sutured, but the patient had died of concealed hemorrhage, due to a rent which had been overlooked in another portion of the organ. As a rule, the spleen ruptured on the posterior surface from the doubling up of the organ.-New York Medical Journal.

Sudden Acute Abdominal Pain; Its Significance. BY BYRON ROBINSON, B. S., M. D., CHICAGO, PROFESSOR OF GYNECOLOGY IN POSTGRADUATE SCHOOL.

Abdominal surgery is no longer a pioneer work. It is the result of the accumulated experience of the past fifty years. Its success is based on well tried processes. It is a jealous field, filled with battles lost and won, dotted here and there with sad regrets, chagrin from unavoidable mistakes, but often brightened by the light of success. A master hand in abdominal surgery is a hard-earned reputation. However, the accumulative experience of fifty years has still left obscure points in abdominal surgery which the genius of

Lawson Tait attempted to set at rest by the exploratory and confirmatory incision.

During the past ten years I have been particularly interested in gynecology and abdominal surgery, and all along these years has risen the question of abdominal pain and its significance. To interpret abdominal pain requires the best skill of the finest heads.

Location. How far can we diagnose abdominal pain by its locality? Only to a limited degree. Associated circumstances must aid in the diagnosis. There are three common localities of acute abdominal pain, or peritonitis, viz., pelvic, ceco-appendicular and that of the gall-bladder region, and as probability is the rule of life, it is well to diagnose acute abdominal pain as a disturbance in one of these three localities of the peritoneum.

Acute abdominal pain in general is referred to the navel-in other words, to the region immediately over the solar plexus or abdominal brain. Acute abdominal pain is due to a disturbance of the peritoneum, owing to a lesion of an adjacent viscus; but since the peritoneal pain can arise from many organs and from several points of the same organ, it demands the most experienced diagnostic acumen and the most mature judgment to interpret the significance of the trouble. No one can decide what kind of wood lies under a tablecloth. I have repeatedly observed in appendicitis that patients say the acute pain, especially in the beginning, is over the whole middle of the abdomen (solar plexus). This may be due to excessive and violent peristalsis of the small intestines. As regards locating the pain at any point of the small intestines, it cannot be done; first, because the loops of the intestine have no distinct order as to locality; second, the patient cannot discriminate a point of pain at any given point— perhaps from lack of practical experience. With few exceptions to locate the seat of trouble in acute abdominal pain, we call to our aid the pain elicited by pressure. Pressing the abdominal walls produces a distinct localized tenderness or pain which suggests localized pathology. Again, rigidity or tension of the abdominal wall is suggestive of a pathologic locality. This symptom is purely reflex, due to irritation passing from the involved viscera to the spinal cord, whence its irritation is transmitted to the periphery of the lower intercostal nerves which control the abdominal muscles over the seat of pain. Dashing cold water on the belly will produce similar protective muscular rigidity. Hence, in general, the location of disease in the abdomen from the patient's feeling of sudden acute pain is quite indefinite. But local tenderness and local pain on pressure aid very much. Localized rigidity of the abdominal wall is suggestive that such tension is protecting the seat of disease from motion, further

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The first class of sudden acute abdominal pain chiefly arises from the digestive tract. The second class arises from the genitourinary.

1. In the category of the digestive tract, producing sudden acute abdominal pain, we place interstitial obstruction from (a) strangulation by bands and through apertures; (b) invagination; (c) volvulus, and (d) perforation. The mode of onset in all of these is sudden and violent and nearly always accompanied by vomiting.

Strangulation by bands and through apertures constitutes one-third of all interstitial obstructions. If the bowel loops slip through an inguinal or femoral aperture, digital examination will detect the cause of the sudden, acute abdominal pain. Obturator and sacrosciatic hernia are seldom diagnosed, so that practically they would come under internal strangulation by peritoneal bands. Sex does not aid in diagnosis, for males and females about even up in peritonitis during life, and hence will possess about the same amount of peritonitic bands to strangulate bowel loops.

A history of previous peritonitis tells the story of strangulation by bands. Vomiting is violent, pain from peristalsis is periodic and general over the abdomen. The pain is not due to stoppage of the fecal current, but to reflex irritation of the bowel at the seat of obstruction. Temperature is not conspicuous and the pulse is not much changed. Tympanitis arises in exact proportion to the peristalsis of the bowel wall above the seat of obstruction. At first the pain is violent, but it subsides with the progress of the case, becoming more continuous and generally diffused. If the patient be quiet, the pain is so slight that it deceives the most elect. No stool, no gas per rectum, no detectable swelling at any hernial aperture with continuous abdominal pain and vomiting demand surgical notice. The temperature and pulse are not

reliable. Strangulation by bands will generally give no tender location on pressure and no detectable swelling, and in fact, I have watched cases with the abdomen quite soft and pliable with no possible physical point of diagnostic value, not even tympanitis. In one case the pain was at first severe, general, and almost subsided the day before the operation, yet fifteen feet of gut was as red as a sunset. The sudden, acute abdominal pain is not due to the constricting band, but to reflex irritation transmitted to the abdominal brain where reorganization occurs, whence it is emitted to the whole digestive tract, inducing violent, disordered and wild peristalsis (colic).

Acute, sudden abdominal pain, due to a constricting peritoneal band, is one of the most obscure matters to interpret. To explore the abdomen in the proper time for such cause requires a wise diagnostician and a bold surgeon. The matters to bear in mind in strangulation by bands are the acute, sudden abdominal pain with a violent onset, vomiting, and the distinct colicky, peristaltic, periodic character of the suffering, not forgetting a previous history of peritonitis. However, the sudden, acute abdominal pain arising from strangulation of a loop of bowel by peritonitic bands is difficult to interpret and seldom diagnosed. It may be asserted that when a patient is suffering from some grave disease, manifest only by sudden, acute abdominal pain, the nature of which cannot be interpreted, an early exploratory laparotomy is justifiable and demanded. Such obscure cases require an experienced and skilled surgeon in abdominal work to meet any emergency. I remember very distinctly the case of a man about forty who gave consent to my colleague, a general practitioner, who was entirely untrained by experience or observation in abdominal surgery. The doctor told me he opened the abdomen and found a band stretching tightly across the ascending colon. But he said "the colon was black, and I did not know what to with it, so I closed the abdomen." It is needless to say that the man made a prompt, fatal exit. But most cases die undiagnosed. The danger of strangulation by bands is gangrene and perforation.

Invagination constitutes about one-third of all interstitial obstructions, and the sudden, acute abdominal pain arising from this cause is more easily interpreted. Age signifies much in this case, for one-fourth of all invagination occurs before the end of the first year of life, and one-half before the end of ten years. Invagination is a disease of childhood. Its mode of onset is sudden and often violent. From some twenty-five experiments in invaginating the bowel of the dog, I am sure the pain is periodic at first. The griping, colicky peristalsis is rhythmic, depending on ir

ritation. At stated times the dog suddenly spreads wide his four feet and arches his back, appearing in severe distress, then gradually recovers his natural attitude. In invagination blood occurs in the stool in 80 per cent. of cases (especially children), and the vomiting is not violent nor even always conspicuous, for the bowel is only partially occluded. Seventy per cent of invagination occurs at the ileo-cecal apparatus-that landmark in man's clinical history-15 per cent in the small intestines, and 15 per cent in the large bowel. Invagination manifests abdominal pain similar to a long enterolith in the bowel which in turning leaves small spaces at its side for the passage of gas and some liquid stool. I have, unfortunately, watched a case of enterolith day after day, not being able to interpret the abdominal pain or to diagnose the case until gangrene of the bowel occurred at the seat of the enterolith, when nature asserted sufficient manifestation to explore the abdomen, but with fatal result. The most skilled of abdominal surgeons repeatedly examined this case, but could not interpret the acute abdominal pain which came on suddenly, though as the days glided on it quietly subsided. The patient was a physician, but could not localize any abdominal pain; it was diffuse. Temperature was about 99 degrees and 100 degrees F., and the pulse was 85 to 95 almost the whole week of illness. The abdomen was generally soft and not tympanitic. Very seldom can an abdominal tumor be felt in the bowel invagination. Shock in young children is quite conspicuous, yet I personally know of two autopsies in infants who were attended in life by three of the most skilled Chicago abdominal surgeons, yet in neither case was the diagnosis of invagination made, which the post-mortems revealed as the cause of death. A skilled and experienced physician, such as was the late Dr. Jaggard, took an eight-months infant and stripped off the clothing to be more thorough in examination, and yet, after all his diagnostic skill, failed to locate disease in the bowels. The child was very pale, cried a little, and died thirty hours after the attack. The autopsy revealed ileo-cecal invagination.

Sudden, acute abdominal pain in a child may with high probability be interpreted as invagination, especially if one can detect the periodic, peristaltic character, its colicky na

Blood following in the stool is almost pathognomonic. A tumor will rarely be found, and pressure on it will not generally elicit tenderness. It is not at all likely that the patient can locate the seat of the disease from the pain. Tympanitis and vomiting are not conspicuous, and the temperature and pulse are unreliable. The danger of invagination is sloughing of the apex or neck and consequent perforation. Invagination present

ing at the anus interprets easily the cause of the pain. Volvulus is so rare that it constitutes about one-fourth of all interstitial obstructions, and occurs about four times as often in men as women. As in invagination so in volvulus, I was always compelled to suture them in position in a dog. But I never succeeded in establishing a permanent volvulus in the dog. Volvulus is characterized by tympanitis, and it is said by severe periodic pain. Volvulus occurs at the sigmoid in 60 per cent of the cases; at the ileocecal valve in 30 per cent, and in the small intestines in 10 per cent. I have seen partial, but never complete, volvulus in man. Senn operated successfully on a man, on the eighth day, for sigmoid volvulus. The man had enormous tympanitis; his pain is not described as severe, but no doubt the suffering is severe.

At first the pain is periodic, but as time advances it becomes more constant, with now and then exacerbations. Vomiting, though not conspicuous, must arise more or less from trauma to the peritoneum. Perhaps the sudden pain, chronic constipation and rapid rise of tympanitis would aid in interpreting volvulus, but seldom can one diagnose such a disease, pain no doubt would be referred to the abdominal brain. Most clinicians note tympanitis as a conspicuous feature of volvulus.

In perforation it is very difficult to interpret the sudden abdominal pain. Associated circumstances would aid. In typhoid fever one would naturally suspect perforation if sudden, acute abdominal pain arose, and my colleague, Dr. Van Hook, successfully operated on a typhoid perforation diagnosed by his medical friend. One might think if he was called to a young woman with sudden, acute abdominal pain that it was a round, perforating ulcer of the stomach, after excluding pelvic and appendicular disease. But the sudden, acute abdominal pain of perforation is so vague and, indefinite that only an exploratory incision would interpret it.

The sudden, acute abdominal pain from appendicitis (perforation) is more apt to be diagnosed. Now probability is the rule of life, and when one is called to a boy or man up to 35 with sudden, acute abdominal pain, it is likely appendicitis. The pain of appendicitis is at first sudden and generally diffuse, and the sudden pain in appendicitis is, in my experience, a characteristic and conspicuous feature of it. The sudden, acute pain in appendicitis is doubtless due to violent appendicular peristalsis (colic) or the rupture allowing the bowel contents to come in contact with the peritoneum, and also inducing violent, irregular peristalsis of the adjacent bowel loops. Rigidity of the abdominal muscles of the seat of pathology in appendicitis is a great aid to interpreting the pain. The

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