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muscular rigidity is protective and due to the transmission of the visceral irritation to the spinal cord which is reflected to the abdominal muscles. There is a nice balance between the peripheral visceral nerves and the peripheral nerves in the abdominal muscles. Local tenderness and local rigidity of the abdominal muscles is a great aid in signification of the sudden, acute pain in appendicitis. It might be well to suggest that the position of the appendix is extremely variable. In 350 autopsies I noted the appendix located all the way from the under surface of the liver to the floor of the pelvis, and also many times where there was more or less of a mesenterium commune, the cecum turned toward the vertebral column, and the appendix is then liable to lie among the small intestines-the dangerous ground of peritonitis. It is likely that the pain in appendicitis depends on the seat of the disease, i. e., the mucous membrane has become ulcerated, inducing appendicular colic (peristalsis), while the sudden exacerbation of violent, diffuse abdominal pain is due to the involving of the peritoneum itself. I see nothing especially worthy of attention in the socalled McBurney point. Pain over the seat of pathology is certainly a natural feature, and generally the appendix lies under a point midway between the umbilicus and the anterior superior spine of the ileum. But it is not always so by any means, for I examined with great and anxious care, a short time ago, a young physician with severe pain over the so-called McBurney point, when on operation the long appendix was down in the pelvis and perforated. It is a fair proposition to say that tenderness and pain on pressure is approximately over the seat of disease, so to speak, of a so-called McBurney point is redundancy. Then, again, pain on pressure may be reflex, bobbing up in remote regions of the abdomen. The sudden, acute, diffuse abdominal pain arising in appendicitis generally subsides to the right iliac fossa after thirty-six hours, and one can nearly always elicit pain on pressure. This pain on pressure is doubtless the motion transmitted to a sensitive, inflamed peritoneum, and not the dragging on an adhesion, as some assert, for adhesions so newly formed can have no nerves formed in them. But man is subject to appendicitis four times as frequently as woman, due, perhaps, to Gerlach's valve being small in man, and thus not allowing the foreign body to escape after entrance, or due to the greater activity of the psoas muscle in man. The appendix lies on the psoas muscle in man more frequently than in woman, and on its longest range of activity, hence when the appendix contains virulent and pathogenic germs the long range of action of the psoas so traumatizes the appendix that it induces
the escape or migration of the accidental virulent pathogenic microbes through the appendicular walls into the peritoneal wall or cavity. Common sense and experience would dictate that the pain on pressure would occur in any point of the abdomen possessing inflamed structures. Since probability is the rule of life, it is well to look to the three great regions of dangerous peritonitis, viz., pelvic, appendicular and gall-bladder region.
The digestive tract has still another common seat for sudden, acute abdominal pain, and that is the gall-bladder region. The sudden, acute abdominal pain in hepatic colic is not generally so violent as many others accompanying acute diseases of the digestive tract. Patients relate that the pain is aching, dragging, and in the active stage cutting or tearing. Some relate a feeling of tightness or fullness. But it depends on whether the stone is attempting to enter the mouth of the duct or whether it has already entered. I have had typical cases where operation proved that the stones only attempted to enter the duct. No doubt these are the cases which say so often that they have some severe pains at any time, but especially after taking hot meals, hot or stimulating drinks, whence arises excessive peristalsis inducing short, temporary hepatic colic. Now, when the gall-bladder has many small stones in it, and when one more or less often attempts to engage in the neck of the gallbladder, the pain is rhythmical. It begins slowly and rises to a maximum. At the maximum the pain is intense. We have observed such cases and afterward operated on them, removing many small stones. Gall-stones are perhaps four times as frequent in women as in men; why, we do not know. In my experience patients can generally localize the pain in gall-stones more accurately and definitely than almost any other sudden, acute abdominal pain. They refer the pain to its proper locality; however, I must admit that this reference is before rupture. After rupture of bladder or duct the pain is indefinite, like other perforations. The sudden, acute abdominal pain in gall troubles is characterized by more slowness, less acute intensity, distinct periodicity than invagination, appendicitis or perforation of the digestive tract. Jaundice is not necessary. Jaundice depends on the color of the eyeball and not the skin. A feature in gall-bladder pain is that it extends well toward the dorsum. Age aids in diagnosing stone in the biliary passages to some extent.
In renal (genito-urinary) colic it must be said that the pain resembles that of the hepatic colic in many ways, in rhythm being paroxysmal. It intermits and is often agonizingly spasmodic. It requires much careful study to differentiate the sudden, acute abdominal pain in hepatic and renal colic from each other. This is important, for the plan of ac
tion is very different. The pain in appendicitis, renal, and hepatic colic are in close relation.
The sudden, acute abdominal pain arising from the genitals (genito-urinary) is more easily interpreted and managed. The pain can be more definitely located by the patient and sudden disorganization of the viscera, being accessible in the pelvis, is much more within control of the gynecologist. The sudden, acute abdominal pain from the genitals is generally a ruptured ectopic pregnancy or the very rare matter of the rupture of a pyosalpinx into the peritoneal cavity. Most other pelvic pains are of slower origin and almost always diagnosable. Sex and the reproductive age aid in the interpretation of the case. Remember the three dangerous peritonitic regions, viz., pelvic, appendicular and gallbladder.
In regard to the character of sudden, acute abdominal pain, it varies as to (a) its mode of attack, and (b) as to the viscera attacked.
If one will closely watch the sudden, acute abdominal pain, it will be quite apparent that the character of the pain in most of the acute affections of the abdomen is very similar. We only observe in reality a difference in degree of pain from the bearable to the agonizing. In perforation the character of the pain is the same in all viscera. In invagination it is paroxysmal and periodic, at least at first, due to irregular and violent peristalsis in internal strangulaton; it is generally intense and periodic, due to violent peristalsis, later continuous and of an aching, dragging character, due to paralysis of bowel segments. In appendicitis the pain is nearly always sudden and intense, i. e., the perforative variety. The variety of appendicitis with slowly increasing pain is likely lymphatic in invasion and not dangerous, simply medical, of course the appendicular mucosa may be perforated. Sudden, acute abdominal pain of a lancinating character, and being quite continuous, is very liable to be perforation of the appendix or digestive tube, and the continuous agonizing character of the pain is a heraldic symptom of diffuse peritonitis, the knell of life.
be remembered that the character of the sudden, acute abdominal pain will depend on the capacity of any viscus for peristalsis, i. e., its capacity to cause colic by violent, wild, irregular muscular action. In peristalsis periodicity must not be lost sight of, and the etiology which gives rise to the irritation, inducing the peristalsis. It may be transitory in character. as food irritation, rapidly forming and reducing invagination or a stone attempting to enter a duct. Or the pain may be continuously periodic, as a stone lodged in some canal, appendix, ureter, small intestine, or biliary ducts.
In regard to the location of sudden abdominal pain we have to consider (a) the seat of
pain as felt by the patient; (b) the pain elicited by pressure (tenderness); (c) local rigidity of the abdominal muscles; and (d) anæsthetic or hyperæsthetic condition of the skin of the abdomen.
In general, sudden, acute abdominal pain is referred by the patient to the umbilical region, to the solar plexus, directly over the abdominal brain. This, in my opinion, is a nervous center, possessing the power of reorganization, receiving and transmitting forces of controlling visceral circulation and of inducing reflex or referred pain. The irritation of peripheral visceral nerves is transmitted to the abdominal brain, whence reorganization may make the pain felt over the abdominal brain, at the seat of pathology or a remote abdominal point due to a very supersensitive nervous system.
As to local tenderness of pain elicited by pressure, it indicates a pathologic condition of the peritoneum (inflammatory). The pain is induced by motion or disturbance communicated to a sensitive inflamed peritoneum.
Local rigidity of abdominal muscles indicates adjacent underlying pathology of organs supplied by the same nerves as the muscles which exercise a protective agency to preserve rest for damaged tissue, to assume repair and prevent further destruction from motion. Hyperæsthesia or sensitiveness of the skin, due to transmitted irritation, is often present, but is not very reliable as to locality, for it is dependent on peculiar symptoms, and accompanies, more or less, though irregularly, most acute abdominal affections. Of course,
it would be expected that the severe, sudden, acute pain in the kidney and gall-ducts, being very near to the abdominal brain, would be difficult to separate from the solar plexus. Lead colic may deceive the most elect as to its etiology or seat.-University Medical Magazine.
Malpractice Suits and Mental Impressions.
The strange popular notions anent the effect of transplantation of animal tissues to man prevalent for centuries, still survive in certain districts. Dr. H. E. W. Barnes of Creston, Ia., reports (Iowa Med. Jour.) that a malpractice suit was recently brought in that state under the following circumstances: The patient had tibial necrosis. Destruction of the bone was so extensive that the surgeon determined to transplant bone, and used the femur of a large mastiff. The patient made a good recovery, but brought suit against the surgeon for "having thus produced in her an uncontrollable impulse to lift her leg when she passed a telegraph pole."-Chicago Med. Recorder.
Time is generally the best doctor.-Ovid.
According to Mr. David W. Cheever in the present feverish condition of operative surgery it may be prudent to ask ourselves what is the object of an operation and how should we regulate our conduct in unforseen contingencies (Boston Medical and Surgical Journal). The problem may be condensed into the following questions: 1. When to operate. 2. When not to operate. 3. When to stop. 4. When not to stop. In regard to the first question, says the author, if we confine our selection of cases to those which clearly come under the cardinal rule for operation-namely, to relieve suffering, to prolong life, or boththere will be very little difficulty in the choice. We must consider whether life is imperilled and whether the suffering can probably be relieved. If we are asked to operate, he says, shall we accept only good risks, and decline the doubtful or hopeless cases? The second question is a difficult one to determine. Operations should not be taken without the full consent of the patient and his family, if it is possible to obtain it, and there should be some responsible person who understands the nature of the operation to be done and what may be reasonably expected from it. No operation should be done when the patient is in a state of shock, unless hemorrhage, apnoea or obstruction of the bowels is present, as in hernia, for example. If there is time the systemic condition of the patient should be fully considered-for example, as to the integrity of the heart, the arteries and the kidneys. In a case of no emergency the age and the prospect of life of the patient should be taken into account. In cases of glandular infiltrations which are so extensive as to preclude perfect removal, he says an operation should not be done; for instance, in a tuberculous organ, or in a sarcoma of the antrum where the sphenoid cells cannot be extirpated. There are two important exceptions to this rule, however: i. To relieve agonizing pain an operation should be done on any slight chance, for, unless the suffering can be palliated, the patient had better die than live. 2. In a forlorn hope, so to speak, after the risk has been fairly stated, the patient is entitled to an operation, if he wishes it, and if he takes the responsibility; here, however, the limit must be those cases in which there are one or more chances
of success. Must we stop when the patient fails? Not always, for the failure may be due to the anesthetic or even to simple nausea. In this case the surgeon should stimulate the patient and consider carefully before giving up the operation. Stopping, he says, is indicated when we come to the end of all that
can be taken out for instance, in a case of malignant tumcr; in an operation in the abdominal cavity, when a glance or a touch reveals that the tumor is not removable and that it has grown into vital parts; in an operation on the surface of the body when stopping will not imperil life so much as going on; in syncope with a pulse at 108, with sighing respiration, and with a colliquative sweat. Concerning the fourth question, says the author, When not to stop, keep on as long as the patient breathes; it is his only chance. The contingencies are: An operation which has so far displaced and broken up a soft internal tumor as to render death from bleeding or from sepsis certain if any is left; an oozing hemorrhage; a difficult tracheotomy; a crushed skull with a pulse of 40 and Cheyne-Stokes respiration, having trephined, he says, we cannot stop until compression is removed and the bleeding checked; extravasation of urine; and a bladder to be drained; if the patient dies in the process we must drain the bladder. we do not do all these things, the patient dies; his only chance lies in their being done. Surrounded with these terrible chances the surgeon, like the executioner, raises or depresses his thumb, and the patient lives or dies. There is no responsibility like this. All this should teach us, first, to be over-careful about getting in so deep that we cannot withdraw, or about meddling with what had better be left alone. Second, not to imperil life to cover our mistakes, for we all make them. Third, in self-defense to withdraw from an operation or from a case at once if our advice is not followed. To bear the responsibility, we must be absolute masters.-Medical Record.
Dislocation of the Fourth Cervical VertebraReduction-Recovery.
BY WILLIAM H. NAMMACK, M. D., NEW YORK.
George W, aged twenty-one, on September 2, 1895, while bathing at Far Rockaway, L. I., dived into shallow water and struck his head against the bottom. The forcible flexion of his head resulted in a dislocation. He became unconscious and remained so for about an hour as a result of the concussion of the brain, but this condition responded readily to the usual remedies.
On examination by Dr. Thomas J. Kearney and myself a marked deformity was apparent. we felt the vertebra prominens, and the sixth and the fifth vertebræ were also found in their normal position. Above these, however, the spine was bent forward, and a wide gap posteriorly was easily felt and was even visible. The head was completely immobile and the malposition of the parts was peculiarly characteristic. There was no paralysis either of motion or of sensation, severe pain, of which
the patient complained, being the only pressure symptom. Deglutition of liquids was difficult and painful, that of solids impossible. By placing the finger in the posterior part of the mouth, the projection forward of the displaced vertebra was easily felt, so that we believed that the articulation between the two vertebræ, the fifth and the fourth, was torn open, that the supraspinous and the infraspinous ligaments, the ligamentum subflava, and posterior common ligament were torn through, while the ligamentum nuchæ remained intact, drawing the occiput downward toward the vertebra prominens and so increasing the deformity.
Upon consultation it was decided to endeavor to reduce the dislocation, and the dangers incident to such a step were explained to the family, who left the treatment entirely to our discretion. Drs. Burns and Bumster, whom I called upon for assistance, acquiesced in the following plan of treatment:
The patient was placed prone upon the table with his head and neck extending beyond its end, and supported in that position during the administration of ether. As soon as the anæsthetic had produced complete relaxation, extension was made from in front with counterextension at the shoulders, the greatest care being taken that no sudden movement should be made. There was an immediate and gratirying response to these efforts, respiration was not at all affected, and we could then distinctly feel the spinous process of the fourth cervical vertebra in line with those below, while there was complete disappearance of the deformity. Having thus reduced the dislocation, the next problem was to retain the bones in their proper position. The solution decided upon was a plaster of Paris cast, which was applied so as to extend from the occiput and the thyroid cartilage above to the first dorsal vertebra and the sternum below, care being taken to allow sufficient room for the neck. The patient was then placed in bed and watched carefully for three hours, during which time. his condition remained satisfactory. He was allowed to go about in a week, the plaster was removed in three weeks, its place being taken by roller bandages, and he was discharged, cured in five weeks from the date of the injury. Since then he has been attending to his work as a compositor, and he is apparently none the worse for the accident.-Medical Record.
American Physicians Honored in China.
Dr. Eli Barr Landis, ex-resident physician of the Lancaster County Hospital and Insane Asylum, has recently received the Order of the Double Dragon from the Emperor of China, in recognition of services rendered by him during the war between China and Japan. The
same distinction had already been bestowed on another American medical missionary, Dr. B. C. Atterbury, for work in connection with the Red Cross Society in the late war.—The Medical Record.
BOOKS AND PAMPHLETS RECEIVED.
"Retinitis and Choroiditis," by L. Webster Fox, M. D., from The Medical News, May 23, 1896.
"Management and Treatment of Tuberculosis in the Asheville Climate, with Report of Cases," by James A. Burroughs, M. D., Asheville, N. C. Reprinted from the N. C. Medical Journal.
Gray's Anatomy, Descriptive and Surgical.
An American Text Book of Applied Therapeutics, edited by J. C. Wilson, M. D., assisted by Augustus E. Eschner, M. D.
"Feeding in Early Infancy," Arthur V. Meigs, M. D.
"Ovarian Tumors Complicating Pregnancy, with Report of a Case," by C. S. Bacon, M. D. Reprinted from the Journal of the American Medical Association, September 12, 1896.
"Constipation; Some of Its Effects and Its Non-Medicinal Treatment," by E. S. Pettyjohn, M. D. Reprinted from the Journal of the American Medical Association, August 1, 1896.
"The Differential Diagnosis of Neurasthenia and Its Treatment," by Elmore S. Pettyjohn, M. D. Reprint from American Medical Association Press.
Technic of Abdominal Salpingo-oophorectomy Without Pedicle," by T. J. Watkins, M. D. From the Medical News, August 8, 1896.
"Craniotomy on the Dead Child," by Joseph B. Delee, M. D. Reprint from the American Medical Association Press, 1896.
"Two Cases of Obstetrical Hemorrhage," by J. B. Delee, M. D. Reprinted from Chicago Medical Recorder, September, 1896.
"The Prismatic Perimeter," by Joseph E. Willets, M. D., reprinted from Annals. of Ophthalmology and Otology, July, 1896.
"Inguinal and Scrotal Cysts, Simple and Complicated, In Infants or Young Children," by Thomas H. Manley, M. D. Reprint from American Medico-Surgical Bulletin, September 12, 1896.
ON BETTER METHODS OF TESTING
BY ROBERT BARCLAY, A. M. (TRIN. COLL.),
Consulting Aural Surgeon to the Hospital Department of the
St. Mary's Infirmary, South Side
Deaf and Dumb Institute,
House of the Good
Mr. President and Gentlemen of the Association:
At your second annual meeting, in May, 1889, I had the honor of presenting a paper' directing your attention to the fact that no safe provision had as yet been made against the dangers arising from deafness among railway employes; and raising the question as to how we should dispose of this, that the corporation might not suffer losses through suits for damages to passengers and freight, and that the employe might not meet with injury or death through this cause. In that paper, an earnest effort was made to emphasize the fact "that railroad service tends to the production of deafness, especially in ears already slightly affected; that it may be developed at any time, without the employe's knowledge; may be ignored by him, when recognized, and may become suddenly aggravated, while on duty; and that it may lead to loss of life, limb and property,"-a copious bibliography being appended in evidence thereof. A suggestion was offered, that you present the subject, in suitable form, to the
1 Read before the National Association of Railway Surgeons at its ninth annual meeting at St. Louis on April 30, 1896.
THE WHISTLE SIGNAL: A PLEA FOR THE MORE SAFE MANAGEMENT OF RAILROADS. Journal of National Association of Railway Surgeons, Fort Wayne, Ind., July, 1889, Vol. II, No. 2, PP. 57-65.