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which the growth of the abdominal distension is much more slow. The pain in pancreatitis and the tenderness are felt across the abdomen in the region of the pancreas. The fever of pancreatitis begins much earlier than that of intestinal stoppage. As regards those inflammatory affections which cause bloating and intestinal paralysis, they are all distinguished by high fever, leucocytosis and abdominal tension and need no further discussion in this place. In the diagnosis of invagination, the finger may often detect the invaginated gut in the rectum in the shape of the end of a tube projecting into the bowel. This feeling, however, may be very deceptive, as I found in a case of Doctor Chapoton's upon which I operated. The child had a severe attack of obstruction and I felt as high up as I could reach a protrusion of this form.. On abdominal section, however, I found no invagination but a volvulus high up. The pelvis was full of distended coils of intestines, whose pressure upon the rectal wall had forced it in and caused the deceptive protusion.
In discussing the symptoms of acute obstruction we must not forget those forms caused by the obturation of the gut by intestinal contents. I was once called into the country to operate on a woman who had the evening before eaten an enormous quantity of pop corn, which she did not even take the trouble to chew. I found her suffering from agonizing pain which had continued for the twenty-four hours. Her abdomen was enormously distended. I was preparing to operate, when she had a sudden evacuation of a great mass of undigested pop corn, and relief from all her symptoms. It is, of course, important to distinguish these cases from those in which the stoppage is due to strangulation or intussusception.
I have not spoken of the later symptoms of obstruction, such a fecal vomiting, high fever, and failing pulse, because the diagnosis should never wait upon their appearance. I am confident that in nineteen cases out of twenty the physician could diagnosticate acute obstruction, if he would become thoroughly conversant with the typical symptoms.
If a patient is seized with an agonizing pain in the abdomen, followed by shock, nausea, vomiting and collapse,-if then there occurs a localized swelling of the abdomen or pelvic cavity, if in that swelling no stimulus can cause vermicular motion, if during the twenty-four hours there is very little abdominal tenderness and no abdominal tension, if the bowels are obstinately constipated, if the abdominal swelling slowly increases until the afferent coils all become distended, if with all of the disturbance there is little or no rise in temperature, there can be no doubt as to the nature of the trouble, for there is no other malady which will offer the same complex of symptoms in the same sequence.
Those cases only are doubtful in which some of these symptoms are lacking or are modified by the existence of other morbid conditions. Thus the localization of the primary swelling may be rendered impossible by a fat abdomen. There may be some chronic inflammatory condition causing abdominal tenderness, tension and swelling. There may
be one or two evacuations of feces which have been lodged below the point of obstruction, and there may be histories of previous attacks of abdominal pain which may prejudice the diagnosis, but even with all the possibilities of mistake, a careful watch and intelligent analysis of the phenomena will usually lead to a correct conclusion.
Even when the diagnosis of obstruction has been made, the occurrence of a fecal evacuation and the subsidence of some of the more distressing symptoms may lead to a mistaken belief that there has been a correction of the morbid condition. The patient may feel relief from pain, but the distension increases, the pulse beats faster and feebler and the temperature rises. It may be laid down as a positive rule that relief from obstruction is always followed quickly by a relief from distension.
This is an index to which the physician should look for guidance when there is an apparent improvement, and never delay operative measures when the distension is persistent. We may hope to cure cases of complete acute obstruction only when we meet the emergency by operation within the first twenty-four hours, and it behooves every practitioner of medicine to study carefully the means of diagnosis and to be prompt in his action.
CLINICAL SOCIETY OF THE NEW YORK POLYCLINIC.
STATED MEETING, DECEMBER 4, 1905.
THE PRESIDENT, JOHN J. MACPHEE, M. D., IN THE CHAIR.
READING OF PAPERS.
DOCTOR JOHN A. BODINE read a paper bearing the above title. He said in part:
The first slipping away from the faith of our forefathers was in "Where and How to Amputate." No article in textual creed is stronger than, "Save all you can in amputations.' The various and multiform amputations through the complex tarsus and metatarsus bones were the result of the necessity for speed before the advent of anesthesia. This golden rule was also strengthened by the argument that in amputations the nearer the trunk the greater the death rate, and still further bedrocked in the belief of the patient that the less of his anatomy lost, the less of a cripple he was. The advent of skilled prosthetic surgery has done away with peg-legs and crutches for the unfortunate victims of amputations, and today instead of traditional anatomic and sentimental arguments, one should be guided by a new article of
faith: "Amputate where the limbmaker can best supply the loss." Save all you can from tip of toe to the tarso-metatarsal joint, and discard every one of the many technical amputations through the tarsus in favor of the Syms' amputation at the ankle-joint. There is weighty prosthetic evidence that even this point of amputation should be discarded in favor of removal seven inches above the ground line. There is but one American firm of limbmakers which claims it can fit partial foot amputations with a satisfactory appliance, and even it admits that the advantage is chiefly economic, the apparatus costing less than in the case of higher amputations.
After leaving the point of seven inches above the ground line, the rule of save every inch possible holds good until within two inches of the knee-joint. In amputations of the thigh above this point, one should save every inch possible.
In the event of future improvements in artificial substitutes, nullifying the potency of the speaker's argument, he submitted that in partial foot amputations the technical and complicated textual amputations should be discarded and the foot treated as one bone, the rule then being, "Save all you can, from toe to hip-joint."
There is a tendency today to attach too much importance to the laboratory verdict in diagnosis of surgical lesions. Important as this evidence is, it is not always pathognomonic, and in few surgical diseases, alone and unaided, can it be relied upon to formulate a diagnosis. It furnished evidence, valuable evidence, but unless clinical history and clinical symptoms support this testimony the laboratory evidence should be discarded. In the surgical lesions of the stomach, can cancer, pyloric obstruction or ulcer be diagnosticated alone by the test-tube or microscope? Can chemical or microscopic examination of the feces locate or even diagnosticate surgical lesions of the intestinal tract? Which should one refuse elective operation, a patient who passed a low quantity of urine, with low specific gravity, or one with full quantity of normal specific gravity, with all the pathologic casts and epithelium discoverable with the microscope?
DOCTOR FERDINAND M. JEffries: So far as Doctor Bodine's remarks concern the laboratory, I must agree with him in the main, but some of his assertions I cannot coincide with. With regard to cancer, I feel that if the pathologist's report is that of cancer, no matter what the clinical findings may be the surgeon should proceed on the assumption that it is malignant in character. Regarding appendicitis, it is generally known that hematology is not the useful diagnostic aid that at one time it was hoped it would be, nevertheless, instances are on record in which it has been of great service. Therefore, the patient should be given the benefit of this examination on all occasions. The surgeon should give the benefit of all clinical aids; the laboratory is one of them.
REPORTS OF CASES.
DOCTOR JOSEPH E. FULD: I wish to show this specimen. The child was born normally, at full term, and on the morning of the third. day vomited material which looked like meconium. It had not defecated since birth, and refused the breast. Physical examination showed a well-formed, healthy baby, with no outward deformities. The abdomen presented marked lateral and median distension, but no signs of hernia. Examination with a large sized Kelly cystoscope showed a distinct narrowing of the lumen of the bowel between one and onehalf and one and three-quarters inches from the anus. In the centre of the narrowest part a small dimple was distinctly visible, and through this a uterine sound was introduced with some difficulty for about one and one-quarter inches. No mass could be felt in the pelvis. A diagnosis of atresia recti was made, and iliostomy was performed under chloroform anesthesia. A median incision two inches long was made below the umbilicus, and in trying to get into the peritoneal cavity the much-distended bladder, which resembled the parietal peritoneum, was nicked and considerable urine escaped. An artificial anus was made in the lowest part of the ileum, which was packed off and surrounded with gauze. The patient left the table in a fair condition, but was not relieved by the operation, and died thirteen hours later, Postmortem examination showed the small intestine to be full of meconium and considerably distended. The pylorus was distinctly thickened for a distance of about three-quarters of an inch, making a firm ring, and producing a slight stenosis. Section through the thickened tissue showed very marked increase of the muscular layer. At the normal end of the ileum, instead of the normal valve there was complete closure. Beyond this the large bowel was patent throughout, communicating below with the rectum. In the centre of the septum was a dimple, corresponding to the ileocecal valve. The large bowel was the size of an adult ureter, and the cecum was about three-quarters of an inch in length and about twice the size of the sigmoid colon.
SPONTANEOUS RUPTURE OF THE UTERUS DURING PREGNANCY.
DOCTOR LOUIS J. LADINSKI: I desire to show a uterus and adnexa which I removed from a patient about a week ago. The history given was that pregnancy followed four years after operation at the Polyclinic Hospital, and just prior to impregnation there was chronic endometritis with mattery discharge. Examination through the vagina during the fourth month of pregnancy showed the uterus to be adherent, but there was no deformity in size, form or position. Three days before operation a small blood spot was noticed, and I advised absolute rest in bed and morphin. There was no further showing of blood, but the following day the patient complained of pain in her back, and two days later she collapsed. Her pulse was rapid and almost imperceptible at times, and she had intense pallor and rapid respiration. Her abdomen
was distended, not in the shape of a dome, but over its entire surface. A diagnosis of ruptured abdominal pregnancy was made, and immediate operation advised. When the patient was placed on the operating table the fetus was found in its sac, floating about in the abdomen. There was a large rent in the uterus. The patient made a good recovery. Uterine rupture during pregnancy is rare, and must not be confounded with rupture during labor. The most frequent cause for the former is the giving way of the scar of a previous Cesarean section, or of the connective tissue formed after a deep curettage. In the case described, one portion of the posterior wall of the uterus was as thin as paper. If a history of the operation performed four years before could be obtained it would assist in determining the cause of this condition.
DOCTOR BENJAMIN TORRENS: Possibly the patient was the same as one on whom I operated about four years ago at the Polyclinic Hospital. On inserting the curet into the uterine cavity, it was found that the instrument entered the abdominal cavity through an opening in the anterior uterine wall. It was immediatly withdrawn, and digital examination disclosed two perforations of the wall, with about one inch of connective tissue separating them. Each of the openings was large enough to admit the passage of two fingers. The uterus was packed with iodoform gauze, the culdesac of Douglas was opened, and the small intestine was found adherent to the anterior uterine wall at the site of perforation. This was detached and the pelvis packed with gauze. The patient made an uneventful recovery.
DOCTOR ROBERT H. M. DAWBARN: This case reminds me of an instance in which I made a diagnosis of abdominal rupture of pregnancy, even going so far as to determine the position of the fetus. There was some bleeding from the uterus, which was enlarged and quite soft. The abdomen, when opened, allowed the escape of a very great amount of bloody material, and this being removed, it was seen that all of the viscera, the bowels especially, were covered with a new growth which proved to be sarcoma, the largest clump of which had been mistaken for the fetus.
DOCTOR DAWBARN: I also wish to show a dermoid cyst which I removed a week ago from a girl nine years of age. The dermoid is much larger than the average specimen of its kind. There is a history of half a dozen paroxysms of pain, and when the specimen was removed the pedicle was found to be twisted upon itself a great many times. Apparently this occurred coincidentally with the pain, and of course occasioned hemorrhage of the sac. The solid portion of the cyst is about the size of a small egg and is filled with teeth and bones.
TENDON TRANSPLANTATION IN THE FOREARM.
DOCTOR JOHN A. BODINE: I wish to present this patient. He is a butcher by trade, and was on the top of a high stepladder when he slipped and caught at a large meat hook on the side of the wall. The