at University College, London. He was a Fellow and ex-president of the Royal College of Surgeons, a Fellow of the Royal Society, of the Royal Academy of Medicine of Belgium, the Imperial Society of Physicans of Vienna, the Academia di Guereti (Rome), the University of New York, and the American Surgical Association, and a member of various other learned and scientific institutions, home and foreign.

At the time of his death Mr. Erichsen was Emeritus Professor of Surgery and consulting surgeon to University Hospital, and to many other medical charities. He had been president of the Royal College of Surgeons of England, of the Royal Medical and Chirurgical Society, and of the Surgical Section of the Great International Medical Congress of 1881. He was appointed secretary to the Physiological Section of the British Association for the Advancement of Science in 1844; was member of the Royal Commission on Vivisection in 1875: was surgeon-extraordinary to the queen, and had been president of University College, London, since 1887.

Mr. Erichsen was the author of many works and essays on physiology and surgery. In compliance with an influential requisition, he contested, but unsuccessfully, the representation of the universities of Edinburgh and St. Andrew's at the general election of 1885.

It is with peculiar sadness that we announce the death of Mrs. Fannie Peckham Thorne, wife of our distinguished ex-president, Dr. S. S. Thorne of Toledo, O.

She died at her residence, 502 Lagrange street, Sunday morning, October 11, at 1:30 o'clock. Mrs. Thorne had been ill for some time and her death was not altogether unexpected. She complained of a sudden sickness during the afternoon and grew rapidly worse as the night wore on, and when the end finally came she passed away in the midst of her family. She was in her 61st year and had been a resident of Toledo for 36 years. She was married to Dr. Thorne at Lockport, N. Y., in 1856 and four years after removed to Toledo, where her husband entered upon the practice of medicine.

She was born in Utica, N. Y., in 1835, and was the daughter of Dr. Peleg B. Peckham. She was the mother of the late Dr. George Thorne, and three other children, Annie, Laura and Alice, all living.

Mrs. Thorne was well known to many members of the National Association of Railway Surgeons, who will join us in extending to Dr. Thorne and his family sincerest sympathy.

Take physic, pomp; expose thyself to feel what wretches feel.-Shakespeare.

Some Recent Cases of Minor Surgery.*

BY F. B. TIBBALS, M. D., DETROIT, MICH.

I am well aware that the only popular surgery of the present decade is gynecological, but as this specialty will not accommodate all of us, the adult female comprising only about twenty-five per cent of the total population, there must of necessity be general practitioners and general surgeons.

The general practitioner of surgical bent, however, occasionally finds surgical cases in which lesions exist outside of the pelvis and abdomen, some of them trivial in character as regards hazard of life, yet all demanding treatment along good surgical lines. I wish to report to-night some cases of this kind-minor surgery-which have come under my care, mostly within the last two years.

Some of these cases seem possibly too trivial to report, but success in little things often pleases the patient, and occasionally lives are at stake as well. For convenience in discussion I will classify my cases under three heads and for brevity's sake avoid all unnecessary detail.

I. ABSCESSES AND POISONED WOUNDS. Retropharyngeal abscess resulting fatally. -The patient was a woman of uncertain antecedents. When first seen she exhibited a temperature of 105 degrees Fahrenheit, and was suffering from dysphagia, vomiting and purging. Examination of the throat disclosed no abnormal condition except diffuse redness of the pharynx. The tongue soon swelled so that further examination was impossible, and the patient died suddenly two days later, suffocated by the bursting of the large abscess disclosed postmortem.

Retrorectal abscess, absolutely painless, rupturing without any premonitory symptoms into the rectum four inches above the anus.—I could pass a probe some six inches into the fistulous tract leading off from the rectum posteriorly, and was thus able to wash out the abscess cavity with hydrogen peroxide and other antiseptics, throwing in afterward, through a powder blower, boric acid plus a little iodoform. The cavity closed down after three months' treatment, but the fistulous track, kept open by the involuntary muscular action, continues at times to discharge a little pus aggravated always by constipation. As this patient has since been assured by several Detroit physicians of supposed intelligence that he never had such an abscess, but, on the *Read before the Detroit Medical and Library Association and published in a recent issue of the Physician and Surgeon.

contrary, catarrh of the stomach with intestinal sequellæ, I take this opportunity of reporting the case at this length.

Superficial abscesses in the cervical and axillary regions are generally due to breaking down of lymphatic glandular tissue and usually heal promptly after free early incision, curettage and packing for drainage. I have a record of a dozen such cases which I will not weary you in detailing. Oftentimes suppuration beginning in this way, if not promptly treated, is carried by metastasis to other glands adjacent or remote, and the case may terminate in general pyemia or general tuberculosis. A striking illustration of this fact has been for nearly a year under my care, the patient being a girl of about twenty without hereditary taint. The trouble began some three years ago in one or two superficial glands of the neck, which were not incised. In a few months all the glands of one side of the neck, both superficial and deep, became infected, and a radical operation then undertaken failed to extirpate more than a part of the diseased tissue. When she came under my care last summer one side of the neck and part of the face was a mass of suppurating fistulous tracts, and there were also four open unhealthy sores elsewhere as sequellæ of abscesses allowed to rupture spontaneously. Within a short time I opened and drained ten other abscesses, all but one subcutaneous. Every effort was made by tonic supportive treatment internally, and stimulating antiseptics locally, to build up the patient and antagonize the autoinfection with, for some months, gratifying success. No new abscesses formed, many of the open sores healed kindly and the patient gained in weight and strength. But on the opening of winter suppuration began anew, attended by emaciation, loss of strength, afternoon temperature and night sweats, and the case is now persistently retrograding. In all probability this poor girl's life might have been saved by timely surgical treatment at the inception.

The same reasoning applies to suppurating nonvenereal glands of the groin. I have four cases recorded-two of which were incised, curetted and packed as soon as pus began to form, and two of which came into my hands at a later stage. The first two healed promptly, while the others dragged a weary course of several months.

Abscesses of this character occurring usually in individuals of the strumous type are frequently obscurely tubercular, and the prompt removal of the local nidus will often prevent secondary systemic infection. Another argument for early surgical interference in all cases in which pus can be diagnosed or even suspected is the prevention of deformity and loss of function. A housemaid came to me a year ago, presenting a useless hand as a result of a neglected felon on one of the fingers. The

wrist was absolutely stiff, the fingers nearly so. I broke up the adhesions by considerable force under anæsthesia with daily passive motion following, repeating this forcible manipulation under anæsthesia every ten days for three months, at which time I had obtained only slight wrist movement, but perfect use of the fingers.

From quite a number of poisoned wounds I select three of the hand in which the cut was made by glass. All were seen immediately after the injury, carefully cleaned, fragments of glass searched for, and antiseptic dressing applied. I do not know whether the irritant is traumatic, chemical or bacteriological, but in my experience wounds of this kind are very slow in healing. Even when there is no pus formation the edges become inflamed and infiltrated, union by first intention being the exception.

II. INJURIES TO JOINTS.

Compound dislocation of the Elbow.-This patient was a locomotive fireman, injured fifty miles outside the city. While oiling his engine the throttle flew open and his arm was caught in the driving wheel, a compound dislocation of radius and ulna backward resulting. The dislocation was reduced, wound dressed, arm put in a rectangular splint, and the patient sent to his home in Detroit. not disturb the dressings until thirty-six hours after injury, when he had a short chill, the temperature rapidly jumping to 103 degrees Fahrenheit. I found the arm doughy, swollen and inflamed to the shoulder and the elbow

I did

joint full of pus. Free incisions were made and drainage tubes introduced in several directions through and about the joint and free irrigation used two or three times daily of hydrogen peroxide, full strength. In forty-eight hours he was out of danger. Passive motion was begun early and to-day the arm is as good

as ever.

Two cases of separation of the lower epiphysis of the humerus treated by angular anterior and posterior splints and early passive motion. The diagnosis between this condition and fracture above the condyles is sometimes difficult, but in children epiphyseal separation is the more common.

I had the pleasure recently of examining a fractured elbow-joint, the result of great indirect violence in a girl of sixteen. There had been a fracture across both condyles, the fragment being split vertically with dislocation of both radius and ulna. The surgeon attending had found it impossible to maintain everything in normal position, and the result after two and one-half months was ankylosis in the true joint, with a good false joint through nonunion of the fracture. I advised, and I think rightly, noninterference, as the arm is free. from pain, and can be perfectly flexed and ex

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, due 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 feature— rest. 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, 101 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.

The hemorrhage had been quickly stopped by packing with iodoform gauze, and therefore it had been assumed that this simple measure would give the patient the best possible chance for his life. The spleen might have been removed, of course, but it would have in all probability greatly increased the risk of the operation.

Dr. J. F. Erdmann said that in this connection he desired to exhibit a spleen in which there was a gunshot wound. He had intended to remove the spleen in this case, but finding the man's condition very bad, owing to five perforations of the ileum and jejunum and one of the omentum, he had finally decided to simply pack the wound with gauze. This had been done, and with the very best results, but six days after the operation the man had died from acute uræmia.

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