Successful Extirpation of the Spleen.

BY WALDO BRIGGS, M. D.,

ST. LOUIS, MO.

College of Physicians and Surgeons.

N presenting to you this first case to-day, we have one that is of the greatest interest to surgeons and one of the acute variety in surgical troubles-one that is really an extreme rariety. This case has the following history: The patient, is a wandering tramp, who, in trying to beat his way to the city, hid himself in a box-car He was discovered on the arrival of the car in East St. Louis, was violently dragged out, thrown upon the ground, kicked and trampled upon. The injuries occurred several days

since, and after their inception he walked the entire distance from East St. Louis, suffering the most excruciating pain in the abdomen. He was picked up by the police and sent to the hospital for treatment. Examining the entire surface of the body, we find no indication of injury, to the superficial structures, except slight discoloration and some cuts on the lower extremities. An examination of the superficial markings of the abdomen shows there is considerable tympanitis, and on percussion from above downward we find dulness extending from the ensiform car tilage to the pubis, and in the lumbar region on the side, from above downward, there is a decided resonance, with the distinct dulness and resonance. On palpation over the entire abdomen there is only one site in which the patient complaims of intense pain on pressure-the left hypochondrium. Observing his physical condition at the present time we see he is not emaciated to any extent, but we notice at once the hurried respiration which is indicative of some serious trouble. The pulse is about 115, temperature 102 degrees. Taking into consideration the history of the case, the injuries produced by blows upon the abdominal cavity, and the dulness upon percussion extending over the full length and breadth of the peritoneal cavity, the intense pain produced by pressure over the left hypochondrium, we diagnosticate a probable rupture of the spleen, with hemorrhage into the peritoneal cavity. The reason of this diagnosis is plainly evident from the above symptoms, and we would hardly consider a differential diagnosis of the case between injuries of the spleen and intestine, as it is of extreme rarity to have serious lesions of the gastro-intestinal tract from such blows on the abdomen, for the reason

that these structures are free and readily yield to blows, while a solid organ, such as a spleen, which is delicate in structure and easily torn, may be ruptured by direct blows, either anteriorly or posteriorly.

We shall now make the operation of laparotomy to determine the condition of affairs and to verify the diagnosis if possible. The incision will be somewhat out of line to the most direct route to this organ, which would be obliquely below the rib in the left hypochondriac region.

We make the incision through the linea alba, extending from the ensiform cartilage to the umbilicus, for we believe we cannot only reach the spleen more readily, but should our diagnosis be incorrect, we can more thoroughly explore all the contents of the abdomen, to learn the source of the hemorrhage. We cut into the peritoneal cavity and, at once passing the hand up to the diaphragm as a guide, we locate the spleen, and with great care withdraw it through the incision. We note on the anterior surface large adherent clots, on removal of which we discover that the capsule is torn throughout the extent of its anterior surface, and considerable hemorrhage follows removal of the clots. We determine the only course to pursue is to remove the entire organ, which we shall do by an entirely new method for the treatment of the pedicle of the spleen-the transfixation of the pedicle between the walls of the incision. The recommendation of some operators -of the ligation of each vessel-is an excellent one, and the ligation of the artery as it comes from the coeliac axis, which is recommended, I believe, by Lagenbeck, is also a good method. As the majority of the methods for the treatment of the pedicle is followed by secondary hemorrhage and death of the patient, I have concluded, for practical reasons, to keep it in this position, so that if secondary hemorrhage should occur it will be easily accessible.

TECHNIQUE OF SPLENECTOMY.

An incision (vertical) three or four inches long is made along the border of the rectus muscle, above the umbilicus, opening the peritoneum. After surrounding it with spnngy packing we turn it out, lower end first. The abdominal opening should be made large enough for the organ to pass without force, and the margins of the wound should be held back to avoid all traction on the pedicle. Starting at lower edge, successive pairs of artery clamps are applied to the pedicle in advance of division, which is then made. between them. The spleen is then removed and the vessels in the grasp of each clamp are ligated separately with silk. As each clamp is removed, bleeding points are sought for and secured. Draw then a ligature moderately tight to lesson the arterial pressure distal to it on the ligature of each vessel.

The patient who forms the subject of this clinical report has entirely recovered without a single unfavorable symptom.

The first successful removal of the spleen was performed in 1549 by Zaccaralla, although this is denied by various authors. Quittenbawn, of Rostock, makes the next claim in 1826, but the patient died in six hours.

The others were as follows:

Kuechler, of Darmstadt, 1855-Removed for malaria. Died of hemorrhage in two hours.

Spencer Wells, 1865-Death in six days.

Peau, in 1867-First well authenticated successful case.

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Wright, in 1888 collected 62 cases; Vulpius, of Heidelberg, in 1893 collected 121 cases. The average number of cases has been about fifty per cent.-St. Louis Clinique.

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Walds Bugge

The Language of Prescriptions.

BY GEO. W. TURNER, M. D.,

ST. LOUIS.

ERE in America, very few of us are classical scholars, and, frequently, the language of our prescriptions is something appalling. One can readily demonstate this in a few minutes, by a glance over the files of his nearest drug store. Campbell says, "In the United States prescriptions are usually written in a language called, by courtesy, Latin, although we doubt very much if Horace or Cicero would ever suspect that the conglomeration of abbreviated medical terms which are sent to our drug stores were specimens of his native tongue."

Chief among our faults, is the use of incorrect Latin word endings. There is no excuse for not using correct Latin terminations, the more especially when we remember that from a dozen to a score of drugs about cover the field of every day practice. By memory, pure, simple and unaided, the endings of these may be mastered; but the principles of Latin case endings are so simple and so few, that they may be readily learned in a couple of hours, by any one with brain enough to memorize the branches of the seventh cranial nerve in the same time.

A favorite sin against terminology is abbreviation. Like the grave, it hides our ignorance. It cuts off mistakes in terminology, of course; they "die a bornin'." Abbreviations are generally inadmissible, and always so with the chief word of the drug name. They are æsthetically objectionable, but the vital objection lies in the fact that mistakes may easily be made in the filling of them-mistakes always fatal to the intended therapeutic result, and often to life. As examples: Acid. hydro. may be hydrocyanic acid, hydrochloric acid or hydrobromic acid; hydr. chlor. may be hydrate of chloral or corrosive sublimate; sulph. stands for sulphur, sulphate, sulphite or sulphide. These examples may be multiplied almost

infinitely. It has been held by the courts, that, on a fatal "accident" following this kind of prescribing, the physician and druggist are equally guilty of manslaughter.

Again, there is the error of barbarism of language-the mixing of two or more tongues in the same term or formula. Stick to one language; do not write "Chinin sulphatis" to keep your patient from knowing that he takes quinine, and then finish with "Extracti gentianæ." It constitutes a barbarism as grievous as those for which Pitou felt the chastising cat-onine-tails, and received the final dismissal by the erudite Abbe Fortier, as related by Dumas in "Taking the Bastile."

When using ad. only, the ingredient is in the accusative case, but when using q. s. ad., it is in the genative; a common error under this head is the use of aquæ ad instead of aquam ad.

When using a simple formula, in which the ingredient is not weighed or measured, but counted, use the accusative case. Thus: R Pilulas phosphori, not R Pilularum phosphori, nor as is more frequently written, B Pillulæ phosphori.

A strict adherence to the rules of grammar dictates that only the first word in a drug name shall be begun by a capital letter, but the custom has been to begin each word by a capital. However, the tendency of the best writers of the day is to follow the grammatical rule, rather than the custom.

While not directly pertaining to the subject under discussion, I cannot refrain from saying, write legibly. If you cannot write, print; if you can not print, you may follow the method of a learned (?) M. D. of our city, have your prescriptions printed in advance--a machine-made practice, so to speak. Often on seeing prescriptions, not one word of which I could read, far less legible than a baby's first crude scrawl, I have been forced to believe that pharmacists are blessed with a special sense, aside from sight, by which they decipher these alleged characters.

These hasty and illy arranged remarks were inspired by the inspection of the files of several drug stores in this city (where we boast of being finde-siecle in medical matters), in the company of a medical friend, educated in England and the Continent. His astonishment at and opinion of our laxity in this respect may well be imagined. We should not forget, that, as "The apparel oft proclaims the man," so the prescription oft proclaims the physician.

8118 North Broadway.

MEDICAL SOCIETY OF THE MISSOURI VALLEY.-The next meeting of the society will be held at Lincoln, Nebraska, Thursday, March 18th, 1897. Please send titles of papers on or before February 25th, 1897.

DONALD MACRAE, JR., M.D., Secretary,

Council Bluffs, Iowa.

DR. W. P. HENRICH has moved from New Baden, to Mascoutah, Ill. We wish the doctor much success in his new location.

A COLORED physician, Dr. Elmer E. Barr, has been appointed by President Healy, of the Chicago Board of Health, to a position on the Cook county medical staff.

THE ratio of physicians to the total population of this country is 1:613. Oklahoma takes the lead with one doctor to 190 people. New Mexico has comparatively the fewest, namely 1 to 1,584.

PHYSICIANS who usually subscribe for several medical publications, will save time and money by submitting their lists to Fassett's Medical Press Bureau, St. Joseph, Mo. Send stamp for catalogue, giving description and price of twenty journals of established value.

ERNEST B. SANGREE, M. D., Professor of Pathology in Vanderbilt University, Nashville, Tenn., has been made Bacteriologist to the State Board of Health, of Tennessee. This is a deserving appointment and we congratulate the State Board of Tennessee, on having the services of such a worthy and scientific man.

AMERICA SHOULD FOLLOW SUIT. A dentist was recently arrested and fined in Berlin for displaying upon the door of his office a plate describing him as a doctor of dentistry, with a diploma granted by an American dental college. The court held that it was against the law for him to use a foreign title in practice in Germany.

A COLORED man of Cincinnati by name of J. Willis Gwinn, added M. D. to his name and embarked upon the practice of medicine only to be sharply wrecked upon the rocks of the Kimmell law. Dr. Scudder of the State Board was instrumental in securing his arrest. "Doctor" Gwinn was found upon examination to be unable to write his own name.-Cleveland Journal of Medicine.

IS IT "PAULINE ?"-Pseudo-Hermaphroditism was the term employed by Dr. Sherman, of 26 East Sixty-third street (N. Y. Med. Record) in sending out invitations to a limited number of professional men on Sunday last, to see at her house an unusual instance of mingled sex. The subject, about twenty-three years of age, presented many features of interest to those who had the privilege of examining it. A woman in feature, voice action, instinct and dress, was found with well-developed penis and testes. The rectal orifice, without external sphincter, presented somewhat the features of a vulva, and high up through an orifice suggestive of a cervix a probe could be passed for about two inches. Through this opening there was a discharge of blood, which had been going on for some days, and which the patient stated occurred regularly each month since the age of fifteen. Urine is passed, as Dr. Sherman has observed, through both channels, partly under the control of the will; and, according to the patient's statement, menstrual blood escapes at times by way of the urethra. No distinct uterus or ovaries could be made out.