Eczema rubrum is usually of more frequent occurrence than any of the other varieties, because the patients do not as a rule come to seek your advice until this condition has supervened and hence has mostly always become chronic, or because there is not much disfigurement in this variety. The acute variety giving rise to disfigurement, they seem to be afraid. This type attacks all ages, and is the one that will confront you most of the time. It may be witnessed as an inflammation, pure and simple, with a slight infiltration, but we may also encounter this condition having much thickening in connection with it.

When the disease attacks the bearded region, it is very likely to present the same appearance as on the scalp, but it never reaches the same proportion, because the patients have a little natural pride and try to make their faces presentable. In this portion of the body we have a yellowish-green crust, as a general rule, but it may often be of a brownish color. The hair becomes filled with it and may also become matted together, and it is not a very easy matter to get it apart. The inflammation often dips down and affects the hair follicles. When this disease attacks the smooth

parts it shows the same characters, but is more visible as it is seen upon the free surface.

The disease rarely affects one ear or one eyebrow or eyelid, but is usually found upon both. When the ear is attacked the hearing is generally diminished.

There are certain trades that have a predisposing cause upon the production of eczema of the face, such as locomotive engineers, wheelsmen on all sea-going vessels, mechanics in certain lines of trade whose hands are likely to come into contact with the face, after becoming soiled by what they are obliged to handle, and this being carried to the face superinduces another attack of the disease, although this rarely is the first exciting cause. The same disease may affect the faces of women, but the causes may be somewhat different. These may be women who are obliged to stand over a hot fire or over the laundry tub, or who may be continuously irritating the face with other irritants.

If the disease is witnessed in an adult, he must confine himself to such articles of diet as will not affect or otherwise derange the intestinal canal. Therefore he must not take any fried articles, pastries, stewed fruits or pork, either fried, as in sausages, or roasted.

He may take all the plain food that may be placed before him, and these may consist of such articles as roasted meats, other than pork, a few potatoes or tomatoes, and green fruits. In addition to these his diet may consist of such articles as have an action upon the flow of urine or that have a tendency to assist the intestinal movements. These may be of the following: cabbage, when unboiled, spinach or kale, clam juice heated, but not too warm, but sufficient only to remove the coldness.

This list is not a complete one of all the patient may or may not take, but it will show in what direction the appetite should be trained. In an adult I am usually in the habit of using a tonic aperient.

morning, one-half hour before breakfast, in a half goblet of water, which should preferably be warm. The acetate of potassium may be given to assist the action of the kidneys, and it may be added to the morning dose of the preceding, or perhaps it would be advisable in some cases to give this salt in doses ranging from 10 to 30 grains every three hours.

Carlsbad, Hunjadi or Freidrichshall waters may possibly be better borne by the patient, and many examples of good results from these waters have been seen in my clinics.

In cases where there seems to be a vitiated constitutional condition it will be advisable to give either the cod-liver oil, pure or in an emulsion, or even some other tonic, as quinine or iron, or whatever may seem best according to the condition of the case.

The local treatment is just as important a measure as the remedial attention to the internal derangements.

In the acute varieties, in which the inflammation is of a high degree, and where possibly there may be a slight or aggravated denuded tissue, it will be advisable to precede treatment with a sedative astringent, such as washes of boric acid or the lotio nigra of the pharmacopoeia, or a mucilaginous preparation, bran or rice flour taking the preference.

The application of the washes of boric acid (saturated solution in water, or on some well chosen cases, in alcohol) or the lotio nigra (grains three to ten to the ounce, as the case may demand) may be applied and kept in contact with the diseased surface from one half to one hour at each application; the part is then to be mopped dry and anointed with some soothing and astringent oinment.

Of this latter class we may choose from the following:

An ointment with which I have received good results is the following:

Should there be much itching, of either carbolic acid 5 to 10 gra mol one to three grains, to the ment will be found beneficial.

In some cases I have advised t with decided advantage :—

This is to be painted on the part with a brush twice a day, care being taken not to get too close to the eyes, because of the burning nature of the collodion.

When applying this remedy the child will probably cry, on account of this burning of the collodion, but immediately after its application the relief will be noticeable, and the child will often go to sleep, a thing which it had not done for some time.

THE

INDICATIONS AND NATURE OF TREATMENT IN SEVERE ABDOMINAL INJURIES AND INTRAABDOMINAL HEMORRHAGES UNACCOMPANIED BY EXTERNAL EVIDENCE OF VIOLENCE.*

BY JOHN B. DEAVER, M. D.,

Professor of Surgery Philadelphia Polyclinic; Assistant Professor of Surgical Anatomy, University of Pennsylvania; etc.

Every surgeon has undoubtedly at some time in his experience, either in private or hospital practice, met with cases coming under the class covered by the title of this paper. These are cases in which the history and general condition of the patient give the impression that there is a serious lesion within the abdomen, and yet, upon examination, we find total absence or only slight evidences of injury. The tendency, I fear with many, is to treat these patients tentatively, only to be awakened at the autopsy to the fact that a rupture or a tear existed in the abdominal cavity, which, by early radical operation,

could have been relieved.

The mortality in these cases is appalling; references to the literature of the subject will amply bear out this statement, which is readily. accounted for by the nature of the injuries. Where the lesion is of the liver or spleen, if the patient does not die of shock or hemorrhage, a violent peritonitis supervenes to which he shortly succumbs. If the liver, spleen, or kidneys are involved, death from hemorrhage may ensue in a very short time. Should the stomach, intestine, or bladder be *Read before the Philadelphia Academy of Surgery, Jan. 7, 1895.

ruptured and their contents poured into the peritoneal cavity, death from peritonitis is the result. In rupture of the mesentery the danger is from hemorrhage, yet, when the opening in the mesentery is small a clot may form sufficiently large to control the bleeding. Should death occur under these circumstances it would be the result of peritonitis caused by the free blood in the peritoneal cavity. I report a case of this character where recovery followed immediate operation. In ruptured extra-uterine pregnancy death is due either to hemorrhage or peritonitis.

The usual history of these cases, with the exception of extra-uterine pregnancy, is that the patient has received a direct injury to the abdomen, which is found to be unaccompanied by external evidence. These injuries may result from railroad accidents, from being caught between shifting cars, or from blows upon the abdomen received in various ways.

This class of injuries is quite common in military surgery, more so in the past when spherical balls were used and only a low velocity attained. A majority were supposed to be caused by the violence of the wind displaced by the passing ball, but we now know that they were due to the impact of the balls almost entirely spent.

Two cases which illustrate this occurred at the siege of Sebastopol. In neither did the clothing or the abdominal walls show any signs of injury, but in both the liver and spleen were comminuted to a pulp, and the intestines extensively lacerated (Mr. Hulke, Lancet, December 31, 1892).

As yet we have no reports from surgeons of the armies engaged in the present strife between Japan and China, but it will be of great interest to read the records of such cases. We can expect, I think, a very full and detailed account from the Japanese surgeons. We have all applauded the work of some brilliant individuals of the Japanese profession, and, in fact, we must assign to Japan in medicine the same standing that she has taken in other walks of civilized life, and which she has demonstrated she can hold.

The most prominent symptom is pain,

which is accompanied by shock, the degree of which is dependent upon the extent of injury and the temperament of the individual.

I might say here that temperament and nationality have a strong bearing in the production of shock. Persons of a highly nervous temperament suffer more from shock than do phlegmatic individuals. For example, Americans are far more liable to suffer a severe degree of shock following injuries or operations than are the Germans.

The pain is peculiar and difficult to describe, but is readily recognized by one who has seen many of these cases and by the patient himself. It is not that of ordinary intra-abdominal affections, but is described by the patient as if something had given way or ruptured, and is usually accompanied by a consciousness of impending death. It is usually accompanied with tenderness, which will be more or less localized, unless the ensuing peritonitis be general. In the early stages of the injury, when shock is most profound, it may not be so pronounced, and if large doses of opium be administered it may be masked throughout the course of the trouble.

When vomiting is present it is usually associated with pain. Rarely does the vomited matter contain blood.

There is often seen a characteristic rigidity of the abdominal walls, which is due to intraabdominal irritation. I have seen this so marked as to recall to mind the checkerboard appearance of the normal abdominal walls as represented in the pictures of the early artists.

In the cases I have observed, consciousness has invariably been retained for varying periods of time. Restlessness is not usual in the early stages except in severe hemorrhage, but later on, when peritonitis develops, it is not an uncommon symptom.

The pulse and temperature vary according to the degree of shock. The former is weak and running, varying from 100 to 160, and the temperature subnormal. If reaction takes place the pulse becomes stronger and less frequent, and the temperature reaches

the normal line. After reaction peritonitis is invariably the rule, and is accompanied by an accelerated and a high-tension pulse. The temperature under these circumstances is unreliable, as it does not correspond to the degree of inflammation or septic infection. A high temperature with a slow pulse is less significant than a rapid pulse with a low temperature. In cases of septic peritonitis, where autopsy revealed a belly cavity full of foul pus, I have seen the temperature run a normal course throughout the disease.

The part the sympathetic system of nerves, which has its distribution in the abdominal cavity, may play in injury to the abdomen is important in considering the differential diagnosis between the simple contusion and contusion accompanied by visceral lesion. In the former the absence of the severe and characteristic pain, of constant and persistent vomiting, of the anxious expression and presentiment of impending death, and of any evidence of loss of blood, associated with the occasional presence of suddenly developed meteorism, will usually be sufficient to establish the differential diagnosis. This condition of meteorism is due to paralysis of the muscular coat of the bowel consequent upon the concussion of the plexuses. There are cases, however, where it is very difficult to say definitely whether there be a visceral complication or not. Under these circumstances one can only wait for a comparatively few hours, when, if improvement is not apparent the operative course is to be pursued. When the solid viscera are the seat of injury hemorrhage will be the main source of anxiety. The pain and the exsanguination give the clew. If the patient should react, which is unusual, unless the kidney is the injured organ, we will find, in addition, dullness on percussion in the flank. Rectal or vaginal examination may afford aid in determining the presence of a collection of blood in the pelvis. blood in the pelvis. The solid organs suffer most from the external violence on account of their fixity, density, and close proximity to the bony structures. The liver is the most often injured, then the uterus, spleen, and kidney in the order named. The stomach is

least often injured, there being very few such cases on record.*

The liver is the organ most often affected because of its position beneath the ribs and against the spine, and because it is held firmly in place by strong ligaments and bloodvessels. It is most commonly ruptured on its upper surface, generally in the right lobe, and in the majority of such cases the injury proves fatal. * * *

The most common form of intra-abdominal hemorrhage is that resulting from ruptured extra-uterine pregnancy. While these cases may be due to traumatism without any external evidence they are usually spontane

ous.

While hemorrhage from the pelvic organs of the female usually occurs from a ruptured extra-uterine pregnancy, it may be due to other non-traumatic causes. Hematosalpinx may occur independent of pregnancy, and rupture either spontaneously or from trau matism. Again, degenerated blood-vessel walls, and especially veins, may rupture under similar circumstances.

Hemorrhage itself is seldom the cause of death, but associated as it is with shock, the degree of which is out of all proportion to the accident, it is frequently fatal in a very short time. When the peritoneum is wounded shock is still more profound, the so-called peritoneal shock.

Hemorrhage within the peritoneum is sometimes very slight and distinctly localized, and may occur several times during the course of the illness. It may take place between the layers of the broad ligament, and soon stop from the pressure. * * *

The immediate effects of an injury severe enough to cause a serious lesion of an abdominal viscus are sometimes so slight as to be misleading. Very often a patient with such a condition will walk to a conveyance or to the hospital, complaining only of a slight pain. In varying periods of time following. the injury more decided symptoms will develop, viz., signs of hemorrhage if the solid organs be involved, and early peritonitis if

*The detailed reports of illustrative cases are omitted. (Editor COLLEGE AND CLINICAL RECORD.)

the hollow viscera be ruptured or torn sufficiently to allow their contents to escape. When this occurs operation is imperatively demanded without delay. This is also true of hemorrhage consequent upon the rupture of an extra-uterine pregnancy, be it traumatic or spontaneous. In ectopic gestation operation will be necessary in every case at some period of its history; therefore, if a diagnosis can be made, or even a well-founded suspicion of the condition exists, rupture should not be allowed to occur. If rupture does occur, however, immediate interference is the only certain means of saving the patient's life. The longer the operation is deferred the greater the risk to life. Hasty operations, often necessitated by the patient's condition, are likewise less liable to reach a favorable termination. Blood clots or intestinal or gastric contents cannot be washed out of the peritoneal cavity except by prolonged and repeated flushing.

The almost universal fatality of intra-abdominal lesions of traumatic origin is so well recognized that it seems as if there could hardly be any question as to the wisdom of opening the abdominal cavity. I would not be understood as meaning that abdominal section should be used as a means of diagnosis, but on the contrary I believe that every known means, with attention to the most minute details, should be exhausted in establishing a diagnosis. When a diagnosis is impossible abdominal section is justifiable only when it becomes the last and only chance for the patient.

I have refrained from using the terms exploratory and diagnostic incisions, believing that they not infrequently serve as a shield to cover a lack of diagnostic ability. It is a moral obligation resting upon every physician and surgeon to develop to the utmost of his ability the highest diagnostic attainments.

Aseptic surgery has undoubtedly been one of the greatest boons to humanity that this nineteenth century has brought forth. But to me it seems that it affords a great temptation to men who have not had experience and surgical training, and who have, therefore, not