Second-Tubercular meningitis. Fourth-Pseudo simulated meningitis or meningism. This gives a broad view of the subject and while it may not lead to a certain conclusion, it is likely to prevent serious error, because having these conditions in mind we can take into account the history, the environment, the age of a patient and trace out the syndrome of symptoms with greater probability of arriving at a correct conclusion. As the last word I want to repeat that lumbar puncture must be employed in suspicious cases, and until this becomes the rule the diagnosis of the variety of meningitis will remain uncertain and frequently unknown. 418 Brandeis Bldg. Rupture of the Liver. *By D. T. QUIGLEY, M. D, North Platte, Neb. The seriousness with which rupture of the abdominal viscera was considered in the past and the hopelessness of the policy of inaction then in vogue is well illustrated in a book published as late as 1898, McDonald's Surgical Diagnoses and Treatment. He says, after describing the symptoms of rupture of the liver, "The treatment must be expectant." In the American Text Book of Surgery, published in 1892, we find this: "An injury sufficient to cause rupture of the liver usually causes equally serious effects in other organs, so that surgical interference is ordinarily of no avail." They cite one case that was reported by H. E. Walton and recovered, saying that the patient made a rapid recovery, going out of the hospital in five weeks. In Progressive Medicine for June, 1901, we find in an article by William B. Coley that Delatour operated successfully on two cases of rupture of the liver. The same article states that "Rupture of the liver is usually followed by death, some writers placing the mortality as high as 85 per cent." Under the head of abdominal contusions in De Sajou's Cyclopedia we find this: "The liver, owing to its friable nature and its size and anatomical position, is the solid organ most frequently injured, because indirect concussion may cause a profound lesion. De Sejous recounts two cases operated on successfully and one case diagnosed as rupture of the liver, post mortem, which was not operated on. *Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911. The number of successful operations for rupture of the liver recorded in the literature of the past is small. The number of unsuccessful operations is much greater. This is because in the past much valuable time was usually lost in waiting to see whether the patient would not recover without operation, with the result that the patient was usually in a desperate condition when operation was attempted. The indications for the undertaker are mistaken for indications for the surgeon, with the result that the very procedure which should have saved the patient before he became exsanguinated hastens his end. Statistics show that danger in these cases increases according to the time lost. Cases operated on early usually live, cases operated on late usually die. It is a proposition that cannot be stated in hours. The only rule is: Operate as soon as possible after a diagnosis is made. The safety of the patient depends upon an early diagnosis and prompt action after the diagnosis is made. The case which I wish to report is as follows: The patient, a muscular man of thirty years, was engaged in the work of handling timbers in the double tracking of a railroad bridge. He was on a flat car and just reaching down to pick up a tie when a steel girder weighing about twelve tons fell and struck the other end of the tie, which projected over the edge of the floor of the car. The end of the tie struck him in the right side of the abdomen about the level of the umbilicus and threw him, according to the men with him, about thirty feet in the air. He turned over three times before alighting. He was immediately brought to St. Luke's Hospital, where I examined him and found him suffering intense pain in the epigastric region, breathing slow and labored, groaning with pain with every breath, pulse 55, irregular, blood pressure 110 when first brought in, fortyfive minutes later 90. Belly was rigid as a board, with epigastric tenderness, and epidermis was peeled off from the level of the umbilicus to the nipple. The right flank was dull on percussion. The patient was conscious, but could talk only with great effort. Diagnosis of rupture of the liver with probable rupture of intestines was made and operation done with the assistance of my colleague, Dr. George B. Dent, about an hour and a half after the patient arrived at the hospital, about three hours after the injury. On opening the belly through the middle of the right rectus nuscle the dark blood gushed out in a considerable stream. I hurriedly examined the anterior surface of the liver, expecting to find the lesion here, but finding nothing wrong, went to the kidneys, spleen, stomach and duode ། num, then the intestines, passing the gut through my hands and examining every inch of gut and mesentery. I did not find any bleeding point, but all the time the blood poured in a steady stream from the lower angle of the wound and kept the cavity of the pelvis full. Inspection of the pelvis showed no bleeding points, so I returned to the liver, and placing my hand behind the liver found on the posterior surface of the right lobe two tears about two inches apart. The larger one was about two and a half with gauze the bleeding at once ceased. The belly was closed. up, leaving the two pieces of gauze projecting through the upper angle of the wound. One piece was removed in eight days and the other in ten days. The gauze on removal was somewhat stained with bile. The patient made an uneventful recovery and left the hospital on the twenty-first day after the operation and has been doing manual labor ever since. The anatomical structure of the liver makes hemorrhage from this organ especially dangerous. The veins are devoid of contractile tissue, the organ contains very little connective tissue or elastic fibers. The tendency is for a wound to remain open with blood vessels gaping. Coley mentions a case where operation was done twelve hours after an injury causing bleeding from a small tear in the liver and hemorrhage had not ceased. Another danger to the patient in these cases is the leakage of bile, which will practically always set up peritonitis, and even though the patient's life be saved by subsequent drainage operations, he is likely to be crippled by adhesions. The indications for operation in my case were first and most important, persistent rigidity of the abdominal wall. To this I may add, besides the history of the case, falling blood pressure and dullness in the right flank. Dr. L. W. Littig of Iowa City, in a paper On abdominal contusions, read before the Western Surgical and Gynecological Association, emphasizes very strongly the importance of the rigid abdomen in diagnosis of severe abdominal injuries. He quotes Trendelenburg and Hildebrand to the effect that a persistently rigid abdominal wall following severe injury is practically always an indication for operation. In closing Littig says: "It may be stated that given an abdominal contusion followed by board-like rigidity which does not quickly disappear, a laparotomy should be immediately per formed." Dr. A. C. Stokes, Omaha: DISCUSSIONS. Rupture of the liver is not so liable to be followed by hemorrhage because the blood pressure is lower here than at any other part of the body. Unless a large artery or a large vein is torn across the bleeding practically controls itself. In an ordinary rupture the presence of a pack firmly placed will control the hemorrhage. I was much interested in the doctor's report. Dr. J. E. Summers, Jr., Omaha: If I understood the doctor correctly, he said ruptures of the liver are more common than those of any other intra-abdominal organ. Of course, the kidney is not an intra-abdominal organ, but rupture of the kidney is more common than rupture of the liver. Several years ago I read a paper in which I reported between twenty and thirty cases. Following an accident with internal injury, I know of no better rule to follow than this: When you have rigidity of the abdomen do not wait, but go in and get to work. I know of nothing harder to control than hemorrhage from the liver if it is torn. I believe these cases can be diagnosed and people will recover. Now as to the method of control. Dr. Van Buren Knott has invented a needle and method of suture which for control of hemorrhage from the liver is the best one I know of. Not only is it good for the control of hemorrhage, but for the closing up of spaces after removal of growths. Dr. J. P. Lord, Omaha: I wish to add just one word. It was not brought out in the discussion and might be of practical help. In suturing the liver I use the blunt end of the needle, making a mattress suture. This practically controls the hemorrhage without any trouble. Dr. D. T. Quigley, closing: There is just one point I wish to mention and that is in regard to the blood pressure as mentioned by Dr. Stokes. The blood pressure in the liver is low, but also there is a greater tendency for the wounds to gape open than in any other organ in the body. The statement that we see most of these cases post mortem is correct. Prostatic Abscess. *By A. C. STOKES, M. D., Omaha One of the most commonly overlooked conditions is infection of the prostate gland. It may be divided for the sake of discussion into: (a) Acute prostatitis. (b) Chronic prostatitis. Acute prostatitis occurs accompanying acute urethral infections, as gonorrhea, and following system infection as, typhoid fever, septicemia, pyemia and local infection of the genitourinary tract, like cystitis and pyo-nephrosis and pyelitis. It may resolve in one of three ways, viz: (1) Only infect the most superficial portions of the pros *Read before the Nebraska State Medical Association, Omaha, May 2, 3 and 4, 1911. tatic ducts leading into the urethra and cease with this, or, (2) It may extend into the deep ramifications of the prostatic follicles and become so deeply buried in the gland itself that the process may slowly extend for a number of years and produce a chronic prostatitis, in which acute exacerbations may Occasionally recur and may form indurated areas in the prostatic gland which are palpable through the rectum. Prostatitis occurs most frequently in early part of life, viz., from 20 to 40 years, becoming very much less frequent after forty than before, even in the presence of gonorrhea. (3) It may end by abscess formation. as we Senile hypertrophy bears no relation to prostatitis so far are at present informed, although Casper in his study of the pathology of prostatitis and Chiechanowsky in his stody of the pathology of prostatitis and Chiechanowsky in his study of conclusions. Yet, we are inclined to the belief that Chienchanowsky's cases were mostly prostatitis rather than true hypertrophy. ABSCESS OF THE PROSTATE. Not alone gonococci, but also pyogenic organisms are found in prostatic abscesses. Any condition which produces an extension of infection from the anterior to the posterior urethra can be a factor in the production of a prostatitis, especially horseback riding, bicycle riding and improper handling of the sexual functions, and an abscess may follow. The more carefully treated cases less frequently have a prostatitis following a gonorrhea than those who are careless in their treatment and in personal care. a few The opportunity of studying the pathology of the prostate during acute prostatitis is rather rarely presented, however, in cases the matter has been studied. In such cases the cut surface of the prostate is hyperæmic, fragile and the follicle or follicles filled with a muco-purulent mass. When it is in the interstitial tissue between the glands a strong infiltrate may press the sides of the glands together so that the secretion is pressed out and the inter-follicular tissue is widened and hyperæmic. Commonly, prostatitis begins with a catarrhal form of the surface of the gland, whereby the duct of the follicle is widened and the epithelium of the glands is infiltrated with leucocytes. When the ducts which carry the secretion of the prostate become filled with debris or closed by the swelling of their sides the secretion is retained and a cyst is formed, and by rectal palpation the prostate may be felt to contain nodules |