1 "ileo-colic circle," and that is in the majority of subjects the These 3 vascular landmarks of the intestine are significant and important in practice. They will increase in practical signification when prophylaxis will become a medical science, when surgery is a dernier resort (as it will be) and when internal medicine shall be supreme. When August Bier's "congestion treatment" is sounded on every "medical corner" and is recognized as the most universal therapeutic agent with the most universal success, it behooves us to be diligent heroes in the strife of medical progress in order to indicate to the popular Bier the location to apply his technique for congestion. The ancients said that blood is the life. The osteopaths confirm this by massaging, enticing blood to desired localities. The gynecologist incites blood currents through the genital vascular circle to cure disease by means of heated fluid (vaginal douche). Joints are restored to health by being flooded with blood by means of a one cent rubber band. A regurgitating aortic valve will cure apical pulmonary tuberculosis by congesting the lung-and it is the blood that cures. Hence we must search for vascular landmarks and devise a technique that will control the blood current-congest or degest at our bidding. CIRCULATION OF THE TRACTUS INTESTINALIS PRESENTING THE "ILEO-COLIC CIRCLE." Fig. 33. I dissected this illustration under formalin. It was drawn as a model by the artist Zan D. Klopper: 1, the "ileo-colic circle," formed by the proximal bifurcation and distal anastomosis of the arteria ileo-colica and arteria mesenterica proximal. From its right circumference originates the arteria appendicularis (in black). 2, at the termination of the arteria ileo-colica are located the "ileo-colic arches," composed of 12 arches or circles. 3, "vas intestini terminale rectum," or "straight terminal vessel of the intestine," located between the mesenteric arches and intestinal border (colon and enteron). They will number in the enteron some 6 to the inch. The arteria media divides, sending a long branch (ramus anastomoticus dexter) to anastomose with the long branch (ramus anastomoticus sinister) from the arteria mesenterica distal (inferior). This is Riolan's arch and Haller's arch. It is significant in surgical practice, as its obstruction would evidently be followed by gangrene. It is the greatest vascular anastomosis in the body-anastomosis maximus. SUBPHRENIC ABSCESS FOLLOWING PNEUMONIA. The case about to be described was referred to me for examination by Dr. C. B. Richmond. The patient, a girl aged 29 months, was accompanied by both parents, who gave the following history: As a baby she had always been well. The mother had nursed her but a short time before having to resort to artificial feeding. This consisted for eight or nine months of condensed milk, and then of boiled cow's milk, until the baby was a year old. After that the diet was one of plain milk and various articles from the table. Preceding their visit to office about five months, the baby had three spasms, followed by gastro-intestinal trouble, in which fever, vomiting and diarrhea were the dominant features. She speedily recovered from this and remained well for three months. She then had two more spasms to mark the beginning of a medium grade of pneumonia, according to diagnosis of family physician. She passed through the crisis, but recovery was not at all complete until three weeks later, when suddenly large quantities of pus was expectorated, continuing for three days. It then ceased rather abruptly, and the patient gradually gained in weight and strength until three weeks prior to visit to office. She then began to fail steadily. The parents observed epigastric pain, temperature ranging about 101° mornings to 104° afternoons, anorexia, emaciation, constipation, gradual abdominal swelling, and oedema of legs to knees. Almost from commencement of symptoms last set forth, the child lost ability to walk. Diagnoses of typhoid fever and abdominal tuberculosis had been made by physicians consulted prior to Dr. Richmond. The family history was negative. At the time of first seeing her the rectal temperature was 102.5°, pulse 144 and respiration 36. The facial expression was anxious, the mucous membrane pale, and the tongue was furred and yellowish. This child was small for age; stripped, there was plainly apparent considerable emaciation, panniculus adiposus markedly reduced. The superficial veins showed prominently over abdomen and face, the legs were quite oedematous and pitted deeply on pressure; the abdomen was greatly and uniformly distended. Stethoscopic examination of the chest was negative, with the exception of a few subcrepitant rales at base of right lung, both anteriorly and posteriorly. Percussion of lung revealed normal superficial areas, but deep dulness on right side to nipple or above. The respiratory excursion on the right side was diminished. There was a slight scoliosis with concavity toward right in lower dorsal region. The adomen was tympanitic over whole area, except in right hypochondriac and epigastric spaces. Extending low as navel to right of median line, the dulness was almost absolute. To left of median line from navel the line of dulness deflected sharply upwards at angle of about 120 degrees. On palpation there was a more resistant feeling over dull area, but the distention was too great to palpate lower margin of liver. Over the normal site of the gall-bladder there was more or less marked tenderness. Over this particular area also there was a tenseness, but no fluctuation could be elicited. The glands of groin, axillae and neck were palpable. There was no history of chills or excessive sweating, though there was noted sweating of head and upper trunk preceding the present illness, and also concurrent with it. The chemical and microscopical examination of the urine was negative. No blood count was made, but the hemoglobin per cent. was 65, and there was relative increase of the neutrophiles. The odor and appearance of the feces were normal. A consultation was now held with Dr. Richmond, and we found that our diagnoses made separately agreed. Starting with the assumption that the diagnosis of pneumonia made by family physician was correct, there ensued an empyema with discharge through bronchus and later an infection of subphrenic space through the diaphragm, limited to right side of suspensory ligament, and with tendency to point over normal site of gall-bladder. Exploratory puncture made here found pus containing pneumococci. Drainage was instituted at this point. A large quantity of pus was evacuated. Improvement was rapid from this time on till an attack of measles supervened just at time when discharge had almost ceased. Immediately after the attack of measles, there was some recurrence of fever, which could not be explained except by imperfect drainage. The opening was enlarged and glass drain used. A difficulty always was for the ascending liver to act like valve in closing, opening and making it kink the rubber at this point, and it was dangerous to use rigid tube for fear of liver trauma and infection. This was overcome by enlarging and changing direction of opening, so glass drain could lie nearly parallel with abdominal wall. After the measles the bacterial findings were constantly staphylococci instead of pneumococci. After the second drainage complete recovery took place, and at this writing the patient is an exceptionally well looking child. THE PREVENTION OF DEFORMITY AFTER INFANTILE STAGE OF RECESSION. By ADONIRAM B. JUDSON, M.D., New York City, N.Y. In the ever-changing treatment of disease the influence of environment is receiving unusual attention, as is seen in the management of tuberculosis of the joints. The influence of the lapse of time is also better understood. Medicines are given in small doses for very long periods, and the effects of time on the body are more clearly seen to influence the course of disease and the action of remedies. In the treatment of infantile paralysis I propose a method which relies exclusively on the influence of environment and the lapse of time. It is applicable only in the very early stage, before the case is likely to be seen by an orthopaedic surgeon. As soon as the disease is recognized I would limit the patient to the recumbent position till there is no possibility of further recession of the paralysis. The period of spontaneous recession extends over several months. During this time the difficult task must be undertaken of keeping a child, well in every other way, off his feet at an age when he should be learning to walk. In some cases 18 months should be occupied in this way. The common belief that such a patient requires exercise, especially of the affected limbs, will give rise to criticism and objections. A simple argument will not prevail in the family circle, and the physician's word will hardly prevent the little patient from having many a romp. And when the case ends. there will be differences of opinion. If some lameness results, it may be said that the patient should have had more exercise, and if there is no disability at all, after the strict observance of recumbency, it may be said that there had been very little. the matter with the child. The argument is as follows: It will be recalled that the ill effects of joint disease are seen more commonly in the lower extremities than the upper because tuberculous action is subject to resolution in the epiphyses of the shoulder, elbow and wrist, but often goes on to destruction of the articulating surfaces of the hip, knee and ankle. And when it is noted that the arms are free while the legs bear the weight of the body, it is reasonably inferred that the joints of the lower extremities when affected, or even suspected, should be protected by either recumbency or appropriate apparatus. The conclusion is a plain proposition and needs no discussion or verification. It |