use of the cast-off shells of mollusks, is atrophied in some of its members and enfeebled in its whole organism. So with the intellectual environment and the mental qualities of man. The pauper and the pampered child of wealth are alike deprived of those qualities of initiative and self-reliance on which their respective environments make no demand. Unnecessary charity is twice cursed; it curseth him that gives and him that takes; all of which goes to prove (if proof were needed) that abuse of medical charity is as bad for the public as it is for the profession.

Life-Saving Abroad and Life-Wasting At Home.

It is significant, and by no means gratifying to our national pride, that President Taft, when desiring to demonstrate the value of modern sanitary methods, was forced to draw all his ern sanitary science has abolished yellow fever in Cuba, discovered the cause and largely controlled the ravages of hookworm anemia in Porto Rico, barred yellow fever and Chagres fever from the canal zone, isolated leprosy in Hawaii and the Philippines and aided in the investigation of beriberi. This work has practically revolutionized conditions in our tropical possesions and has enabled the president to say that "in the short twelve years that we have been responsible for the health of our people in the tropical climates we have made more progress in the discovery of methods of prevention and cure of tropical diseases than all the other countries have made in the past two centuries." Modern sanitary methods, backed up by intelligent and authoritative administration, have indeed worked wonders in the tropics; but what of our own country? Tuberculosis, typhoid, pneumonia and the appalling black plague of venereal infection still lay waste the land. They are tolerated chiefly because we are accustomed to their presence. If tuberculosis were a newly discovered tropical disease, if typhoid fever were limited to the tropics, how horrified would we be at their ravages and how warmly would be applaud any efforts of the national government to control them! But through long association we have become tolerant of their presence and reconciled to their destructiveness. Yet modern sanitation, if permitted, can effect as marvelous changes here as in the canal zone or in Havana.

Ruptured Intestine Due to Injury.

*By R. R. HOLLISTER, M. D., Omaha.

Case of a brakeman 28 years old who was thrown with a good deal of force against the corner of the cupola of the caboose as the cars came together in coupling. As nearly as he could tell the blow hit him over the middle of the abdomen. He had his breakfast at 6:30 a. m., went to work at once, the accident occurred at 8 a. m., soon after which he was seen and given a hypodermic injection. About 9 a. m. he said he vomited all his breakfast. He ate nothing after this, but consumed large quantities of water, as he was very dry. He reached the hospital at 5 p. m.

Physical examination showed a musclar man complaining of severe pain in the abdomen, who looked very sick. The only evidence of external injury was a slight abrasion over left iliac crest. Temperature 99.5, pulse 90, respiration 30 and entirely costal. Head, heart and lungs negative. General abdominal rigidity, point of greatest tenderness just above umbilicus in median line. Catheter drew clear urine from the bladder. Immediate operation decided upon. Abdominal section by median incision below the umbilicus. As the peritoneum was opened out flowed thin serous pus, which was present in the whole field of operation. Superficial review revealed no source. Beginning at the ileocecal valve the intestine was examined as rapidly as possible. After going over many feet of the intestine a linear break an inch long in the side opposite the mesentery was seen. It was closed by a double row of Lembertsutures. As much pus as possible removed by gauze sponges. A large glass tube was inserted in pelvis and wound closed. Fowler position and rectal injection of hot salt solution with a little strychnine. Drainage was free, bowels moved easily, no distention and for the first ten days temperature did not go above 100.5, nor pulse above a hundred. Seemed to be doing exceptionally well in every way. On the eleventh day the temperature began to creep up to 101, a little higher the next day, no pain or tenderness in the abdomen, which was lax, the thirteenth day temperature was 103 and rales and pain in lower left chest, but no dullness nor bronchial breathing. The fourteenth day dullness at base of left chest, no cough nor expecto

*Read before the Nebraska State Medical Association at Omaha, May 2, 3 and 4, 1911.

ration and chest was tapped with a negative result. General condition excellent, symptoms remained about the same. On the seventeenth day there was slight swelling of external tissues in lower left axilla and left chest was opened and a large amount of pus let out. After this his condition became steadily worse and he died of septicemia on the twenty-first day.

There are many things of interest in this case. First, that he vomited a large amount some two hours after eating breakfast, which probably removed nearly all that he had eaten, as there were no particles of food in the abdominal fluid. His drinking considerable amounts of water during the day increased the amount of fluid in the abdominal cavity markedly so that infection was widespread. The smooth course for ten days made one feel that recovery was certain, when the infection began working again, following the lymphatics upward most likely, as there was no pain or tenderness in this region during the first week. Then the question arises, was the trouble phrenic, pleural, or did it form below the diaphragm and break through into the pleural cavity later. Temperature, chills, pain in axila and later a swelling of superficial tissues in lower axilla, dullness in lower part of chest, front and back, with some displacement of heart to right, was all that could be found. No signs or symptoms referable to the abdomen after the first few days. Therefore I believe the infection began in the pleura by extension along the lymphatics from a focus in the abdomen.

As to the most trustworthy data in these cases of abdominal injury which would lead one to operate, there are many factors to be taken into account. First, the history should be gone into in great detail. The nature and direction of the force. Was it a large body moving slowly, giving the muscles time to contract and protect, or a small body moving with lightning rapidity as a knot thrown from a circular saw? Was the site and direction such that the intestines or organs might easily be pressed against bony prominences? If the case is not seen early, were the first symptoms those of hemorrhage or those of peritonitis? Pain, shock and abdominal rigidity are the most trustworthy aids to recognition that we have, yet are not infallible. Put your evidence together, try to reduce the shock and if in the course of a few hours the symptoms do not abate open the abdomen and find out. The cry at once goes up from the ultra-conservative that you are subjecting people to needless operation and danger. The danger in this class of cases is not from operation; the danger is from waiting.

Dr. B. B. Davis, Omaha:

DISCUSSION.

I apologize for coming before you in this way. I know this was a good paper, though I did not hear it. Dr. Hollister never gives anything but a good paper. It is impossible for me to discuss his paper, but I might say a few words in regard to these injuries.

Injuries of the intestines are first of all of emergency character. In the past the majority of these patients were treated expectantly too long. In almost all these cases there is considerable shock. If a man waits to see what is going to develop he waits until the shock of the original injury gradually goes into the shock of the oncoming peritonitis. When he waits until peritonitis develops he puts the patient into unnecessary jeopardy. With injury of the abdomen where there is a probability or a fairly good possibility of rupture of the intestine I have had the feeling that in these cases an exploratory abdominal section does not jeopardize the patient's life as much as to treat the patient expectantly. Even though not quite certain that rupture has occurred it is best to make an incision and explore. Once or twice I have found that rupture had not occurred. In twelve cases I have found injury of the intestine. Where there was not injury they were not made worse by the operation. The cases where I found ruptures had a better chance for recovery than if I had treated them expectantly.

In my opinion it is best to operate on these cases promptly. I have been called into a number of cases where rupture had occurred and they were treated expectantly and they had waited until a good peritonitis had developed.

A slight injury will often produce rupture of the intestine. One case I remember about a man who had slid from the top of a hay stack and a pitch fork stuck into the ground struck him in the abdomen. At first he did not think he was much injured, but in about twelve hours he began to have much acute abdominal pain. I was sent for from twenty-four to thirty-six hours after the injury. Upon operating I found that the sphincter of the colon had been crushed off. The patient died. A great many of these cases of ruptured intestine could be saved if we explored early.

Dr. J. E. Summers, Omaha:

There are two rules by which you may safely decide that you have rupture. When you have pain and muscular rigidity. No man is justified in delaying operation if he has these two symptoms. All the mistakes I have made have been made because I have not observed these rules.

Dr. Hollister says his patient died. these papers are read to be criticised. The patient would probably have died operated on earlier.

Dr. S. C. Beede, David City:

I should like to make a criticism— He should not have waited so long. anyway, but still he should have been

I liked Dr. Hollister's paper very much. It was right to the point and did not take long to deliver. I wish it might have been read before the medical section, as they need it.

The slightest symptoms are often present in such a great injury as rupture of the intestine. I recall a case. A boy of seven or eight was kicked by a horse. There was no evidence of injury. He walked into the house and was all right for twenty-four hours, except some pain and muscular rigidity, as Dr. Summers mentioned. Then he developed severe symptoms, such as vomiting. I opened the abdomen thirty-six hours after the accident. Peritonitis had set in. He only lived an hour after the operation. In case of doubt, explore-you will lose a few patients, but will lose many more by failing to operate when you should.

Dr. A. C. Stokes, Omaha:

I wish to add only one thing. It seems to me that in addition to muscular rigidity and pain in almost every abdominal injury the first symptom is a slight increase in the pulse. With those three things we are very sure of trauma of the peritoneum. Increased pulse, muscular rigidity and pain are signs of peritonitis.

Dr. C. P. Fall, Beatrice:

I did not intend to discuss this paper, but since Dr. Davis mentioned the pitch fork injury I am reminded of a very similar case. A gentleman engaged in haying slid off a load of hay. A pitch fork ran up his rectum. He was taken off the fork and immediately went into a state of shock, so much so as to alarm all. They sent for a physician. I was called later.

I reached there at 12 that night. They showed me the fork.

I found that the fork had followed the colon to the sigmoid flexure, about as far as our tubes go when we give high enemata. Instead of turning around it went through the sigmoid flexure and into the peritoneal cavity for a distance of a foot. I introduced my hand, lubricated with green soap and alcohol, and found the pitch fork had made an opening I could put my fingers through. We could not close the bowel, so I used my ability a little. I took a drainage tube about one and a half feet long wrapped with gauze and expanded the intestine and introduced this dressing above the opening. It drained the intestine until the injury healed. The man got well. It was the first case I know of that got well with an injury just like that. It is rather in line of the discussion of the paper that was presented to you.

Dr. Hull, Omaha:

cases.

The pulse is one of the principal indications in the treatment of these

In one case we had a boy who had been kicked in the abdomen by a horse. His pulse rate increased at once. Upon opening the abdomen we found necrosis had already set in.

An area about the size of a quarter was found in the jejunum which was already necrotic.

The pulse is the surest indicator of rupture.

Dr. A. I. McKinnon, Lincoln:

I do not think there are any symptoms which will tell us whether we have an injury to abdominal viscera. The signs mentioned by Dr. Summers would not hold good in the majority of cases.

I think the only way to diagnose these cases is by intuition. There is an expression on the patient's face which says, "I am sick," it is something hard to describe, but you will be satisfied in your own mind that there is injury to the viscera.

I recall a case I saw. The man had been injured by being squeezed between two cars. There was but little shock and pain. I gave him morphine. He rode home in the buggy with me and went into the house. There I went over him carefully and then sent for another surgeon. The older surgeon advised the man to wait to see what would develop. The temperature was normal, pulse normal, no pain, no shock. My consultant advised waiting and we waited. While waiting I gave a physic after twenty-four hours. The man was seized with severe pain and went into shock. The pulse went up and we prepared to operate. He died before he was completely under the anesthetic. On opening the abdomen we found a clean cut through the ileum. The abdomen was full of fecal matter, calomel pills, etc. In this case there were no symptoms which pointed to a severe injury. The safest rule to follow when there is the slightest doubt is to operate.