(j) The splanchnoptotic appears neurotic, slender, and delicate, poorly nourished, pale, non-energetic, tired, and as a sad, helpless picture. Splanchnoptotics form a distinct class, with peculiar characteristics, like a class of tubercular subjects to which they are related.

FIG. 9,-A lateral view of a female splanchnoptotic, a multipara, suowing relaxed abdominal walls and umbilicus.

(k) Splanchnoptosis is a general disease of all the abdominal viscera; the tractus intestinalis, urinarius and genitalis are equally affected, but from anatomic mechanism the tractus intestinalis suffers the most. All splanchnoptotics have genital ptosis and nephroptosis.

(1) In diagnosis it is well to palpate every abdominal viscus, first in the horizontal position, and second in the erect position. The liver, spleen and kidney may appear dislocated only when standing erect. Frequently the musculi recti abdominales are so diatatic that one can palpate every abdominal viscus through the fascia of the linea alba thinned by the elongation and separation of its fascial fibres.

(m) Since my clinic and private practice has consisted of 90 per cent of women, I cannot estimate the percentage of splanchnoptosis as regards

sex.

(n) Gestation plays an influential role in increasing splanchnoptosis, as when the fascial and muscular fibre of some abdominal walls are once well elongated and separated they do not return to normal.

(0) The second, third, fourth and fifth decades of life are the chief ages of suffering in splanchnoptosis.

(p) The symptoms which predominate in splanchnoptosis are from the side of the nervous system, as depression, melancholy, excitability, irritability and the stigmata of hysteria. The patients complain much of disturbed circulation, causing cardiac palpitation and vigorous aortic pulsation or rhythm. It is a beating tumor, and some physicians mistake it for aortic aneurism, because the aorta is so much uncovered by viscera, and only covered by the abdominal wall.

(q) Two characteristic groups of symptoms of the splanchnoptotic exist, viz. On the one side neurasthenia and sick headache, and on the other indigestion, poor appetite and constipation.

(r) I cannot agree with Meinert in attempting to establish an etiologic relation between chloroisis and splanchnoptosis. I found no such relation in my series of observation.

(s) The large number of women who had not borne children, who have not laced tight, had no wasting disease, but having splanchnoptosis indicates a congenital predisposing factor.

(t) In splanchnoptosis there are two factors to study, viz., (a) congenital and predisposition, (b) exciting cause. The secondary or exciting causes are, any forces which tend to weaken the abdominal walls, as rapid child bearing, abdominal tumors, ascites, septic diseases, constipation, and wasting disease, such as the disappearance of fat in the abdominal wall and adjacent to the viscera.

Splanchnoptosis may exist without any known symptoms to the patient or to the physician, but the rule is that this may be accompanied by almost all kinds of gastro-intestinal disturbances. The chief symptoms of nephroptosis are (a) palpitation, (b) gastric disturbances, and (c) constipation. Though tight lacing and bands are accused of producing splanchnoptosis they are only a factor, as a predisposition in a weak abdominal wall so no doubt must exist.

Gastro-enteroptosis and nephroptosis almost always exist together. Nearly all splanchnoptotics are easily fatigued and show a neurotic exis. tence. In women I observed that splanchnoptosis is commonly accompanied with backache, constipation, flatulence, varied local pains, all of which yield stubbornly to treatment.

Splanchnoptotics manifest vast disturbances in the circulatory system, as (a) palpitation, (b) vigorous beating in the abdominal aorta from partial uncovering of the viscera and thinning of the abdominal wall, also ganglion irritation, (c) compromising of vascular lumen, (d) headaches from irregular cerebral circulation, and (e) extensive abdominal venous statis.

In splanchnoptosis the individual abdominal organs may be distinctly palpated either through the thin linea alba, between the diastatic recti muscles, or through the thin flaccid abdominal walls.

A good test of relaxed abdominal wall is to stand behind the patient and encircle the distal abdomen with the two hands and force the abdomen proximalward, when it will give relief by its support. Also a partial test to elevate the abdomen and suddenly let it drop, when the degree of fall indicates the degree of relaxation.

The gynecologist must analyze with care the differential diagnosis between reflexes from nephroptosis and reflexes from genital disease.

Nephroptosis frequently produces identical symptoms with those arising from genital disease. One of the tests to differentiate between the two organs will be the application of a well-fitting abdominal supporter to replace and retain the mobile kidney. The sympathetic nervous system holds an intimately and finely poised relation among the three systems of the abdominal viscera, viz., tractus genitalis, tractus urinarius, and tractus intestinalis. Disturbance of one system unbalances the others through reflexes.

Observe how nephroptosis from trauma of the plexus renalis produces reflex symptoms on the proximal end of the tractus intestinalis ending in nausea, pain, malassimilation, constipation and neurosis. Renal calculus induces vomiting, and sooner or later nephroptosis and gastric disease coexist. Genital disease gives rise to more gastric disturbances than the reverse, because the gastric secretions are deranged more easily than those of the genitals. Trauma or infection of the nerve periphery of any abdominal system of viscera soon deranges the motion and secretion of the other two abdominal systems. The connection between diseases of the uterus (genitals) and gastric (digestive tract) is profound and intimate. Disease of the uterus and stomach frequently coexist. A differential diagnosis between the symptoms arising from nephroptosis, from the genitals or stomach, is often difficult, as symptoms may be referable to any one of the viscera. This may be due, first, to the nerve tract, whose centre is not in the brain or the spinal cord, but in the sympathetic nervous system. From reflex action symptoms arise which relate to kidney or genitals. The reflex tracts being anastomosis ovarica, anastomosis pudendohemorrhoidalis, anastomosis genito-gastrica, anastomosis cutaneo-cavernosa, collater alis and the nervi splanchnici. Also the anastomosis utero-coelica and anastomosis utero-cerebro spinalis, also anastomosis reno-coelica. The immediate roads of the reflex are direct connections of the vagus (excluding the ganglion-abdominale) with the sympathetic nervous system. The second manner in which mistakes may occur are due to dislocation of the respective organs. The circulation only plays a minor role in this connection.

As splanchnoptosis is a general disease, local operations as nephropexy, uteropexy, will appear of limited yalue.

The tartaric acid and bicarbonate of soda method is a practical means to demonstrate gastro-duodenal dilatation. Inflation of the stomach by air is also a good method. The two operations I offer after five and six years of test are both general and local. The local is gastro-enterostomy which can be immediately followed by a general operation, i. e., the union of the two recti abdominales in a common sheath.

The non-surgical treatment for splanchnoptosis is through water drainage of the tractus intestinalis, tractus urinarius and tractus perspiratorius, with exercise and massage of the muscles.

Of the abdominal supporters I consider the best an ordinary elastic support, with a rubber air pad which can be placed inside the binder and distended with air. I have invented such a pad, and find it gives excellent results.

Glenard, Schwert, Virchow, Stiller, Meinart, Ewald, Landon, Boas, and Ameill have written excellently on splanchnoptosis.

Mosquito Pastilles.—

1. Carbolic acid..

Potassium nitrate, powdered

6 fl. drs.
11 av. ozs.
5 av. ozs.

10 av. ozs.
2 fl. drs.

Insect powder...

Charcoal, powder

Oil of pennyroyal..

Mix. and with powdered tragacanth and water form the whole into a mass, and mold into pastilles and dry.

dry.

Potassium chlorate, powder

Tragacanth, powder.

Oil of pennyroyal.

2 av. ozs.

2 av. ozs.

2 av. ozs.

2 av. ozs.

1 dr.

3 drs.

1 fl. dr.

Mix well, add sufficient water to form a mass, divide into pastilles and

Mosquito Powder.

1. Oil of eucalyptus..:.

Talcum, powder..

Starch, powder..

1 fl. oz.

2 av. ozs.

14 av. ozs.

Mix. This powder is to be rubbed into the exposed parts of the body to prevent the attacks of the insects.

Starch.....

fl. oz.

av. oz. 16 av. ozs.

Mix well and sift. This is to be used like the preceding.-Meyer Bros. Druggist.

W1

Methods of Diagnosis: Surgical.

BY CARL E. BLACK, M. D.,

JACKSONVILLE, ILL.

Read before the Morgan County (III.) Medical Society.

HEN the committee assigned me as one of nine gentlemen to present the subject of "Methods of Diagnosis: Medical and surgical," I was greatly at a loss to know where to begin. As this subject includes all that is most important in both medicine and surgery, and embraces the very foundation of our success in practice, it certainly presents ample field for selection and might appropriately furnish material for this or any other society for at least a five years' course of monthly meetings.

Of course the committee did not expect that we would touch upon any considerable number of subjects, as it would be impossible even to read the briefest outline of the whole subject in the time.

Being assigned to the surgical side of the subject, finally decided to select suppuration as my special topic for presentation. I did this because it is as interesting and important to the specialist as to the general practitioner and to the surgeon, as both.

We are all dealing every day with suppuration, and no doubt every day brings to us the perplexing doubt as to whether our case is simply one of inflammation or has progressed to the stage of suppuration.

We will exclude from our consideration hyperemia or any of its results. In order to be more definite we must recognize that hyperemia, or congestion, may result in speedy resolution. It may form an acute swelling, which may subside for a short time, or which may become a chronic enlargement. Hyperemia may result in gangrene on account of pressure, or may be followed by changes in nutrition leading to either atrophy or hypertrophy. You must bear in mind that the result of hyperemia is exudation, i. e., the escape of blood plasma from the vessels into blood cavities or tissue interspaces (Park 22).

Perhaps before really approaching the sbuject of diagnosis of suppuration, a few words regarding inflammation, which always precedes suppuration, will be in order. Inflammation is an expression of the effort made by a given organism to rid itself of or render inert noxious irritants arising from within, or introduced from without (Sutton modified). In 1870 Burdon Saunderson said, "Inflammation is the succession of changes which occur in the living tissue when it is injured, providing the injury is not of such a degree as to at once destroy its structure and vitality.

I would call your attention especially to the word injury in this definition. Before the days of bacteriology inflammation was considered to be a harmful and destructive process, but now we know that it is really Nature's means of protecting herself against noxious micro-organisms and keeping them out of the general system. I shall call your attention especially to the important point and difference between hyperemia and inflammation. Hyperemia may be non-specific, i. e., accompanied by no microorganisms. True inflammation is always specific, i. e., accompanied by micro-organisms.