the condition of the sacrum, coccyx and the sacro-iliac joint, before we arrive at a positive diagnosis..

DR. LOUIS FRANK: I fully agree with what Dr. Vance has said. I am exceedingly sceptical about this whole business. I am ont one of those who believes everything that is written. I must know the writer personally or by reputation, and even then the statements must be logical and susceptible of proof. It seems to me that the ideas expressed by the essayist are pretty far fetched. The history we have in these cases is not the history of strains or sprains elsewhere in the body I do not know of any sprains that last for years and years and then disappear upon simply putting a bandage on.

Again, I do not see how the support immobilizes the joint. I do not believe that Goldthwaite or anybody else can make out motion in these joints by manual manipulation. There may be apparent but not actual motion.

I believe that many of these pains come from a diseased coccyx. However, some cases in which I have removed the coccyx were not relieved. I have a young woman on hand now whom I believe I will soon refer to Dr. Moren, to see if he can relieve her.

DR. THOMPSON: Would it be possible to strain this joint on one side, without straining the other side?

DR. FRANK: I should not think so. Any injury that would give rise to such a thing as a strain in this joint would, in my opinion, do more damage than that.

Dr. Moren speaks of the position on the operating table causing a strain of this joint. I have never known of a case

of this kind that was not relieved in a few days and none had trouble afterwards.

The mobility of this joint in labor is said to be physiological, and disappears

soon after delivery. If this were not true, with the millions of births we are constantly having, almost every woman. would be a cripple.

DR. J. ROWAN MORRISON: This discussion reminds me of the old story of the blind men attempting to tell by the sense of touch what an elephant was like. One of them called it a tree, another a wall, and so on, according to the part they happened to get their hands on, and it strikes me that it is just about the same proposition in medicine; it all depends upon the point of view.

If we will make a careful analysis of many of these cases, I believe we will find a certain degree of trouble about the sacro-iliac joint. The word "strain" does not mean what it used to; in other words, I believe that we now diagnose a much smaller degree of strain than what we formerly called by that name.. On two` occasions recently, men have come to me with a history that, after having played golf they had gone home and laid down. in a cool wind, and later suffered with severe pain, or lumbago, as one of them called it. This man had exquisite tenderness right over the sacro-iliac joint, and he was relieved and practically walked out of the office, by the application of adhesive strips, and he has had no more pain since. We cannot fix the joint, of course, but certainly we can do a great deal towards fixing it. A great many sewer workers and plumbers, who are more prone to have this condition than any one else, come to the clinic with terrific pain, which they call lumbago, and after putting a strap about their buttocks they walk out feeling fairly comfortable. The joint is naturally fixed; we just fix it a little more permanently. When we have a pleurisy, do we fix the chest? No, sir; we cannot fix the chest, but we can certainly fix the pleurisy.

DR. MOREN (closing): In the first place I want to correct a statement made by Dr. Frank. I did not claim that the simple application of a belt would relieve a pain that had existed for years. The case I mentioned had suffered for only about two months.

The majority of cases that come to me have already had every form of treatment that the family physician knows anything about, and they are sent to me as a last

resort.

I recognize that back-ache can come from many causes; I do not claim that strain of the sacro-iliac joint causes all back-aches, but I do believe it is a plausible cause of many of these pains that we are unable to relieve by ordinary measures. Why is it that so many of these cases of back-ache and pain along the sciatic nerve, that have been treated by regular practitioners without success, go to massage men and get cured? I saw a case last year which I believe was one of sacro-iliac strain. Another man was called who pronounced it disease of the gall-bladder and advised counter-irritation. This poor fellow tried everything and then went to a massage man, and in two months was a well man.

Very frequently I see cases of sciatica. that start as a lumbago. I believe, instead of being true lumbago, these are cases of strain of the sacro-iliac joint, with irritation of the sacral plexes causing the pain. It is possible.

When Dr. Zimmerman sent this man to me he did not respond properly. I then got Goldthwaite's book and read it, and put a belt on him, and in two hours' time he could tell the difference. As far as the coccyx is concerned, the second man had no rectal trouble, but just as soon as the finger was placed on the coccyx he would say he felt better.

Clinical Memoranda

RUPTURED DUODENAL ULCER-RE.
PORT OF CASE.*

BY J. GARLAND SHERRILL, D. D.,
LOUISVILLE, KY.

On the morning of the 28th of December, 1910, I was called to see a man who had been suffering for about eighteen. hours with severe pain in the upper abdomen. He gave a history of having taken, among several things, some beer, and shortly afterwards he had suddenly developed this pain. I was called in by his physician, who stated that he thought the man had an acute appendicitis. I found the man with a distended abdomen, rapid pulse and a rising temperature. He was not in profound shock, but had symptoms of general peritonitis. Most of the pain and tenderness was located in the upper abdomen, and he had not had a movement of the bowels since the doctor had first seen him. I gave as my opinion that he either had perforation in the upper portion of the alimentary tract, or obstruction, and operation was done immediately. Median incision was made, extending somewhat above the umbilicus. and below, going through the ensiform. so as to give access either way. Upon opening the abdomen, there was an escape of purulent fluid, giving evidence of a general peritonitis. I first sought the stomach and searched it very carefully, but found no perforation there. Then I looked over the duodenum and, not seeing anything, came on down over the intestines. After thoroughly searching the upper abdomen and finding nothing, the appendix was examined, but was not involved. The search was continued, but found nothing until the duodenum was reached again, and then I found a little. opening in the wall of the duodenum,

Reported to the Medico-Chirurgical Society.

about of an inch in diameter, and as clean-cut as though made with a punch. Through this opening the intestinal fluid was escaping into the duodenum. It was located about 11⁄2 inches below the pylorus. I closed the opening with three layers of sutures, mopped out the pelvis, put in a drain above and below, and closed the abdomen. The patient did nicely and is now in a fair way to re

cover.

DISCUSSION.

DR. LOUIS FRANK: I think too much operating is done by good surgeons under unfavorable circumstances, and that is one thing that not only occasionally, but frequently, brings good surgery into bad repute. I think, as a rule, patients who are accessible to operators are accessible to transportation, and certainly if they are as close to good hospitals as across the river.

DR. SHERRILL: Dr. Frank seems to have overlooked the fact that this man is getting well, and that this case belongs to a class that do not often get well. This patient was in a hospital when I saw him. and there was nothing else to do but to go ahead and operate.

In regard to excision of the ulcer, I concluded that there was too much thickening, and that any effort to excise the ulcer would prolong the operation and lessen his chance for recovery.

Gastro-enterostomy was not done because I believed that it would prejudice the patient's chances for recovery. However, in the event that the man shows

further symptoms of ulcer, we can readily do a gastro-enterostomy subsequently.

TUBAL PREGNANCY TWICE WITHIN A YEAR IN SAME PATIENT-REPORT OF CASE.

By L. S. MCMURTRY, M. D.,

LOUISVILLE, KY.

exceptional interest, which I have never reported. It is the only one of the kind that I have seen, although there are several on record.

The patient was a young married woman, 27 years of age, who conceived, and missed two menstrual periods, and showed the classical symptoms of pregnancy. At about the tenth week she had a flow, with symptoms that suggested an abortion. I had her put to bed and kept quiet. On the second night afterwards. I was called to see her at one o'clock, and found her with all the symptoms of a ruptured tubal pregnancy, and in collapse. The pulse was barely perceptible at the wrist, she had dimness of vision, and presented the symptoms of profound shock that accompanies this condition. By the use of restoratives-not using saline infusion while active bleeding was going on-but under heat and subcutaneous stimulants she reacted, and was removed to the infirmary, where I opened the abdomen, cleaned out a large blood clot, found the ruptured tube, removed it, closed the abdomen without drainage and placed the woman in bed. She made a prompt and beautiful recovery.

This occurred in the month of July. She left the city and went to a summer resort on the lakes in the northwest, where she rapidly regained her color, flesh and health. In the meantime she and her husband removed from this to

another city.

In the following April she suffered the same symptoms, and on this occasion diagnosed her own case. The family physi

cian was called and told her as soon as he reached her bedside, that she had an extra-uterine pregnancy. I think his diagnosis was materially assisted by her suggestions, and it was easy to detect, upon the side opposite to the one where

ness of the tube. She expressed a desire to have me see her and I was called up by long distance 'phone. She took a train for Louisville that night and was operated upon here the next morning, through the scar of the former incision. The tube was found in the early stage of pregnancy, the choroinic membrane being very distinct after the little sac was opened. I left the ovary and removed. just about one-half of the tube. She made a nice recovery. Menstruation has continued, but whether or not she will ever conceive is, of course, a matter of some doubt, though numerous cases have been recorded where an ovary has been left on one side and a portion of a tube on the other—and not a very good tube at that-and conception has taken place. There was no history of any infection.

Of course, we do not know what causes this lesion. The old teaching was that it was due to a catarrhal inflammation of the tube which destroyed the cilia of the epithelium so that the ovum cannot be carried into the uterus. We know that the ovum fertilizes in the tube and afterwards passes into the uterus. However, cases have been reported in which this lesion occurred, and examination showed the cilia to be active and functionating. It is probable hat some departure from normal conditions, as, for instance, a kinking of the tube, may have something to do with it.

DR. CUTHBERT THOMPSON : Is the anemia in these cases due to the loss of blood, or to the shock? Was there sufficient bleeding in this case to cause anemia?

DR. MCMURTRY: Dr. Thompson has brought up a question that has been a mooted point among gynecologists, and he is correct. The amount of hemorrhage in these cases is not proportionate to the profound degree of shock. Of course, when a woman suddenly has half

a gallon of blood poured out of her system, it will give rise to a profound anemia; as, for example, where the bleeding occurs from an artery in the leg, the shock is not proportionate to what it is in these cases. A great many surgeons and pathologists have attributed it to the pouring out of the blood into the peritoneum. It is certainly one of the most formidable exhibitions of anemia and shock that can be seen from any cause.

DIETARY I IOSYNCRASY-REPORT

OF CASE.

BY J. M. RAY, M. D.,

LOUISVILLE, KY.

A man recently came to see me with the statement that he thought he had swallowed something which had lodged in his throat. His face was swollen until both eyes were practically closed, and he could not stop scratching for a moment. The nasal cavities were completely blocked and he was breathing through his mouth. After some thought, however, he concluded that his trouble could not be due to something having lodged in his throat, and then he recalled that he had eaten celery for lunch that day, and that on a previous occasion after eating celery he had suffered disagreeable symptoms.

This man is a sufferer from asthma. and has been operated upon, a lot of polyps and the middle turbinal being taken out. This had relieved him to a certain extent, and he had gone along without any great discomfort until this trouble occurred.

BIRDSHOT WOUND OF CHIN-RE-
PORT OF CASE.

BY AP MORGAN VANCE, M. D.,
LOUISVILLE, KY.

I have two patients to present to the Society to-night. The first is Master

Charles S., who lives in a neighboring town. In August last, while playing with a little colored boy, the latter shot his chin off with a load of bird-shot. All of the chin was shot away back to the angle of the jaw, and his tongue wagged out in the world. Three weeks ago, after leaving it alone since August, in order that the infiltration and suppuration incident to the torn bone and flesh might heal, I attempted to close it in, believing that was the only thing to do, as no grafting, or putting a plate in there, could be done. I pulled it together, after doing a flapsplitting operation, and fortunately it healed. The improvement in his mouth has been astonishing. It is also astonishing how well he can articulate. He has one lower tooth on the left side-the inferior maxillary, and before I pulled the cheeks around so tight he could grind popcorn between it and his upper teeth. It was a question in my mind whether this tooth, unopposed, would not become elongated as the patient advanced in age. I think it will, but it will take many years. He can scrape apples, potatoes, etc., very satisfactorily with his upper teeth. I think he is the bravest boy I have ever seen; he had never made a murmur through it all, and has been always bright and cheerful.

DISCUSSION.

DR. BEN CARLOS FRAZIER: This case is a very pitiful one. I have never seen any one look quite as appealing and horrible as this little fellow did.

Dr. Vance made the remark that this was the bravest child he had ever seen. He has always been uncomplaining and happy, and as helpful about the ward as he could be. I have never seen him depressed or frightened, or anything but cheerful throughout.

Dr. Roberts has just asked me how many times it was necessary to operate.

I gave the anesthetic in this case, and had no trouble in keeping him under sufficiently for Dr. Vance to work. He closed it up rather rapidly; I do not think the patient was on the table more than twenty-five minutes. I was surprised at the good result obtained. Like some of the other members, I think it was almost a pity that the little fellow lived, but he is absolutely happy.

DR. VANCE (closing): Several surgeons saw this operation, and they were all laughing in their sleeves because I was trying to get this together. However, I felt sure that, unless sepsis occurred, I would get good union.

Like some of the other members, I felt that it was almost a pity that the load of shot was not directed an inch or two further back.

I neglected to mention that this boy has a shoulder full of shot that I have never taken out.

REPORT OF CASE OF DORSAL
MYELITIS.

BY AP MORGAN VANCE, M. D.,

LOUISVILLE, KY.

This gentleman is Mr. S., whom I first saw about four years ago, with Dr. Wilson, at which time he was very much emaciated and run down in health. He had a tumor in his lower bowel, which was removed a short time afterwards, along with thirty inches of the ilium, and end-to-end anastomosis done. This was a fibrous tumor.

The reason I brought him here to-night is that he has developed a condition which puzzles me very much, and is also very interesting. About a year after the operation he developed what I call a "trigger" leg. He walks very much worse in the morning, when he is cold. I examined him thoroughly several weeks ago, but could find no evidence of any intraabdominal trouble. The growth I re