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must also be treated symptomatically. In surgical cases good results are obtained in about twenty per cent of the cases; whereas eighty or ninety per cent can be better treated by proper medical treatment, that is by support, proper dietetic régime, etc.

Another thing that has been over-used in these cases is large enemata or colonic irrigations. Many cases have been aggravated by such treatment. The introduction of large amounts of fluid into an already atonic or dilated gut will only tend to increase the atony or dilatation. I give small amounts of fluid-four ounces-consisting of from one to two teaspoonfuls of a mixture of turpentine, glycerine, olive oil and soft soap in water. This is retained in the rectum for about five minutes. I have had excellent results in obstinate cases of constipation. At the same time there is avoided any danger to the already damaged colon.

DR. H. F. STOLL (Hartford): The man who sees a good many children can materially help in the prevention of the type of which Dr. Gompertz spoke. We know the type of children with very poor musculature, that gets worse as the child grows older. If the men looking after such children will give them exercises to develop their abdominal and back muscles, they will prove a real factor in holding up the viscera when they grow older. It is interesting to remember that Samuel S. Fitch, of this state, who achieved considerable notoriety in treating tuberculosis one hundred years ago, devised an excellent abdominal belt with anterior and posterior pads. The front pads, he said, should not press backward but upward and backward, thus giving a lift to the abdomen.

DR. PAUL SWETT (Hartford): I want to discuss one detail of the support treatment. Any support which simply makes pressure in the attempt to hold up the abdomen from underneath and hangs on the middle of the back defeats its own purpose, for the more it holds up from the front, the more it forces the lumbar spine forward and thus it causes the ptosis. Any support that attempts correction of the visceroptosis must be sure not to aggravate the slumping posture but it must put the patient in the corrected posture.

DR. HENKLE: I wish to emphasize that the neurosis in visceroptosis is not due to the position of the organs but to some form of autointoxication. I also wish to emphasize the importance of postural treatment. If the patient is advised to remain in bed, with raised hips, about two hours after each meal, the stomach contents are much reduced in that length of time, and when the patient is again in the erect position the downward drag on the stomach by the weight of a full meal is greatly lessened.

Abdominal Symptoms in Influenza, Simulating an Acute Surgical Lesion.

THOMAS HUBBARD RUSSELL, M.D., New Haven.

My interest in this subject was aroused by the fact that I have personally seen five cases of influenza presenting pronounced abdominal symptoms, sufficient in every case to have caused the possibility of an acute surgical lesion in the abdomen to be entertained. The first diagnosed her own condition as appendicitis, on account of the severity and predominance of the abdominal pain, and came to me for an operation. Three of the cases I saw in consultation with Drs. Standish and Seabury, of New Haven, and Dr. Perrins, a naval surgeon stationed in New Haven during the war. The fifth case I saw in the New Haven Hospital by courtesy of Drs. Blumer and Tileston, on whose service it occurred. All of these cases were in adults, and all recovered uneventfully without an operation. I hope to report them in greater detail at some future time: the time allowed me for this paper does not permit of it at present.

The subject I believe to be of considerable importance at the present time on account of the seriousness of the recent epidemic, and the probability of our seeing sporadic cases for some time to come, and also on account of the frequency of the abdominal symptoms, and the great difficulty so often encountered in arriving at a correct estimate of their true significance, as well as the danger of an unnecessary operation during the course of the influenza. It is now possible to formulate, on the basis of the available literature, an accurate estimate of their meaning.

We must depend principally on the literature embodied in the periodicals printed during the past two years, for two reasons. In the first place, the character of the cases encountered in the epidemic of 1888-1889 varied somewhat from those found in the recent ones, in the former epidemic, people of all ages having been almost equally affected, and a relatively large number hav

ing had the gastro-intestinal form, characterized by nausea, vomiting, diarrhoea, and hemorrhages into the intestinal tract, which have been very rare in the recent epidemic. Also the acute surgical abdomen, and particularly the pathology of appendicitis were not nearly as well known at that time as they are now. One does, however, find references to "typhlitis" in the literature of that time. Articles on influenza in the standard text books of to-day give scant or no attention whatever to the symptoms and signs frequently occurring in influenza, which would ordinarily suggest an acute surgical abdomen.

The abdominal lesion most often simulated is appendicitis, and a differential diagnosis here is made more difficult by the fact that the two conditions, at least during the recent epidemic, have occurred most frequently at the same time of life, young adults having been chiefly affected. One must, of course, always consider the possibility of a coexistence of the two conditions. It would be strange, indeed, if they did not occasionally coexist.

Let us consider for a moment what lesions are known to occur in the abdomen secondarily to influenza. One of the most frequent is peritonitis, which may be either local or general. When local it occurs most frequently in the upper abdomen, adjacent to the diaphragm. In a large proportion of these cases it appears to be a direct extension from an adjacent empyema. When general it usually is of a fibrinous character. When purulent it is as a rule part of a general pyaemic infection. It is not due to an extension from an infection of the appendix or gall bladder. In some cases a localized collection of sero-sanguinous fluid is found among the coils of intestine. The causative organism may be the streptococcus haemolyticus, pneumococcus or staphylococcus. Where peritonitis is a complication, it almost always comes on during convalescence from pneumonia.

Rupture of the rectus abdominis muscle has frequently occurred during the recent epidemic, and still more frequently during the epidemic of 1888-1889. It occurs in muscles showing a Zenker's degeneration, probably due to a spasmodic contraction of the weakened muscle during coughing. It may result in a hemorrhage into the sheath of the muscle, which not infrequently

becomes secondarily infected, resulting in a deep abscess. The rupture is rarely complete, and usually occurs mid-way between the symphysis pubis and umbilicus. One writer reports eight cases, another has seen twenty. These cases have frequently been operated upon for a supposed appendicitis.

Multiple abscesses of the kidney, and perinephritic abscesses occur infrequently.

A thrombo-phlebitis of the large abdominal vessels has occasionally been reported. Also a general congestion of the intestines with submucous hemorrhages occasionally occurs. case of rupture of the colon has been reported.

One

The above lesions are about the only ones at all likely to appear in the abdomen. In the great majority of cases they have come on during convalescence, or as a terminal process, and an operation would have been useless, or merely have hastened the end.

There are a few who believe that there is a close relationship between appendicitis and influenza, but their statistics are not convincing. The general opinion seems to be, on the contrary, that appendicitis is a very rare complication, although a train of symptoms which would ordinarily substantiate such a diagnosis is exceedingly common.

The best statistics available are from the military camps and base hospitals, as here tremendous numbers of men suffering from influenza were under observation and excellent control. Let me quote freely from a few of those which describe the frequency and the puzzling nature of the abdominal symptoms.

Camp Dix. During the twenty-two days of the epidemic there were 6,000 cases of influenza in the hospital, and 800 deaths due to the epidemic. Synott and Clark report: "In the abdomen, meteorism occurred in some cases; in certain lethal cases it was excessive. Abdominal pain and tenderness were present, possibly not entirely due to pleurisy, but in the light of necropsy findings to infection and hemorrhages in the rectus muscles."

Camp Logan. A daily average of 24,000 men were in camp and 4,126 were admitted to the hospital with a diagnosis of influenza in addition to 567 with a diagnosis of pneumonia. The report states "An interesting feature of the respiratory epidemic

was the great number of cases admitted to the hospital with a diagnosis of acute appendicitis, in which after a few hours' observation we changed the diagnosis to either influenza or pneumonia. About fifty cases were received whose previous diagnosis was wrongly given as appendicitis."

U. S. Naval Hospitals in Philadelphia. Deland reports, on the basis of 3,000 cases of influenza: "Reflex pleuritic pains have been erroneously diagnosed as cholecystitis or appendicitis. ... Usually interlobar and diaphragmatic sero-plastic and purulent pleurisy are not diagnosed, but the latter may be suspected when friction sounds are heard over the borders of the lung or when referred pain occurs in the upper abdominal, gall-bladder or appendix regions. Autopsies showed no pronounced gastro-intestinal pathological change. Referred pleuritic pain is often mistaken for cholecystitis or appendicitis."

Great Lakes Naval Training Station. McNally reports that he saw a considerable number of cases which taxed his diagnostic ability and that of his colleagues on the surgical service. He states "The onset of acute chest conditions gave us concern in many instances. They were confused most often with acute appendicitis although we were occasionally confronted with symptoms resembling acute gall-bladder disease. I have come to have a wholesome respect for the difficulties encountered in making an early diagnosis in these cases." Autopsy findings showed in some cases a moderate amount of turbid liquid in the peritoneal cavity, but the appendix and gall-bladder showed no changes which could be connected with the recent condition. "To have operated upon these cases would have been a fatal mistake."

Royal Naval Hospital, Plymouth. Smith reports: "In the earlier days cases were constantly being sent in to the surgical service with the diagnosis of perforated gastric or duodenal ulcer, less frequently as an acute appendicitis. The true diagnosis is often difficult."

Camp Dodge. Manson reports that at one time there was a total of 8,000 cases in the hospital. The total number diagnosed

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