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gas into the peritoneal cavity. I operated on a casea few hours after an abdominal injury, and found theduodenum torn across, and no free gas present in theperitoneal cavity. Rigidity of the wall, especiallylocalised rigidity, would be strong evidence of severeunderlying injury. But though such rigidity wouldbe a valuable sign if present, its absence is of no

negative value. I have found it absent in rupturedintestine, and this has been the experience of othersurgeons. The passage of blood from the bowelwould seldom be an early enough sign to be of valuein helping to decide the question as to the desirabilityof immediate operation. Vomiting of blood may bepresent after a blow on the upper abdomen, withoutany rupture of the stomach.

I have so far been writing of the differentialdiagnosis of pure shock and injury of viscera or intra-peritoneal haemorrhage. In one of the gravest formsof abdominal injury-rupture of the intestine-noshock may be present, and the patient be able to walkto the hospital. In such a case a fixed pain, or

rigidity of the abdominal wall, might indicate quiteearly the serious nature of the case. The absence ofbruising of the abdominal wall does not negative agrave intra-abdominal lesion. The wall yields beforethe blow, or crush, and is not necessarily the seat ofcontusion. If the patient has not passed urine forsome hours and has an urgent desire to micturate, butonly a little blood-stained fluid escapes from theurethra, and the passage of a catheter shows thatthe bladder is empty, we have strong evidence thatthe bladder is ruptured, and this calls for immediateoperation. In these cases there may be no shock,and if the patient is under the influence of alcohol,and no reliable history is obtainable, diagnosismay be very difficult.

Treatment of Shoc7,.In all cases in which shock is present it should be

treated in the usual way by the application of warmthto the surface (by means of hot bottles) and by raisingthe foot of the bed considerably (not 6 inches or so).The result of raising the bed on small blocks is almostinappreciable on the patient’s trunk as he lies in bed.The lower legs oj. the bed should be raised on chairs,and if the patient is a child lying on an adult’s bed,he should be brought down towards the foot of thebed, so that he may get the full benefit of the tiltedposition. The most rapidly efficient remedy in

combating profound shock is saline infusion by theintravenous method. If intravenous saline infusion isnot resorted to, in view of the importance of keepingthe bowels as much at rest as possible, and of apossible laceration of the colon, the subcutaneousmethod of introducing the saline rather than therectal would be indicated.

Treatment Other than that of Shock.The persistence of pain so severe as to call for a

hypodermic injection of morphine would be suggestiveof the need for exploration, and I have already calledattention to the danger of masking the symptoms inthis way. Moderate pain may be relieved by theapplication of a light fomentation over the abdomen.It is difficult to see how this can do any harm, and suchdrugs as aspirin may be safely administered. Nonourishment should be given by the mouth whilst thequestion of laparotomy is being considered, so as toavoid any stimulation either of the stomach or

intestinal activity. If great thirst is present, frequentadministration of quite small quantities of water is agreat relief to the patient, and can do no harm, but itis advisable to give directions to the nurse as toexactly how much each dose should consist of, or areally large drink might be taken.

Woztreds of the Abdonzen.Exploration is desirable in all cases in which the

depth of the wound is not obviously shallow. Probingis quite unreliable, for the track made by the weapon(perhaps a bullet track) may not be straight enoughfor the probe to detect penetration into the abdominalcavity, and such an opening, if it exists, may, be

plugged by a piece of protruding omentum. Ifpenetration has occurred, from either a stab or gun-shot wound, the intestine may be penetrated, withoutany shock, or other immediate indication of so

serious an injury. If faecal matter escapes from thedamaged bowel it is not likely to be present in thewound, but to become diffused within the peritonealcavity. If the patient has been stabbed, there maybe faecal matter on the weapon, but its absence wouldbe no proof that the gut had not been injured. Bycomparing the entrance and exit wounds of a bullet,and mentally constructing its track, an idea may beformed as to whether it could possibly have damagedthe intestine ; but it must not be forgotten how far outthe colon may extend, for if wounded even on itsextraperitoneal aspect, it would require carefulsurgical treatment. If there was no wound of exit askiagram would indicate the position of the projectileand thus the direction of the track. In all cases ofdoubt it would be safer to explore rather than towatch for symptoms. By exploration I mean explora-tion of the wound under an anaesthetic ; this wouldprobably necessitate enlarging it. If then penetrationis found, the surgeon must be prepared to open theabdomen, and deal with any injury to an intra-peritoneal structure he may find. This may involvethe suture of divided bowel, but in some cases, parti-cularly in gunshot wounds, he may have to performan extensive resection of gut, with union of thedivided ends, so that the exploration of the woundunder an anaesthetic should only be undertaken by asurgeon sufficiently experienced to undertake resectionand union of bowel. Once exploration has beendecided on, it is an obvious advantage to keep theintestines as quiet as possible by the administrationof a full dose of morphine hypodermically. The reliefto the patient following this treatment must not bemisinterpreted, and the surgeon must not allow him-self to be persuaded by the patient or his friendsthat because he feels so much better no operation isnecessary. Apparent improvement under morphineshould never alter a decision to operate previouslymade.

CHARLES A. MORTON, F.R.C.S. Eng.,Professor of Systematic Surgery, University of Bristol ;Consulting Surgeon to the Bristol General Hospital.

Special Articles.THE FOLLOWING-UP OF CASES OF

VENEREAL DISEASE.1

ONE of the most important questions in connexionwith venereal disease is that of the following-up ofthe elusive patient who will not continue treatmentuntil cure has been established. The seventh annualreport of the National Council for Combating VenerealDiseases, covering the period from June, 1921, to theend of June, 1922, contains an analysis of repliesreceived by the Council to a questionnaire whichwas issued to members of the Council, and to branchesand organisations represented on the Council, as onemeans of collecting evidence of opinion with a viewto the introduction of legislation. 75 per cent.of replies favoured the giving of powers to healthauthorities to compel persons suffering from infectivedisease to remain under treatment; 79 per cent.were in favour of fresh legislation. 32 per cent.of replies expressed the belief that public opinionin their districts was ripe for a demand for legisla-tion ; 20 per cent. expressed the opposite view,the remainder being doubtful. Various alternativemethods of protection for the public were suggested

1 Seventh Annual Report of the National Council for Com-bating Venereal Diseases, June, 1921-July, 1922. Publishedby the Council, 80, Avenue Chambers, Southampton-row,London, W.C.1.

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by the dissentients, the proposals covering (1) the treporting by medical officers of venereal disease clinics, iand by private practitioners, of cases of syphilis and igonorrhoea in infants, children, and adolescents up to 1the age of 18 to the school medical officer with a 1

request that the school nurse might follow up caseswhich failed to attend; and (2) Government action 1

making it compulsory for every medical man totreat his own patients. 91 per cent. of repliesattached importance to the proposal that legislationconcerning the suppression of venereal disease shouldbe a public health matter, and should not be combinedwith legislation aiming at the suppression of prosti-tution ; 92 per cent. favoured the confidential treat-ment of persons willing to continue such treatmentuntil they are non-infective, and notification of thosewho discontinue treatment while still infective ;some replies favoured the first part of this proposal,but not the second. 85 per cent. of those personsor bodies questioned saw no reason why publichealth regulations requiring the compulsory con-

tinuous treatment of infective persons should notbe impartially administered between the sexes. Therewas apparently general agreement that any limitedform of notification and compulsory treatmentintroduced should only be operative towards thosewho had discontinued treatment, and that otherwiseconfidential treatment should be retained.

In our last issue we dealt with the report of theCommittee appointed by the New Zealand Minister ofHealth to inquire into the position with regard tovenereal disease in the Dominion. Among therecommendations of the Committee was one relating tolegislation providing for " conditional notification ofvenereal disease," by which it would be the duty ofa doctor to notify to the Health Department, bynumber or symbol only, each case of venereal diseasehe treated. The terms of the recommendation werethat if a patient refused to continue treatment untilcured, and would not consult some other doctor orattend a clinic, it should then be the duty of thedoctor to notify the case by name. If the patientcontinued recalcitrant, the Director-General of Healthshould be empowered to apply to a magistrate forthe patient’s arrest and detention in a public hospitalor other place of treatment until he should be non-infective. The Committee also reconllllended provisionto deal with cases where persons suffering fromvenereal diseases were not under medical treatmentand were likely to infect others. The Director-General should be empowered to call on such a personto produce a medical certificate, which might beprocured free of charge at any hospital or venerealdisease clinic. If the person refused to produce such acertificate he or she could then be taken before amagistrate, who might order a medical examination.Penalties, including detention in a prison hospital,should be provided for recalcitrant cases, and allproceedings should be private unless the defendant Idesired a public hearing. Action along these lineshas already taken place in Queensland, as recorded inthe annual report for 1922 of the Commissioner ofPublic Health for the State. " In accordance withSection 159 (6) of the Health Acts, 1900-1917," 448male patients attending the Brisbane clinics werenotified for failing to report themselves at least oncein every four weeks. Of these, 418 were written toand warned of the consequences of their action ; 205thereupon reported back to the clinic or official advicewas received that they were again under medicaltreatment for venereal disease. The services of thepolice were requisitioned in 221 cases ; the result oftheir action in these cases, and in 127 cases regardingwhom no information was at hand on June 30th, wasas follows : Not traced, 208 ; warned, 74 ; dead orleft State, 13 ; in gaol, 2 ; certificates of cure received,6 ; reports not to hand regarding 45. Nine of thepatients who did not comply with the warnings giventhem were proceeded against, and fines ranging from22 to <85 were imposed. Three other defaulters werefound to have left the State, and proceedings againstthem were withdrawn. Four of the women attending

the female clinic were written to during the year forfailing to continue medical treatment, with the resultthat three again reported, and the other transferredto another medical practitioner, from whom therequisite official advice was received. Anotherwoman, written to in the previous year, was warned bythe police, and on reporting was found to be free of thedisease and given a certificate of cure.The Council for Combating Venereal Diseases, having

considered the American system of notification bynumber and compulsory detention, and variousContinental systems, state in their report that these-contain possibilities of grave abuse, their administra-tion tending to result in a form of regulated prosti-tution, the compulsory clauses being exercised largelyin relation to women. Dominion legislation, likethat quoted above, being more in accordance withprinciples acceptable in this country having beenapplied in the Dominions, the Council communicatedwith the Provincial Health Departments in Canada ;the replies received showed that Canadian medicalofficers are practically unanimous in believing thatthe system of confidential notification does notprevent people seeking treatment. The N.C.C.V.D.finds in this country evidences of a steadily-growingpublic opinion in favour of some form of compulsorycontinuous treatment.

HONOUR TO THE STRETCHER-BEARER."DANS LES BOUES DE LA SOMME."

THE Service de Sante, the medical corps of theFrench Army, was recently honoured by the city ofParis, which presented to the Medico-Military Schoolof Val-de-Grace a fine sculptured group representingtwo stretcher-bearers carrying a wounded man tosafety through the mud of the Somme. This group,exhibited at the Salon in 1921, and bought by theFine Art Commission of the city, is the work of ayoung sculptor, Mr. Broquet, who was himself an

infantry stretcher-bearer and was wounded during:the war. The group has been set up in front of the

A sculptured group representing two stretcher-bearers carryinga wounded man to safety. The group in its setting in frontof the main entrance of the Val-de-Gtrace Medico-MilitarySchool, Paris.

main entrance, at Val-de-Grace, as a monument tothe valour of the " other ranks " of the Service daSante, the officers being commemorated by theirnames on memorial tablets dedicated on the sameday, during May, 1922. The President of the FrenchRepublic, the Minister of War, the President of theMunicipal Council of the city of Paris, Marshal Joffre,and other notable persons were present ; the occasion