Kehr's sign-pain in the left shoulder-has been derided in the past (Knopp and Harkins, 1954; Calamel, Cleveland, and Waddell, 1963) but, as in Tagart's series (1955), it proved to be the most helpful and reliable sign of splenic rupture, particularly in children. Because he can move his shoulder freely and is more concerned about his abdomen, a patient may omit to mention the shoulder pain to the attending doctor. This failure of the patient to appreciate the significance of the pain may account for its apparent low incidence in other series. In a child the shoulder pain can be very severe and remain as the most vivid memory of the whole episode (Bell, 1965).
Little use was made of diagnostic aids in the present series. An elevation of the white-cell count often occurs but is not specific. The urine was tested for blood and, when in doubt, the state of the kidneys was assessed by intravenous pyelography. Apart from this, the main use of radiology was to detect (or exclude) fractures and chest injuries.
Paracentesis abdominis (Morris, 1966) was not resorted to, but undoubtedly it would have been valuable in patients unconscious and unable to respond and in those whose clinical picture was overshadowed by multiple major fractures. It is in these groups that delays in diagnosis and deaths mainly occur. The successful management of the multiply injured patient requires close personal co-operation between the various specialists concerned and vigorous resuscitation by the anaesthetist. With a ruptured spleen, when both thorax and abdomen may be injured, bronchoscopy, timely tracheostomy, and antibiotics may prevent fatal postoperative pulmonary complications.
SUMMARY
I. In the 13-year period 1954-66 there were 45 patients with traumatic rupture of the spleen admitted to hospital in North-east Scotland.
2 . The annual admission rate was not directly related to the number of serious road accidents.
- Left-shoulder tip pain (Kehr's sign) was the most helpful sign.
Unconsciousness and other severe injuries were the principal cause of delay in making the correct diagnosis.
Acknowledgements.-The assistance rendered in the compilation of road-accident statistics by the motor-licensing authorities and police forces in North-east Scotland is gratefully acknowledged. REFERENCES BELL, W. M. (1965)' personal communication.