of the liver, and is usually found in conjunction with injury to other abdominal viscera. The cause of death in the majority of instances is hemorrhage, though it is not apt to occur so soon as in rupture of the liver. This fact is accounted for by the elasticity of the capsule of the spleen and its trabeculæ. Injury to the splenic artery or vein is invariably followed by sudden death. When there has been considerable bleeding and the patient survives, abscess is the result. The spleen may be displaced or even reversed from its normal position by trauma. The symptoms of ruptured spleen are those of exsanguination, precordial pain, gasping and shortness of breath (air hunger), weak, rapid pulse, vomiting and thirst. Slight lacerations of the spleen may be followed by left subdiaphragmatic abscess, when the question of diagnosis between this condition and that of left-sided empyema, particularly if encysted, would arise.

When the spleen has been the seat of the injury under consideration, its removal should follow.

The preferable incision for the removal of the spleen is a longitudinal one through the left semilunar line, commencing at the border of the ribs.

The injuries which result to the kidney from traumatism, to the abdominal wall, or to the loin, are contusion, rupture and laceration.

Rupture of the kidney is not an infrequent sequel of injury to the loin, although anatomically this organ is well protected. Death does not always follow such an accident. The two most important factors in the recovery are the plugging of the renal blood vessels, which controls the hemorrhage, and the compensatory work of the other kidney. If, however, the renal vessels or a large branch be torn, death will promptly follow from hemorrhage. If the peritoneum be involved in the injury, a fatal peritonitis is almost invariable. When the patient survives the immediate effects of the accident, abscesses are apt to form, and, by secondarily involving the peritoneum by sloughing, cause a fatal issue.

Rupture of the kidney varies in intensity and location. There may be one or more small surface tears, or the organ may be torn completely through, either transversely or longitudinally.

Laceration of the pelvis or ureter is not im

mediately fatal, as it is not accompanied by extensive hemorrhage. The inflammation following obliterates the duct, consequently there will be developed in a few days a hydronephrosis, with a corresponding tumor of the loin. In some cases the kidney will become a multilocular abscess after long periods of time when the impervious ureter atrophies.

Simple contusion of the kidney gives by far the best prognosis, both as to life and for the recovery of the organ. Hematuria is usually present, but may be absent from an occlusion of the ureter by clots. The urine is usually voided naturally, although it is mixed with large quantities of blood. Hematuria following injury to the loin or lumbar region is not always symptomatic of ruptured kidney. If clots of blood block up the ureter, the blood and urine cannot reach the bladder and must remain above the obstruction.

The symptoms of severe injury to the kidney or ureter are frequently so indefinite and obscure as to make a diagnosis extremely difficult. The urine may be passed normally and show no sign of any injury. Collapse invariably follows the accident, and is accompanied by pain in the lumbar or hypochondriac region, vomiting, and an anxious countenance. If along with the other symptoms the urine. contains blood and blood-casts, which in a few days begin to gradually disappear, it is safe to believe that the kidney has been contused or slightly lacerated.

If, on the other hand, there is a history of severe injury to the abdomen or loin, followed by faintness, anxious countenance, coldness, vomiting and severe abdominal pain; if the urine contain blood in quantities, either clotted or mixed, immediately or within a day or so after the accident; if in several days pus appear as well as blood; if there is rigidity of the lumbar or abdominal muscles and ureteral pain with. retraction of the testicle; and if these symptoms are followed by enlargement of the lumbar and hypochondriac regions, with percussion dullness, we may be fairly sure that extensive renal laceration has occurred. Rupture of the pelvis of the ureter is extremely rare; in a few cases reported the tear was so close to the hilus of the kidney that practically they may be considered as rupture of the kidney itself. The position of the ureter protects it from the class of injuries under dis

cussion. The symptoms are the same and the treatment identical.

With few exceptions, it is my practice, in exploring the kidney or its space, to carry the incision through the loin, beginning it over the outer border of the erector spinæ muscle, prolonging it obliquely inward, downward and forward. In this wise not only the kidney but the ureter as far as the brim of the true pelvis can be explored without opening the peritoneal cavity. The patient should lie upon the opposite side with a hard pillow under the corresponding flank.

The exposure afforded by this incision and the position of the patient offers increased facility when dealing with the renal vessels.

The stomach is less frequently injured than are the intestines, on account of the position it holds, being protected laterally and partly in front by the ribs and costal cartilages, also by the liver, and from the fact that it is partially surrounded by the intestines. It has been found lacerated in connection with injury to the other abdominal viscera. The rent in the stomach wall may be partial or complete, or the entire organ torn across.

It is not uncommon for a patient in whom the stomach has a complete laceration to succumb immediately after the receipt of the injury.

The stomach is most frequently torn near the pyloric extremity; however, lacerations have been found on either curvature, and the organ has been found completely forn across. In the latter instance this always occurs at or near the pylorus.

Rupture of the large or small intestine, as in the case of the stomach, may be partial or complete. Partial rupture may not be directly followed by any diagnostic signs.

The ileum and jejunum are the most frequent seats of intestinal rupture. The perforation of the bowel may be either primary or secondary to pressure necrosis.

Leakage of the contents of the bowel does not always follow intestinal rupture, although this is more liable to occur when the intestines are filled.

The symptoms of gastro-intestinal rupture are seldom typical; in some instances there is great shock, collapse, nausea, or vomiting, with agonizing pain, followed in a few hours by dissolution; while in other instances the

patient will be able to enter the vehicle unaided, or even walk to his home or to the hospital with but slight assistance. Pain may be absent altogether, or it may not appear for several days.

There are many symptoms common to both gastric and intestinal rupture. I will, therefore, describe them together.

The symptoms to be considered are those. which follow immediately after the receipt of the injury and those occurring secondarily.

The immediate symptoms are faintness, collapse, agonizing pain, either localized or general, weak, rapid pulse, thirst, vomiting, tympanites and rigidity of the abdominal walls, accompanied by extreme tenderness. The facial expression is indicative of the serious. nature of the intra-abdominal lesion.

We should never wait for secondary symptoms if the patient's condition warrants operative interference.

The diagnosis, under ordinary circumstances, is not a difficult one to make; acute pain, tenderness, rigidity, vomiting or bloody stools being present, there should be no hesitancy in advising immediate operation. Any one of the foregoing symptoms may be absent. There is always, however, marked rigidity, tenderness and pain; these in themselves should be considered sufficient evidence.

Where operation has not been resorted to the above symptoms may redevelop, at a later period, in an insidious and unexpected manner, and the patient suddenly expire from either shock or general septic peritonitis, due to intestinal perforation from pressure necrosis.

The prognosis of gastro-intestinal rupture is exceedingly grave unless immediate operative measures are instituted. The fatal result is usually from shock, hemorrhage or perito

nitis.

Incomplete tears of the stomach do not produce sufficient symptoms to render render their recognition possible. They are met with, however, in conjunction with injury to the liver or spleen. Under such circumstances they may be disposed of by the introduction of Lembert sutures. To repair complete tears. of the stomach the mucous membrane should be united with a continuous or interrupted suture, the muscular and serous coats by the continuous Lembert suture.

When the wound is in the immediate neighborhood of the pylorus, and particularly if it is longitudinal, it will be necessary to introduce the sutures in the line of the long axis of the stomach in order to avoid constriction of the orifice, as in the operation for pylorectomy for stricture.

In lacerated wounds of the stomach it may be necessary to pare the edges in order to secure perfect apposition.

When there is a considerable area of contusion with ecchymosis of the walls of the organ rendering the stitches less likely to hold, an omental graft may be necessary.

When the stomach has been completely torn across, the two portions are united by a double tier of sutures, the first including the mucous membrane, and the second the muscular and serous coats.

What has been said of the repair of wounds of the stomach is also true of the intestines under the same conditions, with the exception of a complete tear of the bowel, when it may be best to invaginate either end of the torn bowel and perform lateral anastomosis after the method devised by your worthy president, Dr. Murphy.

Rupture of Stomach.-J. B., aged 19 years, was admitted to the German Hospital, March 25, with the following history: About half an hour previous, while driving a wagon, he was run into by a trolley car, thrown from the wagon, and was struck by his horse upon the abdomen. Though suffering pain, he got up, but in a few minutes had violent epigastric pain, vomiting and dizziness, without loss of consciousness. He was brought to the hospital in the patrol wagon, walked unaided into the dispensary and was at 'once admitted. His temperature then was 97 2-5° F.; pulse-rate 96; he had severe pain over epigastrium and spasmodic attacks of vomiting; no blood in vomitus. Tenderness was marked over the entire abdomen and the rigidity was pronounced, particularly over the recti muscles. Vomiting continued, pain increased despite two hypodermic injections each of one-sixth grain morphine sulphate; at no time, however, was blood found in the stomach contents ejected. Diagnosis was made of internal hemorrhage and immediate operation decided upon. Upon opening the peritoneum about one pint of dark, partially clotted blood spouted

out; the pelvis contained no bleeding point, the incision was prolonged upward, and the bleeding was found to come mainly from recently broken adhesions about a highly-inflamed and infiltrated appendix. Grains of corn and particles of food being noticed, the cecum and intestines were carefully and rapidly examined, but no rupture could be detected. The abdominal cavity was irrigated with a warm normal salt solution; the incision was again prolonged, and a rent in the great curvature of the stomach was found four inches long, extending almost to the pylorus. The opening was closed by Lembert sutures, the abdominal cavity again irrigated, and the wound closed.

The boy was in fairly good condition after operation; peritonitis developed, however, and death ensued forty-eight hours afterward.

The mesentery may be torn in one or more places, from which large quantities of blood are lost.

H. M. C., colored, aged 16 years, was admitted to the German Hospital on the evening of December 3, 1894, with the following history: While playing about some moving freight cars he was accidentally caught between the bumpers, sustaining an injury to his abdomen. Examination upon admission failed to disclose any evidence of external injury. The introduction of the catheter drew clear urine. There was a moderate degree of shock, and the patient complained of severe pain in the abdomen and tenderness on palpation. tion. Further investigation proved negative.

The resident surgeon, not deeming the case of sufficient severity to send for me, treated the patient for shock. When I examined the patient upon the following day, it was very evident from the severity of the abdominal pain and the tenderness associated with decided rigidity of the abdominal walls, that he was suffering from a serious intraperitoneal lesion. I decided to open the abdomen at once. As soon as the peritoneal cavity was opened a large quantity of dark liquid blood escaped. The small intestines were delivered, when the cause of the lesion was found to be a ruptured mesenteric vein, the bleeding from which was arrested by the presence of a large diffused blood clot occupying the interval between the layers of the mesentery. To make sure that there was no other lesion, the large

intestines, the stomach, the liver and the spleen were carefully examined, but with a negative. result. The abdominal cavity was washed out with warm saline solution, glass drainage was introduced into the pelvis and the wound closed. Recovery was uninterrupted.

L. C., male, Italian, aged 35 years, was admitted to the German Hospital, with a history of a fall of about fifty feet, striking upon his abdomen. He was profoundly shocked and exsanguinated. The only external evidences of injury were some slight cuts on the hands and head. From the peculiarity of the pain which was associated with abdominal rigidity, a diagnosis of internal hemorrhage was made, and the abdominal cavity was opened. Dark liquid blood escaped as soon as the peritoneum was opened, and the source found to be the mesenteric vessels. The mesentery was torn half-way across and the intestines lacerated in four places. The mesentery was united with a series of catgut sutures, and the rents in the intestines closed with Lembert sutures. The abdominal cavity was washed out with hot saline solution and closed. He died two hours after the operation.

A very interesting and unusual case of secondary perforation of the intestine, which recovered from the acute symptoms, only to develop, after five months, a fecal fistula, is reported by Dr. Paul F. Eve."

The patient, a brakeman, was injured by falling between the engine and car, his body being caught between the bumpers of the same. He was unconscious for several hours. When Dr. Eve saw him first he was still suffering from shock, and complained of great pain in abdomen and back. He had several vomiting spells, the vomited matter being dark in color and of an unpleasant odor, vomiting commencing three hours after injury. An examination of the back and abdomen brought on attacks of nausea, followed by vomiting of dark, offensive, stercoraceous matter. Examination of the back, after the patient became quiet, revealed two large excoriations extending from the ninth dorsal vertebra to the sacrum. There were no excoriations or evidence of internal injury on the abdomen, although it was tympanitic and tender. He had no action of the bowels for five or six days prior to injury. Temperature 101° F., pulse

*International Medical Magazine, 1893 and 1894, Vol. 11.

130, respiration 28. Free evacuation of bowels was followed by decrease in the pain; the pulse became stronger, temperature fell to 100° F., and the abdomen became flaccid. An examination of the abdomen at this time was negative. The patient slowly improved, and by the end of the fifth week was able to get out of bed and to walk about the room. About the sixth week he complained, however, of some colicky pain in the abdomen, which was attributed to fermentation of food. About the ninth week he was taken suddenly with severe pain in the bowels, accompanied by very audible gurgling sound and a knotting of the intestines, which could be plainly felt through the abdominal walls. Some weeks after a tumescence developed in the hypogastric region, extending to the left inguinal and reaching as far back as the lumbar region. There was no fluctuation. Upon the following day an abscess broke and a large quantity of pus accompanied by gas of a decidedly fecal odor was discharged. The following day fecal matter escaped through the opening. An operation for the relief of the fistula was performed, but the patient rapidly sank and died shortly afterwards.

An autopsy was made upon the following day, and, strange to say, the peritoneum was almost normal in condition, save in the portion around the fistulous tract. There were evidences of inflammation of the solar plexus and the splanchnic nerves.

The early recognition of rupture of the bladder is of paramount importance to a successful termination of a case. The delay for even a few hours of the recognition of this condition may be followed by disastrous results. Rupture of the bladder may be partial or complete and intra- or extraperitoneal. Of the two forms of rupture of this organ the intraperitoneal is of necessity the graver condition. Ordinarily there should be little difficulty in determining the presence of rupture of this viscus. When a patient presents the history of abdominal contusion the bladder should be the first organ explored. The introduction of a catheter into the bladder will definitely settle the question of its rupture. If, upon the introduction of the instrument, no urine escapes, but instead a few drops or a considerable quantity of blood, the inference should be that the organ has been torn. Before the catheter

is withdrawn, a measured quantity of boric acid or normal saline solution should be injected, when, if the full amount thrown in is not recovered, there can be no question of the nature of the injury. If the tear be intraperitoneal, more liquid than that thrown in may be recovered or, perhaps, less; when this is the case after the first injection, therefore, it is advisable to repeat the injection two or three times.

Where the tear is so small as to prevent the free escape of the injected fluid, or where the opening in the bladder is valve-like, occasioned by a loop or intestine becoming herniated through it, this means of diagnosis may fail. In either event the prevesical space should be immediately opened, when it can be decided whether an extra- or intraperitoneal rupture exists. Some surgeons prefer to open the peritoneal cavity at once, believing that it offers greater advantages for exploration on account of the limited amount of room afforded by the prevesical space, for closure of the rent and for the placing of drainage. I cannot agree with the gentlemen taking this position, but, to the contrary, believe that it is best to first open the prevesical space, when it can be determined whether the rupture is extraperitoneal, and, if so, the necessary treatment to be carried out. If the rupture is found intraperitoneal, the abdominal incision is carried upward and the peritoneal cavity opened, when the rent is located and properly disposed of. In the extraperitoneal variety of rupture, the urine will escape in one of the following directions, namely, in the connective tissue around the neck of the bladder, along the sides of the pelvis, in some instances extending up to the kidney space, and between the anterior parietal peritoneum and abdominal walls. When the rent in the bladder is extraperitoneal, it is necessary to drain the prevesical space by a drainage tube carried through the abdominal incision; if the urine. has found its way along the sides of the pelvis, drainage should be introduced laterally. through an incision above and to the outer side of the middle of Poupart's ligament. The bladder is also to be opened by a lateral incision through the perineum.

In the event of diffuse pelvic cellulitis with abscess formation, in order to obtain the most thorough drainage, it may be necessary to

drain posteriorly by the removal of the coccyx alone or in connection with a portion of the

sacrum.

Injury to the vascular system. The most important blood vessels of the abdomen which may be ruptured subcutaneously are the aorta, the celiac axis, the mesenteric, and the spermatic vessels, the vena cava, and the portal vein. The forces which usually cause rupture of these vessels are either of the percussive or crushing variety. If the force applied is not sufficient to cause rupture, the vessel wall may be weakened to such an extent as to produce an aneurism consecutive to the injury. This takes place when the inner coat of the vessel has been torn and the outer one weakened. Lever reports an instance where a female was injured by a sharp blow upon the abdomen which was followed by an aneurism of the common iliac artery.

The symptoms of injury to blood-vessels will depend, first, upon their size, whether the traumatism involved all the coats of the vessels, and if hemorrhage has occurred. When the injury has involved only the walls of the vessel the symptoms do not occur immediately, but appear later, the result of either diminished blood supply or gangrene. An ar

tery and its accompanying vein may be torn simultaneously, and under such circumstances gangrene will invariably follow.

The diagnosis of injury to the vascular system is unsatisfactory at best, as the injury to the vessel or vessels may be complicated by an injury to the abdominal vescera, entirely overshadowing the blood vessel lesion.

The prognosis is grave under all circumstances, even when there has been only a contusion, for we must fear the possibility of future aneurism from weakened vessel wall the result of the trauma.

The almost universal fatality of intra-abdominal lesions of traumatic origin is so well recognized that it seems as if there could hardly be any question as to the wisdom of opening the abdominal cavity. I would not be understood as meaning that abdominal section should be used as a means of diagnosis, but, on the contrary, I believe that every known means, with attention to the most minute details, should be exhausted in establishing a diagnosis. When a diagnosis is impossible, abdominal section is justifiable only