or mesocolon or of the blood-vessels, and sudden violent displacement of the partially movable viscera. Crushing force may cause any of the above-mentioned conditions, and by direct compression cause pulpification of the solid viscera, or partial destruction of the walls of the hollow viscera, which sometimes results in pressure necrosis, and subsequent fecal or urinary fistula.

Every surgeon present has undoubtedly at some time in his experience, either in private or railroad practice, met with cases in the class covered by the title of this paper. These are cases in which the history and the general condition of the patient give the impression that there is a serious lesion within the abdomen, and yet upon examination we find total absence or only slight evidence of external injury. The tendency, I fear, with many is to treat these patients tentatively, only to be awakened at the autopsy to the fact that a rupture or a tear existed in the abdominal cavity, which by early radical operation might have been relieved. The mortality in these cases is appalling; reference to the literature of the subject will amply bear out this statement. The immediate effects of an injury, severe enough to cause a serious lesion of an abdominal viscus, are sometimes so slight, however, as to be misleading. Very often a patient will walk to a conveyance or to a hospital, complaining only of slight pain. In varying periods of time following the injury more decided symptoms develop, namely, signs of hemorrhage, if the solid organs be involved, early peritonitis if the hollow viscera be ruptured or torn sufficiently to allow their contents to escape.

In discussing the lesions of the abdominal viscera, I will speak of them in the order of their frequency. As it is impossible to group the symptoms so as to designate the particular organ or organs injured, the symptoms indicative of injury of each will be detailed. In cases of severe intra-abdominal injury there are a few symptoms which are common to all, and in the majority of instances warrant immediate operative interference. The most prominent of these is pain which is accompanied by shock, the degree of the latter depending upon the extent of the injury, the amount of blood lost and the temperament of the individual. Temperament and nationality have a strong bearing in the production of shock. Persons

of a highly nervous temperament suffer more from shock than do phlegmatic individuals. For example, Americans are far more liable to suffer a severe degree of shock following injuries or operations than are Germans. The pain in these injuries is peculiar and difficult to describe, but is readily recognized by one who has seen many of these cases, and by the patient himself. It is not like that of the ordinary intra-abdominal affections, but is described by the patient as if something had given way or ruptured, and is usually accompanied by a consciousness of impending death. There is present, also, tenderness, which will be more or less localized unless the ensuing peritonitis be general. In the early stages of the injury, when the shock is most profound, the pain may not be so pronounced, and if large doses of opium are administered it may be masked throughout the entire course of the trouble. When vomiting is associated with intense and agonizing pain, and when tympanites is also present, the indications clearly point to either intestinal or vesical rupture. On the other hand, if there is collapse with evidences of rapid exsanguination, this would point to hemorrhage from rupture of one of the larger vessels. or from rupture of the liver or spleen. The vomited matter rarely contains blood unless the injury be one of the stomach or the duodenum, yet, if the injury to either of these organs be such as to establish a communication with the peritoneal cavity, vomiting may be absent, or, if present, may show no evidence of blood.

There is often seen a characteristic rigidity of the abdominal walls, which is due to intraabdominal irritation. I have seen it so pronounced as to call to mind the checker-board appearance of the normal abdominal wall as represented in sketches by artists of former times. This characteristic rigidity will, of itself, in my judgment, warrant, in the bulk of instances, opening of the abdominal cavity. This condition of the belly walls, in my experience, has been invariably associated with some form of serious intra-abdominal lesion. Associated with the peculiar rigidity is the severe abdominal pain, increased by the slightest movement or pressure. The rigidity under the foregoing conditions is quite as characteristic of a severe lesion as is rigidity of the lower right quadrant of the abdominal

walls in acute appendicitis when associated with the two remaining cardinal symptoms of this affection, namely, pain and tenderness.

Restlessness, consequent upon traumatism, while always indicative of a severe type of injury, is especially well marked in the class of injuries under discussion.

In dealing with injuries of the abdomen in the female, pregnancy, extra-uterine pregnancy, ovarian tumors, pyosalpinx, etc., must be borne in mind.

Rupture of any of the solid viscera of the abdomen is usually followed by fatal hemorrhage.

The abdominal organ most commonly injured is the liver. This can be readily understood when one recalls the size of the organ, its location and its friable nature. Further, from its great blood supply it also can be understood why a rent of any size involving this organ will be immediately followed by serious bleeding. In connection with rupture of the liver the gall-bladder is also liable to be torn from the relation it holds to the liver.

The symptoms of rupture of the liver are usually great lividity of the skin, marked embarrassment of respiration, distention of the abdomen which is not altogether tympanitic, itchiness of the skin, and, if the patient survives the immediate effects of the injury, jaundice.

Rupture of the gall-bladder or biliary ducts may occur as the result of blows upon the abdomen, especially if the gall-bladder be filled with gall-stones. The commonest seat of rupture of the biliary organs is the cystic duct.

Peritonitis follows rupture of the gall-bladder or ducts. If the tear be small and the leakage slow, the escaping bile may become encysted and the peritonitis remain localized. If rapid, there will be general peritonitis and death. If there be no rapid extravasation, there will be collapse, vomiting and dyspnea and abdominal pain. If the bile escapes into the general peritoneal cavity, there will be prompt gencral acute peritonitis, with intense jaundice and clay-colored stools. When the gall-bladder has been ruptured death almost invariably follows.

Mr. Battle' reports a case of rupture of the bile duct in a boy 6 years of age, who was run over by a cab, in which there was but slight

'Lancet, London, 1894.

Autopsy. Liver and gall-bladder were intact, but about half an inch beyond the junction of the cystic and hepatic ducts the common duct was found to be torn completely through. No other injury was found.

The treatment of laceration of the liver and of the gall-bladder, the hepatic, the cystic or the common duct resolves itself into prompt surgical interference. The custom among surgeons to treat such injuries by operation after all other means have failed has been universally followed by a fatal result; therefore, if the injury to the viscus is of such a character as to partially or completely destroy its functional activity and the resulting hemorrhage almost sure to cause a fatal issue, it would be far better, even under such circumstances, to give the patient the benefit of a section and possible treatment by operation.

If a tear of the liver be superficial, by early operative interference we are enabled to remove the blood and bile which have escaped into the peritoneal cavity, to surround the rent with strips of gauze with a twofold object: 1. To prevent a second invasion of the peritoneal cavity by blood or bile. 2. To invite adhesions between the liver and parietal perito

neum.

The hemorrhage can be controlled by searing the torn surfaces with the actual or thermal cautery or packing with gauze strips.

When the tear in the liver is of such a character as to permit of suture, the latter, which should include the capsule, should be used. If there is doubt as to the thorough control of the hemorrhage by the sutures, the wound. should be treated by the open method, gauze strips being placed between the liver and the parietal peritoneum to the outer side of the line of suture.

When the gall-bladder, the hepatic, cystic or common duct has been torn alone or in connection with injury to the liver, it may be necessary to establish a biliary fistula; however, the attempt, if possible, to suture the bladder or duct should be made.

Rupture of the spleen is less common than

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 when the question of diagnosis between this. condition and that of left-sided empyema, particularly if encysted, would arise.

abscess,

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 afew 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 torn 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 peritonitis.

Incomplete tears of the stomach do not produce sufficient symptoms to 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.

immediate

When the wound is in the 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. 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