double row of silk sutures, the first row being buried and including the muscular coat and mucous coat, the second row being Halsted sutures; drain; close the wound in the parietes with silkworm-gut; feed by the rectum for four days, and then begin the administration of a very little food by the mouth. In incomplete rupture the danger is perforation. The patient is put to bed, and after reaction has taken place, is fed by the rectum for several days, and morphin is given hypodermatically.

Rupture of the Intestine without External Wound. -The symptoms of this injury are profound shock, tympanites, and pain, rapidly followed by peritonitis if the patient survives. Vomiting comes on soon after the accident, the vomited matters being possibly at first bloody and then stercoraceous. The respiration is thoracic, the tongue is dry, and great thirst exists. The pulse, which is slow at first, becomes small and rapid. A high-tension pulse accompanies tympanites, because the distention of the bowel greatly decreases the amount of blood in its coats, and thus increases the amount of blood in the rest of the system. Any portion of the intestine may rupture, but the ileum is most liable to this accident. Blood in the stools rarely appears early enough to be of diagnostic value. The escape of gas into the peritoneal cavity may cause disappearance of normal liver-dulness. By anesthetizing the patient hydrogen gas insufflated into the rectum will come from the mouth if there is no perforation in the stomach or the intestine; if a perforation exists, tympanites is much increased. To apply rectal insufflation of hydrogen, generate the gas in a bottle by means of zinc and sulphuric acid, catch the gas in a large rubber bag, and attach the tube from the gas reservoir to a tip which is inserted in the rectum. Give the patient ether to relax the abdominal muscles, direct an assistant to press the anal margins against the rectal tip, and when the patient is unconscious turn on the stopcock and press upon the reservoir (Senn).

Treatment. If symptoms point to dangerous hemorrhage operate at once, otherwise do not operate until reaction has been obtained. Give stimulants by the rectum, and a hypodermatic injection of morphin and atropin; asepticize and anesthetize. Perform a laparotomy; check hemorrhage; find the rent, and close it by Helsted sutures if possible. The hydrogen gas test of Senn will discover a perforation. It may be necessary to perform an end-to-end approximation or a lateral anastomosis. Flush out the abdominal

cavity with hot saline solution. Some surgeons cleanse the abdomen by wiping with gauze. Finney eviscerates, wipes out the abdominal cavity, and wipes the intestines as he restores them. Whatever method is used to cleanse the abdomen remember that infectious material is apt to accumulate between the liver and diaphragm and in Douglas's pouch. Drainage is to be used.

"In abdominal operations it is frequently imperatively necessary that the large intestine be recognized with certainty or the small bowel be positively identified. The size of the tube will not always aid in this recognition, as a small intestine may be distended enormously and a large intestine may be contracted to the size of a finger because of obstruction above. The longitudinal muscular fibers of the large bowel are accentuated in three portions; these accentuations constitute the three longitudinal bands which begin at the cecum and terminate at the end of the sigmoid flexure of the colon. Each band is composed of a number of shorter bands, the shortness of these constituent bands permitting the sacculation of the large intestine. Longitudinal bands and sacculation are not met with in the small gut, their presence or absence being a means of identification in many cases; but when the colon is much distended the bands cannot be seen distinctly and the sacculation disappears. From the large intestine only spring the appendices epiploicæ (small overgrowths of fat in pouches of peritoneum), but they are sometimes not well marked except upon the transverse colon, and when emaciation exists they may almost entirely disappear. The relatively fixed position of the large intestine and the free mobility of the small bowel are important points of distinction. The foregoing indicates that it is not always easy to distinguish between colon and small gut, and that, according to old rules, it may often be necessary to make large incisions, to see as well as feel, and to handle a large extent of the bowel. Any scrap of knowledge that will shorten an abdominal operation, that will permit of as certain work through a smaller incision, and that will diminish handling of intraperitoneal structures, tends to increase the chances of recovery. For these reasons the writer suggests a method of bowel-identification which rests upon the facts that each bowel has a posterior attachment, that the origin of the attachment differs according to the bowel it supports, that a single finger can detect the origin of the peritoneal support of any section of the bowel, and, this origin being known, the portion of the bowel it supports

is with certainty deducible. In an exploratory operation, for instance, the finger comes in contact with the bowel: to determine whether it is a large or a small bowel, note first if the structure is movable or is firmly fixed; next, pass the finger over the bowel and let it find its way posteriorly. If dealing with a small bowel, the finger will reach the origin of the mesentery between the left side of the second lumbar vertebra and the right sacro-iliac joint; if dealing with the large bowel, the finger will reach the origin of the mesocolon, or the point where the colon is fixed posteriorly and to the side."

Rupture of the liver may be caused by a blow, a fall from a height, or the concussion of a railroad collision. Occasionally the ends of fractured ribs are driven into the organ.

The symptoms are those previously set forth as attending severe intra-abdominal injury (page 627). In addition there are tenderness over the liver, and often pain in the abdomen and back. As a rule, the signs of hemorrhage are present. Sugar may appear in the urine. The respiration is much embarrassed. After a few days the skin may itch and become jaundiced, but this is rare.

In these cases operate at once if hemorrhage is severe; otherwise operate after bringing about reaction. Stop bleeding in the liver by cautery, by suture, or by packing. In a superficial tear introduce sutures of catgut or silk. In a deep tear suture the liver to the belly-wall, pack with gauze, and surround the rent with gauze.

Rupture of the Gall-bladder and the Bile-ducts. -Rupture of the gall-bladder or the ducts is most apt to happen from injury when gall-stones exist. Peritonitis, general or local, is almost certain to follow such ruptures. Besides those symptoms common to all severe abdominal injuries, there is often intense jaundice (Deaver).

Treatment.-Suture the laceration or make a biliary

fistula.

Rupture of the Spleen.-The spleen may be dislocated as well as ruptured. Rupture of the spleen is rare without. other serious injuries. An enlarged spleen is far more liable to injury than a normal organ. The usual symptoms of abdominal injury are present. In addition there are pain over the spleen and heart, tenderness over the spleen, and great shortness of breath. Hemorrhage is generally violent. Treatment.-At once remove the spleen. Rupture of the Kidney (page 770).

1 The author, in Medical News, June 9, 1894.

Rupture of the Ureter (page 772).

Wounds of the Abdominal Wall.-Non-penetrating wounds are to be treated on general principles. Suture with great care and apply external support. Ventral hernia may follow a large wound.

Penetrating Wounds.-The symptoms of penetrating wounds of the abdominal wall are usually those of shock and hemorrhage, and later of septic peritonitis. Emphysema is apt to occur. Viscera may protrude. In an incised or a lacerated wound some of the contents of the abdomen may protrude. If protruding viscera are uninjured, they are cleansed with hot sterile normal salt solution and returned into the abdomen, the wound being enlarged if necessary. The belly is flushed out with hot salt solution to remove blood-clots, a drainage-tube is inserted, the peritoneum is sutured with catgut, and the muscles and integument are approximated with silkworm-gut. If the viscera are injured, treat them appropriately. In punctured and in gunshotwounds, when the intestine has been perforated, rectal insufflation of hydrogen will often disclose the fact, but evisceration may be necessary. Always arrest bleeding. In punctured wounds enlarge the wound of entrance, examine for injury of viscera, close perforations if any are found, flush out the belly, drain, and close the wound. In gunshot

wounds the bullet may be located by the X-rays. In a case of gunshot-wound look if there is a wound of exit, and determine if the ball is lodged.

If the symptoms point to severe hemorrhage, open the belly at once in the middle line, arrest the hemorrhage (page 267), examine the viscera, and endeavor to repair damage. If the bullet is found, remove it.

If the symptoms do not point to hemorrhage, bring about reaction before operating. When the patient is ready for operation follow the track of entrance by means of a knife and a grooved director; open the peritoneum at the point the bullet entered; arrest hemorrhage; look for perforations and close them; examine viscera; search for the ball, but do not search long, and if it is found, remove it; flush out the belly with hot salt solution; dry with gauze pads; drain; and close the wound. In some cases of penetrating wounds of the abdomen enterectomy and end-to-end approximation will be required. All punctures or tears must be sutured (enterorrhaphy). Irrigation of the cavity is only required when the contents of the stomach or the bowel have escaped or when a considerable hemorrhage has taken place. The surgeon

should drain when the contents of the stomach or the intestines have escaped, when hemorrhage is severe, or when the liver, pancreas, kidney, or spleen is damaged. Active stimulation and artificial heat are needed immediately after the operation to combat shock. In many cases intravenous transfusion of normal salt solution is of great value. It may be given during and after operation. Enteroclysis of hot saline fluid is useful. The after-treatment consists of rest, opium in small amounts to arrest peristaltic action, avoidance of food by the stomach for forty-eight hours, and the administration of brandy and water from time to time. Feed by the rectum for two days. On the appearance of the first sign of peritonitis, forty-eight hours or more after the operation, give a saline cathartic. It is not wise to purge during the first forty-eight hours after the operation. When there is no sign of peritonitis, do not purge until the fourth day. After forty-eight hours liquid food can usually be given by the stomach. Solid food may be given after seven or eight days, but the patient must not leave his bed until the wound is solidly united, because of the danger of ventral hernia. A support should be worn for a long time.

STOMACH AND INTESTINES.

Foreign Bodies in the Alimentary Canal. These accidents are rare except in children, insane people, or drunkards. Most foreign bodies swallowed are passed with the feces, but some lodge. Any body which can pass the esophagus is not too large to pass through the intestines. A foreign body may lodge in the stomach. In some cases there are no symptoms. In other cases symptoms are violent. The severity of the symptoms depends upon the shape and character of the body.

In some cases it is possible to feel the body from without. A metal body in the stomach will deflect a magnetic needle held over the viscus (Pollailon). Many foreign bodies can be skiagraphed. It is not wise to attempt to recover the body by inducing vomiting. In some cases gastrotomy is necessary. When a foreign body has been swallowed the usual treatment is as follows: a purgative should never be given to expedite the passage of a foreign body, because increased peristalsis means increased danger of impaction or of perforation. Endeavor to encrust the foreign body, and thus lessen the danger of perforation, by feeding with bread and milk only for several days, and at the end of this period