A rent is probable after a severe injury if there is collapse, if the pulse becomes more rapid and small, if the patient shows signs of exsanguinity, if the area of liver-dullness on percussion is in creased, and if pain radiating to the scapular region is complained of. Severe injury may exist, however, without these indications.
Diagnosis of rupture of the liver is ren dered difficult by the fact that the local symptoms do not arise till late, while the danger is greatest during the first twenty-four hours. Zeidler (Deutsche med. Woch., Sept. 13, '94).
Case of a boy, aged 16, run over by a cart which had passed over his abdo men. The boy walked a quarter of a mile to the hospital. When admitted he was pale and in great pain, but his pulse was full; no external signs of injury. On the fifth day he had an action, ac companied with severe abdominal pain. speedily followed by collapse and sudden death. Fissure three inches deep was found in the right lobe of his liver. Thomas Bryant (Lancet, Nov. 2, '95).
Lesions of the Gall-bladder or Biliary Duets. — Blows and other conditions capable of causing hepatic rents some times implicate these organs in the le sion. There may be severe pain in the right hypochondrium if a rupture exists, vomiting of food and bile, and icterus. The urine is usually dark-mahogany and the stools ash-gray in color. Tender ness over the hepatic region is usually marked. The intensity of the symptoms depend to a degree upon the quantity of bile voided into the abdominal cavity; but, this secretion being aseptic, peri tonitis only occurs as a complication when the peritoneum is itself implicated in the traumatism, or when the lesion is at the junction of the biliary tract and the intestinal canal, the latter in that case acting as a source of infection.
Case of a man who, after a severe blow in the right hypochondrium from the shaft of a cart, showed all the symptoms of rupture in the biliary tract. Seven quarts of a dark-brown liquid, rich in biliary pigments, biliverdin, etc., with drawn on the fourth day by paracentesis. Prompt recovery. Jules Roux (Mar seille-m6d., Aug. 25, '95).
Case of rupture of the gall-bladder by contusion. Inflammation developed slowly and death resulted in three days. Post-mortem showed the patient had a large gall-bladder with numerous gall stones. If an operation had been made
early the chances would have been favor able. McLaren (Journal Amer. Med. Assoc., July 9, 'OS).
Lesions of the Spleen.—The causes of injury to this organ are the same as those of the liver. Rents, sanguineous infiltration, and partial crushing are the lesions most frequently observed. En largement of this organ through a malarial cachexia renders it susceptible to lesions which traumatism would not give rise to were it in its normal state.
In extensive lesions copious haemor rhage usually takes place and death rapidly follows. If the lesion present is less severe, however, and the Immor rhage be moderate, there is tendency to collapse, increasing pallor, and a feeling of suffocation. The latter symptom and severe radiating pain in the region of the spleen are generally present, besides the signs peculiar to all abdominal juries. If the patient survives suffi ciently long the immediate effects of the traumatism, peritonitis or abscess and other complications frequently result.
Severe local pain generally continues for some time, and chills are not infrequent. Percussion shows the organ to be more or less enlarged.
Case of young man who fell from his horse and was struck on left side of thorax low down in the axillary line by animal's hind hoof. Irought to hospital in state of shock. Patient complained of considerable pain over the left side of the lower ribs, rather toward the back. In fusion of 1200 centimetres of sterile salt solution given. Next day symptoms of internal injury were apparent. Opera tion. The peritoneum purplish in color, bulged forward, and peritoneal cavity completely filled with blood-clots and fluid blood. Rupture of spleen found. Spleen removed, together with blood clots in peritoneal cavity. At this stage of operation patient was in a moribund condition. Vein in arm was opened, and saline infusion of 2000 centimetres given. Recovery uneventful. Charles McBurney (Med. Record, Apr. 23, '98), Four successful cases of splenectomy for rupture without external wound. Di agnosis of ruptured spleen is arrived at from (1) the locality of the injury; (2) the evidence of internal hmmorrhage, and (3) the large fixed dullness in the left flank. Ballance (Practitioner, Apr., '98).