Case in which a crow-bar entered the right thigh in front and emerged below the right shoulder posteriorly about an inch and a half below the angle of the right scapula. Notwithstanding tox emia, hepatic rupture, and the presence of septic fluid in the thorax, patient sur vived the injury three weeks. A. C. Miller (Edinburgh Med. Jour., Oct., '99).
Treatment. — The preliminary meas ures indicated in the treatment of com plicated contusions of the abdomen are also applicable in that of penetrating wounds of that cavity. Protrusion of portions of the intestines, the mesentery, and the omentum through the external wound is an early complication met with in many cases of penetrating wound. If the protruding mass be intestinal and in good condition it should at once be re turned into the abdomen. An easy way of accomplishing this (recommended by Levis) is to raise the middle of the patient's body by means of a pillow, the hands, etc., while he is lying on his back. The anterior portion of the pelvis is thus separated to an abnormal degree from the anterior portion of the thorax, and the increased room in the abdominal cavity thus obtained causes the intes tines to spread out, as it were, and, their weight causing traction upon the pro truding loop, the latter quickly slips in. At times accumulation of gas or fdecal matter checks its inward progress; the gas can easily be let out by inserting a clean hypodermic needle into the pro jecting bowel; the faecal matter can also be reduced in quantity by drawing out an additional portion of the gut—thus increasing the size of the loop—and gently pressing small portions of the contents into the unprolapsed bowel, thus diminishing the tension of the pro truded mass. It is sometimes necessary to enlarge the abdominal wound. If the projecting mass be greatly inflamed the latter procedure is unavoidable. If it be gangrenous it had better be incised and the formation of a faecal fistula per mitted.
An omental protrusion, if healthy, can be immediately returned, but if greatly inflamed or gangrenous it should be transfixed near the abdominal wall and tied with a double ligature; then excised. The stump is then secured in the deeper portion of the wound with ligatures and adhesive strips.
Punctured wounds of the abdomen are frequently recovered from spontaneously, owing to the absence of serious visceral lesions. The same statement may be
made as regards bullet wounds, but with less emphasis. That laparotomy should be performed in every case is a view that wide-spread clinical testimony does not sustain; but that a wound of sufficient importance to cause anxiety be enlarged down to the peritoneum to allow of a careful examination and adequate pro cedures, if need be, and that laparotomy proper should be reserved for lesions. which, from the nature of the symptoms, tend toward a fatal issue, is in keeping with the teachings of the most advanced, but safe, surgery.
The wound of entrance should be en larged, and, if the missile has entered the abdomen, a section is called for. Operation is proper soon after the in jury, before the peritoneal membrane has become infected or much blood lost. Tiffany (Amer. Jour. Med. Sci., May. '96).
llypersthesia of the abdomen is an indication for operation. An increase hi the respirations to twenty-eight or thirty per minute is an absolute indication for operating. Cold extremities are also significant. Le Dentu (Le Progres Med., Oct. 27, '97).
When surgical measures become nec essary, including enlargement of the wound, the patient should be placed un der an anmsthetic. The rectum should be emptied by copious injections con taining a tablespoonful of glycerin to the pint. A subcutaneous injection of morphine grain) is recommended by many surgeons. If, however, there is a tendency to shock without much pain, this agent had better be withheld. Rec tal injections of whisky and warm water, 2 ounces of the former and 4 of the latter, is useful to sustain cardiac action. It may be repeated in an hour if evi dences of impending shock are still present.
If, after a careful examination of the enlarged wound, it is found that the peritoneum is not involved, the exposed tissues are carefully cleansed and the wound is closed, deep sutures being used to hold the tissues in accurate apposi tion. As already stated, the possibility of ventral hernia should be borne in mind: the patient should be kept in bed for some time and a bandage be worn until all local weakness has disappeared.