Five eases of wounds of liver: two by fire-arms and three by a cutting instru ment. Two great dangers are hmmor rhage and infection. Immediately after accident, if there is indication of inter nal haemorrhage, exploratory laparotomy should be performed. For control of haemorrhage tampon may be utilized in grave eases, where work must be done quickly. Suture is method of election. Statistics show, out of 50 cases of oper ative interference in hepatic wounds, 36 resulted in a cure and 14 ended fatally. L. Walton (Amer. Medieo-Surg. Bull., Jan. 10, 'OS).
The spleen is next in order as to pro fuseness of limorrhage. The same pro cedures may be adopted as for the liver, but the introduction of iodoform strips is to be preferred. If these means fail. splenectemy is the only measure left.
Sometimes a portion of the organ pro jects through the wound; removal of the protruding portion should be practiced after passing a ligature around the mass.
Case of prolapse of spleen through a perforating wound of the abdomen of three weeks' standing. Spleen at first considered to be the liver, though on the left side, on account of the size, shape, and color of the organ. Attempts to reduce it failed. It slowly contracted, becoming, within a month, less, by half, in size, and contracted very firm adhe sions to the skin, the peritoneal cavity, meanwhile, being completely shut off. As there had been a compound fracture of the tenth rib, with subsequent necro sis of the broken ends of the bone, a sinus remained, leading from the pro lapsed organ to the bone; and here the adhesions were very vascular. The pleura had escaped uninjured. Splenec tomy. Uneventful recovery. E. Harold Brown (Brit. Med. Jour., Jan. 16, '97).
The walls of the stomach and intes tines may also give rise to marked limm orrhage notwithstanding their compara tive thinness. The number of vessels coursing through them, however, is very great. In these cases it is best to hem the margins of the wounds with fine silk. The bladder may be treated in the same way.
The mesentery sometimes bleeds pro fusely when perforated. The mesenteric vessels should be ligated en masse with fine silk.
of the kidney is arrested in the majority of cases by iodoform gauze package. If this should prove in effectual the organ must be exposed and the vessels tied if possible. If not, nephrotomy or nephrectomy should be resorted to. The latter operation does away with the chances of complication attending the former, while the kidney of the other side assumes the function of
both.
Case in which the patient, a boy of S years, was shot by his brother with a small Flobert pistol, the bullet entering just above the os pubis and passing down toward the right. Considerable urine extruded from the wound, and cedema of the scrotum and penis ap peared. Incisions allowed the escape of considerable urine and the bullet was also extruded. The patient rapidily re covered. B. Bayerl (Miinehener med. Woch., May 7, 1901).
Perforation. — To 'detect the presence of a perforation and its location, Senn's hydrogen test, already mentioned, may be employed.
Senn's method of hydrogen-gas insuf flation, however admissible in recent cases, should be used with great caution after the lapse of a few hours. The dis tension and motion of the intestines caused by the insufflation might rupture inflammatory adhesions, burst open in testinal wounds that bad nearly healed. and make a peritonitis general which had become circumscribed. McGraw (Trans. Amer. Surg. Assoc., vol. vii, '89).
The fact that the intestines are, at times, perforated in twenty spots by a bullet suggests the considerable degree of care that should be given to this part of the procedure, which is carried out in the following way: The perforation nearest the rectum having been detected, the portion of intestine perforated is gently brought into full view. An as sistant causes the gas in the portion of gut below the laceration to escape through the latter by slight pressure. This being done, the next step is to ascertain whether there is another perfo ration above. A fresh, perfectly aseptic glass tube is placed at the end of the insufflating tube and introduced into the wound with the tip directed away from the rectum. The assistant now being directed to compress the intestine below the perforation, a small amount of gas blown above the latter will inflate the upper segment if there is no opening, or indicate the location of the perforation if there is one. As soon as the latter is detected, the tube is withdrawn, the neighboring intestine on each side of the first perforation is disinfected, and the opening is closed. This procedure is renewed until all perforations have been found and closed. This plan renders un necessary the removal of the intestines from the abdominal cavity during any part of the operation, the source of com plications in many cases, and of death by aggravated shock in others, and is now recommended by the majority of Amer ican surgeons.