a hopeful character not justified by the very cases where histories were quoted. I sincerely hope no member of this society will ever either recommend or consent to a patient of his employing the X-Rays to an operable canIf it be inoperable let them have all the hope they can obtain from the X-Ray or Christian Science or condurango root or what else there may be.

cer.

CONTUSIONS OF THE INTESTINE WITHOUT LESION OF THE ABDOMINAL WALL AND WITH LATE APPEARANCE OF SERIOUS SYMPTOMS.

EVERETT JAMES MCKNIGHT, M.D.,

HARTFORD.

After a somewhat careful examination of the medical literature of the past fifty years, the writer is unable to find any extensive recognition of the conditions which exist in the class of cases to be considered in this paper. It has for a long time been known that serious lesions may occur in the abdominal cavity as the result of apparently trivial injury without external marks of violence and with slight or even no immediate symptoms, but the pathology of such cases has evidently not been thoroughly understood, nor their treatment accurately outlined.

This does not refer to those cases where rupture of a viscus, extensive hemorrhage, or other gross lesion occurs immediately, but to those where simple ecchymoses are produced at the time of injury, which in any other part of the body would be of little moment.

In the Guy's Hospital Reports for 1858, page 123, Dr. Alfred Poland says: "A strike, kick or fall on the abdomen, a passage of a wheel over it, or a jam between two opposing bodies, etc., must never be judged lightly of, and must always be regarded with suspicion and treated in a careful and judicious manner. Many a trivial blow in this region has resulted in unexpected and sudden death, although sometimes life has been prolonged for a short period in agony and suffering, terminating in protracted collapse or else in subsequent fatal inflammatory mischief. This can readily be accounted for when we consider the numerous and vital

structures contained in the abdomen. All these struc tures, organs, etc., are moreover enclosed within soft. elastic parietes, capable of great distention, which, although readily able to resist shock and external violence without injury to themselves, yet may allow the force to be transmitted and expended on the contents with dire effect, and yet without leaving a trace or mark on the exterior."

At the fourteenth annual meeting of the International Association of Railway Surgeons at Milwaukee, in June, 1901, the late Dr. W. D. Middleton of Davenport, Iowa, reported three cases of slight injury to the abdomen, in which, although there was some evidence of shock immediately after the injury, it soon passed off and there was an entire absence of unfavorable symptoms until a few days later, when they came on suddenly and death rapidly ensued. In closing the discussion which followed, Dr. Middleton said, (Railway Surgeons, Aug., 1901, page 70): "As an ecchymosis is produced in the eye, so is it produced in the intestinal wall in a case of abdominal contusion. The blood stagnates and settles there. The wall becomes softened in its texture presently, as in the second case narrated, infection takes place through the wall by contiguity, and we have the abdomen filled with pus or a perforation may take place through the softened spot.”

The writer's personal experience has been limited to two cases.

Case 1.-J. T., fifty-nine years old, a farmer, previous health good.

On September 30th, 1902, at about 9 a. m., while trying to prevent a pair of horses from running away, he was thrown to the ground, rolled over, but not stepped upon. The team was stopped with the front wheel of the cart resting against the right side of his chest. Dr. E. T. Davis of Ellington, who was called immediately, found

fracture of two ribs on the right side, but no indication of other injury, and reports that there was no condition of shock noticeable. After having his chest strapped Mr. T. went about his business and at noon ate a hearty dinner.

There were absolutely no abdominal symptoms until about thirty hours after the injury when he began to have some distention and discomfort, remarking to his wife that that was where he was going to have trouble. From that time on he grew steadily worse with incessant vomiting, distention, fever and rapid pulse, all these symptoms increasing in severity up to the time of my first visit, sixty hours after the injury. A diagnosis of serious injury to the intestines was made and an explora tion advised and allowed.

On opening the abdomen the whole intestinal canal was found greatly distended with fluid and gas, and present ing a large number of small ecchymoses, those on the intestinal wall being black, but on the mesentery bright red. Two feet of the small intestine presented a dusky appearance but no other lesion was found. Into this a small incision was made, through which a large amount of gas and fluid was evacuated, the bowel immediately regaining its normal color. The portion of gut incised was fastened loosely to the abdominal wall and packed around with gauze.

The patient rallied well, the pulse and temperature reaching the normal point within two days. Feeding was entirely by rectum for several days. Later he was fed by the mouth for a while, but the opening was so high up in the intestine that he obtained no benefit from the food so taken, as only a very small amount was absorbed. The digestive fluids also acted so powerfully upon the skin of the abdomen that it became necessary to again resort to rectal alimentation. On account of the combined action of the circular and longitudinal fibres the opening in the gut became greatly enlarged

and the mucous membrane protruded much as in a case of prolapse of the rectum.

On October twenty-fifth, twenty-three days after the primary operation, the wound was closed with Lembert sutures, leaving a comparatively good sized lumen, but they soon tore out and the parts lapsed into their former condition. He was finally persuaded to consent to a radical operation, and on November tenth, at the Hartford Hospital, the wound was opened up for the purpose of making a resection of the bowel. To my surprise it was found that firm adhesions had taken place at every point where there had been an injury to the intestine, which it was impossible to separate, without tearing out a part of the structures of one or the other wall. The gut was finally freed and about four inches at the site of the original incision removed, and an end to end anastomosis performed. He stood the operation well and was in excellent condition until twenty-four hours afterwards when he suddenly went into a state of collapse, the pulse going immediately to 160. This seemed to be co-existent with commencing action in the previously unused portion of the intestine, which evidently caused a condition similar to that of shock, and also brought into contact with absorbing surfaces a large amount of decomposing mucus and exfoliated epithelium, which had been accumulating in the intestinal canal. Copious evacuations, very offensive in character, occurred frequently, and later a large amount of fresh bile. It had been supposed that the irrigations into the upper end of the lower segment had passed down through its entire length, but it was shown at the time of operation that this was impossible on account of the numerous twists and adhesions.

Death occurred on November fifteenth, five days after operation, and was due to shock and auto-intoxication through the intestinal mucosa. Examination showed that there was absolutely no leaking at the point of