FEw cases that are brought under the notice of the surgeon cause him greater anxiety than severe injuries of the abdomen, and I think that there are none which call for the exercise of the highest powers of diagnosis and treatment more than those which belong to the class to which I wish to draw attention. It is not claimed that this case presents anything new in the way of treatment ; still, as the damage was more extensive than is recorded in any cases that have been submitted to operation up

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... to the present, it is possible that some useful lesson may be learned from its consideration. At all events, it gives us the chance of appreciating the advances which have been made since Mr. Croft demonstrated to the profession that traumatic rupture of the intestine without external wound could be cured by the surgeon. A stableman aged twenty-four was admitted to St. Thomas's Hospital on Aug. 10th, 1892, suffering from the effects of a kick in the abdomen by one of the horses in the yard in which he worked. The injury occurred about a quarter past two in the afternoon, and the patient was carried to the hospital, where he was received in a very collapsed condition. He had not vomited. The patient was a fair man of slight build, suffering markedly from shock, with anxious, white face, and a small and feeble pulse. He complained much of pain in the abdomen. Below the umbilicus, extending more to the left than to the right of the middle line, was a bruise, not particularly defined, but in the situation where the hoof of the horse had struck him. The abdomen was extremely hard to the touch, somewhat distended, and did not move with respiration. Dulness was found on percussion over the front of the abdomen. A catheter was passed, and about half a pint of clear urine drawn otf ; it escaped with a fair amount of force. Soon after admission to the ward he commenced to vomit, bringing up entirely undigested food. When I saw him about 3 P. Al. he was still suffering much from shock, being cold and shivering. with anxious face; he lay on his right side with limbs and body flexed, and vomited from time to time. He complained much of pain in the abdomen, which was excessively hard and fixed, like a board, and very tender. Light percussion showed that there was dulness over the anterior part of the abdomen, that this dulness was increasing (the house surgeon, Mr. Milton, had noticed it on admission, when it was less extensive), but that it did not extend into the left flank, nor was it evident in the epigastric region. From the symptoms described above (especially the condition of the abdomen, the pain, and the frequent vomiting) and the history of the accident, the opinion formed was that the man had sustained intra-peritoneal rupture of the intestine, and rupture of the mesentery or omentum. As the shock was pronounced, it was decided to wait before operation in order to give him time to rally, and as the diagnosis was made a subcutaneous injection of morphia was administered to relieve the pain. At 8 p. M. he was placed under ether, and a median incision was made, commencing just below the aambilicus. Slight extravasation of blood was present in part of the incision, and the peritoneum bulged forward when reached, looking black in colour, and when it was incised a gush of blood followed. The patient was straining at this moment, and a coil of intestine was forced out. A rent was found in the mesentery of this coil, which was bleeding freely; the haemorrhage was being arrested with clamp forceps when the open end of a piece of intestine sprang into the wound. The other end was found by tracing the mesentery along. This portion of mesentery was much contused and lacerated, and it was found that when fully exposed the damaged portion extended nearly to its parietal attachment, spreading outwards in a fanlike manner beyond a second complete rupture, about eight inches from the first. The intestine was as com-1 A paper read before the Medical Society of London on April 30th, 1894. pletely divided as with a knife, in both places the mucous membrane protruding and curling over the other coats. Only a small amount of intestinal contents had escaped, amongst which were one or two partly-digested beans. Slight haemorrhage was going on from the mesenteric lacerations ; the intestine was contused, and in one or two places the peritoneal surface was somewhat torn. It was evident that the contusion and laceration of the mesentery would result in gangrene of the bowel if it were left, and that it would be difficult, if not impossible, to arrest the ' haemorrhage from the lacerations without removing it. So I decided to resect the bowel with the damaged mesentery. The bowel was divided beyond the rupture on each side, and a large wedge-shaped piece of mesentery removed with it. The bowel removed measured nearly thirteen inches, and the section was made where the gut appeared to be undamaged and its mesentery without laceration. Great care was taken to secure bleeding points, which were numerous. The edges of the incision in the mesentery were sewn up with a continuous suture, and as it was agreed to employ lateral anastomosis at this part the ends of the intestine were turned in and the peritonea] coats brought together by means of a continuous suture inserted after Lembert's method. At this stage in the operation Mr. Milton assisted in suturing the mesentery whilst I was suturing the bowel, thinking that we had probably found the extent of the damage, when another rupture was discovered about a foot beyond. This rupture, which was as cleanly made as the others, did not quite surround the bowel, none of the coats being ruptured for about a quarter of an inch on each side of the mesenteric attachment. Bleeding points having been secured, these two ends were brought together end to end by means of Senn's plates, cut to the required size, and a ring of Lembert's sutures used to further strengthen the union. Neither of these ends was resected, they did not appear bruised, and the mesentery was intact. Returning to the resected closed ends, which had been left for a time, an incision was made into each as nearly as possible opposite the insertion of the mesentery, about two inches and a half from the end ; a Senn's plate was passed into each of these openings, the two parts were brought into apposition, and additional sutures placed around after Lembert's method in order to give greater security. No other injury having been found, the intestine was returned, though with some difficulty, on account of the rigidity of the abdominal walls. The abdomen was then washed out with boracic acid solution, a Keith's drainage-tube was passed into the pelvis, and the remainder of the incision closed with deep silk sutures. During the operation, which was necessarily a prolonged one, lasting more than two hours, the patient suffered severely from increased shock, and five pints of saline solution were injected into the left median basilic vein. This had an immediately good effect on the pulse, which was maintained throughout the rest of the operation. Dur'ng the after-treatment of the case his chief complaint was of thirst ; this was excessive and could hardly be assuaged. Small quantities of warm water were frequently given, but relief was only partial ; ice, which was tried later, gave him more relief. The operation was performed on the 10th, and he had no sickness until the morning of the 12tb, when he vomited frequently small quantities of bile-stained fluid without any effort. On the 13th the vomiting occurred at intervals of from half to three-quarters of an hour, about an unce at a time, of yellowish-brown, acid-smel]idg fluid; in e evening, as the vomiting continued, a simple enema was given, and the bowels acted freely. Afterwards he vomited about three-quarters of a pint of fluid, the pulse increased in frequency, and be complained of some pain in the abdomen ; but this passed off in an hour, and he slept comfortably through the night. No return of the vomiting took place until 6 45 P. M. of the 15th. The morning after the operation it was noted that the abdomen was softer and moved slightly with respiration. About two ounces of blood-stained fluid were removed with a pipette. In the evening only two drachms of fluid were removed, and Keith's tube was taken out ; a suture which had been left in position was tied, thus closing the abdominal wound. On the 14th the abdomen was flaccid and moved well with respiraf;iOll. The patient was at this time doing very well ; he had no pain, his tongue was clean and moist, he had recovered from the shock, and he spoke cheerfully and with a strong voice. The only evidence of anything being amiss was the temperature, which was always 1000 F. or above 1122 MR. W. H. BATTLE ON RUPTURE OF TJIE INTESTINE. in the evening, and never quite normal in the morning. Nothing but warm water, and later ice, was given by the mouth, the patient being fed with nutrient enemata until the 14th, when the administration of milk was commenced, one drachm every half-hour. Next day, the 15th, some meat essence was also allowed, but in small quantities. Until 645 P.M. of the 15th everything appeared to be satisfactory, with the exception of the temperature ; at that hour he vomited, complained of severe pain in the abdomen, and passed into a state of collapse, with local signs of peritonitis. The temperature rose to 101°. It was evident that perforation had occurred. As soon as possible after my arrival at the hospital the patient was placed under ether and the abdominal wound opened up and extended. A coil of intestine presented ; this was found to be the part of the intestine which had been placed in lateral anastomosis. The appearance was that of normal gut, but on handling a hole was found through which some of the contents escaped. This was evidently a suture hole torn by the manipulation, there being no lymph or evident ulceration. Three Lembert's sutures were inserted. More to the left of the abdomen, the other point of suture was found; several stitches had given here, union between the ends had broken down, some of the contents of the bowel had passed through, and the coils of intestine near were covered with flaky lymph. In the condition of the patient it was not possible to resect the bowel and perform enterorrhaphy, so an artificial anus was formed