1833. The ileum of this man contained 92 shot and 120 plum stones.

Buckler reports a case of appendicitis in a child of twelve, in which a common-sized bird-shot was found in the appendix. Packard presented a case of appendicitis in which two pieces of rusty and crooked wire, one 2 1/2 and the other 1 1/2 inches long, were found in the omentum, having escaped from the appendix. Howe describes a case in which a double oat, with a hard envelope, was found in the vermiform appendix of a boy of four years and one month of age. Prescott reports a case of what he calls fatal colic from the lodgment of a chocolate-nut in the appendix; and Noyes relates an instance of death in a man of thirty-one attributed to the presence of a raisin-seed in the vermiform appendix. Needles, pins, peanuts, fruit-stones, peas, grape-seeds, and many similar objects have been found in both normal and suppurative vermiform appendices. Intestinal Injuries.--The degree of injury that the intestinal tract may sustain, and after recovery perform its functions as usual, is most extraordinary; and even when the injury is of such an extent as to be mortal, the persistence of life is remarkable. It is a well known fact that in bull-fights, after mortal injuries of the abdomen and bowels, horses are seen to struggle on almost until the sport is finished. Fontaine reports a case of a Welsh quarryman who was run over by a heavy four-horse vehicle. The stump of a glass bottle was crushed into the intestinal cavity, and the bowels protruded and were bruised by the wheels of the wagon. The grit was so firmly ground into the bowel that it was impossible to remove it; yet the man made a complete recovery. Nicolls has the case of a man of sixty-nine, a workhouse maniac, who on August 20th attempted suicide by running a red-hot poker into his abdomen. His wound was dressed and he was recovering, but on September 11th he tore the cast off his abdomen, and pulled out of the wound the omentum and 32 inches of colon, which he tore off and threw between his pallet and the wall. Strange to say he did not die until eight days after this horrible injury. Tardieu relates the case of a chemist who removed a large part of the mesentery with a knife, and yet recovered. Delmas of Montpellier reports the history of a wagoner with complete rupture of the intestines and rupture of the diaphragm, and who yet finished his journey, not dying until eighteen hours after. Successful Intestinal Resection.--In 1755 Nedham of Norfolk reported the case of a boy of thirteen who was run over and eviscerated. It was found necessary to remove 57 inches of the protruding bowel, but the boy made a subsequent recovery. Koebererle of Strasburg performed an operation on a woman of twenty-two for the relief of intestinal obstruction. On account of numerous strictures it was found necessary to remove over two yards of the small intestine; the patient recovered without pain or trouble of any kind. In his dissertation on "Ruptures" Arnaud remarks that he cut away more than seven feet of gangrenous bowel, his patient surviving. Beehe reports recovery after the removal of 48 inches of intestine. The case was one of strangulation of an umbilical hernia. Sloughing of the Intestine Following Intussusception.--Lobstein mentions a peasant woman of about thirty who was suddenly seized with an attack of intussusception of the bowel, and was apparently in a moribund condition when she had a copious stool, in which she evacuated three feet of bowel with the mesentery attached. The woman recovered, but died five months later from a second attack of intussusception, the ileum rupturing and peritonitis ensuing. There is a record in this country of a woman of forty-five who discharged 44 inches of intestine, and who survived for forty-two days. The autopsy showed the sigmoid flexure gone, and from the caput ceci to the termination the colon only measured 14 inches. Vater gives a history of a penetrating abdominal wound in which a portion of the colon hung from the wound during fourteen years, forming an artificial anus. Among others mentioning considerable sloughing of intestine following intussusception, and usually with complete subsequent recovery, are Bare, 13 inches of the ileum; Blackton, nine inches; Bower, 14 inches; Dawson, 29 inches; Sheldon, 4 1/2 feet; Stanley, three feet; Tremaine, 17 inches; and Grossoli, 40 cm. Rupture of the Intestines.--It is quite possible for the intestine to be ruptured by external violence, and cases of rupture of all parts of the bowel have been recorded. Titorier gives the history of a case in which the colon was completely separated from the rectum by external violence. Hinder reports the rupture of the duodenum by a violent kick. Eccles, Ely, and Pollock also mention cases of rupture of the duodenum. Zimmerman, Atwell, and Allan report cases of rupture of the colon. Operations upon the gastrointestinal tract have been so improved in the modern era of antisepsis that at the present day they are quite common. There are so many successful cases on record that the whole subject deserves mention here. Gastrostomy is an operation for establishing a fistulous opening in the stomach through the anterior wall. Many operations have been devised, but the results of this maneuver in malignant disease have not thus far been very satisfactory. It is quite possible that, being an operation of a serious nature, it is never performed early enough, the patient being fatally weakened by inanition. Gross and Zesas have collected, respectively, 207 and 162 cases with surprisingly different rates of mortality: that of Gross being only 29.47 per cent, while that of Zesas was for cicatricial stenoses 60 per cent, and for malignant cases 84 per cent. It is possible that in Zesas's statistics the subjects were so far advanced that death would have resulted in a short time without operation. Gastrotomy we have already spoken of. Pyloroplasty is an operation devised by Heineke and Mikulicz, and is designed to remove the mechanic obstruction in cicatricial stenoses of the pylorus, at the same time creating a new pylorus. Gastroenterostomy and pylorectomy are operations devised for the relief of malignant disease of the pylorus, the diseased portions being removed and the parts resected. Gastrectomy or extirpation of the stomach is considered by most surgeons entirely unjustifiable, as there is seldom hope of cure or prospect of amelioration. La Tribune Medicale for January 16, 1895, gives an abstract of Langenbuch's contribution upon total extirpation of the stomach. Three patients were treated, of whom two died. In the first case, on opening the abdominal cavity the stomach was found very much contracted, presenting extensive carcinomatous infiltration on its posterior surface. After division of the epiploon section was made at the pylorus and at the cardiac extremities; the portions removed represented seven-eighths of the stomach. The pylorus was stitched to the remains of the cardiac orifice, making a cavity about the size of a hen's egg. In this case a cure was accomplished in three weeks. The second case was that of a man in whom almost the entire stomach was removed, and the pyloric and cardiac ends were stitched together in the wound of the parietes. The third case was that of a man of sixty-two with carcinoma of the pylorus. After pylorectomy, the line of suture was confined with iodoform-gauze packing. Unfortunately the patient suffered with bronchitis, and coughing caused the sutures to give way; the patient died of inanition on the twenty-third day. Enterostomy, or the formation of a fecal fistula above the ileocecal valve, was performed for the first time by Nelaton in 1840, but the mortality since 1840 has been so great that in most cases it is deemed inadmissible. Colostomy, an operation designed to make a fistulous opening in any portion of the rectum, was first practiced by Littre. In early times the mortality of inguinal colostomy was about five per cent, but has been gradually reduced until Konig reports 20 cases with only one death from peritonitis, and Cripps 26 cases with only one death. This will always retain its place in operative surgery as a palliative and life-saving operation for carcinomatous stenosis of the lower part of the colon, and in cases of carcinoma of the rectum in which operation is not feasible. Intestinal anastomosis, whereby two portions of a severed or resected bowel can be intimately joined, excluding from fecal circulation the portion of bowel which has become obstructed, was originally suggested by Maisonneuve, and was studied experimentally by von Hacken. Billroth resorted to it, and Senn modified it by substituting decalcified bone-plates for sutures. Since that time, Abbe, Matas, Davis, Brokaw, Robinson, Stamm, Baracz, and Dawburn, have modified the material of the plates used, substituting catgut rings, untanned leather, cartilage, raw turnips, potatoes, etc. Recently Murphy of Chicago has invented a button, which has been extensively used all over the world, in place of sutures and rings, as a means of anastomosis. Hardly any subject has had more discussion in recent literature than the merits of this ingenious contrivance. Foreign Bodies in the Rectum.--Probably the most celebrated case of foreign body introduced into the rectum is the classic one mentioned by Hevin. Some students introduced the frozen tail of a pig in the anus of a French prostitute. The bristles were cut short, and having prepared the passage with oil, they introduced the tail with great force into the rectum, allowing a portion to protrude. Great pain and violent symptoms followed; there was distressing vomiting, obstinate constipation, and fever. Despite the efforts to withdraw the tail, the arrangement of the bristles which allowed entrance, prevented removal. On the sixth day, in great agony, the woman applied to Marchettis, who ingeniously adopted the simple procedure of taking a long hollow reed, and preparing one of its extremities so that it could be introduced into the rectum, he was enabled to pass the reed entirely around the tail and to withdraw both. Relief was prompt, and the removal of the foreign body was followed by the issue of stercoraceous matter which had accumulated the six days it had remained in situ. Tuffet is quoted as mentioning a farmer of forty-six who, in masturbation, introduced a barley-head into his urethra. It was found necessary to cut the foreign body out of the side of the glans. A year later he put in his anus a cylindric snuff-box of large size, and this had to be removed by surgical methods. Finally, a drinking goblet was used, but this resulted in death, after much suffering and lay treatment. In his memoirs of the old Academy of Surgery in Paris, Morand speaks of a monk who, to cure a violent colic, introduced into his fundament a bottle of l'eau de la reine de Hongrie, with a small opening in its mouth, by which the contents, drop by drop, could enter the intestine. He found he could not remove the bottle, and violent inflammation ensued. It was at last necessary to secure a boy with a small hand to extract the bottle. There is a record of a case in which a tin cup or tumbler was pushed up the rectum and then passed into the colon where it caused gangrene and death. It was found to measure 3 1/2 by 3 1/2 by two inches. There is a French case in which a preserve-pot three inches in diameter was introduced into the rectum, and had to be broken and extracted piece by piece. Cloquet had a patient who put into his rectum a beer glass and a preserving pot. Montanari removed from the rectum of a man a mortar pestle 30 cm. long, and Poulet mentions a pederast who accidentally killed himself by introducing a similar instrument, 55 cm. long, which perforated his intestine. Studsgaard mentions that in the pathologic collection at Copenhagen there is a long, smooth stone, 17 cm. long, weighing 900 gm., which a peasant had introduced into his rectum to relieve prolapsus. The stone was extracted in 1756 by a surgeon named Frantz Dyhr. Jeffreys speaks of a person who, to stop diarrhea, introduced into his rectum a piece of wood measuring seven inches. There is a remarkable case recorded of a stick in the anus of a man of sixty, the superior extremity in the right hypochondrium, the inferior in the concavity of the sacrum. The stick measured 32 cm. in length; the man recovered. It is impossible to comprehend this extent of straightening of the intestine without great twisting of the mesocolon. Tompsett mentions that he was called to see a workman of sixty-five, suffering from extreme rectal hemorrhage. He found the man very feeble, without pulse, pale, and livid. By digital examination he found a hard body in the rectum, which he was sure was not feces. This body he removed with a polyp-forceps, and found it to be a cylindric candle-box, which measured six inches in circumference, 2 1/2 in length, and 1 1/2 in diameter. The removal was followed by a veritable flood of fecal material, and the man recovered. Lane reports perforation of the rectum by the introduction of two large pieces of soap; there was coincident strangulated hernia. Hunter mentions a native Indian, a resident of Coorla, who had introduced a bullock's horn high up into his abdomen, which neither he nor his friends could extract. He was chloroformed and placed in the lithotomy position, his buttocks brought to the edge of the bed, and after dilatation of the sphincter, by traction with the fingers and tooth-forceps, the horn was extracted. It measured 11 inches long. The young imbecile had picked it up on the road, where it had been rendered extremely rough by exposure, and this caused the difficulty in extraction. In Nelson's Northern Lancet, 1852, there is the record of a case of a man at stool, who slipped on a cow's horn, which entered the rectum and lodged beyond the sphincter. It was only removed with great difficulty. A convict at Brest put up his rectum a box of tools. Symptoms of vomiting, meteorism, etc., began, and became more violent until the seventh day, when he died. After death, there was found in the transverse colon, a cylindric or conic box, made of sheet iron, covered with skin to protect the rectum and, doubtless, to aid expulsion. It was six inches long and five inches broad and weighed 22 ounces. It contained a piece of gunbarrel four inches long, a mother-screw steel, a screw-driver, a saw of steel for cutting wood four inches long, another saw for cutting metal, a boring syringe, a prismatic file, a half-franc piece and four one-franc pieces tied together with thread, a piece of thread, and a piece of tallow, the latter presumably for greasing the instruments. On investigation it was found that these conic cases were of common use, and were always thrust up the rectum base first. In excitement this prisoner had pushed the conic end up first, thus rendering expulsion almost impossible. Ogle gives an interesting case of foreign body in the rectum of a boy of seventeen. The boy was supposed to be suffering with an abdominal tumor about the size of a pigeon's egg under the right cartilages; it had been noticed four months before. On admission to the hospital the lad was suffering with pain and jaundice; sixteen days later he passed a stick ten inches long, which he reluctantly confessed that he had introduced into the anus. During all his treatment he was conscious of the nature of his trouble, but he suffered rather than confess. Studsgaard mentions a man of thirty-five who, for the purpose of stopping diarrhea, introduced into his rectum a preserve-bottle nearly seven inches long with the open end uppermost. The next morning he had violent pain in the abdomen, and the bottle could be felt through the abdominal wall. It was necessary to perform abdominal section through the linea alba, divide the sigmoid flexure, and thus remove the bottle. The intestine was sutured and the patient recovered. The bottle measured 17 cm. long, five cm. in diameter at its lower end, and three cm. at its upper end. Briggs reports a case in which a wine glass was introduced into the rectum, and although removed twenty-four hours afterward, death ensued. Hockenhull extracted 402 stones from the rectum of a boy of seven. Landerer speaks of a curious case in which the absorptive power of the rectum was utilized in the murder of a boy of fifteen. In order to come into the possession of a large inheritance the murderess poisoned the boy by introducing the ends of some phosphorous matches into his rectum, causing death that night; there was intense inflammation of the rectum. The woman was speedily apprehended, and committed suicide when her crime was known. Complete transfixion of the abdomen does not always have a fatal issue. In fact, two older writers, Wisemann and Muys, testify that it is quite possible for a person to be transfixed without having any portion of the intestines or viscera wounded. In some nations in olden times, the extremest degree of punishment was transfixion by a stake. In his voyages and travels, in describing the death of the King of Demaa at the hands of his page, Mendez Pinto says that instead of being reserved for torture, as were his successors Ravaillac, and Gerard, the slayer of William the Silent, the assassin was impaled alive with a long stake which was thrust in at his fundament and came out at the nape of his neck. There is a record of a man of twenty-five, a soldier in the Chinese war of 1860, who, in falling from his horse, was accidentally transfixed by a bayonet. The steel entered his back two inches to the left of the last dorsal vertebra, and reappeared two inches to the left and below the umbilicus; as there was no symptom of visceral wound there were apparently no injuries except perforation of the parietes and the peritoneum. The man recovered promptly. Ross reports a case of transfixion in a young male aborigine, a native of New South Wales, who had received a spear-wound in the epigastrium during a quarrel; extraction was impossible because of the sharp-pointed barbs; the spear was, therefore, sawed off, and was removed posteriorly by means of a small incision. The edges of the wound were cleansed, stitched, and a compress and bandage applied. During the night the patient escaped and joined his comrades in the camp, and on the second day was suffering with radiating pains and distention. The following day it was found that the stitches and plaster had been removed, and the anterior wound was gaping and contained an ichorous discharge. The patient was bathing the wound with a decoction of the leaves of the red-gum tree. Notwithstanding that the spear measured seven inches, and the interference of treatment, the abdominal wound closed on the sixth day, and recovery was uninterrupted. Gilkrist mentions an instance in which a ramrod was fired into a soldier's abdomen, its extremity lodging in the spinal column, without causing the slightest evidence of wounds of the intestines or viscera. A minute postmortem examination was held some time afterward, the soldier having died by drowning, but the results were absolutely negative as regards any injury done by the passage of the ramrod. Humphreys says that a boy of eleven, while "playing soldier" with another boy, accidentally fell on a rick-stake. The stake was slightly curved at its upper part, being 43 inches long and three inches in circumference, and sharp-pointed at its extremity. As much as 17 1/2 inches entered the body of the lad. The stake entered just in front of the right spermatic cord, passed beneath Poupart's ligament into the cavity of the abdomen, traversed the whole cavity across to the left side; it then entered the thorax by perforating the diaphragm, displaced the heart by pushing it to the right of the sternum, and pierced the left lung. It then passed anteriorly under the muscles and integument in the axillary space, along the upper third of the humerus, which was extended beyond the head, the external skin not being ruptured. The stick remained in situ for four hours before attempts at extraction were made. On account of the displacement of the heart it was decided not to give chloroform. The boy was held down by four men, and Humphreys and his assistant made all the traction in their power. After removal not more than a teaspoonful of blood followed. The heart still remained displaced, and a lump of intestine about the size of an orange protruded from the wound and was replaced. The boy made a slow and uninterrupted recovery, and in six weeks was able to sit up. The testicle sloughed, but five months later, when the boy was examined, he was free from pain and able to walk. There was a slight enlargement of the abdomen and a cicatrix of the wound in the right groin. The right testicle was absent, and the apex of the heart was displaced about an inch. Woodbury reports the case of a girl of fourteen, who fell seven or eight feet directly upon an erect stake in a cart; the tuberosity was first struck, and then the stake passed into the anus, up the rectum for two inches, thence through the rectal wall, and through the body in an obliquely upward direction. Striking the ribs near the left nipple it fractured three, and made its exit. The stake was three inches in circumference, and 27 inches of its length passed into the body, six or seven inches emerging from the chest. This girl recovered so rapidly that she was able to attend school six weeks afterward. In a case reported by Bailey a middle-aged woman, while sliding down a hay-stack, struck directly upon a pitchfork handle which entered the vagina; the whole weight of the woman was successfully maintained by the cellular tissue of the uterovaginal culdesac. Minot speaks of the passage of one prong of a pitchfork through the body of a man of twenty-one, from the perineum to the umbilicus; the man recovered. Hamilton reports a case of laceration of the perineum with penetration of the pelvic cavity to the depth of ten inches by a stick 3/4 inch thick. Prowse mentions the history of a case of impalement in a man of thirty-four, who, coming down a hay-stack, alighted on the handle of a pitchfork which struck him in the middle of the scrotum, and passed up between the skin and fascia to the 10th rib. Recovery was prompt. There are several cases on record in which extensive wounds of the abdominal parietes with protrusion and injury to the intestine have not been followed by death. Injuries to the intestines themselves have already been spoken of, but there are several cases of evisceration worthy of record. Doughty says that at midnight on June 7, 1868, he was called to see a man who had been stabbed in a street altercation with a negro. When first seen in the street, the patient was lying on his back with his abdomen exposed, from which protruded an enormous mass of intestines, which were covered with sand and grit; the small intestine (ileum) was incised at one point and scratched at another by the passing knife. The incision, about an inch in length, was closed with a single stitch of silk thread, and after thorough cleansing the whole mass was returned to the abdominal cavity. In this hernial protrusion were recognized four or five feet of the ileum, the cecum with its appendix, part of the ascending colon with corresponding portions of the mesentery; the distribution of the superior mesentery, made more apparent by its living pulsation, was more beautifully displayed in its succession of arches than in any dissection that Doughty had ever witnessed. Notwithstanding the extent of his injuries the patient recovered, and at last reports was doing finely. Barnes reports the history of a negro of twenty-five who was admitted to the Freedmen's Hospital, New Orleans, May 15, 1867, suffering from an incised wound of the abdomen, from which protruded eight inches of colon, all of the stomach, and nearly the whole of the small intestines. About 2 1/2 feet of the small intestine, having a whitish color, appeared to be filled with food and had much of the characteristic feeling of a sausage. The rest of the small intestine had a dark-brown color, and the stomach and colon, distended with gas, were leaden-colored. The viscera had been exposed to the atmosphere for over an hour. Having nothing but cold Mississippi water to wash them with, Barnes preferred returning the intestines without any attempt at removing blood and dirt further than wiping with a cambric handkerchief and the stripping they would naturally be subjected to in being returned through the opening. In ten minutes they were returned; they were carefully examined inch by inch for any wound, but none was found. Three silver sutures were passed through the skin, and a firm compress applied. The patient went to sleep shortly after his wound was dressed, and never had a single subsequent bad symptom; he was discharged on May 24th, the wound being entirely healed, with the exception of a cartilage of a rib which had not reunited. Rogers mentions the case of a carpenter of thirty-six who was struck by a missile thrown by a circular saw, making a wound two inches above the umbilicus and to the left. Through the opening a mass of intestines and a portion of the liver, attached by a pedicle, protruded. A portion of the liver was detached, and the liver, as well as the intestines, were replaced, and the man recovered. Baillie, Bhadoory, Barker, Edmundson, Johnson, and others, record instances of abdominal wounds accompanied by extensive protrusion of the intestines, and recovery. Shah mentions an abdominal wound with protrusion of three feet of small intestine. By treatment with ice, phenol, and opium, recovery was effected without peritonitis. Among nonfatal perforating gunshot wounds of the abdomen, Loring: reports the case of a private in the First Artillery who recovered after a double gunshot perforation of the abdomen. One of the balls entered 5 1/2 inches to the left of the umbilicus, and two inches above the crest of the ilium, making its exit two inches above the crest of the ilium, on a line with and two inches from the 4th lumbar vertebra. The other ball entered four inches below and to the rear of the left nipple, making its exit four inches directly below the point of entrance. In their passages these balls did not wound any of the viscera, and with the exception of traumatic fever there was no disturbance of the health of the patient. Schell records the case of a soldier who was wounded July 3, 1867, by a conoid ball from a Remington revolver of the Army pattern. The ball entered on the left side of the abdomen, its lower edge grazing the center of Poupart's ligament, and passing backward, inward, and slightly upward, emerged one inch to the left of the spinous process of the sacrum. On July 6th all the symptoms of peritonitis made their appearance. On July 11th there was free discharge of fecal matter from both anterior and posterior wounds. This discharge continued for three days and then ceased. By August 12th both wounds were entirely healed. Mineer reports a case of a wound from a revolver-ball entering the abdomen, passing through the colon, and extracted just above the right ilium. Under simple treatment the patient recovered and was returned to duty about ten weeks afterward. There are a number of cases on record in which a bullet entering the abdominal cavity is subsequently voided either by the bladder or by the bowel. Ducachet mentions two cases at the Georgetown Seminary Hospital during the late war in which Minie balls entering the abdominal wall were voided by the anus in a much battered condition. Bartlett reports the case of a young man who was accidentally shot in the abdomen with a Colt's revolver. Immediately after the accident he complained of constant and pressing desire to void his urine. While urinating on the evening of the third day, the ball escaped from the urethra and fell with a click into the chamber. After the discharge of the ball the intolerable symptoms improved, and in two or three weeks there was complete recovery. Hoag mentions a man who was wounded by a round musket-ball weighing 400 grains. It had evidently passed through the lung and diaphragm and entered the alimentary canal; it was voided by the rectum five days after the injury. Lenox mentions the fact of a bullet entering the abdominal wall and subsequently being passed from the rectum. Day and Judkins report similar cases. Rundle speaks of the lodgment of a bullet, and its escape, after a period of seven and one-half years, into the alimentary canal, causing internal strangulation and death. Wounds of the liver often end very happily, and there are many cases on record in which such injuries have been followed by recovery, even when associated with considerable loss of liver-substance. In the older records, Glandorp and Scultetus mention cures after large wounds of the liver. Fabricius Hildanus reports a case that ended happily, in which a piece of liver was found in the wound, having been separated by a sword-thrust. There is a remarkable example of recovery after multiple visceral wounds, self-inflicted by a lunatic. This man had 18 wounds, 14 having penetrated the abdomen, the liver, colon, and the jejunum being injured; by frequent bleeding, strict regimen, dressing, etc., he recovered his health and senses, but relapsing a year and a half later, he again attempted suicide, which gave the opportunity for a postmortem to learn the extent of the original injuries. Plater, Schenck, Cabrolius, the Ephemerides, and Nolleson mention recovery after wounds of the liver. Salmuth and the Ephemerides report questionable instances in which portions of the liver were ejected in violent vomiting. Macpherson describes a wound of the liver occurring in a Hindoo of sixty who had been struck by a spear. A portion of the liver was protruding, and a piece weighing 1 1/4 ounces was removed, complete recovery following. Postempski mentions a case of suture of the liver after a stab-wound. Six sutures of chromicized cat-gut were carefully tightened and fastened with a single loop. The patient left his bed on the sixth day and completely recovered. Gann reports a case of harpoon-wound of the liver. While in a dory spearing fish in the Rio Nuevo, after a sudden lurch of the boat, a young man of twenty-eight fell on the sharp point of a harpoon, which penetrated his abdomen. About one inch of the harpoon was seen protruding from below the tip of the ensiform cartilage; the harpoon was seven inches long. It was found that the instrument had penetrated the right lobe of the liver; on passing the hand backward along the inferior surface of the liver, the point could be felt projecting through its posterior border. On account of two sharp barbs on the spear-point, it was necessary to push the harpoon further in to disengage the barbs, after which it was easily removed. Recovery followed, and the patient was discharged in twenty-one days. Romme discusses the subject of punctured wounds of the liver, as a special text using the case of the late President Carnot. He says that in 543 cases of traumatism of the liver collected by Elder, 65 were caused by cutting or sharp-pointed instruments. Of this group, 23 recovered and 42 died. The chief causes of death were hemorrhage and peritonitis. The principal symptoms of wounds of the liver, such as traumatic shock, collapse, local and radiating pains, nausea, vomiting, and respiratory disturbances were all present in the case of President Carnot. From an experience gained in the case of the President, Romme strongly recommends exploratory celiotomy in all penetrating wounds of the liver. Zeidler reports three cases of wound of the liver in which recovery ensued. The hemorrhage in one case was arrested by the tampon, and in the other by the Pacquelin cautery. McMillan describes a man of twenty who was kicked by a horse over the liver and rupturing that organ. A large quantity of offensive fluid was drawn off from the liver, and the man recovered. Frazer reports a case of rupture of liver and kidney in a boy of thirteen who was squeezed between the tire and driving chain of a mill, but who recovered despite his serious symptoms. Allen mentions recovery after an extensive incised wound of the abdomen, liver, and lung. Massie cites an instance of gunshot wound of the right hypochondrium, with penetration and protrusion of the liver. The patient, a boy of seven, recovered after excision of a small part of the protruding liver. Lawson Tait has incised the liver to the extent of three inches, evacuated two gallons of hydatids, and obtained successful recovery in ten weeks. There are several cases of wound of the liver followed by recovery reported by surgeons of the United States Army. Whitehead mentions a man of twenty-two who on June 3, 1867, was shot in the liver by a slug from a pistol. At the time of the injury he bled freely from the wound of entrance continuing to lose blood and bile until daylight the next morning, when the hemorrhage ceased, but the flow of bile kept on. By June 10th there was considerable improvement, but the wound discharged blood-clots, bile, and serum. When the patient left the hospital on July 15th the wound was healthy, discharging less than 1 1/2 ounces during the twenty-four hours, of a mixture of free bile, and bile mixed with thick material. When last heard from--July 27, 1867--the patient was improving finely in flesh and strength. McKee mentions a commissary-sergeant stationed at Santa Fe, New Mexico, who recovered after a gunshot wound of the liver. Hassig reports the case of a private of twenty-six who was wounded in a fray near Paducah, Kentucky, by a conoid ball, which passed through the liver. The ball was cut out the same day. The patient recovered and was returned to duty in May,