ORIGINAL ARTICLES
Blunt Traumatic Kupture of the Uiaphragm James W. Brooks, M.D.
bowel sounds may be present and unremarkable or they may be markedly reduced to absent, depending on the amount of peritoneal irritation. Chest examination may reveal obvious tenderness. If tenderness is present, it is usually indicative of fractured ribs; therefore, crepitation may be heard. Pneumothorax, hemothorax, hemopneumothorax, subcutaneous emphysema, or paradoxical chest wall moBlunt traumatic rupture of the diaphragm is tion could be present and not related to the diarecognized easily provided the physician is phragm injury. All these findings point to chest aware of the injury and recognizes its signs and injury, but obviously are not diagnostic of diasymptoms [7, 8, 10, 13-15, 19, 201. Usually, the phragmatic injury. If intestinal contents or the patient with multiple-system injuries under- liver are in the thoracic cavity, there may be goes procedures for diagnosis and treatment dullness to percussion, diminished to absent that draw the physician’s attention away from fremitus, and diminished to absent breath the more subtle diaphragmatic injuries [l,41. In sounds. All these physical findings denote the this paper the injury is discussed with reference presence of abnormal tissue between the stethoscope and the lung parenchyma. If austo my experience with 42 patients. cultation locates intestinal sounds high in the Material and Method axilla, there could be intestinal contents in the At the Medical College of Virginia Hospitals be- pleural cavity. However, such sounds can be tween 1952 and 1977, 42 patients with blunt transmitted from a normal bowel below the traumatic ruptures of the diaphragm were seen. diaphragm. There were 36 male and 6 female patients. Preoperative diagnosis of blunt traumatic Thirty-eight (90%) of the ruptures were on the rupture of the diaphragm is most frequently left side and four (10”/0),on the right. Mortality suspected and confirmed by chest roentgenowas 14%, and except for 1 patient (Fig l), death grams. In general, any patient who has sustained was caused by other injuries sustained during a blunt chest injury and in whom a chest the same accident. The greatest number of roentgenogram reveals an obscure or abnorblunt traumatic injuries of the diaphragm oc- mal diaphragmatic shadow can have blunt curred in patients between 20 and 30 years old. traumatic rupture of the diaphragm. Further There has been no increase in the yearly inci- studies must be made promptly to establish the dence of blunt traumatic rupture of the dia- true state of the patient’s diaphragm. phragm since 1952. Roentgenographic evidence of an atypical Physical findings frequently are vague. When pneumothorax should alert the surgeon to the conscious, the patient may complain of pain possibility of a ruptured diaphragm (Figs 2, 3). and tenderness or show guarding in the epigas- Confirmation of stomach in the left chest may trium or either upper quadrant of the abdomen. be achieved either by a barium swallow or by At the time of initial abdominal examination, the insertion of a Levin tube into the stomach From the Department of Surgery, Division of Cardiac and for identification and decompression. Solid denThoracic Surgery, Medical College of Virginia of Virginia sities in the chest without gas in the bowel Commonwealth University, Richmond, VA 23298. may also be present in the ruptured diaphragm Presented at the Twenty-fourth Annual Meeting of the (Fig 4). Southern Thoracic Surgical Association, Nov 4-6, 1977, When there is doubt concerning the possibilMarco Island, FL ABSTRACT Blunt traumatic rupture of the diaphragm must be suspected in all patients with massive trauma and especially in those whose chest roentgenogram reveals an abnormal or obscured diaphragmatic shadow. Regular reevaluation is most important. A diagnostic pneumoperitoneum is the most accurate preoperative test available. Transthoracic approach is the operation of choice.
199 0003-497517810026-0304$01.25@ 1978 by James W. Brooks
200 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
Fig 1 . Posteroanterior chest roentgenogram of a 3-year-old boy injured in an automobile accident. Acute gastric dilation resulted in respiratory death before the correct diagnosis could be made and management initiated. The cause of death was confirmed at postmortem examination. A
ity of diaphragmatic injury, the best nonoperative method for investigating possible damage with rupture is a diagnostic pneumoperitoneum using 300 to 500 cc of air (Fig 5), as described by Hollander and Dugan [121 and by Clay and Hanlon [5]. The appearance of a pneumothorax following this diagnostic procedure confirms a communication between the pleura and the peritoneal cavity [9, 18J. To perform a diagnostic pneumoperitoneum, a four quadrant abdominal tap is done with a plastic needle. The tap is completed in the left lower quadrant into which air is injected provided the abdominal tap has yielded no blood or intestinal fluid. Should the abdominal tap be positive, no injection is necessary because exploration of the abdomen is already indicated. The diaphragm can be explored and repaired through the incision made for the tap. Other than the infrequent and well-known complications that follow the induction of a therapeutic PneumoPeritoneum, this Procedure has two obvious disadvantages in the posttraumatic patient undergoing evaluation in the symptoms are emergency ward. (l) mildly intensified and shoulder pain is pro-
B
Fig 2 . ( A )Posttrauma chest roentgenogram showing large air-fluid abnormality in the left chest with mediastinal displacement to the right side. (B) Levin tube indicates decompression of the stomach with the return of the mediastinum to the midline. The tube is above the usual level of the diaphragm.
201 Brooks: Blunt Traumatic Rupture of the Diaphragm
Fig 3 . Roentgenogram made after trauma showing fractured ribs on the left and an "abnormal" lower left pneurnothorax.
duced because introduction of air in the peritoneal cavity causes diaphragmatic irritation. The procedure thus masks or possibly gives false impressions of future abdominal developments if exploration is not carried out. (2) The resulting pneumothorax enhances pulmonary ventilatory problems and therefore should be aspirated rapidly. Occasionally, the diaphragm is torn in such a way as to include the pericardium. This results in the intrapericardial placement of intestines through the rupture in the diaphragm [2, 3 , 6, 11, 16, 17, 211. Blunt traumatic rupture of the diaphragm should be recognized at the time of initial workup in the emergency ward, but definite roentgenographic signs of rupture may not be evident at first, as seen in Figure 6. Some diagnoses are delayed for several weeks, months, or even years because of the gravity of the other injuries or the lack of or failure to recognize definite signs or symptoms that alert the physician to the possibility of a traumatic dia-
Fig 4 . Chest roentgenogram demonstrating a dense shadow in the left lower chest, a clear left costophrenic angle, and marked mediastinal displacement to the right side.
I Pneumothoror
Fig 5. Diagnostic pneumoperitoneum.
phragmatic rupture. Of the 42 instances of blunt traumatic diaphragmatic rupture in this series, 29 (69%) were recognized immediately and 7 (17%) after a period ranging from 4 to 47 days; 5 (12%) had delayed recognition; and 1 (2%) was discovered at postmortem examination. When the initial injury is not diagnosed
202 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
A
B
Fig 6 . ( A ) Initial chest roentgenogram following trauma. (B)Roentgenogram made the following day. (C) Roentgenogram made 40 hours after injury showing definite signs of bowel gas in the left hemithorax.
month of pregnancy. At operation, the patient was found to have a gangrenous stomach herniated through a previous rupture of the left diaphragm. The stomach was resected and the diaphragm was repaired. The patient ultimately lost the fetus, and two weeks after operation she died of erosion of the tracheostomy tube into the innominate artery and exsanguination. When traumatic rupture in the diaphragm is diagnosed, an operation consistent with the patient’s general condition should be performed at that time. A patient should undergo immediate operation if any of the following conditions exist: uncontrolled blood loss in either the C abdomen or thorax; altered cardiopulmonary physiology that is interfering with survival; for many years, it frequently is discovered only undiagnosed internal injuries of a surgical nabecause of obstruction to the gastrointestinal ture; and no contraindications to operation. tract secondary to herniation of intestinal con- Often a patient with blunt traumatic rupture of the diaphragm will have severe concurrent tents into the chest cavity. One patient in this series was injured four injuries that probably will preclude immediate years prior to the establishment of the diag- operation. The thoracic approach is favored in blunt nosis of ruptured diaphragm. Four years after the injury, she was readmitted to the hospital in rupture of the diaphragm because it allows for acute respiratory distress. She was in the eighth the best exposure and repair. If there is concur-
203
Brooks: Blunt Traumatic Rupture of the Diaphragm
3. Brookes US: Intrapericardial diaphragmatic hernia. Br J Surg 40:511, 1953 4. CarlsonRI, Diveley WL, Gobbel WG, et al: Dehiscence of the diaphragm associated with fractures of the pelvis or lumbar spine due to nonpenetrating wounds of the chest and abdomen. J Thorac Surg 36:254, 1958 5. Clay RC, Hanlon CR: Pneumoperitoneum in the thoracotomy approach. differential diagnosis of diaphragmatic hernia. J All b u t 1of the 42 patients h a d surgical repair Thorac Cardiovasc Surg 21:57, 1951 through a thoracotomy. When the hemithorax 6. Cranshaw GR: Herniation of the stomach, transwas opened, 34 of 38 patients with injury to the verse colon, and portion of the jejunum into the left d i a p h r a g m h a d stomach, colon, omentum, pericardium. Br J Surg 39:364, 1962 7. Drews ]A, Mercer EC, Benfield JR: Acute diasmall bowel, a n d spleen in the left chest. In 2 phragmatic injuries. Ann Thorac Surg 16:67,1973 patients, only o m e n t u m and colon were pres8. Ebert PA, Gaertner RA, Zuidema GD: Traumatic ent. In 3 of the 4 patients w i t h injury to t h e diaphragmatic hernia. Surg Gynecol Obstet right d i a p h r a g m only the liver h a d herniated 125:59, 1967 through t h e rupture, a n d in t h e fourth, only t h e 9. Firestone TM, Taybi H: Bilateral diaphragmatic eventration: demonstration by pneumoperismall bowel (ileum). In 1patient only the spleen toneography. Surgery 62:954, 1967 h a d herniated t h r o u g h the rupture. 10. Grisweld FW, Warden HE, Gardner RJ: Acute diaphragmatic rupture by blunt trauma. Am J Surg 124:359, 1972 Results In every instance, t h e a b d o m i n a l contents were 11. Herman PG, Goldstein JE: Traumatic intrapericardial diaphragmatic hernia. Br J Radio1 easily returned to the abdominal cavity and the 38:631, 1965 ruptured d i a p h r a g m w a s repaired with inter- 12. Hollander AG, Dugan D]: Herniation of the liver. rupted permanent sutures without imbrication. J Thorac Cardiovasc Surg 29:357, 1955 The edges of the d i a p h r a g m were clean and did- 13. Hood R: Traumatic diaphragmatic hernia. Ann Thorac Surg 12:311, 1971 not require debridement. 14. Ker H: Closed traumatic rupture of the diaIn only 1 procedure was it necessary to use a phragm. Br J Surg 502391, 1963 prosthesis (Marlex mesh) to repair the hernia, 15. Miller JD, Howie I'D: Traumatic rupture of the a n d this was associated with a delayed diagdiaphragm after blunt injury. Br J Surg 55:423, nosis. 1968 Two patients h a d disruption of the dia- 16. Moore TC: Traumatic pericardial diaphragmatic hernia. Arch Surg 79:827, 1959 phragm from the chest wall. Resuturing based 17. Rabb D: Traumatic diaphragmatic hernia into the upon d i a p h r a g m anchorage to a rib with horipericardium. Br J Surg 50:664, 1963 zontal mattress sutures was required. 18. Stevens GM, McCort JJ: Abdominal pneumoperitoneography. Radiology 83:480, 1964 19. Strug B, Noon Gl', Beall AC Jr: Traumatic diaReferences phragmatic hernia. Ann Thorac Surg 17:444,1974 1. Arbulie A, Read RC, Berkas EM: Delayed symp- 20. 'sutt& JP, Carlisle RB, Stephenson-SE Jr: Trautomatology in traumatic diaphragmatic hernia matic diaphragmatic hernia: a review of 25 cases. with a note on eventration. Dis Chest 47:527,1965 Ann Thorac Surg 3:136, 1967 2. Beddingfield GW: Cardiac tamponade due to 21. Wetrich M, Sawyers TM, Hough GA: Diatraumatic hernia of the diaphragm and pericarphragmatic ruptures of the diaphragm; dium. Ann Surg 6:178, 1968 laparotomy, recovery. Int Surg 23957, 1969
rent abdominal trauma, t h e incision can be extended across the costal arch for exploration of t h e a b d o m e n . In the present series, there were no associated intraabdominal organ injuries. In 50°/0 of t h e ruptures on the left side, t h e spleen was bleeding a n d quite easily removed by the
Blunt Traumatic Kupture of the Uiaphragm James W. Brooks, M.D.
bowel sounds may be present and unremarkable or they may be markedly reduced to absent, depending on the amount of peritoneal irritation. Chest examination may reveal obvious tenderness. If tenderness is present, it is usually indicative of fractured ribs; therefore, crepitation may be heard. Pneumothorax, hemothorax, hemopneumothorax, subcutaneous emphysema, or paradoxical chest wall moBlunt traumatic rupture of the diaphragm is tion could be present and not related to the diarecognized easily provided the physician is phragm injury. All these findings point to chest aware of the injury and recognizes its signs and injury, but obviously are not diagnostic of diasymptoms [7, 8, 10, 13-15, 19, 201. Usually, the phragmatic injury. If intestinal contents or the patient with multiple-system injuries under- liver are in the thoracic cavity, there may be goes procedures for diagnosis and treatment dullness to percussion, diminished to absent that draw the physician’s attention away from fremitus, and diminished to absent breath the more subtle diaphragmatic injuries [l,41. In sounds. All these physical findings denote the this paper the injury is discussed with reference presence of abnormal tissue between the stethoscope and the lung parenchyma. If austo my experience with 42 patients. cultation locates intestinal sounds high in the Material and Method axilla, there could be intestinal contents in the At the Medical College of Virginia Hospitals be- pleural cavity. However, such sounds can be tween 1952 and 1977, 42 patients with blunt transmitted from a normal bowel below the traumatic ruptures of the diaphragm were seen. diaphragm. There were 36 male and 6 female patients. Preoperative diagnosis of blunt traumatic Thirty-eight (90%) of the ruptures were on the rupture of the diaphragm is most frequently left side and four (10”/0),on the right. Mortality suspected and confirmed by chest roentgenowas 14%, and except for 1 patient (Fig l), death grams. In general, any patient who has sustained was caused by other injuries sustained during a blunt chest injury and in whom a chest the same accident. The greatest number of roentgenogram reveals an obscure or abnorblunt traumatic injuries of the diaphragm oc- mal diaphragmatic shadow can have blunt curred in patients between 20 and 30 years old. traumatic rupture of the diaphragm. Further There has been no increase in the yearly inci- studies must be made promptly to establish the dence of blunt traumatic rupture of the dia- true state of the patient’s diaphragm. phragm since 1952. Roentgenographic evidence of an atypical Physical findings frequently are vague. When pneumothorax should alert the surgeon to the conscious, the patient may complain of pain possibility of a ruptured diaphragm (Figs 2, 3). and tenderness or show guarding in the epigas- Confirmation of stomach in the left chest may trium or either upper quadrant of the abdomen. be achieved either by a barium swallow or by At the time of initial abdominal examination, the insertion of a Levin tube into the stomach From the Department of Surgery, Division of Cardiac and for identification and decompression. Solid denThoracic Surgery, Medical College of Virginia of Virginia sities in the chest without gas in the bowel Commonwealth University, Richmond, VA 23298. may also be present in the ruptured diaphragm Presented at the Twenty-fourth Annual Meeting of the (Fig 4). Southern Thoracic Surgical Association, Nov 4-6, 1977, When there is doubt concerning the possibilMarco Island, FL ABSTRACT Blunt traumatic rupture of the diaphragm must be suspected in all patients with massive trauma and especially in those whose chest roentgenogram reveals an abnormal or obscured diaphragmatic shadow. Regular reevaluation is most important. A diagnostic pneumoperitoneum is the most accurate preoperative test available. Transthoracic approach is the operation of choice.
199 0003-497517810026-0304$01.25@ 1978 by James W. Brooks
200 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
Fig 1 . Posteroanterior chest roentgenogram of a 3-year-old boy injured in an automobile accident. Acute gastric dilation resulted in respiratory death before the correct diagnosis could be made and management initiated. The cause of death was confirmed at postmortem examination. A
ity of diaphragmatic injury, the best nonoperative method for investigating possible damage with rupture is a diagnostic pneumoperitoneum using 300 to 500 cc of air (Fig 5), as described by Hollander and Dugan [121 and by Clay and Hanlon [5]. The appearance of a pneumothorax following this diagnostic procedure confirms a communication between the pleura and the peritoneal cavity [9, 18J. To perform a diagnostic pneumoperitoneum, a four quadrant abdominal tap is done with a plastic needle. The tap is completed in the left lower quadrant into which air is injected provided the abdominal tap has yielded no blood or intestinal fluid. Should the abdominal tap be positive, no injection is necessary because exploration of the abdomen is already indicated. The diaphragm can be explored and repaired through the incision made for the tap. Other than the infrequent and well-known complications that follow the induction of a therapeutic PneumoPeritoneum, this Procedure has two obvious disadvantages in the posttraumatic patient undergoing evaluation in the symptoms are emergency ward. (l) mildly intensified and shoulder pain is pro-
B
Fig 2 . ( A )Posttrauma chest roentgenogram showing large air-fluid abnormality in the left chest with mediastinal displacement to the right side. (B) Levin tube indicates decompression of the stomach with the return of the mediastinum to the midline. The tube is above the usual level of the diaphragm.
201 Brooks: Blunt Traumatic Rupture of the Diaphragm
Fig 3 . Roentgenogram made after trauma showing fractured ribs on the left and an "abnormal" lower left pneurnothorax.
duced because introduction of air in the peritoneal cavity causes diaphragmatic irritation. The procedure thus masks or possibly gives false impressions of future abdominal developments if exploration is not carried out. (2) The resulting pneumothorax enhances pulmonary ventilatory problems and therefore should be aspirated rapidly. Occasionally, the diaphragm is torn in such a way as to include the pericardium. This results in the intrapericardial placement of intestines through the rupture in the diaphragm [2, 3 , 6, 11, 16, 17, 211. Blunt traumatic rupture of the diaphragm should be recognized at the time of initial workup in the emergency ward, but definite roentgenographic signs of rupture may not be evident at first, as seen in Figure 6. Some diagnoses are delayed for several weeks, months, or even years because of the gravity of the other injuries or the lack of or failure to recognize definite signs or symptoms that alert the physician to the possibility of a traumatic dia-
Fig 4 . Chest roentgenogram demonstrating a dense shadow in the left lower chest, a clear left costophrenic angle, and marked mediastinal displacement to the right side.
I Pneumothoror
Fig 5. Diagnostic pneumoperitoneum.
phragmatic rupture. Of the 42 instances of blunt traumatic diaphragmatic rupture in this series, 29 (69%) were recognized immediately and 7 (17%) after a period ranging from 4 to 47 days; 5 (12%) had delayed recognition; and 1 (2%) was discovered at postmortem examination. When the initial injury is not diagnosed
202 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
A
B
Fig 6 . ( A ) Initial chest roentgenogram following trauma. (B)Roentgenogram made the following day. (C) Roentgenogram made 40 hours after injury showing definite signs of bowel gas in the left hemithorax.
month of pregnancy. At operation, the patient was found to have a gangrenous stomach herniated through a previous rupture of the left diaphragm. The stomach was resected and the diaphragm was repaired. The patient ultimately lost the fetus, and two weeks after operation she died of erosion of the tracheostomy tube into the innominate artery and exsanguination. When traumatic rupture in the diaphragm is diagnosed, an operation consistent with the patient’s general condition should be performed at that time. A patient should undergo immediate operation if any of the following conditions exist: uncontrolled blood loss in either the C abdomen or thorax; altered cardiopulmonary physiology that is interfering with survival; for many years, it frequently is discovered only undiagnosed internal injuries of a surgical nabecause of obstruction to the gastrointestinal ture; and no contraindications to operation. tract secondary to herniation of intestinal con- Often a patient with blunt traumatic rupture of the diaphragm will have severe concurrent tents into the chest cavity. One patient in this series was injured four injuries that probably will preclude immediate years prior to the establishment of the diag- operation. The thoracic approach is favored in blunt nosis of ruptured diaphragm. Four years after the injury, she was readmitted to the hospital in rupture of the diaphragm because it allows for acute respiratory distress. She was in the eighth the best exposure and repair. If there is concur-
203
Brooks: Blunt Traumatic Rupture of the Diaphragm
3. Brookes US: Intrapericardial diaphragmatic hernia. Br J Surg 40:511, 1953 4. CarlsonRI, Diveley WL, Gobbel WG, et al: Dehiscence of the diaphragm associated with fractures of the pelvis or lumbar spine due to nonpenetrating wounds of the chest and abdomen. J Thorac Surg 36:254, 1958 5. Clay RC, Hanlon CR: Pneumoperitoneum in the thoracotomy approach. differential diagnosis of diaphragmatic hernia. J All b u t 1of the 42 patients h a d surgical repair Thorac Cardiovasc Surg 21:57, 1951 through a thoracotomy. When the hemithorax 6. Cranshaw GR: Herniation of the stomach, transwas opened, 34 of 38 patients with injury to the verse colon, and portion of the jejunum into the left d i a p h r a g m h a d stomach, colon, omentum, pericardium. Br J Surg 39:364, 1962 7. Drews ]A, Mercer EC, Benfield JR: Acute diasmall bowel, a n d spleen in the left chest. In 2 phragmatic injuries. Ann Thorac Surg 16:67,1973 patients, only o m e n t u m and colon were pres8. Ebert PA, Gaertner RA, Zuidema GD: Traumatic ent. In 3 of the 4 patients w i t h injury to t h e diaphragmatic hernia. Surg Gynecol Obstet right d i a p h r a g m only the liver h a d herniated 125:59, 1967 through t h e rupture, a n d in t h e fourth, only t h e 9. Firestone TM, Taybi H: Bilateral diaphragmatic eventration: demonstration by pneumoperismall bowel (ileum). In 1patient only the spleen toneography. Surgery 62:954, 1967 h a d herniated t h r o u g h the rupture. 10. Grisweld FW, Warden HE, Gardner RJ: Acute diaphragmatic rupture by blunt trauma. Am J Surg 124:359, 1972 Results In every instance, t h e a b d o m i n a l contents were 11. Herman PG, Goldstein JE: Traumatic intrapericardial diaphragmatic hernia. Br J Radio1 easily returned to the abdominal cavity and the 38:631, 1965 ruptured d i a p h r a g m w a s repaired with inter- 12. Hollander AG, Dugan D]: Herniation of the liver. rupted permanent sutures without imbrication. J Thorac Cardiovasc Surg 29:357, 1955 The edges of the d i a p h r a g m were clean and did- 13. Hood R: Traumatic diaphragmatic hernia. Ann Thorac Surg 12:311, 1971 not require debridement. 14. Ker H: Closed traumatic rupture of the diaIn only 1 procedure was it necessary to use a phragm. Br J Surg 502391, 1963 prosthesis (Marlex mesh) to repair the hernia, 15. Miller JD, Howie I'D: Traumatic rupture of the a n d this was associated with a delayed diagdiaphragm after blunt injury. Br J Surg 55:423, nosis. 1968 Two patients h a d disruption of the dia- 16. Moore TC: Traumatic pericardial diaphragmatic hernia. Arch Surg 79:827, 1959 phragm from the chest wall. Resuturing based 17. Rabb D: Traumatic diaphragmatic hernia into the upon d i a p h r a g m anchorage to a rib with horipericardium. Br J Surg 50:664, 1963 zontal mattress sutures was required. 18. Stevens GM, McCort JJ: Abdominal pneumoperitoneography. Radiology 83:480, 1964 19. Strug B, Noon Gl', Beall AC Jr: Traumatic diaReferences phragmatic hernia. Ann Thorac Surg 17:444,1974 1. Arbulie A, Read RC, Berkas EM: Delayed symp- 20. 'sutt& JP, Carlisle RB, Stephenson-SE Jr: Trautomatology in traumatic diaphragmatic hernia matic diaphragmatic hernia: a review of 25 cases. with a note on eventration. Dis Chest 47:527,1965 Ann Thorac Surg 3:136, 1967 2. Beddingfield GW: Cardiac tamponade due to 21. Wetrich M, Sawyers TM, Hough GA: Diatraumatic hernia of the diaphragm and pericarphragmatic ruptures of the diaphragm; dium. Ann Surg 6:178, 1968 laparotomy, recovery. Int Surg 23957, 1969
rent abdominal trauma, t h e incision can be extended across the costal arch for exploration of t h e a b d o m e n . In the present series, there were no associated intraabdominal organ injuries. In 50°/0 of t h e ruptures on the left side, t h e spleen was bleeding a n d quite easily removed by the
