A severe blow in the abdomen is likely to occasion either haemorrhage or per foration. In hemorrhage the pulse grows softer, while with perforation and ex travasation the pulse hardens. Turner (Lancet, May 5, 1900).
In collapse or death from blows upon the epigastrium the solar plexus may be disregarded as a factor; the cause of collapse or death is the mechanical vio lence exerted upon the heart-muscle or its nerve-mechanism. W. Crile (Phila. Med. Jour., Mar. 31, 1900).
In the majority of cases, however, severe contusions of the abdominal wall. whether the deep organs are involved or not, are followed by agonizing pain in the region of the injury, restlessness, nausea or vomiting, marked prostration (indicated by a small, rapid, and irreg ular pulse), pallor (sometimes attaining lividity), cold sweats, rigidity of the ab dominal wall, meteorism, anxiety, and fear of a fatal issue.
Diffused rigidity of the abdominal wall in a ease of contusion of this region, even in the absence of any other serious symptom, is a decided indication for im mediate laparotomy, while the absence of contracture, whatever may be the ex tent and gravity of the associated symp toms, contra-indicates surgical interven tion. Of 10 cases in which, owing to the presence of this symptom, laparotomy was performed, this treatment proved successful in 9. Of 17 cases of severe abdominal contusion in which no opera. tire treatment was applied in conse quence of the absence of rigidity, all ended in recovery. Hartmann (Bull. et Ileum. de la Soc. de Chin, Mar. 12, 1901).
All these symptoms bear the imprint of a severe nervous commotion, and, if the extensive distribution of the sympa thetic nervous system in the abdominal cavity is borne in mind, the fact will become evident that symptoms usually witnessed immediately after the receipt of the injury are due mainly to the in fluence of the concussion upon the sym pathetic supply. Sudden death has been known to follow a violent blow, espe cially when received in the region of the solar plexus.
The pain varies according to the loca tion of the traumatism and the sensitive ness of the patient. Very severe at first, it usually becomes less marked after a few hours. It is greatly influenced by
shock, profound prostration reducing its intensity by reducing sensation. Great restlessness usually accompanies abdomi nal pain after injuries, as well as during other diseases, such as appendicitis, when the suffering is due to a localized trouble. The pain may be radiated in various directions,—the shoulder, the umbilicus, the left axilla, the testicles, etc.,—according to the site of the pri mary lesion. Local tenderness is usually marked over the site of the traumatism.
The vomiting varies greatly in inten sity from mere nausea to the most vio lent expulsive efforts, which are liable, by the strain upon the abdominal organs, to suddenly increase the extent of the lesions. The vomited matter sometimes contains blood, especially if the upper portion of the digestive tract is involved in the injury. Constant and persistent vomiting tends to indicate a contusion accompanied by visceral lesions.
In simple eases the vomiting is re peated but two or three times. When the intestine is ruptured the vomiting is persistent and intractable and liver-dull ness is absent. Berndt (Deutsche Zeit. f. Chir., vol. xxxix, p. 516).
The degree of shock depends upon the nature and extent of the injury and es pecially upon the amount of blood lost. When the signs of •collapse gradually become more marked, internal limor rhage from rupture of one or more of the viscera is to be feared.
The pulse, usually rapid and weak at first, gradually becomes stronger and slower if a. favorable reaction is about to take place. If, on the contrary, an unfavorable course is being taken and some complication is to occur, its rapid ity and tension may become increased. Irregularity is not a favorable indication if it persists.
The temperature is independent of the pulse, except when a favorable reaction is taking place, when it may return to the normal line after having gone be yond or below it. The usual belief that a subnormal temperature always follows internal hTmorrhage is fallacious; for it may also be raised. The temperature, therefore, is of no value as a guide.