The character of the force and the mode of its application always appear to be of much value as a help to diag nosis in most cases of intestinal injury, for it would seem that where the force is of diffused rather than of a local ized character the injury is more likely to be extensive or even double. Thus, when a human being is run over, the wheel of a vehicle passing either over the abdomen or the back with the abdomen downward; when he falls from a height upon a plank or beam; is trodden on by a horse; or is crushed between two obtuse bodies, it is most probable that either a solid viseus has been lacerated or that some portion of the small intes tine has been torn in one or more places.
Thomas Bryant (London Laucet, Dec. 7, '95).
Seven eases of severe contusions of the abdomen, with intestinal perfora tion. The seat of perforation is, in the majority of cases, in the small intestine, and successively in order of frequency come large intestine, stomach, and duo denum. Physical signs are in the epigastrium and an area of dullness in the lower portion of the bowel. Adolph Schmitt (Munch. med. Woch., July 12, 'OS).
Case of a boy, aged 16 years, who had been kicked in the abdomen by a horse, but who presented no sign of ex ternal injury. There was vomiting im mediately after the accident, and ex amination showed that the abdominal walls moved in respiration, although not quite freely; no tenderness in any par ticular spot on light pressure; dullness on percussion in the hypognstrium and flanks, in the latter situation changing with the position of the body. Urine was voided without difficulty. The pulse was 116, and the patient suffered from shock. He was put to bed at once. and an effort made to relieve the shock. Two days later his condition suddenly became much worse: he went into collapse and died a few hours later. The autopsy showed several pints of bloody fluid in the peritoneal cavity and a tear in the jejunum near its com mencement, close to the spine, about one and one-half inches long, in the longitudinal axis of the bowel. at it free border. Livingston (Brit. Sled. Jour., Mar. 1, 1902).
Another factor of importance in es tablishing a diagnosis is the size of the instrument causing the injury. Lesions of the digestive canal, for instance, are usually the result of violent and sudden percussion produced by a body over a limited surface of the abdominal wall.
The predisposing factors are the pres ence of solid, semisolid, or fluid matter in the hollow viscera; leanness of the individual, and intestinal adhesions.
Any of the above accidental causes of injury being fulfilled, rupture of some portion of the gastro-intestinal tract is likely, especially if there is loss of con sciousness at the time of the accident, followed by collapse, severe pain, a rapid and weak pulse, vomiting, tympanites due to the escape of intestinal gas into the abdominal cavity, and tenderness and rigidity of the abdominal walls. Such
a diagnosis is further strengthened by hoematemesis or bloody stools, the former tending to indicate a lesion of the stom ach. Death occurs in 96 per cent. of such cases if unoperated.
Two signs which enable the physician to diagnose the occurrence of intestinal perforation before peritonitis has had time to manifest itself: first, distinctness of the murmurs of the heart and respi ration during auscultation of the abdo men,—due to the presence of intestinal gases in the peritoneal cavity. Second, change in the pulse, which, at the moment of perforation, becomes accel erated, to slacken some hours later,—due to the absorption of putrid gases acting as cardiac poison. Gluzinski (Sem. Med., Nov. 6, '95).
ruptured intestine is probably pres ent, though this is not certain, when, after a diffuse injury to the abdomen or a severe local injury as the immediate result of the accident, there is little col lapse, and where vomiting soon becomes a prominent and persistent symptom, with lasting local pain and great thirst, with or without abdominal enlargement. Nineteen cases of rupture of the intes tine adduced confirm the truth of this statement. Bryant (London Lancet, Jan. 11, '96).
After contusions and wounds of ab domen contraction of the muscles of ab dominal wall indicates certainly visceral lesions. Out of ten cases of serious con tusion it was present seven times, and surgical intervention resulted in the dis covery in each case of grave visceral lesions. M. Hartmann (Jou•. des Prat., Oct. 29, '93).
Two cases of rupture of colon. The indications for exploration are the nature and history of the injury, frequent and early vomiting. early development of rigidity of the abdominal walls, local ten derness, and impairment of resonance in the right iliac region; the absence of definite signs of injury to the urinary bladder or solid viscera, combined with the evidence of serious injury, shock, pain, rising pulse. general pallor and per spiration. The special signs—as cellular emphysema, localizing the injury to the uncovered portions of the duodenum and colon, or possibly free gas in the peri toneal cavity—may be present. The presence of any of these signs with a rising pulse above 100 will form indica tions for abdominal exploration. 0. It Makins (Annals of Surgery, Aug., '99).