Symptoms.—As is the case after con tusion, penetrating wounds of the ab domen may give rise to no symptoms capable of affording any reliable clue to the extent of the internal injuries. Pro found shock may be present and no serious lesion exist.
Case of a man brought into one of the surgical wards with an external wound. He was lifted to bed absolutely helpless and a serious gunshot wound of the abdomen suspected from gravity of symptoms. The bullet found in the leg of his drawers. The patient was unable to get out of bed for hours. A. B. Miles (Southern Surg. and Gynec. Trans., vol. vi, p. 1S3, Severely injured individuals may, on the contrary, present no acute symptoms and. perhaps, walk or ride a considerable distance before showing noticeable evi dence of their condition.
Case of 15-year old boy who sustained penetrating wound of the abdomen, with protrusion of more than a foot of intes tine, by being horned by a bull. There was total absence of shock, although the accident occurred six hours before the boy came under observation. and the pa tient was brought in a country-cart over five miles of very hard road. George Bidie (Brit. Med. Jour., Sept. 24, .9S).
Profuse haemorrhage alone gives rise to symptoms denoting a grave lesion: rapidly progressive exsanguination or acute anaemia; nausea or vomiting; weak. rapid, and sometimes irregular pulse; dilated pupils; cold sweats; yawning, is likely to be progressive in these eases.
Fatal cases of marked laceration of liver and bowel in which there was neither shock, haemorrhage, nor high pulse. W. L. Robinson (Jour. Amer. Med. Assoc., Dee. 15, '94).
If the shock is progressive it means internal hmmorrhage. When a patient is first seen he may be profoundly shocked and not be much disturbed, but, if he continues to become more shocked, it means Inemorrhage. Shock at the time of injury does not mean hemor rhage, but later on it does. L. McLane Tiffany (Pacific Record of Med. and Surg., Feb. 15, '90).
The only symptoms that are present in practically all cases are pallor and vomiting: the accompaniments of any severe blow on the abdomen, and there fore of no value whatever as differential signs. The temperature is of no assist ance in these cases.
Cases showing that with normal tem perature a fatal injury (without opera tion) may be present, while, after oper ation, a subnormal temperature may be expected; 95° F. has been recorded. L.
M. Tiffany (Amer. Jour. Med. Sci., May, '96).
Diagnosis. — On general principles dangerous complications are to be ex pected when marked shock, nausea, vomiting, hiccough, anxiety. intense thirst (indicating a probable involve ment of the peritoneum), and insomnia are present. Besides these indications there are others peculiar to each organ which greatly assist in establishing at least an approximately certain diagnosis.
The absence of liver-dullness is of less significance than is usually believed, but the disappearance of liver-dullness is of more value. The most important symp toms in personal cases were tension of the abdominal muscles, local meteorims, and dullness in the region of the wound. The general symptoms were those of peritonitis. Petersen (Mtinchener med. Woch., Apr. 9, 1901).
lets striking the abdomen antero-posteri orly rarely cause more than four per forations, while oblique or transverse shots are likely to produce a much larger number of lesions: from fourteen to sixteen. On general principles, however, a penetrating wound may always he con sidered as having caused a lesion of the intestines.
The most important symptom is the escape of intestinal gases and more or less fluid substances through the wound. The mere presence of emphysema around the wound is of no value, however, since air is generally forced into the wound by the bullet.
Some years ago Senn recommended the of hydrogen-gas to ascer tain the presence of intestinal perfora tion. Having introduced it into the rectum, he ascertained whether it es caped into the peritoneal cavity and thus passed out through the parietal opening. The method was found unreliable, how ever, and has been pretty generally dis carded.
CaQe in NI Lich the absence of intestinal perforation was established by ether in flation of the intestines. The bowels were inflated with ether, which escaped from the mouth. The peritoneal cavity was opened, and the ball was found to have passed above the liver, injuring the diaphragm, and burying itself in the tissues behind. The blood-clots were removed and the abdomen closed. The inflation of the intestines caused a sense of fullness, but no other discomfort. The patient made an uneventful recovery. E. M. Sutton (Jour. Amer. Med. Assoc.. Dee. 30, '99).