Free hemorrhage from the wound tends to indicate an intestinal lesion; if the stools also contain blood the diag nosis may be considered as certain.
In small wounds of the bowel the mucous membrane pouts out and closes the orifice: a; soon as peristalsis occurs it is drawn in, and there may be an escape of a small fcal mass. A large amount of ftecal matter may thus be extruded through a small opening. Klemm (Deutsche Zeit. f. Chin, B. 33, II. 2, 3, '92).
In wounds of the intestines of very short extent (the most frequently met with) the mucous membrane makes a hernia between the lips of the wound, obstructing and thus preventing the flow of the fmcal matter, and in conse quence avoiding the onset of peritonitis. The gas would pass through the wound, facilitating at once the passage of these materials. Tobias Nunez (Brit. Med. Jour., Oct. 9, '97).
Probes have been discarded in pene trating wounds, owing to the irregular course followed by the bullet in many cases and the danger of creating a false passage. Digital exploration of small wounds furnish but little information, while in bullet wounds there is danger of pushing into the peritoneal cavity what foreign substances may happen to be present.
The majority of surgeons now favor enlargement by an incision at least two inches in length, intersecting the bullet or incised wound. Layer after layer of tissue is carefully dissected on each side of the track, the walls of which, in gun shot wounds, are usually darker than the normal tissues, owing to contact with the lead or powder-products of combustion. Using the grooved director to divide the tissues and the haemostatic forceps to grasp any bleeding vessel, the perito neum is finally reached, when the cer tainty that a penetrating wound is present or not may be established. If practiced with strict aseptic precautions, this procedure does not expose the pa tient.
Study of fifty-six cases showing that proof of penetration through peritoneum should be sought by enlargement and careful investigation of original wound.
Penetration having been found, imme diate enlargement of the wound shoull be made. C. L. Scudder (Boston Med.
and Surg. Jour., July 25, '95).
Stomach.—Ilmmatemesis is a frequent symptom of penetrating wound of this organ and a much more valuable one than in contusion, since, in the latter, a slight laceration of the mucous mem brane may produce it. The blood may be pure, but in the majority of instances it is mixed with partially-digested ali mentary semiliquid material. If the wound is sufficiently large to allow the contents to escape through it the nature of the injury is, of course, clear, but an important complication is to be appre hended: extravasation into the perito neal cavity capable of causing peritonitis. If this is circumscribed, adhesions are formed and the patient recovers. Fre quently, however, general peritonitis follows, ending in death. Hence the importance of an early recognition of extravasation.
Besides hxmatemesis and the presence of gastric fluids, there are usually present in such injuries the marked symptoms witnessed in cases of contusion: rapidly progressive ammnia, pallor, fluttering pulse, etc.
Liver. — A wound of the liver gives rise to all the symptoms observed when a contusion has caused laceration of the organ. Intermittent pain, radiating in various directions, especially toward the shoulder, if the convex portion of the organ is torn, and in the direction of the waist, if the concave or inferior portion of the organ is the seat of injury. There is marked pallor, superficial itching, and, later on, jaundice. The stools may be clay-colored, thus indicating the absence of bile.
The haemorrhage varies in these cases according to the cause of the lesion; one caused by a bullet is prone to be accom panied by considerable and frequently fatal bleeding. Stab wounds, when the weapon is not large, do not give rise to considerable haemorrhage. A copious flow of blood from a wound in the hepatic region indicates that the liver is involved. The flow of bile through the wound is a valuable sign, but it is seldom that this secretion can be obtained alone, blood being usually mixed with it.