Lectures on the Principles of Surgical Diagnosis: Especially in Relation to Shock and Visceral Lesions
Authors: F. Le Gros Clark
Journal: BMJ (1869)

shock, and subsequently the severity and fatal character of the visceral LECTURES injury.In many respects, for purposes of diagnosis, organic injury of the ON THuabdominal viscera, whether as the conseqluence of a penetrating wound PRTNCTPLES OF SURGICAL DIAGNOSIS: or ot rupture, may be rega-rded as identical.The unually fatal ch-a- racter of these lesions, vand the causes of that fatality, are the same in ESPECIALLY IN RELATION TO SHOCK AND both cases, though.occurringunder different circumstances.But it is VISCERAL LESIONS, the circumnstances.inquestion which render it desirable to notice these Delivered at the Royal College of Surgeons of England.several forms of injury separately; inasmuch as the manner of their infliction is, in the one case, often presumptive proof of the nature of By~F.LE GROS CLARK, F.R.C.S., the lesion; whereas, in the other, no such conclusion can be drawn from Hunterian Professor of Suirgery and Pathology in the College.Sur-geon to the same source of evidence.It is often a matter of pure speculation, SL Thomas's Hospital;ad.xmeriSugyat the -when the abdomen has been forcibly compressed or violently struck, Uvernt of Lno.what viscus is injured, even when the symptoms are of a nature whichi leaves little or no doubt of the existence of some organic lesion.Cer- tainly the mode in whichi the force was applied, and thec spot whichi LECTUREV.LEs1Ns OF IlE AJIOMEN (ON'S IUEI)).chiefly experienced its violence, rarely suffice to clear up this doubt, ifInfiuries Involving tlhe Abdominal Visce-ra Generally,.-Sy,mptoms:Col. unaided by any local sign of mischief.Thle remarkable variety of in- laps;Tynpantes Vomting Supression or Retenttioni of Urine juythat is met wvitb, under apparently similar circumistances, is often Templeralture; Ihermorrhiage; Paini; 1'eritontitis.-Rn.ptureofPartieuelardifficult to account for, especially in regard to the solid viscera.The Viscera, M1embr-anous andi Solid.-Pce/ierating,lMounds Involving actual state of the membranous viscera, as regards repletion, often de.Different Viscera.-TraumaticCO'stiinAbdIomeni.-F/uctntationt.-Con:-terinines their rupture, and thus affords a clue to a l)rol)al)le diagnosis, sequences of Injztry to Chest anid Abdomen Comtpar-ed.which other symptomis may serve to confirm.'thIis remark applies Mr. PRESIDENT AND GENTrLEMEN,-The diagnosis of wounds pene-especially to the stomachi, duodenum, and urinary bladder; and in a tratig tis peiuiiem israrel a mtter f diheult or oubt.The IUaUor degree to other parts of thie intestinal canial.prot.ruionofll ayp or41t:Uion ael mte of theviseracotetsis conusiv.BT,e It is probable that many structural lesions of the solid organs of thc proruson f ayprtin o th vicerl cntets s cnclsiv.Bt,abdomen nrc healed, withiout ouir being able to form mor-e than a con- even apiart from this demonstrative evidence, the nature of the wound jectural conclusion that such a serious inijury had been inflicted; but and the mode of its infliction generally indicate whether the abdominal this is very rarely the ease with the m-embniranouus viscera: specdy fatality wall has been entirely penetrated.Yet, in some instances this circum-in these cases is the rule, -and recovery the rare exception.stance is doubtful; and, if so, the welfare of the patient forbids any in- Yet, it is not to be inferred, as 1 hiave already ohserved, that the -quisitive attempt to solve the doubt; unless, indeed, the suspected breach in the texture of the organi is, in itself, mnortal or irrecoverable.WVe know, indeed, thlat the colon, and evenl the stomachi, miay be opaened, presence of any foreign body prompt the surgeon to seek for, with a withiout producing any marked constitutional or general disturbance; view of removing, it.Such doubt existed in the case of gun-shot but, immediately the contents of aniy membranouis viscu-, are diffused in wound which I mentioned in my last Lecture; and a similar difficulty the peritonieum, the symptoms of mortal shock succeed, and the patient existed in an instance of self-inflicted mutilation which was under my sinks at once under its prostrating influence, or suirvives jusit long enough 4care.The patient to whom I refer had stabbed or cut himself across the for peritonitis to have a share in determining the fatal issue.The difference, as regards fatality, between penetrating wounds andi abdomen, and remained for some time in a precarious state, but ultimatelY rupture of a membranous viscusi, is certainly in favour of the former; recovered.The far more important inquiry, and one which it is often for the lesion may be of a character--say a puncttire-whiich admits of both necessary and judicious to leave in abeyance is, whether any viscus repair, withiout extravasation of the conitainled miatter; and we know is implicated in the injury.As the consideration of wounds, attended tathcosrtinndrganisation of a musculo-miembranous sac or