The principles and practice of modern surgery

by Roswell Park

—Contusions of the abdominal wall may be followed by serious consequences, even though they have the appearance of being trifling. The injury that may be done implicates not alone the abdominal wall proper, but the viscera beneath. A blow upon the abdomen, followed by immediate collapse of temporary character (as the history of many a prize fight has shown), indicates a sudden reduction of blood pressure, the nausea and other features being due to the mechanism of the semilunar ganglia and the sympathetic nerves.

Contusions of the abdominal walls alone are serious largely in proportion as they are followed by extravasation or hematoma, since from failure of absorption of the latter there may result a cyst, or possibly an abscess should local infection occur. In either event evacuation and suitable local treatment are demanded. But any blow, even without penetration, may give rise to serious disturbances within the abdomen. Thus, as Richardson has said, the hollow viscera are liable to rupture, with extravasation, the solid to fracture with hemorrhage, while lacerations of the omentum or mesentery may produce immediate hemorrhage and subsequent possibility of intestinal obstruction. When extravasation has occurred distention and the ordinary evidences of peritonitis supervene. When the spleen or liver has been torn or crushed there will be obtained evidences of extensive internal hemorrhage.

Of the hollow viscera much will depend upon the degree of their fulness—especially with fluid. In a small tear there may be eversion of the mucosa, which may hinder or even prevent extravasation. Escape of infectious material into the cavity of the lesser omentum may produce local peritonitis, with subsequent development of what is practically a subphrenic abscess. When the patient vomits blood it shows that there has been rupture of the gastric mucosa. Intestinal rupture will be made known by rapid distention and the ordinary evidences of acute peritonitis. These injuries rarely lead to vomiting of blood, but when occurring low in the bowel may lead to the occurrence of bloody stools. Rupture of the spleen or pancreas is rarely diagnosticated previous to exploration, save as a severe abdominal injury. It is not so likely to lead to rapid peritonitis. Rupture of the liver permits of more or less escape of bile, as well as of blood, and rupture of the gall-bladder permits the free emptying of bile into the upper abdomen. As this is usually harmless, in otherwise healthy individuals, the injury is not necessarily so serious as might appear. In such a case the resulting peritonitis will probably be local rather than general.

In this connection may be considered ruptures of the kidney, which are produced by similar injuries to those under consideration, and which may permit escape of urine or blood into the abdominal cavity, as well as the appearance of blood in the urine. While these will be considered in another place the possibility of their complicating abdominal injuries cannot be overlooked.

Considerable laceration will predispose to subsequent hernias, either direct or indirect, in the latter case by absorption following injury. The more serious consequences of abdominal contusions—i. e., the deep hemorrhages and lacerations of viscera—may then include all degrees of such injury, from trifling subperitoneal ecchymosis to extensive ruptures of such organs as the kidney or liver, or perhaps multiple perforations of stomach and bowel. These deep injuries will be considered by themselves when dealing with special organs. It is sufficient here to indicate their possibility and to warn that every severe contusion of the abdomen which is followed by local symptoms, or those which are grave and progressive, may at any time demand exploratory section, which should be made early rather than late. It is advisable to pass a catheter to make sure that there is no blood mixed with the urine, and to make a rectal examination in order to discover blood should it have escaped.

Penetrating wounds of all descriptions, punctured, incised, and gunshot, are again of importance largely in proportion to the damage done to intestines and great vessels. Some of these injuries are so evidently superficial that exploration may be abstained from, but every penetrating wound which has truly penetrated is to be treated either as they are treated on the battle-field, by mere inspection and occlusion, or by careful exploration under all aseptic precautions. What the operator would do deliberately may not be what he can do in an emergency, but if he cannot reach one extreme he would best be content with the other.

Abdominal contusion has been found by Makin to be the cause of about 70 per cent. of the cases of intestinal rupture which have followed sudden or sharp blows, while the other 30 per cent. have been due to the passage over the abdomen of heavy objects. Le Conte has well summed it up in the following words: “If the force be circumscribed, and of high velocity and of small inertia, such as a kick or blow from some rapidly moving object, crushing of the intestine is more likely to occur; while if the force be diffuse, as from a slowly moving, ponderous object of considerable inertia (e. g., a wagon wheel), the belly is more apt to be torn at one of its fixed points or the mesentery injured. Thus out of 61 cases of horse-kicks of the abdomen in 59 intestinal rupture occurred. When the abdominal muscles have been braced in expectation of a blow less harm results than when it has been suddenly inflicted upon a relaxed musculature.” Crile has shown that the more specialized and abundant the nerve supply to a given viscus the more will it contribute to the production of shock when injured.

Pain is not always an immediate symptom. It may be delayed for hours, or possibly even for days. When intestinal rupture has occurred pain is most often referred to the central portion of the abdomen. In rupture of the spleen it is complained of in the left side, while when the kidneys have been ruptured pain follows the course of the ureters to the genitals and there is usually retraction of the testicle.

Muscle rigidity is a sign of equal diagnostic value with pain, and immobilization of the abdominal wall nearly always indicates intestinal rupture. The facial expression is also of importance, it being in the more severe cases almost distinctive. A steadily rising pulse is always a bad sign, usually indicating a developing peritonitis. Vomiting, if long continued, after a patient has rallied from the immediate shock, is considered of itself to justify operation. The same is true of paralysis of peristalsis.

Such injuries to the abdominal walls proper may divide important vessels, such as the epigastric, and give rise to hemorrhage which may be internal rather than external. The first and most important danger of hemorrhage having been passed or being avoided, the next and always urgent risk is of infection. This may come from non-penetrating injuries, as well as those which open a wide path into the interior, and it is sometimes the small punctures which prove most disastrous.