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Chapter 11

Contents

CHAPTER XI

Diagnosis and Preoperative Routine

W. Philip Giddings, M. D., and Luther H. Wolff, M. D.

DIAGNOSIS

The preoperative diagnosis of visceral injuries in battle casualties was necessarily inexact. It was based chiefly on probabilities. It required careful consideration of (1) the site of the wound of entry, (2) the site of the wound of exit, (3) the direction from which the soldier believed he was struck, (4) his posture at the time of wounding, and (5) the position of the retained foreign body as demonstrated by roentgenologic or fluoroscopic examination.

Diagnosis was particularly difficult in multiple wounds of the abdominal wall, since any one, or several, of the fragments which had caused the visible injuries might have penetrated the peritoneal cavity. Exploration for diagnostic purposes was frequently necessary in injuries of this kind. It was also the established routine in any patient in whom the possibility of peritoneal or extraperitoneal visceral injury could not be positively excluded by any other method. In almost every instance of abdominal injury, a final and complete diagnosis was possible only after direct visualization of the peritoneal cavity at laparotomy.

It was always important to determine whether a hollow viscus had been injured, with resultant soiling of the peritoneum, because patients with this type of injury were given priority of treatment. As a rule, the location of the wound combined with unmistakable signs of established peritoneal irritation left no doubt that spillage had occurred, though in the occasional case diagnosis was not so simple. In the evaluation of doubtful cases, the absence of audible peristalsis was a useful diagnostic aid. On the other hand, peristalsis might be present if soiling were localized to the retroperitoneal space or to the lesser peritoneal cavity. Similarly, blood in the peritoneal cavity might give rise to peritoneal irritation, and blood in the urine, gastric contents, or feces was always important diagnostically; but its mere absence in these specimens did not necessarily exclude wounds of the urinary tract or of the stomach (pp. 255, 304). Rectal examination was an essential part of the diagnostic routine, and it was particularly important in wounds of the buttocks and upper thighs. Retroperitoneal injury, uncomplicated by other injuries, occasionally simulated peritonitis.

It was essential to remember, in the evaluation of symptoms and signs in casualties with abdominal wounds, that the clinical picture could be materially altered by the administration of morphine before the examination.

Thoracoabdominal wounds-Experience showed that it was of the utmost importance to establish the presence or absence of an associated abdominal


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injury in every thoracic wound (table 6). Wounds of the chest below the seventh interspace posteriorly and below the fourth rib anteriorly were regarded as possible thoracoabdominal wounds. The potentialities, however, were not limited to these areas. Perforation of the diaphragm was a possibility in any of the wounds caused by missiles which had entered anywhere from the gluteal region to the shoulder, though in most injuries of this kind the wound of entrance was in the lower half of the thorax. Among the 903 thoracoabdominal injuries treated in the period 1943-45 by the 2d Auxiliary Surgical Group, there were 66 (7.3 percent) in which the diaphragm was perforated from below.

Pain in the lower thorax was one of the reasons why the diagnosis of abdominal injuries which were associated with thoracic injuries was often difficult. It was sometimes helpful to reexamine the patient after intercostal nerve block; abdominal rigidity caused by peritonitis persisted after the block, while pain and muscle spasm arising from thoracic injury might be considerably reduced. If, however, too great reliance were placed upon these observations, the conclusions might be erroneous. Pain referred to the shoulder was found to be important evidence of injury to the diaphragm. Though pain was not always present in such cases, it was extremely infrequent in injuries limited to the thorax.

Roentgenologic studies, though often inadequate for practical reasons, were an invaluable aid in suspected thoracoabdominal injuries. Often, however, in spite of the information thus provided, abdominal exploration was regarded as mandatory. It was usually carried out through a thoracotomy incision.

PREOPERATIVE ROUTINE

The preoperative care of the casualty with an abdominal wound included the following measures: Placing the patient on a clean litter; removal of all his clothing; maintenance of body heat by blankets placed under as well as over him; securing a rapid clinical history; making of a rapid but complete physical examination; blood typing and crossmatching; catheterization, if the patient could not void voluntarily, and urinalysis; passage of a Levin tube, with gastric aspiration; and roentgenologic examination. As soon as possible, even before these studies were completed, measures of resuscitation were instituted and penicillin sodium (20,000 to 25,000 units) was administered by the intramuscular or intravenous route. Blood was always administered according to the indications of the special case (p. 124). Hematocrit and hemoglobin values were carefully checked.

Patients with thoracoabdominal injuries presented special problems in preoperative preparation because blood and mucus were likely to accumulate in the pharynx and throat. If they were conscious, they could frequently raise the accumulation by voluntary coughing. If coughing was painful, it could be facilitated by intercostal nerve block by the anesthetist. All unconscious patients, as well as some who were conscious, required tracheobronchial suction for the removal of secretions and improvement of the respiratory exchange.


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The usual method was to pass through the nose a long #16 catheter, with a hole in the side near the proximal end and several holes in the distal end, and to suck out the material through it. If one application of the tube was not sufficient to clear the airway, it was reintroduced. Preoperative thoracentesis was also employed to improve the respiratory exchange in cases of pneumothorax or hemopneumothorax.

The measures described were usually carried out by the shock officer, assisted by the anesthetist (p. 120) and other personnel working under his direction. It was, however, the ultimate duty of the surgeon to assure himself that all the steps of the preoperative routine had been properly carried out. Ideally, the shock officer and the surgeon cared for the patient jointly; but if casualties were heavy, the surgeon was almost always occupied elsewhere, and the ideal was therefore not achieved. Nevertheless, regardless of circumstances, it was the surgeon's responsibility before operation to review the history, physical findings, laboratory data, and roentgenograms, and it was also his responsibility, preferably in consultation with the shock officer, to determine the optimum time for operation in every case.

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