intense, it becomes widely difiused over the peritoneum and causes general peritonitis and death from toxemia. The symptoms will therefore vary; they are of two kinds, those due to toxemia and those caused by interference with the function of the inflamed parts. The following points must be observed in examining patients after abdominal contusions: <Callout type="important" title="Temperature">The temperature: a slight temporary rise is the traumatic fever which may follow any injury; when there is severe bruising of abdominal muscles or of a solid organ such as a kidney, there may be slight fever lasting many days, but in the absence of infection this fever is unaccompanied by other symptoms; a rapid progressive rise is an important sign of infection; in some cases of intense peritonitis especially in old people, the temperature may be but little raised.</Callout> <Callout type="warning" title="Pulse">The pulse: increased frequency is an almost invariable accompaniment of peritonitis throughout its course; when the inflammation is limited the pulse may be small and hard; in diffuse peritonitis the pulse quickly becomes very rapid, soft and thready; an anxious expression, drawn features, slight lividity of the lips, restlessness and wakefulness are very frequent effects of peritonitis. The mind usually remains clear quite to the end, and the patient is unaware of his grave condition.</Callout> <Callout type="risk" title="Vomiting">Vomiting: it is characterized by the slight force with which the contents are ejected, its frequent recurrence, and the dark colour of the vomited matter owing to admixture with blood from the deeply congested stomach; oftentimes single mouthfuls of dark fluid are gently regurgitated.</Callout> Pain: at the onset of peritonitis there may be acute pain either general or referred to the site of the original mischief or to the umbilical region. In localized peritonitis the pain remains localized, and <Callout type="tip" title="Pain Progression">may become more severe when an abscess forms; in diffuse peritonitis there may be no localizing signs at all.</Callout> Intestinal peristalsis is very generally arrested by peritonitis; neither faces nor flatus has been passed, and the bowel does not relax. Abdominal tension is a very frequent symptom in general peritonitis, increases to the end, and often attains an extreme degree; it may attend a localized peritonitis, and in that case it comes on more gradually; in such a case it is often the precursor of a wider extension of the peritonitis. Respiration becomes thoracic in character, partly from the rigidity of the abdominal muscles, partly because of the pain created by any abdominal movement, and later on also from the great abdominal distension. In the late stages of general peritonitis the breathing is rapid, laboured, and ineffective, the blood becoming less and less oxygenated. The circulation gradually fails in general peritonitis, the extremities become cold, the capillary circulation is sluggish, and the pulse may disappear at the wrist for an hour or so before death. The urine is scanty, sometimes suppressed; in general peritonitis it may become albuminous. Leucocytosis is observed in all grades of acute peritonitis; it is more marked in general than in local peritonitis, and when an abscess forms. It is not well to rely for diagnosis upon any one of these signs, but rather upon the combination of many. It must be borne in mind that of them all the pulse is the most important, and next to it rigidity of the abdominal wall. Peritonitis usually arises, if at all, within a few hours of the accident, but in some cases may be delayed for two, three, or even four days; therefore soon after an abdominal contusion the patient complains of pains in his belly or in his back, and temperature is raised, the pulse quickened, the abdominal walls are motionless, and no flatus has been passed, all these symptoms must make the diagnosis of general peritonitis. An anxious expression of face, frequent vomiting, increasing distension, with failing circulation, will make the diagnosis more certain. In a doubtful case, if a blood-count shows a rapid rise in the number of polymorphonuclear leucocytes, this will be an important confirmation of the diagnosis. If the patient complains of pain limited to an area of the abdomen, and this part is tender, with local muscular rigidity, and the temperature and pulse are raised, localized peritonitis is present. With this there may be limited swelling, occasionally vomiting, constipation, and slight leucocytosis. All these symptoms may entirely pass off as the inflammation subsides, but in other cases adhesions persist and make their presence known by occasional paroxysmal pains local tenderness, and cicatricial attachment. When a contusion of the abdomen is followed by the formation of a localized swelling and general febrile disturbance, an abscess must be suspected. Such swelling may follow an obvious bruise of the belly wall, in which case the onset and progress of inflammation are marked by increasing swelling, bright redness, oedema, greater pain, acute tenderness, and then the gradual occurrence of a more or less well-defined swelling may be the result. Examine carefully for fluctuation in the oedema, and for leucocytes and thesae obtained, or the occurrence of a rise in temperature, will render the diagnosis of an abscess more certain. These abscesses may be in one of the compartments of the rectus sheath, in the planes of cellular tissue in the abdominal wall, in the fatty tissue of the mesentery shut off by adhesions, or in the retroperitoneal tissue. The position, outline, mobility, or fixity of the swelling, and its relation to resonant viscera, are the points to which attention must be paid in determining the site of the abscess. Suppuration may occur between the liver or stomach and the diaphragm, and from its deep position its detection is attended with difficulty. For the diagnosis of the varieties of subphrenic abscess, see p. 587. When, some time after an injury to the upper part of the abdomen, a swelling slowly forms which is dull on percussion, and is situated either above the stomach or between the stomach and transverse colon, as shown by the position of the dullness relative to the gastric and colonic resonance, it is a pancreatic cyst. The cyst is of the variety known as pseudo- or traumatic cyst, does not, as a rule, make itself apparent for some months after the injury, and may be accompanied by wasting and by increase of diastase in the urine. When a swelling forms slowly and gradually in one of the lumbar regions after an injury in that situation, is unattended with fever, acute pain, or tenderness, and this swelling is found to fluctuate, a rupture of the ureter, with the formation of a urinary cyst, is to be diagnosed; and if, on tapping the swelling, watery fluid containing urea is drawn off, this diagnosis is confirmed. III. Abdominal wounds.— In examining a wound of the belly the surgeon must determine whether it is limited to the parietes, or penetrates the peritoneal cavity ; if the former, whether it is superficial, or extends through one or more of the muscular and deep aponeurotic layers ; if the latter, whether there is protrusion or wound of any of the viscera, or wound of a blood-vessel ; and, in all cases, whether any foreign body is lodged in the wound. Punctured wounds are those which generally present both the greatest difficulties in diagnosis and the greatest dangers, for their small external size often renders their exploration unsatisfactory, and they are frequently penetrating and complicated with wounds of viscera ; bullet wounds partake of the same characters. Inquiry should always be made as to the manner in which the wound was inflicted, and the instrument used should be examined, to discover, when possible, how deeply it has penetrated, and whether it is entire, and also whether it is stained by stomach or intestinal contents. 1. Is the wound penetrating?— In some cases a wound is obviously non-penetrating, and in others, especially when punctured, it may be impossible to decide without enlarging it. The edges of an incision may be gently drawn aside, and its surfaces explored ; when it extends only through the skin and superficial fatty tissue it is to be called a superficial parietal wound. When, however, it severs a muscle, or the muscular aponeurosis, and opens up the intermuscular planes or the sheath of the rectus muscle, or even still deeper fascia, the danger of subsequent hernia and of diffuse inflammation and suppuration renders it necessary to distinguish it as a deep parietal wound. Should there be any visceral protrusion, or the escape of the contents of any of the viscera (food, bile, faeces, urine) or if clear serous fluid or dark blood flows from the depth of the wound, and flows faster and with more force when the patient coughs or makes any effort, or should there be severe collapse or signs of internal haemorrhage, haematuria, or hematemesis, or the passage of blood per anum, it is a penetrating wound. When a doubt is entertained, the wound should be carefully enlarged and its depth and characters exactly determined. 2 Is there protrusion of a viscus?— This fact can be ascertained quite easily in the majority of cases : the omentum and small intestine are the viscera most commonly protruded ; but the liver, stomach, spleen, and bladder may protrude. All deep wounds must be carefully examined for protruding viscera. Where the protrusion is large there can be no difficulty whatever in recognizing it, although the possibility of a loop of intestine lying behind a fold of omentum must not be forgotten; a small protrusion of omentum between the edges of a wound may be overlooked unless care is taken. The omentum will be recognized by the anatomic arrangement of the fat, by the large vessels appearing on it, and by the fact that when it is gently pulled upon further prolapse takes place, and a distinct pedicle running from its deep surface is left. With ordinary care the smooth glistening appearance of the intestine, stomach, and omentum will be at once detected in a wound. It must be remembered that the urinary bladder when full may be protruded from a wound in the hypogastrium, through the peritoneal cavity not being opened. In such cases in which it is possible that the bladder may be thus protruded, a finger should be inserted and the urine drawn off; this will be followed by collapse of the vesical pro- fusion. Should a silver probe be used its extremity may be made to enter, and be felt in, the projection of viscera, all such projections should be carefully examined to see whether there is any rupture or wound, as well as to remove any foreign bodies that may be adherent to or entangled in them. In the case of omentum and mesentery, note especially whether there is haemorrhage from a wounded artery or vein. The collapse of prolapsed intestine and stomach, and the escape of their contents, gaseous or semi-solid, may at once indicate a wound; but the whole surface should be explored to see whether the peritoneum is torn, or whether there is at any spot a little projection of soft red mucous membrane, indicating a puncture of the gut; a larger wound of the intestine can hardly escape observation. (b) Where there is no protrusion the surgeon may be left in doubt on the point. If undigested or partially digested food, unstained by bile, escapes from the wound, or if the patient vomits blood, a wound of the stomach is to be diagnosed; this lesion may be attended by severe collapse, and be followed by acute peritonitis. When faecal matter escapes from the wound, or when blood is passed per anum, a wound of the intestine is clearly evidenced. When a wound is followed by the escape of urine, or by the occurrence of haematuria, it is the urinary apparatus that has been wounded, and the position of the wound, and the patient's power over his bladder, will determine whether it is a wound of the kidney or of the urinary bladder. Similarly, when bile escapes from a wound in the region of the liver, a wound of the gall-bladder or of one of the bile-ducts must be diagnosed. When a wound is followed by syncope, deepening collapse, and blanching of the mucous surfaces, and especially if dark blood escapes from the wound, or if the belly is distended at any part, or there is dullness in the flanks, which may be noticed to increase, internal haemorrhage is occurring. The position and direction of the wound will enable the surgeon to surmise the source of the bleeding; it may be the liver, the spleen, the vena cava, vena porta, or some other large abdominal vessel. The absence of grave symptoms immediately after a penetrating wound of the abdomen is not a proof that the viscera are not injured. In the absence of such symptoms as have just been mentioned, the subject of a penetrating abdominal wound should be submitted to an exploration—through a separate incision in most cases—and all the viscera in the neighbourhood of the wound examined. The consequences of untreated vascular and visceral wounds are so grave that the surgeon should be prepared to demonstrate their absence rather than wait for conclusive evidence of their presence in the form of fatal collapse or infective peritonitis. 4 Is a foreign body present?— Foreign bodies are nearly always metallic and well shown by X-ray. Diffuse suppuration in the belly, peritonitis, fistula, artificial anus, hernia, considerable diffuse swelling of the skin, pain, and tenderness, and the body temperature is raised, diffuse inflammation of the abdominal wall is proceeding, which, if not quickly subsiding, runs on to suppuration. For the diagnosis of peritonitis, see p. 159. Should the patient recover so far as the general results of the wound are concerned, but the wound through the belly wall remains open as a fistulous track, and through this the contents of any one of the abdominal viscera continue to escape, there is a fistula. If the discharge is unstained with bile, acid in reaction, and contains food undigested or but partly digested, it is a gastric fistula, or possibly a fistula in the upper part of the duodenum, above the entrance of the bile-duct. Should the discharge consist of the contents of the intestine, it is an intestinal fistula. When the matter escaping is soft pultaceous, odourless, or nearly so, and of a light colour, the communication is with the small intestine; and when the discharge is distinctly fetid, dark in colour, with a strong faecal odour, and mixed with much gas, the communication is with the large intestine—meckel's fistula. In any case of doubt a careful chemical examination of the discharge, determining the presence or absence of pepsin, trypsin or skatol, will show what part of the alimentary canal is wounded. Should the discharge be bile unmixed with chyme, or a watery fluid containing urea, it would be respectively a biliary or a urinary fistula. If as the result of an operation, or of the natural separation of a slough of prolapsed intestine, the mucous membrane of the gut is immediately continuous with the skin, the intestine opening directly on the surface, it is an artificial anus. Should there be from such an aperture a soft, bright-red, corrugated projection moistened with mucus, it is a prolapse of the artificial anus. But should there be from the aperture a smooth, rounded projection, covered by the same red mucous membrane, but reducible on gentle compression, leaving the mucous covering collapsed, it is a hernia at the artificial anus. If a cicatrix in the belly wall is found to yield before the pressure of the abdominal contents, and a projection is formed at the spot, smooth, rounded, soft, with an expansile impulse on coughing, and tympanitic on percussion, it is a hernia. It may be reducible or irreducible; the coils of intestine are often visible through the thin cicatrix, or these and masses of omentum may be plainly felt. There is no distinct neck to the sac of such a hernia. Wounds of abdominal viscera may be followed after a varying interval by symptoms pointing to the formation of adhesions between various portions of the intestinal tract. The diagnosis of this condition is considered at p. 582.
Key Takeaways
- Temperature and pulse are critical indicators for diagnosing peritonitis.
- Vomiting, abdominal rigidity, and respiratory changes are common symptoms of peritonitis.
- Penetrating wounds require careful examination to determine if they have damaged internal organs.
Practical Tips
- Always consider the possibility of internal injuries when dealing with abdominal trauma, even if external signs are not immediately apparent.
- Use a combination of clinical signs and laboratory tests (like blood counts) for accurate diagnosis.
- Be prepared to perform exploratory surgery in cases where the nature of the injury is unclear.
Warnings & Risks
- Delayed diagnosis can lead to severe complications like sepsis or organ failure.
- Ignoring symptoms of peritonitis can result in fatal outcomes.
- Incorrectly identifying a wound as non-penetrating when it is, can lead to serious internal injuries going untreated.
Modern Application
While the techniques described in this chapter are rooted in historical practices, many of the principles for diagnosing and managing abdominal trauma remain relevant today. Modern medical imaging and diagnostic tools have improved our ability to quickly identify internal injuries, but the importance of careful clinical observation and prompt intervention remains critical.
Frequently Asked Questions
Q: What are the key signs of peritonitis in a patient with an abdominal injury?
Key signs of peritonitis include a rapid rise in temperature, increased pulse rate, abdominal rigidity, vomiting, and changes in breathing patterns. These symptoms should prompt immediate medical attention.
Q: How can one determine if a wound is penetrating during an emergency response?
Examine the wound closely for any signs of visceral protrusion or escape of internal contents. If there is no obvious protrusion but the patient shows signs like vomiting, dark blood from the wound, or collapse, it may be a penetrating injury.
Q: What should be done if a patient with an abdominal injury does not show immediate symptoms?
Even in the absence of immediate symptoms, patients with suspected abdominal trauma should undergo thorough examination and possibly exploratory surgery to rule out internal injuries that may not present initially but can become life-threatening later.