Abdominal trauma from the standpoint of the railway surgeon

Abstract

I HAVE no startling spectacular new facts to present. I have only some sober, tragic findings to report which I hope may stimuIate some interest in a phase of clinical diagnosis and treatment sorely needed for the benefit of patients. It may be that if we heed some of the Iessons to be gained from a study of clinical experience and the literature, a few patients may be saved. The saving of one life wiII more than justify my efforts. My remarks wiI1 be limited to the non-perforating or non-penetrating types of abdominal trauma. The elasticity of the abdomina1 waI1, free mobility of the hollow viscera and comparative mobility of the solid viscera are responsible for the comparative infrequency of lacerations of the spleen, liver, rupture of the intestines and the stomach, folIowing crushing bIows applied to the surface of the abdomen. There are several axioms which should be accepted when dealing with patients who have had trauma to the abdomen : (I ) Every patient should be hospitalized for a period of at least twenty-four hours. (2) Every patient should be examined carefully; not only a physica examination but x-ray studies should be made and laboratory data accumulated. The reason for the above statements is obvious when one realizes the infinite variety of combinations of injuries which may occur folIowing the initiaI blow. Authorities have classified the etiologic factors in abdominal trauma into: (I) crushing or squeezing, where the patient is impaIed between moving objects; (2) from a direct blow from a bIunt object and (3) from a fal1. To this may be added the classification given by Moty : bursting, crushing and tearing injuries. The statement that the abdomen, like Pandora’s box, is fulI of surprises is clearly proven by this type of case. UnfortunateIy symptoms and signs of the true nature of many of these cases are not manifested early. The Iiterature is fuI1 of statements like the following : “The prognosis is directly related to the promptness of surgical intervention” (Wilensky). “During the first few hours after injury no signs nor symptoms may appear. Decision not to operate in many instances is more dangerous than the hazard of an unnecessary operation” (Poer). “There are many cases of abdomina1 injury on record in which the symptoms at onset are trivial; but, later definite evidence of abdominal lesions requiring operation develop” (Estes). “The time lag between the injury and the definitive treatment must be reduced to as short a time as possible” (Arthur Metz). “Cases of traumatic rupture of the spleen have remained undiagnosed until necropsy ” (Roetting). This statement can be easiIy verified in any large hospital service where cases of trauma are handled. “ Injury due t’o non-perforating abdomina1 trauma is accompanied by symptoms which vary to such an extent that no clear clinical picture can be set down” (Poer). Since the cIinica1 picture is not clear, the signs delayed and the multiplicity of combinations of organs involved, it is incumbent on us to consider each injury as potentialIy serious until evidence proves to the contrary. It is essential to observe and examine carefulIy for a few hours in order to determine the need for an operation that wiI1 save a life. This is certainly better than to have a patient return to the hospita1 in an irreversabIe shock or with peritonitis when surgery, if done as an