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 wasnecessarily inexact. It was based chiefly on probabilities. It required carefulconsideration of (1) the site of the wound of entry, (2) the site of the woundof 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 retainedforeign body as demonstrated by roentgenologic or fluoroscopic examination.
Diagnosis was particularly difficult in multiple wounds of the abdominalwall, since any one, or several, of the fragments which had caused the visibleinjuries might have penetrated the peritoneal cavity. Exploration for diagnostic purposes was frequently necessary in injuries of this kind. It was alsothe established routine in any patient in whom the possibility of peritoneal orextraperitoneal visceral injury could not be positively excluded by any othermethod. In almost every instance of abdominal injury, a final and completediagnosis was possible only after direct visualization of the peritoneal cavityat laparotomy.
It was always important to determine whether a hollow viscus had beeninjured, with resultant soiling of the peritoneum, because patients with thistype of injury were given priority of treatment. As a rule, the location of thewound combined with unmistakable signs of established peritoneal irritation leftno doubt that spillage had occurred, though in the occasional case diagnosis wasnot so simple. In the evaluation of doubtful cases, the absence of audibleperistalsis was a useful diagnostic aid. On the other hand, peristalsis might bepresent if soiling were localized to the retroperitoneal space or to the lesserperitoneal cavity. Similarly, blood in the peritoneal cavity might give rise toperitoneal irritation, and blood in the urine, gastric contents, or feces wasalways important diagnostically; but its mere absence in these specimens did notnecessarily exclude wounds of the urinary tract or of the stomach (pp. 255,304). Rectal examination was an essential part of the diagnostic routine, and itwas particularly important in wounds of the buttocks and upper thighs.Retroperitoneal injury, uncomplicated by other injuries, occasionally simulatedperitonitis.
It was essential to remember, in the evaluation of symptoms and signs incasualties with abdominal wounds, that the clinical picture could be materiallyaltered by the administration of morphine before the examination.
Thoracoabdominal wounds-Experience showed that it was of the utmostimportance to establish the presence or absence of an associated abdominal
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injury in every thoracic wound (table 6). Wounds of the chestbelow the seventh interspace posteriorly and below the fourth rib anteriorlywere regarded as possible thoracoabdominal wounds. The potentialities, however,were not limited to these areas. Perforation of the diaphragm was a possibilityin any of the wounds caused by missiles which had entered anywhere from thegluteal region to the shoulder, though in most injuries of this kind the woundof entrance was in the lower half of the thorax. Among the 903 thoracoabdominalinjuries treated in the period 1943-45 by the 2d Auxiliary Surgical Group, therewere 66 (7.3 percent) in which the diaphragm was perforated from below.
Pain in the lower thorax was one of the reasons why thediagnosis of abdominal injuries which were associated with thoracic injuries wasoften difficult. It was sometimes helpful to reexamine the patient afterintercostal nerve block; abdominal rigidity caused by peritonitis persistedafter the block, while pain and muscle spasm arising from thoracic injury mightbe considerably reduced. If, however, too great reliance were placed upon theseobservations, the conclusions might be erroneous. Pain referred to the shoulderwas found to be important evidence of injury to the diaphragm. Though pain wasnot always present in such cases, it was extremely infrequent in injurieslimited to the thorax.
Roentgenologic studies, though often inadequate for practical reasons, werean invaluable aid in suspected thoracoabdominal injuries. Often, however, inspite of the information thus provided, abdominal exploration was regarded asmandatory. It was usually carried out through a thoracotomy incision.
PREOPERATIVE ROUTINE
The preoperative care of the casualty with an abdominal wound included thefollowing measures: Placing the patient on a clean litter; removal of all hisclothing; maintenance of body heat by blankets placed under as well as over him;securing a rapid clinical history; making of a rapid but complete physicalexamination; blood typing and crossmatching; catheterization, if the patientcould not void voluntarily, and urinalysis; passage of a Levin tube, withgastric aspiration; and roentgenologic examination. As soon as possible, evenbefore these studies were completed, measures of resuscitation were institutedand penicillin sodium (20,000 to 25,000 units) was administered by theintramuscular or intravenous route. Blood was always administered according tothe indications of the special case (p. 124). Hematocrit and hemoglobin valueswere carefully checked.
Patients with thoracoabdominal injuries presented specialproblems in preoperative preparation because blood and mucus were likely toaccumulate in the pharynx and throat. If they were conscious, they couldfrequently raise the accumulation by voluntary coughing. If coughing waspainful, it could be facilitated by intercostal nerve block by the anesthetist.All unconscious patients, as well as some who were conscious, requiredtracheobronchial suction for the removal of secretions and improvement of therespiratory exchange.
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The usual method was to pass through the nose a long #16 catheter, with ahole in the side near the proximal end and several holes in the distal end, andto suck out the material through it. If one application of the tube was notsufficient to clear the airway, it was reintroduced. Preoperative thoracentesiswas also employed to improve the respiratory exchange in cases of pneumothoraxor hemopneumothorax.
The measures described were usually carried out by the shock officer,assisted by the anesthetist (p. 120) and other personnel working under hisdirection. It was, however, the ultimate duty of the surgeon to assure himselfthat 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 ifcasualties were heavy, the surgeon was almost always occupied elsewhere, and theideal was therefore not achieved. Nevertheless, regardless of circumstances, itwas the surgeon's responsibility before operation to review the history,physical findings, laboratory data, and roentgenograms, and it was also hisresponsibility, preferably in consultation with the shock officer, to determinethe optimum time for operation in every case.
