THE INDICATIONS AND NATURE OF TREATMENT IN SEVERE 
ABDOMINAL INJURIES AND INTRA-ABDOMINAL HEMOR- 
RHAGES UNACCOMPANIED BY EXTERNAL 
EVIDENCE OF VIOLENCE. 
BY 
JOHN B. DEAVER, M.D., 
PROFESSOR OF SURGERY, PHILADELPHIA POLYCLINIC; ASSISTANT PROFESSOR OF 
SURGICAL ANATOMY, UNIVERSITY OF PENNSYLVANIA ; ATTENDING SUR- 
GEON TO THE GERMAN AND PHILADELPHIA HOSPITALS; 
CONSULTING SURGEON TO THE GERMANTOWN, ST. 
TIMOTHY’S AND ST. AGNES’ HOSPITALS. 
Read before the Philadelphia Academy of Surgery, 
January 7, /8gj. THE INDICATIONS AND NATURE OF TREATMENT 
IN SEVERE ABDOMINAL INJURIES AND 
INTRA-ABDOMINAL HEMORRHAGES 
UNACCOMPANIED BY EXTER- 
NAL EVIDENCE OF 
VIOLENCE. 
By JOHN B. DEAVER, M D, 
PROFESSOR OF SURGERY PHILADELPHIA POLYCLINIC; ASSISTANT PROFESSOR OF 
SURGICAL ANATOMY, UNIVERSITY OF PENNSYLVANIA ; ATTENDING SUR- 
GEON TO THE GERMAN AND PHILADELPHIA HOSPITALS; 
CONSULTING SURGEON TO THE GERMANTOWN, ST. 
TIMOTHY'S AND ST. AGNES' HOSPITALS. 
Mr. President and Fellows of the Academy of Surgery : 
Contrary to our custom, which has been for the orator on this 
occasion to present an address upon the advances made in sur- 
gery during the preceding year, I would beg the privilege of our 
Honorable President and Fellows to substitute therefor a paper 
upon a subject that must appeal to every practical surgeon, 
namely, “The Indications and Nature of Treatment in Severe 
Abdominal Injuries and Intra-abdominal Hemorrhage Unac- 
companied by External Evidence of Violence.” 
Every surgeon has undoubtedly at some time in his experience, 
either in private or hospital practice, met with cases coming 
under the class covered by the title of this paper. These are 
cases in which the history and general condition of the patient 
give the impression that there is a serious lesion within the 
abdomen, and yet, upon examination, we find total absence or 
only slight evidences of injury. The tendency, I fear with many, 
is to treat these patients tentatively, only to be awakened at the 
autopsy to the fact that a rupture or a tear existed in the abdom- 
inal cavity, which, by early radical operation, could have been 
relieved. 
The mortality in these cases is appalling; references to the 
literature of the subject will amply bear out this statement, 
which is readily accounted for by the nature of the injuries. 
Where the lesion is of the liver or spleen, if the patient does 
not die of shock or hemorrhage, a violent peritonitis supervenes 
to which he shortly succumbs. If the liver, spleen, or kidneys 
are involved, death from hemorrhage may ensue in a very short 2 
time. Should the stomach, intestine, or bladder be ruptured 
and their contents poured into the peritoneal cavity, death from 
peritonitis is the result. In rupture of the mesentery the danger 
is from hemorrhage, yet, when the opening in the mesentery is 
small a clot may form sufficiently large to control the bleeding. 
Should death occur under these circumstances it would be the 
result of peritonitis caused by the free blood in the peritoneal 
cavity. I report a case of this character where recovery followed 
immediate operation. In ruptured extra-uterine pregnancy 
death is due either to hemorrhage or peritonitis. 
The usual history of these cases, with the exception of extra- 
uterine pregnancy, is that the patient has received a direct injury 
to the abdomen, which is found to be unaccompanied by external 
evidence. These injuries may result from railroad accidents, 
from being caught between shifting cars, or from blows upon 
the abdomen received in various ways. 
This class of injuries is quite common in military surgery, 
more so in the past when spherical balls were used and only a 
low velocity attained. A majority were supposed to be caused 
by the violence of the wind displaced by the passing ball, but 
we now know that they were due to the impact of the balls almost 
entirely spent. 
Two cases which illustrate this occurred at the siege of Sebas- 
topol. In neither did the clothing or the abdominal walls show 
any signs of injury, but in both the liver and spleen were com- 
minuted to a pulp, and the intestines extensively lacerated (Mr. 
Hulke, Lancet, December 31, 1892). 
As yet we have no reports from surgeons of the armies 
engaged in the present strife between Japan and China, but it 
will be of great interest to read the records of such cases. We 
can expect, I think, a very full and detailed account from the 
Japanese surgeons. We have all applauded the work of some 
brilliant individuals of the Japanese profession, and, in fact, we 
must assign to Japan in medicine the same standing that she 
has taken in other walks of civilized life, and which she has 
demonstrated she can hold. 
The most prominent symptom is pain, which is accompanied 
by shock, the degree of which is dependent upon the extent of 
injury and the temperament of the individual. 
I might say here that temperament and nationality have a 
strong bearing in the production of shock. Persons of a highly 
nervous temperament suffer more from shock than do phlegmatic 
individuals. For example, Americans are far more liable to 
suffer a severe degree of shock following injuries or operations 
than are the Germans. 3 
The pain is peculiar and difficult to describe, but is readily 
recognized by one who has seen many of these cases and by 
the patient himself. It is not that of ordinary intra-abdominal 
affections, but is described by the patient as if something had 
given way or ruptured, and is usually accompanied by a con- 
sciousness of impending death. It is usually accompanied with 
tenderness, which will be more or less localized, unless the 
ensuing peritonitis be general. In the early stages of the injury, 
when shock is most profound, it may not be so pronounced, 
and if large doses of opium be administered it may be masked 
throughout the course of the trouble. 
When vomiting is present it is usually associated with pain. 
Rarely does the vomited matter contain blood. 
There is often seen a characteristic rigidity of the abdominal 
walls, which is due to intra-abdominal irritation. I have seen 
this so marked as to recall to mind the checker-board appear- 
ance of the normal abdominal walls as represented in the pictures 
of the early artists. 
In the cases I have observed, consciousness has invariably 
been retained for varying periods of time. Restlessness is not 
usual in the early stages except in severe hemorrhage, but later 
on, when peritonitis develops, it is not an uncommon symptom. 
The pulse and temperature vary according to the degree of 
shock. The former is weak and running, varying from ioo to 
160, and the temperature subnormal. If reaction takes place 
the pulse becomes stronger and less frequent, and the tempera- 
ture reaches the normal line. After reaction peritonitis is 
invariably the rule, and is accompanied by an accelerated and a 
high-tension pulse. The temperature under these circumstances 
is unreliable, as it does not correspond to the degree of inflam- 
mation or septic infection. A high temperature with a slow 
pulse is less significant than a rapid pulse with a low tempera- 
ture. In cases of septic peritonitis, where autopsy revealed a 
belly cavity full of foul pus, I have seen the temperature run 
a normal course throughout the disease. 
The part the sympathetic system of nerves, which has its 
largest distribution in the abdominal cavity, may play in injury 
to the abdomen is important in considering the differential diag- 
nosis between the simple contusion and contusion accompanied 
by visceral lesion. In the former the absence of the severe 
and characteristic pain, of constant and persistent vomiting, of 
the anxious expression and presentment of impending death, 
and of any evidence of loss of blood, associated with the occa- 
sional presence of suddenly developed meteorism, will usually be 
sufficient to establish the differential diagnosis. This condition 4 
of meteorism is due to paralysis of the muscular coat of the 
bowel consequent upon the concussion of the plexuses. There 
are cases, however, where it is very difficult to say definitely 
whether there be a visceral complication or not. Under these 
circumstances one can only wait for a comparatively few hours, 
when, if improvement is not apparent, the operative course is 
to be pursued. When the solid viscera are the seat of injury 
hemorrhage will be the main source of anxiety. The pain and 
the exsanguination give the clew. If the patient should react, 
which is unusual, unless the kidney is the injured organ, we will 
find, in addition, dulness on percussion in the flank. Rectal or 
vaginal examination may afford aid in determining the presence 
of a collection of blood in the pelvis. The solid organs suffer 
most from external violence on account of their fixity, density 
and close proximity to the bony structures. The liver is the 
most often injured, then the uterus, spleen and kidney, in the 
order named. The stomach is least often injured, there being 
very few such cases on record. Dr. J. W. Goff (.Medical and 
Surgical Reporter, 1892), reports a case of ruptured stomach fol- 
lowing a horse kick of the abdomen, verified by an autopsy. 
The shock was profound, and there was vomiting with absence 
of blood. The author states that he believes immediate opera- 
tion would have saved the patient’s life. 
In the Glasgow Medical Journal for 1894, vol. xli, Andrews 
reports a case of rupture of the stomach without external evi- 
dence of violence, in which all the symptoms of a serious visceral 
lesion were present with the exception of vomiting. The rup- 
ture was upon the anterior wall; was about an inch long, and 
involved all the layers. I cite this case as one of special inter- 
est on account of the location of the tear and the absence of 
vomiting. 
The liver is the organ most often affected because of its posi- 
tion beneath the ribs and against the spine, and because it is held 
firmly in place by strong ligaments and bloodvessels. It is 
most commonly ruptured on its upper surface, generally in the 
right lobe, and in a majority of such cases the injury proves 
fatal. Dr. H. P. Loomis (Medical Record, January, 1893) re- 
ports a case where the patient was struck by a pole protruding 
from the back of a wagon, which, when the wagon turned the 
corner, struck him on the right side, leaving no external evidence 
of violence. There was a three-inch tear in the right lobe of 
the liver and a pint of blood in the abdominal cavity. The 
patient died in the street from hemorrhage before medical aid 
could reach him. 
Mr. Battle (Lancet, London, 1894), reports a case of rupture of 5 
the bile duct, in a boy six years of age, who was run over by a 
hansom cab, in which there was but a slight shock without 
much pain or tenderness. Vomiting began early and persisted. 
On the fifth day slight jaundice developed. He was operated 
upon on the eighth day, and the abdominal cavity was found 
filled with bile. He died on the morning of the ninth day. 
Autopsy. Liver and gall-bladder were intact, but about one- 
half an inch beyond the junction of the cystic and hepatic ducts 
the common duct was found to be torn completely through. No 
other injury was found. 
J. E., aged forty-six years, was admitted to the German Hos- 
pital on November 17th, 1893, suffering from injuries received 
by being struck by a locomotive. He had a compound fracture 
of the lower jaw, lacerated scalp wound and fracture of four 
ribs on the left side, with no other signs of injury. He died six 
hours later. Post-mortem examination revealed a hematothorax 
of the left side. The peritoneum was not perforated or other- 
wise injured, but the peritoneal cavity was filled with blood. 
The spleen was completely comminuted, and the left kidney had 
been forced from its bed and was floating in the retro-peritoneal 
space. There was an extensive hemorrhage between the layers 
of the mesentery, and a hemorrhagic extravasation of the pos- 
terior wall of the stomach. 
H. M. C., colored, aged sixteen years, was admitted to the 
German Hospital on the evening of December 3, 1894, with the 
following history: While playing about some moving freight- 
cars he was accidentally caught between the bumpers, sustain- 
ing an injury to his abdomen. Examination upon admission 
failed to disclose any evidences of external injury. The intro- 
duction of the catheter drew clear urine. There was a moderate 
degree of shock, and the patient complained of severe pain in 
the abdomen and tenderness on palpation. Further investiga- 
tion proved negative. 
The resident surgeon, Dr. Page, not deeming the case of 
sufficient severity to send for me, treated the patient for shock. 
When I examined him, upon the following day, it was very evi- 
dent from the severity of the abdominal pain and tenderness 
associated with very decided rigidity of the abdominal walls, 
that he was suffering from a serious intra-peritoneal lesion. I 
decided to open the abdomen at once. As soon as the perito- 
neal cavity was opened a large quantity of dark liquid blood 
escaped. The small intestines were delivered, when the cause 
of the lesion was found to be a ruptured mesenteric vein, the 
bleeding from which was arrested by the presence of a large 
diffused blood clot occupying the interval between the layers of 6 
the mesentery. To make sure that there was no other lesion, 
the large intestines, the stomach, the liver and the spleen were 
carefully examined, but with a negative result. The abdominal 
cavity was washed out with warm saline solution, glass drainage 
was introduced into the pelvis and the wound closed. Recovery 
was uninterrupted. 
L. C., male, Italian, aged thirty-five years, was admitted to 
the German Hospital, with a history of a fall of about fifty feet, 
striking upon his abdomen. He was profoundly shocked and 
exsanguinated. The only external evidences of injury were 
some slight cuts on the hands and head. A diagnosis of in- 
ternal hemorrhage was made, and the abdominal cavity opened 
up. Dark liquid blood escaped as soon as the peritoneum was 
opened, and the source found to be the mesenteric vessels. The 
mesentery was torn half way across and the intestines lacerated 
in four places. The mesentery was united with a series of cat- 
gut ligatures, and the rents in the intestines closed with the Lem- 
bert sutures. The abdominal cavity was washed out with hot 
saline solution and closed. He died two hours after the opera- 
tion. The autopsy demonstrated several tears in the gut which 
had been overlooked, and several grapeskins and pieces of fig 
in the peritoneal cavity. 
The most common form of intra-abdominal hemorrhage is 
that resulting from ruptured extra-uterine pregnancy. While 
these cases may be due to traumatism without any external 
evidence they are usually spontaneous. While hemorrhage 
from the pelvic organs of the female usually occur from a rup- 
tured extra-uterine pregnancy, it may be due to other non-trau- 
matic causes. Hematosalpinx may occur independent of preg- 
nancy, and rupture either spontaneously or from traumatism. 
Again, degenerated bloodvessel walls, and especially veins, may 
rupture under similar circumstances. 
M. E., aged twenty-four, nurse, admitted to German Hospital 
January 20, 1893. While lifting a heavy weight from an elevator 
she felt something give way in her abdomen. This was immedi- 
ately followed by severe lancinating pain in the right ovarian 
region. She was menstruating at the time. Pelvic peritonitis 
promptly set in. An examination demonstrated a tumor in the 
right broad ligament about the size of a hen’s egg. The peri- 
tonitis and tumor subsided to treatment, and she made a slow 
recovery. Diagnosis, pelvic haematocele from rupture of an 
engorged ovarian vein. 
Hemorrhage itself is seldom the cause of death, but associ- 
ated as it is with shock, the degree of which is out of all pro- 
portion to the severity of the accident, it is frequently fatal in 7 
a very short time. When the peritoneum is wounded shock is 
still more profound, the so-called peritoneal shock. 
Hemorrhage within the peritoneum is sometimes very slight 
and distinctly localized, and may occur several times during the 
course of the illness. It may take place between the layers of 
the broad ligament, and soon stop from the pressure. 
I report the two following cases of hemorrhage from my list 
of operations for ruptured extra-uterine pregnancies, as they 
illustrate so typically the wisdom of immediate operation : 
Mrs. A. K., aged thirty-one years, admitted to the German 
Hospital, September 21, 1894, with the following history. Six 
months prior to admission she had been subject to attacks of 
vertigo, pain in the back and limbs, and for the last six weeks 
to a constant bloody vaginal discharge. Examination revealed 
a retroflexed uterus with a slight tear of the cervix, and the 
presence of a small movable mass behind and to the left of the 
uterus. 
September 25th, four days after admission, the patient was 
etherized, and the uterus was dilated and curetted. After the 
operation the discharge stopped, but the patient gained in 
strength very slowly. She was advised to submit to abdominal 
section, but preferred to wait until she was stronger. On the 
night of November 22d she awoke with a severe pain in the 
right side, and on attempting to walk to the water closet fainted. 
After being returned to bed she again fainted and went into a 
collapse, the pulse becoming almost imperceptible, and the 
temperature falling to 96°. Under active stimulation she reacted. 
The diagnosis was made of internal hemorrhage from rupture 
of a probable extra-uterine pregnancy. 
The abdominal cavity was found filled with fluid blood and 
clots, and the right tube ruptured. The tube was tied off, and 
the abdominal cavity flushed with hot saline solution, a glass 
drainage-tube introduced and the wound closed. The patient 
was not much shocked by the operation, but on the contrary 
seemed rather improved. The drainage-tube was removed on 
the third day, the wound healed by first intention, and the patient 
made a good recovery. 
Mrs. J. W., aged thirty-six years, was admitted to the German 
Hospital, November 21,1894, with the following history. About 
two o’clock on the morning of admission she was seized with a 
violent pain in the lower abdomen. For this she took some 
whiskey, and was somewhat relieved. At nine o’clock the same 
morning she started for market, and was suddenly taken sick, 
becoming very weak and suffering from a violent pain in her 8 
abdomen. She returned home with difficulty and called in Dr. 
Hand, who advised her immediate removal to the hospital. At 
the time of admission she was very weak, and there was distinct 
tenderness over the abdomen with slight dulness on the right 
side. Immediate operation was advised and consented to. 
When the peritoneal cavity was opened it was found to con- 
tain fluid blood and clots. The right tube was the site of a 
small rupture, and was tied off and removed. The abdominal 
cavity was washed out with hot saline solution, glass drainage 
introduced and the wound closed. The patient was very much 
shocked by the operation and reacted slowly. During the 
operation hypodermatoclysis was practised. The drainage-tube 
was removed on the fourth day, the wound healed by first 
intention, and the patient was discharged, well, on the twenty- 
third day. 
The following case of hemorrhage from ruptured extra-uterine 
pregnancy illustrates the danger of delay as strongly as did the 
two previous cases the efficacy of prompt interference : 
Mrs. P., aged thirty years, was a patient of Dr. S. Cooke 
Ingraham, of Wissahickon, this city, who furnishes the follow- 
ing history: 
I first saw the patient on January 29, 1892. She complained 
of severe abdominal pains, of a bearing-down character, and of 
a sense of fulness in the epigastric region. She had been 
married seven years, but had never been pregnant, and laughed 
at the possibility. For the past three years the menstrual flow 
had been decreasing in amount, and for several months past had 
been very scant. The breasts were slightly enlarged, but the 
areolae were not darkened. The glands of Montgomery were 
a little more prominent than normal. She had suffered from 
morning vomiting for the past month. 
I was hastily summoned to see the patient on the morning of 
February 2d, and found her in a state of collapse, pulseless, and 
with a temperature of 96.4°. She reacted to active stimulation 
and was sent to the German Hospital for immediate operation, 
a diagnosis of ruptured extra-uterine pregnancy of the tubal 
variety having been made. Upon admission her pulse and tem- 
perature were normal. She did not complain of pain. Exami- 
nation of the abdomen and per vaginam and rectum failed to 
reveal any mass, although a circumscribed area of flatness 
could be demonstrated low down and to the right side. She 
continued in this condition until February 12th, when at her own 
request she was discharged. On February 23d she was read- 
mitted at Dr. Ingraham’s earnest request. At the time of th$ 
second admission the abdomen was markedly distended, being 9 
tympanitic above and flat below. Pulse 116, temperature 101.50. 
She complained of considerable pain. 
The following day she was operated on, and when the peri- 
toneum was opened a fetus with clots and fresh blood gushed 
out. The ruptured sac occupied the right iliac region, and was 
tightly adherent to the neighboring coils of small intestines, to 
the cecum and to the vermiform appendix. After a prolonged 
and tedious dissection the sac was enucleated ; this was accom- 
panied by very free bleeding, which necessitated packing of the 
cavity with gauze. The wound was closed with the gauze 
packing in situ. The patient died the following day of hemor- 
rhage. 
The immediate effects of an injury severe enough to cause a 
serious lesion of an abdominal viscus are sometimes so slight 
as to be misleading. Very often a patient with such a condi- 
tion will walk to a conveyance or to the hospital, complaining 
only of a slight pain. In varying periods of time following the 
injury more decided symptoms will develop, viz., signs of hem- 
orrhage if the solid organs be involved, and early peritonitis if 
the hollow viscera be ruptured or torn sufficiently to allow their 
contents to escape. When this occurs operation is imperatively 
demanded without delay. This is also true of hemorrhage 
consequent upon the rupture of an extra-uterine pregnancy, be 
it traumatic or spontaneous. In ectopic gestation operation will 
be necessary in every case at some period of its history; there- 
fore, if a diagnosis can be made, or even a well-founded suspi- 
cion of the condition exists, rupture should not be allowed to 
occur. If rupture does occur, however, immediate interference 
is the only certain means of saving the patient’s life. The 
longer the operation is deferred the greater the risk to life. 
Hasty operations, often necessitated by the patient’s condition, 
are likewise less liable to reach a favorable termination. Blood 
clots or intestinal or gastric contents cannot be washed out 
of the peritoneal cavity except by prolonged and repeated 
flushing. 
The almost universal fatality of intra-abdominal lesions of 
traumatic origin is so well recognized that it seems as if there 
could hardly be any question as to the wisdom of opening the 
abdominal cavity. I would not be understood as meaning that 
abdominal section should be used as a means of diagnosis, but 
on the contrary I believe that every known means, with atten- 
tion to the most minute details, should be exhausted in estab- 
lishing a diagnosis. When a diagnosis is impossible abdominal 
section is justifiable only when it becomes the last and only 
chance for the patient. 
I have refrained from using the terms exploratory and diag- nostic incisions, believing that they not infrequently serve as a 
shield to cover a lack of diagnostic ability. It is a moral obli- 
gation resting upon every physician and surgeon to develop to 
the utmost of his ability the highest diagnostic attainments 
Aseptic surgery has undoubtedly been one of the greatest 
boons to humanity that this nineteenth century has brought 
forth. But to me it seems that it affords a great temptation to 
men who have not had experience and surgical training, and 
who have, therefore, not fully developed their diagnostic skill, 
to do operations which are not necessary for their patients’ 
good or with a scientific precision.