Diagnosis and Management of Blunt Abdominal Trauma JOE JACK DAVIS, M.D., ISIDORE COHN, JR., M.D., FRANCIS C. NANCE, M.D.
The records of 437 patients with blunt abdominal trauma admitted to Charity Hospital, New Orleans, from 1967-1973 have been reviewed and computer-analyzed. There was an 80% increase in the incidence of blunt abdominal trauma when compared with the preceding 15-year experience. Forty-three per cent of all the patients presented with no specific complaint or sign of injury. Blunt abdominal injury was usually diagnosed preoperatively using conventional methods including history, physical examination, and routine laboratory tests and x-rays. Abdominal paracentesis via a Potter needle had an 86% accuracy. The incidence and management of specific organ injuries with associated morbidity and mortality have been discussed. Mortality and morbidity continue to be significant in blunt abdominal- trauma. Isolated abdominal injuries rarely (5%) resulted in death, even though abdominal injuries accounted for 41% of all deaths. Associated injuries, especially head injury, greatly increased the risk. The insidious nature of blunt abdominal injury is borne out by the fact that more than one-third of the "asymptomatic" patients had an abdominal organ injured. A high index of suspicion and an adequate observation period therefore are mandatory for proper care of patients subjected to blunt trauma.
(BAT) is seen with inin rooms and conemergency creasing frequency tinues to be associated with significant morbidity and mortality in spite of its improved recognition, diagnosis, and management. Since 1951, almost a thousand patients with BAT have been treated at Charity Hospital, New Orleans (CHNO)-almost half of these since 1967. Our 22-year experience has been reviewed to establish patterns of injury and to assess the results of management. On the basis of this experience it is possible to describe the most accurate and efficient means to establish a diagnosis, the diagnostic and operative procedures with the best results, and the associated morbidity and mortality. Specific questions which have been asked B LUNT ABDOMINAL TRAUMA
Presented at the Annual Meeting of the Southern Surgical Association, December 8-10, 1975, The Homestead, Hot Springs, Virginia.
From the Department of Surgery, Louisiana State University School of Medicine, 1542 Tulane Avenue, New Orleans, Louisiana 70112
include: 1) What was the major indication for operation in each case? 2) Did delays in getting the patient to the operating room affect the outcome? and 3) To what was death attributable in fatal cases? All cases of BAT treated since 1966 at CHNO were studied and information from each chart was tabulated for computer analysis. Clinical Material During the 15-year period from January 1, 1951 through December 31, 1966, 518 patients were treated for BAT at CHNO. These patients have been reported previously by DiVincenti et al.4 and will not be included in the present review except for purposes of comparison. In the 7 years from January 1, 1967, through December 31, 1973, the general surgery service treated 437 patients for BAT at CHNO-almost twice the frequency experienced during the preceding 15-year period. This review did not include a substantial number of patients with "renal contusion," since these patients were admitted and managed by the urology service and usually did not present a significant diagnostic or therapeutic problem. The 305 males (70%) and 132 females (30%) ranged from infancy to 85 years of age (Fig. 1). Seventy-six per cent of the patients were less than 45 years old; 22% were in the pediatric age group. Automobile accidents accounted for 70% of the injuries: 215 passengers and 90 pedestrians with 62% of the pedestrians being in the pediatric age group. Blows to the abdomen (17%) and falls (6%) were the next most frequent causes of BAT. Motorcycle accidents were not a significant etiologic factor among this patient population.
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BLUNT ABDOMINAL TRAUMA
FIG. 1. Age distribution of 437 patients with blunt abdominal trauma.
673 additional 88 (20o) had micro-
patients (16%), and an hematuria. One hundred-eight patients (25%) had abnormal findings on routine chest x-ray, including 42 (9.6%) with rib fractures, 44 (10%) with hemothorax, pneumothorax, or both; and 9 (2%) with an elevated diaphragm or with abdominal viscera in the chest cavity. Mediastinal widening was seen in only one patient, and none had mediastinal shift. Routine films of the abdomen were abnormal in 49 (21%) patients. Abnormal findings included free intraperitoneal air in 13 (6%) patients, absent psoas shadows in 10 (4%) patients, and ileus, or dilatation of bowel in 12 (6%) patients. Findings reported by other but not noted in this series include evidence of free fluid, absent or abnormal renal shadows, retroperitoneal emphysema, and displacement of normal gas patterns. In patients presenting with hematuria and in most of those patients suspected of having injury near or involving the genitourinary tract, intravenous pyelograms were obtained. Cystograms were obtained in some of these patients and in virtually all who had hematuria with accompanying pelvic fractures. The IVP was abnormal in 34 (22%) patients. Cystography was abnormal in 15 patients (14%). Abdominal paracentesis using the Potter needle was performed in 192 patients (44%). Correct results (positive or negative), as determined by subsequent laparotomy, were obtained in 86%.
Generalized abdominal tenderness and abdominal guarding were the most frequent physical findings, both signs being present in more than 75% of all patients. Rebound tenderness and abdominal rigidity were present in 28% of patients. Twelve per cent of the patients were in hypovolemic shock on admission. Rectal examination rarely gave abnormal findings such as pain or blood (3%). Both rectal examination and nasogastric aspiration should be performed on any patient suspected of intra-abdominal injury, since even negative results aid in diagnosis. One hundred and ninety (43%) of the total patient Associated Injuries population had no specific complaints and no signs or symptoms of intra-abdominal injury when they were first Associated extra-abdominal injuries were encountered seen in the emergency room. Nevertheless, 84 (44%) eventually required exploratory laparotomy, and 64 (34%) frequently (Table 1). These tend to increase morbidity had an intra-abdominal injury. This emphasizes the im- and mortality directly, and indirectly by distracting portance of careful and continuing observation of indi- attention from the abdominal injury. One hundred-twenty (27%) of the 437 patients had viduals with BAT. blunt chest trauma. Thirty-seven patients required either tube thoracostomy or operative thoracotomy. Ten died Diagnostic Procedures (4 of 6 requiring thoracotomy, and 6 of 31 requiring Diagnostic procedures included laboratory tests, x-ray chest tube insertion), a mortality rate of 27% in patients requiring both abdominal and thoracic procedures. examination, and abdominal paracentesis. Fifty-one patients (11%) sustained an associated exOnly 28 patients had a hematocrit less then 30% on admission. Grossly bloodly urine was present in 71 tremity fracture, 15 (3%) sustained pelvic fractures, and TABLE 1. Associated Injuries and Operations
Death Attributable to Abdominal Injury
41 120 69 28 258
6 37 26 8 77
20%o 40% 20%
Operation in Addition Injury Head Thoracic
Orthopedic Combinations Total
19%o 25% 29%
DAVIS, COHN AND NANCE
operative methods for managing the traumatized
TABLE 2. Associated Head Injury Number
Per cent Mortality
14 17 10 41
5 9 7 21
36 53 70 51
liver,17'22 postoperative complications occurred in 40% of
The spleen was the organ injured most frequently (Table 3), almost '6 of the injuries occurring as an isolated intra-abdominal organ injury (Table 4). The overall mortality was 20% for patients with blunt splenic trauma. When the spleen was the only abdominal organ injured, the mortality dropped to 3%. All patients with splenic injury had splenectomy. Approximately ½3 had drains placed in the left subphrenic space. Drains have been avoided if the splenic bed is dry and the gastrointestinal tract is intact.2 The mortality figures for splenic injury compare closely with those of Naylor et al.12 The 20% mortality is an improvement (P < 0.001) from the 28% reported by DiVincenti et al.4 The liver sustained the second greatest number of injuries, slightly more than half as an isolated injury. Blunt liver trauma has always been associated with a high morbidity and mortality rate. In spite of improved
our patients. The overall mortality rate of 29o for patients with liver injuries is similar to other reports,10'17'22 but is a marked improvement over the 49% mortality reported by DiVincenti et al.4 Only 7 duodenal injuries were recognized during the 7-year study period. There was a 50% postoperative complication rate and one death. The single death was the result of sepsis directly related to the abdominal injury. Blunt duodenal trauma rarely occurs as an isolated injury, and this in part accounts for a continuing mortality rate of 20-26% and a high morbidity rate.1'3'19 Retroperitoneal duodenal injury may be overlooked because of associated intra-abdominal injury.3 The surgical approach to duodenal injuries should include debridement, primary repair, and drainage in most patients. The jejunum or ileum was injured in 34 instances with a 15% overall mortality. No deaths occurred when the jejunum or ileum was the only abdominal organ injured. As noted in other reports,14'21 jejunal or ileal trauma was usually located near the points of attachment at the ligament of Treitz and the ileocecal valve. The majority of patients were treated with suture repair, but approximately ½3 required resection of injured bowel. More than half the survivors of these injuries had postoperative complications directly associated with their abdominal injury. Kidney and bladder injuries frequently were associated with pelvic fractures and retroperitoneal bleeding. The overall mortality for kidney and bladder injuries was l9o, and was attributable to the associated severe crush injury, multiple organ injuries, and retroperitoneal hemorrhage. Retroperitoneal bleeding has been approached on a selective basis. Upper abdominal retroperitoneal hematomas above the pelvic brim are explored routinely. Nonexpanding pelvic hematomas in stabilized patients are not opened. 16 In the present report slightly more than
TABLE 3. Abdominal Organs Injured
TABLE 4. Isolated Abdominal Organ Injuries
Closed head injury Skull fracture Closed injury, fracture (Comatose) Total
three patients sustained vertebral fractures. Another 28 (6%) had combinations of associated injuries. Of the 41 patients who sustained a serious head injury in addition to BAT (Table 2), 51% died. The head injury was directly responsible for death in 4/5 of these patients, and the abdominal injury was responsible for death in the remaining 1/5. Seven of 10 patients who were comatose on admission died, a figure comparable to that reported by DiVincenti et al.4 Management of Specific Injuries
Spleen Liver Jejunum, Ileum Kidney Bladder Mesentery Right colon Left colon Pancreas Duodenum Gallbladder Diaphragm Stomach
108 72 34 30 17 15 10 10 8 7 6 6 6
22 21 5 4 5 1 2
Organ (Total Injuries)
5 3 1 5 3 0
67 37 15 15 12 8 4 3 2 1 1 165
15% 13% 29% 7% 20% 50% 38% 14% 83% 50%
Liver (72) Jejunum, Ileum (34) Kidney (30) Urinary bladder (17) Mesentery (15) Left colon (10) Right colon (10) Pancreas (8) Gallbladder (6) Stomach (6) Total (316)
40%o 30%o 25% 17% 17% 53%
Deaths Attributable to Abdominal Injury 2 (3%) 5 (14%) 0 0 1 (8%) 0 0 0 0 0 0 8 (5%)
VOl. 183 . NO. 6
BLUNT ABDOMINAL TRAUMA TABLE 5. Complications
Cardiovascular-Pulmonary Intra-abdominal Wound Urinary tract
126 75 23 22
Per cent Total Patients
in 22 patients, including 7 who developed varying degrees of renal failure.
Mortality In addition to the 15 patients who died in the emergency room, 3 (2.6%) died following nonoperative management, and 40 patients died after operation (Table 6). 105 of 229 postoperative survivors (46%) developed one or more com- This represents a postoperative mortality of 14.8% plications. and an overall mortality of 13.3%. 29% 17% 9% of operated cases 5%
half were explored and drained. The remainder were left intact. External counterpressure" was not utilized during the period under study, but has been employed recently with success in at least two cases. Twenty patients sustained colon injuries with a mortality rate of 35%. Five of the 7 deaths occurred after left colon injuries. Colon injuries usually occur in association with other abdominal organ injury8'9 and the mortality rate is related directly to the number of organs injured. Proximal colostomy was the usual method of management of colon injuries. Of the 8 patients who sustained blunt injury to the pancreas, 3 died, 2 from uncontrolled hemorrhage and one from sepsis. Neither of the 2 patients with isolated pancreatic injury died. Blunt pancreatic injury should be managed by debridement of all nonviable pancreatic tissue coupled with wide drainage, as recommended by Northrup.13 The significant complication rate previously reported from CHNO by Smith and Drapanas18 was duplicated in our experience. Only one patient survived without complications. Morbidity Of the 229 postoperative survivors, 124 (54%) recovered without a complication. Cardiovascular and pulmonary complications occurred in 29% (Table 5). Intra-abdominal complications included peritonitis, p&ncreatitis, subphrenic and subhepatic abscess, liver abscess, fistula, delayed postoperative hemorrhage, and intestinal obstruction. Wound infection, progressing to dehiscence in two patients and evisceration in a third, developed in 9%. Urinary tract complications occurred
Forty-three per cent of the patients in this series gave indication other than history that they had sustained BAT. The subtlety with which organ injury can exist secondary to BAT is exemplified by the figures showing that 84 (44%) of these "asymptomatic" patients were eventually explored and 3 out of 4 had an injury which required repair. Proper management of these patients requires careful initial evaluation followed by a period of observation.7 Diagnostic procedures should be limited to those examinations that have proven effective in BAT and should not delay laparotomy in an unstable patient. One should not jeopardize the care of a seriously injured patient by obtaining examinations of low yield. Utilization of this time to initiate resuscitative measures and to prepare for abdominal exploration is of much greater benefit to the patient.6 The patient who has sustained blunt abdominal trauma may have sustained injury simultaneously to other systems, and it is particularly important to examine for injuries of the head, thorax, and extremities. Care of the injuries in any of these systems may take precedence over the abdominal trauma. Failure to recognize an extra-abdominal injury may contribute to the patient's death, when a relatively simple procedure might otherwise have saved the patient's life. The mortality figures presented here provide evidence of the need for close attention to these other injuries (particularly closed head wounds). In addition to a rapid and accurate history and physical examination, including rectal examination, and which gives special attention to the other areas of the body
TABLE 6. Deaths Attributable to Abdominal Injury
Deaths Attributable to Abdominal Injury
Died in emergency room Admitted for observation Negative laparotomy Surgery, no repair necessary Surgery, repair required Total
15 153 40 30 199 437
15 3 2 4 34 58 (13.3%)
6 0 0 2 15 23 (41%)
DAVIS, COHN AND NANCE TABLE 7. Early Management of Patients with Blunt Abdominal Trauma
1. History and physical 2. Intubate: Airway, nasogastric tube, Foley catheter, IV and CVP lines 3. Lab Work: Urinalysis, CBC, amylase, cross-match 4. X-rays: Chest, abdomen, skull, IVP, cystogram, angiogram, extremities (as indicated) 5. Peritoneal aspiration
just mentioned, the initial evaluation should include basic steps listed in Table 7. The chest x-ray will not only call attention to any associated injuries to the chest and mediastinal structures, but should also indicate if there has been a rupture of the diaphragm with the intrathoracic displacement of some of the abdominal viscera. The abdominal films may reveal the presence of air under the diaphragm, evidence of massive retroperitoneal hemorrhage, enlargement of the kidney, enlargement of the splenic shadow, blurring of the psoas shadows or retroperitoneal air, any one of which should hasten surgical intervention. When hematuria is present, IVP can be obtained while the patient is in x-ray. Once x-rays have been obtained, paracentesis or lavage can be performed where indicated. The trauma center providing initial care ought to be capable of providing any of the listed procedures within a few minutes of a patient's admission to the unit. Abdominal paracentesis, using a Potter needle for either a four-quadrant tap, or a bilateral flank tap proved to be very accurate in assessing the presence of intraperitoneal blood. An abdominal paracentesis was performed on 75 of the 190 patients who originally had no signs or symptoms of injury, and a correct diagnosis was confirmed by subsequent operation in 88%. Paracentesis can be performed rapidly with minimal delay and requires no specialized equipment.5 If positive, the test is highly reliable. Peritoneal lavage15'20 provided the correct diaFnosis in 4 patients for whom it was used. The surgeonf's justification for operation was apparent in all but 9 of the 269 operated cases. The most common indication for operation (45% of those operated upon) was a positive finding on one or more of the diagnostic procedures already discussed. An additional 105 patients (39%) were explored because of physical findings.
Twenty-eight patients (10%) had a laparotomy because of severe hypovolemic shock. The remaining 9 were operated on for miscellaneous reasons. In 95% of the operated cases the managing physician was able to make a preoperative diagnosis using physical findings or one or more of the relatively simple diagnostic procedures described previously. In only 15% was the exploration negative. Only when diagnosis is uncertain are more sophisticated diagnostic methods needed. The time lapse between injury and induction of anesthesia was calculated for each patient, and physician or patient delays were noted. There was no significant difference in morbidity or mortality in the group of patients whose operation was delayed, regardless of the reason. The cause of death was attributable to the abdominal injury in 41% of cases. Associated injuries, especially head trauma, were responsible for the remainder of the fatalities. In patients requiring multiple procedures, the abdominal injury was the cause of death in 27% of cases. If only a single abdominal organ was injured, it was infrequently the cause of death. The overall mortality rate of 13.3% represents an improvement (P < 0.001) when compared with the 23% reported by DiVincenti et al. (Table 8). Central venous pressure monitoring, improved methods of prevention and management of post-traumatic respiratory insufficiency, and a decreased incidence of associated head injury during the latest study period undoubtedly accounted for some of the improvement. References R., Howell, J. F. and Jordan, G.: Traumatic Duodenal An Analysis of 86 Cases. J. Trauma, 1:96, 1961. J., Pierce, W. A. and Diamond, D. L.: Abdominal Their Role as a Source of Infection Following Splenectomy. Ann. Surg., 171:764, 1970. Cohn, I., Jr., Hawthorne, H. R. and Frobese, A. S.: Retroperitoneal Rupture of the Duodenum in Non-penetrating Abdominal Trauma. Am. J. Surg., 84:293, 1952. DiVincenti, F. C., Rives, J. D., Laborde, E. J., et al.: Blunt Abdominal Trauma. J. Trauma, 8:1004, 1968. Drapanas, T. and McDonald, J.: Peritoneal Tap in Abdominal Trauma. Surgery, 50:742, 1961. Fitzgerald, J. F., Crawford, E. S. and DeBakey, M.D.: Surgical Considerations of Non-penetrating Abdominal Injuries. Am. J. Surg., 100:22, 1960. Haynes, C. D., Gunn, C. H. and Martin, J. D., Jr.: Colon Injuries. Arch. Surg., 96:944, 1968.
1. Burrus, G. Injuries: 2. Cerise, E. Drains: 3.
TABLE 8. Mortality
Died in emergency room Nonoperative management Operated Total
153 269 437
15 3 40 58
2.0% 14.8% 13.3%
106 359 518
53 18 49 120
BLUNT ABDOMINAL TRAUMA
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12. 13. 14.
lsaacson, J. E., Jr., Buck, R. L. and Kahle, H. R.: Changing Concepts of Treatment of Traumatic Injuries of the Colon. Dis. Col. Rectum, 4:168, 1961. Kirkpatrick, J. R. and Rajpal, S. G.: The Injured Colon: Therapeutic Considerations. Am. J. Surg., 129:187, 1975. Lucas, C. E. and Walt, A. J.: Critical Decisions in Liver Trauma: Experience Based on 604 Cases. Arch. Surg., 101:277, 1970. McLaughlin, A. P., III, McCullough, D. L., Kerr, W. S., Jr. and Darling, R. C.: The Use of External Counterpressure (G-suit) in the Management of Traumatic Retroperitoneal Bleeding. J. Urol., 107:940, 1972. Naylor, R., Coln, D. and Shires, G. T.: Morbidity and Mortality from Injuries to the Spleen. J. Trauma, 14:773, 1974. Northrup, W. F., III and Simmons, R. L.: Pancreatic Trauma: A Review. Surgery, 71:27, 1972. Orloff, M. J. and Charters, A. C.: Injuries of the Small Bowel and Mesentery and Retroperitoneal Hematomas. Surg. Clin. North Am., 52:729, 1972. Perry, J. F., Jr., DeMeules, J. E. and Root, H.D.: Diagnostic
17. 18. 19.
20. 21. 22.
Peritoneal Lavage in Blunt Abdominal Trauma. Surg. Gynecol. Obstet., 131:742, 1970. Quinby, W. C., Jr.: Pelvic Fractures with Hemorrhage. N. Engl. J. Med., 284:668, 1971. Schrock, T., Blaisdell, F. W. and Mathewson, C., Jr.: Management of Blunt Trauma to the Liver and Hepatic Veins. Arch. Surg., 96:698, 1968. Smith, A. D., Jr., Woolverton, W. C., Weichert, R. F., III and Drapanas, T.: Operative Management of Pancreatic and Duodenal Injuries. J. Trauma, 11:570, 1971. Roman, E., Silva, Y. J. and Lucas, C.: Management of Blunt Duodenal Injury. Surg. Gynecol. Obstet., 132:7, 1971. Thal, E. R. and Shires, G. T.: Peritoneal Lavage in Blunt Abdominal Trauma. Am. J. Surg., 125:64, 1973. Thorlakson, R. H.: Rupture of the Small Intestine Due to Nonpenetrating Abdominal Injuries. Canad. Med. Assoc. J., 82: 989, 1960. Trunkey, D. D., Shires, G. T. and McClelland, R.: Management of Liver Trauma in 811 Consecutive Patients. Ann. Surg. 179:722, 1974.
gation to produce involvement of most of the mesenteric
DR. WILLIAM S. MCCUNE (Washington, D.C.): I rise to reemphasize a complication of blunt trauma which is not often included in a discussion of this subject, and that is mesenteric thrombosis. The interesting thing about this particular complication is that it may not be suspected, and can occur from one to two months following the original injury.
(Slide) Our interest in this began several years ago, when a woman office complaining of abdominal pain. It was not very severe. She was a little bit obtunded mentally. She had some abdominal tenderness, not very specific; she might possibly have a little intra-abdominal fluid. The story is that three weeks previously she had attended a dance, and her partner in the course of the dance threw his arm around her from behind and lifted her, kicking, high in the air. On the following day she went to see her doctor, who said, "You have a little muscle strain. Don't worry about it", and gave her some medication. But apparently it continued, rather naggingly, and so she came in to see us. We gave her the usual diagnostic tests, including an upper g.i. series, a gallbladder series, and a barium enema. But finally, not having a diagnosis, we recommended operation. At surgery she had a gangrenous loop of bowel, which you see depicted in this drawing, about 12 inches below the ligament of Treitz, with thrombosis extending into the mesentery, where it had undoubtedly begun. We resected the bowel, and also the grey area surrounding it, and she did well for about six days, when she again complained of abdominal pain. (Slide) At operation another area of gangrenous bowel was found separated from the first by several inches. Apparently, in removing the mesentery at the first procedure, we had failed to take it back far enough, so that the thrombosis in the mesentery proceeded out a little farther and involved another loop of bowel, separated from the first. (Slide) This was resected, and she was given anticoagulants, which we probably should have used at first. There is a case in the German literature, of a patient who was involved in an altercation in a railway station and thrown against the steps of a train. He had some abdominal trauma, but he got up, vomited a couple of times, and continued on his way. One month later he developed severe abdominal pain, and was operated upon and found to have extensive mesenteric thrombosis. In the post-mortem following his death, the clot in the mesentery was followed back to a well-organized thrombosis in the ileocolic vein, indicating, apparently, the site of his original injury, with gradual propacame into our
We have also found that in inflammatory intraabdominal conditions, the platelet count in the mesenteric blood may be from 1 million to 2 million, as compared with a normal platelet count in the peripheral blood. Thus any trauma, even operative trauma, such as rough packing, and so forth, is more apt to produce mesenteric thrombosis, if there is an inflammatory condition with it. The main points I want to make are that mesenteric thrombosis following trauma often occurs late, when the patient is apparently recovered; secondly, that enough mesentery must be removed to prevent an extension of the thrombosis to another area.
DR. RICHARD J. FIELD (Centreville, Mississippi): Several years Dr. Raymond Martin and 1, who is here today, reviewed 44 cases of retroperitoneal duodenal injury in blunt trauma of the abdomen. want to take you quickly through three points that we thought were very important in this rare-as there were only seven in Dr. Cohn's groupbut very tragic problem. (Slide) The first point is, as he pointed out, with many of the blunt trauma areas of the abdomen, there are very few symptoms which occur early in this problem. There may be none at all, as I am sure you do know. These are fundamental, simple slides, but I want to remind you of this injury, because it is so terribly dangerous. (Slide) The next point is how simply it can occur. As you know, the duodenum is essentially a soft-tissue tube which is partially closed at the distal end, by the ligament of Treitz, and the proximal end by the pyloric sphincter, which filled with gas and fluid, thus a very small force can rupture this tube. If you watch football like I do, it's amazing that all running backs don't have retroperitoneal rupture of the duodenum. (Slide) This slide is simply a diagrammatic description of the hard surfaced vertebra. This portion (indicating) of the duodenum is impinged upon, and six to eight pounds can very easily produce a laceration. (Slide) The high mortality rate which is frequently found is directly related to how long we wait to operate, which is, of course, directly related, as Dr. Barnett mentioned a while ago, in gangrenous bowel, to the index of suspicion of the surgeon. Thus our three points are: How easily it can occur, how few symptoms one has with this, and how important the index of suspicion of the surgeon is. Dr. Jonathan Rhoads spoke of gangrenous bowel as a very vexing problem a few moments ago. I would leave you with the thought that retroperitoneal rupture of the duodenum is a very bewitching problem, and it can only be conquered by a high index of suspicion and prompt action. ago,