PAIN IN THE TESTICLES A SYMPTOM OF RETROPERITONEAL TRAUMATIC RUPTURE

OF THE DUODENUM*

EDMUND BUTLER, M.D., AND EVERETT CARLSON, M.D.

SAN FRANCISCO, CALIF.

T HIS case report is of interest not onIy on account of the Iocation of the Iesion but because of the characteris-

tic diagnostic symptoms, which are not

mentioned in the literature.

The patient, a twenty-four-year oId maIe, was struck in the upper abdomen by the steer- ing whee1 of his automobiIe when it coIIided with a teIephone poIe. He was apparentIy uninjured, though intoxicated, and walked home from the accident. During the night he was awakened by gripping pains in the upper abdomen and terrific acute pain in both testicIes.

Nine hours after the accident he entered the San Francisco HospitaI and on examination, there was found extreme rigidity and tender- ness of the entire abdomen with the area of greatest tenderness in the epigastrium. Recta1 paIpation revealed emphysema of the tissues of the pelvis, the crackles being easiIy eIicited. The puIse was of good quaIity; bIood pressure was 90/65; red bIood count 4,400,000; hemo- gIobin 83 per cent; white bIood count 4300; with 46 per cent poIymorphonucIears, 32 per cent smaII Iymphocytes, and 22 per cent Iarge Iymphocytes. A diagnosis was made of trauma- tic rupture of the bowe1, and the patient was taken to the operating room.

A right paramedian incision was made and a considerable quantity of gas or air was found between the transversaIis fascia and the peri- toneum. Within the peritonea1 cavity there was a Iarge quantity of biIe-tinged, hemorrhagic exudate, the coIon and smaII bowe1 were cya- notic, congested and sIightIy distended. No perforation was found.

The incision was then extended superiorIy and the stomach and pancreas found to be uninjured. A discoIoration and edema of the peritoneum in the region of the descending and transverse duodenum attracted attention to this structure. When the peritoneum to the right of the descending duodenum was opened, a rent in the posterior waI1 of the third portion of the duodenum was found. The retroperi- tonea tissues were deepIy biIe-stained, and fat necrosis was present. The wound in the duo- denum was repaired and two cigarette drains Ieft in the retroperitonea1 region. An enter- ostomy was then done high in the jejunum. The abdomen was fiIIed with warm sahne soIution and cIosed. The patient died the foIIowing day.

CONCLUSIONS

I. The presence of gas or air in the peIvic tissues that can be paIpated by rectum is indicative of a retroperitoneal tear in an air or gas containing viscus.

2. When, upon making an abdomina1 incision, gas or air is found between the

peritoneum and transversaIis fascia in a patient suffering from an injury a retro-

peritoneal rupture of a hoIIow viscus

shouId be suspected. 3. EarIy excruciating pain in the testicIes

foIIowing a severe trauma to the upper abdomen indicates a retroperitonea1 rup- ture of the duodenum with a spreading out of biIe beneath the peritoneum so as to irritate the testicuIar nerves, the sympathetic chain accompanying the sper- matic artery.

* Submitted for pubIication May 16, 1930.

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