[Illustration: FIG. 526

Recurrent carcinoma eight months after incomplete operation in a woman

seventy-five years of age, showing the extensive nodular, ulcerating

surface surrounded by cancerous masses under the skin. The edema of the

right arm from the circulatory obstruction occasioned by metastatic

growths about the axillary vessels is well shown. (Parker.)]

_Recurrence_ is to a large extent inseparably connected with the matter

of both _early and thorough removal_. Only when this can be practised

should any hope of radical cure be offered. While the results attained

by modern methods are very encouraging, they nowise contradict this

statement. The discreet operator will, therefore, be guarded in giving

a favorable prognosis or making promises. Fig. 526 illustrates many of

the sad features pertaining to recurrence.

OPERATIONS UPON THE BREAST.

Every precaution having been taken the operator should decide whether

the operation is to be enucleation of the tumor or complete excision

of the breast, with dissection of the axilla. An evidently innocent

tumor of small size may be removed, either through a straight incision,

which should be placed radially, or by raising a flap with an ovoid

incision, by which more perfect dissection is permitted. Small nodules

and superficial growths may be removed under cocaine anesthesia. The

first essential is to leave behind nothing of the mass which it is

desired to remove; the second is exact hemostasis, and the third is

the closure of the wound. It is possible to remove portions of the

gland itself, as well as to enucleate tumors from within its substance.

V-shaped incisions may be coapted with sutures, by which the size of

the gland is reduced, but its general proportions maintained. Tumors

situated posteriorly may be removed by making an incision beneath the

breast, around its border, raising it from the thorax, and returning

it to place after the necessary excision. It is advisable to provide a

small drain for these cases, as in the more or less loose tissues of

the breast blood is likely to accumulate, and by distending the wound

to interfere with its repair.

_Operations for cancer of the breast_ are performed more radically

than a few years ago. This is due to a more thorough knowledge of the

pathology of the disease, and to the better appreciation of the value

of thorough extirpation of all affected tissues, especially if this

can be done _early rather than late_. Therefore the modern operation

includes not only the removal of the breast and of the axillary

nodes, but of the pectoral fascia and muscle, the fatty tissue in the

neighborhood, and everything in which the disease may lurk.

The essential feature, then, of every case is the _removal of all

tissue which may be involved_. It is therefore necessary to remove the

skin covering the mamma, as well as the structures above mentioned.

This is done by elliptical or ovoid incisions, the amount thus included

being sufficient to take in every particle of skin which shows the

slightest possibility of infection--_i. e._, every nodule or dimple

which may be in any way connected with the primary disease. Inasmuch as

only in cases seen early is it at all safe to be less radical than just

mentioned the pectoral fascia and muscle should be removed. For these

purposes large and long incisions are necessary, extending from the

anterior border of the axilla down toward the costochondral junction,

while the lower part of the opening is divided and the incision made

elliptical, in order that the breast, with its coverings, may be

completely removed. The upper end should follow the lower border of the

pectoral tendon, or at least be placed near it, extending as far as the

insertion of this tendon, since that portion belonging to the muscle

excised should be divided at its insertion and removed with the rest of

the mass. The incisions then are usually carried down first to the deep

fascia, and then through this, in such a way that the underlying muscle

may be lifted from the thorax and detached therefrom. The result is

that there is dissected from the chest wall a total mass of gland, fat,

fascia, and muscle, which is continuous upward and outward toward the

axilla, from which the final dissection is made. Then, commencing on

the outer side of the axilla, so much of the pectoral tendon is divided

as may be necessary; close beneath it will be found the axillary vein,

and this is next to be freed from its cellular and fatty surroundings.

The dissection is now carried toward the deeper part of the axilla,

vessels being secured before division, and the entire contents of the

axilla being carefully removed in one continuous mass. This requires

careful and sometimes tedious dissection, which is made much easier by

exact hemostasis. If the greater part of the great pectoral muscle be

removed, complete exposure of the axilla is easier. When this is not

sufficient, because in the uppermost portion of the axillary cone may

be felt enlarged lymph nodes, at the level of or beneath the clavicle,

then the lesser pectoral should be divided at its middle, and its ends

held apart, this affording a still better exposure of the axillary

depths. By this measure the vessels and plexuses may be easily followed

up to the level of the emergence of the former from the thorax,

especially if the arm be held upward and forward, much depending upon

the position in which the assistant thus holds it.

Everything which is actually involved should be sacrificed. This

might even apply to the axillary vein, which may be doubly ligated

and exsected. It will occasionally happen that it is cut or torn in

some deep dissection. In this event, before resorting to final double

ligation, an effort should be made to suture the opening with fine silk

sutures passed with a round needle, which may be successfully done,

or to secure a small tear within the jaws of a curved hemostat, may

then be left within the dressings for forty-eight hours or longer; by

this time a clot will have formed which will permit its detachment.

While much work may thus be done upon the axillary vein the writer

nevertheless has the feeling that when a case is advanced to such a

degree as to demand this it is scarcely worth while, because recurrence

is practically sure to follow. Nevertheless in the interest of general

thoroughness, if the work has been begun, it is usually well to finish

it as completely as possible.

[Illustration: FIG. 527

Diagram showing skin-incisions: triangular flap of skin, _a_ _b_ _c_,

and triangular flap of fat. (Halsted.)]

[Illustration: FIG. 528

Breast and pectoral muscle completely separated from thorax; axilla

exposed. (Halsted.)]

The operation as thus described has been extended by Halsted to a

degree which requires often much more work, and which has furnished

even better results, since he includes in it, if necessary, the

removal of both pectoral muscles, and even the division of the clavicle

for better exposure of the axillary and lower cervical regions,

and the more thorough extirpation of involved lymphatics. In other

cases he makes a vertical incision along the posterior margin of the

sternomastoid, exposing the junction of the internal jugular and

subclavian veins, and removes the supraclavicular fat by a downward

dissection and the infraclavicular fat by a dissection from below. This

is facilitated by elevating the shoulder, by which the clavicle can be

removed one inch or more from the first rib.

Figs. 527 and 528 illustrate the incision recommended by Halsted and

the general method of attack.

Throughout these operations the primary question is removal of disease,

the matter of subsequent closure of the wound being a secondary

consideration. Nevertheless the extirpation being completed, there

arises the question of how best to close the extensive defect thus

created. This will depend on its size and upon the amount of loose

skin in the vicinity furnished by the patient’s general physique. With

emaciated patients, whose skin is tightly drawn, it is not easy to

furnish flaps, whereas in those who are fatty, with flabby flesh and

skin, it is easy to rearrange the latter. Beck has suggested to make

quadrilateral instead of elliptical incisions, leaving a square defect,

which can then be closed by sliding flaps from two directions. The

names of Warren and Meyer are also connected with elaborately described

plastic operations. Years before any of these were published the writer

was doing similar sliding of flaps, but never endeavoring to make them

conform to a single pattern, raising semilunar flaps, or those of any

other shape, as might best fill the demand, and taking them from that

portion of the thorax, side, or even the abdomen, which would seem best

to furnish them. There is, therefore, no one method to be especially

recommended, for every operator of good judgment will be able to secure

sufficient integument from some surrounding location, so that it is

rarely necessary to leave such a wound uncovered. In those cases which

require an amount of dissection not permitting this it is a question

if operation be advisable. Nevertheless should it happen that for

some reason a sufficient skin covering is not thus easily available,

Thiersch skin grafts may be applied to any uncovered area at the time

of terminating the operation or later, and may be nearly always relied

upon for their destined purpose.

At least one opening should be made in the lateral flap in such a

location as to drain the axillary cavity when the patient is lying upon

her back, and through this a drainage tube of sufficient size should

be inserted. This should rarely be left more than forty-eight hours.

Inasmuch as there will sometimes be considerable tension upon flaps

a certain number of strong and reliable sutures (silkworm or thread)

should be used, to prevent parting of the wound margins, while long

retention sutures may be inserted if required. The balance of the

suturing may easily be done with catgut. The intent should be to leave

no dead spaces. Any isolated mass of fat which stands out by itself

after the dissection is complete should be pared down to the common

level, in order that it may not perish from ill-nutrition, nor disturb

the general level of the adjoining surfaces. It is rarely necessary to

keep patients in bed more than two or three days after even extensive

operations of this kind, but it is necessary to ensure that equable

pressure be made with the dressings, and that the entire arm be bound

to the side and immobilized in such a way that the patient cannot move

it nor disturb the dressing.

CHAPTER XLV.

THE ABDOMEN AND ABDOMINAL VISCERA.

GENERAL CONSIDERATIONS AND CONDITIONS.

That large portion of the human body which with its contents we term

the abdomen was for a long time _terra incognita_ to the surgeon.

Despite the sporadic success of such men as McDowell and others there

was felt, until the latter part of the last century, a universal and

well-merited fear of intrusion upon the peritoneal cavity, because

of the tremendous probabilities of infection and fatal peritonitis.

Until the memorable researches of Lister and the introduction of an

antiseptic, later of an aseptic technique, there was, therefore, the

best of reason for regarding the abdominal cavity as a sanctum to be

entered only when dire necessity required. In spite of the complexity

of its anatomical arrangements, as well as the peculiar and widespread

ramifications and connections of its vessels and its sympathetic

and spinal nerves, with the almost innumerable complications thus

permitted and favored, and the resulting uncertainty of symptoms

and distant disturbances of function, the abdominal cavity became,

first, a favorite seat for laboratory study and experiment, and then

a fascinating field for surgical endeavor. Today this region is

invaded by the surgeon in a manner and with a freedom which would have

been criminal and unjustifiable when the writer of these pages was

a student; and yet, while we have in the main lost our fear of the

peritoneum and our dread of peritonitis, we nevertheless see the latter

occur now and again, as it were as a punishment for forgetfulness or

inattention, the patient unfortunately paying the penalty for the

errors of which he is not guilty. Abdominal surgery has now become a

specialty which has attracted too many of those not thoroughly fitted

by training and by experience. One hears today of many, the older

practitioners especially, insisting that the abdomen is too often

opened; perhaps it would be more just to say that it is opened by too

many. By this expression is meant simply that enthusiasm has not always

been tempered by discretion, and that this is a department of surgery

which has been too enthusiastically cultivated by men who have not

waited to ripen their judgment or perfect their methods. My own feeling

is that not merely large observation should be regarded as an essential

preliminary for such work, but extensive experimentation in a surgical

laboratory; while even here the tyro has to learn, perhaps by severe

experience, that not all human beings can recover after manipulations

which some of the lower animals bear with apparent impunity. Previous

experience as assistant to a skilled operator is of the greatest value.

While uttering this caution we must, at the same time, candidly

acknowledge that accurate diagnosis of deeply seated lesions is by no

means always possible, and that the tendency, especially among the

practitioners of internal medicine, has been, and often is, to waste

valuable time in the application of methods of physical diagnosis, all

of which are valuable, many extremely ingenious, and yet which prove

insufficient or misleading. To give but one illustration--cancer of

the stomach, for instance, is a disease absolutely without a special

symptomatology. If we are to wait for the development of a recognizable

tumor or other features which are unmistakably significant, we wait

until the period for successful surgical attack has nearly or quite

elapsed. Thus rather than permit months of valuable time to be wasted,

it seems to the modern surgeon far more humane to make an early

exploration, in order that he may attack the disease while it has

involved but a minimum of tissue.

The general practitioner has seen himself robbed, as it were, of one

part of the body after another, by the application of this general

principle, until there has developed a feeling of irritation or one

even more pronounced, in certain cases, of rebellion, as it were,

against the cession of this territory to the surgeon; but this is

wrong, and such feeling should not exist. Rather should there take

place the heartiest coöperation between physician and surgeon, while

the operative procedures directed toward the early recognition of

these more or less vague conditions should be regarded more kindly and

the procedures themselves regarded rather in the light of operative

therapeutics. A recognition, then, of the limitations of physical

diagnosis, combined with an earnest desire to do the greatest good to

the patient at the earliest possible time, when cheerfully combined,

and practised by those of ripened experience and cultivated skill, will

redound to the greatest credit of all concerned and afford the greatest

prolongation of human life. It is to be hoped that the day when the

physician shall charge the surgeon with killing his patient, and the

surgeon shall have it in his power to retort that the patient did not

reach him until he was almost dead for lack of surgery, may soon pass

away.

_Diagnosis of abdominal diseases_ requires, first of all, a

comprehensive knowledge of anatomy and physiology, as well as

familiarity with all the methods of biochemical and mechanical

research, on which large volumes have been written, along with a

peculiar tact which in some individuals amounts to a gift, and includes

the cultivation alike of the senses of touch and sight, and the power

of analytical reasoning.

While some of the intra-abdominal lesions may be recognized within a

minute or two, others defy a study prolonged over hours or days. The

general methods to be applied do not differ here from those available

elsewhere, save that they find perhaps an even wider application.

_Transposition of the viscera_ is one of the rare anatomical anomalies

with which we may at any time meet most unexpectedly. This applies

equally well to the thorax and to the abdomen, but the condition is

met with oftener in the latter. It may be met as a surprise or it may

be diagnosticated before operation. In one case upon which the writer

operated for appendicitis he found the thoracic viscera transposed and

the heart upon the right side. The occurrence is so rare as to figure

but seldom in the consideration of a given case, but its possibility

should not be forgotten. Thus acute pain upon the left side, with other

indications of appendicitis, has been known to have an anatomical basis

of this character. It will usually be easy to determine whether the

liver and the spleen have changed places, and if so it may be expected

to find relative rearrangement of all the other abdominal contents.

_Inspection_ should be made with the patient well exposed, in

the dorsal position, divested of clothing, and with fear and

hypersensitiveness allayed as much as possible by tact, and perhaps

even by the administration of some soothing remedy. Inspection should

concern not alone the abdomen but the attitude of every portion of

the body, the character of the breathing, the motility of the chest,

the expression of the face, the degree of muscle spasm, and the fact

whether pain impels the patient to move and toss or to lie quietly. Any

irregularity of abdominal contour, with or without the legs flexed,

should not fail of observation. The cause of any great increase in

normal proportions should be promptly sought and assigned, either to

collection of fat outside of the peritoneal cavity, of fluid within

it, to gaseous distention of the bowels, or to the presence of some

intra-abdominal growth. Any bulging in either side or loin should

also be noted, as the latter may be due to some renal condition. The

existence of a distended bladder should be recognized, while the

appearance of the umbilicus sometimes affords valuable information,

it being flattened in tumor cases or bulging and perhaps containing

fluid in dropsical conditions or tuberculous peritonitis. When the

superficial veins are enlarged it may be felt that there is deep

obstruction to return circulation, which may be often located in the

liver. When the veins of the limbs show the same result it may be

believed that the obstruction is rather of the general circulation

than of the hepatic, and when involving one side alone a unilateral

lesion may be expected. The coexistence of hemorrhoids will indicate

obstruction to the hepatic return, while varicosities of the external

genitals would probably indicate it in the general circulation. Much

importance may sometimes attach to the presence or absence of the

lineæ albicantes, or of those pigmented areas which almost invariably

indicate a previous pregnancy. Fixation of superficial tissues or of

viscera implies either an infectious or a malignant process, while

recognizable local edema may point to a suppurative condition if the

disease be recent and acute, or to venous obstruction if it be old.

_Palpation_ will afford information in proportion to the tactile

sensibility and ability of the observer, and the relaxed, rigid,

collapsed, or distended condition of the patient’s abdomen. It may

afford aid in one case and little or none in another. The value

of what it may reveal is also greatly influenced by the pain and

tenderness which its practise may cause. Its value may also be limited

by hypersensitiveness or reflex contractions, from which some patients

can never voluntarily free themselves. So completely may the value

of palpation be limited or destroyed that every means of producing

relaxation or of abolishing spasm may have to be employed. When these

are present in lesser degree nothing is more efficacious than to

examine the patient just after removal from a hot bath or even while

submerged in hot water. In extreme cases the aid of complete anesthesia

may have to be sought.

_Bimanual palpation_ is of special service in examining the region of

the kidneys or the loins, and may often be advantageously combined with

the finger of one hand in the vagina or rectum. Special rigidity, like

special tenderness, is always a sign of great significance. When the

neurotic or hysterical feature can be eliminated one may almost hold to

the view that it points unerringly to something wrong within. Palpation

should include the recognition of abnormal pulsation in the aorta, and

determination whether this is due to the presence of an overlying tumor

or is one of those cases in which the aorta pulsates more prominently

than it ordinarily should. Any abnormal pulsation should be estimated

as to its expansile or non-expansile character. The recognition of

a _bruit_ may be supplemented by its further identification with a

stethoscope. An intra-abdominal growth once discovered, the surgeon

should obviously learn about it all that he can, regarding its real

location, its origin, its movability, its density, its fluctuation,

etc.; also whether there is free fluid in the abdominal cavity. It is

not infrequently necessary to differentiate tumors in the lower abdomen

and pelvis from pregnancy, either normal or abnormal, and one should

be familiar with the ordinary evidences of this condition, as well as

alert to the possibilities of such a case. The value of palpation is

often enhanced by changing the position of the patient from that upon

the back to the lateral or the genupectoral position.

The value of added vaginal and rectal examinations is sometimes

inestimable, even in conditions which apparently do not involve the

pelvic organs proper. In cases of obstruction of the bowel, for

instance, the finger in the rectum may discover an intussusceptum,

while in the female every tumor of the lower portion of the abdomen can

be better examined and estimated by this combined bimanual palpation.

The value of palpation is increased by the addition of _percussion_ as

part of the procedure, although conditions made evident by the latter

are usually detectable by the former. The surgeon will, however, rely

but little upon percussion alone, although it may be possible in a

large hernia to decide as to the probable nature of its contents by

this test. Auscultation is of especial value in recognizing fetal

heart sounds and placental or aneurysmal bruit. Friction sounds with

splashing in stomach dilatation, and gurgling sounds in certain

subdiaphragmatic abscesses which contain gas, are also discernible

through the stethoscope.

_Measurement_ affords ordinarily small help, save as one may in this

way record the progress of a chronic or inoperable case.

_Inflation_ by means of carbon dioxide or hydrogen was first suggested,

as an aid in abdominal diagnosis, by Ziemssen in 1883, and was applied

especially to recognition of perforating wounds of the intestine by

Senn. Nevertheless it is but little employed, except in estimation

of the degree of dilatation of the stomach or of the lower bowel, as

when, by distending the colon, the kidney may be pushed backward toward

the loin and the gall-bladder up beneath the ribs, the bulging thus

produced settling the question of diagnosis as between enlargement of

one or the other. Even this is not, however, always accurate.

The _aspirating needle_ is now but rarely used, especially by those

most experienced. In those instances where such grave doubt exists as

might indicate its use it generally appears that the welfare of the

patient is better observed by an exploratory incision rather than by

puncture with a needle.

_Pulse and respiration_ nearly always, and _temperature_ frequently,

give information of great value in abdominal conditions. A rising pulse

or a rate over 112 to 120, occurring during any serious intra-abdominal

condition, will stamp it as one of considerable severity, the gravity

being proportionate to the increase above the figures just given. This

is particularly true in acute appendicitis, with or without prominent

local symptoms. A rising pulse rate, then, should always be considered

as a warning. A very rapid, feeble, thready pulse will usually indicate

a condition seen too late to justify surgery, the patient being then

in a condition of practical collapse. Nevertheless if it appear that

this be due to hemorrhage, either from injury or by rupture of an

extra-uterine pregnancy, it may be felt that so long as the pulse is

perceptible the indication is present.

_Respiration_ is markedly affected in many intra-abdominal diseases.

The more thoracic it becomes--_i. e._, the more the abdominal muscles

are disused--the more it bespeaks a serious condition below the

diaphragm. A rigid abdominal wall accompanying frequent thoracic

respirations bespeaks a condition of grave danger. It should never be

forgotten that some of the acute diseases, especially of the lungs

above the diaphragm, cause symptoms and pain referred to the viscera

below. Thus in the early stages of pneumonia and of diaphragmatic

pleurisy there may be thoracic respiration, abdominal spasm, and pain

referred even below the waist line, with strong simulation of acute

appendicitis or of localized or general peritonitis.

_Temperature_ is an uncertain feature. Rapid elevation is usually of

serious import, but one is constantly surprised at the revelations of

an operation, or an autopsy, where temperature is not significantly

elevated or is even subnormal. Small matters may suddenly send it up--a

stitch abscess, for instance--and it is often difficult to distinguish

between the pyrexia of intestinal toxemia and that of actual septic

infection. When elevated temperature is intermittent and accompanied

by chills the surgeon is justified in suspecting the presence of pus,

although the reverse of this is not true, and _pus may form within the

abdomen without causing chills or even fever_. Intermittent fever,

with tenderness in the upper abdomen, points as often to infection of

the biliary tract, usually with gallstones, as to all other conditions

combined. Pyrexia with chills and enlargement of the liver may indicate

hepatic abscess.

When pulse, temperature, and respiration rate seem to keep pace with

each other, no matter what the rate may be, they together afford a fair

indication as to what is going on. A careful blood count, especially

a differential count, will often be of service, though it will

occasionally mislead.

The significance and importance of _pain_ in abdominal diseases are

very great, since nearly all of them are characterized, at least at

some stage, by more or less suffering. Much value attaches to the

history, when it can be accurately obtained, as to the suddenness

of onset, the location and character of the pain; as, for instance,

whether it could be accurately localized or was diffuse. Unusual

intensity of pain may afford an index to the acuteness of the trouble,

but in its location or reference it may be exceedingly misleading. A

large proportion of patients are unable to describe their pains with

sufficient accuracy, and a neurotic patient suffering severely will

evince a widespread hyperesthesia which will be deceptive. It should be

ascertained whether previous and like pains have ever been experienced,

and, if so, where. The pains of acute appendicitis, for instance, are

widely referred, and will sometimes be complained of as intense in the

left side or high up in the abdomen. I have known patients to refuse

operation because they could not be convinced that, with pain on the

left side, it was possible to have acute appendicitis, while even an

experienced practitioner may be tempted to wait too long for similar

reasons. Pain, accompanied or followed by jaundice, or a history of

pain so associated in time past, will point significantly to the

biliary passages. A history of previous pains constantly associated

with taking of food will indicate gastric or duodenal ulcer. Still pain

is probably more often associated with mechanical rather than chemical

conditions. Pain arising from the gall-bladder radiates usually toward

the right infrascapular region, and with adhesions between the stomach

and the gall-bladder pain is frequently referred to the right shoulder,

while when these adhesions are between the stomach and the colon it

is more commonly referred to the left shoulder. Pains due to kidney

lesions usually are referred along the corresponding genitocrural

nerves, although, by association of the renal nerves with the semilunar

ganglia (and thus indirectly with the phrenic and pneumogastric nerves)

we may hear of shoulder pains even in these cases. In most cases of

acute appendicitis the first complaint of actual pain will be in the

umbilical region, since the appendix receives its blood supply from the

superior mesenteric artery and its nerve supply from branches which

accompany this vessel, which are given off from the spine at a higher

level than those which supply the colon and sigmoid. Thus the reflected

pain involves the tenth and eleventh dorsal nerves.

The pain of colicky affections is usually relieved by pressure, while

that of true inflammation is made worse and is continuous. When pain is

accompanied by tenesmus it is generally supposed that the disease will

be found in the lower third of the intestinal tract.

In this connection we may perhaps be a little more specific, and,

following Hemmeter, make out a catalogue somewhat after the following

fashion:

Gastritis will cause sudden abdominal pain, with sensitiveness, made

worse by ingestion of fluids, by which, in all probability, vomiting

will be promptly produced.

Duodenitis will cause constant pain and increased sensitiveness,

especially in the right hypochondriac region, with mucus and perhaps

blood in the stools.

Enteritis causes rather a colicky pain, more widely referred, with a

general unpleasant sensation of pressure, accompanied by distention,

diarrhea, anorexia, and thirst.

Colitis will produce more diarrheic symptoms, with more accurate

limitation of pain and tenderness on pressure, while sigmoiditis

and proctitis will cause characteristic stools, in addition to the

localized pain which they produce. A chronic colitis may cause

backache, sometimes quite sharp, while the same may be produced by a

well-marked condition of enteroptosis.

The more chronic forms of enteric disorders cause irregularly

recurring pains, having definite relation to errors in diet, exercise,

excitement, and environment. The membranous form of colitis nearly

always produces abdominal pain, referred along the course of the

transverse and descending colon. The complaint of pain and the

condition of the stools will be found to have a close relationship.

Fecal impaction rarely produces sharp pain until it proceeds to the

degree of actual obstruction, but does cause feelings of discomfort and

distention, especially in the right iliac region, with more or less

tenesmus.

Lead poisoning produces severe abdominal pain, distention, and

tenderness, with vomiting and alternating constipation and diarrhea,

which may lead to confusion, especially as a subject of lead poisoning

may be a sufferer from one or the other acute abdominal conditions. Of

course, in its chronic forms the characteristic line upon the gums and

the nature of the occupation would aid in diagnosis.

Tuberculosis of the intestines and peritoneum produces more or less

colicky pain, especially in children, with enlarged mesenteric

nodes; while in consumptive patients recurring abdominal pains,

with alternating constipation and diarrhea, would suggest secondary

intraperitoneal involvement.

The possibility of abdominal pain being caused by parasites, especially

by tapeworms, should not be overlooked.

The intestinal ulcerations produce nearly always continual pain,

associated with localized tenderness on pressure. The higher in the

intestinal canal the ulcer be located the more regularly will it

produce pain from one to two hours after eating, while the lower the

location of the ulcer the more likely are we to find recognizable blood

in the evacuations. During typhoid any sudden onset of abdominal pain

associated with bladder irritability, and often with pain in the penis,

may be regarded as indicating perforation.

In appendicitis the pain is usually first referred to the more central

portion of the abdomen, later becoming localized in the right iliac

fossa. Frequently the overlying muscles will be already in a condition

of spasm before this pain is localized beneath them. In this disease,

no matter where pain may be referred, the tenderness will usually be

felt and the resulting tumor detected in significant position. Constant

mild pain and tenderness in McBurney’s region are usually indicative of

a chronic catarrhal and more or less obstructive appendicitis. In the

chronic and relapsing forms the pain is intermittent, but tenderness is

nearly always significantly located.

Strangulated hernias, when external, will usually attract attention

by their presence without reference to pain, even though the latter

be referred to some relatively distant part. Whatever might be

characteristic of strangulation will more or less quickly merge into

symptoms of intestinal obstruction, but no case presenting local

indications should escape detection. Internal strangulations nearly

always defy accurate detection before operation.

Intestinal obstruction from any cause, when acute, produces early sharp

and severe abdominal pain, sometimes localized vaguely, but nearly

always becoming general, and so quickly followed by muscle spasm with

distention and the soreness of vomiting, that, with the accompanying

general disturbances, it lends little aid in accurate diagnosis.

Acute pancreatitis of either clinical type produces a pain which is

central and agonizing and is quickly followed by collapse, with

abdominal rigidity. The resulting pain and tenderness are usually

confined to the upper abdomen and may be expected at least to attract

attention to this part of the belly.

Mesenteric embolism and thrombosis also produce intense pain, with

pronounced depression and speedy collapse, the complaint usually so

widespread as to be suggestive.

Pain made suddenly worse by extra exertion or straining, as perhaps

in defecation, may be due to pressure or to rupture of some part

previously involved. When this is complained of in the lower bowel it

is usually due to some ulcerative condition in the rectum.

Aside from conditions briefly specified as above, there may be numerous

other causes of acute abdominal pain, as, for instance, in connection

with various tumors, either those which involve the bowel, where

there is suddenly precipitated a condition of acute obstruction, or

ovarian cysts and pelvic or other tumors which have undergone a sudden

deprivation of blood supply, as by twisting of a pedicle. In nearly

all of these instances the previous existence of such a tumor has been

learned, or else may be made out by such physical examination as may be

permitted with or without anesthesia. Again rupture of an extra-uterine

gestation may produce intense pain, followed by speedy collapse and a

condition widely referred. I have been repeatedly called to operate for

acute appendicitis when the actual lesion was of this character.

_In general, of abdominal pain_, it may be said that, excluding

hysterical cases, when severe it is usually an indication of a more

acute condition, while mild, chronic and intermittent pain, accompanied

by more or less tenderness, indicates a chronic condition which may not

amount at any given time to an emergency, but which may precipitate one

that may call for immediate intervention. The nearer, anatomically,

the morbid condition to the stomach and the great ganglia the more

likelihood there is of nausea and vomiting of purely reflex character.

When these occur with conditions low in the abdomen or pelvis, vomiting

may be an expression of obstruction rather than a neurosis, pregnancy,

of course, forming a well-marked exception to this statement.

In the presence of severe pain the general practitioner and the surgeon

alike feel inclined, from humane motives, to do everything in their

power to relieve it. While, on one side, it is kind and rational

to give sufficient anodyne, usually morphine, to relieve intense

suffering, it may be felt sometimes that the practise is not to be too

widely extended or commended, since by relief of pain the significant

feature of the disease is masked, and there may be temptation to wait

longer than would be advisable. While wavering, then, as between

advice in either direction, my own view is that most of these cases,

when symptoms are so severe, can be classified by themselves as those

justifying or demanding surgery.

One last caution in this respect is needed, lest the inexperienced

regard the sudden subsidence of pain as necessarily a good sign. When

a patient who has been suffering from acute obstruction or acute

peritonitis becomes suddenly relieved the fear is rather that the

disease has gone beyond all possibility of help, and that such relief

will soon be followed by coma and death. Such cessation of pain, then,

is not necessarily a favorable indication.

_Localized tenderness_ is the next most important sign of value in

determining the location and nature of abdominal diseases. The more

accurately it can be localized the better, since it permits us to

select, in all probability, one organ or one location as the site of

the disease. When it is accompanied by radiating and diffuse tenderness

it may be suggestive rather than indicative.

_Muscle rigidity or spasm_ is the third of the trio of symptoms

which give the surgeon his most imperative indications. Excluding

the hysterical and purely neurotic cases there is no occasion for

pronounced muscular rigidity save some disease concealed beneath it,

which produces these reflex phenomena. This, too, may be localized

or generalized. In the latter case it may indicate, for instance, a

general peritonitis or a local process tending to become generalized.

Of the trio of signs and symptoms it is perhaps the most significant

and reliable.

_Pain_, _tenderness_, and _muscle spasm_ constitute the tripod upon

which the surgeon has most to rely, and which are never absent in

serious disease, while conversely it may be said that serious disease

is rarely ever present without producing them. These with such other

phenomena as special conditions may produce--_e. g._, vomiting,

intestinal hemorrhage, etc.--are our principal aids to diagnosis. When

present and progressive they nearly always indicate necessity for

surgical intervention, the most pronounced being in those instances

where abdominal distention and collapse with other grave features have

already taken the case beyond the help even of the surgeon.

In more deliberate cases aid is also to be obtained from examination

of the discharges from the various viscera, and by examination, for

instance, of stomach contents, as well as by differential blood count.

All of these, however, take time, and the experienced surgeon may see

clearly his indication to operate at once rather than to wait the time

which they require. The whole intent of this paragraph, as, in fact, of

this section, is _not to make light of the ordinary means of diagnosis,

but to insist upon the necessity for early appreciation of important

signs and symptoms in order that one may know when it is not safe to

wait, since too many lives are even now sacrificed to this kind of

delay_.

GENERAL TECHNIQUE OF ABDOMINAL OPERATIONS.

_Abdominal section_, generally called _laparotomy_, though more

properly termed _celiotomy_, is often begun as an exploratory measure,

and then called _exploratory laparotomy_, whose wisdom and safety may

be properly explained to even an ignorant patient, the underlying

intent being a relatively small and safely made opening for the purpose

of orientation and decision. It is with me a rather favorite expression

that the danger of such an operation is insignificant, and that the

danger of whatever may be required, as revealed through the opening, is

proportionate to the gravity of the condition thus indicated.

Abdominal section having once been decided upon, careful general and

local preparation should be made, as indicated elsewhere in this book,

if time be afforded. There are, however, emergency cases in which

moments are valuable and when there must be omitted almost everything

but the considerations of cleanliness. More and more I am impressed

with the value of sterilization of the entire trunk, both front and

rear, since should necessity for posterior drainage be revealed we need

not halt in order to disturb everything else and sterilize the skin of

the back. It is presupposed, then, in this place that all the ordinary

measures have been carried out and that the ordinary equipment is at

hand. There should always be a supply of warm, sterile water (112°) in

order that the intestines may be protected, should it be necessary to

temporarily remove them from the abdominal cavity, and saline solution

at proper temperature should be ready for irrigation purposes, if

needed.

_The abdomen may be opened at any point_, and by incision in almost

any direction. Nevertheless there are provisions which should be

observed. When there is no special reason for a lateral incision

it is to be opened in the middle line; any incision, including the

umbilical region, should be made to pass to the left of the navel

rather than to the right. There is no reason why the entire navel may

not be excised. It is a difficult point at which to insert sutures and

in most individuals is at best an infected region. Therefore there

need be no hesitancy to include it in an oval incision and completely

remove it. It is, furthermore, a wise precaution to drop into the

umbilical region a few drops of tincture of iodine just before the

operation, in order the better to sterilize it. It is my custom to

use one knife for the skin and then lay it aside and employ another

for the deeper work, in order that no germs may be transplanted from

the skin. The surgeon has to cut deeply in fleshy individuals before

reaching the deep aponeurosis, and sometimes it is necessary to pass

through two or three inches or even more of fat. This necessitates a

long, superficial incision. The deep aponeurosis being reached we have

to either go through or between muscle fibers, at least in most places.

It is desirable rather to separate muscle fibers longitudinally. When

opening in the middle, or parallel to the middle line, this may be done

with the fibers of the rectus, the transverse tendinous intersections,

however, always requiring division. Operating in either iliac fossa,

and coming down upon the broad and flat abdominal muscles, there may

be adopted the so-called “gridiron method,” and, after exposing those

fibers which run at a right angle to the line of incision, one may

endeavor to spread rather than divide them. This is done when making

the small openings required in removing the appendix, or in making an

artificial anus. For removal of considerable tumors, or for temporary

disembowelling, large incisions, however, are required.

By suitable disposition of the patient’s body much assistance and

comfort are afforded the operator. When the upper abdomen, especially

the region of the gall-bladder, is to be attacked, the upper part

of the body should be raised with dorsal flexion above the pelvis,

thus permitting gravitation away from the liver and facilitating the

retraction which may be required. Again, in operations upon the pelvic

viscera the reverse position was suggested by Trendelenburg, and it is

of the greatest help, the pelvis and the limbs being elevated until the

body assumes a position at an angle of some 45 degrees. The intestines

then gravitate toward the diaphragm, and the pelvis is more easily

emptied and kept empty. When, however, there is no particular need for

either of these positions the ordinary dorsal position is the best.

With an operation begun in the latter there should be no reason why

position may not be changed, when the exploration reveals necessity for

the same, and all good modern operating tables are so constructed as to

permit of this being rapidly done.

Of late the _transverse incision_ has been received with growing

favor. In 1896, Küstner reported a number of cases where he had used

a transverse suprapubic incision down to the aponeurosis solely for

a cosmetic effect, the method being adopted by Rapin about the same

time. Others went farther and made use of an incision above the pubis

and parallel to it, carried down through the aponeurosis, over the

recti, with vertical separation of the muscles, in order to diminish

the chances of hernia. The incision is made just below the margin of

the pubic hair or in the natural fold of the abdomen. The fascia being

divided in one direction and the muscle in another, there is less

tendency to hernial protrusion, the disadvantages being that there is

limited space through which to work and that more time is required in

its performance. All vessels should be secured so soon as divided. The

incision through the fascia may be somewhat curved, if necessary, at

the outer edges of the recti, by which a sort of horseshoe flap may be

lifted up if desired. The fat should not be dissected from the surface

beneath. Scissors will be required to separate the aponeurosis from the

muscles in the middle line, this separation being made high in the same

line. The peritoneum is opened in the middle with the usual vertical

cut. When more room is required the aponeurosis should be incised

farther on each side, outside of the recti. The method finds its

greatest serviceability in those cases where not more than four inches

in a thin woman and two inches in a fat woman of vertical separation of

the recti muscles will be required.

Ordinarily when the peritoneum is reached there will be no difficulty

in recognizing it. It is a membrane easily shifted, both upon its

attached surfaces, beneath the fat, and over the bowel or whatever may

cause it to protrude into the wound. Unless one is very sure of his

work he will, however, pick it up very carefully, nick it slightly,

and convince himself that he has the desired membrane, and then

will dissect it with care, since the bowel beneath will lie closely

in contact with it, and might easily be wounded were the operator

careless. The peritoneum in the presence of such disease as tuberculous

peritonitis becomes very much thickened, and is then not easy of

recognition. Again, it is sometimes slightly adherent in the presence

of recent exudate, or firmly adherent in the presence of old disease,

to the tumor or viscera beneath. When the tissues are edematous and

become more so as the peritoneum is approached, pus may be found

beneath, and extreme caution should be exercised, making at first a

small opening through which pus may escape, and endeavoring not to

tear adhesions apart nor thus permit escape of pus into the peritoneal

cavity.

The true abdominal cavity once opened, the first endeavor should be

to ascertain the conditions within. Through a small opening this is

done with the finger. This measure, trifling as it seems, requires

a knowledge both of normal and pathological anatomy which cannot be

too great. Unless the normal arrangement, size, density, and location

of all its contents is known and the way which they should feel when

healthy it will be somewhat difficult to distinguish between health

and disease. Again, unless the surgeon is familiar with pathological

conditions he will not know how to interpret what he may thus discover.

Through a small opening it can usually be discovered whether or not

there is a serious condition within. According to knowledge thus gained

there may be justification for enlarging a small opening or closing

it. One caution here is of the greatest importance--an exploratory

operation should never be begun unless the operator is provided with

means for meeting any indication which should thereby be disclosed,

else the patient would be subjected to two ordeals when one should

suffice.

The “diagnostic finger,” having once entered the abdominal cavity,

should be used with extreme gentleness, especially in the presence of

adhesions, which yield easily, and which may point to the existence

of a purulent focus in the neighborhood, as scarcely any disaster

could be more fatal than to rupture such a focus and permit escape of

its contents in every direction before surgical protection has been

afforded. Much will depend upon whether there is reason to suspect

the presence of pus, and it is always best to proceed as though such

a contingency might happen. Again, adhesions which seem firm may be

met with in the presence of malignant or ulcerative disease. In some

instances they will be so firm that surrounding normal structures will

yield before they part, or are closely associated with a dense adhesion

which will be found a weakened area that will tear easily. The process

of separating adhesions, then, should always be conducted with extreme

caution.

When the presence of pus is suspected the adjoining parts should be

protected by “walling off” with gauze. Gauze pads, either of sufficient

length to be secured with forceps or provided with tapes for the same

purpose, by which their loss in the abdominal cavity may be prevented,

are now used almost to the exclusion of the flat sponges formerly

employed, for they are more reliable when properly sterilized. With a

sufficient number of these spread out as carefully as may be, a neat

padding or protective wall of gauze is made and formed around the focus

of disease, into which any discharge of blood or pus may take place,

and by means of which contact of surfaces is prevented. Sometimes a

large amount of gauze is needed for this purpose, and when the abdomen

is widely open sterile towels may be used. The greatest care should

be given that nothing be left within the abdomen at the completion of

the operation, and every loose piece of gauze should be secured with

forceps and every towel accounted for. By this protective “walling

off,” spreading of an infectious process may be prevented, as also the

distribution of infectious material. The gauze should be changed as

often as needed and there is often no apparent limit to the amount that

may have to be employed. Advantageous as the process may be, it has its

disadvantages, in that material so employed is a source of irritation

and is practically a foreign body, intruded within the abdomen in

such a way as to have always a depressing influence. This depression,

however, is but temporary, and is the lesser of two evils, and in the

presence of pus can scarcely be avoided. Instruments, especially the

smaller ones, should also be counted before and after operation, or be

so accounted for that none may remain or be lost.

The general indication having been met, the next question is one

of local cleanliness and resort to irrigation. If the protection

above described has been sufficient there will be a minimum of local

cleansing required. This may be effected with hydrogen dioxide, or with

or without other antiseptics, according to the choice of the operator.

Obviously every focus of disease should be as thoroughly cleansed both

of clotted blood and debris or pus. When this can be accomplished

by gentle wiping or swabbing it may be sufficient. When this is not

possible irrigation and drainage should be provided.

_Irrigation of the abdominal cavity_ has been widely practised, and

has advantages as well as disadvantages which have caused it to be

differently regarded by different operators. While little hesitation

need be felt about washing out a well-localized cavity, it is felt by

many that to use a quantity of water within the complicated peritoneal

cavity is to more widely distribute that which would best be not

disturbed. On the other hand, it is maintained by some that infectious

material so diluted and scattered is more easily capable of disposition

by natural processes. The general trend of opinion is that a localized

condition is best treated by local measures, and that general abdominal

irrigation should be limited to cases of generalized infection. The

temptation to use antiseptic solutions is very strong. Yet one must

remember that any solution, of which a portion must remain, used in

such a cavity and having sufficient strength to kill bacteria, will

prove at least profoundly and perhaps fatally toxic to the individuals,

because the peritoneum is a membrane of tremendous potential

capabilities in the matter of absorption, and those chemicals which are

toxic to germs are also harmful to the human tissues. Strong, then, as

the temptation may be to use antiseptics under these circumstances,

solutions used for the purpose should be made extremely weak if we

are to do more good than harm. Warm sterile water or saline solution

is then the generally accepted irrigating fluid, while a few use such

antiseptics as acetozone in the strength of 1 to 10,000, or others of

the more harmless drugs. In cases of tuberculous peritonitis exception

may be taken to this and a solution used which is sufficiently strong

to have some perceptible immediate effect.

When general abdominal irrigation is practised quarts and even gallons

of fluid should be used, sufficient to accomplish the desired purpose.

Various tubes have been devised for the purpose of conducting the

fluid into the deeper recesses, and yet these, while convenient, are

not essential. Practice varies somewhat as to whether to leave a

considerable amount of saline solution within the abdominal cavity

or try to free it of all fluid. The former practice is desirable, in

theory at least, for if readily absorbed it will help in relieving

shock and keeping the kidneys active. In general it may, however,

be said that unless an isotonic saline solution is employed it is

advisable to remove all that can conveniently be withdrawn before

closing the belly.

The next important question is one of _drainage_, and here, again,

men differ widely in their opinions. A distinctly purulent focus is

doubtless always best drained. The question is argued rather with

regard to the matter of possible spread of infection or in cases of

general doubt. Drainage is always a confession either of fear or of

impossibility of ideal removal of the primary difficulty. It certainly

is less practised than in years gone by, but will always find a certain

field of usefulness. Thus after some deep, extensive pelvic operations,

where the separation of adhesions almost ensures a certain amount of

leakage of blood, one should insert a glass or metal drain for a few

hours, or a day or two, and through it aspirate at intervals such

amounts as may accumulate in the cavity thus emptied. Nearly all cases

of abdominal traumatism require drainage, best applied posteriorly,

and practically all instances of acute pancreatitis, whether purulent

or otherwise, will also require it, posteriorly as well as anteriorly.

All old abscess cavities also demand drainage, no matter where located.

No case of septic peritonitis, general or local, can be safely closed

without similar provision. Drainage through the cul-de-sac is the best

method of all, when available.

_Drainage methods_ include the use of hard tubes made of glass,

aluminum, or celluloid, perforated with numerous openings through

which fluid may escape into their interior. These are used mainly for

drainage of the pelvis through an abdominal wound. Soft-rubber tubes of

varying sizes may be used in many ways, either by themselves or when

split longitudinally, and made loosely to enfold a strip of gauze,

or when lightly wrapped with gauze and covered with perforated oiled

silk. Except when it is desired to drain a gall-bladder or some similar

circumscribed cavity, which can be closed around the tube, such tube

should have numerous large openings cut in it. Cigarette drains consist

of small rolls of gauze wrapped with oiled silk, then fenestrated and

secured with a piece of catgut tied around it to prevent it unwrapping.

Ordinary absorbent gauze or prepared gauze may be used by itself to

any desired extent, but when so used it is usually well to make the

amount sufficient to effect the purpose. Thus a drain at least one inch

in diameter or even exceeding that size will be much more effective

than two or three small strips. In using this it is well to protect

the wound margins with strips of oiled silk, between which the gauze

is deeply passed, as in this way its adhesion to the wound edges is

prevented, such adhesion being undesirable both because it helps to

prevent the escape of fluid and causes pain when the gauze is removed.

In this way it is well to combine the double purpose of drainage, and

pressure to check oozing, by packing in sufficient gauze to accomplish

both. These gauze drains, when well soaked with discharge, are easily

removed. Otherwise they frequently adhere and cause much discomfort

during the act of removal. In such a case it is an advantage to wet

them from the outside, perhaps three or four hours before withdrawing

them. Even with such a gauze drain there is always the danger of

causing fecal fistula if it be left too long _in situ_. It is,

therefore, always undesirable to leave a drain, even of this apparently

innocent character, longer than absolutely necessary.

In not a few cases through-and-through drainage--_i. e._, by a

counteropening--will be of great value, this especially in many cases

of peri-appendicular abscess, where pus has collected behind the

cecum. So-called posterior drainage of the abdomen is also advisable

in cases of acute pancreatitis or deep retroperitoneal phlegmon. Here

the opening is made from the back, by an incision two or three inches

in length, just outside the upper part of the quadratics lumborum and

near the costovertebral angle. In stout individuals a distance of

two or three inches, or even more, must be traversed. After the more

superficial incisions this opening may be effected by blunt dissection,

and is best done with conjoined manipulation, one hand working on

the exterior and the other in the interior of the abdominal cavity.

Occasional necessity for such posterior drainage shows the wisdom of

the practice of sterilizing the back as well as the front of the body

as part of the preparation for operation.

Drainage having been effected by one of the above methods, the best of

good judgment will be called for in determining how long it should be

continued. First of all, no drain which fails to effect the purposes

intended should be allowed to remain, and any drain around rather than

through which material is discharged may be regarded as useless and

a mere deleterious foreign body. Gauze which is supposed to drain by

osmosis often fails, and in some of these drains it may be well to

insert a few strands of silkworm-gut in order that material which is

to become moistened may not collapse and adhere, thus destroying its

own capillarity. A pelvic drain in a non-septic or but slightly septic

case, inserted for removing escaping blood or collecting serum, may

be removed in from twelve to sixty hours, according to the amount of

discharge, which when collected with a syringe should be carefully

estimated. Any cavity which is not filled at a rate faster than 2 or

3 Cm. in an hour may be regarded as capable of disposing of all the

fluid which may collect within it, and every tube which is no longer

needed is an irritating foreign body, whose lower end may press upon

intestine, and even produce ulceration if allowed to make pressure

too long. Appendicular abscesses usually require to drain from two to

three or four days; gall-bladders and hepatic abscesses for a much

longer time. In nearly all instances it may be expected that within

from forty-eight to sixty hours after the establishment of drainage a

natural passage will be formed, by exudate appearing first around the

drain, and remaining after its removal, which should serve drainage

purposes as would a canal. Sometimes the outer end of such a canal

tends to close too quickly, and then with accumulation in the deeper

part there may come retention, with later spontaneous escape, or

possibly rupture into the abdominal depths, which may be serious. In

nearly every instance, however, a large drain may be substituted within

a short time by a smaller one and final removal be thus accomplished.

Any localized cavity whose discharges are offensive or putrefactive

should be cleansed each day, either with hydrogen peroxide or by gentle

irrigation, or with a reasonably strong antiseptic solution--iodine,

silver nitrate, etc. While no such cavity will close until all such

material has escaped, it nevertheless is well to keep the external

opening wide open, in order to hasten the whole process. This may be

accomplished by gauze packing or the insertion of a short tube.

Cavities which persist, with apparently permanent fistulas, require

more radical treatment, which will consist at least of a thorough

curetting and considerable enlargement of the fistulous opening, in

order to permit of this. Such a cavity, then, may be comfortably packed

with gauze for a few days.

The use of massive tampons and the introduction of large-sized pieces

of gauze into the abdominal cavity have been generally discontinued,

largely through the writings of Morris, who stigmatized such practice

as “committing taxidermy upon patients.”

_Abdominal drainage_ may be favored by one other expedient--_i. e._,

_position_. The peritoneum possesses unusual powers of absorption

and is capable of taking care of morbid material up to a certain

point. It has been shown that the peritoneum of the upper abdomen

especially, even that lining the diaphragm, is particularly potent in

this direction--next to it perhaps that of the pelvic cavity. Septic

processes in the upper abdomen are then sometimes advantageously dealt

with by placing the patient in bed in a position with the pelvis

considerably elevated and the head dependent. This is the more valuable

after irrigation has been practised, where there may be considerable

fluid which may thus gravitate. On the contrary, in serious septic

pelvic infections it is often good practice to keep the patient in

the semisitting posture, so soon as sufficiently recovered from the

anesthetic. (Fowler.) These expedients are perhaps the more valuable

when provision is made in either one of the dependent portions for

drainage, gravity thus favoring the accumulation of fluid where it can

be best cared for.

CLOSURE OF ABDOMINAL INCISIONS.

In what may be termed a clean abdominal operation it is seldom that

drainage is provided. Such cases are expected to heal promptly and

the wound to close immediately and without pus formation. It is

only in cases where drainage has been necessitated that there is a

really legitimate excuse for subsequent yielding of the scar, and

the production of _postoperative ventral hernia_. These at least are

the ideal and theoretically correct notions, although it should be

acknowledged that in the practice of even the most competent such

undesirable sequels as ventral hernia do sometimes occur. Foreseeing

the possibility of their occurrence and realizing the conditions

which permit the same, every known precaution should be taken. The

question then of the method of closure of even a small abdominal wound

is one of great importance, which has long engaged the attention of

the most experienced operators, who have not yet united upon what all

consider the ideal or perfect method. In general it may be said that

_suture of each separate tissue layer comes nearest to this ideal_,

along with the employment of a suture material which should serve its

purpose sufficiently long, and yet not remain as a possible future

irritant. When time is afforded, and there are no contra-indications,

the following may be given as the best directions in this regard: A

_suture of the peritoneal edges_, with or without the deep fascia. In

or near the middle line the posterior sheath of the rectus may also be

included in this row. These sutures should be inserted with extreme

care so as not to include any peritoneum of the bowel surfaces. Then

the _muscle edges_ are brought together by a second row, over which

the _deep aponeurosis_ is covered and brought together with a third

row. Rather than fail in accurate approximation of this third row it

would be better to overlap the edges and fasten them together in this

position. These sutures should be made with hardened catgut, of whose

sterility and durability there is no question. It should have been

so treated that reliance may be placed on its remaining for at least

twenty days. The method with the balance of the wound may depend to

some degree upon its thickness. In individuals with fat abdominal walls

it is better, in order to avoid dead spaces, to insert _one or two

rows of buried sutures_, by which the fatty surfaces are brought into

contact. Finally the _skin margins_ may be approximated, either with a

subcutaneous chromic or silkworm suture, or by the ordinary continuous

or interrupted suture, which may be made, according to choice, of

celluloid thread (Pagenstecher’s linen thread soaked in a celluloid

solution and thus made non-absorbent), sterile silk, or fine wire.

The nature and the location of the incision and the thickness of the

tissues, along with the degree of tension which may be made upon

them, will to some extent determine how the more superficial stitches

may be placed. The depressing effect of postoperative vomiting may

be forestalled by placing another set of three or four mattress or

quilted sutures, which may be brought out at a distance of two or three

inches from the incision and guarded with shot, plates, or rolls of

gauze. These sutures have a tendency to take off tension from those

immediately closing the wound and are a valuable means of securing

primary union.

Ordinarily, as stated above, one never drains the abdominal wound

proper. Nevertheless if it has been infected by contact with gangrenous

or infectious material it is better to leave some opening for escape,

or else, as a final precaution, to trim the surfaces which have been

exposed and bring into contact only those which are absolutely fresh

and uncontaminated. _In gunshot wounds_, for example, unless the track

of the missile has been cleanly excised some provision should be made

for drainage thereof.

A further protection should be, however, afforded in the dressings,

by strips of plaster placed over the deeper dressings, by which

again tension is taken off the wound, and still further by such snug

bandaging and arrangement of compresses and dressings as shall complete

this protection.

There are occasions when this procedure, which necessarily consumes

a little time, cannot be completely carried out, and when there

must be haste in order to get the patient off the table in suitable

condition. In such cases the operator usually contents himself with the

application of silkworm-gut sutures, which include the whole thickness

of the abdominal wall, or the use of secondary sutures, which can

be tightened and utilized later. As Binnie has said: “Inexperienced

surgeons, after completing a prolonged operation on an exhausted

individual, sometimes forget that it is better to have a postoperative

hernia in a living patient than a perfectly closed wound in a corpse.”

AFTER-TREATMENT OF ABDOMINAL OPERATIONS.

While in the general principles regarding the after-treatment of

abdominal cases practitioners are well agreed, the world over, they

differ so in regard to minor points that it is difficult to give

explicit directions which shall be acceptable to all. Much will depend

upon whether the patient has had suitable preliminary preparation. If,

for instance, the bowels have been thoroughly emptied there need be no

haste to administer laxatives, as though this had not been the case.

In many instances where this precaution has been neglected catharsis

is, after operation, the most important consideration, and yet this

may be difficult to secure, the difficulty being enhanced by the fact

that an individual just operated on and extremely tender finds it

difficult to give natural assistance to the process of defecation.

The matter is particularly complicated by the difficulty of selecting

an active cathartic which may be retained by a sensitive stomach. One

of the greatest needs of the surgeon, as well as of the physician,

is a suitable medicament of active cathartic properties which can be

satisfactorily administered with a hypodermic syringe. Nothing of this

kind is as yet known.

It is good practice in many cases to throw into the intestine, through

a fine needle connected with a large syringe, a considerable quantity

of saturated solution of Epsom salt before closing the abdomen. This

places it where it will not be rejected by an irritable stomach, and

where it must have the desired effect. The needle so used should be

carefully introduced, in a very oblique direction; while should the

minute puncture bleed or seem to leak it may be included in a suture

or ligature loop, which should take up the peritoneal coat only.

In addition to this, an occasional expedient, the writer usually

administers, before the patient leaves the table, a subcutaneous

injection of ¹⁄₅₀ Gr. of eserine sulphate, the active principle of

Calabar bean, this being a powerful stimulant to the muscular coat of

the intestine. The bowels should be thoroughly emptied in the easiest

manner after every operation.

The next question is one of _pain_. Patients should not be allowed

to suffer when morphine is at hand, and this would always be true

were it not that morphine has, at times, undesirable effects, both

in checking intestinal activity and in “locking up the secretions.”

Moreover, it frequently nauseates. On the other hand, patients who have

undergone serious operations need to be kept absolutely quiet, and to

be prevented from tossing and moving themselves in bed. Some expedient

then is called for in many cases, and one may, if he choose, begin with

the milder of these--such, for example, as the administration of 2 Gm.

each of chloral and sodium bromide, with or without chloretone, in a

little saline solution or sterile water, thrown high in the rectum.

When pain is not severe this is frequently sufficient to soothe and

allay, and often to produce sleep. It reduces or prevents the nausea

with which many patients suffer. This, too, may be given before the

patient leaves the table. Such an enema, with or without asafetida or

other soothing drugs, may be repeated as often as indicated, and does

much to quiet a rebellious stomach.

It is assumed here that the reader is already familiar with the

precautions advised before the administration of anesthetics and that

it is now simply a question of after-treatment. (See Chapter XX.) My

own advice is not to withhold morphine in those cases which seem to

require it, remembering, at the same time, that suitable management

of the stomach is required. It is inadvisable to permit the patient

to take any fluid in the stomach for several hours, for even plain

water will upset a stomach which has seemed to be perfectly calm and

controllable. According to the degree of nausea and discomfort should

the stomach be used, the patient’s need for fluids being supplied by

more or less copious saline enemas. So soon as the stomach becomes

quiet ice pellets or small quantities of water, as hot as can be borne,

may be used, the latter frequently proving the more acceptable.

Until the bowels are freely moved whatever food may be administered

should be fluid, and, under most circumstances, not more than

forty-eight hours should elapse after any operation before the

intestinal canal is emptied. Milder degrees of _nausea_ may be treated

by the use of milk of magnesia, of small doses of orthoform, or by a

mixture which the writer is fond of using, in each dose of which the

patient receives 0.02 of cocaine, one minim of carbolic acid, and one

or two minims of dilute hydrocyanic acid, in a small amount of water. I

have found this in many instances very soothing.

The _after-management_ of many of these cases includes also the

treatment of _shock and collapse_, which have been considered in a

previous chapter. It should include, also, suitable attention to

the bladder, and a catheter should be used within the first ten

or twelve hours if no urine be passed, and as often thereafter as

may be necessary. Catheterization should be conducted with the

same precautions as indicated at any other time. Other details of

after-treatment, such as the removal of drainage materials, change in

position of the patient, etc., have been discussed. Stitches of chromic

catgut need no further attention, while those of silk or thread will

need removal. It is to be emphasized that the great danger of the

so-called _stitch-hole abscesses_ comes not so much from the material

first employed as from failure to protect it and guard it against the

possibility of subsequent infection. Non-absorbable sutures in the

abdominal wall are usually allowed to remain from ten to twelve days,

but any stitch which is seen to fail in accomplishment of its purposes

should be immediately removed, as should also stitches around which a

drop of pus is seen to be escaping.

Certain abdominal wounds, especially in fleshy individuals, seem to

heal perfectly, then part a little and give vent to material which is

hardly pus, but appears more like liquefied or altered fat. Such, in

effect, it often is, and the condition implies a necrosis of a certain

amount of fatty tissue, with its liquefaction and escape instead of

absorption. In this way a small cavity will be left which should heal

by granulation, and this may be hastened by the use of mild nitrate of

silver solution.

A patient having been removed from the operating table in a

satisfactory condition the principal danger is that of _internal

hemorrhage_, which, though fortunately rare, is disturbing when it does

occur. In fact, severe abdominal hemorrhage is one of the most serious

of surgical accidents, either primary or secondary. It may occur from

wounds of all descriptions, as the result of erosion, perhaps of a

foreign body, even of a drainage tube, from the slipping of a ligature,

from reaction after shock, the heart recovering its vigor and pumping

blood out from the vessels which had not previously oozed. In other

instances, of course, it may be the result of rupture of an abdominal

aneurysm or the twisting of the pedicle of an abdominal tumor.

Constitutional causes which contribute toward it are jaundice, both

with or without accompanying cholemia (mentioned more particularly in

the section on the Biliary Passages), hemophilia, scurvy, and that form

of myelogenous leukemia for which splenectomy has been occasionally

performed. In all these cases the patients are abnormally prone to

bleed freely. When this condition is suspected it is well to determine

the coagulation time of the blood. If this be over six minutes the

calcium salts, with iron and fruit acids, should be administered some

time previous to operation.

The most important _symptoms of postoperative or internal abdominal

hemorrhages_ are rising pulse, with fall in temperature, pallor,

and that marked reduction of blood pressure which gives rise to the

ordinary symptoms of shock or collapse, along with extreme restlessness

and disturbance of vision or almost complete blindness. When there

has been any notable collection of blood within the abdomen there may

be found dulness on percussion over the flanks. Richardson has spoken

of the nurse’s duty and the surgeon’s duty under these conditions,

the former being to recognize the indications of increasing shock and

alteration in pulse rate, the latter being to adopt every expedient for

the checking of hemorrhage, including, in many cases, prompt re-opening

of the abdomen. The more promptly this measure is instituted when

demanded the greater the probability of saving the patient.

The principal danger after all abdominal operations, next to

the possibility of hemorrhage, which rarely occurs, is that of

_peritonitis_, a danger so imminent in the pre-antiseptic era as to

have made the abdomen an almost sacred cavity, but one which is now

almost abolished by perfection of aseptic technique, yet calling for

never-ending care and attention to detail, and occurring occasionally

in spite of all the precautions which the most experienced and

conscientious operator can take. This condition is to be feared

when vomiting continues or comes on afresh, and in the presence of

tympanites, with a steadily rising pulse. The first appearance of these

threatening signs will be always a warning, although not invariably

an indication of danger, since the condition producing them may be

averted by catharsis or by meeting some special indication. _Septic

peritonitis_, the great dread of the abdominal surgeon, and practically

the only form with which he as such has to deal, will be considered

by itself a little later. Yet it is always a question whether it is

advisable, even in these cases, to administer powerful cathartics

which provoke undue intestinal motion and favor the distribution of

infection. While it is true that opium masks symptoms and leads to

erroneous conclusions the same is frequently true of cathartics. From

them a really obstructed or really paralyzed bowel suffers harm rather

than good. They are too sparingly absorbed, and if absorbed their

effect is bad. It is much better in these cases to wash out the stomach

with a weak soda solution, and then keep it empty, emptying the lower

bowel by the same means, and thus placing as much as possible of the

intestinal tube at rest. With from 1000 to 2000 Cc. saline solution

introduced beneath the skin each twenty-four hours patients can be

kept from starving for a sufficient length of time to permit of other

treatment for the condition.

INJURIES OF THE ABDOMINAL WALL.

=Contusions.=--Contusions of the abdominal wall may be followed

by serious consequences, even though they have the appearance of

being trifling. The injury that may be done implicates not alone

the abdominal wall proper, but the viscera beneath. A blow upon the

abdomen, followed by immediate collapse of temporary character (as the

history of many a prize fight has shown), indicates a sudden reduction

of blood pressure, the nausea and other features being due to the

mechanism of the semilunar ganglia and the sympathetic nerves.

Contusions of the abdominal walls alone are serious largely in

proportion as they are followed by _extravasation_ or _hematoma_,

since from failure of absorption of the latter there may result a

cyst, or possibly an abscess should local infection occur. In either

event evacuation and suitable local treatment are demanded. But any

blow, even without penetration, may give rise to serious disturbances

within the abdomen. Thus, as Richardson has said, the hollow viscera

are liable to rupture, with extravasation, the solid to fracture

with hemorrhage, while lacerations of the omentum or mesentery may

produce immediate hemorrhage and subsequent possibility of intestinal

obstruction. When extravasation has occurred distention and the

ordinary evidences of peritonitis supervene. When the spleen or liver

has been torn or crushed there will be obtained evidences of extensive

internal hemorrhage.

Of the _hollow viscera_ much will depend upon the degree of their

fulness--especially with fluid. In a small tear there may be eversion

of the mucosa, which may hinder or even prevent extravasation.

Escape of infectious material into the cavity of the lesser omentum

may produce local peritonitis, with subsequent development of what

is practically a _subphrenic abscess_. When the patient vomits

blood it shows that there has been rupture of the gastric mucosa.

Intestinal rupture will be made known by rapid distention and the

ordinary evidences of acute peritonitis. These injuries rarely lead

to vomiting of blood, but when occurring low in the bowel may lead to

the occurrence of bloody stools. Rupture of the spleen or pancreas

is rarely diagnosticated previous to exploration, save as a severe

abdominal injury. It is not so likely to lead to rapid peritonitis.

Rupture of the liver permits of more or less escape of bile, as well as

of blood, and rupture of the gall-bladder permits the free emptying of

bile into the upper abdomen. As this is usually harmless, in otherwise

healthy individuals, the injury is not necessarily so serious as might

appear. In such a case the resulting peritonitis will probably be local

rather than general.

In this connection may be considered _ruptures of the kidney_, which

are produced by similar injuries to those under consideration, and

which may permit escape of urine or blood into the abdominal cavity,

as well as the appearance of blood in the urine. While these will be

considered in another place the possibility of their complicating

abdominal injuries cannot be overlooked.

_Considerable laceration will predispose to subsequent hernias_,

either direct or indirect, in the latter case by absorption following

injury. The more serious consequences of abdominal contusions--_i.

e._, the deep hemorrhages and lacerations of viscera--may then include

all degrees of such injury, from trifling subperitoneal ecchymosis to

extensive ruptures of such organs as the kidney or liver, or perhaps

multiple perforations of stomach and bowel. These deep injuries will

be considered by themselves when dealing with special organs. It is

sufficient here to indicate their possibility and to warn that every

severe contusion of the abdomen which is followed by local symptoms,

or those which are grave and progressive, may at any time _demand

exploratory section_, which should be made early rather than late. It

is advisable to pass a catheter to make sure that there is no blood

mixed with the urine, and to make a rectal examination in order to

discover blood should it have escaped.

_Penetrating wounds of all descriptions_, punctured, incised, and

gunshot, are again of importance largely in proportion to the damage

done to intestines and great vessels. Some of these injuries are so

evidently superficial that exploration may be abstained from, but

_every penetrating wound which has truly penetrated_ is to be treated

either as they are treated on the battle-field, by mere inspection and

occlusion, or by careful exploration under all aseptic precautions.

_What the operator would do deliberately may not be what he can do

in an emergency, but if he cannot reach one extreme he would best be

content with the other._

Abdominal contusion has been found by Makin to be the cause of about 70

per cent. of the cases of intestinal rupture which have followed sudden

or sharp blows, while the other 30 per cent. have been due to the

passage over the abdomen of heavy objects. Le Conte has well summed it

up in the following words: “If the force be circumscribed, and of high

velocity and of small inertia, such as a kick or blow from some rapidly

moving object, crushing of the intestine is more likely to occur; while

if the force be diffuse, as from a slowly moving, ponderous object of

considerable inertia (_e. g._, a wagon wheel), the belly is more apt

to be torn at one of its fixed points or the mesentery injured. Thus

out of 61 cases of horse-kicks of the abdomen in 59 intestinal rupture

occurred. When the abdominal muscles have been braced in expectation of

a blow less harm results than when it has been suddenly inflicted upon

a relaxed musculature.” Crile has shown that the more specialized and

abundant the nerve supply to a given viscus the more will it contribute

to the production of shock when injured.

Pain is not always an immediate symptom. It may be delayed for hours,

or possibly even for days. When intestinal rupture has occurred pain is

most often referred to the central portion of the abdomen. In rupture

of the spleen it is complained of in the left side, while when the

kidneys have been ruptured pain follows the course of the ureters to

the genitals and there is usually retraction of the testicle.

Muscle rigidity is a sign of equal diagnostic value with pain, and

immobilization of the abdominal wall nearly always indicates intestinal

rupture. The facial expression is also of importance, it being in the

more severe cases almost distinctive. A steadily rising pulse is always

a bad sign, usually indicating a developing peritonitis. Vomiting, if

long continued, after a patient has rallied from the immediate shock,

is considered of itself to justify operation. The same is true of

paralysis of peristalsis.

Such injuries to the abdominal walls proper may divide important

vessels, such as the epigastric, and give rise to hemorrhage which

may be internal rather than external. The first and most important

danger of hemorrhage having been passed or being avoided, the next and

always urgent risk is of infection. This may come from non-penetrating

injuries, as well as those which open a wide path into the interior,

and it is sometimes the small punctures which prove most disastrous.

From any wounded abdomen there may protrude omentum, intestine, or

portions of some other abdominal viscus, while extensive abdominal

incisions permit more or less evisceration. There are cases on record

of pregnant women being injured by the horn of an infuriated animal

and having the entire abdomen, as well as the pregnant uterus, ripped

open, everything thus escaping. The omentum is the most likely to

escape through small openings of all the abdominal contents, and this

is fortunate for the patient for reasons to be mentioned in connection

with the omentum and the peritoneum.

When the nature or the appearance of the wound make a complete

perforation of the abdominal wall probable it will always be safer

to be satisfied regarding deeper conditions. The parts having been

thoroughly sterilized the ordinary probe is rarely sufficient, the best

method of orientation being the sterile finger. Its use may require

enlargement of the incision, and this should always be made. Such an

opening being made and proving insufficient should be enlarged to any

desired extent. Possibly a deep condition will be thereby revealed,

which will make it expedient to open the abdomen freely in the middle

line, and to deliberately practise one of the many expedients called

for in such an emergency, such as ligation of vessels, intestinal

suture, removal of a foreign body, and the like. The indication once

met the incisions are closed, an infected wound being suitably drained.

In general it may be said that laparotomy is the wiser course in

nearly every instance, and that it should be done when the surgeon

is in actual doubt as to its necessity, it being better to give the

patient the benefit of the doubt and operate. In all cases with serious

symptoms it is certainly safer than to wait for further symptoms. This

will appear advisable in view of Curtis’ collection of 116 cases of

intestinal rupture which were left unoperated, all of which died.

=Gunshot Wounds.=--In regard to gunshot wounds the principles of

treatment in civil life are different from those obtained in an active

military campaign. In the former the patient is usually given the best

chance by an early exploratory section, with thorough examination of

the abdominal contents, done with every aseptic precaution and every

means for correct work. This is not possible upon the battle-field.

=Foreign Bodies.=--Foreign bodies are occasionally met with in the

abdominal wall. These may be introduced from without by accident or

design, such as needles or splinters, or may result from the escape by

slow process of some foreign body from within, such as a fish-bone, a

needle, and the like. Thus in an abscess of the abdominal wall I once

found a stick-pin over five inches long with a large glass head. This

had been swallowed by an insane patient, who, subsequently recovering

from her mania, went home and developed this disturbance a year or so

after her release from the asylum.

PHLEGMONS AND OTHER SEPTIC INVASIONS OF THE ABDOMINAL WALL.

_Abscesses_ may develop within the abdominal wall, without reference

to deeper phlegmonous processes within. Thus they are occasionally

seen after typhoid and the exanthemas, appearing perhaps as often in

the rectus as anywhere. They may at any time result from superficial

abrasions and travelling infections. They may occur sometimes as the

extension of suppurating bubo, especially after phagedenic chancroid.

They are recognized by signs which are usually unequivocal, and when

once detected should promptly be evacuated.

_Gummas_, both tuberculous and syphilitic, frequently break down and

form abscesses of mixed type. These may burrow deeply behind fascial

planes, and require one or more counteropenings. As the result

of a particularly virulent infection with the specific organisms

that produce it one sees, rarely, about the abdomen expressions of

_gangrenous cellulitis_ or malignant edema, which may spread here from

some adjoining part and involve wide areas. Abscesses also result

from infection of hematomatous or other cysts, while collections of

pus arising in the chest, travelling far, may spread downward along

the subperitoneal connective tissue and appear even low within the

abdomen or externally upon it. Acute _osteomyelitis_ of the bones of

the pelvis, or acute _suppurative spondylitis_, may produce abscesses

which will also involve the abdominal wall, while it frequently

suffers in the effort of pus to burrow toward the surface, as in large

_perinephritic_ collections and the like.

_Erysipelas_ not infrequently involves the abdominal surface, and,

spreading deeply, may produce suppuration or a virulent type of

peritonitis. The latter is more likely to occur in connection with

wounds and other injuries.

Aside from _burns_ of the minor type, which may involve large areas,

there may be seen, especially upon the abdomen, extensive and

distressing expressions of _x_-ray dermatitis, so called, followed by

ulcerations, perhaps with the later development of epithelioma. These

results of injudicious exposure to the cathode rays are always of the

most painful and erethistic type, and most difficult to heal. Resistant

cases are probably best treated by complete destruction of the surface

with knife or spoon and skin grafting.

Upon the abdominal surface are seen some of the characteristic

expressions of the _ulcerative syphilide_ and of _tuberculosis_ of

the skin. The former will require active antispecific medication and

the latter call for the curette or complete excision. In either case

radical treatment is usually promptly successful.

_Actinomycotic_ lesions are also seen, perhaps as often about the

abdomen as anywhere. They are likely to be mistaken at first for

tuberculous or syphilitic disease, but may be differentiated by

appearances elsewhere noted. They require active eradication, combined

with the local and general use of iodine and copper sulphate.

TUMORS OF THE ABDOMINAL WALL.

The abdominal walls are not exempt from _tumors_ which involve similar

textures in other parts of the body. About the ordinary hernial outlets

it is advisable to proceed cautiously with any tumor, lest it may prove

to contain or to be combined with a true _hernia in disguise_. This is

especially true at the umbilicus. _Congenital cysts_ in the walls are

usually met with along the middle line, and will prove to be remnants

of _embryonic cysts_, vitello-intestinal, urachal, echinococcus, or

dermoid. Cysts should be distinguished from fatty tumors and sometimes

from hernias or from cold abscesses.

_Fatty tumors_ are common in all shapes, locations, and sizes. Among

the benign tumors frequently observed are the _fibromas_, especially

those of the type spoken of in Chapter XXVI as _desmoids_--_i. e._,

those arising from the dense, fibrous, aponeurotic tissues, growing

slowly, being exceedingly firm and hard in character, intimately

connected with the fascia or aponeurosis, but not with the overlying

skin nor with the viscera beneath. They are practically painless, may

attain great size, and should always be removed while yet small, in

order that the abdominal wall may not be weakened more than necessary

by taking away the fibrous structures which especially give it strength.

The _vascular tumors_ which call for surgery are uncommon. Pigmented

nevi, however, are occasionally met, and these should always be

promptly removed lest they degenerate into melanosarcomas. Varices

and venous angiomas, sometimes of extensive dimensions, are also not

infrequently found here. Extensive varicosities may have a congenital

cause, the deep venous channels being insufficient, or they may be

due to thrombotic occlusion of the abdominal veins following typhoid,

puerperal fever, or injury.

_Primary carcinoma_ originating within or upon the skin, _epithelioma_

of similar origin, and _sarcoma_ arising from the deeper mesoblastic

tissues, may occur as primary tumors of the abdominal wall. We may

also have _endothelioma_ springing from the peritoneum, with possible

origin elsewhere. Occurring secondarily we may see any of the ordinary

metastatic expressions of any of these forms of growth, as well as

those spreading by continuity, the most frequent example of the latter

being so-called _cancer en cuirasse_ following cancer of the breast.

Finally, for those enormous overdevelopments of fat and connective

tissue which accompany exceedingly pendulous abdomens, such as

most commonly follow pregnancy or elephantiasis, the surgeon has

occasionally to excise large areas, closing the defects thus made by

numerous tiers of buried with strong superficial and retention sutures.

THROMBOSIS AND EMBOLISM FOLLOWING ABDOMINAL OPERATIONS.

It is well known that these conditions occasionally follow parturition

and then lead to sudden death. A similar condition is now generally

appreciated as occasionally following abdominal operation, and

sometimes leading to the same fatal result. It has been said that

thrombophlebitis follows about 3 per cent. of abdominal sections. It

occurs oftener in the left than in the right leg, and its etiology

is obscure. It begins with pain in the calf and groin, the leg

rapidly swelling and then becoming edematous. Various writers have

called attention to the occurrence of pleurisy and pneumonia during

convalescence from appendectomy, and ascribe them to the presence of

small emboli detached from the thrombi formed around the immediate site

of the operation.

Two rather opposite theories prevail at present regarding the

condition--one that it starts as a phlebitis due to infection at

the time of the operation, the other that thrombosis is the primary

lesion and therefore responsible for the phlebitis. Clark and others

have contended that injury to the epigastric veins, by retracting and

holding open abdominal incisions during protracted operations, is the

cause of the trouble.

It would seem rational to hold that mechanical violence to the vessel

walls, at or about the site of the operation, is the actual exciting

cause in non-septic cases. On the other hand, the cases of infectious

type should be accounted for either by local infection or as an

expression of toxemia such as we see when similar thrombophlebitis

occurs during the course of typhoid fevers and the like.

Years ago, Agnew, for instance, stated that after operations in which

much blood has been lost there is always more or less tendency to the

formation of coagula, but certainly the majority of these operations

today are accompanied by very little loss of blood. Embolic pleurisy

and pneumonia may appear without preliminary symptoms, while abdominal

thrombophlebitis rarely shows itself until at least the end of the

first week and sometimes not until the fourth week after operation, and

then more often in the left than in the right leg.

In the treatment of these cases palpation and massage are to be

strongly avoided, lest thrombi be dislodged and thereby produce

pulmonary infarcts. Rest and sorbefacient ointments constitute the best

treatment.

CHAPTER XLVI.

THE PERITONEUM AND ITS DISEASES.

Were the peritoneum spread upon a flat surface it would be found

to equal in area that of the skin which covers the body. In man it

is a closed sac; in woman it is exposed to exterior contamination

through the Fallopian tubes by way of the uterus and vagina. Hence

the frequency with which infections of the latter are transmitted to

the membrane itself. Thickened in some places, or duplicated, for the

purpose of forming ligaments and membranous visceral supports, it is

usually thin, connected with the structures which it lines or covers

by a more or less delicate, cobweb-like connective tissue. In some of

its duplications relatively large amounts of fat may be collected.

While freely supplied with bloodvessels it may be regarded as an

enormous lymph sac, its capabilities of absorption being relatively

immense. It is because of this that human beings escape many of the

possibly fatal consequences of infection. Along it infectious processes

travel, sometimes with wonderful rapidity, while again it throw’s out

exudates and rapidly walls off a serious disturbance, imprisoning it,

as it were, and often effectually. Fluid may escape from it (fluid

exudate) with great rapidity, or it may exude a fluid rich in fibrin

which rapidly accumulates and forms a dense, firm exudate that serves

to bind surfaces together and is often the surgeon’s best friend. In

fact, the surgeon looks for a minimum and desirable amount of this

exudate to ensure the result of whatever sutures he may pass through

the peritoneum and the tissues which it covers. Thus after an ordinary

intestinal suture it is expected that within some six hours the exudate

thus formed will be of itself almost sufficient for the purpose of

safety.

Peritoneum is said to possess the power of absorbing from 4 to 8 per

cent. of the weight of the individual within an hour, but this only

under normal circumstances, since inflammation or previous lesions

delay or interfere with the process. Increased peristalsis hastens

it, the reverse being also true. On the other hand, conditions may

be easily reversed, and the presence of sugar or glycerin within the

peritoneal cavity causes a diluting fluid to be thrown into it at

about the same rate. It is by virtue of a firm, fibrinous exudate

that foreign materials, _e. g._, ligatures, sutures, and even larger

substances, are encapsulated, those which are capable of disintegration

finally disappearing from within this investment. Occasional instances

are on record of instruments, sponges, or pieces of gauze being left

within the peritoneal cavity, in consequence of inadvertence during or

when concluding an operation. Such bodies as these often encapsulate

in this way and have been found years after at postmortem examination,

or have been slowly extruded during life by natural processes. Such

unfortunate occurrences as the latter afford the greatest reason for

care during all such operations.

PERITONITIS.

The term peritonitis has been made to cover so many conditions, of

widely differing pathological character, that it is intended here to

consider only those which have a practical interest for the surgeon.

It is unfair both to terminology and pathology to include under the

same name conditions that may be brought about slowly, or without any

participation of bacteria, with those which are due solely to bacterial

invasion. No attempt will be made here to go into a minute or complete

classification of the various conditions included by different writers

under this name. For instance, they have spoken of an idiopathic form

of peritonitis, thus confessing by use of this adjective ignorance of

the etiology of the condition. The surgeon has neither use for such

an expression nor belief in such a possibility. The thickening of the

peritoneum which may result from the proximity of an old hemorrhage, or

the irritation produced by the circulating fluids in cases of Bright’s

disease, is for him an entirely different entity, and is neither an

idiopathic form nor peritonitis itself.

For surgical purposes we mention especially the following forms:

A. Consecutive;

B. Traumatic;

C. Perforative;

D. Tuberculous;

E. Malignant;

F. Intra-uterine and infantile.

Forms A, B, and C may merge into one another or be confused from the

beginning, or they may themselves be consecutive to D, while E, the

malignant form, is hardly a distinct type, but rather a peritoneal

expression of a more widespread general condition.

Again writers have endeavored to make distinctions by the use of such

terms as “virulent,” “septic,” “putrid,” between which, however, no

lines can be clearly drawn nor sharp distinctions made. They depend to

some extent on the nature of the bacterial invasion, and again upon

the actual virulence of the bacteria involved. The most distinctive

type of surgical peritonitis is the _tuberculous_, which is usually

relatively slow and recognizable as such, but as between the cases

produced by spreading erysipelas, gonorrhea, intestinal perforation or

postoperative infection one can make few, if any, distinctions which

are serviceable or useful.

Anatomically considered there are two types of great importance--the

_circumscribed_ or _local_ and the _general or diffuse_--prognosis

depending in no small degree upon the extent of limitation of the

active process, while at any time the former may merge into the

latter. _Consecutive peritonitis_ may include that which is the

result of direct extension, as from erysipelas, appendicitis, acute

cholecystitis, pyosalpinx, or other acute infections which have

spread to and involve this membrane. Under this head also may be

included those cases due to thrombosis or embolism, of mesenteric or

other vessels, which lead to speedy gangrene of a part or all of the

intestine.

_Traumatic peritonitis_ refers rather to those cases where infection

has been carried directly inward from the exterior. Traumatic

peritonitis may be the result of extension of the same conditions which

produce the first, the consecutive form, or only occur more directly,

as, for instance, those cases produced by rupture of the stomach or

duodenum after ulcerations of the same, or perforation of typhoidal

ulcers, actual rupture and escape of the contents of a suppurating

gall-bladder, appendix, tube, or any other collection of pus, or

perforation due to the gradual extension of tuberculous, syphilitic, or

malignant disease, with final rupture of a viscus.

The nature of the bacterial invasion is of more interest to the

pathologist than to the surgeon as such. In general, however, it may be

said that, in addition to the ordinary pyogenic organisms, the colon

bacilli are perhaps the most frequently to blame, while the more putrid

types are the result of actual escape of bacteria from the intestine,

as through a perforated appendix, and the addition of a mixed type

to one which began perhaps as a simple one. Thus in the so-called

_putrid_ forms multiple bacterial contamination is usually discovered

upon making cultures. The pneumococcus, the capsule bacillus, and the

gonococcus are also not infrequently found, in cases of peritonitis

whose nature and origin will be suggested by the discovery of the

particular germ involved in each case.

=Symptoms.=--While varying much in time and intensity, and even

completely changing their type during the successive stages of the

disease, there are, nevertheless, certain cardinal symptoms which are

universally recognized in cases of surgical peritonitis. These include

_vomiting_, _pain_, _tenderness_, with more or less shock, followed

sooner or later by abdominal _spasm_ and _distention_, while to these

symptoms there is sure to be added _bowel obstruction_ of some type

which becomes, toward the end, perhaps the most profound feature, and

which may even mask the significance of other symptoms. According

as the lesion is localized or generalized _pain_ may be referred to

a particular area or may be general and intense. _Local pain_, with

tenderness, usually implies, at least at first, a localized lesion,

and is not so likely to be accompanied by vomiting as the more diffuse

form. Depression is found to correspond largely to the type and degree

of sepsis, while collapse is a prominent feature in the more severe

cases. The pain, which is sometimes intense, subsides, and it should

be emphasized that a speedy subsidence is not necessarily a favorable

symptom. It too often marks the transition of an ordinarily acute case

into one of intensely septic or even putrid type. _Tenderness_ may

be acute and localized, or diffuse and only evoked on deep pressure.

One of the most significant symptoms is _abdominal rigidity_, which

persists throughout the active state of the disease, and which, when

followed or accompanied by meteorism, may to some extent mask and

obscure all conditions within. If the patient be not seen until this

stage is reached diagnosis can be made only by history and conjecture,

for it is almost impossible to determine anything by palpation.

_Temperature_ is an uncertain factor. It sometimes rises high at first,

and then falls, while if it fall too low the prognosis is serious. The

_pulse_ also shows very irregular variations, usually rising, however,

as the disease becomes more severe, and being often almost uncountable

at the end. A combination of rising pulse and falling temperature is of

serious import.

In addition to the _vomiting_, which is a pronounced early feature of

the disease, we have, as bowel obstruction comes on, an added _fecal

character_ to the vomitus, which sometimes is most characteristic

of complete obstruction. This obstruction is due in part to toxic

paralysis of the muscular coat of the bowels, and in part to the

result of adhesions or fixations by which bowel motility is completely

prevented. Thus in many instances of peritonitis following acute

appendicitis there are loops of intestine glued together by exudate in

such a way as to practically occlude or disable them.

The depression, shock, and final collapse of the disease are

characteristic, as is also the _facial appearance_, the cheeks

becoming discolored and the orbits hollowed out, so that the eyes

early sink back. Other expressions of diminished blood pressure are

not lacking--coldness of the extremities; cold, clammy perspiration;

lividity of the skin, and the like.

While this is a picture of the most common expressions of acute septic

or surgical peritonitis, it is occasionally found that conditions

equally serious arise without such marked symptoms, and that the

patients become rapidly worse, finally dying, who neither vomit

continuously nor show extreme meteorism nor abdominal rigidity.

Such cases are thereby stamped as those of more extreme toxicity,

where systemic reaction is paralyzed almost from the outset, and are

accordingly the more hopeless on that account.

Ordinarily it is not difficult to recognize the onset and the course

of peritonitis in surgical cases. The condition may be confounded with

one of septic intoxication from some focus which has not involved

the peritoneum; otherwise differentiation is rarely difficult. The

occurrence of such a condition does not necessarily indicate faulty

technique on the part of an operator, as the condition is too often

present when the surgeon begins his work. On the other hand, it too

often follows faulty technique and constitutes the strongest argument

for vigilance both in preparation, performance, and after-treatment.

=Treatment.=--But little will be said here about non-operative

treatment, although first it should be emphasized that treatment in the

past was too often of the non-operative type. Many cases of peritonitis

could be saved by operation were it performed while the infection is

still localized, but this is at a period when they too rarely reach

the surgeon’s hands, he being called in as such when the inefficacy

of drug treatment has been already demonstrated. Without denying that

the surgeon is not blameless in all these respects, blame should,

nevertheless, be placed where it properly belongs, at the door of the

man who fails to recognize and carry out plain surgical principles.

The opium treatment for peritonitis, with which the name of Clark will

always be associated, was introduced at a time when many things were

considered as peritonitis which were not necessarily such. It was

furthermore an advance on previous methods and gave better results.

That, however, is no excuse for adhering to it when better means are

at hand. On the other hand it must not be denied that much can be

done medicinally to give comfort and meet certain indications. In

spite of the many disadvantages attaching to the use of opiates it

seems unnatural to let patients suffer as they would without them. It

is justifiable, then, to use them in cases which are hopeless, or in

those which refuse operation; but given indiscriminately and early

they often mask symptoms which, if properly appreciated, would lead

to early diagnosis, and, it is to be hoped, early operative relief.

Views also differ regarding catharsis. It is a great disadvantage

to permit the intestines to retain fecal matter for days and add a

consequent copremia to the other features of the disease. On the other

hand, intestinal activity tends to disseminate infection, and is,

consequently, most undesirable. If at the outset the intestinal canal

could be emptied and then left at rest it would best meet the somewhat

contrary indications.

Ordinarily, however, it is of small advantage to keep bombarding the

stomach with repeated doses of laxatives which are more often rejected

than retained, and which have little effect.

One of the most distressing features is _vomiting_, and here it is well

to follow Berg’s suggestion and test the vomitus with litmus paper.

If it be found alkaline small doses of morphine should be given, each

with a drop or two of aromatic sulphuric acid, in a little chopped

ice. If it be found acid small doses of milk of magnesia are advised

or some such preparation, with minute doses of morphine, frequently

repeated. The greatest relief in these cases, where the upper bowel

is emptying itself into the stomach, will be obtained from _lavage_.

In the same way tympanites and meteorism are best treated by passing

a rectal tube high, leaving it in place, and utilizing it for lavage

of the bowel, using warm water with a little sodium salicylate. Not

the least distressing feature of such a case is the reflex hiccough

which is produced by diaphragmatic spasm, since the phrenic nerve

distributes sensitive fibers as well to the peritoneum. For this there

is no really effective remedy. Small doses of Siberian musk, with or

without morphine, beneath the skin will sometimes quickly relieve it.

Depression and lowered blood pressure are best treated by adrenalin and

digitalis, rather than by strychnine, which stimulates peristalsis.

Fever, when high, should be treated by cold sponging rather than by

antipyretics. The kidneys should be kept active, if necessary by

hypodermoclysis, and the skin equally so by hot-air baths, as through

both of these emunctories much elimination may be effected. The

question of catharsis comes up again in considering what can be done to

improve elimination of ptomains by watery stools, but these are hard to

secure; it is, after all, questionable whether their effectiveness in

this regard has not been greatly over-rated. Richardson, for instance,

is inclined to believe that cases reported as cured by free catharsis

would, in all probability, have recovered without it, it being doubtful

whether the really infectious element be present.

_Surgical treatment of peritonitis_ includes a recognition of the

cause, and, if possible, its removal. Richardson has grouped in the

following suggestive manner the indications for operative intervention

in the early stages, when cases are not without hope:

General pain, becoming local; or local, becoming general, according

to cause;

Tenderness, showing the same indications;

Abdominal rigidity;

Green vomitus;

Rising pulse and temperature;

Diminished peristalsis without too much shock.

On the other hand, in cases of fully developed peritonitis, where the

surgeon may still consider the possibility of intervention, but where

prognosis is far less favorable, the conditions include:

Lessening or vanishing pain;

More general tenderness;

Great distention, replacing rigidity;

Excessive dark or fecal vomitus;

Obstipation;

Rapid and feeble pulse;

Pain extremely severe;

Low temperature and the ordinary evidences of reduced blood pressure.

In such cases the decision rests largely upon the degree of collapse.

To operate upon a moribund patient is hopeless and brings discredit

upon surgery. Before operating upon any serious case of this kind the

circumstances should be fully explained to those concerned, and they

should be impressed with the fact that should the patient die he dies

_not in consequence of the operation but in spite of it_.

The _operation_ itself will in a large measure depend upon what can

be learned of the etiology of the disease and the diffuseness of the

resulting infection. To reach a localized focus the incision may be

made at any point which will best afford access; but in dealing with a

generalized process the middle line, and an extensive incision, will

ordinarily afford the best opportunity for doing whatever is necessary.

The _preliminary incision_ may be made short, as for exploratory

purposes. Unless a loop of distended bowel be at once blown into

the opening there will be prompt escape of fluid, whose character

will reveal much of what has gone wrong within. If reasonably clear

the operator is fortunate. If it be purulent he has to combat a

most serious condition; if it be offensive, it is probably due to

contamination from a septic abscess or from intestinal gases, while if

the fluid be nondescript and contain floating particles of fecal matter

there is an intestinal or gastric perforation. So soon as one comes

upon fixation or adhesion of viscera he will find lymph, in condition

of greater or less organization. Inside the masses thus bound together

he will probably find the greatest centre of pernicious activity.

The more one sees of these intra-abdominal conditions the more respect

he, as a surgeon, feels for the _omentum_. Only recently have surgeons

learned to appreciate the kindly activities of this duplicature of

the peritoneum, with its slight or heavy load of contained fat. It

manifests a tendency which may be almost regarded as a sagacity or

instinct for shifting itself toward a local focus of infection, and

there throwing out lymph by which it becomes attached and helps to

form a protective barrier that often is most effective. Were it not

for this tendency many cases of acute appendicitis, for instance,

which now recover would be lost during the early days of the attack,

in consequence of a quickly disseminated infection. Thus a gangrenous

appendix, or hernia, or gall-bladder, is frequently so wrapped up in

a protective layer of omentum that the operator has first to detach

this, or go through it, before he comes upon the actual site of the

trouble. Some such disposition of the omentum, then, may be easily

discovered during the earliest moments of his exploration, and if later

he conclude to remove a portion of it, because of actual or impending

gangrene, he nevertheless sacrifices it with a feeling of regret

because of the good it has already done.

The further treatment of these cases is essentially a matter of what

can be done to remove the exciting cause. Questions of gravest import,

and often difficult of immediate decision, will present in nearly every

case; as, for instance, whether to resect a portion of intestine,

to remove a gall-bladder, to hunt for an appendix when embarrassed

with the difficulty of the effort and necessity for widely separating

intestinal coils, or of the treatment of distended bowel, which it may

perhaps be impossible to restore to place, of extensive and complete

flushing of the abdominal cavity, or of mere local cleanliness. And

after these questions have been decided, and action taken, there comes

still the question of _drainage_, with the wisdom of or necessity for

counteropening, as in the loin or in the cul-de-sac, and the character

of drain to be used. As to what should be attempted _in general_ there

will rarely be much room for doubt. As to how best to accomplish it

should be decided according to the training, the experience, and the

opportunities of the operator, and the nature of the environment. When

the entire peritoneal cavity is invaded, and flooded with more or

less infectious material the more thoroughly it can be washed out the

better. At the same time to do this with any degree of even apparent

thoroughness requires practical evisceration of the patient, and an

amount of time spent and shock produced by handling the viscera, which

are exceedingly depressing and may of themselves be more than can be

borne. The meteorism, which is so conspicuous a feature of most of

these cases, means the distention of the bowel to such a degree that

when once the intestines lie upon the surface of the body they can

usually be restored with the greatest difficulty; and this would raise

the question of the desirability of either one or more punctures,

through which gas should be allowed to escape, or a sufficiently

wide opening, with the introduction of a Monk tube, and the complete

emptying both of gas and putrefying fecal matter. The latter is

certainly in theory the much more desirable measure, if the patient’s

condition will only justify it. Probably after pelvic drainage the

Fowler semi-sitting posture in bed would be desirable, while after high

drainage the Trendelenburg position, with the pelvis higher than the

thorax, would be preferable.

If free abdominal _irrigation_ is to be practised a large quantity of

warm sterile saline solution should be used, to which may be added

perhaps a small proportion of acetozone or of mercury bichloride. The

silver salts also make equally effective and less irritating fluid, the

nitrate being used in the proportion of 1 to 10,000, or the citrate or

lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts

will coagulate the albuminoid fluids and give to the peritoneum an

opaque appearance, which, however, need cause no alarm.

Another question of importance is that of _enterostomy_. In some of

these cases the acute bowel obstruction is the most predominating and

distressing late feature, and an enterostomy may be attempted, even

though it be known it will serve but a temporary purpose, in order to

relieve distress. There never can be more than sentimental objection to

it, in such cases, with the possibility of something more than mere

temporary relief. It can be effected under local cocaine anesthesia, by

attaching to the parietal peritoneum the first loop of distended small

intestine that presents, and, after firmly fixing it in place, making a

small opening, and then preferably inserting a glass or other tube for

better drainage purposes.

These constitute the precautions to be followed and the advice to be

given in cases of septic or surgical peritonitis. How successful they

may be, or how satisfactory the termination of the case, cannot be

foretold by statistics nor by reports of cases in the hands of others.

Success will depend in large measure upon the early or late period

at which the case is thus treated, and upon the general surgical

discretion and experience of the operator. It is probable that

disappointment will result more often than success. Nevertheless every

life thus saved is one snatched from a certainly fatal termination

without it, and if successful but once in ten times one life has

thereby been saved that may be worth saving, without saving the other

nine. While I would advise to make the attempt in any case which offers

a reasonable prospect of success, caution should be used against doing

it without a full understanding with those concerned that it is an

effort in the right direction, concerning which no promise can be made;

death results not from the operation so much as in spite of it.

Summarizing, briefly, the best methods of treating a diffuse septic

peritonitis we may agree with Le Conte,[53] that they consist of the

following measures: The least possible handling of peritoneal contents,

the elimination of time-consuming procedures, most perfect drainage of

the pelvis by a special suprapubic opening, as well as free drainage

through the operative incision, the semi-sitting posture of the

patient after its conclusion, the prevention of peristaltic movements

by withholding all fluids by the mouth, and perhaps by small amounts

of opium, and the absorption of large quantities of water through the

rectum, by which there may be produced a reversal of the current in

the lymphatics of the peritoneum, making it a secreting rather than an

absorbing surface and increasing urinary secretion. It is inexpedient

to waste time sponging peritoneal surfaces or wiping away lymph, for

danger of septic absorption is increased rather than diminished.

Patients with diffuse septic peritonitis bear brief operations fairly

well, but prolonged ones badly; therefore a minimum amount of work

should be done.

[53] Annals of Surgery, February, 1906.

One of the most valuable procedures in carrying out the above advice

is Murphy’s method of _slowly introducing large quantities of water

into the rectum_. The rectal tube used for the purpose ends with a

sort of nozzle containing three or four openings, and the reservoir

containing the solution is elevated but a few inches above the level of

the bed, the intent being that it shall simply trickle into the bowel

no faster than absorption can occur. In this way from a pint to a quart

may be absorbed each hour, the pressure being continuous, and the flow

so regulated that no accumulation of fluid takes place in the bowel.

Murphy claims that by this method the lymph current in the peritoneal

lymphatics is so reversed that the peritoneum is bathed with free

discharge and that this should be afforded escape by suitable drainage

methods, coupled with Fowler’s (the sitting) posture.

TUBERCULOUS PERITONITIS.

_Acute or chronic tuberculosis of the peritoneum_ assumes usually,

first, the _miliary_ form, after which, in the slow cases, infiltration

and great thickening occur to such an extent as to alter the

appearance, texture, and behavior of the peritoneum itself. It is

rarely a primary condition, but is usually secondary to some other

tuberculous focus, which may be one or more of the mesenteric nodes,

these being involved in consequence of infection from the alimentary

canal; or the peritoneum may be easily infected either from the

genito-urinary tract or directly from the intestine. In children, the

most common path of infection is through the mesenteric nodes; in

females, through the Fallopian tubes, and in males, either through

the intestine or the kidneys or ureters. The peritoneum, under these

circumstances, behaves very much as does the pleura, in the presence of

acute or chronic tuberculous lesions which extend to and involve it.

Thus it may become so thickened, and even “leathery,” as to have lost

all its original characteristics, and to appear more like a dense, firm

membrane than in its original semblance.

_Peritoneal tuberculosis_ appears in three different types: A

_fibrinoplastic_ type, characterized especially by adhesions; an

_ulcerative and sometimes absolutely suppurative_ form, marked always

by the presence of pus and pyoid; and an _ascitic_ type, characterized

by leakage of increasing amounts of serum and the development of

well-marked ascites.

The first, or _fibrinoplastic_, is a localized lesion, and leads to the

formation of dense adhesions, as, for instance, between a Fallopian

tube and the pelvic walls or the other viscera. As the disease spreads

all the tissues become matted together in a mass which renders them

almost indistinguishable, frequently much resembling malignant disease.

In some instances it may be possible to remove the entire affected

area. At other times it is best to let it alone.

The _ulcerative form_ is characterized by more general symptoms of

conspicuous febrile type. It produces rapid loss of strength and

weight, frequently attended with evidences of intestinal ulceration and

with abdominal tenderness and pain. A certain proportion of these cases

justify exploration, though but few of them will be found favorably

disposed for radical surgical measures.

The _ascitic type_ is characterized by rapid accumulation of fluid,

with accompanying malaise and debility. As the abdomen distends and

the diaphragm is pushed upward respiration becomes more difficult and

rapid. A certain _protrusion of the umbilicus_ also characterizes

many of these cases. Their course is not so febrile, but it may be

possible, especially in the early stages, to make out some enlargement

of mesenteric nodes, or involvement of the viscera, which will aid in

diagnosis. It is most common in children, but it may be met with at any

age. In general such a collection of fluid, which cannot be accounted

for by recognizable disease of the heart, liver, or kidneys may be

suspected to be tuberculous.

=Treatment.=--Treatment of tuberculous peritonitis should be _surgical_

when possible. This statement is based partly upon the fact that it

is so commonly a secondary condition. Such treatment will depend, in

large measure, upon the extent to which it may be possible to remove

any exciting foci of the disease; but experience shows that even this

is not always necessary to bring about a cure, as in those cases of

the ascitic type where it is desirable only to wash out the abdominal

cavity and close it again, this simple procedure seeming to suffice.

It is the cases of the _ascitic type_ which seem most benefited by

_incision and irrigation_, usually without drainage, and it is these

which are perhaps as hopeless as any under non-operative treatment.

It was Van de Warker, of Syracuse, who, in 1883, first recognized

the value of simple irrigation in these cases, and while at present

we find it impossible to explain the benefit which so often and so

rapidly accrues, the measure is universally recognized as that offering

the most hope. This, like every other surgical procedure, should be

practised early rather than late, preferably so soon as diagnosis

is made, or, when this is difficult, it should be made a part of an

exploratory operation intended partly for diagnostic purposes. The

measure itself is simple. A small opening in the middle line, between

the pubis and the umbilicus, permits free escape of all contained

fluid, which should be facilitated by changing the position of the

patient, thus preventing plugging of the opening by presenting bowel.

Every drop which can escape having been removed, the abdomen is then

flushed repeatedly with either warm saline solution or a plain watery

solution of acetozone, 1 to 1000, or silver lactate or citrate, in the

same proportion or a little stronger. My own preference has always

been for the latter, and with a silver solution I have obtained a

large degree of success. There is no objection to leaving a small

amount of either of these fluids in the abdominal cavity--_i. e._, no

more than an ordinary effort to empty it before closing the wound.

An incision one inch long, made for this purpose, will serve nearly

every indication. Through it the parietal peritoneum, as well as that

covering numerous loops of intestine, can be inspected, and through

it also a finger may be inserted for exploratory purposes, for the

detection of mesenteric nodular disease or of any other focus. Should

any serious local condition be revealed which might be benefited by

radical measures, this would be the time to practise them.

Before closing the wound margins it would be well to thoroughly

disinfect them, for over them has flowed infected fluid, and we

sometimes see tuberculous foci develop at this point. This fact

explains also the disadvantage obtaining in these cases of making

drainage openings. They serve their purpose admirably for a short time,

but, becoming thus infected, lead to the establishment of tuberculous

fistulas and sinuses, which may call for subsequent operation. Fecal

fistula may even be a more remote consequence. As the peritoneum is

approached it will be found more or less altered, and there may even be

observed bowel or omentum adherent behind it; therefore caution must be

observed.

A final caution should also be given in order that we may avoid

mistaking that form of ascites which is frequently seen in connection

with cancer of the abdominal viscera extended to the peritoneum, and

particularly that form spoken of as _miliary carcinosis_ or _miliary

sarcomatosis_, for a tuberculous collection. While surgeons are

occasionally deceived, one will usually find much in the history of the

case, and in the results of local examination, which may save making

this error, if it be so regarded; but, in effect, the opening and the

evacuation will give relief, even though this character of the disease

makes it less amenable to help from any such source.

CHAPTER XLVII.

INJURIES AND SURGICAL DISEASES OF THE STOMACH.

CONGENITAL MALFORMATIONS OF THE STOMACH.

These malformations are quite rare, at least those raising the question

of possible surgical remedy. _Transposition_ does not require relief,

nor does a stomach abnormally small allow it. More or less _stenosis

of the pylorus_ as a congenital defect has been observed, but it is

extremely rare. Along with it is often associated a certain hypertrophy

of the stomach muscle. _Hour-glass deformity_ may be of congenital or

acquired origin. The latter two conditions permit of easy surgical

remedy. Pyloric stenosis may be atoned for by gastro-enterostomy or

treated directly by a plastic operation, while the hour-glass stomach

permits of an anastomotic rearrangement, either of its dilated portions

with each other or with the bowel below.

The _acquired malformations_ are connected with the consequences

of ulceration and stricture. They include more or less complete

_stenosis_, either cicatricial or malignant, various forms and types of

_gastroptosis_ and _gastric dilatation_, in which sometimes enormous

degrees of distention are produced, with disturbed or practically

destroyed stomach digestion. These cases will be considered by

themselves a little later, along with their surgical relief.

The _anatomical relations of the nerves_ supplying the stomach are

worthy of the surgeon’s especial consideration. Its sympathetic nerve

supply is in particular and intimate relation with the seventh, eighth,

and ninth spinal roots, by which we account for the tenderness of the

overlying surface in ulcer of the stomach, and the pain which is often

referred to the region of the left shoulder-blade. When the stomach is

adherent to the gall-bladder, in cases of biliary calculi, the pain

is often referred to the right shoulder, but so soon as the pylorus

becomes entangled and bound down pain is referred also to the left side

as well.

HOUR-GLASS STOMACH.