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.

##