CHAPTER XLV

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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