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