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.
—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 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.
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.
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.
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.