The principles and practice of modern surgery

by Roswell Park

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.