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.