THROMBOSIS AND EMBOLISM FOLLOWING ABDOMINAL OPERATIONS.
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.
CHAPTER XLVI.
THE PERITONEUM AND ITS DISEASES.
Were the peritoneum spread upon a flat surface it would be found to equal in area that of the skin which covers the body. In man it is a closed sac; in woman it is exposed to exterior contamination through the Fallopian tubes by way of the uterus and vagina. Hence the frequency with which infections of the latter are transmitted to the membrane itself. Thickened in some places, or duplicated, for the purpose of forming ligaments and membranous visceral supports, it is usually thin, connected with the structures which it lines or covers by a more or less delicate, cobweb-like connective tissue. In some of its duplications relatively large amounts of fat may be collected. While freely supplied with bloodvessels it may be regarded as an enormous lymph sac, its capabilities of absorption being relatively immense. It is because of this that human beings escape many of the possibly fatal consequences of infection. Along it infectious processes travel, sometimes with wonderful rapidity, while again it throw’s out exudates and rapidly walls off a serious disturbance, imprisoning it, as it were, and often effectually. Fluid may escape from it (fluid exudate) with great rapidity, or it may exude a fluid rich in fibrin which rapidly accumulates and forms a dense, firm exudate that serves to bind surfaces together and is often the surgeon’s best friend. In fact, the surgeon looks for a minimum and desirable amount of this exudate to ensure the result of whatever sutures he may pass through the peritoneum and the tissues which it covers. Thus after an ordinary intestinal suture it is expected that within some six hours the exudate thus formed will be of itself almost sufficient for the purpose of safety.
Peritoneum is said to possess the power of absorbing from 4 to 8 per cent. of the weight of the individual within an hour, but this only under normal circumstances, since inflammation or previous lesions delay or interfere with the process. Increased peristalsis hastens it, the reverse being also true. On the other hand, conditions may be easily reversed, and the presence of sugar or glycerin within the peritoneal cavity causes a diluting fluid to be thrown into it at about the same rate. It is by virtue of a firm, fibrinous exudate that foreign materials, e. g., ligatures, sutures, and even larger substances, are encapsulated, those which are capable of disintegration finally disappearing from within this investment. Occasional instances are on record of instruments, sponges, or pieces of gauze being left within the peritoneal cavity, in consequence of inadvertence during or when concluding an operation. Such bodies as these often encapsulate in this way and have been found years after at postmortem examination, or have been slowly extruded during life by natural processes. Such unfortunate occurrences as the latter afford the greatest reason for care during all such operations.