CHAPTER XL
DIAGNOSIS OF THE MORE IMPORTANT SEQUELS OF ABDOMINAL OPERATIONS
Immediately after an abdominal operation there may be a certain amomit of slaock, shown by in- creased frequency and lessened tension of the pulse, shallow respiration, and coldness of the extremities. This should quickly pass off, the pulse regain its tension and become slower, the respiration become regular, quiet, and normal in depth, and the feet, hands, and face warmer. The unconsciousness of anaesthesia should pass into normal sleep, from which the patient should awaken and complain only of a little headache, slight abdominal pain, thirst, and nausea, with, perhaps, one or two acts of vomiting due to the anaesthetic.
Next day and subsequently the headache, nausea, vomiting, and thirst should have all passed away, there should be nothing more than trifling local pain, the patient should be able to take and to enjoy food, should not be restless or sleejaless, and the pulse, temperatm-e, and respirations should be normal, micturition should be performed naturally, and flatus should be passed from time to time. There should be neither abdominal distension nor rigidity of the abdominal wall, and the respiratory movement should be abdominal as well as thoracic. The wound, including the suture tracks, should heal by first intention without swelling, redness, or more
583
584
SURGICAL DIAGNOSIS
[chap.
than the least local tcuderucss, and slioidd leave a linear painless and firm scar. The abdominal wall should recover its full freedom and power of mus- cular contraction. The bowels should act naturally, or at any rate respond easily to a laxative. The patient should recover without any abdominal dis- ability or pain and with unimpaired nerve-control.
From this ideal progress there are many depart- ures of all grades of severity. Some of these are common to all operations, such as immediate or delayed chloroform sickness (acidosis), retention of Tume, and traumatic neurasthenia. But there are certain sequela3 of abdominal operations of which the diagnosis may be discussed with advantage, such as —
Severe shock. Internal hajmorrhage. Vomiting, postantesthe- tic.
Vomiting from acidosis.
Vomiting from acute di- latation of stomach.
Vomiting from periton- itis.
Vomiting from intestinal
obstruction. Massive collapse of lung. Intestinal paresis. Peritonitis.
Intra-abdominal abscess. Portal pyajmia. Thrombosis, j Pulmonary embolism.
The diagnosis of shock is given in Chap. IV., and of internal haemorrhage in Chap. XIII.
Vomitiufj is a symptom of many postoperative complications, and it is very important to distin- guish between them. If the vomiting occurs quite shortly after the operation, is attended with much nausea, is excited by taking food, and the vomit smells of the anajsthetic that had been given and consists of normal gastric contents only, it is post- anesthetic vomiting, and usually soon disappears under treatment. But if the vomittng is frequent, occurs independently of taking food, and the patient's
XL]
ABDOMINAL OPERATIONS 585
breath smells of acetone and the urine is found to contain acetone, the case is one of acidosis. This condition is most often met with in children, par ticularly after a second administration of chloro- form, but owing to the greatly lessened use of this ansesthetic is now of rare occurrence, the patients become very collapsed, with sunken eyes and cheeks, and often die. If the vomiting is in .very large amounts of dark-brown fluid, and on examining the abdomen the stomach is found to be enlarged and to extend low down into the belly, the condition is known as acute dilatation of the stomach ; it is attended with collapse and is very often fatal. If the vomiting is in small quantities but frequently repeated, is unattended with nausea, and is a gentle regurgitation of fluid into the mouth, and the vomited matter becomes brown and then darker, even black in colour, it is the vomiting of peritonitis. If the vomiting continues in spite of treatment, and independently of taking food, and the vomit soon loses its acidity, becomes light-brown in colour like pea-soup, and intestinal in odour, while Ihe urine is found to contain much indican, the case is one of intestinal obstruction. If these symptoms have developed immediately after the operation, they are due to failure to relieve obstruction, as, for example, in imperfect reduction of a strangu- lated hernia, or in overlooking a second internal strangulation or stenosis when relieving a first. But if the symptoms come on at an interval of days or weeks from an operation, they are due to an internal strangulation, kinking, or volvulus, or to obstruction developing quite independently of the operation.
Massive c-ollnpsc oi lunt/. — When the patient complains of slioi'tncss of breath, and. the respirations arc hurried and the mucous membranes and nails
586 SURGICAL DIAGNOSIS [chap.
more or less cyanosed, and on examining the chest it is found that one side is more or less motionless, that the percussion note over that base is impaired, and the respiratory murmur weak, tubular in char- acter, or absent, and that the heart's apex-beat is displaced towards that side, the condition is that i described by Pasteur as massive collapse of lung. It may be found after any abdominal operation, ; even so slight a one as the radical cure of an in- guinal hernia, and it may come on in otherwise quite healthy and robust patients. If it afiects both lungs, and both sides of the chest are found motion- j less except at the upper part, with slight dullness and absence of breath-sounds over both lower lobes, the condition is one of great gravity ; in such a case the heart's apex-beat is not displaced. In massive collapse the temperature is raised and the pulse-rate is increased. This complication is observed within two or three days of an operation.
Abdominal distension is another postopera- tive symptom of considerable importance, ^^^lere it is unaccompanied by vomiting, fever, and increased frequency of pulse, it is due merely to intestinal paresis caused by considerable exposure or handUng of the bowel at the operation, or by distension and congestion of the bowel before the operation, some- times aggravated by old age of the patient or long- standing chroni ■ constipation. Its rehef by vigorous appropriate treatment confirms the diagnosis. When the abdominal distension is associated with vomit- ing {see p. 585), restlessness, increased frequency of pulse and respiration, a fall in blood-pressm-e, and slight cyanosis, the condition is due to pcritomtis. There may or may not be pyrexia, and pain ; the distended colon responds with great difficulty, if at all, to purgatives and stimulating enema ta.
XL] PELVIC ABSCESS 587
Intra-abdominal abscess. — When at an in- terval of days (or longer) after an operation the patient complains of localized pain in the belly, and it is found that there is limitation of abdominal movement with more or less local rigidity of the abdominal wall and tenderness on pressure, and a swelhng is felt, and at the same time the tempera- ture has been raised for several days at least, with an evening rise and a morning partial fall, and a blood-count gives well-marked leucocytosis, there is an intra-abdominal abscess. The pulse-rate is rapid, there may be sweating and a rigor or rigors. Of these intra-abdominal abscesses there are several varieties, which are to be distinguished according to their position. If the patient has a fi'equent desire to defsecate and passes large amounts of clear mucus (proctorrhosa), the abscess will be found in the pelvis, pressing upon and about to burst into the rectum, and the finger in the rectum will feel the swelling, and will probably enable the surgeon to recognize that it is a fluid swelling by its globular outline and by its yielding under the finger.
If the swelling is found close above the pubes, possibly also extending into the pelvis, and the patient has great frequency of micturition with much pain and strangury, and the urine is mixed with bright blood and mucus or pus, the abscess is close to, and threatening to burst into, the bladder.
Where there are signs of intra-abdominal suppura- tion and the lower half of the abdomen is neither rigid, immovable, nor tender, and no swelhng can be detected below the level of the umbilicus or in the pelvis, a very careful examination must be made of the upper abdomen for subphrenic abscess. In this concUtion there may be very little, if any, ab- dominal pain, but in most cases there is transient or*
588
SURGICAL DIAGNOSIS ■ [riiAi-.
persistent pain in tlic region of tlic skoulder. The exact seat of tliis pain, and of any local liyper- sesthesia which, accompanies it, must be carefully noted ; for it has been found tliat pain behind the shoulder over the scapula indicates involvement of the posterior part of the diaphragm on that side, and pain on the top of the slioulder, more central inflammation, while pain over the clavicle indicates inflammation of the front half of the dia- phragm. When the signs given below do not make the situation of the abscess clear, this fact of the localization of shoulder pain may determine tlie situation of an exploratory operation. The special points to determine are : (1) the presence of abnormal dullness, especially above the usual level, as either dome of the diaphragm may be pushed up by pus beneath it ; (2) the existence of a tj'^mpanitic area which shifts with the patient's change of posi- tion, due to gas in the abscess ; (3) displacement of the liver downwards ; (4) swelling ; (5) immobility | of the part in respiration ; (6) raising of the heart's apex-beat. ' There may be dullness in one or other side of the chest from consolidation of the base of | the lung or from efiusion into the pleura. A skia- gram is often very useful in showing a collection of pus between the diaphragm and the Uver. In many cases the presence of pus is demonstrated by ex- ploratory puncture.
Six varieties of subphrenic abscess have been described, and can be more or less certainly diagnosed.
If the swelling is at the epigastrium to the left of the middle line and above the level of the umbili- cus, it is a left anlerior subphrenic abscess. There is usually a history of gastric ulcer, the heart's apex is pushed up, and there is a movable area of tym-
XL]
SUBPHRENIC ABSCESS
589
panites over the front of the swelling. If with signs of intra-abdominal abscess there is pain in the right hypochondrium and the right dome of the diaphragm i& raised and the liver is not displaced downwards, there is probably a right anterior subphrenic abscess. A shifting area of tympanites confirms this diagnosis and indicates that the abscess is secondary to gastric or duodenal ulcer.
But if with these signs there is marked displace- ment of the liver downwards, it shows that the abscess is a right extraferitoneal subphrenic abscess between the layers of the right coronary ligament. If the abscess is found beneath and below the lowest ribs on the right side, fillmg out the loin, it is a right posterior subphrenic abscess. If the abscess is simi- larly placed on the left side behind the stomach, it is a left posterior subphrenic abscess. And if with signs of consolidation of the base of the left lung an abscess is detected pointing in the loin, it is probably a left extraperitoneal subphrenic abscess between the layers of the left coronary ligament. These last two abscesses are very difficult to diagnose.
Portal pyremia. — If the patient has a succes- sion of rigors at irregular intervals, with raised and irregular temperature, and becomes more or less jaundiced, it is a case of portal pyasmia due to infec- tion from some part of the area whose veins enter the vena porta. The hver is usually a little enlarged, easily felt below the ribs, and is slightly tender.
Thrombosis.— When the patient has an abrupt rise of temperature and concurrently complains of a dull pain in one groin— more often the left— extend- ing down the thigh in the line of the vessels, and on examination the hollow of the groin is found to be a little filled up, and tender on gentle pressure; to the inner side of the common femoral artery
590 SUEGICAL DIAGNOSIS
there is a femoral thrombosis. Slight oedema al^out the aukle of the same side only, spreading in the course of a day or two up the Hmb, confirms the diagnosis.
Pulmonary embolism. — When, with or with- out previous evidence of venous thrombosis, the patient is suddenly seized with a sharp pain in the chest, acute dyspnoea, and coughs up blood, or blood and mucus, there is a pulmonary emboUsm. A large proportion of such cases end fatally within a few minutes. In the non-fatal cases the severity of the distress is in proportion to the size of the vessel occluded, and the subsequent course depends upon the infectivity of the clot. If the infarct is large, an area of dullness with weak breath-sounds rapidly develops, and, if it is infected, an abscess of the lung or gangrene is likely to follow.