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general principles of abdominal surgery may be discussed. Exploratory Laparotomy.—In many cases of serious intraabdominal disease it is impossible for the surgeon to say exactly what is wrong without making an incision and introducing his See also:

FINGER

finger, or, if need be, his See also:

hand among the intestines. With due care this is not a perilous or serious See also:

PROCEDURE (Fr. procedure, from Lat. procedere, to go for-ward)

procedure, and the See also:

GREAT

great ad-vantage appertaining to it is daily being more fully recognized. It was Dr See also:

Oliver Wendell See also:

HOLMES, OLIVER WENDELL (18o9-1894)

Holmes, the See also:

AMERICAN

American physiologist and poet, who remarked that one cannot say of what See also:

wood a table is made without lifting up the See also:

CLOTH

cloth; so also it is often impossible to say what is wrong inside the See also:

ABDOMEN (a Latin word, either from abdere, to hide, or from a form adipomen, from adeps, fat)

abdomen without making an opening into it. When an opening is made in such circumstances—provided only it is done soon enough—the successful treatment of the See also:

case often becomes a See also:

SIMPLE

simple See also:

MATTER

matter. An exploratory operation, therefore, should be promptly resorted to as a means of diagnosis, and not See also:

LEFT

left as a last resource till the outlook is well-nigh hopeless. It is probable that if the question were put to any experienced See also:

HOSPITAL (Lat. haspitalis, the adjective of hospes, host or guest)

hospital surgeon if he had often had cause to regret having advised recourse to an exploratory operation on the abdomen, his See also:

ANSWER (derived from and, against, and the same root as swear)

answer would be in the negative, but that, on the other hand, he had not infrequently had cause to regret that he had not resorted to it, See also:

POST

post-mortem examination having shown that if only he had insisted on an exploration being made, some See also:

BAND

band, some See also:

ADHESION (from Lat. adhaerere, to adhere)

adhesion, some See also:

TUMOUR (Lat. tumor, a swelling)

tumour, some See also:

ABSCESS (from Lat. abscedere, to separate)

abscess might have been satisfactorily dealt with, which, left unsuspected in the dark cavity, was accountable for the See also:

DEATH

death. A physician by himself is helpless in these cases. Much of the rapid advance which has of See also:

LATE

late been made in the results of abdominal surgery is due to the improved relationship which exists between the public and the surgical profession.

In former days it was not infrequently said, " If a surgeon is called in he is sure to operate." Not only have the 1 Pedro had succeeded to the See also:

THRONE

throne of See also:

PORTUGAL

Portugal in 1826, but abdicated it at once in favour of his daughter. I2 A.D. 1048 1131 • I169 1206 Dec. 13, 1294 1296 1355 S• ept. 29, 1399 . 1415 1439 1^ 444 and 1445 1556 • 1654 1668 public said this, but even physicians have been known tq suggest it, and have indeed used the equivocal expression, the "See also:

APOTHEOSIS (Gr. aaoOeou)

apotheosis of surgery," in connexion with the operative treatment of a serious abdominal See also:

LESION (through Fr. from Lat. laesio, injury, laedere, to hurt)

lesion. But fortunately the public have found out that the surgeon, being an honest See also:

man, does not advise operation unless he believes that it is necessary or, at any See also:

RATE

rate, highly advisable. And this happy See also:

DISCOVERY

discovery has led to much more confidence being placed in his decision. Ithas truly been said that a surgeon is a physician who can operate, and the public have begun to realize the fact that it is useless to try to relieve an acute abdominal lesion by See also:

DIET

diet or dregs. Not many years ago cases of acute, obscure or chronic affections of the abdomen which were admitted into hospital were sent as a matter of course into the medical wards, and after the . effect of drugs had been tried with expectancy and failure, the services of a surgeon were called in. In acute cases this delay spoilt all surgical chances, and the See also:

IDEA (Gr. Ibia, connected with i&eiv, to see; cf. Lat. species from specere, to look at)

idea was more widely spread that surgery, after all, was a poor handmaid to See also:

MEDICINE

medicine. But now things are different.

Acute or obscure abdominal cases are promptly relegated to the surgical wards; the surgeon is at once sent for, and if operation is thought desirable it is performed without any delay. The public have found, that the surgeon is not a reckless operator, but a man who can take a broad view of a case in all its See also:

BEARINGS

bearings. And so it has come about that the results of operations upon the interior of the abdomen have been improving See also:

day by day. And doubtless they will continue to improve. A great impetus was given to the surgery of wounded, mortified or diseased pieces of See also:

INTESTINE (Lat. intestinus, internal, usually in neuter plural intestina. from intus, within)

intestine by the introduction from See also:

Chicago of an ingenious contrivance named, after the inventor, See also:

Murphy's See also:

BUTTON (Fr. bouton, O. Fr. boton, apparently from the same root as bouter, to push)

button. This consists of a See also:

SHORT, FRANCIS JOB (1857– )

short See also:

nickel-plated See also:

TUBE (Lat. tuba)

tube in two pieces, which are rapidly secured in the divided ends of the bowel, and in such a manner that when the pieces are subsequently " married " the adjusted ends of the bowel are securely fixed together and the See also:

canal rendered practicable. In the course of See also:

time the button loosens itself into the interior of the bowel and comes away with the alvine evacuation. In many other cases the use of the button has proved convenient and successful, as in the See also:

ESTABLISHMENT (0. Fr. establissement, Fr. etablissement, late Norm. Fr. establishement, from O. Fr. establir, Fr. etablir, Lat. stabilire, to make stable)

establishment of a permanent communication between the stomach and the small intestine when the See also:

ORDINARY (med. Lat. ordinarius, Fr. ordinaire)

ordinary gateway between these parts of the alimentary canal is obstructed by an irremovable See also:

MALIGNANT (Lat. malignus, evil-disposed, from maligenus)

malignant growth; between two parts of the small intestine so that some obstruction may be passed; be-. tw°en small and large intestine. The operative procedure goes by the name of short-circuiting; it enables the contents of the bowel to get beyond an obstruction. In this way also a permanent working communication can be set up between the See also:

gall-See also:

BLADDER (from A.S. blaeddre, connected with bl¢wan, to blow, cf. Ger. blase)

bladder, or a dilated bile-duct, and the neighbouring small intestine—the last-named operation bears the precise but very clumsy name of choledocoduodenostomy. By the use of Murphy's ingenious apparatus the communication of two parts can be secured in the shortest possible space of time, and this, in many of the cases in which it is resorted to, is of the greatest importance. But there is this against the method—that some-times ulceration occurs around the rim of the See also:

metal button, whilst at others the loosened metal causes annoyance in its passage along the alimentary canal.

Some surgeons therefore prefer to use a bobbin of decalcified See also:

bone or similar soft material, while others rely upon See also:

DIRECT

direct suturing of the parts. The last-named method is gradually increasing in popularity, and of course, when time and circumstances permit, it is the ideal method of treatment. The cause of death in the case of intestinal obstruction is usually due to the See also:

BLOOD

blood being poisoned by the absorption of the products of decomposition of the fluid contents of the bowel above the obstruction. It is now the See also:

CUSTOM (from O. Fr. costume, costume or coustume; Low Lat. costuma, a shortened form of consuetudo)

custom, therefore, for the surgeon to See also:

COMPLETE

complete his operation for the See also:

RELIEF

relief of obstruction by See also:

DRAWING

drawing out a See also:

LOOP

loop of the distended bowel, incising and evacuating it, and then carefully suturing and returning it. The surgeon who first recognized the lethal effect of the absorption of this stagnant fluid—or, at any rate; who first suggested the proper method of treating it—was' See also:

Lawson See also:

Tait of See also:

BIRMINGHAM

Birmingham, who on the occurrence of See also:

GRAVE

grave symptomsafter operating on the abdomen gave small, repeated doses of See also:

EPSOM

Epsom salts to See also:

WASH, THE

wash away the harmful liquids of the bowel and to enable it at the same time to empty itself of the gals, which, by distending the intestines, was interfering with respiration and circulation. Amongst still more See also:

RECENT

recent improvements in abdominal surgery may be mentioned. the placing of the patient in the sitting position as soon as practicable after the operation, and the slow See also:

ADMINISTRATION (Lat. administrare, to serve)

administration of a hot saline See also:

SOLUTION (from Lat. solvere, to loosen, dissolve)

solution into the See also:

LOWER

lower bowel, or, in the more desperate cases, of injecting pints of this " normal saline " fluid into the loose See also:

TISSUE (Fr. tissu, tissue, participle of tisser, Lat. texere, to weave)

tissue of the armpit. Hot See also:

WATER

water thus administered or injected is quickly taken into the blood, increasing its See also:

VOLUME

volume, diluting its impurities and quenching the great thirst which is so marked a symptom in this See also:

CONDITION (Lat. condicio, from condicere, to agree upon, arrange; not connected with conditio, from condere, conditum, to put together)

condition. Gunshot Wounds 'of the Abdomen.—If a revolver See also:

BULLET (Fr. boulet, diminutive of boule, ball)

bullet passes through the abdomen, the coils of intestine are likely to be traversed by it in several places. If the bullet be small and, by See also:

CHANCE (through the O. Fr. cheance, from the Late Lat. cadentia, things happening, from cadere, to fall out, happen; cf. " case ")

chance, surgically clean, it is possible that the openings may tightly See also:

close up behind it so that no leakage takes See also:

PLACE (through Fr. from Lat. platea, street; Gr. IrAar6s, wide)

place into the general peritoneal cavity. If increasing collapse suggests that serious bleeding is occurring within the abdomen, the cavity is opened forthwith and a thorough exploration made. When it is uncertain if the bowel has been traversed or not, it is well to wait before opening the abdomen, due preparation being made for performing that operation on the first See also:

APPEARANCE (from Lat. apparere, to appear)

appearance of symptoms indicative of perforation having occurred. Small perforating wounds of the bowel are treated by such suturing as the circumstances may suggest, the interior of the abdominal cavity being rendered as See also:

FREE

free from septic micro-organisms as possible.

It is by the malign See also:

INFLUENCE (Late Lat. influentia, from influere, to flow in)

influence of such germs that a fatal issue is determined in the case of an abdominal See also:

WOUND (O. Eng. wund,connected with a Teutonic verb, meaning to strive, fight, suffer, seen in O. Eng. winnan, whence Eng. " win ")

wound, whether inflicted by firearms or by a pointed weapon. If aseptic procedure can be promptly resorted to and thoroughly carried out, abdominal wounds do well, but these essentials cannot be obtained upon the field of See also:

BATTLE

battle. When after an See also:

ACTION

action wounded men come pouring into the field-hospital, the many cannot be kept waiting whilst preparations are being made for the thorough carrying out of a prolonged aseptic abdominal operation upon a solitary case. Experie'nce' in the See also:

South See also:

AFRICAN

African See also:

war of 1899-19oe showed that Mauser bullets could See also:

PIERCE, FRANKLIN (1804—1869)

pierce coils of intestine and leave the soldiers in such a condition that, if treated by See also:

mere " expectancy," more than 5o % recovered, whereas if operations were resorted to, fatal septic See also:

PERITONITIS

peritonitis was likely to ensue. In the close proximity Of the . fight, where time, assistants, pure water, towels, lotions and other necessaries for carrying out a thoroughly aseptic operation cannot be forthcoming, gunshot wounds of the ab- domen had best not be interfered with. Stabs of the abdomen are serious if they have penetrated the abdominal See also:

wall, as, at the time of injury, septic germs may have been introduced, or the bowel may have been wounded. In either case a fatal inflammation of the peritoneum may. be set up. It is inadvisable to probe a wound in See also:

order to find out if the belly-cavity has been penetrated, as the probe itself might carry inwards septic germs. In case of doubt it is better to en-large the wound in order to, determine its See also:

DEPTH

depth, and to disinfect and close it if it be non-penetrating. If, however, the belly-cavity has been opened, the neighbouring pieces of bowel should be examined, cleansed and, if need be, sutured. Should there have been an See also:

ESCAPE (in mid. Eng. eschape or escape, from the O. Fr. eschapper, modern echapper, and escaper, low Lat. escapium, from ex, out of, and cappa, cape, cloak; cf. for the sense development the Gr. iichueoOat, literally to put off one's clothes, hence to sli

escape of the contents of the bowel the " See also:

TOILET

toilet of the peritoneum " would be duly made, and a drainage-tube would be left in. If the stab had injured a large blood-See also:

VESSEL (O. Fr. vaissel, from a rare Lat. vascellum, dim. of vas, vase, urn)

vessel either of the abdominal cavity, or of the liver or of some other organ, the bleeding would be arrested by ligature or suture, and the extravasated blood sponged out.

Before the days of antiseptic surgery, and of exploratory abdominal operations, these cases were generally allowed to See also:

DRIFT (from "drive ")

drift to almost certain death, unrecognized and almost untreated: at the See also:

PRESENT

present time a large number of them are saved. Intussusception.—This is a terribly fatal disease of infants 'and See also:

CHILDREN, LAW RELATING TO

children, in which a piece of bowel slips into, and is gripped by, the piece next below it. Formerly it was generally the custom to endeavour to reduce the invagination by passing See also:

air or water up the rectum under pressure—a speculative method of treatment which sometimes ended in a fatal rupture of the distended bowel, and often—one might almost say generally—failed to do what was expected of it. The teaching of modern -surgery is that a small incision into the abdomen and a prompt withdrawal of the invaginated piece of bowel can be trusted to do all that, .and more than, injection can effect, without blindly risking a rupture of the bowel. It is certain that when the surgeon is unable to unravel the bowel with his fingers gently applied to the parts themselves, no speculative distension of the bowel could have been effective. But the outlook in these distressing cases, even when the operation is promptly resorted to, is extremely grave, because of the intensity of the See also:

SHOCK, or COLLAPSE

shock which the intussusception and resulting strangulation See also:

ENTAIL (from Fr. tailler, to cut; the old derivation from tales haeredes is now abandoned)

entail. Still, every operation gives them by far the best chance. See also:

Cancer of the Intestine.—With the introduction of aseptic methods of operating, it has been found that the surgeon can reach the bowel through the peritoneum easily and safely. With the peritoneum opened, moreover, he can explore the diseased bowel and See also:

DEAL

deal with it as circumstances suggest.. If the cancerous See also:

mass is fairly movable the affected piece of bowel is excised and the cut ends are spliced together, and the continuity of the alimentary *Canal is permanently re-established. Thus in the case of cancer of the large intestine which is not too far advanced, the surgeon expects to be able not only to relieve the obstruction of the bowel, but actually to cure the patient of his disease. When the lowest part of the bowel was found to be occupied by a cancerous obstruction, the surgeon used formerly to secure an easy escape for the contents of the bowel by making an opening into the See also:

colon in the left See also:

LOIN (through O. Fr. loigne or logne, mod. lunge, from Lat. Iambus)

loin.

But in recent years this operation of lumbar colotomy has been almost entirely replaced by opening the colon in the left See also:

GROIN

groin. This operation of inguinal colotomy is usually divided into two stages: a loop of the large intestine is first See also:

DRAWN

drawn out through the abdominal wound and secured by stitches, and a few days after-wards, when it is firmly glued in place by adhesive inflammation, it is cut across, so that subsequently the motions can no longer find their way into the bowel below the artificial anus. If at the first See also:

STAGE (Fr. 6/age; from Lat. stare, to stand)

stage of the operation symptoms of obstruction are urgent, one of the ingenious See also:

glass tubes with a See also:

RUBBER, INDIARUBBER

rubber conduit, which Mr F. T. See also:

Paul has invented, may be forthwith introduced into the distended bowel, so that the contents may be allowed to escape without fear of soiling the peritoneum or even the See also:

SURFACE

surface-wound. (E.

End of Article: ABDOMINAL SURGERY

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