³1username³2BryceHarrington³2name³2text_default³2version³21³2ts³2980844538³2ip³264.81.18.202³2data³2newauthor³31³3minor³30³3text³3ABDOMINAL SURGERY.---The diseases affecting this region 
are dealt with generally in the article DIGESTIVE ORGANS, 
and under their own names (e.g. APPENDICITIS). The term 
``abdominal surgery'' covers generally the operations which 
involve opening the abdominal cavity, and in modern times this 
field of work has been greatly extended.  In this Encyclopaedia 
the surgery of each abdominal organ is dealt with, for the 
most part, in connexion with the anatomical description of 
that organ (see STOMACH, KIDNEY, LIVER, &c.); but here the 
general principles of abdominal surgery may be discussed. 

Exploratory Laparotomy.---In many cases of serious intra-abdominal 
disease it is impossible for the surgeon to say exactly 
what is wrong without making an incision and introducing his 
finger, or, if need be, his hand among the intestines.  With 
due care this is not a perilous or serious procedure, and the 
great advantage appertaining to it is daily being more fully 
recognized.  It was Dr Oliver Wendell Holmes, the American 
physiologist and poet, who remarked that one cannot say of 
what wood a table is made without lifting up the cloth; so 
also it is often impossible to say what is wrong inside the 
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 case often becomes a 
simple matter.  An exploratory operation, therefore, should 
be promptly resorted to as a means of diagnosis, and not left 
as a last resource till the outlook is well-nigh hopeless. 

It is probable that if the question were put to any experienced 
hospital surgeon if he had often had cause to regret having 
advised recourse to an exploratory operation on the abdomen, 
his 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, post-mortem examination having 
shown that if only he had insisted on an exploratioui being 
made, some band, some adhesion, some tumour, some abscess 
might have been satisfactorily dealt with, which, left 
unsuspected in the dark cavity, was accountable for the 
death.  A physician by himself is helpless in these cases. 

Much of the rapid advance which has of 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 public said this, but even physicians have been known to 
suggest it, and have indeed used the equivocal expression, 
the ``apotheosis of surgery,'' in connexion with the operative 
treatment of a serious abdominal lesion.  But fortunately 
the public have found out that the surgeon, being an honest 
man, does not advise operation unless he believes that it is 
necessary or, at any rate, highly advisable.  And this happy 
discovery has led to much more confidence being placed in his 
decision.  It has 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 diet or drugs.  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 idea was more widely spread that surgery, after all, was 
a poor handmaid to 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 bearings.  And so it has come about that the results of 
operations upon the interior of the abdomen have been improving 
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 intestine by the introduction from 
Chicago of an ingenious contrivance named, after the inventor, 
Murphy's button. This consists of a short nickel-plated 
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 canal rendered 
practicable.  In the course of 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 establishment of 
a permanent communication between the stomach and the small 
intestine when the ordinary gateway between these parts of 
the alimentary canal is obstructed by an irremovable malignant 
growth; between two parts of the small intestine so that 
some obstruction may be passed; betw:en smal' 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 gallbladder, 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 
sometimes ulceration occurs around the rim of the 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 bone or similar soft 
material, while others rely upon 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 
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 custom, therefore, for the surgeon to 
complete his operation for the relief of obstruction by drawing 
out a 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 Lawson Tait of Birmingham, 
who on the occurrence of grave symptoms after operating on 
the abdomen gave small, repeated doses of Epsom salts to wash 
away the harmful liquids of the bowel and to enable it at the 
same time to empty itself of the gas, which, by distending the 
intestines, was interfering with respiration and circulation. 

Amongst still more 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 administration of a hot saline solution into the 
lower bowel, or, in the more desperate cases, of injecting 
pints of this ``normal saline'' fluid into the loose 
tissue of the armpit.  Hot water thus administered or 
injected is quickly taken into the blood, increasing its 
volume, diluting its impurities and quenching the great 
thirst which is so marked a symptom in this condition. 

Gunshot wounds of the Abdomen.---If a revolver 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 chance, surgically clean, it is possible that the openings 
may tightly close up behind it so that no leakage takes 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 uncettain lf 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 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 free from septic 
micro-organisms as possible.  It is by the malign influence of 
such germs that a fatal issue is determined in the case of an 
abdominal 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 
battle.  When after an 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.  Experience in the South African war of 1899-1902 showed 
that Mauser bullets could pierce coils of intestine and leave 
the soldiers in such a condition that, if treated by mere 
``expectancy,'' more than 50% recovered, whereas if operations 
were resorted to, fatal septic 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 abdomen had best not be interfered with. 

Stabs of the abdomen are serious if they have penetrated the 
abdominal 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 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 enlarge the wound in order to determine its depth, 
and to disinfect and close it if it be non-penetrating.  If, 
however, the bellycavity has been opened, the neighbouring 
pieces of bowel should be examined, cleansed and, if need be, 
sutured.  Should there have been an escape of the contents of 
the bowel the ``toilet of the peritoneum'' would be duly made, 
and a drainage-tube would be left in.  If the stab had injured 
a large blood-vessel either of the abdominal cavity, or of the 
hiver 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 drift to almost certain death, unrecognized and almost 
untreated: at the present time a large number of them are saved. 

Intussusception.---This is a terribly fatal disease of 
infants and 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 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, 
infection 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 shock which 
the intussusception and resulting strangulation entail.  
Still, every operation gives them by far the best chance. 

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 deal with it as circumstances suggest.  
If the cancerous 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 
colon in the left loin.  But in recent years this operation of 
lumbar colotomy has been almost entirely replaced by opening 
the colon in the left groin.  This operation of iniguinal 
colotomy is usually divided into two stages: a loop of the 
large intestine is first drawn out through the abdominal 
wound and secured by stitches, and a few days afterwards, 
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 stage of the operation symptoms of 
obstruction are urgent, one of the ingenious glass tubes 
with a rubber conduit, which Mr F. T. 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 surface-wound. (E. O.*) 

----
Source:  An unnamed encyclopedia from a project that puts out-of-copyright texts into the public domain.  This is from a *very* old source, and reflects the thinking of the turn of the last century.  -- BryceHarrington
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