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 OliverWendellHolmes?, 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.*)