750 



SURGERY. 



testines the peritonaeum and peritonitis was 

 almost necessarily fatal. The peritonaeum is 

 now opened with impunity whenever occasion 

 seems to justify it, and even as a means of 

 diagnosis. If, after the opening is made, the 

 diagnosis is confirmed, the operation, what- 

 ever it may be, is completed ; if the diagnosis 

 be not confirmed, or the condition be found 

 to be incurable, the wound is cleansed and 

 closed, and the patient is but little worse 

 than if the abdomen had not been opened. 

 This discovery of the comparative impunity 

 with which the abdomen may be explored has 

 opened to the range of the surgeon an entirely 

 new field of work. All of the abdominal or- 

 gans were a few years ago considered beyond 

 the reach of surgical interference ; now almost 

 every one of them may be, and indeed has been, 

 reached by the surgeon's knife and hand; and 

 entirely new surgical operations, by which 

 many lives have been saved, are the result, a 

 few of which may be enumerated. 



Operations npon the Alimentary Canal. The num- 

 ber of successful operations which may be 

 practiced for diseases of various parts of the 

 alimentary canal has increased greatly. Begin- 

 ning with the stomach, it is now not an unusual 

 thing to open successfully the abdomen, seize 

 the stomach, stitch it to the wall of the abdo- 

 men, open into it, and thus establish a means 

 of conveying food into the system when the 

 natural channel of the gullet has been occluded 

 by disease at some point between the mouth 

 and the stomach. In this way a person may 

 be fed for any length of time, as has always 

 been known ; but the operation for opening 

 the stomach, formerly so fatal, has now become 

 comparatively successful. 



By a very similar operation a cancer of the 

 stomach may be removed, the opening caused 

 by its removal closed with stitches, the organ 

 returned to its place, and the abdomen closed, 

 with a successful result. It is not an uncommon 

 thing for the bowel to become closed at some 

 part of its length by disease, or to become so 

 twisted upon itself that its caliber shall be oc- 

 cluded, and the condition is necessarily fatal 

 unless it be remedied. Only a few years ago 

 these cases were treated medicinally, and those 

 which did not recover, either spontaneously 

 through the efforts of nature or as a result of 

 general treatment, were lost. No surgeon 

 dared to cut into a patient's abdomen, find out 

 by actual exploration with the hand the exact 

 nature of the obstruction, and endeavor to re- 

 lieve it. These operations have now become 

 exceedingly frequent. If, from the symptoms, 

 the surgeon is led to believe that the bowel has 

 become twisted upon itself, he opens the abdo- 

 men, first of all to discover if his opinion be 

 correct ; if correct, he gives what relief he can, 

 and often directly saves a life. If the disease 

 prove to be a stricture or contraction of some 

 portion, he may be able to relieve the condition ; 

 if a cancer of the bowel be found, it may be cut 

 out and the two ends above and below the 



disease stitched together ; if the condition be 

 found to be entirely unrelievable (for the diag- 

 nosis of these troubles is exceedingly difficult), 

 the wound in the abdomen may be closed and 

 the patient's chances of recovery be none the 

 less. 



M. Kceberle recently reported the most suc- 

 cessful case of excision of a portion of the in- 

 testine that has thus far been brought to the 

 notice of the profession. The patient was a 

 girl, aged twenty-two years, who had suffered 

 for a long time with symptoms of intestinal 

 obstruction, though the symptoms were not 

 such as enabled him to arrive at any satisfac- 

 tory conclusion as to the exact pathological 

 condition. As the trouble was steadily in- 

 creasing in severity, and the patient losing 

 ground from suffering and malnutrition, an 

 exploratory incision was made in the median 

 line of the abdomen. Four cicatricial contrac- 

 tions were discovered in the small intestine, 

 involving between them about two metres of 

 the bowel, and the whole affected portion was 

 consequently removed rather than retire from 

 the operation and leave the patient to certain 

 death. The result was a perfect success, and 

 established several points which were before 

 doubtful. It proves among other things that 

 considerable portions of the small intestine 

 may be removed without interfering to any 

 appreciable extent with digestion, and that, 

 practiced under certain conditions, the opera- 

 tion is to be considered as perfectly legitimate. 



The operation of excision has also been ap- 

 plied to cancers of the large intestine, the sig- 

 moid flexure, and the upper part of the rectum. 



This operation, to which the name of " colec- 

 tomy " has been applied, has now assumed a 

 definite place in surgery. It dates from the 



time of Reybard, of Lyons, who in 1833 re- 

 moved a tumor the size of an orange from the 

 sigmoid flexure of a man aged twenty-eight 

 years. In this case the tumor could be felt 

 through the abdominal wall, far down on the 

 left side, and an incision was made over it. 

 The tumor was drawn out through this wound 

 and excised with three inches of the adjoining 

 intestine. The two ends of the bowel were 

 stitched together * and replaced within the ab- 

 domen, and the abdominal wound was com- 

 pletely closed. There was considerable local 

 trouble for a few days, but on the thirty -eighth 

 day the wound had entirely healed, and natu- 

 ral passages were restored. The operation 

 thus successfully inaugurated in 1833 was re- 

 vived in 1877, with some modifications, espe- 

 cially as to the best point for making the in- 

 cision, and as to the best way of disposing of 

 the cut ends of the bowel after the removal of 

 the disease ; since which time seven additional 

 cases have been reported. There seems to be 

 little difference in the mortality, whether the 

 ends of the divided intestine be sewed together, 

 dropped into the abdominal cavity, and the 

 wound in the abdomen closed, or the upper 

 end be stitched to the surface of the body at 



