Louis Philippe, king of the French . . . . .Feb. 24, 1848
Louis Charles of Bavaria . . . . . . . . . .Mar. 21, 1848
Ferdinand of Austria . . . . . . . . . . . . Dec. 2, 1848
Charles Albert of Sardinia . . . . . . . . .Mar. 23, 1849
Leopold II. of Tuscany . . . . . . . . . . .July 21, 1859
Isabella II. of Spain . . . . . . . . . . . June 25, 1870
Amadeus I. of Spain . . . . . . . . . . . . Feb. 11, 1873
Alexander of Bulgaria . . . . . . . . . . . Sept. 7, 1886
Milan of Servia . . . . . . . . . . . . . . .Mar. 6, 1889
1 Pedro had succeeded to the throne of Portugal in
1826, but abdicated it at once in favour of his daughter.
ABDOMEN (a Latin word, either from abdere, to hide,
or from a form adipomen, from adeps, fat), the belly,
the region of the body containing most of the digestive
organs. (See for anatomical details the articles ALIMENTARY
CANAL, and ANATOMY, Superficial and Artistic.)
ABDOMINAL 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
