CHAPTER XLVII
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INJURIES AND SURGICAL DISEASES OF THE STOMACH.
CONGENITAL MALFORMATIONS OF THE STOMACH.
These malformations are quite rare, at least those raising the question of possible surgical remedy. _Transposition_ does not require relief, nor does a stomach abnormally small allow it. More or less _stenosis of the pylorus_ as a congenital defect has been observed, but it is extremely rare. Along with it is often associated a certain hypertrophy of the stomach muscle. _Hour-glass deformity_ may be of congenital or acquired origin. The latter two conditions permit of easy surgical remedy. Pyloric stenosis may be atoned for by gastro-enterostomy or treated directly by a plastic operation, while the hour-glass stomach permits of an anastomotic rearrangement, either of its dilated portions with each other or with the bowel below.
The _acquired malformations_ are connected with the consequences of ulceration and stricture. They include more or less complete _stenosis_, either cicatricial or malignant, various forms and types of _gastroptosis_ and _gastric dilatation_, in which sometimes enormous degrees of distention are produced, with disturbed or practically destroyed stomach digestion. These cases will be considered by themselves a little later, along with their surgical relief.
The _anatomical relations of the nerves_ supplying the stomach are worthy of the surgeon’s especial consideration. Its sympathetic nerve supply is in particular and intimate relation with the seventh, eighth, and ninth spinal roots, by which we account for the tenderness of the overlying surface in ulcer of the stomach, and the pain which is often referred to the region of the left shoulder-blade. When the stomach is adherent to the gall-bladder, in cases of biliary calculi, the pain is often referred to the right shoulder, but so soon as the pylorus becomes entangled and bound down pain is referred also to the left side as well.
HOUR-GLASS STOMACH.
Hour-glass stomach is now more common, and is to be attributed more to results of pathological conditions than to any congenital anomaly, it being now well established that it is usually the result of perigastric adhesions of chronic ulceration, with cicatricial constriction, as well perhaps of subsequent malignant implantation. Cancerous infiltration may produce the so-called _“leather-bottle” stomach_. Moynihan suggests, among other methods of _diagnosis_, the passage of a stomach tube and lavage with a quantity of fluid. If there be loss of a certain amount of this, when it is returned, it will indicate that a portion has escaped into the distal sac of the stomach. Again if the stomach be washed until the fluid returns clear, and then if there suddenly comes an amount of offensive fluid, or if the stomach be washed clean, the tube withdrawn and passed again a few moments later, and if then offensive fluid escape, the facts can be best explained on the hypothesis of an hour-glass constriction. “Paradoxical dilatation” may also be noted, _i. e._, the fact that palpation will still elicit a splashing sound after a stomach tube has been passed and while the organ is apparently empty.
Moynihan has suggested still another method of recognition. The area of stomach resonance being outlined, a Seidlitz powder in two halves is then administered. After about twenty or thirty seconds great increase in resonance of the upper part of the stomach will be found, while the lower part remains unaltered. If now a bulky pouch can be felt or outlined the diagnosis is determined, as the increase in resonance occurs in the distended cardiac segment.
The method of treating an hour-glass stomach will consist either, in selected cases, of a plastic operation by which an incision made in one direction is closed in the opposite, _i. e._, a measure like that practised at the pylorus for benign stricture, or else the separate sacs of the stomach must be united by an anastomotic opening and a _gastrogastrostomy_ thus performed.
FOREIGN BODIES IN THE STOMACH.
These are most commonly those which have been swallowed, either by design or through inadvertence, and may consist of almost all imaginable substances. In those animals that have the constant habit of licking their own fur or that of others, and thus scraping off a quantity of hair, _hair-balls_ in the stomach are frequently formed, and, as may be seen in museums, these sometimes obtain relatively enormous size--a foot or more in diameter. Hair-balls in the human being are of rare occurrence, and are the result of the habit of chewing the hair, observed in some hysterical or insane patients. There are several instances now on record of successful removal of such hair-balls from human stomachs. _Artificial dentures_, partial or complete, are not infrequently passed into the stomach, sometimes during sleep. In dealing with a case of this character extreme caution should be exercised, because many individuals have deceived themselves, or have been deceived, and the missing teeth supposed to have been swallowed have been found in some place where they have been mislaid and forgotten. Children have a habit of swallowing almost anything left loose in the mouth, and all sorts of toys and small playthings have disappeared into their stomachs, sometimes causing death, and occasionally passing through the alimentary canal. The insane sometimes show a maniacal tendency to swallow foreign bodies, such as nails or anything else which they can get into the mouth. Hysterical patients and museum freaks evince the same habit, and it is wonderful how tolerant the stomach becomes in some of these individuals, and what objects seem to pass the pylorus and escape externally without doing serious harm. Still, sooner or later nearly every one of these individuals comes to grief. Thus from one patient at the Erie County Hospital, in Buffalo, Gaylord removed an astonishing amount of junk, including nails, screws, pieces of glass, knife-blades, and the like. As a general rule, any reasonably smooth object which can pass through the esophagus may also pass through the pylorus.
=Symptoms.=--The symptoms produced by these foreign bodies will vary according to their size, number, and character. A hair-ball may lie for a long time within the stomach, producing few symptoms, and none by which it may be recognized. So long as no perforation of the entire thickness of the stomach walls occur, nor any infection which may produce a local peritonitis, the disturbances they set up may be limited to those included under the name “dyspepsia.” So soon, however, as pain, tenderness, or septic indications, or those of local peritonitis supervene, the abdomen should be promptly opened. Today we have the cathode rays as an aid in diagnosis, which will clear up doubt in most instances, and afford a definite indication for operation. Nevertheless a negative result does not necessarily imply that no foreign body is present.
=Treatment.=--The operation indicated is _gastrotomy_, _i. e._, opening of the stomach at a suitable or convenient point, removal of the foreign body or bodies, and the complete closure of the wound as well as of the abdominal incision, without drainage. If due care be maintained throughout, and the element of previous infection be excluded, prognosis is good. When perforation with local peritonitis, and perhaps abscess, has already occurred, there is a local indication as to exactly where to open; one should then complete the operation with the establishment of suitable drainage.
WOUNDS OF THE STOMACH, INCLUDING RUPTURE.
As already indicated, the stomach maybe ruptured, especially if weakened by previous disease, by severe abdominal contusion. It is subject to all possible wounds by perforation, either gunshot or by puncture. As it is more protected than the bowel below it is less liable to perforating injuries. Much will depend upon the nature and the extent of the injury. A small perforation may be protected by prolapse of the mucosa in such a way that little escape of contents takes place. On the other hand it may be extensive, and nearly the entire gastric contents may be poured out into the upper abdomen. The location of the stomach lesion by no means necessarily corresponds to that of the abdominal wall, this being particularly true in gunshot cases. Extravasation depends in amount and rapidity upon the stomach contents and their fluidity. If the posterior wall alone be injured it will empty rather into the cavity of the lesser omentum. Stomach injury may always be diagnosticated if, after abdominal injury, the vomited matter contains blood. The pain is usually severe and involves generally the entire upper abdomen. In proportion as the lesion lies near the diaphragm the breathing may be affected. Collapse is usually prompt and may be due to hemorrhage from a vessel of considerable size. _Pain_, _collapse_, and _hematemesis_ constitute indications for the promptest possible opening of the abdomen and investigation, with suitable suture of the stomach wound, toilet of the peritoneal cavity, and drainage, which should be posterior as well as anterior. Every ragged or compromised margin of a stomach wound, especially gunshot, should be neatly excised, and sutures applied in such a way as to only bring clean and fresh surfaces together. An external opening of sufficient length should be made to permit easy and complete withdrawal of the entire stomach, and a complete search over both its surfaces in order that no lesion may escape detection. If the opening made into the stomach be sufficiently large to permit, it would be best to thoroughly empty its contents and gently wipe it out, in order that it may be left not only empty but clean. Should the puncture be very small it would be well to pass a stomach tube from above and wash out the stomach, protecting the opening by pads and pressure, and thus preventing contamination of the peritoneum.
While _apparently spontaneous rupture_, _i. e._, without previous ulcer or disease, is most rare, there are a few cases on record where patients have been seized with intense paroxysmal pain and have died more or less quickly, and where the condition has been found with little or nothing to explain it. Immediate operation might possibly have saved some of these had the possibility of its occurrence been recognized. _Perforation from within_ may also occur, as it is known to have happened in the cases of sword or knife swallowers.
_Suture of the stomach_ is practised in exactly the same way in these cases as for other purposes and the method will be described later, along with the other operations upon this viscus.
TUBERCULOSIS AND SYPHILIS OF THE STOMACH.
The gastric mucosa presents a remarkable contrast to that of the intestinal tract, the latter being exceedingly likely to succumb to _tuberculous infection_, which is exceedingly rare in the former. _Primary tuberculous ulceration_ of the stomach, then, is most unusual. When tuberculous ulcers are found there they are usually the result of a secondary or perforating process. Such ulcers may attain great size, as in one case reported by Simmonds where the ulcerated area measured four by eight inches, yet produced no symptoms during life. This would correspond almost to a lupus of the gastric mucosa. Tuberculous _gummas_ are even more rare, and, occurring in the stomach, are pathological curiosities rather than surgical possibilities.
_Syphilis of the stomach_ is met with either as gumma or ulcer, the latter leading almost inevitably to more or less stricture as recovery follows suitable treatment. Although it is claimed that 10 per cent. of cases of chronic ulcer of the stomach have suffered from syphilis at some time, it by no means follows that such ulcers are to be considered as of genuinely syphilitic origin, as a syphilitic patient is not exempt from other stomach conditions. However, symptoms of gastric ulcer, associated with actual manifestations of syphilis, might well indicate associated syphilitic lesions and would probably yield, with the others, to suitable treatment.
Lesions of either character, which do not subside under proper medical treatment, and which require a surgical operation, would be equally benefited by it whether of one of these types or of the other.
DILATATION OF THE STOMACH.
The _acute form of gastric dilatation_ was described by Fagge in 1872, the chief symptoms being excessive vomiting and anuria, and the disease proving fatal within three days, the dilatation being enormous. For a condition occurring as rapidly and progressively as this does there is as yet no satisfactory explanation, careful autopsy failing to disclose a sufficient reason. It has been known in at least twelve instances to follow surgical operation, four only of which were upon the abdomen, and none of them upon the stomach proper, in all instances the patients apparently progressing favorably. The stomach becomes rapidly and enormously distended, and bent upon itself with a sharp kink in the lesser curvature. Thus it seems to occupy the entire upper abdomen. Two factors at least seem to assist in the condition: A paresis of the gastric musculature, and the fact that as it becomes distended it itself produces obstruction of the duodenum, and thus aggravates the primary condition.
It has been suggested that these acute cases of _postoperative dilatation_ are closely connected with certain cases of ileus and obstruction after abdominal operations, the dilatation once initiated tending to more and more obstruct the duodenum, as well as cause upward pressure on the diaphragm and embarrassment of the heart’s action. Hence the value of the stomach tube in treatment of such conditions.
=Symptoms.=--The symptoms are usually sudden and fulminating, beginning with intense pain, which finally involves the entire abdomen. Vomiting comes early and persists, the vomited fluid being greenish in color and large in amount, changing later to a brownish color and having an offensive odor. The act of vomiting is passive rather than active or violent. In spite of it the stomach never seems to empty itself. The outline of the dilated stomach may be seen through the abdominal wall, bulging being often extreme. With the passage of the stomach tube there may be escape of a large amount of gas as well as of fluid. Thirst is intolerable and never satisfied. The amount of urine is almost always reduced and sometimes anuria is practically complete.
=Treatment.=--The treatment is too often ineffectual, since the condition itself is lethal almost from the beginning. Early and frequent lavage, or perhaps leaving the stomach tube in place, would be indicated. It might be practicable to pass a small tube through the nostril and leave it, as is done with the insane. Gastrostomy would be theoretically indicated, could it be done sufficiently early. The same is perhaps true of gastro-enterostomy, although it has never had a fair trial, these cases coming to the surgeon too late to permit of much help.
=Chronic Dilatation of the Stomach.=--Chronic dilatation of the stomach, often spoken of as _gastrectasis_, is a frequent complication of various other conditions, being essentially a consequence rather than a primary condition. It may be due to:
1. Pyloric stenosis or its equivalent in the first part of the duodenum:
(_a_) From cicatricial processes following ulcers of the pyloric region;
(_b_) From perigastritis with cancer of the stomach;
(_c_) From pylorospasm and hypertrophy continuing after recovery from ulcer, and including more or less thickening of the biliary region;
(_d_) From neoplasms outside the pylorus proper;
(_e_) From cancer of the pyloric end of the stomach;
(_f_) From pressure upon the duodenum by pancreatic lesions;
(_g_) From the results of gallstones ulcerating and causing great local disturbances;
(_h_) From displacement of the pylorus, due either to falling of the stomach or dragging of an attached but movable right kidney.
2. A dilatation due to old lesions which have subsided, the atonic stretching not having been repaired.
It will be seen, then, that the condition may be met as a sequel to many different pathological processes. As such, therefore, it has no constant etiology nor necessarily distinctive features. In general it is recognized by tardiness in escape of gastric contents, associated with vomiting, the vomitus being distinctive, consisting often of old and undigested food, or perhaps of food which has rested in the stomach until putrefaction has occurred. The vomitus also contains evidences of fermentation, with sarcinæ and yeast cells and much mucus. In cases of ulcer it is usually very sour, owing to excess of free hydrochloric acid. When due to cancer the acid is usually due to excess of lactic acid, while hydrochloric acid may be nearly or totally absent. Even if vomiting does not occur after ingestion of food, heaviness and discomfort, with much eructation of gas, are produced. Constipation and diminished urine secretion are almost invariable accompaniments. When the obstruction is of the mechanical type a visible peristaltic wave can often be seen and felt, and this is a sign which should be regarded as always indicating operation.
Patients gradually lose flesh and become anemic and run down, suffering from what has been often vaguely called indigestion, their lives sometimes being terminated by starvation, occasionally by gastric tetany. The question of diagnosis can usually be settled by having the patient swallow the dissolved separate parts of a Seidlitz powder, one after the other, when the carbon dioxide released within the stomach will cause it to balloon up and assume that shape and position which the amount of its dilatation permits.
_Gastric dilatation which does not quickly yield to lavage and suitable medication is of itself always an indication for operation._ When accompanied by a tumor, especially if this move and change position with the stomach, a cancerous condition may be assumed, which, while not permitting a cure, may nevertheless be ameliorated by a gastro-enterostomy. In the absence of actual cancerous conditions the surgical treatment of chronic dilatation is exceedingly satisfactory.
This surgical treatment consists in the application of one at least of the following expedients:
1. Local relief of mechanical pyloric obstruction, as by any one of the pyloroplastic methods;
2. Gastroplication, by which the capacity of the stomach is materially reduced;
3. Gastro-enterostomy, by which mechanical obstruction is atoned for by a free outlet, provided at a point where gravity as well as peristalsis shall assist in completely emptying the viscus.
The methods in vogue a few years ago for opening the stomach and merely stretching the pyloric outlet have been supplanted by other plastic operations which have proved more satisfactory because of the greater permanency of their results.
GASTROPTOSIS.
The downward displacement of the stomach, to which the term _gastroptosis_ has been given, implies not only more or less actual dilatation, but also a stretching or lengthening of the upper attachments and peritoneal folds which should hold the stomach up in place. When these yield and the stomach is thus permitted to drop, more or less obstruction of the pylorus and kinking of the duodenum are apt to occur. The condition regarded surgically is not essentially different from that of chronic dilatation. When the stomach is distended with carbon dioxide its normal position may be easily recognized, while, at the same time, it is determined that it is perhaps but little dilated.
The causes which lead to this condition, aside from those which affect the stomach proper, include tight lacing, by which the supporting viscera are forced downward and the stomach permitted to fall with them. In addition to such a cause any previous disease by which the abdominal viscera have been affected or ligaments weakened would be of more or less effect. The condition leads sooner or later to one of dilatation, and always merges into it. Its symptoms are those of dilatation, only in milder degree. On account of the dragging upon the upper supports patients frequently complain of intense lumbago, and they nearly always become neurasthenic.
=Treatment.=--The ordinary routine treatment failing to give relief, one may, in mild cases, adopt an external mechanical treatment, consisting of a suitable abdominal bandage which should press the viscera up from beneath, and thus relieve splanchnic congestion and weight.
Mechanical support failing and symptoms persisting, the surgeon is able to afford relief by _gastropexy_, first suggested by Duret, and consisting of an exposure of the stomach through the middle line and its fixation to the anterior abdominal wall. This, however, has its theoretical disadvantages, since it might be followed by symptoms similar to those resulting from pathological adhesions. The method has been more or less modified, sutures being passed through the gastrohepatic omentum and gastrophrenic ligament in such a way as to bring them into close contact and looking to their complete union. Thus, Beyer, of Philadelphia, has reported four cases apparently successfully operated upon in this fashion. Bier has added four others, all of which seem to afford much encouragement to operative treatment of gastroptosis. Furthermore, Coffey has modified the technique in such a way as to include a sort of suspension of the stomach by making a hammock out of the great omentum. He did this by stitching the omentum to the abdominal peritoneum, about one inch above the umbilicus, with a transverse row of sutures about one inch apart.
GASTRIC TETANY.
Gastric tetany has but relatively small interest for the surgeon, save as it may complicate some of his results or prevent his endeavor to secure them. The condition is usually characterized by peculiar, disturbed sensation in the extremities, with a feeling of coldness or numbness in the limbs, and drowsiness, vertigo, and disproportionate weakness after exercise. Somewhat severe attacks are sometimes precipitated by lavage, and are then begun with a complaint of formication, followed by tetanic contraction of the muscles of the extremities. Instead of tonic spasm the muscles may be in more or less constant motion. The muscles of the face, neck, and abdomen are also involved. The facial expression changes, and patients may complain of loss of vision. During these paroxysms they may even mutter or speak unintelligibly. Chvostek some time ago showed how to produce these spasms, when the condition is present, by tapping over the facial nerve just at its exit from the cranium, and Trousseau demonstrated that during the attack the paroxysms may be produced at will by compressing the affected parts in such a way as to impede venous or arterial circulation through them. Some of these spasmodic attacks are accompanied by severe pain, while spasm is usually made less painful by gently yet forcibly overcoming it by pressure. The condition is essentially toxic, usually autotoxic, and yet, inasmuch as it may complicate the best efforts of the surgeon or complicate the case upon which he would wish to operate, it is deserving of this brief description here, largely in order that it may not be mistaken for true tetanus or be misinterpreted in any other way.
CARDIOSPASM.
This is a term recently suggested by Mikulicz for a peculiar contraction of the lower end of the esophagus and the cardiac orifice of the stomach, which is occasionally met with, and until fully described by him was somewhat misunderstood. In consequence of the spasmodic stricture thus produced there occurs dilatation of the esophagus above and formation of a sac, which may be discovered by the bougie or tube, or by a good radiogram, after having been filled with a weak bismuth emulsion. Such sacculation had always been previously regarded as due to esophageal diverticulum, which it greatly simulates at first and in time practically becomes. It is due either to primary and unexplained spasm of the muscular coat at this level, or to a primary atony for the esophageal muscle above the stricture. It has been ascribed also to paralysis of the circular fibers and spasm of the cardia, due to vagus involvement and to primary esophagitis. The view that it is of congenital origin can scarcely be sustained.
=Symptoms.=--The symptoms and signs produced are not widely different from those of a capacious diverticulum. It is difficult, often impossible, to pass a stomach tube into the stomach, it being diverted into the upper cavity. The patient moreover, vomits material which is undigested and more or less putrefactive, and, at the same time, without evidences of actual stomach disease. Such a sac may hold even two pints, and thus it will be seen how much material may be vomited or washed out by lavage which, at the same time, never entered the stomach. Should it be possible to enter the stomach the two sets of contents will be found quite different.
=Treatment.=--While more or less benefit and relief may be obtained from frequent washing of the abdominal sac thus produced the real cure will only come, as shown by Mikulicz, from opening of the stomach and dilatation of its constricted upper orifice.
PYLORIC STENOSIS.
Reduction in caliber of the pyloric opening, amounting in extreme cases to absolute closure, may be met with at various ages and following various conditions.
A congenital stenosis has been observed, although very infrequently.[54]
[54] Fiske (Annals of Surgery, July, 1906) states that there are at present on record 121 cases of hypertrophic stenosis of the pylorus in infants. The three theories advanced to account for the condition as occurring before birth presuppose either a true malformation with muscular hypertrophy, a secondary hypertrophy due to prenatal pyloric spasm, or a spastic condition of the pyloric region without definite gross anatomical lesion. None of these theories satisfies the condition in any but a small proportion of cases, although either of them doubtless is or may be correct in certain instances; 71 of these cases have now been operated upon, of which 33 died, gastro-enterostomy giving 57 per cent. of recoveries and pyloroplasty 54 percent.
_Pyloric constriction following cicatricial contraction of healed ulcers_ is perhaps the most common non-malignant form. This rarely proceeds to absolute closure, but is frequently sufficient to lead to dilatation.
Conversely any condition of the stomach which drags it out of shape and leads to kink or abrupt angulation near the pylorus may lead to early postural and later to actual structural contraction.
The pressure or alteration of shape produced by neoplasms, either within the substance of the stomach or more frequently without, will cause more or less irregular contraction of the pyloric end amounting to pyloric stricture.
By _old adhesions_ similar conditions are produced, while a definite form of _spastic contraction_, corresponding much to cardiospasm just described, will cause more or less pyloric obstruction.
Finally _malignant tumors_ involving the pyloric region invariably spread to the pyloric ring, and not only infiltrate it but cause it to become inflexible and diminished in size, to a degree finally amounting to almost complete or to absolute obstruction.
=Symptoms.=--No matter what the cause the symptoms are essentially the same, in that they produce dilatation of the stomach and frequent vomiting. According to the cause there will also be a history of pain and hemorrhage, suggesting ulcer, or of biliary colic, denoting perigastric adhesions, or of pancreatic disease, accounting for adhesion of the duodenum and displacement of the pylorus. The discovery of tumor or the results of examination of stomach contents may also suggest or corroborate the diagnosis of cancer.
The essential feature being the failure of the gastric contents to pass onward into the bowel, and their accumulation in the stomach or rejection by vomiting, the condition will be seen to have a purely mechanical as well as a pathological aspect. The case, therefore, must be extreme in which a mechanical remedy will not afford at least temporary relief.
=Surgical Treatment.=--This remedy obviously is either to overcome the stricture by dilatation, or plastic operation upon the region involved, or to form a new opening by which the stomach shall connect with the upper intestine--_i. e._, _gastro-enterostomy_. The latter has gradually supplanted the former in the choice and in the hands of most surgeons, although occasionally a case may be met which invites the performance of a pyloroplasty, by either the Heinecke-Mikulicz or the Finney operations, which will be described later. In the absence of malignant disease few serious operations give more satisfactory results than do these.
GASTRIC ULCER.
During the past few years the studies of internists, of pathologists, and of surgeons have all served to show that _gastric ulcer_ in any form is a more common lesion than was suspected by the previous generation. At first it nearly always comes under the care of the internist, but too often, becoming chronic, it is too long continued under his care until a serious, perhaps almost fatal, hemorrhage makes operative relief more dangerous, if not impossible, or until a chronic ulcer has degenerated into a cancer, and this is permitted to go on until the patient pays with his life the penalty for such inattention.
_Ulcers in the gastric mucosa_ vary from a simple _fissure_ (such as may be seen in the mucosa of the lip or the anus) to extensive and deep ulcerations, which weaken the stomach structure in spite of protective infiltration and even adhesions, until a final perforation may terminate the case, either by hemorrhage or septic peritonitis. While surgical teaching has of late pointed more and more definitely to the importance of ulcers resulting from simple erosions, or apparently mere abrasions which have not been appreciated, most pathologists and surgeons fail to realize that even from so trifling a surface alarming hemorrhages may occur. Such lesions appear upon the postmortem table to be minute and unimportant, but, occurring during life, they have an importance of their own.
Gastric ulcers, then, should be referred to as _erosions_, as _simple or complicated ulcers_, and as _ulcerating cancers_, in addition to which there may be mentioned the rare lesions produced by tuberculosis and syphilis. These ulcers are always to be regarded seriously, because in their milder expressions they cause pain and various forms of dyspepsia and indigestion, while their more serious consequences include hemorrhage, which may be fatal, and perforation, which is essentially so unless surgical intervention be prompt and complete.
=Symptoms.=--The symptoms and discomforts which they produce include _pain_, which is nearly always most pronounced within a short time after the ingestion of food, and which may be accompanied by local tenderness more or less constant. As the case progresses, with the pain usually comes vomiting, by which the former is relieved, the vomitus nearly always containing excess of hydrochloric acid and sometimes fresh or old blood. The pain of gastric ulcer is usually referred to the back. The indigestion and the frequent vomiting together are sufficient to produce a well-marked anemia, which is more pronounced when much blood is lost. Blood may not be vomited but escape into the duodenum, and will then give to the stools a tarry character, which should always be looked for and identified when discovered. The greater the loss of blood in either direction the more pronounced will be the anemia. _Pain_, _vomiting_, and evidence of _loss of blood_ constitute the most distinctive features of gastric ulcer. When these are accompanied by tenderness in the epigastrium, and by pain in the back, the diagnosis is almost complete. In the more chronic cases there may have already occurred contraction of the pylorus and consequent dilatation of the stomach. Thus symptoms of the latter may be added to those of the previous condition.[55]
[55] In doubtful cases accompanied by pain it will sometimes be of value to try the effect of orthoform in ¹⁄₂ Gm. doses, to see if it will relieve it. This remedy will not anesthetize nerve endings which are protected by skin or mucous membrane. The fact, then, that it affords relief implies an ulcerated or exposed area.
The two ever-present and alarming _dangers_ are those of _hemorrhage_ and _perforation_. Serious hemorrhage permits the escape by the mouth of large quantities of bright, fresh blood, with a corresponding degree of shock or collapse, and depression. Perforation is indicated by sudden onset of intense pain, with collapse, rapidly spreading tenderness, with abdominal rigidity and increasing distention. In other words the _symptoms of perforation are those of acute local peritonitis of abrupt origin_.
In either of these events the paramount indication is for prompt intervention, unless the patient is already too weak to withstand the shock of any operation. In one case this will consist of gastro-enterostomy, with or without a gastrotomy for the purpose of discovering the bleeding vessel and making local hemostasis. In the other it will consist of free incision, complete toilet of the peritoneum, with removal of all escaped material, and local attention to the site of the perforation, doing there whatever may be needed.
=Treatment.=--Should the surgeon see a case of gastric hemorrhage due to ulcer after the apparent cessation of the active loss of blood he may easily decide to wait for a few days until the patient has in some degree recovered strength and atoned for such loss. On the other hand if he see the case during its active stage he need not hesitate to open the abdomen, withdraw the stomach, open it sufficiently for exploration, and then attack the source of hemorrhage, be it large or small, in such manner as he may see fit--either with the actual cautery, with a sharp spoon, with complete excision of the ulcerated area and union of its borders by suture, or by merely including a bleeding vessel in a loop of suture, addressing himself at once to the formation of an anastomosis, preferably posterior, between the stomach and the uppermost loop of the small intestine. This procedure, which is wise in all instances, would be imperative in nearly all save those perhaps where an ulcerated area could be cleanly excised and its margins neatly sutured. Should it prove that suture of the stomach wall were impracticable its edges might be fastened to those of the abdominal wound, a gastrostomy thus resulting, which could be later closed by another operation.
_For perforation_ the surgeon might have to rely, in emergency, on a gastro-enterostomy as a relief opening, accompanied by local gauze tamponage; the point of perforation could not be made accessible for suture, but one should prefer suture for all cases that permit of it. In these cases a considerable margin should be enfolded and included within the grasp of the suture, or else the margins should be completely excised until healthy tissue is reached. In rare instances it has been feasible to fit into a perforation a drainage tube, or to pack about it a gauze strip which should conduct from the stomach cavity directly to the abdominal wound. The question of _excision of the entire ulcerated area_ should rest entirely upon the possibility of repairing the defect by sutures, and this will depend in large degree upon the location of the ulcer and the freedom with which the stomach can be manipulated, especially with which it can be withdrawn into the wound.
Practically every case of perforation thus operated will demand posterior as well as anterior drainage. Aside from the treatment of the stomach itself the general peritoneal cavity needs the same thoroughness of cleansing and the same care in every manipulation that would be given in a case of well-marked peritonitis already established.
GASTRIC FISTULAS.
This term has reference especially to _external fistulous openings_, which are an exceeding rarity save as relics of injury or of operation. They have been known to occur spontaneously by perforation of an ulcerated and adherent stomach, such perforations occurring either in direct line or irregularly in the direction of least resistance. _Traumatic fistulas_ result usually from gunshot or stab wounds, or are due to incomplete union of an opening deliberately made. In any event they permit of the escape of more or less of the stomach contents. Their tendency is usually toward spontaneous repair, but this is often so slow or so incomplete that it needs to be hastened by stimulation of the fistulous tract with silver nitrate, the actual cautery, curetting, or by a complete resection of the entire tissue involved, and a neat reunion with suture.
_Intra-abdominal gastric fistulas_ result usually from perforation of gallstones or the escape of foreign bodies. Produced in this way they empty usually, though not always, into some neighboring portion of the intestinal canal.
TUMORS OF THE STOMACH.
_Benign tumors_ are occasionally found in the stomach, and are most often of the adenomatous type. Papillomatous growths into the stomach have also been observed. Beneath the peritoneum, or in the submucous tissue near the pylorus, fatty tumors have also been seen. Myomas of mixed type have been described, and cysts have been met in the walls of the stomach. These have rarely attained a size larger than a hen’s egg. All of these non-malignant tumors are of pathological rather than surgical interest. Every one of them, however, will admit of successful surgical remedy when once recognized, operation consisting of excision, with suitable suturing.
CANCER OF THE STOMACH.
_Carcinoma_ is perhaps as frequently seen in the stomach as in any part of the body, the breast possibly excepted. In about three-fifths of the cases it involves the pyloric region, in one-tenth of them the cardiac end, the balance occurring in the intermediate part. It is usually of the round-cell or scirrhous variety, and is generally supposed to be a disease of adult or advanced life. While this is generally true there have been exceptions. It is occasionally met in the young, and has been reported even in early childhood. True sarcoma of the stomach is exceedingly rare. It spreads especially in the submucous tissue and evinces a tendency to involve especially the lesser curvature.
The duodenum evinces an extraordinary immunity from malignant disease, even that involving the pyloric region. When the pyloric end is involved the lesion is frequently complicated by adhesions, which are present in considerably more than half of the cases. The lymph nodes of the adjoining mesentery are nearly always involved, practically always in cases which come to the surgeon for operation. As the disease advances it spreads in several directions, and adjoining viscera may be involved, or even those at considerable distance, while metastases to other parts of the body are common. It is somewhat more common in males than females. In proportion as the pyloric ring itself becomes infiltrated and involved pyloric obstruction is an early feature, with the inevitable gastric dilatation and greater frequency of vomiting. Pathologists and surgeons are learning that the _most frequent cause of gastric cancer is gastric ulcer_, and recent investigations are to the effect that in at least 80 per cent. of cases there has been ulceration which has been followed by this malignant change. This affords additional reason, then, for regarding gastric ulcer as a surgical disease and operating upon it early and before such transition has occurred.
=Symptoms.=--As repeatedly emphasized throughout this work _cancer is a disease without a pathognomonic symptomatology_. For this reason it is rarely diagnosticated in its early stage, the symptoms which it produces being those of indigestion or dyspepsia.
The most _distinctive features_ met with in gastric cancer are _pain_, _vomiting_, more or less _dilatation_, and presence of _tumor_. _Pain_ is an early and constant symptom, the complaint at first being of heaviness and oppression, made worse after the ingestion of food, and later referred to as actual pain, which may be limited or may radiate to either side or to the back. Much will depend upon whether the cancer develop from the site of a previous gastric ulcer or independently.
Individual complaints are variant regarding the intensity and reference of this pain. In large measure it is due to the formation of adhesions, and its reference will depend much upon their location.
_Vomiting_ is an equally constant and perhaps even more important symptom, being met in nine-tenths of the cases. When the growth involves the pyloric end the vomitus is copious in amount, while the intervals between attacks of vomiting are relatively long. When the more central areas of the stomach are affected and its capacity is thus reduced vomiting is more frequent, usually following soon after taking of food, and the amount of vomitus is consequently less. In general the character of the vomited material depends upon the length of time it has been retained, upon the possible presence of bile or blood, the presence of small amounts of blood giving to it a somewhat characteristic appearance, indicated by the term “coffee-grounds.” As the ulceration proceeds the amount of blood may be increased, and it may even come up fresh and red. The degree of actual ulceration will be indicated by the odor and the more or less putrefactive character of the materials ejected.
Too much reliance has been placed upon examination of the stomach contents. The amount of hydrochloric acid present therein depends in large measure upon the area involved. The same is true of pepsin. The glands which produce these digestive materials are found especially in the more central area, and when this is involved their amounts will be much reduced, whereas as long as these are free they are not necessarily so affected. The presence or absence, then, of hydrochloric acid may prove most misleading. The Oppler-Boas bacilli are perhaps of more significance, but even here the surgeon is often deceived. I regret thus to appear to belittle the significance of features upon which internists place so much reliance, but I have so frequently seen their unreliability that I think it is a sad error to wait for weeks in order to make a diagnosis by means of material secured through a stomach tube.
McCosh believes that for diagnostic purposes the stagnation test is of greater value than any examination of stomach contents. This consists simply in the discovery by lavage of food within the stomach when it should have left it. Thus an ordinary meal should pass out of the stomach within five hours, but if after six hours undigested food still remains there it denotes sluggishness of digestion. Food remaining ten hours makes positive the fact of stagnation. This being once established it should be determined whether it is from atony, spasm, pyloric stenosis, peritoneal adhesions which kink the opening, or cancer. In all of these except the first, surgical intervention is necessary.
_Tumor in the stomach region_, in connection with symptoms already mentioned, is corroborative. In nearly every case it can be felt sooner or later. Too many have waited, however, for this corroborative symptom before considering the case a surgical one, or even one of unmistakable cancer. Anyone can make a diagnosis when he can discover the tumor. What is needed is recognition of the condition before it has advanced to that stage. When it escapes detection it is usually because it is situated in the posterior stomach wall, high up, or else because the abdomen is enormously fat. The tumor when felt will be found firm and usually tender, sometimes regular in outline, sometimes quite the reverse, usually movable, but occasionally firmly attached either to the abdominal wall or to the viscera, usually the liver. Such a tumor, changing its position with the change in shape of the stomach produced by its inflation with carbonic dioxide, may be regarded as almost certainly a cancer of this organ. One rarely detects lymphatic involvement through the abdominal wall, but in many instances it may be noted at the root of the neck. The tumor usually rises or falls with respiration. Occasionally it will not be discovered until the stomach has been washed out and completely emptied.
However, further aids to diagnosis may be furnished, for instance, by the discovery of cancer cells in the vomitus or washings, by the presence of adventitious materials, such as lactic acid, whose especial significance is rather that of stagnation and motor paresis.
It is of great importance, when possible, to decide as between ulcer and actual cancer. In general the following aids to diagnosis may be considered: Ulcer is a disease of the earlier years of life, cancer rather of the later; in ulcer the pain is direct and boring (extending to the back), in cancer it may be widely referred to the shoulders; in ulcer the vomited blood is usually fresh, in cancer it furnishes the so-called “coffee-grounds;” in ulcer there is ordinarily no tumor present, in cancer this is a late but sure sign; the history of a case of ulcer will often be a long one, that of a case of cancer is rarely long, but steadily progressive; in ulcer there may be distinct anemia, whereas in cancer it assumes rather the type of a peculiar cachexia; and the free hydrochloric acid which is increased in ulcer is usually diminished or absent in cancer.[56]
[56] Sahli has suggested what he calls a _desmoid test_ for free hydrochloric acid. A small amount of methylene blue is enclosed in a small gutta-percha bag, and this is tied by means of a small strand of raw catgut. This catgut will not be affected by pancreatic juices, and will only dissolve in the stomach in case there be free hydrochloric acid present. The fact of its solution and the liberation of the methylene blue is made evident by the peculiar color given to the urine in a short time. If, therefore, this appears within an hour or so after the material has been swallowed one maybe sure there is free hydrochloric acid present in the stomach. The test is not absolutely accurate, but will often serve as a fairly reliable one and a substitute for the more disagreeable and ponderous method of a test meal and lavage. In some respects it is perhaps even more reliable.
_The question in cases of gastric ulcers is whether they have yet advanced to actual malignancy._ Probably no surgeon has ever attacked a case of gastric cancer which has not been under treatment for a time for so-called “dyspepsia or indigestion,” perhaps with a more definite diagnosis. Too many internists have waited for the discovery of a tumor before thinking of surgery. It is the business and the duty of every surgeon to impress upon the profession that _the only way to treat cancer successfully is to treat it radically, and the only way to do this is to operate early_. This applies equally well to the viscera or to the external portions of the body. _Gastric cancer is essentially a surgical disease_, and could it be recognized early and treated radically it could often be cured.
What are we to do then in the absence of early and indicative symptoms? The following rule may be laid down as one to which there is no exception: _A well-founded suspicion of cancer of the stomach (or of any part of the alimentary canal) justifies an exploratory operation for its detection and recognition, which then should be extended into an operation for its complete removal should circumstances justify it_. If this rule were followed we would not hear of cases of this description remaining for months or years under drug treatment, and then perhaps being finally turned over to the surgeon for relief of pyloric obstruction at a period when strength is so reduced that no operation should be seriously considered.
_Gastric cancer is, then, at least in its earlier stages, a surgical disease._ How is it to be recognized? By exploratory incision when there is serious doubt as to the nature of dyspepsia or indigestion which fails to promptly improve under suitable treatment. In an early stage even this might not be easy, especially for the inexperienced. Nevertheless any cancer of the stomach which produces distinct disturbances of digestion will have advanced to a degree of infiltration and thickening which will permit of its recognition by the touch of a practised operator. The discovery, then, of thickening in the stomach wall will imply the presence therein of either an ulcerated or cancerous area, which will in either event demand relief. In such a case the stomach may be opened and the mucosa exposed to sight and touch. Should the lesion prove to be malignant the same rule will apply with greater force, with the sole difference that the area should be much larger and that the surgeon should keep clear of suspicious tissue. This may necessitate a more or less complete removal of a considerable portion of the stomach. The greatest care should be exercised in the discovery and removal of all infected _lymph nodes_, which will be found especially along the curvatures and within the peritoneal fold. When retroperitoneal lymph involvement is discovered a hopeless aspect is put upon the case. Life may be prolonged for two or three years, even under such circumstances, and the patient is certainly entitled to whatever can be afforded him. If the cancerous process has advanced to a point or a degree making radical removal impossible, one may at once select the other alternative and perform a gastro-enterostomy at a point of election, by which relief may be afforded for at least a number of months.
Only by exploration, then, can it be decided whether to attempt a radical measure or a palliative procedure. It is scarcely fair to quote statistics in this regard, especially any but the most recent, as only lately have these cases been referred for early operation. Obviously the less wide the removal the less reduced the patient, the more favorable is his condition to withstand operation, and the more favorable the aspect of his case. Thus pylorectomy before gastric dilatation has occurred is more promising than pylorectomy when half the stomach is involved. In proportion, then, as these cases are submitted to early operation, statistics will improve and better results be attained, while if physicians and surgeons can be made to _coöperate early_ an ever-growing number of cases will be seen and operated at a favorable time.
The various operations practised, including gastrectomy, pylorectomy, etc., will be discussed with the other operations upon the stomach.
PERIGASTRITIS.
To this term attaches about the same force and significance as to perihepatitis or perisplenitis. The expression implies the consequences of a _local peritonitis_, usually of low grade, by which adhesions are produced that may anchor the stomach in whole or in part, in any possible direction and to any of the surrounding viscera or part of the abdominal wall. Such adhesions are more common at the pyloric end than elsewhere. Their causes may be intrinsic or extrinsic, among the former ulceration and cancer being by far the more common; among the latter gallstones, tuberculous processes, and occasionally the remote consequences of typhoid ulceration. In the majority of cases the adhesions thus produced are protective and purposive, although they often constitute a serious obstacle to surgical work. While they may be suspected in almost any of the conditions above named, they are rarely discovered or identified until the abdomen is opened. Nevertheless, distention of the stomach with gas and the discovery of its irregular movements or shape because of fixation will afford good ground for suspicion as to the condition itself. When it can be shown that these adhesions are producing pain or discomfort, as they often do, operation, _gastrolysis_, affords the only legitimate and reasonably certain relief. Time sometimes permits a stretching of adhesions or the possible absorption and amelioration of symptoms, but only by surgical intervention can anything radical or prompt be offered.
PHLEGMONOUS GASTRITIS.
Under this term is included a _suppurative or necrotic inflammation of the stomach wall_, beginning probably in the submucosa, but extending in both directions. It appears in two forms--the circumscribed and diffuse.
=Symptoms.=--The symptoms of the latter are those of an intensely acute gastritis with rapid, almost inevitably fatal course, beginning with severe pain, quickly followed by faintness and collapse, with early vomiting, vomited matter being first bile-stained, then containing blood. The sensation of nausea is extreme and a complaint of thirst constant. Frequently there are hiccough and peculiar and uncontrollable general restlessness. Pain is, however, a variable feature, and some cases are too rapidly necrotic to afford much pain or tenderness. The pulse is rapid, weak, and poor, and the temperature usually runs high. After a short time the abdomen may be much distended, while symptoms of paralytic ileus (_i. e._, obstruction), supervene, though occasionally there is offensive diarrhea. A well-marked case of this type comes on with fulminating suddenness, patients later becoming apathetic and dying in stupor.
About all this there is nothing peculiarly characteristic, and similar symptoms might be caused by mesenteric thrombus, by acute pancreatitis, or acute gangrenous cholecystitis.
_Symptoms of the more circumscribed form_ are similar to those just described, but of less severity. The pain and vomiting appear suddenly, but are less intense. If time be afforded for formation of abscess a distinct tumor may be felt. Appetite is lost and food regurgitated. A localized lesion favorably placed might lead to adhesions and circumscribed collection of pus, assuming the subphrenic or some less typical form. The pyloric end of the stomach is more commonly involved in such a process and affords evidence to the effect that it begins as an infection, the port of entry being usually a gastric ulcer.
=Treatment.=--Treatment would be surgical if any were available, but has never yet been applied sufficiently early to save an acute, generalized case. On the other hand, when the lesion has been local and has led to subsequent phlegmon, cases have been successfully opened and drained.
OPERATIONS UPON THE STOMACH.
In every instance, when time is afforded, certain preparations should have been made by which the stomach has been put in an aseptic condition. Not only should it be emptied of food in the ordinary sense, but it should have been washed out at least once, and in most instances repeatedly, first with cleansing lavage and then with a fluid containing a small proportion of borax, with the intent that by a mildly alkaline solution its contained mucus may be more thoroughly washed away. This alone, however, is not sufficient, for quantities of septic material may be introduced by the patient from his nose and throat. Frequent use of the toothbrush, with a strong antiseptic powder or solution, and frequent rinsing of the mouth with a suitable antiseptic mouth-wash, should be practised at frequent intervals for two or three days before such an operation. If offensive mucus be dropping from the nasopharynx this also should be cleansed and sprayed. In other words the possibility of contamination from the nose and mouth should be prevented as completely as possible.[57]
[57] The first deliberate operation upon the stomach seems to have been that by Crolius, in 1602, for removal of a knife, and a similar operation was made eleven years later by Günther. Up to 1887, however, only thirteen such gastrotomies had been reported. The first unsuccessful gastrotomy was done by Sédillot in 1839; the first successful one by Jones, thirty-five years later. While pylorectomy was suggested by Merrien in 1810, it was not actually performed until 1879 by Péan. Gastro-enterostomy was first done by Wölfler in 1881. The first operation for hemorrhage from gastric ulcer was performed by Mikulicz in 1889. It will thus be seen how recent is the whole matter of modern surgical attack upon the stomach.
=Operation for Penetrating Wounds.=--When the stomach has been opened by gunshot, stab, or other wounds it should be closed at the earliest possible moment. The operation intended for this purpose may be simple or difficult, and may be complicated by the fact of injuries to other organs. A simple opening is easily closed, when exposed, by sutures, of which there should be at least a double row, the internal devoted entirely to the mucosa, whose edges should be brought together and held by a continuous chromicized catgut suture, with stitches at intervals sufficiently short to prevent the possibility of hemorrhage, and interrupted occasionally to prevent puckering. A second row of sutures, of fine silk or thread, is then applied, by which the serous and muscular coats are firmly approximated, care being taken that the needle is not allowed to perforate a vessel and thus produce hemorrhage. The stomach walls are so thick that two layers of sutures thus applied usually suffice. If thought advisable a third suture may be applied after the manner of the second. A round needle is usually preferable to a flat one with cutting edges.
Great care should be maintained to _prevent escape of stomach contents or infection of the peritoneal cavity_, if this has not already occurred. In some cases after exposing the stomach wound it may be advisable to pass a stomach tube and wash out the stomach, holding the wound with a compress in order that no leakage at this point can occur. Unless there is some good reason for not doing this it should be the method of choice. Two dangers particularly characterize cases requiring _gastrorrhaphy_: the first that of assuming that there is but one wound and failing to discover others which may co-exist; the second that of infection by the stomach contents which have already escaped. The first is to be avoided by careful observation and examination; the second by a careful toilet of the peritoneum, both before and after suturing. Drainage may be provided according to the necessities of the case.
A _gunshot wound_ produces more or less contusion of the tissues in its immediate vicinity. Liberal allowances should then be made in suturing that gangrene and subsequent perforation may not occur; or, better still, when it can be properly done, the margins of gunshot wounds should be smoothly excised and fresh clean surfaces thus brought together.
=Gastrotomy.=--The stomach is opened for purposes of _exploration_ or _for removal of foreign bodies_, as may be needed, and then promptly and completely closed when the opening has permitted such diagnosis or removal, or after a diseased area in its interior has been exposed by incision. Such may be the procedure in certain cases of gastric ulcer, where the stomach is opened, its entire lining examined and the sharp spoon or cautery applied, with or without linear suture. The stomach is also opened for dilatation of its orifices as in cases of cardiospasm or pyloric stenosis, although the latter procedure has given way to anastomotic methods, which are more permanent in their results.
The stomach having been exposed, usually by a sufficiently long median incision, it is brought out and divided at a point of election, the incision being made of sufficient length to permit introduction of forceps or finger, or even of more or less eversion of its interior surface in order that it may be carefully inspected. The purposes of the opening having been achieved, it is closed as indicated above, with at least two layers of sutures. A perfectly clean wound will scarcely call for drainage. One which has been infected should be protected in this way.
Gastrotomy has also been done in order to permit of the retrograde division of strictures of the esophagus, when it has been impossible to pass even the smallest bougie from above. In these cases it has been occasionally possible after exposing the stomach to introduce a whalebone bougie which, passing upward, may follow the tortuous passage and be made to appear in the pharynx. To its upper end may then be attached, by strong silk, the small end of another bougie, and thus guide it downward as the first one is withdrawn. This procedure has been improved on by Abbe, who has thus been able to pull down from the mouth a stout piece of coarse silk, bringing it out through the stomach opening, and then, by a species of sawing manipulation, divide the tightest and densest part of an esophageal stricture sufficiently to permit of the passage of some other instrument. This having been accomplished the stomach wound is immediately closed.
=Gastrostomy.=--This term implies making an opening into the stomach by which its cavity may be directly connected with the exterior abdominal surface, and the communication thus established maintained indefinitely. The procedure itself is necessary in cases of dense stricture or malignant disease of the esophagus, or the growth of such a tumor in its vicinity as shall occlude it, and thus cause slow starvation unless atoned for in some manner. In one instance recently, where I expected to do a gastrostomy, because the stomach itself had been so destroyed by powerful caustic that not only was the esophagus ruined as such, but the stomach decreased in size and motility, I found the stomach too immovable to permit of this procedure, and accordingly utilized the duodenum just beyond the pylorus, thus making essentially a _duodenostomy_; the indications, however, being the same as for gastrostomy. We have, in other words, to effect a _permanent gastric fistula_, the older method being to make the most direct possible communication between the stomach and the surface of the body, and then to introduce a tube, or resort to some similar expedient for preventing cicatricial contraction, and perhaps even subsequent closure. Silver tubes were formerly used, whose openings were corked and kept closed when the tube was not in use. In consequence of this foreign body with the irritation it produced there was always more or less leakage and discomfort. The more recent methods have been devised with an intent of making a tunnel rather than a direct opening, through which, as needed, a soft rubber tube may be introduced, whose walls shall collapse at other times and close themselves, if necessary, with a little assistance, by pressure, thus preventing leakage. Sometimes it is possible to attain this ideal. At other times a rubber tube is worn a greater part at least of the twenty-four hours.
[Illustration: FIG. 529
Gastrostomy: Witzel’s method. Tube in position; sutures ready to tie. (Richardson.)]
[Illustration: FIG. 530
Gastrostomy: Witzel’s method. Tube in position; sutures ready to close abdominal wall. (Richardson.)]
[Illustration: FIG. 531
Gastrostomy by Frank’s method: cone of stomach stitched into the peritoneal wound. (Richardson.)]
All operative methods include fixation and consequent adhesion of the anterior stomach wall to the parietal peritoneum, just below the border of the ribs. Of the many methods employed the following will be described, most of which can be easily appreciated in diagram:
Figs. 529 and 530 illustrate, for instance, Witzel’s method, where a sterile, soft rubber catheter is infolded in the stomach wall, and finally passed into its cavity through the smallest opening that may suffice for the purpose, after which the outer layer of the stomach is completely closed over it. The stomach itself is stitched to the deep margins of the external wound, and these are then closed without drainage. If everything has been neatly done feeding may be begun within a few hours. Care should be exercised about passing into a stomach which has long been without much food a quantity which may disturb it, or of a quality which may distress it. A procedure very much like Witzel’s is that described by Marwedel, who first sews the stomach to the abdominal wound after drawing it partly into the wound, in order to afford sufficient working material, and then infolds the tube and inserts its lower end through a small opening. This is perhaps preferable, since the stomach being so fastened up at once there is no possibility of leakage into the abdomen.
Figs. 531, 532 and 533 illustrate Frank’s method, where the stomach is pulled up through a sufficiently long incision and drawn out into a cone, whose apex is then brought out through a second small incision, parallel to the first and at a distance of an inch or so from it. Here an actual opening is made into the stomach, while the cone is fastened to the skin here and to the peritoneum through the other opening, which is then completely closed. This method cannot be applied to a contracted stomach.
[Illustration: FIG. 532
Gastrostomy by Frank’s method: cone of stomach pushed through the second skin incision. (Richardson.)]
[Illustration: FIG. 533
Gastrostomy by Frank’s method: suture of abdominal wound; stomach stitched in the skin incision. (Richardson.)]
=Cardiospasm.=--Operation for this condition consists essentially in a gastrotomy as above, the opening being made sufficiently near to the cardia in order that either with finger or with suitable dilating instrument passed upward from below, the contracted cardiac orifice may be stretched, or, if necessary, nicked at several points, and then forcibly dilated, in this latter procedure great care should be given that stress be distributed as much as possible. If it be practicable to introduce any dilating instrument a four-bladed uterine dilator would probably be ideal for the purpose.
=Operations for Pyloric Stenosis.=--Among the earliest suggestions of a method of _pylorodiosis_ was that of Loreta, who opened the stomach near the pyloric end and deliberately introduced through the constricted pyloric ring a dilating instrument, fashioned much after the shape of the ordinary glove stretcher, which, in fact, might be used for such a purpose should emergency require. The operation is simple and but slightly dangerous, but it was found that strictures here as elsewhere tend to contract, even after forcible dilatation, and that the method, while temporarily successful, was but seldom permanently so. It was applicable only to the cicatricial, _i. e._, the non-malignant cases.
A _plastic_ method was then suggested independently by Heinecke and Mikulicz, with which their names are often connected and which is referred to as _pyloroplasty_. It consists essentially in making a buttonhole incision in one direction and then closing it in the opposite, as illustrated in Figs. 534, 535 and 536.
[Illustration: FIG. 534
Linear pyloroplasty. Seat and length of cut. (Richardson.)]
[Illustration: FIG. 535
Linear pyloroplasty. Appearance of cut sutured transversely. Two more sutures to be applied. (Richardson.)]
[Illustration: FIG. 536
Pyloroplasty. Shape of cut when more than a linear incision is desirable. (Richardson.)]
When cicatricial tissue is not too dense, and the parts not infiltrated, it has given satisfactory results. Even here it has been found to be frequently reduced in size by subsequent contraction, and the method suggested by Finney is more serviceable.
[Illustration: FIG. 537
Finney’s pyloroplasty: posterior suture. (Bergmann.)]
[Illustration: FIG. 538
Finney’s pyloroplasty: anterior sutures drawn aside; incision made. (Bergmann.)]
[Illustration: FIG. 539
Finney’s pyloroplasty: posterior suture of mucous membrane. (Bergmann.)]
[Illustration: FIG. 540
Finney’s pyloroplasty: anterior stitches inserted but not tied. (Bergmann.)]
_Finney’s pyloroplasty_ consists in making an anastomotic opening between the pyloric end of the stomach and the first part of the duodenum, and will be best appreciated from the accompanying illustrations (Figs. 537, 538, 539, 540 and 541).
[Illustration: FIG. 541
Finney’s pyloroplasty: anterior suture completed. (Bergmann.)]
The opening can be made as extensively as desired, and it is not easy to see how it can be subsequently reduced to a degree disadvantageous to the patient.
_Gastro-enterostomy_ may be needed in non-malignant cases, because of fixation and the impossibility of bringing the pyloric end of the stomach out sufficiently to make operation feasible. It will be required in cases of cancer when pylorectomy is not indicated. The method of making gastro-enterostomy will be described later.
=Operations for Dilatation of the Stomach.=--_Gastroplication_ consists of taking a number of “tucks” in the stomach wall and thus reducing its capacity. The purpose and the method of the operation will be appreciated by the accompanying illustrations. These operations are mainly indicated, however, in the absence of pyloric stenosis, for if a free opening be afforded from the dilated stomach into the upper bowel the gastric enlargement will usually be spontaneously reduced (Figs. 542 and 547).
_Gastropexy_ is a term applied to fixation of the stomach to the anterior abdominal wall. It has been thus stitched up in a few cases when greatly dilated or depressed into the lower abdomen. Fig. 548 illustrates the method. The stomach has also been suspended by shortening the gastrohepatic and gastrophrenic ligaments, as illustrated in Fig. 549.
[Illustration: FIG. 542
Gastroplication. When the threads _a_ _a´_, _b_ _b´_ are drawn up a fold is formed. (Bircher.)]
[Illustration: FIG. 543
Sectional view to show result of operation.]
=Operations for Gastric Ulcer.=--In dealing surgically with an ulcer of the stomach the selection has to be made between anastomosis and direct exposure of the stomach wall with the performance of a gastrotomy (_i. e._, opening the stomach) and then discovering the site of the ulcer, either treating it with the actual cautery, the curette, or, preferably, when this general method is adopted, completely excising the involved area and bringing the margins of the wound thus made together with sutures, which over the mucosa only may be of chromic gut. Should it seem advisable to excise the entire thickness of the stomach wall it would be better to suture in two layers, making the external one of thread or silk, while the inner one may be made of reliable chromic catgut. If this operation be attempted the incision into the stomach should be made sufficiently large to permit of thorough exploration. Nothing being found in the anterior wall, the gastrocolic omentum should be opened and the entire stomach palpated between the operator’s hands. Any suspiciously indurated spot on the posterior wall may then be so manipulated as to be brought into view through the anterior opening. Other surgeons besides myself have noted the occurrence of serious hemorrhage, which, upon exposure, must have come from small fissures or cracks in the mucous membrane. In fact the lesion which may furnish a considerable amount of blood may thus be so small and concealed as to be really difficult of exposure. However, exploration should be made as thoroughly as possible. The stomach having been opened and the ulcer found, it should be treated by one of the above methods. If, on the other hand, nothing be found the surgeon still has the measure of gastro-enterostomy. Any ulcer, however, which is threatening perforation can usually be recognized by the sense of touch alone, corroboration being afforded by inspection. An ulcer which is recognized and found to be favorably situated may be completely excised. It has been found, however, that this ideal measure of local attack gives but little better results than does the general procedure of gastro-enterostomy, while, on the other hand, it is less satisfactory in some respects and seems to be an equally if not more dangerous procedure.
[Illustration: FIG. 544
Surface view of the result.]
[Illustration: FIG. 545
Sectional view of the result when two folds are turned in.]
[Illustration: FIG. 546
Gastroplication. (Brandt.)]
[Illustration: FIG. 547
Sectional view of the result.]
The _rationale_ of making an anastomotic opening between the stomach and the upper end of the bowel is simply this: that thereby the stomach is given a degree of physiological rest to which it has long been a stranger, and that food may pass easily from the stomach into the upper bowel without irritating or aggravating the ulcerated portion, which is usually at the pyloric end. It should be understood, then, that gastro-enterostomy, done for this purpose, is simply a means of carrying out the universally applicable canon of physiological rest for diseased organs or surfaces. The operation of making this anastomosis will be described below.
=Pylorectomy and Gastrectomy.=--A complete removal of the pyloric end of the stomach is usually referred to as _pylorectomy_, while still more extensive extirpation of portions of the stomach proper are spoken of as _gastrectomies_. In a few instances it has been possible to practically remove the entire stomach, this having first been done by Schlatter. Such an operation would be spoken of as _total gastrectomy_. These operations are done almost exclusively for removal of areas involved in cancerous growth. Obviously the more extensive the growth the greater the amount of stomach which should be removed. For some reason as yet unknown cancer of the stomach rarely transgresses the pyloric ring, and thus the first part of the duodenum usually escapes involvement, even though the stomach be extensively diseased. All these operations, therefore, include simply the removal of a part terminating with the pyloric ring proper. It is seldom necessary to take away any of the duodenum. Removal of the pylorus may be also applicable in certain cases of benign strictures, where the mere plastic operations would seem insufficient, as well as in the cases of ulcers encroaching upon the pyloric ring itself.
For all of these operations the stomach is exposed through a median incision, or, if a tumor presents distinctly upon the right side, the incision may be made even far to the right and near the semilunar line. Through an opening sufficiently liberal the stomach and the movable part of the duodenum are withdrawn and carefully examined. When the pylorus is so fastened by dense adhesions within the abdomen that it cannot be withdrawn it is best to abstain from this particular procedure, as the mechanical difficulties too greatly enhance its dangers. Suitable clamps, whose blades are protected with soft rubber, are essential in order that the duodenum may be clamped beyond the line of its division, and that the stomach as well may be fixed between their blades, for the double purpose of controlling hemorrhage and preventing escape of contents. The omentum along the involved part of the stomach should then be carefully tied off, in a series of loops, before its vessels are cut, and one should take great pains to hunt out enlarged lymph nodes and include them in the area to be removed, or else make a separate incision for those that cannot be thus extirpated. To leave lymph nodes which are perceptibly involved in the cancerous process is to invite the speediest possible return of the disease, even though the operation should be successful. The upper and lower borders of the stomach being thus freed, the surgeon is then at liberty to cut away all the diseased portion, going at least an inch beyond the apparent limit of the disease. There will result from any such operation two divided ends of the alimentary canal, _i. e._, one, that of the divided stomach, much larger than the other, which is the upper end of the duodenum.
[Illustration: FIG. 548
Rovsing’s operation for gastroptosis: _V_, stomach; _V_₁, position of the stomach before operation; _U_, urinary bladder; _N_, right kidney; _A_, _B_, _C_, silk sutures; _x_, _x_, scarifications. (Bergmann.)]
Two procedures are now open to the surgeon: He may entirely close each of these openings with sutures and then make a posterior gastro-enterostomy, making new openings for this purpose, and by the common method described below, or he may reduce the size of the stomach opening and endeavor to fit it to that of the duodenum in such a way as to bring the two openings opposite each other, where they are then approximated as in ordinary end-to-end resection of the intestine. The earlier operation of Billroth and his followers was made according to the latter plan. It has been found usually easier and more successful to adopt the former method, as it is easier thus to prevent leakage and consequent infection; that is, the majority of operators would today probably completely close the stomach and the duodenum, and proceed at once to make a posterior gastrojejunostomy.
[Illustration: FIG. 549
Suspension of stomach by three rows of interrupted stitches through the gastrohepatic and gastrophrenic ligaments: 1, 2, 3, single stitches of the three rows. (Beyea.)]
[Illustration: FIG. 550
Resection of the pylorus. Suture completed. (Richardson.)]
Figs. 550, 551 and 552 give a fair idea of the procedure of end-to-end reunion. The edges of the mucosa should be united with chromic gut, the stitches being close to each other, to prevent leakage and to control hemorrhage from small vessels. The external sutures of silk or thread should be placed sufficiently deep to afford a strong bond of union, and, at the same time, to escape the mucosa. Some difficulty is met here, for the thin wall of the duodenum should be attached to the thick wall of the stomach, but with care it can be done. When the divided stomach end has been reduced or trimmed off in such a way as to leave only a portion to be matched with the duodenal opening, there is need for extreme care at the corners and angles of the suture margins, as here tearing of stitches or separation by tension, perhaps during the act of vomiting, are most likely to occur. Fig. 553 indicates the first of the procedures above mentioned.
[Illustration: FIG. 551
Resection of the pylorus. This figure illustrates the method of fitting the duodenum to the stomach when the gap in the stomach is too large to fit the duodenum. (Richardson.)]
[Illustration: FIG. 552
Resection of the pylorus. (The same as Fig. 551). Suture of the stomach to the duodenum completed. (Richardson.)]
[Illustration: FIG. 553
Resection of the pylorus according to Billroth’s second method. (Bergmann.)]
In performing _complete gastrectomy_ the cardiac end of the stomach is brought down and fitted to the upper end of the divided duodenum, after removal of the stomach, which will usually be possible under favorable circumstances, but which exposes the patient to great risks of tearing apart reunited surfaces by undue tension.
=Gastric Anastomosis.=--This consists in making an anastomotic opening between the stomach and the uppermost part of the jejunum, the duodenum proper being too bound down in its course to permit of its utilization for this purpose. Gastro-enterostomy, then, should be referred to as _gastrojejunostomy_. In brief, it consists in making an opening by which the stomach shall empty directly into the upper bowel, and while, for this purpose, one of the uppermost loops would theoretically suffice, it has been found that the shorter the loop, _i. e._, the portion between the duodenum proper and the upper part of the bowel used for this purpose, the better for the patient.
Gastrojejunostomy is, first of all, referred to as _anterior_ or _posterior_, according to whether a loop of bowel be brought up in front of the omentum and around it, and attached to the anterior and exposed wall of the stomach, or whether the lesser peritoneal cavity be opened by perforating the omentum behind the colon and below the stomach, so that the posterior wall of the latter is found, drawn into the wound, and made accessible and utilized for the purpose. The anterior operation is the easier of performance, but the posterior is far preferable in most instances. Should it be found that the posterior wall of the stomach is far more involved in cancerous infiltration than the anterior, the anterior operation should be performed.
Simple as is the procedure in theory there are about it one or two complications which were not at first foreseen. Perhaps the most important of these is that bile emptied into the duodenum passes downward until it has an opportunity to escape through the opening directly into the stomach, usually in the direction of least resistance. This may then carry it where it is a most undesirable fluid, and prevent its passage onward into the intestine, where it is physiologically needed. This circulation of bile has been spoken of as the “_vicious circle_” and it is the formation of a vicious circle which has complicated not a few of the anastomotic stomach cases, and which has engaged the attention of not a few clinicians and operating surgeons.
The second objection is that the contact of stomach contents with the mucous membrane at a point below where the bowel is normally prepared for it, and before intestinal contents have been prepared by bile or materials alkalinized by this fluid, sometimes leads to the formation of _ulcer_ just opposite the opening, and this has been referred to as _peptic ulcer of the jejunum_. This is a possible though not a frequent complication, but has added weight to the other considerations regarding the best way of performing anastomosis. Again, it has been feared that this anastomotic opening would contract in time, or sometimes completely close. This objection obtains especially with anastomosis, made with a Murphy button, or its equivalent, and can rarely be made against the ordinary suture methods. Again, if the opening in the intestine be made too long the intestine itself may be narrowed, for too much of the circumference of the bowel may be taken up in the formation of the anastomosis, and thus there will be mechanical obstruction with vicious circle.
“Vicious circle” produces symptoms which do not appear until the lapse of at least three days after the operation. If vomiting should persist and retain a bilious character it is to be feared that some complication of this kind has occurred. Under these circumstances when lavage is practised a large amount of fluid mixed with bile, perhaps blood, may be returned.
Much depends also on the exact location of the attachment of the intestinal loop to the stomach. Other difficulties arise from possible twisting of the loop of small intestine, or its strangulation by being entangled beneath the bridge of the jejunum, which is always made in every anastomosis. Again the small intestine may become incarcerated in an imperfectly closed opening made in the mesocolon. It will thus be seen that the posterior method has disadvantages which need to be fully appreciated. On the other hand it has this great advantage, that it permits of drainage or emptying of the stomach into the jejunum by gravity, in almost any position which the patient would ordinarily assume, either sitting or lying. Many operators have devised methods of preventing formation of the vicious circle.
Fig. 554 illustrates how valves may form which there is no sure method of preventing. Fig. 555 represents the suggestion of Braun, to make a second anastomotic opening between the small intestine above the stomach opening and below it, hoping that in this way bile, for instance, may pass directly through this opening, which it will first meet, into the intestine below, and thus not pass on and into the stomach. Others have divided the loop of jejunum after making the second anastomosis, in this way planting the efferent portion of the bowel in the stomach and then planting the afferent portion of the bowel into the side of the efferent part. This is the so-called _Y-gastrojejunostomy_. Roux does much the same thing, save that his method is all carried out behind the colon instead of in front of it. The principal argument in favor of the use of the Murphy button, in this procedure, is that vicious circle is less frequent after its use than after most of the suture methods, all of which would simply indicate that vicious circle is largely a matter of valve formation, and that by the time the button is loosened and passed on the danger period seems to have elapsed, and the current in the new direction to be well established. Nevertheless the button is now discarded by almost everyone in favor of the suture.
[Illustration: FIG. 554
Formation of valves in gastro-enterostomy: 1, intestinal valve; 2, right-sided gastro-intestinal valve. (Bergmann.)]
[Illustration: FIG. 555
Gastro-enterostomy with entero-anastomosis according to Braun. (Bergmann.)]
=Gastro-enterostomy.=--Artificial anastomotic opening between the cavity of the stomach and some part of the intestine below is indicated in a number of conditions, which have been discussed. It is done mainly, however, for two good reasons: first, to atone for pyloric stenosis, and, secondly, to give the stomach a more physiological rest in cases of gastric ulcer, permitting food to pass readily from it into the jejunum, with a minimum of gastric activity or disturbance. This
## particular form of anastomosis is but the application to these viscera
of a general principle, which in various ways, in different parts of the body, has constituted one of the greatest features in the advance of modern surgery.
The operation is practised in two ways. In the _anterior_ operation the highest accessible loop of small intestine is brought up in front of the omentum, or else the omentum is fenestrated in such a way that the bowel shall be brought through its window, and then attached to the anterior wall of the stomach, where the latter is much more accessible. In this operation there is less handling of the stomach and bowel, and, in general, it is easier of performance. Nevertheless the bowel loop itself may become adherent to the abdominal wound and give rise to pain, or even obstruction simulating the vicious circle. Volvulus of the jejunum has also followed it. Another objection is that as the patient gains flesh the weight of the transverse colon and omentum sometimes causes dragging upon the loop, which may cause serious trouble. The opening thus made is not where gravity will afford the best drainage of the stomach, and it is now considered undesirable in almost all cases save those where one is compelled to its performance, either by necessity for haste, or because the posterior wall of the stomach is so involved in cancerous infiltration as to afford no suitable area for fixation and opening. This method is of use mainly in dealing with malignant disease.
The _posterior operation_ calls for all the resources of a perfected technique, and takes longer in performance. Nevertheless when once the anastomosis is safely effected it is more satisfactory.
The posterior operation alone, therefore, will be described at length in this place, and only that form of it which discards the anastomotic loop, the writer quite agreeing with the Mayos, who have had larger experience with this operation than any other surgeons, and who advise the direct attachment of the jejunum, as near as possible to the termination of the duodenum, without further complication by operative procedure. The direction of active propulsion from the stomach comes from its pyloric end, the larger end of the stomach being mainly for storage purposes and having thus a forceful action; consequently the preferable site for the stomach opening is on a line with the longitudinal part of the lesser curvature, with its lower end at the bottom of the stomach. The Mayos have abandoned reversing the jejunum and now apply it directly to the posterior wall of the stomach from right to left exactly as it lies under normal conditions, having had better results with this method than with any other.
In brief the operation is as follows: Incision is made a little to the right of the median line, the transverse colon is withdrawn by steady traction to the right and upward, and the mesocolon made to follow it until the jejunum comes into view. The latter is then grasped at a distance of three or four inches from its origin. When, now, it is drawn tight the fold of peritoneum which covers the so-called ligament of Treitz is demonstrated; this is a small band containing muscle fibers, having its origin on the transverse mesocolon and extending down to the beginning of the jejunum, thus acting as a suspensory ligament. It leads to the base of the vascular arch of the middle colic artery, and indicates the place where the mesocolon should be torn through in order to expose the posterior wall of the stomach. At this point, in the least vascular area which can be discovered, the mesocolon is first incised and then torn, until a good liberal opening is made, through which the posterior wall of the stomach is easily exposed, and, later, drained. It should be forced through this opening by combined manipulation with one hand introduced above it and gently urging it through the opening where it presents. It may be easily identified by its resemblance to its anterior surface in its thickness, the arrangement of its vessel and the like. The posterior wall alone is then secured and drawn through the mesocolic window, in such a way that after the jejunum is attached to it the anastomotic opening can be made at a point one inch above the greater curvature and ending at the bottom of the stomach two and a half inches to the left of the pylorus. This area having been exposed and prepared, a considerable portion of it is drawn into a pair of specially constructed clamps (Doyen’s or Moynihan’s), whose blades are usually protected with rubber. The Mayos prefer to have the handles lying to the right and to direct the forceps transversely to the body axis. Moynihan prefers to reverse this direction and make them point to the right shoulder. The stomach being thus protected, and prevented from slipping by suitable tightening of the clamps, the jejunum is similarly secured with forceps lying in a direction parallel to the first, having within their grasp a portion of the gut extending between points one and a half and three and a half inches from its origin. If this be properly effected the left low point of the stomach lies in the grasp of one pair of clamps and the first part of the jejunum in that of the other, and these two portions should be easily brought into close contact with each other. A gauze pad having been placed behind the damps in order to avoid soiling, should there be any leakage of intestinal contents, the clamps should now be carefully and attentively held by an assistant, and their distal ends may even be bound together in such a way that, after the suturing process has once begun, nothing shall disturb the perfect contact between the surfaces thus mutually applied. The first row of sutures, usually of the ordinary continuous type, is made of silk or thread, the serous and muscular coats being seized and united over a line some two inches in length, the suture being carefully secured at either end of this line. Next, with a scalpel, an incision is made through the serous and muscular coats, parallel to the line of sutures, at a distance of about one-quarter of an inch, and over a length a trifle less than that of the line which they occupy. Here the vessels will bleed freely and forceps may be momentarily used for their securement. Through the opening thus made the mucous membrane will prolapse. Moynihan especially has shown that it is not enough to merely incise this membrane in the same direction as the other coats, but that a narrow elliptical portion of it should be excised, since it tends to prolapse. Therefore with knife or scissors a strip of the mucosa, perhaps a half-inch in width, should be cut away from either surface, thus widely opening into and exposing the interior respectively of the stomach and of the gut. Extreme pains should now be given to prevent both leakage and soiling, and instruments used upon the mucosa should be discarded after it has been divided and sutured. Now with reliable chromicized catgut a row of continuous sutures is applied by which all three coats of both cavities are bound snugly together, the needle passing through six distinct layers as each stitch is made. These sutures should be drawn sufficiently and secured at frequent intervals so as not only to ensure perfect application but sufficient pressure to prevent hemorrhage when the clamps are released. The lower side having been first closed the same character of sutures is continued until the upper margin of the buttonhole-like opening is thus completely closed. The fourth line of sutures, this time of the same material as those used in the first, is applied in a similar fashion, and with it the serous and muscular coats are accurately affixed to each other in such a way that there can be no leakage. Two or three extra sutures at either end of the line may be inserted for greater security. The clamps are now withdrawn, the gauze behind the anastomotic opening is removed, and it should be found that the smaller bowel is neatly and perfectly fastened to the posterior stomach wall and that no possibility either of hemorrhage or of leakage remains. This being accomplished there remains only to tack the margins of the mesenteric opening to the posterior wall of the stomach, at a distance sufficient to prevent all possibility of subsequent constriction or strangulation, after which the parts are carefully cleansed, restored to the abdomen, the colon and omentum dropped back and made to cover them, and the abdominal wound closed as usual. (See Figs. 556, 557 and 558.)
[Illustration: FIG. 556
Anterior wall of stomach grasped by forceps passed through from behind. (Case of saddle-ulcer of lesser curvature near pylorus.) (Mayo.)]
[Illustration: FIG. 557
Mesocolon lifted and posterior wall of stomach drawn through the opening made in it. Dotted lines show site of proposed anastomotic openings. (Mayo.)]
[Illustration: FIG. 558
Stomach and jejunum in the grasp of the large clamps, made ready for suturing. Small forceps still marking low point of stomach. (Mayo.)]
Such is the operation with suture, which may occupy from thirty to forty minutes in performance, it takes a little longer than the methods either with the button or with the elastic ligature, but seems to be the method generally used. In this method, as stated at the outset, no special provision is made as against “vicious circle,” because it has been found that it is seldom that this unpleasant complication ensues. If, however, the anastomosis with the jejunum has been made at a point twelve inches or more beyond its beginning, there is a likelihood of finding that vicious circle will cause later complications, and perhaps necessitate the performance of a second anastomotic opening in the small intestine above and below the stomach opening.
Of course all the precautions mentioned previously for prevention of infection, such as washing out the stomach previous to the operation, and ensuring both its emptiness and that of the upper bowel, are a part of these procedures and cannot be safely neglected in any of them.
Many an ingenious device for effecting the same kind of communication between the stomach and the bowel, or between various parts of the alimentary canal, has been placed before the profession, though but a few will be considered more in detail when dealing with the operations upon the intestines proper. The most prominent of them, and the one which has found the most lasting favor in the eyes of the profession, is the _Murphy button_, or some similar expedient, by the use of which time is economized and the operations in some respects simplified. All devices of this character, however, depend upon a necrotic process for their eventual success, as the intent is that parts compressed between the halves of the button shall first adhere and then slough, the button falling through the opening thus made and passing on. But to rely upon a necrotic process is much like relying upon a criminal for the performance of a serious duty. The button, therefore, has gone out of general favor for purposes of gastro-enterostomy, although for other intestinal work it is still frequently used.
McGraw, of Detroit, has devised a different and equally ingenious method of keeping surfaces in contact with each other until adhesion shall have occurred, and then effecting a further necrotic process by which opening shall be finally accomplished. This is the so-called method with the _elastic ligature_. In many respects it is simplicity itself, and permits of ready and rapid employment. One needs especially a round rubber cord, about 2 Mm. in diameter, of the purest gum obtainable and sufficiently fresh to be reliable. The surfaces to be united are first approximated by a posterior row of silk or thread sutures which shall include their outer surfaces. Then a long straight needle armed with this rubber cord is passed into the intestine and out again at a distance of from 5 to 10 Cm. An assistant now holding the intestine, the operator stretches the rubber suture until it is very thin and then draws it rapidly through the bowel. This same step is repeated in the opposite direction within the stomach. A strong silk ligature is next passed across and underneath the rubber between the latter and the point where the stomach and the intestine are to come together and a single knot is then made in the rubber after it has been tightly drawn. Another silk ligature is passed around beyond the ends of the rubber ligature where they cross and is here securely tied. The rubber ends thus released are then cut off. The original silk suture is next continued around in front until the point of its beginning is reached. In this way the rubber ligature and the parts which it includes are surrounded with an elongated ring of silk sutures, and with this the operation is complete. Here it is the continuous pressure of the elastic suture which first shuts off the circulation and finally cuts its way through both coats, and permits the communication between the bowel and the stomach. This method is as applicable to other portions of the alimentary canal as to the stomach.
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