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washed clean, the tube withdrawn and passed again a few moments later,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.
CHAPTER XLVIII.
THE SMALL INTESTINES.
CONGENITAL ANOMALIES OF THE SMALL INTESTINES.
The entire intestinal canal is sometimes too short and sometimes fails
to develop sufficiently in caliber, or sections of it may remain
undeveloped. None of these changes have interest or importance for the
surgeon as such, save those which produce acute or chronic obstruction
or conduce to acute inflammatory affections.
_Intestinal diverticula_ are usually of that type described by Meckel
and everywhere known by his name. Aside from these the others usually
met are irregular sacculations or hernial protrusions which may be due
to previous disease or to some congenital anomaly of structure. These
are sometimes seen in multiple form, and in one case recently under my
observation over one hundred of them were found scattered along the
intestinal canal, but, inasmuch as the patient died practically of old
age without a history of serious previous disease, it could not be
ascertained whether the pouches were of congenital or acquired origin.
The genuine Meckel diverticulum is a relic of the tubular structure
which leads from the primitive intestine to the vitelline or yolk sac,
and which should persist until about the end of the second month of
embryonic life. After this time it should be completely obliterated
and disappear. When this does not happen there may result a fecal
fistula at the navel, which is then usually referred to as _persistent
omphalomesenteric duct_, and which implies a continuous passage-way
between the skin and the interior of the bowel.
When the umbilical portion alone persists there results a small cyst on
the posterior side of the navel.
When the intestinal end alone persists a protrusion or sacculation will
remain to mark its site.
The duct may become obliterated and yet fail to disappear, thus
leaving a fibrous cord which represents the original omphalomesenteric
structures and vessels, which will be probably mistaken for an
inflammatory band and may serve as a later cause of acute obstruction.
If such bands lead to the umbilical region their identity may be easily
established.
The presence of Meckel’s diverticulum may cause serious abdominal
mischief. It may become involved in a localized process exactly
as the appendix often does, which may then be referred to as a
_diverticulitis_, where ulceration and perforation may occur. It may
constitute the whole or a portion of the contents of a hernial sac. I
have twice found it in inguinal hernia, once in umbilical hernia, and
by others it has been reported in all the ordinary hernial locations.
Porter has collected from literature 184 cases in which its presence
caused serious abdominal crises. The condition itself is probably
present in at least 1 per cent. of mankind, and is stated by Halsted
to be the cause of intestinal obstruction in 6 per cent. of cases.
In the 184 collected cases above mentioned it caused obstruction in
101. Out of 21 cases of the above collection it was not only found in
the hernial sac, but in all but 1 was shown to be the actual cause
of the trouble. In 5 of these cases the diverticulum was open at the
umbilicus. In such a case if the opening be large the gut wall might
prolapse and thus form a hernia.
Diverticulitis has been repeatedly mistaken for appendicitis, its
symptomatology not being distinctive. Exact diagnosis is seldom
possible before operation.
On general principles, considering their possible dangers, it would
be well to remove all diverticula which are found in the course of
ordinary abdominal operations, whether they appear to be causing
trouble at the time or not.
While the average length of Meckel’s diverticulum is three inches
it may exist as a mere nipple-like projection, or it may be a free
tube attaining a length of several inches. Its attached end is
usually larger than its distal portion and its diameter usually less
than that of the gut from which it arises. It may be provided with
a scanty mesentery or may hang independently. While ordinarily its
distal end is free it may nevertheless be continued as a solid cord
attached, as above mentioned, to the umbilicus. This cord frequently
contracts secondary adhesions, and it is under these conditions that
it most often constricts the bowel by forming a loop within which the
intestine becomes entangled. Free diverticula of sufficient length are
sometimes found tied in a genuine knot in a manner which is absolutely
inexplicable. There are numerous ways by which such a diverticulum may
produce strangulation of the normal bowel; thus, by formation of a ring
in which its own free end projects, in which is later entangled a bowel
loop, or by surrounding the pedicle of an intestinal loop as might a
noose. Again bowel is sometimes tightly drawn over such a diverticular
band, just as a shawl may be thrown over the arm, obstruction following
in the displaced bowel. When much contraction is brought to bear the
gut may be so acutely bent as to become occluded. Finally the bowel at
the point of origin of the diverticulum may undergo gross structural
changes, the result of long-continued traction, which may lead to
cicatricial narrowing. More indirectly diverticula seem in some unknown
way to predispose to intussusception at their point of origin, or
they have been found inflated and hanging from the intestine after
obstructing it (Fig. 559).
[Illustration: FIG. 559
Meckel’s diverticulum still attached at the umbilicus and producing
obstruction. (Lejars.)]
ACQUIRED MALFORMATIONS OF THE SMALL INTESTINE.
Of acquired malformations of the small intestine we have mainly to
deal with those which are produced by injury or disease. Among the
former would be the results of violent contusions or of any of the
lacerated, incised, or gunshot wounds to which the bowel is so often
exposed. Should recovery ensue cicatricial contraction is likely
to result. On the other hand, such previous disease conditions as
ulcerations--tuberculous or typhoidal--or the so-called chronic
catarrhal or malignant, may in one way or another occlude and thus
finally obstruct the lumen of the bowel. Distention diverticula may
also result, which correspond to the traction diverticula of the
esophagus already described.
WOUNDS OF THE SMALL INTESTINE.
The small bowel, like the larger or the stomach, may be ruptured in
consequence of abdominal contusions, the condition depending on the
nature of the injury, the degree of fulness of the bowel itself,
and other obvious causes. This character of injury has been already
sufficiently considered in dealing with rupture of the stomach. Their
symptoms are not essentially different, neither are the principles of
ordinary surgical treatment. Of all gunshot wounds those of the abdomen
constitute about 6 per cent., being more frequent than stab wounds.
=Gunshot Wounds.=--Gunshot wounds of the intestine would by themselves
fill an interesting chapter in a work on surgery. In such an epitome
as this they can be given but short consideration. The condition was
for centuries hopeless, until the American surgeons Parkes, Bull, and
Senn took up the subject and taught the profession how to more quickly
recognize the injury as well as to treat it. The special dangers of
all punctured wounds of the bowel, like those of the stomach, are
hemorrhage and escape of fecal contents. The great length of the
intestinal tube, and its coiled arrangement within the abdominal
cavity, subject it to the possibility of multiple punctures, from a
dozen to twenty having been inflicted by the passage of one bullet.
The multiplicity of these injuries, therefore, gives a still more
formidable character to their presence. Much will depend upon the size
and velocity of the bullet and the distance from which it is fired. The
perforated gunshot wounds of the abdomen which occur in civil life are
usually inflicted by a smaller bullet than those occurring in actual
warfare, while, at the same time, the distance is usually short.
Gunshot wounds are followed by an apparently disproportionate amount
of collapse. There is no accurate method of recognizing from the
exterior the amount of harm done by the passage of a bullet into or
through the abdominal cavity. This constitutes one of the greatest
arguments in favor of immediate exploration, an argument which is
strengthened by the fact that almost every penetrating wound of the
abdomen is complicated by injury of some abdominal organ. The greatest
danger attaches to perforation of the transverse colon or of the small
intestine, because these are the most movable parts of the intestinal
canal. The dangerous wounds are those which lie in the frontal plane.
Bullets which pass through the abdomen obliquely are perhaps less
likely to produce fatal result. Astonishing differences prevail between
the severity of those accidents received upon the field of battle and
in civil life. In battle men are shot through the abdomen and not
conspicuously disabled, recovering sometimes with no other treatment
than antiseptic occlusion. It is impossible to assume that the bowels
have not been injured, and yet they recover. The fact thus stated best
indicates the reason for abstention from intervention on or near the
firing-line in battle, and its most prompt and early performance when
the patient is in a well-managed civil hospital.
=Symptoms.=--The symptoms of _intestinal perforation_ in these cases
are not so prompt as when the stomach is wounded. Blood may occur in
the vomitus or in the stools, but only ordinarily after the expiration
of a few hours. Should fecal matter be found within the external wound
evidence would be complete, but this is rarely the case. The probe may
show whether the abdominal wall has been completely perforated or not;
beyond this it will give little information. By far the best probe
is the sterile finger, introduced through the opening enlarged for
the purpose. With this more distinct information may be gained. Some
years ago Senn proposed the method of inflating the colon and small
intestine with hydrogen gas, on the expectation that it will escape
through any intestinal perforation into the abdominal cavity, which it
would distend, and that then by inserting a small glass tube in the
abdominal wound it could be lighted and made to thus identify itself
at the distal orifice of this tube; but this method requires special
conveniences which are rarely at hand in emergency cases, and has been
practically abandoned.
A study of the direction of the abdominal wound which may be sometimes
made from an accurate account of the accident, and at other times by
noting the location of the wounds of entrance and exit, will do much to
determine whether intestines were probably in or out of harm’s way. If
it can be established that the bullet has probably avoided them then
some would wait for the inception of the first serious sign of mischief
before exploring. On the other hand, if it should seem inevitable that
such injury must have occurred, or, without such reasoning, if the
patient present a serious condition, he should be promptly operated
unless practically moribund.
The general principles of recognition and treatment of gunshot wounds
have been considered in an earlier chapter and the subject will not be
further considered here except as regards treatment.
=Treatment.=--The principles of surgical treatment for gunshot wound
of the intestines include a free abdominal incision, an inspection of
the entire length of the intestinal canal, which can only be made by
passing it through the examining fingers while exposed to sight upon
the abdominal surface, the accurate securement of all bleeding vessels,
and the closure of all punctures. Any portion whose blood supply has
been so completely cut off as to threaten or produce gangrene should
be removed by resection, with end-to-end or a lateral anastomosis.
The patient having been thus eviscerated and the intestinal viscera
examined, the abdominal cavity should be further explored, not so much
to find the missing bullet as to discover what further harm may have
been done; while if such be found the indication should be met. Then
after an exceedingly careful toilet of the peritoneum the intestines
may be restored, it being of course assumed that every puncture has
been fully recognized and properly sutured and secured. Nearly all of
these cases will call for some abdominal drainage, which may or may not
be posterior, as shall seem best.
_The location of the bullet is a matter of minor importance._ Should
it lie where it can be easily identified and removed this should be
done. Otherwise one should not waste valuable time in hunting for it,
remembering that he is performing not an autopsy but an operation.
ULCERS OF THE SMALL INTESTINES.
There is no point of the intestinal tube between the pylorus and the
anus which may not be involved in an ulcerative process, either acute,
chronic, or malignant. Acute ulcers of the upper bowel are usually of
typhoidal origin, while those of the lower bowel may be due to either
typhoid, tuberculosis, or syphilis. At certain points ulcers assume
somewhat distinctive character. Thus the acute catarrhal ulcer, so
called, seems to have a more definite entity than a declared pathology,
it being somewhat difficult to account for its existence. The peculiar
duodenal ulcers which have been met with after operations or burns
have been elsewhere discussed, and are to be regarded as of an acutely
toxic origin. A special type of ulcer of the duodenum has also been
noted opposite the anastomotic opening which is made in the ordinary
gastro-enterostomy, for whatever purpose performed. This appears to be
due to the outpour of the gastric juice upon a surface not normally
prepared for it, upon which it acts as an irritant, in time producing
more or less acute ulceration. This is the so-called _peptic ulcer of
the duodenum_, an occasional complication of gastro-enterostomy.
=Duodenal Ulcer.=--Duodenal ulcer of a type corresponding to gastric
ulcer has been recently determined to be a more frequent lesion
than has been supposed. A series of over fifty operations for this
condition, reported by Moynihan, in 1905, thus occurring in the
practice of one surgeon, will dispose of the question as to its
great rarity. Its symptoms are often so characteristic as to admit
of reasonably easy diagnosis, and it has, therefore, become more and
more a matter of greatest interest to the surgeon, since duodenal like
gastric ulcer is essentially a surgical condition.
These ulcers are usually located in the first portion of the duodenum,
_i. e._, in at least 90 per cent. of cases. They may be solitary or
multiple, and may be associated with gastric ulcers. In the ordinary
postoperative peptic ulcer the sequence of events is usually gastric
ulcer, hyperchlorhydria, and duodenal lesion. It may occur at any age,
and is the frequent cause of melena of the newborn or of the young.
=Symptoms.=--Symptoms of duodenal ulcer include pain, hematemesis, and
melena. Pain may be a vague uneasiness or may be severe. It is usually
described as of a burning character, felt mainly in the middle line or
along the right costal margin. It becomes gradually more severe and may
finally disable. It is sometimes described as cramp-like. When severe
it is referred to the right of the middle line. In cases where there
are adhesions to the liver or gall-bladder, pain radiates upward to
the right breast, or even around the chest to the back. The pain is
associated, by more or less marked time limit, with the ingestion of
food, coming on from two to four hours after a meal, whereas that of
gastric ulcer comes soon after eating. Sometimes it is even regarded
as a “hunger pain,” and patients find that the taking of a little
food will give relief. So soon, however, as this is digested pain
returns, when they again call for more food. Hematemesis and melena
may be present together or either may appear without the other. Small
quantities of blood in the vomitus is more likely to attract attention
than considerable quantities in the stools. It has been estimated that
in from 25 to 30 per cent. of acute cases hemorrhage is frequent,
and occurs in 40 per cent. of chronic cases. In the stools blood is
found in perhaps one-half of the instances. The amount of blood may
be considerable, even sufficient to produce faintness. In fact, the
intestine has been found full of blood when the abdomen was opened, and
Moynihan has seen even the colon distended with blood.
The more serious _complications of duodenal ulcer_, aside from
hemorrhage, are those of _perforation_, cicatricial contractions or
_stricture_ formation (obstructing the bowel or the common duct, or
both), _local peritonitis_, cancer, and indirectly gall-bladder or
pancreatic disease. Next to hemorrhage perforation is more likely to
occur in a duodenal than in a gastric ulcer and with more disastrous
consequences. Such perforation affords a peculiar mimicry of acute,
gangrenous appendicitis which, as Moynihan has shown, is due to the
direction taken by the extravasated fluid down along the right of the
transverse mesocolon toward the iliac fossa. In fact, the condition
is more likely to be mistaken for one of acute appendicitis than for
anything else.
With a primary ulcerative lesion in the duodenum it is easy to realize
that infection may readily travel up the common duct, involving
both the pancreas and the biliary passages, while the resulting
cholecystitis will intensify and spread the local peritonitis
previously produced, and all combined will cement the viscera in
this region into one common mass in which anatomical identity is
easily lost. A good history, when obtainable, will help very much in
diagnosis, especially when the absence of previous gastric symptoms can
be established. This, with the symptoms already given above, and the
tenderness over the duodenum, which is rarely absent, will afford good
basis for diagnosis in the more chronic cases. Duodenal perforation may
even be mistaken for rupture of an extra-uterine pregnancy, as well as
for perforation of the stomach or of the gall-bladder, or, as mentioned
above, of an appendix.
Quite recently attention has been called to a condition of the duodenum
resembling that known as hour-glass stomach, and produced in much the
same way. It seems to be the result of cicatricial contraction of
an old ulcerated area, and may cause almost complete constriction.
_Hour-glass duodenum_ is amenable to surgery only, and should be
treated either by gastrojejunostomy or possibly by a resection with
end-to-end suture.
=Treatment.=--For duodenal ulcer when recognized before perforation,
there is but one treatment, _i. e._, _gastro-enterostomy_, preferably
posterior, performed exactly as for gastric ulcer, for the same
reason, and with the same prospect of relief, inasmuch as it affords
physiological rest for the diseased area. In rare instances it may be
possible to so expose the duodenum as to make it justifiable to attack
the ulcer directly, but the simplest and, in general terms, the best
procedure is that just mentioned.
_For perforated ulcer of the duodenum_ the indication is not alone for
a gastro-anastomosis, but for exposure of the site of perforation,
removal of all extravasated material, a most careful toilet of
the peritoneum, and suture of the perforated area, this being the
indication when possible. Provision should be made for drainage, while
at the same time affording a direct outlet from the stomach into
the first portion of the jejunum beyond. Should the surgeon operate
apparently for appendicitis and discover that he has to deal with a
perforated duodenum he should extend far upward the incision made for
the former purpose, and, having thus widely opened the abdomen, should
thus find himself perhaps better provided with space in which to work
than had he opened at first directly over the duodenum.
=Typhoidal Ulcers.=--Typhoidal ulcers of the intestines have a
tremendous surgical interest in that they not infrequently lead to
perforation, and that this almost always is fatal if let alone. It may
be possible, however, by prompt recognition of the occurrence of the
perforation and by immediate intervention to cleanse the peritoneal
cavity of extravasated feces and close the opening thus made.
=Symptoms.=--The symptoms of perforation are at first not unlike those
of hemorrhage, in that shock is immediate and profound, and pain,
usually intense, is produced. These are quickly followed by abdominal
rigidity, while a blood count will show a rapidly increasing and high
leukocytosis. To the expressions of local peritonitis are quickly added
those of one which is generalized, with well-marked rigidity and great
meteorism.
The condition having occurred admits of but one remedy--namely,
operation. One of the latest collections of statistics includes 63
operations for typhoid perforation, with 11 recoveries, although
probably today the percentage is somewhat better than in 1903.
_Operations to be effective should be immediate._ Patients are
usually too profoundly collapsed to justify general anesthesia,
unless perhaps this may be secured with ethyl chloride or somnoform.
Many of them have been operated under local anesthesia. This has
its disadvantages, however, in that it is so difficult to make free
opening and exploration or free toilet. Opening having been effected,
the loops of intestine must be successively examined until the site
of the perforation is discovered. Here sutures must be applied, if
possible. Should the condition of the bowel render it absolutely
unreliable, _i. e._, should it be too extensively gangrenous to retain
sutures, it should be brought out and an artificial anus made, at
least for temporary purposes. In addition to these measures the most
careful toilet of the peritoneum is needed, perhaps including extensive
irrigation, unless it can be shown that the area contaminated by
extravasation is localized and shut off.
_Perforation of tuberculous, dysenteric, cancerous, or other ulcers_
will cause symptoms very much like those of typhoidal perforation, and
the case will differ essentially only in this respect, that in most of
the latter the general condition of the patient will not be so extreme,
and the danger of administering an anesthetic or of operating not so
great. Otherwise the indication, the necessity, and the method do not
differ.
=Tuberculous Ulcers.=--Tuberculous lesions of the small intestines
produce less destructive features than when situated in the colon.
Tuberculous infection of the intestinal tract occurs more often through
the swallowing of infected sputum, and, consequently, is a frequent
condition among consumptives. Such lesions in the small intestines will
lead to infection of the mesenteric nodes which, in time, may become
serious or even fatal, or it may lead to tuberculous peritonitis with
its finally disastrous consequences. As a rule, however, tuberculous
ulcers are not so likely to perforate, this being in large measure due
to the frequency with which they contract adhesions or affix diseased
surfaces to others, thus rather guarding against such an accident.
=Symptoms.=--Tuberculosis may also appear throughout the intestinal
tract in miliary form, or we may find _tuberculous gummas_, either
in the folds of the peritoneum or subperitoneally in the wall of the
bowel. Any of these lesions may lead to any of the others, and by
the time the case has been diagnosticated or has come to operation
or autopsy it is sometimes difficult to say what was the primary
lesion. Diagnosis is made partly with the thermometer and partly by
inspection and palpation, where one may be able to discover mesenteric
enlargements or the presence of fluid, as it usually collects in
tuberculous peritonitis; and perhaps partly by the general appearance
of the stools, in which a careful search may possibly, although by no
means with certainty, reveal the tubercle bacilli.
=Treatment.=--The treatment of such tuberculous lesions is largely
constitutional. When the case assumes the aspect of tuberculous
peritonitis much more can be accomplished by abdominal section
and irrigation, at which time it may be possible to remove some
localized focus without thereby doing more harm than good. The usual
constitutional measures, including oxygen, are indicated; but there
maybe difficulty in forcing hypernutrition because of the actual state
of ulceration. In this case foods which are cared for by the stomach
should be given in preference. Such intestinal antiseptics as creosote
or other remedies of its class may also be pushed to the point of
toleration.
The other _granulomas_ produced by either _syphilis_ or _actinomycosis_
may give rise to ulceration and its consequences and sequels, in a
way resembling those of tuberculosis. While the lesions they produce
may give rise to uncertain symptoms, a diagnosis can hardly be made
without accurate history and without the co-existence of other
lesions in more accessible parts of the body, by whose character
they may be determined. Primary actinomycosis of the intestinal
tract is more common than is generally realized. As it develops it
tends to spread to adjoining viscera and form tumors which later may
break down. The debris thus resulting will be indicative, especially
when the characteristic calcareous particles are felt in it, or
the characteristic ray fungus discovered with the microscope. (See
Actinomycosis.)
STRICTURE OF THE INTESTINES.
Save in rare instances where stricture may be due to congenital defect
the condition is never primary, but is secondary to some previous
and active disease. Stricture proper should be distinguished from
obstruction produced by compression from without and should usually
be made to include those cases due to intrinsic disease of the
intestinal wall. Here it is in the vast majority of cases either due to
cicatricial contraction, following the healing of some previous lesion,
or else to the infiltration and progress of malignant disease. In the
former instances a great deal may be accomplished by operation. In the
latter much will depend upon the relative period at which the case is
seen by the surgeon.
=Symptoms.=--The symptoms of stricture are those of bowel obstruction.
The tumor which produces it may be identified by palpation, or by
the fecal impaction, at least accumulation, which is likely to occur
above it, which may appear as a tumor and be mistaken for it until
cleared away by suitable cathartic measures. Ordinarily the surgeon
never recognizes stricture of the small intestines, then, save by its
obstructive features.
=Treatment.=--The treatment consists in what can be done by radical
surgical measures, and this can only be determined after exploratory
abdominal section.
TUMORS OF THE SMALL INTESTINES.
Benign tumors of the small bowel are relatively infrequent, perhaps
the most common being the lipomas which develop along the mesenteric
border, usually as excessive epiploic appendages. But circumscribed
and even pedunculated lipomas are seen occasionally in this location
and are of surgical interest largely because, at points where they are
located, intussusception is peculiarly liable to occur. In fact, the
condition figures as one of the predisposing causes of invagination.
Fibromas develop occasionally in the intestinal walls and adenomas grow
from the glandular structures which abound therein. Other benign tumors
are exceedingly rare.
Besides predisposing to intussusception these tumors are innocent, save
that in time they constrict or obstruct the lumen and produce one form
of stricture with obstruction, which will first be chronic and then
terminate acutely and fatally unless promptly relieved.
All benign tumors of the bowel should be removed with the least harm
possible to the bowel itself, but when a neat extirpation without
reduction of intestinal caliber is not possible no hesitation should be
felt about resecting a sufficient portion of the gut; or should this be
impracticable in making an anastomosis, thus excluding that part of the
bowel involved.