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Dalia Banks, MD, FASE
Clinical Professor
Division Chief of Cardiothoracic Anesthesiology
Director of Cardiothoracic Anesthesiology Fellowship
Clinical Director of Sulpizio CVC and PTU
University of California San Diego
San Diego, California

Paul G. Barash, MD
Professor Emeritus and Past Chair
Department of Anesthesiology
Yale University School of Medicine
Honorary Attending Anesthesiologist
Yale-New Haven Hospital
New Haven, Connecticut

John F. Bebawy, MD
Associate Professor of Anesthesiology & Neurological Surgery
Northwestern University
Feinberg School of Medicine
Chicago, Illinois

Itay Bentov, MD, PhD

Associate Professor
Anesthesiology and Pain Medicine
Adjunct Associate Professor
Department of Medicine
University of Washington School of Medicine
Harborview Medical Center
Seattle, Washington

Honorio T. Benzon, MD
Professor of Anesthesiology
Northwestern University Feinberg School of Medicine
Chicago, Illinois

Marcelle E. Blessing, MD
Assistant Professor of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut

Michelle Y. Braunfeld, MD
Professor and Vice Chair

8
Department of Anesthesiology
David Geffen School of Medicine at UCLA
Chair, Department of Anesthesiology
Greater Los Angeles VA Hospital
Los Angeles, CA

Ferne R. Braveman, MD
Vice-Chair for Clinical Affairs
Director of Division of Obstetrical Anesthesiology
Professor of Anesthesiology and Obstetrics, Gynecology and Reproductive
Medicine
Department of Anesthesiology
Yale School of Medicine
New Haven, Connecticut

Sorin J. Brull, MD, FCARCSI (Hon)

Professor of Anesthesiology
Department of Anesthesiology
Mayo Clinic College of Medicine
Mayo Clinic Florida
Jacksonville, Florida

Brenda A. Bucklin, MD
Professor of Anesthesiology
University of Colorado School of Medicine
Aurora, Colorado

Michael K. Cahalan, MD
Professor and Chair
Department of Anesthesiology
The University of Utah School of Medicine
Salt Lake City, Utah

Levon M. Capan, MD
Professor of Clinical Anesthesiology
New York University School of Medicine
Associate Director of Anesthesia Service
Bellevue Hospital Center
New York, New York

Louanne M. Carabini, MD
Assistant Professor
Department of Anesthesiology

9
Northwestern University Feinberg School of Medicine
Chicago, Illinois

Christopher G. Choukalas, MD, MS

Associate Clinical Professor
Department of Anesthesia and Perioperative Care
University of California, San Francisco
San Francisco VA Medical Center
San Francisco, California

Amalia Cochran, MD, MA

Associate Professor of Surgery
Vice-Chair of Education and Professionalism
University of Utah School of Medicine
Salt Lake City, Utah

Edmond Cohen, MD
Professor of Anesthesiology and Thoracic Surgery
Director of Thoracic Anesthesia
Icahn School of Medicine at Mount Sinai
New York, New York

Christopher M. Conley, MD
Clinical Assistant Professor of Anesthesiology
Boston University School of Medicine
Boston, Massachusetts

Christopher W. Connor, MD, PhD

Associate Professor of Anesthesiology and Biomedical Engineering
Department of Anesthesiology
Boston Medical Center
Boston, Massachusetts

C. Michael Crowder, MD, PhD

Allan J. Treuer Endowed Professor and Chair
Department of Anesthesiology and Pain Medicine
Adjunct Professor of Genome Sciences
University of Washington School of Medicine
Seattle, Washington

Marie Csete, MD, PhD

President and Chief Scientist
Huntington Medical Research Institutes

10
Pasadena, California
Professor of Anesthesiology
Keck USC School of Medicine
Los Angeles, California
Visiting Associate
Medical Engineering
California Institute of Technology
Pasadena, California

Bruce F. Cullen, MD
Emeritus Professor
Department of Anesthesiology and Pain Medicine
University of Washington School of Medicine
Seattle, Washington

Albert Dahan, MD, PhD

Department of Anesthesiology
Leiden University Medical Center
Leiden, The Netherlands

Rossemary De La Cruz, MD
Academic, Media, and Risk Management Associate
Department of Anesthesiology
Boston Medical Center
Boston, Massachusetts

Steven Deem, MD
Director, Neurocritical Care
Swedish Medical Center
Physicians Anesthesia Service
Clinical Professor of Anesthesiology
University of Washington
Seattle, Washington

Stephen F. Dierdorf, MD
Professor of Clinical Anesthesia
Department of Anesthesia and Perioperative Medicine
Medical University of South Carolina
Charleston, South Carolina

Karen B. Domino, MD, MPH

Professor and Vice-Chair for Clinical Research
Department of Anesthesiology and Pain Medicine

11
University of Washington School of Medicine
Seattle, Washington

Thomas J. Ebert, MD, PhD

Vice-Chair for Education
Professor of Anesthesiology
Medical College of Wisconsin and Zablocki VA Medical Center
Milwaukee, Wisconsin

Jan Ehrenwerth, MD
Professor Emeritus
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut

John H. Eichhorn, MD
Professor of Anesthesiology
College of Medicine
Provost’s Distinguished Service Professor
Department of Anesthesiology
University of Kentucky Medical Center
Lexington, Kentucky

James B. Eisenkraft, MD
Professor
Department of Anesthesiology
Icahn School of Medicine at Mount Sinai
New York, New York

Alex S. Evers, MD
Henry S. Mallinckrodt Professor and Head
Department of Anesthesiology
Professor of Developmental Biology and Internal Medicine
Washington University School of Medicine
St. Louis, Missouri

Ana Fernandez-Bustamante, MD, PhD

Associate Professor
Department of Anesthesiology
University of Colorado School of Medicine
Aurora, Colorado

Lynne R. Ferrari, MD

12
Chief, Perioperative Anesthesia
Medical Director, Operating Rooms and Perioperative Programs
Department of Anesthesiology, Perioperative and Pain Medicine
Boston Children’s Hospital
Boston, Massachusetts

Scott M. Fishman, MD
Professor, Department of Anesthesiology and Pain Medicine
Chief, Division of Pain Medicine
Vice-Chair, Department of Anesthesiology and Pain Medicine
Director, Center for Advancing Pain Relief
University of California Davis School of Medicine
Sacramento, California

Michael A. Fowler, MD, MBA

Assistant Professor
Residency Program Director
VCU Department of Anesthesiology
Richmond, Virginia

J. Sean Funston, MD
Professor
Department of Anesthesiology
The University of Texas Medical Branch
Galveston, Texas

Tong J. Gan, MD, MHS, FRCA

Professor and Chairman
Department of Anesthesiology
Stony Brook University
Stony Brook, New York

Steven I. Gayer, MD
Professor of Anesthesiology
University of Miami Health System
Miami, Florida

Sofia Geralemou, MD
Department of Anesthesiology
Stony Brook University Hospital
Stony Brook, New York

Loreta Grecu, MD

13
Clinical Associate Professor of Anesthesiology
Stony Brook University School of Medicine
Stony Brook, New York

Dhanesh K. Gupta, MD
Professor of Anesthesiology
Chief of Neuroanesthesiology
Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina

Carin A. Hagberg, MD
Joseph C. Gabel Professor and Chair
Department of Anesthesiology
UTHealth Medical School
Houston, Texas

Matthew R. Hallman, MD
Assistant Professor
Department of Anesthesiology and Pain Medicine
University of Washington School of Medicine
Seattle, Washington

Kylene E. Halloran, MD
Assistant Professor of Anesthesiology
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Stephen C. Haskins, MD
Assistant Anesthesiologist
Hospital for Special Surgery
Clinical Assistant Professor of Anesthesiology
Weill Cornell Medical College
New York, New York

J. Steven Hata, MD, MSc

Vice Chairman, Education Continuum
Center for Critical Care
Anesthesiology Institute
Cleveland Clinic
Cleveland, Ohio

Tara M. Hata, MD

14
Clinical Assistant Professor
Department of Pediatric Anesthesia
Cleveland Clinic
Cleveland, Ohio

Laurence M. Hausman, MD
Professor of Anesthesiology
Vice-Chair, Academic Affiliations
Director, Ambulatory Anesthesia
Department of Anesthesiology
Perioperative and Pain Medicine
Icahn School of Medicine at Mount Sinai
New York, New York

Salim M. Hayek, MD, PhD

Professor
Department of Anesthesiology
Case Western Reserve University
Chief, Division of Pain Medicine
University Hospitals Cleveland Medical Center
Cleveland, Ohio

Christopher L. Heine, MD
Assistant Professor
Department of Anesthesia and Perioperative Medicine
Medical University of South Carolina
Charleston, South Carolina

Thomas K. Henthorn, MD
Professor, Anesthesiology
Department of Anesthesiology
University of Colorado
Aurora, Colorado

Simon C. Hillier, MB, ChB

Professor
Departments of Anesthesiology and Pediatrics
Geisel School of Medicine
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Natalie F. Holt, MD, MPH

Assistant Professor

15
Department of Anesthesiology
Yale University School of Medicine
Medical Director
Ambulatory Procedures Unit
VA Connecticut Healthcare System
West Haven, Connecticut

Robert S. Holzman, MD, MS (Hon), FAAP

Senior Associate in Perioperative Anesthesiology
Department of Anesthesiology, Perioperative and Pain Medicine
Boston Children’s Hospital
Professor of Anesthesia
Harvard Medical School
Boston, Massachusetts

Harriet W. Hopf, MD
Professor and Vice-Chair
Department of Anesthesiology
University of Utah School of Medicine
Salt Lake City, Utah

Robert W. Hurley, MD, PhD

Professor and Vice-Chair
Department of Anesthesiology
Medical College of Wisconsin
Milwaukee, Wisconsin

Adam K. Jacob, MD
Associate Professor of Anesthesiology
Mayo Clinic College of Medicine
Rochester, Minnesota

Farid Jadbabaie, MD
Associate Professor of Medicine (Cardiology)
Director of Echocardiography Laboratory
VA Connecticut Healthcare System
Yale School of Medicine
New Haven, Connecticut

Rebecca L. Johnson, MD
Assistant Professor of Anesthesiology
Department of Anesthesiology
Mayo Clinic College of Medicine

16
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Rochester, Minnesota

Sharma E. Joseph, MD
Instructor of Anesthesia
Boston University School of Medicine
Boston Medical Center
Boston, Massachusetts

Jonathan D. Katz, MD
Clinical Professor of Anesthesiology
Yale University School of Medicine
Professor of Anesthesiology
Frank H. Netter MD School of Medicine at Quinnipiac University
Attending Anesthesiologist
St. Vincent’s Medical Center
Bridgeport, Connecticut

Christopher D. Kent, MD
Associate Professor
Department of Anesthesiology and Pain Medicine
University of Washington
Seattle, Washington

Meghan A. Kirksey, MD, PhD

Assistant Attending Anesthesiologist
Hospital for Special Surgery
Clinical Assistant Professor of Anesthesiology
Weill Cornell Medical College
New York, New York

Sandra L. Kopp, MD
Associate Professor of Anesthesiology
Department of Anesthesiology
Mayo Clinic College of Medicine
Rochester, Minnesota

Catherine Kuhn, MD
Director & Associate Dean, Graduate Medical Education
Designated Institutional Official
Professor of Anesthesiology
Department of Anesthesiology
Duke University
Durham, North Carolina

17
Jerrold Lerman, MD, FRCPC, FANZCA
Clinical Professor of Anesthesiology
Women and Children’s Hospital of Buffalo
State University of New York
Buffalo, New York

Jerrold H. Levy, MD, FAHA, FCCM

Professor of Anesthesiology
Associate Professor of Surgery
Division of Cardiothoracic Anesthesiology and Critical Care
Duke University School of Medicine
Co-Director, Cardiothoracic ICU
Duke University Hospital
Durham, North Carolina

Adam D. Lichtman, MD, FASE

Associate Professor of Anesthesiology
Director of Vascular Anesthesia
Weill Cornell Medical College
New York Presbyterian Hospital
New York, New York

J. Lance Lichtor, MD
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut

Yi Lin, MD, PhD

Assistant Attending Anesthesiologist
Hospital for Special Surgery
New York, New York

Spencer S. Liu, MD
Clinical Professor of Anesthesiology
Weill College of Medicine at Cornell University
Department of Anesthesiology
Hospital for Special Surgery
New York, New York

Justin B. Long, MD, FAAP

Assistant Professor
Emory University School of Medicine
Department of Pediatric Anesthesiology

18
Children’s Healthcare of Atlanta at Henrietta Egleston Hospital for Children
Atlanta, Georgia

Stephen M. Macres, MD, PharmD

Professor
Department of Anesthesiology and Pain Medicine
University of California Davis Medical Center
Sacramento, California

Peter Mancini, MD
Assistant Clinical Professor
Department of Anesthesiology
Yale University School of Medicine
New Haven, CT

Aaron J. Mancuso, MD
Assistant Professor of Anesthesiology
Geisel School of Medicine
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire

Gerard Manecke, MD
Chair, Department of Anesthesiology
UCSD Medical Center
San Diego, California

Melissa M. Masaracchia, MD
Assistant Professor of Anesthesiology
Dartmouth-Hitchcock Medical Center
Geisel School of Medicine
Lebanon, New Hampshire

Joseph P. Mathew, MD, MHSC, MBA

Jerry Reves, MD, Professor and Chairman
Department of Anesthesiology
Duke University Medical Center
Durham, North Carolina

Kathryn E. McGoldrick, MD, FCAI (Hon)

Professor and Chair of Anesthesiology, Emeritus
Advisory Dean, Emeritus
New York Medical College
Valhalla, New York

19
Accreditation Council for Graduate Medical Education
Department of Institutional Accreditation
Chicago, Illinois

Joseph H. McIsaac III, MD, MS

Associate Clinical Professor of Anesthesiology
Associate Adjunct Professor of Biomedical Engineering
University of Connecticut
Avon, CT

Sanford M. Miller, MD
Clinical Professor (Emeritus) of Anesthesiology
NYU School of Medicine
Former Assistant Director of Anesthesiology
Bellevue Hospital Center
New York, New York

Shawn L. Mincer, MSW

Research Coordinator
Department of Anesthesiology and Pain Medicine
University of Washington
Seattle, Washington

Peter G. Moore, MBBS, PhD, FANZCA, FICM

Professor of Anesthesiology and Pain Medicine and Internal Medicine
University of California, Davis Health System
Sacramento, California

Candice Morrissey, MD, MSPH

Assistant Professor
Department of Anesthesiology
University of Utah
Salt Lake City, Utah

Michael J. Murray, MD, PhD

Department of Critical Care Medicine
Geisinger Medical Center
Danville, Pennsylvania

Sawyer A. Naze, MD
Resident
Department of Anesthesiology
Feinberg School of Medicine

20
Northwestern University
Chicago, Illinois

Steven M. Neustein, MD
Professor of Anesthesiology
Icahn School of Medicine at Mount Sinai
New York, New York

Marieke Niesters, MD, PhD

Department of Anesthesiology
Leiden University Medical Center
Leiden, The Netherlands

Mark C. Norris, MD
Director of Obstetric Anesthesia
Boston Medical Center
Clinical Professor of Anesthesiology
Boston University School of Medicine
Boston, Massachusetts

E. Andrew Ochroch, MD, MSCE

Professor of Anesthesiology, Critical Care, and Surgery
University of Pennsylvania
Philadelphia, Pennsylvania

Rafael Ortega, MD
Professor
Vice-Chairman of Academic Affairs
Department of Anesthesiology
Boston University School of Medicine
Boston, Massachusetts

Charles W. Otto, MD, FCCM

Professor of Anesthesiology
Associate Professor of Medicine
Department of Anesthesiology
University of Arizona College of Medicine
Tucson, Arizona

Frank Overdyk, MSEE, MD

Department of Anesthesiology
Roper St. Francis Health System
Charleston, South Carolina

21
Exploring the Variety of Random
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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