Chapter XLVII (1)

INJURIES AND SURGICAL DISEASES OF THE STOMACH.

CONGENITAL MALFORMATIONS OF THE STOMACH.

These malformations are quite rare, at least those raising the question of possible surgical remedy. _Transposition_ does not require relief, nor does a stomach abnormally small allow it. More or less _stenosis of the pylorus_ as a congenital defect has been observed, but it is extremely rare. Along with it is often associated a certain hypertrophy of the stomach muscle. _Hour-glass deformity_ may be of congenital or acquired origin. The latter two conditions permit of easy surgical remedy. Pyloric stenosis may be atoned for by gastro-enterostomy or treated directly by a plastic operation, while the hour-glass stomach permits of an anastomotic rearrangement, either of its dilated portions with each other or with the bowel below.

The _acquired malformations_ are connected with the consequences of ulceration and stricture. They include more or less complete _stenosis_, either cicatricial or malignant, various forms and types of _gastroptosis_ and _gastric dilatation_, in which sometimes enormous degrees of distention are produced, with disturbed or practically destroyed stomach digestion. These cases will be considered by themselves a little later, along with their surgical relief.

The _anatomical relations of the nerves_ supplying the stomach are worthy of the surgeon’s especial consideration. Its sympathetic nerve supply is in particular and intimate relation with the seventh, eighth, and ninth spinal roots, by which we account for the tenderness of the overlying surface in ulcer of the stomach, and the pain which is often referred to the region of the left shoulder-blade. When the stomach is adherent to the gall-bladder, in cases of biliary calculi, the pain is often referred to the right shoulder, but so soon as the pylorus becomes entangled and bound down pain is referred also to the left side as well.

HOUR-GLASS STOMACH.

Hour-glass stomach is now more common, and is to be attributed more to results of pathological conditions than to any congenital anomaly, it being now well established that it is usually the result of perigastric adhesions of chronic ulceration, with cicatricial constriction, as well perhaps of subsequent malignant implantation. Cancerous infiltration may produce the so-called _“leather-bottle” stomach_. Moynihan suggests, among other methods of _diagnosis_, the passage of a stomach tube and lavage with a quantity of fluid. If there be loss of a certain amount of this, when it is returned, it will indicate that a portion has escaped into the distal sac of the stomach. Again if the stomach be washed until the fluid returns clear, and then if there suddenly comes an amount of offensive fluid, or if the stomach be washed clean, the tube withdrawn and passed again a few moments later, and if then offensive fluid escape, the facts can be best explained on the hypothesis of an hour-glass constriction. “Paradoxical dilatation” may also be noted, _i. e._, the fact that palpation will still elicit a splashing sound after a stomach tube has been passed and while the organ is apparently empty.

Moynihan has suggested still another method of recognition. The area of stomach resonance being outlined, a Seidlitz powder in two halves is then administered. After about twenty or thirty seconds great increase in resonance of the upper part of the stomach will be found, while the lower part remains unaltered. If now a bulky pouch can be felt or outlined the diagnosis is determined, as the increase in resonance occurs in the distended cardiac segment.

The method of treating an hour-glass stomach will consist either, in selected cases, of a plastic operation by which an incision made in one direction is closed in the opposite, _i. e._, a measure like that practised at the pylorus for benign stricture, or else the separate sacs of the stomach must be united by an anastomotic opening and a _gastrogastrostomy_ thus performed.

FOREIGN BODIES IN THE STOMACH.

These are most commonly those which have been swallowed, either by design or through inadvertence, and may consist of almost all imaginable substances. In those animals that have the constant habit of licking their own fur or that of others, and thus scraping off a quantity of hair, _hair-balls_ in the stomach are frequently formed, and, as may be seen in museums, these sometimes obtain relatively enormous size--a foot or more in diameter. Hair-balls in the human being are of rare occurrence, and are the result of the habit of chewing the hair, observed in some hysterical or insane patients. There are several instances now on record of successful removal of such hair-balls from human stomachs. _Artificial dentures_, partial or complete, are not infrequently passed into the stomach, sometimes during sleep. In dealing with a case of this character extreme caution should be exercised, because many individuals have deceived themselves, or have been deceived, and the missing teeth supposed to have been swallowed have been found in some place where they have been mislaid and forgotten. Children have a habit of swallowing almost anything left loose in the mouth, and all sorts of toys and small playthings have disappeared into their stomachs, sometimes causing death, and occasionally passing through the alimentary canal. The insane sometimes show a maniacal tendency to swallow foreign bodies, such as nails or anything else which they can get into the mouth. Hysterical patients and museum freaks evince the same habit, and it is wonderful how tolerant the stomach becomes in some of these individuals, and what objects seem to pass the pylorus and escape externally without doing serious harm. Still, sooner or later nearly every one of these individuals comes to grief. Thus from one patient at the Erie County Hospital, in Buffalo, Gaylord removed an astonishing amount of junk, including nails, screws, pieces of glass, knife-blades, and the like. As a general rule, any reasonably smooth object which can pass through the esophagus may also pass through the pylorus.

=Symptoms.=--The symptoms produced by these foreign bodies will vary according to their size, number, and character. A hair-ball may lie for a long time within the stomach, producing few symptoms, and none by which it may be recognized. So long as no perforation of the entire thickness of the stomach walls occur, nor any infection which may produce a local peritonitis, the disturbances they set up may be limited to those included under the name “dyspepsia.” So soon, however, as pain, tenderness, or septic indications, or those of local peritonitis supervene, the abdomen should be promptly opened. Today we have the cathode rays as an aid in diagnosis, which will clear up doubt in most instances, and afford a definite indication for operation. Nevertheless a negative result does not necessarily imply that no foreign body is present.

=Treatment.=--The operation indicated is _gastrotomy_, _i. e._, opening of the stomach at a suitable or convenient point, removal of the foreign body or bodies, and the complete closure of the wound as well as of the abdominal incision, without drainage. If due care be maintained throughout, and the element of previous infection be excluded, prognosis is good. When perforation with local peritonitis, and perhaps abscess, has already occurred, there is a local indication as to exactly where to open; one should then complete the operation with the establishment of suitable drainage.

WOUNDS OF THE STOMACH, INCLUDING RUPTURE.

As already indicated, the stomach maybe ruptured, especially if weakened by previous disease, by severe abdominal contusion. It is subject to all possible wounds by perforation, either gunshot or by puncture. As it is more protected than the bowel below it is less liable to perforating injuries. Much will depend upon the nature and the extent of the injury. A small perforation may be protected by prolapse of the mucosa in such a way that little escape of contents takes place. On the other hand it may be extensive, and nearly the entire gastric contents may be poured out into the upper abdomen. The location of the stomach lesion by no means necessarily corresponds to that of the abdominal wall, this being particularly true in gunshot cases. Extravasation depends in amount and rapidity upon the stomach contents and their fluidity. If the posterior wall alone be injured it will empty rather into the cavity of the lesser omentum. Stomach injury may always be diagnosticated if, after abdominal injury, the vomited matter contains blood. The pain is usually severe and involves generally the entire upper abdomen. In proportion as the lesion lies near the diaphragm the breathing may be affected. Collapse is usually prompt and may be due to hemorrhage from a vessel of considerable size. _Pain_, _collapse_, and _hematemesis_ constitute indications for the promptest possible opening of the abdomen and investigation, with suitable suture of the stomach wound, toilet of the peritoneal cavity, and drainage, which should be posterior as well as anterior. Every ragged or compromised margin of a stomach wound, especially gunshot, should be neatly excised, and sutures applied in such a way as to only bring clean and fresh surfaces together. An external opening of sufficient length should be made to permit easy and complete withdrawal of the entire stomach, and a complete search over both its surfaces in order that no lesion may escape detection. If the opening made into the stomach be sufficiently large to permit, it would be best to thoroughly empty its contents and gently wipe it out, in order that it may be left not only empty but clean. Should the puncture be very small it would be well to pass a stomach tube from above and wash out the stomach, protecting the opening by pads and pressure, and thus preventing contamination of the peritoneum.

While _apparently spontaneous rupture_, _i. e._, without previous ulcer or disease, is most rare, there are a few cases on record where patients have been seized with intense paroxysmal pain and have died more or less quickly, and where the condition has been found with little or nothing to explain it. Immediate operation might possibly have saved some of these had the possibility of its occurrence been recognized. _Perforation from within_ may also occur, as it is known to have happened in the cases of sword or knife swallowers.

_Suture of the stomach_ is practised in exactly the same way in these cases as for other purposes and the method will be described later, along with the other operations upon this viscus.

TUBERCULOSIS AND SYPHILIS OF THE STOMACH.

The gastric mucosa presents a remarkable contrast to that of the intestinal tract, the latter being exceedingly likely to succumb to _tuberculous infection_, which is exceedingly rare in the former. _Primary tuberculous ulceration_ of the stomach, then, is most unusual. When tuberculous ulcers are found there they are usually the result of a secondary or perforating process. Such ulcers may attain great size, as in one case reported by Simmonds where the ulcerated area measured four by eight inches, yet produced no symptoms during life. This would correspond almost to a lupus of the gastric mucosa. Tuberculous _gummas_ are even more rare, and, occurring in the stomach, are pathological curiosities rather than surgical possibilities.

_Syphilis of the stomach_ is met with either as gumma or ulcer, the latter leading almost inevitably to more or less stricture as recovery follows suitable treatment. Although it is claimed that 10 per cent. of cases of chronic ulcer of the stomach have suffered from syphilis at some time, it by no means follows that such ulcers are to be considered as of genuinely syphilitic origin, as a syphilitic patient is not exempt from other stomach conditions. However, symptoms of gastric ulcer, associated with actual manifestations of syphilis, might well indicate associated syphilitic lesions and would probably yield, with the others, to suitable treatment.

Lesions of either character, which do not subside under proper medical treatment, and which require a surgical operation, would be equally benefited by it whether of one of these types or of the other.

DILATATION OF THE STOMACH.

The _acute form of gastric dilatation_ was described by Fagge in 1872, the chief symptoms being excessive vomiting and anuria, and the disease proving fatal within three days, the dilatation being enormous. For a condition occurring as rapidly and progressively as this does there is as yet no satisfactory explanation, careful autopsy failing to disclose a sufficient reason. It has been known in at least twelve instances to follow surgical operation, four only of which were upon the abdomen, and none of them upon the stomach proper, in all instances the patients apparently progressing favorably. The stomach becomes rapidly and enormously distended, and bent upon itself with a sharp kink in the lesser curvature. Thus it seems to occupy the entire upper abdomen. Two factors at least seem to assist in the condition: A paresis of the gastric musculature, and the fact that as it becomes distended it itself produces obstruction of the duodenum, and thus aggravates the primary condition.

It has been suggested that these acute cases of _postoperative dilatation_ are closely connected with certain cases of ileus and obstruction after abdominal operations, the dilatation once initiated tending to more and more obstruct the duodenum, as well as cause upward pressure on the diaphragm and embarrassment of the heart’s action. Hence the value of the stomach tube in treatment of such conditions.

=Symptoms.=--The symptoms are usually sudden and fulminating, beginning with intense pain, which finally involves the entire abdomen. Vomiting comes early and persists, the vomited fluid being greenish in color and large in amount, changing later to a brownish color and having an offensive odor. The act of vomiting is passive rather than active or violent. In spite of it the stomach never seems to empty itself. The outline of the dilated stomach may be seen through the abdominal wall, bulging being often extreme. With the passage of the stomach tube there may be escape of a large amount of gas as well as of fluid. Thirst is intolerable and never satisfied. The amount of urine is almost always reduced and sometimes anuria is practically complete.

=Treatment.=--The treatment is too often ineffectual, since the condition itself is lethal almost from the beginning. Early and frequent lavage, or perhaps leaving the stomach tube in place, would be indicated. It might be practicable to pass a small tube through the nostril and leave it, as is done with the insane. Gastrostomy would be theoretically indicated, could it be done sufficiently early. The same is perhaps true of gastro-enterostomy, although it has never had a fair trial, these cases coming to the surgeon too late to permit of much help.

=Chronic Dilatation of the Stomach.=--Chronic dilatation of the stomach, often spoken of as _gastrectasis_, is a frequent complication of various other conditions, being essentially a consequence rather than a primary condition. It may be due to:

1. Pyloric stenosis or its equivalent in the first part of the duodenum:

(_a_) From cicatricial processes following ulcers of the pyloric
region;

(_b_) From perigastritis with cancer of the stomach;

(_c_) From pylorospasm and hypertrophy continuing after recovery from
ulcer, and including more or less thickening of the biliary region;

(_d_) From neoplasms outside the pylorus proper;

(_e_) From cancer of the pyloric end of the stomach;

(_f_) From pressure upon the duodenum by pancreatic lesions;

(_g_) From the results of gallstones ulcerating and causing great
local disturbances;

(_h_) From displacement of the pylorus, due either to falling of the
stomach or dragging of an attached but movable right kidney.

2. A dilatation due to old lesions which have subsided, the atonic stretching not having been repaired.

It will be seen, then, that the condition may be met as a sequel to many different pathological processes. As such, therefore, it has no constant etiology nor necessarily distinctive features. In general it is recognized by tardiness in escape of gastric contents, associated with vomiting, the vomitus being distinctive, consisting often of old and undigested food, or perhaps of food which has rested in the stomach until putrefaction has occurred. The vomitus also contains evidences of fermentation, with sarcinæ and yeast cells and much mucus. In cases of ulcer it is usually very sour, owing to excess of free hydrochloric acid. When due to cancer the acid is usually due to excess of lactic acid, while hydrochloric acid may be nearly or totally absent. Even if vomiting does not occur after ingestion of food, heaviness and discomfort, with much eructation of gas, are produced. Constipation and diminished urine secretion are almost invariable accompaniments. When the obstruction is of the mechanical type a visible peristaltic wave can often be seen and felt, and this is a sign which should be regarded as always indicating operation.

Patients gradually lose flesh and become anemic and run down, suffering from what has been often vaguely called indigestion, their lives sometimes being terminated by starvation, occasionally by gastric tetany. The question of diagnosis can usually be settled by having the patient swallow the dissolved separate parts of a Seidlitz powder, one after the other, when the carbon dioxide released within the stomach will cause it to balloon up and assume that shape and position which the amount of its dilatation permits.

_Gastric dilatation which does not quickly yield to lavage and suitable medication is of itself always an indication for operation._ When accompanied by a tumor, especially if this move and change position with the stomach, a cancerous condition may be assumed, which, while not permitting a cure, may nevertheless be ameliorated by a gastro-enterostomy. In the absence of actual cancerous conditions the surgical treatment of chronic dilatation is exceedingly satisfactory.

This surgical treatment consists in the application of one at least of the following expedients:

1. Local relief of mechanical pyloric obstruction, as by any one of
the pyloroplastic methods;

2. Gastroplication, by which the capacity of the stomach is
materially reduced;

3. Gastro-enterostomy, by which mechanical obstruction is atoned
for by a free outlet, provided at a point where gravity as well as
peristalsis shall assist in completely emptying the viscus.

The methods in vogue a few years ago for opening the stomach and merely stretching the pyloric outlet have been supplanted by other plastic operations which have proved more satisfactory because of the greater permanency of their results.

GASTROPTOSIS.

The downward displacement of the stomach, to which the term _gastroptosis_ has been given, implies not only more or less actual dilatation, but also a stretching or lengthening of the upper attachments and peritoneal folds which should hold the stomach up in place. When these yield and the stomach is thus permitted to drop, more or less obstruction of the pylorus and kinking of the duodenum are apt to occur. The condition regarded surgically is not essentially different from that of chronic dilatation. When the stomach is distended with carbon dioxide its normal position may be easily recognized, while, at the same time, it is determined that it is perhaps but little dilated.

The causes which lead to this condition, aside from those which affect the stomach proper, include tight lacing, by which the supporting viscera are forced downward and the stomach permitted to fall with them. In addition to such a cause any previous disease by which the abdominal viscera have been affected or ligaments weakened would be of more or less effect. The condition leads sooner or later to one of dilatation, and always merges into it. Its symptoms are those of dilatation, only in milder degree. On account of the dragging upon the upper supports patients frequently complain of intense lumbago, and they nearly always become neurasthenic.

=Treatment.=--The ordinary routine treatment failing to give relief, one may, in mild cases, adopt an external mechanical treatment, consisting of a suitable abdominal bandage which should press the viscera up from beneath, and thus relieve splanchnic congestion and weight.

Mechanical support failing and symptoms persisting, the surgeon is able to afford relief by _gastropexy_, first suggested by Duret, and consisting of an exposure of the stomach through the middle line and its fixation to the anterior abdominal wall. This, however, has its theoretical disadvantages, since it might be followed by symptoms similar to those resulting from pathological adhesions. The method has been more or less modified, sutures being passed through the gastrohepatic omentum and gastrophrenic ligament in such a way as to bring them into close contact and looking to their complete union. Thus, Beyer, of Philadelphia, has reported four cases apparently successfully operated upon in this fashion. Bier has added four others, all of which seem to afford much encouragement to operative treatment of gastroptosis. Furthermore, Coffey has modified the technique in such a way as to include a sort of suspension of the stomach by making a hammock out of the great omentum. He did this by stitching the omentum to the abdominal peritoneum, about one inch above the umbilicus, with a transverse row of sutures about one inch apart.

GASTRIC TETANY.

Gastric tetany has but relatively small interest for the surgeon, save as it may complicate some of his results or prevent his endeavor to secure them. The condition is usually characterized by peculiar, disturbed sensation in the extremities, with a feeling of coldness or numbness in the limbs, and drowsiness, vertigo, and disproportionate weakness after exercise. Somewhat severe attacks are sometimes precipitated by lavage, and are then begun with a complaint of formication, followed by tetanic contraction of the muscles of the extremities. Instead of tonic spasm the muscles may be in more or less constant motion. The muscles of the face, neck, and abdomen are also involved. The facial expression changes, and patients may complain of loss of vision. During these paroxysms they may even mutter or speak unintelligibly. Chvostek some time ago showed how to produce these spasms, when the condition is present, by tapping over the facial nerve just at its exit from the cranium, and Trousseau demonstrated that during the attack the paroxysms may be produced at will by compressing the affected parts in such a way as to impede venous or arterial circulation through them. Some of these spasmodic attacks are accompanied by severe pain, while spasm is usually made less painful by gently yet forcibly overcoming it by pressure. The condition is essentially toxic, usually autotoxic, and yet, inasmuch as it may complicate the best efforts of the surgeon or complicate the case upon which he would wish to operate, it is deserving of this brief description here, largely in order that it may not be mistaken for true tetanus or be misinterpreted in any other way.

CARDIOSPASM.

This is a term recently suggested by Mikulicz for a peculiar contraction of the lower end of the esophagus and the cardiac orifice of the stomach, which is occasionally met with, and until fully described by him was somewhat misunderstood. In consequence of the spasmodic stricture thus produced there occurs dilatation of the esophagus above and formation of a sac, which may be discovered by the bougie or tube, or by a good radiogram, after having been filled with a weak bismuth emulsion. Such sacculation had always been previously regarded as due to esophageal diverticulum, which it greatly simulates at first and in time practically becomes. It is due either to primary and unexplained spasm of the muscular coat at this level, or to a primary atony for the esophageal muscle above the stricture. It has been ascribed also to paralysis of the circular fibers and spasm of the cardia, due to vagus involvement and to primary esophagitis. The view that it is of congenital origin can scarcely be sustained.

=Symptoms.=--The symptoms and signs produced are not widely different from those of a capacious diverticulum. It is difficult, often impossible, to pass a stomach tube into the stomach, it being diverted into the upper cavity. The patient moreover, vomits material which is undigested and more or less putrefactive, and, at the same time, without evidences of actual stomach disease. Such a sac may hold even two pints, and thus it will be seen how much material may be vomited or washed out by lavage which, at the same time, never entered the stomach. Should it be possible to enter the stomach the two sets of contents will be found quite different.

=Treatment.=--While more or less benefit and relief may be obtained from frequent washing of the abdominal sac thus produced the real cure will only come, as shown by Mikulicz, from opening of the stomach and dilatation of its constricted upper orifice.

PYLORIC STENOSIS.

Reduction in caliber of the pyloric opening, amounting in extreme cases to absolute closure, may be met with at various ages and following various conditions.

A congenital stenosis has been observed, although very infrequently.[54]

[54] Fiske (Annals of Surgery, July, 1906) states that there are at
present on record 121 cases of hypertrophic stenosis of the pylorus
in infants. The three theories advanced to account for the condition
as occurring before birth presuppose either a true malformation
with muscular hypertrophy, a secondary hypertrophy due to prenatal
pyloric spasm, or a spastic condition of the pyloric region without
definite gross anatomical lesion. None of these theories satisfies
the condition in any but a small proportion of cases, although
either of them doubtless is or may be correct in certain instances;
71 of these cases have now been operated upon, of which 33 died,
gastro-enterostomy giving 57 per cent. of recoveries and pyloroplasty
54 percent.

_Pyloric constriction following cicatricial contraction of healed ulcers_ is perhaps the most common non-malignant form. This rarely proceeds to absolute closure, but is frequently sufficient to lead to dilatation.

Conversely any condition of the stomach which drags it out of shape and leads to kink or abrupt angulation near the pylorus may lead to early postural and later to actual structural contraction.

The pressure or alteration of shape produced by neoplasms, either within the substance of the stomach or more frequently without, will cause more or less irregular contraction of the pyloric end amounting to pyloric stricture.

By _old adhesions_ similar conditions are produced, while a definite form of _spastic contraction_, corresponding much to cardiospasm just described, will cause more or less pyloric obstruction.

Finally _malignant tumors_ involving the pyloric region invariably spread to the pyloric ring, and not only infiltrate it but cause it to become inflexible and diminished in size, to a degree finally amounting to almost complete or to absolute obstruction.

=Symptoms.=--No matter what the cause the symptoms are essentially the same, in that they produce dilatation of the stomach and frequent vomiting. According to the cause there will also be a history of pain and hemorrhage, suggesting ulcer, or of biliary colic, denoting perigastric adhesions, or of pancreatic disease, accounting for adhesion of the duodenum and displacement of the pylorus. The discovery of tumor or the results of examination of stomach contents may also suggest or corroborate the diagnosis of cancer.

The essential feature being the failure of the gastric contents to pass onward into the bowel, and their accumulation in the stomach or rejection by vomiting, the condition will be seen to have a purely mechanical as well as a pathological aspect. The case, therefore, must be extreme in which a mechanical remedy will not afford at least temporary relief.

=Surgical Treatment.=--This remedy obviously is either to overcome the stricture by dilatation, or plastic operation upon the region involved, or to form a new opening by which the stomach shall connect with the upper intestine--_i. e._, _gastro-enterostomy_. The latter has gradually supplanted the former in the choice and in the hands of most surgeons, although occasionally a case may be met which invites the performance of a pyloroplasty, by either the Heinecke-Mikulicz or the Finney operations, which will be described later. In the absence of malignant disease few serious operations give more satisfactory results than do these.

GASTRIC ULCER.

During the past few years the studies of internists, of pathologists, and of surgeons have all served to show that _gastric ulcer_ in any form is a more common lesion than was suspected by the previous generation. At first it nearly always comes under the care of the internist, but too often, becoming chronic, it is too long continued under his care until a serious, perhaps almost fatal, hemorrhage makes operative relief more dangerous, if not impossible, or until a chronic ulcer has degenerated into a cancer, and this is permitted to go on until the patient pays with his life the penalty for such inattention.

_Ulcers in the gastric mucosa_ vary from a simple _fissure_ (such as may be seen in the mucosa of the lip or the anus) to extensive and deep ulcerations, which weaken the stomach structure in spite of protective infiltration and even adhesions, until a final perforation may terminate the case, either by hemorrhage or septic peritonitis. While surgical teaching has of late pointed more and more definitely to the importance of ulcers resulting from simple erosions, or apparently mere abrasions which have not been appreciated, most pathologists and surgeons fail to realize that even from so trifling a surface alarming hemorrhages may occur. Such lesions appear upon the postmortem table to be minute and unimportant, but, occurring during life, they have an importance of their own.

Gastric ulcers, then, should be referred to as _erosions_, as _simple or complicated ulcers_, and as _ulcerating cancers_, in addition to which there may be mentioned the rare lesions produced by tuberculosis and syphilis. These ulcers are always to be regarded seriously, because in their milder expressions they cause pain and various forms of dyspepsia and indigestion, while their more serious consequences include hemorrhage, which may be fatal, and perforation, which is essentially so unless surgical intervention be prompt and complete.

=Symptoms.=--The symptoms and discomforts which they produce include _pain_, which is nearly always most pronounced within a short time after the ingestion of food, and which may be accompanied by local tenderness more or less constant. As the case progresses, with the pain usually comes vomiting, by which the former is relieved, the vomitus nearly always containing excess of hydrochloric acid and sometimes fresh or old blood. The pain of gastric ulcer is usually referred to the back. The indigestion and the frequent vomiting together are sufficient to produce a well-marked anemia, which is more pronounced when much blood is lost. Blood may not be vomited but escape into the duodenum, and will then give to the stools a tarry character, which should always be looked for and identified when discovered. The greater the loss of blood in either direction the more pronounced will be the anemia. _Pain_, _vomiting_, and evidence of _loss of blood_ constitute the most distinctive features of gastric ulcer. When these are accompanied by tenderness in the epigastrium, and by pain in the back, the diagnosis is almost complete. In the more chronic cases there may have already occurred contraction of the pylorus and consequent dilatation of the stomach. Thus symptoms of the latter may be added to those of the previous condition.[55]

[55] In doubtful cases accompanied by pain it will sometimes be of
value to try the effect of orthoform in ¹⁄₂ Gm. doses, to see if it
will relieve it. This remedy will not anesthetize nerve endings which
are protected by skin or mucous membrane. The fact, then, that it
affords relief implies an ulcerated or exposed area.

The two ever-present and alarming _dangers_ are those of _hemorrhage_ and _perforation_. Serious hemorrhage permits the escape by the mouth of large quantities of bright, fresh blood, with a corresponding degree of shock or collapse, and depression. Perforation is indicated by sudden onset of intense pain, with collapse, rapidly spreading tenderness, with abdominal rigidity and increasing distention. In other words the _symptoms of perforation are those of acute local peritonitis of abrupt origin_.

In either of these events the paramount indication is for prompt intervention, unless the patient is already too weak to withstand the shock of any operation. In one case this will consist of gastro-enterostomy, with or without a gastrotomy for the purpose of discovering the bleeding vessel and making local hemostasis. In the other it will consist of free incision, complete toilet of the peritoneum, with removal of all escaped material, and local attention to the site of the perforation, doing there whatever may be needed.

=Treatment.=--Should the surgeon see a case of gastric hemorrhage due to ulcer after the apparent cessation of the active loss of blood he may easily decide to wait for a few days until the patient has in some degree recovered strength and atoned for such loss. On the other hand if he see the case during its active stage he need not hesitate to open the abdomen, withdraw the stomach, open it sufficiently for exploration, and then attack the source of hemorrhage, be it large or small, in such manner as he may see fit--either with the actual cautery, with a sharp spoon, with complete excision of the ulcerated area and union of its borders by suture, or by merely including a bleeding vessel in a loop of suture, addressing himself at once to the formation of an anastomosis, preferably posterior, between the stomach and the uppermost loop of the small intestine. This procedure, which is wise in all instances, would be imperative in nearly all save those perhaps where an ulcerated area could be cleanly excised and its margins neatly sutured. Should it prove that suture of the stomach wall were impracticable its edges might be fastened to those of the abdominal wound, a gastrostomy thus resulting, which could be later closed by another operation.

_For perforation_ the surgeon might have to rely, in emergency, on a gastro-enterostomy as a relief opening, accompanied by local gauze tamponage; the point of perforation could not be made accessible for suture, but one should prefer suture for all cases that permit of it. In these cases a considerable margin should be enfolded and included within the grasp of the suture, or else the margins should be completely excised until healthy tissue is reached. In rare instances it has been feasible to fit into a perforation a drainage tube, or to pack about it a gauze strip which should conduct from the stomach cavity directly to the abdominal wound. The question of _excision of the entire ulcerated area_ should rest entirely upon the possibility of repairing the defect by sutures, and this will depend in large degree upon the location of the ulcer and the freedom with which the stomach can be manipulated, especially with which it can be withdrawn into the wound.

Practically every case of perforation thus operated will demand posterior as well as anterior drainage. Aside from the treatment of the stomach itself the general peritoneal cavity needs the same thoroughness of cleansing and the same care in every manipulation that would be given in a case of well-marked peritonitis already established.

GASTRIC FISTULAS.

This term has reference especially to _external fistulous openings_, which are an exceeding rarity save as relics of injury or of operation. They have been known to occur spontaneously by perforation of an ulcerated and adherent stomach, such perforations occurring either in direct line or irregularly in the direction of least resistance. _Traumatic fistulas_ result usually from gunshot or stab wounds, or are due to incomplete union of an opening deliberately made. In any event they permit of the escape of more or less of the stomach contents. Their tendency is usually toward spontaneous repair, but this is often so slow or so incomplete that it needs to be hastened by stimulation of the fistulous tract with silver nitrate, the actual cautery, curetting, or by a complete resection of the entire tissue involved, and a neat reunion with suture.

_Intra-abdominal gastric fistulas_ result usually from perforation of gallstones or the escape of foreign bodies. Produced in this way they empty usually, though not always, into some neighboring portion of the intestinal canal.

TUMORS OF THE STOMACH.

_Benign tumors_ are occasionally found in the stomach, and are most often of the adenomatous type. Papillomatous growths into the stomach have also been observed. Beneath the peritoneum, or in the submucous tissue near the pylorus, fatty tumors have also been seen. Myomas of mixed type have been described, and cysts have been met in the walls of the stomach. These have rarely attained a size larger than a hen’s egg. All of these non-malignant tumors are of pathological rather than surgical interest. Every one of them, however, will admit of successful surgical remedy when once recognized, operation consisting of excision, with suitable suturing.

CANCER OF THE STOMACH.

_Carcinoma_ is perhaps as frequently seen in the stomach as in any part of the body, the breast possibly excepted. In about three-fifths of the cases it involves the pyloric region, in one-tenth of them the cardiac end, the balance occurring in the intermediate part. It is usually of the round-cell or scirrhous variety, and is generally supposed to be a disease of adult or advanced life. While this is generally true there have been exceptions. It is occasionally met in the young, and has been reported even in early childhood. True sarcoma of the stomach is exceedingly rare. It spreads especially in the submucous tissue and evinces a tendency to involve especially the lesser curvature.

The duodenum evinces an extraordinary immunity from malignant disease, even that involving the pyloric region. When the pyloric end is involved the lesion is frequently complicated by adhesions, which are present in considerably more than half of the cases. The lymph nodes of the adjoining mesentery are nearly always involved, practically always in cases which come to the surgeon for operation. As the disease advances it spreads in several directions, and adjoining viscera may be involved, or even those at considerable distance, while metastases to other parts of the body are common. It is somewhat more common in males than females. In proportion as the pyloric ring itself becomes infiltrated and involved pyloric obstruction is an early feature, with the inevitable gastric dilatation and greater frequency of vomiting. Pathologists and surgeons are learning that the _most frequent cause of gastric cancer is gastric ulcer_, and recent investigations are to the effect that in at least 80 per cent. of cases there has been ulceration which has been followed by this malignant change. This affords additional reason, then, for regarding gastric ulcer as a surgical disease and operating upon it early and before such transition has occurred.

=Symptoms.=--As repeatedly emphasized throughout this work _cancer is a disease without a pathognomonic symptomatology_. For this reason it is rarely diagnosticated in its early stage, the symptoms which it produces being those of indigestion or dyspepsia.

The most _distinctive features_ met with in gastric cancer are _pain_, _vomiting_, more or less _dilatation_, and presence of _tumor_. _Pain_ is an early and constant symptom, the complaint at first being of heaviness and oppression, made worse after the ingestion of food, and later referred to as actual pain, which may be limited or may radiate to either side or to the back. Much will depend upon whether the cancer develop from the site of a previous gastric ulcer or independently.

Individual complaints are variant regarding the intensity and reference of this pain. In large measure it is due to the formation of adhesions, and its reference will depend much upon their location.

_Vomiting_ is an equally constant and perhaps even more important symptom, being met in nine-tenths of the cases. When the growth involves the pyloric end the vomitus is copious in amount, while the intervals between attacks of vomiting are relatively long. When the more central areas of the stomach are affected and its capacity is thus reduced vomiting is more frequent, usually following soon after taking of food, and the amount of vomitus is consequently less. In general the character of the vomited material depends upon the length of time it has been retained, upon the possible presence of bile or blood, the presence of small amounts of blood giving to it a somewhat characteristic appearance, indicated by the term “coffee-grounds.” As the ulceration proceeds the amount of blood may be increased, and it may even come up fresh and red. The degree of actual ulceration will be indicated by the odor and the more or less putrefactive character of the materials ejected.

Too much reliance has been placed upon examination of the stomach contents. The amount of hydrochloric acid present therein depends in large measure upon the area involved. The same is true of pepsin. The glands which produce these digestive materials are found especially in the more central area, and when this is involved their amounts will be much reduced, whereas as long as these are free they are not necessarily so affected. The presence or absence, then, of hydrochloric acid may prove most misleading. The Oppler-Boas bacilli are perhaps of more significance, but even here the surgeon is often deceived. I regret thus to appear to belittle the significance of features upon which internists place so much reliance, but I have so frequently seen their unreliability that I think it is a sad error to wait for weeks in order to make a diagnosis by means of material secured through a stomach tube.

McCosh believes that for diagnostic purposes the stagnation test is of greater value than any examination of stomach contents. This consists simply in the discovery by lavage of food within the stomach when it should have left it. Thus an ordinary meal should pass out of the stomach within five hours, but if after six hours undigested food still remains there it denotes sluggishness of digestion. Food remaining ten hours makes positive the fact of stagnation. This being once established it should be determined whether it is from atony, spasm, pyloric stenosis, peritoneal adhesions which kink the opening, or cancer. In all of these except the first, surgical intervention is necessary.

_Tumor in the stomach region_, in connection with symptoms already mentioned, is corroborative. In nearly every case it can be felt sooner or later. Too many have waited, however, for this corroborative symptom before considering the case a surgical one, or even one of unmistakable cancer. Anyone can make a diagnosis when he can discover the tumor. What is needed is recognition of the condition before it has advanced to that stage. When it escapes detection it is usually because it is situated in the posterior stomach wall, high up, or else because the abdomen is enormously fat. The tumor when felt will be found firm and usually tender, sometimes regular in outline, sometimes quite the reverse, usually movable, but occasionally firmly attached either to the abdominal wall or to the viscera, usually the liver. Such a tumor, changing its position with the change in shape of the stomach produced by its inflation with carbonic dioxide, may be regarded as almost certainly a cancer of this organ. One rarely detects lymphatic involvement through the abdominal wall, but in many instances it may be noted at the root of the neck. The tumor usually rises or falls with respiration. Occasionally it will not be discovered until the stomach has been washed out and completely emptied.

However, further aids to diagnosis may be furnished, for instance, by the discovery of cancer cells in the vomitus or washings, by the presence of adventitious materials, such as lactic acid, whose especial significance is rather that of stagnation and motor paresis.

It is of great importance, when possible, to decide as between ulcer and actual cancer. In general the following aids to diagnosis may be considered: Ulcer is a disease of the earlier years of life, cancer rather of the later; in ulcer the pain is direct and boring (extending to the back), in cancer it may be widely referred to the shoulders; in ulcer the vomited blood is usually fresh, in cancer it furnishes the so-called “coffee-grounds;” in ulcer there is ordinarily no tumor present, in cancer this is a late but sure sign; the history of a case of ulcer will often be a long one, that of a case of cancer is rarely long, but steadily progressive; in ulcer there may be distinct anemia, whereas in cancer it assumes rather the type of a peculiar cachexia; and the free hydrochloric acid which is increased in ulcer is usually diminished or absent in cancer.[56]

[56] Sahli has suggested what he calls a _desmoid test_ for free
hydrochloric acid. A small amount of methylene blue is enclosed
in a small gutta-percha bag, and this is tied by means of a small
strand of raw catgut. This catgut will not be affected by pancreatic
juices, and will only dissolve in the stomach in case there be
free hydrochloric acid present. The fact of its solution and the
liberation of the methylene blue is made evident by the peculiar
color given to the urine in a short time. If, therefore, this appears
within an hour or so after the material has been swallowed one maybe
sure there is free hydrochloric acid present in the stomach. The test
is not absolutely accurate, but will often serve as a fairly reliable
one and a substitute for the more disagreeable and ponderous method
of a test meal and lavage. In some respects it is perhaps even more
reliable.

_The question in cases of gastric ulcers is whether they have yet advanced to actual malignancy._ Probably no surgeon has ever attacked a case of gastric cancer which has not been under treatment for a time for so-called “dyspepsia or indigestion,” perhaps with a more definite diagnosis. Too many internists have waited for the discovery of a tumor before thinking of surgery. It is the business and the duty of every surgeon to impress upon the profession that _the only way to treat cancer successfully is to treat it radically, and the only way to do this is to operate early_. This applies equally well to the viscera or to the external portions of the body. _Gastric cancer is essentially a surgical disease_, and could it be recognized early and treated radically it could often be cured.

What are we to do then in the absence of early and indicative symptoms? The following rule may be laid down as one to which there is no exception: _A well-founded suspicion of cancer of the stomach (or of any part of the alimentary canal) justifies an exploratory operation for its detection and recognition, which then should be extended into an operation for its complete removal should circumstances justify it_. If this rule were followed we would not hear of cases of this description remaining for months or years under drug treatment, and then perhaps being finally turned over to the surgeon for relief of pyloric obstruction at a period when strength is so reduced that no operation should be seriously considered.

_Gastric cancer is, then, at least in its earlier stages, a surgical disease._ How is it to be recognized? By exploratory incision when there is serious doubt as to the nature of dyspepsia or indigestion which fails to promptly improve under suitable treatment. In an early stage even this might not be easy, especially for the inexperienced. Nevertheless any cancer of the stomach which produces distinct disturbances of digestion will have advanced to a degree of infiltration and thickening which will permit of its recognition by the touch of a practised operator. The discovery, then, of thickening in the stomach wall will imply the presence therein of either an ulcerated or cancerous area, which will in either event demand relief. In such a case the stomach may be opened and the mucosa exposed to sight and touch. Should the lesion prove to be malignant the same rule will apply with greater force, with the sole difference that the area should be much larger and that the surgeon should keep clear of suspicious tissue. This may necessitate a more or less complete removal of a considerable portion of the stomach. The greatest care should be exercised in the discovery and removal of all infected _lymph nodes_, which will be found especially along the curvatures and within the peritoneal fold. When retroperitoneal lymph involvement is discovered a hopeless aspect is put upon the case. Life may be prolonged for two or three years, even under such circumstances, and the patient is certainly entitled to whatever can be afforded him. If the cancerous process has advanced to a point or a degree making radical removal impossible, one may at once select the other alternative and perform a gastro-enterostomy at a point of election, by which relief may be afforded for at least a number of months.

Only by exploration, then, can it be decided whether to attempt a radical measure or a palliative procedure. It is scarcely fair to quote statistics in this regard, especially any but the most recent, as only lately have these cases been referred for early operation. Obviously the less wide the removal the less reduced the patient, the more favorable is his condition to withstand operation, and the more favorable the aspect of his case. Thus pylorectomy before gastric dilatation has occurred is more promising than pylorectomy when half the stomach is involved. In proportion, then, as these cases are submitted to early operation, statistics will improve and better results be attained, while if physicians and surgeons can be made to _coöperate early_ an ever-growing number of cases will be seen and operated at a favorable time.

The various operations practised, including gastrectomy, pylorectomy, etc., will be discussed with the other operations upon the stomach.

PERIGASTRITIS.

To this term attaches about the same force and significance as to perihepatitis or perisplenitis. The expression implies the consequences of a _local peritonitis_, usually of low grade, by which adhesions are produced that may anchor the stomach in whole or in part, in any possible direction and to any of the surrounding viscera or part of the abdominal wall. Such adhesions are more common at the pyloric end than elsewhere. Their causes may be intrinsic or extrinsic, among the former ulceration and cancer being by far the more common; among the latter gallstones, tuberculous processes, and occasionally the remote consequences of typhoid ulceration. In the majority of cases the adhesions thus produced are protective and purposive, although they often constitute a serious obstacle to surgical work. While they may be suspected in almost any of the conditions above named, they are rarely discovered or identified until the abdomen is opened. Nevertheless, distention of the stomach with gas and the discovery of its irregular movements or shape because of fixation will afford good ground for suspicion as to the condition itself. When it can be shown that these adhesions are producing pain or discomfort, as they often do, operation, _gastrolysis_, affords the only legitimate and reasonably certain relief. Time sometimes permits a stretching of adhesions or the possible absorption and amelioration of symptoms, but only by surgical intervention can anything radical or prompt be offered.

PHLEGMONOUS GASTRITIS.

Under this term is included a _suppurative or necrotic inflammation of the stomach wall_, beginning probably in the submucosa, but extending in both directions. It appears in two forms--the circumscribed and diffuse.

=Symptoms.=--The symptoms of the latter are those of an intensely acute gastritis with rapid, almost inevitably fatal course, beginning with severe pain, quickly followed by faintness and collapse, with early vomiting, vomited matter being first bile-stained, then containing blood. The sensation of nausea is extreme and a complaint of thirst constant. Frequently there are hiccough and peculiar and uncontrollable general restlessness. Pain is, however, a variable feature, and some cases are too rapidly necrotic to afford much pain or tenderness. The pulse is rapid, weak, and poor, and the temperature usually runs high. After a short time the abdomen may be much distended, while symptoms of paralytic ileus (_i. e._, obstruction), supervene, though occasionally there is offensive diarrhea. A well-marked case of this type comes on with fulminating suddenness, patients later becoming apathetic and dying in stupor.

About all this there is nothing peculiarly characteristic, and similar symptoms might be caused by mesenteric thrombus, by acute pancreatitis, or acute gangrenous cholecystitis.

_Symptoms of the more circumscribed form_ are similar to those just described, but of less severity. The pain and vomiting appear suddenly, but are less intense. If time be afforded for formation of abscess a distinct tumor may be felt. Appetite is lost and food regurgitated. A localized lesion favorably placed might lead to adhesions and circumscribed collection of pus, assuming the subphrenic or some less typical form. The pyloric end of the stomach is more commonly involved in such a process and affords evidence to the effect that it begins as an infection, the port of entry being usually a gastric ulcer.

=Treatment.=--Treatment would be surgical if any were available, but has never yet been applied sufficiently early to save an acute, generalized case. On the other hand, when the lesion has been local and has led to subsequent phlegmon, cases have been successfully opened and drained.

OPERATIONS UPON THE STOMACH.