the edges of the ulcer were inverted into the intestine, and the suture was
tied. The closure was further strengthened, and the tension upon the purse
string relieved by four Lembcrt stitches of catgut, introduced along a line
parallel with the axis of the gut. The remainder of the greater peritoneal
cavity was then examined. A considerable quantity <>( bile-Stained, cloudy
fluid was found at the bottom of the pelvis, and the intestines were everywhere
moderately reddened and coated with disseminated patches of fibrin. The
edges of the wound were held wide apart, and the entire abdomen was repeatedly
flushed out with hot water and salt, without evisceration, the fluid being gently
Stirred aboul with the hand in the abdomen. The entire cavity was wiped
dry with large pads of sterile gauze. A Strand of gauze packing was then
54 SURGICAL DISEASES OF THE STOMACH '
introduced down to the site of the ulcer and brought out at the upper angle
of the wound. The remainder of the wound was then closed with sutures.
The patient did not suffer from shock. He was fed per rectum for forty-eight
hours. His temperature, on the day following the operation, rose to 101° F.,
after which the elevations of temperature were trifling. The superficial wound
was dressed on the third day, and appeared to be slightly infected. The skin
sutures were thereupon removed. The deep packing was removed on the fourth
day, and was found to be clean. Excepting the superficial infection of the skin
wound, which necessitated the prolonged use of adhesive straps in order to
encourage union of the skin edges, the patient's convalescence was uninter-
rupted. He remained in bed four weeks after the operation, and six weeks
after the operation he appeared to be in the best of health.
This man was kept under observation for a year; he remained in good
health and developed no symptoms of duodenal stenosis.
Untreated surgically, the peritonitis ends fatally in most instances. In a
few cases (two such have come under my observation) a localized abscess is
formed between the duodenum and the liver. Right-sided subphrenic abscess
is a common complication of these cases. If the perforation takes place on
the posterior retroperitoneal surface of the duodenum, erosion and opening of
a large blood-vessel, as already described, may occur ; in other cases a retro-
peritoneal phlegmonous inflammation with fatal results. In both localized
abscess and retroperitoneal phlegmon gas is apt to be present in the exudate.
In a certain proportion of duodenal ulcers without either perforation or serious
bleeding there are associated severe pain and marked disturbances of digestion,
these are the cases in which obstruction of the duodenum, as the result of cicatri-
cial contraction, occurs. (See Intestinal Obstruction.) The cases of chronic
ulceration and slow perforation with the formation of extensive adhesions to gall-
bladder, liver, cystic duct, and gastrohepatic omentum will usually be diag-
nosticated as affections of the biliary passages. The cases associated with
marked gastric disturbances, often with ulcer of the stomach, will be regarded
as cases of gastric ulcer.
The surgical indications in the cases where operation is not done for per-
foration or hemorrhage are : ( 1 ) Rest for the duodenum and the relief of
obstructive symptoms, if such exist ; these are best accomplished by posterior
gastro-enterostomy. (2) Separation of adhesions which may be interfering
with the function of the biliary passages or the pylorus or duodenum. (3)
Excision of the ulcer, if suitably placed, or if perforation is threatening. The
position of the ulcer in chronic cases may often be detected by a white spot
on the surface of the gut or an area of palpable infiltration.
From the foregoing, it will be seen that ulcer of the duodenum is a very
dangerous and often fatal disease. The fact that an ulcer may exist for a
long time and give no symptoms, suddenly to perforate or bleed the patient to
death makes the outcome appear like a fatal bolt of lightning out of a clear
sky, and renders the exact diagnosis exceedingly difficult. It nearly always
GASTRIC TETANY
happens when perforation oecura thai n«> exacl diagnosis i- made until after
opening the belly, and in many instance- the condition lias been bo deep
thai the cause of the peritonitis has no! been found until alter death.
ACUTE SUPPURATIVE GASTRITIS: ABSCESS OF THE STOMACH.
PHLEGMONOUS INFLAMMATION OF THE STOMACH
Acute purulent inflammation of the wall of the stomach, originating not in
the mucous membrane, nor in the peritoneum, bul in the submucous fibrous
layer of connective tissue, may occur as a localized process (abscess of the
stomach) or as a diffuse purulent infiltration (phlegmonous gastritis). For-
tunately a rare disease, since only a very few of the recorded cases have sun
(among them one is recorded by von Mikulicz, one by Lcngemannj.
Diffuse Phlegmon of the Stomach
The causation of the condition is sometimes entirely obscure; in oilier cases
the lesion of the stomach occur- as a metastatic hematogenous process in the
course of pyemia or septicopyemia, in some cases as a complication of puerperal
sepsis. In a certain number of instances an ulcerated carcinoma was present
in the stomach; much more rarely a simple peptic ulcer. Some cases have
followed trauma, either subcutaneous injuries, accidental open wounds, or sur-
gical operations upon the stomach; in a few cases ulceration of the stomach
wall from the pressure of foreign bodies, occasionally the swallowing of caustic
liquids. The phlegmonous variety has been observed in the course of anthrax.
The abscess or phlegmon is commonly situated near the pyloric end of the
stomach. Perforation may take place through the mucous membrane into the
cavity of the stomach or into the peritoneal cavity, or both.
The symptoms are those of an intense, acute sepsis, associated with those
of an acute inflammatory process of the stomach. The course of the disease
is usually short, death occurring in a few days. The patient is seized with
severe pain in the stomach, repeated uncontrollable vomiting, extreme tender-
ness, and rigidity id' the upper part of the abdomen. The constitutional symp-
toms are severe and progressive until death. There is usually a marked rise of
temperature, great prostration, ami a progressively rapid and feeble pulse. The
diagnosis in the mosl acute cases is apt to be that of perforation of gastric ulcer
ami diffuse peritonitis. Tn those not quite -.. acute, the diagnosis of a local-
ized abscess from slow perforation of gastric ulcer will be made; the infil-
trated wall of the stomach may feel like a circumscribed peritoneal exudate on
palpation. Marly operative drainage gives the only possible hope of recovery.
GASTRIC TETANY
In certain rare cases of injuries and diseases of the stomach tbere occur
Convulsive seizures of a peculiar kind, sometimes accompanied by loss of con-
56 SURGICAL DISEASES OE THE STOMACH
scionsness. The picture bears a certain resemblance to tetanus, on the one
hand, and to epilepsy on the other. The disease has been fatal in a large pro-
portion of cases treated by medical means. Operation in suitable cases has
been followed by recovery (stomach drainage by gastroenterostomy). A num-
ber of theories have been advanced to account for the condition ; probably it is
a toxemia caused by the absorption from the stomach of poisonous decomposi-
tion products developed in the stomach contents. (See also Tetany after Re-
moval of the Thyroid Gland.) In nearly all the observed cases there has
been motor insufficiency, a dilated stomach, and stagnation of gastric contents
due to pyloric or duodenal stenosis from one cause or another; rarely has this
factor been absent. Hyperacidity is commonly present. The attack may occur
spontaneously in the course of chronic disease of the stomach or may follow
a surgical operation or an injury to the organ, or, as in one case (Warbasse),
the retention in the stomach of a large number of foreign bodies. An unusual
case was observed by Hermann Fischer, following seventeen days after an
operation for fibro-lipoma of the stomach. The patient recovered. It is prob-
able that mild grades of tetany are not uncommon in cases of dilated stomach
with retention and fermentation of stomach contents. Cramer has called
attention to these cases ; the symptoms are muscular twitching and paresthesia ;
he considers these signs an indication for surgical interference in cases of
dilated stomach.
The convulsive seizures often follow the effort of the distended stomach to
empty itself by vomiting ; sometimes the passage of a stomach-tube ; occasion-
ally an attack may be induced by tapping the abdomen over the stomach. The
convulsions consist in typical cases of tetanic spasms and fibrillary twitchings
of certain groups of muscles. Usually the muscles of the forearm are first
affected. The position assumed by the hand is characteristic. The metacarpo-
phalangeal joints are flexed, the phalanges are extended, the thumb is adducted
into the palm, the so-called " obstetrical hand." The wrist and elbow are
often strongly flexed. The contractions may be confined to the muscles of the
upper extremity or may spread to the muscles of the abdomen, back, and legs.
The condition of opisthotonos is sometimes present. Usually the patient loses
consciousness. The spasms may last a number of minutes or half an hour, and
gradually subside, to be renewed at irregular intervals.
Isolated spasms may be produced by mild electrical stimulation of the mus-
cles, by pressure on the blood-vessels and nerves of the arm (Trousseau's phe-
nomenon), kept up for a minute or more. Tapping the cheek in front of
the lobule of the ear over the facial nerve causes spasmodic contraction of the
orbicularis oris muscle on that side and elevation of the corner of the mouth,
sometimes spasm of the entire side of the face (Chvostek's symptom). In bad
cases the muscular spasms are widespread, the duration of the tetanic contrac-
tions is considerable. The diaphragm may be involved and threaten death
from respiratory failure. The attacks are frequently repeated, and continue to
become more severe until death. In milder cases removal of the obstruction,
TUMORS OF THE STOMACH 57
or the mass of foreign bodies, as the case may be, or gastric lavage <â– â–
improvement and final cure.
An unusual case was reported by Gatzsky, following a subcutaneous injury
t.t the 1 1 1 » i »« • i- pari of the abdomen by blunt violence. The patienl had severe
pain in the stomach, frequenl vomiting, tenderness and rigidity of the abdom-
inal wall. Tetany began four weeks after the injury, and was speedily fatal
in spile of gastric lavage. At the autopsy enormous acute dilatation of the
stomach was found, caused by total obstruction of the descending portion of
the duodenum due to the pressure of a large retroperitoneal hematoma. In
\Yarl>asse's case the individual was a professional swallower of foreign bodies,
win) was twice operated upon for the removal of accumulations of metal objects
— nails, knives, spoons, chains, etc. — from his stomach. For a period of several
years be lia<l suffered from occasional tetanic seizures with loss <>f conscious-
ness, the nature of which had not been recognized. There was no pyloric
obstruction. The stomach was nearly normal in size and appearance, although
the weight of metal objects had caused a slight pouch along the greater curva-
ture. Upon emptying the stomach the attacks ceased.
Warhasse says: "Sometimes during the intervals between attack- the pa-
tient regained consciousness, and entered into conversation, at oilier times the
spasms followed in quick succession. These seizures presented three sti s
(1) All of the attacks were preceded by vomiting or a violent effort at vomit-
ing. (2) This was always followed by a sensation of choking, as though he
were being strangled and could not get air, evidently a spasm of the glottis
muscles. (3) lie then fell unconscious to the floor, and the convulsions imme-
diately supervened. During the first two stages there was always a sensation
of dizziness. After from one to six or eight convulsions the attack subsided,
and the patient went about his business."
Warhasse considers that this case favors the theory of the mechanical
causation of gastric tetany. It has been observed in a good many cases of
dilated stomach with stagnation of stomach contents that the introduction of a
stomach-tube and washing of the stomach has been followed by an attack of
tetany. It is believed that dilution of the stomach contents may have rendered
the poisonous ingredients more readily absorbable. It is therefore wise in
these cases to remove as far as possible the contents of the stomach by aspira-
tion and siphonage before introducing water into the stomach.
TUMORS OF THE STOMACH
Cancer of the Stomach. — From time to time benign tumors are observed in
the stomach as surgical rarities, sometimes producing symptoms, more often
not. Carcinoma, on the other hand, is exceedingly common, and here, as else-
where, carries the patient to his grave with absolute certainty. The duration
of life in cancer of the stomach is very short : after the disease is so far devel-
oped that the diagnosis is plain, the average duration of life is only one year.
58 SURGICAL DISEASES OF THE STOMACH
At the present time no topic is of greater interest to surgeons than the opera-
tive treatment of diseases of the stomach. The labors of Billroth, Czerny,
Wolfler, Kronlein, Maydl, von Hacker, Hartmann, Cuneo, Moynihan, Mayo
Robson, the Mayos, and others have so far developed the surgery of the stom-
ach as to demonstrate that in cases of cancer, early, thorough operative removal
is not attended by an unduly high mortality, presents no insurmountable
technical difficulties, prolongs life in many cases, and cures permanently a
certain number of unfortunates otherwise doomed.
Murphy collected 189 cases of operation; of these, 17, or eight per cent, lived
three years. The general mortality from the operation was fifteen per cent.
There were, however, a few recurrences after this period. A certain number
are doubtless permanently cured. The statistics of von Mikulicz's clinic were
as follows:
Of 58 cases who survived the operation, 20 lived from six months to eight and
a quarter years; of these, 17 more than a year, 10 more than two years, 4 more
than three and a half years; the last 4 still remained alive and well, and might,
therefore, be regarded as permanently cured.
W. J. Mayo's statistics, October, 1905, are as follows:
Eeport of 81 gastric resections, with mortality of 14.5 per cent, including "early
operations: 31 patients operated upon in the last thirty months with a mortality
of 8 per cent; 25 consecutive with 1 death, 4 per cent. As to relief, 11 operated
upon too recently to be of value as to cure; 5 failed to live six months; 38 lived
six months to a year, and 24 are alive now; 21 from one to two years, and 13 alive;
10 from two to three years, and 8 alive; 4. from three to four years, and 3 alive;
as only 16 were operated upon more than three years ago, this gives 25 per cent
living three years. One is alive and well after, four years and ten months.
In discussing the symptoms and diagnosis of cancer of the stomach it is
to be borne in mind that most advanced cases present unmistakable symptoms,
such that the diagnosis is entirely simple, but that when this stage is reached
the disease has spread beyond the power of surgery to eradicate it, palliation
is alone possible. The early diagnosis of cancer of the stomach thus becomes
a problem of the greatest importance. Unfortunately, there are no clinical
signs and symptoms enabling us to make a certain diagnosis at a very early
period of the disease. The general statement was formerly made, and believed
by many, that when a palpable tumor was present the disease was already too
far advanced for radical operative relief; further experience has, however,
shown that this view, while generally true, is not always so. As has been
pointed out by W. J. Mayo and others, a small movable pyloric tumor may be
a rather favorable sign than otherwise, and by no means indicates a hopeless
condition. Nor is the absence of a palpable tumor a favorable sign. The most
hopeless cases are the cancers of the body, posterior wall, and cardiac portion
of the stomach; lying, as they do, deeply placed behind the ribs ; they may
TUMORS OF THE stomach
go on i<- a fatal issue, and even grow to a large size without al any time becom-
ing palpable.
The dictum of modern surgery is thai cases of stomach disturbance pre
Benting symptoms leading i" ;i suspicion of cancer should be told the i
state of our knowledge on the subject The dangers of delay should be dwelt
upon ami the individual given the opportunity of an accurate diagnosis, only
obtainable bj an exploratory incision. The risks of the procedure are -mall,
the information thus obtained is definite and furnishes the surgeon with a
certain guide to the radical or palliative treatment of the case. Should the
condition be found inoperable, the patient will have suffered bu! little addi-
tional pain and discomfort, ami need be confined to bed only a few days.
Indeed, with proper methods of suturing, the sooner he is oul of bed the better,
since these individuals rapidly lose strength when kept recumbent, and are
apt to develop hypostatic pneumonia. With these preliminary remarks
may proceed to discuss the characters of the disease.
Causation. — We know as little of the causes of cancer of the stomach as
of other cancers — namely, very little. The disease occurs not infrequently
upon an open chronic ulcer of the stomach or upon a scar where an ulcer
formerly existed. As is true of all cancers, trauma, and especially long-con-
tinued mechanical irritation, appear to be to some extent determining factors
in the location of the disease. The narrower portions of the stomach being
exposed to more mechanical insults are the seats of predilection — i. e., the
pyloric portion of the lesser curvature, the pylorus, less often the cardia. Sud-
den direct trauma is probably a very rare cause, indeed. In a certain propor-
tion of cases there will have been a history of injury to the abdomen preced-
ing the symptoms of cancer, in many of these the growth was no doubt present
at the time the injury was received, and has grown the faster a- the resull of
such an injury. In others the new growth appears, no doubt, quite inde-
pendently, hut is referred by the patient to some insignificant injury remem-
bered to have occurred at perhaps an unduly remote date.
OCCURRENCE. — Cancer of the stomach is the most frequent seat of human
cancer. The percentage of its occurrence varies in different statistics: Welch
gives it as 21.4 per cenl of all cancers; Virchow, 35 per cent: others, as high as
I" per cent. The disease affects men and women equally. It is, in general, a
disease of advanced life; two thirds of the eases occurring between the a -
of forty and sixty years. It does, nevertheless, occur at earlier ages; in the
third and fourth decade-, and even earlier. I operated on ;i boy, aged fifteen
years, for an undoubted carcinoma of the stomach. The most frequenl starting
points are the pylorus and the lesser curvature close to the pylorus; the latter
situation being probably the more frequent of the two. About three fourths
of the cancers start in one id' these two places. About ten per cent begin in the
cardia: the remainder are distributed throughout the rest of the stomach.
Varieties. — Several varieties of cancel- occur in the stomach, although of
no great moment from a diagnostic point of view. They may be here men-
60 SUKGICAL DISEASES OE THE STOMACH
tioned. Borrmann's classification : (1) Carcinoma simplex — carcinoma solidum
(Borrmann). Cells in strings and irregular masses, with a variable amount
of connective-tissue stroma, and a corresponding variability in rapidity of
growth. (2) Colloid cancer — originating as such, or a degeneration form
from Number 1; of slow, sometimes of rapid growth. (3) Diffuse polymorph-
ous-celled cancer (Borrmann). An infiltrating cancer without microscopic
boundaries, spreading especially in the subserous tissue. (4) Cylinder-celled
cancer, of slow growth. A tubular cancer. Tubules lined with one or more
layers of cylindrical epithelium. (5) Glandular cancer, adenoma malignum.
(6) Mixed forms. Any of these, with the exception of the diffuse infiltrating
form, may assume the type of scirrhous carcinoma.
Macroscopically, we may distinguish circumscribed sharply bounded tumors
of the stomach wall and those which show a tendency to infiltration more or
less insidious and widespread ; a very large part of the stomach may thus be
involved in the growth. The stomach may be greatly thickened and its cavity
much diminished in size. The mode of growth of cancer of the stomach is
important from the surgical point of view. The spread of the disease follows
the course of the lymphatic circulation of the stomach. In this connection
it is to be borne in mind that, as a rule, only those tumors originating in and
confined to the pylorus and adjacent portion of lesser curvature are amenable
to operative removal.
Lymphatics of tiie Stomach. — The course of lymphatics of the stom-
ach was carefully worked out by Cuneo and Most The following are some of
the important data as given by them :
The general lymphatic circulation of the stomach empties into a series of lym-
phatic glands grouped about the celiac axis, " celiac lymph glands."' lying behind
the stomach along the upper border of the pancreas, extending to the right behind
the pylorus and to the left as far as the spleen. Before arriving at these glands the
lymphatics of the stomach pass through a number of smaller glands grouped along
the lesser and greater curvatures and about the cardia. According to the arrange-
ment of the lymph channels in reference to these glands, the stomach may be
divided into three lymphatic territories, including both anterior and posterior walls
of the stomach :
(1) The largest of these territories drains itself into lymph glands situated
along the lesser curvature and near the cardiac — " the superior gastric lymph
glands." These glands receive the lymph from the largest portion of both anterior
and posterior walls of the stomach. (2) A few lymph channels and lymph glands
are to be found along the right half of the greater curvature and at the pylorus.
The lymph current is from left to right. They accompany the gastroepiploic
artery and are more numerous in the vicinity of the pylorus. These are known
as " inferior gastric lymph glands." They empty into lymph channels passing to
the celiac glands. (3) The smallest territory, comprising the left or fundus half
of the greater curvature, empties into glands lying in the hilus of the spleen. A
few of these channels pass direct into the celiac glands along the border of the
pancreas.
I UMORS OF 'I Ml. STOMACH i,l
Lymphatic involvemenl "rein - \<ty early in cancer of the stomach, and the
possibility of cure depends upon the radical removal of ;ill infected struc-
tures. The following practical deductions derived from pathological Btudy
and operative results have been developed by von Mikulicz, Hartmann, Moyni-
ban, Robson, \V. J. Mayo, and others. Cancer of the lesser curvature requires
the removal of the entire lesser curvature and its associated lymphatics as far
as the gastric artery, including the lesser omentum (von Mikulicz). The
glands along the right half of the greater curvature are also to be removed,
although nol always infected. In canceT of the pylorus both of these groups
are infected a1 an early date. When the celiac glands are also infected, their
removal, owing to their position, is always difficult, frequently impossible.
The fad thai glands are enlarged does nol necessarily indicate thai they are
carcinomatous. Enlarged glands occur both in ulcer and ulcerating earcinom-
ata from inflammatory hyperplasia merely. The presence of ;i large tumor
does qoI necessarily indicate extensive lymphatic infection.
Owing in the arrangement of lymphatic drainage in the stomach, it is often
possible to preserve the fundus and a large part of the greater curvature with-
diii risk. The actual poinl of section depends upon the extent of disease; it
should be well to the left of the group <>f pyloric glands on the greater curva-