Problems Relating to Surgery of the Stomach

1902 Boston Medical and Surgical Journal  
In the preparation of the subject to be discussed, I have thought it wise to confine myself to the practical aspects of gastric surgery, using for this purpose the material obtained from a single hospital, which, by reason of the fixed character of the agricultural community in which it is situated, gives fairly accurate data upon which some general observations can be based. This method of treating the questions brought forward is not due to a lack of appreciation of the grand work of the
more » ... nd work of the pioneers in this branch of our art, a work in which the surgeons of Boston have played so conspicuous a part, but rather with the hope that the limited experience of an observer in a somewhat distant field might be of the greater interest. Gastric surgery is, to a large extent, still in the developmental stage, and this is due to the lack of definite knowledge upon which to base a surgical diagnosis. Volumes have been written upon the diseases of the stomach from a medical standpoint, but as the statements made are based upon the symptoms of the patient or the results of postmortem examinations, we gain but little as to that great middle ground in which the surgery of expediency will find its field of usefulness. The debatable territory is now being explored, and we shall shortly have a more exact knowledge. At the present time our own experience would seem to indicate that in the medical diagnosis there were four important lines of inquiry to be pursued : (1) The history of the patient; (2) the "Size and position of the stomach; (3) tumor or localizing point of tenderness; (4) interference with the progress of the food. The examination of the stomach contents has some corroboratory value, especially with reference to the stagnation or retention of ingesta. The chemical and microscopical findings are unreliable in the early phases of disease, but possess some significance later in its course. Examination of the blood, the urine, the feces, etc., is of interest and occasionally helpful. The use of the gastroscope, gastrodiaphanoscope, x-ray, etc., is still experimental. The mechanics of the stomach is the most interesting feature to the surgeon ; from this point of view the function of the stomach is largely mechanical. It absorbs fluids, equalizes the temperature of the ingesta, and the weak solution of hydrochloric acid and pepsin which is secreted breaks up the food masses, forming a homogeneous material which is fed down into the small bowel, where the real work of digestion and absorption takes place. It may be said to act like the magazine of a furnace, the accumulation in the reser-voir self-feeding through the pylorus. The more experience one acquires with the operative side of the question, the more one is impressed with the correctness of this view. Any interference with the outlet promptly produces symptoms corresponding with the degree of obstruction, while ulcération or other disease involving the wall of the stomach, preventing it from acting as a reservoir, is also quickly resented. The distress in each case causes the patient to unconsciously try to adjust the quality of food and its quantity, to the loss of this peculiar function of the stomach. The result of obstruction at the pylorus is to increase the capacity of the stomach, and this is often the only objective sign to which our attention is called before operation. Dilatation is to be expected in the first group, of which pyloric stenosis is the type, but unless the disease of the wall is sufficiently near the pylorus to add mechanical features, it is not present in the second group, of which ulcer is the chief example. Dilatation, due to benign obstruction at the pylorus, is followed by increase in the muscular wall of the stomach, the hypertrophy enabling the damaged organ to carry on its function. This degree of compensation is often aided by the patient through a selected diet. In these cases compensation, alternating with dilatation and its discomforts, gives a clinical picture which may be aptly compared to cardiac insufficiency. Why is it that these patients, with far greater symptoms than would be tolerated in either the appendiceal or gall bladder regions, are allowed to go unrelieved ? It is not only that we are unable to know before operation the exact nature of the trouble, but that we also distrust our ability to make a diagnosis even at the operating table. In the beginning, every operation upon the stomach partakes of an exploratory incision, and too often the proposed operation stops, upon exposure of an extent of disease beyond intervention. This is particularly true of cancer. The surgical examination of the stomach may not prove easy. The pylorus and anterior wall are open to inspection, and gross lesions of all parts can be ascertained, but not so the more minute forms of disease, such as the round ulcer. Ouiplan has been to explore by sight and touch, the more accessible portions of the stomach wall. Then, by opening into the lesser cavity of the peritoneum through the gastrocolic omentum, to pass the hand behind the stomach and search its posterior wall (Tiffany). To explore the interior of the gastric cavity, a transverse incision is made three inches in length through the anterior wall half way between the pylorus and cardiac orifice. Into this a short rectal speculum, two inches in length and one and one-half inches in diameter, is inserted and the fluids removed by suction. With the hand behind the stomach, nearly the whole of its mucous surface can be passod in review before the end of the speculum under direct light. (This is a modification of the method first brought out by Maylard at the International Congress, 1900.)
doi:10.1056/nejm190205011461801 fatcat:ez2o3jysdbfbfjjnhjpkivs4fm