Rutherford Morison
1898 The Lancet  
where four cases are recorded), and at various medical society meetings I drew attention to the advantages of pyloroplasty. Since that time no cases in abdominal surgery have given me so much satisfaction. It is because I believe that the safety and advantages of this operation are not yet sufficiently realised by the profession that I am venturing once more to draw attention to the subject. Pyloroplastỹ is without rival in cases of strictured pylorus. I cannot say anything from personal
more » ... nce of Loreta's operation, but n, knowledge of the pathology of these cases teaches that stretching in the majority of instances would be dangerous and generally useless. The same lesson has, I believe, been learned by surgeons who have practised this operation sufficiently often. Gastro-enterostomy as ordinarily performed is still worse. In the surgical section of the British Medical Association annual meeting, 1893,1 I remarked: "If a large opening is made between the stomach and jejunum there is every reason why the intestinal contents should regurgitate into the stomach unless that viscus offers some resistance. Into the dilated stomach intestinal contents pass easily and fill it up. The stomach when in a fairly healthy state is tonically contracted, its walls lying firmly apposed when empty and embracing their contents when full." At the same meeting I exhibited specimens bearing on this statement which increased experience has confirmed. Whether this explanation be accepted or not it is a fact that in four cases of much dilated stomach ,on which I have performed gastro-enterostomy by the accepted methods death resulted a few days after the operation from constant vomiting of intestinal contents, and the vomiting in each case was not prevented -either by posture or frequent washing out. Post-mortem -examination demonstrated in each that the principle of the operation was at fault and not the technique, for union of the visceral and parietal wound was perfect and nothing was found to account for death except the regurgitation of intestinal contents into the stomach. In addition to my own -experience I have had the opportunity of observing similar results in the hands of other surgeons, so that I feel justified in making strong objections to this operation in the class of case now under consideration. I have performed pyloroplasty in eleven cases ;2 all recovered. Ten are now alive and in perfect health. Eight of the ten (Cases 1, 3, 5, 6. 7, 8, 10, and 11) are striking results; from a condition of the most feeble, miserable invalidism they rapidly rose to robust tiealth. Case 2 (previously recorded in THE LANCET of Oct. 24th, 1896) relapsed from fresh gastric ulceration after the operation, but is now well; and Case 9 had not suffered sufficiently long to be markedly feeble or emaciated wben the operation was performed. Case 4 (recorded in THE LANCET of Oct. 24th, 1896) died eighteen months after the operation from cancer of the pylorus. An -early malignant stricture was mistaken in her for the -ordinary simple stricture of the pylorus (and treated by pyloroplasty) ; and as yet I know of no certain method of distinguishing clinically (even after abdominal section) a -commencing malignant stricture from the ordinary cicatricial one. I have previously pointed out that a long history is against malignancy, but in this case the patient 'had been troubled with indigestion all her life. Adhesions and scarring would also be in favour of an inflammatory rather than a malignant lesion. A moveable nodular pylorus of the size of a walnut or larger is probably infiltrated by malignant growth, as it is seldom that an inflammatory swelling remains so localised and reaches such a size. Nevertheless, on Aug. 3rd, 1897, I excised a pylorus forming such a tumour from a man of middle age with , history of only ten months' illness and rapid emaciation. Before and after opening his abdomen the tumour 1 Brit. Med. Jour., 1893, vol. ii., p. 149. 2 Since writing the above I have successfully operated on a twelfth case. was diagnosed as malignant; not until it was split open and its interior exposed was it suspected that the diagnosis might be wrong. A typical punched-out ulcer surrounded by a large mass of inflammatory origin was the cause of all this mischief. In two cases I have opened the abdomen expecting to perform pyloroplasty but found that in one it would be useless and in the other impossible to do so. The first case was that of a middle-aged man with a typical history and the starved, emaciated appearance of pyloric stricture of long standing due to gastric ulcer. On opening his abdomen the pylorus was found to be buried and attached to the pancreas by firm adhesions and there were two yellowcoloured glands of the size of filberts in the gastro-hepatic omentum. The glands and what I took to be the pylorus to which one of them was attached were separated and excised together. On examining the portion of viscus removed and the cut surfaces left it was discovered that the first portion of duodenum had been removed and the pylorus, which was much contracted, left. I then split the pylorus and attached it to the cut duodenum. In separating the dense adhesions I wounded the pancreas and to this I attribute the patient's death on the sixth day after operation. He died from acute perforating peritonitis probably due to digestion of the newly-formed lymph by escaped pancreatic juice. Numerous old cicatrices of round ulcers were found (post mortem) in the neighbourhood of the pylorus, which was a little thickened. A portion of the pylorus and the glands were examined microscopically and found to be infiltrated with columnar-celled carcinoma. The second case also was that of a middle-aged man with the typical appearance and signs of pyloric stenosis. No tumour could be felt, but his pylorus was found to be buried in dense adhesions. A vigorous attempt was made to separate the pylorus, but the adhesions were so thick and firm that the notion of performing pyloroplasty had to be abandoned. Gastroenterostomy was performed by a new method, which I hope to show at a later date is applicable to such cases. For the two days following operation the patient occasionally brought up mouthfuls of green, stinking fluid, evidently bile and pancreatic juice, but after a Seidlitz powder in hot water the regurgitation finally ceased. On the fourth day he appeared to be safe. On the fifth day the symptoms and signs of acute peritonitis developed and on the seventh day after operation he died. Post-mortem examination showed that death was caused by general septic peritonitis due to leakage from a hole the size of a pinhead outside of an active ulcer in the stomach close to the pylorus. The hole had been made and overlooked during the attempt to separate the adherent pylorus. The duodenum down to immediately above the opening for the bile and pan creatic ducts was scarred by recent and old ulcers, The pancreas, duodenum, and pyloric end of tha stomach were inseparably united by dense adhesions. All the new openings were very firmly united and watertight. I have included these two cases to make my record of pyloroplasty complete and to illustrate the fact that both diagnosis and operation may sometimes be impossible. Nevertheless, in the great majority a diagnosis of those suitable for the operation is easy. The most promising are those in which a moveable nodule can be felt in the neigh.bourhood of the pylorus; in addition the ordinary symptoms of chronic dilatation are present-viz., vomiting of large quantities of yeasty fluid at intervals and the well-recognised disturbances of chronic dyspepsia, chiefly vertigo, pronounced constipation, depression of spirits, marked emaciation, and loss of appetite. In these cases the operation is as safe as any in abdominal surgery; the moveable pylorus makes it so easy that it can be performed in less than half an hour, and the after results ire a surprise to those unaccustomed to watch such patients. Every case in which dilatation of the stomach is a marked feature, with a history of failing stomach powers, should, I believe, be explored with a view to operation. It will seldom be found that the diagnosis of strictured pylorus is wrong or that pyloroplasty will fail o bring about complete relief of all symptoms and a -estoration to health. With regard to the pathology my opinion 3 that most of ;he cases of pyloric stricture "are due to cicatricial contraciion following ulceration " is confirmed by further experience THE LANCET, Oct. 24th, 1896
doi:10.1016/s0140-6736(01)95366-8 fatcat:f3en7a7zpjdt5jx2vuxx37ztoq