SOME PROBLEMS IN GASTRO-INTESTINAL SURGERY
Journal of the American Medical Association
The title chosen for this paper may seem, perhaps, a trifle ambitious when one considers the short time at my disposal; therefore let me hasten to state that I shall attempt to consider but a few of the problems presented in the surgery of the gastro-intestinal tract, and even these I shall discuss only in a very desultory manner. It will be my aim to give expression to some observations of my own, and to personal impressions and ideas deduced therefrom, rather than to present an exhaustive
... y of the voluminous literature on the subject. That the gastro-intestinal tract does present many most interesting and intricate problems will be readily admitted, I am sure, by every one who has had any considerable experience in this branch of surgery. Happily, owing to much careful observation and thoughtful consideration, combined with technical skill, scientific accuracy and painstaking effort on the part of many laborers in this field, problems which have for a long time baffled the best minds in the profession are one after another nearing solution. Indeed, it is not too much to say that already some of them have been solved, while undoubtedly the near future will witness the solu¬ tion of others which now appear well-nigh hopeless. It is certainly most encouraging if we for a moment look back on what has been accomplished during the surgical lifetime of many of those present. Let us take, for example, the operation of gastro-enterostomy. It has been a matter of only a very few years since after every uastro-enterostomy, the possibility of the vicious circle (now little more than an unpleasant memory), stared the surgeon in the face. The anxious questionings of former days as to the use of the long loop or the short loop, anterior fixation or posterior fixation, spur forma¬ tion, closure of the pylorus, the particular method of suture or kind of suture material, are little understood by the .younger generation of surgeons. To-day the operation of gastro-enterostomy is undertaken with as much assurance of success on the part of the surgeon, and almost as little fear on the part of the patient, as an interval operation for appendicitis. Let us for a moment look the facts as regards this particular operation squarely in the face. Theoretically and physiologically it is all wrong, but practically, when performed under proper conditions and for definite indications, and in competent hands, it is followed, as a mil·, by most satisfactory results. And why? Is the Read before the Buffalo Academy of Medicine, Buffalo, N. Y., Feb. 7, 1911. improvement in the symptoms the result of better drain¬ age, as some would have us believe, or is it clue to the neutralization of the over-acid contents of the stomach, a chemical process, pure and simple, as claimed by others? And why does an operation which is capable of producing such satisfactory results in one case fail utterly or even make matters worse in another present¬ ing similar clinical phenomena? These are hard ques¬ tions to answer. The teehnic of this operation has been worked out so satisfactorily that its principles are no longer subjects for discussion. Unimportant details alone remain unsettled, such, for instance, as to whether in making the anastomosis the jejunum should point toward the right or toward the left, following respectively the method of Mayo or of Moynihan. I may add, by way of parenthesis, that in this particular controversy it appears to me that it matters little whether the jejunum points to the left or to the right, so long as the loop of jejunum is not rotated on its long axis at the point of union with the stomach wall, for if it is so rotated a valve formation with obstruction is very likely to be produced thereby. In the hands of masters, such as the two whose names have just been mentioned, little concerning this opera¬ tion is left to be desired; but, unfortunately, in the hands of ordinary surgeons, not especially skilled in abdominal surgery, the results at times are, to say the least, disappointing. Pain, troublesome indigestion, régurgitation of food, bilious vomiting, anorexia and loss of weight are some of the unpleasant symptoms occasionally observed. If these unsatisfactory results are carefully analyzed it will generally be found that in the beginning the indications for the operation had not been sufficiently definite; in other words, an unneces¬ sary and ill-advised operation had been clone, or that it had been hurriedly or unskilfully performed. It can be said of this operation, I think, as truthfully as of almost any other, that its indications are known and its limitations at least fairly well determined. What is true of the operation of gastro-enterostomy is in varying degrees true of other operative procedures that have to do with the stomach and intestinal tract throughout. In reviewing our experiences in this particular line of surgery, what has given rise to the gravest doubts? What to the greatest difficulties? Have they been prob¬ lems of diagnosis or have they been technical problems of execution ? While each undoubtedly possesses its own peculiar vexations, still I fancy that the most of you have had a like experience to my own. namely, that the difficulties of diagnosis have, on the whole, far out¬ weighed those of execution. I am not as yet prepared to go quite so far as a well-known English surgeon who, in the course of conversation with me on this subject Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/15/2015 while I was on a visit to his clinic during the past sum¬ mer, remarked : "It has come to this in abdominal surgery, that none but problems of diagnosis any longer excite interest. Since operative surgery has developed into so exact a science it has become little more than one of the mechanical arts, and hence too easy." I envy anyone this happy frame of mind, but the memories of certain situations fraught with danger and full of dif¬ ficulty and anxious doubt, which, unexpectedly or not, developed after having opened an abdomen, are as yet too vivid to allow me to indulge myself in any such alluring fancies. There is, however, an element of truth in what the eminent surgeon just quoted has said, and right here lurks a danger and a real one, too. Because, on the one hand, diagnosis is admittedly so difficult in many cas^s, and the more recent special tests demand of the examin¬ ing physician special training in their making, and superior knowledge in their proper interpretation, while, on the other, operation has become so much more safe and exact, the temptation on the part of some to curtail a history or to slur over an examination and to rely on an exploratory incision because it is so easy, becomes increasingly more difficult'to resist. In order to avoid the performance of an unnecessary operation, which is always a reproach to surgery, or to prevent unpleasant results, at least four things should be borne in mind: (1) A correct diagnosis should be made; (2) every care and detail should be observed in order to make the operation technically perfect; (3) existing conditions should be accurately observed and properly interpreted; (4) the results of operative pro¬ cedures should be carefully watched and recorded in sufficient numbers and covering long enough periods of time to enable one to judge of the end-results of given lines of treatment. While hitherto it must be admitted, I think, by a candid observer, that in this particular field of surgery the physician, by his acts of omission in not promptly calling in the aid of the surgeon, has been the greater sinner, still this does not absolve the surgeon from the sins of commission just referred to. In arriving at a diagnosis too much care and thought cannot be exercised in the study of all the phenomena presented by the indi¬ vidual case, nor can too great scrutiny be imposed on a patient before submitting him to a surgical operation. If the surgeon offener accompanied the physician through his wards or to his laboratory, or if the phy¬ sician offener followed his patient into the operatingroom and saw what the surgeon sees, there would be far less point to these remarks. Fortunately this happycooperation already exists in a number of clinics in this country, and the productive activity of these centers bears eloquent tribute to its effectiveness. As stated above, while many of the problems in execu¬ tion and some in diagnosis as well are nearing solution, a goodly number-are still far removed from it. Let me report a case which well illustrates several points to which I wish to direct attention. Case 1.-Patient.-Miss S. S., aged 27, native of Pennsyl¬ vania, no occupation, was referred to me by Professor Barker, from the medical side of the Johns Hopkins Hospital. June ft, 1910. Complaint.-General nervousness and stomach trouble. History.-Patient comes from a long-lived, healthy family. As a child, she enjoyed good health. She had had the usual children's diseases, except scarlet fever and diphtheria. She had had a mild case of what was diagnosed as typhoid fever. Menstruation began at 17 and has always been painful; she has usually had to remain in bed for several days. During these periods she was very nervous witli occasional hysterical manifestations, crying, laughing, etc. She has had more or less local treatment for this condition by specialists, from which she derived little benefit. She was operated on in a neighboring city five years ago for rétroversion of the uterus, with little or no relief. A year later, another operation was pei formed, the exact nature of which she did not know, and as a result of which she thinks she grew worse instead of better. Three years ago, at a third operation, the appendix was removed, and at the same time a fixation of the uterus was performed. After this, she was improved for a while. One benefit she noted was that she did not have to remain in bed during the menstrual periods. All this time she has been very nervous and has had much trouble with digestion. Exam¬ ination of the eyes, ears, nose and throat was negative. There were neither cough, dyspnea nor night sweats. There were no cardiac symptoms except nervous palpitation at times. There was no swelling of ankles. Stomach never pained, but food seemed to remain in it for a long time. She was never com-fortrMe except when the stomach was empty. There were nausea and vomiting when food was forced, and she vomited after almost every meal. The vomitus was not sour, no blood. She was of constipated habit, but lately bowels had been more normal. She had no diarrhea, no blood, no urinary symptoms. She worried much about herself. For the past three years, her ill health had prevented her marriage, and she had become much discouraged. She complained especially of a heavy feeling in the stomach after eating, with nausea and vomiting, and often went a whole day without food in order that she might feel well enough to go to the theater at night. She had frequent and severe headaches. Examination.-Blood showed: Reds, 5,000,000; white, 7,400; hemoglobin, 75 per cent. Stomach Examination : This showed moderate increase of mucus, no free hydrochloric acid. Total acidity 7.5 per cent. Rennin and pepsin present in good amounts. No occult blood. The patient had been kept on the medical side for some weeks under the care of Dr. Barker on rest and forced diet. She complained generally of gastric fulness, insomnia and depression. She appeared very excitable, buoyant at times, then much depressed, weeping, etc. She was very restless. Further History.-During the time she was under observa¬ tion on the medical side, the symptoms described continued with slight variation. Repeated examinations of stomach contents showed practically the same condition except that the free hydrochloric reappeared in small quantity. The vomitus had changed a little in character, becoming sour and irritating her throat. Pain also became something of a feature, associated with attacks of vomiting. The pain was described as epigastric in character, radiating to the left shoulder and between the scapula? and back. Not having received any matt-Hal benefit from the forced feeding and rest, she was trans ferred by Dr. Barker to the surgical side, and on June 10, 1910, I operated on her through a right rectus incision. Operation.-On opening the abdomen, a marked general enteroptosis was revealed. The stomach was enlarged, its walls being pale, thin and flabby. The pylorus was wide open and twice its visual diameter, the first portion of the duodenum was dilated to a diameter of about 5 cm., its walls were thin and pale. The cecum was distended and displaced well down into the pelvis, the transverse colon apparently filling up the whole lower portion of the abdomen with several extra folds. The walls were thin and pale and the diameter about twice the usual size. The descending colon and sigmoid showed a similar condition. The whole lower portion of the abdomen seemed full of large intestine, behind which the coils of small intestine were collapsed and ribbon-like. The gall-bladder and ducts were normal. The uterus was adherent to the anterior abdominal wall. Tubes and ovaries were apparently normal. Solid viscera, liver, spleen, kidneys were normal but sharing in the general prolapse. It was thought best to excise the transverse colon and the two flexures, hepatic and splenic, as this portion of the colon seemed to be the seat of the prin¬ cipal abnormality. This was done between two clamps, the free ends were ligated and the stumps inverted as in an appen dectomy. The bowel was divided with the actual cautery. A Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/15/2015 lateral anastomosis was made between the two segments of the colon. It was then decided, owing to the marked dilata¬ tion of the upper portion of the duodenum, to anastomose this portion of the intestine with the jejunum. A lateral duodenojejunostomy was, therefore, performed. This was rendered easy by the previous division of the mesentery of the trans¬ verse colon which had been made. In this way, it was hoped to obviate the possibility of an obstruction to the passage of food through the duodenum by the mesenterio vessels, the so-called gastromesenteric ileus. So far as I know, this is the first time that this operation has been combined with that of resection of the colon. Post-Operative History.-The time of operation was a little over an hour. The patient stood it well, and returned to the ward in excellent condition. There was considerable pain for the first forty-eight hours, which was easily controlled by small doses of morphin. Nausea and vomiting were also pres¬ ent for the first few hours, the nausea continuing for three days. In other respects, she made an uneventful convales¬ cence. A marked improvement in the mental condition was early noted. The patient left the hospital on July 2, 1910, very much improved in every way. I have heard from her recently, and this improvement was continued unabated up to the time of the last communication. Case 2.-Patient.-Mrs. E. 0. P., aged 46. Complaint.-(1) Pain in right side, running down leg into calf regarded as sciatic rheumatism; began twenty-five years ago. (2) Pain in right lower abdomen, localized; onSet five years ago, was regarded as gall-bladder trouble. (3) Persist¬ ent constipation for past ten years; mucous colitis for several years History.-Exploratory laparotomy was done three years ago. Adhesions were found around gall-bladder, appendix, etc. The appendix was removed. She had right floating kidney. Explor¬ atory laminectomy was done three months ago. No spinal cord tumor or other lesion was found to account for pain under the shoulder and spasms in right leg, etc. (sensory disturb¬ ances). Wassermann reaction was negative; stool examination was negative, abdomen was also negative on examination. Xray plates showed, however, redundant colon. Operation. -Dec. 22, 1910. Cecum and colon were excised as far a-tin-splenic flexure. Lateral anastomosis was done, as in previous case. Recovery was uninterrupted. Patient was discharged Jan. 29, 1910, markedly improved. (ask :!.-Patient.-Miss H.. aged 33. Complaint.-Constant dull headache, occipital in character. Pain in neck and down spine. Nausea and vomiting. Numb¬ ness of the left leg and hand. Family History.-This was unimportant. Personal History.-Patient was always a delicate child, and had suffered from stomach trouble for many years. Appetite had been rather poor. Digestion had never been good. Bowels have always been constipated. She had suffered a great deal from abdominal discomfort and six years ago the appendix was removed and the right kidney suspended. Present Illness.-In September, 1908, she was admitted to the Johns Hopkins Hospital with general nervous breakdown, severe headache and chronic constipation. She remained there three months at the end of which time she was discharged somewhat improved. Three weeks after she left, however, the old symptoms reappeared. In March, 1909, she had another nervous breakdown with great weakness, headache and nausea and vomiting; she was in bed six weeks. She was then oper¬ ated on for the relief of postoperative adhesions supposed to be due to the previous appendix operation. Four weeks after this operation, she had an attack which was supposed to be meningitis. In January, 1910, she had another spell of illness lasting six or seven weeks; she was in bed with weakness, headache, loss of appetite, insomnia and some nausea and vomiting. Since that time she has not been at all well. Her chief complaint has been obstinate constipation, abdominal dis¬ ti ess and a general feeling of lassitude and disinclination to exertion of any sort. An exploratory incision was advised witli the idea of resecting » portion of the colon, if conditions justi¬ fied it. Operation.-On Jan. 27, 1911, the abdomen was opened through a right rectus incision. The cecum was found to be very much distended, its walls thin and flabby. The ascending portion of the colon, the hepatic flexure and the transverse colon were all involved in this process. It was thought best to excise the distended and redundant portion of the colon which was done. The ileum was divided about two inches above the ileocecal valve and the transverse colon just in front of the sigmoid flexure. This portion of the colon was excised and a lateral anastomosis macte between the ileum and sigmoid flexure. The patient made an uninterrupted recovery and when last seen about three and one-half months after the operation, she expressed herself as perfectly well, not having had to use a cathartic since the operation, and having gained about 25 pounds. These are the histories of typical gastro-intestinal neurasthenics, a type of case with which, I am sure, all physicians, to their sorrow, are familiar. Fortunately for the profession, and greatly to its credit, the diag¬ nosis of neurasthenia is to-day becoming more and more infrequent and, when made, at once lays its author open to at least a suspicion öf using this term as a cloak to hide ignorance or lack of skill. It was perfectly evident that there was something rad¬ ically wrong with the first patient, both physically and mentally, but without an incision we were unable to make an accurate diagnosis of her condition. The opera¬ tion revealed a state of affairs which, from experience with other cases of this particular class, we had been led to expect with some degree of probability. Beyond this we were unable to go. Of course, it was possible, with a reasonable amount of certainty, to exclude many con¬ ditions, but to tell beforehand just what " pathologic process would be found, or to explain satisfactorily the manner of its production, was beyond our diagnostic ability. But here is food for reflection : Two pathologic conditions revealed by the operation, to which I wish to call especial attention, were: (1) the great dilatation of the upper portion of the duodenum, with the wide open pylorus, and (2) the great redundancy of the colon, particularly of the transverse portion, together with its malposition. This condition of the duodenum first attracted my attention about fifteen years ago, and so far as I know was first described by me. although it had been observed over fifty years ago by Peebles and later by Bobinson. I was at that time unable to explain it. After a good deal of thought and many subsequent observations I am still unable to explain it. I do not believe that the explanation of those who would ascribe it to a chronic gastromesenteric ileus will account for all the cases. Possibly some may be due to this cause. Still more unsatisfactory is Ochsner's idea of the circu¬ lar muscle fibers in the duodenum, with their sphincteric action. Associated with this condition are almost invariably to be found changes in the external appearance and feel of the pancreas, sometimes changes similar to those which have been characterized by Mayo Robson as ' "chronic pancreatitis" ; at others an apparent atrophy of the gland is observed. I cannot but feel that in some way or other changes in the structure or function of the pancreas are more or less intimately concerned in the production of this condition of the duodenum, and are, perhaps, the chief factors. In just what way I am unable to say. In this connection the interesting investigations of Weinland are worthy of note. Always one finds that the walls of the duodenum are thinned, and that the mucous membrane is atrophied, and that the normal folds have become obliterated. Codman, Stavely and Downloaded From: http://jama.jamanetwork.com/ by a University of Michigan User on 06/15/2015 others would have us believe that many of these cases are due to the taut mesenterio vessels compressing the duodenum against the bodies of the vertebroe-a chronic gastromesenterie ileus. It is conceivable that this cause may be active in a certain percentage of cases, but after careful and systematic examination of a large number of patients on the operating table I have been unable to demonstrate it to my own satisfaction, or that of spec¬ tators or assistants, more than once or twice. Then, too, if this compression were the real cause of the trouble, it would furnish an almost ideal indication for a gastroenterostomy, and complete relief ought to follow this operation. On the contrary, however, this is not the case. The usual operative methods have, in my experience, failed utterly to relieve the trouble, and until quite re¬ cently, when this condition has been found at operation.