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ADDRESS IN SURGERY.
EXCISIONS OF PORTIONS OF THE ALIMENTARY
CANAL COVERED BY PERITONEUM.
BY WILLIAM A. BYRD, M.D.,
The history of excision of portions of the alimentary canal by surgeons dates back but a few years, and may be said to be the result of evolution, beginning with McDowell's first ovariotomy. In cases of obstruction from stricture, medicine had tailed for ages to afford relief, and surgery offered no hope. Occasionally, where the constriction was caused by the strangulation of an extruded bowel in hernia, the intestine would slough, be thrown out through an abscess, and nature would form an artificial anus. The great fear of entering the peritoneal cavity deterred surgeons from hoping for anything better, or resorting to any more radical means for the relief of the poor sufferers.
Dr. Nicholas Senn, of Milwaukee, Wis., in a very able and exhaustive report to the Wisconsin State Medical Society on the recent progress of surgery, says: “That Merren suggested the propriety of extirpation of carcinomatous pylorus in man in 1810. Pean performed the first operation of this kind in 1879.* The cancer (scirrhus) was located in the pylorus, a section of which, with a portion of the omentum, was removed. The resected ends were united with catgut sutures.” The patient died. Now, turning to the Medical Press and Circular for March 29, 1882, p. 279, under the head of “ Statistics of Resection of the Stomach,” I find, not quoting literally :
First.-Resection of stomach by Billroth, January 29, 1881, woman aged 43, tumor size of apple, removed as far as duodenum through a transverse abdominal incision. Died four months afterwards from peritonitis.
* Pacific Med. and Surg. Journal, January, 1880.
Second.—Resection of stomach by Billroth, February 28, 1881, woman aged 39, multiple adhesions. Vomiting, with dilated stomach, after operation without peritonitis. Obstruction persisting, wound was reopened on the seventh day, and search made for obstruction. Died thirty hours after second operation.
Third.—Resection of stomach by Billroth, March 12, 1881, man aged 38, extensive adhesions. Died in ten hours after operation from collapse. (Shock ?)
Fourth.—Resection of stomach by Wolfen, April 8, 1881. Tumor size of apple. Patient doing well six weeks after operation.
Fifth.—Resection of pylorus by Burdenheur. Woman aged 57.
Died twenty-six hours after operation from secondary hemorrhage.
Sixth.—Resection of stomach by Czerny. Successful.
Seventh.—Mr. F. A. Southam, of Manchester, removed the pylorus, and nearly a third of the stomach, from a man aged 43, April 5, 1882. The man died of acute septicæmia fourteen hours after the operation.—Medical News, May 20, 1882, p. 542.
Eighth.—“ Resection of stomach has again been performed with success by Dr. Nebinger, of Bamberg:--Detroit Clinic, May 24, 1882.
The above are all of the cases of excision of the stomach that I can find a record of. The results may not at first seem promising, but when we come to review the earlier history of ovariotomy, the picture is nearly as dark, and it must be taken into consideration that many of these operations were undertaken after extensive adhesions had formed and neighboring tissues had become involved. May we not hope, with earlier and more accurate diagnosis, that the diseased mass may be removed, so as to restore the patient to years of health and usefulness?
The details of the “ technique” of the operation are so well described in a report of Dr. F. J. Lutz to the St. Louis Medical Society, and published in the St. Louis Medical Journal for April, 1882, that I forbear to quote, and hope all my hearers that are interested in the subject will read it with the accompanying report of the discussion upon the paper.
I yet cannot forbear quoting the remarks of our late beloved and illustrious friend and fellow-worker, Dr. John T. Hodgen. The others who took part in the debate still live, and can speak for themselves. He says: “I should be free of adverse criticism of the gentleman growing out of experience in connection with the operation, but I have two points to suggest in connection with the operation. The doctor described very carefully the manner of opening the stomach, and it occurred to me that when the stomach was opened first on the gastric side, instead of cutting entirely through, it would be well to make a small opening, insert a tube, and draw off the contents of the stomach, swabbing out the contents. If this is done, the probabilities of regurgitation are very much lessened. Another point is in connection with the application of the ligatures in finally closing the operation. The first part of the operation is done from the mucous membrane side, as the doctor very clearly showed, the last part hardly as well, but also from the mucous surface, except the last half-dozen sutures, which were left long, the needle is introduced from the free mucous side, and carrying it back from the mucous surface, leaving the ends outside long. Those last sutures may be tied with the knots inside the stomach quite as well as the sutures in the beginning are tied with the knots inside the stomach; the last one being the only one which offers any difficulty at all to returning the knot to the mucous side, and that could be done readily by passing the free ends of the last ligature through the opening between the sutures. It occurred to me that this suggestion might be worth mentioning, as there is a possibility of some one attempting this operation in this city. The question of the propriety of the operation cannot be determined now. We cannot now say what the result will be. Abdominal surgery has made such strides within the last fifteen or twenty years, that it is impossible to know that this may not be a standard operation in coming time, when we make the diagnosis early enough, when we locate definitely the site of the disease, when antiseptic surgery is carried so far that the abdominal cavity can be opened as freely as any part of the body, we are justified in the conclusion that it is probable that this operation will one day be a standard operation. Up to the time of Spencer Wells the mortality in ovariotomy amounted to seventy-five per cent., now it amounts to about twenty per cent. .. I saw a case of cancer of the pylorus, the other day, in which the tumor moved very freely through the space of four inches. I could feel it very definitely through the abdominal wall, and determined its size. The cardiac extremity seemed to be the fixed point, and, as it contracted, would draw the stomach towards the left side of the abdomen, beyond the median line, and then return to the opposite side of the median line. Evidently this tumor was quite free; not at all adherent; every part was free and movable, and it seemed to me to be a favorable case for operation. Dr. Johnson, one of these days, will be forced to pass from the doctrine he has held so long, that cancer is necessarily and primarily a constitutional disease. It is always a local disease in the beginning, and, if removed early enough, will never return."
Resection of a portion of the stomach for gastric ulcer. In the N. Y. Medical Record, February 25, 1882, p. 211, is recorded a case of resection of a portion of the stomach, including the pylorus. The patient, a woman aged 38, the operator, Dr. Rydygier, of Kuhn. The pyloric orifice was so narrowed as to only permit the passage of a No. 9 bougie; the walls were greatly thickened. There had been for two or three years attacks of acid indigestion with vomiting of large quantities of liquids, and solids indicating dilatation. The patient was prepared for the operation by washing out the stomach daily with a solution of salicylic acid. The temperature would at times rise to 102° or 103° F., but the progress was so good that in six weeks the woman considered herself well. Todoform was used as an antiseptic.
Resection of bowel for stricture and cancerous growths.
The first case of removal of a portion of bowel for stricture, of which I can find a record, was done by Koeberlé, of Strasburg, and I take the liberty of quoting the description of the operation as reported in the N. Y. Medical Journal for May, 1881, pp. 610 and 611: “ The patient was a girl twenty-two years old, who had suffered for a long time with symptoms of intestinal obstruction, though the symptoms were not such as to enable him to arrive at any satisfactory diagnosis as to the exact pathological condition. As the trouble was steadily increasing in severity, however, and the patient losing ground from suffering and malnutrition, an exploratory incision was made in the median line. Four cicatricial contractions were
discovered in the small intestine involving between them about two metres of the bowel, and the whole affected portion was consequently removed, rather than retire from the operation and leave the patient to certain death. The result was a perfect success, and from this case and the analogous ones which the author has studied he draws the following conclusions :
“1. Resection of the small intestine may be done to a considerable extent without interfering in any appreciable degree with digestion.
“2. Practiced under suitable conditions, the operation is to be considered perfectly legitimate.
“3. The resection may be performed by bringing the divided ends directly into apposition, and closing the abdominal wounds, by forming an artificial anus and doing a subsequent enterotomy, or by making an incomplete union of the intestine combined with artificial anus. The second and third procedure expose to less subsequent danger.
“4. Resections of fibrous and cicatricial strictures, which are probably more frequent than is generally supposed, may cause a radical cure, and the same is the case with epitheliomata. On the contrary, resection of cancerous obstructions gives only temporary relief, and at a great risk. By proper diet after the operation, the risk of fecal extravasation may be reduced to a ininimum, and the best diet for this purpose is one containing as little fluid as possible.
“ 5. By introducing liquids per anum, and drink in the same way, water is absorbed as by the mouth, and there is no sense of thirst; the flow of intestinal fluids is less considerable, and the patient is more comfortable. The patient made a perfect recovery.
Here perhaps will be the proper place to mention an operation by Mr. Thomas Bryant, where he cut as for left lumbo-colotomy, and finding a stricture just above the sigmoid flexure he excised that portion of the bowel, making an artificial anus to be cured by a future operation. Reported in the British Medical Journal for April 1, 1882. Although I have seen post mortem cases of stricture in the same locality that were freely movable, and that would have admitted of easy ablation, still I believe with Mr. Harrison Cripps and others who were debating the report, that the operation would be better made in