Gastrotomy, simple incision followed by immediate closure of the stomach, is done first and principally for the pur pose of removing foreign bodies from the gastric cavity. These may have been swallowed or been found in the stomach. The operation is indicated: 1. If the swallowed body is not smooth, but irreg ular, with sharp edges which may injure the tissues. 2. If it is too large to pass through the pylorus and at the same time gives rise to disturbances: pains, nausea, vomiting, etc. 3. In rare in stances in order to examine the interior of the stomach with reference to the presence of malignant superficial neo plasms, ulcers, or ruptured blood-vessels in the case of profuse haemorrhage. Max Einhorn (Med. News, Nov. 25, '99).
Very frequently the foreign body may be felt through the abdominal wall, and the history of the case generally leaves little doubt as to the diagnosis. If there is any question as to the cause of the condition in the case of children, insane persons, etc., the use of the x-rays will often clear up the doubt.
Gastrotomy for the relief of stricture of the oesophagus may be necessary in cases in which it is impossible or undesirable to dilate by means of a bougie passed by the mouth. If the oesophagus is dilated or pouched above the stricture, or if the stricture is situated low down near the stomach, dilatation is often practically impossible except after gastrotomy. A close constriction may be divided by Lange's specially constructed knife blades or by Abbe's bowstring method; in other cases in which the stenosis is less marked, immediate dilatation by boogies or the fingers may be practiced. In such cases it is sometimes possible to close the stomach immediately. If the stricture is more extensive, however, re peated dilatation is generally required, and a temporary gastric fistula may be established. This will either close spon taneously or may be closed by a subse quent operation.
Operations.—Abbe's Bowstring Method. —A firm cord is passed into the oesopha gus through the mouth or — perhaps better—through an opening into the oesophagus in the neck; it is carried through the oesophagus into the stomach and out through the gastric incision. A boogie is then introduced to the site of stenosis, making the stricture tense, and the string, when sawed back and forth, divides only the tense stricture, and not the relaxed portion of the (esophagus.
Loreta's operation for stenosis of the pylorus consists in dilatation, either by means of instruments or by the fingers after preliminary gastrotomy. The mor tality by this method of operation has been considerably greater than after pyloroplasty, and for this reason, as well as from the fact that the pylorus often recontracts, the operation has fallen into disfavor.
General Operation.—The introduction of S or 12 ounces of sterile milk or water into the stomach before operating may prove of aid in locating the organ accu rately. Some surgeons have suggested distension of the stomach by large quan tities of gas, but in case ulceration is present, or if the stomach-wall is nearly perforated by a foreign body, or if it is friable from disease, this procedure is not without danger of rupture and sub sequent infection of the peritoneum.
The incision may be made parallel to the lower border of the left ribs, or, in case of Loreta's operation or in operation for the removal of a large foreign body, in the median line. Before opening it the stomach should be brought out of the abdominal cavity if possible and carefully examined to make certain that the stomach, and not the transverse colon, is being dealt with. The colon is recognized by its longitudinal muscu lar bands, its sacculation and the pres ence of the epiploim. Iodoform gauze should be packed about to avoid danger of contamination of the peritoneum, and a continuous circular fixation suture is of advantage for the same reason, as well as that it holds the organ firmly during the operation. The line of in cision in the stomach-wall is perhaps best made parallel to the course of the blood-vessels,--that is, transversely to the curvatures; but much will depend upon the object of the operation. After this is accomplished the opening is closed by Lembert's or Halsted's mat tress-sutures and the abdominal wound is closed without drainage.
is the op eration by means of which a permanent fistula is established through the abdom inal and gastric walls for the purpose of introducing food.
The operation is indicated to prevent death from starvation in case obstruction exists in the digestive tract above the stomach which prevents the introduction of food. Such obstructions arise from congenital closure, syphilitic stricture, diverticulurn, or cicatricial contraction of the oesophagus, which may be caused by destruction of its walls from caustic chemicals, traumatism, scalding water, or eruptive fevers, such as typhoid fever. The obstruction may also result from the pressure of growths outside the oesophagus, but benign growths of the thorax, neck, or of the walls of the oesophagus are comparatively rare. Aneurisms of the aorta or the innomi nate artery or tumors of the larynx are also possible causes of obstruction.