Of the various mechanical contriv ances, Murphy's button has been most generally used. Continuous purse-string sutures are placed around the margins of the incision and the openings are drawn closely around the halves of the button; the halves are then joined and locked, and the operation is complete. If the condition of the stomach and intestine and the general condition of the patient permit, union by suture is perhaps safer, and the Laplace anastomotic forceps or those of Downes are aids of great value. Whatever method of union is chosen. the intestine is first squeezed empty and clamped on both sides of the pro posed incision, leaving a clear space of 10 or 12 centimetres. An incision may be made in the long axis of the gut, or. as Kocher recommends, transversely to the axis of the gut through one-half its circumference on the free border. A fold of gastric wall is pinched up near the greater curvature and an incision of the same length as that in the intestine is made. The jejunum is then sutured to the stomach in a position perpendicu lar to the greater curvature, thus favor ing free escape of gastric contents. If the method by suturing is adopted, the ends of the two incisions are united by separate single sutures and the lower or posterior lips of the incisions are united by continuous suture which perforates all the coats; the anterior or upper lips are sutured in the same manner, except that, to facilitate their insertion, the stitch-loops are left loose and not tied until all have been inserted. The edges are carefully inverted as the sutures are tightened, so as to bring the serous sur faces into apposition, and a second row of Lembert or Halsted sutures are usually placed to reinforce the first, pass ing through the serous, muscular, and submucous coats. The mortality of gas tro-enterostomy is about 35 per cent. for malignant cases operated upon during the past few years; in non-malignant cases it is much less.
Pylorectomy. — This term is gener ally used to designate the operation of resection, not only of the pylorus, but of as much of the duodenum and of the stomach as is diseased.
Almost the only indication for the performance of this operation is car cinoma of the pylorus, although it has been practiced in a number of cases for ulcer and cicatricial contraction. The encouraging results following this oper ation in the hands of skillful and experi enced operators during the past few years seem to indicate that it is the com ing operation for the treatment of car cinoma ventriculi. Physicians who are in doubt as to the possible existence of carcinoma should consult with a surgeon early, for, in the present state of medical knowledge, it is impossible to determine absolutely the existence of carcinoma in its incipiency. An exploratory opera tion is of slight danger, and if the dis ease exists, and the operation is to be more than palliative, it must be under taken early. Considering the harmless ness and simplicity of exploratory coon otomy, and the fatal consequences of delay, it seems not only justifiable, but urgent, that, if obstinate gastric dis turbances do not yield to medical means, operation should be undertaken, even in the absence of a palpable tumor. Fac
tors of aid in the diagnosis are the exist ence of cachexia, age past 40, the ab sence of free hydrochloric acid, the pres ence of the Oppler bacillus, excess of lactic acid, Inematemesis, and diminished amount of haemoglobin and number of red blood-corpuscles.
the severity of the operation, preparation should be made for maintaining the body-heat of the patient, for free stimulation, and the intravenous injection of salt solution. A median incision between the ensiform cartilage and the umbilicus is usually made, and the field of operation is walled of with iodoform gauze to avoid infec tion of the peritoneum. Various meth ods of operation have been employed. Billroth resected the tumor, and, as the opening in the stomach is so much larger than that in the duodenum, the stomach wound was partially closed by suture until an opening was left of suffi cient size for an end-to-end anastomosis with the duodenum. In order to facili tate the escape of gastric contents, the point selected for anastomosis should be below the upper or middle of the gastric opening, depending upon the amount of growth resected. Kocher first clamps both the stomach and the duodenum, re sects the growth, and closes the wound in the stomach first by continuous deep sutures, then covers these by continu ous Lembert suture; he then makes a posterior end-to-side anastomosis by in serting the duodenum into the opening in the posterior wall of the stomach. When the duodenum is not freely mov able enough to allow it to be drawn up for the insertion of circular sutures, he prefers to use the urphy button; in other cases he uses sutures. Czerny first performs posterior gastro-enterostomy with Murphy's button and then, after re section of the tumor, he closes the stom ach and duodenum. The Laplace or Downes forceps may be used in any of these procedures with advantage. The mortality of the operation has always been great,—in cases complicated by ex tensive adhesions about 72 per cent.; but a considerable number of cases have been reported in which patients have survived the operation two or five years, and one of Kocher's patients is living and in good health nine years after the opera tion. In the practice of skillful opera tors the mortality is believed to be 39 or 49 per cent., while several individual operators have attained over 75 per cent. of successes.
Itydygier's claim of having originated the method commonly called Billroth's method of performing circular pylorec tomy not sustained. The first operation of this kind was done by Pdan, in 1879; the second by llyoygier, in 1SSO. Both patients died. BiBroth performed the first successful circular pylorectomy in 1SS1, and described the procedure. Both Merrem and Gussenbauer had made ex periments upon animals at this time. No doubt remains that the first method of resetting the pylorus was and the second Billroth's. Alfred Stieda (Deutsche Archiv f. Chir., May, 1901).