Gastrectomy. — By the term "gastrec tomy" should be understood the removal of the entire stomach; but as recent investigations have seemed to indicate that it is impossible to distinguish a well-marked boundary-line between the epithelium of the stomach and esopha gus, it is difficult to say when the entire organ is removed. Probably a consider able number of cases that have been re ported as total removals of the stomach have, in reality, been only partial gas treetomies. The operation may possibly ' be indicated in cases of very extensive malignant growths which have not in volved or become extensively adherent to neighboring organs and which have not caused metastases. It should cer tainly be performed only in the rarest and most unusually favorable cases, and only by surgeons of skill and wide ex perience in abdominal surgery. Suffi ciently extensive operations to deserve the name of total gastrectomies have been performed in 11 cases, with 5 re coveries. Death resulted from recur rence of the growth in the ease of 2 of these patients and from peritoneal in fection in a third. No reports of the later results have yet been given in the other 2 cases.
gastro-colic and gas tro-hepatic ligaments are first tied and divided; then, after carefully packing gauze about to prevent possible peri toneal infection, the pyloric end is di vided from the duodenum between double clamps; the esophageal end is then divided in a similar manner. In several cases the duodenum has been found sufficiently movable to make an anastomosis with the esophagus. This was done, in the cases of two patients that recovered, by means of a Murphy button. If it is impossible to bring the duodenum up to anastomose with the esophagus, the end of the duodenum is closed and a loop of jejunum is brought up and an end-to-side anastomosis with the esophagus is made.
Study of the metabolism in Schlatter's case of total resection of the stomach. Six and a half months after the opera tion the patient had gained 5.4 kilo grammes in weight. The amount of nitrogen present in the stools varied within normal limit-, but during the six days a complete nitrogenous balance was not obtained as occurs in health. There was a retention of from 1 gramme to 1.4 grammes of nitrogen. This retention is known to occur in convalescence from acute illnesses, etc. There was no in crease in weight during the first period of observation. A month and a half later a further investigation was made with a more varied diet, and here the absence of the stomach seemed of no importance. A nitrogenous balance could now be established, showing that the regenera tion of the blood was so far complete that there was no longer any need of retention of nitrogen. The retention of
phosphorus was also marked. Fatty matters were satisfactorily dealt with, so that of 8.5 grammes taken only 464 grammes were excreted.
The absence of the hydrochloric acid in this case was without influence upon putrefactive processes in the alimentary canal.
As regards the quantity of chlorides in the urine, there was no decrease after the chief meal in this case. This con firms the current view that the diminu tion of the chlorides in the urine after a meal is due to the hydrochloric acid excreted by the stomach. The absolute acidity of the urine was higher in this case than in ordinary individuals. The retention of sodic chloride was striking, without there being any increase in the body-weight. There was no relationship between the excretion of chlorides and the acidity of the urine in the different periods of the day. Hoffmann (Munch. med. Woch., May 3, '95).
(See also ABDOMEN, INJURIES or', vol ume i.) Case of removal of the entire stomach for carcinoma by successful cesophago duodenostomy. The patient was a woman of good constitution, aged 66.
On opening the abdomen the tumor was found to comprise nearly half of the wall of the stomach; there was no marked glandular involvement or adhe sions, and it was determined to remove the whole organ. The greater and lesser omentum were tied of and divided; the duodennin was clamped and a ligature was placed around it half an inch above the clamp, and the tissues were divided between the two. The ends were washed in salt solution and wrapped in iodoform gauze. The same method was employed with the (esophagus and the cardiac end of the stomach. It was found that the (esophagus and duodenum could be brought together, and they were united by a Murphy button to shorten the op eration. No Lembert sutures were ap plied, as the approximation was good. The peritoneum was closed by catgut suture and the abdominal incision by silk-worm gut. There was practically no loss of blood. The operation lasted two hours and a quarter, and was followed by a considerable amount of shock. The patient, however, made a complete recov ery. Where there are no adhesions, re moval of the stomach is not very diffi cult; with ordinary care hwmorrhage is not likely to occur. The effect of sur gical shock upon the patient is most to be feared, and should be guarded against by heat, stimulants, and quick work in operating. C. B. Brigham (Boston Med. and Surg. Jour., May 5, '98).