STOMACH AND INTESTINES, SUR GERY OF.
Surgery of the Stomach.
— When possible, it is specially desirable to clear the intestinal tract by a thorough purge, and, as preliminary to most operations, it is of great advantage to wash out the stomach. These measures are of unusual importance in gastric surgery; first, be cause they lessen the danger of contami nation of the peritoneum by the escape of the gastric contents, and, secondly, because they lessen the likelihood of post-amesthetic vomiting and retching. These, in some instances, if severe, may entirely defeat the end of the operation by causing the sutures to give way.
Surgical Treatment of Gastric Ulcer. —Surgical treatment may be indicated in certain cases of non-perforating gastric ulcer; but immediate operation is always indicated in cases of perforating ulcer. Operation is always indicated in non-per forating ulcers which give rise to danger ous and repeated hremorrhage and ex tremely severe pain and intractable vom iting and indigestion, provided all med ical measures have been tried without avail. It is also indicated if there is any suspicion of malignant degeneration. In case of hremorrhage. operation is indi cated only when the loss of blood has been excessive, whether from frequent small hemorrhages or more than one vere ha7morrhage. After severe liwinor rhage excision of the ulcer and suturing by Lernbert or Halsted sutures is probably the preferable operation, for erosion of a large blood-vessel is usually present. In less severe gastro-enteros tomy or pyloroplasty may be performed; these operations, by favoring emptying of the stomach, tend to put the ulcer at rest, and in some instances have been combined with excision, it has been thought, with advantage.
The duration of life after perforation of the stomach may be estimated at twenty-four hours; hence the impor tance of early and distinct diagnosis can not be exaggerated. The shock follow ing perforation is severe, and its effects can be observed to increase so rapidly that it is apparent the chances of suc cess are diminishing in direct proportion to the length of time that is allowed to elapse between the occurrence of the in jury and its repair by surgical means. Morse (Brit. Med. Jour., Feb. 13, '97).
The most important factor influencing the result of a laparotomy for a per forated gastric ulcer is the length of tirne which has elapsed since the perfora tion. In no recorded case has recovery
ensued if the operation has been post poned for more than twenty-four hours unless extensive peritoneal adhesions ex isted prior to the perforation. F. S. Toogood (Lancet, Jan. 15, '98).
Twenty-one cases of simple ulcer of the stomach personally operated upon with but a single death. The indications for operation are recurrence of ulceration with marked deterioration of general health; resistance to medical treatment followed scrupulously for a long period; intense pain, especially when accom panied by obstinate vomiting; recurrent htematemesis; emaciation and cachexia; gastric dilatation; the formation of a palpable tumor, and the development of an extensive adhesive peritonitis. Gas tro-enterostomy is preferred, and is ap plicable in all cases, no matter what may be the state of the lesion. Tricomi (Re vue de Chir., Feb. 10, '99).
Cases of gastric ulcer occurring at the Massachusetts General Hospital during the years 1SSS-OS, inclusive, studied. In 1S7 cases haemorrhage was present in 81 per cent., and caused death in 17 per cent. of the male patients, but only in 1.27 per cent. of the females. No woman under thirty years of age died of hmmor rhage. Perforation occurred in 3.2 per cent. of the cases, and all of these proved fatal. Of 114 patients, 80 per cent. were discharged cured or relieved, but at the end of an average of five years only 40 per cent. remained well. The mortality in these from gastric disease was 20 per cent. Among the males it was 30 per cent.; with the females, 9 per cent. The mortality of S per cent., and the failure of medical treatment to effect a lasting cure in 60 per cent. of the patients, indi cate the need of surgical intervention in other than emergency cases of this dis ease. Greenough and Joslin (Amer. Jour. Med. Sci., Aug., '99).
Gastric ulcer occurs in 5 per cent. of the eommunity, and the mortality of this condition is from 10 to 50 per cent. As soon as gastric ulcer is diagnosed the patient should be informed of the seri ous nature and the of careful treatment, rest in lied, and long-eon limed care in diet. Personal mortality from surgical treatment in this condi tion is about 5 per rent. 7 per cent. represents the mortality in all cases of hmmorrhage. A. W. Mayo Rob son (Lancet, Feb. 9, 1901).