These operations have practically given way to (6) Gastro-enterostomy or gastro-jejunostomy, the latter title implying the portion of intestine which is usually selected for the anastomosis. No. 5 is, strictly speaking, a gastro-enturostomy operation, but to prevent confusion it is better to associate the term gastru-enterostomy with gastro-jejunostomy. The object of this operation is to effect an anastomosis through an opening between the stomach and small intestine so that the gastric secretion and food pass directly through the stenosed organ into the intestine by the newly made route. There are two methods of performing the operation, which are known by the terms anterior and posterior, according to whether the fistulous opening is to be made in the anterior or posterior wall of the stomach. l;y: common consent posterior gastro-entcrostomy is regarded as the most suitable for nearly every case of pyloric obstruction due to cicatricial contraction, though the anterior operation is more expeditiously and easily performed, and is often more suitable in cancer of the stomach. A free incision being made in the middle line or through the right rectos muscle, the colon and stomach are drawn out of the wound and turned upwards; an aperture is made in the mesu-colon in order to expose the posterior wall of•the stomach, and a line on the latter is selected for the site of the fistulous opening. This should be near the lower curvature extending downwards in the direction of the long axis of the portion of jejunum. The portion of jejunum to be opened is next sought for; the site of its incision is an important matter in order to avoid the danger of kinking afterwards. The best point, according to Moynihan, should he as close to the duodeno-jejunal flexure as possible, the anastomosis being made vertical and in the middle line, thus avoiding a loop. An elliptical piece of mucous membrane is then to he excised from the stomach and intestine, and the anastomosis completed by a double row of sutures.
Mayo makes the opening run obliquely from above downwards and to the left, the piece of jejunum running from right to left. The meso-colic aperture is to be carefully closed round the anastomosed bowel by sutures in order to avoid the possibility of a future hernia.
The parts are returned to the abdominal cavity after a scrupulous toilet has been effected and all bleeding-points arrested, and the edges of the wound in the different layers of the abdominal wall are brought together by separate sutures.
Upon being put to bed with his shoulders raised, rectal injections of normal saline are to be commenced and continued till all efforts at vomit ing have passed away, after which small quantities of water, followed by similar amounts of liquid nourishment, may be cautiously administered by the mouth.
The mortality of the operation has by improved methods in technique fallen to a trifle; thus in the hands of Moynihan gastro-enterostomy for gastric ulcer has not exceeded i per cent.
Stenosis of the pylorus in infants is either due to muscular spasm or hypertrophy of the circular muscular fibres, and is speedily followed by gastric dilatation, which usually fails to respond to restricted feeding, and must be promptly met by gastro-enterostomy. Sometimes this state is met with in adults as a remnant of the congenital condition, and such cases get along fairly well for a long period by resorting to liquid diet and constant lavage, but ultimately a pyloroplastv or gastro-enterostomy will be required. 'When the condition is met with in aged and debilitated patients who have suffered for many years, restricted feeding and lavage afford a better prospect for prolongation of life than that held out by an operation.