PYLORIC OBSTRUCTION.* By W. A. BRYAN, Nashville, Tenn. It is not the purpose here to argue falsely that any man who has a mechanical turn may not learn to do a gastro-enterostomy successfully so far as technic goes; but to say that a vast amount of experience and skill are required to know just when, in the midst of the ever-varying pathological pictures presenting in the upper abdomen, gastro-enterostomy of fers the best net results to the patient. Too many gastro-enterostomies have been done, are being done now, and, as all who have taken pains to study surgical therapy of stomach lesions in their end results, with too few cures and too many cases made positively worse, having swapped the devil for fire. The diagnostic skill that leads these cases of stomach surgery to the operating table, requires to be of the first order. It requires patience to make a correct diagnosis of stomach lesions: often enough it cannot be done at all: but patience is always necessary unless the case is so well advanced that the traditional wayfaring man could recognize it at once. If it is diagnosed in time, not only must patience be employed, but a lot of work, a careful examination, often repeated examinations, physical, microscopical, chemical, X-rays, and a most careful history of the case in which the ill advised and deceptive word, indigestion, is not permitted to enter, unless with the most precise definition. I am pretty safe in saying that, from a surgical standpoint, operations on the stomach present relatively about the same order of difficulties that the diagnostician finds in his efforts to unravel the long and fluctuating symptoms he meets in his examination of stomach patients. The subject of this paper has been chosen not because it is the easiest phase of surgical stomach pathology from a diagnostic point, although it is unquestionably, but because by studying pylorie obstruction, we may gain a broader conception of the various phases surgical relief may be required to assume, than from any other single condition. The rule is, that pylorie obstruction conveys the idea of a cicatrix or ulcer, or cancer, representing the pathology present, and gastro-enterostomy representing the relief to be offered. As far as it goes the conception of the pathology is correct, but it falls woefully short of the facts; and the treatment goes too far, for pyloric obstruction does not signify by any means that gastro-enterostomy is the only surgical treatment. *Read before the Warren County Medical Society Pyloric obstruction means any condition primary or secondary, that so affects the outlet of the stomach as to retard or prevent. partially or completely, the escape of stomach contents. No doubt, there are numbers of cases of pyloric obstruction so mild as to produce no symptoms, or to produce symptoms so mild that no mechanical relief is required. The conditions which commonly interfere with the passage of food through the pylorus are: (1) Congenital stenosis; (2) Ulcer, with or without marked infiltration and situated either within the pylorus or on the gastric or the duodenal side, or on both sides as in the saddle ulcers; (3) Stricture, resulting from previously healed ulcer; (4) Cancer, primary or secondary; (5) Other tumors within the wall of the stomach, or pedunculated intragastric tumors, or tumors in organs adjacent to the pylorus and either invading it, or presscollapsing its lumen; (6) Adhesions due to ing upon it from without and permanently ly obstruct the pylorus by drawing it away adjacent inflammatory processes, which usualgenital bands; (8) Gastroptosis, which not from its normal anatomical position; (7) Cononly requires the stomach to lift its contents to an abnormally high level for expulsion, but becomes inadequate; (9) A form of acute obalso causes it to be so ill-shaped that the outlet in individuals without a previous history of struction, if it be obstruction, which comes up gastric disturbance and passes away without the need of surgical interference. I am frank to admit my ignorance of the nature of this condition. If we omit the last condition of the above group of nine, which is acute, apparently nonsurgical, which is rare and could not possibly be confused with the other eight forms of pyloric obstruction, I think we would be conserving the best interests of our patients to say that all the first eight conditions should be relieved surgically, at least after a course of treatment of a few weeks has failed to give relief, and always when a history of recurrence is to be had. All of them, if we omit ulcer, should be subjected to surgery as soon as possible, for delay can only mean decrease in the immediate risk of recovery and the remote risk of cure. It is by no means certain that an exception should be made of ulcer, for the chance of complications and sequellae which may at any time pass beyond our control. probably far outweighs anything that might be gained by a temporizing, procrastinating course. When we advise non-operative treatment of gastric or duodenal ulcer, it should always be done after weighing well the part that perforation, hemorrhage and cancer may play in our ultimate prognosis. 1. The possibility of a stenosis in new born children, that may not only interfere with normal development or cause a loss of weight, but cause death soon or late, slowly or rapidly, should be borne in mind by every obstetrician and pediatrist and by the general practitioner and surgeon as well, for I think surgeons are quite as prone to forget things as any other members of the profession, although of all men it is he who imagines himself least capable of forgetting. The habit of young infants to vomit, is a deceptive sign in these cases and the consultant is likely to forget that it may occasionally mean something much more serious than an overloaded stomach. The baby with a normal stomach and an abnormally large food supply vomits; but always vomits less than he ingests: this baby gains weight and has normal function. Reduction of the amount of food taken stops the vomiting. The baby with stenosis, however, vomits more of the ingested food in direct proportion to the degree of stenosis, but does not retain enough to keep its weight increasing and function normal. It may even vomit as much as it takes into the stomach. It does not void a sufficient quantity of urine, because the liquids do not enter the blood in sufficient quantity. This is true only in complete stenosis; otherwise we call it, because the food does not enter the intestines in quantity sufficient to assure bowel movements of normal amount and frequence. We have doubtless permitted many such cases to escape us in the past. The remedy is purely surgical, namely the performance of gastro-enterostomy. Its success depends very largely upon the degree of inanition reached before the operation is undertaken. 2. Ulcer is so comprehensive a subject that one can scarcely touch upon even a narrow phase of it in the narrow limits imposed by its position in this paper, namely as a factor in the etiology of pyloric obstruction. It may cause obstruction in any possible way; the facts, if not the urgency of treatment remain the same. I am not supposing that it will bleed or perforate or become malignant just here, but simply that it is interfering with the passage of gastric contents into the duodenum. The imperativeness of action in a given case may be emphasized by the recognition of one of these complications, and the line of treatment may be materially altered by their presence. But suppose we admit simply obstruction without any untoward complication. What is to be done? Surgery or medicine? The cause of the obstruction may be inflammatory infiltration and edema of the tissues affected or it may be cicatricial stenosis. The former may be relieved by cure of the cause, or the ulcer by internal measures, but it is difficult to understand how the hardened cicatrix, the result of years of ulceration and inflammation is to be relieved by such measures. If the case is not too urgent and if rational internal measures have not been employed, I think they should have a trial; and this means a trial with the same attention devoted by the patient and physician toward getting a cure that would be employed were it a surgical case. Otherwise, it is not a trial; and internal medicine has lost many a laurel and much of her glory by compromising between the necessities of the case and the demands of the patient. Men do not recover from ulcer of the stomach and attend to their business affairs at the same time. It is impossible and it's a shame to take the money. Let us treat him if we pretend to, put him to bed and regulate his diet and his habits and study the needs of the case and satisfy them. Short of this is mockery. If this cures him, not if it improves him, if it cures him all is well. If it fails, if the ulcer recurs, if hemorrhage occurs, if perforation occurs, or if it is feared, and by all odds if cancer is even suspected, the case is surgical. But this is not saying much in the light of our present status of surgery for ulcer. Ten years ago gastro-enterostomy was the finest feather in our plumage: we were so surprised that it really could be done, so hopeful, so certain that it would cure all ulcers. To-day, we know that gastro-enterostomy is one of the real things of surgery, really beneficial, we know what it will do and what it will not, and one of the things it will not do is to cure ulcer invariably. I hate to admit this, the operation is so beautiful, the theory so splendid; but it will not and honesty compels me. I do not deny that it has cured ulcers, that it has benefitted others, that it will benefit and cure yet others, who will call it blessed: but the past ten years have taught us much and one is this thing of the fallibility of gastro-enterostomy. We have learned that there must be a man with brains behind the gastro-enterostomy, not a machine, who can apply it to the right cases and who has sufficient self control to refrain from its indiscriminate, indiscreet use. It is granted nothing else can be done in certain ulcer cases, still I am one of those who believe that where it can be practiced, excision of the ulcer is far preferable, because it adds a very little to the mortality in the hands of those who know how to do stomach surgery, because it removes the chance of hemorrhage, of infection, of perforation, of cancer, and this gain assuredly is sufficient to affect the one or two per cent. increase of mortality; especially if we recognize that excision cures the ulcer and gastro-enterostomy not only may not do so, but frequently is the cause of establishment of new ulcers whose cure lies out of the domain of surgical therapy. In all these ulcer cases we should not forget when our operation is finished, when the wound is healed and the patient dismissed, that there were certain causes active in the production of the first ulcer, errors of diet, foci of infection, and that their continued activity may serve to cause a second ulcer. Hence, they should be supervised for a long time after cure and directed along the safest course for the maintenance of their reestablished health. 3. Stricture, by which I mean a cicatricial stenosis, resulting from an an inflammatory or ulcerative process, is very simple from the standpoint of treatment, since it is the one condition which probably offers the best result from gastro-enterostomy. This result is ideal only when the pylorus is occluded: hence, when the pylorus is only partially occluded. it must be blocked by artificial means if ideal results are to be obtained, for the stomach is as set in its ways as an old maid, and refuses to permit anything to go the wrong way so long as the old path will admit the passage of even small amounts of its contents: the consequence is that the new opening gradually narrows until its patency is lost. Under certain circumstances Finney's pyloroplasty is better adapted than anastomosis and excision is to be done if there is any question as to the possibility of malignancy: and if it could be done just as safely I should have called this the ideal treatment for pyloric stricture. A slight improvement in the technic will give it precedence. 4. Cancer of the stomach when primary is to be considered from three standpoints by the surgeon, first, prevention: second, cure: third, reestablishment of the stomach outlet: when it is secondary, it is to be considered only from the third point of view just mentioned. From our present ignorance concerning cancer we are safe in asserting that the best way to reduce cancer mortality is to prevent it, to remove the precancerous lesions and to do radical operations early, which being interpreted means that we are to forget and to unteach at least half of what we think we know of cancer. We must know and we must teach our patients that when cancer of the internal organs is far enough advanced to produce a palpable tumor, it is already too far advanced to save more than a very small percentage of cases. We should remember that cancer of the stomach represents approximately one-third of all cancers. This is somewhat discouraging from a diagnostic standpoint, for I am sure we do not diagnose onethird our cancers as arising in the stomach: more's the pity, for the infallible test to prove diagnoses is the operating table and the postmortem, and they reveal the fact. Prevention of cancer of the stomach may be briefly summed up in the statement "cure your gastric ulcers and if operation is necessary, excision is the better plan," for it not only removes the ulcer, it avoids the presence of a scar, the tendency of which to produce cancer we know in general, and especially in this great cancer organ. The second item of cancer of the stomach is its cure by excision and the same rules of cure obtain here as elsewhere for operative relief of cancer, namely total excision of the growth. This sounds simple enough, but probably nine-tenths of the cases come too late. They have doctored themselves for indigestion into that realm that lies just beyond the point of curability, from which no traveler returns. Let me repeat, what I have hinted at already, that any case that has an intrinsic stomach lesion and fails, under correct treatment to show definite improvement or positive cure after six to eight weeks of intelligent treatment, and any case having so improved, if a relapse or a regression occurs, will do himself the greatest blessing to have the abdomen opened. They argue, maybe it won't Maybe dynamite won't explode. won't hurt me.' The third phase of cancer of the stomach, producing pyloric obstruction, is that in which secondary growths interfere with the outlet. They are either metastatic or the direct invasion of the stomach from more or less remote tumors, the most interesting of which is cancer of the breast. I have seen a woman conceal a mammary scirrhus for ten years and then reveal the presence of her trouble only when the pylorus refused longer to open. Gastro-enterostomy gave her thirteen more months of life and comfort. We must, as a profession, learn not to cast our incurable cancer cases aside hopelessly: but must add to their comfort and their expectancy, for it is the operation is intended to reestablish a gasnot our whole duty to cure. In these cases tric outlet at a point as far removed as possible from the advancing margin of the tumor. 5. This item of non-cancerous tumor causing obstruction demands but little attention in the first place because they are exceedingly rare, and in the second place because treatment consists in removal of the growth whether pylorectomy is or is not necessary. important one in my experience, for the num6. This group has proved to be a rather ber of such cases has been relatively large. The adhesions are usually due to pericholecystitis or to peritonitis resulting from perforation of the gall-bladder, which is itself, I believe, of more frequent occurrence than we usually suppose. The treatment of pyloric condi tion must be determined by the findings on entering the abdomen. For in one instance the adhesions are of such nature that the right end of the stomach may be replaced to its normal position and fixed there securely and maintained in a state of patency. If this can be done, it is the correct course to pursue: we should by all means avoid getting gastroenterostomy mania. If the normal channel cannot be restored with certainty then we should make certain, as certain as we can, that it is rendered permanently functionless, and a gastro-enterostomy done. It cannot be impressed too often or too firmly that surgeons should never trust two outlets to the stomach, for it will surely make trouble; the stomach cannot serve two masters: it will hate the one and love the other. 7. I have seen only one case belonging to this division, and have so far not read or heard of another, I will therefore, report the important facts in the case. A young woman, single, age twenty-two, had had occasional vomiting spells as long as she could remember. At last a very protracted one came on and lasted for months, incapacitating her for her work and rendering life miserable. She vomited every variety of food or drink ingested. She lost weight continuously for this period of months, although some food must have passed to the intestine; otherwise she could not have lived. Examination revealed nothing: test meals nothing except the known fact that food would not remain long in the stomach. The contents were normal. Exploratory section revealed a narrow band oneeighth of an inch wide, lying across the pylorus, leading from the gastro-hepatic to the gastro-colic ligament. It was removed and complete cure obtained. 8. Gastroptosis has usually been passed by with a sneer and a diagnosis of neurasthenia, whatever that may be; frankly, I believe it is a figment of the doctor's brain, nothing But this is rapidly developing into one of the most fruitful and grateful fields of surgery. and the number of invalids now riding from mountain to sea-shore, from continent to continent, from clinic to clinic, with no benefit is legion. Now do not understand me to recommend surgery for this condition of ptosis when it is symptomless, it will require a hundred years of busy work for surgeons to relieve those who are suffering and who are being comforted by serious sounding statements that it is hopelessly a case of nerves; then it's more sea-shore, another spring and a course, in peanut butter and bull. But I am wandering afield: only one little item in ptesis concerns me here, namely that which has as one its symptoms, nay, as its most important symptom, obstruction to the outlet of the stom ach. We will discard all other symptoms and their relief and all the sympathy and lies that may be wasted in attempted psychic treatment of this form of neurasthenia, and devote our attention to the patient whose stomach lies at the bottom of the belly instead of at the top and thereby has to lift the contents back from the pelvic floor to the normal site of the pylorus and then find the latter collapsed by sheer dragging of the descended. stomach on its fixed attachments. Then the stomach dilates. They tried gastro-enterostomy on these cases and failed until finally it dawned on somebody that the stomach might be replaced and held in position and the trick was done. I may add that in such cases the cause consists in one of two factors, or both. In one, the virginal type, there is too little room in the lower abdomen where the stomach does not belong. But I cannot enter here into the details of operative treatment. me simply add that it will be a little while yet before even the surgeons are convinced of the efficacy of the treatment, but there are enough. who have faith to prove the results. Let 9. I shall talk a moment of a condition of which I know nothing certain. It is not a surgical condition apparently. My statements are based upon two cases. The patients who have not been operated upon, and in whom no cause is revealed by immediate or subsequent examination. One of my cases occurred in a young man who had a severe organic heart lesion: the other in a young woman in perfect health. They did not vomit, and their one symptom was distress from the dilated stomach. Physical examination showed nothing but a dilated stomach, which in the young lady's case was so large that it filled the abdomen, extending from ribs almost to the pubis. Emptying the stomach with the tube confirms the diagnosis and at the same time seems to effect a cure. Significance of Pain in the Right Side in Young Women. Dr. Randolph Winslow, of Baltimore, states (Southern Surg. and Gynecol. Assoc.) that unless the symptoms of appendicitis in young women are frank and clear, the condition is probably something else. Pain and tenderness in the right side, without rigidity, elevation of temperature and leucocytosis is usually not appendicitis. Apparently severe and long-continued pain in the right side in girls is more likely to be neurotic than appendicular. Pain may also be reflected from the pelvic organs or some of the other viscera, and the primary seat of the disturbance may be determined by a more careful examination. The author thinks we frequently operate too hastily after a diagnosis of appendicitis, without considering sufficiently the other possibilities in a case.-American Medicine. SKIN GRAFTING AND REPORT OF CASES.* By WILGUS BACH, Jackson. As early as 1847 Dr. Hamilton devised a plan to cover a surface denuded of skin, by using a pediculated flap and trusting to nature that the flap would act as a nucleus to form more skin and cover the area. As time progressed various means have been used to accomplish a successful operation for grafting, some methods dating back many years, while others are quite recent discoveries. These methods which are described as follows, have been tried at various times and places with a varied degree of success. Reverdin's method devised in 1869, by which means he cut from the patient's body, the skin to be used, as follows: The surface from which the skin was to be cut was cleansed thoroughly with bichloride, then washing all bichloride away with normal saline. The surface upon which the grafts were to be placed is to be prepared by washing carefully with saline, then scrape away all tissue down to healthy granulations and put on compresses to stop any bleeding that may occur. A sterilized needle is thrust through the skin and is raised to such a position that the operator may cut the skin to such thickness and size as may be convenient for his use. They are placed upon the raw surface and in such a manner as to allow drainage in case there be any discharge, or in case of death of one graft the others would not be affected. The wound is then dressed with gutta percha tissue moistened in saline, covered with aseptic gauze which is also moistened in saline, over which is placed a rubber dam, absorbent cotton and bandage. In 48 hours all dressings except gutta percha tissue may be removed and the wound irrigated with normal saline and be dressed again, within seven days this special dressing may be removed and ordinary sterile dressings applied. This method does not limit the amount of cicatricial contraction to any degree, and the skin is apt to break down for some time after it has completely healed. Wolfe's method was to cut the skin slightly larger than the wound, the entire thickness of the skin, allowing the edges of the graft to overlap the skin on the body around the edges of the wound. No fat is to be upon the graft and in case it is necessary to hold the graft in place it may be sutured in place and dressed in a moist chamber. In case the graft dies of course it must be removed. *Read before the Kentucky Valley Medical Association, Winchester. Olier and Thiersch's method is most followed to-day. Asepticize the wound or ulcer and the site from which the graft is to be removed, by washing carefully with bichloride followed with normal saline so that no mercurial preparation remains. Scrape the wound and its edges or rub off the granulations with a piece of sterile gauze. Compress the wound to arrest hemorrhage. The skin to be removed is put on the stretch, and while it is being cut by the surgeon the assistant is to irrigate continually, the graft with saline. A sharp knife or razor may be used in cutting these grafts, but a hollow ground instrument is very unsatisfactory. The grafts being removed are pressed firmlow the grafts to overlap the edge of the ly upon the wound in such a manner as to alwound in lattice fashion to allow drainage beeach other. The method of dressing skin tween grafts, or may be allowed to overlap grafts vary according to the surgeons ideas I have used the Riverdins method of dressing and locatio nof the wound. In some instances while often I find this dressing can not be applied. I have made appliances of wire netting which was moulded so as to eliminate all pressure and apposition of dressings to the grafts without disturbing the wound. and allowing the nurse to use the saline often Another method which has been very successful is to apply the grafts, over which adhesive plaster is placed, allowing the ends to reach well on the true skin, the adhesive should be in narrow strips, so that the excretions from the wound will escape between the strips, and the pressure will prevent excessive granulation while the grafts are held continually in their original place. In case this method of dressing is used care should be used and not remove adhesive too early as the graft would stick to the adhesive. At first it was thought best to graft skin from the patient's own body, later it was found that skin would grow when taken from another individual. Epithelium from some of the lower animals. have been successfully grafted upon patients, and very often epidermic scales when scraped from a patient and placed upon a wound will form new skin. The methods for obtaining skin for grafts vary according to the surroundings, as well as the views of the surgeon. 1st. The skin may be taken from the patient himself by scraping or cutting with knife or scissors. 2nd. It may be removed from another person or even from lower animals in like man ner. |