Operations upon the gastrointestinal tract have been so improved in the modern era of antisepsis that at the present day they are quite common. There are so many successful cases on record that the whole subject deserves mention here.
Gastrostomy is an operation for establishing a fistulous opening in the stomach through the anterior wall. Many operations have been devised, but the results of this maneuver in malignant disease have not thus far been very satisfactory. It is quite possible that, being an operation of a serious nature, it is never performed early enough, the patient being fatally weakened by inanition. Gross and Zesas have collected, respectively, 207and 162 cases with surprisingly different rates of mortality:
that of Gross being only 29.47 per cent, while that of Zesas was for cicatricial stenoses 60 per cent, and for malignant cases 84per cent. It is possible that in Zesas's statistics the subjects were so far advanced that death would have resulted in a short time without operation. Gastrotomy we have already spoken of.
Pyloroplasty is an operation devised by Heineke and Mikulicz, and is designed to remove the mechanic obstruction in cicatricial stenoses of the pylorus, at the same time creating a new pylorus.
Gastroenterostomy and pylorectomy are operations devised for the relief of malignant disease of the pylorus, the diseased portions being removed and the parts resected.
Gastrectomy or extirpation of the stomach is considered by most surgeons entirely unjustifiable, as there is seldom hope of cure or prospect of amelioration. La Tribune Medicale for January 16, 1895, gives an abstract of Langenbuch's contribution upon total extirpation of the stomach. Three patients were treated, of whom two died. In the first case, on opening the abdominal cavity the stomach was found very much contracted, presenting extensive carcinomatous infiltration on its posterior surface. After division of the epiploon section was made at the pylorus and at the cardiac extremities; the portions removed represented seven-eighths of the stomach. The pylorus was stitched to the remains of the cardiac orifice, making a cavity about the size of a hen's egg. In this case a cure was accomplished in three weeks.
The second case was that of a man in whom almost the entire stomach was removed, and the pyloric and cardiac ends were stitched together in the wound of the parietes. The third case was that of a man of sixty-two with carcinoma of the pylorus.
After pylorectomy, the line of suture was confined with iodoform-gauze packing. Unfortunately the patient suffered with bronchitis, and coughing caused the sutures to give way; the patient died of inanition on the twenty-third day.
Enterostomy, or the formation of a fecal fistula above the ileocecal valve, was performed for the first time by Nelaton in 1840, but the mortality since 1840 has been so great that in most cases it is deemed inadmissible.
Colostomy, an operation designed to make a fistulous opening in any portion of the rectum, was first practiced by Littre. In early times the mortality of inguinal colostomy was about five per cent, but has been gradually reduced until Konig reports 20cases with only one death from peritonitis, and Cripps 26 cases with only one death. This will always retain its place in operative surgery as a palliative and life-saving operation for carcinomatous stenosis of the lower part of the colon, and in cases of carcinoma of the rectum in which operation is not feasible.
Intestinal anastomosis, whereby two portions of a severed or resected bowel can be intimately joined, excluding from fecal circulation the portion of bowel which has become obstructed, was originally suggested by Maisonneuve, and was studied experimentally by von Hacken. Billroth resorted to it, and Senn modified it by substituting decalcified bone-plates for sutures.
Since that time, Abbe, Matas, Davis, Brokaw, Robinson, Stamm, Baracz, and Dawburn, have modified the material of the plates used, substituting catgut rings, untanned leather, cartilage, raw turnips, potatoes, etc. Recently Murphy of Chicago has invented a button, which has been extensively used all over the world, in place of sutures and rings, as a means of anastomosis. Hardly any subject has had more discussion in recent literature than the merits of this ingenious contrivance.
Foreign Bodies in the Rectum.--Probably the most celebrated case of foreign body introduced into the rectum is the classic one mentioned by Hevin. Some students introduced the frozen tail of a pig in the anus of a French prostitute. The bristles were cut short, and having prepared the passage with oil, they introduced the tail with great force into the rectum, allowing a portion to protrude. Great pain and violent symptoms followed; there was distressing vomiting, obstinate constipation, and fever. Despite the efforts to withdraw the tail, the arrangement of the bristles which allowed entrance, prevented removal. On the sixth day, in great agony, the woman applied to Marchettis, who ingeniously adopted the simple procedure of taking a long hollow reed, and preparing one of its extremities so that it could be introduced into the rectum, he was enabled to pass the reed entirely around the tail and to withdraw both. Relief was prompt, and the removal of the foreign body was followed by the issue of stercoraceous matter which had accumulated the six days it had remained in situ.
Tuffet is quoted as mentioning a farmer of forty-six who, in masturbation, introduced a barley-head into his urethra. It was found necessary to cut the foreign body out of the side of the glans. A year later he put in his anus a cylindric snuff-box of large size, and this had to be removed by surgical methods.
