1282 THE ORGANS OF DIGESTION 



the skin, over the margin of the costal cartilage, above and a little to the outer side of the first 

 incision. If Fenger's incision were used, the second incision should be above the margin of the 

 cartilages. With a pair of dressing forceps a track is made under the skin through the subcu- 

 taneous tissue from the one opening to the other and the diverticulum of the stomach is drawn 

 along this track by means of this suture inserted into it; so that its apex appears at the second 

 opening. A small perforation is now made into the stomach through this protruding apex and 

 its margin carefully and accurately sutured to the margin of the external wound. The remainder 

 of this incision and the whole of the first incision are then closed in the ordinary way and the 

 wound dressed. 



In cases of gastric ulcer, perforation sometimes takes place, and this was formerly regarded 

 as an almost fatal complication. In the present day, by opening the abdomen and closing 

 the perforation, which is generally situated on the anterior surface of the stomach, a consider- 

 able percentage of cases are cured, provided the operation is undertaken within twelve to fifteen 

 hours after the perforation has taken place. The opening is best closed by bringing the peri- 

 toneal surfaces on either side into apposition by means of Lembert sutures. 



Pylorectomy or excision of the pylorus is performed, particularly for early cancer, but is also 

 done for cicatricial stricture and for ulcer. The mortality after operation for cancer was, until 

 recently, very great, but of late years it has been notably reduced, though it is still much higher 

 than that which follows operations for any non-malignant condition. 



In operating for cancer, bear in mind Cuneo's study of the lymphatics (p. 795). These 

 observations indicate that the fundus and two-thirds of the greater curvature are free from 

 lymphatic involvement in pyloric cancer. 1 In every operable case of cancer of the pylorus 

 the entire lesser curvature must be removed up to the gastric artery (Mikulicz's point), and 

 the greater curvature must be removed to the left of the involved lymph nodes (Hartmann's 

 rule). 



Gastroenterostomy is an operation which establishes a fistulous communication between the 

 stomach and jejunum. The operation is often called gastrojejunostomy. The opening may be 

 made upon either the anterior or the posterior wall of the stomach, between the cardia and the 

 seat of pyloric disease. The operation is employed for stricture of the pylorus (benign or malig- 

 nant), and occasionally for ulcer of the stomach. 



Hypertrophy and spasm of the circumferential muscular coat of the pylorus coming on 

 during the first few weeks of life, and somewhat erroneously described as congenital hyper- 

 trophic stenosis of the pylorus, is a rare but serious disorder of infancy. It is characterized by 

 abdominal pains and obstinate vomiting coming on after food has been given, and gastric 

 peristalsis can be observed by inspection of the child's epigastrium after it has been fed and 

 before vomiting has occurred. Progressive wasting for want of nourishment and death from 

 exhaustion tend to ensue. Treatment should be by washing out the stomach, and the admin- 

 istration at frequent intervals of small quantities of easily digested food. Surgical interference 

 pyloroplasty or pylorectomy entailing a severe operation, gives less favorable result. 



Total gastrectomy is the removal of the entire stomach. It is only used for cancer. It was first 

 performed by Conner, of Cincinnati. The first successful operation was done by Schlatter, of 

 Zurich, in 1898. A number of successes have been reported. It is a justifiable operation only in 

 a case in which almost the entire stomach is cancerous, in which the viscus is movable, in which 

 there are no secondary deposits, and no irremovable diseased lymph nodes. 



Gastrogastrostomy is an operation employed in hour-glass stomach. In this operation an 

 anastomosis is made between the pyloric and cardiac ends of the stomach. 



Gastroplication is the operation of suturing the stomach wall into folds or reefs, in order to 

 lessen its size. It is employed in some cases of gastric dilatation. 



Gastroptosis is a condition in which the stomach is displaced downward. In some of these 

 cases the greater curvature almost reaches the level of the symphysis pubis, and the lesser curva- 

 ture is midway between the umbilicus and ensiform cartilage. The condition is usually associated 

 with enteroptosis and movable kidney (nephroptosis). In this condition the gastrohepatic omen- 

 turn is pulled upon and lengthened. The best operation for gastroptosis was devised by Beyea. 

 He applies sutures so as to make folds in and thus shorten the stretched omentum. Thus the 

 stomach is elevated to its proper position, and its mobility is not lessened, as it is in other opera- 

 tions which suture it to the abdominal wall. 



THE SMALL INTESTINE (INTESTINUM TENUE). 



The small intestine is a convoluted tube, extending from the pylorus to the 

 ileocecal valve, where it terminates in the large intestine. It is about twenty feet 



1 William J. Mayo, Annals of Surgery, March, 1904. 



