The question in cases of gastric ulcers is whether they have yet advanced to actual malignancy. Probably no surgeon has ever attacked a case of gastric cancer which has not been under treatment for a time for so-called “dyspepsia or indigestion,” perhaps with a more definite diagnosis. Too many internists have waited for the discovery of a tumor before thinking of surgery. It is the business and the duty of every surgeon to impress upon the profession that the only way to treat cancer successfully is to treat it radically, and the only way to do this is to operate early. This applies equally well to the viscera or to the external portions of the body. Gastric cancer is essentially a surgical disease, and could it be recognized early and treated radically it could often be cured.

What are we to do then in the absence of early and indicative symptoms? The following rule may be laid down as one to which there is no exception: A well-founded suspicion of cancer of the stomach (or of any part of the alimentary canal) justifies an exploratory operation for its detection and recognition, which then should be extended into an operation for its complete removal should circumstances justify it. If this rule were followed we would not hear of cases of this description remaining for months or years under drug treatment, and then perhaps being finally turned over to the surgeon for relief of pyloric obstruction at a period when strength is so reduced that no operation should be seriously considered.

Gastric cancer is, then, at least in its earlier stages, a surgical disease. How is it to be recognized? By exploratory incision when there is serious doubt as to the nature of dyspepsia or indigestion which fails to promptly improve under suitable treatment. In an early stage even this might not be easy, especially for the inexperienced. Nevertheless any cancer of the stomach which produces distinct disturbances of digestion will have advanced to a degree of infiltration and thickening which will permit of its recognition by the touch of a practised operator. The discovery, then, of thickening in the stomach wall will imply the presence therein of either an ulcerated or cancerous area, which will in either event demand relief. In such a case the stomach may be opened and the mucosa exposed to sight and touch. Should the lesion prove to be malignant the same rule will apply with greater force, with the sole difference that the area should be much larger and that the surgeon should keep clear of suspicious tissue. This may necessitate a more or less complete removal of a considerable portion of the stomach. The greatest care should be exercised in the discovery and removal of all infected lymph nodes, which will be found especially along the curvatures and within the peritoneal fold. When retroperitoneal lymph involvement is discovered a hopeless aspect is put upon the case. Life may be prolonged for two or three years, even under such circumstances, and the patient is certainly entitled to whatever can be afforded him. If the cancerous process has advanced to a point or a degree making radical removal impossible, one may at once select the other alternative and perform a gastro-enterostomy at a point of election, by which relief may be afforded for at least a number of months.

Only by exploration, then, can it be decided whether to attempt a radical measure or a palliative procedure. It is scarcely fair to quote statistics in this regard, especially any but the most recent, as only lately have these cases been referred for early operation. Obviously the less wide the removal the less reduced the patient, the more favorable is his condition to withstand operation, and the more favorable the aspect of his case. Thus pylorectomy before gastric dilatation has occurred is more promising than pylorectomy when half the stomach is involved. In proportion, then, as these cases are submitted to early operation, statistics will improve and better results be attained, while if physicians and surgeons can be made to coöperate early an ever-growing number of cases will be seen and operated at a favorable time.

The various operations practised, including gastrectomy, pylorectomy, etc., will be discussed with the other operations upon the stomach.

PERIGASTRITIS.

To this term attaches about the same force and significance as to perihepatitis or perisplenitis. The expression implies the consequences of a local peritonitis, usually of low grade, by which adhesions are produced that may anchor the stomach in whole or in part, in any possible direction and to any of the surrounding viscera or part of the abdominal wall. Such adhesions are more common at the pyloric end than elsewhere. Their causes may be intrinsic or extrinsic, among the former ulceration and cancer being by far the more common; among the latter gallstones, tuberculous processes, and occasionally the remote consequences of typhoid ulceration. In the majority of cases the adhesions thus produced are protective and purposive, although they often constitute a serious obstacle to surgical work. While they may be suspected in almost any of the conditions above named, they are rarely discovered or identified until the abdomen is opened. Nevertheless, distention of the stomach with gas and the discovery of its irregular movements or shape because of fixation will afford good ground for suspicion as to the condition itself. When it can be shown that these adhesions are producing pain or discomfort, as they often do, operation, gastrolysis, affords the only legitimate and reasonably certain relief. Time sometimes permits a stretching of adhesions or the possible absorption and amelioration of symptoms, but only by surgical intervention can anything radical or prompt be offered.

PHLEGMONOUS GASTRITIS.

Under this term is included a suppurative or necrotic inflammation of the stomach wall, beginning probably in the submucosa, but extending in both directions. It appears in two forms—the circumscribed and diffuse.

Symptoms.

—The symptoms of the latter are those of an intensely acute gastritis with rapid, almost inevitably fatal course, beginning with severe pain, quickly followed by faintness and collapse, with early vomiting, vomited matter being first bile-stained, then containing blood. The sensation of nausea is extreme and a complaint of thirst constant. Frequently there are hiccough and peculiar and uncontrollable general restlessness. Pain is, however, a variable feature, and some cases are too rapidly necrotic to afford much pain or tenderness. The pulse is rapid, weak, and poor, and the temperature usually runs high. After a short time the abdomen may be much distended, while symptoms of paralytic ileus (i. e., obstruction), supervene, though occasionally there is offensive diarrhea. A well-marked case of this type comes on with fulminating suddenness, patients later becoming apathetic and dying in stupor.

About all this there is nothing peculiarly characteristic, and similar symptoms might be caused by mesenteric thrombus, by acute pancreatitis, or acute gangrenous cholecystitis.

Symptoms of the more circumscribed form are similar to those just described, but of less severity. The pain and vomiting appear suddenly, but are less intense. If time be afforded for formation of abscess a distinct tumor may be felt. Appetite is lost and food regurgitated. A localized lesion favorably placed might lead to adhesions and circumscribed collection of pus, assuming the subphrenic or some less typical form. The pyloric end of the stomach is more commonly involved in such a process and affords evidence to the effect that it begins as an infection, the port of entry being usually a gastric ulcer.

Treatment.

—Treatment would be surgical if any were available, but has never yet been applied sufficiently early to save an acute, generalized case. On the other hand, when the lesion has been local and has led to subsequent phlegmon, cases have been successfully opened and drained.

OPERATIONS UPON THE STOMACH.

In every instance, when time is afforded, certain preparations should have been made by which the stomach has been put in an aseptic condition. Not only should it be emptied of food in the ordinary sense, but it should have been washed out at least once, and in most instances repeatedly, first with cleansing lavage and then with a fluid containing a small proportion of borax, with the intent that by a mildly alkaline solution its contained mucus may be more thoroughly washed away. This alone, however, is not sufficient, for quantities of septic material may be introduced by the patient from his nose and throat. Frequent use of the toothbrush, with a strong antiseptic powder or solution, and frequent rinsing of the mouth with a suitable antiseptic mouth-wash, should be practised at frequent intervals for two or three days before such an operation. If offensive mucus be dropping from the nasopharynx this also should be cleansed and sprayed. In other words the possibility of contamination from the nose and mouth should be prevented as completely as possible.[57]

Operation for Penetrating Wounds.

—When the stomach has been opened by gunshot, stab, or other wounds it should be closed at the earliest possible moment. The operation intended for this purpose may be simple or difficult, and may be complicated by the fact of injuries to other organs. A simple opening is easily closed, when exposed, by sutures, of which there should be at least a double row, the internal devoted entirely to the mucosa, whose edges should be brought together and held by a continuous chromicized catgut suture, with stitches at intervals sufficiently short to prevent the possibility of hemorrhage, and interrupted occasionally to prevent puckering. A second row of sutures, of fine silk or thread, is then applied, by which the serous and muscular coats are firmly approximated, care being taken that the needle is not allowed to perforate a vessel and thus produce hemorrhage. The stomach walls are so thick that two layers of sutures thus applied usually suffice. If thought advisable a third suture may be applied after the manner of the second. A round needle is usually preferable to a flat one with cutting edges.

Great care should be maintained to prevent escape of stomach contents or infection of the peritoneal cavity, if this has not already occurred. In some cases after exposing the stomach wound it may be advisable to pass a stomach tube and wash out the stomach, holding the wound with a compress in order that no leakage at this point can occur. Unless there is some good reason for not doing this it should be the method of choice. Two dangers particularly characterize cases requiring gastrorrhaphy: the first that of assuming that there is but one wound and failing to discover others which may co-exist; the second that of infection by the stomach contents which have already escaped. The first is to be avoided by careful observation and examination; the second by a careful toilet of the peritoneum, both before and after suturing. Drainage may be provided according to the necessities of the case.

A gunshot wound produces more or less contusion of the tissues in its immediate vicinity. Liberal allowances should then be made in suturing that gangrene and subsequent perforation may not occur; or, better still, when it can be properly done, the margins of gunshot wounds should be smoothly excised and fresh clean surfaces thus brought together.

Gastrotomy.

—The stomach is opened for purposes of exploration or for removal of foreign bodies, as may be needed, and then promptly and completely closed when the opening has permitted such diagnosis or removal, or after a diseased area in its interior has been exposed by incision. Such may be the procedure in certain cases of gastric ulcer, where the stomach is opened, its entire lining examined and the sharp spoon or cautery applied, with or without linear suture. The stomach is also opened for dilatation of its orifices as in cases of cardiospasm or pyloric stenosis, although the latter procedure has given way to anastomotic methods, which are more permanent in their results.

The stomach having been exposed, usually by a sufficiently long median incision, it is brought out and divided at a point of election, the incision being made of sufficient length to permit introduction of forceps or finger, or even of more or less eversion of its interior surface in order that it may be carefully inspected. The purposes of the opening having been achieved, it is closed as indicated above, with at least two layers of sutures. A perfectly clean wound will scarcely call for drainage. One which has been infected should be protected in this way.

Gastrotomy has also been done in order to permit of the retrograde division of strictures of the esophagus, when it has been impossible to pass even the smallest bougie from above. In these cases it has been occasionally possible after exposing the stomach to introduce a whalebone bougie which, passing upward, may follow the tortuous passage and be made to appear in the pharynx. To its upper end may then be attached, by strong silk, the small end of another bougie, and thus guide it downward as the first one is withdrawn. This procedure has been improved on by Abbe, who has thus been able to pull down from the mouth a stout piece of coarse silk, bringing it out through the stomach opening, and then, by a species of sawing manipulation, divide the tightest and densest part of an esophageal stricture sufficiently to permit of the passage of some other instrument. This having been accomplished the stomach wound is immediately closed.

Gastrostomy.

—This term implies making an opening into the stomach by which its cavity may be directly connected with the exterior abdominal surface, and the communication thus established maintained indefinitely. The procedure itself is necessary in cases of dense stricture or malignant disease of the esophagus, or the growth of such a tumor in its vicinity as shall occlude it, and thus cause slow starvation unless atoned for in some manner. In one instance recently, where I expected to do a gastrostomy, because the stomach itself had been so destroyed by powerful caustic that not only was the esophagus ruined as such, but the stomach decreased in size and motility, I found the stomach too immovable to permit of this procedure, and accordingly utilized the duodenum just beyond the pylorus, thus making essentially a duodenostomy; the indications, however, being the same as for gastrostomy. We have, in other words, to effect a permanent gastric fistula, the older method being to make the most direct possible communication between the stomach and the surface of the body, and then to introduce a tube, or resort to some similar expedient for preventing cicatricial contraction, and perhaps even subsequent closure. Silver tubes were formerly used, whose openings were corked and kept closed when the tube was not in use. In consequence of this foreign body with the irritation it produced there was always more or less leakage and discomfort. The more recent methods have been devised with an intent of making a tunnel rather than a direct opening, through which, as needed, a soft rubber tube may be introduced, whose walls shall collapse at other times and close themselves, if necessary, with a little assistance, by pressure, thus preventing leakage. Sometimes it is possible to attain this ideal. At other times a rubber tube is worn a greater part at least of the twenty-four hours.

All operative methods include fixation and consequent adhesion of the anterior stomach wall to the parietal peritoneum, just below the border of the ribs. Of the many methods employed the following will be described, most of which can be easily appreciated in diagram:

Figs. 529 and 530 illustrate, for instance, Witzel’s method, where a sterile, soft rubber catheter is infolded in the stomach wall, and finally passed into its cavity through the smallest opening that may suffice for the purpose, after which the outer layer of the stomach is completely closed over it. The stomach itself is stitched to the deep margins of the external wound, and these are then closed without drainage. If everything has been neatly done feeding may be begun within a few hours. Care should be exercised about passing into a stomach which has long been without much food a quantity which may disturb it, or of a quality which may distress it. A procedure very much like Witzel’s is that described by Marwedel, who first sews the stomach to the abdominal wound after drawing it partly into the wound, in order to afford sufficient working material, and then infolds the tube and inserts its lower end through a small opening. This is perhaps preferable, since the stomach being so fastened up at once there is no possibility of leakage into the abdomen.

Figs. 531, 532 and 533 illustrate Frank’s method, where the stomach is pulled up through a sufficiently long incision and drawn out into a cone, whose apex is then brought out through a second small incision, parallel to the first and at a distance of an inch or so from it. Here an actual opening is made into the stomach, while the cone is fastened to the skin here and to the peritoneum through the other opening, which is then completely closed. This method cannot be applied to a contracted stomach.

Cardiospasm.

—Operation for this condition consists essentially in a gastrotomy as above, the opening being made sufficiently near to the cardia in order that either with finger or with suitable dilating instrument passed upward from below, the contracted cardiac orifice may be stretched, or, if necessary, nicked at several points, and then forcibly dilated, in this latter procedure great care should be given that stress be distributed as much as possible. If it be practicable to introduce any dilating instrument a four-bladed uterine dilator would probably be ideal for the purpose.

Operations for Pyloric Stenosis.

—Among the earliest suggestions of a method of pylorodiosis was that of Loreta, who opened the stomach near the pyloric end and deliberately introduced through the constricted pyloric ring a dilating instrument, fashioned much after the shape of the ordinary glove stretcher, which, in fact, might be used for such a purpose should emergency require. The operation is simple and but slightly dangerous, but it was found that strictures here as elsewhere tend to contract, even after forcible dilatation, and that the method, while temporarily successful, was but seldom permanently so. It was applicable only to the cicatricial, i. e., the non-malignant cases.

A plastic method was then suggested independently by Heinecke and Mikulicz, with which their names are often connected and which is referred to as pyloroplasty. It consists essentially in making a buttonhole incision in one direction and then closing it in the opposite, as illustrated in Figs. 534, 535 and 536.

When cicatricial tissue is not too dense, and the parts not infiltrated, it has given satisfactory results. Even here it has been found to be frequently reduced in size by subsequent contraction, and the method suggested by Finney is more serviceable.

Finney’s pyloroplasty consists in making an anastomotic opening between the pyloric end of the stomach and the first part of the duodenum, and will be best appreciated from the accompanying illustrations (Figs. 537, 538, 539, 540 and 541).

The opening can be made as extensively as desired, and it is not easy to see how it can be subsequently reduced to a degree disadvantageous to the patient.

Gastro-enterostomy may be needed in non-malignant cases, because of fixation and the impossibility of bringing the pyloric end of the stomach out sufficiently to make operation feasible. It will be required in cases of cancer when pylorectomy is not indicated. The method of making gastro-enterostomy will be described later.

Operations for Dilatation of the Stomach.

—Gastroplication consists of taking a number of “tucks” in the stomach wall and thus reducing its capacity. The purpose and the method of the operation will be appreciated by the accompanying illustrations. These operations are mainly indicated, however, in the absence of pyloric stenosis, for if a free opening be afforded from the dilated stomach into the upper bowel the gastric enlargement will usually be spontaneously reduced (Figs. 542 and 547).

Gastropexy is a term applied to fixation of the stomach to the anterior abdominal wall. It has been thus stitched up in a few cases when greatly dilated or depressed into the lower abdomen. Fig. 548 illustrates the method. The stomach has also been suspended by shortening the gastrohepatic and gastrophrenic ligaments, as illustrated in Fig. 549.

Operations for Gastric Ulcer.

—In dealing surgically with an ulcer of the stomach the selection has to be made between anastomosis and direct exposure of the stomach wall with the performance of a gastrotomy (i. e., opening the stomach) and then discovering the site of the ulcer, either treating it with the actual cautery, the curette, or, preferably, when this general method is adopted, completely excising the involved area and bringing the margins of the wound thus made together with sutures, which over the mucosa only may be of chromic gut. Should it seem advisable to excise the entire thickness of the stomach wall it would be better to suture in two layers, making the external one of thread or silk, while the inner one may be made of reliable chromic catgut. If this operation be attempted the incision into the stomach should be made sufficiently large to permit of thorough exploration. Nothing being found in the anterior wall, the gastrocolic omentum should be opened and the entire stomach palpated between the operator’s hands. Any suspiciously indurated spot on the posterior wall may then be so manipulated as to be brought into view through the anterior opening. Other surgeons besides myself have noted the occurrence of serious hemorrhage, which, upon exposure, must have come from small fissures or cracks in the mucous membrane. In fact the lesion which may furnish a considerable amount of blood may thus be so small and concealed as to be really difficult of exposure. However, exploration should be made as thoroughly as possible. The stomach having been opened and the ulcer found, it should be treated by one of the above methods. If, on the other hand, nothing be found the surgeon still has the measure of gastro-enterostomy. Any ulcer, however, which is threatening perforation can usually be recognized by the sense of touch alone, corroboration being afforded by inspection. An ulcer which is recognized and found to be favorably situated may be completely excised. It has been found, however, that this ideal measure of local attack gives but little better results than does the general procedure of gastro-enterostomy, while, on the other hand, it is less satisfactory in some respects and seems to be an equally if not more dangerous procedure.

The rationale of making an anastomotic opening between the stomach and the upper end of the bowel is simply this: that thereby the stomach is given a degree of physiological rest to which it has long been a stranger, and that food may pass easily from the stomach into the upper bowel without irritating or aggravating the ulcerated portion, which is usually at the pyloric end. It should be understood, then, that gastro-enterostomy, done for this purpose, is simply a means of carrying out the universally applicable canon of physiological rest for diseased organs or surfaces. The operation of making this anastomosis will be described below.

Pylorectomy and Gastrectomy.

—A complete removal of the pyloric end of the stomach is usually referred to as pylorectomy, while still more extensive extirpation of portions of the stomach proper are spoken of as gastrectomies. In a few instances it has been possible to practically remove the entire stomach, this having first been done by Schlatter. Such an operation would be spoken of as total gastrectomy. These operations are done almost exclusively for removal of areas involved in cancerous growth. Obviously the more extensive the growth the greater the amount of stomach which should be removed. For some reason as yet unknown cancer of the stomach rarely transgresses the pyloric ring, and thus the first part of the duodenum usually escapes involvement, even though the stomach be extensively diseased. All these operations, therefore, include simply the removal of a part terminating with the pyloric ring proper. It is seldom necessary to take away any of the duodenum. Removal of the pylorus may be also applicable in certain cases of benign strictures, where the mere plastic operations would seem insufficient, as well as in the cases of ulcers encroaching upon the pyloric ring itself.

For all of these operations the stomach is exposed through a median incision, or, if a tumor presents distinctly upon the right side, the incision may be made even far to the right and near the semilunar line. Through an opening sufficiently liberal the stomach and the movable part of the duodenum are withdrawn and carefully examined. When the pylorus is so fastened by dense adhesions within the abdomen that it cannot be withdrawn it is best to abstain from this particular procedure, as the mechanical difficulties too greatly enhance its dangers. Suitable clamps, whose blades are protected with soft rubber, are essential in order that the duodenum may be clamped beyond the line of its division, and that the stomach as well may be fixed between their blades, for the double purpose of controlling hemorrhage and preventing escape of contents. The omentum along the involved part of the stomach should then be carefully tied off, in a series of loops, before its vessels are cut, and one should take great pains to hunt out enlarged lymph nodes and include them in the area to be removed, or else make a separate incision for those that cannot be thus extirpated. To leave lymph nodes which are perceptibly involved in the cancerous process is to invite the speediest possible return of the disease, even though the operation should be successful. The upper and lower borders of the stomach being thus freed, the surgeon is then at liberty to cut away all the diseased portion, going at least an inch beyond the apparent limit of the disease. There will result from any such operation two divided ends of the alimentary canal, i. e., one, that of the divided stomach, much larger than the other, which is the upper end of the duodenum.

Two procedures are now open to the surgeon: He may entirely close each of these openings with sutures and then make a posterior gastro-enterostomy, making new openings for this purpose, and by the common method described below, or he may reduce the size of the stomach opening and endeavor to fit it to that of the duodenum in such a way as to bring the two openings opposite each other, where they are then approximated as in ordinary end-to-end resection of the intestine. The earlier operation of Billroth and his followers was made according to the latter plan. It has been found usually easier and more successful to adopt the former method, as it is easier thus to prevent leakage and consequent infection; that is, the majority of operators would today probably completely close the stomach and the duodenum, and proceed at once to make a posterior gastrojejunostomy.

Figs. 550, 551 and 552 give a fair idea of the procedure of end-to-end reunion. The edges of the mucosa should be united with chromic gut, the stitches being close to each other, to prevent leakage and to control hemorrhage from small vessels. The external sutures of silk or thread should be placed sufficiently deep to afford a strong bond of union, and, at the same time, to escape the mucosa. Some difficulty is met here, for the thin wall of the duodenum should be attached to the thick wall of the stomach, but with care it can be done. When the divided stomach end has been reduced or trimmed off in such a way as to leave only a portion to be matched with the duodenal opening, there is need for extreme care at the corners and angles of the suture margins, as here tearing of stitches or separation by tension, perhaps during the act of vomiting, are most likely to occur. Fig. 553 indicates the first of the procedures above mentioned.

In performing complete gastrectomy the cardiac end of the stomach is brought down and fitted to the upper end of the divided duodenum, after removal of the stomach, which will usually be possible under favorable circumstances, but which exposes the patient to great risks of tearing apart reunited surfaces by undue tension.

Gastric Anastomosis.

—This consists in making an anastomotic opening between the stomach and the uppermost part of the jejunum, the duodenum proper being too bound down in its course to permit of its utilization for this purpose. Gastro-enterostomy, then, should be referred to as gastrojejunostomy. In brief, it consists in making an opening by which the stomach shall empty directly into the upper bowel, and while, for this purpose, one of the uppermost loops would theoretically suffice, it has been found that the shorter the loop, i. e., the portion between the duodenum proper and the upper part of the bowel used for this purpose, the better for the patient.

Gastrojejunostomy is, first of all, referred to as anterior or posterior, according to whether a loop of bowel be brought up in front of the omentum and around it, and attached to the anterior and exposed wall of the stomach, or whether the lesser peritoneal cavity be opened by perforating the omentum behind the colon and below the stomach, so that the posterior wall of the latter is found, drawn into the wound, and made accessible and utilized for the purpose. The anterior operation is the easier of performance, but the posterior is far preferable in most instances. Should it be found that the posterior wall of the stomach is far more involved in cancerous infiltration than the anterior, the anterior operation should be performed.

Simple as is the procedure in theory there are about it one or two complications which were not at first foreseen. Perhaps the most important of these is that bile emptied into the duodenum passes downward until it has an opportunity to escape through the opening directly into the stomach, usually in the direction of least resistance. This may then carry it where it is a most undesirable fluid, and prevent its passage onward into the intestine, where it is physiologically needed. This circulation of bile has been spoken of as the “vicious circle” and it is the formation of a vicious circle which has complicated not a few of the anastomotic stomach cases, and which has engaged the attention of not a few clinicians and operating surgeons.

The second objection is that the contact of stomach contents with the mucous membrane at a point below where the bowel is normally prepared for it, and before intestinal contents have been prepared by bile or materials alkalinized by this fluid, sometimes leads to the formation of ulcer just opposite the opening, and this has been referred to as peptic ulcer of the jejunum. This is a possible though not a frequent complication, but has added weight to the other considerations regarding the best way of performing anastomosis. Again, it has been feared that this anastomotic opening would contract in time, or sometimes completely close. This objection obtains especially with anastomosis, made with a Murphy button, or its equivalent, and can rarely be made against the ordinary suture methods. Again, if the opening in the intestine be made too long the intestine itself may be narrowed, for too much of the circumference of the bowel may be taken up in the formation of the anastomosis, and thus there will be mechanical obstruction with vicious circle.

“Vicious circle” produces symptoms which do not appear until the lapse of at least three days after the operation. If vomiting should persist and retain a bilious character it is to be feared that some complication of this kind has occurred. Under these circumstances when lavage is practised a large amount of fluid mixed with bile, perhaps blood, may be returned.

Much depends also on the exact location of the attachment of the intestinal loop to the stomach. Other difficulties arise from possible twisting of the loop of small intestine, or its strangulation by being entangled beneath the bridge of the jejunum, which is always made in every anastomosis. Again the small intestine may become incarcerated in an imperfectly closed opening made in the mesocolon. It will thus be seen that the posterior method has disadvantages which need to be fully appreciated. On the other hand it has this great advantage, that it permits of drainage or emptying of the stomach into the jejunum by gravity, in almost any position which the patient would ordinarily assume, either sitting or lying. Many operators have devised methods of preventing formation of the vicious circle.

Fig. 554 illustrates how valves may form which there is no sure method of preventing. Fig. 555 represents the suggestion of Braun, to make a second anastomotic opening between the small intestine above the stomach opening and below it, hoping that in this way bile, for instance, may pass directly through this opening, which it will first meet, into the intestine below, and thus not pass on and into the stomach. Others have divided the loop of jejunum after making the second anastomosis, in this way planting the efferent portion of the bowel in the stomach and then planting the afferent portion of the bowel into the side of the efferent part. This is the so-called Y-gastrojejunostomy. Roux does much the same thing, save that his method is all carried out behind the colon instead of in front of it. The principal argument in favor of the use of the Murphy button, in this procedure, is that vicious circle is less frequent after its use than after most of the suture methods, all of which would simply indicate that vicious circle is largely a matter of valve formation, and that by the time the button is loosened and passed on the danger period seems to have elapsed, and the current in the new direction to be well established. Nevertheless the button is now discarded by almost everyone in favor of the suture.