—The operation indicated is gastrotomy, i. e., opening of the stomach at a suitable or convenient point, removal of the foreign body or bodies, and the complete closure of the wound as well as of the abdominal incision, without drainage. If due care be maintained throughout, and the element of previous infection be excluded, prognosis is good. When perforation with local peritonitis, and perhaps abscess, has already occurred, there is a local indication as to exactly where to open; one should then complete the operation with the establishment of suitable drainage.
WOUNDS OF THE STOMACH, INCLUDING RUPTURE.
As already indicated, the stomach maybe ruptured, especially if weakened by previous disease, by severe abdominal contusion. It is subject to all possible wounds by perforation, either gunshot or by puncture. As it is more protected than the bowel below it is less liable to perforating injuries. Much will depend upon the nature and the extent of the injury. A small perforation may be protected by prolapse of the mucosa in such a way that little escape of contents takes place. On the other hand it may be extensive, and nearly the entire gastric contents may be poured out into the upper abdomen. The location of the stomach lesion by no means necessarily corresponds to that of the abdominal wall, this being particularly true in gunshot cases. Extravasation depends in amount and rapidity upon the stomach contents and their fluidity. If the posterior wall alone be injured it will empty rather into the cavity of the lesser omentum. Stomach injury may always be diagnosticated if, after abdominal injury, the vomited matter contains blood. The pain is usually severe and involves generally the entire upper abdomen. In proportion as the lesion lies near the diaphragm the breathing may be affected. Collapse is usually prompt and may be due to hemorrhage from a vessel of considerable size. Pain, collapse, and hematemesis constitute indications for the promptest possible opening of the abdomen and investigation, with suitable suture of the stomach wound, toilet of the peritoneal cavity, and drainage, which should be posterior as well as anterior. Every ragged or compromised margin of a stomach wound, especially gunshot, should be neatly excised, and sutures applied in such a way as to only bring clean and fresh surfaces together. An external opening of sufficient length should be made to permit easy and complete withdrawal of the entire stomach, and a complete search over both its surfaces in order that no lesion may escape detection. If the opening made into the stomach be sufficiently large to permit, it would be best to thoroughly empty its contents and gently wipe it out, in order that it may be left not only empty but clean. Should the puncture be very small it would be well to pass a stomach tube from above and wash out the stomach, protecting the opening by pads and pressure, and thus preventing contamination of the peritoneum.
While apparently spontaneous rupture, i. e., without previous ulcer or disease, is most rare, there are a few cases on record where patients have been seized with intense paroxysmal pain and have died more or less quickly, and where the condition has been found with little or nothing to explain it. Immediate operation might possibly have saved some of these had the possibility of its occurrence been recognized. Perforation from within may also occur, as it is known to have happened in the cases of sword or knife swallowers.
Suture of the stomach is practised in exactly the same way in these cases as for other purposes and the method will be described later, along with the other operations upon this viscus.
TUBERCULOSIS AND SYPHILIS OF THE STOMACH.
The gastric mucosa presents a remarkable contrast to that of the intestinal tract, the latter being exceedingly likely to succumb to tuberculous infection, which is exceedingly rare in the former. Primary tuberculous ulceration of the stomach, then, is most unusual. When tuberculous ulcers are found there they are usually the result of a secondary or perforating process. Such ulcers may attain great size, as in one case reported by Simmonds where the ulcerated area measured four by eight inches, yet produced no symptoms during life. This would correspond almost to a lupus of the gastric mucosa. Tuberculous gummas are even more rare, and, occurring in the stomach, are pathological curiosities rather than surgical possibilities.
Syphilis of the stomach is met with either as gumma or ulcer, the latter leading almost inevitably to more or less stricture as recovery follows suitable treatment. Although it is claimed that 10 per cent. of cases of chronic ulcer of the stomach have suffered from syphilis at some time, it by no means follows that such ulcers are to be considered as of genuinely syphilitic origin, as a syphilitic patient is not exempt from other stomach conditions. However, symptoms of gastric ulcer, associated with actual manifestations of syphilis, might well indicate associated syphilitic lesions and would probably yield, with the others, to suitable treatment.
Lesions of either character, which do not subside under proper medical treatment, and which require a surgical operation, would be equally benefited by it whether of one of these types or of the other.