Treatment.
—The ordinary routine treatment failing to give relief, one may, in mild cases, adopt an external mechanical treatment, consisting of a suitable abdominal bandage which should press the viscera up from beneath, and thus relieve splanchnic congestion and weight.
Mechanical support failing and symptoms persisting, the surgeon is able to afford relief by gastropexy, first suggested by Duret, and consisting of an exposure of the stomach through the middle line and its fixation to the anterior abdominal wall. This, however, has its theoretical disadvantages, since it might be followed by symptoms similar to those resulting from pathological adhesions. The method has been more or less modified, sutures being passed through the gastrohepatic omentum and gastrophrenic ligament in such a way as to bring them into close contact and looking to their complete union. Thus, Beyer, of Philadelphia, has reported four cases apparently successfully operated upon in this fashion. Bier has added four others, all of which seem to afford much encouragement to operative treatment of gastroptosis. Furthermore, Coffey has modified the technique in such a way as to include a sort of suspension of the stomach by making a hammock out of the great omentum. He did this by stitching the omentum to the abdominal peritoneum, about one inch above the umbilicus, with a transverse row of sutures about one inch apart.
GASTRIC TETANY.
Gastric tetany has but relatively small interest for the surgeon, save as it may complicate some of his results or prevent his endeavor to secure them. The condition is usually characterized by peculiar, disturbed sensation in the extremities, with a feeling of coldness or numbness in the limbs, and drowsiness, vertigo, and disproportionate weakness after exercise. Somewhat severe attacks are sometimes precipitated by lavage, and are then begun with a complaint of formication, followed by tetanic contraction of the muscles of the extremities. Instead of tonic spasm the muscles may be in more or less constant motion. The muscles of the face, neck, and abdomen are also involved. The facial expression changes, and patients may complain of loss of vision. During these paroxysms they may even mutter or speak unintelligibly. Chvostek some time ago showed how to produce these spasms, when the condition is present, by tapping over the facial nerve just at its exit from the cranium, and Trousseau demonstrated that during the attack the paroxysms may be produced at will by compressing the affected parts in such a way as to impede venous or arterial circulation through them. Some of these spasmodic attacks are accompanied by severe pain, while spasm is usually made less painful by gently yet forcibly overcoming it by pressure. The condition is essentially toxic, usually autotoxic, and yet, inasmuch as it may complicate the best efforts of the surgeon or complicate the case upon which he would wish to operate, it is deserving of this brief description here, largely in order that it may not be mistaken for true tetanus or be misinterpreted in any other way.
CARDIOSPASM.
This is a term recently suggested by Mikulicz for a peculiar contraction of the lower end of the esophagus and the cardiac orifice of the stomach, which is occasionally met with, and until fully described by him was somewhat misunderstood. In consequence of the spasmodic stricture thus produced there occurs dilatation of the esophagus above and formation of a sac, which may be discovered by the bougie or tube, or by a good radiogram, after having been filled with a weak bismuth emulsion. Such sacculation had always been previously regarded as due to esophageal diverticulum, which it greatly simulates at first and in time practically becomes. It is due either to primary and unexplained spasm of the muscular coat at this level, or to a primary atony for the esophageal muscle above the stricture. It has been ascribed also to paralysis of the circular fibers and spasm of the cardia, due to vagus involvement and to primary esophagitis. The view that it is of congenital origin can scarcely be sustained.
Symptoms.
—The symptoms and signs produced are not widely different from those of a capacious diverticulum. It is difficult, often impossible, to pass a stomach tube into the stomach, it being diverted into the upper cavity. The patient moreover, vomits material which is undigested and more or less putrefactive, and, at the same time, without evidences of actual stomach disease. Such a sac may hold even two pints, and thus it will be seen how much material may be vomited or washed out by lavage which, at the same time, never entered the stomach. Should it be possible to enter the stomach the two sets of contents will be found quite different.