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.