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]
[57] The first deliberate operation upon the stomach seems to have been that by Crolius, in 1602, for removal of a knife, and a similar operation was made eleven years later by Günther. Up to 1887, however, only thirteen such gastrotomies had been reported. The first unsuccessful gastrotomy was done by Sédillot in 1839; the first successful one by Jones, thirty-five years later. While pylorectomy was suggested by Merrien in 1810, it was not actually performed until 1879 by Péan. Gastro-enterostomy was first done by Wölfler in 1881. The first operation for hemorrhage from gastric ulcer was performed by Mikulicz in 1889. It will thus be seen how recent is the whole matter of modern surgical attack upon the stomach.
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.