CANCER OE THE INTESTINAL TRACT: 
OPERATIONS FOR THE REMOVAL 
OF 
Vlalignani Slriclures of Pylorus 
AND INTESTINES. 
TOGETHER WITH A BRIEF REVIEW 
OF THE 
HISTORICAL DEVELOPMENT OF MODERN 
ABDOMINAL SURGERY. 
BY 
REUBEN A. VANCE, M. D., 
PROFESSOR OF OPERATIVE SURGERY AND CLINICAL SURGERY IN 
THE MEDICAL DEPARTMENT OF THE UNIVERSITY 
OF WOOSTER, ETC., CLEVELAND, OHIO. 
An Argument Submitted to the Cuyahoga County Medical Society. April yd, 
1883, upon the Question of the Justifiability of Operations for 
the Removal of Cancer of the Intestinal Tract. 
RE-PRINTED FROM COLUMBUS MEDICAL JOUR^Mj 
HANN & ADAIR, PUBLISHERS, COLUMBUS, O. 
T 883. CANCER OF THE INTESTINAL TRACT: 
OPERATIONS FOR THE REMOVAL 
OK 
Vlalignanl Strictures' of Pylorus 
AND INTESTINES. 
TOGETHER WITH A BRIEF REVIEW 
OK THE 
HISTORICAL DEVELOPMENT OF MODERN 
ABDOMINAL SURGERY. 
BY 
REUBEN VANCE, M. I). 
PROFESSOR OF OPERATIVE SURGERY AND CLINICAL SURGERY IN 
THE MEDICAL DEPARTMEMT OF THE UNIVERSITY 
OF WOOSTER, ETC., CLEVELAND, OHIO. 
An Argument Submitted to the Cuyahoga County Medical Society, April yd, 
t88j, upon the Question of the Justif ability of Operations for 
the Removal of Cancer of the Intestinal Tract. 
RE-PRINTED FROM COLUMBUS MEDICAL JOURNAL. 
HANN & ADAIR, PUBLISHERS, COLUMBUS, O. 
1883. 3 
CANCER OF THE INTESTINAL TRACT. 
BY REUBEN A. VANCE, M. D„ CLEVELAND, O. 
Professor of Operative Surgery and Clinical Surgery, in the Medical Department of Wooster 
University, etc. 
In order to discuss the justifiability of operations for the removal of can- 
cerous tumors of the intestinal tract—the stomach and intestines—we 
must first ask, Why should cancers be removed at all? It would take too 
much time to even glance at this question, so I will take for granted the 
axiom in surgery that malignant growths of all forms demand immediate 
and complete removal. To this rule there are few exceptions, and these 
more apparent than real. Cancerous tumors of the brain are not operated 
upon for the simple reason that the organ from which the morbid mass 
takes its origin is too delicate a structure for the necessary manipulations 
of the surgeon. The same is in a measure true of cancer of the liver; 
here it is not the peculiar structure of the organ affected so much as it is 
the danger of hemorrhage that prevents the surgeon cutting away malig- 
nant growths developed in the hepatic substance. No such dangers 
attend upon the excision of cancerous masses from the intestinal canal— 
on the other hand there are cogent reasons demanding their removal. It 
is but infrequently that the physician or surgeon can know beforehand 
just what will be found in the abdomen when necessity demands that its 
recesses be explored, and as there are special circumstances occasionally 
demanding excision of malignant growths of the intestinal tract, as well as 
a series of real and imaginary dangers attending any operation in the 
abdomen, I ask the patient attention of the Society while I briefly review 
the Historical Development in recent years of , the Surgery of the Abdo- 
men. This necessitates a consideration of the various methods of treating 
penetrating wounds of the abdomen, as well as an outline of the opera- 
tions resorted to for the relief or cure of surgical affections of the abdom- 
inal viscera. I know of no course, so well calculated to afford a correct 
idea of the real nature of surgery ; none that will so well reflect the pro- 
gressive improvement of surgical art, or so truly exhibit the gradual elimi- 
nation of truth from error. * 4 
The action of that ecclesiastical council which forbade the clergy per- 
forming bloody Operations drove Chierurgery from the Monasteries, and 
developed a class of practitioners who finally assumed power and profes- 
sional consequence in the French Academy of Surgery. Our present 
inquiry requires us to devote a moment to the physiological views and 
pathological speculations of one of the eminent representatives of this 
Academy—the great surgeon, John L. Petit. While recognizing the 
fatality of abdominal wounds as the rule, this observer felt constrained to 
offer an explanation of the curious fact that occasionally an individual 
would recover from an injury of this character. It was with this object 
in view that Petit announced those physiological speculations that since 
his day have played so important a part in the surgical pathology of the 
abdominal viscera. Briefly stated they are as follows: The abdominal 
organs are maintained constantly under pressure; this pressure serves to 
keep the visceral and parietal layers of peritoneum in contact, and suffices 
in cases of penetrating wound puncturing stomach or intestines to drive 
any food or feces that exude into the wound and out of the body, thus 
obviating all danger of effusion of extravasated material into the peritoneal 
cavity. Furthermore, in the mutual relations of abdominal walls and 
contained contents, while in respiration there is a direct movement of 
mass, there is no change of position on the part of individual constituents 
of the abdominal viscera. Thus, a given portion of the intestines, for 
instance, always remains behind that part of the abdominal wall in the 
rear of which it was originally developed. Consequently a knife driven 
into the abdomen makes a wound in which the deep portion always re- 
mains in direct contact with the superficial opening. It is readily seen 
how these ideas elucidate cases of recovery from penetrating wound of 
the abdomen. The absence of change of relation on the part of the 
viscera, and the persistence under all circumstances of particular organs 
in contact with given areas of the abdominal walls, together with the in- 
fluence of pressure between the muscular walls below and the diaphragm 
above explain completely these occasional cases of recovery. 
Upon these speculations the Italian surgeons founded a line of practice 
known as Scarpa’s method relating mainly to the treatment of wounded 
intestines that had protruded. The principle of letting alone wounded 
intestines that remain in place, tacitly assumed to have emanated from 
Petit, was carried to its logical conclusion in the practice of Scarpa in the 
management of wounded and protruded intestines Assuming as correct 
the conditions of the abdominal viscera taught by PetiU—the uniform 
pressure and absence of relational movement, especially—what was more 5 
proper than the return unclosed of these wounded organs, if the opening 
in the gut could not deviate from the incision in the wall, and the general 
compression under which all these organs were maintained sufficed to 
eject through the wound the food or feces that chanced to approach the 
region of the intestinal lesion? Here, then, is a line of practice endorsed 
by eminent surgeons as justifiable and proper, to which a moment’s atten- 
tion should be given. Is it not worth our while, now that we are assem- 
bled confessedly to pass upon the justifiability of a modern surgical pro- 
cedure that we devote a moment’s thought to the manner in which this 
paocedure of Scarpa became the orthodox surgical method of treating 
wounded and protruded intestines? 
But surgery then as now was not the exclusive property of any nation 
or of any race; Jchn Bell, the illustrious expounder of surgical pathology 
in Edinburgh, in his eloquent lectures upon wounds, reviewed in a mas- 
terly manner, these lesions of the abdomen. Accepting the doctrines of 
Petit, and even adding to them his own conceptions, he nevertheless re- 
jected the practice of the Italians. Granting the truth of Petit’s teachings 
as to the uniformity and constancy of pressure, and the absence of rela- 
tive movement in the abdominal viscera, John Bell denied the presence 
of anything like a cavity in the peritoneum during life, and held that the 
adhesive process, by uniting the edges of the wound, checked the pro- 
gress of inflammation and saved the patient from fatal peritonitis. Thus, 
the student of surgical opinion can trace the progress of certain theoreti- 
cal conceptions and review the practice founded on them from France, 
through Italy, into Scotland. These theories of what the abdomen should 
be, were not based upon the revelations of Nature, but founded on the 
conceptions of representative teachers. We see Scarpa accepting as 
eternal truth the ideas of Petit, and basing on them practices involving 
life or death. Bell, although an advocate and exponent of theory, in 
practice departed from the plan of Scarpa, and introduced a method of 
his own—that of stitching the edges of the wounded gut to the borders of 
the cutaneous incision. Here we are again presented with the same 
problem that confronts us to-day: here is a surgical leader daring to devi- 
ate from the precepts of the time, and introduce as justifiable an operative 
procedure not in conformity with the theoretical conceptions of the ruling 
schools of the period. To see how this daring innovator was censured by 
the orthodox practitioners of the time one has but to glance at contem- 
porary historical records—the surgeon who, in opposition to the ideas of 
Petit and the practice of Scarpa, did not return the open gut from which 
fecal matter was dripping into the delicate cavity of the peritoneum, was 6 
denounced as a “cutter and slasher” by the self-constituted authorities of 
that day, just as to-day, similar innovators are censured by modern repre- 
sentatives of the same class that so persistently hounded John Bell! 
But science is slow of growth, and truth is revealed only by degrees. 
Just as representatives of French, Italian and Scotch surgery successively 
grasped this question, and each contributed his mite to the Historical De- 
velopment of Abdominal Surgery, so it proved in the end as regards 
English and American surgery. Benjamin Travers was the first inquirer 
who turned the rays of scientific experiment and observation on this topic, 
and his work is a mine of valuable truths. The fact he unfolded with 
which we are mainly concerned relates to the treatment of wounded and 
i protruded intestines. He did not deny the truth of Petit’s and Bell’s 
theories—he even added the weight of his authority to the ideas they en- 
tertained of the way Nature manages and occasionally cures penetrating 
wounds of the abdominal viscera. He showed that as regards the appli- 
cation of Petit’s and Bell’s theories, an intestine in place and one protruded 
were very differently situated. Granted, says Travers in effect, that 
Petit’s universal pressure and absence of rational movements will keep the 
visceral and parietal surfaces of the peritoneum together and force extra- 
vasated food or feces into the wound and out of the body—granted, with 
Bell, that there is practically no peritoneal cavity into which effusion can 
occur, and that the irritation due to the ejection along the walls of the 
wound of food or feces, blood or urine, causes the peritoneal edges to 
melt down into a glutinous mass that will make them adhere and cut off 
the passage of inflammation to the peritoneum—granting all this, yet no 
one can successfully maintain that there is any similarity between the con- 
dition of an intestine in place, and one that has been extruded. The ex- 
trusion of an intestine carries it away from the segment of abdominal wall 
with which normally it is in contact, and we can never make sure that 
in efforts to return the gut we will get it into its right place. There- 
fore, to return a wounded gut, with the wound open, is to place 
the abdominal viscera in a condition quite unlike that Nature would effect 
had there been no protrusion. So Travers unfolded a line of practice 
that has proved a permanent addition to surgical science. He stitched 
up the wound in the intestine before returning it. But this innovation 
did not pass unchallenged, and just as Bell was denounced for deviating 
from the method Scarpa founded on the theories of Petit, so Travers was 
censured for following a plan different from that introduced by Bell. May 
I not be permitted to suggest that in these lessons from the pages of sur- 
gical history a precedent be found for our guidance to-day; is it not bet- ter that our practice in matters involving life or death be founded on ob- 
servation and experiment rather than on theory and authority? 
To those remaining undecided let me cite the next incident in this his- 
torical retrospect: one in which we are doubly interested, for it not only 
unfolded truth, but sprang from the brain of an American, Samuel D. 
Gross, then a Professor of Pathological Anatomy in this State. Gross 
followed the English school, by resorting to experiment; he deviated 
from them by daring to question the infallibility of Petit’s and Bell’s 
theories, and while adopting the practice of Travers, he rejected abso- 
lutely the methods of Scarpa and Bell. He showed that the presence or 
absence of effusion made the difference between life or death in the 
horribly fatal cases of penetrating wounds of the abdomen in which the 
intestine remained in place; the cases in which according to Scarpa, Bell 
and Travers, Nature has best calculated to deal advantageously with this 
lesion. The light cast on this subject by the observations and experi- 
ments of Gross placed matters in a different position. We can now see 
why it was Petit only formulated his ideas of the behavior of the abdom- 
inal viscera as an explanation of the rare and exceptional cases that 
recovered. One can now see the fearful blunder of adducing these theo- 
retical conceptions of what the abdomen should be,as laws of Nature, and 
founding upon them a line of surgical practice ! The innumerable pages 
written to unfold the views of Petit and John Bell have been set at naught 
by the experiments of Gross. The whole superstructure erected upon the 
idea that the forces of the abdomen were sufficient to prevent effusion 
into the peritoneal sac, has fallen to the earth. It is instructive to note 
that the only observations that have proved fruitful in all this history, are 
those based cn actual experiment. The practice of Scarpa, based as it 
was on the theoretical conceptions of Petit, proved horribly fatal; that of 
Bell, founded on Nature’s method of dealing with intestinal fistulae, was a 
grand step towards truth ; while that of Travers has not been improved 
upon since. Contrast this with their practice in cases where the intestines 
were wounded but not protruded. Notwithstanding that Petit only 
advanced his peculiar views as an explanation of the mechanism of 
recovery in the exceptional cases that escaped death, his ideas were made 
the foundation of Scarpa’s practice, accepted and added to by Bell, and 
adopted even by Travers. The latter went so far as to claim that recov- 
ery from penetrating wounds of the intestines was not the exceptional 
event, but the general rule. To Gross we are indebted for the overthrow 
of these ideas, and the introduction of'true views of abdominal physiology. 
Gross demonstrated that effusion depends largely upon the size of the 
7 8 
wound and the condition of the intestine. He also advocated abdominal 
exploration in cases of effusion. Travers improved upon the methods of 
Bell, and formulated our present practice in cases of wounded and pro- 
truded intestines; Gross exhibited errors in the views of Petit, Bell and 
Travers, and enunciated the correct rule of procedure in penetrating 
wounds of the abdomen attended by effusion. Have we not food here 
for reflection, and so on an occasion like this, assembled as we are to dis- 
cuss, and it may be to pass upon, the justifiability of an operation involv- 
ing the same results, situated in the same field and environed by the same 
fallacies as the ones just reviewed, does it not behoove us to give this mat- 
ter careful thought, and before coming to a conclusion, to weigh well all 
the evidence bearing upon this subject, as well as dismiss from our minds 
all preconceptions based on mere authority ? 
These historical researches would not be barren were there no further 
facts to be deduced from them than those regarding penetrating wounds 
of the abdomen. French, Italian, Scotch and English surgeons were 
content to extol, as the perfection of treatment, a method in which Nature, 
unaided, did all that was done for the patient’s restoration—a system that 
lost more than nine out of ten cases—and the myths upon which 
this practice was based were only exploded by the labor of a man still 
living. We find here the lesson so frequently taught by modern progress: 
that reliance upon authority, and neglect of observation and experiment 
are the main enemies of science. Not only that: we find operations 
based on error, and attended almost invariably by death, perpetuated by 
authority as the correct practice, while the proper method was denounced 
by self-constituted leaders of the profession as a reprehensible proceeding. 
May we not learn from this historical retrospect to be a trifle cautious in 
either lauding established practice, or denouncing new measures as un- 
justifiable? 
We have now reached a point where inquiry can profitably be made as 
to the hesitancy of our surgical predecessors in exploring the abdominal 
cavity in cases of intestinal wound, or intra-peritoneal disease. Monro, of 
Edinburgh, many years ago, announced that the air exercised a corrosive 
influence upon exposed serous membranes; that penetrating wounds of 
the abdomen were fatal because the air thus gained access to the perito- 
neum. It is thought by many that we have an explanation of the specu- 
lation of Petit, and the practice of the French and Italian surgeons; the 
mortality of abdominal wounds was due to air reaching the peritoneum 
and exciting fatal inflammation—those patients that escaped were the 
fortunate few who were aided in the manner already detailed by Nature’s 9 
supposed conservative provisions ! Although John Bell protested against 
the imaginary irritating qualities of the air, the doctrine still remained 
fixed in the professional mind, and to-day has many advocates. Gross 
had to contend against it when he advocated exploration in cases of effu- 
sion, and the only doctrine that bids fair to supplant it, is the view that 
has gained ground since the recent extension of the surgery of the abdo- 
men in the removal of ovarian tumors, that the great mortality of abdom- 
inal lesions is due to septic rather than inflammatory causes. It seems as 
if no amount of mere mechanical irritation can develop peritonitis ; that 
the peritoneal sac can be opened and its contents handled with impunity, 
provided only that the exposed surfaces are properly cleansed, and the 
abdominal cavity freed from extraneous organic substances. Yet, on the 
other hand, the slightest amount of organic matter—food, feces, blood, 
pus or urine—in the peritoneal cavity suffices to initiate a series of 
changes that result in death from blood-poisoning. It is septic substance, 
and no mere traumatic irritation that stimulates the peritoneum to the 
effusion of products that poison the patient; remove this material, and 
the subsequent dangers are trivial! 
It would take altogether too much time for me to follow further the 
progress of abdominal surgery ; to show how very slowly true views of 
the manner in which Nature deals with intestinal sutures gained credence; 
or how gradually surgery has reached its present comparatively perfect 
method of treating intestinal lesions. The necessity demanding excision 
of foreign bodies accidentally reaching the stomach demonstrated the non. 
fatality of gastric wounds, the accidents attending strangulated hernia 
revealed the fact that large portions of the intestines could be removed 
and the patients still recover. The study of the morbid anatomical ap-. 
pearances presented by these patients in after years, together with the 
intestinal lesions in individuals dying of intus-susception immediately 
after the strangulated part was voided, cast light upon the mechanism of 
recovery. These facts, supplemented by experiments upon animals, show 
that the peritoneum can be opened, a portion of the intestinal tract—seg- 
ments of either stomach, or large or small intestines—excised and by 
properly approximating the peritoneal edges of the wound, the continuity 
of the gut can be re-established. It is now more than forty years since 
Reybard, of Paris, took out a section of the colon in excising a cancerous 
mass from the large intestines. In recent years Spencer Wells has not 
hesitated to remove a portion of the intestines intimately attached to an 
ovarian tumor. Cases that have passed through my own hands convince 
me that in the vast majority of instances of primary cancer of the intes- 10 
tines, excision of the diseased part is not only justifiable as a surgical pro- 
cedure, but it is one of the most promising of all the measures developed 
by recent researches. It would indeed be singular were educated and 
skillful representatives of modern surgery to reject as unjustifiable, 
an operation that not only relieves obstruction of the bowels, and prevents 
immediate death, but removes the primary encroachments of a fatal 
malady, while yet of a local character! 
Obstruction of the bowels is generally the first evidence of cancer of the 
intestinal tract. In those rare instances in which it is not the symptom 
drawing attention to the condition of the abdomen, it is one of the pheno- 
mena soon developtd by malignant disease of the pylorus, small intestines, 
cecum, colon or rectum. The necessity of opening the abdomen and 
searching for, and if possible removing, the cause of the obstruction, is 
acknowledged by representative surgeons the world over. Mr. Bryant, 
of London, says : “Indeed, I believe a surgeon may as well delay in cut- 
ting the rope in a case of suicide by hanging whilst he is speculating as to 
the influences which have led the man to perpetrate the act, as to delay 
operative interference in a case of acute intestinal obstruction with the 
hope that he will be able to make a scientific diagnosis of the case, or that 
something will turn up by which relief may be obtained.” Dr. Carson, of 
Cincinnati, claims that “it is not required of the surgeon to diagnosticate 
thtprecise cause of the obstruction so long as the diagnosis of its existence can 
be determined.” To this I would add that not only is it the duty of the 
surgeon to explore the abdomen in all cases of intestinal obstruction, but 
he should open the peritoneal sac and investigate the condition of stomach 
and adjacent parts in tumors of the pylorus impinging upon the passage- 
way between stomach and duodenum. This rule would expose to view 
the first manifestations of malignant disease of the abdomen, and enable 
the surgeon by excising strictured portions of the intestinal tract to make 
sure of removing cancer in its incipiency. I would urge this rule, not so 
much for its application to intestinal excisions—for there its propriety is 
little questioned by experienced surgeons—but with special reference to 
the pylorus. If the disease be limited to a slight area of stomach, and have 
not implicated adjacent parts, the surgeon can reasonably expect to effect 
a complete removal of the morbid mass, and his patient will partake of 
the advantages incident to early and efficient excisions of malignant 
growths. Not only this: there are so many cases in which a condition 
simulating scirrhus of the pylorus develops and causes death, in which 
nothing but fibroid degeneration of this part of the stomach can be proved 
to exist, that an early and efficient excision is of equal benefit to the pa- 
tient without regard to the malignancy or non-malignancy of the tumor. 11 
There are certain points connected with excisions of portions of the in- 
testinal tract covered with peritoneum, common to all these operations, 
which demand consideration in case. These relate mainly to ex- 
tent of disease, treatment of adhesions, management of viscera during 
operation, and disposition of parts afterwards in manner calculated to 
facilitate recovery. In the first place, no procedure of this character should 
be undertaken save with the distinct understanding between patient and 
surgeon, friends and assistants, that the operation is primarily of an ex- 
ploratory character, and made, first of all, for the purpose of revealing 
the true nature of obstruction of the bowels, or obscure lesions of the ab- 
dominal viscera. This leaves the surgeon free to act according to the dic- 
tates of his best judgment wheif the site of disease is revealed and its true 
character exposed. 
Rokitansky has shown by the unanswerable evidence of morbid anatomy, 
the rarity with which cancer extends from pylorus to duodenum. The 
researches of Gussenbauer and Winiwarter prove that the pylorus is by far 
the most frequent site of primary cancer of the stomach, and their statistics 
reveal that neighboring organs are implicated at a comparatively late stage 
of the disease. It has also been demonstrated that cancer at any part ot 
the intestinal tract may develop, and produce obstruction of the bowels 
without adhesions occurring. It very rarely happens that adhesions are 
found in any stage of the affection which would prove an obstruction to 
the surgeon’s design. If they do exist the surgeon can compress them 
with an instrument like Liston’s bone forceps, and after thus crushing 
them, can sever them without the least danger of hemorrhage. The 
original incision in the abdominal wall should be so situated as to expose 
thoroughly the area of disease. Should the surgeon ultimately determine 
to cut out the cancerous mass he should primarily take such precautions 
as will render the opening of the peritoneum harmless. While dismissing 
the dogma of Monro as to the corrosive quality of the external air, and 
sending with it, as exploded doctrines, the speculations of Bell and 
Travers, it by no means follows that peritoneal wounds are as free from 
danger as incisions of the limbs. The peritoneum has an enormous surface, 
constantly moist, and one, which, when exposed, leads to such rapid 
cooling of the blood, that immediately reflex paralytic contractions of the 
heart, and even death, are threatened. Nussbaum points out another 
source of danger in the almost unlimited power of absorption which the 
peritoneum possesses; thus, any exudation which has undergone un- 
healthy metamorphosis may poison the blood. Peristaltic action, by 
which any exudation in the peritoneal sac is stirred up and spread over 
the whole peritoneal surfaces, and the respiratory [movements, combine 12 
together to facilitate freedom of absorption. Again, peritoneal wounds 
are dangerous on account of the innumerable little spaces existing every- 
where, into which secretions find their way, lie hidden and decompose. 
Finally, there is the deleterious influence of the ill-smelling intestinal 
gases which especially favor sepsis; gases which find their way in and 
out even when the bowel itself is in a healthy state. Since these dangers 
have been understood and the means by which they may be overcome 
have been learned, the judicious surgeon is enabled to obviate them. 
Every possible precaution should be taken to guard against infection ; 
the spray must therefore be used. The incision in the exploratory opera- 
tion should be made in the middle line, and if possible over the tumor. 
Should the tumor extend to one side, a‘lateral incision can be made at 
right angles to the original opening when excision of the pylorus has been 
determined upon. If other viscera are involved—especially the liver, pan- 
creas or descending duodenum—or the disease extend over the greater 
part of the stomach, the wound must be closed and the patient abandoned 
to his fate. When there are few if any adhesions, the disease limited to a 
circumscribed region of the pylorus, and the patient in good general con- 
dition, the case is one favorable for excision. The operation is not con- 
tra-indicated even in combined gastric and intestinal cancer, provided 
the latter is limited to an accessible part. A patient in whom the pylorus 
is alone affected can be operated upon in this way: The tumor exposed 
and its extent and character determined, it is drawn as far as possible 
into the wound and the line of incision determined upon. This depends 
upon the size of the mass, and the region of stomach impinged upon. In 
the first illustration it will be seen that the symmetry of the stomach de- 
pends largely upon the precedure adopted. The first and second figures 
show that a very unsightly angle may be made at the terminal portion of 
greater curvature unless the primary incision be directed as denoted in 
figure three. Figures four and five exhibit certain advantages that attend 
upon the attachment of the duodenum to the greater curvature of the 
stomach. The line of incisions decided upon—and this necessitates a 
conclusion as to the place of insertion of intestine into stomach—the next 
step is the isolation of the tumor. To do this pylorus and adjoining por- 
tions of stomach and duodenum must be freed from adjacent parts. Un- 
less the surgeon is supplied with the requisite appliances, he will find this 
the most difficult part of the whole operation. With an instrument like 
Liston’s bone forceps, the omentum can be severed, blood- vessels com- 
pressed and hemorrhage prevented. Any blood vessel that the surgeon 
hesitates to leave without additional security can be tied with a double 
ligature and severed between. In some cases the omentum has been re- 13 
moved without any tendency to hemorrhage. The greater curvature is 
isolated, the lesser curvature is freed, the tumor separated from omental 
attachments and all enlarged glands extracted. The stomach can now be 
drawn through the wound and in great part out of the abdominal cavity: 
a large, soft sponge, just wrung out of hot water, is placed under the 
tumor, and the subsequent proceedings are extra-peritoneal. These relate 
to the excision of the diseased mass. A glance at the accompanying 
illustration will show how important it is to have the line of incision prop- 
erly directed through the stomach in order that the organ may preserve 
its symmetry after the tumor is extracted. If the duodneum is to be 
attached to the stomach near the lesser curvature, as shown in figure 
three, the procedure illustrated in figure one and two can be adopted. 
The surgeon makes a slight opening in the anterior wall of the stomach 
on the line of incision, and through this opening a glass tube is inserted. 
This is connected with a reservoir of water by elastic tubing, and the cav- 
ity of the stomach is alternately distended and emptied of the 
fluid returns clear; the surgeon then proceeds with his incisions. Scis- 
sors are used, and after each cut, the hemorrhage is checked. In check- 
ing hemorrhage from vascular membranes I know of no device equal to a 
back stitch made with a small, well waxed thread, mounted on a slender 
needle, the whole bleeding surface being guarded by a line of stitches 
passing through mucous and muscular coats about one-eighth of an inch 
from the border of the wound. In this method each loop includes one- 
half of its predecessor, and is encroached upon by one-half its successor, 
and thus, by drawing the threads tight, all danger of hemorrhage is effec- 
tually avoided. As the incision is carried forward, hemorrhage is checked 
in the manner provided for above, and steps are taken to close the open- 
ing in the stomach in excess of the aperture required for the insertion of 
the duodenum. This is accomplished by passing sutures after the method 
of Lembert—through the serous membrane alone, entering at a half inch 
from the incision and emerging one-eighth of an inch from its edge, cross- 
ing the incision, entering the serous membrane one-eighth of an inch 
from the edge of the wound and emerging a half inch from it; a suture 
that accurately approximates tho serous borders, but one which in this 
operation needs to be supplemented by firm stitches through the mucous 
membrane internally. In figure two the progress of the surgeon’s manip- 
ulations can be traced to the point where the Lembert sutures to unite 
upper and posterior borders of the gastric opening with like borders of the 
wound in the duodenum have been inserted. The ends of the sutures in 
the lower part of the stomach were left long in order to afford a conven- 
ient method of handling the organ. The hemorrhage following incisions 14 
in the duodenum is to be checked by back stitching, just as in the stom- 
ach ; during this time the tumor grasped with forceps in the hands of an 
assistant, has served to hold the duodenum in place. Hemorrhage 
checked, the cut surfaces of the duodenum are united with corresponding 
borders of the stomach, and the edges of the mucous membrane are 
stitched together. This process is continued until the tumor is free, the 
hemorrhage controlled, the Lembert sutures inserted and tied, and the 
borders of the mucous membrane sewed together over all but the last 
fourth of the opening; here, the necessities of the case demand different 
measures. Heretofore all the stitches and threads were fastened so that 
they could in time be discharged into the cavity of the intestine; 
it is essential now to employ a few interrupted sutures that in the nature 
of things cannot be so favorably placed. Lembert sutures are inserted, 
the serous borders of the opening at the junction of duodenum and stom- 
ach are everted, and the sutures tied; this closes the aperture, but does 
not make the union sufficiently firm—interrupted sutures going through 
all the coats are inserted between the Lembert sutures, tied, and cut 
short; this remedies the defect. It also completes the operation so far as 
removal of tumor and re-establishing communication between stomach 
and duodenum are concerned. Figure three gives an idea of the appear- 
ance of the stomach; figures four and five show deviations demanded 
when the union between stomach and duodeum is effected at the greater 
curvature. Figure six exhibits the manner in which Lembert’s suture 
approximates peritoneal surfaces in this operation ; it also illustrates the 
manner in which the mucous surfaces are united over the attached serous bor- 
ders of the wound. This illustration while showing the apposition of serous 
borders brought about by the Lembert suture does not exhibit the true 
site of the knot in the stitch passing through the peritoneal tissues. This 
knot varies with the side from which the suture is inserted. In the true 
Lembert suture the thread is not only introduced from the serous surface, 
but it returns through it. Yet the sixth illustration reveals the manner in 
which these tissues are approximated when necessity demands these 
stitches be inserted from the inner surface of the viscera. Take the con- 
dition of affairs revealed in figure two, and instead of inserting the Lem- 
bert sutures shown loosely extending from duodenum to stomach, remove 
the tumor, approximate the edges to be united, and insert the needle 
from within, through muscular and serous coats of stomach, into the serous 
and muscular walls of duodenum, then draw the suture tight and tie. 
This will place the knot in the position shown in figure six; by subse- 
quently uniting the mucous surfaces with interrupted sutures the precise 
condition there shown will be produced. The long ends of the sutures, 15 
left so in order to afford a firm grasp of the organs operated upon, can now 
be severed, the abdominal cavity cleansed and the external wound 
closed. 
When we consider the circumstances under which this operation has 
heretofore been performed—the exhaustion of the patient and the consti- 
tutional implication—the only wonder is that they survived. Reverse 
this state of affairs, operate early, excise the tumor while yet local, before 
the constitution is broken down and the patient on the verge of death 
from exhaustion, and at once the surgical aspect of this procedure is revo- 
lutionized. This will place patients with cancer of the pylorus on the 
same plane with those suffering from malignant diseases of the intestine ; 
those with simple fibroid degeneration of the terminal orifice of the 
stomach on a par with those having a benign stricture of the gut. In both 
cases the surgical principle involved is simple; it is to excision, and ex- 
cision alone, that the patient can look for relief, and the man who fails to 
afford such a sufferer the relief he seeks, and give him the benefit of the 
chances left him, is unworthy the name of surgeon. 
The shock of the operation soon passes off, and although one can con- 
ceive of dangers incident to rupture of sutures by excessive gaseous dis- 
tension, and collapse from extravasation, still such consequences are 
rarely encountered. Again, although hemorrhage is possible, septic con- 
ditions, due to peritoneal effusion, are the real danger. This is indicated 
by changes in pulse and temperature, and is attended by the presence of 
an acrid fluid in the peritoneum. The practical fact is that the advent of 
phenomena indicating septic conditions should at once lead to explora- 
tion of the abdomen, and. if necessary, cleansing of the peritoneal sac. 
In bringing this statement to a close, permit me to again urge the im- 
portance of deciding questions of operative procedure upon Surgical 
Principles, and not upon the fears, the preconceptions, or the prejudices 
of any man or any set of men. As the excision of malignant growths of 
the intestinal tract involves the local or constitutional nature of cancer, 
the mechanism of repair in intestinal lesions, and the safety of all abdominal 
operations, let the appeal be made to the solution which Modern Surgery 
gives these important problems. Judged in this way there can be but 
one decision, and that to the effect that these operations are justified by 
all the Precepts and Experiences of Modern Scientific Surgery !