In the operation I have described such an accident could not occur, as there is no long jejunal loop.

(8) Death From Asthenia

In the eighties and early nineties it was considered absolutely essential to abstain from feeding by the mouth after any stomach operation, and as gastric operations were then always delayed until the patient was extremely weak, it followed as a necessary consequence that asthenia, or, in other words, starvation, was a real danger.

Asthenia from this cause is now seldom seen, as feeding is begun immediately the patient has recovered from the anaesthetic. In my own practice I do not hesitate to let the patients have liquid or semi-liquid nourishment in small quantities every half hour as soon as they can take it, and seeing that in gastroenterostomy anaesthetic vomiting does not occur, the patient is usually able to have some food within four hours of the operation, this being supplemented by nutrient enemata of normal saline solution containing liquid peptonoids and brandy. (See after-treatment and feeding after gastroenterostomy, p. 168.)

(9) Haemorrhage

Haemorrhage as a cause of death after gastroenterostomy is not likely to occur as the result of the operation itself, as the continuous suture applied through the whole thickness of the margins of the anastomotic opening acts as an efficient compress to the vessels. It may, however, occur from ulcer or cancer just as it might have happened had no operation been done in such cases. The administration of adrenalin, the abstention from mouth-feeding, and the injection of lactate of calcium under the skin or by rectal enemata will be found useful, and the treatment will be as in other cases of haematemesis or melaena. Should the bleeding persist, the question of further operation will arise, in order to discover and treat the bleeding points.

The After-Results Of Gastrojejunostomy

(1) In considering the various complications, it seems quite definitely proved that the use of the Murphy button is attended with uncertain results, both on account of the subsequent tendency to contraction of the anastomotic opening and the retention of the metal instrument in the stomach.

(2) If the anastomotic opening be made of too small a size it is apt to prove unsatisfactory and to lead to relapse.

(3) The methods which do not secure continuity of the mucous membranes of the anastomosed viscera are apt to be followed by undue contraction or even complete closure of the new passage.

(4) The risk of peptic jejunal ulcer, even after all the methods that have been described, is probably under 2 per cent., but if the posterior operation be performed and the anastomotic opening be made sufficiently large, the .risk is hardly appreciable, certainly nothing like 1 per cent.

(5) If the method of union by suture that I have described be performed, and the opening be made of sufficient size, considerably over 90 per cent, of patients suffering from pyloric stenosis of a simple character, or from gastric ulcer, will be completely and permanently relieved of their symptoms, and those suffering from cancer should derive considerable relief. I have had cancer cases to survive for over two years, and to lose all pain and discomfort for long periods.

(6) As a number of patients suffering* from non-malignant diseases have regained their normal weight and lived for many years in good health-some even for twenty years-there seems to be no reason to suppose that the operation of gastroenterostomy per se tends to shorten life.

Chemico-Pathological Evidence

The experiments performed by Joslin (10) were carried out on patients who had had gastroenterostomy performed for cancer of the pylorus. His conclusions, therefore, which seem to prove that the operation leads to a marked diminution of absorption of nitrogenous foods as well as of fats and hydro-carbons, cannot be taken seriously, as cancer itself is capable of producing these results. Moreover, Mr. H. J. Paterson and Dr. Francis Goodbody (11) carried out a series of experiments on four patients in whom gastroenterostomy had been performed for simple disease of the stomach, which proved very clearly that metabolism is practically unaffected after gastrojejunostomy, as in none of the cases did the unabsorbed nitrogen amount to more than 2 per cent, above the amount usually passed in the faeces by a healthy individual, while the amount of fat passed unabsorbed did not on any occasion exceed 7.7 per cent, of the fat taken in the food, that is, just over 2 per cent, above the amount usually passed in the faeces by a healthy man.

References

1. Mayo, W. J., " The Technique of Gastrojejunostomy."- Annals of Surgery, April, 1906.

2. Yon Eiselsberg.-Trans, of Internat. Congress of Surgery, Brussels, 1905.

3. Mumford.-Annals of Surgery, 1906, p. 88.

4. Dastre.-Archivfiir Physiol., 1890, p. 316.

5. Moynihan.-Brit. Med. Journ., 1901, p. 1136.

6. Mayo Robson.-Diseases of the Stomach, 3rd edition, p. 236.

7. Moynihan.-Brit. Med. Journ., 1903, vol. ii, p. 1592.

8. Barker and Alexander.-Lancet, February 24th, 1906, p. 497.

9. Barker, A. E.-Lancet, November 5th, 1904, p. 1277.

10. Joslin.-Berlin. Iclin. Wochensch., 1897, p. 1047.

11. Patterson, H. J., and Francis Goodbody.-Lancet, February 24th, 1906, p. 495.

12. Mayo, W. J., American Surgical Association, June, 1902. -Annals of Surgery, 1902.

13. Paterson, " Hunterian Lectures."-Lancet, 1906.

14. Mayo Robson and Moynihan.-Diseases of the Stomach, 2nd edition, Bailliere, Tindall tand Cox.

15. Gray.-Lancet, August 29th, 1904.