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Home , Billroth I, Billroth II, Gastrectomy, Gastroenterostomy

706 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from

THE HISTORY OF GASTRIC JAMES 0. ROBINSON, M.D., M.Chir., F.R.C.S. Department of Surgery, St. Bartholomew's Hospital, London, E.C.I

The history of gastric surgery is one of the most In 1876, Carl Gussenbauer and Von Wini- complex in the annals of medicine. The practice warter31 performed many successful pylorectomies of this surgery depended upon the growing know- on dogs, and suggested the feasibility of this pro- ledge of the pathology of gastric diseases. This cedure on the human subject. At the same time knowledge, together with animal experiments and in a clinic in Vienna, Czerny and Kaiserl9 while the introduction of anaesthesia during the last working as assistants to Billroth, were performing century, led to the first successful planned opera- similar experiments. In one instance they re- tion for a disease of the . The last 20 sected the entire stomach of a dog, which survived years of the nineteenth century saw the intro- and flourished for five years. Under the guidance duction of many gastric operations, some of which of their professor they were beginning to outline were to become established and modified during the principles ofgastric surgery, which were to lead the ensuing years. the world in this field. In the writings of Celsus14 in the first century The first operation is believed to have been theProtected by copyright. and Galen29 in the second century, vague re- removal of a knife from the stomach of a pro- ferences were made to ulcers of the stomach, but fessional knife thrower, by a barber and surgeon of it was not until the revival of medicine in the Prague named Florian Mathies (quoted by von sixteenth century, with its attendant increase in Eiselsberg26) in I602. Thirty-three years later, post-mortem examinations, that further examples on July 9, 1635, a similar successful operation was were recorded. performed in Konigsberg by Christopher In 1596 Marcellus Donatus2l described the Schwabe (quoted by Ehrhardt23). He removed by autopsy on a man of 59 years, who was found to gastrotomy a knife which a young farm hand, have a gastric ulcer. Littre46 reported, from the named Andrea Grunheide, had swallowed whilst diary of a Lady-in-Waiting to Henrietta Anne, tickling the back of his throat to induce vomiting. Duchess of Orleans and daughter of King Charles This procedure was somewhat barbarous; twice I of England, how the Duchess had died, in I670, the barbers and theologians strapped their victim from a perforated gastric ulcer, following years of to a board before finding and opening the stomach. dyspepsia. The writings of John Bauhin in the Both patients survived these ordeals. http://pmj.bmj.com/ Sepulchretum of Boneti'0 in I679 give a full No further recorded operation can be found until description of a physician's wife, aged I9, who died I849 when Charles Sedillot, Professor of Surgery from a perforated gastric ulcer. at the French School of Military Medicine in The first accurate and extensive description of Strasbourg, performed a after three gastric ulcers and cancer is attributed to Mathew experiments on dogs,72 but the patient succumbed Baillie in I7932. Duodenal ulceration was not within a few hours of the operation. Thirty- until the early of the nineteenth three further unsuccessful were made recognized part attempts by on September 27, 2021 by guest. century when Benjamin Travers76 reported on two Sedillot, but it was not until I875 that Sydney cases which had died of perforations. This was Jones,42 an English surgeon, reported the first followed by an excellent description by John successful case. Abercrombie' in his Pathological and Practical On April 5, I879, Jules-Emile Pean63 claimed Researches on the Diseases of the Stomach to have undertaken the first pvlorectomy for a published in I830. pyloro-duodenal cancer, at the Frere St. Jean de Experimental surgery on the stomach began in Dieu Hospital in Paris, but the patient died on the I8Io when Karl Theordor Merrem,51 a student at fifth post-operative day. A post-mortem was the University of Giessen, demonstrated that the unfortunately refused, but it is interesting to note of dogs could be removed successfully, that Pean felt that it might have been wiser to have and without any apparent effect on their well- made the anastomosis with silk rather than catgut, being. which may have been responsible for its disruption. December 1960 ROBINSON: The History of Gastric Surgery 707 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from

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FIG. 2.-T. Billroth. this procedure. He knew well the dangers and FIG. I.-L. von Rydygier the mortality which would occur when this operation was performed by surgeons untrained Nineteen months later, on November I6, I88I, and unskilled. In defence of his operation he said Ludwig von Rydygier68, 69 attempted the second ' To reassure those who are of the opinion that my pylorectomy with the same result. Rydygier was present operation is a foolhardy experiment on a proud Polish surgeon, who had started a private man is beside the question. Resection of the Clinic in Chelmo, and it was here that he did this stomach has been as completely worked up second pylorectomy at the age of 30. It is believed anatomically, physiologically and technically by that he was the first surgeon to attempt gastro- my students and myself as any other new operation. enterostomy. He performed this operation in Every surgeon who has had experience in experi- http://pmj.bmj.com/ I88067 on a 63-year-old man named Julius ments on animals and similar operations on man Mickotajewicz who was known to have a duodenal has reached the conviction that resection of the ulcer. Chloroform anaesthesia was used during stomach must and will succeed. To establish the 4 hours duration of the operation. The the indications and contra-indications, and to patient succumbed 12 hours later from circulatory work out the technique for the widely different failure. cases, must be our next concern, and the object of On I88I, Professor Theodor our further studies '. He his well January 29, taught pupils on September 27, 2021 by guest. Billroth at his Clinic in Vienna completed the and sent them out into the cities of Europe to first successful partial on Therese practise and further this type of surgery. His Heller, a 44-year-old woman who had developed teaching ability is reflected in the names of such a pyloric carcinoma 8 The first success was not men as Czerny, von Mikulicz, Woelfler and von one of chance; for years he and his assistants had Hacker, who were to lead others in the modifica- worked carefully and methodically to this end, and tions which Billroth knew to be essential for its a few years before7 while operating on a case of ultimate success. gastric , he had remarked that it was but a In the following month, in November, short step to the day when the human stomach Woelfler,80, 81 when operating upon a 38-year-old could be removed surgically. This was to be a man with a pyloric carcinoma, found that the bold step, but his foresight had forearmed him growth had infiltrated the , which made against the criticism which he knew would herald the case unsuitable for gastrectomy. He therefore 708 POSTGRADUATE MEDICAL JOURNAL December 1960 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from not to be repeated until I3 years later when Carl Schlatter71 of Zurich performed the first successful total gastrectomy. He effected communication with the digestive tract by anastomosing a loop of to the lower end of the oesophagus. The .Y.WG.k.,'" patient recovered and in two months had gained sEl 8 lb. in A " weight. second successful case of total "".rl ";":I.-r. ,;·;..·*I gastrectomy was reported from Boston, Massa- chusetts, in I898 by Brigham.12 In this case ,.,, 9p anastomosis was effected between the oesophagus ·g ".%...... '':g . .I .:'."·;ii·.··;.·.iA. .. i and .:.:.·'.''' .'P:".. the around a Murphy's button, "; ;-i."''.i.Pue.;E. u.u uy .;.'·;?.· ;.·i which had been introduced into surgery some six i ...:· . years previously. ·.;·.;; f.i Von .r· Hacker,32 writing from Billroth's Clinic in .;" .;h·"9rr··b . I.GscrLL C? I885, referred to the operation which has become ,,..i.BC known as the Billroth II ..L.' partial gastrectomy. ?. "·; .ir···;·;;s; I' .··,:·';1 Billroth .. performed a on a very debili- -iu·xsl·r··.-' I .p;r-rl.·· tated man of 48 with a large but mobile pyloric carcinoma. It was impossible to resect the tumour and perform his original gastroduo- denostomy. He, therefore, anastomosed a loop ofjejunum to the stomach above the growth in the first instance, and finding the patient had with- stood this initial step proceeded to resect the tumour and close the cut ends of the stomachProtected by copyright. and duodenum. The high mortality rate gave cause for further FIG. 3.-J. von Mikulicz-Radecki. thought particularly in non-malignant cases. Loreta47 had tried digital dilatation of both the cardiac and pyloric orifices through a gastrotomy. performed a gastrojejunostomy which became the The recurrence rate was high and the procedure, first successful one. Four days later Billroth therefore, seemed unjustifiable. Heinecke34 and tried the same procedure, but the patient died on Mikulicz,53 working as Billroth's assistants, at- the tenth post-operative day from continuous tempted the first pyloroplasty in I885. Through a biliary vomiting. Post-mortem examination re- comparatively small abdominal incision they vealed a greatly distended afferent loop which divided longitudinally the white scar tissue, which communicated with the stomach, but there was had replaced the pylorus, and closed the defect only a small narrow stoma to the efferent loop, transversely with good results. which was kinked at the site of the anastomosis and The next ten years gave time to continue with http://pmj.bmj.com/ was not draining the stomach. Up to I884 only and modify the procedures of pylorectomy, two of the seven cases of gastroenterostomy and pyloroplasty, which had which had been reported had survived; it was little become fairly well established. During this wonder that this operation had gained no popu- period article followed article dealing with suc- larity in its early stages. In I88382 Woelfler per- cesses and failures, and new techniques which formed the first anastomosis-en-y in order to were thought to improve upon the old. the which had occurred in or as it had

prevent kinking Pylorcctomy, partial gastrectomy on September 27, 2021 by guest. Billroth's case, an operation which was later to be now become to be known, was established as the popularized by Roux of Lausanne.66 In this correct procedure for operable cases of cancer of same year Courvoisier16 had performed the first the pylorus. A few surgeons, notably Rydygier, ' Gastroenterostomie retrocolique posterieure had suggested that partial gastrectomy might be of transmesocolique', with a fatal outcome. some value in the treatment of simple gastric Across the Atlantic, in North America, Phinneas ulcers, and reported the first case in which he Connor of Cincinnati,15 in I884 operated upon a removed part of a stomach containing a large 55-year-old woman with an extensive carcinoma posterior ulcer. On November 2I, 881, Rydygier of the stomach involving the cardia. He was operated on a 30-year-old woman, Karolina forced to attempt total extirpation, but unfortu- Pfennig, for a posterior gastric ulcer which was nately the patient died on the table before he had lying close to the pylorus, penetrating the pancreas, completed the excision. It was an heroic attempt, and had caused a pyloric stenosis.68 Nineteen December I960 ROBINSON: The History of Gastric Surgery 709 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from method is known, but it is reasonable to demand that with a name one is able to draw a correct mental picture, and furthermore be able to execute the method exactly'. Gastroenterostomy rapidly gained in popularity as a treatment for ulceration and ir- removable carcinoma. The two main technical I·.s·. .,;, problems were biliary regurgitation and un- over the anastomosis. this CB certainty Loops way and loops that way were tried. Roux popu- ..;. larized the ' in -I;.·;..cj*l.e+lssl.-'--. -Ill.rssm.-.: en-y' type i897,66 formerly described Woelfler. There were .··F··;.8.. by pull-through .;"·.· operations, cones, valves, bone plates, raw hide, i: ;a decalcified bone silver a i C i.i.sE "gg bobbins, perforated plates and a button, which Murphy60 introduced in I892, '" and was heralded some as the technical rd,, by greatest advance in intestinal anastomosis, being held responsible for the falling mortality. It was . r. pertinent when Kocher"3 said ' It is well that Nature is not so ungracious as the surgeon. She rr allows, just as God allows the sun to shine on good and evil, methods which theoretically are good and bad to be successful'. Biliary regurgitation had become such a that some it

problem thought Protected by copyright. necessary to by-pass the pyloric obstruction by gastro-duodenostomy. This was first carried out by Jaboulay4l in I894. Mortality rates had already begun to fall. Mikulicz4 in 1897 had said that ' ... the danger to life from gastric ulcer is at least not less, but probably far greater than the danger of a complete FIG. von modern operation'. In England Mayo-Robson50 4.-A. F. Eiselsberg. in 1900 reported a I6.4% mortality on i88 con- secutive gastric operations. years later she was in good health and was proudly More and more stress was being laid upon the shown at a surgical congress.70 importance of early diagnosis of cancer of the There was little alteration in the technique of stomach. A great advance in this field came in both the and II procedures, until about 1895 when Hemmeter,35 following Roentgen's use the turn of the century. However, von Hacker33 of the X-ray, reported a method of visualizing http://pmj.bmj.com/ did express the opinion that he could see no the stomach with radio-opaque lead acetate reason why the divided end of the stomach within a gutta-percha bag. Two years later Kuhn could not be anastomosed directly on to the side described a spiral sound which he introduced into of the jejunal loop; it would be both easier and the stomach, performing a curettage. This, quicker. In i888 Kroenlein44 practised this however, was not received very favourably, for it modification on a 24-year-old man with pyloric was feared that fragmentation of the cancer cells in whom there was a narrow lead to of the stenosis, particularly might spread disease. Mikulicz52 in on September 27, 2021 by guest. pyloric antrum. This he joined to the side of a 1881 had described the use of the gastroscope in loop of jejunum, but the patient died within 24 differentiating innocent from malignant lesions, hours and at autopsy it was shown that the but it was not held in high regard for it was anastomosis was not functioning, because the difficult, uncertain and caused considerable dis- jejunal loop was kinked at the suture line, with tress to the patient. It was about this time that complete obstruction to the afferent loop. Anton Mikulicz became the first surgeon to attempt von Eiselsberg24 one year later performed this same closure of a perforated gastric ulcer,55 but the manoeuvre with success. This type of anasto- patient died in three hours. mosis was to gain in popularity and become It was now becoming evident that with the recommended by such surgeons as Mikulicz, lowered mortality rate and longer survival, the Reichel, Polya, and Finsterer28 who said ' It is in end-result of-the operation had taken on greater my opinion quite indifferent by what name this significance. The last 20 years- of the nineteenth 710 POSTGRADUATE MEDICAL JOURNAL December I960Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from century had justified operations upon the stomach, However, on the continent of Europe it was still and had made them a relatively safe procedure; in vogue, and its cause was furthered by the new century turned its energy towards im- Burdenko13 who said that the permanent exclusion proving this safety, and above all to modifying of the duodenum might lead to a functional dis- techniques which would prevent the post- turbance of the pancreas and eventual atrophy. operative syndromes, which were already making Against it was the feeling that, in cancer, stenosis their appearance. was likely to occur if any residual growth was left Petersen64 in Germany had been carrying out in the pyloric or supra-pancreatic lymph nodes, or several experiments which were destined to over- indeed in the pancreas itself, and that this new come the major problems in gastroenterostomy. growth might strangle the anastomosis. In He studied the relation of the highest portion of the duodenal or prepyloric ulceration the dense ad- jejunum to the stomach, demonstrating that this hesions, which so often accompanied these lesions, high loop of jejunum always lay above the greater required division, and it was felt that they would curvature of the stomach, even in the normal, and reform in greater strength and tenacity and thus would be considerably higher in patients with an produce kinking with obstruction. enlarged stomach due to pyloric stenosis. He In I9I Shoemakei73 introduced his new found that it was possible to anastomose this high technique which was reported to make the Billroth jejunal loop to the posterior surface of the stomach. I procedure safer. With the use of a special This would obviate the long loop, which in the curved clamp he divided the stomach, removing past had so often become obstructed, and would a great portion of the lesser curve, so that a avoid the more ccmplicated Roux-en-y type of tubular structure formed by the greater curvature anastomosis, which had been designed to ac- was left which would be easily anastomosed to the complish this very purpose. This paper came duodenum. from Czerny's Clinic, and its importance was Finsterer28 reported that Hofmeister in I908Protected by copyright. recognized throughout the world, particularly by described his valve, which he formed byclosing the Moynihan in England and by Mayo in America. upper end of the stomach first, and then anasto- It formed the basis for the established posterior mosing a small portion ofthe stomach at the greater gastroenterostomy of today. Rydygier70 still curvature to the jejunal loop, exactly as in the believed that, in cases of gastric ulceration, no less Mikulicz procedure. A search of the literature an operation than local excision of the ulcer was fails to reveal any scientific publication by justified, condemning gastroenterostomy for Hofmeister himself describing the operation which gastric ulcer, because he believed that cancer has come to bear his name, but his use of the could still develop on the edge of a healed ulcer. valve is reported by Stumpf.75 He was a great In I899 Braunl' described the first jejunal ulcer advocate of the short posterior loop and disagreed resulting from a gastroenterostomy, and a short with Balfour3 who recommended a long anterior time later it was noted that these ulcers tended to loop, but later5 modified this with an accompanying occur more frequently in cases in which a Roux- enteroenterostomy to prevent retention of pan- en-y type anastomosis had been performed. creatic and biliary juices within the duodenum. In i905 Moynihan58 described his 'line' for The introduction of partial gastrectomy intohttp://pmj.bmj.com/ gastroenterostomy. This was situated on the the treatment of duodenal ulceration had begun to posterior surface of the stomach i in. proximal raise the problem of how to deal with the 'difficult' from a line drawn perpendicularly down from the ulcer, particularly when there was deep penetra- oesophageal-hiatus. tion into the pancreas, or involvement of the com- Hertz37 (later Sir Arthur Hurst) in I913 pub- mon by the surrounding inflammatory lished a paper on certain unfavourable after- mass. Eiselsberg in i89525 had advocated the use effects of In Charles of exclusion for irremovable cancers of the gastroenterostomy. I922 pyloric on September 27, 2021 by guest. Mix56 in America published the first article on pylorus. Finsterer in I9i828 used this principle, what he called the ' '. This but also removed a portion of the stomach above followed in a patient upon whom an anterior the pylorus, which he closed before performing a gastroenterostomy had been performed four years gastrojejunostomy. Within a few years he began previously. to get a high incidence of gastrojejunal ulcers. Gastroenterostomy was from now on to change Devine in I92520 advocated the old antral exclusion little, and so thoughts were turned once more to operation of Eiselsberg, whereby the pyloric the improvements required in gastric resection. antrum was divided, the stump closed and the The Billroth I operation had lost some of its proximal cut end of the stomach anastomosed to a original popularity because of the dangers of loop of jejunum, but no stomach tissue was leakage, and the tension at the anastomosis which removed. Recurrences were still high. In 1932 did not occur with the Billreth II operation. Bancroft6 modified the Devine procedure by coring December I960 ROBINSON: The History of Gastric Surgery 711 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from selection of patients with gastroduodenal haemor- rhage, except in some clinics, remained a fairly haphazard procedure until in 1946 Gordon- g~ Taylor30 recommended' Selective Surgical Inter- . a ference' for which he gave various criteria. Many modifications were introduced to over- come certain technical difficulties, but few were to ...... still fewer to be a become recognized and accepted. Balfour in i9214 reported on a method ofdiathermy ...... excision of gastric lesions, which proved to be safe ...... '::~~~~~''~; and effective, but was not destined to replace Al', partialgastrectomy. Pauchet in I92061 stressed the importance of removing the greater omentum in continuity with the stomach for carcinoma, and clearing the pyloric and pancreatic lymphatic field. He introduced the now famous wedge exci- sion for high gastric ulcers on the lesser curve.62 Moynihan59 had introduced his two types of gastrojejunal anastomosis following gastric re- section. His first modification was the Roux-en-y principle but it did not gain favour. The Moynihan II operation is still practised today by a few surgeons. It consists of an antecolic anti- peristaltic anastomosis fashioned from the full width of the gastric remnant. Protected by copyright. Connell"7 from Wisconsin suggested ' fundu- sectomy ' as a rational way of removing the major acid bearing portion of the stomach. A few years later in I933 George Crile18 of Cleveland, Ohio, FIG. 5.-H. Finsterer. introduced the theory that peptic ulcer formation might be the result of sympathetico-adrenal out the antral mucosa before closing the sero- irritability, which could be controlled by adrenal muscular stump; although he still did not remove denervation. Wangensteen introduced two new any stomach the gastrojejunal ulcer rate began to methods for removal of the acid bearing area of the fall. Finisterer was not satisfied with these stomach. The first in I94077 removed most of the methods and combined his original procedure of greater curvature of the stomach, but this failed antral exclusion with partial gastrectomy with the and had to be abandoned because of the high rate mucosal coring manoeuvre of Bancroft. This of recurrent ulceration. In 195278 he removed all method, often referred to simply as the Bancroft the stomach except for a cuff at the cardia and a http://pmj.bmj.com/ procedure, is practised widely today, but it is portion of the pylorus. He anastomosed the two questionable whether it is better than a method portions and finished by doing a pyloroplasty. introduced by McKittrick49 in which the pylorus This had been attended with apparent success, but is excluded, a standard gastric resection per- the follow-up period is not sufficiently long for any formed and the pyloric stump removed six weeks definite conclusions to be drawn from such a small later. number of cases. A new era in the treatment of ulceration Roscoe Graham65 of Toronto advocated exterior- peptic on September 27, 2021 by guest. ization of the duodenal ulcer when it had become was ushered in by Dragstedt and Owens in I943,22 fixed to the pancreas. He divided the posterior when they reported on two cases of duodenal ulcer wall of the duodenum distal to the mobile duo- treated by . This was not a new con- denum. Welch79 advised a catheter duodenos- ception in therapy for it was certainly practised tomy with or without a catheter in in the I900 to 1920 period. The history at this cases in which the duodenal stump could not be time is muddled and only a few isolated cases closed easily. were reported, and it is doubtful whether total During the early part of this century gastro- vagal section was achieved. Exener,27 in 19II, duodenal haemorrhage was treated medically, referred to two cases and made the clear observa- there being no place for surgery. Finisterer in tion that he had been able to pull down the I92328 strongly opposed these views and reported oesophagus 3 cm. into the abdominal cavity by on his relative success with early operation. The mobilizing the cardia. He was thus able to make 712 POSTGRADUATE MEDICAL JOURNAL December 1960 Postgrad Med J: first published as 10.1136/pgmj.36.422.706 on 1 December 1960. Downloaded from certain that he had divided all the vagal fibres. account, but an attempt has been made to refer to Exener was concerned about the failure of the those men who have done much for gastric stomach to empty itself during the immediate surgery, many of whom have been selected post-operative phase, and so accompanied the because their writings are easily accessible. neurosection with a gastrostomy. REFERENCES In Bircher9 20 cases of sub- 1920 reported upon I. ABERCROMBIE, J. (1830),' Pathological and Practical Research section, but his results were so of the Stomach, the Intestinal Canal, the and other diaphragmatic good Viscera of the Abdomen,' 2nd ed., p. 103. Edinburgh: that it is doubtful whether he could have divided Balfour & Co. all the nerves, for none of the 2. BAILLIE, M. (1793), ' The Morbid Anatomy of Some of the patients developed Most Important Parts of the Human Body,' p. 87. London: any of the immediate post-operative symptoms, L. Johnson. with which we are familiar. Latarjet45 reported 3. BALFOUR, D. C. (1917), Surg. Gynec. Obstet., 25, 473. cases of like 4. BALFOUR, D. C. (1921), Surg. Clin. N. Amer., I, 5, 1233. upon 24 incomplete vagotomy. He, 5. BALFOUR, D. C. (1925), J. Amer. mred. Ass., 84, 876. Exener, was concerned about the delayed gastric 6. BANCROF'', F. W. (1932), Amer. J. Surg., I6, 22. emptying and suggested that a gastrojejunostomy 7. BILLROTH, T. (1877), Wien. med. Wschr., 27, 913. should the 8. BILLROTH, T. (i88i), Ibid., 31, 162. complement operation. 9. BIRCHER, E. (I920), Schweiz. med. Wschr., 50, 519. A new form of therapy for gastroduodenal io. BONETI, T. (1679), 'Sepulchretum sive anatomia practica ex ulceration was introduced by Somervell74 and cadaveribus mortis denatis,' vol. 2, p. 3. Geneva: Chouet. who the arterial blood to the Ii. BRAUN, H. (1899), Zbl. Chir., 28, 94. Hey38 ligated supply 12. BRIGHAM, C. B. (1898), Boston med. surg. J., 138, 415. stomach in an attempt to reduce acidity without 13. BURDENKO, N. (I914), Int. Beitr. ErhahsStor., 2, 321. mutilation. Hey reported upon nearly 400 cases in 14. CELSUS, A. C. (I479), ' de Medicina,' Bk. 4, para. 12, p. 82. which he had divided the arterial and ac- 15. CONNOR, P. (1884), Med. News, 45, 578. supply 16. COURVOISIER, L. J. (1883), Zbl. Chir., 10, 794. companied this by a gastroenterostomy in all but 17. CONNELL, F. G. (1929), Surg. Gynec. Obstet., 49, 696. six cases. Only one patient died, and one de- 18. CRILE, G. W. (1933), Sth. Surg., 2, 273. 19. CZERNY, V., and KAISER, F. F. (i878), ' Bitrage zur opera- veloped a gastrojejunal ulcer. He performed a tiven V. von Ferdinande, Enke. chirugie, p. 93. Stuttgart: Protected by copyright. fractional test meal before and after operation on 20. DEVINE, H. (1925), Surg. Gynec. Obstet., 40, I. i6o and showed that in all cases where there 21. DONATUS, M. (1586), 'de Medica Historia Merabile,' cases, vol. 4, p. 3. had been a pre-operative elevation of the gastric 22. DRAGSTEDT, L. R., and OWENS, F. M. (1943), Proc. Soc. this had been reduced to normal exp. Biol. (N.Y.), 53, 152. acidity, acidity 23. EHRHARDT, O. (1902), Janus, 7, ioi. and remained so for the follow-up period of from 24. EISELSBERG, A. F. VON (I889), Arch. klin. Chir., 39, 785. four to six years. 25. EISELSBERG, A. F. VON (I895), Ibid., 50, 919. Total gastrectomy had become the standard 26. EISELSBERG, A. F. VON (1936), Wien. med. Wschr., 86, 3. cancer the but 27. EXENER, A. (I9II), Dtsch. Z. Chir., III, 576. treatment for extensive of stomach, 28. FINSTERER, H. (1923), ' Anaesthesia in Abdominal Surgery,' the post-operative distress of many of the patients, trans. by J. P. F. Burke, p. 15. New York: Redman & Co. 29. GALEN, C. (x856), ' Euvres Anatomique, physiologique et without any great increase in the survival rate, led medicale de Galen,' trans. by Darenberg, ch. 2, pp. 6, 668. many surgeons to alter their opinions about this 30. GORDON-TAYLOR, G. (1946), Brit. J. Surg., 33, 336. radical Some believed 31. GUSSENBAUER, C., and WINIWARTER, A. VON (1876), operation. that, providing Arch. klin. Chir., 19, 347. the gastric section was well clear of the growth and 32. HACKER, V. VON (I885), Verh. dtsch. ges. Chir., I, 74. that an adequate lymphatic clearance could be 33. HACKER, V. VON (i885), Arch. klin. Chir., 32, 6i6. a small of the stomach should 34. HEINECKE, J. (I836), Inaug. Dissert,' Furth, p. 13. http://pmj.bmj.com/ undertaken, portion 35. HEMMETER, J. C. (I896), Boston med. Surg. J., I34, 609. be left, whether it be at the pyloric or cardiac end. 36. HENLEY, F. A. (1952), Brit. J. Surg., 40, 18. This became known as either a high or low radical 37. HERTZ, A. F. (1913), Ann. Surg., 58, 466. subtotal To overcome the total 38. HEY, W. H. (I947), Brit. med. J., ii, 395. gastrectomy. 39. HUNNICUTT, A. J. (1952), Arch. Surg., 65, i. absence of the stomach several 'replacement' 40. HUNT, J. C. (1952), Ibid., 64, 6oi. operations were introduced. In 1952 Hunt40 in 41. JABOULAY, M. (1899). Quoted by E. D. McCrea (1926), America the stomach with a Brit. J. Surg., 13, 621. replaced pouch 42. JONES, S. (I875), Lancet, i, 678. fashioned from a of The of T. ' Textbook of 200. loop jejunum. loop 43. KOCHER, (1903), Operative Surgery,' p. on September 27, 2021 by guest. was anastomosed in the usual end-to-side New York: Macmillan & Co. jejunum 44. KROENLEIN, R. V. (x888), Korrespl.-Bl. schweiz. Arz., 18, 317. manner to the oesophagus; the loop was then 45. LATARJET, A. (1922), Bull. Acad. Med. (Paris), 87, 681. anastomosed to itself for several inches. He also 46. LITTRI, M. P. E. 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