706

THE HISTORY OF GASTRIC SURGERYJAMES 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 mostcomplex in the annals of medicine. The practiceof this surgery depended upon the growing know-ledge of the pathology of gastric diseases. Thisknowledge, together with animal experiments andthe introduction of anaesthesia during the lastcentury, led to the first successful planned opera-tion for a disease of the stomach. The last 20years of the nineteenth century saw the intro-duction of many gastric operations, some of whichwere to become established and modified duringthe ensuing years.

In the writings of Celsus14 in the first centuryand Galen29 in the second century, vague re-ferences were made to ulcers of the stomach, butit was not until the revival of medicine in thesixteenth century, with its attendant increase inpost-mortem examinations, that further exampleswere recorded.

In 1596 Marcellus Donatus2l described theautopsy on a man of 59 years, who was found tohave a gastric ulcer. Littre46 reported, from thediary of a Lady-in-Waiting to Henrietta Anne,Duchess of Orleans and daughter of King CharlesI of England, how the Duchess had died, in I670,from a perforated gastric ulcer, following years ofdyspepsia. The writings of John Bauhin in theSepulchretum of Boneti'0 in I679 give a fulldescription of a physician's wife, aged I9, who diedfrom a perforated gastric ulcer.The first accurate and extensive description of

gastric ulcers and cancer is attributed to MathewBaillie in I7932. Duodenal ulceration was notrecognized until the early part of the nineteenthcentury when Benjamin Travers76 reported on twocases which had died of perforations. This wasfollowed by an excellent description by JohnAbercrombie' in his Pathological and PracticalResearches on the Diseases of the Stomachpublished in I830.

Experimental surgery on the stomach began inI8Io when Karl Theordor Merrem,51 a student atthe University of Giessen, demonstrated that thepylorus of dogs could be removed successfully,and without any apparent effect on their well-being.

In 1876, Carl Gussenbauer and Von Wini-warter31 performed many successful pylorectomieson dogs, and suggested the feasibility of this pro-cedure on the human subject. At the same timein a clinic in Vienna, Czerny and Kaiserl9 whileworking as assistants to Billroth, were performingsimilar experiments. In one instance they re-sected the entire stomach of a dog, which survivedand flourished for five years. Under the guidanceof their professor they were beginning to outlinethe principles of gastric surgery, which were to leadthe world in this field.The first operation is believed to have been the

removal of a knife from the stomach of a pro-fessional knife thrower, by a barber and surgeon ofPrague named Florian Mathies (quoted by vonEiselsberg26) in I602. Thirty-three years later,on July 9, 1635, a similar successful operation wasperformed in Konigsberg by ChristopherSchwabe (quoted by Ehrhardt23). He removed bygastrotomy a knife which a young farm hand,named Andrea Grunheide, had swallowed whilsttickling the back of his throat to induce vomiting.This procedure was somewhat barbarous; twicethe barbers and theologians strapped their victimto a board before finding and opening the stomach.Both patients survived these ordeals.No further recorded operation can be found until

I849 when Charles Sedillot, Professor of Surgeryat the French School of Military Medicine inStrasbourg, performed a gastrostomy after threeexperiments on dogs,72 but the patient succumbedwithin a few hours of the operation. Thirty-three further unsuccessful attempts were made bySedillot, but it was not until I875 that SydneyJones,42 an English surgeon, reported the firstsuccessful case.On April 5, I879, Jules-Emile Pean63 claimed

to have undertaken the first pvlorectomy for apyloro-duodenal cancer, at the Frere St. Jean deDieu Hospital in Paris, but the patient died on thefifth post-operative day. A post-mortem wasunfortunately refused, but it is interesting to notethat Pean felt that it might have been wiser to havemade the anastomosis with silk rather than catgut,which may have been responsible for its disruption.

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

December 1960 ROBINSON: The History of Gastric Surgery 707

-.

:'r'C.' v. . ...:'....

.....

... .......

Ji a<

:4.t : -

AbILa

FIG. I.-L. von Rydygier

Nineteen months later, on November I6, I88I,Ludwig von Rydygier68, 69 attempted the secondpylorectomy with the same result. Rydygier wasa proud Polish surgeon, who had started a privateClinic in Chelmo, and it was here that he did thissecond pylorectomy at the age of 30. It is believedthat he was the first surgeon to attempt gastro-enterostomy. He performed this operation inI88067 on a 63-year-old man named JuliusMickotajewicz who was known to have a duodenalulcer. Chloroform anaesthesia was used duringthe 4 hours duration of the operation. Thepatient succumbed 12 hours later from circulatoryfailure.On January 29, I88I, Professor Theodor

Billroth at his Clinic in Vienna completed thefirst successful partial gastrectomy on ThereseHeller, a 44-year-old woman who had developeda pyloric carcinoma 8 The first success was notone of chance; for years he and his assistants hadworked carefully and methodically to this end, anda few years before7 while operating on a case ofgastric fistula, he had remarked that it was but ashort step to the day when the human stomachcould be removed surgically. This was to be abold step, but his foresight had forearmed himagainst the criticism which he knew would herald

N'rc-M?.~.?T

....:'··--

........i

FIG. 2.-T. Billroth.

this procedure. He knew well the dangers andthe mortality which would occur when thisoperation was performed by surgeons untrainedand unskilled. In defence of his operation he said' To reassure those who are of the opinion that mypresent operation is a foolhardy experiment onman is beside the question. Resection of thestomach has been as completely worked upanatomically, physiologically and technically bymy students and myself as any other new operation.Every surgeon who has had experience in experi-ments on animals and similar operations on manhas reached the conviction that resection of thestomach must and will succeed. To establishthe indications and contra-indications, and towork out the technique for the widely differentcases, must be our next concern, and the object ofour further studies '. He taught his pupils welland sent them out into the cities of Europe topractise and further this type of surgery. Histeaching ability is reflected in the names of suchmen as Czerny, von Mikulicz, Woelfler and vonHacker, who were to lead others in the modifica-tions which Billroth knew to be essential for itsultimate success.

In the following month, in November,Woelfler,80, 81 when operating upon a 38-year-oldman with a pyloric carcinoma, found that thegrowth had infiltrated the pancreas, which madethe case unsuitable for gastrectomy. He therefore

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

708 POSTGRADUATE MEDICAL JOURNAL December 1960

.Y.WG.k.,'"

sEl

" "".rl ";":I.-r. ;..·*I,;·

,.,,.%..... .9p·g ".'':g.I .:'."·;ii·.··;.·.iA. .. i

.:.:.·'.''' .'P:".."; "''.i.Pue.;E.;-i..;.'·;?.·u.u uy ;.·i

i

...:·.

·.;·.;; f.i.r·

. .;h·"9 . I.GscrLL;" rr··bC?

,,

..i.BCL.'.. "·;?. .ir···;·;;s; I' .··,:·';1.. -iu·xsl·r··.-'

I .p;r-rl.··

FIG. 3.-J. von Mikulicz-Radecki.

performed a gastrojejunostomy which became thefirst successful one. Four days later Billrothtried the same procedure, but the patient died onthe tenth post-operative day from continuousbiliary vomiting. Post-mortem examination re-vealed a greatly distended afferent loop whichcommunicated with the stomach, but there wasonly a small narrow stoma to the efferent loop,which was kinked at the site of the anastomosis andwas not draining the stomach. Up to I884 onlytwo of the seven cases of gastroenterostomywhich had been reported had survived; it was littlewonder that this operation had gained no popu-larity in its early stages. In I88382 Woelfler per-formed the first anastomosis-en-y in order toprevent the kinking which had occurred inBillroth's case, an operation which was later to bepopularized by Roux of Lausanne.66 In thissame year Courvoisier16 had performed the first' Gastroenterostomie retrocolique posterieuretransmesocolique', with a fatal outcome.

Across the Atlantic, in North America, PhinneasConnor of Cincinnati,15 in I884 operated upon a55-year-old woman with an extensive carcinomaof the stomach involving the cardia. He wasforced to attempt total extirpation, but unfortu-nately the patient died on the table before he hadcompleted the excision. It was an heroic attempt,

not to be repeated until I3 years later when CarlSchlatter71 of Zurich performed the first successfultotal gastrectomy. He effected communicationwith the digestive tract by anastomosing a loop ofjejunum to the lower end of the oesophagus. Thepatient recovered and in two months had gained8 lb. in weight. A second successful case of totalgastrectomy was reported from Boston, Massa-chusetts, in I898 by Brigham.12 In this caseanastomosis was effected between the oesophagusand the duodenum around a Murphy's button,which had been introduced into surgery some sixyears previously.Von Hacker,32 writing from Billroth's Clinic in

I885, referred to the operation which has becomeknown as the Billroth II partial gastrectomy.Billroth performed a laparotomy on a very debili-tated man of 48 with a large but mobile pyloriccarcinoma. It was impossible to resect thetumour and perform his original gastroduo-denostomy. He, therefore, anastomosed a loopofjejunum to the stomach above the growth in thefirst instance, and finding the patient had with-stood this initial step proceeded to resect thetumour and close the cut ends of the stomachand duodenum.The high mortality rate gave cause for further

thought particularly in non-malignant cases.Loreta47 had tried digital dilatation of both thecardiac and pyloric orifices through a gastrotomy.The recurrence rate was high and the procedure,therefore, seemed unjustifiable. Heinecke34 andMikulicz,53 working as Billroth's assistants, at-tempted the first pyloroplasty in I885. Through acomparatively small abdominal incision theydivided longitudinally the white scar tissue, whichhad replaced the pylorus, and closed the defecttransversely with good results.The next ten years gave time to continue with

and modify the procedures of pylorectomy,gastroenterostomy and pyloroplasty, which hadbecome fairly well established. During thisperiod article followed article dealing with suc-cesses and failures, and new techniques whichwere thought to improve upon the old.

Pylorcctomy, or partial gastrectomy as it hadnow become to be known, was established as thecorrect procedure for operable cases of cancer ofthe pylorus. A few surgeons, notably Rydygier,had suggested that partial gastrectomy might be ofsome value in the treatment of simple gastriculcers, and reported the first case in which heremoved part of a stomach containing a largeposterior ulcer. On November 2I, 881, Rydygieroperated on a 30-year-old woman, KarolinaPfennig, for a posterior gastric ulcer which waslying close to the pylorus, penetrating the pancreas,and had caused a pyloric stenosis.68 Nineteen

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

December I960 ROBINSON: The History of Gastric Surgery 709

.,;,I·.s·.

CB

..;.

-I;.·;..cj*l.e+lssl.-'--. -Ill.rssm.-.:

F·· ..·· ;.8..;"·.·

;ai:C i.i. sE gga i "

'" d,,r

. r.

rr

FIG. 4.-A. F. von Eiselsberg.

years later she was in good health and was proudlyshown at a surgical congress.70There was little alteration in the technique of

both the Billroth I and II procedures, until aboutthe turn of the century. However, von Hacker33did express the opinion that he could see noreason why the divided end of the stomachcould not be anastomosed directly on to the sideof the jejunal loop; it would be both easier andquicker. In i888 Kroenlein44 practised thismodification on a 24-year-old man with pyloricstenosis, in whom there was a particularly narrowpyloric antrum. This he joined to the side of aloop of jejunum, but the patient died within 24hours and at autopsy it was shown that theanastomosis was not functioning, because thejejunal loop was kinked at the suture line, withcomplete obstruction to the afferent loop. Antonvon Eiselsberg24 one year later performed this samemanoeuvre with success. This type of anasto-mosis was to gain in popularity and becomerecommended by such surgeons as Mikulicz,Reichel, Polya, and Finsterer28 who said ' It is inmy opinion quite indifferent by what name this

method is known, but it is reasonable to demandthat with a name one is able to draw a correctmental picture, and furthermore be able to executethe method exactly'.

Gastroenterostomy rapidly gained in popularityas a treatment for peptic ulceration and ir-removable carcinoma. The two main technicalproblems were biliary regurgitation and un-certainty over the anastomosis. Loops this wayand loops that way were tried. Roux popu-larized the ' en-y' type in i897,66 formerlydescribed by Woelfler. There were pull-throughoperations, cones, valves, bone plates, raw hide,decalcified bone bobbins, perforated silver platesand a button, which Murphy60 introduced in I892,and was heralded by some as the greatest technicaladvance in intestinal anastomosis, being heldresponsible for the falling mortality. It waspertinent when Kocher"3 said ' It is well thatNature is not so ungracious as the surgeon. Sheallows, just as God allows the sun to shine on goodand evil, methods which theoretically are good andbad to be successful'. Biliary regurgitation hadbecome such a problem that some thought itnecessary to by-pass the pyloric obstruction bygastro-duodenostomy. This was first carried outby Jaboulay4l in I894.

Mortality rates had already begun to fall.Mikulicz4 in 1897 had said that ' ... the danger tolife from gastric ulcer is at least not less, butprobably far greater than the danger of a completemodern operation'. In England Mayo-Robson50in 1900 reported a I6.4% mortality on i88 con-secutive gastric operations.More and more stress was being laid upon the

importance of early diagnosis of cancer of thestomach. A great advance in this field came in1895 when Hemmeter,35 following Roentgen's useof the X-ray, reported a method of visualizingthe stomach with radio-opaque lead acetatewithin a gutta-percha bag. Two years later Kuhndescribed a spiral sound which he introduced intothe stomach, performing a curettage. This,however, was not received very favourably, for itwas feared that fragmentation of the cancer cellsmight lead to spread of the disease. Mikulicz52 in1881 had described the use of the gastroscope indifferentiating innocent from malignant lesions,but it was not held in high regard for it wasdifficult, uncertain and caused considerable dis-tress to the patient. It was about this time thatMikulicz became the first surgeon to attemptclosure of a perforated gastric ulcer,55 but thepatient died in three hours.

It was now becoming evident that with thelowered mortality rate and longer survival, theend-result of-the operation had taken on greatersignificance. The last 20 years- of the nineteenth

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

710 POSTGRADUATE MEDICAL JOURNAL December I960

century had justified operations upon the stomach,and had made them a relatively safe procedure;the new century turned its energy towards im-proving this safety, and above all to modifyingtechniques which would prevent the post-operative syndromes, which were already makingtheir appearance.

Petersen64 in Germany had been carrying outseveral experiments which were destined to over-come the major problems in gastroenterostomy.He studied the relation of the highest portion of thejejunum to the stomach, demonstrating that thishigh loop of jejunum always lay above the greatercurvature of the stomach, even in the normal, andwould be considerably higher in patients with anenlarged stomach due to pyloric stenosis. Hefound that it was possible to anastomose this highjejunal loop to the posterior surface of the stomach.This would obviate the long loop, which in thepast had so often become obstructed, and wouldavoid the more ccmplicated Roux-en-y type ofanastomosis, which had been designed to ac-complish this very purpose. This paper camefrom Czerny's Clinic, and its importance wasrecognized throughout the world, particularly byMoynihan in England and by Mayo in America.It formed the basis for the established posteriorgastroenterostomy of today. Rydygier70 stillbelieved that, in cases of gastric ulceration, no lessan operation than local excision of the ulcer wasjustified, condemning gastroenterostomy forgastric ulcer, because he believed that cancercould still develop on the edge of a healed ulcer.

In I899 Braunl' described the first jejunal ulcerresulting from a gastroenterostomy, and a shorttime later it was noted that these ulcers tended tooccur more frequently in cases in which a Roux-en-y type anastomosis had been performed.

In i905 Moynihan58 described his 'line' forgastroenterostomy. This was situated on theposterior surface of the stomach i in. proximalfrom a line drawn perpendicularly down from theoesophageal-hiatus.

Hertz37 (later Sir Arthur Hurst) in I913 pub-lished a paper on certain unfavourable after-effects of gastroenterostomy. In I922 CharlesMix56 in America published the first article onwhat he called the ' Dumping Syndrome'. Thisfollowed in a patient upon whom an anteriorgastroenterostomy had been performed four yearspreviously.

Gastroenterostomy was from now on to changelittle, and so thoughts were turned once more tothe improvements required in gastric resection.The Billroth I operation had lost some of its

original popularity because of the dangers ofleakage, and the tension at the anastomosis whichdid not occur with the Billreth II operation.

However, on the continent of Europe it was stillin vogue, and its cause was furthered byBurdenko13 who said that the permanent exclusionof the duodenum might lead to a functional dis-turbance of the pancreas and eventual atrophy.Against it was the feeling that, in cancer, stenosiswas likely to occur if any residual growth was leftin the pyloric or supra-pancreatic lymph nodes, orindeed in the pancreas itself, and that this newgrowth might strangle the anastomosis. Induodenal or prepyloric ulceration the dense ad-hesions, which so often accompanied these lesions,required division, and it was felt that they wouldreform in greater strength and tenacity and thusproduce kinking with obstruction.

In I9I Shoemakei73 introduced his newtechnique which was reported to make the BillrothI procedure safer. With the use of a specialcurved clamp he divided the stomach, removinga great portion of the lesser curve, so that atubular structure formed by the greater curvaturewas left which would be easily anastomosed to theduodenum.

Finsterer28 reported that Hofmeister in I908described his valve, which he formed by closing theupper end of the stomach first, and then anasto-mosing a small portion of the stomach at the greatercurvature to the jejunal loop, exactly as in theMikulicz procedure. A search of the literaturefails to reveal any scientific publication byHofmeister himself describing the operation whichhas come to bear his name, but his use of thevalve is reported by Stumpf.75 He was a greatadvocate of the short posterior loop and disagreedwith Balfour3 who recommended a long anteriorloop, but later5 modified this with an accompanyingenteroenterostomy to prevent retention of pan-creatic and biliary juices within the duodenum.The introduction of partial gastrectomy into

the treatment of duodenal ulceration had begun toraise the problem of how to deal with the 'difficult'ulcer, particularly when there was deep penetra-tion into the pancreas, or involvement of the com-mon bile duct by the surrounding inflammatorymass. Eiselsberg in i89525 had advocated the useof pyloric exclusion for irremovable cancers of thepylorus. Finsterer in I9i828 used this principle,but also removed a portion of the stomach abovethe pylorus, which he closed before performing agastrojejunostomy. Within a few years he beganto get a high incidence of gastrojejunal ulcers.Devine in I92520 advocated the old antral exclusionoperation of Eiselsberg, whereby the pyloricantrum was divided, the stump closed and theproximal cut end of the stomach anastomosed to aloop of jejunum, but no stomach tissue wasremoved. Recurrences were still high. In 1932Bancroft6 modified the Devine procedure by coring

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

December I960 ROBINSON: The History of Gastric Surgery 711

.........

................

a

.g~a

........'::~~~~~''~;

Al',

FIG. 5.-H. Finsterer.

out the antral mucosa before closing the sero-muscular stump; although he still did not removeany stomach the gastrojejunal ulcer rate began tofall. Finisterer was not satisfied with thesemethods and combined his original procedure ofantral exclusion with partial gastrectomy with themucosal coring manoeuvre of Bancroft. Thismethod, often referred to simply as the Bancroftprocedure, is practised widely today, but it isquestionable whether it is better than a methodintroduced by McKittrick49 in which the pylorusis excluded, a standard gastric resection per-formed and the pyloric stump removed six weekslater.

Roscoe Graham65 of Toronto advocated exterior-ization of the duodenal ulcer when it had becomefixed to the pancreas. He divided the posteriorwall of the duodenum distal to the mobile duo-denum. Welch79 advised a catheter duodenos-tomy with or without a catheter jejunostomy incases in which the duodenal stump could not beclosed easily.During the early part of this century gastro-

duodenal haemorrhage was treated medically,there being no place for surgery. Finisterer inI92328 strongly opposed these views and reportedon his relative success with early operation. The

selection of patients with gastroduodenal haemor-rhage, except in some clinics, remained a fairlyhaphazard procedure until in 1946 Gordon-Taylor30 recommended' Selective Surgical Inter-ference' for which he gave various criteria.Many modifications were introduced to over-

come certain technical difficulties, but few were tobecome recognized and still fewer to be accepted.Balfour in i9214 reported on a method ofdiathermyexcision of gastric lesions, which proved to be safeand effective, but was not destined to replacepartial gastrectomy. Pauchet in I92061 stressed theimportance of removing the greater omentum incontinuity with the stomach for carcinoma, andclearing the pyloric and pancreatic lymphaticfield. He introduced the now famous wedge exci-sion for high gastric ulcers on the lesser curve.62Moynihan59 had introduced his two types of

gastrojejunal anastomosis following gastric re-section. His first modification was the Roux-en-yprinciple but it did not gain favour. TheMoynihan II operation is still practised today bya few surgeons. It consists of an antecolic anti-peristaltic anastomosis fashioned from the fullwidth of the gastric remnant.

Connell"7 from Wisconsin suggested ' fundu-sectomy ' as a rational way of removing the majoracid bearing portion of the stomach. A few yearslater in I933 George Crile18 of Cleveland, Ohio,introduced the theory that peptic ulcer formationmight be the result of sympathetico-adrenalirritability, which could be controlled by adrenaldenervation. Wangensteen introduced two newmethods for removal of the acid bearing area of thestomach. The first in I94077 removed most of thegreater curvature of the stomach, but this failedand had to be abandoned because of the high rateof recurrent ulceration. In 195278 he removed allthe stomach except for a cuff at the cardia and aportion of the pylorus. He anastomosed the twoportions and finished by doing a pyloroplasty.This had been attended with apparent success, butthe follow-up period is not sufficiently long for anydefinite conclusions to be drawn from such a smallnumber of cases.A new era in the treatment of peptic ulceration

was ushered in by Dragstedt and Owens in I943,22when they reported on two cases of duodenal ulcertreated by vagotomy. This was not a new con-ception in therapy for it was certainly practisedin the I900 to 1920 period. The history at thistime is muddled and only a few isolated caseswere reported, and it is doubtful whether totalvagal section was achieved. Exener,27 in 19II,referred to two cases and made the clear observa-tion that he had been able to pull down theoesophagus 3 cm. into the abdominal cavity bymobilizing the cardia. He was thus able to make

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

712 POSTGRADUATE MEDICAL JOURNAL December 1960

certain that he had divided all the vagal fibres.Exener was concerned about the failure of thestomach to empty itself during the immediatepost-operative phase, and so accompanied theneurosection with a gastrostomy.

In 1920 Bircher9 reported upon 20 cases of sub-diaphragmatic section, but his results were so goodthat it is doubtful whether he could have dividedall the nerves, for none of the patients developedany of the immediate post-operative symptoms,with which we are familiar. Latarjet45 reportedupon 24 cases of incomplete vagotomy. He, likeExener, was concerned about the delayed gastricemptying and suggested that a gastrojejunostomyshould complement the operation.A new form of therapy for gastroduodenal

ulceration was introduced by Somervell74 andHey38 who ligated the arterial blood supply to thestomach in an attempt to reduce acidity withoutmutilation. Hey reported upon nearly 400 cases inwhich he had divided the arterial supply and ac-companied this by a gastroenterostomy in all butsix cases. Only one patient died, and one de-veloped a gastrojejunal ulcer. He performed afractional test meal before and after operation oni6o cases, and showed that in all cases where therehad been a pre-operative elevation of the gastricacidity, this acidity had been reduced to normaland remained so for the follow-up period of fromfour to six years.

Total gastrectomy had become the standardtreatment for extensive cancer of the stomach, butthe post-operative distress of many of the patients,without any great increase in the survival rate, ledmany surgeons to alter their opinions about thisradical operation. Some believed that, providingthe gastric section was well clear of the growth andthat an adequate lymphatic clearance could beundertaken, a small portion of the stomach shouldbe left, whether it be at the pyloric or cardiac end.This became known as either a high or low radicalsubtotal gastrectomy. To overcome the totalabsence of the stomach several 'replacement'operations were introduced. In 1952 Hunt40 inAmerica replaced the stomach with a pouchfashioned from a loop of jejunum. The loop ofjejunum was anastomosed in the usual end-to-sidemanner to the oesophagus; the loop was thenanastomosed to itself for several inches. He alsoproposed that this pouch should be swung acrossand anastomosed to the duodenum as a secondstage procedure. McAleese, Perrone andMcAleese48 and Hunnicutt39 suggested using theright colon, anastomosing the terminal ileum tothe oesophagus and the colon to the jejunum.Henley36 demonstrated the use of an ileal loop,and Moroney67 used the transverse colon.A great deal has been omitted in the above

account, but an attempt has been made to refer tothose men who have done much for gastricsurgery, many of whom have been selectedbecause their writings are easily accessible.

REFERENCESI. ABERCROMBIE, J. (1830),' Pathological and Practical Research

of the Stomach, the Intestinal Canal, the Liver and otherViscera of the Abdomen,' 2nd ed., p. 103. Edinburgh:Balfour & Co.

2. BAILLIE, M. (1793), ' The Morbid Anatomy of Some of theMost Important Parts of the Human Body,' p. 87. London:L. Johnson.

3. BALFOUR, D. C. (1917), Surg. Gynec. Obstet., 25, 473.4. BALFOUR, D. C. (1921), Surg. Clin. N. Amer., I, 5, 1233.5. BALFOUR, D. C. (1925), J. Amer. mred. Ass., 84, 876.6. BANCROF'', F. W. (1932), Amer. J. Surg., I6, 22.7. BILLROTH, T. (1877), Wien. med. Wschr., 27, 913.8. BILLROTH, T. (i88i), Ibid., 31, 162.9. BIRCHER, E. (I920), Schweiz. med. Wschr., 50, 519.

io. BONETI, T. (1679), 'Sepulchretum sive anatomia practica excadaveribus mortis denatis,' vol. 2, p. 3. Geneva: Chouet.

Ii. BRAUN, H. (1899), Zbl. Chir., 28, 94.12. BRIGHAM, C. B. (1898), Boston med. surg. J., 138, 415.13. BURDENKO, N. (I914), Int. Beitr. ErhahsStor., 2, 321.14. CELSUS, A. C. (I479), ' de Medicina,' Bk. 4, para. 12, p. 82.15. CONNOR, P. (1884), Med. News, 45, 578.16. COURVOISIER, L. J. (1883), Zbl. Chir., 10, 794.17. CONNELL, F. G. (1929), Surg. Gynec. Obstet., 49, 696.18. CRILE, G. W. (1933), Sth. Surg., 2, 273.19. CZERNY, V., and KAISER, F. F. (i878), ' Bitrage zur opera-

tiven chirugie, p. 93. Stuttgart: V. von Ferdinande, Enke.20. DEVINE, H. (1925), Surg. Gynec. Obstet., 40, I.21. DONATUS, M. (1586), 'de Medica Historia Merabile,'

vol. 4, p. 3.22. DRAGSTEDT, L. R., and OWENS, F. M. (1943), Proc. Soc.

exp. Biol. (N.Y.), 53, 152.23. EHRHARDT, O. (1902), Janus, 7, ioi.24. EISELSBERG, A. F. VON (I889), Arch. klin. Chir., 39, 785.25. EISELSBERG, A. F. VON (I895), Ibid., 50, 919.26. EISELSBERG, A. F. VON (1936), Wien. med. Wschr., 86, 3.27. EXENER, A. (I9II), Dtsch. Z. Chir., III, 576.28. FINSTERER, H. (1923), ' Anaesthesia in Abdominal Surgery,'

trans. by J. P. F. Burke, p. 15. New York: Redman & Co.29. GALEN, C. (x856), ' Euvres Anatomique, physiologique et

medicale de Galen,' trans. by Darenberg, ch. 2, pp. 6, 668.30. GORDON-TAYLOR, G. (1946), Brit. J. Surg., 33, 336.31. GUSSENBAUER, C., and WINIWARTER, A. VON (1876),

Arch. klin. Chir., 19, 347.32. HACKER, V. VON (I885), Verh. dtsch. ges. Chir., I, 74.33. HACKER, V. VON (i885), Arch. klin. Chir., 32, 6i6.34. HEINECKE, J. (I836), Inaug. Dissert,' Furth, p. 13.35. HEMMETER, J. C. (I896), Boston med. Surg. J., I34, 609.36. HENLEY, F. A. (1952), Brit. J. Surg., 40, 18.37. HERTZ, A. F. (1913), Ann. Surg., 58, 466.38. HEY, W. H. (I947), Brit. med. J., ii, 395.39. HUNNICUTT, A. J. (1952), Arch. Surg., 65, i.40. HUNT, J. C. (1952), Ibid., 64, 6oi.41. JABOULAY, M. (1899). Quoted by E. D. McCrea (1926),

Brit. J. Surg., 13, 621.42. JONES, S. (I875), Lancet, i, 678.43. KOCHER, T. (1903), ' Textbook of Operative Surgery,' p. 200.

New York: Macmillan & Co.44. KROENLEIN, R. V. (x888), Korrespl.-Bl. schweiz. Arz., 18, 317.45. LATARJET, A. (1922), Bull. Acad. Med. (Paris), 87, 681.46. LITTRI, M. P. E. (I872), 'Medicines et Medicins,' p. 429.

Paris: Dilier et Cie.47. LORETA, P. (1882), Mem. R. Acad., Bologna, Sci. Fis., 4, 353.48. McALEESE, J. J., PERRONE, F. P., and McALEESE, G. B.

(I952), Amer. J. Surg., 84, 712.49. McKITTRICK, L. S., MOORE, F. R., and WARREN, R.

(I944), Ann. Surg., 120, 53I.50. MAYO-ROBSON, A. (1900), Lancet, i, 671.51. MERREM, D. C. T. (I8io), ' Animadversions qualdam chirur-

gicae experimsntio in animalibus factis illustratae, p. 46.Gollinger: Gressae, Tasche et Mueller.

52. MIKULICZ-RADECKI, J. VON (1881), Wien. med. Pr., 22,571.

References continued on next page.

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from

December I960 ROBINSON: The History of Gastric Surgery 71353. MIKULICZ-RADECKI, J. VON (I888), Arch. klin. Chir.,

37, 79.54. MIKULICZ-RADECKI, J. VON (I897), Zbl. Chir., 24, 69.55. MIKULICZ-RADECKI, J. VON (I880), vide (1897), Arch.

klin. Chir., 55, 84.56. MIX, C. L. (1922), Surg. Clin. N. Amer., 2, 617.57. MORONEY, J. (I95I), Lancet, i, 993.58. MOYNIHAN, B. G. A. (1905), quoted by W. J. Mayor (1905),Ann. Surg., 42, 21.59. MOYNIHAN, B. G. A. (1928), 'Abdominal Operations.Philadelphia: W. B. Saunders & Co.60. MURPHY, J. B. (I892), WMed. Rec., 42, 665.61. PAUCHET, V. (1920), trans. by I. Macdonald (1920), Lancet,i, 308.62. PAUCHET, V. (1923), Paris chir., 15, 273.63. PEAN, J. E. (1879), Gaz. Hop. (Paris), 52, 473.64. PETERSEN, W. (1901), Beitr. klin. Chir., 29, 597.65. ROSCOE GRAHAM, R. (1938), Surg. Gynec. Obstet., 66, 269.66. ROUX, J. C. (1897), Rev. Gynae., I, 67.

67. RYDYGIER, L. VON (1880), Przegl. lek., 19, 637.68. RYDYGIER, L. VON (1882), Berlin. klin. Wschr., 19, 39.69. RYDYGIER, L. VON (1882), Zbl. Chir., 9, I98.70. RYDYGIER, L. VON (1901), Dtsch. Chir., 58, I97.71. SCHLATTER, C. (1897), Beitr. klin. Chir., 19, 757.72. SEDILLOT, C. E. (I849), Gaz. med. Strasbourg, 9, 566.73. SHOEMAKER, J. (1911), Arch. klin. Chir., 94, 54I.74. SOMERVELL, J. H. (I945), Brit. J. Surg., 33, 146.75. STUMPF, R. (I908), Beitr. klin. Chir., 59, 55I.76. TRAVERS, B. (1816), 'Med. Chir.,' trans., vol. 8, p. 231.

London.77. WANGENSTEEN, O. H. (1940), Surg. Gynec. Obstet., Io, 59.78. WANGENSTEEN, O. H. (1952), J. Amer. med. Ass., 149, I8.79. WELCH, C. E. (1949), Ibid., 141, Ii3.80. WOELFLER, A. (x88i), Wien. med. Wschr., 3I, 1427.81. WOELFLER, A. (x88I), Zbl. Chir., 45, 705.82. WOELFLER, A. (1883), Verh. dtsch. ges. Chir., 12, 22.

DIABETES(Postgraduate Medical Journal, May 1959)

Price 6s. 6d. post free

ORAL HYPOGLYCAEMIC DRUGS SOCIAL PROBLEMS OF THE DIABETICJ. D. H. Slater, M.A., M.B., M.R.C.P. Iris Holland Rogers

DIABETES IN CHILDREN PREDIABETES-A SYNTHESISJames Robertson, M.B., M.R.C.P. W. P. U. Jackson, M.A., M.D., M.R.C.P.,D.C.H.

AETIOLOGICAL FACTORS IN DIABETES THE OCULAR COMPLICATIONS OFD. A. Pyke, M.D., M.R.C.P. DIABETES

P. D. Trevor-Roper, M.A., M.B., B.Chir.,PLASMA INSULIN ACTIVITY IN DIABETICS F.R.C.S.

J. Vallance-Owen, M.A., M.D. (Cantab.), THE DETECTION OF LATENT DIABETESM.R.C.P. Joan B. Walker, M.D.

AUTONOMIC NEUROPATHY IN DIABETES THE GLUCOSE TOLERANCE TESTMELLITUS Jovce D. Baird, M.A., M.B.Ch.B., and LeslieHarry Keen, M.B., M.R.C.P. J. P. Duncan, B.Sc., M.B.Ch.B., M.R.C.P.E.

Published byTHE FELLOWSHIP OF POSTGRADUATE MEDICINE

9, Great James Street, W.C.1

RUTHIN CASTLE, NORTH WALESA Clinic for the diagnosis and treatment of Internal Diseases (except Mental or Infectious Diseases). The

Clinic is provided with a staff of doctors, nurses, technicians, modern Radiological and Physiotherapydepartments.The surroundings are beautiful. The climate is mild. There is central heating throughout. The annual

rainfall is 30.5 inches, that is less than the average for England.The Fees are inclusive and vary according to the room occupied.

For particulars apply to THE SECRETARY, Ruthin Castle, North Wales.Telegrams: Castle, Ruthin. Telephone: Ruthin 66

by copyright. on A

pril 23, 2020 by guest. Protected

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.36.422.706 on 1 D

ecember 1960. D

ownloaded from