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Gastrostomy

1946; Elsevier BV; Volume: 72; Issue: 4 Linguagem: Inglês

10.1016/0002-9610(46)90402-3

1879-1883

Felix Cunha,

Diet and metabolism studies

Among the writing craft there exists a motto: “If you steal from one author, it is plagiarism; if you steal from many, it is research.” In the realm of psychology probably lies the explanation of a type of conduct one finds so consistently present in the evolution of some particular surgical technic. So consistently and even persistently does one find it that it cannot by any chance be attributed to mere coincidence. To the non-psychologist, but one having some experience in the detached scrutiny of the ways of human conduct there is only one explanation. A terrifically frustrated ego exists which drives eternally for expression, for a labeling or attachment of self by way of name to something—in medical and surgical parlance—some step in treatment or procedure in surgical technic, that the individual hopes may go down into posterity, thereby perhaps justifying one's having passed through this cosmos called world. This seems to be a part of the makeup of so many men in the field of medicine. How else can one explain the making of an incision a half inch or so to this side or that side and calling it a “new method”; or reversing a suture line, starting at the top or vice versa at the bottom, or the accidental happening upon some procedure, which some less fortunate colleague used years before, and then rushing into print with a grand flourish, “a new method.” One sees this type of thing so much in a search or study of the medical literature of the past that one becomes stonily cynical and rather hard boiled in approach to anything labeled “a new.” However, as a matter of historical accuracy it behooves some of us to scan with a degree of honesty, yet critically current contemporary claims to priority in these so-called “new methods” of doing this or that. Medical achievement has been gradual and step by step. This is as it should be. One person here makes an observation and records it. Fortunate indeed that it should be this way. In another place some one tries it, and possibly finds it wanting and strives to improve upon it, adding a little something. Somebody else points out some deficiencies and tries to solve them. Thus by an evolution of ideas final perfection may be reached or approached. Medical historians in later years scan these contributions and give priority where it is due because there exists material evidence and corroboration in the printed word—in the original publication—in which the ideas were set forth for the use of the medical world at large. This is particularly well illustrated in the historical evolution of the procedure of gastrostomy. We know and have proof, documented proof, that a military surgeon named Egeberg, in statements before a medical society in Christiania made the following remarks: “I cannot see why the indications should not be just as great to open the intestinal canal to put nourishment in as to open it to take a foreign body out.” We surmise that Egeberg may have been influenced by reading of the experiences of another military surgeon, Wm. Beaumont with “old fistulous Alexis,” illustrating to him that a man could live in health with a permanent opening in his stomach. We surmise this because we are aware that Dr. Beaumont's experience was much publicized in Europe and in addition because there exists a certain co-incidence as to dates and time. From here on we find that process of evolutionary step by step improvement upon the original. A French surgeon, Sedillot in 1846, lifts a cone-shaped segment of the anterior wall of the stomach through an abdominal incision and behold you have the first completed operation of gastrostomy. But for reasons mentioned in the body of this article the patients died. Therefore, although the idea is a good one it must be made to work better. Along in 1888, in 1890 and in 1893, three men, Girard, Von Hacker and Jaboulay proposed that instead of bringing the cone of stomach wall directly to the skin through the abdominal wall, it should be brought through the subcutaneous tissues in such manner that the rectus abdominis muscle shall act in a sphincteric manner as to stop leakage around the attachment. Although this was a minor improvement it did not solve the problem of spillage, skin excoriation, etcetra. So we find more names attached to contributions, one Sabanieff, one Hartmann, and a Frank, in the years from 1890 to 1893. These suggested various and sundry complicated passages of a cone or anterior gastric wall through and between the subcutaneous tissues and muscles. One suggested bringing the cone through the skin between the costal cartilages hoping to utilize the latter for sphincteric action. It is important to realize and emphasize that these men all were using a cone of tissue in view of what is coming later. In 1894 and 1902, two men suggested twisting this cone of tissue so that when fastened to the abdominal wall, the torsion of the tissues would obstruct leakage and spillage. These men were Ullmann and Souligoux.28 We return to France and the French school of surgery for the first milestone in evolution oj the operation, and give credit where credit is due. In 1893, Penieres proposed constructing a valve from gastric mucosa to combat leakage, and proceeded to perform the operation on dogs in his laboratory in Toulouse; whereupon another Frenchman, Fontan, not, however, without giving due credit to his countryman, proceeds to perform the operation on humans, differing in technic from his confrere in that he made his valve using all the layers of stomach wall instead of mucosa alone as did Penieres. The operation now consisted of a canal instead of a cone with a valve arrangement to prevent leakage. That was the operation as proposed by Fontan and Penieres, a completed operation, the principles originated and laid down by them and the basis upon which any subsequent minor changes were laid. To these men should go the credit for the development of the procedure. The operation to many was still one which could be improved upon. Here again crops up that curious conduct on the part of the surgical mind. Where one man would propose placing a catheter through a stab wound into the stomach, then plicating the serosa over it by means of one or two purse-string sutures, one would rush into print with “a new method.” The “new” consisted of placing first the stab wound a half inch or so higher or lower than the first proposer or instead of one or two layers of purse-string sutures advocating three or four, as providing greater strength to the finished canal, therefore, greater safety. Then along came the men who courageously departed a bit farther and who may have been honest and upright in their thinking and advocacy of their ideas. These were the men who advocated the substitution of other hollow viscera as tubes between the stomach and skin. Such was the isolated pedicled loop of jejunum as advocated by Roux and Lexer and the isolated segment or pedicled loop of transverse colon advocated by Vuillet in 1911, and Kelling in the same year. Somehow one gets an impression that Roux must have been in his seventh heaven playing with loops of intestines, attaching here and there, the more complicated, the more enthusiastic and delighted he was, much as a child with an erector set, but he used gut, instead of blocks or metal. It is a laborious piece of work to read of the different anastamoses he made and proposed. Then along came the men who proposed the construction of tubed pedicled flaps from the stomach wall. Most prominent of these were Depage and Janeway and both names were used connectedly to describe a technic and procedure originated by Depage in 1901; but the story goes that Janeway was using and had originated a similar operation, entirely unaware of Depage's work, so somewhere the idea got abroad that he should be given credit with Depage and the operation has since been spoken of as the Depage-Janeway technic. It is curious that Depage's article describing his procedure appeared in 1901, and Janeway's in 1913, a considerable discrepancy in time. Here again that curious pattern of conduct: Depage made his tubed flap with the base at the lesser curvature. Janeway made his with the base at the greater curvature, and insisted that his was the better method because it had a better blood supply, at any rate it was a “new method.” Watsudjii combined Von Hacker's and Fontan's operations giving them credit while Spivack combined Fontan's and Depage's operations and described it an “original”—“new method” without allocating proper credits. Then came the tubed flap made by partial severance of the greater curvature of the stomach with the base at cardia and another with base at the fundus. These were: (i) the operation worked out in the laboratory by Alexis Carrell with Beck and called the Carrell-Beck procedure, and (2) the method of Jianu used successfully by Dr. George Pack. It is quite possible that a more detailed and thorough perusal of available literature on the subject of gastrostomy might have brought to light even more material than is quoted here. 29,30 However, over fifty different technics or plans of operation have been published by various authors and the predominent part of these had “A New Method” as part of their title. However, in the past thirty-five years nothing new has been added to our technical knowledge concerning gastrostomy and no surgeon of recent times, or contemporary to the day is warranted lifting the work of the men who actually made the contribution and applying bis own name to it. Sufficient documentary proof exists in published articles with names and dates to make any such conduct too easy to refute and make a lie.