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B. ARMSTRONG, M.D., AMistant Professor ot Clinical Sutgery in MoGill University : Surgeon to tlie Montreal Greneral Hospital ; Attending Surgeon to the Western HospitaL {Reprinted from Ou Mmtreed Medieal Joutmal, January, 1896.) p^B^^^f^l^^S^^^^^I^^^^^^^^^^^^^^P^^^^^pl^^^^^^^^^^y^^^^ 'm ^ r?' n? ., - t J - ; ^. 9 L \^ r"® .1 »'-M'jfr. stomaoh or duodenum,, permitting the contents to escape into the g^l^eral peritoneal cavity, and there lighting up a fatal septic peritonitis. Although gastric ulcer is more common on the .posterior wall of the stomaoh than on the anterior, perforation occurs more frequently on the anterior wall. The reason for this is that ulcers on the posterior wall more frequently cause adhesions, especially to the pancreas, and thus a perforation into the general peritoneal cavity is avoided. Another reason why perforation is more common on the anterior wall is that the symptoms of a gastric ulcer in this situation are less marked — which means that the ulcer is less readily recognized, and there- fore less frequently subjected to rest and proper dietetic treatment It is very important that you should be able to diagnose a perforation of the stomach when it occurs. In fact the life of the patient depends upon an early diagnosis and i»'ompt closure of the perforation. The symptoms are not many, but they are urgent and characteristic They have been very clearly detailed to you in the report, which you have just heard read, of this case before you. When an anaamie young woman, with a history of indigestion, is suddenly seized witk symptoms of acute peritonitis, you should at once wake up to the fact that you may be dealing with a case of perforating gastric ulcer. This young woman, aged 20, was admitted to the Montreal General Hospital about 6 p.m. on Hxe 9th October, 1895. On October the 8th, aJbout midnight, she had been suddenly seized with intense pain in the epigastric region. She could put the end of her finger on the spot where the severe pain first appeared, and where the greatest tender- ness to pressure still remaintd. During the night the pain spread along the left costal margin and then over the whole abdomen, which had already, 18 hours after the onset of pain, become very much swollen. The pain was of a sharp shooting character, becoming more dull toward morning, but at once rendered acute by any movement of the body. She had vomited several times during the night. Her pulse was 118, of fair quality, rather high tension. Temperature 103° F. Respiration, thoracic, quick and shallow. She gave a history of having been treated in the out-door department of the hospital dar- ing the past summer for indigestion. She had sufiered from flatulence and vomiting after meals, followed two or three hours later by pain in the epigastrium, which was relieved by taking food. Dr. Byers, the House Surgeon who admitted her, at once suspected the condition present, and summoned the staff for a consultation When I saw her she was lying in bed with an anxious expression of countenance. Pulse, temperature and respiration as noted above. On making a physical examination the abdomen was found mode* ;"■.«? t '^ u * y niifeely disleaded On uakimg her where the pain was most severe she pat her finger on a point about two ioekes below the ensiform cartilage and a little to the left off the uiedian Hue. On palpation, the abdomen WAS everywhere tender, bat moderate pressure eouid be borne over the centre in the nutbilical region, over the hypo||aBtriun) on both sides, and ov^r the Mituotion of the appendix, but over the point where pain was first felt the slij^htest touch caused the patient to cry out. In perforative peritonitis there is always a point of maximum tenderness and that point is over the seat of perforation. la a{>pendicitis it is u\ er the appendix at the so-called McBurnoy'^ point, or if the appendix is tiimod up behind the colon it may bu in the right loin. In perforating gastric ulcer it is over the stomach. Pain may be more generalixud, but the point of maximum tender- ness is always over the seat of perforation and is the most impor- tant and reliable gnido by which to localize the lesion. As far as I could judge about half the liver dulness hod disappeared. The lower half of the normal area of liver dulness was tympanitic. The presence of a tympanitic note on percussion over the region of the liver is very su^estivo of a perfonition of scnne part of the alimentary canal and the escape of gas into the peritoneal cavity! The urine was high coloured, sp. gi*. 1030, acid reaction, no albu- men, no sugai*, urea grs. xiii. to the ounce. The history and symptoms rendered the diagnosis of perforated gastric ulcer pretty certainly correct 'The prognosis was that if left alone the girl would certainly die in 24 to 48 hours of toxaemia from septic peritonitis. The indica- tion clearly was to open the abdomen, close the hole ir the stomach, and remove so £ar as possible all matters that had aliCAi ^y escaped together with the serum or sero-pus already formed, .tind it was important that this should be done at once, before the infection and inilammatiion of the peritoneum had gone so far that a favourable result would be unattainable. Twenty-two hours hod already elapsed since perforation hod taken place. Fortunately the matters escaping from a hole in the stomach are not as virulent and irritating as those escaping from the intestine, and I think that this is the reason why peritonitis from an e.scape of stomach contents is less rapidly fatal tiian peritonitis caused by escape of intestinal contents, rather than, as Mr. Treves states in his Lettsomian lectures, . to a difference in the character of the peritoneum itself in the upper part of the abdomen. The girl was taken to the operating room at once and I mode- an incision in the median line between the ensiform cartilage and the umbilicus, as you see by this cicatrix. As soon as the peritoneal »^Vl»-A.'W purulent iluid escaped. The stoniach was carefully packed around with sterilized giMze to prevent further escape into the peritoneal cavity and the opening in the anterior wall of the Htoinach readily discovered. It admitted my forefinger easily. The edges of the opening were, I should say, an inch or more thick. The greater pnrt of the thick edge proved to be lymph. Now, one cannot stitch lymph. It will not hold a sniure. The suture cuts out as soon as any tension is put on it. I had, therefore, to gently peel off the thick layer of lymph that I might get sound stomach wall to hold the sutures. On removing the lymph, I found that the ulcer had Seen evidently closed for a time by it, and that escape of Stomach contents had occurred only when this reparative material had failed in its object, and that the ulcer was a very large one. When it was drawn out with it.s edges together the sew line measurad 3^ inches. The edges- were everted, and the mucous membrane had become adherent to the border of the rent throughout- its entire extent I closed the opening in the manner that you have seen done in wounds of the intestines, that is, first a continuous suture passing through all the coats of the stomach wall. This I believe to be an important part of the suturing. I then inverted tlie suture line and paased a continuous Lembert suture from one end of the rent to the other. If this is done neatly and carefully, it effects a closure absolutely water tight and air tight. I closed a typhoid perforation in this manner the other day, and, although the patient died about three hours after the closure, Dr. -Johnston, at the post-mortem, tested the closure and found it quite impervious to water or air. After the closure was completed I wiped out all the fluids and lymph that could be reached, passed a glass tube surrounded by iodoform gauze down to the suture line, passed another small strip of the same down the calibre of the tube and closed the incision with two rows of sutures, catgut being used for the deep layer and ^ilk-worm gut for the skin. I then made a small opening in the median line, midway between the umbilicus and the symphysis pubis, just large enough to admit a ^ inch glass drainage tube, which I passed down to the bottom of the pelvis. It was well that I did this, otherwise I might have lost my patient, for there escaped through this tube fully 20 ozs. of yellowish sero-purulent fluid. The tubes were removed on the fifth day. The patient has made an easy recovery. .Enemata of peptonized beef tea, with half an ounce of brandy, were given every four hours for seven days, and were well retained During the first three days nothing was allowed by the mouth except a tcaspoonful of water every half hour to allay the thirst On the +-1 5 i ■;$^ \.. ffTS^?« '3 ■r i* 8rd day she was given an dunce of peptoniaed milk every two hours. This was gradually increased day by day. Oh the fifteenth day she was given custard and a softly boiled egg. Then milk toast and arrow-root At the end of the third week fish and chicken were allowed; and she now takes three pretty good meals daily. This patient on the left was operated on by my colleague, Dr. Kjrkpatrick, about a year ago. She made a perfect recovery and has remained in perfect health ever since. So far as I know these are the only cases of perforated gastric ulcer that have been operated upon in Montreal, and as you see they have both fortunately been successful. In his Ingleby lecture Barling has reported 37 cases by various operators, with 13 recoveries. Several operations for perforating duodenal ulcer have been reported with, so far as I know, only one recovery. Closure of a perforated ulcer on the posterior wall of the stomach is more difficult. Probably the better plan would be to approach it through an incision in the anterior wall of the stomach. In that case the Lembert suture would be applied iirst and the through and through suture afterwards. The opening in the anterior wall of the stomach being closed in the same way that I closed the opening caused by the perforating ulcer. it. j^