WAMPOLE'S

Bismuth Hydrate Compound

(DIARRHOEA MIXTURE.).

Antiseptic :: Astringent :: Carminative

Will check Diarrhoea, relieve pain, and produce an aseptic condition throughout the entire digestive tract

.

Soothing in Effect, Prompt in Action, Non-poisonous and Non-irritating.

EIGHTEEN CONSECUTIVE CASES OF OPERATION FOR

PERFORATED GASTRIC ULCER.*

BY F. M. CAIRD, F.R.C.S. (EDIN.),
Surgeon Royal Infirmary, Edinburgh.

Addressing, as I have the honor to do, a body of brother practitioners, I have sought to find a subject of general interest to all. I, therefore, direct your attention to personal experiences of a consecutive series of eighteen cases of perforated gastric ulcer, and in doing so crave pardon for inflicting upon you so much that is well known and commonplace.

We are ignorant of the direct cause of gastric ulcer. The ulcer may pursue a symptomless course, and there may be perfect health until the disastrous rupture into the peritoneal cavity takes place, and even then the diagnosis may be obscure. As a rule, however, there are very definite indications which lead us to a correct conclusion. A history of indigestion can nearly always be obtained, either of recent date and comparatively mild, or prolonged and intermittent. The dyspepsia is associated with pain after food and with vomiting, which often

*Read before the Canadian Medical Association, Halifax, August, 1905.

gives relief. The more classic evidences of gastric ulcer, hematemesis and melena, are usually lacking. Perforation may occur at any time, and under any circumstance, and is favored by muscular strain. Sudden intense pain, referred to the umbilical region, gives warning of the perforation. The patient becomes faint and collapsed, has to lie down, and generally vomits. As a rule the passage of flatus ceases, and symptoms

Diagram of stomach to show sites of perforation: A., Cardiac Portion; B., Fundus; C., Middle; D., Pyloric Portion; E., Pylorus. The figures refer to the cases 2, 7, 15, 16 on the posterior aspect of the stomach.

simulating those of obstruction may arise. Occasionally there is a movement of the bowels.

The initial condition of shock varies in degree and prolongation. Generalized abdominal pain is felt; the abdomen becomes board-like and rigid, no longer participating in the respiratory wave. The most useful indication of danger is

found in the shabby, rapidly quickening, pulse. Respiration increases and the temperature has a tendency to rise. On palpitation the abdominal wall is hyperesthetic, and marked local tenderness is evinced in the epigastric region and above the pubis. There may be diminished liver dullness. Rectal examination sometimes reveals tenderness, but there is rarely bulging in the Pouch of Douglas. There is not any difficulty or pain: experienced during micturition. Careful notes should be taken when the patient is first seen. On re-examination it may be

found that the liver dullness has entirely disappeared. More especially is this noticed after the patient has been lifted or: moved. The general symptoms tend to become rapidly aggravated and merge into those of general peritonitis.

Perforation of gastric ulcer, acute appendicitis, acute pancreatitis, and the rupture of carcinomatous ulcers of the intestine may mimic each other. Influenzal gastric pains, and the gastric colic associated with adhesions have occasionally led the surgeon

astray. A small exploratory incision may be required to clear up a diagnosis in doubtful cases.

The salient features which determine operation are the sudden onset of painful symptoms, the previous history of gastric ailment, the localized epigastric and supra pubic tenderness, along with the abdominal rigidity and changes in the extent of the liver dullness. To this we may add the progressive frequency of the pulse rate.

Perforations leading to acute symptoms occur mainly on the anterior aspect of the stomach where there is less chance of

adhesion to neighboring structures. They are most frequent towards the lesser curvature and the pylorous. There may be more than one perforation. The ulcer varies in type from the characteristic small sharply cut terraced form, with comparatively healthy surroundings, to the large ragged rent in the midst of a chronic indurated perigastritis with edematous serosa.

It would appear that as the acrid acid stomach contents escape into the peritoneal cavity that the whole serous membrane reacts, and a rapid effusion of an alkaline nature takes place