SURGERY AT SEA: A CASE OF PERFORATING DUODENAL ULCER; OPERATION; RECOVERY

HughW. Bayly
1905 The Lancet  
351 presence of some poison in the blood and manifested by high of arterial tension and such symptoms as breathlessness, se palpitation, tachycardia, arrhythmia, and others already 1C referred to, are treated here on thoroughly rational and h scientific lines. With a view of checking the manufacture of the poison diet is regulated and with the object of di insuring its disposal metabolism is increased and excretion, nE renal and cutaneous, is vigorously promoted. Moreover, the g( real
more » ... e g( real inwardness of his complaint is carefully impressed upon ol the patient who is given to understand that if he does not si wish his functional troubles to progress towards organic c( disease, such as granular kidney, angina pectoris, and o diabetes, to say nothing of heart disease proper, he must be h careful to observe the hygienic rules in which, down to the w minutest detail, he is there instructed and the advantages w of which he very soon learns to appreciate. h Although France is, in Chatel-Guyon, Salins Moutiers, o Chateau-neuf, St. Nectaire, and Royat, provided with several well-appointed spas the waters of which contain a great deal fl of carbonic acid gas, it is only the last named, and that quite n recently, which has shown any tendency to specialise in the h treatment of cardiac complaints. The action of effervescing a baths not only upon cardiopaths but also upon healthy r people has been here studied in great detail 15 and the conu clusions arrived at are entirely in consonance with those of l: Broadbent 16 and other unprejudiced writers on the subject. c Royat being originally a gouty spa, and being possessed of a waters exceptionally rich in 002, it is eminently fitted both by nature and experience for the rational treatment of i circulatory disorders. The place 17 is rather more bracing either than Bourbon-Lancy (800 feet) or Evian (1250 feet), t being situated in a valley which runs east and west, 1500 feet above sea-level. The relative humidity is low and the surs roundings are exceptionally agreeable. The close proximity of the large town of Clermont-Ferrand (one and a half miles) affords a source of interest to visitors which is not common l at health resorts. For cases which are amenable to treatment 1 on Nauheim lines in which Nauheim itself, from its moderate elevation (400 feet), its comparatively unsatisfactory climatic conditions, or from other considerations 18 is deemed unsuitable, Royat is very well adapted, and it is especially suited to such patients as require mildly bracing conditions in charming surroundings. ON April 27th, 1905, at noon, I was asked by Mr. Aubrey D. Knight, at that time the surgeon to the Royal Mail Steam Packet Company's ship La Plata, then three days out from Barbados on the homeward voyage, to meet him in consultation over a Government passenger (a soldier) who was suffering from severe abdominal pain. The history of the case was as follows. The patient, aged 24 years, had been suffering from "indigestion" for several years and said that he had many times been under treatment for " gastric ulcer " and had at one time been several weeks in hospital, when he had been placed on rectal feeding. He had several times had haematemesis, the last occasion being about three months previously. Since joining the ship his motions had been black. He was a bad sailor and had been seasick for 24 hours before I saw him. At 10.20 A.M. he had been seized with a sudden sharp pain situated about three inches to the right and at the level of the umbilicus. I found the patient lying on his right side on a mattress on the floor of his cabin with his legs drawn up and in great pain and distress. On inspection the breathing was seen to be entirely thoracic and the abdominal walls were absolutely rigid. On percussion there was hyper-resonance over the right side of the abdomen but no loss of liver dulness. There was extreme tenderness on pressure over the whole 15 Le Bain Carbo-gazeux, son Action, Physiologique et Thérapeutique, dans les Maladies du Cceur, par le Dr. Mougeot; Paris, Rousset, 1905. 16 Loc. cit. 17 Vide Journal of Balneology, October, 1904, p. 277. 18 Consult McGregor Robertson's paper already mentioned. of the right side of the abdomen but the left side was not so sensitive. The temperature was 96° F. and the pulse was 100, weak but regular, and not running. There bad been no haematemesis. I diagnosed perforating duodenal ulcer and advised immediate operation, but before proceeding to operation in the necessarily somewhat unfavourable circumstances I suggested to Mr. Knight the advisability of taking another opinion. He therefore asked Mr. G. W. Paterson, Government surgeon at Grenada, to see the case with us. Mr. Paterson considered that the case was either one of perforation of, or hsemorrhage from, a duodenal ulcer and as in his practice ! he had recently met with a case with very similar symptoms ! which turned out to be only haemorrhage and recovered without operation he advised watching the case for four hours before proceeding to the somewhat desperate resource , of abdominal ection in a cabin on a rolling ship. L At 4 P.M., therefore, we saw the patient again and we then L found that the pulse was 120 and that the temperature was : normal, and that there was distinct distension of the right e hypochondrium and right half of the epigastrium. We all & c c e d i l ; agreed that surgical aid was now indicated and Mr. Knight yrequested Mr Paterson as the most experienced surgeon to undertake the operation. Mr. Paterson unfortunately was a f bad sailor and subject to attacks of gindiness, so, though . offering us the invaluable aid of his advice, experience, and f assistance, asked me to operate. The ship's carpenter fixed :1 up a board table two feet wide across the cabin, thus dividing f it into two portions. Mr. Paterson, who kindly acted as my assistant, and Mr. Knight, who gave the anaesthetic, I, took the outside on the right of the patient, while t I myself and the hospital assistant remained on the inner '-side of the table next to the door of the cabin. I made an y incision in the middle line from the ensiform cartilage to an inch above the umbilicus and was somewhat hampered by n the fact that there were only two scalpels available and that It they had both been recently blunted by opening an abscess e in the horny hand of a stoker. As soon as the peritoneal ic cavity was opened a considerable quantity of fluid escaped which, however, did not smell offensively. The ulcer was of ly about the size of a sixpence and was situated on the upper is and anterior surface of the first part of the duodenum, almost encroaching on the pylorus. I first closed the ulcer with a purse string suture and then invaginated it with Lembert's sutures. I made a suprapubic pelvic drain and washed out the peritoneal cavity with normal saline solution and sponged it -as well as I could, but the patient showed signs of collapse and I had to hurry over the peritoneal toilet and stitch the abdomen up quickly. I left a gauze drain at the site of the ulcer and another leading to the bottora of the pelvis. With the help of strychnine and ether hypodermically, a hot brandy and saline enema, and hot bottles the state of shock gradually passed off. I should have liked to perform a gatro-jejunostomy but D. neither the condition of the patient nor the instruments ,m at my disposal would allow of this and as there appeared m to be plenty of room at the site of the ulcer I hoped ;a-the operation would not produce so serious a stenosis of er-the gut as to be of material importance. In 13 hourser viz., on the morning of the 28th-the temperature was 100° ase and I thought that it would be advisable to remove the ergauze drains. As the patient, however, seemed very weak he and as he had taken no nourishment for 24 hours before the r " operation owing to sea sickness, and as he had lost a conhe siderable quantity of fluid viii the peritoneum, I fir.-t transfused him with two pints of normal saline solution. I had ;hs no proper transfusion apparatus but with the help of a ;en stomach-tube and an exploring needle, the point of which 24 one of the t:ngineers kindly filed off for me, an efficient ied sut stitute was soon made. he After the transfusion the pulse considerably improved and Mr. Knight gave an anaesthetic of equal parts of chloroform ess and ether and I removed the gauze drains. The upper wound eat was clean but a considerable amount of purulent material to escaped from the suprapubic incision. I washed out the ely pelvis with normal saline solution and put in a rubber she drainage-tube. On the morning of April 29th I washed out ss. the pelvis again but there was practically no pus and the ole patient was now taking half-ounce doses of milk and water -every half hour. In the afternoon the temperature rose to ue, 101° and the pulse to 120, so as I suspected some accumula-5. tion of pus I examined the pelvis with the finger and washed it out again. I could not, however, find a pocket of pus but on the morning of the 30th when I dressed the patient
doi:10.1016/s0140-6736(01)11880-5 fatcat:dv7mmepe2rbllhfois6rhrwrnu