Operations for Gastric Ulcer, Acute and Chronic1

R. Parker
1902 BMJ (Clinical Research Edition)  
by the colon. stonfach, and thickened neighbouring tissues below; its posterior part was the opening communicating with the left lung. The spleen was contained in the centre of this abscess cavity. On opening the chest so ise clear seruin and lymph were found in the left pleural cavity, and several pleuritic adhesions wereapparent. On distendin the stomach no fluid escaped. The wound in the viscus had quite healed, but four of the silk sutures were in situ: the others had disanpeared. On the
more » ... oils surface a small depression slhowed wlhere the ulcer had existed. There was no ulcer on the posterior surface. CASE Ill.-My third case I saw late at night in consultation with Dr. Fisher, of Sheil Road. The patient, a clerk, with a dyspeptic history, was dining in a cafe when he was seized with excruciating pain, and fell on the floor writhing in agony. He vomited soon afterthe onset. A medical nan saw him, prescribed morphine,and sent him home, where heremained for s,ome lhours until Dr. Fisher was called. He stated that his stomach had troubled him for two years, chiefly by way of pain of a burning kind. On one occasion there had been haematemesis. Pressure over the stomach always gave him discoiimfort. Pain generallv came on before food, and was usually eased when food was taken. Five or six weeks ago the pain was more constant and more severe. and was localized to the epigastric region. He was fragile, emaciated, and anaemic. I saw nim twelve hours after the onset, and found him lying In bed, haviog several times vomited. His face was drawn, his pulse iIo and very compressible. There was only a suggestion of distension. The liver dullness was notably diminished, and slight rigidity of tlle abdomiien, absence of abdominal respiration, and marked shock. The histor-y and symptoms pointed to perforation, and two hours later (or fourteen after the onset) we operated upon him in the hospital. The anterior aspect of the stomach was explored, when an opening was found about 3 in. from the pylorus near tlle lesser curvature. Some undigested matter had escaped into the abdomlien, and some was noticed issuing from the orifice. Around the opening, wlhich was with difficulty brought to the surface, a considerable lymph exudate was noted, which was carefully removed before dealing with the ulcer. The edges of the ulcer were freshened, inverted, and occluided by a double row of Lembert sutures, and some omentum was stitched over the omentum line. Care was taken not to douche the abdomen, and the stomach exudate was ierely mopped up by dry aseptic dabs. ThIe operation, which lasted half an hour, left the patient very collapsed, and we had recourse to hot cloths and strychnine. The patient inade an uneventful but slow recovery, now and again vomiting, and once ridding himself of a lemon pip. The treatment consisted of saline clotlhs to relieve thirst, alcoholic nutrient enemata, morphine under the skin, and every four hours a teaspoonful of iced water. Feeding by the stomacll was very cauitiouisly begun on the fourtli day. The patient at this date, eiglhteen montlhs after the operation, is very fit, having become stout and strong, witlh barely any dyspeptic trouble. CASE IV.-My last case, a woman of sO lhad heen an inmate of tlle hospiat under the care of my colleag-e, Dr. William Williams. Slue had been treated for gastric ulcer. and had so far improved that shee was a lowed to go out. Some weeks later she experienced a sudden pain in tlie abdomen, accompanied by a faintness and retclling but no vomiiiting. In seven or eight hours she reached the hospital, and an hour later slhe was on the operating table. Her abdomen was tense and rigid, her liver dullness increased, her breathing tlioracic, and she was suffering from slightcollapse. On examining-the stomiiach a clean punched-out opening was noted on the anterior aspect from which issued a thick milky fluid. The openimig was grasped by two forceps and drawn up into the wound; tllis prevented the escape of fluid. A purse-string suture was introduced arouud the opening nearly 1 in from the edges, and with the two forceps to the outside of tlle suture ring the stomachl was held, while tihe forceps holding the edges of the wound were depressed and the edges inverted. The circular suture was now made tense, and the operation completed by a row of cpntinuious Leuibert sutures. No water was introduced into the abdominAl cavity, which was lhurriedly cleansed by aseptic. dry dabs. The patient made an uninterrupted recovery with the exception of a non-suppurative parotiditis, and is now, eight months after operation, working, fat and well. REMARKS. The first case was as simple as the second was complex. A freely movable ulcer, localized extravasation, and immediate operation were enough to ensure success. My second case was under chloroform for fifty minutes inconsequence of adhesions which had to be separated and the involvement of the cardiac end, the fixation of which rendered suturing a matter of considerable difficulty. Both my last cases are very enecouraging, the third inasmuch as opeXration was not performed for fourteen hours after rupture. Although leakage had occurred in the last case the stomach contents did not appear to be of a very irritating kind. It is of interest to note that over 95 per cent. of cases unoperated upon die, while life is rarely prolonged over thirty hours. While ulcers are more frequent on the posterior sur-fa3e of the stomich perforations are much more frequently mAt with on the anterior aspect by the operating surgeon. This is probably due to the greater facility with which buttressing adhesions form behind. Jacobson states that out of go cases operated upon the perforation in 86 was on the anterior surface. What is the cause of a subphrenic absceqs not obviously connected with the wound area ? With an ulcer on the posterior aspect it is easily explained, but it is noteworthy that niany cases occur where with an anterior perforation abscess at the back of the stomach is found. This may be, accounted for in one of two ways: (a) By direct trickling of septic material through the foramen of Winslow, or (b) by lymphatic absorption. In an ulcer on the anterior surface the gastric contents have but to travel round the right free border of the lesser omentum and both the peritoneal cavrities are soiled, and if the foramen of Winslow be closed by adhesions the invasion of an abscess in the lesser cavity will be obstructed. With regard to operative technique, I ttiink it is well in all cases to se-rape the surfaces and edges of the ulcer, and when practicable to. use a purse-string suture as a preliminary measure., This can be done in a few seconds, and all extra,vasation stopped while the final occlusion is c6mpleted. I am also convinced that the use of dry dabs should supersede irrigation which serves to dilute, disseminate, and make more soluble the toxic contents. As Turner has suggested, one can easily infect the lesser peritoneal cavity by irrigation of the greater. Mr. Tobin of Dublin raises a very interesting question when he pleads that no case of perforated gastric ulcer should be removedfrom wherethelesion has occurred. To any one who has noted the effect of movement on the escape of the stomach contents the plea has much to recommend it, and if the diagnosis be correct the simplest appliances only are needed. Boiled towels, cocaine, a few forceps, domestic needles and tlread. are all the real requirements in the average case. Many a life has been lost in transit from lhome to hospital.
doi:10.1136/bmj.2.2187.1702 fatcat:mtm4ovppcvgahgoir56g6mg73y