Vol. 71, 1915 - The University of North Carolina at Chapel Hill

made through the incission, and also
through a suprapubic stab. After a
stormy convalesce the patient made a
good recovery. Strange to say, when
seen some 3 months later he reported
that his stomach symptoms had entirely
disappeared, the ulcer having apparently
healed over.
Case No. 3—Presents a history very
similar to No. 2. A man, 48 years of age,
with a vague history of dyspepsia, heart
burn, gas, inabilaty to eat greasy food,
etc, was suddenly taken violently ill while
picking cotton on his farm. His physician
quickly realizing the serious nature
of the attack, placed him in an automobile
and hurried him to Chorlotte, a distance
of 22 miles, where he was operated upon
at 2 o'clock in the morning, soon after
arrival, or 10 hours after the beginning
of his attack. He was clammy, almost
pulseless, with an anxious countenance,
but the abdomen was not, as yet, much
distended.
At operation a perforation of the
pyloric portion of the stomach was found,
surrounded by such a mass of indurated
diseased tissue that the stitches tore out
almost as fast as they were placed, and it
was necessary to supplement the closure
with an omental graft. A posterior Gastroenterostomy
was then done, and the
usual drains placed. For 24 hours after
the operation the patient was almost
pulseless, but finally rallied, vomiting
ceased, bowels moved and strong expectations
of his recovery was entertained,
but an omenous change in his
condition appeared on the afternoon of
the third day, and he died four days after
his operation. An autopsis was not held,
and I am unable to say whether death
was the result of his original peritonitis,
or whether the gastro-cnterostomy became
leaky and added another complication
to his already exhausted system.
While it is always a temptation in these
cases to do a gastrostomy in the hopes
of making a complete cure of the ulcer,
the additional time consumed often
makes it
a questionable proceedure.
Case No. 4—Was a man 40 years of
age, and gave the usual history of gastric
derangement over a long period. He was
THE CHARLOTTE MEDICAL JOURNAL.
taken rather violently sick with abdominal
pain and vomiting on Wednesday,
and I saw him first on Friday. At that
time his temperature ranged from 100 to
101 Far., white blood count was 12000,
abdomen was rigid and tender only on
the right side, and the general appearance
of the case suggested an appendix.
On Saturday morning a rectus incission
showed a free pus—like fluid in the
cavity, marked signs of peritonitis, and
a red highly inflammed looking appendix.
But here again it was evident that the
grave symptoms present could not be
accounted for by an appendage in the first
stages of inflammation. The incission
was extended upwards and investigation
revealed a perforation of a duodenal ulcer,
high up under the liver. The opening
was imperfectly plugged by adhesion to
the great omentum, which permitted only
a comperetively slow leakage, a condition
to which, no doubt, this patient
owed his life.
The opening was closed with considerable
difficulty because of the induration,
and the same use was made of an omental
graft, as in the preceeding case. He made
a fairly prompt recovery and left the
hospital in about three weeks. The
operation was done in April 1914, and the
man tells me that his digestion is better
than before his sickness, although he has
to exercise a certain moderation in eating.
I have suggested to him the wisdom of
having a gastroenterostomy for the cure
of his ulcer, in case the symptoms should
warrant it, but for the present he seems
very well satisfied.
In reporting these four cases of perforation
of the stomach and duodenum
from ulcer, I have purposely omitted
much of the purely surgical minutiae,
technical points of great interest to the
surgeon but of no special value to the
general practitioner, or the internist. In
order not to transgress too far upon your
patience I have also barely mentioned in
outline a few of the more important
facts in the clinical history of peptic ulcer.
It will be noted, however, that even in
this small series of cases there is a close
correspondence to the generally accepted
views regarding peptic ulcer of a chronic
type. 'AH the patients were males, all
had reached mature age, all had a history
of prolonged gastric symptoms, and the
point of perforation was in each instance
cither the pyloric portion of the stomach,
or the duodenum.
The two special points I desire to emphasize
are, first, that cases with long
continued digestive disturbances, resistant
to intelligent medical treatment, and
but Icmpororly influenced by diet, etc.,
are usually dependent upon some difinite
anatomic lesion, which in quite a large
percentage of instances, can only be
satisfactorily handled by surgical means.
Secondly, in the presence of perforation,
the success of operative means is
in almost direct proportion to the prompt-