1195MR. D’ARCY POWER: ACUTE DUODENAL PERFORATION.

careful examination of the washed stomach and duodenum revealed nosign of ulceration. The pylorus was much thickened but this aftermicroscopical examination was thought to be due to muscular hyper-tHphy.CASE 23. (Mayo Robson and Moynihan. Diseases of the Stomach,

second edition, p. 277.)-A female, aged 33 years. There was yiolenthaemateme1is a week before, the day before, and on the day seen. Shehad had slight indigestion. The stomach was opened ; seven bteedingpoints were seen; posterior gastro-jejunostomy was performed. Sherecovered completely and a year later had had no recurrence.CASE 24. (Mayo Robson and Moynihan, Diseases of the Stomach,

second edition, p. 277.)-A female, aged 28 years. On April 8th she felt-quite well; on the 9th she vomited a pint of blood. On the 14th shevomited much blood and passed some per rectum. On the 18th moreblood was vomited. The stomach was opened ; all that was seenabnormal was a considerable number of bleeding points, three of whichwere ligatured; posterior gastro-jejunostomy was performed. Thepatient recovered from the operation and did well afterwards.CASE 25. Moynihan (Report on Surgical Treatment of the Non-

malignant Diseases of the Stomach, presented to the Surgical Sectionof the British Medical Association at Leicester, July, 1905).-A female,aged 19 years. For several weeks she had pain after food. A largequantity of blood was vomited on the evening of Oct. llth and fourtimes in the next 12 hours. Operation failed to show any ulcer.Posterior gastrojejunostomy was performed. The patient recovered.CASE 26. Moynihan (same report, Case 149).-A female, aged 47 years.

The stomach and duodenum were explored for ulcer; none was found.Posterior gastro-je,junostomy was entirely satisfactory. The patientwas sent by Dr. A. Stanley Green of Lincoln and he wrote in June,1905: "This patient is not any better; she still continues to havehaematemesis and meleena, but these disappear if she is kept in bedand put on a milk diet."CASE 27. Mansell Moullin (British Medical Jotcrnal, May 13th, 1905,

Case8).-A female, aged 33 years. She had had pain and vomiting forfour years; haematemesis occurred once. There was no ulcer or scarfound at operation. Posterior gastro-jejunostomy was done. Sym-ptoms returned five months later and she now has pain and sicknessand has brought up blood once.CASE 28.-A female, aged 24 years, was admitted into Guy’s Hospital

under the care of Dr, Hale White in Septsmber, 1906. Dr. G. K. Levickreports that he has watched her for four years and during that timeshe has had repeated attacks of gastric pain, vomiting, and hsemat- Iemesis. No treatment has done any good. On admission examinationof the abdomen revealed nothing abnormal. The administration ofbismuth and the application of the x rays showed the stomach to be ofnormal size. She looked quite healthy. The opinion was expressedthat probably no ulcer was present, but as she had not bled for sometime and was in good general condition it was, after consultation withMr. Fagge, decided to explore; in case there was an ulcer a gastro-jejunostomy would relieve. The interior of the stomach was carefullysearched; the mucous membrane appeared perfectly healthy. Theblood contained 5,400,000 red cells per cubic millimetre. Thehemoglobin was normal.

-

CASE 29.-A female, aged 32 years, was admitted into Guy’s Hospitalon Jul, 19th. 1902, under the care of Mr. Symonds. Had had pain inthe stomach for several years and many attacks of haematemesis duringthe past nine months. She looked quite healthy. The interior of thestomach and duodenum were thoroughly explored and no ulcer could befound, nor was any abnormality seen. She recovered completely fromthe operation.

A Clinical LectureON

ACUTE DUODENAL PERFORATION.Delivered at St Bartholomew’s Hospital on

Oct. 31st, 1906,

BY D’ARCY POWER, F.R.C.S.ENG.,SURGEON TO, AND LECTURER ON SURGERY AT, ST. BARTHOLOMEW’S

HOSPITAL.

GENTLEMEN,—I am going to tell you to-day about one ofthe dramatic conditions of surgery-a condition of whichit may well be said that, like the soldier’s lot,

" HoraeMomento cita mors venit, aut victoria laeta."

(In the twinkling of an eye comes swift death or the joy ofwinning.) Duodenal perforation strikes down a man who isto all appearances in perfect health and not only strikes himdown but brings him at once to the verge of the grave,whence he is only rescued by the most prompt action ofthose who thoroughly appreciate the nature of his illnessand the danger of delay. No one can tell how many liveshave been lost by overlooking the signs and symptoms ofduodenal perforation, but this I know, that many are stillignorant of the existence of such a condition, that deathsstill occur without any attempt having been made to closethe perforation and even in ignorance that there is a per-foration. With this knowledge I need offer no excuse for

drawing your attention to the following case. The notes Iowe to my friend Dr. D. McCrae Aitken, assistant medicalofficer at the Bolingbroke Hospital, who conducted the caseto a successful issue.A compositor, aged 24 years, living at Stoke Newington,

had suffered from occasional indigestion during the pastthree or four months and had vomited once or twice duringthe same period. He gave no history of severe abdominalpain, melsena, or hæmatemesis. His appetite had alwaysbeen good and he had never suffered any pain associatedwith the taking of food. On Jan. 20th, 1906, he ate a largemeal at 3 o’clock in the afternoon and started for a bicycleride at half-past 3, going to Epsom and back, a distance ofnearly 50 miles. At 8 P.M., whilst drinking a glass of beerat Bilham, he had such an attack of pain in his abdomenthat he was taken at once to the nearest medical man. Hebecame collapsed and almost pulseless whilst he was in themedical man’s consulting-room. Strychnine was administeredhypodermically, he was put in a cab, and was taken to theBolingbroke Hospital ; on the way he vomited..The patient was admitted to the hospital at 10.15 P]Bf.

He was then very cold and collapsed. The temperature was97 6° F. and the pulse was 96 and of fair volume and force.His facies was drawn as if with pain and he complained ofsevere abdominal pain, stating that he had felt some "windypain " in the upper part of the abdomen in the morning andalso on the previous day. Examination of the abdomenshowed that there was practically no movement during

respiration. It was very rigid all over and it was tenderover the right iliac fossa. The patient looked better athalf past ten. He was in less pain and the abdomen wasless rigid on the right side. The liver dulness was present.At half past 11 I examined the patient and discoveredtenderness in the epigastric region as well as in the rightiliac region. The right rectus abdominis was more tense thanthe left and I made the diagnosis of "a a small perforationnear the pylorus, most probably on the duodenal side." Theurine was examined. It was of specific gravity 1032, andcontained no sediment or mucus and no albumin or sugar.Ether was administered at 11.45 P.M. by Dr. R. C. Twigg

and I made a three-inch incision to the right of the middleline of the abdomen and half way between the ensiformcartilage and the umbilicus. The pyloric end of the stomachwas found immediately and brought into the wound. A smallcircular perforation with sharp edges and about one-sixteenthof an inch in diameter was found in the duodeuum half aninch beyond the pylorus. There was no lymph exudate andthere were no adhesions. No gas escaped from the peri-toneal cavity when it was opened but there was a smallquantity of dark-brown fluid exuding from the perforation.The hole was closed with two sets of Lembert’s sutures ofsilk and a large drainage tube was left in the wound.A second opening was made into the peritoneal cavity overthe region of the appendix and a tube was inserted therealso. A fair quantity of turbid fluid escaped. The operationlasted 20 minutes. During the night the patient was givena rectal injection of 10 ounces of salt solution every fourhours and this was continued during the next day. He hada little bronchitis on the day following the operation. He

passed his urine but did not expel any flatus. The pulseremained steady at 100 and the temperature at 100’ 8° F. OnJan. 22nd he had sips of water from 10 A.M. which weregradually increased to a drachm every hour. He then had

peptonised milk and water, two ounces every two hours.His pulse during the day was 88 and his temperature was99.2°. The tube in the upper part of the abdomen wasremoved on Jan. 23rd and the tube in the right iliac regionon the 24th. On the 25th the patient had jelly and custard ;on the 26th bread and butter; on the 28th pounded fish; andon the 30th minced chicken. He sat up in a chair onFeb. llth and was discharged on St. Valentine’s day. The

temperature during his convalescence varied from 99° to 1000and his pulse from 76 to 88. There were no complications.He has reported himself several times since he left thehospital as being in good health.Compare the following case with that about which I have

just told you and you will notice that there is a superficialresemblance in the symptoms but the signs and course werevery different. Some of you may remember a carman, aged22 years, who was admitted into my wards late one Sundayevening in summer. He said that he had been seized

suddenly with such severe abdominal pain whilst he wasdriving that "it fair doubled him up and threw him back-wards into his cart." At any rate the pain was so bad thathe was brought straight to the hospital and he vomited onthe way. On admission he was found to be complaining ofgreat pain and some tenderness over the upper 1art of hisabdomen. The abdominal walls moved freely during respira-tion but they were held rigid when they were touched, more

1196 MR. D’ARCY POWER : ACUTE DUODENAL PERFORATION.

especially on the right side and at the upper part. Therewas no pain or rigidity in the region of the appendix norwas there anything to be felt by a rectal examination. Thearea of liver dulness was markedly diminished. The tem-

perature was 99.6° F. and the pulse was 104. He had a

leucocytosis of 28,000. The patient said that he hadsuffered severely from indigestion for the last two or threeyears, though he had never had such an acute attack ofpain as the one from which he was now suffering. Hefurther said that he had been "off his feed" for thelast two or three days, though he confessed to having hada good breakfast of bacon and eggs and a hearty dinnerof beefsteak; he had also been drinking though hewas not drunk. As he did not seem collapsed, in spiteof his physical signs, Mr. R. Foster Moore, who was thenmy house surgeon, contented himself with reporting hiscondition to me but made no preparations for an operation.We thought that the patient was suffering from an attack ofacute dyspepsia and we agreed to await further developments.Two hours later the patient vomited twice and each timebrought up a large mass of badly chewed meat. He thenrecovered quickly ; his pain left him ; his pulse fell to 88 ; hehad a good night’s sleep and I discharged him on the nextday with a caution not to bolt his food and not to drink toexcess.

These two cases present accurate pictures of two widelydifferent conditions, either of which may come under yourobservation. The symptoms somewhat resemble each otherbut you must carefully distinguish between them. In thecase of duodenal perforation the patient will die if you donot operate at once ; in the case of acute indigestion you willdo him more harm than good by operating. It is of theutmost importance therefore that an accurate diagnosisshould be made as soon as possible and I will try to trace outfor you the mental processes by which we arrived at acorrect result in these two cases. In each case the firstinformation came by telephone that a young man apparentlyin good health had been seized suddenly with suchan agony of pain in his stomach as to make him

helpless. The patient with duodenal perforation fell offhis bicycle, the man with indigestion rolled backwards intohis cart, and both vomited. There was no question there-fore about the reality of the pain or the suddeness of itsonset. Now there are not many abdominal conditionscoming on suddenly in young men which induce such

complete collapse as to make them seek instant admissionto a hospital. In the case of duodenal perforation the

patient was a compositor by trade and he might thereforehave been seized with lead colic. His healthy appearance,the absence of any blue line round the gums, and the

regularity with which his bowels were opened immediatelynegatived this cause. He was not suffering from simplecolic due to indigestion, for he had ridden many miles andhis stomach was empty as it was more than five hours sincehe had eaten anything. Renal colic was excluded by thefact that his urine was absolutely healthy and by his feelingthe pain over the whole abdomen, though it was rather morelocalised to the right iliac region. He was clearly notsuffering from biliary colic and although somewhat similarsymptoms are produced by the impaction of a gall-stone inthe intestine, such impaction, so far as I have seen it, onlyoccurs in much older people.The man with colic presented a different set of signs and

symptoms. He was in pain but neither his face, his pulse,nor his temperature showed him to be in a state of collapse.He had recently had a hearty meal; his abdominal wallsmoved freely during respiration though the muscles becamerigid as soon as they were touched. They were thus in avery different state from that of the poor fellow who hadduodenal perforation, whose abdominal muscles were heldrigid against all movements. I had very little difficulty inarriving at a conclusion as to the cause of his pain and feltcertain that as soon as he vomited he would obtain relief.But it was different with the case of duodenal perfora-

tion. The various forms of colic having been excluded thediagnosis was limited to some condition causing sudden andviolent irritation of the peritoneum. The irritation mustnaturally have arisen within the abdominal cavity as thepatient had not received any external injury. I had there-fore to pass in review the various conditions occurring in ayoung man which may lead to sudden and spontaneousirritation of the peritoneum. They are perforation of somepart of the alimentary canal, acute inflammation of theappendix, intussusception, and the strangulation of a piece of

bowel either by a band of adhesion or by the slipping of aloop into one of the retro-peritoneal pouches, for we had, ofcourse, excluded the ordinary forms of hernia. When I sawthe patient I set to work to exclude these different con-ditions as rapidly as possible. The pain and rigidity inthe upper part of the abdomen seemed to me to excludethe likelihood of a retro-peritoneal hernia or of inclu-sion by a band, for in these cases the abdomen oftenremains slack during the early periods ; for the same

reason and because there was nothing discoverable by rectalexamination I dismissed intussusception. The pain andtenderness over the appendix region pointed to that part ofthe alimentary canal as the source of the symptoms. Butit is a well-known fact that when the duodenum is per-forated its contents trickle downwards into the right iliacfossa and many perforated duodenal ulcers have been mis-taken for cases of appendicitis. I therefore examined theabdomen to ascertain whether there was not another andequally tender spot higher up in the abdomen. There wasno difficulty in demonstrating the existence of such a pointof maximum tenderness in the immediate neighbourhood ofthe pylorus. It was pretty certain, therefore, that the patientwas suffering from a perforation either of the stomach or ofthe duodenum close to the pylorus. The previous goodhealth of the patient, the absence of any well-markedhistory of indigestion, and the suddenness and completenessof the collapse made it practically certain that the patientwas suffering from a perforation of the duodenum ratherthan of the stomach. It was possible, too, to go furtherthan this and to say that the perforation was not of anygreat size, because as soon as the initial shock was over thepatient began to rally, since his pulse was obviously betterwhen I saw him at half-past 11 than when he was firstseen by Dr. Aitken, and it was better then than when themedical man who saw him two hours earlier had injectedstrychnine hypodermically because he was pulseless. This

rallying power of patients with duodenal perforationmust always be kept in mind, because it has misledmany surgeons into waiting for more definite signsor into underestimating the severity of the case. The

explanation of this power of rallying seems to be that

perforation of the duodenum occurs usually in persons whoare otherwise healthy : the perforation is small and thecontents of the duodenum are alkaline, not very septic, andfree from partially digested masses. When the peritoneumhas recovered from the first shock of invasion by theintestinal contents it only resents mildly the presence of theduodenal secretion until the multiplication of pyogenicorganisms sets up a general suppurative peritonitis. Untilone has seen a case of duodenal perforation and watched itsprogiess untreated it is difficult to believe that the patientlying before you in tolerable comfort with his abdomenmoving fairly well and with only a tender spot over hispylorus and some fulness and tenderness in one or both iliacregions and a rapid pulse is really on the brink of death andthat you have waited too long to save his life by any surgicaloperation. But here is a case in point. It occurred someyears ago when less was known of duodenal perforation thanat present and it was one of the first cases I saw.A porter, aged 41 years, was admitted to the hospital on

May 23rd, 1901, saying that he was at work and quite welluntil 11 A.M., when he was suddenly attacked with pain inthe epigastrium. The pain continued and he vomitedseveral times before coming to the hospital. He had not

passed flatus since the pain began ; his bowels had been wellopened the day before he was taken ill. He was a temperateman and there was no history of indigestion. On his ad-mission to the hospital at 2 P.M. the patient was reported tobe a well-nourished man in obvious pain. His tongue wasclean and moist ; his respirations were very shallow and 60 aminute ; his pulse was of fair volume and tension, regular,and 100 a minute. In the chest the percussion note wasimpaired at the right base and the entry of air over this areawas weaker than on the left side. There were no additionalsounds. The pain in the abdomen was not localised but thepatient complained of it chiefly over the upper half anddown the left side. The abdomen was not distended but itmoved very little during respiration. The movement, how-ever, was equal all over, though the abdomen was held some-what rigid. It was tender all over and tympanitic every-where except that the liver dulness was present. Nothingabnormal could be felt.

It was thought to be impossible at this time to make anydefinite diagnosis and directions were left that he should be

1197MR. R. H. RUSSELL: SACCULAR THEORY OF HERNIA & RADICAL OPERATION.

carefully watched on the assumption that the case was ratherone of pulmonary than of abdominal trouble. There wasno definite change at 6 P.M. An enema saponis had beenretained but the pain had not been relieved by poulticing.The temperature at this time was 99.8° F., the pulse was120, and the respirations were 60. At midnight there wasstill no material change in the condition of the patient,whose temperature was 99’ 80 as before, pulse 120, andrespirations from 60 to 70. A little liquid had beenvomited. At 1 A.M. the abdomen was distended and the

patient was slightly collapsed with a pulse of 144, almostrunning. At 2 A.M. he was still more collapsed and I sawhim for the first time as I was doing the night work of oneof my senior colleagues. He appeared to me to be so illthat I decided to explore his abdomen at once. I therefore

opened it in the middle line above the umbilicus. Liquidcontents escaped as soon as the peritoneum was incised, thestomach was drawn up into the wound, and a perforatedulcer was found apparently on the posterior aspect. Theaperture was large enough to admit a full-sized probe andthere was a considerable deposit of lymph round its edge.An attempt was made to close the perforation by Lembert’ssutures, but the operation was very difficult, partly onaccount of the awkward position of the ulcer and partlyowing to the rotten state of the surrounding tissues whichwere too softened to retain the silk sutures. Four sutureswere passed and it seemed as though the opening had beenclosed successfully. During the insertion of the suturesthere was an abundant flow of clear and thin liquid fromthe interior of the duodenum, but this ceased when the lastsuture was tied. The peritoneal cavity was then cleansedand the wound was closed. The patient bore the operationbadly and died five and a half hours later. A post-mortemexamination at 3 P.M. on the same day showed that thewhole peritoneum was acutely infiamed, its endothelial aspectbeing covered with a layer of fibrino-purnlent lymph. Therewere collections of purulent matter at the bottom of therecto-vesical pouch, in the lumbar region, and in the rightsubphrenic space, this space being almost completely shutoff from the rest of the peritoneal cavity. A conical ulcer

measuring half an inch at its widest part was situated at theupper and back part of the first portion of the duodenum.It had sharply-cut edges but there was no infiltration of itsmargins. The floor of the ulcer had perforated but mysutures were not applied accurately because water andintestinal contents passed easily through the perforation.The particular interest of this case lay in the fact that

the localised peritonitis must have lasted a much longertime than the sudden onset of symptoms would have led oneto suspect, whilst the symptoms when they appeared were soobscure as to make it appear to competent observers that thepatient was suffering from pneumonia rather than from peri-tonitis. It is interesting, too, because it is a record of the I,course taken by a case of perforated duodenal ulcer which, I

though carefully watched, was practically untreated and itshows the suddenness with which a patient in this conditionpassed from comparative ease into the jaws of death.The prognosis in cases of duodenal perforation is bad

and the average mortality is much higher than in per-foration of the stomach. Many die from shock, some fromperitonitis, others from pneumonia ten days or a fortnightafter the perforation and just as the surgeon is beginning tohope that he has got his patient beyond any fear of a relapse.The prognosis of duodenal perforation will improve as the

condition is more generally recognised and its specialdangers are more widely understood. Perforated gastriculcer had as bad a prognosis a few years ago, though thesigns which accompany it are far plainer than those ofduodenal perforation. Gradually we have become alive tothe facts and have learnt that immediate operation isfollowed by recovery in most cases, whilst to wait almostcertainly means death to the patient. Cases are now sent tous much more quickly than they used to be-indeed, the lastman I operated upon was at work at half-past twelve onemorning, had signs of gastric perforation at one o’clock, andby three the same afternoon I had operated upon him andhe was safely back in bed. It is needless to say that herecovered without a bad symptom. The advice that I wouldoffer you, therefore, in cases of duodenal perforation is tooperate at once when you have reasonable grounds to

suppose that such a catastrophe has taken place. Do notwait until you have definite signs to depend upon. Thepulse, the temperature, and the degree of movement of theabdominal walls may all deceive you. The patient will

recover from the initial shock if he be watched and yet allthe time his peritoneum is becoming more and more involved,so that valuable time is being lost if you allow his generalcondition to weigh against the advisability of an operation.When you are in doubt examine the abdomen. Fulness andtenderness over the appendix region should not mislead you,but you should at once ascertain whether there is not an

equally tender spot with resistance higher up and on thesame side of the abdomen over the situation of the duodenum.If there is such a tender spot and it be associated with theother signs and symptoms of duodenal perforation thenoperate without more ado, for in this way, and in this wayonly, you will reduce the mortality to a minimum.The operation will be difficult or easy according to the

position and surroundings of the ulcer which has led to theperforation. A duodenal ulcer is usually conical, its apex isdirected outwards, and the actual perforation therefore issmall, often no larger than the point of a probe. One ortwo sutures may be enough to close it. It is situated in themajority of cases in the first part of the duodenum, close tothe pylorus and on the upper and anterior wall. The moredifficult cases, some of which it is impossible to close bysuture, are those situated on the posterior aspect of theduodenum or in its second or third parts as well as thosewhere the intestinal wall is softened by inflammatory pro-ducts or is surrounded by adhesions. The perforation isclosed with sutures of No. 1 silk inserted with a quarter-curved needle after the intestine has been brought as closeto the surface as possible ; when it is impossible to bringit into the wound I have often found a cleft palate needleand cleft palate forceps serviceable, so I have these in-struments put out for me whenever I have a case ofgastric or duodenal perforation to operate upon. Whenthe perforation is closed and the intestine has been re-

placed in the abdominal cavity a large drainage tube with-out any holes in the sides is passed into the abdominalcavity and the incision is closed in the usual manner. I thenopen the peritoneal cavity in each iliac region as a matterof routine and insert a large drainage-tube on each side.There is nearly always a considerable escape of fluid fromthese lateral incisions and they continue to discharge longerthan the first wound over the duodenum. The tubes are

emptied twice a day by sucking up their contents with a maleglass urethral syringe to which a small rubber tube isattached. It is a better plan than that of taking the tubesout and syringing the sinus. The tubes should be dispensedwith as soon as possible, because adhesions quickly formround them and shut them off from the general cavity ofthe peritoneum and they then serve no good purpose but actas irritants and increase the amount of discharge. Theymay be removed within the first week and the wounds arethen packed lightly with gauze. When the patients recoverthey do so perfectly, for they do not seem to be subject to therelapses which are so common in cases of perforated gastriculcer. One other point and I have finished. Duodenal

perforation occurs four times more often in men than inwomen, and no one knows why.

THE SACCULAR THEORY OF HERNIAAND THE RADICAL OPERATION.

BY R. HAMILTON RUSSELL, F.R.C.S. ENG.,SURGEON TO THE ALFRED HOSPITAL, MELBOURNE ; CONSULTING SURGEON

TO THE MELBOURNE HOSPITAL FOR SICK CHILDREN.

BY the saccular theory of hernia I mean the theory thatrejects the view that hernia can ever be "acquired" in thepathological sense and maintains that the presence of a

developmental peritoneal diverticulum or sac is a necessaryantecedent condition in every case of ordinary abdominalhernia. In the numerous articles which I have contributedto THE LANCET during the last seven years on this subject 1 Ihave always been content to speak of the " congenitalorigin" of hernia or of "hernia into a congenital sac"; butfor reasons that I have pointed out on several previousoccasions there are special inconveniences associated withthe use of the word " congenital " in connexion with hernia,and I am therefore prompted to suggest a name which has

1 THE LANCET, Nov. 18th, 1899, p. 353; Oct. 20th, 1900, p. 1128;May 31st, 1902, p. 1519; March 12th, 1904, p. 707; and Jan. 7th, 1905,p. 7.