The incision is made through a vertical line lying one inch to the right of the middle line above the umbilicus. A perforation will usually reveal itself by a puff of gas when the parietal peritoneum is incised. The perforation is then incised; the edges are rapidly drawn together by 2 or 3 sutures of stout catgut; and these sutures covered in by a Lembert suture or by a purse-string suture including peritoneum and muscle. Owing to the oedematous nature of the tissues around a per foration it is necessary to place the sutures wide of the perforation, other wise they will cut through and allow the opening to gape.
There is now hut little diversity of opinion in regard to the necessity for performing a gastro-enterostomy in all cases of perforation. In the writer's opinion the only contra-indication is the general condition of the patient. If the general condition is even fair the subsequent manage ment of the case will be made incomparably easier by a well done posterior gastro-enterostomy.
Unless a septic peritonitis is established it is unnecessary to spend time on sponging out extravasated fluid. This removes a highly pro tective material from the abdomen and renders the bowel wall more susceptible to the toxins. But provision should be made for free drainage
by placing a wide-bore tube with gauze wick deep down into the pelvis and sometimes also into the right kidney pouch.
The patient is then returned to bed, placed in the Fowler position, normal saline solution is instilled drop by drop into the rectum by the Murphy method; fluids are not allowed by the mouth for 24 hours, but after that time a little warm soda bicarbonate solution may be allowed in teaspoonfuls.
The treatment of so-called chronic perforation in which adhesions have formed and a localised peritonitis or perigastric abscess results, and of the subacute or leaking perforation, must differ with the different con ditions found after an exploratory incision. Where the ulcer is on the anterior surface of the stomach the operation of Gastralysis may be undertaken; this consists in separating the adhesions and dealing with the ulcer by excision or otherwise. But as these chronic perforations are usually inaccessible and situated on the posterior surface, suturing of the ulcer is often not possible, and the best routine procedure is to perform a gastro-enterostomy and allow the adhesions to remain undisturbed without attempting a gastrolysis.