PERFORATION OF DUODENAL ULCER.—This must be met by immediate operation, and the technique follows closely that described for the treat ment of a perforated gastric ulcer.
The question of the necessity of performing a gastro-enterostomy is practically settled by recent experience, as after the suturing of the margins of the perforation the ulcer should always be freely infolded, and this leads to more or less occlusion of the duodenal route. Hence the posterior operation should be performed when possible in all cases. Sometimes the anterior operation may be indicated where expedition is a vital point and the condition of the part determines its suitability. It will be often a wise precaution to wash out the stomach during the operative proceedings.
After the .completion of the operation the patient should be propped up in bed by pillows in the sitting posture, and Murphy's method of continuous rectal infusion should be started at once; this relieves thirst and diminishes the risk of septic infection.
The recent results of operation for duodenal perforation in chronic ulcer must he considered as somewhat startling; my colleague A. B. Mitchell has performed the operation with complete success in no less than 17 con secutive cases. I ie points out that the reflex closure of the pylorus which usually follows perforation of the duodenum limits the amount of extravasation into the abdominal cavity, and hence better results may always be expected than when the stomach has perforated.
In chronic perforation the procedure should be upon the same lines. The abdomen heingopened, the abscess should be incised and free drainage established; a fistula, however, often remains. The pylorus should in these cases be occluded by in folding and a posterior gastro-enterostomy performed.