In cases of perforation of an ulcer all that can be done is to give anodynes to ease the pain and make the patient's condition as comfortable as possible. Schlipp recommends that when perforation is threatened on account of gaseous distention of the stomach, the stomach tube should be used to evacuate the organ.
The mechanical treatment, washing out the stomach with the stomach tube or stomach pump is contraindicated in cases of ulcer, as more damage can be done by such procedure than good.
ORIGINAL ARTICLES
THE RECOGNITION OF MORTIFIED BOWEL IN
OPERATIONS FOR THE RELIEF OF
STRANGULATED HERNIA.
By REUBEN A. VANCE, M. D., CLEVELAND, OHIO.
The medical practitioner who has been hastily summoned to operate upon a patient with strangulated hernia finds himself confronted with problems, the gravity of which can alone be appreciated by those who have frequently met them. The medical treatment to be adopted, the extent to which taxis should be employed, and the time it is prudent to delay operative interference when other measures have proved fruitless, are grave questions upon the solution of which the life of the patient depends. The operation decided upon, the particular method to be employed and the manner of dealing with the stricture—with or without opening the sac—are matters of minor consequence, and affairs that should be settled in the mind of every practitioner by a reference to sound surgical principles and the teachings of experience. There are questions connected with the condition of the parts strangulated that must be solved by the surgeon during the progress of the operation, about which much less is said in works on surgery than their importance warrants. These pertain to the vitality of the part that has been strangulated, and the duty of the surgeon in the premises. If the part is still living, it matters not how much damaged by compression, it should be returned at once into the abdomen; upon this step the patient's life depends. If the part is mortified and dead, to return it within the cavity of the belly is to insure the patient's destruction; if he is to have a chance for life, other measures must be adopted.
Again, the decision of the operator can but rarely be guided or aided by aught but the conditions revealed by his knife during the operation. The state of the patient and the history of the case may indicate the imminence of mortification of the bowel; in the end the appeal is to the senses of the surgeon, and upon the conclusion at which he then arrives will depend the fate of the patient.
Under these circumstances it behooves every man who may be placed in position to make such a momentous decision to at least go to the task, sustained by every aid that can be derived from the experience of those who themselves have been placed in this dilemma and compelled to act with such lights as they then possessed—whose records, next to personal experience, become the best guide for those forced to follow in their footsteps.
The history of the case may throw some light upon the state of the intestine. This is especially so in those cases in which the severity of the symptoms suddenly subsides without the rupture having been reduced. The pain is violent, the abdomen distended and singultus and stercoracious vomiting present; suddenly the patient's suffering cease, and were it not for the cold extremities, flickering pulse and persistent tumor—but above all, the teachings of experience—the surgeon could not but acknowledge that all tangible appearances portended a change for the better. Yet, almost invariably gangrene of the gut has taken place, and the fallacious evidences of improvement above noted are in reality its best clinical exponent. Certain almost as these signs are, when present, yet it comparatively seldom happens that the surgeon has their aid in guiding him in the measures he must adopt; they form, but infrequently, a part of the history of cases submitted to operation. If present, the surgeon is reasonably sure of what he will find when he operates; they may be absent and mortification yet exist. The patient's chance of life depends upon the surgeon's ability to recognize mortification of the bowel when he sees it, and his promptitude and skill in dealing with it when present.
It scarcely need be said that mere darkening in color of the bowel, effusion of fluid into the sac, or exudation of lymph about the stricture are of no special significance in this connection, and bear in no way upon the presence or absence of mortification. It has been again and again repeated in manuals treating of hernia operations that a deep, purplish discoloration of the bowel and absence of circulation indicate mortification; that when these physical signs are present the surgeon should press upon the strictured part, and if the color remains unchanged when the finger is removed, the bowel is dead. It requires but little practical experience in dealing with these cases to appreciate the fallacious character of these signs; the gut may be fairly black from congestion and yet alive; the color may remain unchanged under pressure and still that fact have no bearing on the question of mortification, for a band of stricture, as yet unappreciated, may be the sole cause of the persistent hyperæmia.