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Related post: L indicating a spot on the left, midway between the umbilicus and ensiform. A physician dia^osed vc4vuius, and tried by enemata and massage to re- lieve the pain. In five hours vomiting ceased and the pain subsided somewhat and was referred to the lower abdomen. No fecal matter nor gas passed the anus. There was no tympanites nor difficulty in passing water. Sixteen hours after the attack he was admitted to the hospital. The abdomen was retracted and board-like, the pain was less and vomiting had ceased. There was costal respiration and the expression of the face indicated severe abdominal trouble, the nose pinched, the eyes sunken, the hands clammy and the patient in a half stupor. Diagnosis was throught to lie between appendicitis and duodenal perforation. Nineteen hours after the attack an incision was made in the median line from the pubis to above the umbilicus. The abdomen con- tained nwi-feculcnt fluid, and there were light ad- hesions on the intestinal coils. Appendix nor- mal ; no intestinal lesion ; pelvis normal. Incision prol(Higed upward and stomach searched; ^s found escaping from under liver, and perforation near pylorus on anterior surface of duodenum sutured. Abdomen wiped and drained from site of duodenum. Several saline injections amount- ing to 4200 c.c. in all. Death in twenty hours from peritonitis ; suture tight.'" Case 26. — M., aged twenty-six years; health perfect, never any gastric symptoms. Two hours after his usual light breakfast, while making a slight effort to open a sack, the patient experi- enced an intense pain in the left side of his ab- domen. He was taken almost at once to a hos- pital. Diagnosis of appendicitis; treatment by ice and opium. Following day a feeble pulse, without fever; abdcnnen distending; tenderness in left iliac fossa. On second day Cyclogyl Price vomiting set in becoming bloody and bilious. About fifty-six hours after the attack, Sebileau made an incision as for appendicitis, permitting the escape of non- feculent fluid, like bouillon. The appendix Cyclogyl 1 was normal. The patient was already collapsed, and nothing further was done, except to drain with ^uze and give a saline injection. Death after mcessant vomiting in thirty hours. Autopsy: Abdomen contained fluid. There was general peritonitis ; perforation in the anterior wall of the duodenum i cm. from the pylorus." Case 2y. — M. ; an attack of sudden pain like lead colic. Incision from the ensiform downward. There was food under the liver, and a perforation was found in the first part of the duodenum. Su- ture. Death in twelve hours." Case 28. — M.. policeman, of alcoholic habit and history of gastric attack. While on duty the pa- tient had a sudden attack of pain which made him writhe in agony. His bowels had moved a short time before. When seen soon after the abdomen was retracted, as hard as a board, ex- cessively tender, especially under the ribs and in the right flank. Diagnosis of hepatic colic. Compresses were applied and morphine adminis- tered. The following day he felt better. An in- jection resulted in a large stool. Milk and vichy were administered. There was no fever and not much pain, but the abdomen was still retracted. Thirty hours after the attack vomiting set in, soon becoming bilious. The abdomen swelled and the patient was taken to a hospital. Diag- nosis, appendicitis, intestinal obstruction or vd- vulus. Abdomen opened forty-eight hours after the attack. Nothing but general peritonitis dis- covered. Dieulafoy, operator. Death in one hour. Autopsy: Perforation of the duodenum in the anterior wall just below the pylorus." Case sg. — F., aged twenty-five years, servant, giving history of gastric trouble with vomiting, but never of blood. An increase of gastric pain, with general tenderness and abdominal swelling. Was followed four days later by marked disten- tion. Palpation showed the greatest tenderness to be in the cecal region. There was no fever. A needle thrust into the right iliac fossa brought out gas and an odorless fluid, containing flakes of fibrin. An incision was made over the appendix which was congested. There was general peri- tonitis. Death four days after the operation. Autopsy: Pus in the pelvis and about duodenum, in the lower wall of which close to the pylorus there was a perforated ulcer. A second ulcer Cyclogyl Eye Drops was situated in the Buy Cyclogyl posterior wall." Case $0. — F., aged thirty-four years, servant, with a history of gastric troubles for twenty years, with frequent vomiting of blood; last at- tack one week before admission to the hospital, the vomiting being followed by bloody stools, pulse 84, regular, strong ; rectal temperature 98.6° F. Maximum pain midway between ensi- form and umbilicus to the right of the median line. Ice-bag on abdomen, nothing but ice by mouth. Next day pain involved the whole right side ; was relieved by morphine, but recurred with vomiting, a small pulse of 106, and cold sweat. More morphine was given. Two hours later the pulse was 130, there was tenderness all over the abdomen, and edema, in the epigastrium. Diag- nosis, gastric ulcer. Laparotomy two days after admission to the hospital (thought by the opera- tor to be "at least fifteen hours after perfora- tion") through the left rectus above the umbili- cus ; gas and fluid escaped ; no adhesions ; general peritonitis. Perforation at pylorus, thought to be in the lesser curvature, sutured. Abundant irrigation ; gauze drainage ; 700 c.c. saline in- jected. Death twenty-four hours after operation. Autopsy: Perforation in the superior wall of the duodenum near the pylorus. The suture was
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