Perforated Peptic Ulcer: *

Perforated Peptic Ulcer: *An Analysis of 206 Consecutive Cases with Emphasis

on Pathophysiologic Changes and Deaths

JAMES D. HARDY, M.D., F.A.C.S., GEORGE R. WALKER, JR., M.D.,J. HAROLD CONN, M.D., F.A.C.S.

From the University and Veterans Administration Hospitals, and the Department ofSurgery, University of Mississippi Medical Center, Jackson

ALTHOUGH perforated peptic ulcer fre-quently is considered a rather benign con-dition, this process is associated with anover-all mortality rate that still rangesfrom ten to 15 per cent. Several deaths onour surgical services prompted us to ex-amine our own experience with this prob-lem, and the series of 206 consecutivecases of perforated peptic ulcer was re-viewed. Particular attention was directedto careful analysis of the cause of death inthe fatal cases, and certain pertinent patho-physiologic problems were investigatedfurther in the experimental laboratory.There were 24 deaths for an 11.6 per centmortality rate. Peritonitis with resultantshock was the most common cause ofdeath. The mechanism of shock in peri-tonitis due to perforated peptic ulcer wasmade a central consideration in the study.

Case Material

The 206 cases of perforated peptic ulcerwere treated at the University of Missis-sippi and the Veterans Administration hos-pitals. The fact that these two groups ofpatients had been cared for by the samegeneral group of surgeons and residentstaff offered a certain uniformity of philos-ophy and policy. However, there were afew important differences between the

case material from the two hospitals; forexample, the women and children were alltreated at the University Hospital. Thepatients from the VA Hospital were ad-mitted between 1947 and November 1960;those from the University Hospital wereall admitted between 1955 and December1960. Obviously the length of follow upwas short in many instances, but the dataregarding the natural history of the ulcerdiathesis in our series were remarkablysimilar to the extensive experience reportedin the literature.6, 7, 13, 19, 20, 25, 7-29, 33, 36, 41,47. 49, 51, 54, 59, 60, 62

The diagnosis was established in thenonoperated cases by the history, clinicalfindings and roentgen studies. A prominentfeature of these cases was the remarkablyconsistent set of clinical findings en-countered and the high degree of pre-operative diagnostic accuracy achieved inthose later operated upon and perforatedpeptic ulcer proven. Therefore, it is con-sidered unlikely that many cases wereerroneously diagnosed as having perfor-ated peptic ulcer whose final dischargediagnosis was something else, causing thecharts to be filed under other headingsand thus to exclude errors in diagnosis atthe time of admission. Cumulative data aregiven in Table 1.Age Incidence. The distribution of cases

by age is shown in Figure 1. There wasone patient below the age of 10 in theUniversity group. The largest group at the

* Presented before the Southern Surgical Asso-ciation, Boca Raton, Florida, December 6-8, 1960.

Aided by U.S.P.H. Grant No. A-4206 (C4).

911

HARDY, WALKER AND CONN

TABLE 1. Cumulative Admiiission Data (206 Patients)

SexMlenWomen*

Race

1988

White 126Colored 80

SeasonSpring 50Summer 42Fall 53Winter 61

Alcohol intake

Heavy 18Moderate 69None 34Unknown 85

Previous ulcer historyYes 142 (68.7%-)No 64

Previous perforationsYes 16 (7.8c%)No 190

Other complicationsYes 29 (14.1%)No 177

Rigid abdomenYes 136 (66d7)No 70

Free air

Yes 124 (60.2%)No 75

Cultures (operative cases)Positive 17Negative 47Not cultured 112

Interval between perforation and surgery

University Hospital 24.7 hrs.VA Hospital 12.9 hrs.Average 17.03 hrs.

Deaths**

OperativeCasesDeathsPercentage

ConservativeCasesDeaths1'ercentagt

176116.3

301343.3

* All at University Hospital.** Within 30 days of operation or admission.

University Hospital was that for the fifthdecade of life, while the largest group atthe VA Hospital was that for the thirddecade. In a survey of 2,334 cases,

DeBakey15 found that the greatest num-

ber of cases occurred during the fourthdecade.

Sex Incidence. Of the 74 cases admittedto the University Hospital, eight were

women and 66 were men. This great pre-

ponderance of men over women is ofcourse reflected in all reports dealing withthe incidence of peptic ulceration in theWestern world. Various explanations forthis preponderance have been suggestedincluding an effect of the female hor-

mones.'1 However, it must be borne inmind that prior to 1900, perforated ulcerwas as common in women as in men.65

The sex incidence of perforated pepticulcer in Great Britain and Western Europewas studied by Jennings 26 and his resultsreported in 1940. It was found that be-tween 1850 and 1900 there was an essen-

tially equal sex incidence, with youngwomen particularly affected. However,shortly following 1900 this almost equal sex

incidence began to change radically. By1920, only one of every ten perforations was

in a woman, while the other nine were inmen. Thus young women undergoing perfo-ration due to peptic ulcer formed a sharplydefined group, one which increased rapidlyat the beginning of the 19th century andthen declined suddenly at the beginningof the 20th century-similar findings beingreported from England, France, Scandi-navia, Germany, and the United States.64Jennings concluded that environmentalfactors must be conspicuously importantin producing this change of incidence,since constitutional or genetic factors couldnot have been altered so quickly in wholepopulations.The psychosomatic significance of this

rather abrupt and dramatic change in theincidence of peptic ulceration in men

versus women was studied at the New

912 Annals of SurgeryJune 1961

Volume 153Number 6

PERFORATED PEPTIC ULCER

60-

.3%I 40-

C)w

0.

0 -9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-9YEARS

AGE INCIDENCE IN 206 CASES OF PERFORATED ULCER

20-

0-

913

Hospital odmissions ofwhite vs. colored

approx.3:2

WflI I C (ULUA¶uRACE INCIDENCE IN 206 CASESOF PERFORATED ULCER

SUMMER FALL

SEASONAL INCIDENCEIN 206 CASES OF PERFORATED ULCER

SITE OF PERFORATED ULCER IN206 CASES

FIG. 1. Upper Left. The incidence of perforated peptic ulcer by decades is shown. Upperright. Negro patients exhibited perforated peptic ulcer as frequently as did white patients ifsuitable corrections were made for the total number of hospital admissions of each race.Lower left. The lowest incidence of perforation was recorded in the summer months, thehighest in the winter. Lower right. As in virtually all reported series, duodenal perforation wasfar more common than gastric perforation, though the latter was associated with a muchhigher mortality rate.

York Hospital by Mittelmann and WVolff.39The findings of Jennings witlh regards tosex incidence in Western Europe were

fully confirmed. From 1880 to 1900 it was

found that women had perforated ulcer

about as commonly as men. Beginning inthe period of 1901 to 1906, however, theratio of men to women changed, with men

being affected more frequently thanwomen. On the basis of these and numer-

30-

20-

z

wa.

I0-

60o-

40-

zw

20

0.-i

2.4%

MARGINAL

85%

ha.


FLUID LOSSES IN PERFORATED PEPTIC ULCER

GASTRIC -

INTRAPERITONEAL 8

INFLAMMATORY FLUID

PERFORATEED DUODEAL LATE ILEUS WITH INTRALUMINALULCER FLUID LSS

FIG. 2. The movement of a massive volumeof fluid into the peritoneal cavity in peritonitisdue to perforated ulcer is probably the most im-portant cause of shock met during the first 48hours following perforation. This sequestered fluid,the result of the internal chemical bum, is notphysiologically available for the maintenance ofan adequate interstitial fluid and plasma volume.This "lost" fluid must be replaced parenterally ifhypovolemic shock is to be consistently avoided.

ous other studies relating stress and dis-ease, they concluded that the change ofsex incidence of peptic ulcers with perfora-tion is a dramatic exhibition of the reper-

cussions of a changing social order on therelations of the sexes and the subsequenteffects on health; while women have at-tained an increased status in society withtremendously increased job opportunitiesand other means of self expression, the roleof the husband in marriage has changedprofoundly and often declined. And whereasthe working wife can withdraw fromher job at any time and not be considereda failure for doing so, the husband cannotfail to be a good provider without in-curring the criticism of his society and theloss of the emotional support of his wife.In fact, a wife's humiliation of her husbandunder circumstances of his failure to "pro-vide" is endorsed by cultural sanctions,as pointed out by Wolff.64 Thus whilesociety's requirements of the man are

essentially as stringent as before, the emo-

tional support accorded him by his familyand in particular by his wife bas decreased,

The shift of primary incidence of pepticulceration from women to men may wellbe related to such changes in the socialorder of the Western world at this time.

Race. Frequently it is believed that Ne-groes are subjected to less emotional stressand thus have fewer peptic ulcers than domembers of the white race. This was notthe case in the present series nor in thelarge series recently reported by Rogers.48In the University Hospital group therewere 38 white patients and 36 Negro pa-tients. In the Veterans Administration Hos-pital group there were 88 white patientsand 44 Negro patients. In the combinedhospitals there were 126 white patientsand 80 Negro patients. However, sincethere is almost a 2:1 preponderance ofwhite patients over colored patients ad-mitted to the Veterans Hospital, while thegroups are approximately equal on thewards of the University Hospital, it isapparent that the incidence of pepticulceration with perforation in the Negroeswas about the same as in the white popu-lation (Fig. 1).

Seasonal Incidence. It is commonly re-ported that peptic ulceration tends to bemore common and severe in the spring andfall months. Therefore the frequency withwhich perforation occurred in the fourseasons of the year was determined. It maybe seen in Figure 1 that there was a some-what higher incidence of ulcer perfora-tion in the fall and winter months than inthe summer and spring. Yet the only statis-tically significant difference was betweensummer and winter. Since cold weatherfrequently does not begin until Decemberin Jackson, the fall season of the North-eastern United States may be essentiallycomparable to the winter in Mississippi.

Previous Ulcer History. Of the totalseries of 206 patients, 142 (68.9%o) gavea positive history of previous ulcer symp-toms. Sixteen (7.7%o) of the 206 patientshad perforated on a previous occasion,



Furthermore, 29 (14%o) of the 206 patientshad manifested other ulcer complicationssuch as bleeding and pyloro-duodenalobstruction. These findings underscore thevalue of a careful history in the evaluationof all patients who have symptoms whichsuggest a perforated peptic ulcer.

Location of Ulcer. There were 172 per-forated duodenal ulcers, 26 gastric ulcers,five marginal ulcers occurring at the site ofa gastrojejunostomy (Fig. 1), and threecases in which the site was not definitelydetermined. Only one of the gastric ulcerswas due to malignancy. At operation forsimple closure a biopsy of the wall of thegastric ulcer had been taken which dis-closed lymphosarcoma and soon thereaftera gastric resection was performed for thisdisease. In no other incidence was a

malignancy of the stomach encountered inconnection with a perforation.

Clinical Findings: Frequency of RigidAbdomen. The remarkably consistent groupof clinical findings at the time of initialexamination of the patient was a strikingfeature of this series of cases, as it has beenin other reported series. The classic findingof a rigid or board-like abdomen was

present in 136 of the 206 patients (66%o).Although lesser degrees of abdominaltenderness and rigidity were encounteredin the other patients, the term "board-likerigidity" was encountered time and againin the written notes of the initial examiner.Few other intra-abdominal conditionscause such rigidity so rapidly, acutehemorrhagic pancreatitis being the diseasewhich does cause a rapid spread of highlyirritative material throughout much of theperitoneal cavity to produce inflammationof the parietal peritoneum and reflex mus-

cular rigidity. Early perforation of thegallbladder or appendix usually is notattended by such widespread distributionof rigidity, perforation of a colonic diverti-culum usually is associated with relativelylocalized rigidity in the left lower abdomen

or both lower quadrants of the abdomen,and perforation of the bowel due to mech-anical obstruction is commonly precededby a rather typical history and is oftenstill not accompanied by the degree of ab-dominal rigidity.Blood Pressure on Admission: Impor-

tant Prognostic Import. The most severelyill patients were likely to exhibit arterialhypotension on admission or shortly there-after. This finding was frequently of seri-ous prognostic import because it usuallyreflected extensive peritonitis. Rogers 48and Reynolds et al.46 have emphasized thepositive correlation between shock on ad-mission, degree of peritonitis and mortalityrate. In some of our cases it was found"impossible" to get the patient out ofshock so as to permit surgical intervention;the fact that such fatal cases were listedin the conservatively managed group re-

sulted in an unfair increase in the numberof deaths associated with the conservativemethod. In retrospect, it is apparent thatmany of these patients received far toolittle electrolyte and colloid solutions inreplacement thereapy, and in some theshock was probably not truly "irreversible."

In most reported series of perforatedpeptic ulcer peritonitis is listed as the mostfrequent cause of death, and subsequentlyin this discussion the mechanism of shockin peritonitis will be further examined.Notwithstanding, it has also been shownthat the chronicity of the peptic ulcerationin the given case, as well as serious as-sociated disease, has much to do withthe prognosis for survival of an acuteperforation.Roentgen Studies. The presence of free

air in the peritoneal cavity was routinelysought, the roentgen study being per-

formed with the patient in either the up-right or one or the other lateral decubituspositions, usually the left. Free air was

demonstrated in 124 of the 206 cases

(60%o). This fraction of approximately

Volume 153Number 6 915


three-fifths is in accord with that reportedin the literature.4

Positive roentgen findings have beenachieved in a larger percentage of cases bythose who chose to introduce additionalair into the stomach through a nasogastrictube, or to introduce a radiopaque mediumsuch as Urokon to demonstrate the per-foration; these measures have also beenemployed by some to determine whetheror not the perforated ulcer had sealed off,as an aid in supporting the election ofconservative management. We have not in-jected air but we have employed radio-paque medium from time to time, thoughnot routinely.

Air in the peritoneal cavity need not, ofcourse, represent a free perforation of a

peptic ulcer. Colon perforation may attimes release a very large volume of air.However, of particular interest are the re-

ports of localized walled-off gas pockets,often in the subhepatic area 18, 30 that maybe associated with minor contamination inperforated peptic ulcer, perhaps in the"formes frustes" type.53 Careful fluoroscopymay disclose free air when this was notvisible on the plain film. The finding ofair in the biliary tract suggests the pres-

ence of a biliary-enteric fistula.

Laboratory Data

Hemoglobin and Hematocrit Values.The finding of an elevated hemoglobin or

hematocrit level on admission almost in-variably accompanied collateral clinicalevidence of marked fluid loss into theperitoneal cavity due to peritonitis causedby the "internal chemical burn." Un-fortunately these blood studies were fre-quently not helpful in detecting dehydra-tion because the patient was previouslyanemic from chronic nutritional disease or

bleeding. In other words, when hemocon-centration is found to be present one can

usually assume that fluid loss from theextracellular space has been substantial,but the absence of an elevated hemoglobin

or hematocrit level does not exclude mas-sive translocation or sequestration of fluidin the peritoneal cavity.Plasma Electrolytes. The plasma elec-

trolyte values were determined on admis-sion in 57 of the 206 cases. The findings,when abnormal, most often reflected amoderate hyponatremia, at times a degreeof hyperchloremia, and not infrequently ameasure of metabolic acidosis as impliedby a reduction in the carbon dioxide com-bining power; rarely was a blood pHdetremined. In no instance of early perfora-tion was the plasma sodium level below130 mEq./L., however.Thus the measurement of plasma elec-

trolyte levels on admission was not particu-larly useful in the initial management ofthe patient with perforated peptic ulcer,since massive fluid losses into the peri-toneal cavity (Fig. 2) often result inbalanced fluid losses, the ionic compositionof the reduced extracellular fluid and itsplasma component remaining relatively un-

changed. Nevertheless, patients whoseperitonitis has existed for several days fre-quently do develop electrolyte imbalance,and frequent determination of plasmaelectrolyte values is often indicated.Serum Amylase Level Not Elevated.

It is widely believed that many patientswith perforated peptic ulcer exhibit a sig-nificant elevation of the serum amylaselevel.52 However, the findings in the pres-

ent series of cases decidedly do not supportthis clinical impression. The serum amylaselevel was determined on admission in 41 ofthe 206 cases. The level was substantiallyelevated in only one patient (500 units)and in this individual, a chronic alcoholicwith an ulcer history, strong collateral evi-dence of free ulcer perforation such as

free air in the peritoneal cavity was lack-ing. And though this patient was judgedclinically to have sustained a small local-ized perforation of his chronic ulcer offour years duration, it is quite possible thathis upper abdominal pain was due to



pancreatitis associated with alcoholism.'4Thus while extensive upper alimentaryleakage might occasionally produce an

elevation of the serum amylase level, as itusually will produce an elevation of theserum bilirubin level due to bile absorp-tion, a serum amylase level above 400 unitsshould suggest pancreatitis rather thanperforated peptic ulcer in the vast majorityof cases where the diagnosis is in doubt.

Diagnostic ErrorsMost surgeons of experience have oper-

ated for appendicitis or acute cholecystitisonly to find the cloudy fluid secondary toperforated peptic ulcer or pancreatitis.This may happen particularly when no

free air is found in the peritoneal cavityand when the physical findings are mostprominent in the right peritoneal gutter or

in the right lower quadrant of the ab-domen. However, from a careful analysisof our experience we are led to believethat errors in diagnosis associated withsignificant leakage due to perforated ulcerare uncommon-accurate diagnosis beingachieved in the vast majority of cases bythe history of ulcer with the dramaticand often sudden symptoms of perforation,characteristic "board-like" rigidity of theabdomen, and free air in the peritonealcavity in from about three-fifths to two-thirds of cases. Even so, small localizedbut walled-off perforations, often causingback pain, can present a very confusingclinical picture. In such instances Cassel,Ruffin and Bone 9 found the pancreas tohave been involved in 76 of their 100 cases

and the liver next most frequently. Perfora-tion was often heralded by a definitechange in the previous ulcer distress, andincrease in the severity of symptoms, andfrequently pain in the back. In our se-

ries of patients, diagnostic confusion was

most often due to the presence of pan-

creatitis. In one instance perforated pepticulcer was mistakenly diagnosed as partialsmall bowel obstruction and in an oc-

casional instance an unsuspected per-forated ulcer was disclosed at autopsy.

Types of Management in Present SeriesThe basic plan of management was that

of prompt operative intervention withsimple closure of the ulcer,43' usingsimple Lembert sutures and an omentaltab.2' However, both conservative manage-ment and primary subtotal gastric resec-tion 22, 23, 38, 40, 42 were also used in selectedcases. It has been shown that either con-

servative or operative management can

afford acceptable results if skillfully ap-plied.24 3 Operation was performed in176 of the 206 cases (85.4%) with 12deaths (6.3%o). There were 18 complica-tions (10.2%). Conservative managementwas employed in 30 cases (14%) with 13deaths (43.3%). Again, it should berealized that among those treated con-

servatively were patients considered too illfor surgery, many of whom were hope-lessly ill and who died. Conservativemanagement was also used in patients whowere obviously recovering from a perfora-tion 24 to 48 hours old, or when surgerywas declined, or when associated otherdisease rendered surgery unduly hazard-ous. Furthermore, in one or two instancesautopsy disclosed that death had beencaused by an undiagnosed perforatedpeptic ulcer.

Primary subtotal gastrectomy was per-

formed in eight patients with one fatalityfrom a pulmonary embolus. For the mostpart these patients were operated upon

within the past year or so, when there hasbeen renewed interest in the more fre-quent use of primary gastric resectionwhen indicated. Our experience and theextensive experience of others 12, 17, 32, 56, 65fully vindicates the feasibility of primarysubtotal gastric resection in properly se-

lected cases. In the patient who has acuteperforation of a gastric ulcer-or who has

a perforated duodenal ulcer and a history ofhemorrhage, previous perforation or a long



TABLE 2. Cultures in Operative andNonoperative Cases

NotCul-

TIypes Pos. Neg. tured47 141

*Streptococcus (nonhemolyticand/or anaerobic) 10

Staphylococcus (nonhemolyticand coag. negative) 3

Staphylococcus (coag. positive) 1"Yeast" 1Candida 1Saccharomyces 1

Unknown growth in paracolon 1

Totals 18 47 141

* One case was found associated with pneumococcus,one case with proteus, and one case with Neisseria.

history of ulcer symptoms on good medicalregimen-subtotal gastric resection is fullyjustified if the extent and duration ofperitoneal soiling plus other individualfactors do not preclude such a course ofaction. Certainly subtotal resection at thetime of perforation, when justified, wouldsubject the patient to no more total riskthan would the imposition of an additionalanesthesia-operation in the future.At operation antibiotics were not rou-

tinely introduced into the peritoneal cavity,nor were drains routinely placed. Mildcleansing of the most heavily contaminatedareas with sterile saline solution was car-ried out occasionally. Parenteral antibioticswere used in vitually all cases, since sub-diaphragmatic abscess is a most seriouspostoperative complication.

Bacterial Cultures from Peritoneal Cav-ity Taken at Operation. Cultures weretaken and the results recorded in 65 ofthe 206 Patients. Of these 65 cultures, 47were negative; 18 were positive, but oftenthe growth was scant and the organisms"nonpathogenic" (Table 2). Many of thepatients had received antibiotic therapy,and unquestionably some of the cultures

were processed in a less than optimalmanner. Nevertheless, a most salient find-ing was the relative absence of stronglypositive cultures when the ulcer had beenperforated for less than 24 hours. This isimportant to an understanding of the eti-ology of shock due to perforated ulcer inthe first few hours following perforation.The fact is, bacteremic shock due to theliberation of endotoxins is not an import-ant consideration in the hypotension metin patients with an acutely perforatedpeptic ulcer. Days, weeks or even monthslater the patient may of course develop a

subdiaphragmatic abscess, and at this timebacteremic shock may supervene. Never-theless, early shock is due largely to theloss of water, electrolytes and other plasmaconstituents into the peritoneal cavity.Such a state of fluid translocation usuallyresponds readily to prompt and vigorousfluid replacement.Time Interval Between Perforation and

Operation. The average length of time be-tween perforation and operation in thisseries was 17.03 hours, as recorded in 162patients. At the University Hospital theaverage interval was 24.7 hours (62 pa-tients) and at the Veterans AdministrationHospital it was 12.9 hours in 100 patients(Table 1).Clearly these figures reflect a delay in

bringing many patients to operation, andthis fact is borne out by a mortality rateof 43.3 per cent in 30 patients treatedconservatively. Inasmuch as prompt sur-

gical intervention has been the desidera-tum, it is apparent that many of thesepatients were so ill that no surgical pro-

cedure was attempted.There are a number of reasons why

delays occurred in this series where theUniversity Hospital and the Veterans Ad-ministration Hospital in Jackson serve

as referral centers for the more ruralareas. First, there is the inevitable delayentailed with processing in the home com-

munity. Then the patient must be ac-


Volume 153 PERFORATEDNumber 6

cepted for referral and transported longdistances by car or ambulance. And, finally,delays may occur once the patient hasreached the hospital. The University Hos-pital is a relatively new institution and itspatients often arrive from long distances,perhaps at night, and perhaps for the firsttime; delays inevitably occur. In contrast,the patient population of veterans at theVeterans Administration Hospital has longbeen familiar with that institution throughprevious visits, pension conferences andother contracts-for the hospital and re-gional office for veterans affairs are com-bined. Thus this group of patients, orientedsince military service to seek medical carepromptly, can be expected to contact theVA Hospital without delay, and this orien-tation is apparent in the relatively shorttime interval which elapsed there betweenperforation and operation as comparedwith the University Hospital experience.

Considerations such as these are im-portant when one seeks to compare thetreatment results in perforated peptic ulcerreported from one clinic with those fromanother.

Fluid in Peritoneal Cavity. One of themost striking findings in this series of pa-tients, and the one which first interestedus in a more careful analysis of the causeof fatal shock in perforated peptic ulcer,was the large volume of fluid found in theperitoneal cavity in many patients. Ofcourse, frequently only a small amount offluid was found, but usually a moderate tomarked amount of fluid was found in theabdomen at either operation or autopsywhen a number of hours had elapsed sincethe perforation (Table 3). For example,in one patient 5 liters of fluid were re-covered from the peritoneal cavity at au-topsy. In another fatal case there were"two to three gallons" of fluid in the ab-domen at the time of surgery. It is clearthat in a number of these patients theamount of fluid actually measured, in ad-dition to that which could not be meas-

) PEPTIC ULCER 919ured, represented a fluid loss more thansufficient to deplete the extracellular fluidand plasma volume to an extent to pro-duce shock. A massive volume of intra-peritoneal fluid was also found in somepatients who survived, but in general thegreatest fluid losses were present in pa-tients who died, found either at operationor autopsy.

Deaths in Present SeriesThere were 24 deaths in the present

series (Table 3). The mortality rate in theconservative series was 43.3 per cent (13of 30 so treated) and that in the operativegroup was 6.3 per cent (11 of the 176 sotreated), but these figures would be mis-leading without further comment. Asemphasized previously, the general policywas that of operative intervention exceptwhere the perforation appeared to be al-ready sealed with the patient rapidly im-proving, or when operation was declined,or when the patient was too ill from theperforated ulcer or other disease to tolerateany operative procedure. Thus some pa-tients were treated conservatively becausethey were too ill for operation. Converselywith some patients in whom for one reasonor another conservative management wasused initially, operation was resorted towhen their clinical condition deterioratedrapidly (Case 2). Actually, the perforatedulcer was readily closed under local anes-thesia upon occasion, and in one patientwith cirrhosis of the liver on steroidtherapy who was emerging from hepaticcoma the use of local anesthesia may havebeen life-saving. Perforation of gastriculcers carried a worse prognosis than per-foration of duodenal ulcers (Table 4).

In this series, as in most reported series,peritonitis was the major cause of death.Accordingly, it is of considerable interestto consider mechanisms by which peri-tonitis may produce shock which mayterminate fatally. Since the majority ofcultures taken at operation were negative,


TABLE 3. Cumtlative Data on Deaths

Sex Interval from Interval fromRace Perforation Perforation

Name Age to Operation to Death

l. P.S. F 13 hrs. 13 das.w49

L P.L. M 36 hrs. >24 hrs.C44

R.W. M 24 hrs. 1 wk.W68

L. J.J.P. M 24 hrs. 5 das.C48

i P.W. M 18 hrs. 7 das.W52

C.J. M - 4 das.W64

' V.A. M 31 hrs. >24 hrs.C53

G.C. M >48 hrs. >24 hrs.W46

.ES. M 18 hrs. 8 das.C38

G.S. M 3 das. 14 das.C65

. O.V. M >36 hrs. 5-6 hrs.

12. W.W.

13. H.C.

14. B.S.

15. J.D.R.

16. S.W.

W

70

M

W

46

FW

81

M

W

60

M

C

40

M

C

61

Probable cause of Death

Thrombophlebitiswith pulmonaryembolus

Shock with cardiacarrest; Peritonitis

Myocardial infarction

Reperforation;hemorrhage; shock

Peritonitis; partialwound separation

Peritonitis and multipleabscesses

Peritonitis; shock,cardiac arrest

Hemorrhage assoc. withulcer

Peritonitis

cc

conser.

2 das.

5 das.

15-18 hrs.

Fluid inAbdomen

(Vol.) Culture

Moderate Neg.

2,000- None3,000 cc.

2,000 cc. None

Large Neg.

Moderate None

1,500 cc. None

2,000 cc. Coag. pos.Staph.

Moderate None

Large None

Large Candida

3,000 cc. Neg.

5,000 cc. None

2,000 cc. at Noneautopsy

None

None

3,000 cc. at B. coli &autopsy Strep. at

autopsy


3

4

5

6

7

8,

9.

10.

IL

Volume 153Number 6

PERFORATED PEPTIC ULCER 921TABLE 3.- (Continued)

Sex Interval from Interval from Fluid inRace Perforation Perforation Abdomen

Name Age to Operation to Death P'robable cause of Death (Vol.) Culture

17. M.G. M Large NoneC39

18. W.B. M 10 das. Marked NoneC59

19. W.P. M Peritonitis, shock NoneW72

20. J.M. M 2 das. Peritonitis, severe NoneWV heart disease73

21. B. L. M Peritonitis NoneC52

22. J.H. M 30 hrs. 4,000 cc. at NoneC autopsy24

23. H.S. M 1 day Moderate NoneW None59

24. C.M. M Peritonitis; chronic 2,000 cc. at NoneC renal failure, autopsy58 endocarditis

it is reasonable to conclude that septicemiawith endotoxin shock was not a prominentfeature in patients who died within 48 to72 hours following perforation of the ulcer.Rather, the primary effect of the essentiallysterile but highly irritative effects of theacid gastric juice is to produce a massiveinternal chemical burn involving the peri-toneum, whose surface area has been con-

sidered equal to that of the skin. Thisresults in a depletion of the plasma volume,interstitial fluid volume and doubtless theintracellular volume with resulting hypo-volemic shock.

Certain pertinent data for the 24 fatalcases are presented in Table 3, includingsite of ulcer, age, sex, volume of fluids inperitoneal cavity and time interval fromperforation to operation when operativetreatment was employed. Aside from the

time lag prior to operation, longer intervalspermitting more extensive soiling of theperitoneum, most authors have concludedthat perforation of the more chronic ulcerscarried a worse prognosis than perforationof acute ulcers. Too, older patients exhibit ahigher mortality (Table 5) rate because oftheir reduced capacity to resist almost anytype of metabolic onslaught as compared

TABLE 4. Mortality Associated with Site of Ulcer

No. No. eTypes Cases Deaths %

Marginal 5 3 60.0Gastric 26 13 50.0Duodenal 172 6 3.5Unknown (not recorded) 3 2

Totals 206 24 11.1

HARDY, WALKER AND CONN Annals of SurgeryJune 1961

TABLE 5. MIortality Associated wit/i Age

Operative Conservative lTotal

Decade Cases Deaths ' Cases Deaths % Cases Deaths %

0-9 1 0 0 0 1 010-19 3 0 0 0 3 020-29 38 0 5 1 20.0 43 1 2.330-39 31 1 3.2 1 1 100.0 32 2 6.340-49 42 4 9.5 6 2 33.3 48 6 12.550-59 31 2 6.5 6 5 83.3 37 7 18.960-69 23 3 13.1 9 2 22.2 32 5 15.070-79 4 1 25.0 2 1 50.0 6 2 33.380-89 2 0 - 1 1 100.0 3 1 33.3

Unknown 1 0 0 0 - 1 0

Totals 176 11 6.3 30 13 43.3 206 24 11.1

with young adults. Serious hemorrhage,secondary to or associated with the per-forated ulcer, was a major contributingcause of death in three patients.

Previous Perforations and Other Non-fatal Complications of Ulcer

Previous perforation "' had been re-

corded in 16 patients (7.5%). Althoughulcers which perforate are sometimesthought unlikely to bleed, alimentaryhemorrhage had been recorded in an ad-ditional 21 (10.2%), and this problem was

emphasized by Ladin.31 Transient pyloricobstruction occurred in two (1 %). Thus18.3 per cent of the 206 patients studiedhad previously had the significant ulcercomplications of perforation, hemorrhageor transient pyloric obstruction. It is inprecisely this group, plus certain othercases with a long ulcer history, that we

would propose primary subtotal gastricresection at the time of operation forperforation.

Follow Up Studies in Our SeriesDue to the relatively short time interval

that has elapsed since the majority of our

patients were treated for the perforatedulcer, detailed late follow up studies were

not considered worthwhile or meaningful.

Nevertheless, the patients have been fol-lowed as a routine and the results to dateparallel the remarkably consistent findingsreported in the literature for late resultsfollowing perforated peptic ulcer. In brief,it has been found that approximately one-

third of such patients will have no furtherulcer symptoms; in this fortunate groupare apt to be most of the patients withacute ulcers where there was a brief or

absent history of ulcer symptomatologyprior to perforation. A second third willhave recurrent ulcer symptoms, usuallywithin six months, but careful medicalmanagement suffices and operation isavoided. A third group will eventuallyrequire definitive surgery for recurrentperforation, hemorrhage, obstruction or

intractability. Of course, most perforatedgastric ulcers should be managed by gas-

tric resection, performed either at the timeof perforation or on an elective date. Pa-tients with a history of chronic ulcer,women, and young men who perforate are

apt to have a relatively poor prognosis forpermanent absence of symptoms.

Three Cases of Special Interest

Some of the problems met in decidingupon operative vs. nonoperative treat-ment, or upon simple closure vs. subtotal

922


gastric resection, are illustrated by the fol-lowing case reports.

Case 1. Failure of Conservative Treatmentwith Death. W. W., a 46-year-old white alcoholicand morphine addict who had recently been ina mental hospital, was admitted to the UniversityHospital on 6/19/56 with a febrile illness. Themost conspicuous physical finding was that of amassive sloughing pseudomembranous lesion inthe posterior pharynx which was repeatedly re-ported on biopsy to consist of acute and chronicinflammation and granulation tissue. Diphtheriawas considered as a possible diagnosis and he wastreated for this, but massive antibiotic therapyfailed to lyse his fever. On 6/25/56 his feverrose to 41.1° C. and he had severe upper ab-dominal pain. The WBC count, previously 15,000,was now 17,400, and there was free air underthe diaphragm. A perforated ulcer was consideredvirtually certain, but because of addiction with-drawal problems and his poor general condition-in addition to the fact that most observers be-lieved his extensive necrotic pharyngeal lesion torepresent as yet undiagnosed tumor-conservativemanagement was elected. The results of con-tinuous nasogastric tube suction, further anti-biotics therapy, and parenteral fluid replacementwere most gratifying: his severe symptoms wererelieved within 24 hours, and his general con-

dition improved. By 6/29/56 the abdomen was

soft, bowel sounds had returned to normal andhe had been passing gas for 24 hours. He hadbecome mildly icteric. Because of the pharyngeallesion it was decided to remove the nasogastrictube. Water was given by mouth uneventfully,but when later in the day a small glass of milkwas given he experienced sharp epigastic pain.The nasogastric tube was re-introduced but there-after his condition steadily declined, and he

died on 7/5/56, ten days following the initialperforation. By this time he was quite jaundiced,and at paracentesis 2,500 ml. of cloudy bile-stained fluid had been obtained.

At autopsy five liters of sanguinous bile-con-taining fluid was aspirated from the peritonealcavity. Two perforated ulcers were found, one

in the stomach and one in the duodenum. Therewas complete absence of suirrounding peritonealreaction, and no tendency toward healing was

present. No more specific classification of thepharyngeal lesion could be achieved.

Comment. This case is representative ofothers we have encountered where theomentum and other surrounding tissues

were not attracted to seal the perforation.In such patients, where nasogastric suc-tion does not result in sealing of the per-foration, even the most ardent advocatesof conservative management recommendsurgical closure. Unfortunately it is oftennot possible to identify this type of pa-tient until the clinical situation has de-teriorated markedly. The case above wastreated conservatively because of his verypoor general condition initially.

Case 2. Failure of Conservative Treatmentwith Subsequent Successful Operative Closure.G. M., a 64-year-old white man, was admittedto the VA Hospital at 7:00 p.m. on 5/17/60. Hewas uncooperative, restless and dehydrated. Theinadequate history obtained from patient andthe police who brought him indicated that hispresent illness had begun 48 hours prior to admis-sion, and had consisted of diffuse, severe ab-dominal pain. He was cold and clammy but theblood pressure was 110/70. The abdomen wasrigid and x-ray revealed a large amount of freeair beneath the diaphragm. The hemoglobin levelwas 16.5 Gm.% and the hematocrit 50%; serumamylase was 115 units, BUN 33, Na 149, K 4.6,Cl 110 and "C02" 21.6 mEq./L.

The diagnosis of perforated peptic ulcer wasconsidered certain, and the operating room per-sonnel were alerted. However, the patient re-fused operation, and conservative managementwith nasogastric suction was instituted. By 10:45p.m. the blood pressure had declined to 92systolic but the administration of intravenousfluids improved matters, though when the dripinfiltrated at 12:10 a.m. (5/18/60) the bloodpressure fell to 60/40. The saphenous vein was

cannulated and rapid infusion of fluid raised thesystolic blood pressure to 120. Up to this pointthe patient had received 2,000 ml. of isotonicsaline solution and 1,000 ml. of 10% dextrose inwater. At this time 50 mg. of Neosynephrine wasplaced in 1,000 ml. of 10% dextrose in water,and connected into the drip of a new liter ofisotonic saline-the pressor amine to be usedonly if the saline drip did not maintain the bloodpressure above 100 mm. Hg. Nevertheless,throughout the early morning hours Neosynephrinewas required. At 6:05 a.m. (5/18/60) the ab-domen was noted to be distended, and a pint ofblood was "pumped in." Soon thereafter the patientfinally consented to operation and this was per-formed at 10:25 a.m., 16.5 hours after admission



FIc. 3. This nine-year-old boy first had avagotomy-gastroenterostomy for a large posteriorlysituated duodenal ulcer which had bled re-peatedly. Unfortunately the jejunum perforated attwo sites just distal to the anastomosis 11 days fol-lowing the first operation. These sites were closedbut 11 days later a gastric ulcer perforated justat the stoma. Emergency gastric resection wasperformed in the face of the extensive peritonitisand adhesions. The patient is shown at his lowestebb above when he had a wound infection. Herecovered, however, and was discharged regain-ing weight rapidly.

and almost 60 hours after perforation. A 1.5-cm.open ulcer on the anterior surface of the duo-denum was closed, after a large amount of cloudyfluid ("several liters") had been aspirated fromthe peritoneal cavity.

Postoperative complications included a "neo-synephrine slough," pneumonitis and wound in-fection. It was found necessary to continue neo-synephrine for 48 hours postoperatively tomaintain the blood pressure above 90 systolic.Thereafter the pressor amine support was stopped,and he eventually was discharged on an ulcer diet.

Comment. This case represented an in-stance in which the general condition ofthe patient deteriorated while he refusedoperation. It must be admitted, however,that fluid replacement was perhaps in-adequate during the first 12 hours follow-ing admission, for although the hemoglobinand hematocrit levels were elevated on ad-mission these values were subnormal lateron. Even after almost three days there waslittle progress toward sealing off of theduodenal perforation.

Case 3. Emergency Gastric Resection forPerforated Marginal Ulcer in Child. F. B., a9-year-old Negro boy (Fig. 3), was well untilMlarch, 1958, when he began to complain of

severe epigastric pain and later had tarry stools.

Admitted to the University Hospital on 4/16/59,roentgen studies disclosed changes in the stomachand duodenum which were considered to be com-patible with lymphosarcoma.

At the first operation, on 4/27/59, a large andactive posterior duodenal ulcer was found.Vagotomy and gastroenterostomy were performed,but a remarkable and later pertinent observationwas that while the gastroenterostomy was beingperformed large amounts of gastric secretioncontinued to flow from the stomach. Post-operatively the child did fairly well, but 1,560ml. of a highly acid secretion was aspiratedthrough the nasogastric tube within the first 24hours. He developed a rapid pulse and mild hy-potension, and parenteral fluid therapy includingmore saline solution (3%) had to be administeredenergetically. An analysis of the fluid obtainedby gastric suction revealed the following: Na 30mEq./L., K 6.8 mEq./L., and chloride 139mEq./L.

On 5/14/59 severe abdominal pain developed,and an x-ray revealed free air under the dia-phragm. At the second operation performed thatday two large perforations in the jejunum justdistal to the gastroenterostomy were closed, alongwith lysis of adhesions and reduction of an upperjejunal intussusception that may have beenproducing partial alimentary obstruction. Post-operatively the ulcer diet regimen was intensi-fied as soon as possible, but his condition wasgenerally poor and he had lost much weight(Fig. 3).

On 5/25/59 the patient suddenly went intoshock associated with severe abdominal pain. Athird operation disclosed a large amount of asciticfluid and fluid within the bowel, associated with alarge gastric perforation adjacent to the gastrojeju-nostomy stoma. At this point it was clear that theulcer diathesis had to be controlled immediately,for the patient would not survive another episodeof perforation. Accordingly, under the most dif-ficult of circumstances due to the peritonitis,distended bowel and exceedingly dense adhesionsa radical Billroth II gastric resection was per-formed. No tumor of the pancreas was soughtunder the circumstances. The postoperative coursewas stormy and rather prolonged, but the pa-tient was discharged on 7/6/59 convalescingrapidly, and his course thereafter has beensatisfactory.Comment. This case reflects the inade-

quacy of vagotomy-gastroenterostomy inthe young person with a malignant ulcerdiathesis. The jejunum perforated 11 daysfollowing the gastroenterostomy.



Discussion

Mechanism of Shock in Peritonitis Dueto Perforated Peptic Ulcer. Most instancesof shock can be explained by either inade-quate blood volume, failure of the heart,inadequate peripheral resistance, or com-

binations of two or more of these.From a therapeutic form of view, it is

important to consider which of these are

important in precipitating the hypotensivestate. which may prove fatal in patientswith a perforated ulcer unless therapeuticmeasures are effective. Since it has beenseen that in most cases the material as-

pirated from the peritoneal cavity atoperation within six to 12 hours followingperforation is essentially sterile, bacterialinvasion with its often disastrous effectsupon peripheral resistance and, to a muchlesser extent the heart, are absent. Thus ifthere is no reason to incriminate cardiac ac-

tion and peripheral resistance, at least earlyin the course of the condition, one would bereasonable in concluding that the primarycause of shock in early perforated ulcer ishypovolemia due to the loss of fluid andplasma into the peritoneal cavity. This isof course a fortunate circumstance, for itis the inadequacy which is most readilyamenable to effective therapy with intra-venous fluid administration.

Clinical Evidence for Massive FluidTranslocation Leading to "Dehydration"from Present Series of Cases. It was foundthat in virtually all the seriously-ill pa-

tients who were operated upon and inthose patients who died there were con-

siderable amounts of fluid in the peri-toneal cavity, being measured at a volumeof many liters. When it is realized thatan absolute loss of from four to five litersof fluid by any route over a period of 12hours can produce serious shock in many

patients, it is readily plausible that themeasured losses of fluid in many of thesepatients were adequate to account for mostof the hypotension recorded. Many pa-

INTRAPERITONEAL INJECTION OFGASTRIC JUIJCE (2cc/kg.)

70-60<50-4030-2010

Plasmavolume

Homotocrit

0 1211C0N

TFR I2HR.0

-700-600-500-400-300-200- 100_no

FIG. 4. Fluid translocation following experi-mental peritonitis in dogs: typical experiment.The effects of gastric juice in producing hemocon-centration with depletion of plasma volume arewell illustrated. At autopsy such dogs exhibitedlarge amounts of fluid in the peritoneal cavity.

tients with perforated peptic ulcer andhemorrhagic pancreatitis are grossly under-treated with fluid replacement therapy.This continues to be so at times in ourown hospitals despite an active interestin the problem and an awareness of howgreat these fluid losses into the peritonealcavity and retroperitoneal space can be.It is also to be remembered that the pa-tient with a perforated ulcer may have re-ceived no fluid by mouth or parenterallythrough many of the hours prior to hiscoming to the hospital, while continuing tolose fluid not only into the abdomen butalso as urine and as insensible fluid lossand at times by vomiting. The promptresponse of the blood pressure to thevigorous replacement of the electrolyte andcolloid containing fluids is further evi-dence of the fact that such fluids are

needed and frequently in large volumes.Experimental Data. The magnitude of

fluid loss following the instillation ofsterile gastric juice into the peritonealcavity of recipient animals has beenstudied in the laboratory in dogs.6' Thechanges in the plasma volume and thehematocrit level in a typical dog followingthe injection of 2 cc. of gastric juice perkilogram are shown in Figure 4. It may beseen that there was a marked increase inthe hematocrit level and a sharp decrease



in the plasma volume in these dogs. Similarresults have been obtained in approxi-mately 15 dogs who received gastric juiceand another 15 dogs who received bile. Itis clear that the chemically irritative effectsof both bile and gastric juice can resultin a marked outpouring of fluid into theperitoneal cavity, and these changes involumetric measurements obtained in theliving animal were amply confirmed at sub-sequent autopsy.Thus it may be safely concluded that

fluid loss into the peritoneal cavity is a

major cause of shock following the per-

foration of peptic ulcers. This fluid lostinto the peritoneal cavity and retroperi-toneal space is not readily available forthe maintenance of plasma and extra-cellular fluid volume and it must be re-

placed parenterally. In other words thepatient with peritonitis secondary to pepticulcer will actually gain weight if he isadequately treated with fluid replacementto prevent shock.

Management of Patients with SuspectedPerforated Peptic Ulcer: Further Com-ment

Diagnosis. The problem of reaching a

correct diagnosis in the patient with a

perforated peptic ulcer has usually notbeen a difficult one in our experience. Thehistory of chronic peptic ulceration in themajority of patients, plus the finding offree air in the peritoneal cavity on roentgenstudy in the majority of patients, plus thetypical physical findings of intense ab-dominal rigidity all combine to offer a cor-

rect diagnosis in most instances. Radio-paque material may be introduced into thestomach to demonstrate the perforation,but we have not often used this maneuver.

It is again pointed out that the amylaselevel was not significantly elevated in any

patient with demonstrated perforated pep-

tic ulcer in whom the amylase level was

determined. Accordingly, the perforated

peptic ulcer should not be confused withpancreatitis very often.

Fluid Therapy. The main requirement isfor a volumetric replacement of a balancedelectrolyte solution. It was found fromstudies of the plasma electrolytes on ad-mission in the present series that it wasuncommon for a marked derangement ofplasma electrolyte values to develop early.Therefore, if preliminary measurementsindicate that no marked hyponatremia or

acidosis has developed, the need is for theprompt replacement of a sufficient volumeof electrolyte-containing fluid to dissipatethe usual clinical and laboratory signs ofdehydration. Thus the skin turgor shouldimprove, the urine volume should increase,the blood pressure should rise if previouslylow and become stabilized, the hematocritlevel should decline, and the general con-

dition and appearance of the patientshould improve.4 If it is borne in mind thatthe patient admitted in shock may havelost from three to five liters of fluid intothe peritoneal cavity, an adequate re-

placement volume will usually be given torestore reasonably adequate plasma andextracellular fluid volumes. Furthermore,many patients have lost considerableamounts of plasma protein in the form ofplasma into the peritoneal cavity, and a

colloid solution such as dextran and/orblood will be found useful on many oc-

casions. Plasma may be used if a prepara-

tion is available in which the hazard oftransmitting serum hepatitis virus has beeneliminated.

Nonoperative Versus OperativeTreatment

In reviewing published reports dealingwith operative versus nonoperative man-

agement,24' 37' 63 one is more than anythingelse impressed with the fact that mostauthors are really in basic agreement re-

garding the form of treatment to be usedin given circumstances. Those who ad-


Volume 153Number 6

vocate the policy of conservament 3, 50, 55, 57, 58 are usuall)point out that certain patienwell under conservativeWhen this is found to be tiexceptionally careful clinicalfrequent intervals, the advo4servative management recomi

surgical intervention to closethe other hand, those who adclosure,16 vagotomy-pyloroplamary gastric resection 1, 2, 5, 8, 1policy of management in th4are equally careful to point (patients arrive in the hospitaproving and in these patientsthat no operation is requiimore, even the strongest advmary gastric resection or op

vention of one type or anot]that some patients are far tctype of surgery and that thes4managed conservatively.

In substance, the concensu

be that which we also ha)namely, that one or the o

management is usually rath(dicated in the given patient.management is employed if Ialready improving, where thedicates that his perforated ulcoff, or where he is too ill t(type of operative interventhere is no particular reason rupon the patient, the majorit'and perhaps internists woulioperative intervention is indthe abdomen has been open

decide whether simply to cl4or to carry out gastric resectjudgment of the operating su

tric resection is feasible. Wewith those who believe ro

resection following an isolateof a peptic ulcer is unwarrantresult in the complicationsfactory physiologic circumst

PERFORATED PEPTIC ULCER 927

ttive manage- may attend gastric resection in many pa-y careful to tients in whom simple closure of the ulcerts do not do with postoperative medical managementmanagement. would prove quite satisfactory. However,ie case using in those patients who have previously hadevaluation at a perforation of their ulcer or bleeding, orcates of con- in whom there exists some degree of pyloricmend prompt or duodenal stenosis, we do not hesitate tothe ulcer. On do primary gastric resection and havevocate simple found this a very satisfactory operation,sty45 or pri- under appropriate circumstances. When a10 as the basic gastric ulcer has perforated, we would beeir institution particularly inclined to perform primary)ut that some gastric resection to avoid having to comeL1 already im- back to resect a gastric ulcer which wouldit is obvious not heal. If conditions did not warrant

red. Further- primary gastric resection, we would simplyocates of pri- biopsy the gastric ulcer and then close it inerative inter- a routine manner, returning later shouldher point out the biopsy indicate a malignant tumor.)o ill for any Lastly, one must acknowledge the dif-e had best be ferent levels of training of surgeons who

may be called upon to close perforatedis appears to peptic ulcers. A great many of these opera-ve embraced, tions are done in small community hos-lther type of pitals, and in university hospitals by theer clearly in- more junior residents. It would seem to usConservative that more patients would be better treatedthe patient is over the long run if a reasonably conserva-evidence in- tive policy is taught regarding the indica-

qer has sealed tions for primary gastric resection follow-o permit any ing acute perforation of an ulcer. It cannotition. Where be ignored that the more senior and experi-iot to operate enced the surgeon, the better is he abley of surgeons to reach a mature judgment regarding thed agree that probabilities of success which will attendlicated. Once the management of a given type of path-ed, one must ology in a patient whose condition may orose the ulcer may not be optimal.ion, if in theirgeon a gas- Summary and Conclusionswould agree 1. A series of 206 consecutive cases of

iutine gastric perforated peptic ulcer have been ana-d perforation lyzed. There were 24 deaths (11.17%). Theed and would age sex, race, season, site of ulceration,and unsatis- clinical findings, presence or absence of:ances which free air, certain laboratory data and type

8HARDY, WALKER AND CONN Annals of Surgery928~~~~~~HAD,June 1961

of treatment were tabulated for each pa-tient and these findings summarized.

2. When the hematocrit and hemoglobinlevels were elevated, the patient usuallyhad lost a considerable volume of fluidinto the peritoneal cavity. If the "dehy-dration" so produced had resulted in shock,the prognosis was poor regardless ofwhether conservative or operative manage-ment was employed.

3. The serum amylase level was deter-mined in 41 of the 206 cases. In no instanceof proved perforated ulcer was the levelelevated substantially.

4. Bacterial cultures of fluid taken fromthe peritoneal cavity at operation wereperformed in 65 of the 206 cases, 47 beingnegative and 18 positive. It was consideredunlikely that shock in the first 12 to 24hours following perforation was due toperitonitis with septicemia.

5. There was a positive correlation be-tween the volume of fluid found in theperitoneal cavity at operation, the inci-dence and severity of shock, and the mor-tality rate. Furthermore, the larger theperforation and-especially-the greater thetime lapse between perforation and opera-tion, the greater was the volume of fluidlost into the peritoneal cavity.

6. Data concerning body fluid transloca-tions in experimental peritonitis in dogshave been cited.

7. The question of conservative versusoperative management of perforated ulcerhas been carefully examined. It is apparentthat most authors are actually in sub-stantial philosophic agreement, regardlessof whether they advocate a basic policyof conservatism with operation in selectedcases or a basic policy of operative inter-vention with conservatism employed inselected cases. The latter policy is the onewhich we and the majority of authorsprefer. Clearly, primary gastric resectionfor perforated peptic ulcer is a soundoperation with an acceptable mortality ratewhen the indications for its use are valid.

Such indications would usually consist ofa history of previous perforation and/orbleeding, pyloric obstruction, certain gas-tric ulcers, or a long history of ulcer symp-toms despite careful medical management.When the indications are clear and neithersevere peritonitis nor other contraindica-tions such as serious associated diseaseexist, primary gastric resection at the timeof perforation probably entails less totalrisk to the patient than would an addi-tional anesthesia-operation for gastric re-section at a later date.

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DISCUSSIONDR. J. WILLIAM HINTON: I merely want to

report two cases to support what Dr. Knight hasstated.

My first experience with this problem occurredin 1947. Since then, I have personally done 11cases, the last one a week ago today. We shouldnot have made the diagnosis we did on thefirst patient. We thought he had a pyloric ma-lignancy, but he had a marked hypertrophy ofhis pyloric muscle without an ulcer. He had threex-rays series going back for some 15 months withlittle change in the x-ray picture.The last case, and he brings in some of the

points as to etiology, had symptoms of a verylong duration. The youngest patient we operated

upon was 25. Practically all of them were in theirfifties or sixties. The last one, done a week ago,was 82. Many of my patients were in the fiftiesand had been treated for ulcers by a well-knowngastro-enterologist, or in a clinic.

Our impression of our 11 patients was thatthey had an ulcer but at operation six had noulcer and five had an associated duodenal ulcer.

I will refer to the last patient done a weekago, an 82-year-old man whose daughter is awell trained physician and his son-in-law agastro-enterologist of national reputation. Hisdaughter, who is in her late fifties, said that asfar back as she can remember her father hadsymptoms which were thought to be due to anulcer. A definite ulcer was known for 20 years.

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Perforated Peptic Ulcer: *