Acute Perforation and Hæmatemesis in Duodenal Ulcer

Acute perforation is a grave complication of duodenal ulcer and its surgical treatment is one of the greatest urgency. The following case has so many unusual features that it seems worthy of record :? Mrs. K. B., aged 16, was admitted under my care with an ' acute abdomen \ History of present illness.?Just over two days ago, the patient complained of a sudden attack of severe pain over the pit of the stomach. During the next few hours, there was some relief of pain, but gradually it became generalized and most of it was felt over the lower abdomen. Collapse was complete by the time the patient was brought down to Calcutta for treatment. History of past illness.?About eight years ago, she had an attack of cholera. There was no previous history of indigestion, but the patient suffered from habitual constipation. Condition on admission.?Temperature?99?F.; pulse ?150, and respiration?30 per minute. The radial pulse was just palpable. On examination.?Tongue?dry and coated; cheeks? sunken ; abdomen?marked distension. No local tenderness or rigidity was present. Liver dullness was obliterated, but shifting dullness was present. On vaginal examination, fluid was detected in the pouch of Douglas and there was a scanty blood discharge from the vagina. Menstrual history.?Last period 10 days ago; no period was missed. The patient was married one year ago, but there was no issue. Her menstrual periods were rather irregular, but the discharges were normal. Operation.?(Anaesthesia: open ether and chloroform.) One ounce of saline with glucose was administered intravenously during the operation. A right paramedian incision was made opposite the umbilicus. The peritoneal cavity was full of cloudy sero-purulent fluid but without any odour. No pelvic abnormality was discovered, and the appendix was found normal. On enlarging the incision upwards, wellmarked fat necrosis of the omentum was instantly noticed. A perforation was discovered in the first part of the duodenum, admitting the tip of the little finger. It was closed by means of Lembert sutures and over it an omental graft was apposed. The right paracolic gutter and the pelvic cavity were full of fluid; this was carefully mopped out. Rutherford Morison's pouch