GASTROTOMY. 93 



act as a double protection against the exit of fluid from the 

 stomach. 



With a gastric ulcer the chief trouble lies in the difficulty 

 of making an accurate diagnosis ; the operative procedure 

 consists in making an elliptical incision so as to remove all 

 the necrosed edge and drawing the sound portions of the 

 wall together as already described. The abdominal cavity 

 must be examined for any material which may have escaped, 

 this being removed with antiseptic swabs. 



Foreign bodies in the lower part of the oesophagus usually 

 consist of large pieces of bone, gristle, etc., which have been 

 greedily swallowed, and which cannot enter the cardiac 

 orifice of the stomach and cannot be pushed down with the 

 probang or brought up by an emetic. In one case we were 

 successful in removing a very large piece of gristle by means 

 of a strong slender pair of dressing forceps passed up the 

 oesophagus through the stomach wall when all attempts to 

 move it with the probang had failed.^ The method of opening 

 the stomach and closing the wound is as already described. 



The after-treatment consists in keeping the patient as quiet 

 as possible, allowing nothing but a little water, or milk and 

 water, containing three or four grains of boric acid, during the 

 first forty-eight hours, nutrient enemata of beef tea or mutton 

 broth being given per rectum every six or eight hours. On 

 the third day a little milk or beef extract may be allowed in 

 addition, apd at the end of the fourth or fifth day some finely 

 minced meat or fish. Care must be taken during the first 

 fortnight that the stomach never becomes distended, on 

 account of the risk of tearing out the sutures. 



As regards sequelje, the prognosis must always be grave, as 

 the operation is a major one, but if the diagnosis is certain 

 and the patient not too debilitated it ought certainly to be 

 adopted as giving an otherwise doomed patient another 

 chance. 



'Journal of Comparative Pathology and Therapeutics,' Vol., XII., p. 262. 



