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190 POST-GRADUATE MEDICAL JOURNAL June, i945MEDICAL ASPECTS OF CHRONIC

PEPTIC ULCERBy R. SLEIGH JOHNSON, M.D., M.R.C.P.

(Physician, London Chest Hospital, Southend GeneralHospital, and Royal Waterloo Hospital)

CHAPTER IGeneral ConsiderationsPathology and PathogenesisSymptoms anid Physical SignsDiagnosis and Special Investigations

CHAPTER IITreatment

Chapter I

Chronic Peptic UlcerGeneral ConsiderationsFew diseases, whether from their commonness

or their difficulties in treatment, can claim a moreconstant place in medical attention than pepticulcer, a comment applying with equal force tophysician and to surgeon, to hospital and togeneral practice. Figures of emergency admissionsshow few conditions higher on the medical sidethan acute gastric haemorrhage, while surgicalcomplications demand a like proportion. In suchan ever-present disease, it is a disturbing thoughtthat despite a welter of clinical study and experi-mental work, the aetiology should defeat exactinvestigation and remain largely obscure, andperhaps no less disturbing that so little uniformityof agreement should have been reached on policiesof treatment, particularly in stages where medicaland surgical aspects overlap. In consequencethe results of treatment of peptic ulcer cannot yetbe claimed to be satisfactory, whether ensuingeither from medical zeal or -from surgical enthu-siasm, and an attempt to review and co-ordinatecurrent opinion may not therefore be out of place.

AetiologyIn distribution peptic ulcer is world-wide

without respect of race, occupation, or class, andoccurs within a wide range of ages. From autopsyfindings it is estimated that at some period in hislife one person in ten is so affected.The age group most commonly involved lies

between 20 and 40 years, but acute ulcers revealedby haemorrhage are met with in infancy or earlychildhood.A familial factor is often easily traced.It is probable that many more gastric ulcers

than duodenal are relatively symptomless, and

autopsy findings show a higher incidence of healedulcers in the stomach, but from the clinical stand-point duodenal ulcer is much the commonerdisease, in proportions of at least three to one,and correspondingly more resistant to treatment.

Regarding the sex incidence, duodenal ulceris between three and four times commoner inmales, whereas gastric ulcer is relatively morefrequent in females. From two aspects, physiqueand mental make-up, an "ulcer type" may bereadily recognised in the spare lean build andanxious over-active manner, the more so whenthe site is duodenal. It occasions no surprise thatthe incidence of peptic ulcer appears to haverisen considerably during the past thirty years, inresponse to strain and stress of living and theincreased pace of life; part of this apparent riseis no doubt the result of improved facilities fordiagnosis, but after allowance for this there iscertainly a real increase, particularly in thefrequency of duodenal ulcer. The greater incidenceof this lesion in men is reflected anatomically inthe hypertonic type of stomach known to pre-dominate in the male, with its hypersecretion andrapid rate of emptying, whereas simple gastriculcer is less constantly linked with hyperacidityand excess of tone, and is therefore by no meansrare in the asthenic anaemic type of woman withlow-lying or hypotonic stomach. This distinctionof type is further emphasised in the differentpsychological and emotional background of the-two groups.

Occupational factors in aetiology are inconstant.Whereas a type of employment demanding physi-cal rush and mental strain, with hasty and irregularmeals, no doubt contributes to break-down inthose predisposed, peptic ulcer is common enoughamong all classes of occupation and society.Although ulcer symptoms, including perforation,not infrequently follow nervous stress, anxietyor emotional upset, these are probably contri-butory rather than causative factors. Onset isoften insidious and difficult to date, and accen-tuation by such factors may readily be mistakenfor start of the disease.The relation of tobacco and alcohol to peptic

ulcer is similar; while there is no proof that smoking,even in excess, is a direct causative factor, it isgenerally agreed that the swallowing of nicotineexcites free secretion of gastric juice, which canonly be undesirable and harmful to an emptystomach.Teeth which are carious or infected, or are

deficient in number, impair the preparation offood for gastric digestion and may through sepsisset up a contributory gastritis.Acute infections of any kind may act in a similar

way to nervous worry, fatigue, or rushed or un-

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June, I945 GASTRIC AND DUODENAL ULCER 191

suitable meals, in precipitatiag the acute exacer-bations so characteristic of the disease.

Pathology and PathogenesisPeptic ulcer is usually a single lesion but separate

ulcers are not uncommon in stomach and duode-num, or more than one ulcer may be present inthe stomach. Similarly active and healed lesionsmay co-exist, or a single ulcer may show extensionand healing in different directions at the same-time, although one of these processes is usuallypredominant. The region liable to peptic ulcerationcorresponds accurately with the extent of exposureto the acid gastric secretion. The great majorityof ulcers are included within the lesser curvatureof the stomach, particularly its central third, orwithin the first two inches of the duodenum, theduodenal cap or bulb; the pylorus is frequentlyinvolved and its function affected by a pre- orpost-pyloric ulcer. For the same reason a charac-teristic lesion is common in the atea of jejunumdirectly opposed to a patent gastro-enterostomy,while rarely a typical peptic ulcer may developin ectopic gastric mucosa at the lower end of theoesophagus or in a Meckel's diverticulum. Thegreater curvature of the stomach is a rare sitefor benign ulceration, and this situation aloneshould arouse suspicion of malignancy.

Opportunities for direct study of peptic ulcera-tion in its varying stages were formerly confinedto operative or post-mottem inspection. Withinthe last few years, however, our knowledge ofits life history and pathology has been greatlyextended and clarified by the direct inspection inthe living subject afforded by gastroscopy.An acute stage necessarily precedes the develop-

ment of every chronic peptic ulcer, and is revealedas a sharply circumscribed loss of tissue beginningin the mucosa. This forms a shallow erosion, oftensmall in size, with clean cut punched-out edgesand smooth floor, sometimes covered by white oryellowish slough. Signs of inflammation of thesurrounding mucosa may or may not be present,but at this stage there is no protective thickeningof the peritoneal surface. Such an ulcer, if destruc-tion is progressive, may rapidly penetrate alllayers of the gut, unresisted by any barrier offibrosis and terminate in perforation.

Healing, on the contrary, frequently takesplace at this early stage by growth of a thin layerof mucosal cells across the defect, leaving eithera normal looking surface or little more than astellate puckering of the mucosa. Should thehealing process fail, the ulcer extends both insurface area and by a progressive penetrationinto the deeper submucous and muscular layers ofthe viscus or beyond.

The chronic ulcer commonly becomes thickenedand indurated by inflammatory connective tissueformation, with deep and terraced margins, insome cases undermined. The floor of such anulcer may be clean in appearance and covered withgranulation tissue, or concealed beneath a fibrinousexudate or slough, in which thrombosed vesselsof considerable size may be situated. Adhesionsto adjacent organs are of frequent occurrence inan ulcer of long duration, so that the liver orpancreas may come to form its base. Scarringfrom ulcers of marked chronicity may also leadto gross deformity and obstruction within theorgan, such as pyloric stenosis or hour-glassstomach, while spasm and oedema may closelymimic organic occlusion.The fluctuating life-cycle of a chronic peptic

ulcer, reflected clinically in periodic remissionsand exacerbations 6f symptoms, is found patho-logically to correspond with phases of freshulceration and partial healing. Periods ofquiescence or complete absence of symptoms temptboth patient and clinician to assume that the ulcerhas healed, and pathological and X-ray tests maylend support to this erroneous conclusion, butdirect inspection will frequently show that thelesion is merely inactive and dormant. What isoften thought to be a fresh ulceration is but reactivityor breakdown of an old lesion. For this reasonalso, a sudden unexpected haemorrhage or per-foration may be the first indication that all is notas well as was thought.

Malignant transformation of benign gastric ulceris a controversial and unsettled subject as to itsfrequency and even occurrence, opinion of itsincidence varying from nil to IO per cent. ofchronic simple ulcers. The writer's personal viewis that it is a rarity, though its possibility cannotbe denied. The common site of carcinoma inthe stomach differs radically from that of simpleulcer; carcinoma practically never occurs in thefirst part of the duodenum, where as a sequel tolong-standing initation of chronic ulcer it would befrequently anticipated. Similarly unknown ismalignant disease at a gastro-jejunal stoma. Inthe great majority of cases of carcinoma of thestomach, moreover, the age incidence affects anolder period, and the history of digestive disorderis relatively short, the disease appearing clinicallyto start de novo rather than as a sequel to long-standing dyspepsia. It is recognised that owingto digestive changes the histological features ofbenign and malignant ulcer may be closely similar.

Theories of Causation of Peptic UlcerMany theories of causation of peptic ulcer

have been advanced, and attempts made to repro-

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192 POST-GRADUATE MEDICAL JOURNAL june, I945duce their effects experimentally. It is clear thatthey are unrelated to any specific bacteriology;the occasional association of acute ulcer withsevere generalised infection, revealed for the mostpart post mortem, shows no common identity oforganisms and, as in its rare sequel to burns, theulcer here is probably a reaction to the absorptionof tissue-breakdown or histamine products. Ulcersproduced experimentally in animals by injectionof organisms into the gastric mucosa show rapidhealing and no tendency to progress to a .chronicstage; traumatic ulcers of the stomach, both in theanimal and the human subject, caused by theswallowing of a foreign body show a similar promptresolution.The frequent demonstration of thrombosed

vessels in the base of a chronic ulcer has suggestedthat a local vascular spasm of the mucosal arteriolesmay be the primary factor, bringing about a lossof blood-supply to the area with necrosis of mucousmembrane by infarction. Such a theory is atonce disproved by the free anastomosis of vesselsfound in the stomach, wide ligature of which failsexperimentally to produce ulceration; the throm-bosis so often seen is the result and not the causeof the lesion. Similarly an attempt to explainthe production of peptic ulcer by a neurogenicdisturbance carries little weight; the sole neuro-logical association which can be demonstratedin ulcer subjects is a vagal overaction, a reasonableexplanation of the hypersecretion and hyper-mobility of the stomach which is present.While the responsible factors for initiation of

tissue loss remain obscure, the failure of healingof the breach of surface, when once begun, is lessdifficult to understand. There is present in thesesubjects with considerable constancy an inabilityof the mucous membrane to resist the digestiveaction of the acid gastric juice, a defect roughlyproportional to the degree of hyperacidity present.Whether the ultimate cause is the excess of hydro-chloric acid itself or some other abnormal conditionof the gastric secretion is a moot point, for acidity.by no means represents the sum-total of pepticactivity. Again, whether the weak spot in defenceis a lack of cellular resistance to digestion or a lackof cellular protection by mucus-secreting cells(a secretion lessened in ulcer subjects) is equallyunknown. The important point is that the presenceof hydrochloric acid in excess is the main knownfactor in maintaining the activity of peptic ulcer.

Time-factors are of no less significance. Where,as in ulcer-subjects, the duration of exposure ofthe mucosa is prolonged, for example during thenight or for long fasting hours between badlyspaced meals, times during which the normalstomach would produce little *or no acid, thisabnormal digestive process is intensified.

This relation of. hyperchlorhydria to pepticulcer is confirmed in a number of ways. The siteof ulceration is confined strictly to those portionsof the digestive tract coming into direct contactwith the acid gastric secretion. Simple ulcer,on the contrary, is never found among the IO percent or so of the population with a congenitalhistamine-achlorhydria. Gastric ulcers producedartificially in animals fail to heal if the normalneutralisation of acidity by duodenal contents isprevented, or if an abnormally high level of acidityis maintained in the stomach, either by directadministration of acid or by maintaining a hyper-secretion by histamine injections.

Despite this evidence the question of acidity isclearly- not the whole story. Although a greathypersecretion of acid (up to 0.4 per cent HCl)is the common finding in peptic ulcer, especiallyof the duodenum, other patients will show normallevels of acidity, and it has to be admitted thereforethat the problem is still incompletely understood.Of scarcely less importance in the aetiology of

peptic ulcer is the question of muscle tone andcontractility. Duodenal ulcer subjects in par-ticular commonly have a hypertonic stomach,undergoing violent peristalsis with rapid emptyingof acid secretions into the duodenum. In othercases, pylorospasm will be the cause of a persistentlyhigh acidity of gastric contents from delay in thestomach emptying. Much stress has been laidby gastroscopists upon the even closer anatomicalrelationship of ulcer incidence to hyper-rugosityof the stomach mucosa.

Symptoms of Peptic UlcerThe outstanding symptom of peptic ulcer is

pain related to the taking of food. This may beso characteristic in its features as to be practicallydiagnostic; two significant aspects are nearlyalways present, the long duration of the painover months or years, and the periods of freedomfrom symptoms for a few days or more oftenweeks or months, during which the ulcer is quiescentbut usually not healed. WVith progress of timethe tendency is for the spells of pain to becomemore frequent and prolonged and often ofgreater severitv, with shorter intervals of freedom.In character the pain is usually described asaching or gnawing, sometimes burning or colicky,varying from a mild discomfort to severe distress,and felt over a range of situations in the upperabdomen. It is felt most commonly in the centralepigastrium, being often localised to a small area,but may be referred alternatively to one or otherhypochondrium or to a combination of thesesites. Diagnosis of the probable seat of ulcerationfrom the point of reference of pain is of little or

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June, I945 GASTRIC AND DUODENAL ULCER 193no value, although duodenal pain is more commonlyfelt to the right of the abdomen. Radiation of thepain to the back or around the right costal arch,especially when it is severe and unrelieved by theusual measures, often indicates a deep, penetratingulcer adherent to the posterior abdominal wall orpancreas. Pain from a jejunal ulcer after gastro-enterostomy is apt to be experienced in the leftmid-abdomen or. below.The daily rhythm of the pain, as distinct from its

longer periodicity, is shown in its clockworkregularity after the taking of food, at an intervalvarying from a few minutes to three hours or more.The heavier the meal the more severe the pain,which may sometimes only follow the main mealof the day. As with site, the time-relation of thepain is no certain guide to the situation of theulcer. In general, however, pain from duodenalulcer occurs at a long interval after food, which itoften appears to precede rather than to follow.It is an especial feature in the small hours of themorning, waking the patient from sleep. Reliefin uncomplicated ulcer is afforded with consider-able constancy by alkalis or a further meal, or byvomiting, while partial relief is obtained by rest.The almost immediate alleviation by radicaldieting is so marked in many cases as to confirmthe diagnosis. The association of the pain withcraving for food and the relief so given leads to itsapt designation as "hunger-pain". In mechanismof production, pylorospasm and irregular muscularcontractions are partly responsible; there are alsothe factors of increased sensitivity of the mucosato mechanical or chemical stimuli, e.g. a raisedhydrogen ion concentration or inflammatorychanges in or around the ulcer. The normalgastric or duodenal lining is insensitive andhyperacidity alone does not produce pain; acidityin a given case shows little variation in degreewhether the ulcer is active or healing, but a loweredthreshhold of sensation causes pain to be felt.Reduction of acidity by the neutralising effect ofalkali or food, or by emptying the stomach throughvomiting, then gives relief of pain.More severe pain- will arise where inflammation

extends beyond the confines of the ulcer, causinga perigastritis or periduodenitis, and is thencontinuous and accompanied by persistent abdo-minal tenderness, with only slight relief fromfood, alkali or emptying of the stomach.

Appetite in simple ulcer is normally retainedor increased unless associated gastritis be present,but food intake may be restricted from fear ofpain and some loss of weight may thus ensue.Nausea is not a usual feature. Vomiting mayoccur as a reflex phernomenon at the height ofulcer pain, giving relief; sometimes from rapiddistension of the stomach with blood and resultant

haematemesis. Alternatively it may be secondaryto obstruction of the food channel through thestomach. In many cases this is temporary frommuscular spasm, with or without local inflammatoryoedema, a form responding generally to treatment;in some it signifies organic stricture from cica-trisation of the ulcer base. Sensations of acidregurgitation into the mouth and water-brash,with excessive salivation, are very common accom-paniments of ulcer.

Constipation is frequent, but a lienteric type ofdiarrhoea in some subjects is apt to follow theperformance of gastro-enterostomy.

Complications of perforation and haemorrhageare dealt with in a subsequent section, but it maybe noted here that bleeding of clinical significanceoccurs in at least half the cases of chronic ulcer.Recurrent fulminating haemorrhage may dominatethe clinical picture, or the bleeding may be ofless dramatic order, with milder degree of anaemia,frorm a slowly oozing ulcer.

Physical. SignsRoutine clinical examination may frequently

fail to elicit physical signs in cases of peptic ulcer,especially during periods of relative quiescence.Nutrition is usually preserved and anaemia isnot a feature apart from blood-loss. Localtenderness is common in the central epigastriumor to either side of the upper abdomen, corre-sponding with the site of pain, sometimes withcutaneous hyperalgesia, and may be accompaniedby muscular rigidity of the upper rectus to avariable degree. Rarely a tender mass may befelt where acute inflammation has followed a slowleak through the ulcer base, and may be confusedwith carcinoma. Obstruction will outline thedistended stomach or portion thereof, with peri-staltic waves of characteristic type. Splashing isreadily elicited in dilatation of the stomach withretention of its contents, but is of no pathologicalsignificance within two and a half hours of a meal.

Special InvestigationsRadiologyApart from these sparse findings diagnosis of

peptic ulcer depends upon a combination of acareful history and of special investigations.Of these radiology takes the lead. In good hands,a high proportion of ulcers should be demonstratedby means of an opaque meal. Thus it should bepossible to diagnose some go per cent of gastric,and 75 per cent of duodenal ulcers; the difficultiesand errors being higher, the deeper and less acces-sible the site. Of anastomotic ulcers perhaps the

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194 POST-GRADUATE MEDICAL JOURNAL June, I945majority will be revealed. Despite the mostcareful radiological examination fallacies willsometimes occur, and the rule for the clinicianshould be to accept a diagnosis of peptic ulcer,particularly duodenal, based on strong clinical-evidence in the absence sometimes of X-rayconfirmation. -The same comment applies withregard to tests of cure.

Gastric AnalysisSupport for radiological evidence is given by

chemical laboratory tests, in chief by gastricanalysis. Examination of a single specimen ofgastric contents after a one-hour interval is amethod of little value and of historic interestonly, the fractional test meal being universallyemployed. As with X-ray examination, it isbest carried out in the early morning and thepatient's last meal must have been. not later than8 p.m. the previous evening, all drugs beingomitted on the day of the test. The fastingstomach contents or "resting juice" are completelywithdrawn after the swallowing of a Ryle's tube,the meal prepared from fine oatmeal gruel is thengiven, and sa,mples of about IO to I5 C.C. of gastriccontents withdrawn at regular intervals, preferablyhalf-hourly, for a total of 24 hours, by which timethe stomach is normally empty.The specimen of greatest importance is the

resting juice; this is examined for volume, odour,consistency, presence of blood, mucus, and foodresidues, and microscopically for red cells, pus cells,epithelial and malignant cells, with chemicalestimation of free and total acidity. Similarlyeach specimen is examined for volume, total acidity,free HCl, mucus, bile, blood and starch, and theresults recorded graphically upon a chart.The interpretation and significance of the test

meal may be briefly described: In uncomplicatedgastric ulcer the curve may either be normal orshow a hyperchlorhydria. Sometimes an initiallow acidity is found from associated gastritis, theproduction of acid being increased after gastriclavage. In duodenal ulcer it is the rule to find amarked hyperchlorhydria from irritability andhypersecretion of the stomach, irrespective of thephase of activity of the lesion. The resting juicealso is usually highly acid.Two types of curve can commonly be distin-

guished. In the first, or "climbing" curve, afteran initial fall in acidity due to dilution of theresting juice and fixation of free acid by the meal,there is a gradual rise in its level throughout thewhole period of observation. Slow emptying ofthe stomach from pylorospasm, with delayed bilereflux and little or no regurgitation from theduodenum causes a continued rise in the level of

HCl past the 24 or 3 hours period. In the secondor "hurry" type of curve a high initial acidity ofresting juice after a slight temporary drop risessharply to a still higher plateau level, which iseither sustained or shows a premature fall within anhour or so, due to rapid emptying of the stomachunimpeded by pylorospasm.

In the interpretation of these findings it must beremembered that while many cases of carcinomaof the stomach show an absence of hydrochloricacid, its presence in normal amount or even inexcess by no means excludes a diagnosis of malig-nancy. Other lesions apart from gastric may ofcourse be accompanied by achlorhydria. Con-versely a complete lack of HC1 production in atest meal which includes the giving of histamineis strong evidence against benign ulceration.As mentioned in considerations of treatment,

the healing of the ulcer has little effect upon theacid secretory levels of the gastric juice; this indeedis one of the potent factors in recurrence. Refer-ence is made later to the means whereby effectiveneutralisation of the gastric acidity may bemeasured.

Occult Blood TestBleeding detectable only by chemical test is

sufficient evidence of active ulceration, grantedcertain well-known safeguards in technique andinterpretation, such as the exclusion of haemo-globin- and chlorophyll-containing foods and ofbleeding from other alimentary sites. A positiveoccult blood test or benzidene reaction in the stoolsthen indicates a breach of surface epithelium.The test is so sensitive that slight or doubtfulreactions may be ignored. The disappearance ofoccult blood from the stools is useful evidence ofhealing of an innocent ulcer and makes malignancyimprobable.

Gastric AspirationGastric aspiration, apart from a test meal, is a

measure of value both in diagnosis and treatment.In the normal empty stomach there should be notmore than 25 c.c. of resting juice; an excess indicatesgastric irritability and hypersecretion, and becomesmarked in the event of obstruction of outflow,whether of spasmodic or organic nature. In thesecircumstances many ounces, rarely pints, ofresidual stomach contents may be found, perhapsof dirty malodorous fluid containing mucus, blood,stale food or malignant cells, and of high acidityfrom foreign acids due to putrefactive organisms.Routine aspiration of such fluid and subsequentlavage with o-i per cent HC1 will do much toallay the accompanying gastritis and relieve the

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obstruction present. Even in non-obstructivelesions the removal of highly acid gastric juice byaspiration is a measure of value, as noted later.

GastroscopyDirect inspection of the stomach by gastroscopy

is fast becoming the riiost valuable single measurein diagnosis and in assessment of progress of pepticulcer. It has been rendered possible by theintroduction and development of the flexiblegastroscope by Schindler in Germanv twelveyears ago, and particularly by the improvements ofHermon Taylor in this country. With premedi-cation and local anaesthesia, combined with skilland experience of the operator, the examination isnot unduly uncomfortable to the patient. Itsvalue is, of course, greater in the case of gastricthan of duodenal lesions. While not infallible,the increased accuracy of diagnosis which itaffords should make it a routine measure in theinvestigation and control of gastric disease. Itin no way replaces or diminishes the importance ofradiology, but provides an additional and moreexact means of determining pathological changesin the stomach and their course under treatment.

Benign gastric ulcers usually show sharp,crater-like margins and a smooth or but slightlyirregular yellowish-white floor, though afterhaemorrhage it may be brownish or dark-red incolour. The adjacent mucosa is often normal inappearance, but may show local inflammatoryswelling around the margins of the ulcer. Coinci-dent gastritis produces an oedematous dull mucosawith sticky adherent mucus or mucopus, andsometimes petechial submucous haemorrhages,indicating the need for gastric lavage. Rarely thelikelihood of impending haemorrhage may besuspected from an exposed or oozing vessel in theulcer base. As the ulcer heals it becomes shallower,with cleaning and granulation of the base andsubsidence of local oedema at its margins, and aconverging stellate pattern develops in the sur-rounding mucosa from contracture around theulcer floor.

Too comprehensive a survey must not be expectedfrom gastroscopy, for some areas of the stomach,chiefly the fundus, and sometimes the pre-pyloricregion, are inaccessible to direct vision. Itsgteatest value lies in the determination of progressof a given gastric ulcer, through all stages tocomplete healing, and in limited measure in thediagnosis from malignant disease.

In the differentiation of benign from malignantulcers gastroscopy is of much value in skilled hands,but features of malignancy are not necessarilyconclusive at a single observation. A carcinoma-tous ulcer usually has more rounded edges, less

well demarcated from the mucosa; its floor iscommonly irregular with nodular prominencesor ridges; and is more frequently of a reddish brownor dirty grey colour than yellow. In contrast withthe excavation of the simple ulcer, it is usuallyelevated above the surrounding mucous membrane,which may, like the ulcer itself, show nodularirregularities.

Size alone is no guide; a small ulcer may bemalignant and a benign reach a diameter of severalinches.

It follows, therefore, that a single examinationis often inconclusive, and no final decision as tomalignancy or otherwise should be sought there-from. The value of gastroscopy lies rather inserial observation. Wherever the malignancy ofa gastric ulcer is in question, gastroscopy shouldbe repeated after a period of three weeks' intensivemedical treatment by complete rest, dieting andalkalis. An innocent ulcer will certainly duringthis time decrease in size and show other evidenceof healing. If, on the other hand, the appearancesof the lesion are unchanged, it is right to regard itas probably malignant and to treat the patient,if otherwise suitable, bv subtotal gastrectomy.In some cases the later gastroscopy will revealthat the ulcer has extended and become morenodular and infiltrative, and in these its malignancywill not be in doubt. Wherever therefore symp-toms of peptic ulcer are unrelieved or inadequatelyrelieved by medical treatment, gastroscopy shouldbe carried out.

Malignancy apart, in simple ulcer the surestevidence of healing is given by periodic gastro-scopy. Caution is taught by the observationthat weeks or months after the patient is symptom-free and X-ray findings are negative, the ulcermay still be present as a shallow crater with smoothfloor and uninflamed margins. Recurrent boutsof pain, thought clinically to be due to fresh ulcera-tion, axe revealed as no more than the lightingup of an ulcer which has never completely healed.It follows then that where an ulcer is within therange of vision it should be gastroscopicallycontrolled until it is known to be healed, and thatany fixed duration of hospital treatment anddieting is a bad routine and not necessarily ade-quate. Where, moreover, it is shown by gastro-scopy that an ulcer persistently fails to heal bythese means, the indication is clear for surgicaltreatment.The duodenum, unfortunately, remains cloaked

from view, and diagnosis of ulceration here mustrest upon means previously described. Gastroscopy,nevertheless, is not without its value, especiallyin decisions of appropriate treatment. Degreeof hyperacidity bears a close relation to the totalacid-secreting surface of the stomach and hence

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196 POST-GRADUATE MEDICAL JOURNAL June, I945to the degree of rugosity of the mucosa. Wherethe folds are markedly deep and numerous, thehyperplastic type, difficulties and delay in healingby conservative treatment may be expected, andconsiderations of surgery apply. Simple short-circuit procedures in such a case are likely to befollowed by jejunal ulceration, and good groundsare present for a choice of subtotal gastrectomy.

Jejunal ulcer may sometimes be diagnosed bygastroscopy, which is, however, technically difficultand often affords but a partial view of the stoma.

Clinical differentiation of Innocent andMalignant Gastric Ulcer

Some of the points aiding this distinction willhave already been noted. Clinical aspects are nosure indication. An ulcer of the stomach beginningafter the age offorty should be suspect of malignancyuntil the converse is proved. Age itself is ofuntrustworthy significance, however, for carcinomamay occur in the third decade and simple ulceris not unknown in the sixth or seventh. A prolongeddyspeptic history favours a benign lesion, butcarcinoma of the stomach may arise in a patientthe subject of long-standing indigestion whetherfrom simple ulcer or any other cause.

Conversely a worsening of symptoms in a knowncase of innocent ulcer does not necessarily meana malignant change. Marked loss of appetite,weight and strength are more likely to occur inmalignant disease, as is anaemia not due to blood-loss. A palpable swelling, though a late sign,nearly always indicates carcinoma. Early ob-structive svmptoms also point to malignancy.Haematemesis and melaena may be initial orearly symptoms of either disease, but gross bleedingis commoner from a simple ulcer. The continuedpresence of occult blood in the stools after two orthree weeks' full medical treatment which includesrecumbency is suspicious of gastric carcinoma,since most cases of simple ulcer lose this signwithin that time upon an efficient regime. Con-.versely, a persistently negative occult blood -testsuggests that the ulcer is innocent, although noabsolute rule applies. The fallacy of relying uponfractional test meal findings has .been noted,50 per cent or more of early gastric carcinomatabeing accompanied by free HCl in the stomach,sometimes in excess. On the contrary, a completeachlorhydria after the giving of histamine practi-cally excludes a simple peptic ulcer.The value of X-ray and gastroscopic evidence

has been discussed. It may be noted that ulcersof the greater curvature are nearly always neoplastic,and the farther away the ulcer is from the lessercurvature the greater is the probability that it is

malignant. Carcinomatous ulcers tend in X-rayappearance to be more ragged and irregular inoutline, the gastric rugae being distorted andinterrupted in precipitate manner instead ofconverging in radial fashion upon the ulcer siteas in an innocent lesion. The demonstration ofa meniscus sign is practically diagnostic of carci-noma. The final judgmentf of serial X-ray andgastroscopic investigation has been emphasised.If treatment on a medical regime brings abouta striking relief of pain and gain in weight, withclearance of the stools, a benign ulcer is likely,but even this is not absolute evidence, since theimprovement of a gastritis in cases of carcinomaby rest and dieting will often lead to a temporaryregain of appetite. The value of the visual check,th'erefore, needs no further emphasis.

Chapter II

Treatment of Chronic Peptic UlcerGeneral ConsiderationsThe problem of treatment falls into two stages;

firstly the healing of the ulcer, and secondly theprevention of recurrence, and of these the firstis the simpler task. The treatment of an uncom-plicated chronic peptic ulcer is fundamentallythe same wherever its position may be. Therapyis essentially medical, and surgery where indicatedis undertaken for specific complications, which areconsidered later. The over-riding principle in themedical treatment of ulcer is to treat the patientand not solely the lesion.The importance of the general well-being and of

complete bodily and mental rest may easily beoverlooked by considerations of detail in diet anddrugs.Any ambulant treatment at the outset of the illness

is unsatiifactory and wasteful of time, few chroniculcers healing while' the patient is up and about.A minimum of four to six weeks' complete bed-restis essential, followed by a like period of quietconvalescence where progress is satisfactory. Itis often difficult to convince the patient of thenecessity for this strict regime, the more so whenhe is of the irritable, restless type. Rapid disap-pearance of pain and early return of well-beingrender the enforced recumbency irksome, whileanxiety over business or economic affairs oftenleads to pressure upon the medical attendant torelax restrictions prematurely. A clear explana-tion is required that relief of symptoms does notimply that the. ulcer has healed.For these reasons care must be taken to ensure

for the patient adequate mental relaxation, withquietness, sleep and freedom from worry, mental

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ILLUSTRATIONS

GASTRIC AND DUODENALULCER

R. SLEIGH JOHNSON, M.D., M.R.C.P.

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Method of feeding by continuous milk drip.

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June, 1945 GASTRIC AND DUODENAL ULCER 197

rest being no less important than physical. Socialadjustments in this will play their part, but seda-tives are often required in addition, phenobarbitonebeing usually of more value than bromides. Needswill vary with the patient's individual type andcircumstances, the aim being by encouragementand advice to promote a wholesome psychologicaloutlook. It is common experience that therequired regime is more easily and efficientlycarried out in hospital than at home.At this stage of treatment smoking should be

wholly forbidden and alcohol avoided. Attentionmust be paid to the teeth to obtain a clean mouthand adequate facilities for mastication.

Principles of DietingPerhaps too much emphasis in the past has been

placed upon the relative merits or demerits ofparticular schemes of dieting in peptic ulcer, andupon the neutralising of gastric acidity, to theneglect of a balanced diet providing sufficientcalories, salts and vitamin requirements. Treat-ment is necessarily prolonged and nutrition andhealth must be maintained. Frequencv of feedsis at least as important as their nature, grantedthe exclusion, of obviously unsuitable foods.Wthile it mav be true that the presence of hydro-chloric acid in excess is the chief factor in main-taining active ulceration, treatment is not solelya simple chemical equation of its neutralisationby appropriate alkalis. Nevertheless it is bycombating the effects of acidity that the maintherapeutic result is obtained. Drugs, includingalkalis, play an important part in control ofhyperacidity and are for convenience consideredlater. Food is the primary and essential bufferin virtue of the acid-combining, power of its food-proteins.To render this maximal the following principles

should be observed:(a) the food must be soft, smooth, fluid when

ingested, and free from coarse elements to avoidirritation of the ulcer area.

(b) the bulk of the individual feeds must besmall, and their character bland, to prevent dis-tension of the stomach and excessive secretionof gastric juice.

(c) feeds must be given frequently so that theprocess of neutralisation is continuous, the totalintake of food sufficient to maintain nutrition, andthe stomach is not left empty for prolonged periodsexposed to acid gastric secretion.With regard to the second of these principles,

it may be noted that the quantitative differencesin gastric secretion produced by various foods isless than formerly thought, and that although fatsdo inhibit gastric secretion and emptying, they

play less part in maintaining gastric neutralitythan does the acid-combining property of protein-foods.The main ingredient of all such diets is milk,

itself an efficient alkali, neutralising an equalvolume of gastric juice containing 0.3 per centHCI. The systems of diet first introduced in theLenhartz and Sippy regimes, based chiefly uponmilk and eggs and milk and cream respectively,were each deficient in caloric value and are nowseldom used in their original form, though modi-fications are still in favour in many hospitals,details of which are readily available. A morebalanced diet with greater variety is that devisedby Hurst, the most widely used scheme, the firststage of which is based upon feeds at hourly inter-vals alternately of citrated milk, five ounces, anda fruit, vegetable or carbohydrate puree. Morerecently a still more generous regime has foundfavour with many physicians in the form ofMeulengracht's diet, embracing whole milk, por-ridge, barley, rusks, cream crackers, fruit andvegetable purees, eggs, fish and even meat;recommended at first for the more generous feedingof patients after haematemesis, it is also usedin the ordinary stages of ulcer treatment, andincludes quite large and varied meals. Thereaction against semi-starvation after gastro-duodenal haemorrhage is fully justified, but in-most hands greater safety and better results areobtained from adherence to Hurst's fundamentalprinciples. Hurst's regime includes a number ofdrugs, whereas in Meulengracht's scheme theseare practically excluded.The first stage of dieting (the strict ulcer regime)

is continued not for any stated number of weeks,but until there is freedom from all spontaneouspain or discomfort, tenderness and muscularrigidity are no longer present, and the stoolsshow a negative test for occult blood on threeconsecutive occasions. Where pain is severeand resistant, gastric spasm a marked feature,or emptying of the stomach is delayed by a partialobstruction from this cause or from oedema, andfurther where it is desired to afford the stomachthe maximum degree of rest, as after haematemesisor melaena, feeding by a continuous milk drip giveseven better results than a first stage Hurst diet.A Ryle's tube made non-irritant with 2 per centcocaine ointment is passed into the stomach,preferably through the nose, alternatively throughthe mouth, and fixed in position by strapping tothe cheek. Through this, from a height of abouttwo feet, the patient is given a continuous drip ofcitrated milk, day and night, from a suitable con-tainer such as a transfusion bottle, fixed to a standor bed-extension and adjusted to a rate of about40 drops per minute (Fig. i). The patient receives

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198 POST-GRADUATE MEDICAL JOURNAL June, I945in this way a total of five pints of milk in the24 hours, and where desired the caloric value andprotein content of the diet may be increased bythe addition of glucose and of a IO per cent solu-tion of casein hydrolysate, a pint of the latterbeing added to the five of citrated milk. Alkalisand other drugs needed may be given either inthe drip or separately by mouth, the latter beinggenerally preferred. Most patients will toleratefeeding in this way for periods of up to three weeks.some for much longer. Rest of the stomach is ascomplete as may be obtained. Appetite secretionis minimised, and the stomach is never left exposedat night or for other interim periods to the actionof highly acid gastric secretion, neutralisation ofwhich is made a continuous process. Nutritionis well-maintained, and healing is more rapid bythis method in the writer's experience than byany other. An initial soreness of nose or throatfor the first day or two is seldom maintained.A period of milk-drip feeding in this way may wellbe followed by a first stage Hurst diet.Whichever method be used, when tests have

confirmed a satisfactory response, this initial stageof dieting is followed by an intermediate one, inwhich some of the milk feeds are replaced bylightly cooked and easily digested meals allowinggreater liberty of choice. This second stage mustbe maintained as long as any evidence of activeulceration is present, and may therefore occupymany weeks or months. It is not possible fromclinical observations alone to tell when healinghas taken place or to assess its degree, for it isnot complete until the defect is closed and coveredby a normal glandular mucosa; this stage isdelayed long after the disappearance of pain andeven after vanishing of the crater seen on X-raypictures.Most failures of medical measures arise from an

insufficient length of treatment. Control by periodicX-ray and gastroscopic examination is requiredat intervals of three to four weeks, until completehealing can be demonstrated, or the need foralternative treatment decided upon. The valuein diagnosis by these means of malignant ulcerhas already been mentioned. In duodenal ulcera greater measure of reliance has to be placed uponradiology alone.

Maintenance of nutrition should be checked bya weekly observation of weight, and where anaemiais present, as after haemorrhage, periodic bloodcounts are required.

Drugs in the Treatment of Peptic Ulcer(a) Acid-neutralisation. Sippy's aim in neutral-

ising hydrochloric acid was to inactivate pepsin,but it is now known that high acidity is in itself

more destructive upon an ulcer than the solventaction of the peptic ferment.- The object never-theless remains unchanged to maintain a neutrali-sation of all free HCO while food and its accompany-ing secretion is present in the stomach; it is alsonecessary, and more difficult, to neutralise thecontinued secretion of acid gastric juice duringthe night hours when the stomach is empty offood.

Alkalis are the most widely used as well as themost abused remedies in the treatment of pepticulcer. In their rapid relief of pain lies theirdanger in ignorant hands; advertisements of pro-prietary "stomach-powders" fil the daily pressand lull their victims into a false security. Properlyused, alkalis are of the greatest value and secondonly to correct dieting in treatment.A wide range of ant-acids is available, with their

special advantages or otherwise according to thecase. Sodium bicarbonate has a quick thoughshort neutralising action, but produces distensionof the stomach by liberated CO2 and a markedsubsequent secretion of acid, rendering it unsuitableas an alkali for this purpose. In view of its greatersolubilitv it is moreover more prone than areother alkalis to produce alkalosis. The' moregradually acting magnesium and calcium saltsare fully effective, and may be combined in pro-portion to regulate the bowels, the former beingmildly aperient and the latter astringent. Mag-nesium oxide, carbonate and tribasic phosphateare excellent; the trisilicate has come into favourwith some, but is a more costly preparation andno more efficient than its fellows. Effective dosagerequirement varies with the degree of aciditypresent; commonly (as in Hurst's scheme) dosesof a drachm of one of the above salts in powderform are sufficient, given with water before eachof the puree feeds, and one drachm or more ofemulsio magnesiae B.P.C. (containing grs. v ofmagnesium oxide) before each of the alternatingmilk feeds; a double dose of alkaline powder isgiven at night. Calcium preparations, in thecarbonate or tribasic phosphate, are useful alter-natives, and a good case has lately been madefor colloidal aluminium hydroxide, in the form ofaludrox in similar dosage. Bismuth salts are feeblealkalis in their degree of neutralising power andthe idea of their forming a protective coating to theulcer floor belongs to past days; thev are, likecalcium salts, mildly constipating.

In applying the continued drip theory the rolesof food and alkali may sometimes with advantagebe reversed, and a constant administration ofalkali in solution or suspension, e.g. as aludrox,may be given through a Ryle's tube, with hourlyor two-hourly feeds by mouth.Sodium citrate, besides inhibiting rennin and

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June, I945 GASTRIC AND DUODENAL ULCER 199,

preventing clotting of milk, is also an effectivealkali and is added to all milk feeds in proportionto two grains to the ounce.Where hypersecretion is marked or a measure

of obstruction present, alkali administration byitself is insufficient to ensure continued neutralityof stomach contents throughout the twenty-fourhours, the more so at night. Routine aspirationof the stomach at bed-time, or oftener, should inthese cases be carried out, thereby shortening theperiod during which the ulcer is exposed to theaction of the acid gastric juice. It affords,moreover, a means of assessment of correct alkalidosage; if this is adequate, the stomach contentsthirty minutes after a dose of the powder shouldcontain no free acid; its presence then is a call formore frequent or larger dosage. In non-obstructivecases it is the rapidly emptying stomach whichmost needs aspiration at night, food contentsand alkali having been quickly passed on, anda collection of highlv acid secretion being thenpoured out into the empty stomach to remainthere during the -night. The case is clear alsofor gastric aspiration in obstructive ulcer, whetherfrom pylorospasm or duodenal stenosis, and thisshould be continued at least twice a day until theresidual contents are not more than 50 to 100 C.C.

AlkalosisThe indiscriminate giving of alkalis in excess,

especially when accompanied by vomiting orindependent renal disease, may cause a seriousdisturbance of the acid-base equilibrium andchloride content of the blood, a condition knownas alkalosis. This is most often seen where acontinued depletion of chlorides has occurredthrough low salt intake and vomiting, especiallywith pyloric obstruction, benign or malignant.Symptoms include irritability, lassitude, mentalconfusion and headache, with loss of appetite,nausea and distaste for milk, followed by profusevomiting and drowsiness, and in serious cases thedevelopment of a state closely simulating uraemia,with low output, albuminuria and high blood-urea,perhaps progressing to coma and tetany. Thechloride content of the blood is always greatlylowered. Treatment' called for is- the immediatestopping of alkalis and the giving of large amountsof sodium chloride as normal saline solutionintravenously, with glucose and abundant fluidsby mouth, supplemented where it can be taken byoral administration of sodium chloride and ammo-nium chloride in capsules in large doses. If tetanyoccurs intra-venous calcium gluconate is given.Prophylactically, in conditions where alkalosi's isa likely complication three to five grammes ofsodium chloride may with advantage be addedto the daily milk ration.

(b) Inhibitory Drugs. Acid neutralisation byalkalis is commonly supplemented by measuresclaimed to diminish the secretion of gastric juice,and of these belladonna or its alkaloid atropine-is the most used. Its action in restraining gastricsecretion is doubtful, but its effect as an anti-spasmodic is more certain, and it is hence ofdefinite value in inducing relaxation of spasm atthe pylorus or at the site of ulceration. It isgiven as routine in the Hurst's diet in doses ofII/00-1/50 gr. in a drachm of water by mouthbefore two of the daily feeds, and a double dosebefore the I0 p.m. feed, and more may be givenif spasm persists, short of producing blurring ofvision and dryness of the mouth. As eveningand nocturnal secretion is the most difficult tocheck, late afternoon or bed-time is the time ofchoice.

Fats in general inhibit gastric secretion. Oliveoil or in war-time arachis oil taken twice dailybefore meals in ounce doses has this effect besidesforming a valuable food. The addition of creamto the milk feeds is of similar benefit.

(c) Sedatives.-The indications for and value ofsedative drugs in moderate doses in the quieteningof the mental state have already been mentioned.

(d) Haematinic drugs. Anaemia of some gradefrom slight blood-loss over a long period is socommon in peptic ulcer that regular blood investi-gation should always be made. Where haemo-globin deficiency is found, iron is indicated inliquid form as iron and ammonium citrate orcolliron in appropriate dosage; after frank hae-morrhage early and massive iron administrationis required, begun as soon as the bleeding hasceased. In view of the low iron content of ulcerdiets, a minimum of five grains of a ferrous saltper day as supplement is a good routine, despitethe absence of demonstrable anaemia, for aUlpatients upon the restrictive stage of dieting.

(e) Vitamins. The most likely deficiency in thisregard arises from the limitation of fresh fruitsand vegetables, and a long-continued ulcer dietshould always be supplemented by Vitamin B)2,000 units andVitamin C as ascorbic acid I00 mgm.given daily. There is no objection to the givingas well of fresh orange or other fruit juice.

(f) Control of bowels. Straining at stool isobviously undesirable, particularly if recent bleed-ing has occurred. Where regulation of the dietand additional magnesia do not suffice, agar andliquid paraffin preparations will help towards aneasily passed stool.

(g) Histidine. The injection of histidine pro-ducts recently had a short-lived vogue in themedical treatment of peptic ulcer. It has sincebeen shown to be entirely unsupported by evidenceor by results, and its use has now been discarded.

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200 POST-GRADUATE MEDICAL JOURNAL June, I945

After-care, of Peptic Ulcer

"Post-ulcer" regimeThe plan of treatment outlined is maintained

either so long as any evidence of active ulcerationremains, or until the conclusion is reached thatmedical means alone are inadequate after a pro-longed trial. Where healing is established, thepatient is allowed up by stages and progresses onto a post-ulcer regime of diet and habits, whichhe is instructed to follow for a minimum of twoyears or if possible permanently. From - theinstructions he will be taught to maintain smallfrequent meals with intervals of not more thantwo hours, to adhere to soft readily digested foodsand avoid hard, irritant or highly seasoned articleswith indigestible residue. Above all he will beadvised to obtain ample time and regularity forhis meals, to rest before and afterwards, and toavoid excessive fatigue and as far as possibleintercurrent infections. He must pay properregard to his teeth and his bowels and continueto take an alkaline powder after each of hismain meals. Smoking and alcohol are bestavoided altogether. Any return of symptomscalls for a prompt resumption of bed-rest and strictdieting.

Could this ideal or even pious advice alwaysbe followed, the prognosis of medical treatmentof peptic ulcer would be much better than it is.Prospects of remaining well vary greatly withsocial status and economic means. The patientin comfortable circumstances may be able to.continue the whole regime religiously and remainfree from symptoms, with a careful diet and shel-tered life quite impossible for a working man withliving to earn and family to support. The occu-pation followed may be a stumbling-block andits type is not easily changed. Even grantedthe best of after-care, no guarantee can in factbe given of freedom from recurrence of ulceration.Strong arguiment obtains therefore, for the indefinitefollowing-up of all ulcer patients in clinics organisedfor the purpose, supported by X-ray and otherspecial investigations as required.

Indications for Surgical TreatmentThe best efforts of medicine in this disappointing

disease are not always blessed with success. It ispertinent therefore to consider what are the indi-cations for surgical treatment. Some will beobvious and are by nature emergency procedures;others should be embarked upon only after care-fully weighing the pros and cons of individualcircumstances.

(a) Failure of Medical TreatmentThis is the most frequent reason for operation;

it presupposes that medical treatment should havebeen really adequate, and not a half-hearted trial.It more commonly applies in intractable duodenalulcer than in gastric, and apart from any compli-cations of the dramatic order.The type of patient with prolonged history of

pain interspersed with increasinglxy frequent andsevere relapses is not best served by repeatedvain attempts at medical cure, but should ifotherwise fit be treated surgically to avoid a life-long dyspepsia. Within this group will be manywith deep penetrating ulcers embedded in callousscar tissue and adherent to other organs. Insome cases the failure to heal of a gastric or jejunalulcer after gastro-enterostomy will be an indicationfor more radical surgical treatment.The trend of opinion in these medical failures

is increasingly in favour of partial gastrectomy,but in choice of surgery the degree of hyperplasiaand hvpermotility of the stomach will be a factor.Suitability for operation on grounds of age,pulmonary or cardio-vascular condition has ofcourse to be considered.

(b) Inability or unwillingness to maintain a fullmeasure of efficient medical treatment.Lack of co-operation on the part of the patient

will often indicate the advisability of surgery.This is sometimes concerned with psychologicaltype and temperament. Frequently, however,it is due to economic reasons, nature of occupation,pressure of time or domestic circumstances out ofhis control; it may be essential in such a case torestore if possible the ability to pursue a heavy orexacting type of employment, the prospects ofwhich depend upon successful operation alone.

(c) Recurrent haemorrhage.Most of the fatalities from bleeding follow

repeated blood-loss. While the immediate treat-ment of ulcer-haemorrhage is by general agreementmedical, it is certain that recurrent haematemesisshould be followed by operation as soon as thepatient's general state permits.

(d) Suspected malignancy.The failure of a gastric ulcer to respond to full

medical treatment within at most a few weeksindicates the advisability of exploration, to confirmdiagnosis and where suitable to carry out a sub-total gastrectomy.

(e) Perforation of the ulcer.This is an obvious need for immediate surgerv.

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(f) Organic obstruction.Obstruction which is largely due to oedema and

spasm will frequently be relieved by dieting,antispasmodic drugs, aspiration and lavage.Where, howeber, the obstruction is of organicorigin, as in hourglass stomach, duodenal orpyloric stenosis, surgical treatment alone canrelieve it.

REFERENCESHURST, A. (I936), Post-Graduate Surgery (Ed. R. Maingot), 1, 573.MORLOCK, R. (I944), Proc. Staff Meeting Mayo Clinic, 19, 449.SIPPY, B. (i9i5), J.A.M.A., 64, I625.WINKELSTEIN, ASHER, CORNELL, ALBERT and HOLLANDER

(I942), J.A.M.A., 120, 743.

X-RAY APPEARANCES OF GASTRIC,DUODENAL AND JEJUNAL ULCER

By H. C. H. BULL, M.A., M.B., B.Ch.,M.R.C.P.(Lond.)

(Hon. Radiologist Southend General Hospital)

Gastric UlcerA gastric ulcer is first an erosion of the mucous

membrane which subsequently penetrates thedeeper layers of the submucosa muscle and perito-neum. Radiology is shadow diagnosis and so theburrowing and eroding ulcer becomes to us a nicheor projection from the clearly defined stomach walldemonstrated in shadow by the contrast mediumfilling it.

Of gastric ulcers go% are found on or about thelesser curvature above the incisura angularis. Thelesser curvature differs anatomically from the restof the stomach and is the direct pathway of foodand fluids entering, but just why it is the seat ofulceration is not known.Of the remaining io% some are found on the

lesser curvature between the incisura and pylorus;the others-and they are few, probably less thanI%-are on the anterior wall of the pyloric end ofthe stomach.

Simple ulcers have been recorded on the greatercurvature. I have not seen one other than amalignant ulcer, but there are a few publishedcases.The outstanding fact and diagnostic feature-the

"direct evidence" of gastric ulcer-is the niche

seen in profile or tangential view projecting out-wards from the cavity of the stomach illustratingin shadow picture the identical form seen in post-mortem pathology (Fig. i).

These gastric ulcers may be small or large, recentor of long standing. The size is some estimate ofchronicity, but any size above one inch diametercarries with it a suggestion of malignancy. Despitethe work, pathological and surgical, devoted tostudy of the early malignant changes in gastriculcer there is direct evidence that chronic gastriculcers- often develop malignant change. Whenlarge the ulcer is usually old and certainlypenetrating in the sense that it has brokenthrough and passed beyond the natural boundariesof the stomach. Once an ulcer has reached theperitoneum, established adhesions between it andan adjacent viscus, usually the pancreas or theliver, and broken down the peritoneal boundary,erosion proceeds rapidly and the crater becomes alarge cavity of irregular outline. Such an ulcertends to show a relatively narrow passage at thepoint of exit through the peritoneum, expandinginto a large cavity beyond.

In shape gastric ulcers vary a good deal accordingto chronicity and position. The small ulcer pro-jects from the lesser curvature as a blunt point ora rounded bud and its outline is relatively smooth.The larger ulcer which has penetrated through theperitoneum will often show a fluid level with a gasbubble above when the patient is in the erectposition.An ulcer situated between the incisura and

pylorus on the lesser curvature has the same generalcharacters as that above the incisura but, asgravity plays a part, it does not hold barium sowell in the erect position. Examined under thescreen, barium can be pushed up into the crater,but when the pressure is released a certain amountonly sticks on to the rough surface, and is betterdemonstrated on the films taken with the patientprone.

Carman, in I920, described the saddle ulcer lyingastride the lesser curvature between incisura andpylorus, an ulcer with rolled edges holding guttersof barium when pressure was applied so that theappearance was that of detachment. To this hegave the name "meniscus" and he said it wasalways malignant. Such an ulcer is not common.Even a simple ulcer often has thick rolled edges,thus retaining barium, and it has been my ex-perience that an innocent ulcer can show the.meniscus sign. If we add to Carman's dictum thatthe meniscus sign in an ulcer of one inch or morediameter spells malignancy, then we are approach-ing nearer the truth.

Thick rolled edges, to which mention has beenmade in connection with malignancy, is a feature

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hospital, royal hospital) · mentofevery chronic peptic ulcer, andis revealed as asharply...

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