the complications of gastric and duodenal ulcermeulengracht (i934) to produce a profound and...

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THE COMPLICATIONS OF GASTRIC ANDDUODENAL ULCER

By A. K. MoNRo, M.A., M.D., F.R.C.S.Assistant Lecturer in Surgery, Post Graduate Medical School of London; Surgeon, Southend General Hospital, and

St. John's Hospital, Leicester Square

1. HAEMORRHAGEHaemorrhage is the commonest complication of

gastric and duodenal ulceration. It has beenestimated to occur, in gross form, in about 20 percent of all cases. It may be of any degree, fromthe slight haemorrhage which only discolours thestools or the persistent small haemorrhages whichcause a severe anaemia, to the more common, pro-fuse and dramatic haematemesis which at times isso severe as in a few minutes to endanger thepatient's life.

PathologyIn acute gastric erosions haemorrhage is a

common complication but, being caused by asuperficial lesion, it does not endanger life. Inmore penetrating acute gastric or duodenal ulcershaemorrhage may be severe and even, on occasion,fatal; this is, however, a rare event.

In all active chronic peptic ulcers minutehaemorrhages are almost constant as shown by thepresence of occult blood in the stools. Such bleed-ing comes from small vessels in the walls of theulcer. Larger vessels, however, may be involved,particularly the pancreaticoduodenal, left gastricand more rarely the splenic arteries and theirbranches. As the arterial wall becomes eroded, atime comes when the wall is unable to contain thepressure of the arterial pulse and haemorrhageoccurs. In the case of a large vessel brisk haemor-rhage continues probably for 10-15 minutes inwhich time 2-3 pints of Blood may be lost. Fromrapid distension of the stomach the patient islikely to vomit, whilst from loss of blood he feelsweak or faints. Various factors then come intoplay which tend to stop the haemorrhage,namely:-

(a) Fall of blood pressure.(b) Retraction of the inner coat of the vessel.(c) The coagulability of the blood.

In favourable circumstances a clot forms in theopen vessel. If this clot is allowed to become firm,danger is, at least temporarily, past. Any variationof the above three factors may affect unfavourablythe development and retraction of the clot. Rest-

lessness ormovement ofthe patient, or injudiciouslyrapid intravenous infusion may raise the bloodpressure. Retraction of the inner coat may beprevented by arteriosclerosis of the vessel's wallor by its fixation in thick scar tissue, whilst thecoagulability of the blood may be diminished byvitamin deficiency, by starvation or as the result ofrepeated haemorrhages. These three last are es-pecially noteworthy, because they may all three bepresent under the starvation regime. Under nor-mal conditions the coagulability of the blood isincreased after a single haemorrhage (Moon, 1941),whilst blood transfusion has a similar effect.

Methods of Treatment and ResultsUntil recent years the recognized method of

treatment of peptic ulcer haemorrhage was medical,comprising a starvation, morphia, gradually in-creasing diet regime. Later blood transfusion wasadded, at first given rapidly, then by the slowcontinuous drip method of Marriott and Kekwick(1935). Surgery was undertaken only for thosecases which were despaired of under medicaltreatment, and, not unexpectedly, was attended bya huge mortality.The results of this treatment have been widely

discussed and figures for mortality reported fromall parts of the world. They showed a wide varia-tion, ranging from 4.2 per cent. (Crohn andLerner, New York, 1939) to 58 per cent. (Ross,Melbourne, I930), but the average figure lay be-tween 9 and I2 per cent. The following arerepresentative:Mortality Statistics. Starvation RegimeLondon, Aitken .. 1934 I I per cent.Birmingham, Bulmer .. 1932 10.7Denmark, Christiansen 1934 7.9Norway, Frostad .. 1934 9.4Sweden, Mossberg .. 1933 9.0

Germany, Umber .. 1935 9.5Boston, Jankelson .. 1938 9.0San Francisco, Goldman 1937 11.5This method of. treatment therefore has a very

considerable mortality. It is furthermore open tothe grave objection that a number of deaths and

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I78 POST GRADUATE MEDICAL JOURNAL April 1948

considerable morbidity result from the treatmentrather than from the disease. Chest complica-tions are largely responsible for this whilstMeulengracht (1937) vividly describes the miseriesof a patient who died from ascending parotitisafter 8-10 days under strict medical regime.The reversal of the starvation policy in the treat-

ment of ulcer haemorrhage was first suggested byAndresen in I927. His routine included the two-hourly administration of a gelatin-water mixturebut he did not publish the results of his methoduntil I939, when he reported a mortality rate of2.5 per cent. in 120 patients. It remained toMeulengracht (i934) to produce a profound andwidespread impression by his advocacy of animmediately liberal diet in the treatment of pepticulcer haemorrhage. He advocated three-hourlyfeeds of a light, soft diet including tea, cocoa,bread and butter, a variety of soups, minced meatand fish, representing about 2,300 calories, to-gether with alkalis, extract of hyoscyamus andiron. The worse his condition, the greater theimportance laid on the patient taking his feeds;from the first day he was allowed to move about inbed. In 1937, Meulengracht reported 368 con-secutive cases of haematemesis and melaena frompeptic ulcers, acute and chronic, treated on theselines, with a mortality of 1.3 per cent.These claims have been fully substantiated by

subsequent writers. Witts (I937) in a most ex-cellently reasoned article states that patients sotreated look, feel and do much better than anyprevious series he has seen. The followingfigures, from various sources, are representativeof the results obtained :

Mortality Statistics. Prompt FeedingRegimeJones, St. Bartholomew's

Hospital .. .. 939 2.0 per cent.Lineberry, Birmingham .. I937 3.6 ,, ,,Scott, Glasgow .. 1940 3.3 ,Woldman, St. Luke's

Hospital ... .. 94 2.0o ,Thorsted, Detroit .. 1942 2.8 , ,A comparison of the results shown in these two

tables leaves little doubt as to the efficacy of theprompt feeding regime. The following suggestionshave,been put forward as reasons for its success ascompared with the starvation regime :-

I. Peristaltic action is diminished when thestomach contains food.

2. Food neutralizes the gastric juices whichtherefore do not come into contact, un-diluted, with the ulcer.

3. The deleterious effects of deprivation offluid, food and vitamins on shock, clotting

of blood, blood regeneration and con-valescence are avoided.

4. The patient's morale is much improved.Thus the most effective medical treatment at

the present time is a combination of promptfeeding with a moderate calorie, high vitaminvalue diet together with iron, alkalis, anti-spasmodics, moderate doses of morphia and bloodtransfusion by the drip method. In the last tenyears with the development of this treatment, themortality rate of peptic ulcer haemorrhage has beenvery much reduced, in fact to about 3 per cent.It is rare now, therefore, for a patient to die ofthis condition and there is an inclination to acceptthe remaining mortality as inevitable. Meulen-gracht (I937) voices this by stating that with solow a mortality the question of operation does notarise.When figures for surgical treatment of this

condition in past years are quoted with mortalityrates up to Ioo per cent. (Hurst and Ryle, I937),there is a tendency to take the view that thesecases represent the complete failure of surgery inhaemorrhage from gastric and duodenal ulcers.It can be argued with greater truth that, as surgerywas invoked only as a last desperate venture, thefailure lay primarily in not recognizing theseverity of the haemorrhage earlier in its course,before the patient had entered the stage of irre-versible shock.

Is it possible to predict which cases are likely todie from peptic ulcer haemorrhage ?

Statistics from many sources have shown thatulcer haemorrhage is rarely fatal (a) in women,(b) under the age of 45, (c) from acute ulcers, andthat in fatal cases arteriosclerosis is a commonpost-mortem finding (Blackford and Allen, 1942;Thorsted, I942). Cullinan and Price (I932)showed that a recurrent haemorrhage is muchmore likely to be fatal that a first haemorrhage,although Blackford (I942) shows that first haemor-rhages are responsible for 75 per cent. of thefatalities. From these facts it appears that there isa group in which the mortality is considerablyhigher than the average figure, namely, in men (i),over 45 years of age (ii), known to have chroniculcers (iii), which have previously caused grosshaemorrhage (iv), the outlook being furtherworsened by the presence of arteriosclerosis. Thewriter is of the opinion that the mortality figuresin this group would be of very considerable in-terest and may well prove to be in the region of30 per cent.Can anything be learned by division of the cases

into two groups, mild and severe ? Variouscriteria have been put forward to differentiate thetwo. The earlier suggestions such as a red cell

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count below 2,000,000 per c.mm. or a haemo-globin below 40 per cent. have been shown to beunreliable owing to the variability of haemo-dilution after haemorrhage. Such cases are now,in any case, routinely transfused, which furthervitiates the result. Witts (1937) regards as seriousany case in which the blood urea rises above75 mgm. per cent., but this has not been widelyfollowed up. Recent methods of examination ofthe blood promise more reliable information as tothe severity and progress of the case. They in-clude determination of the blood specific gravityby the hanging-drop method of Barbour andHamilton (I926), blood haematocrit readings andthe estimation of plasma protein values. Scudder(1939) showed that in conditions of massive hae-morrhage the blood specific gravity falls from thenormal 1056.6 to 1040 or less. From these orsimilar estimations new criteria may emerge bywhich it will be possible early in the event todifferentiate between mild and severe haemorrhage.

Hinton (1939) proposed a therapeutic test. Hesuggested that, if the haemoglobin level and theblood pressure remain low after the administra-tion of two blood transfusions of 500 cc. each, alarge vessel has been involved and surgery isindicated.Has surgery then a place in the treatment of

ulcer haemorrhage ? Firstly, let us agree that, as alast resort where prolonged haemorrhage hasfailed to respond to the best medical treatment,surgical intervention holds out very slender hope.If, however, this same case be brought to opera-tion earlier in the course of the haemorrhage theoutlook is very different. Finsterer (I939), whofirst advocated immediate operation for massiveulcer haemorrhage reported a mortality of 5.I percent. in 78 cases operated upon within 48 hours ofthe onset of haemorrhage. After 48 hours hismortality rate rose to 29.7 per cent. Gordon-Taylor (1935) in similar circumstances records amortality of 19 per cent. in 32 cases. Rankin(I939,) is of the opinion that surgery is advisable inmassive haemorrhage from a known chronic ulcerwhich has failed to respond to medical treatment,as well as in recurrent haemorrhage, but mostwriters avoid absolute indications stating merelythat operation should be considered.On the surgical side advances have been made in

the fields of rapid and controlled shock therapy,in anaesthesia and in post-operative care. Theoperation of choice is partial gastrectomy with re-moval of the ulcer; if the patient's condition doesnot permit this, the ulcer is exposed by openingthe stomach or duodenum and haemorrhage iscontrolled either by sutures passed under anobvious bleeding vessel, or by mattress sutures

underrunning the whole ulcer. The chief dangersare shock and haemorrhage, ileus and post-operative chest complications. Rapid and con-tinuous blood transfusion, the indwelling gastricor jejunal suction tube and cyclopropane an-aesthesia with its smooth induction, rapid elimina-tion and absence of post-operation vomiting,together with chemotherapy and suction-broncho-scopy if necessary, have done much to diminishthese risks. Provided, therefore, firstly that thepatient is in other respects a good anaestheticrisk: secondly that he has not entered an irre-versible state of shock, and thirdly that a com-petent surgical team, anaesthetist and blood trans-fusion facilities are immediately available, surgeryholds out good hope. The problem revolves roundthe possibility of bringing the serious case tooperation (luring the early stage of the haemor-rhage, that is, within 24 or perhaps 48 hours of itsonset.

ConclusionThe treatment of haemorrhage from chronic

peptic ulcers of the stomach and duodenum iswithout doubt medical. Since the introductionof the prompt feeding regime by Meulengrachtresults have been encouraging and the mor-tality has been greatly reduced. Deaths aretherefore uncommon but they are none the lessdistressing.

If the fatal tendencies of the serious cases can beforetold during the early stages ofthe haemorrhage,surgery, in otherwise healthy individuals, holdsout good hope. In a certain group of cases themortality under medical regime remains high,namely in recurrent haemorrhages in men over45 years of age known to have chronic ulcers,especially in the presence of arteriosclerosis. Inthis group, provided that the patient is otherwisehealthy and that competent surgical, anaestheticand transfusion teams are at hand, operation isindicated within 24-48 hours of the onset ofhaemorrhage.

In first haemorrhages, which are responsiblefor a high proportion of the fatalities in this con-dition, surgery has been advocated, not unreason-ably, in cases of known chronic ulcer which, inspite of full medical treatment, proceed to bleed(Rankin). In general, however, we are as yetunable to form an opinion early in the disease ofthe potentialities of such cases. With furtherresearch, perhaps by a combination of bloodexamination and of a therapeutic test, we may beable to pick out the serious cases within 24 hoursor less of their onset. Surgery may then be ableto play a further part in the reduction of themortality from ulcer haemorrhage.

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POST GRADUATE MEDICAL JOURNAL

2. PERFORATIONGeneral Consideration

Since Mikulicz first closed a perforated ulcer in88o0, the treatment of perforation of peptic ulcers

has been the subject of perennial discussion andenquiry. More especially has this been so inrecent years because the incidence of the conditionhas been shown to be increasing, whilst in spite ofall efforts the mortality in the last ten years hasshown little change, remaining for general hospitalseries in the region of 20-25 per cent. For thepatient, perforation is one of the most agonizingcatastrophies; for the surgeon, it is especially a chal-lenge, because the majority of his cases are usefulmembers of the community in young middle life.

Historically, the death at the Court of LouisXIV, of the Duchess of Orleans, daughter of KingCharles I of England, from a perforated gastriculcer was most vividly described by Madame dela Fayette, and was epitomized by Bossuet inthese famous words: 'O nuit effroyable, oufretentit tout a coup, comme un eclat de tonnerre,cette e tonnante nouvelle: Madame se meurt!Madame est morte !' (Bossuet, 1760).The first successful operation for closure was

performed by Heussner in I892 (Kriege, i892).Braun (I897) introduced the addition of gastro-enterostomy, whilst von Haberer (I919) advisedpartial gastrectomy in suitable cases, a procedurenow popular in certain clinics on the continent.It has long been known, however, that all casesdo not necessarily die without operation. Hall(1892) reported six cases of spontaneous recovery,whilst Blackford (1942) mentions 28 cases treatedby gastric suction through a Levine tube, withoutoperation, with three deaths. Occasional caseshave been similarly treated in this country, withcomparable results (Turner 1945).

It appears to be impossible to estimate satis-factorily what percentage of ulcers perforate, butthere can be no doubt that the incidence of per-foration has greatly increased in the last 20 years(de Bakey, 1940). Furthermore, from beingmainly an affection of women (Brinton, I856 : 68.4per cent. females) it is now largely restricted tomen (92.2 per cent., collected figures, de Bakey;90 per cent., Southend General Hospital). Thediminished incidence of acute ulceration in youngwomen accounts in part for this change, but forthe higher incidence in men some factor in oureveryday life would appear to be responsible.Much evidence points to increased tobacco smok-ing as the important factor. Bager (I929) drawsinteresting parallels between the annual tobaccoconsumption and the perforated ulcer incidence inSweden. Records of the percentages of smokersand non-smokers developing perforations wouldbe of considerable interest.

All age groups are affected, from early infancy(two days, Stern, 1929) to old age (84 years, Kelly,I939), but the majority of cases occur between theages of 20 and 50 years. Judine (I939) shows thatthe average age of duodenal perforations in hisseries was 32 years, whilst that of gastric per-forations was 46 years. A slight seasonal variationwas noticed by him, possibly due to an increaseafter influenza epidemics.There has been much discussion as to whether

perforation of gastric or duodenal ulcers is com-moner. Widely differing figures have been pub-lished. It would appear that-this divergence ofopinion has arisen in part at least, from thedifficulty at operation of defining the exact positionof the pylorus. It is a common experience to findthat a perforation, first thought to be pyloric (andtherefore gastric), on closer inspection proves tobe duodenal. In 54 cases at the Southend GeneralHospital six were gastric, giving a ratio of 8: i infavour of duodenal perforations.

Judine (I939) from careful macro- and micro-scopical examination of stomachs resected for per-foration states that 87.5 per cent. of 928 cases wereduodenal. Other recent figures bear out thispreponderance (de Bakey 1940).

Controversy has raged also over the question,is it the acute or the chronic ulcer which per-forates ? At operation, with the whole area grosslyoedematous, it may be difficult to establish theexact nature of the underlying ulcer. The patient'sprevious history is therefore a more accurate guideand should be enquired into a second time duringconvalescence. In the agony of perforation a manmay well forget earlier comparatively trivialattacks of indigestion. In 54 cases at the SouthendGeneral Hospital 38 gave a definite history ofattacks of dyspepsia (70 per cent.). Higher figuresare common (90 per cent., Graves, 1933 ; 95 percent., Judine, I939). Walton (193q) states that of42 cases which came to autopsy, 41 showed chroniculcers. Chronic ulcers are therefore responsiblefor the majority of perforations, but without doubt,acute ulcers can perforate, and, in so doing, pro-duce their first symptom.The only point of agreement amidst these con-

troversial matters is that it is the anterior ulcerwhich perforates. Posterior ulcers penetrate butrarely perforate. They perforate only (a) into thelesser sac, which is rare, as the sac is usuallyobliterated near the ulcer by adhesions, or (b) byinvolving the superior surface of the stomach orduodenum, and so the general peritoneal cavity.The diagnosis is not as a rule difficult. Dimin-

ished liver dullness, elicited with the chest raised,is an important sign. It can frequently be, con-firmed by an X-ray taken with the patient sitting,when a crescent of gas is seen under the diaphragm.

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A duodenal perforation not infrequently simulatesacute appendicitis, owing to escape of duodenalcontent down the right paracolic gutter; thisprovides one of the commonest sources of error inabdominal diagnosis. It is of interest that althoughthe inflammation produced by perforation of pepticulcers is in close proximity to the diaphragm andis a fruitful source of subphrenic abscess, painreferred to the shoulders is not common (deBakey, I940).Moynihan (1928) pointed out that patients

suffering from perforation are rarely in a state oftrue surgical shock, as shown by rise of pulse rateand fall of blood pressure. He refers to their stateas one of prostration. Soutter (I941) states thatonly 20 of his series of 335 cases showed signs oftrue surgical shock. If true shock is present theprognosis is grave.The bacteriology of the peritoneal exudate has

been extensively studied and has been shown to bevaluable in prognosis. It is now also of consider-able value in influencing 'the choice of chemo-therapy. In the first six hours the fluid is oftensterile, in the second six hours it is usually, andthereafter always, infected. The sterility in theearly stages is probably due to the gastric acidity.As the acid is neutralized after perforation, so thebacteria are able to multiply. The prognosis ismore serious in infected cases. Trout (1935)advocated a study of the bacterial content of themouth, teeth and throat, pointing out that thebacteria in the stomach will correspond to thosein the mouth. This bears out the clinical observa-that the prognosis of a perforation in a patientwith dental sepsis is grave.

TreatmentThe surgical treatment of a perforation of a

peptic ulcer is only an incident, though a majorincident, in a full course of medical treatment.

During the last six years the following routinehas been developed in the treatment of perforationsat the Southend General Hospital:

(i) Pre-operativeAs soon as the diagnosis has been made morphia,

gr. -, or in robust individuals, gr. i, is given. ARyle's tube is then passed through the nose to lieexactly in the lowest point of the stomach. Thepatient is turned and made to lie on his left side,so that any further escape through the perforationis only gaseous. The stomach is then emptied bysuction through the Ryle's tube. If solid food ispresent which cannot be aspirated through a Ryle'stube, a small stomach tube, size 12 or 14 E, replacesit. An intravenous drip infusion is then started,most conveniently into a vein in the middle of theleft forearm, the patient lying on his left side. The

fluid administered at first is plasma, as being nearin composition to the fluid lost into the peritonealcavity. It is continued later with normal salineand 5 per cent. glucose, or by i normal saline with4.3 per cent. glucose according to the estimatedneeds of the patient. The stomach is kept emptyby frequent aspirations, the mouth is cleaned, and,with the drip running, the patient is given 45minutes' rest. If further morphia is thoughtnecessary, small doses are injected without dis-turbance into the drip near the vein.

Although the average case is not suffering fromtrue surgical shock, after such treatment hepresents a very different picture. In place ofagonized anxiety he shows a drowsy, reassuredindifference. A considerable rise of blood pressurehas on occasion been observed, but, in all cases,the mouth is clean, the stomach empty, the bloodchemistry partially righted and the menta! con-dition changed beyond recognition.(2) OperativeThe patient is brought to the theatre with his

eyes covered, the Ryle's, tube in his stomach andthe intravenous drip running. Throughout theoperation the stomach is aspirated at short inter-vals by the anaesthetist.

Local anaesthesia, copsisting of an upper ab-dominal field block with i per cent. novocain(without adrenalin), has been the anaesthetic ofchoice in this series. In exceptionally muscular ornervous cases this has been supplemented withcyclopropane.The incision is made through the inner margin

of the right rectus, centred one half inch to theright of the mid point between the umbilicus andthe sterno-xiphoid junction, that is, over thesurface marking of the pylorus, and is of theshortest convenient length. An average is 31inches. Escape of gas is looked for. Fluid isremoved from the peritoneal cavity by suctionand the liver margin is raised with a Deaver'sretractor in the right upper part of the incision,held by the assistant's right hand. The pylorusnow lies exposed in the centre of the wound, thestomach being empty and flaccid. A gauze stripis placed on the pylorus and, with the index andmiddle fingers of the left hand on this gauze, thepylorus is retracted to the patient's left. Theperforation is thereby brought into view.Without moving the left hand three sutures are

passed through the whole thickness of the duodenalwall, one above, one through and one below theperforation. A suitable piece of omentum isbrought up and laid within the sutures, which arethen tied, thus firmly closing the perforation. Bothcatgut and fine silk have been used for thesesutures.

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Fluid is further removed by suction from theaccessible parts of the abdomen which is closedwithout further manipulation of any kind. In theearlier part of this series closure was effected byburied interrupted sutures of No. 8 plaited silk,including all layers except the skin. The resultsleft room for improvement; wound infection andseparation of the skin edges were not uncommon.A number of stitch sinuses resulted which weretroublesome, but were easily dealt with by theimmediate removal, under local anaesthesia, ofthe offending sutures. Other methods have beenused, including strong silk, linen thread and wirethrough all layers including the skin, as in therepair of a burst abdomen. These wounds arestrong, heal well, but produce unsightly scars.

Drainage of the abdominal cavity has not beenemployed in any case of less than I2 hours' dura-tion. Drainage of the wound has been carriedout in an increasing number of cases in view of thefrequent occurrence of fluid collections. It seemsa rational procedure. After closure the wound iscovered with an Elastoplast dressing which sealsit completely. No bandage or binder is used, inorder to be certain that chest expansion is notimpeded.

(3) Post-operativeThe patient returns to bed with the Ryle's tube

still in his stomach and the intravenous driprunning. Being conscious, after only local an-aesthesia, he is placed immediately in Fowler'sposition and at hourly intervals he is made to movehis arms and legs, to breathe deeply and, with hishand firmly supporting his wound, to cough.Within 48 hours he is expected to sit forwardwithout assistance and to move down the bed andback for his pillows to be arranged. Morphia isgiven in small but repeated doses into the intra-venous drip (gr. i-i). In the early stages inorder to lessen the pain caused, the patient doeshis exercises 30 minutes after an injection ofmorphia. His mouth is cleaned every two hours,but for 48 hours he is allowed to swallow only sipsof clear fluid. These are immediately aspiratedthrough the Ryle's tube by which means thestomach is kept empty and at rest.

Aspirations are continued until the fluid ob-tained from the stomach is clear and auscultationof the abdomen shows that bowel sounds havereturned. This occurs usually in 36-48 hours,when the Ryle's tube is removed. During thistime the patient receives 5 pints of fluid intra-venously each 24 hours. For the most part thisconsists of * normal saline with 4.3 per cent.glucose; to this are added vitamins B and C infull doses, chemotherapy, and at least i pint ofblood or plasma. More recently a sterile solution

of amino acids in the form of a casein hydrolysatesolution has been added to supply, at least inpart, the patient's protein requirements.

Physical signs of poor aeration of the bases ofthe lungs has been a constant finding. If signsof collapse of an area of lung develop the patientis put on the ' stir-up regime' (A.M.A. Subcom.on Anaesth., 1942). He is made to move his armsand legs, to breathe deeply and to cough every15 minutes. Firm percussion over the affectedarea has been tried. If the signs of collapse arenot considerably improved in six hours, suction-bronchoscopy is performed.

Chemotherapy. In the early part of this series nochemotherapy was used. Later, intramuscularsulphapyridine was given to those cases whichshowed evidence of respiratory infection. Recentlysoluble sulphathiazole has been given routinelyintravenously (2 gm., followed by i gm. four-hourly) the course being completed by mouthafter the infusion has been discontinued. Penicillinhas not until now been available.

Diet. After 48 hours, bowel sounds beingpresent and stomach aspirations clear, two-hourlyfeeds are started together with alkalis, anti-spasmodics and phenobarbitone in sufficient doseto keep the patient restful. Alternatively, if thepatient has tolerated his nasal tube well, it is re-inserted into the stomach and a milk drip isstarted. This forms the start of a full course ofmedical treatment. It is needless to say thatsmoking is strictly prohibited.Owing to bed shortage patients in this series

have been allowed home in two to three weeks tocomplete their treatment at home.

DiscussionAlthough patients after perforation are, as

Moynihan said, in a state of prostration ratherthan of true surgical shock, there can be noquestion that one to two hours spent in pre-operative preparation effects a great improvementin their condition. Provided that no furtherleakage is permitted into the peritoneal cavity, thewriter is of the opinion that this time is time wellspent. Leakage is prevented by aspiration of thestomach content and by turning the patient on tohis left side. By this means any remainingstomach content lies to the left, in contact with thegreater curvature, and cannot escape through aperforation on the lesser curvature, at the pylorusor in the duodenum. Furthermore, at operation,the stomach is empty and flaccid.

Local anaesthesia is preferred because by itsmeans the cough reflex is never lost and the patient,being conscious throughout, is able to be proppedup at once on return to bed, to move, to breathedeeply and to cough. If, on account of restless-

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ness, failure of relaxation or the presence of agastric perforation away from the pylorus, localanaesthesia is unsatisfactory it is supplementedby general anaesthesia. Cyclopropane is theanaesthetic of choice owing to smoothness of in-duction, rapid return of consciousness and absenceof post-operative vomiting. It has the furthergreat advantage that within a few hours the patienthas lost all feeling of having been anaesthetized.

In this series the chances have been 8 to i thatthe perforation would be in the first part of theduodenum. The incision has accordingly beenmade through the inner margin of the rightrectus muscle, centred over the pylorus. In mostcases, a length of 3A in. has proved ample. Theincision is placed to the right of the midline forthese reasons, (a) it is placed directly over thepylorus, (b) a few fibres of the rectus muscle lefton the inner side of the incision add strength tothe closure, and (c) the resulting scar does notimpede subsequent surgery should this benecessary. If difficulty is encountered the in-cision is at once prolonged.The method of closure of the perforation

described is the simplest and causes the leastpossible trauma. No exteriorization of the stomachor pylorus, and no further exploration of theabdomen has been permitted. The object of theoperation has been solely to close the perforation.For this reason neither gastro-enterostomy norpartial gastrectomy has been performed. It isimpossible to cause stenosis by the application ofan omental plug.

Practical, rather than theoretical evidence hasyet to be produced that closure by an omentalplug is more likely to be followed by persistenceof the ulcer than other methods. In either casethe ulcer heals by granulation, and so by scartissue. Admittedly this may be slightly less inamount if the size of the ulcer is diminished bysuture. At the same time, sutures introducetension and so more fibrosis.

Strong silk and through and through sutureswere used in closure of the wounds in order to givethe strength particularly needed for early move-ment, breathing exercises and coughing. Themethod used prevents efficient wound drainage.The penalty has been some increase of woundinfection.

In the post-operative treatment morphia hasbeen used freely, but in small doses. Usedjudiciously, the patient being stimulated to move,breathe and cough every hour, the writer holdsthe view that morphia can help to prevent ratherthan to promote chest complications. The im-mediate institution of movements and exercises is

of the first importance in the prevention of chestcomplications.

Rest. The cause of the condition having been,as far as possible, removed at operation by theclosure of the perforation, the acutely inflamedstomach is kept at complete rest until it shows areturn of function. This is achieved by continuoussuction or by repeated aspirations through theRyle's tube which is maintained until (a) the fluidaspirated from the stomach is clear, and (b)auscultation shows that intestinal peristalsis hasrecommenced. Forty-eight hours is an averagetime. Even without fluids by mouth considerablequantities of fluid may be aspirated from thestomach, having reached it by regurgitation fromthe duodenum or by being poured out from theinflamed storrach wall. Fluids given by mouthduring this time only tend to increase this ac-cumulation, to stimulate an inflamed organ andpossibly to produce vomiting which, at all costs,must be avoided.

Fluids. For 48 hours or more under this regimethe patients gastro-intestinal tract is kept entirelyat rest. During this time therefore he must relyentirely for his intake on his intravenous infusion.As far as is possible this should supply all hisrequirements. Fluids are given according to thepatient's needs, 5 pints being an average dailyallowance, but this may be increased if the patientis dehydrated. Plasma is given initially, butthereafter the standard fluid used in this series hasbeen I normal saline with 4.3 per cent. glucosewhich supplies the patient's water, salt and glucoserequirements (Naunton Morgan and Avery Jones,1938). To this are added full doses of the shortterm vitamins B and C and, as already mentioned,chemotherapy. The protein requirements havebeen in part met by the inclusion of i pint ofplasma or better, of whole blood each 24 hours.Recently the protein requirements have been morefully supplied by the addition of amino acids inthe form of a sterile solution of casein hydrolysate(Gaunt, 1943). Much research is being carriedout into the fascinating field of protein require-ments in health and disease. For instance, Croftand Peters (I945) have shown that methionine isparticularly in demand for tissue repair. Suchwork may bear fruit in the near future in the pro-duction of a fluid synthesized to contain all therequirements for metabolism, which may be ofthe greatest value in helping the patient in hisreturn to health.

Chemotherapy. The two chief causes of deathin this condition are (i) peritonitis and (2) lungcomplications (57.2 per cent. and 20.8 per cent.respectively of 952 deaths; de Bakey, 1940). Bothare bacterial in origin. There is good reason,therefore, for the routine use of chemotherapy.

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In this series the drug of choice has been sulpha-thiazole, the soluble form being used in the intra-venous drip, the course being completed by mouthafter the drip has been discontinued. Penicillinmay be valuable. From present knowledge, acombination of penicillin and sulphathiazole maywell prove to be a very potent weapon againstinfection.

Medical Treatment. It cannot be over-em-phasized that the surgical treatment of a per-forated peptic ulcer is only a prelude to a fullcourse of medical treatment. Early in the con-valescence, therefore, a physician is consultedwith regard to medical treatment which consistsessentially of a gradually increasing diet of frequentmilk feeds; together with alkaline powders, anti-spasmodics and sedatives in sufficient dose to makethe patient restful. Phenobarbitone is extremelyuseful in this respect. When the patient is con-valescent he is transferred to the care of thephysician who undertakes the further treatment.After three months the patient returns for aroutine X-ray examination, subsequent treatmentdepending on its findings. In 1,525 cases treatedby closure with an omental plug collected from theliterature by de Bakey (1940) more than half re-mained symptom-free; the remainder developedsubsequent ulcer symptoms, and 17 per cent. ofthe total required further surgical treatment.From these figures there is therefore a more than50 per cent. chance of cure following simpleclosure of a perforation. Strict medical treatmentwill improve this chance.

SummaryThe key to success in the treatment of perfora-

tion of peptic ulcers still lies in the hands of thegeneral practitioner in the shape of early diagnosis.

Surgical treatment is the prelude to a full courseof medical treatment.One to two hours are well spent in pre-operative

preparation.Local anaesthesia supplemented if necessary by

cyclopropane, is the anaesthetic of choice.The operative procedure should be the mini-

mum necessary to close the perforation securely.Drainage of the peritoneal cavity is rarely

necessary in cases of less than I2 hours' duration.Chemotherapy should be used routinely.Early movements and exercise are of the greatest

importance in the prevention of chest com-

plications.Morphia, judiciously used, can prevent rather

than promote chest complications.Over 50 per cent. of cases of perforation sub-

sequently remain symptom-free. For those caseswhich subsequently develop symptoms, further

treatment should be decided upon after dueconsideration, not at the time of perforation.

3. CARCINOMASince early last century it has been recognized

that carcinoma of the stomach may be associatedwith a chronic gastric ulcer. At necropsy ofpatients dying from carcinoma of the stomachunmistakable signs have from time to time beenfound of the presence of a chronic gastric ulcerwhich have been confirmed by a long history ofulcer symptoms. The growth has usually beentoo advanced to state that it arose from the ulcer,but appearances have been suggestive. With thedevelopment of gastric surgery specimens wereobtained showing carcinomata arising obviouslyin the edges of chronic ulcers, a picture morerecently seen in vivo by means of the gastroscope.Histologists have gone further by showing thepresence of carcinoma in the edge of ulcers whichto all macroscopic appearance were benign.

In I909, MacCarty aroused widespread dis-cussion by his statement that 68 per cent. of thegastric ulcers resected at the Mayo Clinic wereassociated with carcinoma, and that 7I per cent. ofthe resected carcinomata of the stomach wereassociated with chronic gastric ulcers. Moynihan(1926) lent some weight to these views by hisstatement that two thirds of his cases of carcinomaof the stomach gave a long history of dyspepsia.In the following years other views were expressed.Morley (1923), for instance, was frankly critical ofthe Mayo Clinic figures. In his series of 50 gastriculcers thought macroscopically to be benign,histological examination showed five to be definitelymalignant and a further six to be ' possibly under-going malignant transformation,' making a totalof 22 per cent. certainly or possibly malignant.Cabot and Adie (I925) in a severely critical articleshowed the enormous variation in the publishedestimates of ulcer-cancer incidence and stated thatmany figures were entirely valueless owing to laxityin pathological diagnosis. In their own series of56 cases diagnosed as simple ulcers, five proved tobe cancerous (9 per cent.). Stewart (I925) report-ing with meticulous histological criteria on 216operation specimens, found I34 simple ulcers, 68carcinomata and 14 ulcer-cancers. He concludedthat 9.5 per cent. of the resected ulcers had there-fore become malignant. Klein (I938) was com-pletely sceptical and on most critical pathologicalgrounds stated that ulcer-cancer is rare, the maindifficulty being the establishment of the existenceof a pre-existing ulcer. More recently Kirklinand MacCarty, jun. (1942), state that between ioand I2 per cent. of all gastric ulcers radiologicallyand macroscopically benign are in fact malignant.

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Finisterer (i939) states that I5.2 per cent. of 487apparently benign gastric ulcers resected by himproved to be malignant. Allen and Welch (I941)state that of 69 ulcers resected by them as benign,30 (43 per cent.) proved histologically to bemalignant. Maingot (I942) found that in anoperative series of 50 apparently benign ulcers inwomen, i i proved to be undergoing malignantchange (22 per cent.).

These figures concern only cases treated sur-gically. They are likely to comprise thereforeonly the more severe chronic ulcers which haveresisted medical treatment. Such operative seriesshould by no means be confused with total serieswhich contain all ulcers referred for treatment.In this latter group, Allen and Welch (I94I)report that of 277 cases originally diagnosed asgastric ulcer, 39 (14 per cent.) finally proved tohave cancer, whilst Judd and Priestley (1943)report on the subsequent history of I46 cases ofgastric ulcer treated, apparently successfully,medically and followed up for at least five years.Of these 146 cases:

46.5 per cent. were cured.15.8 per cent. well on medical regime.4.8 per cent. ulcer shown to persist.

i 1.0 per cent. underwent operation for gastriculcer.

9.6 per cent. developed carcinoma ofstomach.

0o.7 per cent. died from haemorrhage.I I.6 per cent. died from unrelated causes.

These figures are of considerable value. Theyshow the subsequent course of a series of cases ofgastric ulcer treated medically at the Mayo Clinicin which a follow-up study was possible, namely,that 46 per cent. were cured, that a further I5.8per cent. remained well on diet, whilst 9.6 per cent.developed carcinoma of the stomach. It can beobjected that a number of these carcinomata mayhave been unconnected with an ulcer. This mayhave been so, but the figures still show the in-cidence of carcinoma of the stomach in a series ofcases of gastric ulcer. To sum up, therefore,(i) There is clear evidence that an ulcer whichclinically, radiologically and even macroscopicallyappears benign, may in fact be malignant. Theaverage percentage error in diagnosis is at least10 per cent.

(2) To prove the actual development of car-cinoma in a previously benign ulcer of the stomachis impossible. It would involve microscopy ofthe complete original ulcer in order to exclude thepossibility of malignancy from the start. Circum-stantial evidence is, however, very strong. Thedevelopment of carcinoma in 9.6 per cent. ofJudd and Priestley's series of 146 cases treated

originally medically with apparent healing isnoteworthy.

Therapeutic Test. In view of these facts atherapeutic test has been employed in the treat-ment of gastric ulcers. The diagnosis beingestablished by clinical, radiological and gastro-scopical evidence the patient is given a six weeks'course of strict medical treatment. The investi-gations are then repeated. If the ulcer is healedit is considered benign. If improved, but not yethealed, a further six weeks' treatment is prescribedand the investigations are repeated a third time.If still unhealed, the ulcer .is probably malignantanc surgery is indicated. If the ulcer is healed,the patient is allowed up but must continue hismedical regime and must understand that recu-rence of the ulcer is possible and may be serious.He should report at once any return of symptomsand should return for further examination at three-and later six-monthly intervals. These examina-tions are physical, radiological and gastroscopical.Herein lies one of the most useful spheres ofgastroscopy. By its means a recurrence of theulcer or an irregular or nodular appearance at thesite of the scar, indicating an early carcinoma, maybe seen before either symptoms develop or radio-logical signs become positive. If surgical inter-vention is delayed until anorexia, wasting and apalpable mass are present, the chances of cure aretragically small.

In all such cases, therefore, it is of the utmostimportance that routine examination be carriedout at regular intervals. Any recurrence of theulcer indicates (i) that it is malignant or (2) thateven if the ulcer is benign, further medical treat-ment is unlikely to be successful. Recurrence istherefore an indication for surgery.This therapeutic test combined with medical

treatment is, however, by no means infallible.From the writer's experience it is often difficult topersuade a patient of middle or advancing years toattend for routine gastroscopy. He may feel welland be disinclined to see the importance of therepetition of an, at least, unpleasant experience.The writer has seen four such cases, apparentlycured by medical treatment, return later withinoperable carcinomata of the stomach. Again,improvement under medical regime by no meansrules out the possibility of malignancy, as Walters(I942) confirms. Furthermore, a carcinoma maydevelop rapidly between the routine examinations,whilst by no means all patients are capable ofadhering to a regime which includes dieting andrestraint from tobacco and alcohol. Lastly, Juddand Priestley (i943) in a careful follow-up surveyshow that the chances of cure by medical treat-ment are less than 50 per cent.

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Consideration. Under a medical regime there is,in the first place, the danger that the lesion, thoughapparently benign, may in fact be malignant.Errors of diagnosis even in the best hands are notuncommon and amount to some io per cent. of allcases. Secondly, carcinoma may develop sub-sequently. In addition there are risks fromhaemorrhage, perforation, and stenosis, togetheronly a 50 per cent. chance of cure.

In surgical clinics in which the mortality forpartial gastrectomy for gastric ulcer is between3 and 5 per cent. other considerations obtain.The risk of ulcer cancer is here greater than thatof operation. The combined risks of haemorrhage,perforation, and cancer are much greater thanthose of operation in otherwise healthy cases. Thetreatment of chronic gastric ulcer in such casesshould, therefore, it is held, be surgical. Ex-ceptions are made in the case of (i) patients under45 years of age, in whom the risk of cancer and ofother serious complications is small, and (2)patients of advancing years or of infirmity fromother causes in whom the risks of operation aregreat. In these groups medical treatment isadvised but careful follow-up examinations mustbe carried out.Summary. Evidence from a number of sources

shows that, in the diagnosis of chronic gastriculcer, with our present methods of examinationeven in the best hands there is an error of i o percent. At least i in o of such ulcers is in factmalignant. Strong circumstantial evidence existsthat others will become malignant, especially inpatients over the age of 45. The total risk fromthese two sources is without doubt more than 10per cent. and may well prove to be double thatfigure.Where the mortality of gastrectomy is 20 per

cent., the risk of ulcer cancer is of little significancein the choice between medical or surgical treat-ment. Where the mortality of gastrectomy isbetween 3 and 5 per cent. the risk of ulcer cancerbecomes of very considerable significance. Underthese circumstances the combined risks of haemor-rhage, perforation, and cancer in patients of middlelife materially exceed, in otherwise healthy in-dividuals, the risks of gastrectomy.- For suchpatients the treatment of choice is surgical, andonly by means of surgery can the death rate fromulcer cancer be reduced.

In patients under the age of 45, the risks ofcancer as well as those of other serious complica-tions are small. Medical treatment may thereforebe advised but careful follow-up examinations areessential. Recurrence is an indication foroperation.

In patients of advancing years and in those ofpoor health from other causes the risks of surgery

are greater than those of complications andtreatment should again be medical.

4. THE COMPLICATIONS OF OPERA-TION FOR GASTRIC AND DUODENALULCERFor convenience of discussion the complications

of operation for gastric and duodenal ulcer areconsidered in three groups, (i) immediate, oc-curring at or within 24 hours of operation, (2)intermediate, occurring during the remainder ofthe patient's hospital stay, and (3) remote,occurring subsequently.Immediate Complications

i. Collapse under Anaesthesia. During thecourse of anaesthesia collapse may occur fromshock, as in gross primary haemorrhage, fromdeficiency of oxygen which may be due either toan obstructed airway or to an actual failure of theoxygen supply, or from anaesthetic abnormalities.Shock is not a prominent feature in gastric surgery,and with good technique haemorrhage should beminimal. If either is anticipated, an intravenousinfusion should be started before operation, andthrough it sufficient suitable fluid should be givento anticipate the onset of shock. Any blood lossis immediately replaced. At the conclusion ofanaesthesia danger arises from the sudden drop inoxygen tension of the gases respired when the maskis removed. Sudden collapse from anoxia mayfollow. It is wise to bring the patient's B.L.B.mask and oxygen cylinder to the theatre and tocontinue the administration of oxygen forthwith.During the period of recovery from anaesthesia

there is a risk of aspiration of vomitus if anyfluid is allowed to collect in the stomach. Theuse of cyclopropane for anaesthesia greatlyshortens the period of recovery and almost rulesout post-anaesthetic vomiting. The removal of allfluid from the stomach by means of frequentaspiration through an indwelling gastric suctiontube removes the risk.

2. Haemorrhage. Severe primary haemorrhageshould not occur in non-urgent gastric surgery.It is prevented by careful ligation of vessels. Anyblood lost during operation lies either in Ruther-ford-Morison's pouch or under the left side of thediaphragm. An ooze, for instance, from the leftpart of the divided gastrocolic omentum collectsnear the spleen. If such collections are not care-fully sought and removed at the close of operationthey are likely to cause at least post-operativepyrexia and malaise, if not frank subphrenic in-fection. If infections and adhesions are to beavoided, haemostasis must be complete.

Reactionary haemorrhage is possible. If clamps

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are used, their release before the insertion of theanterior sutures of the anastomosis diminishes thisrisk. Anastomosis without clamps, however,combined with under-running the vessels in thegastric submucosa after dividing the seromuscularcoats does everything that is possible to eliminateit. By this method any haemorrhage is im-mediately seen and is immediately controlled.That it is successful is shown by the fact thatstomach aspirations after I2 hours are almostinvariably free from blood.

3. Peritonitis. This may result either fromsoiling at the time of operation or from subsequentleakage from the anastomosis. For the first, theperfection of the aseptic method of anastomosisas advocated by O'Hara (i900), Wangensteen(1942), and by Pannett (I945) may entirely ruleout operative soiling. If this is not attainable,proper preparation of the stomach, repeated aspira-tion during operation by means of the indwellinggastric suction tube, and good technique serve tominimize the chances of infection. Leakage fromthe anastomosis results either from faulty suturingor from stretching of the anastomosis by sub-sequent ileus. The use of three layers of suturesfor the anastomosis, the outer layer consisting ofinterrupted sutures, is a very considerable safe-guard at the time of operation.Acute dilatation of the stomach and upper

intestine which was a fruitful cause of tension onthe anastomosis and so of leakage, is now almosteliminated by means of the indwelling gastricsuction tube. This, a Ryle's tube, is passedthrough the nose two hours before operation andis then used to give the stomach a final wash out.It remains in situ during operation, when it enablesthe anaesthetist to keep the stomach empty, andafter operation, when it serves to keep the stomachat rest, to prevent distension and to provideevidence of the stomach's return to function. Itis removed only when aspirations are clear, whenfluids taken by mouth are evidently passing onfrom the stomach and when auscultation showsthe return of bowel sounds, in fact, usually after36-48 hours.

After a gastro-enterostomy in a case of pyloricobstruction from a duodenal ulcer in a man of 68,I7 pints of fluid were aspirated from the stomachby means of an indwelling suction tube in threedays. The question of the nature of the fluids tobe given intravenously to replace this loss was aninteresting one. The patient recovered.

4. Vomiting and Acute Intestinal Obstruction.With the use of continuous gastric aspiration,vomiting after gastric operations has become rare.It may be troublesome after gastro-enterostomy.It is largely prevented by a well-planned stoma.

If it occurs, it is best treated by keeping thestomach empty and clean and by supplying thepatient's fluid, glucose and vitamin requirementsintravenously. Acute upper intestinal obstructionmay occur at any time after operation. Its onsetis dramatic. The patient collapses, his pulse rateis rapid, his eyes become sunken. The differentialdiagnosis from haemorrhage or general peritonitismay be impossible. Likely causes are a retrogradeintussusception of the jejunum through the stoma,obstruction of a loop of jejunum passing throughthe aperture in the transverse mesocolon or rota-tion of the ascending or descending loops in ananterior anastomosis.

In a recent case after a difficult partial gas-trectomy with an anterior Polya anastomosis fora large chronic gastric ulcer, the patient's progressfor 20 hours was good. He then suddenly col-lapsed. His face was blanched, his eyes sunken,his pulse rate i6o; he complained of pain in theepigastrium. The abdomen revealed only someepigastric tenderness. He died four hours later.Autopsy showed that the proximal loop, from theduodeno-jejunal flexure to the anastomosis, hadfallen back and to the left behind the distal loop,and was acutely obstructed behind the mesenteryof the jejunum forming the anastomosis. It thusformed a closed loop obstruction. This could havebeen prevented by the use of the Y-shaped suctiontube suggested by Wangensteen (1942), or bypassing the tube at operation beyond the anasto-mosis into the proximal loop and subsequentlyusing a second tube to aspirate the stomach.

5. Chest Complications. These are includedadvisedly in the immediate group. It is whilstthe cough reflex and the respiratory movementsare impaired that the foundations of almost allchest complications are laid.

Before operation it is important to rule out pre-existing chest disease and to eliminate septic focifrom the teeth. Throughout anaesthesia the air-way must be unimpeded; this is best achievedby means of an intratracheal tube. The effects ofanaesthesia should preferably be quickly dispelledso that the patient may sit up soon after his returnfrom the theatre and the aeration of the bases ofhis lungs may be thereby improved. There shouldbe no post-operative vomiting. In these tworespects cyclopropane is invaluable.The operation itself (i) must be sound and

should not give rise to a severe peritoneal inflam-mation which will impair the movement of thediaphragm, and (2) the wound must be well andstrongly sutured to allow early movement andexercises. Mimpriss (1944) emphasizes thesepoints.

After operation, as soon as the patient becomesrestless, morphia is given freely but in moderate

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doses, usually gr. i, at once followed by gr. t,repeated when necessary. Thirty minutes afterhis injection the patient is made to move his kneesup and down as in cycling, to do deep breathingexercises and, with his hands firmly supportinghis wound, to cough. At two-hourly intervals heis stimulated to move, to breathe and to cough upany sputum which may be present. Within 24hours of operation he is expected to be able to sitforward by himself. This immediate movementregime is carried out largely by the nursing staffand involves a certain amount of bullying. If theexercises are carried out at first half an hour afterinjections of morphia, however, the pain is re-lieved. After doing his exercises and clearing hisbronchi the patient sinks back into a sound andrefreshing sleep.

In the opinion of the writer morphia used in thisway prevents, rather than promotes, chest com-plications.

In the immediate post-operative period signs ofpoor air entry to the bases of the lungs are to beexpected. Signs of an area of collapse must becarefully sought. If they appear, the full' stir-up 'regime (A.M.A. Subcom. on Anaesthesia, I942)is employed, the patient being made to move,breathe, and cough every I5 minutes. If thesigns of collapse do not rapidly improve, suction-bronchoscopy is employed.

Provided that the lungs were previously healthythe response to this routine is satisfactory. Inheavy smokers and in cases of chronic bronchitisthe patient has difficulty and pain in coughing upthick, purulent sputum and sinks back exhaustedafter the effort. In such cases it is better to spendthree weeks in pre-operative treatment for the cheatcondition, than to spend three months coughingup a lung abscess and developing an incisionalhernia.

6. Venous Thrombosis. Here, again, the founda-tions of trouble are laid 'during the period ofimmobilization. To prevent thrombosis, there-fore, as soon as the patient is conscious he is madeto move his arms and legs and, as soon as possible,he is expected to help himself up and down thebed whilst his pillows are rearranged. No knee-pillow is permitted because :-

(i) It impedes the venous return in the poplitealveins during sleep, and

(ii) it prevents full movement of the legsduring exercise.

Admittedly the patient tends to slip down fromthe full Fowler position whilst asleep, but this iscounteracted by nursing care at least two-hourly,and the exercise involved in returning to thecorrect position is by no means harmful.

Intermediate Complicationsi. Chest Complications. In this group, chest

complications are of first importance. Mimpriss(I944) gives an excellent account of the complica-tions he met in ioo consecutive cases of gastrec-tomy. He divides them into (i) bronchitis, (2)lobar atelectasis, and (3) lobular atelectasis.Bronchitis is the commonest post-operative chestcomplication and is usually an exacerbation of apre-existing condition. It may cause the patientmuch pain in coughing but, by all possible means,he should be encouraged to cough up any sputumwhich may be present. Lobar atelectasis is rare,but its presence should be carefully sought at leasttwice daily. If it develops it is treated at once bythe ' stir-up' regime previously described and,if necessary, by suction-bronchoscopy. Lobularatelectasis, as Brock (1936) pointed out, is acommon post-operative development, the fre-quency of its diagnosis depending on whether thesurgeon is looking for it. Mimpriss found it in29 of his ioo cases, but shows that in 25 it provedto be mild and transitory. In the remaining fourcases it progressed to more serious conditions,bronchopneumonia in three and empyema in one,but three of these cases were associated withserious infection below the diaphragm. In onlyone case uncomplicated by abdominal infectiondid the lobular atelectasis proceed to a fatalbronchopneumonia.

If signs of infection or atelectasis develop,chemotherapy is instituted immediately. Sulpha-thiazole, in the writer's experience, has been thedrug of choice and is given in full doses intra-venously or, later, by mouth. It has entirelyaltered the prognosis of infective chest com-plications.

2. The Wound. Wound infections result fromlack of care at operation in allowing spillage ofgastric content, in imperfect protection of thewound edges with impermeable packs or in in-complete haemostasis. Serous collections in thewound are more common with catgut but are lessserious than with silk, which may cause a sinusuntil the offending stitch is removed. Providedthat the wound is well and truly sutured a burstabdomen is a rare complication of operations forpeptic ulcer. If it occurs it is the result of cough-ing combined with wound infection. Where thewound is covered with an occlusive dressing thefirst sign of separation of the wound edges is anout-pouring of fluid which soaks through thedressing. Its significance may not be immediatelyappreciated. Treatment consists of immediateresuture of the wound with strong silk or wirethrough all layers including the skin. Such woundsheal well but leave unsightly scars with ' cross-

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hatching.' Strong arguments can be advanced forthe primary closure of the wound by this method inall cases of carcinoma, of chronic bronchitis and inelderly, or for other reasons, frail patients.

3. Subphrenic Abscess. This is a rare complica-tion. It may arise from (i) subsequent infectionof blood collections not removed at operation,(2) spillage of content from a badly preparedstomach, (3) the base of an ulcer left in the pan-creas or liver, (4) injury to the common bile duct,(5) leakage from an imperfect anastomosis or (6)bursting of the duodenal stump. A duodenalfistula may follow. Such fistulae may heal spon-taneously; continuous suctibn is of the greatestvalue in treatment.

4. Diarrhoea. This is a common sequel ofgastric operations and may cause the patient muchinconvenience. It commonly starts five to sevendays after operation and lasts three days or more.If it were due to absence of acid from the stomach,the administration of hydrochloric acid by mouthshould be effective. If purely bacterial in origin,it might be susceptible to sulphaguanidine orsulphasuxidine. All three are useless. It appearsmore likely that the diarrhoea is due to an un-accustomed irritation of the small bowel, eitherphysical or chemical, by food not previouslypartially digested in the stomach. This wouldexplain the fact that the best treatment at presentappears to be a temporary limitation of diet com-bined with kaolin and a soothing mixture. Pre-digested foods may prove to be of value.

5. Thrombophlebitis. With movement andstimulation of the patient from the earliestpossible movement after operation, this complica-tion is rare. When it has occurred it has resultedfrom intravenous therapy and has been caused byimperfect asepsis either at the time of insertion ofthe needle or cannula, or in subsequent care. Ifit occurs heparin, or possibly dicoumarin, shouldbe used to prevent further thrombosis, the bloodcoagulation time being carefully checked.

6. The Anastomosis. In any non-urgent opera-tion for a gastric or duodenal ulcer the stomachshould be well prepared and its walls should behealthy. There is, therefore, no excuse for leak-age. The greatest safeguard in this respect is athree-layer anastomosis, the outer layer consistingof interrupted, preferably mattress, non-absorb-able, seromuscular sutures which take the weightof the jejunum, thus preventing any tension on theinner catgut layers. Great care is taken at theupper and lower angles of the stoma to see thatthe inner sutures are complete and reach wellabove and below the incisions in the jejunum andstomach.A well-planned anastomosis should function

satisfactorily as soon as the stomach and jejunumreturn to activity. Occasionally after gastrectomythe patient complains of discomfort after food inthe left upper quadrant of the abdomen. Thisusually subsides within ten days and has beenascribed to jejunitis. X-ray confirmation of thisdiagnosis may be obtained in the shape of' feathering ' of the upper jejunum;Remote Complications

i. Anastomotic Ulcer. This complication mayfollow any operation in which gastric and jejunalmucosa become continuous. Its incidence ishighest in operations in which the bile is divertedfrom the anastomosis, as in the Roux-in-Y opera-tion, now abandoned. This has been confirmedin animal experiments in which the bile has beendiverted to the ileum, in which case ulceration islikely to occur throughout the jejunum.

After gastrojejunostomy the incidence of anasto-motic ulceration has been estimated varingly upto 32 per cent. (Marshall, 1942), occurring par-ticularly in young men having a high gastricacidity. After partial gastrectomy, it was found tobe not uncommon after operations in which themucous membrane of the pylorus and of thepyloric antrum were not removed (Ogilvie, 1938;Kiefer, I942). It may occur after more completegastrectomies but its incidence is rare. If it doesoccur it is probably an indication that an insuf-ficient amount of stomach has been removed,leaving sufficient acid-producing area to producefurther ulceration.An anastomotic ulcer is situated on the line of

the anastomosis or immediately beyond it in thedistal loop of the jejunum. It has all the charac-teristics of a gastric or duodenal ulcer, is likely tobe associated with inflammation and spasm of theanastomosis and is liable to haemorrhage, to per-foration and, by adhesion to the transverse colon,to form a gastro-jejuno-colic fistula.

Clinically, if anastomatic ulceration is to occur,it does so usually within a year of the primaryanastomosis. It gives rise to typical symptoms,namely, pain to the left of the umbilicus, severeand gnawing in character, not necessarily relatedto food, but making the patient afraid to eat andcausing considerable loss of weight. The painmay make life a burden. Occult blood is con-stantly present in the stools. Frank haemorrhagemay occur at any time. If perforation occurs, theanastomosis being posterior, the escaping fluid liesbeneath the shelf of the transverse mesocolon andpasses down to the left iliac fossa, where tender-ness and rigidity are most marked. The upperabdomen is protected by the mesocolon and maybe relatively little involved.

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In the presence of a chronic stomal ulcer, theoverlying transverse colon is liable to be involvedat first in adhesions, later in the actual ulcerativeprocess. The results of the formation of a gastro-jejuno-colic fistula are serious. The patientdevelops a persistent diarrhoea with the passage ofundigested food in the stools, he has an unbearablehallitosis, loses weight rapidly, and may developnutritional oedema. There are few states morepitiable. Barium taken by mouth may be shownto pass immediately into the colon, whilst a bariumenema may at once outline the stomach. Thelatter is often better seen.

Treatment. The medical treatment of anasto-motic ulceration has proved disappointing. Im-provement and relief of symptoms may be obtainedbut, even with complete adherence to a medicalregime, symptoms are likely to recur and thepatient to become a semi-invalid. He is unableto work and his life revolves round his diet, hissleep, and his bowels.

Surgical treatment, on the other hand, offers agood chance of cure. The operation of choice issub-total gastrectomy, removing a large proportionof the acid-bearing area of the stomach, andclosing the jejunal stoma with or without resection.

If the gastro-jejunostomy has been done withouta loop, the separation of the proximal portion ofjejunum may be the most difficult part of theoperation. If a loop is present, separation of theanastomosis may be much simpler. Great caremust be taken not to damage the middle colicvessels. The jejunal opening may be closed mostsimply by repairing it transversely, in ratherlonger time by the method of Pauchet (I934) or,if necessary, by resection and end-to-end anasto-mosis. The jejunum distal to this closure is usedfor the subsequent anastomosis, which, in view ofthe necessarily wide resection of stomach, is bestof the anterior Polya type. With good anaesthesiaand transfusion facilities the mortality of thisoperation in skilled hands is low. Marshall (i944)quotes 62 cases with three deaths, representinga mortality rate of 4.8 per cent.Haemorrhage from an anastomotic ulcer is

treated as from a gastric or duodenal ulcer. Theoutlook of recurrent haemorrhages is poor;resection is advisable.The serious results of a gastro-jejuno-colic fistula

are not due to the loss of gastric content into thecolon, but are due to persistent gastro-enteritiscaused by faecal contamination of the stomach.The whole bowel is in a constant state of acuteinflammation. This is proved by the strikingimprovement effected by a defunctioning colos-tomy. At a preliminary operation the hepaticflexure is mobilized and brought out as a Paul-

Mikulicz colostomy through a right-sided obliqueor transverse incision. If the area of the fistulacan be inspected with retraction, the whole areais seen to be grossly inflamed and oedematous.For a week or two after opening this colostomythe still inflamed intestine pours forth fluid faeces,and the skin around the colostomy may becomered unless this possibility is carefully foreseen.The patient and his attendants may lose heart andfeel that the colostomy was useless. With dailywashouts, however, both from the colostomy andfrom the rectum, the distal loop of colon graduallybecomes clean and contains only a small amount offluid which has passed through the fistula. Nofurther faecal contamination of the stomach occursand gradually the inflammation of the wholeintestine subsides, colostomy actions becomefewer, and the patient's condition improves. Heloses his hallitosis and oedema, his appetitebecomes excellent, he puts on weight and feelsvastly improved. It should be noted that theimprovement after colostomy is not immediate.

Six to eight weeks after the preliminary colos-tomy, the second operation is performed. Anintravenous infusion is maintained throughout theoperation. The inflammation noted at the timeof colostomy has subsided. The first problem isthe separation of the colon. Only a small areaof it is usually involved and can be dealt withsimply by inversion. The bowel being defunc-tioned, little risk arises from this source. Theremainder of the operation is as for an uncom-plicated gastro-jejunal ulcer.Ten days after the gastrectomy the spur of the

colostomy is crushed, restoring the continuity ofthe colon, and three weeks later the colostomy isclosed extraperitoneally, with careful inversion ofits margins. Delayed primary suture has beenfound of much value in closing these wounds.

Objections to this routine of treatment are,firstly that it involves at least three months inhospital, secondly, that it involves the unpleasant-ness of a colostomy, and, thirdly, that it requiresthree stage operations. These are, however, theprice the patient has to pay for safety in the shapeof a greatly reduced mortality, as compared tothat of the one-stage operation. There is no moregrateful patient than a man who has been curedof a gastro-jejuno-colic fistula.

2. Post-gastrectomy Dyspepsias. The conditionof patients after gastrectomy for gastric andduodenal ulcer has been the subject of much dis-cussion. It is generally agreed that, for gastriculcer, the results are almost uniformly satisfactory.For duodenal ulcer, after the Polya type of anasto-mosis occasional cases occur in which the patientcomplains of a feeling of distension soon after food

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April 1948 MONRO : The Complications of Gastric and Duodenal Ulcer 191

and even retching and vomiting may occur. Abarium meal in these cases usually shows that theanastomosis is lying transversely and that a con-siderable part of the meal has passed into theconsiderable part of the meal has passed into theproximal blind loop of the duodenum. Suchpatients often find that after a meal they have tolie down for a time, preferably on the left side,after which the distension is relieved and they feelwell again. The discomfort may make the patientafraid to eat. This symptom tends to diminishwith time as the patient learns to adjust his diet.It may be avoided by placing the stoma obliquely,proximal jejunum to lesser curvature, with theproximal loop brought up to the upper part of thelesser curvature well above the anastomosis. Foodis thereby diverted into the distal loop of thejejunum and so, without obstruction, into 21 feetof small intestine. The effect may be increasedby closing the upper half of the cut surface of thestomach, which acts as a valve, directing the fooddistally (Hofmeister, I905). The results of thisoperation have proved satisfactory, the patientsbeing subsequently well and able to eat, drinkand smoke as they please, provided that the resec-tion has been sufficiently radical in removing theacid-bearing portion of the stomach.

3. Post-gastrectomy Anaemia. Since the recog-nition of the fact that, provided the resection hasbeen sufficiently radical, subsequent dieting isunnecessary, anaemias, both micro- and macro-scopic, have been almost unknown. Occasionallyadministration of iron for a few weeks after opera-tion may help the patient to restore his haemo-globin, but its continued administration is seldomnecessary. The writer has yet to see a case ofmacrocytic anaemia following gastrectomy.

4. Incisional Hernia. The great cause of in-cisional hernia is wound infection. With goodtechnique this should be rare. With the evolutionof aseptic anastomosis it may be eliminated. Inorder to be able to move the patient immediatelyafter operation and to make him do breathing andcoughing exercises, a strong closure is essential.Buried interrupted silk sutures through all layersexcept the skin give the strongest possible closure.With this method of closure one can with con-fidence assure the patient that he will not damagehis wound by coughing. Silk is, however, liableto cause sinuses which persist until the silk isremoved. Catgut is not liable to sinus formation,but does not give such a strong closure.

SummaryIn undergoing any operation for gastric or

duodenal ulcer, the patient runs the risk of anumber of complications. These may prove fatal

or they may cause merely a hitch in the smoothprogress of his convalescence. In either case withproper knowledge they should be largely avoidable.

In the prevention of chest conrplications whichare the patient's greatest enemy, four factors areof prime importance :

I. Careful pre-operative preparation with specialcare to rule out pre-existing chest disease.

2. Good anaesthesia, allowing rapid return ofconsciousness and not being followed byvomiting.

3. Sound operative technique, preventing peri-toneal soiling.

4. The 'stir-up' regime, which aims at rapidand complete re-expansion of the lungs. Itfurther has the advantage of restoring thevenous circulation and so of reducing theincidence of venous thrombosis. Lastly,the indwelling gastric suction tube haseliminated the danger of tension on thesuture line caused by upper intestinal ileus.

In this field, above all, prevention is better thancure.

BIBLIOGRAPHY

I. HAEMORRHAGEAITKEN, R. S. (I934), Lancet, x, 839.ANDRESEN, A. F. R. (1939), Am. J. Digest. Dis., 6, 641.BARBOUR, H. G., and HAMILTON, W. F. (I926), Jour. Biol.

Chem., 69, 625.BLACKFORD, J. M., and ALLEN, A. (I942), J.A.M.A., Iao, S x.BULMER, E. (I932), Lancet, 2, 720.CHRISTIANSEN, T. (I935), Acta Med. Scand., 84, 374.CROHN, B. B., and LERNER, H. H. (I939), Am. y. Digest. Dis.,

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Rep., 65, 185.FINSTERER, H. (I939), Surg., Gyn. Obst., 69, 291.FROSTAD, S. (I934), Norsk. Mag. Laegevidensk, 95, 578.GOLDMAN, L. (1938), Am. J. Surg., 40, 545.GORDON-TAYLOR, G. (1935), Lancet, 2, 8Ix.HINTON, J. W. (939), Ann. Surg., 10o, 376.HURST, A. F., and RYLE, J. A. (I937), Lancet, I, I.JANKELSON, I. R., and SIEGEL, M. A. (1938), New Eng. J.

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192 POST GRADUATE MEDICAL JOURNAL April 1948BLACKFORD, J. M. (1942), J.A.M.A., 120, 825.BOSSUET, Oraisons Funebres (Hachette. Boulevard, St. Germain,

Paris).BRAUN, H. (1897), Zentralb. f. Chir., 24, 739.BRINTON, W. (1856), Brit. and For. Med.-Chir. Rev., 17, 159.CROFT, P. B., and PETERS, Prof. R. A. (March 3rd, 1945),

Lancet, 266. |DE BAKEY, M. (1940), Surgery, 8, 852 and Io28.GAUNT (I943-44), Nutrition Abstracts and Reviews, 13, 50I.GRAVES, A. (1933), Ann. Surg 98, 197.HALL, W. W. (I892), Brit. Med. Jour., I, 64.JUDINE, S. (1939), J. internat. de Chir., 4, 219.KELLY, M. W. (1939), Surgery, 6, 524.KRIEGE, H. (I892), Berlin Klin. Wchnschr., 29, 1244.MIKULICZ, J. (1897), Zentralbl. f. Chir., 24, 69.MORGAN, C. N., and AVERY JONES, F. (X939), Lancet, 2, 6ix.MOYNIHAN, SIR BERKELEY (W. B. Saunders Co., 1926),

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AND DUODENAL ULCERA.M.A. SUBCOM. ON ANAES. (A.M.A. Press, Chicago, 1944),

Fundamentals of Anaesthesia, I65.BROCK, R. C. (1936), Guy's Hosp. Rep., 86, I91.HOFMEISTER, quoted by Spivak (1936) in The Surgical Technic.

of Abdominal Operations, 431-436.KIEFER, E. D. (1942), Jour. A.M.A., 120, 819.MARSHALL, S. F, (1942), Surg. Clin. North. Am., 24, 624.MIMPRISS, T. W., and ETHERIDGE, F. G. (Oct., 1944), Brit.

Med. Jour., 466.OGILVIE, W. H. (1938), Lancet, 2, 295.O'HARA, J. W. (1990), Am. your. Obst. (St. Louis), 42, 8I.PANNETT, C. A. (1945), Brit. Your. Surg., 32, 418.PAUCHET (x934), Pratique chir., 19, 132.WANGENSTEEN, Prof. O. H. (Chas. Thomas, Springfield, Illinois,

1942), Intestinal Obstructions, 232.

A NEW JOURNALWe have just received a copy of a Journal which

is at once both new and old. It is the.first Britishnumber of The Journal of Bone and Joint Surgerywhich will in future be published alternately inBoston and London.

This publication fills a long felt want in thiscountry where there has been no Journal devotedexclusively to orthopaedic and fracture surgery.It has been produced in complete conformity withits American cousin and probably most subscriberswill bind both issues together, thus obtaining arecord of modem orthopaedic surgery as it ispractised on both sides of the Atlantic.

It augurs well for the future of this venture thatthe British Editor is Sir Reginal Watson-Jones,and the Chairman of the Editorial Board, Sir HarryPlatt. They are assisted by an Editorial Boardmade up of leading orthopaedic surgeons in thiscountry, Australia, Canada, New Zealand andSouth Africa. His Majesty the King has conveyedhis best wishes for the success of this new pub-lication in a letter which is printed as a frontispiece.The editorials describe how the British Journal

of Bone and Joint Surgery was born and introducea symposium of articles on the treatment of recur-rent dislocation of the shoulder. The latter arecontributed by no less than twelve authors rangingfrom Toronto to Stockholm, seven being fromLondon. Smith-Petersen of Boston contributes acharacteristically forceful account of the Evolution

of Mould Arthroplasty of the Hip Joint, an oper-ration which he has introduced and perfectedduring many years. It is based on a MoynihanLecture delivered in the University of Leeds lastMay, and W. E. Gallie's article on RecurringDislocation of the Shoulder is likewise based on aMoynihan Iecture given at the Royal College ofSurgeons in September.K. I. Nissen writes on Morton's Metatarsalgiaand in a lucid and well documented article des-

cribes the results he has obtained by local resectionof the plantar digital nerves on 35 occasions.There are numerous other valuable contributions,but quite outstanding amongst them is Sir ThomasFairbank's review of Osteogenesis Imperfecta,which is illustrated by thirteen cases of this rarebut interesting condition. Sir Thomas's know-ledge of bone diseases must be well nigh un-rivalled in this country, and one hopes that thisarticle one day may form a single chapter in anatlas of skeletal affections by this author.The new Journal also contains very full accounts

of current orthopaedic meetings in Great Britainand the Dominions and in addition some inter-esting historical footnotes. An enormous amountof care has been expended in publishing thisperiodical and the excellence of the printing andreproductions is one of its notable features. Weare delighted to welcome our new contemporary,and we wish it the success which it well deserves.

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the complications of gastric and duodenal ulcermeulengracht (i934) to produce a profound and...

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