November 1948 CRAIG: The Changing Nature of Gastric and Duodenal Ulceration 593

tions a waste of time and effort. Examination ofthe blood is, perhaps, a wise precaution; but sero-logical tests and E.S.R. estimations are very rarelyhelpful. In my patients radiography of the chestand tuberculin tests contributed nothing towardsthe elucidation of the problem, though the case isarguable for carrying them out on all childrensuffering from any symptoms whatsoever. Suchprocedures as blood-sugar estimations, sigmoid-oscopy, and intravenous pyelography (which werecarried out in a few cases) have proved unjusti-fiable in the absence of positive indications.

It will be seen from the above discussion that inthe vast majority of cases simple investigations,which are readily carried out in one interview,alone prove necessary.

Conclusions' Umbilical colic,' the recurrent peri-umbilical

pain of childhood is, in the large majority of cases,

due to non-specific mesenteric lymphadenitis.Nevertheless, umbilical colic may be the expres.sion of other, and more serious lesions, and theseshould be excluded. The process of eliminationcan almost always be completed during the courseof one clinical examination together with anaccurate history, and aided by a few simpleancillary investigations.

BIBLIOGRAPHYCAMERON, H. C. (I946), 'The Nervous Child.' London.FITZSIMONS, J. (I946), N.Z. Med. Journ., 45, 248.KINSELLA, V. J. (I940), Brit. Journ. Surg., 27, 449.MAITLAND-JONES, A. G. (1947), 'Diseases of Children.' (Garrod

Batten and Thursfield), Vol. I, London.MALLOY, H. R. et al. (I945), Amer. _'ourn. Surg., 67, 8i.MORLEY, J. (I93I), 'Abdominal Pain,' Edinburgh.POSTLEWAIT, R. W. et al. (I942), Amer. Journ. Surg., 57, 304.RAY, B. S. and NEILL, C. L. (I947), Ann. Surg., 126, 709.ROSENBURG, S. (I937), Arch. Surg., 36, 28.SHORT, A. R. (I928), Lancet, 2, 909.TALBOT and BROWN (I920), Amer. _ourn. Dis. Child., 2o, I68.TOVERUD, K. U. (I925), Brit. _ourn. Child. Dis., 33, 22.

THE CHANGING NATURE OF GASTRIC ANDDUODENAL ULCERATION

By J. DONALDSON CRAIG, M.D., M.R.C.P.Research Fellow in Medicine, St. Mary's Hospital, Medical School

'There are gastric ulcers and there are duodenalulcers. The differences between them are notmerely geographical. In my opinion no realadvance in our knowledge of the aetiology, clinicalmanifestations or treatment of these two diseases,gastric ulcer and duodenal ulcer, will be made ifwe speak of them as one.'

MOYNIHAN. (I 928).

IntroductionAcquired disease is the product of disharmony

between constitutional and environmental factors.It is therefore to be expected that in the course ofthe years there should be considerable change inthe nature, prevalence and distribution of manydiseases. In the present survey, an attempt hasbeen made to trace the evolution of gastric andduodenal ulceration from earliest times to thepresent day.From this review, it emerges that not only have

the total incidence, the age and sex distributionand the clinical picture of peptic ulcerationchanged very considerably, but that the evolutionof gastric and of duodenal ulcer have been along

very different lines. It is therefore suggested thatalthough, as postulated by Hurst, individual con-stitutional variations may play a large part in thegenesis of peptic ulcer, environmental factors areof even greater importance, and it is to such factorsthat attention should be directed in an attempt tocontrol these diseases. Further, the history of thedevelopment of gastric and duodenal ulcerationthrough the ages being so distinct, one is inclinedto suspect that the differences between the twoprincipal types of ulcer are more than geographical.It should not therefore be too readily assumed thatgastric and duodenal ulceration are of entirelysimilar pathogeaesis.

The Classical Period and Middle AgesThe earliest reference to gastric disease is found

in the Ebers Papyrus (circa I500. B.C.) in whichcancer of the stomach is mentioned. Hippocrateswas familiar with haematemesis and melaena, bothof which he regarded as of serious import, partic-ularly if associated with fever, but there is nothingin his writings to suggest that he recognized theulcer syndrome. Gastric ulceration as such is first

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mentioned by Celsus, in his ' de Medecina'(A.D. 30). Dealing with the rules governing dietfor the preservation of health, he wrote, ' but ifulceration attack the stomach . . . milk and glutin-ous food are given, but not to satiety ; all acrid andacid things are withheld.' It is tempting to believethat this fundamentally sound counsel was basedupon actual observation of cases of gastric ulceroccurring in the upper strata of Roman society inwhich he practised, but this is the sole referencewhich can be found. Careful search has failed todiscover either clinical or pathological descriptionof the condition and his advice would be equallyvalid for the dyspepsia, which, it may legitimatelybe inferred, was liable to follow over-indulgencesin food and drink. Galen (A.D. 131-200), refer-ring to the prevalence of dyspepsia, mentionedhaematemesis, and gave recognizable descriptionsof both dysenteric intestinal ulceration and hepaticcirrhosis, but he did not mention gastric ulceration.By this time dissection of the human body hadbeen declared illegal, a disadvantage which wouldeffectively prevent the recognition of gastric ulcer.It was not until the fifteenth century, in Italy, thathuman dissection appears to have become at all acommon practice again, and it is therefore notsurprising that all consulted writings of the middleages are devoid of references to the study of gastricpathology, a subject which does not reappear inthe literature until the end of the sixteenth century.

The Sixteenth to Eighteenth CenturiesThe writings of many morbid anatomists during

this period are open to the suspicion that they werebased more upon imagination than actual observ-ation. Such was the delay in carrying out post-mortem examination, in many instances, that evenJohn Hunter regarded as normal the finding ofgastric contents in the peritoneal cavity, thestomach having undergone self-digestion afterdissolution of ' the vital principle ' which normallyprotected it from this fate. Clearly then, no signif-icance can be attached to absence of accounts ofpeptic ulceration from the works of many of thewriters of this period. These shortcomings werehowever, by no means universal, and by the endof the i8th century the literature contained severalcarefully documented case histories of fatal pepticulcer, writings which have the ring of truth aboutthem and present every evidence of having beencompiled by reliable witnesses. The earliest casehistory of this period is that recorded by MarcellusDonatus of Mantua in 1586. Describing his post-mortem examination of a fatal case of pyloricstenosis he wrote, ' at the pylorus or lower orificewe found that the inner coating was ulcerated,and we had no doubt that this had been the causeof the malady.' The antecedent history briefly

outlined is suggestive of a diagnosis of gastriccarcinoma rather than of simple ulceration. Thesignificant point is that this is not only the earliestrecord of a case of pyloric stenosis but the onlyexample which has come to light in a thoroughsearch of the literature over many years of thisperiod.One other case history is perhaps worth recount-

ing in some detail, for its historical as well as itsmedical interest. Ironically, this, the first des-cription of the clinical features of perforationcomes, not from the profession but from a lay-woman, Madame de la Fayette, lady-in-waitingto Princess Henrietta Maria, daughter of Charles Iof England and wife of Philip, Duke of Orleans.The Princess, 26 years of age, had always been offrail constitution, subject to recurrent attacks ofright-sided pain. While staying at the Court ofVersailles, she ate a large midday meal and, as washer wont, retired to her couch for the afternoon.On awaking she complained of a return of herabdominal pain and was given a cup of chicorywater to produce relief. Immediately after drink-ing it she collapsed, crying out in pain, and' turnedpale with a wan lividity which astonished us.'The royal physician, on being called, tactfullydiagnosed the illness as an attack of colic, and thenapparently proceeded to treat her as a case ofpoisoning. His insight into the ways of his royalbetters, however, was, this once, unrewarded, forthe carminative and purgative oils which he pres-cribed merely increased the poor lady's pain, andshe died after drinking a bowl of soup, just ninehours from the onset of her collapse. It appearsthat attendance at post-mortem examination atthat time was one of the duties or privileges of thespiritual adviser of the deceased, for we have anaccount of the autopsy from Bossuet, who sur-passed even htis normal flight of eloquen-ce inmaking the funeral oration, in which he gave darkhints of his belief that death had come from poison-ing. A fairly full account of the necropsy findingsis contained in the ' Memoirs of a Surgeon to theKing of England, who was present at the Openingof the Body of Madame.' Foetid gas escaped whenthe abdomen was opened; the omentum wasgangrenous, the intestines discoloured; the peri-toneal cavity contained a large quantity of oilyfluid but, in contrast with the intestines, thestomach was normal save for a small hole anter-iorly near the lesser curvature ' due to the inadver-tence of the surgeon who cut it.' Our informantremarks, with evident self-satisfaction, that thisalleged breach of technique was overlooked by all-others present. Like Bossuet, the court physiciansquietly assumed that death had resulted fromadministration of poison smuggled from Rome bythe Chevalier de Lorraine, one of Philip's inti-

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mates, but, with greater prudence, the cause ofdeath was officially stated to be ' une trop grandeeffusion de bile.' There the matter rested till I872when Littre, familiar with the clinical picture ofperforation from the teachings of Cruveilhier andLudwig Mueller, reopened the discussion. Hepointed out the true nature of the seizure, remark-ing that the oil found in the peritoneal cavity wasthat which had previously been given medicinally,the hole in the stomach being of course the per-forated ulcer.

Although the true causation of this particularseizure was overlooked at the time, during theeighteenth century several writers described casesof fatal gastric perforation or haemorrhage.Bonetus of Geneva in I700 wrote of a girl of i8who died of peritonitis four days after melaena,autopsy showing the presence of a perforatedgastric ulcer. Four years later, M.P.E. Littre founda prepyloric ulcer in a man who had died of haem-atemesis and melaena, and in I729 ChristopherRawlinson described a case of pyloric stenosis offour years standing, terminating in gastric per-foration.The earliest recorded instance of duodenal per-

foration is that described in I746 by George Ham-berger of Jena, a fatal seizure in an apparentlyhealthy young woman, necropsy showing thepresence of what appears to have been a chroniculcer of duodenum. In a footnote to his paper onlead colic, Sir George Baker described in I772 afatal case of haematemesis and melaena fromduodenal ulceration.

All these however were merely isolated instances.None of the writers appears to have had experienceof more than one case nor had any of them recog-nized the disease in the living subject. Morgagni,whose knowledge was derived not only fromclinical studies but from careful post-mortemexaminations, carried out in nearly every instancebefore rigor mortis had set in, obviously regardedpeptic ulceration as a rarity. He quoted severalexamples from contemporary physicians and des-cribed a few cases of his own, but even of this verysmall series at least two are almost certainlyinstances of carcinoma. Only once does he refer tothe finding of an abnormal condition of the duo-denum, and that is in the case of a woman who,having long suffered from hypertensive heartfailure, collapsed and died suddenly, autopsyshowing the presence of multiple erosions of thestomach and duodenum.

All these are instances where the nature of thedisease was recognized only at post-mortem exam-ination, and there is little detail of antecedentsymptoms. The earliest well documented casehistory recording such symptoms is that writtenby Jacobo Penada of Padua, in 1793. Dominico

Miazzo, a butcher of that city, a man of immensephysical strength and grossly intemperate habits,was in the habit of eating but little, i.e. little asjudged by the prevailing standards of the time.Despite these regrettable deviations from the cur-rent mode of behaviour, he remained in excellenthealth and worked hard at his trade until May 25th,1791, when he began to suffer from para-umbilicalpain of great severity, occurring immediately aftermeals but unaccompanied by any desire to vomit.After an hour or so the pain generally abatedsufficiently to allow him to continue with his work.Having apparently but little faith in the minis-trations of his physician, and lacking the benefit ofeducation in such matters as is now provided byadvertisements in the lay press, Dominico con-cluded that his pain resulted from ' the flatulencein the intestinal tubes.' Determined to evict thisunwanted flatus, he embarked on an enthusiasticcourse of self medication, taking large amounts of' spirits of wine and other spirituous liquors.'Little is recorded of his response to this heroicform of treatment save that his pains continuedand became more severe, until the 2oth of June,1791, when he developed ' suppression of theurine and faeces.' Fortified, no doubt by his medi-caments, he ignored these distresses and continuedat work until the early morning of the 23rd whenhe collapsed with an extremely severe attack ofabdominal pain. Penada's description of the sub-sequent course of events is brief and masterly.' His pulse was feeble but irregular, but there wasno trace of fever. His face was pale and pinched.The eyes were sunken in and the extremities coldto the touch. The muscles of the abdomen weretense, and he was doubled up. From hour to hourour patient grow worse ... and at sunset he died.'Although Padua at that time was a flourishing

medical centre, it is clear from this account thatthe case was regarded as unique. Great interestwas aroused among all the physicians of the city,most of whom attended the post-mortem exam-ination on the following day. It was then foundthat the peritoneal cavity was full of fluid: thestomach appeared normal, but' that which formedthe special interest of the present case and thesubject of our discourse was in the duo&enum.'A beautiful line engraving accompanying thepublication tallied closely with Penada's descrip-tion of an oblong hole in the first part of the duo-denum lying in the midst of 'a peculiar morbidulcer which was of considerable thickness' hard,indurated, and surrounded by multiple smallulcers extending onto the posterior duodenal wall.

Reading such case histories as this, obviouslythe work of skilled and diligent inquirers, onecannot help feeling that such illnesses must havebeen of relatively rare occurrence in their practice.

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The writings of such morbid anatomists as Mor-gagni are obviously the work of masters who wereaware of the occurence of peptic ulcer and dis-played a keen interest in the disease. One is there-fore left with the impression that, had pepticulceration been as prevalent then as it is today, itwould have been discovered and reported muchmore often.

This belief in the uncommonness of peptic ulceris borne out by reference to contemporary workson military medicine. In his work Diseases of theArmy, published in 1753, John Pringle gave thefirst written account of those maladies to whicharmies in the field are peculiarly subject, devotingchapters to dysentery, fevers, pneumonia, phthisis,jaundice, ophthalmia, quinsy, and 'the itch' prob-lems still important in military medicine, but theheading' Inflammation of the Stomach and Intes-tines' is foUowed by only a few lines. On thesubject of the effect of army diet, a factor which heregarded as of little import, he remarked ' a soldierin time of war is by the smallness of his pay,secured against excess of eating, the commonesterror in diet.' Macgregor, in another excellentwork 50 years later dealt with the same type ofsubject matter, but apart from discussing dysentery,he made no reference to digestive diseases.

It is to be remembered that, at this time, menpassed into the army without preliminary medicalselection and thereafter lived under most arduousconditions. When one remembers the rapiditywith which previous sufferers from peptic ulcera-tion broke down, many of them seriously, underthe incomparably better conditions prevailing inthe armed forces during the late war, then itbecomes apparent that in this particular age andsex group, peptic ulcer must have been exceedinglyuncommon. So, making every allowance for thedifficulties of diagnosis and the limited nature ofpathological investigation, one is forced to theconclusion that, till the end of the eighteenthcentury, in Europe peptic ulcer was a rare con-dition. From almost every important medicalcentre isolated cases had been reported, and themajority of them appear to have aroused consid-erable interest, yet, with the exception of Mor-gagni,-whose experience was extremely extensive,no one had reported a series, nor, since the time ofCelsus had any suggestions been made regardingtreatment.

The Late-Eighteenth and NineteenthCenturiesTo Matthew Bailhie, nephew of John Hunter,

must be accorded credit for the first successfulattempt to recognize the symptoms of gastriculcer. In 1793 he outlined the protracted courseof the disease, attended by abdominal pain and

vomiting. Clearly distinguishing the conditionfrom carcinoma, he described the round, punched-out appearance of the ulcer with little surroundinginflammation, ' sometimes destroying a portion ofall the coats, forming a hole in the stomach.' Sixyears later he published drawings of two speci-mens, the one showing four ulcers in the stomachand one in the duodenum, the second, ' from Mr.Hunter's museum ' being an example of perforatedgastric ulcer.

In I817, Benjamin Travers and John Crampton,quoting from Morgagni, described from theirjoint experience, three instances of perforatedgastric ulcer ' which, although not of frequentoccurrence has been described by several anato-mists.' The description of the clinical sequence isso complete and so concise that one is justified inbelieving that the authors would not overlook thetrue nature of cases of perforation coming withintheir practice, yet their total experience comprisedonly three cases. Abercrombie of Edinburgh (i828)described instances of fatal perforation, haem-orrhage, and gastro-colic fistula, but he failed todraw a clear distinction between simple ulcera-tion and gastric carcinoma, at least one of hiscases being an example of the latter. Stressing thedifficulties encountered in diagnosis of digestivedisorders he noted that in the great majority of hiscases coming to post-mortem, he was unable tofind any lesion to account for the symptoms occur-ring during life. He gave advice on recognition ofduodenal disease in life, writing ' The leadingpeculiarity of disease of the duodenum so far aswe are at present acquainted with it, appears to bethat food is taken with relish and the first stage'ofdigestion is, not impeded, but the pain beginsabout the time the food is passing out of thestomach or about two to four hours after a meal.'He quoted several fatal cases of perforation orhaemorrhage, the diagnosis being confirmed atpost-mortem examination.

Meanwhile, French physicians were keenlystudying gastric ulcer, most of their findingsbeing published in thesis form. Their work waslargely embodied in Cruveilhier's masterly des-cription (I835) accompanied by beautifully clearillustrations. Distinguishing carcinoma fromsimple ulcer and defining the latter as ' une pertede substance spontanee,' he noted the prevalentoccurrence on the lesser curvature, posterior sur-face and in the pyloric region. He accurately des-cribed the symptoms, chief of which was ' tris-tesse insurmontable,' noted the common compli-cations, and outlined the methods of treatment hehad successfully employed, these being based onrest and dietary control.

This work of Cruveilhier, which achieved wide-spread recognition, was carried out largely on

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hospital in-patients, a highly selected group anddid not, therefore, give a representative picture ofthe disease as it affected the population at large.The studies of William Brinton, (I857) did notsuffer from this disadvantage. Reviewing a col-lected series of post-mortem cases, he concludedthat gastric ulcer was twice as common in womenas in men, that about five per cent of the popu-lation developed gastric ulcer at some time or otherin their lives, and that, in about half of thoseaffected, spontaneous healing occurred. He alsobelieved that the liability to ulceration increasedwith age, but since the series on which this argu-ment was based included not only active ulcers butscars of indeterminate age, this conclusion cannotbe accepted. His views on the clinical features ofgastric ulcer were based on a study of hospitalout-patients, of whom he saw no less than 4,000new cases every year. Of these, some 40 patients,i.e. about one per cent, he diagnosed as sufferingfrom gastric ulcer and, although the difficultiesinherent in out-patient practice prevented his con-firming the diagnosis in every case, yet he was ableto follow a sufficient proportion of these patientsto the post-mortem room to convince himself ofthe substantial accuracy of his conclusions. Thedescription of the clinical features of gastric ulcerwas extremely full and accurate. Perforation, hebelieved, occurred in not more than one case ineight, while haemorrhage, by many previouslyregarded as a cardinal symptom, affected not morethan one sufferer in ten or twenty. It has alreadybeen noted that both clinically and pathologicallythe diagnosis was made twice as commonly inwomen as in men. It was therefore remarkablethat haemorrhage occurred twice as often in menas in women, in both sexes being most prevalentin the fifth decade and uncommon in youngwomen. Of I99 cases of perforation, 139 occurredin women, chiefly in the age group 14-30, whereasin men perforation was most common in the fifthand sixth decades. This age and sex distributionis very different from that obtaining today, andthe discrepancy is to be explained, partly, by theformer relative commonness of acute perforatingulcer in young women, many of whom had somedegree of anaemia.The association of the chlorotic state and gastric

disturbances is an interesting one. Latour, in I828,writing on gastric ulceration and haemetemesis,noted that in several cases in his experience post-mortem examination had failed to reveal any lesionof the alimentary tract to account for the haem-orrhage. Ashwell of Guy's Hospital, in I836, inan excellent account of the severe anaemia inyoung women suffering from amenorrhoea, wroteof ' a vicarious discharge of blood from the stomachby vomiting ' which might produce considerable

debility and he stressed that even in milder casesthere was 'some impairment of digestion.' InBrinton's series, normal menstruation was the rulein sufferers from chronic ulceration, except in thesmall proportion who had had severe haemorrhage.The majority of cases of perforation in youngwomen however, he regarded as being in a classapart. In these there was but a brief antecedenthistory of dyspepsia, and at post-mortem exam-ination the ulcer, clear-cut and devoid of surround-ing fibrosis or other evidence of attempted healing,was clearly different from the scarred ulcers occur-ring in older people. While recognizing theanaemia of these patients, Brinton did not acceptthem as typical examples of chlorosis, contrastingtheir pallor with the typical greenish hue of thelatter, but one wonders if the difference which hestressed was more one of degree than fundamentalnature. He was however quite emphatic thatvicarious menstruation was an entirely mythicalconcept.He believed gastric ulcer to be most common in

the hospital class of patient-' those who sufferfrom the ills implied by penury in this metropolis,excessive toil, insufficient and unwholesome food,foul air, mental anxiety and those habits of intemp-erance which are the effects as well as the cause ofsuch misery,' and these remarks represent theearliest attempt to elucidate the pathogenesis ofulceration.

Neither Cruveilhier nor Brinton mentionedmorbid conditions of the duodenum. Cooper(I839) described two fatal cases of duodenal ulcerfollowing burns, and three years later, Curling, towhom the credit for recognizing this syndrome isgenerally accorded, published a small series, includ-ing the two cases already reported by Cooper.Hodgkin, lecturing in I840, stated that he hadrarely encountered duodenal ulcer, and that in thecases where it had been present it was sometimesthe result of tubercle or breakdown of adjacentneoplastic masses. Trier, of Copenhagen (I863),was able to collect only 54 recorded cases of duo-denal ulcer, including 26 of his own, gathered overa period of twenty years. From his extensiveinvestigations he concluded that ulceration was tentimes more common in the stomach than in theduodenum, men being the principal sufferers fromthe latter condition. He divided his cases into twogroups, viz. those who presented after perforationhaving previously enjoyed good health, and asecond class who had had previous symptomsindistinguishable from those ctf gastric ulcer.Bucquoy (I887), stressed the importance of

duodenal ulceration, primarily a disease of males,as a condition to be distinguished from gastriculcer. He instanced five cases, all of whom hadbled, and noted the absence of vomiting and the

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maintenance of appetite, particularly after haem-orrhage. Perhaps his most interesting patient wasa young commandant of artillery, who sufferedsevere abdominal pains three hours after mealsuntil one of his travelling companions on a trans-Atlantic ship advised the taking of sodium bicar-bonate, which produced rapid relief. It almostappears that the laity had anticipated Sippy bysome half century in the recognition of this sove-reign palliative.

Brinton's views on the incidence of gastric ulcerand its complications were confirmed by otherwriters, including Samuel Fenwick, who in i868again stressed the clinical and morbid anatomicaldifferentiation between chronic and acute perfora-ting ulcer. He noted that the latter might give riseto haemorrhage rather than perforation in youngwomen, but agreed with Brinton that on the whole,haemorrhage was more common in men. In theyears up to the turn of the century, haemetemesisfrom acute ulceration appears to have becomeprogressively more common in women. Osler,in his first text book, noted the frequent associationof chlorosis and gastric ulcer in young women, butat this time he had seen only nine cases of duo-denal ulcer, seven of them in men. Perry andShaw, in I893, reviewed the reports of the 17,652necropsies which had been performed at Guy'sHospital during the years I826-92, beginningwith 'Dr. Hodgkin's green inspection books,'and concluded that duodenal ulcer had been foundin only 0.4 per cent of cases, in about half of whichit had been associated with burns, Bright's disease,or general septic conditions.

The Twentieth CenturyDuring this period of history considerably mnere

data became available which permit of fairly definiteconclusions on the changing nature and incidenceof peptic ulceration in Great Britain. Advancesin surgical technique had made abdominal opera-tion relatively safe, thus permitting the confirm-ation of diagnosis. Hurst and Stewart, studying avery large post-mortem series, conducted withespecial regard to the incidence of the variousforms of peptic ulcer, had shown beyond doubtthe magnitude of the problem. Diagnostic radi-ology of the alimentary tract became a reliableroutine investigation. As from I90I, gastric ulcerwas shown under a separate heading in the Regis-trar General's returns, and duodenal ulcerationwas separately listed as from I9II: the figures, soprovided, furnish a wealth of information. Finally,the two major wars necessitated for the first timea comprehensive health survey of a large propor-tion of the population.At the turn of the century gastric ulcer still pre-

dominantly affected women. An increasing pro-

portion of cases of haemetemesis, formerly confinedto males and older women, now began to occur inyounger females. It was observed that, althoughthe diagnosis of gastric ulcer was made in womenmore often than in men, women were less likelyto die from the disease. The Fenwicks' analysis ofa post-mortem series of cases of gastric ulcer isshown in Table I.

Males Femalesper cent. per cent.

Acute gastric ulcer 3 30Chronic gastric ulcer 48 I9

It will be noted that the deaths in males andfemales are approximately equal, whereas inBrinton's series females predominated by two toone.

This apparently low mortality in females wascommented upon by Hale White in I906. Hepointed out the commonness of the syndrome ofchronic dyspepsia, chlorosis, amenorrhoea, andrecurrent haemetemesis in women between theages of 2o and 40, rarely fatal and seldom compli-cated by perforation or by pyloric stenosis, whichin a series published by Somerville Hastings ayear later was twice as common in men Ps inwomen. In the few instances in which operationshad been undertaken to control haemorrhage nomacroscopic lesion had been discovered. Accord-ingly, conservative treatment was advised fdr thesecases for which Hale White coined the term' gastrostaxis,' and which are now recognized asexamples of acute superficial ulceration. That themajority of cases of haemetemesis at this timewere due to this condition is suggested by the lowmortality-four per cent.-in Conybeare's seriesof 6oo cases treated between I9II and 1920, afigure which has not been equalled in any recentseries in this country despite advances in treatment,in particular the introduction of drip transfusionand Meulengracht's practice of early feeding. InBrinton's experience such cases were infrequent.The condition appears to have been one of increas-ingly common occurrence during the last quarterof the nineteenth century, and, like the associateddisease, chlorosis, it virtually disappeared at aboutthe time when the first world war brought aboutthe emancipation of women.

In the early years of the century nearly allauthorities still regarded duodenal ulcer as a raredisease. In I900 the Fenwicks were able to quoteover 26o references in the bibliography on duo-denal ulcer, yet, for all their extensive experienceand keen interest they were able to gather only68 cases, 25 of them acute ulcers resulting fromburns, acute infections and pyaemic states. Thework done was out of all proportion to the numberof cases discovered. It has generally been advancedthat this apparent rarity of duodenal ulcer was the

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result of failure to recognize the condition, andundoubtedly many cases were missed. None theless, when one views the situation against the broadbackground of earlier writings, it is difficult toescape the conclusion that this improvement indiagnosis occurred at the same time as an increasein the relative and absolute frequency of duodenalulceration. Review of more recent years providesstrong evidence of still greater prevalence and thisprobability becomes a virtual certainty.

In Moynihan's first published series of I62cases of relatively unselected examples of chroniculcer dyspepsia, the lesion was found in the duo-denum 51 times, a ratio of duodenal ulcer: gastriculcer of approximately i : 2. By 1926, in hiscomplete series of 798 cases, he had found a duo-denal ulcer in 71 per cent. of cases, and both duo-denal and gastric ulcer in a further four per cent.,this latter experience tallying with Wilkie's findingthat duodenal ulceration was six times more com-mon than gastric ulceration. That the absolute aswell as the relative incidence of duodenal ulcerhas increased is borne out by almost every reviewpublished. For example, in I906, 26 cases ofduodenal ulcer were admitted to the EdinburghRoyal infirmary, 22 of them for perforation,whereas in I926 there were 236 admissions ofwhich 1b2 were for perforation.The high incidence of peptic ulceration was

brought out by the publication of the investi-gation of 4,000 consecutive post-mortem examina-tion; in Leeds by Hurst and Stewart, who foundactive gastric ulcer in 2.23 per cent. and activeduodenal ulcer in 3.83 per cent., healed scarsbringing the total incidence to approximately ioper cent. of all cases. Duodenal ulcer was morecommon in male than in female in the ratio of 7: 2,but females were more more frequent sufferersfrom gastric ulcer in the ratio io: 8. These findingshowever cannot be held to give an accurate idea ofthe incidence of peptic ulceration in the com-munity today. The investigation was based on aselected section of the populace, viz. those whofor one reason or another were admitted to hos-pital and, having been admitted, died. Secondly,there is every reason to believe that the incidenceof the various forms of peptic ulceration has under-gone further change since this series was investi-gated. The statistics of the Registrar Generalhave been analysed over the past forty years (TidyI944, Craig I948) and these provide striking evi-dence of the increase in peptic ulceration. Onlyabout one in twenty of peptic ulcer sufferers diesas the direct result of this corndition, so these figuresdo not give an entirely representative picture asthey affect the populace at large, but certain trendsare apparent.The -mortality from gastric ulcer in women

has greatly decreased, particularly in the youngerage groups, largely as the result of the virtualdisappearance of acute ulceration. In all othergroups mortality has either remained steady des-pite therapeutic advance, or has actually increased.This increase is most marked in men over 45, andthe change is only partially due to the generalageing of the population. Although it is agreedthat duodenal ulcer is now much more commonthan gastric ulcer yet gastric ulcer is responsiblefor about two out of every three peptic ulcer deaths.It might be argued that this is an artefact due tofaulty certification, but of peptic ulcer deaths inthe Services during the war about 6o per cent.were due to gastric ulcer. It is in accord withexperience to assume that in some go per cent. ofinstances the diagnosis was confirmed by autopsy,so that the figures quoted probably give a fairlyrepresentative indication of the relative mortalityof the two diseases.

Dyspepsia presented no great problem to earliermilitary surgeons and in the first world war diges-tive diseases ranked low in the list of disabilities.During the late war, duodenal ulceration wassecond in importance only to neurosis as'a medicalcause of invalidism, and one is therefore forced tothe conclusion that in the period between the twowars there had been a very great increase in thenumber of young men affected with this disease.In fact gastric and duodenal ulceration as we knowthem today are discases of the twentieth century.

ConclusionsIt would therefore appear that gastric ulceration

approached its present prevalence sometime in thefirst half of the nineteenth century, since when itsdistribution and clinical pattern have changedconsiderably. Duodenal ulcer seems now to presentthe same clinical picture as formerly, but it hasbecome very much more common during the pastfifty years, and now represents a most importantsource of chronic ill-health in young men.These changes are, presumably, the result of theoperation of changing environmental factors, andso the view that the increasing prevalence of thesediseases is a concomitant of life under modern con-ditions, is, to a large extent, substantiated. In allprobability, the nature of these diseases will con-tinue to change. They may even disappear almostentirely as has the acute gastric ulceration of youngwomen, either as the result of therapeutic advanceor from the elimination of those environmentalfactors which favour their development. In themeantime, the great body of sufferers may derivea little consolation from Voltaire's remark that ' itis a pleasant fact that thought entirely dependsupon the stomach and that, in spite of that, thebest stomachs are not the best thinkers.'

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6oo POST GRADUATE MEDICAL JOURNAL NVovember 1948

SummaryI. The history of gastric and duodenal ulcera-

tion is surveyed.2. From this review it appears that gastric ulcer

was uncommon till the middle of the nineteenthcentury, and duodenal ulcer was rare till thebeginning of the present century.

3. Gastric ulcer has become a comparativelyrare disease in females and, in particular, the acutetype of ulcer frequently associated with chlorosisis no longer encountered.

4. Duodenal ulcer in males became very muchmore common in the period between the two majorwars.

5. The increased mortality from peptic ulcer islargely accounted for by the greater number ofdeaths.of men over 45 from duodenal ulcer.

6. Although duodenal ulcer has increased infrequency, there is no evidence of change in itsclinical pattern, but gastric ulcer has clearlychanged greatly.

7. The causes of these changes and consequentlyof the disease themselves are to be sought in envir-onmental thanges rather than constitutional factors.

8. There is historical support for the suggestionthat these diseases are yet another penalty of thepresent day mode of life.

9. It is to be expected that the nature and inci-dence of these diseases will continue to change.

BIBLIOGRAPHY

ABERCROMBIE, J. (i828), 'Diseases of the Stomach.' Edinburgh.ASHWELL (1836), 'Chlorosis and its Complications.' Guy's

Hospital Reports, i, 529.BAILLIE, M. (1793), 'Morbid Anatomy of Some of the Most

' Important Parts of the Human Body.' London.BAKER, Sir G. (I772), Med. Trans. CoU. Phys., i, I75.BONETUS, T. (I700), ' Sepulchretum sive Anatomia Pratica.' Lib.

iii, Sect. XXI, Observatio XXV.

BRINTON, W. (I857), 'Ulcer of the Stomach.' London.BUCQUOY, S. (I887), Arch. Gen. de Med., 398, 526, 691.CLARK, A. (1867), Brit. Med. J., i, 66i, 731.CONYBEARE, J. J. (I935), Lancet, ii, IOI7 (and quoted by Hurst).COOPER, S. (I830), Lond. Med. Gaz., 23, 837.CRAIG, J. D. (I948), B.M.J., (in Press).CRUVEILHIER, J. (I835), ' Anatomie Pathologique,' i, X, I. Paris.CURLING, T. B. (1842), Med. Chir. Trans., 25, 260.DONATUS, M. (1586), De Medica Historia Mirabili, Lib. IV, Cap.

iii, i96.FENWICK, S. (I868), 'The Morbid States of the Stomach and

Duodenum.' London.FENWICK, S. and FENWICK, W. S. (I900), 'Ulcer of the

Stomach and Duodenum.' London.HAMBERGER, G. (1746), 'de Ruptura Intestini Duodeni.' Jena.HASTINGS, S. (1907), Med. Chir. Trans., XIX, 335.HAWKINS, H. P. and NITCH, C. A. R. (1907), ibid, XIX, 339.HODGKIN, T. (I840), 'Lectures on the Morbid Anatomy of the

Serous and Mucous Membranes,' Vol. ii, 368.HUNTER, J. (I786), 'Observations on Digestion.' London.HURST, A. F. and STEWART, M. J. (1929), 'Gastric and Duo-

denal Ulcer.' Oxford.LATOUR (I828), 'Histoire Philosophique et M6dical des Haem-

orrhages.' Paris.LITTRE (I872), 'Medecine et Medecins.' Paris.MACGREGOR, J. (I804), 'Medical Sketches of the Expedition

to Egypt from India.'MORGAGNI, J. B. (1769), 'Seats and Causes of Diseases,' ii, 244.MOYNIHAN, B. G. A. (I9OI), Lancet, ii, I656.MOYNIHAN, B. G. A. (I905), Lancet, i, 340.MOYNIHAN, B. G. A. (1905), 'Surgical Treatment of Non-

Malignant Disease of the Stomach.' London.MOYNIHAN, B. G. A. (I9IO), ' Duodenal Ulcer.' London.MOYNIHAN, B. G. A. (1928), Brit. Med. _J. ii, 1021.OSLER, W. (1892), 'Principles and Practice of Medicine.' London.PERRY, E. C. and SHAW, W. E. (1893), Guy's Hospital Reports, 50,

171.POWER, d'A. (1925), Med. J7. and Record, 122, 4I5.PRINGLE, J. (I753), 'Diseases of the Army.' London.PENADA, J. (I793), 'Saggio d'osservazioni e Memorie Sopra

alcuni casa Singolari.' Padua. (Quoted by Malloch).RAWLINSON, C. (1727), Phil. Trans. Roy. Soc., XXXV, 361.REGISTRAR GENERAL (1905-45), Statistics.TIDY, Sir H. (I944), Brit. Med. J7., i, 677.TRAVERS, B. (I817), Med. Chir. Trans., VIII, 232.TRIER, F. (I863), ' Ulcus Corrosivum Duodeni.' Copenhagen.TRIER, F. (1864), Gaz. Hebdomadaire, 2nd Series, i, 475. (Review).TRIER, F. (1864), Brit. and Foreign Med. Chir. Review, xiii, 157

(Review).WHITE, W. H. (I9OI), Lancet, i, I8I9.WHITE, W. H. (I906), ibid, ii, II89.WILKIE, W. P. D. (1927), ibid, ii, 1228.

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