GASTRIC AND DUODENAL ULCER TREATMENT*

WARREN WOODEN, M.D., F.A.C.S.

ROCHESTER, N. Y.

NALYSIS of this subject by the A faithfu1 reader and patient Iistener, for an agreeable Iength of time,

Ieads one to the consideration of three definite but somewhat overIapping issues. Firstly, there is the border warfare to estabIish a medico-chirurgical boundary Iine, a perennia1 parity conference, with the dipIomacy not aIways in evidence. SecondIy, there is a constant striving for standardization of procedure, an endeavor common to both medica and surgica1 interests. And thirdIy, one observes the effort to express the Iast word, that one may sIump back into the comforting embrace of the fuIIy crystaIIized idea.

These curious smaI1 erosions of a sIight fraction of man’s vuInerabIe surface, a matter of indefmite consideration in past ages of medica knowIedge, were subjected first to an inteIIigent anatomica and pathoIogica1 consideration by CruveiIhier aImost exactIy a century ago. His treat- ment, compiIed from his own observation and the experience of others, discIoses that the modern method of non-surgica1 attack became authoritative at that time. In summarized form, he advocated twenty- four hours’ abstinence from food, to be foIIowed thereafter by severa teaspoonfuIs of miIk every four hours, to be augmented Iater by geIatinous or starchy foods, gas- eous waters and soups. He advised the use of caIcined magnesia, carbonate of mag- nesia, Iime water, peppermint tea and the sucking of sugar to promote saIivary secretion. Note the earIy approva1 of the Iatest advances, nameIy, the superiority of caIcium carbonate over aIkaIies that cause aIkaIinization, the pharmacoIogic retarda- tion of peristaIsis by essentia1 oiIs, and the utiIity of sugar as a salivary stimuIant.

Expressing it briefly, for the require- ments of this meeting, the proper non- surgica1 approach of the probIem has been

in evidence, with slight variation, for a hundred years. The empiric principIe of rest and frequent miIk plus feedings, the reversion to the caIcium of CruveiIhier, the abandonment of excessive aIkaIiniza- tion furnish a program of contracted scope and Iimited variety comprehensibIe to everyone.

Experience in the so-caIIed medica conduct of this condition has eIicited vaIu- abIe information on accompanying physi- ca1 states, essentia1 CIassifactory tabuIa- tions, differentia1 diagnostic facts and proper appreciation of psychoneurotic inff uences.

But, from a Iong period of commendabIe appIication of the internist’s virtues of patience, fideIity and persistence, we have received scant reward. A smaI1 group of cases, probabIy best described as possessing acute uIcers, show satisfactory response and fuIfiI1 requirements as to proper cri- teria of cure. This group perhaps sub- stantiates the dictum that medica treat- ment shouId be given a tria1 in most newIy discovered cases. But the great buIk of uIcers are of the chronic type with cIear pathoIogica1 characteristics. These a11 tend toward deveIopment of obstruction (34 per cent) gross hemorrhage (40 per cent) and perforation (6 per cent) in the duodena1 area, pIus maIignancy in the gastric area. In weighing the vaIue of the Iast factor one finds authority for any figure from 7 to 70 per cent. Regardless of whether this is a coincidenta or causa1 finding, about 2

per cent of operations performed pureIy on evidence of gastric uIcer discIose the presence of maIignancy.

Our medica measures consistentIy usu- aIIy retard this progress, but eIiminate pathoIogy but rareIy. With the resuIt not often suffIcientIy appreciated or admitted, that we have under our care a more com- fortabIe patient but a sick individua1, a

* Read at. a meeting of the staff of the Rochester General HospitaI, February 23, 1930.

23

24 American Journal of Surgery Wooden-UIcer Treatment

sIave to forms and times of eating, drink- ing, sleeping and defecation, a person to whom the elementa joys of Iiving are restricted painfuIIy, whiIe the sword of DamocIes hangs over his or her pyIorus.

Thus, owing to concomitant, if not causaI reIationship of’disturbed aIimentary function, possibIe foca1 infection factors, vagotonic states, and socia1 and menta1 probIems, and due to occasiona striking response or surgica1 contraindications some few are medica a11 of the time. But the enormous genera1 probIems raised by the high requirements from the patient of a proIonged time investment, faithfu1 cooper- ation, and adequate soIution of persona1 economics, with a high rate of recurrence as a reward for their combined soIution Ieave one in a pessimistic state of mind. The faiIure of medica treatment Iies in its insuffIciency rather than its potentiaIity. To be successfu1 such treatment must be rigorous and protracted. The IoyaI coopera- tion of the patient is essentia1. Very few patients now receive any treatment offer- ing a reasonabIe prospect of heaIing of the uIcer. It has been observed that in most hospita1 groups the enthusiasm for a11 this resides with the younger cIinicians, that oIder men as a ruIe exhibit Iess forcibIe advocacy.

From this state of affairs our surgica1 endeavors take origin. The satisfactions of resort to surgica1 measures in this instance are those common to surgery in generaI: the correction of diagnosis resuIt- ing so frequentIy from direct observation, the prompt eIimination of pathoIogy, the opportunity to eradicate associated pathoI- ogy, notabIy appendicitis and choIecystitis in this instance, and a Iowered incidence of return to the origina probIem.

It is my beIief that these principIes are best applied to the uIcer problem in the routine of what may be described as the average hospita1 by the conservative pro- cedures which accompIish removal of Iesion and modification of physioIogy, rather than by radica1 measures which consist in re- mova1 of the ulcer-bearing area.

AImost a11 duodena1 uIcers that we are encountering Iend themseIves to the three chief surgica1 attacks, (I) the ex- cision pyIoropIasty after the method of HorsIey, (2) the pyIorectomy, usuaIIy best concIuded by anastamosis between the end of the stomach and the side of the mobiIized second portion of the duo- denum, the Haberer-Finney gastroduo- denostomy, or (3) by cautery excision pIus gastrojejunostomy.

The first two procedures permit compIete visuaIization of the probIem, incIuding the specia1 factor of exposure of extra uIcers, pIus remova of the pathology and a physioIogica1 correction of pyIoric spasm; the Iast secures the same resuIts in cases where Iocarion of Iesion or degree of pyIoric adhesions and stenosis predicate unsatisfactory handIing of the pyIorus.

Most gastric uIcers Iend themseIves to v-resection, or IocaI cautery excision pIus pyIoropIasty or gastrojejunostomy, in the interests of reduction of recurrence. The more radica1 procedures of gastrectomy with remova of a Iarge area of stomach pIus various methods of gastrojejuna1 anastamosis have been practiced enthusi- asticaIIy in certain compact weII-standard- ized cIinics but generaIIy represent a Iowered incidence of recurrence at the price of too high a mortaIity. The appIi- cation of these operations to cancer or presumptive cancer is of course not in question.

The burden of surgery, whiIe working under this program, must be frankIy and accurateIy considered. The first and great- est probIem is that of mortality. Herein it is my conviction, based on our own experience, that conservative procedures encounter a Iower death rate than usuaIIy appreciated, a rate at Ieast as low as that of medica treatment. Our 40 excision pyIoropIasties for duodena1 uIcer in the last four years, usuaIIy accompanied by appendectomy and twice by choIecystec- tomy, have been accompIished without a death. Our gastrojejunostomies have been a IittIe Iess successfu1 in mortaIity rate but

NEW SERIES VOL. XII. No. I Wooden-UIcer Treatment American Journal of Surgery 25

shouId not be used freeIy as a critica standard, because when properly appIied they secure a high percentage of exceIIent resuIts (go per cent) in a group of cases representing advanced probIems, of ad- hesions, stenosis and medical hopeIessness. Here mortaIity rates are not the whoIe story, as may be we11 iIIustrated by reference to the fact that no one objects to a 50 per cent death rate in the surgica1 treatment of perforated uIcer out of respect to the gravity of the probIem presented.

The greatest burden of mortality con- sists, as aIways in surgery, in the conscious- ness that death has foIIowed an aggressive wiIfu1 procedure of one’s own hand and decision.

The second important aspect of surgica1 treatment is the recurrence rate. Working without fuI1 appreciation of cause or pre- vention, we are not surprised at a definite rate of recurrence, especiaIIy in our younger cases. But the fact remains that observance of this event is overwheImingIy more common after non-surgica1 treatment. This may be reIated to the fact that surgery usuaIIy removes a probabIe cause, nameIy, an area which has undergone certain retrogressive circuIatory changes. In any case, particuIar stress shouId be Iaid on the fact that the faiIure of surgica1 treat- ment in the form of recurrence is frequentIy not a weighty probIem. In one of our excision pyIoropIasties, symptoms per- sisted as a resuIt of recurrence or operative overIooking of a second uIcer. Six months of medica regime made sIight impression on the symptoms. Gastrojejunostomy, easiIy performed, then brought immediate and compIete reIief.

The third question raised by surgica1 treatment is that of compIications. Of these, pneumonia, peritonitis and puI- monary emboIism represent depressing probIems but ones of rare occurrence and their discussion beIongs to genera1 surgica1 studies. Postoperative hemorrhage does not exist as far as we are concerned, Suturing these regions with the finest

chromic (ooo,ooo), Moynihan has not been betrayed by a singIe strand in over 2000 operations, and without crowding him very cIoseIy numericaIIy our exper- ience is the same.

Most significant of the compIications is that of jejuna1 or gastrojejuna1 uIcer foIIowing any of the gastrojejuna1 anasta- moses. The recognition and treatment of this condition are aIways diffIcuIt but usuaIIy satisfactory. Our 2 cases, of course, foIIowing the other feIIow’s gastrojejunos- tomies, have made perfect recoveries. But it shouId be emphasized that the occur- rence is rare (about 2 per cent), and being definiteIy Iowered by proper appreciation of probabIe factors in causation, nameIy, Iocation of gastric opening, degree of operative trauma, type of suture materia1 and detection of persistent postoperative high acidity.

Turning to the second issue, there is a specific point to make. It has been inti- mated that standardization of procedure in non-surgica1 treatment is in actua1 practice; it shouId be emphasized that standardization of surgica1 approach is stiI1 in the formative period. When one considers that the surgica1 appIication by Lister and others of Pasteur’s principa1 contribution to medica science, occurred within the recoIIection of many here, that WiIIiam H. WeIch in a comprehensive review of the uIcer probIem in 1885 devoted nine pages to medica treatment and but one paragraph to the surgica1 treatment of pyIoric stenosis, that uIcer surgery was born IargeIy in the nineties and was stiI1 in its infancy in the first decade of this century, that fifteen years ago in this hospita1 practicaIIy a11 the uIcer surgery was for perforation or advanced conditions with tota disabiIity, it becomes evident at once that the most important ingredient in the composition of a surgica1 formuIa, the time factor, has been aIIotted insuff& cient opportunity for deveIopment. Two of the three procedures herein described as conservative, the excision pyIoropIasty of HorsIey and the gastroduodenostomy of

26 Amcricnn Journal ol Surgery U’ooden--Ulcer Treatment APRIL. ,931

Haberer and Finney have been originated MedicaIIy we are at a standstiI1, an in the last eight to nine years and are as unsatisfactory standstiI1, with only the yet not properly represented in most hope of some ultimate discovery leading pubIished series of results. to knowledge of cause and cure.

We are still in the stage surgically where Surgically, we have under consideration fraiIity of human though can produce both a mobile state of affairs in which progress the unconvincing conservatism of a Lahey has been so rapid and so recent that there and the illogical radicaIism of a Finsterer; seems to be a Iack of genera1 appreciation but throughout there runs a definite of its victories. Most anti-surgical expres- evidence of progression, the lowering of sions quote oId figures, or rely upOn views mortaIity, the reduction of incidence of of extremists that are strikingIy omni- complications and more appropriate appli- present in a11 formative periods. Many cation of particuIar procedures. Opera- such views are enthusiastically foIlowed. tion with a fixed determination to do a Goethe said, “Some men make the Iast certain kind of operation is being reIegated. book they have read the master of them.”

One of the biggest factors in our control One might paraphrase, that some who and progress is the enormous value of the seek a soIution for our compIex uIcer roentgenoIogica1 contribution, during every probiems, make last week’s medica journa1 phase of uIcer management. It makes it the sealed treasure house of their faith. In harder for medica men to diet cases even the words of Robinson’s “Tristram”: unto death, and restrains surgeons from operating on everything in sight. It has Wisdom is not one word and then another,

done away to a great extent with the TiIl words are like dry Ieaves under a tree;

pseudo-criterion of cure, nameIy, the pa- Wisdom is like a dawn that comes up slowly

tient is comfortabIe. Out of an unknown ocean.

This issue of standardization might we11 To some, surgica1 approach of the uIcer be left in terms of VaIIeix’s conclusions on probIem is stiI1 in the scavanger stage, a the uIcer subject expressed in his medical cIean-up business as a Iast resort. ActuaIly treatise of I 853 : the resuIts of surgica1 approach are not

Must I now present a summary and r&s? satisfactory to any of us, but this dissatis-

I think not; for this would be choosing to give faction can not be disassociated from the

an air of precision to a subject which, in the evidences of progress. actual state of science cannot be had. It is “It is a dangerous man who believes necessary that the physician know that which has been put to use, but he is not to believe,

everything he says,” but analysis of this

without an attentive and preliminary study, in whole probIem in its broader aspects,

order to consider the conditions which this case discloses, I believe, that the treatment of

presents to him and the means to combat them. gastric and duodena1 ulcer is making unsteady but definite progress with the

LastIy arrives the third issue, the surgical interests constantIy increasing approach to the concrete message. their share of the load.

aze