Surgery and the duodenal ulcer

T H E IRISH J O U R N A L M E D I C A L S C I E N C E THE OFFICIAL JOURNAL OF THE ROYAL ACADEMY OF MEDICINE IN IRELAND

OF

SIXTH SERIES. No. 149. h~Y, 1938.

SURGERY AND THE DUODENAL ULCER ~.

By GAENETT WRIGHT (Manchester).

I AIVI afraid that you will think that the subject I have chosen to-night for my address has been worn threadbare. That this is so I agree, but at the present time it has taken on new life

and become highly controversial, so that I hope some interest and profit may result.

Surgery was first employed in the treatment of duodenal ulcer only for perforation and stenosis, and at the present time it is still universally recognised as the sole treatment of the one and the treatment of choice of the other complication.

In 1901, however, Moynihan began to operate for uncomplicated duodenal ulcer, and in a few years operation became the standard treatment for all patients who relapsed after a course of medical treatment or in whom the symptoms were of long duration. While it is true that some physicians, notably Hurst, protested against

th i s view, many actively supported it and referred their patients freely for surgical treatment. Later on patients began to be sent by their family doctors directly to the surgeon, and it is no t too much to say that surgery became the routine treatment. There was, of course, an operative mortality and an immediate post- operative complication--vicious circle vomiting--which was responsible for part of the operative mortality and some unsatisfactory late results. These disadvantages were held to be counter- balanced by the supposed prevention of perforation and h~emerrhage. The operative mortality has steadily diminished and now is probably about 1.5 to 2 per cent. in ordinary hands. Vicious circle vomiting has been abolished by the short loop posterior gastro-enterostomy with t he fixation of the mesocolon to the stomach well away from the site of anastomosis.

Numerous papers appeared claiming excellent results, and for a time everything in the garden appeared to be lovely. A chill

*Address delivered (by invitation) to the Section of Surgery, Royal rAcademy of Medicine in Ireland, March llth, 1938.

194 IRISH JOURNAL OF MEDICAL SCIENCE.

and blighting wind began to arise, however, and the blossom began to shrivel. I t became evident that though many patients were cured, some were not relieved and others were even worse than they had been before operation. Hoemorrhage and perforation were found to occur after operation, and other unpleasant sequel,e were discovered. Medical as opposed to surgical treatment began to be urged and this was supported by evidence such as that of Forsyth, who, in 1924 analysed the cases of 59 doctors treated for duodenal ulcer and found the period of invalidity rather greater in the operated than the non-operated, while the recurrence rate was about equal in the two groups.

In 1935 Bashford and Scott reviewed the after-histories of 200 operated cases and of 40 non-operated cases of duodenal ulcer in post office employees. The inquiry had special reference to loss of working time after treatment, and yielded results which at first sight are most depressing both as regards medical and surgical treatment. Thus, of the 200 surgical cases, 24 per cent. incurred an average subsequently yearly incapacity for work of less than a week, 16 per cent. of 7 14 days, 26.5 per cent. of 14 28 days, and 33.5 per cent. of more than a month.

The medical treatments gave slightly better results. I t is not possible to form any idea from the tables as to the nature of the operations in many of the cases, and the authors base these per- eentages on absence from work from all causes. They have not made a similar analysis for loss of working time due to digestive disorders, but merely give the average yearly absence from these causes. In my opinion this gives a false impression, as one or two bad results with prolonged absence seriously affect the average. The data are contained in the tables, however, and I find that 39 lest no time at a l l for digestive troubles, and 69 lost less than a week. This gives a total of 108 (54 per cent.) in whom the results from a digestive point of view can be considered satisfactory. In only 21, i.e., about 10 per cent., did the average yearly loss of time exceed 30 days.

Similar analysis of the 40 medically treated patients gives 8 with no loss of time and 15 with less than a week, a total of 23 ; roughly 57 per cent. In only 3 was the loss of time more than 30 days, i.e., 7.5 per cent.

I t will be seen then that the results are not quite so gloomy as they appear at first sight, but even at the best they are poor. Of course, it may be argued that the loss of time from other conditions is 1rally due to general lowering of the resistance, but there is noth- ing to indicate this and it would be necessary to carry out a series of observations on controls in order to prove it.

Numerous reports of ill results from gastro-jejunostomy have appeared from time to time, especially the occurrence of secondary ulceration at and near the stoma which we call gastro-jejunal ulcer. At first this was regarded as a rare complication and estimates of its incidence varied from 2 per cent. to under 1 per cent. Further

SURGERY AND THE DUODENAL ULCER. 195

experience has shown that these estimates are grossly too low. In an inquiry undertaken on behalf of the Association of Surgeons I formed the opinion that 6 to 8 per cent. was probably correct, and it is interesting to find that Somervell and Orr found exactly 6 per cent. in their very large series of cases in India.

Walton had 3.9 per cent. in patients observed for 10 years, and here again it is interesting that his estimate had risen by 1 per cent. from an earlier one.

I do not think it is possible to arrive at an exact figure, because the search for these complications varies in its intensity with different surgeons and different criteria are used in arriving at a diagnosis. I shall have more to say of this later. I believe, however, that the extremely high incidence of 25 to 30 per cent. cited by Lewisohn and others is no more correct than the extremely low estimates of the older school. I believe the incidence to be not less than 6 per cent. and not more than 10 per cent.

The risk of gastro-jejunal ulcer has induced many surgeons, notably Finsterer in Vienna and other Continental surgeons, to advocate a high partial gastrectomy in order to remove a large amount of the acid-secreting part of the stomach and also t o increase the emptying rate. The advocates of this method of treatment claim that in all cases examination of the removed portion of stomach shows well marked gastritis of what they call the hypertrophic type, which is associated with hyperchlorhydria. These appearances, however, are so common as to arouse the sus- picion that they may be within the normal.

Pannett, in England, began by excising the duodenum, and later the pylorus with this, and now he removes the greater part of the stomach in the usual way, while Ogilvie and others of the younger school follow Finsterer in advocating extensive gastrectomy as the method of choice in dealing with the non-stenosing duodenal ulcer which requires surgical treatment.

The feeling has, therefore, gradually grown that surgery for the non-stenosing duodenal ulcer is rarely required and that when it is necessary gastro-jejunostomy is attended with such a risk of gastro~ jejunal ulcer that it should be displaced by gastrectomy. Also that surgery is necessary for the treatment of stenosis following duodenal ulcer and that gastro-enterostomy in this condition is much less prone to be followed by secondary ulcer and gives much better results.

I propose to examine these theses in the light of my own experience, based on 198 cases of chronic duodenal ulcer treated in my wards at the Salford Royal Hospital from 1926 to the middle of 1937, and on 55 cases of perforated duodenal ulcer since 1930 to the same period.

Of the 198 chronic cases, gastro-jejunostomy was the treatment in 137. A very careful enquiry has been made into the remote results in these patients and these are shown in Table 1.


Ta~L~ I. Gastro]ejunostomy.

M. ,Total ... 137 112 Letters returne'd ~ ... 20 No reply . . . . . . . . . 20 Traced . . . . . . . . . 96

137

Well ... . . . . . . . . . 63 Much improved . . . . . . . . . 14

Fr 25

Stenosis Cases. Total . . . . . . . . . 35 Untraced . . . . . . . . . 5 Traced . . . . . . . . . 30

Well . . . . . . . . . . . . Poor ... . . . . . . . . . I-Isematemesis . . . . . . . . . Jejunal ulcer ... . . . . . . Immediate deaths . . . . . .

24 1 2 2 1

30

There were three operative deaths in the total number of 137 cases, a mortal i ty of about 2.2 per cent. This is on the high side and one, if not two of the deaths might have been avoided. One died of hsemorrhage from the meso-appendix, the appendix having been removed with difficulty through the upper abdominal incision. I cannot help feeling that this may be quite a risky manoeuvre, as the structures are on the stretch all the time and a vessel may easily escape when the tension is relaxed and the parts have sunk down out of sight. When the removal of the appendix is judged to be essential and the technical difficulties are great I believe it is better to remove it through a separate incision. Another pat ient with stenosis recovered well from the immediate operation, but a for tnight later developed an acute obstruction of the stoma with acute dilatation of the stomach and 'vomit ing of the usual coffee-ground type. I re-operated and did an entero-anastomosis and a jejunostomy, but the patient got no relief and died in a few days. I think it would have been better to t reat him with an in-dwelling tube and an intravenous drip, but this method had not been-evolved at that time.

The third was shocked after the operation and never rallied. These three deaths happened in the first sixty of the series and there have been none since.

Apar t f rom these the history of a fur ther 94 has been traced

Poor ... 4 Secondary'ulcer proved by'operation 4 Secondary ulcer proved by z-ray ... 2 Diagnosed becau,se of bleeding ... 3 Late deaths . . . . . . 4 Immediate mortall~y . . . . . . 3

97

One of ~he secondary ulcer patients died five yea~s after operation in an infectiou~ diseases hospital, making ~he late death~ 5 in number.

SURGERY AND T H E DUODENAL ULCER. 197

Those who are called " wel l" are living ordinary lives and eating ordinary food, except that a few avoid certain foods such as boiled puddings and pork. They do their work without any loss of time and in many cases this is laborious work, such as dock labouring. One man played several seasons in first class Rugby League football after an operation of gastro-jejunostomy and cautery of a lesser curve ulcer for double ulcer--duodenal and lesser curve. These people are well and do not carry out any elaborate after-care, such as Hurst insists on in the case of medical treatment. This group represents 67 per cent. of the patients who survived operation.

The second group, cal led" much improved ", are people who have occasional slight indigestion, i.e., pain or occasional vomiting, usually after some indiscretion in diet, and may lose a little time off work, but not more than a week in a year. In both these groups the result may reasonably be considered satisfactory. These groups combined give about 80 per cent. I t is significant that the figure of 80 per cent. good results was arrived at many years ago by Paterson, and an exactly comparable figure was found by Somervell and Orr when they followed up 635 cases in Indians. Pyrah followed up the after histories of 389 patients operated on in the General Infirmary, Leeds, and found 79 per cent. satisfactory results.

When different observers arrive at such similar results, I think we may take it as proved that gastro-jejunostomy offers an 80 per cent. chance of cure in the ordinary hospital patient, without any real after-treatment.

In four cases the results were unsatisfactory owing to persistence of the indigestion, but no evidence of jejunal ulcer was found.

The incidence of secondary ulceration in the series is high. This is because all cases of hmmorrhage after operation have been classified as jejunal ulcers, whether or no there were any other symptoms or x-ray evidence. On this basis there were nine cases of jejunal ulcer which I propose to treat in some detail because, some interesting facts emerge. Four were proved by operation--one undoing of the gastro-jejunostomy and three for acute perforation. The first of these perforated many years ago, while giving an anaesthetic, and the perforation was sutured there and then. After he had had about 14 years of persistent indigestion, I did a posterior gastro- jejunostomy in March, 1934. Within a few months pain recurred, and in June, 1935, I operated again and found ulceration on the anastomosis. I undid the anastomosis and restored the natural conditions. For a time he was much better, but recently an acute coryzal infection has produced a severe recurrence of his pain. This is now subsiding under medical treatment but he has developed a pyloric stenosis.

Of the .three perforas cases, one, a man of 32, had posterior gastro-jejunostomy in February, 1929, for duodenal ulcer, and I am indebted for his after-history to my friend, Mr. It. tI. Rayner.

After a few months of perfect freedom from digestive troubles he sud- denly perforated. The perforation was sutured, but kept recurring so that m all he had five perforations up to 18 months ago, when Mr. Rayner Qndid hi, s gastro-enter~stomy. He was well ~ix months later.

198 I R I S H J O U R N A L OF M E D I C A L S C I E N C E .

The .second case firs~ came under my care in July, 1932, at the age of 31 with a perforated duodenal ulcer which was sutured. In November. 1933, I did a posterior gastro-]ejunostomy for continued symptoms and bleeding. Two years later, in November, 1935, he had a perforation of a jejunal ulcer which was sutured and he recovered. I have been unable to trace this patient further as he has changed his address and it is not known where he has gone.

The third is a very interesting case. In February, 1928--when he waa 36 years old--I did a posterior gastro-jejunostomy for duodenal ulcer with stenosis. He was apparently quite cured and was eating anything and everything when in October, 1933, almost six years a f a r his operation, he perforated without any warning in ~he shape of indigestion. He was brought 80 miles to the Salford Royal Hospital, where the perforated gastro-jejunal ulcer was sutured and he recovered. I have seen him within the last few days and he has been well ever since. He leads an ordinary life, does his work as a fishmonger without losing any time, bu~ he now diets very carefully, because he has learned his lesson.

These are the cases of je junal ulcer proved by operation. Of the five remaining, one had posterior gastro- jejunostomy in 1929. Pa in recurred within two years and in J anua ry , 1933, a small cra ter was seen radiologically in the afferent loop one inch distal to the stoma. This pa t ien t has remained on medical t r ea tment ever since both f rom mysel f and f rom a physician, but he is constantly breaking down and having to rest. Another, a man aged 46, had posterior gast ro- je junostomy in Ju ly , 1927. H e was an in-pat ient again in May, 1929, with hmmorrhage, and the radiologist reported tha t there was x- ray evidence of je junal ulcer. This pa t ien t died in December, 1933, of phthisiu.

In addit ion to these five cases proved by operat ion or x- ray there are three pat ients who have had one bleeding since the gastro- jejunostomy.

One was originally operated on by me in April , 1931, for duodenal ulcer, the operat ion being pyloroplas ty and eauterisation of a posterior duodenal ulcer. The operat ion was a fa i lure and in September, 1931, when he was 51 years old, I did a poster ior gastro- je junos tomy with pyloric exclusion. Twelve months la ter he had bleeding and was in bed ten days. He had no pain or vomit ing be:fore or a f t e r this bleeding, and the ten days he spent off work then is the only t ime he has lost f rom work since his operation four and a half years ago.

A woman, aged 44, operated on in September, 1933, was quite well unti l five weeks ago when she had a hmmorrhage following one week 's indigestion. She has had no pain since, bu t is still t ired and lang~uid.

The last was a man of 38, operated on October, 1936, who had a severe h~ematemesis four months ago. No pa in before or since, but he is still easily t i red and somewhat anmmic.

I have described these eases in some detail, because they seem to me to fall into two classes, viz., acute and chronic ulceration.

The last three eases of hmmorrhage and the ease of the man with the single per fora t ion seem to me to be examples of acute je junal ulceration. They have had no symptoms before or since these events, and it is quite likely they never will have any more trouble, i f they exercise reasonable care. I have known quite a number of


people who have had a single bleeding after a gastro-jejunostomy and have lived for many years after with no further trouble. In 1920 I saw a doctor who two years after an operation of gastro- jejunostomy in London had a severe h~emorrhage. He had had at least one attack of severe pain after the operation, but since th~ h~emorrhage he has lived a busy and very full life and he tells me he does not know that he has a stomach except that fats nauseate him. From these and other cases I have formed the opinion that h~emorrhage is not necessarily a sign of failure of the operation, and that a single hmmorrhage is not incompatible with many years of comfort afterwards.

The other cases illustrate (1) the recurrent type of perforation Which is very common with secondary ulcer; (2) the chronic type with persistent symptoms which is so difficult to cure, and in whom persistent pain is a constant and most distressing feature.

Although, therefore, there are nine patients classified under the heading of secondary ulcer, two of these might quite reasonably be regarded as good results in that they have had no symptoms at all for the last three and a half years and have only had one set-back in four and a half years and nine years respectively since the operation. Two others have had a single bleeding recently, and only time will show whether any further trouble will ensue, but they had none before and have had none since, and I have high hopes that the ultimate result will be successful. In this series there are no examples of the fantastic histories which are so frequently met with in jejunal ulcer, except for the man with repeated perforations. I believe that these extraordinary results can be largely avoided by recognising that thepatient is a persistent ulcerator and, therefore, one should restore the normal anatomical conditions and leave him merely his duodenal ulcer to cope with.

Five patients are known to have died since the operation. One of them was the patient with secondary ulcer and h~emorrhage who died of phthisis six years after his operation. One died of pneumonia, and the cause of death is unknown in the other three.

The numerous articles decrying the surgical treatment of duodenal ulcer together with the gradually increasing school among the younger surgeons in favour of extensive resection operations because of the risk of secondary ulceration and the fact that ia the ordinary hospital routine I only see the failures among my cases, had all combined to make me wonder whether I had not spent a large part of my .working life in work which was not merely ineffective but actually harmful. The result of this enquiry, I submit, dispels that illusion. The patients were almost entirely of the~ working class, doing laborious work and living under conditions which make any effective after-treatment very difficult, so that it is rarely carried out by the patient, whatever instructions are given and yet 80 per cent. of them are cured.

The importance of strict after-treatment for the rest of the patient's life after medical treatment is strongly emphasised by Hurst, mud while I agree with him I do not believe it is possible to

200 IRISI-I JOURNAL OF MEDICAL SCIENCE.

get the ordinary working-class patient to submit to it. I f it could be enforced after the operation of gastro-jejunostomy I believe that the recurrence rate and the incidence of secondary ulcer would be reduced to very small proportions indeed.

The statistics of the results of medical treatment, at the New Lodge Clinic in 1927 show good results in a rather smMler pro- portion of patients, but the recurrence rate is certainly higher than in my figures. Fifteen out of 90 patients required operation subsequently, and 11 more are stated to have had recurrences. Of course~ there were no deaths as the result of medical treatment, though I notice that in deaths stated to be due to intercurrent disease, one is said to have been from " alkalosis ", a rather suggestive term. In contrasting these two series it is necessary to remember that the New Lodge patients are in more comfortable circumstances than hospital patients and can spend more time and trouble on their after-treatment.

Now, although I am making these comparisons, it is not because I am hostile to medical treatment. Far from it. I believe that it is most unfortunate that physicians and surgeons have grown away from each other in the treatment of this disease, and that medical treatment carried out by a skilled physician should have a thorough trial, surgery being resorted to after consultation between the two. This does not obtain at the present time, but it is the true ideal to be aimed at. I differ from t turs t in his views that it is only in rare eases that the non-stenosing ulcer will require operation. This is probably true where the social surroundings of the patient are favourable, but in my experience it is emphatically not so in the hospital patients. They come into the medical wards time after time and keep on breaking down, until finally operation becomes imperative.

I submit that the results obtained in this series of ordinary hospital patients fully justify the use of surgery. In actual fact there are only nine patients in addition to the three deaths in whom the operation can be said to have been a complete failure, i . e . , four cases of persistence of symptoms and five persistent secondary ulcer patients. The drawback of the risk of secondary ulceration is a very real one, and so far as I know there are no technical factors of great importance in the production of these ulcers which we could rectify. I f the work of my friend, Mr. Wilson H. Hey, on the ligature .of practically all the blood vessels supplying the stomach, an operation which he terms " gastric ligation ", fulfils the claims he makes for it, then a very noticeable advance will have been made. I-Ie claims that it cures ulceration, especially jejunal ulceration, and that if done at the time of the gastro-jejunostomy it will prevent jejunal ulceration. How it acts is not yet known, but it has been suggested that the action is due to a permanent lessening of the amount of gastric secretion. Much work requires to be done, and I should say a number of years must elapse before this work can be finally appraised.

The second point to be examined is whether gastro-jejunostomy


is a very much better operation for stenosis cases than for the non- stenesed, and particularly whether there is any less liability to secondary ulceration. This has been claimed with increasing frequency in recent years, and the reason given is that the ulcer has healed and the cause of the ulceration has disappeared.

I have never believed this, because many years ago when I studied the literature of the early recorded cases of secondary ulcer, most of them followed operations for stenosis.

In this present series 35 of the cases had stenosis" of these 30 were traced, 24 were perfectly well, one was a poor result, one died subsequently, and there were two cases of perforation of jejunal ulcer and two of h~ematemesis, presumably from acute jejunal ulceration. Thus in about one-third of the total number of operations there were four-ninths of the cases of jejunal ulcer. This series, then, does not support the view that stenosis produces a partial immunity from secondary ulceration. In actual fact the relief experienced after the operation is greater on the whole than in the non-stenosing cases, and this is only to be expected, as the symptoms before operation have usually been much more severe.

Finally we have to consider the claim that the logical operation when the non-stenosed patient requires one is a very high partial gastreetomy. The best known advocate of this is Finsterer, though other continental surgeons do the same, and there is an increasing number of surgeons in this country who advocate this operation. The reasons given are : (1) the constant presence of a hypertrophic gastritis in the pyloric half of the stomach, tending to produce future ulceration; (2) the removal of a large part .of the acid secreting area of the stomach, with consequent diminution of the gastric juice.

Somervell and Orr give a curious diagram of the various parts of the stomach which does not correspond to the ordinary descrip- tions of the anatomical textbooks, in which what is normally labelled the body of the stomach is called the fundus, and what is usually called the fundus is described as the cardiac portion, so that a high gastrectomy according to this dia~oTam would remove practically the whole of the acid-secreting part of the stomach. In actual fact the portion left behind is rich in acid-secreting cells and the reduction of acidity after this operation depends partly on the reduction in the amount of secretion, and partly on the fnet that the small portion of stomach which is left empties very rapidly. The reduction in acidity undoubtedly is achieved in many cases, and this will help to prevent the occurrence of secondary ulceration, which is the main claim put forward for this operation for simple duodenal ulcer. I f it can be established that this operation does abolish secondary ulcer, then it becomes logical provided that the mortality can be kept low enough. There can be no doubt that the mortality in skilful hands can be kept very low. My friend, Professor Morley, has a series of 189 Schoemaker gastrectomies for ulcer with a mortality of 2.8 per cent. This operation is not a good one for duodenal ulcer, as the risk of recurrence of ulceration is greater than after


the Polya operation, but I have no doubt that the surgeon who can achieve such a low mortality in the one operation will be able to do so in the other. The ordinary surgeon, however, is very unlikely to reach anything like so low a figure and I should say that if the average mortality were kept down to 5 per cent. it would be a very good achievement. I t will in any case be appreciably higher than that of gastro-jejunostomy in similar hands.

What of the immunity from secondary ulceration? I know from experience, and also from the experience of others, that high gastrectomy performed for established jejunal ulceration is followed quite frequently by further jejunal ulceration, and I have know- ledge of jejunal ulceration developing after a high gastrectomy had been done for duodenal ulcer in the hope of preventing such an occurrence.

I am prepared to believe that the incidence will be smaller than that after gastro-jejunostomy, but that there will be cases I have no doubt. Only time can show whether the diminution will lm sufficiently great to compensate for the undoubtedly higher mortality of the primary operation. In any case the development of a jejunal ulcer after a gastrectomy is a terrible condition indeed, and there is no possibility of retreat such as exists where it follows gastro-jejunostomy. I would hesitate myself to adopt that operation as a routine, when gastro-jejunostomy affords such excellent results and the failures are more easily treated.

I do not propose to say much about the technique of gastro- jejunostomy, but there is one point on which I would like to comment. It is that of post-operative bleeding from the azmstomosis. I t is only too common to trust to the inner layer of sutures and the under-running of visible vessels with the outer suture. When the operation is performed with clamps it is not possible to see what~ bleeding there is from the posterior part of the anastomosis, unless the clamps are loosened after completing this layer. I personally always clamp and ligature all vessels seen on the gastric mucosa after dividing the sero-muscular coat, and since adopting this about fifteen years ago I have had no h~emorrhage at all.

About nine or ten years ago, when gastro-jejunostomy wan falling out of favour, operations of the pyloroplasty type and gastro- duodenostomy were much advocated~

Finney, of Baltimore, had been doing his special form of pyloroplasty for years and Shelton Horsley modified the ordinary pyloroplasty. Gastro-duodenostomy had many adherents, notably Wilkie. All these methods were advocated on the grounds that they inter- fered less with normal physiolo~ than did gastro-jejunostomy; that the stomach delivered its contents into the duodenum where they belonged.

For a time I tried these methods, especiMly the Shelton ttorsley type of pyloroplasty, but eventually I found recurrence too frequent. In all, in the period since 1926 I have done 41 operations of one or other of these types. One patient died of acute dilatation of the stomach after gastro-duodenostomy, due, I have no doubt, to kink-

SURGERY AND T H E D U O D E N A L ULCER. 203

ing of the duodenum at the junct ion of the mobilised and non- mobilised parts. I found, in common with other surgeons, tha t post-operative vomiting was unduly common af ter gastro- duodenostomy, and I think the cause I have indicated is responsible.

TABLE II. Pyloroplas~y and Gas~roduodenos~olr~y.

Tota]--41. Traced . . . . . . . . . 25

W e l l . . . . . . . . . 9 Fairly well"" . . . . . . . . . 8 R e c u r r e n c e . . . . . . 3 o , .

Further operation . . . . . . 4 Died . . . . . . . . . . . . 1

2 5

Medica~ Treatments. ~l'otal--19 Traced . . . . . .

W e l l Occasionai"Indige~tion R e l a p s e . . . . . . P e r f o r a t i o n ...

(2 perforation; 2 posterior gastro-j ej unostomy)

... 17 ~ 1 7 6

. . ~

. . . 9

. . . 4

~ 3

. . ~ 1

17

The after-results did not prove near ly so satisfactory as those of gastro-jejunostomy : 25 patients were traced and of these nine w e r e

well and eight moderately well, i.e., 68 per cent. In three there was recurrence of the duodenal ulceration, and no

less than four required subsequent operat ion-- two for perforat ion and two had gastro-jejunostomy. Both the la t ter patients are now well.

In consequence of the decidedly inferior results of these operations in my hands I have now abandoned them. In addition to these there is one example of gastrectomy by the Billroth I method, the patient dying two years la ter of cancer of the msophag~s.

One recent case of high PMya gastreetomy for persistent duodenal ulcer in a young man with high acidity is still well, but it is less than a year since his operation.

In the same period two patients have been operated on for duodenal ulcer and lesser curve ulcer existing at the same time. In both the operation was a high anterior Polya operation, and both patients are well.

This review of my patients convinces me that there is still a place f o r the operation of gastro-jejunostomy in the t reatment of the persistent non-stenosing duodenal ulcer. This t rea tment will be required more f requent ly in the manual labourer and others who find it difficult to nurse themselves and to diet efficiently, and I am not at all sure tha t it is not the t rea tment of choice in the ordinary hospital pat ient who has had trouble of a fa i r ly severe type for two years or more. One should, however, be chary about advising operation in the case of the young patient, especially with a high acidity. F o r the past year or two I have been t reat ing hospital patients in my wards on medical lines, where the ulcer has been

204 I R I S H J O U R N A L OF M E D I C A L S C I E N C E .

of short duration, or where medical t rea tment has not had a reasonable trial. There are 19 such pat ients and 17 have been traced. Nine are well, four have occasional indigestion, not of a severe type, three have had definite relapses, and one has had a perforation. These pat ients have been observed over a short period only, but the results so f a r bear out the contention that cure can be obtained in a good proport ion of patients.

Pe~rforation o'f Duoden~al Ulca:

There is not very much to be said about the surgical t rea tment of per fora ted duodenal ulcer, which is now p r e t t y well standardised. The series presented consists of pat ients t rea ted in m y wards f rom 1930 onwards to the middle of 1937. Most of these pat ients were operated on by the resident surgical officers, and I think the results reflect credit both on these young men, and also on the pract i t ioners who have sent the pat ients into hospital sufficiently ear ly to enable these good results to be obtained.

The total number t reated is 59, and of these five are included under the cases of gastro-jejunostomy. The immediate mor ta l i ty was six, jus t over 10 per cent., and none of these deaths was among t h e pat ients who had gast ro- je junostomy at the time.

TAB~ I I I . l~esul~s o] l:'er]ora~ion Gases.

T r a c e d . . . . . . . . . 33 W e l l . . . . . . . . . . . . 12 O c c a s i o n a l p a i n . . . . . . . . . 8 S o m e i n d i g e s t i o n . . . . . . 4 S u b s e q u e n t o p e r a t i o n . . . . . . 4 H m m a t e m e s i s . . . . . . . . . 1 D i e d s i n c e . . . . . . . . . 4

33

(3 gastrojejunostomy, o n e of whom later had a p e r : forated jejunal ulcer; 1 perforated d u o d e n a 1 ulcer)

Deduct ing the deaths and the cases where gast ro- je junostomy was done at the t ime we are lef t with 48 patients. Of these 33 have been traced, and the af ter-resul ts are shown in the table. About 60 pe r cent. are reasonably well. This suppor ts the findings of Grey T u r n e r in his H u n t e r i a n lecture of 1925, and justifies the usual practice in this count ry o.f restr ict ing the operat ive t rea tment to the suture of the perfora t ion and the toilet of the peri toneum.

Nevertheless, there are times when the stenosis a t the t ime of operat ion is so severe as to call for gast ro- je junostomy and occasion- ally where this has not been done it m a y be necessary to reopen the pa t ien t and do i t as an urgency.

Case Report. The patient w~s a man aged 48 years on whom I lhad successfully resected

a carcinoma of the transverse colon 4 years before. On November 6the 1937, he had a perforation of a duodenal ulcer, which had given him indigestion for many years. The perforation was accompanied by copious dark brown vomit. He was operated on by the resident surgical officer, who found a perforation of a chronic ulcer on the anterior wall of the t l r s t part of the duodenum and sutured this, covering over Vhe suture line with omentum. I t was no~ed at the time that the ~tomach was d i s t e n d e d and the patient again vomited dark brown fluid on the table.

S U R G E R Y A N D T H E D U O D E N A L U L C E R . 205

~he patient did not do very well. The pulse gradually rose from 100 to 130 in the fir.st four day~ and the patient had much nausea, and vomited dark treacly fluid. An indwelling tube and intravenous drip were employed without improvement and the ,stomach contents remained black and treacly. On November 9th I reopened the abdomen and found the stomach enormously distended with fluid. Thi~ I emptied through a gastrostomy opening with a suction tube; I then closed the gastrostomy and did a posterior gastro-iejunostomy. The pat ient made a rapid recovery.

I n o rde r to avoid s tenos ing the d u o d e n u m by the closure of the p e r f o r a t i o n I use two, or p e r h a p s th ree su tu res t h r o u g h all the coats o f the viscus, t ak ing the b i te t h r o u g h hea l thy t issues beyond the cedematous area. These su tu res are t h e n t ied so as m e r e l y to a p p r o x i m a t e the edges of the pe r fo ra t ion , thus closing it. O m e n t u m is nex t s u t u r e d over the area . I n th is way t he r e is no in fo ld ing , and no s tenosis is added to w h a t e v e r is a l r eady present .

References. Hurst and Stewart : Gastric and Duodenal Ulcer. H. Milford, Oxford

University Press, 1929. Bashford and Scott: Lancet, 1935, it, 710. Somervell and Orr: British Journal ot Surgery, 1936-37, xxiv, 2~7. Pyrah: P~oc. Roy. Soc. Med., 1934, xxvii, Sect. Med., 21. Forsyth: Brit . Mcd. Jo., 1924, i, 780. Garnett Wright : Brit. Jo. Surg., 1934-5, xxii, 433. Walton: Brit. Jo. Surg., 1934-5, xxii, 33.

Discussion. T ~ PRESIDenT, in declaring Mr. Garnett Wright 's paper open for

discussion, said. Everyone present will have been most forcibly struck by the extreme candour of Mr. Wright 's description of his cases. The results which he has placed before the Section bear the absolute stamp of scientific truth. We all feel that Mr. Wright has given us an absolutely accurate account of a problem which is at present intriguing every surgeon in this as in other countries. I t has been appropriately observed in another connection that " What Manchester says to-day, England thinks to-morrow."

MR. SETON PRINGLE: I may start by saying that my more than thir ty years of practice cover the entire life-history of the surgery of duodenal ulcer, yet here we are still debating the best method of treatment, and will, I fear, continue debating the subject until the essential causes of duodenal ulceration are discovered; then perhaps the treatment will become standardised.

The best contribution I can make to the discussion is to state, as con- cisely as possible my own personal position. To do so I would like t~ divide chronic duodenal ulcers into (1) uncomplicated cases, and (2) cases complicated by stenosis, hmmorrhage or perforation.

In the uncomplicated cases I have followed the modern trend towards adopting purely medical treatment. I confess that I feel rather ashamed of mvself for so doing. There are some exceptions, however, among these uncomplicated cases where surgery must step in. First of all, we have those cases which will not ~Tield to strict medical t reatment; these are very few. Then there are those patients who will not follow the regime for the necessary length of time, but who after a few weeks or months of relief be~in to take liberties with their diet and relapse, not once but several times. Again, there are patients who, for economic reasons, certainl~ cannot follow the necessary regime. These comlorise a large pronor~ion of hosvital cases. In these three classes of chronic uncomvli- cared ulcers I have no hesitation in uerformin~_ a ~astro-enterostomy if the gastric acidity is only moderate. We must not forget the 80 per cent. or so of excellent results we were able to obtain while gastro-enterostomv was still re~arded as the treatment of choice in all cases irrespective of gastric acidity. I cannot help thinking that the operation of gastro-

206 I R I S H J O U R N A L O F M E D I C A L S C I E N C E .

enterostomy resembles too much the dog with the bad name. In those eases with very high acidi ty I do a hemi-gastrectomy. I divide t h e duodenum distal to the ulcer (except where such a procedure would be so difficult as to unduly increase the risk) and I complete the operat ion af ter the Polya I method.

In a small proport ion of the uncomplicated relapsing cases one finds a t operat ion an ulcer on the an te r ior wall of the duodenum : in these I merely excise a lozenge-shaped area on the an te r ior wall of the pyloric region, as advocated some years ago by the Mayos. On the whole the results have been satisfactory, if reasonable care be taken as regards diet subsequently.

Coming now to complicated cases: in those where there is a definite hold-up of the stomach contents by e i ther cicatr icial contract ion of the first s tage of the duodenum or by the development of a large inf lammatory mass, I believe tha t a posterior gastro-enterostomy is all t h a t is required. I n the cicatr icial cases there is no act ive ulcer to need removal , and in the act ive inf lammatory cases the condit ion is such as to render any

"a t t empt a t resection of the ulcer a very dangerous and difficult procedure. Now as regards duodenal hmmorrhage: this is not the t ime to en ter

into the pros and cons of operation~ and I will therefore t ry to s ta te my present opinions in as few words as possible. They a re : t ha t acute hmmorrhage ought to be t rea ted conservat ively by rest, small doses of morph ia and l ight d i e t ; t ha t the stomach ought to be washed out if there is reason to believe t h a t i t is loaded with blood or blood c lo t - -a ~listended stomach means an engorged circulat ion and delayed coagula t ion; t h a t only a small blood t ransfusion of e ight or t en ounces to promote c lot t ing ought to be given in the average case; t h a t a massive transfusion should be reserved for those comparat ive ly ra re cases in which i t soon becomes obvious tha t conservat ive tre-atment will not succeed on account of the continuous or rapidly recurr ing hmmorrhage, causing the h~emoglobin to fal l below 30. I n o ther words, massive t ransfusion is only justifiable as a p repara t ion for an operat ion designed to a t tack and control the bleeding vessel.

I n acute perfora t ion , for many years I did a posterior gastro-enterostomy when the pa t i en t ' s condit ion was good, but nowadays I content myself by merely su tu r ing the perforat ion. About 50 per cent. of these require surgical in terference la te r on.

PROF. lCI~NRy MOOR~: F rom an experience of several hundred cases of duodenal ulcer I believe tha t , in the absence of pyloric obstruction, about 75 per cent. can be cured by medical means, provided t h a t there is co- opera t ion by the pa t i en t , t ha t a pre l iminary period of hospital t r e a t m e n t is followed by months of careful die te t ic regulat ion, t ha t adequate measures are ins t i tu ted to control gas t r ic acidity, t ha t sources of focal infect ion are removed and t h a t rest is obtained in the ear ly stages of t r ea tment .

I r egard the finding of hyperchlorhydria with the f ract ional tes tmeal a n

impor t an t diagnost ic poin t and the control of hyperchlorhydria a condit ion mecessary for success in t r ea tment .

l~yperchlorhydria itself is a potent ia l ly dangerous s ta te and i t pre- disposes to the format ion of duodenal ulcer ; i t may be a p r imary con- s t i tu t iona l condit ion (Hurs t ' s hypersthenic gastr ic diathesis) or i t may resul t f rom or be intensified by the presence of duodenal ulcer. In the l a t t e r case the ulcer operates by in te r fe r ing with the pyloro-duodenal neuro-motor regula tory mechanism which permits regurg i ta t ion into the s tomach of a lkal ine juices from the upper small in tes t ine at cer ta in periods of the gastr ic digestion cycle (the Boldyreff hypothesis). These in tes t inal juices b.v neutra l isa t ion, and, according to recent views, especially by di lut ion, p reven t the gas t r ic acidi ty from ris ing to a high concentrat ion. Recen t research has shown tha t there also exists a com-

passed into the in tes t ine there is an inhibi t ion of the intes t inal phase of gastr ie acid secretion, especially a f te r the stomach has empt ied ; this mechanism is h indered if pvloric re laxat ion is imperfect as is often the case when duodenal ulcerat ion is present , l~Ivperchlorbydria, therefore , is a l ink in a chain of a vicious circle and this condit ion must be con- trolled by medical or surgical means if the ulcer is to heal. Thus i t can be easily understood how the persistence of an antecedent hyperchlorhydria

S U R G E R Y A N D T H E D U O D E N A L U L C E R . 207

or of hype rch lo r hyd r i a r e s u l t i n g f rom t he ulcer will m i l i t a t e a g a i n s t heal- ing and promote pers is tence of t he ulcer. P robab ly the exis tence of sub- acu te pyl0rie g a s t r i t i s in duodena l ulcer cases is no t an uncommon cause of severe hype rch lo rhydr i a and i t may lead to pa r t i a l pyloric obs t ruc t ion m some cases; t h i s form of p a r t i a l pyloric obs t ruc t ion of ten yields to medical t r e a t m e n t ( inc luding lavage) an<l if ope ra t ion is decided on i t should always be t r e a t e d medical ly in t he f irst ins tance , in order to o b t a i n a less u n h e a l t h y s tomach wall for the surgeon. Indeed, pyler ic ga s t r i t i s a lone can give r i se to a cl inical p i c t u r e difficult to d i f fe ren t ia te f rom duodena l ulcer and i tself m ay cause m a r k e d hype reh lo rhydr i a ; F a b e r t h i n k s i t is t he chief cause of t he c l imbing curve hyperch lo rhydr i a found so of ten wi th duodena l ulcer.

Clinical exper ience and an imal e x p e r i m e n t a t i o n have a b u n d a n t l y shown t h a t the ac t ion of f ree hydrochlor ic acid on t h e a l i m e n t a r y mucous mem- b r a n e is one i m p o r t a n t fac tor in t he pa thogenes i s of pep t i c u lcer ; of course i t is obviously no t t he only one.

W h e n hype rch l o r hyd r i a is cons t i t u t iona l i t may pers i s t for years a f t e r successful t r e a t m e n t of duodena l ulcer, unless chronic gas t r i t i s supervenes.

W h e n ope ra t ion is decided upon, a course of medical m a n a g e m e n t before and a f t e r ope ra t ion is h ighly advisable and may be an i m p o r t a n t f ac to r in t he avoidance of subsequen t u lce ra t ion a t t he anastomosis . One c a n n o t help b u t comment upon the u n h e a l t h y s t a t e of m a n y s t o m a t a as seen w i th t he gast rescope and one is inc l ined to believe t h a t a pos t -opera t ive course of medical t r e a t m e n t would, if con t i nued long enough, min imise t h i s undes i rab le s t a t e of ai~airs.

The medical t r e a t m e n t , and indeed t he surgica l also, for t h a t m a t t e r , ma in ly consists in p r o c u r i n g as much res t as p rac t i cab le for the s tomach and in keep ing t he gas t r i c ac id i ty as low as possible for t he g r ea t e r p a r t of t he 24-hours. This is achieved by some modif icat ion of t he S ippy d i e t a r y r ~ i m e and by t he inges t ion of a lka l ine powders. I used to use chiefly calc ium and magnes ium carbona te , b u t in t he las t year or so s y n t h e t i c magnes ium t r i s i l i ea te has a lmost en t i r e ly displaced o the r neu t ra i i se r s in my own prac t ice . The p a r t i c u l a r a d v a n t a g e of syn the t i c m a g n e s i u m t r i s i l i ca te is t h a t , in su i tab le dosage, i t s immed ia t e neu t r a l i s a - t i on ac t ion on t he I~C1 is con t inued a t a slow r a t e for some two or t h r e e hours. By su i tab ly spac ing the food, t he mi lk cream mix tu re s and t he doses of th i s drug , t h e gas t r i c acid can be k e p t neu t r a l i s ed for prac t i - . cally t he whole 24 hours for weeks or even months , w i thou t any dange r of a lkalosis ; an t i spasmodics are , of course, also used. This t r e a t m e n t in my eases usual ly gives very sa t i s fac tory resul t s and I coun t on g e t t i n g w i t h i t abou t 75 pe r cent . of successful resu l t s in co-opera t ive p a t i e n t s as j udged over a pe r iod of several years .

MR. I t . MEAD~: No case of duodena l ulcer should come to a surgeon unless t h e p a t i e n t has first had a course of medical t r e a t m e n t . I n cases w i t h s tenosis I am in f avour of t he s imple gas t ro-en te ros tomy. I n eases w i t h o u t stenosis I v a r y my l ine of t r e a t m e n t . I n cases in which t he ulcer is very fixed I do no t do gas t rec tomy, b u t in all o the r cases I do, and on t h e whole t he resul ts have been sa t i s fac tory . I have seen very few cases of gas t ro - j e juna l ulcer. I n m a n y of these ulcer cases the p a t i e n t s a re qu i t e u n a b l e to ca r ry ou t t he lon~ d ie t which H u r s t has recommended ; personal ly , I usual ly have my p a t i e n t s prac t ica l ly on m e a t in a week a f t e r ope ra t ion . F o r six months , I w a r n them. they should n e v e r t ake a ful l meal , b u t should t a k e several small meals d u r i n g t he day. I forb id alcohol absolutely. I n cases of j e juna l ulcer , if a loop be no t made to allow for m o v e m e n t to t ake place, one is l ikely to find onself c a u g h t up in t rouble . I neve r use clamps unless when p e r f o r m i n g gas t roc tomy, a n d I use fine silk for su tures , as I bel ieve t h a t if th ick c a t g u t is p u t i n to t he mucous m e m b r a n e i t would pe r fo ra te . The bes t ope ra t ion in my opin ion for chronic duodena l ulcer is a p a r t i a l gast roctomy.

DR. V. 1~. S]rNO]r: Twenty years a~o in Dub l in i t used to be un ive r - sal ly recognlsed t h a t all cases of duodenal ulcer, once dia_~nosed, should be sen t to a surgeon. Since t h a t t ime , however, t he p e n d u l u m has been g radua l ly swing ing in t he opposi te d i rec t ion . Mr. G a r n e t t W r i g h t one m i g h t safely describe as a t ]east ha l f a phys ic ian . One ve ry i m n o r b a n t r ecommenda t ion in his p a p e r was t h a t every case of chronic abdomina l disease should see a phys ic ian f i rs t before be in~ seen by a surgeon. The real ly i m p o r t a n t t b i n ~ abou t duodenal ulcers is to real ise t h a t the cause is no t known. All t h a t we do know is t h a t i t is some sor t of d~athesis. There a re a g r e a t m a n y fac tors which seem to make up th i s diathesls .

208 I R I S H J O U R N A L O F M E D I C A L S C I E N C E .

One hea r s of a g r e a t m a n y d i f f e ren t l ines of t r e a t m e n t for duodenal ulcer, all of which a re accompan ied by a f a i r a m o u n t of success. I am of op in ion t h a t duodena l ulcers have a t endency to hea l on t h e i r own account. The o r d i n a r y acu te case o~ duodena l ulcer genera l ly ge t s well on i ts own~ b u t t h e p a t i e n t of course has to be he lped w i t h advice f rom the physic ian r e g a r d i n g die t , etc. A very la rge n u m b e r of these cases ge t well w i thou t be ing hospi ta l i sed a t all. Cases in which t h e ulcer is bigger and more chron ic are more difficult to deal wi th , b u t w i th p.ersistent and careful medica l t r e a t m e n t t hey usual ly ge t well and r e m a i n well. Sometimes sur,gery is ve ry su~ccessful in these cases, b u t medical t r e a t m e n t should always be g iven a t r i a l first. I f t h i s fails, t h e n resor t can be had to surgery . Nor should we overlook t he g r e a t help which physic ians ge t f rom radiologis ts in these cases. Some cases seem to have a t endency to r e c u r r e n t hmmorrhage . This is somet imes cured by medica l t r e a t m e n t and somet imes by surgery , b u t in a l a rge p ropor t ion , no m a t t e r wha t is done t he hsemorrhage cont inues . There is a common type of case in which t he p a t i e n t compla ins of pa in a f t e r food, and in which i t is impossible to be c e r t a i n whe t he r a duodena l ulcer is p r e s e n t or not . These cases were t r e a t e d medical ly in t he pas t , and did no t improve ; they were t h e n t a k e n in to hosp i ta l and st i l l t hey d id no t improve. I n some of them, ope ra t ion was done and n o t h i n g a t all was found. W h a t exact ly does Mr. G a r n e t t W r i g h t consi~der these cases a re? Is i t l ikely t h a t t he condi t ion is some form of nervous spasm? H as Mr. W r i g h t ever ope ra t ed for duodenal ulcer and found n o t h i n g ?

MR. F. J . M o R ~ N : There can be no ques t ion a t all t h a t t h e t h e r a - peu t i c m a n a g e m e n t of cases of duodena l ulcer cons t i tu tes a ma io r problem. Duodena l ulcer undoub ted ly is on the increase. I have been s t ruck by t he fac t t h a t in m e e t i n g m a n y surgeons they do no t seem to r e g a r d these cases as problems a t all, and a p p e a r to cure t h e m all. Mr. G a r n e t t W r i g h t has said t h a t he does no t cure every case, and t h a t in a g r e a t m a n y cases compl ica t ions occur which add to t he sever i ty of t he case. I n a young p a t i e n t who has no stenosis I .consider t h a t t he f a r t h e r t h e surgeon is k e p t away, t he b e t t e r for t he p a t i e n t . I n middle-aged p a t i e n t s i t is d i f fe ren t ; w i th t h e m i t is a case of t r y i n g tO cure t he u n h e a l t h y gas t r i c condi t ions found in t h e s tomach. The ques t ion i s : w h a t con- s t i t u t e s real ly efficient medica l t r e a t m e n t ? I n m a n y - p a t i e n t s any d ie te t ic r e s t r i c t ions are absolutely prec luded owing to economic causes. There is no use in p u t t i n g a hospi ta l p a t i e n t on a d ie t which you know qu i t e well he c a n n o t possibly follow. Amongs t th i s class of cases m i g h t be g rouped t h e cases of mul t ip le hmmorrhages . I n these cases t o t a l gastrec~omy is t he bes t t r e a t m e n t , and t he use of con t inuous i n t r a v e n o u s d r ip t r a n s f u s i o n ha s been an e x t r a o r d i n a r y help in th i s condi t ion .

DR. E. T. F ~ A N : Mr . G a r n e t t W r i g h t ' s surgical successes have been 80 pe r cent . , a n d of t he cases t h a t he t r e a t e d medical ly his successes were 76 p e r cent . These a re very sa t i s fac tory results , w i th prac t ica l ly t he same p e r c e n t a g e in su rge ry and in medic ine , and they t e n d to show t h a t t h i s cond i t ion may be t r e a t e d e i t he r surgical ly or medical ly and w i th prac- t ica l ly t he same resul ts . The reason for th i s is t h a t t he rea l cause of duodena l u lcer is no t known. The p r inc ipa l t h i n g is to keep t he s tomach neu t ra l i sed . This can be done by doing a gas t ro -en te ros tomy or by g iv ing a lka l ine t r e a t m e n t . I n s imple cases, by medical t r e a t m e n t t he p a t i e n t r uns no r i sk wha teve r , whereas in surgery , a l though t he risl~ m i z h t be very small , t h e r e is always a r isk. I have h a d p a t i e n t s who got one hmmor rhage a f t e r a n o t h e r in which n e i t h e r medical no r surg ica l t r e a t -

as f a r as these p a t i e n t s a re concerned. I n ear ly cases in which, owin~ to economic causes, i t is known t h a t t he p a t i e n t will no t be able to c a r r y ou t any d ie te t ic t r e a t m e n t , ope ra t i on should always be careful ly con- s idered. W h e n t he p a t i e n t c a n n o t car ry ou t a p roper die t , he is much b e t t e r advised to s u b m i t to ope ra t ion . A person who keens on t r v i n ~ to work on a d ie t which is def ic ient in p r o t e i n and in v i t amins is bound to be in a condi t ion of p e r m a n e n t i l l -heal th . Cases of j e juna l ulcer a re no t seen very f r equen t ly in I r e l a n d ; th i s m ay possibly be due ~o t he t r u e of food which is ea ten . I n o t h e r count r ies pickles and o the r tvnes of food which ured]suose to ]e iunal ulcer are ea ten rmlch more t h , n tbe~ are in I r e l and . This may h a v e someth in~ to say in t he sequela of ]e.~unal ulcer.

T ~ P ~ s I n ~ T : Surgeons on t he whole see t he medica l fa i lures , whi~e t he phys ic ians usual ly see t he surgica l fai lures. One bad re su l t is a p t to

S U R G E R Y AND T H E D U O D E N A L ULCER. 209

loom very large in one's estimate of other people's results, bu~ not of one's own results. In Ireland wo have an extremely eo-ol~erative body of physicians and surgeons whoso common concern is to do the very bes~ they can for the individual ease under their care without very much bothering as to v~hether statistics point one way or the other. Regarding the medical and surgical treatment of gastric and duodenal ulcers there is one great difference, namely, that in 99.5 per cent. of cases the surgeon knows what he is operating for. He can see the ulcer, he can feel it, and he knows definitely that it is there. He is dealing with absolutely certain observation. The physician has not the same accuracy of observation. He goes by x-ray pho~graphs and by his clinical observations, but neither of these is infallible. I t is important in estimating %he results of any series of statistics to know exactly on what points the diagnosis in the various cases has been based. X-ray diagnosis of any of these structures leaves a certain amount of doubt in one's mind, and in dealing with statistics one should try to limit one's observations to results of cases in which the ulcer has been proved actually to be present. The .Section has heard from Mr. Garnett Wright this evemng one of the most stimulating, illuminating and instructive addresses which have ever been delivered in this room.

Mm GARXETT WmGHT (in reply) : Purposely, I did not enter into the question of hmmorrhage in my paper, as I consider it to be very largely a question of medicine and not of surgery. I n the vast major i ty of cases the t reatment of hemorrhage is medical. Most of my remarks have been based on th e hospital class of patient, not on the private patient, and the question is different in these two classes. 1 do not agree with Mr. Meade regarding the use of gastrectomy. There will probably never be any really satisfactory treatment of these ulcers unti l their p r imary cause is known. When this happens, gastric ulcer will become entirely a medical disease. I agree with Mr. Morrin that, for the most part, a young patient is not a suitable person for operation for duodenal ulcer. I do not think that my cases are at all a comparable series, as my medical figures have been based entirely on early cases, whereas many of my surgical cases were late ones. Medical t reatment should be given a proper trial by a really efficient physician before surgical treatment is employed. There is, however, a definite pla2e for surgery in cases of non-stenosing duodenal ulcer, especially in the hospital class of patient. I quite agree that there is a tendency for cases of chronic duodenal ulcer to heal whether they are treated or untreated. Af te r operation I always give my patients printed instructions regarding diet, etc., which I hope they will car ry out, but in a great many cases I have not very much faith that they will.

BOOI~S I~ECEIVED. CAI~ETON~ H. M. ttistological Technique. Milford: Oxford University

Press. 1716. GLAISTE~, J . Medical Jurisprudence and Toxicology. 6th Ed. Living-

stone. 251-. WA]i~LEY, O. P. O. Moder.r~ Treatment in General Practice. Reprinted

from the Medical Press anc~ Circular, 1938. Bailli~re. 1G]6. H~R~N, L. The Practice o] Urology. Saunders. 45]-. Thee Medical Annual, 1938. Wright. 20]-. Report on the Health o] the Army ]or 1936. H.M.S'.O. 3]-. BVC~ANAN, S. The Doctrine of Siomatures. Kegan Paul. 7]6. PAT~SON, D. Sick Children. 3rd Ed. Cassell. 1216. WELLS, C. S~urgery for Nurses. Livingstone. 10]6. JAM*ESON, E. B. Illustrations of Anatomy for Nurses. Livingstone. 7]6. Transactions ot the American Gynecological ,%ciety, 1937. Vol. 62.

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Surgery and the duodenal ulcer