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MEDICAL ASPECTS OF CHRONIC PEPTIC ULCERBy R. SLEIGH JOHNSON, M.D., M.R.C.P.

Physician, London Chest Hospital, Southend General Hospital, Royal Waterloo Hospital

General ConsiderationsFew diseases, whether from their frequency of

incidence or their difficulties in treatment, canclaim a more rightful place in medical attentionthan peptic ulcer, a comment applying with equalforce to physician and to surgeon, and to hospitalas well as to general practice. Figures of hospitalemergency admissions show few conditions moredemanding on the medical side than acute gastrichaemorrhage, while surgical complications ofpeptic ulcer demand a like proportion of beds. Insuch an ever-present disease, it is a disturbingthought that despite unceasing clinical study andexperimental work, the aetiology should defeatexact investigation and remain largely obscure,and perhaps no less disturbing that so littleuniformity of agreement should have been reachedon policies of treatment, particularly in circum-stances where medical and surgical aspects over-lap. In consequence, the results of treatment ofpeptic ulcer cannot yet be claimed to be whollysatisfactory, whether the path chosen be that ofmedical zeal or of no less enthusiastic surgery. Anattempt to review and co-ordinate these varyingtrends of opinion may not, therefore, be out ofplace.

IncidenceIn distribution peptic ulcer is world-wide and

without respect of race, occupation or class,occurring within a wide range of ages. In in-cidence it is without doubt one of the commonestafflictions of mankind. From autopsy findings it isestimated that at some period in his life one personin ten is so affected, though not always is the lesionrevealed by symptoms. The age group mostcommonly involved lies between 20 and 40 years,but acute ulcers revealed by haemor-rhage or evenperforation are met with in infancy or early child-hood. A familial factor is often easily traced, andis found in about a quarter of all cases. It isprobable that many more gastric ulcers thanduodenal are relatively symptomless and thereforeundiagnosed, autopsy findings of healed ulcersconfirming a higher incidence in the stomach, butfrom the clinical standpoint duodenal ulcer ismuch the commoner dis'ease, in a proportion of at

least three to one, and correspondingly more re-sistant to treatment. With regard to sex incidence,duodenal ulcer shows a marked preponderancefor the male subject, being between three andfour times commoner in men, whereas gastric ulceris relatively more frequent in women. In tworespects, those of physique and of psychologicalmake-up, an ' ulcer-type' may be readily recog-nized in the spare, lean build and anxious over-active manner, predominantly seen when the siteis duodenal.

It occasions no surprise that the incidence ofpeptic ulcer appears to have risen considerablyduring the past 30 years, and even more during thepast decade, in response to strain and stress ofliving and the increased pace of life; part of thisapparent rise is no doubt due to improved facilitiesfor diagnosis, and part to a failure to distinguishrecrudescence from primary disease, but afterallowance has been made for these factors there iscertainly a real increase, particularly in duodenalulcer. The greater incidence of this lesion in menis reflected anatomically in the hypertonic type ofstomach known to predominate in the male, withits hypersecretion and rapid rate of emptying,whereas simple gastric ulcer is less constantlylinked with hyperacidity and excess of tone, andis therefore by no means rare in the asthenic,anaemic type of woman with low-lying or hypo-tonic stomach. This distinction of type is furtheremphasized in the different psychological andemotional background of the two groups.

AetiologyThe problem of causation of peptic ulcer is

still unsolved. Occupational factors in aetiologyare unconvincing. Whereas a type of employmentdemanding physical rush and mental strain, withinconstant hours, hasty and irregular meals, nodoubt contributes to break-down in those pre-disposed, peptic ulcer is common enough amongall classes of occupation and society, humble orwell-to-do. Of greater influence and. importanceare psychological factors. It is common knowledgehow frequently ulcer symptoms, including per-foration or haemorrhage, may immediately followa period of nervous stress, anxiety or emotional

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POST GRADUATE MEDICAL JOURNAL March 1948

upset; the engorging effect upon the mucosa, theoversecretion and muscular spasm of the stomachwhich follow such disturbances can be seen withthe eye and are sufficient explanation of events.Yet in most cases these are probably contributoryrather than causative factors, responsible moreoften for the breakdown and recrudescence whichmay so readily be mistaken for the start ot thedisease, for onset is insidious and few patients canaccurately define it.

HabitsThe relation of tobacco and alcohol to peptic

ulcer is similar; while there is no proof thatsmoking, even in excess, is a direct causativefactor, it is generally agreed that the swallowing ofnicotine excites free secretion of gastric juice,which can only be undesirable and harmful to anempty stomach. The renewal of pain whichfollows a lapse into the cigarette habit or analcoholic indulgence is sufficient reminder. Ofgreater importance are habits of eating, thoughgiven less attention and emphasis than details ofdiet. Rushed and irregular meals, eaten againsttime, perhaps in uncongenial surroundings, withan unsuitable choice of food, may initiate symp-toms or lead to breakdown in the predisposed.Inadequate preparation of food for gastric diges-tion may ensue from defective or carious teeth,and a contributory gastritis be set up. Acute in-fections of any kind may act in a similar way tonervous worry, fatigue, or faulty habits, in pre-cipitating the acute exacerbations so characteristicof the disease. In some patients a seasonal in-cidence of breakdown is noted, mainly at thechange to colder weather.

Pathology and PathogenesisChronic peptic ulcer is usually a single lesion,

but separate ulcers are not uncommon in stomachand duodenum, or more than one ulcer may bepresent in the stomach. Similarly, active andhealed lesior.s may co-exist, or a single ulcer mayshow extension and healing in different dirwctionsat the same time, although one of these processesis usually predominant. The region liable topeptic ulceration corresponds accurately with theextent of exposure to the acid gastric secretion.The great majority of ulcers are included in a sitewithin the lesser curvature of the stomach, par-ticularly in its central third, or within the firsttwo inches of the duodenum, the duodenal cap orbulb; the pylorus is frequently involved and itsfunction affected by a pre- or post-pyloric ulcer.For the same reason a characteristic lesion iscommon in the area of jejunum directly opposedto a patent gastro-enterostomy, while rarely atypical peptic ulcer may develop in ectopic gastric

mucosa at the lower end of the oesophagus or ina Meckel's diverticulum. The greater curvature ofthe stomach is a rare site for benign ulceration, andthis situation of itself should arouse suspicion ofmalignancy.

Opportunities for direct study of peptic ulcera-tion in its varying stages were formerly confinedto operative or post-mortem inspection. Withinthe last few years, however, our knowledge of itslife history and pathology has been greatly ex-tended and clarified by the direct irspection in theliving subject afforded by gastroscopy.An acute stage necessarily precedes the develop-

ment of every chronic peptic ulcer, and is revealedas a sharply circumscribed loss of tissue beginningin the mucosa. This forms a shallow erosion,often small in size, with clean cut, punched outedges and smooth floor, sometimes covered bywhite or yellowish slough, and tending to becometerraced as it reaches the subacute stage. Signs ofinflammation of the surrounding mucosa may ormay not be present, but at this stage there is noprotective thickening of the peritoneal surface.Such an ulcer, if destruction of tissue is rapid andprogressive, may quickly penetrate all layers ofthe gut, unresisted by any barrier of fibrosis, andterminate in perforation with its dramaticconsequences.

Healing, on the contrary, frequently takes placeat this early stage by growth of a thin layer ofmucosal cells across the defect, leaving either anormal looking surface or little more than astellate puckering of the mucosa to mark the site.Many such acute ulcers are wholly unproductiveof symptoms. Should the healing process fail orbe incomplete, however, the ulcer slowly extendsboth in surface area and in depth, with a pro-gressive penetration into the submucous andmuscular layers of the viscus or beyord. Such aprocess may exteAd over a period of years, surfacehealing failing to keep pace with the rate of ulcera-tion. The chronic ulcer resulting commonlybecomes thickened and indurated by inflammatoryconn ctive tissue formation at its base, with deepor terraced margins, in some cases undermined.The floor of such an ulcer may appear clean andcovered with granulation tissue, or be concealedbeneath a fihrinous exudate or slough, in whichthrombosed vessels of considerable size may besituated. Adhesions to adjacent organs are usualiI: an ulcer of long duration, and the liver, pan-creas or omentum may form part of its base.This process of scarring in ulcers of markedchronicity may also promote a gross deformity andobstruction within the organ, seen in pyloricstenosis or hour-glass stomach, while organicocclusion may be closely simulated by muscularspasm and oedema.

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March I948 SLEIGH JOHNSON: Medical Aspects of Chronic Peptic Ulcer III

This fluctuating life-cycle of a chronic pepticulcer, reflected clinically in periodic remissions andexacerbations of symptoms, is found pathologicallyto correspond with phases of fresh ulceration andpartial healing. Periods of quiescence or com-plete absence of symptoms tempt both patientand clinician to assume that the ulcer has healed,an error often supported by pathological and X-rayt(sts. Direct inspection, however, in these caseswill frequently show that the lesion is not healed,but merely inactive and dormant. What is oftenthought to be a fresh ulceration is but the re-activity or breakdown of an old-standing lesion.For like reason, a sudden unexpected haemorrhageor perforation may sometimes be the first indica-tion that all is not as well as was thought.A further pathological aspect of a benign but

indolent gastric ulcer is the possibility of malignantchange, a question which has been the subject ofprolonged and intensive study. Widely differingviews are held by experienced observers as to thefrequency of such change, and even as to itsoccurrence, opinion of its incidence varying fromnil up to ten or more per cent. The feasibility ofpossible malignant transformation of an in-flammatory lesion which is constantly subjectedto external irritation is paralleled in the case ofother body surfaces, notably the skin. Yet thereare many difficulties in accepting this view of so-called ' ulcer-cancer' production. The commonsite of carcinoma in the stomach, with its pre-dilection for the pyloric zone or greater curvature,differs radically from that of simple ulcer; car-cinoma is practically unknown in the first part ofthe duodenum, where as a sequel to long-standingirritation of chror.ic ulcer it would be frequentlyanticipated, even more commonly than in thestomach. Similarly unmet is malignant disease ata gastro-jejunal stoma. In the great majority ofcases of carcinoma of the stomach, moreover, theage incidence affects an older period, and thehistory of digestive disorder is relatively short, thedisease appearing clinically to start de novo ratherthan as a sequel to long-standing dyspepsia. Fromserial inspection of very large numbers of benignulcers over a period of years, gastroscopists ofwide experience have stated that they have yet tobe convinced of malignant change occurring, andsurgeons in this country of the experience ofOgilvie' hold the view that these are diseases ofcompletely differing aetiology. With this viewthe present writer concurs. The contrary view ofa frequent malignant change has ieceived its rrainsupport from evidence based upon the naked eyeand histological features of ulcers removed atoperation, and has been favoured in particular byAmerican surgeons, i"cluding MacCarty andBroders2 and Allen and Welch3. It is well

recognized, however, that owing to digestivechanges the histological features of benign andmalignant ulcers may be closely similar, whilesecondary inflammatory reaction at the marginsof a gastric carcinoma is of common occurrenceand a further source of confusion. Naked eyedifferentiation is accepted as being of little or novalue, and size is of no significance-a carcinomamay be small, a simple ulcer enormous.The importance of this differentiation is

stressed in its bearing upon policies of treatment,notably in the forming of a right judgment be-tween the respective claims of medicine andsurgery. If the danger of malignant change isgreat, every chronic ulcer should be removedforthwith; if remote, then decisions of surgeryare to be based upon other grounds, and eachcase assessed upon its merits.

Theories of Causation of Peptic UlcerIn the development of a peptic ulcer, the lining

membrane of the stomach or duodenum at theaffected site, normally impervious to the actionof the gastric juice, is by some means madesusceptible to digestive action, and consequent*ulceration, by predisposing factors still not whollyunderstood. Many differing theories of causationhave been advanced, and attempts, mostly un-successful, made to reproduce their effects ex-perimentally. Brief mention may be made of someof these hypotheses. Firstly, the view has beenput forward of a common specific infectivecausation. In this regard it is clear that the lesionsof peptic ulcer are unrelated to any specificbacteriology; the occasional association of acuteulcer with severe generalized infection, revealedfor the most part post-mortem, shows no commonidentity of organisms, and, as in its rare sequel toburns, the ulcer here is probably a reactior to theabsorption of tissue-breakdown or histamineproducts. Moreover, no similarity of bacteriologyhas been demonstrated as affecting the ulcerlesions and oral infection when this is preseu:t.Ulcers produced experimentally in animals by in-jection of organisms into the gastric mucosa showrapid healing and no tendency to progress to achronic stage; traumatic ulcers of the stomach,both in the animal and the human subject, causedby the swallowing of a foreign body show asimilar prompt resolution.

Vascular anomalies have been similarly credited,by interfering with the nutrition of the affectedzone of digestive mucosa. The frequent demon-stration of thrombosed vessels in the base of achronic ulcer has suggested that a local vascularspasm of the mucosal arterioles from excessivestimulation of sympathetic nerve supply may bethe primary factor, bringing about a loss of blood

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112 POST GRADUATE MEDICAL JOURNAL March i948

supply to the area with necrosis of mucous mem-brane by infarction. Alternatively, a spasticcontraction of the muscularis mucosae has beenadduced, with supposed compression of smallvessels producing anaemia of the mucosa andsubsequent digestion. Such theories are at oncedisproved by the free anastomosis of vesst Is foundin the stomach, wide ligature of which fails ex-perimentally to produce ulceration; the throm-bosis so often seen is the result and not the causeof the lesion. Similarly, an attempt to explain theproduction of peptic ulcer by a neurogenic dis-turbance carries little weight; the sole neuro-logical association which can be demonstrated inulcer subjects is a vagal overaction, a reasonableexplanation of the hypersecretion and hyper-mobility of the stomach which is so often present.A further theory of causation pronounced is thelack of a supposed specific protective substance(named ' anti-pepsin' or ' defendin ' by its advo-cates) and regarded as normally inhibiting auto-digestion by the gastric secretion. Such a view isof theoretical interest only, and unsupported byany demonstrable evidence, in common with anumber of other suppositions of aetiology.While the responsible factors for initiation of

tissue loss remain obscure, the failure of healing ofthe breach of surface, when once begun, is lessdifficult to understand. There is present in thesesubjects with considerable constancy an inabilityof the mucous membrane to resist the digestiveaction of the acid gastric juice, a defect roughlyproportionate to the degree of hyperaciditypresent. Thus, broadly speaking, the healing of aduodenal ulcer, with its higher level and moreconstant association of gastric acidity, is a moreprolonged and difficult task than the healing of abenign gastric ulcer. Hyperacidity is, moreover,not a necessary requirement, for mucosal resistanceso impaired may still be inadequate to allow ofhealing, even in the presence of normal gastricacidity, as is found in the chronic gastric ulcers ofmany patienits of asthenic build. Similarly, ageneral state of diminished tissue resistancethroughout the body associated with uhder-nutrition, or with toxic or irfective processes inother systems, will from its inclusion of the gastricfunctior s readily be understood as contributoryto ulcer breakdowi; an inadequate-secretion ofprotective mucus locally by the stomach in thesestates may have similar result.Whether the ultimate cause is then the excess

of hydrochloric acid itself or some other abnormalcondition of the gastric secretion is a moot point,for acidity by no means represents the sum total ofpeptic activity. Again, whether the weak spot indefence is a lack of cellular resistance to digestionor, as noted, a lack of cellular protection by

mucus-secreting cells (a secretion lessened in ulcersubjects) is equally unknown. The importantpoint is that the presence of hydrochloric acid inexcess is the main certain factor in maintaining theactivity of peptic ulcer.Time factors are of no less significance. Where,

as in ulcer subjects, the duration of exposure ofthe mucosa is prolonged, for example during thenight or for long fasting hours between badly-spaced meals, times during which the normalstomach would produce little or no acid, thisabnormal digestive process is intensified.

This general relation of hyperchlorhydria or the'acid-pepsin ' factor to peptic ulcer is confirmedin a number of ways. The site of ulceration, forexample, is confined strictly to those portions ofthe digestive tract coming into direct contact withthe acid gastric secretion, a generalization trueeven in the case of unusual sites of ulceration, suchas the oesophagus. Simple ulcer, in corollary, isnever found among the io per cent. or so of thepopulation with a congenital histamine-achlor-hydria. Confirmation of the significance of acid-exposure is given by the varying results of surgicalresection in treatment. Where this is adequate andachlorhydria is produced, recurrent ulceration doesnot occur. Where, however, the removal of acid-producing gastric mucosa is of insufficient extent,this liability to recurrence remains. The legacy ofstomal or jejunal ulceration after an ill-chosengastro-jejunostomy in a patient with high acidityis a further example of the inadequacy of anytreatment which fails to eliminate acid production.

Experimental work in animals gives similarconclusions. Gastric ulcers produced artificiallyin animals fail to heal if the normal neutralizationof acidity by duodenal contents is prevented, or ifan abnormally high level of acidity is maintainedin the stomach, either by direct administration ofacid or by maintaining a hypersecretion byhistamine injections.

Despite this evidence from various sources, thequestion of acidity is clearly not the whole storyand the problem of causation remains a complexone. Although a great hypersecretion of acid (upto 0.4 per cent. HCI) is the common finding inpeptic ulcer, especially of the duodenum, otherpatients will show normal levels of acidity or less,and it has to be admitted, therefore, that theproblem is still incompletely solved.Of scarcely less importance in the aetiology of

peptic ulcer is the question of muscle tone andcontractility. Duodenal ulcer subjects in particularcommonly have a hypertonic stomach undergoingviolent peristalsis, with rapid emptying of acidsecretions into the duodenum. In other cases,pylorospasm will be the cause of a persistentlyhigh acidity of gastric contents from delay in

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March 1948 SLEIGH JOHNSON: Medical Aspects of Chronic Peptic Ulcer 1I3

emptying of the stomach. Much stress has beenlaid by gastroscopists upon the even closeranatomical relationship of ulcer incidence to hyper-rugosity of the stomach mucosa, the more so induodenal cases.

Symptoms of Peptic UlcerIn the establishment of diagnosis of peptic

ulcer, symptoms far outweigh physical signs inimportance, and a detailed study of the patient'scomplaints and of factors affecting them shouldlead far along the road. Detailed history-taking ina suspected case of peptic ulcer is of such out-standing value that it should never be omitted orcurtailed; in itself it may be almost conclusive,and place the realm of physical examination andlaboratory tests into that of confirmatory measures.The outstanding symptom of peptic ulcer is

pain related to the taking of food. Its specialfeatures may be so characteristic as to be practicallydiagnostic and will include the following con-siderations.-

(a) Duration and periodicity.(b) Relation to the taking of food.(c) Situation and paths of spread.(d) Character and severity.(e) Aggravating and relieving factors.These may be considered in detail.

(a) Duration and periodicityIn time-relations two special features are com-

monly revealed in history-taking. The first re-lates to the total duration of pain, which in mostcases of ulcer extends over a period of months oryears. The second feature is the nearly constantoccurrence during this time of periods of freedomfrom symptoms, partial or complete, for spells ofa few days, weeks or even months, during whichthe ulcer is quiescent but not healed. Such freeintervals often bear a seasonal relationship, thoughnot constantly so; frequently, however, no reasoncan be assigned for the fluctuations of illness.With progress of time the tendency is for thespells of pain to become more frequeDt and severe,with shorter intervals of freedom, and less readyrelief. In some cases bouts of pain may followdietary indiscretions ox intercurrent illness, but inothers they recur in spite of the most carefulregime. Great diagnostic significance may safelybe placed upon this periodicity of ulcer pain,more especially in the case of duodeixal ulcer.

(b) Relation to the taking offoodThe daily rhythm of the pain, as distinct from

its lox. ger periodicity, is shown in its clockworkregularity after the takiing of food, at an intervalvarying from a few minutes to three hours ormore. The heavier the meal the more severe the

pain, which may sometimes only follow the mainmeal of the day. As with site, the time relation ofthe pain is no certain guide to the situation of theulcer. In general, however, pain from duodenalulcer occurs at a long interval after food, which itoften appears to precede rather than to follow. Itis an especial feature in the small hours of themorning, often waking the patient from sleep. Itis, in fact, a diagnostic principle that pain ofsufficient severity to awaken a patient who hasonce fallen asleep should be regarded as due toorganic disease rather than to functional dyspepsia,unless completely proved otherwise. In the samesubject considerable constancy is the rule in thecharacter and time relations of his ulcer pain.

(c) Situation and paths of spreadUlcer pain is felt most commonly in the central

epigastrium, where it is often sharply localized toa small area. Alternatively, it may be located toone or other hypochondrium or to a combinationof these sites. The exact situation of pain is oflittle or no value in the differential diagnosis of theprobable site of ulceration, although in duodenalulcer the reference is more commonly to the righthypochondrium. In contrast to peptic ulcer, thepain of nervous dyspepsia is less well-defined, andis usually referred widely to the upper abdomen.Radiation of pain through to the back or around thecostal margin, especially when severe and resistantin type, commonly indicates involvement of theposterior abdominal wall by a deep penetratingulcer, with its special dangers of haemorrhage.Jejunal ulcer has a reference of choice to the leftmid-abdomen at about the umbilical level, withtenderness at this site. Inflammatory spread be-yond the confines of an ulcer, with involvement ofperitoneum, leading to a perigastritis or peri-duodenitis, may widen the reference of pain, andits intensity and relentlessness, to any degree.

Finally, in regard to pain production, it must benoted that a few active ulcers, for reasons riotunderstood, may fail to cause any pain whatever,and the first evidence of their presence may besevere haemorrhage or perforation.

(d) Character and severityUlcer pain may be of any grade from a mild dis-

comfort to severe distress. At onset it may scaicelymerit the term pain at-all, and be no more than adull upper abdominal discomfort or feeling ofemptiness. Later, with established ulceration,definite pain as opposed to mere discomfort is therule, a point of value in distinction from the manyforms of nervous dyspepsia. It is then commonlyof burning or boring character, and may from itsseverity lead the patient drastically to reduce hisdiet in fear of its recurrence. In degree and

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114 POST GRADUATE MEDICAL JOURNAL March i948development it is commonly of ingravescent or'crescendo' character, rising to a maximumseverity within a few minutes of onset after food.The pathognomonic linking of pain with a cravingfor food, and the'relief commonly given- thereby,has aptly led to its designation as ' hungei-pain,'a feature most characteristic' and constant induodenal ulcer. I

(e) Aggravating and relieving factorsThe essential relation of ulcer pain to food is

concerned no less definitely with the amount'andcharacter of the food partaken. An unwise choiceof diet, whether of highly-flavoured or unsuitablefoodstuffs, or of immoderation in size of meal, willin each case render pain more certain and severe.The immediate effect upon pain of the taking offood will vary with the situation of the ulcer inthe patient concerned ; in duodenal ulcer relief ischaracteristically given, with recurrence as thestomach empties; in gastric ulcer exacerbation ofpain is the rule.

In no less degree does relief of pain in simpleulcer follow the inception of suitable dietarymeasures, with accompanying bed rest. So markedand constant is this relief, in fact, as to bepractically diagnostic. Should it fail to occur, andpain remain unaltered, one of two conclusions maysafely be drawn. Either the diagnosis is in error,and search should be made, in explanation, forsome other organic disease; or the ulcer hasundergone complications beyond its confines bydevelopment of external adhesions, inflammatorychanges, leak or obstruction, little relief then beinggiven by dietary measures.

Complications of this order apart, relief bydieting in simple ulcer is fully equalled by therelief from giving alkalis, to which an equaldiagnostic significance may be attached. Whereverthe site of ulceration, the neutralization of gastricacidity so afforded brings an immediate thoughtemporary cessation of pain.

External tactors, less directly concerned withfood, may also greatly influence the pain and othersymptoms of peptic ulcer. Anxiety, physical andnervous strain of all kinds, general illness, ex-posure to cold, may all promote exacerbation, ortheir correction bring relief.

Causation of Ulcer PainAs with visceral pain in general, the pain of

peptic ulcer is primarily of muscular origin, pro-duced either by tension or by stretching of tissuesin the ulcer neighbourhood from distension of thestomach or from irregular and violent muscularcontractions or spasm, particularly of the pylorus.Relief of pain by antispasmodics is thereforereadily explained. Neither the normal mucosa

nor the ulcer itself is directly tender or seisitiveto touch, but the threshold of pain appreciationmay be lowered by inflammatory changes in theregion of the ulcer or by excess of acid secretion.Hyperacidity of itself does not produce pain, beingfrequently present in health, and the severity ofpain in ulcer cases is not necessarily related to thedegree of acidity present, which in fact often re-mains unchanged whether the ulcer is in an activeor a healing stage. The most severe association ofpain with peptic ulcer is that which accompaniesinvolvement of peritoneum or erosion of thepancreas or posterior abdominal wall.

Other Gastric SymptomsAppetite in uncomplicated peptic ulcer is

normally retained or increased, unless an as-sociated gastritis be present, but a commonfinding, is a voluntary restriction of food intakefrom fear of ensuing pain, and some loss of weightmay follow. Nausea is similarly unusual apartfrom obstruction, and is a more common featureof gall-bladder disease. Vomiting is frequent insevere cases; it may occur reflexly at the heightof pain, giving relief, or may indicate an obstruc-tion to the food channel. In some cases the latteris a temporary hold-up from oedema or muscularspasm, a form of obstruction amenable to medicaltreatment ; in others it is of graver issue andsignifies an organic stricture from cicatrization ofthe ulcer base. For a time its effects may be over-come by more powerful peristalsis, visible aswaves of contraction proceeding from left to rightacross the epigastrium, but eventually increasingdilatation follows, leading to forcible ejection ofstagnant food and retained fluid, at irregularintervals atid often in large amount.Acid regurgitations into the mouth, with

paroxysms of excessive salivation or water-brash,are common accompaniments of ulcer, but are oflittle diagnostic value,. occurring in many otherforms of dyspepsia, organic or functional. Gastricflatulence is sometimes present, usually from asubconscious aerophagia to. relieve pain, but isagain of scant differential significance, and less inevidence than in nervous dyspepsia or chole-cystitis.

Constipation is a common finding in peptic ulcerand tends to accentuate the degree of pain.Looseness of bowels may follow excess of laxativesin treatment, while a lienteric form of diarrhoeais worthy of note as tending to follow the per-formance of gastroenterostomy, at least for a timeuntil a nervous adjustment of the altered mechanicsis developed.Anaemia is not a direct feature of simple peptic

ulcer unaccompanied-by haemorrhage, apart fromits possible sequence to prolonged and excessive

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March I948 SLEIGH JOHNSON: Medical Aspects of Chronic Peptic Ulcer iI5restriction of diet, and therefore of iron andvitamin intake.The subjects of perforation and haemorrhage,

the most urgent and important complications ofpeptic ulcer, are considered separately in anothersection, but no survey of symptomatology wouldbe complete without reference to the great fre-quency with which some degree of blood lossoccurs. Bleeding of clinical significance is foundto occur at some phase, in at least half the totalcases of chronic ulceration, either as haematemesis,melaena or both. In acute ulceration it may bethe first and only symptom. A large haematemesismuch more frequently arises from a simple ulcerthan from a carcinoma of the stomach with itsmore gradual and limited oozing. Other causes ofprofuse bleeding which sometimes cause confusionin diagnosis include multilobular cirrhosis of theliver, haemorrhagic purpura and splenic anaemia.Differentiation of the site of ulceration, as betweengastric and duodenal, from the circumstance ofhaematemesis or of melaena, is fallacious, themode of voidance being dependent more upon therapidity or otherwise of gastric distension byblood than upon the exact site of bleeding.What factors determine the hazard of severe

haemorrhage in chronic ulceration is often obscure,and the onset of sudden haematemesis is fre-quently unpredictable. Bleeding sometimes sur-prises the patient apparently fit and symptom-free; in other instances it follows a heavy meal,or further complicates a phase of acute exacerba-tion of symptoms.The danger to life from haemorrhage lies

mainly in its repetition; a single haemorrhage,however large, seldom proves fatal. A frequentoccurrence, unfortunately, is for the initial bleed-ing to be followed by further substantial bloodloss within an interval of a few hours or days, towhich the already exsanguinated patient may suc-cumb. The event of haemorrhage from an ulceris not always readily discerned. Quite severehleeding into the lumen of the stomach or duo-denum may fail to promote local symptoms, andthe history present itself as one of unexplainedfaintness, collapse and weakness, or of pallor anddyspnoea without apparent reason. The pos-sibility of ulcer haemorrhage may easily be over-looked should there be failure later, on thepatient's or the physician's part, to note the darkmotions which almost always follow.

In this way recurrent fulminating haemorrhagemay dominate the clinical background, but inother cases a prolonged though less obvious loss ofblood may lead gradually to the development of ananaemia of milder grade without the signpost ofhaematemesis. The clue will be given by routineexamination of' the stools for occult blood, an

investigation which in unexplained anaemia shouldalways be made. Reviewing gastric ulceration inits widest sense, a sound rule for clinical guidanceis that dyspepsia accompanied by significantanaemia indicates the likelihood of bleeding ulceror of growth.To summarize the role of history taking in

diagnosis, it may be said that a full survey ofsymptoms, in peptic ulceration will of itself fre-quently justify a provisional diagnosis, the mainplace of special investigations being confirmatory.In other cases the confirmation of diagnosis maybe afforded not by instrumental means, but byclinical criteria in the development of one of thewell-recognized complications of ulceration suchas perforation, leak, haemorrhage or obstruction,so modifying the clinical picture as to prove thediagnosis beyond doubt.

Physical SignsPhysical signs in peptic ulceration are less

constant in nature and in significance, and routineclinical examination may frequently fail to elicitany abnormal findings, especially during periods ofrelative quiescence. Although a spare nervousduodenal type is recognized, physique and t(m-perament are too variable to be of diagnostic value.Nutrition is usually preserved and anaemia is nota feature apart from blood loss. Local tendernessupon deep pressure is common in the centralepigastrium or to either side of the upper abdomen,usually well-localized and corresponding with thesite of pain, and sometimes associated withcutaneous hyperalgesia. The site of tendernessusually remains constant in the individual patient,and is often accompanied by muscular rigidity ofthe upper rectus to a variable degree. Rarely, atender mass may be felt where acute inflammationhas followed a slow leak through the ulcer base,and may be confused with carcinoma. Obstruc-tion will outline the distended stomach or portionthereof, with peristaltic waves of characteristictype. Splashing is readily elicited in dilatation ofthe stomach with retention of its contents, but is ofno pathological significance within two and a halfhours of a meal.

Special InvestigationsRadiology. Apart from these sparse findings,

diagnosis of peptic ulcer depends upon a com-bination of careful history and of special in-vestigations. Of the latter radiology takes the lead,and in good hands will reveal a high proportion ofulcers by means of an opaque meal. Thus itshould be possible to diagnose some go per cent.of gastric and 75 per cent. of duodenal ulcers, thedifficulties and errors being higher the deeper andless accessible the site. Of. anastomotic ulcers

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perhaps the majority will be revealed. Despitethe most careful radiological examination fallacieswill sometimes occur, and the rule for the clinicianshould be to accept a diagnosis of peptic ulcer,particularly duodenal, based on strong clinicalevidence in the absence sometimes of X-ray con-firmation. The same comment applies with re-gard to tests of cure.

Satisfactory radiological examination of thegastro-intestinal tract requires that the patientshall be fit enough to stand for some minuteswithout fear of faintness or collapse. Recenthaemorrhage will clearly preclude such examina-tion, usually for a period of a month to six weeks.A further requirement is that the stomach mustbe completely empty at the time of survey, amorning investigation, therefore, being preferable.

Screening rather than films constitutes the moreinformative aspect of the test, and to be of fullvalue observation will be needed in a series ofplanes, posterior-anterior, both obliques andsometimes in the recumbent position. Details ofthe examination are discussed elsewhere, butreference may be made here to its essential objects.The size and type of stomach is revealed, and anestimation made of its tone, peristalsis and thecharacter of its rugae. Direct demonstration of aniche or crater is the most convincing X-rayevidence of an ulcer, either in the stomach orduodenum, but short of this it may be shown in-directly by the muscular spasm by which it isfrequently accompanied, especially in its activephases. Thus a.fixed localized spasm or incisuramay be found opposite the ulcer site, or in othercases a marked spasmodic contraction of thepyloric segment or duodenal bulb, with difficultyand delay in gastric emptying. Repeated examina-tion may in these cases be required after an in-terval of treatment by antispatsmodics, so as todifferentiate the nature of the obstruction, whetherspasmodic or organic stricture, as well as to clarifythe cause of duodenal deformity, whether simplespasm or distorsion by active ulceration or byscarring. The latter point is greatly helped by thedetermination of local tenderness or otherwiseupon X-ray palpation. Tenderness of the ulcersite is valuable evidence of active ulceration,especially when accompanied by irritability anddisordered motility.

Confirmation of obstruction will be givenradiologically by dilatation of the affected organor segment and its delayed emptying, while ad-hesions to surrounding organs may usually bedemonstrated by palpation under the screen.While not decrying its great value in diagnosis,

too much weight should not be given to radio-logical investigation alone, nor its conclusions re-garded as infallible. Negative investigation by no

means excludes an ulcer, nor proves its healing.Its greatest value lies in serial observation and inthe assessment of progress in the established case.

Gastric analysis. Support for radiologicalevidence is given by chemical laboratory tests, inchief by gastric analysis. Examination of a singlespecimen of gastric contents after a one-hourinterval is a method of little value and of historicinterest only, the fractional test meal being nowuniversally employed. As with X-ray examina-tiop, it is best carried out in the early morning andthe patient's last meal must have been not laterthan 8 p.m. the previous evening, all drugs beingomitted on the day of test. The fasting stomachcontents or 'resting juice' are completely with-drawn after the swallowing of a Ryle's tube, themeal prepared from fine oatmeal gruel is thengiven, and samples of about IO to 15 cc. of gastriccontents withdrawn at regular intervals, pre-ferably half-hourly, for a total of 24 hours, bywhich time the stomach is normally empty.The specimen of greatest importance is the

resting juice; this is examined for volume, odour,consistency, presence of blood, mucus, and foodresidues, and microscopically for red cells, puscells, epithelial and malignant cells, with chemicalestimation of free and total acidity. Similarly,each specimen is examined for volume, t6talacidity, free HCI, mucus, bile, blood and starch,and the results recorded graphically upon a chart.The interpretation and significance of the test

meal may be briefly described. A wide variationin gastric secretion may be found. In uncom-plicated gastric ulcer the curve may either benormal or show a hyperchlorhydria. Sometimesan initial low acidity is found from associatedgastritis, the production of acid being increasedafter gastric lavage. Acidity, moreover, in gastriculcer increases with proximity of the ulcer to thepylorus. In duodenal ulcer it is the rule to find amarked hyperchlorhydria, with irritability andhypersecretion of the stomach, irrespective of thephase of activity of the lesion. The resting juicealso is usually highly acid.Two types of curve can commonly be dis-

tinguished, particularly in duodenal ulceration.In the first, or ' climbing curve,' after an initialfall in acidity due to dilution of the resting juiceand fixation of free acid by the meal, there is agradual rise in its level throughout the wholeperiod of observation. Slow emptying of thestomach from pylorospasm, with delayed bile re-flex and little or no regurgitation from the duo-denum causes a continued rise in the level ofHCI past the 2 or I hours period. In the secondor ' hurry' type of curve, a high initial acidity ofresting juice after a slight temporary drop risessharply to a still higher plateau level, which is

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either sustained or shows a premature fall withinan hour or so, due to rapid emptying of thestomach unimpeded by pylorospasm.A further point of value in assessment of test

meal findings lies in the volume of resting juice.In the normal stomach being usually of notgreater volume than 25 cc., in active ulceration itis commonly increased in volume in like mannerwith the acidity, so that even without obstructionits amount may rise to a level of ioo to 300 cc. ormore, from the combined effect of hypersecretionand pylorospasm.An alternative method of fractional analysis,

now extensively used, is by the substitution ofalcohol in place of gruel as an excitant of gastricsecretion, giving IOO cc. of 7 per cent. alcohol, andwithdrawing samples of gastric contents at inter-vals. Cleaner specimens are obtained for analysisby this method, easier of filtration and of micro-scopic examination. Whichever method be used,the giving of histamine as added stimulus of acidsecretion when required is a valuable accessorymeasure in the test. Briefly, histamine is irnjectedsubcutaneously in dosage of 0.25 to I.O mgm.,according to body weight, should the fasting juiceand first two or three specimens collected fail toshow free hydrochloric acid. Should this bepresent in the early specimens, the giving ofhistamine is unnecessary.

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

the healing of the ulcer has little effect upon theacid secretory levels of the gastric juice; thisindeed is one of the potent factors in recurrence.Reference is made later to the means wherebyeffective neutralization of the gastric acidity maybe measured.

Occult blood test. Bleeding detectable only bychemical test is sufficient evidence of active ulcera-tion, granted certaini well-known safeguards intechnique and interpretation, such as the exclusionof haemoglobin and chlorophyll-containing foodsand of bleeding from other alimentary sites suchas the teeth and lower bowel. The further fallacyof examining a constipated stool must also beavoided. A positive occult blood test or bernzid(nereaction in the stools, with these provisos, thenindicates a breach of surface epithelium. Thetest is so sensitive that slight or doubtful re-

actions may be ignored. The giving of inorganiciron does r,ot cause a positive reaction. Glovewashings after rectal examination are a satis-factory substitute in cases of failure to pass a stoolfor the tests.

In interpreting this simple test, the need for re-peated examination should be borne in mind. Asingle negative test does not exclude pepticulceratioij or other organic lesion, but the sus-tained disappearance of occult blood from thestools is strong evidence of healing of a simpleulcer and makes malignancy an improbability. Inconverse, repeated positive results, given adequateprecautions against fallacy, point strongly to or-ganic disease and throw great doubt upon adiagnosis of functional dyspepsia.

Gastric aspiration. Aspiration of stomach con-tents, apart from its inclusion in a test meal, is ameasure of value both in diagnosis and treatment,especially in suspected obstruction. It has beennoted that in the normal empty stomach thereshould be not more than 25 cc. of resting juice;an excess indicates gastric irritability and hyper-secretion, and becomes marked in the event ofobstruction of outflow, whether of spasmodic ororganic nature. In these circumstances manyounces, rarely pints, of residual stomach contentsmay be found, perhaps of dirty malodorous fluidcontaining mucus, blood, stale food or malignantcells, and of high acidity from foreign acids dueto putrefactive organisms. Routine aspiration ofsuch fluid and subsequent lavage with o. i percent. HCI will do much to allay the accompanyinggastritis and relieve the obstruction present. Evenin non-obstructive lesions the renroval of highly-acid gastric juice by aspiration is a measure ofvalue, as noted later.

Gastroscopy. Of all methods of examinationvisual inspection is the most certain, and in thisgeneralization the stomach shares. Direct in-spection of the stomach by gastroscopy is fastbecoming the most valuable single measure indiagnosis and in assessment of progress of pepticulcer; feared for long from the undoubted dangersof rigid instrumentation, it has been renderedpossible and safe by the introduction and develop-ment of the flexible gastroscope by Schindler inGermany I2 years ago, and particularly by theimprovements of Hermon Taylor 4 in thiscountry. With premedication and local an-aesthesia, combined with skill and experience ofthe operator, the examination is not unduly un-comfortable or dangerous to the patient. Itsvalue is, of course, greater in the case of gastricthan of duodenal lesions. While not infallible, theincreased accuracy of diagnosis which it affords,particularly in acute ulcers, should make it aroutine measure in the investigation and control of

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gastric disease. It in no way replaces or diminishesthe importance of radiology, but provides anadditional and more exact means of determiningpathological changes in the stomach and theircourse under treatment; the two methods aretherefore to be regarded as complementary ratherthan competitive modes of investigation.

Before gastroscopy is undertaken, a preliminaryradiological investigation by barium swallow andmeal should always be made, in order to excludean obstructive organic lesion of the oesophagus.As with X-ray examination, the stomach must beempty, preferably after an overnight fast. Localanaesthesia is employed, so securing the patient'sactive co-operation, preceded by a premedicationof morphia gr. I and hyoscine gr. 1/150. Half anhour before the examination the patient is given atablet of decicaine o.i gm., to be dissolved slowlyin the mouth and then swallowed, after which thepharynx and pyriform fossae are carefully an-aesthetized with 2 per cent. anethane solution.The left lateral position is the one usually em-ployed, and the gastroscope, lubricated withliquid paraffin, is introduced quickly but withoutpressure, guided by the operator's left indexfinger and following the movements of deglutition.After entry into the stomach, gentle inflation by abellows, combined with appropriate rotation of theinstrument, enables the interior of the stomach tobe visualized, as far as accessibility will allow.After gastroscopy is completed and the instru-ment withdrawn, the patient should rest recum-bent for at least an hour and refrain from all foodand drink until recovery from the local anaesthesia.

Benign gastric ulcers usually show sharp crater-like margins and a smooth or but slightly irregularyellowish-white floor, though after haemorrhage itmay be brownish or dark-red in colour. Theadjacent mucosa is often normal in appearance, butmay show local inflammatory swelling around themargins of the ulcer. Coincident gastritis pro-duces an oedematous dull mucosa with stickyadherent mucus or mucopus, and sometimespetechial submucous haemorrhages, indicating theneed for gastric lavage. Rarely, the likelihood ofimpending haemorrhage may be suspected froman exposed or oozing vessel in the ulcer base. Asthe ulcer heals it becomes shallower, with cleaningand granulation of the base and subsidence of localoedema at its margins, and a converging stellatepattern develops in the surrounding mucosa fromcontracture around the ulcer floor.Too comprehensive a survey must not be ex-

pected from gastroscopy, for some areas of thestomach, chiefly the fundus, and sometimes thepre-pyloric region, are inaccessible to direct vision.An area hidden from view on one examinationmay, however, be revealed at a subsequent in-

spection, and as with radiology the value of therepeated test is often proved in this. way. Thegreatest use of gastroscopy lies in following theprogress of a known gastric ulcer through allstages to complete healing, and in limited measurein the diagnosis of innocent from malignantdisease.While in the differentiation of benign from

malignant ulcers gastroscopy is of much value inskilled hands, features of malignancy are notnecessarily conclusive at a single observation. Acarcinomatous ulcer usually has more roundededges, less well demarcated from the mucosa; itsfloor is commonly irregular, with nodular prom-inences or ridges, and is more frequently of areddish-brown or dirty grey colour than yellow.In contrast with the excavation of the simpleulcer, it is usually elevated above the surroundingmucous membrane, which may, like the ulceritself, show nodular irregularities. Size alone is ofno guide; a small ulcer may be malignant and abenign reach a diameter of several inches.

It follows, therefore, that a single examinationis often inconclusive, and no final decision as tomalignancy or otherwise should be sought there-from. The value of gastroscopy lies rather inserial observation. Wherever the malignancy of agastric ulcer is in question, gastroscopy should berepeated after a period of three weeks' intensivemedical treatment by complete rest, dieting andalkalis. An innocent ulcer will certainly duringthis time decrease in size, and will show othervisual evidence of healing. If, on the other hand,the appearances of the lesion are unchanged, it isright to regard it as probably malignant and totreat the patient, if otherwise suitable, by sub-total gastrectomy. In s6me cases the latergastroscopy will reveal that the ulcer has extendedand become more nodular and infiltrative, and inthese its malignancy will not be in doubt.Wherever, therefore, symptoms of peptic ulcer areunrelieved or inadequately relieved by medicaltreatment, serial gastroscopy should be carried out.

Apart from considerations of malignancy, thesurest evidence of healing of a simple ulcer is givenby periodic gastroscopy. Caution is taught bythe observation that weeks or months after thepatient is symptom-free and X-ray findings arenegative, the ulcer may still be present as a shallowcrater with smooth floor and uninflamed margins.Recurrent bouts of pain, thought clinically to bedue to fresh ulceration, are revealed as no morethan the lighting up of an ulcer which has nevercompletely healed. It follows then that where anulcer is within the range of vision it should begastroscopically controlled until it is known to behealed, and that any fixed duration of hospitaltreatment and dieting is a bad routine and not

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necessarily adequate. Where, moreover, it isshown by gastroscopy that an ulcer persistentlyfails to heal by these means, the indication is clearfor surgical treatment.The duodenum unfortunately remains cloaked

from view, and diagnosis of ulceration here mustrest upon the indirect means previously described.Gastroscopy nevertheless is not without its value,especially in decisions of appropriate treatment.Degree of hyperacidity bears a close relation to thetotal acid-secreting surface of the stomach andhence to the degree of rugosity of the mucosa.Where the folds are markedly deep and numerous,as in the hyperplastic type of stomach, difficultiesand delay in healing by conservative treatmentmay be expected, and considerations of radicalsurgery apply. Simple short-circuit procedures insuch a case are likely to be followed by jejunalulceration, and good grounds are present for achoice of subtotal gastrectomy.

Jejunal ulcer may sometimes be diagnosed bygastroscopy, which is, however, technically difficultin this case and often affords but a partial view ofthe stoma.

Clinical differentiation of innocent and malignantgastric ulcer. Peptic ulcer may be mimicked byvarious forms of dyspepsia, but the differentialdiagnosis of paramount importance is from gastriccarcinoma. Some of the points aiding this dis-tinction will have already been noted. Clinicalaspects are no sure indication, and differentiationis often difficult. An ulcer of the stomach be-ginning after the age of 40 should be suspect ofmalignancy until the converse is proved. Ageitself is of untrustworthy significance, however,for carcinoma may occur in the third decade andsimple ulcer is not unknown in the sixth orseventh. A prolonged dyspeptic history favours abenign lesion, but carcinoma of the stomach mayarise in a patient the subject of long-standingindigestion whether from simple ulcer or anyother cause.

Conversely, a worsening of symptoms in aknown case of innocent ulcer does not necessarilymean a malignant change. Marked loss ofappetite, weight and strength are more likely tooccur in malignant disease, as is anaemia not dueto blood-loss. A palpable swelling, though a latesign', nearly always indicates carcinoma. Earlyobstructive symptoms alsoQ point to malignancy.Haematemesis and melaena may be initial or earlysymptoms of either disease, but gross bleeding iscommoner from a simple ulcer. The continuedpresence of occult blood in the stools after two orthree week's full medical treatment which includesrecumbency is suspicious of gastric carcinoma,since most cases of simple ulcer lose this signwithin that time upon an efficient r6gime. Con-

versely, a persistently negative occult blood testsuggests that the ulcer is innocent, although noabsolute rule applies. The fallacy of relying uponfractional test meal findings has been noted, 50per cent. or more of early gastric carcinomatabeing accompanied by free HCI in the stomach,sometimes in excess. On the contrary, a completeachlorhydria after the giving of histaminepractically excludes a simple peptic ulcer.The value of X-ray and gastroscopic evidence

has been discussed. It may be noted that ulcersof the greater curvature are nearly always neo-plastic, and the farther away the ulcer is from thelesser curvature the greater is the probability thatit is malignant. Proximity to the pylorus similarlycarries a proportionate likelihood of malignancy.Carcinomato4s ulcers tend in X-ray appearance tobe more ragged and irregular in outline, the gastricrugae being distorted and interrupted in pre-cipitate manner instead of converging in radiatfashion upon the ulcer site, as in an innocentlesion. The demonstration of a meniscus sign ispractically diagnostic of carcinoma. The finaljudgment of serial X-ray and gastroscopic in-vestigation has been emphasized. Clinical observa-tion is also helpful. If treatment on a medicalregime brings about a striking relief of pain andgain in weight, with clearance of the stools fromoccult bleeding, a benign ulcer is likely, but eventhis evidence is not absolute, since the improve-ment of a secondary gastritis in cases of carcinomaby rest and dieting will often lead to symptomaticrelief and a temporary regaining of appetite. Thevalue of the visual check by barium meal andgastroscopy, reviewed at appropriate intervals,therefore needs no emphasis.

TREATMENT OFCHRONIC PEPTIC ULCER

Assessment of MethodIn their requirements of treatment no two

patients are identical, and a correct approach totherapy must, therefore, include a careful assess-ment of individual circumstances. Many casescall for a balanced decision between medical andsurgical methods, and the ideal course is clearlyfor the closest co-operation in treatment betweenphysician and surgeon.

General considerations of TreatmentIn a disease essentially of remission and relapse

the problem of treatment falls into two fields;firstly the healing of the ulcer, and secondly theprevention of recurrence, and of these the first isthe simpler task. While the response is variableaccording to site, the general scheme of treatmentof an uncomplicated chronic peptic ulcer is

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fundamentally the same wherever its position maybe. Therapy is essentially medical, and surgery,where indicated, is undertaken for specificcomplications, which are considered later.The over-riding principle in the medical treat-

ment of ulcer is to treat the patient and not solelythe lesion, and this will include all aspects of hisdaily life. The importance of the general well-being and of complete bodily and mental rest mayeasily be overlooked by considerations. of detailin diet and drugs. How the patient eats, for ex-ample, is no whit less cogent than what he eats.Any ambulant treatment at the outset of illness isunsatisfactory and wasteful of time, few chroniculcers healing while the patient is up and about.A minimum of four to six weeks' complete bedrest, including bed toilet, is essential; followed bya like period of quiet convalescence where pro-gress is satisfactory. It is often difficult to con-vince the patient of the necessity for this strictregime, the more so when he is of the irritabletype. Rapid disappearance of pain and earlyreturn of well-being render the enforced recum-bency irksome, while anxiety over business oreconomic affairs often leads to pressure upon themedical attendant to relax restrictions unwiselyand prematurely.* A clear explanation is requiredthat relief of symptoms does not imply that theulcer has healed. Factors leading to nervous oremotional upset should be fully elucidated anddealt with.

SedationFor these reasons, care must be taken to ensure

for the patient adequate mental relaxation, withquietness, sleep and freedom from worry, mentalrest being no less important than physical. Socialadjustments in this will play their part, butsedatives are often required in addition. Thefull and proper use of sedatives has perhaps notbeen accorded sufficient place in the medicaltreatment of peptic ulcer, and is certainly no lessimportant than dieting and the giving of alkalis.Of the sedatives employed, phenobarbitone isusually of more value than bromides, with the morerecently introduced barbiturates such as sodiumamytal and nembutal. Sleep is essential and shouldbe promoted by liberal dosage where required.Needs will vary with the patient's individual typeand circumstances, the aim being by encourage-ment and advice to promote a wholesome psycho-logical outlook. It is common experience that therequired regime is more easily and efficientlycarried out in hospital than at home.

HabitsIn their relationship to peptic ulcer, both

aetiological and therapeutic, habits of eating are of

greater importance than variation in diet, and inthese the ulcer subject is a well-known offender.Any instructions upon food which are mere listsof what may be eaten fall short of requirement, andadvice must be included upon how they are tobe eaten. Food must be eaten slowly andthoroughly masticated, with regularity and fullallowance of time for meals. Long intervals be-tween meals are particularly harmful, and at notime should the ulcer patient over-eat. Goodhabits in these regards should be followed per-manently. Preliminary attention must be given tothe condition of the teeth, to ensure a clean mouthand mechanical efficiency.

Alcohol is a gastric irritant and a powerfulstimulator of secretion, as its use in test mealsdemonstrates. It is best avoided at all stages oftreatment, and in any case should be strictly for-bidden at the onset of treatment. Tobacco alsoshould be wholly excluded in the initial stages, andpreferably throughout, where the patient can be sopersuaded. Where the deprivation causes in-creased restlessness, however, a single cigaretteafter a meal as sedative may be good policy.

Principles of DietingOpinions upon the fundamentals of dieting in

peptic ulcer have been greatly changed in the pastfew years. Perhaps too much emphasis in the pasthas been placed upon the relative merits or de-merits of particular schemes of dieting in pepticulcer, and upon the neutralizing of gastric acidity,to the neglect of a balanced diet providing sufficientcalories, salts and vitamin requirements. Earlydiets were inadequate to the point of semi-starvation. Treatment is necessarily prolonged,and nutrition and health must be maintained, andprogress has been towards the acceptance of moreliberal feeding. Frequency of feeds is at least asimportant as their nature, granted the exclusionof obviously unsuitable foods. While it may betrue that the presence of hydrochloric acid inexcess is the chief factor in maintaining activeulceration, treatment is not solely a simple chemicalequation of its neutralization by appropriatealkalis. Nevertheless, it is by combating theeffects of acidity that the main therapeutic result isobtained. Drugs, including alkalis, play an im-portant part in control of hyperacidity and are forconvenience considered later.Food is the primary and essential buffer in

virtue of the acid-combining power of its foodproteins. To render this maximal the followingprinciples should be observed:

(a) The food must be soft, smooth, fluid wheningested, and free from coarse elements, to avoidirritation of the ulcer area.

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(b) The bulk of the individual feeds must besmall, to prevent distension of the stomach andexcessive secretion of gastric juice.

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

it may be not-ed that the quantitative differences ingastric secretion produced by various foods is lessthan formerly thought, and that although fats doinhibit gastric secretion and emptying they playless part in maintaining gastric neutrality thandoes the acid-combining property of protein foods.The adoption of these principles still leaves a

considerable margin of variety and individualchoice within which a satisfactory diet may bechosen. In some quarters, so far has the principleof liberal dieting in peptic ulcer been extendedthat details are regarded as of small moment, andchoice is left entirely in the patient's hands to eatwhat he likes. For the great majority of patients,however, such a step is unwise and not calculatedto impress upon the ulcer subject the disciplineand care with which he must adapt, not only hisfeeding, but his general mode of living to hiscondition.The main ingredient of all such diets is milk,

itself an efficient alkali, neutralizing an equalvolume of gastric juice containing 0.3 per cent.HCI. The systems of diet first introduced in theLenhartz and Sippy regimes, based chiefly uponmilk and eggs and milk and cream respectively,were each deficient in calorie value and are nowseldom used in their original form, thoughmodifications are still in favour in many hospitals,details of which are readily available. A morebalanced diet with greater variety is that devisedby Hurst, the most widely used scheme, the firststage of which is based upon feeds at hourlyintervals alternately of citrated milk, 5 ozs., and afruit, vegetable or carbohydrate puree. Morerecently a still more generous regime has foundfavour with many physicians in the form ofMeulengracht's diet, embracing whole milk,porridge, barley, rusks, cream crackers, fruit andvegetable purees, eggs, fish and even meat;recommended at first for the more generousfeeding of patients after haematemesis, it is alsoused in the ordinary stages of ulcer treatment, andincludes quite large and varied meals. The re-action against semi-starvation after gastro-duodenal haemorrhage is fully justified, and theimproved results confirmed statistically, as notedlater. Hurst's regime includes a number of drugs,whereas in Meulengracht's scheme these arepractically excluded.

The first stage of dieting (the strict ulcer regime)is continued not for any stated number of weeks,but until there is freedom from all spontaneouspain or discomfort, tenderness and muscularrigidity are no longer present, and the stools showa negative test for occult blood on three consecutiveoccasions.When tests have confirmed a satisfactory

response, this initial stage of dieting is followed byan intermediate one, in which some of the milkfeeds are replaced by lightly cooked and easilydigested meals allowing greater liberty of choice.This second stage must be maintained as long asany evidence of active ulceration is present, andmay, therefore, occupy many weeks or months. Itis not possible from clinical observations alone totell when healing has taken place or to assess itsdegree, for it is not complete until the defect isclosed and covered by a normal glandular mucosa;this stage of recovery is delayed long after the dis-appearance of pain, and even after vanishing of theX-ray crater. Most failures of medical measuresarise from insufficient length of treatment. Dura-tion of the graded stages of dieting, in this as insimilar schemes, is not to be fixed by arbitraryperiods of time, but controlled by clinical andpathological surveys until evidence of healing isobtained. Then only is it desirable to progress toa more permanent post-ulcer r6gime of treatment.Control by periodic X-ray and gastroscopicexamination is required at intervals of three tofour weeks, until complete healing can be demon-strated, or the need for alternative treatment de-cided upon. The value in diagnosis by thesemeans of malignant ulcer has already been men-tioned. In duodenal ulcer a greater measure ofreliance has to be placed upon radiology alone.

Maintenance of nutrition should be checked bya weekly observation of weight, and whereanaemia is present, as after haemorrhage, periodicblood counts are required.

Diet after HaemorrhageWhile inadequacy of diet is undesirable at any

stage of treatment as being unconducive to healing,after substantial haemorrhage further importantconsiderations apply beyond the obtaining ofphysiological rest to the stomach. The acuteblood loss involved leads to a state of circulatoryshock, in which a policy of severe restriction eitherof food and of fluid is unwarrantable, as increasingmortality and delaying recovery. This betterunderstanding of the problems of bleeding wasfirst obtained by Meulengracht 6 7 8 in hisadvocacy of more liberal feeding directly aftergastric haemorrhage. He was able to show thatthe response to a full mixed diet, supplementedwhere needed by blood transfusion, was greatly

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superior to the results of treatment on moreorthodox and conservative lines by starvation andsupporting means, or of treatment by operation.In a series of 273 unselected cases of ulcer haemor-rhage treated by his method the mortality was onlyi per cent., the effect of early feeding being toprevent death from exhaustion and to provideadequate calories and vitamins for the promotionof healing and recovery. His policy has furtherproved the detrimental effect of keeping thestomach empty of food and exposed to the freesecretion of gastric juice, whereby peristalsis isstrongly stimulated, at a time when gastric rest ismost desired. Apart from leading to a reductionin immediate mortality, adequate feeding wasfound substantially to lessen, rather than to in-crease, the liability to recurrent bleeding, thegreatest danger to life in ulcer haemorrhage.Apart from lowering of mortality, moreover, thebenefit of more liberal feeding is shown in ashortening of the average stay required by thepatient in hospital.A practical difficulty in the adoption of Meulen-

gracht's full dietary regime, with its three fullmeals a day and supplements, has been an in-ability or disinclination on the part of some acutelyill or weakened patients to accept so large a foodintake. This objection has been largely overcomein a modified dietary scheme introduced by Witts9which, while accepting the principle of earlyfeeding, provides a more fluid diet with adequatecalories of from 2,500 to 3,500 per day upon atwo-hourly feed basis, with vitamin supplementsand additional measures to restore fluid balance tothe body where required.

Continuous Drip TherapyWhatever care is devoted to ensuring a bland

quality of diet, any system of intermittent feedingis open to the objection that at some phases of theday, and still more of the night, the stomach isleft empty and exposed to the harmful and ex-cessive secretion of the gastric juice. The funda-mental principle of obtaining effective acidneutralization throughout the 24 hours is in thisway defeated. The effects are clinically apparentin cases where over-secretion is marked andacidity high, and routine treatment upon a Hurstor Sippy regime may fail to relieve symptoms, andother measures be required. Consideration ofthis problem led to the introduction, in I932, byWinkelstein 10 11 12 13 of continuous intra-gastricdrip therapy. It is most fruitfully employed wherepain is severe and persistent, despite usual methodsof dieting, where gastric spasm is a marked feature,or where emptying of the stomach is delayed by apartial obstruction from spasm or oedema. Inany circumstances, in fact, where it is desired to

afford the stomach the maximum degree of rest,as after haematemesis or melaena, this method maywell be adopted as an alternative mode of feeding,since full calorie and fluid requirements are soprovided. Other indications include the intractablepain from a deep penetrating ulcer, resistantgastro-jejunal ulceration, and unsuitability of thepatient from age or impaired general condition foroperative treatment which would otherwise beindicated. In all these types of patient, rapid re-lief of symptoms frequently follows the adoptionof drip feeding, the results of which, in general,are superior to those of a first-stage Hurst's diet.Acidity is thereby neutralized throughout the 24hours by a regular and constant introduction intothe stomach of ant-acid and buffer substances insmall quantities, avoiding the recurrent stimulusof secretion inevitable with intermittent feeding.As originally' introduced, the continuous drip

consisted of the ant-acid buffer itself, the mostsatisfactory choice for the purpose being analuminium phosphate gel. The more usual andeffective method is for the feeding itself to be bycontinuous drip, using milk instead of the alumin-ium gel from a simple gravity flask. Using thismethod, a Ryle's tube made non-irritant with 2per cent. cocaine ointment is passed 'into thestomach, preferably through the nose, alternativelythrough the mouth, and fixed in position bystrapping to the cheek. The tube need not ex-tend deeply into the stomach, but should be longenough to allow the patient to turn comfortably inbed at night. Through this tube, from a height ofabout 2 ft., the patient is given a continuous dripof citrated milk, day and night, from a suitablecontainer such as a transfusion bottle, fixed to astand or bed extension and adjusted to a rate ofabout 40 drops per minute. The patient receivesin this way a total of five pints of milk in the 24hours, and where desired the calorie value andprotein content of the diet may be increased by theaddition of glucose and of a io per cent. solutionof casein hydrolysate, a pint of the latter beingadded to the five of citrated milk. Alkalis andother drugs needed may be given either in thedrip or separately by mouth, the latter beinggenerally preferred. Most patients will toleratefeeding in this way for periods of up to threeweeks, some for much longer. Rest of thestomach is as complete as may be obtained.Appetite secretion is minimized, and the stomachis never left exposed at night or for other interimperiods to the action of highly-acid gastricsecretion, neutralization of which is made a con-tinuous process. Nutrition is well maintained,and healing is more rapid by this method, in thewriter's experience, than by any other. An initialsoreness of nose or throat for the first day or two

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is seldom maintained. A period of milk-dripfeeding in this way may well be followed by afirst-stage Hurst diet.A few practical points may be noted. Special

care in the cleanliness of the mouth and teeth isrequired, and the tube should be changed everythird or fourth day to avoid blockage or perishingand possible loss. Its position in the stomachmay be adjusted as needed, and in high ulcers anintroduction as far as the lower oesophagus maybe sufficient. In subsequent stages of treatmentthe use of drip feeding may satisfactorily berestricted to the night hours, as a supplementalmethod to the normal scheme of intermittent ulcertherapy, and maintained if desired even for manymonths after the ambulant stage is reached.

It must be noted, finally, that any infection ofthe upper respiratory tract makes the adoption ofdrip therapy unsuitable.

Drugs in the Treatment of Peptic UlcerThe administration of drugs does not constitute

the chief aspect of treatment, being of less vitalimport in the programme for healing than generalmeasures of physical rest and dieting, which itcan never be made to replace. NevePtheless arational use of drugs forms a valuable supple-mentary measure of treatment. It is directedtowards three main objects, neutralization ofacidity, inhibition of gastric activity, both motorand secretory, and sedation of the nervous system,while other minor forms of symptomatic treat-ment may also be required.

(a) Acid neutralization. Sippy's aim in neu-tralizing hydrochloric acid was to inactivate pepsin,but it is now known that high acidity is in itselfmore destructive upon an ulcer than the solventacfton of the peptic ferment. The object, never-theless, remains unchanged to maintain a neu-tralization of all free HCI while food and itsaccompanying secretion is present in the stomach;it is also necessary, and more difficult, to neutralizethe continued secretion of acid gastric juice duringthe night hours when the stomach is empty offood.

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

special advantages or otherwise according to thecase. Two broad groups are recognized accordingto solubility or otherwise. Those most readilysoluble are in consequence the most rapidly

absorbed, whilst those that are comparatively in-soluble are correspondingly more gradual andprolonged in action, acting as buffer salts orneutralizing agents without the undesirable libera-tion of free alkali. The latter group is, therefore,greatly to be preferred ; any excess above require-ment merely remains in the stomach until neu-tralized, without danger of systemic alkali intoxica-tion or of the stimulation of a secondary secretionof acid by the stomach.

Typical of the first or soluble group is sodiumbicarbonate, which has a quick though shortneutralizing action, but produces distension ofthe stomach by liberated CO2 and a markedsubsequent secretion of acid, rendering it un-suitable as an alkali for this purpose. In view ofits greater solubility it is, as noted, more pronethan are other alkalis to produce alkalosis. Themore gradually acting magnesium and calciumsalts are fully effective, while free from this risk,and may be combined in proportion to regulatethe bowels, the former being mildly aperient andthe latter astringent. Magnesium oxide, carbonateand tribasic phosphate are excellent; the trisilicatehas come into favour with some, but is a morecostly preparation and no more efficient than itsfellows. Effective dosage requirement varies withthe degree of acidity present; commonly (as inHurst's scheme) doses of a drachm of one of theabove salts in powder form are sufficient, givenwith water before each of the puree feeds, and onedrachm or more of emulsio magnesiae B.P.C.(contaiaing grs. v of magnesium oxide) beforeeach of the alternating milk feeds ; a double doseof alkaline powder is given at night. Calciumpreparations, in the carbonate or tribasic phos-phate, are useful alternatives, and a good case haslately been made for a gel preparation of colloidalaluminium hydroxide, in the form of aludrox insimilar dosage. Bismuth salts are feeble alkalis intheir degree of neutralizing power, having about afifth of the potency of magnesium salts, and theidea of their forming a protective coating to theulcer floor belongs to past days ; they are, likecalcium salts, mildly constipating. Sodium citrate,besides inhibiting rennin and preventing clottingof milk, is also an effective alkali, and is added toall milk feeds in proportion to two grains to theounce. As with all other drugs in the treatment ofpeptic ulcer, alkalis should always be given insuspension or solution and not in tablet form.

Gastric AspirationAs a supplementary method of ant-acid therapy,

alkali administration may be fortified wherenecessary by a direct removal of the acid gastricjuice. Where hypersecretion is marked or ameasure of obstruction present, alkali administra-

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tion by itself is insufficient to ensure continuedneutrality of stomach contents throughout the 24hours, the more so at night, when nocturnal painmay be a distressing feature. Routine aspirationof the stomach at bed-time, or oftener, should inthese cases be carried out, thereby shortening theperiod during'which the ulcer is exposed to theaction of the acid gastric juice. It affords, more-over, a means of assessment of correct alkalidosage ; if this is adequate, the stomach contents30 minutes after a dose of the powder shouldcontain no free acid ; its presence at that time isa call for more frequent or larger dosage. Innon-obstructive cases it is the rapidly emptyingstomach which most needs aspiration at night,food contents and alkali having been quicklypassed on, and a collection of highly-acid secretionbeing then poured out into the empty stomach, toremain there during the night. The case is clearalso for gastric aspiration in obstructive ulcer,whether from pylorospasm or duodenal stenosis,and this should be continued at least twice a dayuntil the residual contents are not more than 50to IOO cc. In obstructive cases with foul stomachcontents, aspiration may be usefully combinedwith gastric lavage.

AlkalosisThe indiscriminate giving of alkalis in excess,

especially when accompanied by vomiting or in-dependent renal disease, may cause a serious dis-turbance of the acid-base equilibrium and chloridecontent of the blood, a condition known asalkalosis. This is seen most often where a con-tinued depletion of chlorides has occurred fromlow salt intake combined with vomiting, especiallyin the presence of pyloric obstruction, benign ormalignant. Symptoms include irritability, lassi-tude, mental confusion and headache, with loss ofappetite, nausea and distaste for milk, followed byprofuse vomiting and drowsiness, and in seriouscases the development of a state closely simulatinguraemia, with low urinary output, albuminuria andhigh blood urea, perhaps progressing to coma andtetany. The chloride content of the blood isalways greatly lowered. Treatment called for isthe immediate stopping of alkalis and the givingof large amounts of sodium chloride as normalsaline solution intravenously, with glucose andabundant fluids by mouth, supplemented where itcan be taken by oral administration of sodiumchloride and ammonium chloride in capsules inlarge doses, or the latter may in urgent cases begiven intravenously in 2 per cent. solution. Iftetany occurs, intravenous calcium gluconate isgiven. Prophylactically, in conditions wherealkalosis is a likely complication, 3 to 5 grs. of

sodium chloride may with advantage be added tothe daily milk ration.

(b) Inhibition ofgastric activity. T'he functionalover-activity of the stomach in ulcer subjects is atleast partly the result of an exaggerated vagal tone,inducing over-secretion and hypermotility. Acidneutralization by alkalis is fryitfully supple-mented by measures claimed to diminish this toneand hence the secretion of gastric juice, and ofthese the giving of belladonna or its alkaloidatropine is the most widely used. Its action inrestraining gastric secretion is doubtful, but itseffect as an anti-spasmodic and inhibitor ofperistalsis is more certain, and it is hence of markedvalue in inducing relaxation of spasm at the pylorusor at the site of ulceration. It is included asroutine in the Hurst's diet, in doses of 1/150 - 1/100gr. in a drachm of water by mouth before two ofthe daily feeds, and a double dose before the iop.m. feed, while more may be given if spasmpersists, to the point of producing blurring ofvision and dryness of the mouth, small doses beingineffective. As evening and nocturnal secretion isthe most difficult to check, late afternoon or bed-time is the time of choice for administration.Benefit may be derived in some cases from com-bining atropine with ephedrine gr. -1-i, further toinhibit vagal overtone, while papaverine gr. 1-2and pethidine hydrochloride 50-o00 mgm. bymouth or by injection are additional anti-spasmodics and analgesics of value. Many pro-prietary combinations of efficiency are available.

Fats in general also inhibit gastric secretion andmotility. Olive oil or the more readily obtainablearachis oil, taken twice daily before meals in ouncedoses, has this effect, besides forming a valuablefood and being mildly laxative. The addition ofcream to the milk feeds is of similar benefit.

(c) Sedation. The importance has already beennoted of obtaining quietness of the mental stateand relief of nervous anxiety or restlessness. Achoice of barbiturates is available for this purpose,the most valuable and generally employed beingphenobarbitone, given in liberal dosage. Whererequired, sedation may be combined with anal-gesia and relief of spasm by employing a drugpossessing each of these qualities, such aspapaverine grs. I to 2, or its equivalent syntheticpreparation in the form of perparine 0.04 gm.;atropine gr. i/I00, or novatropine gr. 1/25, areuseful supplements in this regard. The place ofmorphia as more powerful sedative in the shock ofmajor bleeding needs no emphasis.Apart from these main therapeutic needs, other

drugs may in some cases be required, and includethe following:

(d) Haematinic drugs. Anaemia of some gradefrom slight blood loss over a long period is ,so

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common in peptic ulcer that regular blood in-vestigation should always be made. Wherehaemoglobin deficiency is found, iron is indicatedin liquid form as iron and ammonium citrate orcolliron in appropriate dosage; after frankhaemorrhage, early and massive iron administra-tion is required, begun as soon as the bleeding hasceased. In view of the low iron content of ulcerdiets, a minimum of 5 grains of a ferrous salt perday as supplement is a good routine, despite theabsence of demonstrable anaemia, for all patientsupon the restrictive stage.

(e) Vitamins. The most likely deficiency in thisregard arises from the limitation of fresh fruits andvegetables, and a long-continued ulcer dietshould always be supplemented by vitamin B1,2,000 units, and vitamin C, as ascorbic acid,I00 mgm. given daily. There is no objection tothe giving as well of fresh orange or other fruitjuice.

(f) Control of bowels. Straining at stool isobviously undesirable, particularly if recent bleed-ing has occurred. Where regulation of the dietand additional magnesia do not suffice, agar andliquid paraffin preparations will help towards aneasilv passed stool. Enemata rather than drugswill sometimes be required, but are to be used withgreat caution, especially after haemorrhage. Therule should be to leaye the bowels undisturbed forat least a week after a haematemesis has occurred.

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

After-Care of Peptic Ulcer: 'Post-UlcerR6gime'The treatment of the acute ulcer is compara-

tively straightforward. The most difficult decisionsof treatment arise in the chronic or resistant case.The plan of treatment outlined is maintainedeither so long as any evidence of active ulcerationremains, or until the conclusion is reached thatmedical means alone are inadequate after a pro-longed trial. Where healing is established, thepatient is allowed up by stages and progresses on toa post-ulcer regime of diet and habits, which he isinstructed to follow for a minimum of two years or,if possible, permanently. The dangers of re-currence and the need for long-term care must beemphasized to him. From these instructions hewill be taught to maintain small frequent mealswith intervals of not more than two hours, toadhere to soft readily-digested foods and avoidhard, irritant or highly-seasoned articles with in-digestible residue. Advice upon diet should bepositive and not merely a list of forbidden foods;

those recommended should also be within a rangewhich he can obtain and afford to purchase.Above all he will be advised to obtain -ample timeand regularity for his meals, to rest before andafterwards, and to avoid excessive fatigue and, asfar as possible, intercurrent infections. He mustpay proper regard to his teeth and his bowels andcontinue to take an alkaline powder after each ofhis main meals. A patient's own teeth may bemore serviceable for eating than an empty mouth,and a programme of clearance should include re-placement by efficient dentures. Smoking andalcohol are best avoided altogether. Any return ofsymptoms calls for a prompt resumption of bedrest and strict dieting.

Could this ideal advice always be followed, theprognosis of medical treatment of peptic ulcerwould be much better than it is. Prospects of re-maining well vary greatly with social status andeconomic means. The patient in comfortable cir-cumstances may be able to continue the wholeregime religiously, and remain free from symptomswith a careful diet and sheltered Ffe quite im-possible for a working man with living to earn andfamily to support. The occupation followed maybe a stumbling block, and its type is not easilychanged; the best choice is often that with whichthe patient is most familiar. Even granted thebest of after-care, no guarantee can, in fact, begiven of freedom from recurrence of ulceration.Strong argument obtains, therefore, for the in-definite following-up of all ulcer patients inclinics organized for the purpose, supported byX-ray and other special investigations as required.

Indications for Surgical TreatmentThe best efforts of medicine in this disappoint-

ing disease are not always blessed with success.Despite a high proportion showing initial improve-ment, it is certain that a considerable percentage ofcases relapse after apparent medical cure, and ofall patients treated medically not more than 30 to40 per cent. remain permanently well. It does not,of course, necessarily follow that of these medicalfailures all are amenable to successful surgicaltreatment, but with proper choice many will bebenefited thereby. It is pertinent, therefore, toconsider what are the indications for surgicaltreatment. Some will be obvious and are bynature emergency procedures; others should beembarked upon only after carefully weighing thepros and cons of individual circumstances. Themost generally agreed indications are as follows

(a) Failure of Medical Treatment. This is themost frequent reason for operation; it pre-supposes that medical treatment should have beenreally adequate, and not a half-hearted trial. Itmore commonly applies in intractable duodenal

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ulcer than in gastric, not considering those com-plications of dramatic order calling for urgentsurgery. The type of patient with prolongedhistory of pain unrelieved by dieting and alkalis,and interspersed with increasingly frequent andsevere relapses, is not best served by repeated vainattempts at medical cure, which serve merely toprolong the duration of his ill-health, but shouldif otherwise fit be treated surgically to avoid alife-long dyspepsia. Within this group will bemany with deep penetrating ulcers embedded incallous scar tissue and adherent to other organs.In some cases the failure to heal of a gastric orjejunal ulcer after gastro-enterostomy will be anindication for more radical surgical treatment.The trend of opinion in these medical failures isincreasingly in favour of partial gastrectomy asbeing the most radical means of extirpating theacid-producing area, but in choice of surgery thedegree of hyperplasia and hypermotility of thestomach will be a factor. Suitability for operationon grounds of age, pulmonary or cardiovascularcondition has, of course, to be considered. Freshhope of success has recently been aroused in anew measure of surgical treatment aimed at con-trolling the excessive secretion and muscularactivity of the stomach, namely bS the operationof vagus nerve resection or vagotomy (Allen,A. W.14). A less drastic and extensive procedurethan gastrectomy, it has been shown to be of somevalue and may acquire a permanent place in thetreatment of intractable duodenal and anastomot;culcer.. Sufficient time has not yet elapsed to per-mit of its proper assessment in therapeutics, butimmediate results are encouraging.

(b) Inability or unwillingness to maintain a fullmeasure of efficient medical treatment. Lack of co-operation on the part of the patient will oftenindicate the advisability of surgery. This issometimes concerned with psychological type andtemperament. Frequently, however, the reasonsare economic rather than medical, in the nature ofoccupation followed, pressure of time for the moreprolonged medical treatment or domestic citcum-stances out of the patient's control; it may beessential in such a case to restore, where possible,the ability to pursue a heavy or exacting type of

employment, the prospects of which are affordedby successful operation alone.

(c) Recurrent haemorrhage. Most of the fatalitiesfrom bleeding follow repeated blood loss, and inany event each such episode entails a long andtedious illness. While the immediate treatmmnt ofulcer haemorrhage in most cases is by generalagreement medical, it is certain that recurrenthaematemesis should be followed by radicaloperation as soon as the patient's general statepermits. In a small proportion of cases of ful-minating bleeding not responding to medicaltreatment, an immediate gastrectomy after masstransfusion is the one way of saving the patient'slife.

(d) Suspected malignancy. The failure of agastric ulcer to respond to full medical treatmentwithin, at most, a few weeks, indicates the ad-visability of exploration, to confirm the diagnosisof malignancy and, where suitable, to carry out asubtotal gastrectomy.

(e) Perforation of the ulcer is an obvious needfor immediate surgery.

(f) Organic obstruction. Obstruction which islargely due to oedema and spasm will frequentlybe relieved by dieting, antispasmodic drugs, as-piration and lavage. Where, however, theobstruction is of organic origin from cicatricialstenosis, as in hour-glass stomach, duodenal orpyloric stenosis, surgical treatment -alone can re-lieve it, and should not be unduly postponed.To summarize this attempt at balancing the

scales of treatment, medical measures then carrythe bogy of relapse, surgical of a not negligibleimmediate mortality and a fairly high incidence ofminor post-operative troubles and digestive symp-toms. On the other hand, medicine can offer tothe chronic sufferer nothing to equal the almostcomplete immunity from perforation and re-current bleeding given by a successful gastrectomy.

Perhaps if any lesson may be fruitfully drawnfrom this discussion, it is to stress the paramountimportanqe of a fusing of medical and surgicalopinion in this protean disease. Only in this waymay proper assessment be made and the patient'sbest interests served.

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Method of feeding by continuous milk drip.

REFERENCESa. OGILVIE, W. H. (1g39), 'Cancer of the Stomach,' Su7rg.

Gyn. and Obst., I68, 295-305.2. MACCARTY, W. C., and BRODERS, A. C. (941),' Chronic

Gastric Ulcer and its Relation to Gastric Carcinoma. Re-view of 684 specimans,' Arch. lt. Med. 13, 208-223.

3. ALLEN, A. W., and WELCH, C. E. (iq4.i, 'Gastric Ulcer.The Significance of this Diagnosis and its Relationship toCancer, Ann. Sutr., II4. 489-So9.

4. TAYLOR, H. (1937),' Gastroscopy: History, Technique and- Clinical Value,' Brt._Y. Surg., 24, 469-500.

S. TAYLOR, H. (X941), 'Practical Evaluation of Gastroscopy,'Lancet, I, 131-135.6. MEULENGRACHT, E. ('ge) 'Treatment of Haematemesis

and Melaena with food, 'Acta med. Scand., Suppl., 59,375-381.

7. MEULENGRACHT, E. (1935),' Treatment of Haematemesisand Melaena with Food; Mortality,' Lancet, 2, 1220.

8. MEULENGRACHT, E. (1936), ' Beandlung von Hiema-temesis und Melaena mit U.ein eschrnleter Kost,' WienKlin. Wschr., 49, 148!,

9. WITTS, L. J. (r937), 'Haematemnesis and Melaena,' BitM.J9., I, 847-852.

so. WINKELSTEIN, A. (19x2), 'Studies in Gastric SecretionDuring the Night, with a Preliminary Note on a NewTherapy for Peptic Ulcer,' Am Y. Surg. i5 23-524.

II. WINKELSTEIN, A., CORNELL, A., and H6TLLANDER,F. (1942), ' The Efficiency of the Milk Drip Method in theReduction of Gastric Acidity,' Am 7. Di. Dis., 9,332-338.

22. WINKELSTEIN, A., CORNELL, A., and HOLLANDE1t,F. (1942), 'An Improved Continuous Drip Apparauswith Especial Reference to the use of Aluminium Gels inthe Therapy of Peptic Ulcer,' Rev. Gastroenterol., 9,3 I-58.

I3. WINKELSTEIN, A., CORNELL, A., and HOLLANDER,F. (1942), ' Intragastric Drip Therapy for Peptic Ulcer-A Summary of Ten Years' Experience,' ..A.M.A., IsO,10, 743.

I4. ALLEN, A. W. (1947), 'Moynihn Lecture.on DuodUlcer,' Brit, M.47., 3,540.

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