170 The Treatment o t Gastric Ulcer.

ment of bad stomachs has been somewhat suggested by the fact that of late years a few people have consulted me for stomachs which still gave them great trouble, and when noting the principal signs I found myself obliged to mention that " there is a scar five inches" long " in the linea alba.

ART. VI. - -The Treatment of Non-malignant Gastric Ulcer. ~ By SIR CHARLES BALL, M.Ch., Univ. Dubl. ; F.R.C.S.I. ; Hon. F.R.C.S. Eng. ; Hon. Surgeon to His Majesty the King ; Regius Prof. of Sux.gery Univ. Dubl. ; Surgeon to Sir Patrick Dun's Hospital.

A CONSID~.RATION Of the causes which produce gastric ulcer and the conditions which tend to interfere with its healing when once established is obviously of first importance in deciding upon the best form of treatment to effect its cure.

The more or less circular outline, flat base, and sharp- walled edges of ulcer of the stomach are very special characters which at once suggest the operation of some special cause, and the exposure of the stomach surface to a higMy acid digestive fluid has been assumed to be the explanation. That the normal stomach is immune to autodigestion is, of course, obvious. Weinland (Halliburton's " Handbook of Physiology," 6th edition, page 489) considers that this immunity is due to the formation by the stomach epithelium af an antipepsin, and that in the same way the intestinal epithelium forms an antitrypsin. If, then, the mucous membrane is injured by direct traumatism from hard sub- stances swallowed, by septic infection from the ingesta, or by necrosis following embolic infarction, this theory supposes that autodigestion occurs in the damaged area, and thus the ulcer is extended in dimensions, and its healing is interfered with. This theory has received very general acceptation ; so we see, even in the most modern text-books, the disease spoken of as " peptic ulcer of the stomach." I am confident that this is one of the somewhat numerous fallacies which

Read before the Section of Medicine in the Royal Academy of Medicine in Ireland, onFriday, January 18. 1907.

By SIR CHARLES BALL. 171

have been adopted from time to time in medicine without question, although opposed to directly ascertainable facts. The evidence obtainable by post-mortem examination, by clinical observation, and by surgical experience clearly demonstrates that peptic action has nothing whatever to say to the origin or maintenance of gastric ulcer.

I t is common to find at post-mortem examinations cicatrices in the stomach showing that gastric ulcers have undergone spontaneous cure. If autodigestion had been the cause of these ulcers how is it possible that the delicate process of healing by granulation and epitheliasation could go on while exposed to the same influence ? It is notorious that a large proportion of cases of gastric ulcer get well under treatment by rest in bed, rectal feeding, and little or no fluid nourishment by the mouth. Physiologists tell us that gastric juice is secreted independently of the ingestion of solid food, that the sight of meat to a hungry dog causes a free flow, and that fluid meat extracts stimulate secretion. I t is a popular ex- pression that at the sight of dainty food the " mouth waters " ; it would alike be true to say that under similar circumstances the "stomach juices."

Let us take now the case of a chlorotic girl lying in bed in hospital undergoing the routine treatment for gastric ulcer; possibly in the next bed may be a case convalescent from some acute disease. When dinner hour arrives the con- valescent is provided with a succulent mutton chop, the stomach case with a rectal injection and possibly a table- spoonful of chicken broth. Our knowledge of physiology tells us that the latter must have a free secretion of gastric iuice, which, not getting the coveted mutton chop on whichto expend its energies, might reasonably be expected to act more vigorously on the ulcer than if she had received a solid meal.

Surgical experience tells us that stomach wounds when closely sutured up heal with the utmost facility; it is usual in such wounds to bring the divided edges of mucous membrane together by a continuous silk suture, which must produce a certain amount of necrosis, and which eventually cuts its way out into the lumen of the stomach. Surely under these

172 The Treatment o] Gastric Ulcer.

circumstances if gastric digestior/ of living stomach tissue ever occurred these wounds would not heal, or at any rate leakage would be of frequent occurrence, but we know tha t with proper modern technique leakage seldom or never occurs. This satisfactory healing of stomach wounds appears to in- dicate tha t the immuni ty against autodigestion is not confined to the mucous membrane, but is present also in the deeper coats. The theory, therefore, of Weinland tha t the gastric epi thel ium forms an antipepsin appears to be scarcely a sufficient explanation.

A consideration of these facts renders the theory of peptic action as a cause of gastric ulcer quite untenable.

Septic infection, especially coming from suppuration in connection with bad teeth, has been suggested as a cause of gastric ulcer, and in all probabili ty this may be frequently an initial element of the disease ; but it is hard to imagine tha t it can be the cause of a chronic ulcer remaining open for months or years, especially when we see tha t gastro-enter- ostomy performed when there is an open ulcer in the stomach so rarely becomes infected.

The mechanical effect of solid food being churned about in the stomach is sometimes mentioned as the reason why gastric ulcers, which may have had their origin in traumatism, sepsis, or infarction necrosis, do not readily heal, and although hitherto it has usually been considered as of secondary im- portance to the peptic theory, I am convinced that it is the true explanation not only of the characteristic appearance of gastric ulcer, but also of the known facts relating to spon- taneous cure and the results of medical and surgical t reatment.

Many years ago, as a medical student, I saw an old surgeon make an issue in the back of a patient 's neck for the t rea tment of severe facial neuralgia. A piece of adhesive plaster with a small circular hole in it was first applied, and caustic potash was rubbed in so as to produce a circular slough of skin where it was exposed in the hole in the plas ter ; when the slough separated an ulcer was left, and as the neuralgia had not been cured, the surgeon decided to " keep the issue open " ; this was done by the simple process of keeping a pea in the ulcer by

By SIR C~IARLES BALL. 173

means of a piece of adhesive plaster. By this method the issue could be kept from healing as long as was considered neces- sary, and the characters of the ulcer thus produced, with flat base and sharp cut edges, closely resembled the appearances we are familiar with in chronic gastric ulcer. As the pea kept the issue from healing, so the frequent passage of solid food over the surface of a gastric ulcer retards its cicatrisation.

We know tha t pain--sometimes very severe pain---follows the introduction of solid food into a stomach which is the site of ulcer. This may be so great that the patient instinc- tively avoids solids, and thus affords the stomach that rest which is necessary to permit of spontaneous cure.

Our modern treatment of gastric ulcer, which is quite un- intelligible on the peptic theory, is readily explained if we believe that the continuance of ulcer is caused by the mechanical effect of solid food.

I t is certain tha t a large proportion of cases of gastric ulcer will get quite well by rest in bed, rectal feeding, with- holding solid food, and strict limitation of the amount of fluids taken by the mouth ; but it is well to remember that there are limits to this plan of treatment, and that if carried too far it will defeat its object, as there can be no doubt tha t a condition of semi-starvati~on seriously interferes with the healing process, and tha t surgical operations undertaken under these conditions are not satisfactory. I would strongly urge that all cases of uncomplicated ulcer of the stomach should, in the first instance, be treated by a short but efficient course of rest and limited diet, and tha t those cases which do not show rapid and marked improvement should be dealt with by surgical operation, and tha t cases of recurrence of symptoms after apparent cure by rest and limited diet should at once be operated on.

The operation now recognised as best in these cases is posterior gastro-enterostomy. Excision of the ulcer can be practicable in only a small minority of cases, and although it may occasionally, in suitable cases, be considered as an addition to gastro-enterostomy, it should not be undertaken as a substitute, as the essential object of surgical operation

174 The Treatment o] Gastric Ulcer.

should be the provision of a free outlet from the lower portion of the stomach into the jejunum, the free exit thus provided for the contents of the stomach affording the ulcer the rest essential for its healing, and tending to prevent recurrence in the future.

My personal experience of gastro-enterostomy and pylo- roplasty extends to forty cases, but in only four of these was uncomplicated gastric ulcer found present; all the four recovered well, and--so far as I know--remain quite free from recurrence. The results obtained by others who have had larger experience show that the dangers of the operation are comparatively trivial, and the proportion of cases in which complete cure follows is large--in many instances patients who for months or years have been in misery being made perfectly well.

The brilliant results of modern gastric surgery have tended sometimes to engender surgical recklessness. We occasionally hear of gastro-enterostomy being performed in purely neurotic cases, in the gastric crises of tabes," and even in dyspepsia due to chronic renal disease. Such proceedings do much to bring discredit upon this operation, which, in properly selected cases, is often such a conspicuous success.

The immediate risk of posterior gastro-enterostomy in ordinary cases is probably not more than two or three per cent. It is, however, necessary to consider certain results of the operation which occasionally give trouble, and which are directly consequent on making a free communication between the stomach and jejunum, and of these the most frequent is the regurgitation of duodenal contents into the stomach, producing vomiting. The occurrence of vomiting after gastro- enterostomy is an interesting physiological problem. We are accustomed to believe that the act of vomiting is caused by, first of all, a closure of the pylorus, followed by a reflex peri- stalsis forcing the stomach contents up the (esophagus. If now a gastro-enterostomy is present, and as it is unprovided with any sphyncteric apparatus, it is reasonable to expect that an attempt to vomit would empty the stomach into the jejunum rather than up the oesophagus. I t is obvious that

By S m CHARLES BALL. 175

for vomiting to take place under these circumstances there must be an associated spasm in the intestine, and also, probably, in the voluntary muscles of the abdominal wall.

Regurgitation of duodenal contents into the stomach, followed by persistent vomiting, is, however, not so trouble- some with modern surgical technique as it was formerly. Katzenstein (Medical Press, Dec. 6th, 1906) states as a result of his investigations, principally on experimental gastro- enterostomy in animals, that a flow of duodenal contents containing bile and pancreatic juice into the stomach is constant for a considerable period after gastro-enterostomy, and, adopting the peptic theory of gastric ulcer, he suggests that the neutralisation of the gastric juice by the alkaline duodenal contents is the explanation of the good results obtained by gastro-enterostomy. It must, however, be remembered, as pointed out by Ewald, that it is unsafe to draw conclusions from the results of gastro-enterostomy in animals, as the horizontal posture in them favours the flow of intestinal contents into the stomach more than in the case of man; moreover, it is common surgical experience that bilious vomiting following gastro-enterostomy can generally be stopped by putting the patient in the sitting posture, and so facilitating drainage. Should, however, regurgitant vomit- ing prove serious, lateral anastomosis between the two limbs of the loop of jejunum involved in the gastro-enterostomy will usually prove effectual. In two of my forty eases of gastro- enterostomy this was necessary.

Another after-complication of the operation is the occurrence of so called peptic ulcer, sometimes leading to perforation, in the jejunum. An interesting paper by Dr. Watts in the Johns Hopkins Hospital Bulletin for July, 1903, deals with this subject. The author performed gastro- enterostomy on a dog, and three months after, it died of perforating jejunal ulcer. A review of the literature of the subject shows that up to date on fourteen occasions similar ulcerations have been recorded in the human s~lbjeet ; it is remarkable that they all have been recorded in Germany. The question whether such ulcers are really peptic is an

176 The Treatment o/ Gastric Ulcer.

interesting one. Al though the jejunum is normally immune to alkaline trypsin digestion, it is quite possible tha t it may not be, like the stomach, immune to acid pepsin digestion; it is also unaccustomed to the presence of large quantities of un- dissolved food, such as it must receive after gastro- enterostomy. I t appears at present impossible to say which of these factors is the most operative ; at any rate its occur- rence is so rare tha t it cannot be held to be a contraindication to operation in suitable cases.

A curious sequence to gastro-enterostomy, which I have not seen described elsewhere, occurred in one of my cases. The portion of jejunum corresponding to the stomach anasto- mosis became dilated to quite four times its normal size, forming a sort of secondary stomach, and produced obstruction by kinking of the distal portion of intestine, with continuous vomit ing; a lateral anastomosis below the dilatation quite relieved the symptoms. This was done a year ago, and the patient at present remains in good health. I am quite at a loss to account for this condition.

In conclusion, I would urge, after the fullest consideration of the risks of operation, both immediate and remote, tha t all cases of uncomplicated gastric ulcer which have had a reason- able trial of t reatment by rest and limited diet without very marked improvement, should be subjected to gastro-enter- ostomy. There are, however, many points both pathological and physiological in connection with this most interesting subject which still require further elucidation.

ART. VII.--Gastric Ulcer : its Diagnosis and Treatment. a By JAMES ALEXANDER LINDSAY, M.D., F.R.C.P. (Lond.), M.A. ; Professor of Medicine in Queen's College, Belfast.

GASTRIC ULCER must be decidedly common in the North of Ireland, as I find from the reports of the Royal Victoria Hospital tha t we had 110 eases in 1905, 70 in the previous year, and 69 in the year before that.

a Contribution to a discussion in the Section of Medicine in the Royal Academy of Medicine in Ireland, on Friday, January 18, 1907.