surgery of peptic ulceration and its complications · 577 surgery of peptic ulceration and its...

577

SURGERY OF PEPTIC ULCERATIONAND ITS COMPLICATIONS

NORMAN C. TANNER, M.D., F.R.C.S.

Part III·

Stomal UlcerationStomal ulceration may follow anastomosis of the

stomach to any other part of the alimentary canal.I have indicated in my first lecture that by I954,stomal ulceration had followed in over 50 per cent.of the cases in which I had carried out a gastro-jejunostomy for duodenal ulcer in I943. In suchcases at the second operation, the duodenal ulcer,although often reported as active by the radio-logist, is almost invariably healed and inactive,though sometimes stenosed. The only occasionson which I have found activity in the duodenalulcer was when there was a gastro-colic fistula orstenosis of the gastro-jejunal stoma. The jejunalulcer is usually on the jejunal side of the stoma,near the efferent loop, but is occasionally quiteapart from the stoma and sometimes multiple.If an ulcer is seen on the gastric side and is not onthe stoma, it almost invariably means that thepatient has had a gastro-jejunostomy for, or in thepresence of, a gastric ulcer. In such cases thejejunum is usually intact, but the gastric ulcer mayremain active. I have on several occasions seenboth an active gastric ulcer and a healthy gastro-jejunostomy in the same field at gastroscopy.

After gastrectomy for gastric ulcer, stomalulceration is of the greatest rarity. I had person-ally performed 690 gastrectomies for gastric ulcerbefore operating on the first case which subse-quently developed a stomal ulcer, and in well overa thousand resected in our clinic, this remains theonly known case. It was indeed an unusual onein that the gastric ulcer appeared in the prepyloricregion on the greater curve side of the stomach.The patient was a man of 45, who had taken aspirindaily for some years. Although the ulcer almosthealed under a medical regime, we felt it wiser toresect it in view of its position, and ulcer symp-toms recurred within a year. In the follow-up of6i i of our gastrectomies for peptic ulcer by Mr.Colin Craig and Dr. Chippendale, there were norecurrent ulcers among the gastric ulcer resections,

but five proven and one doubtful stomal ulceramong 244 resections for duodenal ulceration-arecurrent ulcer rate of 2.5 per cent. Here againstomal ulceration following gastric resection is, inmy experience, invariably in the jejunum andnever in the stomach. Occasionally, post-operativedeformities mimic a recurrent gastric ulcer, butI have never failed to disprove its presence bygastroscopy or by subsequent operation.

It is interesting to consider why the stomachdoes not undergo peptic ulceration after gastrec-tomy, either for gastric or duodenal ulcer. Theproblem is a difficult one and its solution dependson the causation of ulcer and ulcer pain. I havepointed out previously (Tanner, i95I) that duringdigestion there is varying intensity in the con-centration of acid in different parts of the stomachafter a meal, the acidity probably being higher atthe upper level of gastric chyme. I believe thatprolonged contact with this concentrated levelmay play some part in the development of ulcer,and that the time when this level comes oppositethe ulcer is the time when ulcer pain occurs.After gastrectomy there is a more rapid descentof the top level of gastric chyme. The acid con-centration is diminished because there is a dimi-nished volume of gastric juice, and there is moremixing as a result of the constant inflow of biliaryand duodenal juices into the gastric remnant. Thejejunum, however, is more susceptible to ulcera-tion. Possibly the unbuffered intercibal secretionsplay an important part in producing jejunal ulcera-tion, which occurs where the acid concentrationis greatest, near the efferent loop, and at the siteof greatest weakness, the jejunal side of the sutureline scar.

Stomal Ulcer following Gastro-JejunostomyIt is well first of all to consider the treatment of

stomal ulcer following gastro-jejunostomy. Plasticoperations on the stoma and local excision of thestoma are of only temporary help. Restoration to

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578 POSTGRADUATE MEDICAL JOURNAL November 1954

the normal by removing the gastro-jejunostomyhas been practised in cases where it was foundthat the duodenal ulcer had healed. In such casesre-ulceration of the duodenum usually occurs.Restoration to normal is only permissible whenthe gastro-jejunostomy is giving mechanical, andnot stomal ulcer troubles, and when it is knownthat the gastric acidity has fallen since the originaloperation. This leaves us with only two orthodoxoperations for anastomotic ulcer, dismantling thestoma followed by partial gastrectomy, or vagusnerve section. As I have indicated before, theresults of the latter operation are not fully knownand no one can yet define its indications or limita-tions. We can, however, state that if there is muchdistortion of the stoma by ulceration, or stenosis ofthe stoma, or stenosis of the jejunum (Figs. 20and 21), the vagotomy should not be used. Itshould not be used if the stomal ulcer is fixed tothe colon, for I have known of a gastro-colicfistula which only became apparent in the con-valescence from vagotomy in such a case. I haveonly used it four times, in patients with X-rayevidence of excellently functioning stomas andminimal scarring, and in these cases the vagotomyhas been successful.

In the more common case where there is de-formity and scarring from a stomal ulcer followinggastro-jejunostomy, or in the rare cases of per-sistent gastric ulcer following gastro-jejunostomy,a partial gastrectomy is the most satisfactoryprocedure.A few technical points may be of interest.

Division and closure of the duodenum is usuallyvery easy because of the inactivity of the ulcer.So far as the anastomosis is concerned, I carefullycut through the line of the previous anastomosisin order to dismantle it. If one cuts exactly in theline of the scar it is almost bloodless. Aftertemporarily suturing the opening in the stomachthe jejunum is repaired. Any ulcer edge isexcised from it and if there is any stenosis, a smalllongitudinal incision is made through the stenoticpart along the bowel. The previously longitudinalopening is closed transversely. It is true that thisleaves a rather ugly looking piece of bowel, but itfunctions perfectly, in fact it is wider than normaljejunum. Resection of the affected jejunumfollowed by end to end jejuno-jejunostomy isneater, it takes a little longer and is particularlyindicated if there is very gross jejunal ulceration,particularly on its mesenteric side, if it is verydeformed, or if its blood supply is precarious.At times an unsuspected fistula into the colon isfound. The colonic opening is closed trans-versely. After repair of the jejunum and colonand closure of the opening in the mesocolon, apartial gastrectomy is carried out, followed by a

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FIG. 20o.-Operative view of grossly dilated afferentjejunal loop due to stenosed stomal ulcer.

fresh gastro-jejunal anastomosis. As gastrectomyfor gastro-jejunal ulcer carries a slightly higherstomal ulceration rate than gastrectomy forduodenal ulcer, it is wise to make a higher re-section in such cases.Now of this type of operation we have carried

out Io6 operations as follows:

GASTRECTOMY AFTER DISMANTLINGGASTRO-JEJUNOSTOMY

Cases Deathsi. Jejunal ulceration:

(a) Interval ..... . 97 I -

(b) For massive haemorrhage .. 2 I2. Gastric ulceration:

Interval ...... 9 0Total:

(a) Interval .. .... I06 I(b) For massive haemorrhage .. 2 I

Stomal Ulcer following GastrectomyGastro-jejunal ulceration following partial gas-

trectomy presents a more difficult problem. Thefirst essential in such cases is to ensure that thereis no technical reason why an ulcer shouldappear. They are as follows:

i. Prepyloric section and failure to remove thepyloric antrum.

2. The presence of a Roux form of anastomosis,short circuit between the loops, or a jejunal inter-position between stomach and duodenum.

3-. Inadequate gastrectomy (e.g., Antrectomy).In the first type of case all that is theoreticallv

necessary is to remove the pyloric segment. In



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November I954 TANNER: Surgery of Peptic Ulceration and. its Complic tions 579

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FIG. 2I.--X-ray of another case of jejunal stenosis due to stomal ulcer. The uppershadow of barium is in the stomach and the lower in the afferent jejunal loop,24 hours after ingestion of the meal.

practice, however, once a stomal ulcer has occurred,recurrent ulceration occurs on minimal stimula-tion, and so it is wise to make a new anastomosis ifthere is gross stomal scarring or ulceration. Inthe second group a Roux anastomosis should beundone and a new loop anastomosis made to takeduodenal juices over the stoma once more. Ajejunal transplant should be removed. If there isa short circuit of the loops the case can be treatedlike a stomal ulcer without a short circuit of theloops. A very low gastrectomy should be remaderemoving at least half, preferably two-thirds of thebody of the stomach.

Stomal Ulcer after Gastrectomy withoutTechnical Faults

Until recently we had no means of dealing withthis condition apart from higher and higherresections, until in some cases almost a totalgastrectomy was made. Plastic operations on scardeformities are useless, they last but little longerthan the patients' convalescence, for they do notaffect the basic tendency to ulceration.

During the last seven years a new method ofdealing with these has arisen, namely vagal re-

section, and to my mind it has entirely altered theoutlook of these unfortunate patients. In order toattain success from this operation two things areadvisable.

i. The vagus must be well seen and all itsbranches identified and resected as previouslydescribed. The operation may be a little moredifficult because of the adhesions and because thenerve becomes more slender and more fragile aftergastrectomy.

2. If there is gross stomal deformity or anactively penetrating or a fixed ulcer, it is helpful toexcise or refashion the stoma. An ulcer scar isalways more prone to re-ulcerate than an operativesuture line, probably because its centre is composedof thin epithelium covering fibrous tissue, it is thusmore rigid and possibly produces less antipepticfactor.

However, many cases have done well withoutfurther resection of the previous anastomosis. Inorder to deal with a damaged stoma, and to con-firm the diagnosis, and because it is generallysatisfactory, I usually use an abdominal approach,but under certain circumstances a transthoracicapproach is advisable-(a) where a previous



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'--;

i. MEOIASTINAL STOMACH 2. INCOMPETENT CARDIA- REFLUX OF JUICES

UP OESOPHAGUSFIG. 22.-(I) Represents a congenital anomaly with gastric mucosa lining the lower oesophagus.(2) Is the commonest cause of reflux of gastric juice into the oesophagus.

incomplete abdominal vagotomy has been done-(b) where there have been multiple operationsand an X-ray shows good stomal function.

Case of C.J., aged 46, who came to me in I950with the following history: I944, Onset dyspepsia;1947, Partial gastrectomy (Military Hospital);I949, Perforation stomal ulcer; I949, Six monthslater-second perforation of stomal ulcer; I949,vagotomy; 1950, three months later--third per-foration of a stomal ulcer.He had no dyspepsia before either perforation

and was on a strict diet. He was very thin, 105lb. only. Now I suspected that the vagotomy maywell have been incomplete, though no data of thetechnique used had been given. An insulin testmeal was carefully done with X-ray control of thesite of the stomach tube. It showed that thevagus was functioning quite normally. ThereforeI decided to repeat the vagotomy. X-ray andgastroscopy showed a good functioning gastro-jejunal stoma. I did not want to re-enter theabdomen as he had had three perforations repairedand a vagotomy within I2 months, and so I dida transthoracic vagotomy. The posterior gastricnerve appeared to have been missed at the previous

operation. A subsequent insulin test meal nowconfirmed that the vagotomy was complete.Three years have now passed since this operation

with no further trouble at all.This demonstrates the great importance of care-

ful technique and confirmation of the result by anequally careful insulin test meal.To sum up our results to date in the treatment

of stomal ulceration following partial gastrectomy.No. of cases .... 20

ProvedRecurrent

Operation No. Deaths UlcerVagotomy only .... x I o oVagotomy and excise ulcer

edge .. .. .. 3 o oVagotomy and remake

stoma .. .. .. 6 I 0Total ...... 20 I

The length of follow-up is in all cases over ayear, two have passed over five years. In myexperience, stomal ulceration after gastrectomyonce having started gives little respite, and so Iregard even a one-year follow-up as significant.Those who have treated this type of case know



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November 1954 TANNER: Surgery of Peptic Ulceration and its Complications

of the unremitting and severe nature of thedisease. I believe that in vagotomy we-have amost valuable and dramatic weapon against it.To those who have failed to get satisfactory resultsI would respectfully suggest that they look to thevagotomy technique and consider the advisabilityof making a new stoma in the cases where theulcer is deeply penetrating or the stoma badlydeformed.

Peptic Oesophagitis and Oesophageal UlcerThis diagnosis is made with ever increasing fre-

quency of late years. There is no doubt thatmuch of the increase is more apparent than real,and is due to more accurate diagnosis, togetherwith increasing awareness of the condition. Weowe much of our present knowledge to Harringtonof the Mayo Clinic, Dunhill and Barrett of London,and to Allison and Johnstone of Leeds. Only tenyears ago, few radiologists made special examina-tions to discover the presence of oesophagealreflux or hiatus herniation, whereas now it isalmost a routine addition to the radiological exa-mination of the stomach and duodenum. Endo-scopists have been made familiar with the typicaloesophagoscopic appearance of peptic oesophagitis,the lax gullet full of digestive secretions, themobile and often patulous cardiac orifice, the con-gested, granular and sometimes ulcerated andstenosed lower oesophagus. However, pepticoesophagitis may, like other forms of peptic ulcera-tion, be changing in frequency and some of theincrease may be real. Evidence at present appearsto show that peptic oesophagitis may be due toeither (Fig. 22):

I. Reflux of peptic juice into the oesophagus asa result of (a) an oesophageal hiatus hernia, (b) anincompetent cardia, (c) a surgical anastomosis ofthe oesophagus to the stomach or surgical damageto the cardia.

2. A congenital anomaly, either (a) the presencein the lower oesophagus of gastric mucosa so thatthe ulcer is really in or at the edge of gastric tissuein an organ which externally resembles oeso-phagus, or (b) a congenitally short oesophaguswith stomach high in the chest. These two condi-tions are basically similar and need similar treat-ment, despite the fact that a gross hiatus herniamay be present in the second form.

It seems that the cause of the disease is pro-longed contact of gastric juice with the oesophagealmucosa. The changes in the oesophagus havebeen very aptly likened to those which occur inthe skin around a gastric fistula. There are, how-ever, many patients with severe oesophageal refluxwho have no oesophagitis and who may not evenhave the most typical symptom, namely heartburn.It may be as in the case of duodenal ulceration,

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FIG. 23.-Simple stricture of lower oesophagus, follow-ing reflux oesophagitis due to hiatus hernia.

that ulceration can be resisted for years until somefactor, perhaps a period of excessive peptic secre-tion, or a period when there is excessive contactof gastric juice with the gullet, or local damage tothe oesophagus occurs which sets off the cycle ofulceration and healing, so typical of ulcer disease.It is notable that some patients date their symp-toms from an operation carried out in the Tren-delenberg position, or associated with much vomit-ing, or they date it from a pregnancy, at whichtime there is at least a temporary period ofincreased oesophageal hiatus strain. McCreath(i953) has pointed out that many women withheartburn, and erratic symptoms of discomfort inthe neck and dorsal regions, globus hystericus,etc., have unjustifiably been considered hystericalwhile in fact suffering from severe oesophagealreflux.The main complications of peptic oesophagitis

are stricture formation (Fig. 23) and anaemia frompersistent bleeding. Acute oesophageal obstructionfrom impaction of a food bolus or fruit stone abovethe narrowed area sometimes occurs, and acuteperforation is a great rarity. Occasionally hiatushernia is associated with a gastric or duodenalulcer. I have found hiatus herniation present in21 of my cases of carcinoma in the cardia region.



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582 POSTGRADUATE MEDICAL JOURNAL November I954

It is possible that reflux oesophagitis predisposesto cancer in this region.

In prophylaxis it is important to avoid gastro-oesophageal anastomosis for cardiospasm or forsimple oesophageal stricture.

Treatment of Peptic OesophagitisI do not propose to say anything about the

medical management.Surgical treatment is at present in a somewhat

confused state, because while we all know a cer-tain cure, namely end-to-end anastomosis of theoseophagus to a Roux loop of jejunum, this is toodrastic for most of the cases and simpler and safermethods are under trial. I will try to give aresume of the methods we have used and of theirresults. The various methods can be divided intofour groups: (i) operations to prevent reflux;(2) operations to reduce the digestive activity ofthe regurgitated juice; (3) resection of the involvedarea of the oesophagus; and (4) by-passing of theaffected oesophagus.

I. Repair of the hiatus hernia. It is probablethat the development of a sliding hiatus herniachanges the mechanism of the cardia, making itincompetent and so is the primary cause of mostcases of reflux oesophagitis and oesophageal ulcer.Repair of the hernia would seem to be the mostlogical step whenever possible. It cannot be doneif the gullet is too short and is fixed by chroniculceration-for in such cases the ulcer may ruptureduring manipulation and the cardia may not reachthe diaphragm. It is, however, remarkable howoften an oesophagus apparently 5 to Io cm.shorter than normal will reach the oesophagealhiatus in the diaphragm without difficulty. Repairof the hiatus is, of course, useless in the cases wherestomach mucosa extends up into the gullet as acongenital anomaly.

Repair of the hiatus hernia demands reduction,and then repair of the two stretched retentivestructures. The first is the phreno-oesophagealligament which normally passes from under thediaphragm to the cardia region and is analogousto the transversalis fascia. The second and mostimportant is the muscular margin of the oeso-phageal hiatus in the diaphragm. The oesophagealopening in the diaphragm becomes somewhatkidney-shaped when herniated because of thepresence posteriorly of the aorta. In the past itwas the custom to repair the hiatus anterior to theoesophagus. This type of repair gained a badreputation for recurrence, for the hiatus was merelymade triangular with a broad base on its aorticaspect, through which recurrence rapidly occurred.Nowadays we find it infinitely more satisfactoryto make a posterior repair, strengthening thehiatus on its aortic side and reducing it to a

narrow anterior opening near the dome of thediaphragm. This renders the course of the oeso-phagus a little shorter, a great advantage. Follow-ing this the phreno-oesophageal ligament is notrepaired, for it is too thinned to repair in suchcases, but it is replaced by a row of unabsorbablesutures between the stomach at the level of thecardia, and the inferior surface of the diaphragm(not merely the peritoneum) around the newoesophageal hiatus.As most of the early inefficient repairs were by

the abdominal approach, this route fell into somedisrepute and many surgeons came to prefer thetransthoracic route. The transthoracic route isadvisable if there is a fixed or penetrating ulcer, ifthere is a suspicion of oesophageal malignancy, orif there has been a previous abdominal repairwhich has failed, and perhaps in exceptionallyobese patients. In all other cases, I much preferan abdominal approach. It has a lower morbidityand mortality rate and it is to be remembered thatmany of the patients requiring surgery for thiscondition are elderly, obese and are poor surgicalrisks. It has been stated that it is not possible toget an adequate view of the hiatus by the abdominalapproach. This is not so if the correct approach isused. A high mid-epigastric incision is made, andthe xiphoid process is removed. The anteriordiaphragmatic fibres are divided. The left tri-angular ligament of the liver is then divided andthe liver pulled over to the right, when withadequate relaxation and correct manipulation, agood view of the region of the hiatus is usuallyobtained. If it is not obtained then it is possibleto improve the view by division of the sternumthrough its middle, up to and into the fourthintercostal spaces. I have used this addition formany conditions, though as a matter of fact havenot yet found it necessary in dealing with a hiatushernia.The stomach and other contents of the hernial

sac are now reduced into the abdomen. Aftermaking an incision through the peritoneum andligament in front of the oesophagus, a rubberretractor, such as I use for vagotomy is passedthrough the lesser sac and over the gastric fundusto control the stomach. The hernial sac is with-drawn from the posterior mediastinum-it may bemainly anterior or mainly posterior to the oeso-phagus. The peritoneal sac with its coat ofstretched phreno-oesophageal ligament is cut awayand discarded. The stretched crurae of the dia-phragm can now be exposed and cleared of allfatty and peritoneal tissue. A stitch is placed inthe anterior extremity of the margin of the oeso-phageal hiatus as a tractor. Sutures of non-absorbable material are now carefully placedthrough large bites of each crus of the diaphragm



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NVovenmber I954 TANNER: Surgery of Peptic Ulceration and its Complications 583

'ii :::···L :.iii.::::· ... ....i ...iiiiii:·:ii::ii:~iii;........... ...::·

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I'1G. 24.-Abdominal repair of oesophageal hiatus hernia. There is a traction suture on the anteriorpart of the hiatal edge. Sutures have been placed between the margins of the hiatus, posterior tothe oesophagus. The right crus is clearly seen.

to draw them together behind the oesophagus(Fig. 24), from the aorta upwards and forwardsuntil the oesophagus is snugly surrounded. It isimportant to have no shreds of fat or other tissuebetween the crurae when they are sutured together.The material I use at present is floss nylon. Theoesophagus is now fed into the mediastinum untilthe cardiac orifice lies just below the diaphragm.It is unwise to leave a great length of gullet insidethe abdomen, for this will alter the importantoesophago-gastric angle of entry-the importanceof which has been shown by Barrett. Next, non-absorbable, fairly deep sutures are placed betweenthe cardia region and fascia below the diaphragmround the new oesophageal hiatus. The liver isreplaced and the wound closed.

The Results of the Abdominal Repair of aHiatus Hernia

Repairs posterior to the oesophagus by theabdominal route have been made in 64 cases,one-third being aged over 6o. All have beentraced, and of 35 operated on between one andfour years ago, the present state is as follows:

POSTERIOR REPAIR OF HIATUS HERNIA, ABDOMINALROUTE, I TO 4 YEARS, POST-OPERATION

No. Per cent.Satisfactory .. .. .. .. 23 65.7Improved .. .. .. .. 7 20.0I.S.Q........... 5 I4.3The reports on the X-rays of 25 patients done

over a year ago are interesting when comparedwith the clinical state. It should be noted thata higher proportion of patients with a poor resulthave an X-ray examination.

ClinicallySatis- Im-

X-ray Report factory proved I.S.Q.No hiatus hernia, no reflux 2Hiatus hernia, no reflux .. 2 3Hiatus hernia and reflux .. I 2 3Reflux but no hiatus hernia I - I

This shows that there is a tendency for theX-ray and clinical results to coincide roughly, andit is noticeable that all cases without reflux orrecurrent hernia on X-ray also had satisfactoryresults.

Simple phrenic division sometimes relieves



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584 POSTGRADUATE MIEDICAI, JOURNAI, Nozenilber 1954

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FIc. 25.-' Jower partial gastrectomy' (Polya opera-tion) for stenosing peptic oesophagitis. Case \I..A-July 20, 1949, before operation. B--February22, 1951, I8 months after operation. C-April 5,I95I. D--February 2, 1954. Symptoms nowslight.



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November 954 TANNER: Surgery of Peptic Ulceration and its Complications 5A5

.. ... :: .:::.l

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peptic oesophagitis. A-Pre-operative X-ray ofbarium swallow. B-The specimen with only ashort segment of ulcerated oesophagus. C-Post-operative barium swallow. Note the absence of anypost-vagotomy delay at the pylorus, which has beentreated by pylorotomy.



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some symptoms of hiatus hernia. The leftphrenic is divided despite the fact that most of thefibres round the oesophagus are supplied by theright phrenic nerve. Its effect is not to relaxthe oesophageal ring, but probably rather byelevation of the left diaphragm to lessen the intra-abdominal pressure and to raise the pressure in themediastinum so that the hernial contents remainmore readily in the abdomen under the diaphragm.It will not cure reflux and is inadequate foroesophageal ulcer. We used it in four senilefragile cases with reflux and discomfort fromincarceration of the fundus in the thorax and alldeclare themselves improved.

2. Reduction of the volume and digestivepowers of the regurgitated peptic juices. In 1949,Wangensteen advocated lower partial gastrectomy-as for duodenal ulcer-in the treatment ofstenosing peptic oesophagitis. It would be a veryuseful method if satisfactory, particularly as not afew of the cases also have duodenal ulceration.In a series of five cases of peptic oesophagitis dealtwith in this way, three are satisfactory and two areimproved (Fig. 25 a, b, c and d). The progressappears to be steady but fairly definite. Partialgastrectomy was used in four other cases ofassociated duodenal ulcer and hiatus hernia withsome reflux oesophagitis, and all have done well.

3. Resection of the Oesophagus and UpperStomach. If simple resection of the stricturedpart of the oesophagus is carried out, the refluxwill continue more freely than ever and despite thevagal section, oesophagitis will recur. Theminimum of resection must be of the stricture anda good proportion of the body of the stomach,preferably uniting the gullet to the pyloric part ofthe stomach (Fig. 26 a, b and c). This is asatisfactory procedure on the whole. In view ofthe vagotomy it will add to the patient's comfortif a gastro-jejunostomy or pylorotomy is added.(Tanner I95I.) The oesophagus in such cases isusually fibrotic just above the stricture and holdssutures much better than in carcinoma cases.The morality of this operation is less than thatof resection for carcinoma.

4. Oesophago-jejunal Anastomosis. The mostcertain way of curing oesophagitis is by transectingthe oesophagus and uniting it to a mobilized Rouxloop of jejunum in the thorax. Resection of thestrictured part of the gullet is advisable to preventcontinued action of gastric juice on it, but totalgastrectomy need not necessarily be carried out.

In the post-operative cases, and in the caseswith true congenital shortening of the gullet (a veryrare anomaly) and in cases in which gastric mucosareplaces the lower oesophagus-the only satis-factory treatment is by resection of the loweroesophagus, uniting the oesophagus either to the

pyloric part of the stomach or to the jejunum.These operations have not the mortality and neednot be so extensive as the cancer operations-andthey are often easier to carry out.

Case of L.B. An Italian female had cardio-spasm dating from her teens. At the age of 24,an oesophago-gastric anastomosis was made inPadua in 1949. Following this the swallowingbecame perfect, but she began to suffer from severeretrosternal pain radiating into the back, and acidregurgitations.On oesophagoscopy, the lower dilated oeso-

phagus was seen to be filled with gastric juice andthere was ulceration at 38 cm. Medical treatmentgave no relief and so in October i95 I, an abdominalBillroth I partial gastrectomy was carried out tolower the gastric acidity. Relief from this wasincomplete and subsequent oesphagoscopy stillshowed a congested bleeding lower oesophagus.Therefore, in January 1952, the lower oesophaguswas exposed and removed by a transthoracicroute, and the end of the oesophagus connected toa mobilized Roux loop of jejunum. Eighteenmonths after this, she had only minor troubles.

Results of TreatmentI am giving, of course, an interim report. I hope

to be more certain of the relative efficiency of thevarious procedures in five years' time, but a reviewat the present time is valuable.

Perforation of Peptic UlcerAll of us present at this lecture tonight have been

brought up to believe that early surgical closureis the best treatment for acute perforation of apeptic ulcer. We know how it has greatly reducedthe mortality of perforated ulcer compared withthe days before Heusner first successfully closed agastric ulcer perforation in I 892. We havelearned that avoidance of delay in effecting closureis the most important single factor in reducing themortality. Latterly, we have found the mortalityof this complication drop to a new low level withgreater care in pre-operative preparation of thepatient, with better anaesthesia and with theintroduction of the antibiotics. For many yearspast, an occasional patient has been treated withsuccess by conservative measures because he wasto ill or arrived too late for surgery, or because thediagnosis was missed, or surgery was unavailable.Occasional cases have also been treated by immedi-ate gastric resection because of associated massiveulcer haemorrhage, or because the ulcer wasmalignant, and I think that at times we have beenagreeably surprised to find how well they did.Nevertheless, with simple suture giving everimproving results, it has required some temerityfor the advocates of routine conservative treatment



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November 1954 TANNER: Surgery of Peptic Ulceration and its Complications 587

of perforation on the one hand, or of routinegastrectomy on the other hand, to try to demon-strate the good points of these methods.

Conservative Treatment of Acute UlcerPerforationNow as far as conservative treatment is con-

cerned, it has been shown that this will succeedin what Mr. Hermon Taylor (Taylor, H., I951)described as one of its objects, namely to avoidthose complications which are associated with theoperation for perforated ulcer, e.g. wound infection,disruption or hernia, anaesthetic and pulmonarycomplications and post-operative adhesions. Addedto this it has been shown that in the hands ofdevoted clinicians a low mortality comparable withthat obtained by simple suture may be obtained.Nevertheless the method has not been universallyadopted, partly because it has not lowered themortality of perforation and partly because of thegreat demands on the nursing and medical attend-ants for prolonged and anxious observation. Thereis also always the possibility of a disastrous mis-diagnosis of the cause of the acute abdominalcatastrophe. My present opinion is that themethod is unsuitable for routine usage. There isno doubt, however, that we owe a great debt tothe pioneer work of those surgeons who haveimproved the technique of the conservative, or asHermon Taylor calls it, the' aspiration treatment 'of ulcer perforation. By their work they will havesaved many lives among those patients with acuteulcer perforation, for whom either by reason ofunfitness for anaesthesia or by geographical situa-tion, surgery is inadvisable or unavailable.

Immediate Gastrectomy for UlcerPerforation

In 195I in the Macarthur lectures, I remarked(Tanner, I95I): ' So far as urgent gastrectomy isconcerned... Many figures have been presentedshowing that resection can be done with a lowmortality. So far, however, and I have lookedcarefully to find them, no figures have appeared toshow that the over-all mortality of all cases ad-mitted with perforation of peptic ulcer has beenlowered or even kept level by performing gastrec-tomy on some of them.... I long to see somestraightforward and unbiased figures on this sub-ject, because it is worthy of trial.' Since thattime, we have had no proof that immediategastrectomy will lower the over-all mortality ofulcer perforation, and indeed when such low mor-talities for simple suture as those achieved byAvery Jones and his colleagues at the CentralMiddlesex Hospital are put forward, it is obviouslygoing to be very difficult to better them. Never-theless, in view of the fact that some 6 per cent.

of perforated apparently simple gastric ulcers turnout to be malignant, and because of the increasedpost-operative complication rate for perforatedgastric ulcer, we have, since I950, carried outimmediate gastrectomy in the treatment of per-foration of large pre-pyloric or mid gastric ulcers,in addition to what might be called the orthodoxgroup, namely sealed off perforations with onlylocalized peritonitis, concomitant haemorrhage andperforation and perforated gastric carcinoma. Ithas since been shown, notably by Professor A. G. R.Lowdon when he was at Edinburgh, that immediategastrectomy in expert hands does not appear tolead to a higher mortality than simple suture ofperforation (Lowdon, I952).

J. Gilmour (Gilmour, 1953) in a recent reviewof his cases confirmed the increased mortality ofperforation with increasing age and with delay insurgical intervention, but he also made two othersignificant observations. The first was that themortality chiefly affected the patients with chronicpeptic ulcer. The second was that in a latefollow-up of cases of ulcer perforation treated bysimple suture, one-quarter of the acute ulcer per-forations had severe relapses of symptoms, andthree-quarters remained well, but of 65 chroniculcer perforations all had relapsed, two-thirdsrequiring further operative treatment. This in-dicated that unless immediate gastrectomy couldoffer a significantly lowered mortality from perfor-tion it was wiser to continue with simple suturein acute ulcer cases. In the case of chronic ulcer,however, immediate gastrectomy would have muchin its favour in view of the poor late prognosis.

After careful weighing-up of these points wedecided at St. James' Hospital, London, in MayI953, to undertake immediate partial gastrectomyunder the following conditions.

i. In general the patient should be between theages of 30 and 6o. Exceptions to this might bethe patient under 30 with symptoms dating backover many years, and the patient over 6o inexcellent general condition.

2. Length of history: (a) Gastric ulcers-Resectall which fall into the above age qualification, pro-vided the patient is considered fit enough;(b) Duodenal ulcers-Resect when a patient underthe age of 45 has a history of at least one yearand a patient over 45 with over six months'dyspeptic symptoms. Resect in all cases wherethere is evidence of bleeding, either past or present.Resect in all cases where there is evidence ofpyloric stenosis.

3. The general condition of the patient willnaturally influence the decision as to treatmentby resection, simple suture or intravenous dripand gastric suction.



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POSTGRADUATE MEDTCAL JOURNAL 'November 1954

4. Perforated stomal ulcer-Simple suture inall cases.

5. Perforated gastric carcinoma-Resect if oper-able and the patient fit enough, otherwise simplesuture combined, if thought advisable, with appro-priate palliative procedure.The period under review, six months, is too

short to make a significant effect on our over-allmortality. Our clinical impression is that con-trary at least to my own expectations, the over-allmortality is diminished. A clinical impression isalways more reliable when supported by hardmortality figures. I give our figures for the fouryears since October I949. The over-all surgicalmortality is 8.6 per cent. but including the i8 casestoo ill for surgery it is 14.5 per cent. The onedeath following gastrectomy was a patient who diedof coronary thrombosis three weeks after a gas-trectomy for concomitant haemorrhage andperforation.

PERFORATED PEPTIC ULCER-IMMEDIATE RESULTSNo.of Operation Mortality

Cases Deaths Per cent.Simple suture, P.D.U. 133 10 7.5Simple suture, P.G.U. 20 4 20.0Simple suture, P.G.J.U. 5 I 20.0Emergency gastrectomy:P.D.U. ..... 25 I 4.0P.G.U. 2.. ..

Total (Surgical) .. i85 i6 8.6No operation ..1.. I8 3 72.0

Total (all cases) .. 203 29 14.5

However, perhaps one of the most significantoccurrences concerns the very remarkable im-provement following urgent gastrectomy in twopatients with late perforations and frank pus in theperitoneal cavity. The second case meritsrecounting.

A.B., aged 63, an obese bronchitic man with oldrheumatic heart disease and a long ulcer historywas admitted in poor condition 24 hours afterperforation. His systolic blood pressure wasaround 60 mm. Hg. but after i 1 hours resuscita-tion he was recovered enough for surgery. Hiswas a type of case in which simple suprapubicdrainage of the peritoneal cavity might have beenconsidered the optimum treatment by many.However, a severe perforation of a vast stenosingposterior penetrating duodenal ulcer was dis-covered. In view of the extreme difficulty ofclosure of the perforation, my colleague, Mr.Andrew Desmond, carried out a partial gas-trectomy. His condition the next day wasconsiderably better and he has continued to makean excellent recovery.

It should be added that about a third of these

gastrectomies for acute perforation have beencarried out by surgical registrars, though of coursenot until they have had very good experience ofupper abdominal surgery, and they have unusualopportunities of gaining experience of this workat St. James' Hospital. I need hardly add thatin view of the very favourable progress of ourcases, we are in favour of continuing the presentpolicy of resection of at least the chronic ulcers inthe treatment of ulcer perforation.Massive Gastro-Duodenal Bleeding as aResult ofPeptic Ulceration

I pointed out in my first lecture that Sir GordonGordon-Taylor in his 1945 Lettsomian Lectureshad enunciated the principles of selection of casesfor surgical treatment and had discussed the resultsof surgery. I can add but little on these aspectsand so instead will give some of our up to dateresults in the treatment of this complication.Some of you may know that at St. James'

Hospital, we have since i94i tried to stabilize ourmedical management of massive gastro-duodenalbleeding, but have from time to time after carefulconsideration, varied our indications for surgeryarnd then finally reviewed the results obtainedduring the different periods (Tanner, I949).By the end of I949 we found that our best resultswere obtained by early and fairly frequent surgery-to be exact, surgical intervention in 6o per cent.of the cases. It occurred to us that the improvementmight be in part due to advances in chemotherapyand increases in the numbers of our senior staffsince the war. Therefore in i95o and I95I wereverted to ' selective surgical intervention'using surgery in only i 9 per cent. of the cases.By this term we mean that certain criteria which areknown to indicate a dangerous form of bleedingare also indications for early surgery. In I952and I953, we have reverted again to a modifiedform of the Finsterer (Finsterer, 1947) regime.By the Finsterer regime, we mean roughly that if apatient is admitted with massive gastro-duodenalbleeding and has a history of chronic pepticulceration, he is operated on at once. Finstererargues that such early surgery carries little morerisk than interval surgery, and the patient withchronic ulceration needs an operation anyhow.If, on the other hand, the patient has only a briefhistory or no history of ulceration, he is treatedconservatively, but if bleeding is repeated orcontinues, exploratory operation is at once-undertaken.

By' Finsterer over 45 ' we mean much the sameas the Finsterer r6gime, except that in view of theextremely low mortality in cases of haematemesisunder 45, we only operate under that age if thehaematemesis is repeated in the hospital, even



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November I954 TANNER: Surgery of Peptic- Ulceration and its Complications 589

s_ _HAEMATEMESIS a MORTALITY RATE 19+1 -195519 1 1942 19+3 944t 195 1946 1941 1948 1949 19s0 "51 1952 1955

rLVI@ KOItWAN WAtBLEEDING

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FIG. 27.-Graph showing the varying numbers of cases of haematemesis and melaena admitted to St. James' Hospital,month by month.

though the patient may have a chronic ulcerhistory.

Before proceeding to our results it is well tosee the type of case we treat, because it will at oncebe seen that we deal with a high percentage ofgastric ulcers-the type in which surgery is mostoften required.CASES OF MASSIVE HAEMATEMESIS AND MELAENA,

I941-53Gastric Ulcer .. .. .. .. 649Duodenal Ulcer .. .. .. 478Gastro-jejunal Ulcer .. .... 63Oesophageal U. .. .. .. 8Gastritis .. .. .. .. .. 97Hiatus hernia ...... I8Portal hypertension ...... 41Carcinoma of stomach .. .. 45Carcinoma of oesophagus .. .. ISimple gastric neoplasm .. .. 9Gastric diverticulum .. .. .. IAneurysm aorta .. .. .. IPancreatitis .. .. .. .. 2Carcinoma of pancreas .. .. 3Uraemia ... . .. .. ISwallowed foreign body .. .. IRetrograde intussusception .. .. IUncertain .. .. .. 71

1,490

In addition, it will be seen that many of thepatients are elderly and this is another factor tobear in mind when considering our results. Inour last two year series 55 per cent. of the caseswere aged over 6o years of age, 27 per cent. over70 and 5 per cent. over 80. The influence of ageon mortality can also be seen. In our last seriesthe mortality of massive ulcer haemorrhage underthe age of 70 was 3.6 per cent. but over the age of70 it was 25 per cent.

It is interesting to see the effect of externalcircumstances on the incidence of ulcer bleeding-and so I have made a graph of the varying numbersof cases of haematemesis admitted to St. James'Hospital, month by month (Fig. 27). You willnotice in particular the abrupt rise at the time ofthe commencement of the ' fly-bomb' attacks onLondon during the war. The sudden drop whichfollows is associated with a temporary evacuationof many wards when the hospital was damagedand the increased evacuation from London laterno doubt also had some effect. There is also aninteresting peak in December, 1952.

I would now like to show you the present stateof our long term results in varying our indicationsfor surgery from time to time. We usually



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590 POSTGRADUATE MEDICAL JOURNAL November I954

GASTRO-DUODENAI. HAEMORRHAGE, 1941-53Peptic Ulcer and Gastritis Groups

(Incidents of Bleeding)No. of Aged over Operated Over-all Average age

Period Cases 60 on mortality at deathPer cent. Per cent. Per cent.

I. i941-1943. Operations avoided until late .. . 93 33 5 10 62II. December 1943-December 1947. Selective interven-

tion .. .. .. .. . . 372 34 12 12 64III. January I948-December I949. ' Finsterer' .. 215 43 59 7-5 65IV. January I95o-December 195 I. Selective interven-

tion .. .. .. .. .. .. . 274 46 19 Io 70V. January I952-December I953. ' Finsterer over 45' 266 55 30 9.5 69

change-if we think a change worthy of trial, atthe end of December after a two year period.Comments on ResultsWhat do these figures show? First of all, it is

evident that our patients with gastro-duodenalbleeding are of increasing age year by year. Inparticular you will notice the jump in average ageof patients treated from 34 per cent. aged over 6oto 43 per cent. between periods two and three.I have pointed out the remarkable increase inmortality found with increasing years, no matterwhether you take 50, 60, 70 or 8o as the dividingline. Indeed, we have not lost one patient under40 in the last I,ooo ulcer and gastritis cases, andthe one we had aged 40 was a man who steadfastlyrefused surgery until he became unconscious.Therefore I regard the improvement betweenGroups II and III as very significant, bearing inmind both the increased age of the patients andthe lowered mortality.Some of this improvement may have been due

to the ending of the war and to the increasingavailability of penicillin. It was not due to in-creased availability of blood-which we had inadequate supply. It was not due to improvedanaesthesia, for we have stabilized that variablefactor by using local anaesthesia throughout thewhole period.

Reversion to selective surgical intervention inI950 increased the over-all mortality slightly,though there was still a creep-up in average age.A return to 'Finsterer over 45 ' has slightlydiminished our mortality, but this group containsa very high number of octogenarians and youwill see that the average age of the patients hasrisen abruptly and 55 per cent. are aged over 6o.Therefore I again regard the reversion to morefrequent surgery as a significant improvement inour results.No doubt our better results obtained when we

greatly widen the indications for surgery are inpart due to the advanced ages of the patients-theoldest series, I believe, ever recorded. It is alsobound up with the fact that a high percentage of

the bleeding ulcers are gastric-a type carrying ahigher mortality, and in which surgery is par-ticularly advisable.

Diagnosis of the Cause of BleedingA knowledge of the cause of bleeding is of the

greatest value in deciding whether to operate on aparticular case. It will be seen from my table ofall the causes of bleeding, that in over 50 per cent.of the cases, the cause lies in the stomach. There-fore in all cases in which immediate surgery is notconsidered necessary, and indeed in some casesprior to immediate surgery, a gastroscopic exa-mination is made within one to three days ofadmission to hospital. In addition to good viewsof the stomach being obtained in most cases, ifair is gently blown into the gullet during extractionof the instrument, excellent views of any oeso-phageal varices may be obtained, and at times ahiatus hernia can be diagnosed. It is not, ofcourse, a reliable instrument in diagnosing oeso-phagitis because a little bleeding will obscure theview, and'only small areas are seen. If an ulcer ispresent in the stomach, its position, size and depthand chronicity can often be judged. The ulcermay still be oozing, or the crater may be filled withclot. Often the sealed vessel end can be seen.On one occasion we saw an aneurysm in an ulcercrater ballooning up with each heart beat, but thiswas a case which had not yet bled. Furthermore,if an atrophic gastritis is seen, we know we canexclude duodenal ulceration as a cause of thebleeding. In a number of the cases where thecausative lesion is not evident, an atrophic gas-tritis is found. At operation-which we alwaysconduct under local anaesthesia, the cause of thebleeding is usually evident. It is not uncommonto find that the ulcer is small and shallow andcontaining a vessel end almost as big as the ulcercrater. Similar cases have been described as casesof rupture of atheromatous gastric vessels, but Ibelieve they are in reality gastric ulcers which havealmost healed but there is failure of epithelializa-tion over the sclerotic vessel-which acts almostlike a foreign body in preventing healing. In



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November I954 TANNER: Surgery of Peptic Ulceration and its Complications 59

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FIG. 28.--Progress of aneurysm in duodenal ulcer crater to a fatal termination, despiterapid healing of ulcer after partial gastrectomy in which the duodenum and antralmuscularis were preserved. There is a probe through the rupture in the aneurysm.

such cases the most careful examination of thestomach and duodenum must be made, not onlywith the fingers but with the eyes. Sometimesonly the bristle-like vessel end or a little localrigidity in the wall can be felt, or a fine local scaror blush with local glandular enlargement can beseen. The upper part of the posterior wall of thestomach must be examined with especial care.

If an ulcer is discovered a partial gastrectomyshould be carried out. Local resections are oftenas time consuming and as difficult as a gastrectomy--it is difficult to excise the whole edge, and laterecurrence is always a likely possibility. I haveused sleeve resection only once and found twoulcers. Care must be taken in cases of multipleulceration that the highest ulcer is removed.At times, but in my experience extremely rarely

-the ulcer cannot be found despite the most carefulsearch, and a presumptive diagnosis of gastriticbleeding is made. In such cases, provided thebleeding had been truly massive, then a partialgastrectomy followed by gastro-jejunal reconstruc-tion should bc done. At times a small ulcer will

be found in the specimen, or several small erosions.Even if some of the gastritic erosions remain in thefundus the bleeding will lessen because of thediminished blood supply to the fundus consequenton the gastrectomy. I have never found it neces-sary to do a total gastrectomy for a non-malignantbleeding gastric lesion.Not infrequently it will be found at operation

that bleeding from the ulcer is temporarilyarrested. The problem arises as to whether insuch an eventuality it is safe to leave a hazardous-looking duodenal ulcer in the hope that, cut offfrom the gastric chyme, bleeding would not recurand the ulcer would rapidly heal. Now I believethat this is a reasonable procedure to follow inmost cases, though I was unfortunate on the onlyoccasion that I followed it.H. T., aged 60, was admitted to St. James'

Hospital from a mental hospital, having hadrecurrent haematemesis and melaena for fourteendays. He had schizophrenia, a large bed-sore,and had attempted suicide. We operated becausebleeding was repeated after transfer to us. A



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huge posterior penetrating duodenal ulcer in-volving the region of the bile ducts was found.The prepyloric region was opened and it wasfound that clear bile and no fresh blood came backfrom the duodenum, and so presumably thebleeding had ceased. After removing the antralmucosa, the sero-muscularis of the antrum wasclosed, and a partial gastrectomy performed.Following this he improved day by day, but onthe eighth day, massive melaena recurred. I feltthat the ulcer could hardly be active after thisspace of time and so we treated him conservativelythereafter. He died of repeated bleeding abouta week later.At autopsy, the ulcer indeed was found to have

practically healed (Fig. 28), the small unhealedpart being entirely occupied by a ruptured aneu-rysm, the rupture of which had no doubt led tothe repeated bleeding.Another conservative method for bleeding pos-

terior duodenal ulcer favoured at times and whichwe used for a period, was duodenotomy, arrest ofbleeding by suture together of the ulcer edges-followed by gastro-jejunostomy. I used this oneight occasions, but in two patients, the bleedingrecurred and one died of it. I do not use thismethod now.

After recounting my experiences with the variousregimes in the treatment of ulcer haemorrhage,you will see that I am inclined to favour surgery.That does not mean that I am advocating surgery

universally. There is a considerable variation inthe type of case treated in different places, and ourpreponderance of elderly gastric ulcer cases makessurgery particularly suitable. It is not withoutsignificance that we have such a volume of workthat we are able to keep in practice for theseoperations.

I have gone over a very wide field and so have,perhaps, only been able to give an over-all im-pression of our present practices in dealing withpeptic ulcer and its complications.

BIBLIOGRAPHYBRAIN, R. H. F., and STAMMERS, F. A. R. (I95I), Lancet, i, I 137,CAPPER, W. M., and BUTLER, T. J. (I95I), Brit. med. J., ii, 265.FINSTERER, H. (I947), Wien, med. Wschr., 97, 3.GILMOUR, J. (I953), Lancet, i, 870.GORDON-TAYLOR, G. (I945), Trans. med. Soc. Lond., 64, I97.LOWDON, A. G. R. (1952), Lancet, i, 1270.McCREATH, N. D. (I953), Personal communications.MIMPRISS, T. W., and BURT, St. J. M. C. (1948), Brit. med. J.,

ii, Io095.MORONEY, J. (I95I), Lancet, i, 993.POLLARD, H. M., BOLT, R. J., RANSOM, H' K., and ORE-

BAUGH, J. E. (1952), J. Amer. med. Ass., I50, I476.QUINN, W. F., and GIFFORD, J. H. (195o), California Med.,

72, 18.SHANKS, S. C. (I952), Trans. med. Soc. Lond., 67, 136.SWYNNERTON, B. F., and TANNER, N. C. (1953), Brit. med. J.,

ii, 841.TANNER, N. C. (I949), Ibid., i, I 0.TANNER, N. C. (19SI), Langenbeck's Arch. u. Deutsch Z. Chir.,

267, 369.TANNER, N. C. (I95I), Edin. med. J., 58, 288.TANNER, N. C. (1952), Ann. Roy. Coll. Surg., 10, 45.TAYLOR, H. (I95I), Lancet, i, 7.WANGENSTEEN, O. H. (1949), Surg. Gynec. and Obstet., 88, 56o.

Refercnces continued from page 576-Simo:z Behrman, B.Sc.(Hon.)Lond., M.R.CP.,Lond.17. FETTERMAN, G. H., and MORAN, J. J. (194I), Arch.

Path., 32, 251.I8. CORDAY, E., ROTHENBERG, S. F., and PUTNAM,

TRACY J. (I953), Arch. Neurol. Psych., 69, 55I.I9. WOLF., H. G., and LENNOX, W. G. (1930), Ibid., 23, I097-20. WOLF, H. G. (1936), Physiol. Rev., x6, 545.21. BEHRMAN, SIMON (I95I), Arch. Ophthal., 45, 458.22. WALSH, F. B., and KING, A. B. (1942), Ibid., 27, I.23. ASKENAZY (1952), Folia Psych., 55, 55.24. Personal Case.25. STROBOS, R. R. J., and MOUNT, L. A. (1953), Arch,

Neurol. Psych., 69, i I8.26. SWEET, W. H., and BENNETT, H. S. (5948), 7. Neurosurg., 5,

178.

27. DENNY-BROWN, D. E. (I95I), M. Clin. Nth Amer., 35,I457.

Z8. DUNNING, H. S. (1953), Arch. Neurol. Psych., 70, 53I.29. HYLAND, H. H. (Case 3) (I933), Ibid., 30, 342.30. KING, A. B., and LANGWORTHY, O. R. (Case I), (I941),

Ibid., 46, 835.3I. DUTAILLIS, P. (I949), Rev. Neur., 8I, 997.32. SHAPIRO, R. (Case I) (1952), Radiol., 58, 94.33. LE BEAU, M. J. (I949), Rev. Neur., 8I, Ioz9.34. ABBOTT, K., quoted by HAMBY, W. B. (1952), 'Intra-

cranial Aneurysms,' Thomas, Springfield, U.S.A.35. SKILLICORN, S. A., and AIRD, R. B. (1954), Arch. Neurol.

Psych., 71, 367.36. CHAO, W. H., KWAN, S. T., LYMAN, R. S., and LOUCKS,

H. H. (1938), Arch. Surg., 37, Ioo.



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