Subtotal Gastrectomy with Ulcer Exclusion in the Treatment of Chronic Peptic Ulcer

The so-called peptic ulcer occurs in the stomach, the duodenum and the jejunum, when the latter is brought within the range of the acid gastric juice by the performance of a gastrojejunostomy. It is occasionally seen also at various points throughout the small intestine and in the lower oesophagus. The occurrence, however, of these ectopic ulcers is of little more than academic interest, and the ulcers which concern us most are those situated in the first part of the duodenum and the stomach. As it now seems certain that the chronicity of the classical peptic ulcer is due, in the main, to the action of acid so it would really be more logical to refer to it as an acid ulcer ?a suggestion made long ago by Moynihan. It is exceedingly common in South India and Probably constitutes our commonest major abdominal surgical condition. The ulceration is predominantly duodenal, affecting the first Part of the duodenum in 94 per cent of cases. approximate!}' 4 per cent of cases both duodenal and gastric ulcers occur. The re|ative rarity of pure gastric ulceration is really remarkable and it is seen in not more than 2 per cent of cases in the Madura hospital. While it is almost universally held that the treatment of such ulceration is Primarily medical, particularly in the case duodenal ulcers, in India, apart from the question of chronicity alone, the treatment is Nearly always justifiably surgical. Economic factors and the impossibility of inducing the Patient to exist on a suitable ' ulcer' diet for a^y length of time force us to treat practically all these patients, who come mainly from the ryot and coolie classes, by surgical means. . The chronic duodenal ulcer, as seen in India, ls Usually large when seen at operation, and is remarkable not only for the degree of inflammatory thickening in its walls but also for its Readiness to adhere to neighbouring structures. Respite the size of the ulcer, the absence of stenosis in many cases, as indicated by the size and appearance of the stomach, and the ability t? invaginate a finger through the pylorus and duodenum is no less remarkable. The removal such an ulcer would be a formidable procedure under any circumstances, and in the absence of such aids to recovery as repeated or continuous blood transfusions, it is often surgically impossible. It is more common to find a Sastric ulcer in association with a duodenal ulcer, than to find one alone. When, however, it is seen alone, it is often very large and penetrating the pancreas and even the root of the /mesocolon. In some of the cases, it is so large