DUODENAL ULCER.
The general indications are mainly the same as in ulcer of stomach— rest and milk feeding; but it is not clear that spoon-feeding is so desirable. Larger amounts of milk with cream may be given every couple of hours, and a large dose of alkali, as in Sippv's method, should be administered every hour or two till the gastric acidity is neutralised and kept at a low standard. Antilytic Serum (fresh normal horse serum) administered by the mouth has an almost specific action, and it should always be tried for the relief of hiemorrhage whilst awaiting operative procedures.
Four operations, according to Moynihan, are available: i. After opening the abdomen the ulcer is searched for, and if found to be very small and situated upon the anterior surface of the duodenum it may be simply excised. This is done by making two horizontal in cisions, including a narrow elliptical piece of the duodenal wall con taining the ulcer; the lips of the wound thus formed are forcibly retracted so as to convert the horizontal aperture into a vertical slit, in which position it is then sutured. A modification of this operation consists in prolonging the extremity of each end of the horizontal incision so as to reach the stomach and extend towards the second part of the duodenum, after which the large wound is to be dealt with as in Finney's operation.
2. The duodenum may be resected with or without the pyloric portion of the stomach.
3. Resection and end-to-side anastomosis, the pylorus being left intact, following Bland-Sutton's method.
4. Gastro-enterostomy.—This is the procedure suitable in the very great majority of all cases of simple duodenal ulcer. The posterior no-loop operation, with a vertical application of the jejunum to the stomach, gives the most satisfactory results; the steps of the operation are described under Gastric Dilatation. A. B. Mitchell has shown the necessity of partially occluding the duodenal route by a free infolding of the ulcer, and Moynihan adopts this procedure as a necessary routine in all cases. After all suturing has been completed and dressings applied the patient is placed on his back in bed for a couple of hours, when he should be well propped up and permitted to swallow a small quantity of water, and Moynihan allows a cup of tea after a few hours, to he repeated 3 or 4 times during the first 24 hours. Solid food, fish, sweetbread and bread and butter may be permitted in 8 or ro days, and ordinary diet at the end of the third week.
Moynihan, in his brilliant classic on " Duodenal Ulcer," gives the details of almost 200 cases upon which he has operated, and states that his mortality up to the end of 19°9 was p6 per cent. for his entire series; there was no death amongst his last I2I cases operated upon.