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A Few Days Later, When Operating on a Man for a Patients. in Three of Them I 391 The cut edges of the duodenum and stomach are gastro-jejunostomy for the relief of chronic duodenal sutured in the manner of an end-to-end anastomosis. ulcer with an unobstructed pylorus would soon be I always use thin sterilised silk for this purpose and abandoned. for ligatures. It is tedious and unnecessary to Experience proves that posterior gastro-jeju- describe in detail the methods available for sewing nostomy with an obstructed pylorus is a beneficent the cut end of the duodenum to the hole in the operation, in spite of the risk the patient runs of stomach. It is like stitching a sleeve in a shirt; getting a new ulcer for an old one. The new ulcer the clever sempstress varies her methods according has been evolved in this generation by alterations to the material and the size of the garment. So in the environment of the jejunum brought about with the In a case of extensive resection by surgery. surgeon. ______________ (Fig. 3) the line of suture in the stomach was 6 inches across. Not wishing to imperil the safety .of such a long line of suturing by joining the TRENCH NEPHRITIS.1 I the cut of the duodenum to it, implanted margins BY W. LANGDON BROWN, M.D. CANTAB., into a fresh in the duodenum opening posterior F.R.C.P. wall of the stomach. In of the careful LOND., spite ligature ASSISTANT PHYSICIAN, ST. BARTHOLOMEW’S HOSPITAL; PHYSICIAN, of vessels there is usually some post-operative METROPOLITAN HOSPITAL ; CAPTAIN, R.A.M.C. (T.F.) oozing from the tissues in the wound area, and it is wise to drain for 48 hours. The abdominal IN May last the Medical Research Committee, at wound is closed with through-and-through sutures, the request of the Director-General of the Army fascia into with inter- the being brought apposition Medical Services, made arrangements for a number mediate sutures of thin silk. of cases of trench nephritis to be investigated in The first I submitted to for patient pylorectomy wards under my care at the St. Bartholomew’s duodenal ulcer was a woman, aged 35, at the Hospital Section of the lst London (City of London) Middlesex in 1909. Hospital Gastro-jejunostomy General Hospital. More than 100 cases have been had been three months but performed previously, under my care, but of these only 58 were specially the pain remained unrelieved. I excised the investigated. pylorus and the segment of the duodenum contain- It is difficult to choose a name for the condi- ing the ulcer. She made a quick and uneventful tion which shall not beg the question of its I have since lost of this " recovery. sight patient. origin. "Epidemic nephritis" assumes what I A few when on a man for a days later, operating am trying to prove. " Trench nephritis " is not duodenal I found the conditions so favourable ulcer, strictly accurate, since I have had cases among for pylorectomy that I excised the pylorus and orderlies from base hospitals, and others who have the bulbus duodeni with the ulcer. Six years not been in the trenches. Still, the condition later I re-examined him with the help of X rays cannot be said to be prevalent outside the trenches, and an opaque meal, and found the gastric efflux so the name will serve. satisfactory. Acute nephritis is not a common disease in civil I have excised the pylorus for chronic duodenal practice; it is not possible to give exact figures, ulcer to the method described in 2Q according since it is not a notifiable disease, but Sir Wilmot patients. In three of them I had previously per- Herringham found that at St. Bartholomew’s formed In one the gastro-jejunostomy. symptoms Hospital, with an average number of 7000 medical returned three months after the gastro-jejunostomy, admissions a year, only 166 cases of acute nephritis, in another and in a third two One six years, years. 120 being males, were admitted during nine years. the sixteenth in the died. He was a patient, series, I found that in a period of five years only 26 cases man from Dr. Essex aged 38, transferred Wynter’s occurred here in men of military age. ward to mine with typical symptoms of chronic Now whereas typhoid and dysentery have in the an ulcer was duodenal ulcer. At the operation past dogged most campaigns, acute nephritis, as found close to the pylorus on the anterior wall of a rule, has not. I have not been able to find that a duodeni. I from well-marked bulbus departed it was prevalent in the Franco-Prussian War, the my usual method and sewed the cut edges of the Chino-Japanese War, the Soudan War, the Hispano- The man made mucous membrane with catgut. American War, or the Russo-Japanese War. It was fifth when his tem- :good progress until the day, certainly rare in the South African War. Thus, the perature rose to 103° F. ; he died on the nineteenth late Dr. Washbourn reported that " acute nephritis The suture line had day after the operation. was singularly infrequent." At Deelfontein there in two I attribute this unfavour- sloughed spots. were only 6 cases of acute nephritis. Dr. Tooth able result to the use of catgut. reported that at the Portland Hospital they only SUMMARY. saw 3 cases, and in these the kidney lesion was Since the treatment of duodenal ulcer passed almost certainly not acquired during the campaign. into the province of surgery it has become the Personally, I did not see a single case in South routine practice to perform gastro-jejunostomy for Africa. its relief in the hope that by diverting the chyme On the other hand, there was a very considerable through the new stoma into the jejunum the ulcer outbreak of the disease in the American Civil War. will heal. If the pylorus is obstructed by the ulcer I have drawn up a curve (see figure) by adding the results are usually good, because the chyme together the cases classified as general dropsy, must pass through the new stoma; but when the Bright’s disease, and inflammation of the kidney. pylorus is patent the chyme flows through it This is necessary, as the diagnosis of Bright’s and in some instances ignores the new route. The disease, which was not made till September, 1862, efflux can be watched with the help of an opaque gradually replaced that of general dropsy, which meal and X rays. I believe it is better whenever was discontinued in December, 1863. The curve practicable to excise the pylorus with the ulcerated will therefore include cases of chronic nephritis, but portion of the duodenum and rejoin the stomach this would not affect the extraordinary rise which and duodenum on the of an end-to-end principle 1 Being an introduction to a discussion held by the Medical and anastomosis. If this method could be made safe Therapeutical Sections of the Royal Society of Medicine on Feb. 15th. 392 I ..... I ......i Curve showing incidence of nephritis per 1000 troops during first part of American Civil War among the Northern Armies. The armies of the Central Region were attacked earlier and more severely by the disease. Black continuous line = central region. Dotted line = rest of army. took place between March, 1862, and March, 1863. imagine that theory died a natural death as the The case-incidence per 1000 troops rose earlier in summer came on and the number of cases increased. the armies of the Central Region and reached a Still as I am not sure that exposure has been given higher level than that for the rest of the army. up as the cause, I will add the following arguments. In subsequent years there was no similar rise, but a When I was in Bloemfontein during the South small secondary one during the warmer months of African War I saw the mirage between 2 and 4 P.M., 1864. In the Central Region the incidence reached while by 6.30 the ground was covered with hoar- 1’5 per 1000. Throughout the war there were 14,187 frost. There could hardly have been such a violent cases (see table). It is of great interest to recall fluctuation of temperature as this in Flanders; that in the American Civil War the military condi- yet, as I have already said, nephritis was rare in tions resembled those of the present war in some the South African War. In the Russo-Japanese important particulars. There was the sudden dash War during the month of February, 1905, the ther- of the Confederates northwards, which was checkedi mometer showed great differences between the and followed by prolonged trench warfare. minimum and maximum readings, such as from 14° to 83° F. and from 26° to 75°. Yet I do not read Cases in American Civil War in Northern Armies. of Nephritis that there was an outbreak of Periods. Cases. Deaths. nephritis. Again; Average strength. look at the incidence in the American Civil War. May-June, 1861 ...... 42,500 ... 27... 0 How can a climatic cause account for an outbreak July-June, 1861-62 ...... 279,000 ... 1,790 ... 45 which started in March and lasted for a whole " " 1862-63 ...... 614,000 ... 6,603 ... 148 but was not in the ... ... which " z 1863-64 ...... 619,700 2,677 81 year, repeated subsequent " ., 1864-65...... 574,000 ... 2,744 ... 77 years of the war ?? However, I made careful ... 346 ... 9 " 1865-66...... 101,800 inquiry as to exposure in the 58 cases which were the subject of special investigation ; in 20 cases the - Totals , ......
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