Abortion
I have found from prolonged observation that, as in typhoid, constipated patients with haematemesis or melaena rarely die, and most clinicians now feel that an emergency operation should be offered to some of the patients in whom severe haemorrhage recurs after admission to hospital.
Abstract
Without knowing what happened to the other patients with bleeding peptic ulcers in Newcastle-upon-Tyne, it is difficult to accept Ogilvie and Spencer's mortality figures at their face value. On the larger issue, haemorrhage from peptic ulcers ceased some time ago to be solely the preoccupation of physicians, and now even the most conservative recognize that surgery has a place in the treatment of that emergency. Few will be found to subscribe to the idea that all, or even the majority of, cases of such haemorrhage should be operated on as a matter of course, and the balance of present-day opinion inclines to the view that there is a definite, though not very large, percentage of cases in whom operation would be a lifesaving measure. Most clinicians now feel that an emergency operation should be offered to some of the patients in whom severe haemorrhage recurs after admission to hospital. Obviously a number of such patients will not be fit for operation for a variety of reasons, while others , may refuse surgical aid, and the crux of the matter is to balance in the remainder the probability of death without and with operation. The problem would be easy if only there were a way of divining whether bleeding comes from an opening in a sizeable a'rtery, often eroded tangentially in the floor of a chronic ulcer, because it is then that an imminent threat to life exists. Few will disagree that in such instances an operation, preferably a partial gastrectomy, should be performed. In the various series of cases of haematemesis and melaena recorded I have yet to find a reference to the type of patient who is admitted-sometimes shocked, sometimes in a fair condition-who in spite of recognized treatment continues to lose ground in a rather insidious way. The blood count of such patients goes on dropping to a level far below that for which haemodilution would account; frequently they do not vomit or pass melaena stools, and one must assume that in them continued seepage of blood into the bowel is taking place. I am sure others will recognize in that description a large group of cases whose place is between those who go all one way and give rise to little anxiety and, at the other extreme, those in whom a sharp recurrent haemorrhage gives clear warning of impending disaster. The patients in this middle grotp often benefit from blood transfusion, and with experienced management they will rarely need an operation. This letter is not the place for giving an account of the routine treatment of haemorrhage from peptic ulcers adopted in the hospital at which I work-this has been done already by Baker in his report-but one of the points I insist on in my patients is the avoidance of any aperients or enemata in the first week after admission, or even longer if melaena continues. I have found from prolonged observation that, as in typhoid, constipated patients with haematemesis or melaena rarely die. I feel that injudicious stimulation of the bowel in a precariously balanced patient may start bleeding again. It is true that an occasional subject has to pay for my view with faecal impaction, but, while this may give rise to considerable discomfort, it can be relatively easily relieved and does not endanger life. Finally, those charged with the care of patients suffering from haematemesis and melaena will agree with the views expressed in your leading article (p. 153) that there is a real need for further clinical studies of this serious and all too commonplace problem.-I am, etc.,