A. W., aged 28 years, was admitted nine years ago with symptoms of duodenal ulcer. Appendicectomy was performed and medical treatment instituted. Two years later he was admitted with perforated duodenal ulcer; the perforation was closed by operation. Nine months later still he was admitted with pyloric obstruction, and a posterior gastrojejunostomy was performed.
On June 4, 1931, he was admitted with perforated jejunal ulcer. The gastrojejunostomy was undone, the stomach and transverse mesocolon were repaired, and the portion of the jejunum containing the ulcer was excised, so that the original anatomy was restored. The pylorus was examined, and, though evidently contracted, it was hoped that it might prove adequate, as the patient had had enough.
He did well for three weeks after this operation, but then began t o vomit, at first a little, but gradually increasing until no food was retained. On July 28, the patient being very ill, the abdomen was again opened and an anterior gastrojejunostomy was performed as rapidly as possible.
The patient made an uneventful recovery from the last operation, and remained well until fourteen days before his readmission on Oct. 2, 1932. He was vomiting and had a tender lump in the abdomen, 2 in. above the umbilicus and under the left rectus. This was correctly diagnosed t o be a jejunal ulcer and he was put on Hurst's ulcer diet, under which treatment he improved considerably. It was decided to remove a large portion of his stomach in the hope of producing a permanent achlorhydria to prevent the formation of further ulcers.
At operation on Oct. 11 the jejunal ulcer was found perforated into the anterior abdominal wall and there attached. The ulcer was detached and the gastrojejunostomy was undone. This part of the operation was made difficult and tedious by adhesions. The damaged jejunum was resected. The hole in the anterior wall of the stomach was not repaired, but a partial gastrectomy of the P6lya type was proceeded with-the pylorus was found to be completely occluded. The portion of the jejunum used for the anastomosis was just distal to the resected portion and it was brought up anterior to the transverse colon. A gastric ulcer on the lesser curve, hitherto unsuspected, was found in the portion of stomach removed.