1039 PEPTIC ULCERATION IN SOUTHERN NIGERIA PETER G. KONSTAM, F.R.C.S.E. SENIOR LECTURER IN
SURGERY, UNIVERSITY COLLEGE, IBADAN, NIGERIA
DUODENAL ulceration in the African has received little
attention ; in spite of the reports published by Aitken (1933) and Ellis (1948) it has often been ignored, or its
incidence has been denied. I review here 20 consecutive cases of proved peptic ulcer which came under my care in nine months in 1953-54 at Adeoyo Hospital, Ibadan.
Ibadan, a town of nearly 500,000 people, is situated among hills in the deciduous forest zone of the Western Region of Nigeria. The mean rainfall is 483 in., mean minimal temperature is 705°F, and mean maximal temperature 88-5°F. A large proportion of the inhabi. tants go out to work on small farms ; there is much trading but, apart from a tobacco factory, no industry. Clinical Picture and
Ellis
Pathology
full study of the incidence, clinical picture, and pathology of peptic ulcer at Lagos. The ulcers seen at- Ibadan, Abeokuta, and Ijebu districts are of the same nature. Personal communications from Benin, Port Harcourt, and Enugu reveal the presence of the disease in these districts also. Thus peptic ulceration is prevalent in both the Western and the Eastern Regions of Southern Nigeria. The sex-distribution was 15. males to 5 females. The numbers are too small to allow any conclusions to be drawn. All patients were Africans, unemancipated in customs and eating-habits, and the large majority were poor. Long intervals between meals have been incriminated ; but this does not apply to the women, who partake of frequent meals in the market places. The history was usually long. The initial stages of the disease had often been treated elsewhere. Ages ranged from 13 to 65. The very young appeared by no means immune. The signs and symptoms are exactly what would be duodenal ulcer at various expected from a stages of cicatrisation. The diagnosis was often easily made on clinical grounds. In the usual long-standing cases there were splash, visible peristalsis, dehydration, and emaciation-all of them sometimes extreme. Alcohol test-meals, given to all the patients and to an equal number of controls, showed an unquestionably significant tendency to more free acid in the patients. A low-acidity fasting juice (less than 20) could not be taken as evidence for or against an ulcer. A higher acidity (more than 40) made it more likely that an ulcer was present. Hippuric-acid liver-function tests showed no deviation from the normal. Plasma-protein levels were also normal, the albumin/globulin ratio often being reversed, as is common in Africans. No gastric ulcer was found in this series. Ellis (1948) writes that the ulcer is situated on the anterior duodenal wall. He practised gastrojejunostomy almost without mortality. It is, however, impossible to ascertain the site of the West African ulcer by inspection or palpation alone ; a most extensive fibrous-tissue reaction often covers the entire first part of the duodenum. Only by exploring the duodenum as in gastrectomy can the site be determined. The ulcer is, in fact, predominantly a posterior-wall lesion, for which reason free anterior perforations are rare. It is tempting to speculate on the nature of the fibrous-tissue reaction. There has been no opportunity so far to investigate the state of
(1948) made
a
’
long-standing
the adrenals in these cases. The phenomenon may even be related to endomyocardial fibrosis. There have been 6 liver biopsies, which showed changes commonly seen in various conditions in Nigeria, ; but their specific relationship to peptic ulcer could not be determined. There were 2 cases of associated carcinoma of the antrum. Treatment Medical treatment offers little prospect of a lasting cure. As regards the hazards of gastrojejunostomy, those with much experience of our problem are emphatic that jejunal ulcer does not readily develop in Southern Nigeria. Admittedly. Nigeria is a statisticians’ nightmare where " follow-ups " are difficult to achieve. However, no case has been seen so far at Adeoyo. Those patients with a high degree of stasis offer no problem. In them operation becomes urgent and must be simple. Here the results of gastrojejunostomy are dramatic. It is the less urgent case that presents the problem. Neither test-meal nor clinical signs, and not even operative findings, reveal whether the crater is The stomach may be enormous, active or extinguished. yet there may be inflammatory oedema around, or recent filmy adhesions at the site of, the ulcer. It is because of the theoretical possibility that stomal ulcer may develop after gastrojejunostomy that partial gastrectomy has been my treatment of choice. There have been 13 partial gastrectomies, 6 gastrojejunostomies, and 1 closure of a late anterior perforation, with 3 deaths.
Pathogenesis : Role of Diet be discounted as a cause of Nigerian Smoking duodenal ulcer. The simple people affected smoke, if at all, in moderation. " Hot " spices also are to be discounted ; peppers are eaten all over Nigeria and India. And ulcer patients respond to medical treatment even when the consumption of condiments is allowed to go on (T. H. Somervell, personal communication). The present concept of the psychosomatic aspect of peptic ulceration also cannot be applied ; our patients have their ration of anxiety, but there is no " hurlyburly of modern existence," and life goes on in the villages much as it did centuries ago. The Northern Hausas, who do not readily develop ulcer, are stolid fellows, securely anchored to their Koran, but the Southern bush farmers, who do so also are quiet and placid. One is compelled to look for other causes. I believe that the peptic ulcer of Nigeria and that of Southern India may be closely related. If this is so, the common denominator may be found in geographic and dietary peculiarities. In Nigeria, as in India, duodenal ulcer has a geographical distribution. An inquiry made by correspondence and by a journey to the North of Nigeria has elicited the fact that peptic ulceration is common in the Southern regions of rain and deciduous forest but not in the Northern semi-arid plains. The staple diet of the South is cassava and yam (Nicol 1952), but that of the North two forms of millet (McCulloch 1929, 1930). By courtesy of Dr. E. A. Beet, of Kano City Hospital, I saw 2 patients with proved duodenal ulcer in that institution. They were both Ibos from the South adhering to their own yam and cassava diet ; but I came across no cases among the indigenous population in that large Northern hospital. The diet of the unemancipated Southern Nigerian is deficient in proteins, but the food of the Hausas and Town Fulanis of the North is also poor in them (McCulloch 1929,1930). All parts of Nigeria seem to share the shortage of high-class protein except the areas where fish is abundant. As regards accessory food factors, however, there are essential differences between the two parts of the country. can
1040 Nicol (1949, 1952) studied the diets in the Northern of Bida and in the Southern district of Warri. In Warri he found the daily intake of thiamine to be 0-69 mg. compared with 3.20 mg. in Bida-12 mg. is considered to be the daily requirement for tropical man by the National Research Council, Food and Nutrition
province
Board (1948). I visited several villages round Ibadan and found the same figures as Nicol did for Warri. Since thiamine is concerned with carbohydrate metabolism, the requirement for it varies with the intake of carbohydrate. The yam and cassava diet is unbalanced in favour of carbohydrate. The diet is very bulky, and a vicious circle is presumably set up once the ulcer begins to interfere with the function of the pylorus and prohibits ingestion of the required large amounts. The imbalance may become even more pronounced through the almost invariable presence of hookworms and roundworms in the intestines. Chance and Dirnhuber (cited by Nicol 1952) believe that these parasites absorb large quantities of B-complex vitamins. Hookworm occurs all over Nigeria, but the large ascaris thrives mainly in the humid South. As regards the other vitamins, there is a deficiency of riboflavine in all parts of Nigeria ; there is an adequate supply of nicotinic acid and of ascorbic acid ; and vitamin A, as carotene, is freely available in the South, where palm-oil is consumed widely. In discussing diet and peptic ulcer it may be permissible to draw attention to the situation in India. If we substitute the yam and cassava diet for rice and tapioca (cassava), the position in Southern India closely resembles that of Southern Nigeria. A warm humidity is one of the special features of Southern India’s climate. Peptic ulcer is 58 times more common in the South than in the North, and is predominantly duodenal (Dogra 1940). As regards social status, the main feature is the poverty of those affected. There is a distinct difference in diet between the peoples of the South and of the North (Orr and Rao 1939). The diet of large areas of North India consists of whole-meal flour, milk, and milk products. In Southern India the staple diet is rice, and, in Travancore, rice and
tapioca. Tropical peptic ulcer, unlike its European counterpart, seems to develop where specific diets are consumed. It is not my opinion that the Southern Nigerian variety is due to a gross deficiency in thiamine (neuritic lesions are uncommon). But there is an uneasy balance, and intake of minimal requirement may merge into subminimal intake through local or personal conditioning factors. This concept is supported by experiments on animals (Drummond et al. 1938) in which ulcers were produced by feeding subminimal doses of vitamin B1 for long
periods. It is possible, though unlikely, that the Nigerian lesion can be ascribed to a single component. Further study is essential to determine specific food factors and dietary patterns which may be responsible for this common, crippling, and dangerous ailment.
G. H. Drew, A. J. M. Stevenson, M. L. Catell, G. W. Moore, S. M. Studzienski, J. Gatt, and R. Jelliffe, of the Nigerian Medical Service, for valuable information. REFERENCES
Aitken, A. B. (1933) W. Afr. med. J. 6, 63. Dogra, J. R. (1940) Indian J. med. Res. 28, 145, 481. Drummond, J. C., Baker, A. Z., Wright, M. D., Marrian, Singer, E. M. (1938) J. Hyg., Camb. 38, 356. Ellis, M. (1948) Brit. J. Surg. 36, 60. McCulloch, W. E. (1929) W. Afr. med. J. 3, 8, 36. (1930) Ibid, 3, 62.
P.
M.,
-
Research Council. Food and Nutrition Board (1948) Survey of Food and Nutrition Research in the United States,
National
1947.
Nicol, B. M. (1949) Brit. J. Nutr. 3, 25. (1952) Ibid, 6, 34. Orr, I. M., Rao, M. V. R. (1939) Indian J. med. Res. 27, 159. -
TREATMENT OF TETANUS WITH AND
CURARISATION, GENERAL ANÆSTHESIA, INTRATRACHEAL POSITIVE-PRESSURE VENTILATION
H. C. A. LASSEN M.D. Copenhagen PROFESSOR OF EPIDEMIOLOGY IN THE UNIVERSITY OF COPENHAGEN
MOGENS BJØRNEBOE M.D.
BJØRN IBSEN Copenhagen
M.D.
Copenhagen
CHIEF
PHYSICIAN, MEDICAL DEPARTMENT, BLEGDAM HOSPITAL, COPENHAGEN
CHIEF ANÆSTHETIST, KOMMUNEHOSPITALET,
COPENHAGEN
FRITS NEUKIRCH M.D.
Copenhagen
PHYSICIAN, BLEGDAM HOSPITAL, COPENHAGEN From the Blegdam Hospital, Copenhagen
DEPUTY CHIEF
_
DURING the poliomyelitis epidemic in Copenhagen in 1952 we learned that tracheotomy and positive-pressure ventilation can be life-saving in many cases of brain. stem poliomyelitis, especially the " wet " cases with accumulation of secretions in the airway. Naturally we felt that this treatment should be applicable to severe cases of tetanus in which complete curarisation is the only means of preventing convulsions. The literature shows that it has in fact been used with success (Abate and Profazio 1953, Bjorneboe et al. 1953, Helsingen and Kristensen 1953, 1954, Saint et al. 1953, Shackleton 1954), but only in a few cases. Because this treatment presents many difficulties, it may be worth reporting in detail a small series of cases of tetanus treated along these lines in the past year. Case 1, which has previously been published (Bjorneboe et al. 1953), was remarkable for the fact that the patient, a boy aged 10 years, was kept under general anaesthesia (nitrous oxide and oxygen) for seventeen days. This duration of general anaesthesia is the longest of which we are aware. As this case has been published only in Danish, it is included here (case 1).
Case-reports
Summary
Peptic ulcer is common in Africans in Southern Nigeria, the North being relatively free. The lesion is typically a posterior duodenal ulcer surrounded by a wide area of fibrosis, and occurs in both of the poorer classes. Gastric ulcer is rare.
sexes
Evidence is presented that diet plays an important role in the pathogenesis of duodenal ulcer both in Southern Nigeria and in Southern India. Prof. B. M. Joly for her generous encouragement ; Prof. A. Brown and Dr. J. Lauckner for referring cases ; the late Dr. W. Silvera for reporting on sections ; Miss 1. E. Florence for the biochemical reports ; and Drs. B. M. Nicol, R. G. A. Savage, N. M. B. Dean, D. McLaren, I
am
grateful to
FIRST CASE
admitted on May 9, 1953. Six days boy, aged 10, previously he had scratched his left knee, and had been treated in a surgical emergency station, where, owing to some misunderstanding about earlier immunisation against tetanus, he received only an injection of tetanus toxoid. Five days later he complained of stiffness of the neck and back. When first seen in the hospital he had trismus, incipient risus sardonicus, rigidity of the legs, and stiffness of the neck and back. His general condition was fair and temperature normal. A
was
Treatment and Progress The wound was excised, and Clostridium tetani was cultured from the tissue. Tetanus antitoxin 15,000 i.u. was given intravenously and 5000 i.u. around the wound. Treatment with penicillin was also started. In the next two daysthe boy’s temperature rose and his condition worsened in spite of