RUPTURE OF THE STOMACH COMPLICATING GASTRIC HÆMORRHAGE

485 The use of larger doses of ferrous sulphate-e.g., up to 2 g. of ferrous sulphate, or 720 mg. of elemental iron, daily, as recommended by Whitby and Britton (1953)-dates from the time when iron by mouth was the only practical means, apart from transfusion, of treating hypochromic anaemia. However, since the introduction (Nissim 1947, Slack and Wilkinson 1950) of a stable and relatively non-toxic intravenous preparation, and with the subsequent development of a reliable intramuscular preparation of iron, the treatment of cases resistant to oral iron has few difficulties either in hospital or in general practice. It seems that smaller doses of ferrous sulphate with a smaller incidence of intolerant patients should be effective. The relatively small proportion of patients who are intolerant to. these smaller doses should then be tried on one or other of the organic iron preparations ; and if they are still intolerant of them parenteral therapy should be substituted. Although the lower incidence of intolerance in patients receiving these organic iron preparations is an advantage, nevertheless the variations in cost and the greater expense of many of these preparations make their routine prescription at present a matter for thought. It is therefore of interest to consider this aspect of cost. Our chief pharmacist, Mr. J. B. Lloyd, has kindly worked out for us the approximate cost of these preparations, when prescribed on E.c.l0, at the current rates. From our figures given above, the treatment of patients with iron-deficiency hypochromic anaemia with 210 mg. of elemental iron daily for 30 days costs with ferrous sulphate 2s. 6d., with ferrous gluconate 7s. 6d., and with ferrous succinate 11s. 6d. Since there is practically no difference in the efficacy of these three preparations given in equivalent dosage, it is clear that some further readjustment in cost will be necessary to justify the use of the two latter preparations, except in very few cases. There is little doubt that, because of their relatively non-irritating properties, however, they do represent an alternative in the therapeutics of hypochromic anaemia.

Summary A therapeutic trial was made of four commonly used oral iron preparations-ferric hydroxide, ferrous sulphate, ferrous succinate, and ferrous gluconate-in doses of 210 mg. of elemental iron given daily to eighty patients. Ferric hydroxide in the small daily dose given was unsatisfactory, but the three other preparations produced almost equal and satisfactory haematological responses. Patients refractory to one oral preparation were refractory to all but responded to parenteral iron. Intolerance was observed after ferrous sulphate in 13%, and after ferrous succinate and gluconate in 4% of patients. Ferrous sulphate is effective in smaller doses (210 mg. daily) than are in general use at present. The relative costs of treating hypochromic anaemias with these ferrous salts in equivalent dosage are compared. Ferrous sulphate is much cheaper than the others and equally efficacious. It maintains its position as a

satisfactory therapeutic agent. REFERENCES

Benstead, N., Theobald, G. W. (1952) Brit. med. J. i, 407. Bland, P. (1832) Rev. méd. franç. étrang. 1, 357. Brendstrup, P. (1948) Ugeskr. Laeg. 110, 945. Conway, H., Meikle, R. W. (1953) Brit. med. J. ii, 1019. Fowler, W. M., Barer, A. P. (1937) Arch. intern. Med. 59, 561. Gatenby, P. B. B., Lillie, E. W. (1955) Lancet, i, 740. Gillhespy, R. O. (1955) Med. Illus. 9, 147. Baler, D. (1952) Brit. med. J. ii, 1241. (1953) Med. Pr. March 11, p. 234. Lancet (1954) ii, 954. Moore, C. V. (1955) Amer. J. clin. Nutr. 3, 3. Nissim, J. A. (1947) Lancet, ii, 49. Reznikoff, P. (1940) Amer. med. Ass. 114, 2213. Slack, H. G. B., Wilkinson, J. F. (1949) Lancet, i, 11. Whitby, L. E. H., Britton, C. J. C. (1953) Disorders of the Blood. 7th ed., London ; p. 227. -

RUPTURE OF THE STOMACH COMPLICATING GASTRIC HÆMORRHAGE D. E. BOLT M.B. Brist., F.R.C.S. SURGICAL REGISTRAR

W. B. HENNESSY M.B.

Sydney, M.R.C.P.

HOUSE-PHYSICIAN

WEST MIDDLESEX HOSPITAL, ISLEWORTH

number of cases of spontaneous of the has been reported. Majone (1948) stomach rupture collected 64 cases, but none of these was associated with intragastric haemorrhage. In most recorded cases the rupture has been due to gross gaseous distension, often though not always following an excessive meal (Hillemand et al. 1947, Leger and Maës 1947, Chipail et al. 1948, Ladkin and Davies 1948). In none of the cases reported has any local lesion been found which would account for the actual tear or slit in the stomach wall ; but in some there was associated disease elsewhere in the stomach or duodenum. A

CONSIDERABLE

Rejthar (1952) reported spontaneous rupture of the stomach in a woman of 67, who survived. She had pyloric stenosis due to a chronic gastric ulcer, and had had persistent almost unproductive vomiting for two days. At operation there was a 1-inch slit near the cardia fairly close to the lesser curvature.

Greene and Gose (1953) reported perforation of the stomach in a 13-day-old male infant who had associated atresia of the duodenum. ’

So far

as we are

aware,

of the stomach complihas not hitherto been

rupture

cating gastric haemorrhage described.

Case-records Case 1.—Mrs. A, aged 56, was admitted to hospital on Dec. 8, 1954, with a history of anorexia, occasional vomiting, and loss of weight for a year and of pain in the back for a month. For three weeks she had been in bed because of extreme weakness, and for three days she had had melaena. Apart from pallor, there were no abnormal physical signs, and her haemoglobin was 6-9 g. per 100 ml. (47%). After blood-transfusion (3 pints) she continued to pass tarry stools. On Dec. 14 transfusion was resumed and laparotomy with probable gastrectomy was decided upon.

When the patient was being moved to the theatre she suddenly

collapsed and had a considerable haematemesis-her first. Operation was postponed and transfusion continued. At this time she complained of mild abdominal pain, and gradually increasing abdominal distension was noted. When a total of 7 pints of blood had been given laparotomy was undertaken. Under a bilateral intercostal and splanchnic block the abdomen was opened through an upper midline incision. The peritoneal cavity contained much liquid and clotted blood (some dark, some bright red). Exploration

a large rent in the anterior wall of the stomach, through which a very large posterior gastric ulcer could be felt. Despite continued transfusion the patient’s general state did not permit any further surgical procedure and the abdomen was closed. She died shortly after return to the

showed

ward. At necropsy, thirty-six hours after death, the rent in the stomach was found to be quite separate from the ulcer. It measured 11/2 X 21/2 in. and was situated in the anterior wall a little to the left of the incisura and rather nearer the greater than the lesser curvature. There was a very large, simple posterior gastric ulcer, measuring 1 X P/2 in., its base being formed by the body of the pancreas with erosion of the

splenic artery.

Case 2.-Mrs. B, a widow, aged 74, was admitted to on Dec. 19, 1954, following a small haematemesis and the passage of several tarry stools in the preceding twentyfour hours. A gastric ulcer had been treated medically ten years previously and she had since had slight bouts of epigastric discomfort at long intervals. For three weeks before admission she had suffered from persistent epigastric pain.

hospital

486 She was rather frail and moderately pale. Her bloodpressure was 130/75 mm. Hg and her hsemoglobin 9-1 g. per 100 ml. (61%). Early on Dec. 20 her condition suddenly deteriorated, and over the next twelve hours she was given 3 pints of blood. There was temporary improvement, but on Dec. 21 she again collapsed, the blood-pressure being unrecordable. In the next four hours she received 5 pints of blood, but her condition never improved enough to allow laparotomy. Her abdomen gradually became very distended and she began violent retching in an effort to empty her stomach. At 3.35 P.M. on Dec. 21 she vomited 2 oz. of bright red blood, and at 4.0 P.M. she had a sudden massive haematemesis and died.

The torn mucosa in case 2

Necropsy was carried out eighteen hours after death. The stomach was grossly distended by red blood-clot. There were three shallow non-indurated oval ulcers near the lesser curve, one of which showed a prominent bleeding-point in the base. A series of tears was noted in the mucosa of the cardia,

roughly parallel figure).

and

converging

on

the

cesophagus (see

Comment

In many of the cases in the literature, the rupture was a linear split, close to the cardia, and commonly this has been associated with several further tears in the adjacent mucosa, resembling those seen in case 2. In both the cases we have described there was massive gastric haemorrhage, and at necropsy large quantities of blood-clot were still present in the stomach. As both patients had vomited repeatedly, it seems probable that the gastric rupture (case 1) and mucosal splitting (case 2) were induced by violent muscle contraction endeavouring to expel this clot. Possibly, indeed, this complication is attributable in part to liberal blood-transfusion, since without rapid replacement of blood a patient would hardly survive loss of a quantity of blood sufficient to precipitate rupture of the stomach. The risk of rupture is increased by gastric distension ; and in cases of haematemesis where massive transfusion is undertaken, a special watch should be kept for clinical ,evidence of such distension, which, if it develops, must be regarded as a further urgent indication for surgical intervention. Our thanks are due to Dr. N. F. Coghill, Dr. R. P. K. Coe, and Mr. W. J. Ferguson for permission to publish these cases, and to Dr. A. C. Counsell for his help in elucidating the

UNILATERAL DIGITAL-ARTERY THROMBOSIS AN INDUSTRIAL ACCIDENT

STEWART H. HARRISON F.R.C.S.E., L.D.S. CONSULTANT PLASTIC

PLASTIC

SURGERY

SURGEON,

AND

THE

MOUNT VERNON CENTRE FOR

WINDSOR

GROUP

OF

HOSPITALS

THROMBOSIS of a digital artery from direct pressure, incurred by occupation, is either very rare or often goes unrecognised, for I have found no specific instance on record. It is an industrial accident, and in view of its medicolegal implications I should be interested to hear of other cases. A man aged 53 was given the job of binding with plastic material half an inch wide. This material had to be stretched by hand and drawn taut during the process of tacking, and in this procedure the patient used the radial side of his left ring finger as the maximum pressure point or fulcrum. For 11 days, working 9 hours a day, there were no unusual symptoms ; but on the 12th day he had severe pain in the finger radiating proximally, and noticed that the finger-tip had become white with loss of sensation. These symptoms were precipitated by cold and minor trauma, until it became necessary for him to discontinue working. Shortly after his initial symptoms he noticed a small lump on his finger which was tender on pressure. He was referred to the hand clinic at the Industrial Health Centre in Slough. A small nodule was palpable under the skin on the radial side of the left ring finger in the line of the neurovascular bundle, and opposite the terminal interphalangeal joint. Pressure on this nodule caused pain which radiated proximally. Sensation was normal and there were no colour changes in the finger. There was no evidence of local injury and the hand appeared otherwise normal. The diagnosis of glomus tumour was made. A month after-his first symptoms, the skin of the flexor surface of the finger was turned back as a flap and the radial digital artery was exposed. It was found to have a hypertrophied lumen over a distance of 1-5 cm. with a thrombus in the centre segment (see figure). The involved area was excised and it was observed that the digital nerve was normal. After this operation his symptoms disappeared.

That

a digital artery subjected to pressure, over a will thrombose is interesting ; but that this period, thrombosis will give rise to radiating pain and reflex spasm of the opposite artery, sufficient to produce a Raynaud’s type of syndrome, induces speculation on the nerve-supply of digital arteries and the neurovascular

linkage in the finger. The hypertrophied lumen of the artery implies a degree of intermittent trauma preceding the actual thrombosis, and this might cause spasm and temporary occlusion from cold, proceeding to complete occlusion of the vessel a thrombus due to intimal damage. The symptoms strongly suggest neurovascular dysfunction of either local or proximal origin. The presence in the finger of a small tumour which was painful on pressure, and the localisation of the symptoms to one finger, would exclude a cause arising proximally, such as Raynaud’s disease or vascular occlusion. Of the local causes, both the glomus tumour and partial division of a digital nerve could give rise to these symptoms ; but there was no evidence of local injury to suggest that the nerve had been directly damaged. At no time, before operation, was the digital artery regarded as the only structure responsible for these symptoms.

with

pathology. REFERENCES

Chipail, G. G., Wassermann, L. Lazarovici, I. (1948) Arch. Mal. App. dig. 37, 479. Greene, W. W., Gose, D. F. (1953) Amer. J. Dis. Child. 85, 47. Hillemand, P., Leger, L., Renault (1947) Bull. Soc. méd. Hôp. Paris, 63, 607. Ladkin, R. G., Davies, J. N. P. (1948) Brit. med. J. i, 644. Leger, L., Maes, J. (1947) J. Chir., Paris, 63, 35. Majone, P. (1948) Rif. med. 62, 126. Rejthar, R. (1952) Brit. med. J. ii, 324.

The

portion of the digital artery removed, showing central thrombus.

the