Peptic ulcer of the oesophagus.

The patient with peptic ulceration of the lower oesophagus has for a long time suffered his ulcer in a sort of " no-man's-land " to which the abdominal surgeon could not reach and to which the physician had no access. The radiologist passed it by as quickly as the force of swallowing would take him. The endoscopist saw it as through a glass darkly on the distant boundary of his territory, but was glad to withdraw to more familiar fields. The development of a safe surgical approach to the cardia has helped to revive interest in the condition. It has been looked for with greater care. Not only has its presence been confirmed by the surgeon, but ulceration has also, all unwittingly, been produced surgically. A lack of detailed investigation in the past led to the easy assumption that the oesophagus suffered acid digestion as a result of congenital maldevelopment. Its failure to reach its full length left the fundus of the stomach in the posterior mediastinum so that the normal barriers to acid reflux were ineffective. Peptic ulcer of the oesophagus and congenitally short oesophagus became almost like the Beaver and the Butcher: " You could never meet either alone ! " Although such a congenital abnormality cannot be denied, the burden of this report is that .short oesophagus is usually an acquired condition due to defects in the diaphragm which allow a .sliding hernia of the stomach. In the early stages the oesophagus may remain elastic so that the hernia can be reduced, but, after peptic ulceration and fibrosis have developed, permanent shortening occurs. This hernia may be present in infancy or may be acquired later in life. As will be seen, it is the predisposing cause of most peptic ulcers of the oesophagus. In recent years the backing of clinical suspicion by accurate observation has led to more frequent .diagnosis of these ulcers, and so it is that seventyfour have been studied in the thoracic surgical unit at the General Infirmary at Leeds. Four of these followed excision of the lower oesophagus and fundus of the stomach for carcinoma. Seven were found in children between the ages of six months and five years, and sixty-three were in adults. These groups will be considered separately even though the aetiological factors may be the same or similar in them all.