Simultaneous occurrence of gastric and duodenal ulcer has drawn many attentions in the past. Most of the studies concerning this combined ulcers, however, is the radiographic discription and no detail of the behavior has been well documented.
In view of this, an attempt was made to analyse their clinical, radiographic and laboratory findings in combined ulcers to elucidate their characteristics.
A total of 291 of combined ulcers were observed at the Icho-Hospital in Tokyo from 1950 to 1959. Among these, 220 cases were diagnosed by X-ray, and 71 cases were confirmed at the operation. In 94 cases, the pre and post ulcer studies were available. Besides of these combined ulcers, a total of 32 cases with an alternative gastric and duodenal ulcer were subjected for the study.
The frequency of the combined ulcer The combined ulcers occurred in 4.9% of the total peptic ulcer cases and it was found one in every 8.2 and 11.4 cases of gastric and duodenal ulcer respectively. Although the incidence of gastric ulcer has been decreasing and that of the duodenal ulcer has been increasing at this hospital in the past several years, the frequency of the combined ulcers has neither tendency.
The sexual distribution of the combined ulcer
The sexual difference in the occurrence of the combined ulcers is similar to that of the duodenal ulcer and it was found 7.1 times greater among male than female.
The age distribution of the combined ulcer Although in general, the duodenal ulcer is more common among younger group of the patients, no characteristic of combined ulcers was found.Syomptoms of the combined ulcer

There may be a hunger epigastric pain typical of the duodenal ulcer but nocturnal pain is very infrequent. Nausea, vomiting, melena, hematemesis and positive occult blood are more common and more pronounced in the combined ulcer than those in gastric and duodenal ulcer alone.
X-ray findings of the combined ulcer
The size of the gastric ulcer occurring in cases of the combined ulcer is smaller than that in the usual gastric ulcer. On the other hand, no definite crater was seen in duodenum in csses of the combined ulcer. Sixty-five percents of these deformity has been proved to have an active duodenal ulcer in our previous report. Thus it seems to indicate that the observation of the crater in the duodenum is not absolutely necessaryin making the diagnosis of the combined ulcer. In contrary to the statement of Johnson and Dragstedt, only 8% of the combined ulcer had pyloric stenosis. In 34 cases in which the pre and post ulcer studies were available, 20 cases of the duodenal ulcer preceded by the gastric ulcer.
Clinicalcourse
There was no case in which the simultaneous healing of both gastric and duodenal ulcer was noted. In general, gastric ulcer occurring in the combined ulcer heals faster than that of the duodenum but on the other hand, the frequency of the reoccurrrence of the ulcer was also greater in gastric ulcer than duodenal ulcer. In 71 cases with formation of the operation data, there was a tendency of multiple gastric ulcers which is agreeable with the findings of Ohi, Ito and Comfort.
Histological examination was made in 31 cases of the combined ulcer, no difference was noted in comparison to the usual type of either gastric or duodenal ulcer.
In conclusion, no definite difference was found in the behavior of the each ulcer in cases of combined and usual peptic ulcer after the follow up stuies of the combined ulcer.

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This study was done to clarify the correlations of internal pressure of the bile duct and the duodenum. There has been no established knowledge on them. Experiments were made on 76 male dogs under the intravenous anesthesia using pentobarbital sodium (0.5 cc/kg). Catheters were inserted into the gallbladder and the common duct. Cystic duct were set to be able to open or close at will. Another catheter with or without balloon was inserted into the duodenum at the site of Ampulla Vater. All of these catheters were connected to mechanical or electrical amplifier including manometer, tambour and strain gauge, to record the changes of internal pressures simulateneously. Common duct was irrigated with 1 cc of physiological saline solution per minutes during these expriments.
The results are as follows:
(1) Internal pressures of gallbladder and bile duct are almost identical. At resting andfasting condition, they measures 110mm H₂O in average and increase more than 100-350mm H₂O by the pharmocological stimuli. Because of the concomitant increase of internal pressures of gallbladder and bile cuct, no vulvular structures can be thought between them.
(2) Tonus rhythm of gallbladder appears between 80-100mm H₂O of internal pressure, especially when the cystic duct is closed or ligated. Contraction of the gallbladder with the increase of its internal pressure is usually controlled by the changes of the resistance at the terminal portion of the bile duct. So it does not bring any increase of the internal pressure of common duct in most of the cases.
(3) On the contrary, the internal pressure of gallbladder is regulated by that of common duct, which was strongly influenced by the resistance at the terminal portion of bile duct. So that the resistance at the terminal portion of bile duct is thought to play main role in the regulation of internal pressure of the bile tract. Gallbladder plays only offseting action of the introductal pressure.
(4) No contrary innervation is recognized between gallbladder and the internal portion of the bile duct. Bile can flow out balancing internal pressure of bile duct and duodenum.
(5) Internal pressure of the duodenum is 40mm H₂O at rest and increases more than 48-360mm H₂O by the pharmacological stimuli. Change of internal pressure influences the introductal pressure through the terminal portion of bile duct, but it is not the main factor of regulation.
(6) Internal pressure of common duct of cholecystectomized dog shows rather high pressure, however, response to the pharmacological stimuli is quite same regardless of the removal of the bladder.

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Observations were made on 55 clinical cases of gastric and hepatic diseases and Banessyndrome in order to elucidate the hemodynamics of the portal system in conduction of the portal venography from the viewpoints of diseases, age, hepatic function, roentgen picture of the blood vessels, histopathological finding of the liver, etc. Further experimental observations were made on 20 dogs to study the influence upon the portal circulation of several drugs including 40% glucose solution, 30% urea solution, adrenalin and pituitrin among which the former two hypertonic solutions are supposed to have the same effect as the contrast media and also to study the part played by the spleen in association with those drugs. Results are as follows:
1. Clinically in the portal venography in which a simultaneous photography of the veins of the gastric wall and the hepatoportal system is made the portal pressure rose in 33% and fell in 67% by injection of the contrast media, while the arterial pressure rose in 78%, did not change in 15% and fell in 7%. None of cases with abnormal vascular pictures such as cola teral circulation ever showed rise of the portal pressure, and otherwise there was no correlation between those pressure fluctuations and diseases, age, hepatic function, roentgen picture of the portal vein and the histopathological finding of the liver.
2. The portal hemodynamics under administration of several drugs were studied experimentally on dog, and increase of the portal pressure, portal blood flow and total hepatic blood flow was noticed on administration of hypertonic solutions such as 40% glucose and 30% urea solutions.
3. Pituitrin, when administered for treatment of hemorrhage of the portal system, causes not only fall of the portal pressure but also reduction of the portal blood flow and total hepatic blood flow, and may induce danger of giving rise to hypoxia of the liver.
4. Splenectomy changes the reactivity of the portal hemodynamics against medicaments, i. e., it causes chiefly narrowing of the range of the portal pressure fluctuation. This leads to a new understanding of the effect of splenectomy in treatment of portal hypertension that it has not only a static effect, which has been the sole benefit ascribed to it so far, but also a dynamic effect as has been found in this research.

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