GASTRO-DUODENAL ULCERATION.

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Spasm of the colon is very apt to develop in any condition of irritation or inflammation of the large bowel; and it is perhaps not enough recognised how large a part unsuitable diet plays in the maintenance of this condition. Especially does this seem to be the case when for various reasons imperfectly digested meat fibre reaches the large bowel, there to undergo putrefaction, with the production of offensive alkaline stools. It would appear that the products of the protein putrefaction may themselves irritate the large bowel ; at all events, in many cases the forbidding of meat or fish, and the institution of a lactovegetarian diet (vegetables or fruit being given .en puree) over a period of several weeks, produce even without the aid of drugs most satisfactory results. Enemata in cases of diverticulitis should be regarded In the first case as somewhat dangerous weapons. of this disease which I ever saw, a " good enema " had been given-so good that it had evidently gone through one of the weak points of the gut wall, into the abdomen.-I am, Sir. yours faithfully, ROBERT COOPE.

details of the eight cases we have seen at New Lodge Clinic, I find that only one had any pyloric obstruction and only one any definite renal disorder. All the others had normal urine, a normal cardiovascular system and normal blood pressure, but two had a sJight excess of blood-urea. In every case the bloodurea was much raised, though the urine remained normal, when the first symptoms appeared, this being doubtless a result and not the cause of the alkalosis, as it fell rapidly when the treatment was discontinued Dr. Geoffrey Fildes states that it was assumed in the paper written by himself and his colleagues that " the present-day practitioner was sufficiently conversant with modern practice not to overlook such an The obvious possibility of trouble " as oral sepsis. fact remains, however, that, as I pointed out in my last letter, about 70 per cent. of the cases sent to the Clinic were found on expert dental examination to have oral sepsis.-I am, Sir, yours faithfully, ARTHUR F. HURST. New Lodge Clinic, Windsor Forest, Berks, March 12th, 1928.

NEWSPAPER INSURANCE FROM A MEDICOLEGAL POINT OF VIEW. To the Editor of THE LANCET. SIR,-When, recently, two London daily newspapers with a huge combined circulation (Daily Mall and Daily Express) decided to extend their free accident insurance benefits to include 2100 for every fatal accident, it must have given some food for thought to many a medical practitioner. Was the fatal illness of to-day to become the fatal accident of to-morrow ? After 20 years of the Workmen’s

GASTRO-DUODENAL ULCERATION. :/0 the Li‘162tOr

OJ

THE LANCET.

SIR,-In your issue of March 10th your three

correspondents appear to think that I am not in favour of the intensive alkaline treatment of gastroduodenal ulceration. But I have used it continuously since 1919 and have written and spoken about its excellent results on numerous occasions. My advocacy of the treatment did not, however, prevent me from feeling distressed when one of my patients died in coma from alkalosis or from feeling satisfied when the recognition of the early symptomsdepression, anorexia, headaches, and nausea-in seven other cases may have saved them from a similar fate. Several deaths have been reported in America, and it is absurd for Dr. Cameron to speak about my " theory of alkalosis," or for Prof. MacLean and his colleagues to regard it as a " theoretical condition," simply because they have been fortunate It is admittedly so far in not seeing a similar case. cases representing about 2 per cent. rare, my eighttreated in some 350 by this method. Investigations are being carried out at Guy’s Hospital and New Lodge Clinic with the object of eliminating the danger, and it is for this reason that it is important to study by modern physicochemical and biochemical methods the effects of the different alkalis, though Prof. MacLean apparently thinks that such investigations are waste of time-a curious view for the director of a professorial unit. So far as wehave gone, we believe that alkalosis can be prevented without any diminution in the favourable effect of the treatment by avoiding sodium bicarbonate and magnesium oxide and carbonate, all of which have the further disadvantage of stimulating the secretion of gastric juice after they have neutralised the acid present in the stomach at the moment of administration. If sodium citrate is given with each feed and the triple phosphates of magnesium and calcium (in proportions depending upon the state of the bowels) are given in powder form, the contents of the stomach can be kept permanently neutral, as we have been able to demonstrate by examining fractions taken at intervals throughout the day. The dose of alkali required is greatly reduced if the feeds are given hourly instead of twohourly. It is difficult to see why Prof. MacLean advocated the use of bismuth oxycarbonate in his paper, as he now states that he realised that it does not act as an alkali under the conditions present in the stomach ; or why he only referred to the anticlotting effect of sodium citrate, although he knew that it was one of the most potent factors in the alkaline treatment he described. American writers have laid great stress on the and renal disease importance of pyloric obstruction in connexion with alkalosis, but on looking into the

Compensation Act, cases are still being fought out in the courts as to " what is an accident." In one case that went to the House of Lords it was laid down that " it might be just as serious to be hit in the eye by a single microbe as by a cricket ball." Newspaper insurance opens up a similar vista of difficulties. The strain of opening or closing a window on a person with a diseased heart might well be called an accident, especially if f:100 depended upon the terminology used. The registrar of deaths or the coroner would probably have to use discretion in the matter. I have recently been interested in " falling out of window " cases. They would appear to be on the increase. They occur in all sorts of places, hotels, institutions, private residences, and offices. In several cases an " open verdict " has to be returned owing to lack of evidence. Taken as a class, they might be the result of-niurder, manslaughter, suicide, misadventure, accident, or sudden illness. A man might drop dead in a room beside an open window. If in doing so he happened to fall out of the window on to the ground below, it would be a difficult point to decide or prove the exact cause of death. It has no parallel to the case of a dead body thrown into the river to simulate drowning. Newspaper insurance may add yet another responsibility on the already over-burdened medical practitioner.-I

am,

Sir,

yours

faithfully,

r<.,

-

.

J. J. SCANLAN.

DISPOSAL

OF

7’0 the Editor

I

of

THE

DEAD.

THE LNCE2.

public towards the should not be difficult instil present moment, when the conception of the ideal of health is developing, that the dead are unclean and dangerous ; that handling and kissing a body is revolting ; that a nice corpse " is an abomination, and not a thing to be made much of by friends and relations. In our temperate climate rapid putrefaction does not usually occur, and this tends to the belief that there is no danger in a body remaining in a house for a period up to a week. While it is difficult to prove that this danger exists, I think it is safe to assume it, SIR,-The education

of the

of cremation is slow, but it I ideal to into its mind at the

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