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GASTRO-JEJUNAL ULCERATION
370 fatal
among 50 cases so examined, as with 3 fatal cases among 25 where no examination was offered. Cancer of the bladder is 38 times as frequent in chemical workers as in the male insured population, due apparently to contact with certain coal-tar derivatives. Fourteen cases of cancer of the nose, 13 of them fatal, among those employed at a nickel refinery works remain as yet unexplained. Further investigation of dusty trades has found in sand-blasting a grave risk of silicosis ; fortunately, in most instances sand can be replaced by steel shot in the blast, and this almost eliminates the risk. Attention is called in the report to the way in which dust opaque to X rays may simulate fibrotic deposits in radiograms of the chest, and so introduce a difficulty in diagnosis. Diethylene dioxide, used in making artificial silk, gave rise to five deaths from acute hsemorrhagic nephritis with suppression of urine and uraemia ; the toxicity of this compound no
ending
compared
previously not recognised. Notwithstanding the prevalence of unemployment, several instances are quoted of excessive hours of work : unbroken spells of 22 and 37!hours, 89 was
and 78 hours per week. The two-shift system has its value in emergency and has in a few industries been adopted as a regular method. Welfare accommodation, particularly at mess rooms, is becoming so general, although not compulsory, that workers conplain if it is not provided, thinking its absence to be illegal. The psychological effect of bright workplaces is receiving attention ; in one case the walls, fronts of galleries, and doors are painted primrose, handrails light green, steel columns, beams, gantries, and roof trusses aluminium; in another machines are painted light blue to show up against a dark background, and the jibs of fixed cranes and runways are a brilliant red. Indeed, throughout the report there are instances of advance and progress, rather than, as of old, of backsliding and grinding the. face of the labourer.
proved
A REGIMEN FOR RHEUMATISM
THE idea of "soil and seed," as applied to disease of the joints, enables us to make a broad distinction between the mainly infective (arthritis) and those in which infection is reduced to a minimum (arthroses). For the latter group, which are sometimes termed degenerative, a failure of nutrient substances to construct or preserve normal bone and cartilagei.e., a metabolic disorder-is often held responsible. Such a " faulty metabolism " might arise from gastrointestinal disturbances resulting in interference with absorption of foodstuffs, and Burnett and Ober,! of the arthritis clinic of the Peter Bent Brigham Hospital, Boston, describe the regimen by which they try to get this absorption back to normal. Their emphasis is laid on the need for proper habits of mastication of food and for its unhurried passage through the colon in order that complete absorption may be obtained ; indeed their desideratum is to obtain the dejecta completely formed and entirely segmented, which in their view signifies satisfactory digestion or "anabolic nutrition." By means of charcoal or millet seeds the intestinal rate was determined, and two-thirds of their patients were shown to have an irritable colon and rapid intestinal rate. The general plan of dieting adopted is to give little food at breakfast or lunch but a substantial amount at dinner ; the total caloric value should be sufficient to supply the needs of those who are actively occupied. The diet must be complete and must 1 Burnett, F. L., and Ober, F. R.: Amer. Jour. Med. Sci., July, 1934, p. 93.
contain a fair amount of vegetables to make the aliment alkaline. Fruit is taken according to requirement and not till the later meals of the day, so that the consistency of the dejecta after breakfast may be a guide. An essential is the omission of all laxatives, oils, or enemata. Two glasses of water are advised at each meal, one more on rising, and one at bedtime. Exercise is greatly restricted where there is much wasting, and adequate sleep is necessary. If the digestive fluids are deficient dilute hydrochloric acid, gastric enzymes, and enteric-coated pancreatic preparations may be useful. Injections of insulin are sometimes helpful to patients who are abnormally lean. The usual physical methods of treatmentrest, heat, massage, or exercise-are employed to reduce the swelling, alleviate the pain, and restore the action of the joints. Finally, as it takes months and years of anabolic nutrition to overcome the deficiencies in these cases, constant encouragement towards greater activity is very necessary. Of several hundred patients at the clinic, many could not be taught or would not cooperate ; but of those who followed the instructions for at least five months more than a quarter are said to have been cured, with relief of pain and swelling and normal motility of the joints, while about half have improved. GASTRO-JEJUNAL ULCERATION EXAMINATION of the records of patients on whom gastric operations were performed 20 or 30 years ago is making it easier to understand the cause of gastrojejunal ulceration. Mr. A. J. Walton, who has lately written in these columns1 on the prognosis of peptic ulcers treated byoperation,has also described2 in detail his experience of this particular complication. In 1859 gastric operations which he personally performed, there were, he says, 31 cases in which gastro-jejunal
ulcer subsequently developed-an incidence of only 1-6 per cent. They are divided into those in which operation was done between the years 1913 and 1922 inclusive, and those operated on in the ten years since. In the first ten-year period 765 cases show an incidence of 2-3 per cent. (18 developed gastro-jejunal ulceration) and this lends support to the assertion that the number of cases increases with the time Such figures, over which the patients are followed. however, cannot be interpreted aright without consideration of other factors, such as the experience of the operator and the nature of the operation. Walton does not find any evidence in his cases for an increased incidence with anterior gastro-jejunostomies, and his general conclusion is that gastro-jejunal ulceration is almost entirely a complication of gastro-enterostomy for ulcers in the region of the pylorus and the duodenum. In only 2 of his 31 cases did it follow partial gastrectomy, and he believes that the more extensive the gastrectomy the less chance there is of anastomotic ulcer. The nature of the original lesion is of paramount importance : thus anastomotic ulcer never follows an operation for carcinoma-a fact which in part at least explains its low incidence after gastrectomy. Of the setiological factors hyperchlorhydria is generally considered to be the most important, and it is noteworthy that the average acidity of the gastric juice has been found to be higher with duodenal than with lesser curve ulcers, and to be relatively higher, again, in those cases of duodenal ulcer which later developed gastro-jejunal ulceration. Walton agrees with other observers that infection elsewhere is liable to increase the incidence of ulceration. He also finds some reason to believe that 1 THE LANCET, July 7th, p. 37. 2 Brit. Jour. Surg., July, 1934, p. 33.
371
incomplete apposition of the gastric mucosa, such as may occur at the point at which the continuous mucosal suture is begun and ended, may determine the site of an ulcer-more especially when there has been excision of the redundant mucosa along the Unabsorbent sutures have not the in the production of these ulcers which was once attributed to them. Two clinical types are described by Walton. One shows haemorrhage as the main symptom, and he states his opinion that haemorrhage after gastroenterostomy for duodenal ulcer always comes from a marginal ulcer and never from the original ulcer. The other shows symptoms of indigestion, more or less mimicking the original lesion, but with vomiting conspicuous and pain often referred to the left side and to the lower abdomen rather than the epigastrium. Taking all the cases together pain is much the most prominent symptom. For treatment Walton strongly advocates partial gastrectomy and quotes Finsterer as stating that if three-quarters of the stomach is removed recurrence never takes place. His own figures show 1 recurrence in 61 cases.
suture line.
importance
TREATMENT IN THE OXYGEN CHAMBER
A CHEMICAL study of the changes brought about in normal persons, and in patients suffering from cardiac and pulmonary disease, on breathing an atmosphere containing 45 per cent. of oxygen for periods of a week or more has been made by D. W. Richards and A. L. Barach.l The chief changes found in two normal subjects after a week in the oxygen chamber were a considerable fall in pulserate and a small increase in arterial oxygen satura. tion and in the level of the CO2-dissociation curve. The patients investigated fell into three main groupsarterio-sclerotic heart disease, rheumatic heart disease, and pulmonary fibrosis with cardio-respiratory insufficiency. A majority had congestive heart failure with oedema, and all had failed to improve on usual measures such as rest, digitalis, diuretics, and oxygen by nasal catheter. On transference to the 45 per cent. oxygen chamber there was usually some relief of dyspnoea and restlessness within a few hours, and in some the relief was progressive, becoming complete in several days. This was accompanied by a raising of arterial oxygen saturation to normal levels, increase in the blood CO2, diuresis, and increase in the urinary chloride, and a fall in pulse-rate and in venous pressure. The arteriosclerotic and pulmonary groups gave a much better response than the rheumatic group. It is interesting to note that dilution of the blood appeared to occur as the signs of congestive failure cleared up ; and Richards and Barach correlate this with the decrease of vital capacity of the lungs sometimes observed at this time, suggesting a further widening of the pulmonary blood depot. When the changes brought about by treatment in the oxygen chamber are compared with those which accompany the relief of congestive failure without oxygen treatment, the differences are found to be a greater quantitative main increase in arterial oxygen saturation, increase in blood CO2, and decrease in blood chloride in the oxygen-treated cases. This form of treatment seems to be useful in any case of cardio-pulmonary disease in which dyspnoea resists other measures, and anginal pain, too, is said to be relieved by it ; presumably this refers especially to angina occurring at rest and apart from recent coronary occlusion. From the chemical point of view Richards and Barach state 1 Quart. Jour. Med., July, 1934,
p.
437.
while a low arterial oxygen saturation is a certain indication, oxygen-want may be present when this is within normal limits. Cyanosis also is not a safe criterion of oxygen-want ; thus the treatment . may be beneficial when cyanosis is slight and of little use when it is conspicuous.
that,
AIDS TO CHOLECYSTOGRAPHY
THE introduction of tetraiodophenolphthalein marked a great step forward in the diagnosis of gall-bladder diseases, but this method has the disadvantage that the drug is somewhat troublesome to administer and takes several hours to enter the gall-bladder. Attempts have been made to speed up the process, and S. Zanetti, of Bologna,l has used for this purpose a subcutaneous injection of 1 mg. of adrenaline an hour after the patient has taken 80-100 g. of sugar. In healthy persons, Zanetti says, the shadow appears two hours and sometimes less after the injection and lasts for several hours more. Its depth varies with the standard of hepatic and biliary function, and delay in appearance is, it is stated, of diagnostic importance, showing a failure to reduce glycogen or to concentrate bile rapidly which ordinary cholecystography would not reveal. Somewhat similar investigations have been made by D. Barbieri and F. F. Tosattiwho have studied the rapidity with which the tetraiodide shadow is obtained in normal persons following the intravenous injection of a number of substances, including
adrenaline, pituitrin, urotropine, histamine, acetylcholine, and hypertonic and isotonic solutions of sodium chloride. Of all these substances acetylcholine served to give the earliest shadow, the gallbladder being visible within half an hour, and consistently and clearly seen within an hour, of the injection of the tetraiodide. The dose was 3 cg. of acetylcholine injected intravenously a quarter of an hour before the tetraiodide. Urotropine, they also found, caused some acceleration in the appearance of the shadow, satisfactory cholecystograms being obtained in 1 hour 45 minutes from the time of injection. With adrenaline, however, the gall-bladder only became visible after about 4 hours and 40 minutes, and Barbieri and Tosatti conclude that whereas acetylcholine, urotropine, and pituitrin all accelerate the procedure of cholecystography, adrenaline and histamine could not be shown to do Their results were obtained on 20 normal so. patients, and have not as yet been applied to cases of hepatic disease. The difference between these findings and those of Zanetti are not perhaps as surprising as appears at first sight, for the number of cases examined is relatively small, and much variation has been noted in normal persons when tetraiodide is employed alone. THE BACKWARD AFRICAN NATIVE
IN December last the Secretary for the Colonies asked the governor of Kenya whether he was in favour of the proposal put forward by Dr. H. L. Gordon for a collaborative research into the nature and causes of native backwardness in East Africa A memorandum written by the director of medical services and approved by the director of education and the chief native commissioner has now been signed by the governor and sent to the Colonial Office. It is strongly in favour of the proposal. In a recent address to the Kenya Society for the Study of Race Improvement, Dr. Gordon pointed out that East African backwardness was formerly attributed 1 Presse méd., May 23rd, 1934, p. 849. 2 Policlinico, June 25th, 1934, p. 963.
among 50 cases so examined, as with 3 fatal cases among 25 where no examination was offered. Cancer of the bladder is 38 times as frequent in chemical workers as in the male insured population, due apparently to contact with certain coal-tar derivatives. Fourteen cases of cancer of the nose, 13 of them fatal, among those employed at a nickel refinery works remain as yet unexplained. Further investigation of dusty trades has found in sand-blasting a grave risk of silicosis ; fortunately, in most instances sand can be replaced by steel shot in the blast, and this almost eliminates the risk. Attention is called in the report to the way in which dust opaque to X rays may simulate fibrotic deposits in radiograms of the chest, and so introduce a difficulty in diagnosis. Diethylene dioxide, used in making artificial silk, gave rise to five deaths from acute hsemorrhagic nephritis with suppression of urine and uraemia ; the toxicity of this compound no
ending
compared
previously not recognised. Notwithstanding the prevalence of unemployment, several instances are quoted of excessive hours of work : unbroken spells of 22 and 37!hours, 89 was
and 78 hours per week. The two-shift system has its value in emergency and has in a few industries been adopted as a regular method. Welfare accommodation, particularly at mess rooms, is becoming so general, although not compulsory, that workers conplain if it is not provided, thinking its absence to be illegal. The psychological effect of bright workplaces is receiving attention ; in one case the walls, fronts of galleries, and doors are painted primrose, handrails light green, steel columns, beams, gantries, and roof trusses aluminium; in another machines are painted light blue to show up against a dark background, and the jibs of fixed cranes and runways are a brilliant red. Indeed, throughout the report there are instances of advance and progress, rather than, as of old, of backsliding and grinding the. face of the labourer.
proved
A REGIMEN FOR RHEUMATISM
THE idea of "soil and seed," as applied to disease of the joints, enables us to make a broad distinction between the mainly infective (arthritis) and those in which infection is reduced to a minimum (arthroses). For the latter group, which are sometimes termed degenerative, a failure of nutrient substances to construct or preserve normal bone and cartilagei.e., a metabolic disorder-is often held responsible. Such a " faulty metabolism " might arise from gastrointestinal disturbances resulting in interference with absorption of foodstuffs, and Burnett and Ober,! of the arthritis clinic of the Peter Bent Brigham Hospital, Boston, describe the regimen by which they try to get this absorption back to normal. Their emphasis is laid on the need for proper habits of mastication of food and for its unhurried passage through the colon in order that complete absorption may be obtained ; indeed their desideratum is to obtain the dejecta completely formed and entirely segmented, which in their view signifies satisfactory digestion or "anabolic nutrition." By means of charcoal or millet seeds the intestinal rate was determined, and two-thirds of their patients were shown to have an irritable colon and rapid intestinal rate. The general plan of dieting adopted is to give little food at breakfast or lunch but a substantial amount at dinner ; the total caloric value should be sufficient to supply the needs of those who are actively occupied. The diet must be complete and must 1 Burnett, F. L., and Ober, F. R.: Amer. Jour. Med. Sci., July, 1934, p. 93.
contain a fair amount of vegetables to make the aliment alkaline. Fruit is taken according to requirement and not till the later meals of the day, so that the consistency of the dejecta after breakfast may be a guide. An essential is the omission of all laxatives, oils, or enemata. Two glasses of water are advised at each meal, one more on rising, and one at bedtime. Exercise is greatly restricted where there is much wasting, and adequate sleep is necessary. If the digestive fluids are deficient dilute hydrochloric acid, gastric enzymes, and enteric-coated pancreatic preparations may be useful. Injections of insulin are sometimes helpful to patients who are abnormally lean. The usual physical methods of treatmentrest, heat, massage, or exercise-are employed to reduce the swelling, alleviate the pain, and restore the action of the joints. Finally, as it takes months and years of anabolic nutrition to overcome the deficiencies in these cases, constant encouragement towards greater activity is very necessary. Of several hundred patients at the clinic, many could not be taught or would not cooperate ; but of those who followed the instructions for at least five months more than a quarter are said to have been cured, with relief of pain and swelling and normal motility of the joints, while about half have improved. GASTRO-JEJUNAL ULCERATION EXAMINATION of the records of patients on whom gastric operations were performed 20 or 30 years ago is making it easier to understand the cause of gastrojejunal ulceration. Mr. A. J. Walton, who has lately written in these columns1 on the prognosis of peptic ulcers treated byoperation,has also described2 in detail his experience of this particular complication. In 1859 gastric operations which he personally performed, there were, he says, 31 cases in which gastro-jejunal
ulcer subsequently developed-an incidence of only 1-6 per cent. They are divided into those in which operation was done between the years 1913 and 1922 inclusive, and those operated on in the ten years since. In the first ten-year period 765 cases show an incidence of 2-3 per cent. (18 developed gastro-jejunal ulceration) and this lends support to the assertion that the number of cases increases with the time Such figures, over which the patients are followed. however, cannot be interpreted aright without consideration of other factors, such as the experience of the operator and the nature of the operation. Walton does not find any evidence in his cases for an increased incidence with anterior gastro-jejunostomies, and his general conclusion is that gastro-jejunal ulceration is almost entirely a complication of gastro-enterostomy for ulcers in the region of the pylorus and the duodenum. In only 2 of his 31 cases did it follow partial gastrectomy, and he believes that the more extensive the gastrectomy the less chance there is of anastomotic ulcer. The nature of the original lesion is of paramount importance : thus anastomotic ulcer never follows an operation for carcinoma-a fact which in part at least explains its low incidence after gastrectomy. Of the setiological factors hyperchlorhydria is generally considered to be the most important, and it is noteworthy that the average acidity of the gastric juice has been found to be higher with duodenal than with lesser curve ulcers, and to be relatively higher, again, in those cases of duodenal ulcer which later developed gastro-jejunal ulceration. Walton agrees with other observers that infection elsewhere is liable to increase the incidence of ulceration. He also finds some reason to believe that 1 THE LANCET, July 7th, p. 37. 2 Brit. Jour. Surg., July, 1934, p. 33.
371
incomplete apposition of the gastric mucosa, such as may occur at the point at which the continuous mucosal suture is begun and ended, may determine the site of an ulcer-more especially when there has been excision of the redundant mucosa along the Unabsorbent sutures have not the in the production of these ulcers which was once attributed to them. Two clinical types are described by Walton. One shows haemorrhage as the main symptom, and he states his opinion that haemorrhage after gastroenterostomy for duodenal ulcer always comes from a marginal ulcer and never from the original ulcer. The other shows symptoms of indigestion, more or less mimicking the original lesion, but with vomiting conspicuous and pain often referred to the left side and to the lower abdomen rather than the epigastrium. Taking all the cases together pain is much the most prominent symptom. For treatment Walton strongly advocates partial gastrectomy and quotes Finsterer as stating that if three-quarters of the stomach is removed recurrence never takes place. His own figures show 1 recurrence in 61 cases.
suture line.
importance
TREATMENT IN THE OXYGEN CHAMBER
A CHEMICAL study of the changes brought about in normal persons, and in patients suffering from cardiac and pulmonary disease, on breathing an atmosphere containing 45 per cent. of oxygen for periods of a week or more has been made by D. W. Richards and A. L. Barach.l The chief changes found in two normal subjects after a week in the oxygen chamber were a considerable fall in pulserate and a small increase in arterial oxygen satura. tion and in the level of the CO2-dissociation curve. The patients investigated fell into three main groupsarterio-sclerotic heart disease, rheumatic heart disease, and pulmonary fibrosis with cardio-respiratory insufficiency. A majority had congestive heart failure with oedema, and all had failed to improve on usual measures such as rest, digitalis, diuretics, and oxygen by nasal catheter. On transference to the 45 per cent. oxygen chamber there was usually some relief of dyspnoea and restlessness within a few hours, and in some the relief was progressive, becoming complete in several days. This was accompanied by a raising of arterial oxygen saturation to normal levels, increase in the blood CO2, diuresis, and increase in the urinary chloride, and a fall in pulse-rate and in venous pressure. The arteriosclerotic and pulmonary groups gave a much better response than the rheumatic group. It is interesting to note that dilution of the blood appeared to occur as the signs of congestive failure cleared up ; and Richards and Barach correlate this with the decrease of vital capacity of the lungs sometimes observed at this time, suggesting a further widening of the pulmonary blood depot. When the changes brought about by treatment in the oxygen chamber are compared with those which accompany the relief of congestive failure without oxygen treatment, the differences are found to be a greater quantitative main increase in arterial oxygen saturation, increase in blood CO2, and decrease in blood chloride in the oxygen-treated cases. This form of treatment seems to be useful in any case of cardio-pulmonary disease in which dyspnoea resists other measures, and anginal pain, too, is said to be relieved by it ; presumably this refers especially to angina occurring at rest and apart from recent coronary occlusion. From the chemical point of view Richards and Barach state 1 Quart. Jour. Med., July, 1934,
p.
437.
while a low arterial oxygen saturation is a certain indication, oxygen-want may be present when this is within normal limits. Cyanosis also is not a safe criterion of oxygen-want ; thus the treatment . may be beneficial when cyanosis is slight and of little use when it is conspicuous.
that,
AIDS TO CHOLECYSTOGRAPHY
THE introduction of tetraiodophenolphthalein marked a great step forward in the diagnosis of gall-bladder diseases, but this method has the disadvantage that the drug is somewhat troublesome to administer and takes several hours to enter the gall-bladder. Attempts have been made to speed up the process, and S. Zanetti, of Bologna,l has used for this purpose a subcutaneous injection of 1 mg. of adrenaline an hour after the patient has taken 80-100 g. of sugar. In healthy persons, Zanetti says, the shadow appears two hours and sometimes less after the injection and lasts for several hours more. Its depth varies with the standard of hepatic and biliary function, and delay in appearance is, it is stated, of diagnostic importance, showing a failure to reduce glycogen or to concentrate bile rapidly which ordinary cholecystography would not reveal. Somewhat similar investigations have been made by D. Barbieri and F. F. Tosattiwho have studied the rapidity with which the tetraiodide shadow is obtained in normal persons following the intravenous injection of a number of substances, including
adrenaline, pituitrin, urotropine, histamine, acetylcholine, and hypertonic and isotonic solutions of sodium chloride. Of all these substances acetylcholine served to give the earliest shadow, the gallbladder being visible within half an hour, and consistently and clearly seen within an hour, of the injection of the tetraiodide. The dose was 3 cg. of acetylcholine injected intravenously a quarter of an hour before the tetraiodide. Urotropine, they also found, caused some acceleration in the appearance of the shadow, satisfactory cholecystograms being obtained in 1 hour 45 minutes from the time of injection. With adrenaline, however, the gall-bladder only became visible after about 4 hours and 40 minutes, and Barbieri and Tosatti conclude that whereas acetylcholine, urotropine, and pituitrin all accelerate the procedure of cholecystography, adrenaline and histamine could not be shown to do Their results were obtained on 20 normal so. patients, and have not as yet been applied to cases of hepatic disease. The difference between these findings and those of Zanetti are not perhaps as surprising as appears at first sight, for the number of cases examined is relatively small, and much variation has been noted in normal persons when tetraiodide is employed alone. THE BACKWARD AFRICAN NATIVE
IN December last the Secretary for the Colonies asked the governor of Kenya whether he was in favour of the proposal put forward by Dr. H. L. Gordon for a collaborative research into the nature and causes of native backwardness in East Africa A memorandum written by the director of medical services and approved by the director of education and the chief native commissioner has now been signed by the governor and sent to the Colonial Office. It is strongly in favour of the proposal. In a recent address to the Kenya Society for the Study of Race Improvement, Dr. Gordon pointed out that East African backwardness was formerly attributed 1 Presse méd., May 23rd, 1934, p. 849. 2 Policlinico, June 25th, 1934, p. 963.