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MEDICINE.
THE BRITISH MEDICAL ASSOCIATION.
371
THE SECTIONS.
THE
MEDICINE. THURSDAY, JULY 25TH. President: Professor T. R. GLYNN (Liverpool). Sir BERTRAND DAWSON (London) opened a discussion on The Pathogenesis, Diagnosis, and Medical Treatment of Gastric Ulcer. He said that throughout the discussion the terms" mucous ulcer"and chronic ulcer"would be employed. Mucous ulcer denoted an ulceration of the mucous membrane. It was usually a subacute condition, tending to heal quickly
BRITISH MEDICAL ASSOCIATION. EIGHTIETH ANNUAL MEETING IN LIVERPOOL.
Mr. F. W. Lowndes, of Liverpool, writes to ns in connexion with the recent meeting of the British Medical Association in the city where his long official and professional work has earned him universal regard :-A remarkable feature in the history of Liverpool is its rapid rise from a poor fishing completely. Sometimes, however, it progressed rapidly village in the middle of the seventeenth century, with and into perforating ulcer or took on the characteristics of a Our and of St. Nicholas one church-the Chapel Lady (the chronic lesion. By chronic ulcer was meant a condition which patron saint of all sailors)-to its present position with involved most or all of the coats of the stomach, and could a population of three-quarters of a million. Towards the usually be appreciated by sight and touch without opening end of the eighteenth century it had a population of 30,000 the stomach. Duodenal ulcer was included in the discussion. and five churches ; it was a town of shipowners and sea- The duodenum above the common duct was embryologically, functionally, and pathologically closely related to the men, merchants, brokers, their clerks, and warehousemen. stomach, and the problem on the two sicles of the pylorus It had suffered much from malignant plague, or black was the same. Mucous ulcers were associated not only with death, which more than once decimated the popula- the terminal stages of fatal diseases like septicaemia and tion and caused the formation of a burial ground outside Bright’s disease, but with curable gastric disorders. They St. Nicholas’s Church in place of that at Walton Parish were seen not only in the post-mortem room, but on the table. They were produced by the combined effect Church, three miles distant. In the eighteenth century operating of (1) lowered vitality or damage of the mucous membrane ; there were physicians and surgeons of mark, notably (2) acid juice. Damage might be by local bacterial infection, Matthew Dobson, Houlston, Currie, Henry Park, and gastrotoxins, or mechanical injury. Like the mucous ulcer, Alanson. The first infirmary was opened in 1749 with a chronic ulcer existed where the hydrochloric acid juice existed. seamen’s hospital. Dr. Matthew Dobson’s name has been Its appearance suggested chronic irritation and efforts at Pathological anatomy supported the development of quite recently quoted for his epoch-marking paper, as repair. the chronic from the mucous ulcer. The defensive forces Dr. Garrod called it, on sugar in the urine of diabetics. of the gastric mucous membrane were considerable, and Henry Park died in 1832, and the first meeting in mucous ulcers healed rapidly. On reaching the subLiverpool of the Provincial Medical Association was held mucous coat this specially defensive mechanism disthe invading force was strong and its very soon after, the President making feeling allusion to appeared. If, then, acute progress rapid, perforating ulcer occurred, whereas if Park and others resting in the tomb. The late Mr. Reginald it was less strong and its progress slow, chronic ulcer Harrison, in his address on Surgery at the last meeting of developed. Mucous ulcers were multiple, whereas chronic the British Medical Association in Liverpool,l gave the ulcer usually occurred singly ; mucous ulcers existed over following quotation from an article in the Edinburgh Review, the whole of the stomach, whereas chronic ulcers were usually October, 1872 : "In the latter portion of the last found in the region of the pylorus ; the different age and sex in the two conditions were facts which might be held (18th) century when a vigorous flash of originality seemed incidence to support the separate origin of chronic ulcer. The clinical to light up the progress of surgery, Park, of the Liverpool picture of ulcer had altered. Whereas formerly the typical Hospital (Infirmary), may be said to have completed the first patient was most often a young woman who had pain after act of conservative surgery. His patient, a sailor, to whomL food relieved by vomiting, with or without hæmatemesis, the loss of a foot and leg would have been tantamount to the now the patient was more often a man, usually over 30, and The. loss of his means of getting bread, determined him to make food more often relieved pain than produced it. of view was due to surgery. In the pre-operative change the experiment of simply excising the diseased parts-the group a case here and there came to necropsy for perforaknee-joint-and retaining the foot and leg. This he did sc tion or haemorrhage ; the remaining cases recovered, and it successfully that, to use his own words, the patient severalL was a natural inference that they consisted of ulcers which years after the operation made several voyages to sea irl had healed under treatment. Pain, tenderness, vomiting, which he was able to go aloft with considerable agility ancL haematemesis characterised other conditions besides ulcer, and bleeding need not have a focal origin. Analysis of to perform all the duties of a seaman, that he was twict) causes in the pre-operative group showed chronic ulcer as shipwrecked and suffered great hardship without feeling an3now understood; gastritis, due to food or drink irritafurther complaint in that limb. This was a crucial test ofE tion, to intoxications, and to chronic infections, aided in success that should have stamped the operation as one of th() many instances by impaired motility ; disordered secreset up by distant irritation (in, say, appendix or like of the time. so But, greatest surgical triumphs man3 tion, and associated or not with pyloro- or cardio-spasm. other great strides taken in that age of extreme vivification ’ colon), ulcers were Mucous no doubt sometimes present, but they it was in advance of its fellows and was destined to btno and called for no different manifestations, special gave arrested for the better part of another half century." On< ) treatment. They were of interest for what they could lead reason, says Mr. Lowndes, for this want of appreciation wa;; to if the conditions with which they are associated are pictures illustrating foregoing : (1) The Henry Park’s modest and retiring disposition, also hi: not treated.ofClinical the anæmic young women; (2) gastric hatred of pen, ink, and paper. There is such a thing a1’ dyspepsia symptoms and trouble in the colon ; (3) gastric symptoms being before the time, but being behind the time is worse , and the appendix; (4) gastric symptoms and morbid and Park, though somewhat unappreciated in his day, nov condition of mouth, nose, and pharynx. The clinical shares in the farne that has comealike to his city and hii3 picture of chronic zslcer(Developed structural stenosis of the pylorus was excluded because it gave evidences profession. Park’s body was buried in St. James’s cemetery,’ of its own and presented no difficulty) ; objective which is situated near Rodney-street, in which street man3’ and their value; tenderness, cutaneous hyperfindings physicians and surgeons reside, and near which is the churcr æsthesia; size and position of stomach ; test supper dedicated to St. Luke. The newly rising cathedral is clost and breakfast disclosing acid content and motility ; to St. James’s cemetery. bacteriological examination ; X ray examination. Haematemesis and melsena needed separate consideration because 1 THE LANCET, Feb. 24th, 1912, p. 483. they might occur alone as well as in conjunction with F3 ,
. ,
-
372
THE BRITISH MEDICAL ASSOCIATION.
If in conjunction, they made the :symptoms than the chronic variety, and either recovered abovesymptoms. ’ulcer picture clearer. DiagnosisSystemic disease might or died quickly. He was guided in considering operation wear the guise of stomach disorder, but seldom presented much by the circumstances of the patient and choice of£ difficulty to -the experienced clinician. The conditions operator. that did present difficulty were : (1) Malignant disease of the Dr. A. MACLENNAN (Runcorn) compared gastric with stomach ; (2) infective or toxic gastritis associated with stercoral ulcers. He affirmed that 70 per cent. occurred on disease of gums, tonsils, pharynx, and nose ; (3) gastric the small curvature and posterior wall. In normal condisturbance caused by disease of gall-bladder, appendix, ditions the mucous membrane was protected by local and and colon ; (4) hyperchlorhydria of unknown origin. general defences. Experimental observations suggested the Treatment included rest in bed, which was of .paramount existence of an antiferment. Superficial ulcers occurred importance, sparing energy and diminishing the need for mainly in young women, and in this connexion he called food. The diet should be milk given frequently in small attention to the fact that in chlorosis the blood was less quantity for several days, being extended by the addition of alkaline than normal. Treatment by nutrient enemata was more substantial ’articles as recovery progressed. Resistance liable to induce acetonuria and so do harm. Normal saline to treatment proved the existence of ulcer, but tonics could solution was more satisfactory, or olive oil by the mouth. usually be given towards the end of a week. Chronic Iron given hypodermically in chlorotic cases was of value. ulcer called for similar diet and, in addition, alkali to Chronic pancreatitis, when present, involved obstruction of neutralise the effect of gastric juice, for it was essential to the gall-duct and gave rise to symptoms suggestive of gallkeep down the gastric acidity even at night and when the stones. Dr. S. H. HABERSHON (London) expressed himself as stomach was empty. The indicationsfor gastro-enterostomy were stenosis of pylorus and the persistence of chronic opposed to the view advocated by Dr. Hunter, inasmuch as ulcer, wherever situated. The artificial stoma acted as a the association of ulcer with hyperchlorhydria, so common safety-valve, preventing distension, keeping the organ in young women, fulfilled the requirements of antisepsis. mnpty, even of its own secretion, and even allowing the Apart from this, other sources might be a B. coli infection or the cytotoxin of Dr. Bolton. He suggested that an acute ’ingress of alkaline duodenal secretions. Professor R. SAUNDBY (Birmingham) dwelt on the mucous ulcer might ensue on superficial erosion or small ,difficulty of discriminating between major and minor con- embolism. The superficial ulcer did not induce pyloric ditions, and considered it wise to treat all on the lines of spasm, but that might ensue later from deeper ulceration. ulcer. He did not feed during hoematernesis, otherwise he In pyloric ulcer the symptoms culminated two to four hours ,a,greed to administering a gradually increasing diet. Opera- after food or at the end of the day; there were variable tion availed nothing iiii acute hsematemesis, but should be dilatation of the stomach and hunger pain. ’reserved for pyloric stenosis and hour-glass contraction, Mr. HERBERT PATERSON (London) advocated waiting six ’though the possibility of spasm accounting for both these months rather than two before resorting to surgery in gastric ’conditions should be borne in mind. ulcer. He had found duodenal ulcer common, but gastric Professor MITCHELL CLAR’EE (Bristol) considered after a ulcer rare, on the operating table. The pyloric vein formed review of cases that the age of 35 years formed a line of an easy landmark between the two regions. Operating for demarcation between the two forms of gastric ulcer. Those and during hæmatemesis was usually fatal. In gastrostaxis under 35 were chiefly females suffering from mucous ulcer, blood was effused between the cells of the mucous memwhile from 35 onwards the cases included both men and brane, and this was also the case when bleeding occurred women mainly suffering from chronic ulcer. He attributed with ulcer. His own experience bore out the association of - the complaint to employment of articles of food involving hyperchlorhydria with pyloric ulcer and hypochlorhydria in elsewhere. A great number ultimately ,delayed digestion, attended by over-acidity, especially in association ,
.
with ulcer
’working girls.
required surgical aid whether the ulcer was near the pylorus Dr. WILLIAM HUNTER (London) thought gastric ulceror not. Gastro-jejunostomy was more efficient physiosupervened on an inflammatory state of the stomach of logically than mechanically owing to the diminution of - streptococcic origin, constituting gastritis with necrosis, the acidity. later induration resulting from the effect of exposure to Dr. J. M. BUCHANAN (Liverpool) said that it was common -gastric juice. ’’Oral sepsiswas a potent factor, and in to find spasm in the pharynx or oesophagus associated with all cases attention should be directed to the teeth and gums. gastric ulcer. The temperature was raised, and when interIn his experience the temperature was raised in early stages mittent was a warning of impending perforation. There - a fact which supported the view of infection ; so that he were also toxic symptoms, such as aching limbs and back, was satisfied with careful treatment of the mouth, leaving indicating a fresh outbreak. Treatment should include the stomach to recover with time and suitable dietary. It absolute rest in bed for a prolonged period, six weeks or had been constantly asserted that the stomach had anti- more. Serum given by mouth relieved pain. After opera- septic power, but this was exerted only by the hydrochloric tion the artificial stoma worked intermittently. Dr. A. F. HERTZ (London) emphasised the value of : acid, and was fully efficient only two hours after a meal. In anaemia and ill-health it might fail altogether. X rays with the bismuth meal in elucidating organic gastric Dr. CHARLES MILLER (London), who had examined histo- conditions. In 50 duodenal cases he found the stomach logically specimens obtained in the post-mortem room or by small 2 inches above the umbilicus, owing to hypertonic operation, described the minute changes especially in con- peristalsis. The stomach emptied itself rapidly, the mexion with vascular disease. With endocarditis and minute duodenum itself looking dilated. In gastric ulcer the viscus emboli small ulcers were found, and with thrombosis emptied slowly, and presented hour-glass contraction due to blocking arteries, necrosis and ulceration occurred on a more spasm. Intermediate meals relieved pain in duodenal, but extensive scale. Miliary tuberculosis and heart disease were not in gastric, ulcer. When the stomach was dilated he frequently the cause, and thrombosis was met with in the recommended operation, but thought the small hypertonic gastric venules. The lymph follicles, which were absent in condition was better treated medically. Olive oil diminished infants and scanty at 2 years, were well developed in adults gastric pain and supplied the maximum nourishment for its .’and resembled the solitary follicles in the colon. They were bulk. Belladonna succeeded in other cases. There appeared ,found enlarged and projecting in irritated areas, and when to be an ulcerating diathesis, seeing how readily ulcers healed
inflamed, swollen and necrotic. There were definite and reformed. Olive oil should be continued before meals, unicroscopic changes in the ulcerated spots and adjacent; mastication thoroughly effected, and the first indications of and he cited observations and experiments on mucous relapse attended to :a.re&s, immediately. miembrane proving that hydrochloric acid would disintegrate Sir BERTRAND DAWSON replied, and the meeting closed. tissue when the circulation failed. Professor VAUGHAN HARLEY (London), from chemical analysis of stomach contents, said that in gastric ulcer .there was no pyloric spasm, and the test meal showed normal changes, though there might be apepsia. A permanent cure was difficult to ensure. Rest in bed and hot ;applications to the abdomen were the most effective remedies. He did not advocate opeiation. Dr. W. J. TYSON (Folkestone) said that acute cases off
gastric ulcer at 20-25 years of age showed
more
marked
SURGERY.
THURSDAY, JULY 25TH. President, Professor RUSHTON PARKER (Liverpool) Professor E. HURRY FENWICK (London) opened a discussion on Diagnosis and Treatment of Tuberculous Disease of the Urinary Tract. He began by saying that the bedrock fact of the subject was
The
,
371
THE SECTIONS.
THE
MEDICINE. THURSDAY, JULY 25TH. President: Professor T. R. GLYNN (Liverpool). Sir BERTRAND DAWSON (London) opened a discussion on The Pathogenesis, Diagnosis, and Medical Treatment of Gastric Ulcer. He said that throughout the discussion the terms" mucous ulcer"and chronic ulcer"would be employed. Mucous ulcer denoted an ulceration of the mucous membrane. It was usually a subacute condition, tending to heal quickly
BRITISH MEDICAL ASSOCIATION. EIGHTIETH ANNUAL MEETING IN LIVERPOOL.
Mr. F. W. Lowndes, of Liverpool, writes to ns in connexion with the recent meeting of the British Medical Association in the city where his long official and professional work has earned him universal regard :-A remarkable feature in the history of Liverpool is its rapid rise from a poor fishing completely. Sometimes, however, it progressed rapidly village in the middle of the seventeenth century, with and into perforating ulcer or took on the characteristics of a Our and of St. Nicholas one church-the Chapel Lady (the chronic lesion. By chronic ulcer was meant a condition which patron saint of all sailors)-to its present position with involved most or all of the coats of the stomach, and could a population of three-quarters of a million. Towards the usually be appreciated by sight and touch without opening end of the eighteenth century it had a population of 30,000 the stomach. Duodenal ulcer was included in the discussion. and five churches ; it was a town of shipowners and sea- The duodenum above the common duct was embryologically, functionally, and pathologically closely related to the men, merchants, brokers, their clerks, and warehousemen. stomach, and the problem on the two sicles of the pylorus It had suffered much from malignant plague, or black was the same. Mucous ulcers were associated not only with death, which more than once decimated the popula- the terminal stages of fatal diseases like septicaemia and tion and caused the formation of a burial ground outside Bright’s disease, but with curable gastric disorders. They St. Nicholas’s Church in place of that at Walton Parish were seen not only in the post-mortem room, but on the table. They were produced by the combined effect Church, three miles distant. In the eighteenth century operating of (1) lowered vitality or damage of the mucous membrane ; there were physicians and surgeons of mark, notably (2) acid juice. Damage might be by local bacterial infection, Matthew Dobson, Houlston, Currie, Henry Park, and gastrotoxins, or mechanical injury. Like the mucous ulcer, Alanson. The first infirmary was opened in 1749 with a chronic ulcer existed where the hydrochloric acid juice existed. seamen’s hospital. Dr. Matthew Dobson’s name has been Its appearance suggested chronic irritation and efforts at Pathological anatomy supported the development of quite recently quoted for his epoch-marking paper, as repair. the chronic from the mucous ulcer. The defensive forces Dr. Garrod called it, on sugar in the urine of diabetics. of the gastric mucous membrane were considerable, and Henry Park died in 1832, and the first meeting in mucous ulcers healed rapidly. On reaching the subLiverpool of the Provincial Medical Association was held mucous coat this specially defensive mechanism disthe invading force was strong and its very soon after, the President making feeling allusion to appeared. If, then, acute progress rapid, perforating ulcer occurred, whereas if Park and others resting in the tomb. The late Mr. Reginald it was less strong and its progress slow, chronic ulcer Harrison, in his address on Surgery at the last meeting of developed. Mucous ulcers were multiple, whereas chronic the British Medical Association in Liverpool,l gave the ulcer usually occurred singly ; mucous ulcers existed over following quotation from an article in the Edinburgh Review, the whole of the stomach, whereas chronic ulcers were usually October, 1872 : "In the latter portion of the last found in the region of the pylorus ; the different age and sex in the two conditions were facts which might be held (18th) century when a vigorous flash of originality seemed incidence to support the separate origin of chronic ulcer. The clinical to light up the progress of surgery, Park, of the Liverpool picture of ulcer had altered. Whereas formerly the typical Hospital (Infirmary), may be said to have completed the first patient was most often a young woman who had pain after act of conservative surgery. His patient, a sailor, to whomL food relieved by vomiting, with or without hæmatemesis, the loss of a foot and leg would have been tantamount to the now the patient was more often a man, usually over 30, and The. loss of his means of getting bread, determined him to make food more often relieved pain than produced it. of view was due to surgery. In the pre-operative change the experiment of simply excising the diseased parts-the group a case here and there came to necropsy for perforaknee-joint-and retaining the foot and leg. This he did sc tion or haemorrhage ; the remaining cases recovered, and it successfully that, to use his own words, the patient severalL was a natural inference that they consisted of ulcers which years after the operation made several voyages to sea irl had healed under treatment. Pain, tenderness, vomiting, which he was able to go aloft with considerable agility ancL haematemesis characterised other conditions besides ulcer, and bleeding need not have a focal origin. Analysis of to perform all the duties of a seaman, that he was twict) causes in the pre-operative group showed chronic ulcer as shipwrecked and suffered great hardship without feeling an3now understood; gastritis, due to food or drink irritafurther complaint in that limb. This was a crucial test ofE tion, to intoxications, and to chronic infections, aided in success that should have stamped the operation as one of th() many instances by impaired motility ; disordered secreset up by distant irritation (in, say, appendix or like of the time. so But, greatest surgical triumphs man3 tion, and associated or not with pyloro- or cardio-spasm. other great strides taken in that age of extreme vivification ’ colon), ulcers were Mucous no doubt sometimes present, but they it was in advance of its fellows and was destined to btno and called for no different manifestations, special gave arrested for the better part of another half century." On< ) treatment. They were of interest for what they could lead reason, says Mr. Lowndes, for this want of appreciation wa;; to if the conditions with which they are associated are pictures illustrating foregoing : (1) The Henry Park’s modest and retiring disposition, also hi: not treated.ofClinical the anæmic young women; (2) gastric hatred of pen, ink, and paper. There is such a thing a1’ dyspepsia symptoms and trouble in the colon ; (3) gastric symptoms being before the time, but being behind the time is worse , and the appendix; (4) gastric symptoms and morbid and Park, though somewhat unappreciated in his day, nov condition of mouth, nose, and pharynx. The clinical shares in the farne that has comealike to his city and hii3 picture of chronic zslcer(Developed structural stenosis of the pylorus was excluded because it gave evidences profession. Park’s body was buried in St. James’s cemetery,’ of its own and presented no difficulty) ; objective which is situated near Rodney-street, in which street man3’ and their value; tenderness, cutaneous hyperfindings physicians and surgeons reside, and near which is the churcr æsthesia; size and position of stomach ; test supper dedicated to St. Luke. The newly rising cathedral is clost and breakfast disclosing acid content and motility ; to St. James’s cemetery. bacteriological examination ; X ray examination. Haematemesis and melsena needed separate consideration because 1 THE LANCET, Feb. 24th, 1912, p. 483. they might occur alone as well as in conjunction with F3 ,
. ,
-
372
THE BRITISH MEDICAL ASSOCIATION.
If in conjunction, they made the :symptoms than the chronic variety, and either recovered abovesymptoms. ’ulcer picture clearer. DiagnosisSystemic disease might or died quickly. He was guided in considering operation wear the guise of stomach disorder, but seldom presented much by the circumstances of the patient and choice of£ difficulty to -the experienced clinician. The conditions operator. that did present difficulty were : (1) Malignant disease of the Dr. A. MACLENNAN (Runcorn) compared gastric with stomach ; (2) infective or toxic gastritis associated with stercoral ulcers. He affirmed that 70 per cent. occurred on disease of gums, tonsils, pharynx, and nose ; (3) gastric the small curvature and posterior wall. In normal condisturbance caused by disease of gall-bladder, appendix, ditions the mucous membrane was protected by local and and colon ; (4) hyperchlorhydria of unknown origin. general defences. Experimental observations suggested the Treatment included rest in bed, which was of .paramount existence of an antiferment. Superficial ulcers occurred importance, sparing energy and diminishing the need for mainly in young women, and in this connexion he called food. The diet should be milk given frequently in small attention to the fact that in chlorosis the blood was less quantity for several days, being extended by the addition of alkaline than normal. Treatment by nutrient enemata was more substantial ’articles as recovery progressed. Resistance liable to induce acetonuria and so do harm. Normal saline to treatment proved the existence of ulcer, but tonics could solution was more satisfactory, or olive oil by the mouth. usually be given towards the end of a week. Chronic Iron given hypodermically in chlorotic cases was of value. ulcer called for similar diet and, in addition, alkali to Chronic pancreatitis, when present, involved obstruction of neutralise the effect of gastric juice, for it was essential to the gall-duct and gave rise to symptoms suggestive of gallkeep down the gastric acidity even at night and when the stones. Dr. S. H. HABERSHON (London) expressed himself as stomach was empty. The indicationsfor gastro-enterostomy were stenosis of pylorus and the persistence of chronic opposed to the view advocated by Dr. Hunter, inasmuch as ulcer, wherever situated. The artificial stoma acted as a the association of ulcer with hyperchlorhydria, so common safety-valve, preventing distension, keeping the organ in young women, fulfilled the requirements of antisepsis. mnpty, even of its own secretion, and even allowing the Apart from this, other sources might be a B. coli infection or the cytotoxin of Dr. Bolton. He suggested that an acute ’ingress of alkaline duodenal secretions. Professor R. SAUNDBY (Birmingham) dwelt on the mucous ulcer might ensue on superficial erosion or small ,difficulty of discriminating between major and minor con- embolism. The superficial ulcer did not induce pyloric ditions, and considered it wise to treat all on the lines of spasm, but that might ensue later from deeper ulceration. ulcer. He did not feed during hoematernesis, otherwise he In pyloric ulcer the symptoms culminated two to four hours ,a,greed to administering a gradually increasing diet. Opera- after food or at the end of the day; there were variable tion availed nothing iiii acute hsematemesis, but should be dilatation of the stomach and hunger pain. ’reserved for pyloric stenosis and hour-glass contraction, Mr. HERBERT PATERSON (London) advocated waiting six ’though the possibility of spasm accounting for both these months rather than two before resorting to surgery in gastric ’conditions should be borne in mind. ulcer. He had found duodenal ulcer common, but gastric Professor MITCHELL CLAR’EE (Bristol) considered after a ulcer rare, on the operating table. The pyloric vein formed review of cases that the age of 35 years formed a line of an easy landmark between the two regions. Operating for demarcation between the two forms of gastric ulcer. Those and during hæmatemesis was usually fatal. In gastrostaxis under 35 were chiefly females suffering from mucous ulcer, blood was effused between the cells of the mucous memwhile from 35 onwards the cases included both men and brane, and this was also the case when bleeding occurred women mainly suffering from chronic ulcer. He attributed with ulcer. His own experience bore out the association of - the complaint to employment of articles of food involving hyperchlorhydria with pyloric ulcer and hypochlorhydria in elsewhere. A great number ultimately ,delayed digestion, attended by over-acidity, especially in association ,
.
with ulcer
’working girls.
required surgical aid whether the ulcer was near the pylorus Dr. WILLIAM HUNTER (London) thought gastric ulceror not. Gastro-jejunostomy was more efficient physiosupervened on an inflammatory state of the stomach of logically than mechanically owing to the diminution of - streptococcic origin, constituting gastritis with necrosis, the acidity. later induration resulting from the effect of exposure to Dr. J. M. BUCHANAN (Liverpool) said that it was common -gastric juice. ’’Oral sepsiswas a potent factor, and in to find spasm in the pharynx or oesophagus associated with all cases attention should be directed to the teeth and gums. gastric ulcer. The temperature was raised, and when interIn his experience the temperature was raised in early stages mittent was a warning of impending perforation. There - a fact which supported the view of infection ; so that he were also toxic symptoms, such as aching limbs and back, was satisfied with careful treatment of the mouth, leaving indicating a fresh outbreak. Treatment should include the stomach to recover with time and suitable dietary. It absolute rest in bed for a prolonged period, six weeks or had been constantly asserted that the stomach had anti- more. Serum given by mouth relieved pain. After opera- septic power, but this was exerted only by the hydrochloric tion the artificial stoma worked intermittently. Dr. A. F. HERTZ (London) emphasised the value of : acid, and was fully efficient only two hours after a meal. In anaemia and ill-health it might fail altogether. X rays with the bismuth meal in elucidating organic gastric Dr. CHARLES MILLER (London), who had examined histo- conditions. In 50 duodenal cases he found the stomach logically specimens obtained in the post-mortem room or by small 2 inches above the umbilicus, owing to hypertonic operation, described the minute changes especially in con- peristalsis. The stomach emptied itself rapidly, the mexion with vascular disease. With endocarditis and minute duodenum itself looking dilated. In gastric ulcer the viscus emboli small ulcers were found, and with thrombosis emptied slowly, and presented hour-glass contraction due to blocking arteries, necrosis and ulceration occurred on a more spasm. Intermediate meals relieved pain in duodenal, but extensive scale. Miliary tuberculosis and heart disease were not in gastric, ulcer. When the stomach was dilated he frequently the cause, and thrombosis was met with in the recommended operation, but thought the small hypertonic gastric venules. The lymph follicles, which were absent in condition was better treated medically. Olive oil diminished infants and scanty at 2 years, were well developed in adults gastric pain and supplied the maximum nourishment for its .’and resembled the solitary follicles in the colon. They were bulk. Belladonna succeeded in other cases. There appeared ,found enlarged and projecting in irritated areas, and when to be an ulcerating diathesis, seeing how readily ulcers healed
inflamed, swollen and necrotic. There were definite and reformed. Olive oil should be continued before meals, unicroscopic changes in the ulcerated spots and adjacent; mastication thoroughly effected, and the first indications of and he cited observations and experiments on mucous relapse attended to :a.re&s, immediately. miembrane proving that hydrochloric acid would disintegrate Sir BERTRAND DAWSON replied, and the meeting closed. tissue when the circulation failed. Professor VAUGHAN HARLEY (London), from chemical analysis of stomach contents, said that in gastric ulcer .there was no pyloric spasm, and the test meal showed normal changes, though there might be apepsia. A permanent cure was difficult to ensure. Rest in bed and hot ;applications to the abdomen were the most effective remedies. He did not advocate opeiation. Dr. W. J. TYSON (Folkestone) said that acute cases off
gastric ulcer at 20-25 years of age showed
more
marked
SURGERY.
THURSDAY, JULY 25TH. President, Professor RUSHTON PARKER (Liverpool) Professor E. HURRY FENWICK (London) opened a discussion on Diagnosis and Treatment of Tuberculous Disease of the Urinary Tract. He began by saying that the bedrock fact of the subject was
The
,