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GASTRIC ULCERATION.

THE LANCET.

LONDON: SATURDAY, DECEMBER 29, 1923.

THE thoughtful surgeon has an inveterate convictionof the ephemeral nature of his work. He knowsthat there can be no finality in surgery until surgeryis banished from the treatment of disease. Eventually, z,

injury alone will demand the exercise of surgical skill. ’’,This change is slowly but surely taking place before Iour eyes. Not many years ago the excision oftuberculous cervical glands was amongst the com-monest of operations performed in a London hospital ; ’Inow it is almost a rarity. Improved methods of com- Ibating disease have allowed us to dispense with theresort to the knife. Dr. A. R. NELIGAN reminds us inthis issue how, in the treatment of liver abscess, openincision is giving place to aspiration. The same revolu-tion has taken place in the treatment of tuberculousjoints, whilst it seems fairly safe to predict the elimina-tion of surgery in the treatment of malignant diseasewhen the secrets of this scourge have been revealedto scientific investigation. It is therefore to beaccredited as a virtue, when a surgeon is found to Irelinquish an established method for one he findsmore effective in accomplishing his purpose. Thesetruths of surgery are driven home by Sir BERKELEYMOYNIHAN in two recent lectures on the Treatmentof Gastric and Duodenal Ulcer.l 1 " A physiciandoomed to practise surgery," as the author callshimself, Sir BERKELEY MOYNIHAN has brought anessentially critical mind to bear upon problemsarising out of an experience of no less than 718 casesof ulceration of the stomach and duodenum, wherethe diagnosis was established by actual inspection onthe operating table. The conclusions to which he hasbeen impelled by sheer weight of evidence demandour attention and enforce our belief.

In the diagnosis of a gastric ulcer the authorrelies upon two things, the history of the illness andthe radiographic examination. There is only one wayof establishing the existence of an ulcer beyonddispute. It is to see it. X rays will often render theulcer visible before the withdrawal of the " curtain Iof the anterior abdominal wall." As to the symptoms,there is a rhythm which is characteristic of gastriculcer, another significant of duodenal ulcer, and a sortof rhythm of activity alternating with apathy, witha period lasting over weeks or months. Punctualityin the onset of pain or relief from it is of diagnosticimport. In this series of cases, duodenal ulcer wasencountered much more often than gastric ulcer, andSir BERKELEY MOYNIHAN maintains that the latteris seldom within 2 inches of the pylorus and so doesnot commonly give rise to pyloric stenosis. Narrowingin this region is the result of extension of duodenalulceration, a process which may go beyond the

pylorus into the stomach itself, where a malignantchange may supervene. It is possible at this stageto come to some conclusion of value concerning thatdifficult decision as to the efficacy of medical methods ’Iof treatment at our disposal. Medical treatment Irarely leads to sound healing and

demands

such Ienduring care on the part of both patient and physician,1 Gastric and Duodenal Ulcer. By Sir Berkeley Moynihan.

Bristol: John Wright and Sons, Ltd. 1923. Pp. 48. 2s. 6d.

that it becomes too irksome as a practical measurefor those who must take part in the ordinary inter-course of the world. Sir BERKELEY MOYNIHAN, incases where the only possible operation was a jejunos-tomy, has been able to watch the alteration in X rayappearances from time to time. He finds that

healing, as evidenced by change of shadow outline, isalways a matter of many months and in some casesof years. Neither is the disappearance of the niche,as seen by barium meals, always proof of healing.This fallacy was demonstrated by E. HOLLANDER. 2Many gastric ulcers resemble those intractable legulcers which repeatedly break down and persist untilthe end of life. It is without exaggeration to saythat the medical mortality from perforation and

haemorrhage is vastly greater than that incidental tosurgery, which in a very high percentage of patientsleads to a permanent cure. In Sir BERKELEYMOYNIHAN’S large personal series, there has been nooperative death since 1912. There is one other

argument brought forward to support the surgicalattitude in the treatment of gastric ulcer, the beliefthat cancer arises in the simpler lesion. This does notcarry the weight of the considerations set forthabove, for a very competent group of pathologistsdeny the frequency of malignant degeneration onfirm histological grounds. Cancer, according to them,does sometimes originate in the margin of an ulcer,but quite rarely.However this may be, surgery seems definitely to have

established itself as the only effective treatment forgastric ulcer. What should be the method of surgicalattack is an almost equally vital question to decide.Opinion is not quite unanimous yet on this point.Sir BERKELEY MOYNIHAN has tried many procedures.Generally speaking, he has concluded that gastro-jejunostomy is most widely applicable and effective induodenal ulceration, whilst excision of the pyloricsegment of the stomach with lateral implantation intothe jejunum by the " no-loop " method, devised byhimself, is almost ideal in the treatment of the gastriclesion.

INSANITY ON ARRAIGNMENT.

I OF the minor points arising out of the recent reportof the Committee which has been considering thelegal effects of insanity in criminal trials therewas one-not covered by our recent summary-which has not had to wait long for illustration.A young man was found guilty of the murderof a woman in a taxi-cab in the Brompton-road. There had been a preliminary question of hisfitness to plead to the charge. Dr. W. N. EAST,senior medical officer of Brixton Prison, expressedthe opinion that the man was unfit to take his trial.Mr. Justice AvoRY, however, with some remarksupon the divergence between medical and legalviews, instructed the jury that, if the man was able(as he seemed to be) to follow what was going on incourt, they could say that he was fit to plead. The

jury found him fit to plead, and the case proceeded,with the result already stated. -VVe alluded tothis case more in detail under the heading ofMedicine and the Law, and need only note herethat the divergence of opinion to which the

judge referred was merely the notorious difference

between legal and medical conceptions of insanity.Had the jury found the man unfit to plead, his subse-quent treatment would have occasioned a furtherdivergence of opinion which is worth examination.

2 Jour. Amer. Med. Assoc., 1923, lxxx., 29.