535

schools, and has issued an admirable syllabus of the subject;but now arises a great difficulty. The subject is new, theteachers of the three R’s have not been trained in it, andwho is to teach the teachers (1 We want, for the °ake ofthe country, a central institute for physical training, whichmight be on the same lines as the London University,with colleges all over the country, where the teachers couldbe themselves taught, while the central institute mightexamine as to their fitness and grant a certificate, but it

is exceedingly difficult to get people to see the necessityof this. They all complain of the expense and wish to

lessen the education rate below what it is at present. I for

one should be quite pleased to do this, but it ought to be bycutting off a lot of extraneous subjects, teaching the threeR’s thoroughly, and building up the physique of the children.But any scheme of physical training would have been liable,as I have said def ore, to do harm instead of good, unless itwere preceded by compulsory medical examination of schoolchildren. This, fortunately, we have now got, so that, asmedical men, with the good of the country before us, wemust now do the best we can to ensure proper physicaltraining. By obtaining this we shall diminish the number ofcripples and of unemployed ; by strengthening the physiquewe shall, I think, strengthen the morale; and, as I said in anaddress I gave some two or three years ago, it is cheaper tospend pence upon children than pounds upon paupers.

ON

PEPTIC ULCER AND DILATATION OF THESTOMACH.

Delivered before the St. Helens (Lancs) Medical Societyon May 4th, 1910,

BY T. R. BRADSHAW, M.D.DUB., F.R.C.P.LOND.,SENIOR PHYSICIAN TO THE LIVERPOOL ROYAL INFIRMARY ; PRESIDENT

OF THE LIVERPOOL MEDICAL INSTITUTION.

GENTLEMEN,-It is no part of my business now todiscuss the causation of ulcer of the stomach or of theduodenum. It is sufficient to note that simple ulceration ofthe type met with in these organs does not occur in anyother part of the alimentary tract except under very specialcircumstances ; that, in fact, it is strictly limited to thoseparts that are bathed with the acid gastric juice. I am at

present chiefly concerned with the problem of the diagnosisof peptic ulcer when it already exists, with its treatment,and with the recognition and treatment of certain well-knownmorbid conditions which may follow in its train.

DIAGNOSIS.As regards the differential diagnosis between gastric and

duodenal ulcer, I doubt whether it can be made with anyconfidence, unless the associated conditions point strongly toa lesion at the cardiac end of the stomach, when the questionof duodenal ulcer is not likely to arise. Duodenal ulcer ismore frequently found post mortem in men than in women,but the Royal Infirmary reports for the last 13 years showthat even in men gastric ulcer is twice as frequently met withas duodenal ulcer, so that the male sex only slightly increasesthe probability of the ulcer being duodenal. The statisticsof operation are not far different.Nor is the location of the ulcer on one or other side of the

pylorus of much importance in practice, as the treatment isessentially the same in both cases. The anxious problem-theproblem which concerns not merely the immediate treatmentof the case but the future prospects of the patient, and it maybe the reputation of the medical attendant-is the determina-tion whether ulceration is present or not.

Apart from acute symptoms indicating perforation andcalling for immediate operation, the signs and symptomspointing to ulceration of the stomach are notoriouslyequivocal and uncertain. They practically resolve them-selves into three-viz., pain with or without tenderness,vomiting after food, and hasmatemesis or melasna. Wherethis triad of symptoms is present a provisional diagnosis ofpeptic ulcer is justified, and the absence of one or other ofthe three by no means excludes it. In the nervous type of

patient, however, pain, unless very severe, is obviously anuntrustworthy guide, and no one can fully gauge the extentof another’s suffering. Vomiting also is not uncommonwithout ulcer, especially in chlorotic girls of nervous tem-perament. The vomiting of blood or the passage of melasnaseems to offer more solid ground for a diagnosis. Still evenhere certainty is not easy to attain. Blood may be vomited,or appear to be vomited, when the source of bleeding is notin the stomach. Young women sometimes have a practice ofsucking their gums at night, and, especially if cariousstumps are present, blood flows, is swallowed, and is subse-

quently vomited. I always suspect this source of the bleedingif I am told that it has occurred in the morning before break-fast. Blood from the naso-pharynx also may be swallowedand then vomited, and some time ago I saw in consultation agentleman who had a small ruptured vein in the soft palate,the intermittent bleeding from which had given rise to aserious alarm that he was in the early stage of cirrhosis of theliver.But apart from such cases we are faced with the question

whether bleeding directly from the stomach wall, withoutany other indications of a hasmorrhagic tendency, may notoccur without the breach of continuity and loss of substancewhich constitute ulcer. Such a possibility was recognisedby the older physicians, who taught that hemorrhage mightbe vicarious to the catamenia, and Dr. Hale White has of lateyears directed special attention to bleeding occurring apartfrom ulceration under the name of gastrostaxis. In the

year 1901 a young woman, aged 23 years, was admitted tothe Liverpool Royal Infirmary with pain in the chest andvomiting, followed two days later by hmatemesis. Laparo-tomy was performed, the stomach and the duodenum wereopened, but no ulcer was found. A week later basmatemesisrecurred and she died. At the post-mortem examinationtwo erosions of the size of a pin’s-head were found in themucous membrane near the lesser curvature of the stomach,and microscopically there were numerous engorged capillaries,not arteries, opening into them. May it not be that manycases of seeming bleeding ulcer which get well are merelycases of such capillary oozing ?

STATISTICS AND CONCLUSIONS DERIVED FROM THEM.

We will now inquire what light, if any, the examination ofstatistics may throw upon the problem. During the 13 yearsending 1908 the total admissions into medical wards of casesin which a diagnosis of gastric ulcer was made were 389-33 men and 356 women-and the mortality was 4, 3 per cent.It thus appears that, whether correctly or not, the diagnosisis made ten times more often in women than in men, andthat as seen in the medical wards of a hospital the mortalityin such cases is low. When we come to the surgicalstatistics we find a somewhat different state of affairs. Thecases here will manifestly be the graver cases, and those inwhich the diagnosis is more likely to be certain. I only takethe figures from the beginning of 1901, since before that dategastric surgery hardly existed. Here I find that out of 77cases diagnosed as simple gastric ulcer 72’5 5 per cent. werewomen, and out of 56 cases of perforated gastric ulcer theproportion of women (71’ 5 per cent.) is practically the same.If, however, we take performance of plastic opetations,gastroenterostomy and pyloroplasty, as indications of formerulceration we find its incidence about equal in both sexes-viz., 89 men and 84 women. As regards post-mortemstatistics there is a slight excess of gastric ulcer in womenover men, but if we include ulcer of the duodenum, which, asI have said, cannot as a rule be differentiated clinically fromgastric ulcer they are practically equal-24 men and 26women. Duodenal ulcer was so rarely diagnosed and soseldom perforated (2 males and 1 female) that it was notworth while including it in the clinical statistics.

I think we may draw the following conclusions from thesefigures. 1. Acute ulcer of a kind liable to lead to perfora-tion is nearly three times as common in women as in men.2. Chronic ulceration, which is likely to give rise to cicatricialdeformity and to call for plastic surgical operations, is

equally common in both sexes. 3. Fatal ulceration is

equally common in both sexes. In the face of these figureshow are we to interpret the fact that in the medical wards356 women were diagnosed as suffering from gastric ulcerand only 33 men ? ‘! Two explanations are possible : (1) itmay be that the great majority of these women were not

suffering from gastric u:cer at all ; or (2) it may be that

536

gastric ulcer is really more common in women, but that in s1

them there is a greater tendency for it to get well T

quickly and without cicatricial deformity. My own t

view is that both these factors are present. The sl

occurrence of gastrostaxis, oozing of blood without ulcera- sl

tion, has been proved to be possible. The tendency of t]the ulcer in women to perforate is not incompatible with a n

tendency to heal rapidly if this accident is averted. On the gcontrary, our general experience of pathology is that the s

more acute a disease is at the commencement the more likely u

it is to get well if the patient survives the first onslaught. I asuggest that of the many women admitted to the hospital pwith hsematemesis and other indications of gastric ulcer, a n

large proportion, though I cannot say how large, have no v

ulcer at all, and that a large proportion have an ulcer which i]

places them for a time in imminent danger, but which getswell under rest and careful medical treatment. t

GASTRIC ULCER AND APPENDICITIS. 1. yMr. Moynihan, in a recent address which has excited no t

small amount of discussion, suggests that in Dr. Hale White’s a

instances in which a diagnosis of ulceration of the stomach c

had been made, in which also hasmatemesis had occurred, cbut in which no perceptible lesion was present, the patients twere in reality suffering from appendicitis. That symptoms s

pointing strongly to gastric ulcer may be due to an appendi--citis otherwise latent I readily admit, and I published such acase briefly in the British Medioal Journal three weeks afterthe appearance of Mr. Moynihan’s paper, but to assume, ashe does, that all similar cases in which there is no ulcer are icases of appendicitis is a hasty generalisation for which there (is no adequate foundation in fact. t

SITUATION OF ULCER IN RELATION TO COMPLICATIONS tAND SEQUELAE. 1

l The most frequent situation for peptic ulcer is at or near 1

, the pylorus and on the posterior wall. Much less frequently i, it occurs on the anterior surface of the stomach and at the i

cardiac end. The location has an important influence on I

the complications and sequoias of the ulcer. Thus-if a pyloriculcer heals with cicatrisation it is likely to lead to stenosis 1and gastrectasis, a condition I shall deal with at length cpresently. An ulcer on the moveable anterior surface is i

likely to perforate into the peritoneum, while an ulcer at the iback is more likely to contract protective adhesions to theadjacent structures. In the rare instances in which the ulceris at the cardiac end complications connected with the leftpleura are liable to occur. Over a year ago I saw, in con-sultation with Dr. Banks of Liscard, a young lady who had afoetid left empyema apparently produced by extension ofinflammation through the diaphragm from a gastric ulcer.The signs and symptoms were sufficient to convince us ofthe correctness of the diagnosis, but as drainage wasfollowed by complete recovery it was not verified. Quiterecently, however, I had a woman admitted to hospital with- signs of left pleurisy in whom acute abdominal symptoms ledto operation a few days later, and an ulcer was found at thecardiac end of the stomach which had led to the formationof a subdiaphragmatic abscess in the neighbourhood. The

possibility of a gastric origin ought always to be kept in mindin dealing with a left-sided pleurisy or empyema.

If the possibility of true hasmatemesis without ulceration,gastrostaxis, be admitted, as indeed it must be, the dia-gnosis of acute gastric ulcer can rarely be made at once withcertainty apart from the occurrence of perforation. Ourduty, however, will be to look upon all instances of gastricpain and hasmatemesis as cases of the graver condition and totreat them accordingly.

TREATMENT.

As regards the treatment of gastric ulcer, my practicefor many years has been to withhold all food by themouth for three days after the last appearance ofblood in the vomit or the stools, and to administernutrient enemata four times a day. On the fourth

day I would begin to administer small amounts of milkdiluted with soda-water or lime-water, perhaps only a tea-spoonful every three hours at first, and gradually wouldincrease the amount every day. Under this treatment

relapses rarely took place and progress, though slow, wassure. Latterly, since Lenhartz published his views, I havetried giving more food from the very first, a pint of milkwith a beaten-up egg in the first 24 hours and the amount

steadily increased, and I have certainly seen no harm result.The theoretical basis of this treatment is that the adminis-tration of nutrient enemata, while little more than slow

starvation, excites a flow of acid gastric juice in thestomach which irritates the ulcer, while, on the other hand,the proteids in the egg-and-milk not only maintain thenutrition of the patient but combine with the acid of thegastric juice and render it inoffensive. I have not hadsufficient experience as yet of this method to feel justified inurging its use. In one case of abundant hasmatemesis in ananasmic young woman it was followed by a rapid and com.plete restoration to robust health, and so far I have seenno harm from its employment. Whatever other meanswe adopt, absolute rest, physical and mental, must beinsisted on.The administration of antilytic horse serum has lately

been extolled in this disease. I am at present giving it to ayoung woman with symptoms of gastric ulcer, and the effecthas certainly been highly satisfactory. It seemed to relievethe pain in a marked degree, so that when I stopped it aftera few days she asked me to put her on it again. On theoreticconsiderations it seems worthy a trial, and in cases whichdo not yield quickly to rest and careful dieting it ought tobe given. I have long used uncooked mutton, extracted withsalt-and-water, with apparent advantage.

AFTER-RESULTS.

I know of no statistics to show in what proportion of caseswhich have recovered from symptoms suggestive of pepticulcer stenosis, dilatation or other results of cicatricialchanges are likely to occur. Considering the frequency ofsymptoms suggesting ulcer in women, one is inclined to thinkthat the great majority at least in them leave no permanenttrouble. On the other hand, in cases where permanentpyloric stenosis or other organic deformities are present it isthe rule to find a history of long antecedent gastric trouble,including the vomiting of blood. Further, it is not possiblein practice absolutely to separate cases of ulceration fromthose affected by cicatricial contraction. As likely as notwhen a stomach is dilated from a cicatricial contracted

pylorus a chronic open ulcer will be found at the marginof the orifice ; and where the symptoms point to activeulceration extensive cicatricial contraction will also notinfrequently be found to exist.

DILATATION OF THE STO1TACH.Dilatation of the stomach in a greater or less degree may

be met with in a variety of conditions, and it is no easymatter to determine where physiological distension ends andpathological dilatation begins. The size of the normalstomach must vary almost from hour to hour, and its formand position alter greatly according to the position of thebody, whether erect or reclining. Where great dilatation ispresent, such as results from marked stenosis of the pylorus,the signs and symptoms are very obvious. The patient willtell you that for weeks or months past he has been subject toattacks of vomiting at various intervals, that the vomit isusually brought up in enormous amounts, so as to fill achamber or a wash-basin either at once or in the course oftwo or three hours. The vomit will probably be described asfrothy or barmy, or it may be simply watery or stainedbrownish from altered blood. If you are shown a specimenof the vomit you will find it strongly acid, and with the

microscope you will probably nnd sarcinas present in thesediment. Physical examination of the stomach will yieldappearances which differ according to the period of theexamination. When the stomach is full and relief from vomit-ing has not taken place the outlines of the distended organwill be distinctly visible. In marked cases the greatercurvature is seen sweeping across the abdomen two or three

, inches or more below the umbilicus ; the lesser curvature may! also be seen if there is visceral ptosis ; between the two there, is a convex protuberance which may be seen to alter its form. as the result of peristaltic movements of the stomach wall.On palpation with both hands coarse succussion splash may: be easily elicited, and also by gently shaking the patient. from side to side. Percussion will yield extensive tym-I panitic resonance over the stomach area anddulnessinthe5left flank. After relief has been obtained by vomiting, thei signs of dilatation may be but slight or may be impossible to detect. Some splashing sounds may usually be elicited onL sharply depressing the anterior abdominal wall, but the samemay occur in subjects apparently healthy.

537

INTERMITTENT PYLORIC OBSTRUCTION.A very remarkable condition is that of intermittent pyloric

obstruction, a condition particularly described by Sir CliffordAllbutt, and of which I will narrate two instances in my ownpractice. One was that of a young man who was admittedto the Royal Infirmary with a history of vomiting such asI have described. To physical examination the stomach

appeared normal. A few days later (he having remainedquite well in the meantime) I found the stomach

enormously distended. I came to the conclusion that therewas some pathological condition about the pylorus, pro-bably adhesions, which caused the stomach to become

acutely bent or kinked so as to produce complete occlusion,and I asked my colleague Mr. W. Thelwall Thomas to per-form an exploratory laparotomy. This he did, when he foundadhesions around the pyloric end of the stomach, and wasable to show me how a slight dropping of the organ couldcause complete occlusion of its lumen. Gastro-enterostomywas performed, rapid recovery took place, and I have heardno more of the patient. In another case to which I shallhave occasion to refer more fully later the patient has been foryears liable to temporary complete pyloric occlusion withenormous distension of the stomach relieved by vomiting. Onone occasion a remarkable form of relief took place. Duringone of these attacks she passed a grumous, frothy, liquidstool measuring about a pint and a half, much resembling inappearance the liquid vomited a day or two before. Afterthe evacuation she felt better, the abdomen was flatter, and thestomach, which I had found much distended in the morning,appeared to me to be much smaller. I believe that in thiscase the pyloric stenosis was in part due to torsion or

kinking of the part, and that by some fortunateaccident it had become untwisted. Sir Clifford Allbuttquotes a case on the authority of the late SirWilliam Broadbent in which such an event frequentlyoccurred. The patient after retiring to rest would have asense of the gushing of fluid within her, and on seeking thecloset a profuse liquid discharge would issue from the rectum.After such a discharge the stomach was no longer perceptibleby the physical signs which had previously been only toomanifest. Ultimately a necropsy was obtained and non-

malignant stricture of the pylorus was found. In the

upright position the pylorus was probably closed by acuteflexion of the part at the point of suspension.

DIFFICULTIES IN DIAGNOSIS.

In cases where the distension of the stomach is great itmight seem that the diagnosis would present no difficulty,but where the obstruction is intermittent, as in the two caseswhich I have named, this is far from being the case if the

practitioner does not happen to be consulted during theattack of complete obstruction. In such cases also thevisible peristaltic movements, which are rightly regarded asan important sign of pyloric stenosis, will probably at notime be present, since the obstruction is of too brief durationto induce much hypertrophy of the muscular coats of thestomach. The sudden unaccountable attacks of gastric painand vomiting may, I believe, be mistaken for the gastric crisesof locomotor ataxy, and lead to the diagnosis of that disease, aserious, perhaps fatal, error in view of the possibilities ofsurgery. Two years ago a gentleman, aged 40 years,married three years, was brought to me by his medicalattendant. He had lately seen a physician in London, arecognised authority on the nervous system, who suspectedthat he had locomotor ataxy. He assured me that he hadnever exposed himself to the possibility of acquiringsyphilis. There was no family history of nervous disease.He used to enjoy good health, but for the past year he hadsuffered from periodical attacks of gastric pain and vomitingand had lost a good deal of weight. He told me he hadvomited as much as two pints at a time. Finding that hispulse was 100 or more I thought of the possibility of loco-motor ataxy, but abandoned the idea on finding the knee-jerks brisk and equal. The pupils were not quite equal, butthey reacted normally to light and to accommodation ; therewas no unsteadiness on standing with the eyes closed, andthere was no ataxy of the arms. There had been pains inthe legs, but they were not like lightning pains, but seemedto be of a rheumatic nature, since they made the patientlimp in his walk. There had been temporary weakness ofthe external rectus of one eye. I found marked splashingin the stomach, which seemed to be dilated, and the urinecontained indican. In the absence of syphilis, of the Argyll I

Robertson pupil, and of ataxy, and with the knee-jerks brisk,I felt justified in assuring the patient and his wife thatwhatever else might be the matter he was not the victim oflocomotor ataxy. I inclined to the view that he had pyloricobstruction with occasional complete occlusion from twistingor kinking of the viscus. This gentleman had consulted atleast three other physicians, one of whom, a general physicianwith leaning to neurology like myself, held with me thathe had not got locomotor ataxy. It is only right, however,that I should state that since he saw me he consulted anotherLondon neurologist who believed that he had locomotor

ataxy. However, a year after I saw him he died, wornout by the gastric attacks, and I am told that the knee-

jerks were retained to the last. He had refused operation.With such an after-history I leave you, gentlemen, to drawyour own conclusions between the diagnosis of a chronicspinal degeneration and of organic disease of the stomach.Whenever we meet with clear indications of dilatation from

pyloric obstruction we may advise gastro-enterostomy withthe greatest confidence of success.DIFFERENTIAL DIAGNOSIS OF ORGANIC AND FUNCTIONAL

DISEASE.In the great majority of cases of organic disease of the

stomach, accompanied or preceded by ulceration, the signsand symptoms are much less distinctive than those I havedescribed and the differential diagnosis from functional dis-orders becomes more difficult. Apart from the mere persist-ence of chronic ulcer, which may be attended with pain andvomiting and occasional hasmatemesis, we meet with variousforms of cicatricial contraction. Pyloric stenosis leading togreat dilatation I have already considered ; in other casesthe dilatation may be comparatively slight. Again, thecicatrix may be in some other portion of the stomach andmay constrict it in such a way as to produce an hour-glassstomach or other deformity. Finally, the existence ofexternal adhesions, the result of former inflammation

spreading to the serous coat, may fix the stomach to

neighbouring parts, prevent its normal expansion, and limitits movements in various ways. In cases such as thesethe symptoms will be mainly those of chronic indiges-tion-pain after food, acid eructations, flatulence, andoccasional vomiting. There will probably be a gooddeal of wasting, whether resulting from the diseaseor from the treatment, for when patients are sentto me with such symptoms they have generally been sub-jected to a rigidly restricted diet for a considerable time.On physical examination it may be that some hardness maybe felt in the epigastrium, or visible peristaltic movementsmay be seen ; more often the only objective sign is the

presence of audible and palpable splashing in the sameregion. If there is pain and a history of recent vomitingthe probability of organic obstruction is considerable ; inthe absence of these for hours or days the existence offunctional dyspepsia and atony of the stomach is more

probable. Much will depend on the habit and mode of lifeof the patient. You will sometimes find that an anxious,over-wrought patient, with a flabby stomach, will be quiteable to digest a solid meal when he is taken away from hiswork and made to sit still for half an hour before his dinner.I could give you illustrative cases did time allow.

In deciding to submit these chronic cases to operation themere size of the stomach is of less importance than the timein which the organ passes its contents onwards into theduodenum. Gastric stasis may be asserted to be present ifsome six hours after a meal some of the food still remains inthe stomach. A good plan is to order a light meal with atablespoonful of currants to be taken at bedtime and thenwash out the stomach the first thing in the morning. If noneof the currants are recovered the motor power of the stomachis not seriously impaired. Of late years we have come to

rely more and more on radioscopy in determining the sizeand motility of the stomach. By this means we can watchthe progress of a bismuth meal through the alimentary tract.When we find distinct delay in transmission, accompaniedwith local and constitutional symptoms, we may generallyadvise gastro-enterostomy. t...

’_ - — A REMARKABLE CASE.

I now propose to bring this long discourse to an end byrelating the case of a lady, a friend and patient of my own,which presents some features which, as far as I know, arequite unique.A widow lady, 64 years of age, first consulted me in

H 2

538

October, 1900. A good many years before she had beenattended by a well-known physician, since retired, forhoematemesis, and subsequently for mitral regurgitation.When I saw her she had gastric pain, there was vomiting,and the stomach was distended. At times the distension wasgreat and was relieved by copious vomitings of wateryfiuid containing a little blood, sarcinse, and a good deal offree hydrochloric acid. The patient was clearly sufferingfrom temporary complete occlusion of the pylorus. A surgeonwho saw her with me was unwilling to operate on account of Bthe patient’s age and the presence of valvular disease. The ipatient also declined operation and after one trial of lavageresolutely refused to allow me to repeat the process. Forsome days she was fed entirely by the rectum ; even then thestomach continued to fill up with its own secretions. On oneoccasion the spontaneous evacuation through the pylorus andthe bowels, which I have already described, took place.After some days the power of retaining a little food returned,but any slight increase in the amount was liable to befollowed by complete occlusion. To make a long storyshort, my patient found that she had to submit to live

entirely on fluids and not too much of them. A small pieceof solid food no bigger than a grain of corn seemed capableof plugging the pylorus ; any distension of the stomachcaused it to drop and the pyloric end to become kinked.For 8 years she lived-I am not exaggerating-on a pint offluid and two or three crumbly biscuits per diem, and inspite of this care had an attack of complete occlusion every8 or 12 months, each one of which I thought would prove tobe the last. She wore an abdominal belt, which certainlyseemed of some service in supporting the stomach. It was

surprising how she retained her mental and bodily vigourunder this regimen. Two years ago, however, she was evi-dently failing from want of proper nutriment, and while I

spending the summer at the seaside she began to sufferfrom a peculiar hallucination. She told her family,obviously in good faith, that I had said she might eat any-thing she liked, and insisted on consuming meat andvegetables in considerable quantity. The result was, asmight have been expected, that an attack of haemorrhagetook place. However, she persisted with the new and enlargeddietary, and instead of getting worse she improved, andafter being confined for eight years to a daily allowance of apint of liquid she found that she was now able to take

ordinary food in normal amounts. She began to put onflesh, and for the last two years she has enjoyed good health,takes her meals as do others, and has had no return of vomit-ing or other serious symptoms of gastric trouble. Apparentlythe disturbance from the taking of solid food two years agoled to the ulceration or stretching of the adhesions thatrestrained the pylorus. If this was madness there was

method in it. One often feels that nature is a good physicianbut a bad surgeon, but here a beneficent process of ulcera-tion or of extension had brought about a complete and lastingrelief which could scarcely be improved on by the knife ofthe most skilful surgeon.

A CASE OF MIGRAINE ASSOCIATED WITHCHLORINE RETENTION.

BY HUBERT HIGGINS, M.A. CANTAB., M.R.C.S. ENG.,L.R.C.P. LOND.,

LATE DEMONSTRATOR OF ANATOMY, UNIVERSITY OF CAMBRIDGE, ANDASSISTANT SURGEON TO THE ADDENRROOKE’S HOSPITAL,

CAMBRIDGE.

THIS pa.per dea.ls with records of observations made in acase of long-standing neurasthenia and migraine in a well-preserved man aged 43 years, who had not been strong frombirth and who had suffered from liver complaint whenyoung. There was also a history of scarlet fever complicatedby abscesses in the neck. From the age of 8 to 12 years hewas much stronger ; a meat diet was prescribed ; he was ableto take a great deal of exercise, mainly bicycling. From12 to 16 he went to school in France, where he was badlyfed and was practically without exercise. He returned to

England overgrown, thin, and weak. It was subsequent tothese experiences that his headaches commenced. From17 to 24 he was continually travelling, mainly on the conti-nent, but he also visited the Colonies and America. From

21 to 31 he was subjected to serious family and financial

)rries in addition to excessive work. During thisriod he consulted Dr. A. Haig and adopted his dietr nearly a year without benefit; large doses of sali.late of sodium and bromide of potassium were pre.ribed. Though he resumed a meat diet he was stillLder the influence of the uric acid idea," which inducedm to take only a small proteid ration ; at thisme he became a teetotaler. He paid three visits toihmann’s sanatorium at Dresden, where the poisonous"talities of meat were again insisted on ; in addition, he wasformed that sodium chloride was a poison, and that itLould be omitted from his food. Since this period-that is! say, since 1905-he has omitted the use of salt except on,re occasions ; he also instructed his cook not to use it in)oking. His health became so great an anxiety to him fivesars ago that acting under medical advice he gave up hisork as a manufacturer, built a house in the country andent in for fruit-farming. He lived mainly on cheese andyaltry, and he undertook as much physical work as hisirength allowed. During the past year he has been reduced) the minimum of both physical and mental work. He

egan to complain of cardiac weakness, with the mostivincible depression and lassitude.Present condition.-His height was l’ 68 metres, weight

tripped) 75’ 6 6 kilogrammes ; chest measurements, 107entimetres in inspiration and 90 centimetres on expira.ion ; and circumference at the level of the umbilicus,3 centimetres. The lips were a good colour. Nothingbnormal was discovered on examination of the heartr lungs. His blood pressure was 70 millimetres ofIg. Though his appetite was "too good" he had.ot complained of indigestion, and his bowels were

practically always regular. The abdominal walls were

Labby and covered with fat. There was a distinct bulge ofhe muscular wall below the umbilicus. Fs3ces and a decided

pasm were felt on examination of the descending colon. Theransverse colon could not be felt. He stated thatheex-)erienced a decided sensation of support and relief on firm)ressure being applied over the pubes from behind (Glenard’s, épreuve du sangle "). The charcoal test was carried out..2 charcoal lozenges were given at night; the fasces wereiot discoloured till the second day ; on the third day onlyasmall quantity was found in the first part of the motion.Chis showed an early stage of coprostasis from spastic colon.During the time the patient was under observation he was

lirected to take the minimum of exercise, to do everythingslowly, never under any circumstances to get fatiguedtientally or physically, to abstain from pappy starch foods,K) "poltophagise" " his dextrinised starches as carefully aspossible, and to keep the colon empty with cascara andoccasional water enemas. The main indications, revealed bythe urinary analyses, were to secure dechlorination by assimple means as possible, and to administer magnesium,calcium, and phosphorus in the form ’of eggs. It was clearthat the full re-mineralising ration (earthy and vegetablesalts in addition to eggs and meat) produced too great a

reaction as it changed the day quotient from 1’ 1 to 0 ’7 innightthe case of urea, and from 1’ 0 to 0 - 6 in the case of uricacid. (See diagrams 1 and 2.) During the rest of the timehe was under observation he was allowed rather more thanhis ordinary ration without vegetable salts.

The analytical observations fo2cnd to be associatcd with svb.jective sensations.-The chief subjective sensations com-

plained of were as follows : 1. Sensations of exaggeratedfatigue, which the French express by the word courbatme"and the Italians by I I taglia gambe (literally, the legs cutfrom under one). 2. Mental depression of the overwhelm-ing, unreasoning kind so characteristic of "neurasthenia."3. Headaches lasting sometimes as long as three days,accompanied by the usual migraine symptoms ; they usuallycaused insomnia, as he was obliged to sit up in bed to easethe pain ; so soon, however, as he slipped down he was

awakened with a fresh exacerbation. Depression and fatiguesensations were always associated, analytically, with" Joulie " hypoacidity and more or less decided increasein the Jacquemet

"

reaction ; on several occasions the tubeused in the latter test could be held upside down for as longas 10 seconds before the layer of colloid would allow it tofall. These symptoms were invariably and quickly removedby means of not more than 70 drops of phosphoric acid. Oneach occasion there was a decided increase in the indican.