Clinical Congress

s of the papers there presented follow: THE MANAGEMENT OF GASTRIC AND DUODENAL ULCER: MEDICAL AND SURGICAL FRANK H. LAHEY, M. D., Director of Surgery, Lahey Clinic, Boston. The cause of gastric and duodenal ulcer is unknown. In the majority of instances there is an associated hyperacidity and certain other general factors are usually present. In the past a difference of symptomatology in the two types has been postulated. It is better to assume that the symptomatolQgy is similar. The important factors in diagnosis are the history of the pain and the X-ray findings. Usually, in the same individual, the time period of the pain is the same every day. Late pain relieved by food is a reliable symptom. The periodicity is important in differentiating from carcinoma. X-ray examination may be misleading and should not be overvalued. Extra-gastric lesions may simulate the X-ray, picture of ulcer. Fluoroscopy is of greater value than are cold plates; it shows the altered pyloric physiology which is associated with all ulcer lesions. The evidence indicates that the symptoms of ulcer are probably due to altered pyloric physiology. Vomiting or the administration of alkali removes the hyperacidity, and the effect of pylorospasm ceases. Operative procedures effect cures either by providing a passageway which prevents the accumulation of acid in the stomach or by the removal of the pylorus itself, along with the lesion, thus overcoming the effect of pyloric spasm. In our attitude on the handling of ulcer cases we must cease membership in either medical or surgical camps. The mortality of the radical operations is high and there is recurrence in the form of gastrojejunal ulcer in about 8 per cent of cases after gastroenterostoniy. On the other hand, we must admit that even under the best medical management many patients must come to surgery. YALE JOURNAL OF BIOLOGY AND MEDICINE All patients, excepting those with perforation (which is an indication for immediate operation), should go through a period of medical regime before being considered as candidates for surgery. This regime must be much more carefully and accurately determined than it has been in the past. Hemorrhage and suspected malignancy are not indications for immediate surgery. No patient with hemorrhage should be operated upon without having had a period of medical treatment. Before operation for malignancy the diagnosis must be definite and the surgeon prepared to do a resection. Questionable cases should be hospitalized for trial on medical treatment to determine the effect on the X-ray shadow. Pyloric obstruction with active ulcer symptoms may open under rest, diet and neutralization, and does not necessarily require surgery. After medical management fails to free patients from pain, hemorrhage and hyperacidity, they become candidates for surgery. Following operation the patient should again be placed under medical regime. A discussion of various operative procedures and the surgical problems presented by different situations was illustrated by lantern slides. GASTRO-INTESTINAL NEUROSES ARTHUR L. HOLLAND, -M. D., Assitmant Professor of Clinical Medicine, Cornell University Medical College,