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The positive roentgenologic diagnosis of gastric ulcer can only be based upon the presence of one of two signs: viz., the niche or the accessory pocket. Other signs which are corroborative but not diagnostic of themselves are: (1) the incisura, (2) hour-glass stomach, (3) residue in the stomach after six hours, (4) lessened mobility, (5) localized pressure-tender point, (6) delayed opening of the pylorus, (7) acute fish-hook form of the stomach with displacement to the left and down, (8) gastric hypotonus, and (9) antiperistalsis.

Von Eiselberg in his recent address before the Clinical Congress in London said: "In spite of the progress made in the diagnosis of gastro-intestinal disease, among which I place the Roentgen examination first, the choice of the method of operation for gastric ulcer and its complications can best be made on the operating table when the abdominal cavity is opened. It is most important that the operator should satisfy himself whether there exists an uleer with an unhealed surface or a healed ulcer, in fact a scar, and whether the ulcer is situated at the pylorus or at a distance from it."

When in possessionof these facts he is in a position to decide which operation is to be recomended-gastro-enterostomy only, pyloric exclusion or as a last resort, resection.

The early recognition of gastric ulcers is not only of value for the immediate relief of the present distressing symptoms and the great risk of acute perforation, but also of that lurking danger of a cancerous formation on the old chronic ulcer base.

This danger is ever present although some of the greatest authorities seem to differ as to the percentage of its occurrence. Wilson and MacCarty examining specimens furnished by the Mayo clinic estimate that 71 per cent of the callous ulcers of the stomach present lesions of cancerous development, while others assign only 10 per cent. as the average frequency of a cancerous degeneration of gastric ulcers.

Hartmann, of Paris, says: "Without going so far with certain authors as to deny the existence of ulcero-cancer, which would be too radical, we think, nevertheless, that the development of a cancer upon a chronic ulcer of the stomach is rarer than certain recent au

thors consider it to be." Kuttner, of Germany, further says that the termination of ulcer in cancer is extremely rare and that the apparent callous ulcer is often nothing but a cancer primarily.

The clinical signs of ulcer of the stomach and of the duodenum, as that of alimentary stasis, a sign of stenosis due to a lesion situated in the immediate neighborhood of the Pylorus which may be on the gastric or the duodenal side, are generally well known.

Moynihan, of England, has even gone so far as to say that the typical syndrome of duodenal ulcer is a story of late pain, a painful sensation of hunger relieved by the taking of food, and that this is sufficient to determine in his opinion a diagnosis of ulcer by correspondence with the patient, even without an examination.

Considering the surgical treatment, and it might be well to emphasize the fact that for chronic gastric and duodenal ulcers there is no other means of safe and permanent cure, free from the after menace of cancer development, the tendency of the present is to excise completely the ulcer whenever possible.

Gastro-jejunostomy has been generally accepted as the most beneficial of all the surgical procedures for gastric and duodenal doubts as to malignancy, a radical resection is ulcers, but where there are complications and the only thing to be considered. Rodman has for several years advocated the radical operation and says: "If the ulcer, or ulcers, are situated at or near the pylorus, as they are in about 80 per cent. of all cases, and the pyloric end of the stomach and proximal portion of the duodenum can be easily mobilized, pylorectomy which gets rid of the existing ulcers, and prevents future ones to a large extent, removing as it does four-fifths of the ulcer-bearing area, is certainly the operation of choice. The frequency with which hemorrhage, perforation and cancer, especially the latter, follow gastro-enterostomy, show it to be wholly inadequate."

Crile has recently voiced the opinion of the majority of the best operators when he said: "In cases of gastric ulcer, partial gastrectomy is the operation of choice, partly because of the uncertain cure by gastroenterostomy; and partly because of the probability of cancer development. In cases of duodenal ulcer, however, there is but slight probability of cancer development and the ulcer is curable by gastroenterostomy. The cure of duodenal ulcer may be hastened by the temporary closure of the pylorus."

Only a few years ago it was believed that gastroenterostomy was the ideal treatment of chronic gastric and duodenal ulcers, but our failures to obtain a larger percentage of

permanent cures led to further investigation. From a careful resume of the whole subject, we come to the conclusion that the best authorities are fairly well agreed that gastroenterostomy alone will permanently cure only a small percentage of cases; that those cases where there is no pyloric obstruction are less liable to cure unless we make a temporary or permanent closure of the pylorus; that all gastric ulcers, on account of the subsequent cancer development, should be resected by the knife or actual cautery; that duodenal ulcers, if possible, should likewise be resected; and lastly, that the Finney operation and partial pylorectomy have a larger field of usefulness than was formerly supposed.

DISCUSSION.

D. Y. Keith: I believe most American operators use both screens and plates in their X-ray work. Dr. Kelly and Dr. Church, of Boston, rely mainly upon plates. They make as many as thirty-five plates in practically every case. Dr. Church told me that, in his opinion, gallstones show on practically every plate. He said that he had recently gone over plates made eight or nine years ago, and that many of them showed gallstones that had never before been recognized.

I think it will tax the ingenuity of any one to distinguish between the shadows of gastric ulcer and spasni. Frequently one plate will show a shadow that looks very much like that of an ulcer, and another plate of the same stomach will show the duodenum absolutely normal. The use of atropin has been advocated to aid in this respect, the idea being that if a spasm exists, it will relax under atropin. That we may have spasm of the stomach and duodenum from adhesions in the abdomen, or from appendicitis, has been demonstrated. To make a diagnosis in these cases requires time and the use of many plates, and even then we cannot always be certain.

A. D. Willmoth: I believe that, with proper technique, a majority of gastric ulcers can be demonstrated by means of the X-rays.

With reference to operative procedure, the relief afforded by surgery is mechanical, and it must be done in a workmanlike manner. Where we simply make a gastro-enterostomy for the relief of ulcer of the stomach, it does not afford complete relief in many instances for the reason that the opening from the stomach into the gut will not serve to carry the contents of the stomach for very long; it soon closes to such an extent as to force the pyloric end of the stomach to do the majority of the work. Furthermore, it has been demonstrated that it is impossible to close the pyloric end of the stomach and make it remain closed. The Finney operation is far superior to a gastro-entrostomy, for the reason that

we do away with the vicious circle made by attempts on the part of the pylorus to continue its work.

M. Casper: Improved X-ray methods have practically revolutionized stomach surgery in the past few years. With the diagnosis once made, the technique of operation can be more readily mapped out.

In regard to gastro-enterostomy, it has been shown, by experiments upon animals, that, following a gastro-enterostomy, bismuth given by the mouth enters the duodenum from the stomach through the pyloric opening. Other experiments upon dogs with the use of a lead ball attached to a thread, has shown that it passed into the duodenum through the pyloric opening in nine cases out of ten. In the other instance, it passed out through the gastro-enterostomy opening, then back into the stomach and out through the duodenum. One advantage of gastro-enterostomy is that it permits the biliary contents and the secretions from the duodenum to get back into the stomach, thus neutralizing the excessive acidity which is usually present.

Jno. R. Wathen, (Closing): Statistics from Mayo's clinic shows that 90 per cent of cancers of the stomach, 80 per cent. of the gastric ulcers, and sixty to sixty-five per cent of duodenal ulcers can be accurately diagnosed by means of the X

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The Early Diagnosis of Pulmonary Tuberculosis. The prolongation of life by the suppression of preventable disease is of much greater value. to the state than the cost of the means employed. To ward off the calamity of disease and to prevent the spread of a pestilence is to increase the sum of human happiness and to elevate the race. In the entire realm of preventive medicine, there is no factor more potent than early diagnosis, first, because disease is far more amenable to treatment in the early stages, and second, because carly diagnosis affords greater advantages in preventing the spread of infection to others. It is the belief that a proper exercise of preventive medicine is of incalculable benefit to the people of the state and through it, this greatest pestilence may be limited in its spread to an absolute minimum and thousands of those afflicted with it may be saved.-Illinois State Board of Health.

NUCLEIN.*

By WM. SANDERS, Louisville.

There are in our materia medica a great number of neglected remedies which if employed in properly selected cases would yield wonderful results. The virtues of many drugs remain unknown for years until some medical bellwether sounds the tosein, then they are heralded around the world. Witness the iodine craze among our surgical friends. Iodine was discovered in 1812, and less than five or six years ago any suggestion of its use as a local antiseptic would have been met with derision. It took one hundred years to popularize it.

Nuclein is a remedy that could and should be more widely used, therefore it may not be time wasted for us to spend a few minutes in its consideration.

By nuclein is meant that constituent of the cell by virtue of which this histologic unit grows, develops, and reproduces itself. Chemically, the nucleins are complex sub

stances resembling compound proteids. They

are arranged according to the products of decomposition of nucleoproteids, into three divisions.

1st. Cell nucleins, or true nucleins, yielding a proteid, orthophosphoric acid, and xanthine bases. Neucleoproteids, containing true nucleins, occur chiefly in the nuclei of the cell, but are found also in the protoplasm and may pass into the animal fluids when the cell is destroyed.

2nd. Pseudo-nucleins yielding a proteid and ortho-phosphoric acid. but no xanthine bases. They are widely diffused in animals and vegetables, occurring in the solid tissues and in the fluids of the organism.

3rd. Nucleinic acid yielding orthophosphoric acid and xanthine bases, but no proteid.

Therefore it may be noted that the nucleins are complex proteid bodies notable for the large amount of phosphourus they contain.

Nuclein is a component of various portions of the animal economy, for instance the liver. spleen, salivary glands, lungs, festes, semen, ovaries spermatozoa, brain, spinal cord and other nervous tissues, thymas and thyroid glands haye been examined chemically with the result that nuclein has been found to be the most portant proteid substance present. Wherever nature provides for ike elmmation of poison or waste products of any descrip tion, there we find nuclein present beth in the secretions and in the tissues. With our present knowledge of the structure of the white and red Wood corpuscles and of the lymph

*Read before the Jefferson County Medical Society.

corpuscles we are justified in stating that the most important constitutent of them is nuclein.

Nuclein is administered to increase the defensive power of the blood against infections. It was the epoch-making theory of Metchnikoff that the leukocytes. or the phagocytes, as he called them, are natural defenders of the body's health, having the power to meet and repell an invading bacterial army, which first led to its use.

In nearly all of the infectious diseases, except typhoid fever, influenza and measles, there is a marked increase in the number of leukocytes. Metehnikoff regarded the multiplying cells as the "army of defense."" If its integrity could be maintained, the invasion might be repulsed; if it failed, as often happened in severe cases of pneumonia, the day was lost.

Dr. Vaughn, of Ann Arbor, was one of the first to suggest the use of nuclein to therapeatically utilize this great fact. Since "the

polynuclear white blood-corpuscles are active agents in preventing or retarding the multiplication of pathogenic germs in the body, it is rational therapy to give a medicine which will increase these substances. This increase in the polynuclear corpuscles," said Vaughn, may be induced by introducing into the animal the most destuctive constituent of these cells which is nuclein."

Therefore it is a reasonable deduction that naclein should prove of value in treating conditions where it is desired to increase the

germicidal properties of the blood, and this includes practically all of the infectious discases and local infections and applies to the prevention of disease as well as to its cure.

Although nuclein is given to produce an increase in the number of leucocytes, there is some evidence that it raises the opsonic index. The leucocytes destroy germs by virtue of some constituent or secretion, to which is due the germicidal properties of the blood serum. It is possible that their secretion is the substance called opsonins, if so, the more leucocytes, the higher the opsonic index. Two observers, Chautemerse and Nilhit, did find that in a case of intestinal perforation the opsonie index normally 1.6 rose to 2.5 within twenty-four hours after the injection of nuclein. My own experience leads me to believe that its use enhances the value of vaccines.

I have given nuclein in all cases of infeetions of whatever character for the past ten years and I am now more than ever satisfied with my results.

Cohen in his System of Physiologic Therapeuties has this to say of it: "Nuclein has been found to be a stimulant to all animal

cells. Given by the mouth or hypodermically it causes a marked leucocytosis in a few hours, principally affecting the active phagocytes. If in acute infections, protective leukocytosis is not sufficiently pronounced nuclein is of considerable value. It is indicated in such bacterial diseases as diphtheria, scarlet fever pneumonia and septicemia. Nuclein has been strongly recommended in tuberculosis and,

with streptococcus infection, it would seem good treatment to increase the fighting power of the leukocytes. The value of nuclein as a carrier of phosphorus should cause it to be utilized in cases of nervous debility, depression and degenerations.”

Nuclein is marketed in tablet form and in solution, either as a nucleinic acid or a sodium nucleinate according to the company which manufactures it. It is a white amorphous powder, soluble in water and insoluble in alcohol. It may be administered by the stomach, dissolved on the tongue, subcutaneously or intravenously. The stomach route is the least effective. However, when so given it should be administered frequently in large doses and on an empty stomach. It should not be taken within an hour after eating.

The buccal route has given better results in the hands of many. and is to be preferred when the subcutaneous or intravenous methods are rejected. The dose depends upon the age, weight, the character of the infection and frequency of administration, varying from 2 to 60 minims. In acute conditions 2 to 10 minims may be dropped on the tongue every hour, in chronic cases 10 to 60 minims two to four times daily. The tablets which represent 2, 5 and 20 minims of the solution, will be found very convenient.

The hypodermic method is employed where a marked physiological action is desired. The dose is 10 to 30 minims. Intravenously it is given diluted with physiological salt solution, dose 30 to 60 minims, using the ordinary technic for such work.

I will briefly mention three surgical cases in which I feel sure nuclein gave some very good results.

Case I. E. S., male, age 32, operated on for hemorrhoids on March 13, 1913. Six days later he came to my office complaining of the delightful odor of the colon bacillus infection. He was given the 5 minim nuclein tablets, one to be dissolved on his tongue every three hours, and in forty-eight hours the odor had disappeared and a slimy, unhealthy appearing wound had changed to one with a clean, granulating surface.

Case 2. C. W., male, age 35, typical symptoms of appendicitis, operation by Dr. Farmer July 2, 1913, about 60 hours after the onset

of the attack. The appendix was found to be gangrenous, there was no meso-appendix except on the distal third. It was bound down to the bowel so that it was necessary to split the peritoneal covering and dissect it out. It was so friable that with scarcely any traction it ruptured. The contents escaping into the peritoneal cavity on the outer side of the cecum. This was carefully sponged out and free drainage was instituted. He was given 15 to 30 minims of nuclein solution on his tongue every three hours. In 36 hours his temperature was normal and in a few days he remarked that since they had been putting that stuff on his tongue he was feeling so much better and stronger. He left the hospital on the 21st with the wound so nearly healed that it required only two more dressings. He was also given one C.C. of Van Cotts vaccine several days after the operation for the relief of a troublesome cough.

Case 3. R. K., female, age 12, latent sinus infection complicating mastoiditis, further complicated by arthritis in angle joint from infected thrombus. Ligation of the internal jugular by Dr. Jno. R. Wathen, radical mastoid and opening of the lateral sinus by Dr. G. C. Hall. I had her under observation about one week before the operation during which time she received the 5 minim nuclein tablets, one dissolved on the tongue every three hours and one dose of Van Cott's vaecine.

After the operation she received 15 minims of the solution dropped on the tongue with a medicine dropper, and in a short time not over three or four days the temperature which had been at times as high as 105 degrees after the chills, had dropped to normal and the arthritis had disappeared. She made a very quick recovery.

I could, if time permitted cite a great number of cases not surgical in which nuclein has been employed. They would cover the whole field of infections, general and local. All ages and conditions.

There is one fact that canot be disputed. Nuclein will do no harm. There will be no bad effects, no matter how large the dosage, except perhaps in some patients, if given over a length of time some gouty pains from the increase of uric acid. In such event give alkaline diuretics and, if necessary, diminish the dosage.

Nuclein is a non-poisonous germicide which if given persistently would often change the course of many a desperate case to a favorable termination.

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Moynihan's late work on abdominal operations cites some experiments in which a number of dogs were given injections of nuclein, the abdomens opened, incisions made in the intestines and the entire contents expressed into the immediate neighborhood of the abdominal incision. Of the five dogs in which this was done, all died but one and he was very sick. In another series of ten dogs, nuclein was introduced intraperitoneally, and the same operative procedure carried out, and all of these dogs recovered.

The theory of the injection of nuclein is that it produces an increased leucocytosis, which is an important factor in the prevention of infection.

OF SCHOOL

MEDICAL INSPECTION OF
CHILDREN.*

By C. J. ROSENHAM, LOUISVILLE. The experimental period of the medical inspection of school children has long passed. Long ago the great good that comes from the careful inspection of the child, the recognition of insidious diseases in their incipiency, calling attention of the parents and teachers to the same, and then seeing to it, that the child receives the attention needed, has brought results and proofs, putting the question beyond all controversy.

The most astonishing view of this question now, is that it was unrecognized and neglected so long, and a matter of surprise and regret even to-day, is that in some quarters the support is only half-hearted, and the appropriation to cover the expense of this work is alto gether inadequate to bring the best results.

Brussels, Belgium has the honor of first recognizing and putting into practical operation the medical inspection of schools, in the year 1874, and the other countries of Europe following close thereafter. In the United States of America, Boston, Mass., is the city first to introduce regularly the school inspection, in 1894; other cities throughout the States following rapidly this most excellent example, until to-day we have over five hundred American cities with medical inspection in their schools.

*Read before the Jefferson County Medical Society.

When work along this line was first tried out in England, it was with the school nurse alone. In other countries of Europe they experimented with the doctor alone. Neither of these plans gave good results, as may very readily be understood, the nurse was not able or privileged to make diagnosis, the doctor could not do the follow-up work into the homes, and it takes both of these working together, to bring about the desired result. While both doctor and nurse are absolutely necessary to carry on the fight against disease, the doctor, ever alert and on the lookout for physical defects, communicable diseases or parasitic infections, excluding from school if necessary for the protection of the many; notifying parents of insidious troubles, to consult their own physicians for diagnosis, and treatment, and actually, keeping a watch on the child to see that attention is given to the warning. The nurse is needed, when the school doctor finds that no attention has been given to the child, the nurse is given the child's name, residence and diagnosis and her duty is to visit the home, ascertain the cause of non-attention.

In the great majority of cases it is found that the inability of the parents to pay for service is the cause of seeming neglect. When the nurse is convinced of this condition, it then becomes her duty to see that the child is taken, either to the office of the doctor who is willing to give of his time and knowledge for humanity's sake, or to one of the public clinics, naturally the city hospital gets most of the work, however as a rule not until the nurse has paid several visits to the home to explain the necessity, our honesty of purpose, and that we are not urging the matter from any selfish motive. When this is accomplished, it most frequently happens that the nurse is compelled to accompany the child to the hospital and pay the carfare, the parents not being able to do so, or indifferent; this takes considerable time, and the necessity and vital importance of the work I am sure you appreciate. The associated and federated charities surely do, for in the one item alone of defective vision, they paid for the glasses of something like one hundred and fifty children, during the past year. I do not propose to occupy your time by giving statistics, a summary of it all can be found in the annual report of the health office, a copy of which is either mailed to every physician in the city or can be had for the asking. We have to-day about one hundred public schools and thirtyfive parochial schools to look after; forty-two thousand children. The work is divided among four medical inspectors and two school nurses. Every child in the schools must be carefully examined at least once a year. You

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