1228 PROF. D. P. D. WILKIE: DUODENAL ULCER IN THE FEMALE.

body of the shaft and for the tarsal extremity or base.and a secondary centre for the distal or phalangealextremity. But, probably under reversionaryinfluences, the tubercle of the fifth metatarsal maypresent itself as a separate bone, os vesalianum ofPfitzner. Testut 6 had seen only a single case of this,but quotes Griiber as having come across threeinstances ; and Pfitzner met with only one instanceof the separate os vesalianum after an anatomicalexamination of more than 1000 feet. Spronk, quotedby Poirier and Charpy,7 found os vesalianum in anewly born infant which showed polydactylism of thehands and feet; each foot had seven toes, the twosupernumerary toes being carried by the fourth andfifth metatarsal bones. The separate os vesafianumin this case articulated with the cuboid bone and withthe base of the fifth metatarsal. A somewhat similaranatomical variation may occur behind the bases ofthe first and second metatarsal bones, in the form ofossa intermetatarsa. The second metatarsal boneappears to be especially liable to what must be calledspontaneous fracture, when the fracture occurs

without any history of violence. But as the fracturein this case occurs through the thinner part of the shaftof the bone, the possibility of the existence of aseparate os intermetatarsum is of interest only inconnexion with radiographic diagnosis.The tubercle of the fifth metatarsal being developed

from what was originally one of the tarsal bones, it isinteresting to note that another of the 11 true ossiclesof the tarsus (os trigonum) recognised by Pfitzner,8in cases in which it has coalesced with the rest of theastragalus, is liable to separation. Os trigonum, whenattached, is represented by the lateral tubercle onthe groove in which flexor longus hallucis runs atthe back of the astragalus, but occurs as a separateossicle far more frequently than does os vesalianum.Pfitzner estimates that it remains uncoalesced inabout 7 per cent. or 8 per cent. of cases. MajorBrooke Churchill, R.A.M.C., has recently published 9radiograms showing the separate bone, and also theappearances in fracture.

’

There is little to be said about the treatment ofavulsion fracture of the tubercle of the fifth metatarsalbone. All the cases, except No. 1, were satisfactorilytreated by resting the foot until union had beeneffected. In Case 1 the fracture was not treatedat all, and somewhat prolonged disability was theresult. Considering the tendency of the tubercle to betilted backwards by the attached peroneal muscle,it is obvious that in walking the weight of the bodywill tend to widen the separation between thetubercle and the rest of the bone, with delayed Iunion as a result-as happened in this case.

References.1. Jones, Robert: Fracture of the Fifth Metatarsal Bone

by Indirect Violence, Annals of Surgery, 1902, xxxv.,697.

2. Brickner, W. M. : Fracture of the Base of the Fifth MetatarsalBone by Indirect Violence, Amer. Jour. Surg., October, 1906,xx., 306.

3. Sylvester, C. S.: Boston Med. and Surg. Jour., 1903, cxlix.,735.

4. Cotton, F. S.: Ibid., 1906, clv., 229.5. Eisendrath, D. N.: Keen’s Surgery, 1914, ii., 279.6. Testut, L.: Traité d’Anatomie Humaine, Paris, 1921, tome i.,

384.7. Poirier, P., and Charpy, A.: Ibid., Paris, 1911, tome i.,

p. 567.8. Ibid., tome i., p. 553.9. Churchill, Brooke: A Note on the Os Trigonum, Jour.

Royal Army Medical Corps, 1927, xlviii., 131.

NORFOLK AND NORWICH HOSPITAL.-Sir KingsleyWood, Parliamentary Secretary to the Ministry ofHealth, recently opened an extension of this institution,which has been provided by public subscription as a

memorial to the men of Norfolk and Norwich who fell inthe war. The new building includes a large waiting-room,five consulting and attached examination rooms, roomsfor the treatment of ear, nose and throat cases, an operatingblock, a recovery room for minor operations, and a casualtyroom.

DUODENAL ULCER IN THE FEMALE.THE CHOLECYSTODUODENAL SYNDROME.

BY D. P. D. WILKIE, M.CH. EDIN., F.R.C.S. ENG.,PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH.

WHEN we compare statistical tables of the diseasestreated in our large hospitals to-day with those of20 years ago, perhaps the most striking single differ-ence in the present day is the frequency of duodenalulcer. In the Royal Infirmary, Edinburgh, in 1906,24 cases of duodenal ulcer were treated, 18 by medicaland 6 by surgical measures. During the same year22 cases of perforated duodenal ulcer were dealt within the hospital. During 1926, on the other hand,236 cases were treated, 73 in the medical and 163in the surgical wards. Does this difference meanthat there has been an actual increase in the incidenceof ulcer, or does it merely indicate that diagnosis hasimproved ? It is notorious that we only see whatwe look for ; hence, in part, the great disparity inthe recorded incidence of different diseases in thepractice of different observers in different districtsor, it may be, even in the same district. In view ofthe number of ulcer cases treated by operation in1926, the number of cases of perforated ulcer wouldbe expected to show a perceptible decrease if theincidence of the disease had not varied. On thecontrary, we find that in 1926 the hospital admitted102 cases of perforated duodenal ulcer, more thanfour times the number of 20 years ago, and-this despitethe fact that, in the small provincial hospitals withinthe area served by the Royal Infirmary, operationsfor perforated duodenal ulcel’ are now quite common.(Table I.)TABLE I.-Incidence of Duodenal Ulcer in the Royal

Infirmary, Edinburgh.

M.=male. F.=female.

The only inference to be drawn from these figuresis that duodenal ulcer has actually increased in

frequency during the past 20 years.There is apparently a fairly widespread opinion inthis country that duodenal ulcer is rare in the female.Experienced surgeons have told me that they couldnot recall more than one or two cases in many yearsof surgical practice. In my experience, duodenalulcer is much commoner than gastric ulcer in bothsexes, so that I venture to record my observations,

TABLE IL-Incidence of Ulcer Operated on 1921 to 1927.

and with them a statement of what I believe to be afrequent, cause of failure to diagnose this disease inthe female. Data are now available which pointvery clearly to the ulceration being infective and,indeed, streptococcal in origin, and it is not unreason-able to suppose that a streptococcus with a specialacquired affinity for the duodenal wall is prevalent,and accounts for the increasing frequency of thecondition.

1229PROF. D. P. D. WILKIE : DUODENAL ULC’ER IN THE FEMALE.

’hzciderzee of Ulcer.An analysis of ulcer cases

operated on by me during thepast six years shows that, outof a total of 413 cases, there were94 cases of duodenal ulcer in thefemale. In 18 of the latter therewas a coincident gastric ulcer.

(Table II.)Duodenal ulcer occurs in the

female, as in the male, at allages. My youngest patient wasa girl of 16, whilst three patientswere 70 or over. The averageage at the time of operation was45. It occurs both in the thinasthenic type of female and, per-haps even more often, in thestout, well-favoured type. Itoccurs with almost equal fre-quency in hospital and privatepractice (51 in hospital, 43 in

private practice). There wouldappear to be an undoubted here-ditary tendency to ulcer, par-ticularly in females. I have hadto deal with two families in eachof which three sisters have beenoperated on for duodenal ulcer.More than 80 per cent. of thepatients were non-smokers.

/Mp<Om6CO</!/.In many cases a typical his-

tory was given : periodic attacksof indigestion with hunger-pain, relief from food, long Iperiods of freedom from symptoms in the early stage,and more constant trouble as time went on, but in

-

FiG. 2.

Same case as in Fig. 1 two hours after fatty mea and immediately after bariummeal. Gall-bladder partly emptied and pronounced deformity of duodenal cap.

Fm. l.

Radiogram of gall-bladder 12 hours after injection of 3 g. of dye in case presentingcholecystoduodenal syndrome.

quite a large proportion (35 per cent.) the history was

not classical. Flatulence was often the chief com-plaint ; associated with this were attacks of acute

pain, apparently without any definiterelation to food, occasionally associatedwith vomiting and sometimes followedby a faint tinge of yellow in the skin.At such times the patient complained ofmuch acidity and heartburn. On at leastten occasions I have operated on a

diagnosis of cholecystitis, only to finda normal gall-bladder and a typicalduodenal ulcer.

Gradually we have come to recognisea clinical picture which I have termedthe cholecystoduodenal syndrome. Thepatient is usually somewhat stout, com-plains of

" wind " and attacks of pain inthe epigastric region to the right of themidline. She is uncertain of the rela-tion of the pain to the taking of food,but has usually lived for some time on arestricted diet, avoiding potatoes and all" heavy " articles of diet. She describesattacks of pain lasting for a few hours,very suggestive of biliary colic. Oncareful questioning, however, theseattacks are found to be less severe thantrue colic. When questioned as to jaun-dice, she will state that friends haveremarked on a yellowish tint in her skinat these times (duodenitis with catarrh).Leading questions will elicit that atsome time or other, and almost alwayson more than one occasion, she has hadan attack of indigestion, lasting for afew weeks, of almost typical duodenaltype.Whether it be that the average female

is less observant, or is merely moretolerant of a recurrent pain than themale, or whether the pylorus in thefemale does not react so readily byrecurring spasm to duodenal irritation,is uncertain. It is undoubtedly true,however, that a somewhat vague andindefinite history of flatulence and

1230 PROF, D. P, D. WILKIE : DUODENAL ULCER IN THE FEMALE.

FiG. 3.

Faint gall-bladder shadow and defor-mity of duodenal cap. Early chole-cystitis and duodenal ulcer.

irregular pain is the commonstory in the female. The mostprobable explanation of theabsence of the typical hunger-pain in the female is the pre-valence of the habit, amongthose engaged in householdduties, of taking food betweenregular meal-times and thus ofanticipating the onset of hunger-pain. The male, with fixed hoursfor work, has longer fasts andless opportunity of warding offthe hunger-pain. Whatever thecause, it is a fact of experiencethat in many cases of duodenalulcer in the female the classicalhistory is not volunteered, andcan only be elicited with diffi-culty, and then imperfectly. Inthe majority of my cases thepatients had suffered from dys-peptic symptoms for many yearsand, whilst a tentative diagnosisof cholecystitis had frequentlybeen made, their pseudocolicattacks had never been con-

sidered sufficiently severe or

disabling to warrant surgicalinterference.

Accecrccte Diagnosis byCholecystography.

During the past year I havehad to deal with five cases,admitted to hospital with a pro-visional diagnosis of cholecystitisand gall-stones, in which pre-liminary investigation by chole-

cystography has led to a positivediagnosis of duodenal ulcer and normalgall-bladder. The patients have all beenfemales, and the histories in all were cer-tainly more suggestive of gall-bladderthan of duodenal mischief.The technique which we now follow,

at the suggestion of Dr. WoodburnMorison, is important. On the night ofadmission the patient is given a dose ofliquorice powder. The following day apreliminary X ray photograph is taken.That evening at 9 o’clock an intravenousinjection of 3 g. of sodium tetraiodo-phenolphthalein is given in 40 c.cm. ofdistilled water. At 9 o’clock the follow-ing morning an X ray (with Buckydiaphragm) is taken. The patient is thengiven a barium meal, and the stomachand duodenum observed on the screen

and a second photograph taken. At1 P.M. a fatty meal is given, and at 3 P.M.the final X ray is taken.

In the five cases referred to the gall-bladder gave a normal cholecystogram,and the barium meal in each instanceshowed an unmistakable deformity ofthe duodenal cap. (Figs. 1 and 2.) Atoperation, one or more duodenal ulcerswere found in each case, and the gall-bladder was normal. In a sixth case thecholecystogram showed a shrunken gall-bladder with stones, as had beenexpected, but in addition a duodenalulcer. At operation both conditionswere dealt with successfullv.

I have no hesitation in stating that in

FIG. 4.

I

Same case as in Fig. 3. Stomach allowed to fall over to left, demonstratingduodenal ulcer with stenosis.

1231DR. B. A. PETERS: ALKALI TREATMENT IN FEVERS.

the combined cholecystography and barium meal testdescribed above we have a most valuable diagnosticaid in female patients presenting the cholecysto-duodenal syndrome.

Operative Treatment.I have found that some form of conservative short-

circuiting operation has been uniformly successful.There does not appear to be the same tendency topeptic ulcer of the jejunum in the female as in themale. The relatively mobile duodenum in the femalemakes a gastro-duodenostomy (Eiselsberg) an easyand safe operation, and I have latterly preferred thisor a Finney’s operation to gastro-jejunostomy as

being more physiological. In the 76 cases in whichno gastric ulcer was present, posterior gastro-enteros-tomy was performed in 47 cases, gastro-duodenostomy Iin 20, Finney’s operation in 4, and excision withpyloroplasty in 5 cases.When a coincident gastric ulcer is present, as it was

in 18 out of the 94 cases here recorded, the treatmentmust vary according to the local condition and theage of the patient. When a chronic penetrating gastriculcer was present, excision of the ulcer followed bygastro-enterostomy was the operation of choice. Forsmall active gastric ulcer, high on the lesser curvature,the cautery was used. In six of my patients, allelderly, an hour-glass contraction of the stomach,due to an old and practically healed gastric ulcer,was present ; a gastro-gastrostomy followed bygastro-enterostomy in the lower sac (five cases), ora double gastro-enterostomy and a lateral anastomosisbetween the limbs of the jejunal loop (one case) gavecompletely satisfactory results. In nine cases chole-cystitis with gall-stones was found, associated withthe duodenal ulcer. (Figs. 3 and 4.) In six of thesecholecystectomy, in two a cholecystostomy, and inone a cholecystectomy and a choledochostomy wereperformed. The appendix was diseased and wasremoved in approximately one-third of the cases.

In one case, besides the duodenal ulcer, an activegastric ulcer, a subacute cholecystitis, and a pro-liferative chronic appendicitis were present. The gall-bladder, appendix, and gastric ulcer were excised,and a gastro-duodenostomy performed.

I have yet to be convinced of the necessity forextensive resection for simple ulcer of either stomachor duodenum or both.

Summary.1. Duodenal ulcer appears to be a much commoner

disease now than it was 20 years ago. 2. Duodenalulcer is a common disease in the female, more sothan gastric ulcer. 3. The typical history is muchless frequently given than in the male, hunger-painoften being absent. 4. The " catch meals " of thehousewife are probably responsible for the indefinitepicture. 5. Under the term cholecystoduodenalsyndrome a clinical picture, often confused with thatof cholecystitis, is described. 6. Operative treatmenton conservative lines is recommended.

ALKALI TREATMENT IN DIPHTHERIAAND SCARLET FEVER.

BY B. A. PETERS, M.D., D.P.H. CAMB.,MEDICAL OFFICER, HAM GREEN HOSPITAL AND SANATORIUM;LECTURER IN INFECTIOUS DISEASES, UNIVERSITY OF BRISTOL.

THE present writer showed, in 1918, that anacidosis (a reduced alkali reserve), associated withketonuria, occurred in the more toxic cases ofdiphtheria, and that the administration of alkaliestended to prevent the pernicious vomiting andcirculatory failure which may occur in the secondweek of the disease. Since then the routine treat-ment of all cases of diphtheria in this hospital hasincluded the administration of 30 g. sodium bicar-bonate, 5 g. potassium bicarbonate, and 7 g. calciumcarbonate in four-hourly doses, until the morningurine is alkaline to litmus, which takes three or four

days. For younger children the dose is halved.My colleague, F. J. Hector,2 has confirmed theseobservations and shows that the reduced alkalinereserve is associated with some defect in carbohydratemetabolism.

In a report on wound shock,3 it was veryclearly demonstrated that experimentally produced" acidosis " will not in itself cause any appreciablesymptoms, even when the alkali reserve is reducedto what is probably a lower level than would everoccur naturally. The original explanation of theundoubted benefit derived from these measures istherefore untenable. Richet 4 and others have shownthat anaphylactic shock may be prevented byadministering saline with the second dose of serum.Moore 6 considered that in a severe toxic state, suchas cholera, the crystalloid-colloid balance is upset,and that " electrolytes are wanted to combine withcirculating toxic colloids and tissue colloids and toprevent these linking on to each other." Crystalloidsare also necessary to tug the toxic colloid throughthe excreting channels. This is probably the explana-tion of the advantage of drenching the patient withbasic salts. It is important, therefore, to give largedoses of these salts in the early stage of disease, toprevent fixation of the toxin to the tissues until theantitoxin has had time to do its work. It is alsovitally important to discontinue their administrationwhen the acute stage is over, as an alkalosis mayproduce an anoxaemia or may damage an alreadypartly poisoned heart.7 7 It is interesting to notethe craving of febrile children for fruit and theircomplete distaste for other foods. This may be an in-stinctive attempt to make up a deficient alkali reserve.

In this communication I attempt to assess theclinical value of these measures from a study ofrecords extending over 18 years. Although we havecareful records of 10,000 cases treated with andwithout alkalis, it is impossible to bring forwardincontrovertible statistics because a new andimmeasurable factor was introduced-viz., the out-break in 1920 of a much more severe type of diseasewhich is only now reverting to the former type aftera widespread and virulent epidemic. This type wascharacterised by great swelling of the throat and neck,appearing within 24 hours of onset ; by delayedformation of membrane, causing great difficulty indiagnosis, and in many cases by the death ofthe patient from overwhelming toxeamia withinthree days. During this time 20 per cent. of thenursing staff were very severely attacked, one nursedying on the fourth day, although 40,000 units of anti-toxin were administered within six hours of the onsetof symptoms. This was before Schick methods wereused. The death-rate, therefore, is no guide. In fact, thealkali-treated group show a death-rate of 6-4 per cent.,compared to 5-6 per cent. for the other group.

I have therefore attempted to arrive at someconclusion by comparing those in each group whoshowed the cardiac vomiting syndrome.

The Cardiac Vomiting Syndrome.Between 1903 and 1917 4894 cases of diphtheria

were treated in this hospital without alkalis;148 cases (3 per cent.) showed the cardiac vomitingsyndrome. Of these, 102 died (one survived a

month, only to die of diaphragm paralysis), 46recovered-i.e., more than two-thirds died, or

2-1 per cent. of the whole group untreated by alkalis.In the second group, from 1918 to 1927, 5880 cases

were treated by alkalis. Of these, 65, or 1-1 percent., died with cardiac vomiting symptoms (i.e., halfthe former number), 148 showed some vomiting withheart weakness, but eventually recovered, while tenof the vomiting cases recovered from the vomitingstage only to expire of diaphragm paralysis. Thisincrease of paralytic cases was also noted after theintroduction of antitoxin, and the explanation isprobably similar&mdash;i.e., that a large proportion of thesevere cases lived long enough to develop thesesymptoms. Therefore, although we are dealing witha much more severe type of disease, with a higher