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tary and voluntary forces were vigorous and little or no resistance existed to interfere with the normal termination of the labor. The

one dose-morphin 1/6 and scopolamin 1/100-is also valuable in dystocia, given preliminary to the administration of ether or chloroform, when the labor is soon to be terminated by instruments or section, under which circumstances the amount of ether or chloroform may be reduced one-half."

Dr. J. W. Bovee, professor of obstetrics in the George Washington University, Washington, D. C., well points out the necessity of confining the "twilight" treatment to obstetrical experts, and in part remarks:

"It has a place in obstetrics, though a very limited one. It should be used only by those who are expert first in obstetric practice and second in the physiological action of the powerful drugs employed, especially when administered to women in labor.

"It demands careful, continuous and tedious observation on the part of the obstetrician and an isolation of the patient and attendants away from family, which latter, from the standpoint of obstetrical cleanliness, might always be advantageous. I believe, too, it endangers the welfare of the infants."

Chronic Headaches, in which the cause cannot be found and satisfactorily explained, should be carefully examined as to refraction and ocular balance. This should never be neglected.

FYFE.

Report of Meeting of Committee of the Board of Regents on Proposed Legislation.

The Regents Committee consisted of Vice-Chancellor Sexton, Dr. Vandeveer and Regent Adelbert Moot. There were present the members of the Council, the State Board of Medical Examiners and representatives from the State Eclectic Medical Society and the New York State Medical Society, the Osteopaths and the Dean of the Homeopathic Medical College. The first topic discussed was that students be admitted to the study of medicine conditioned in Chemistry, Physiology and Biology. It was recommended that Biology and Physiology should be allowed to be regarded as suitable subjects for condition. A division of sentiment was held in regard to Chemistry and some recommended that condition in this subject be permitted, by others that one year in chemistry should be required.

The second topic: An addition to the authority of the Regents to be passed by the Legislature authorizing the Board of Regents to enact changes in its rules regulating the requirements and standards regarding the preliminary requirements of students and the extent of the medical course and its character in the colleges and that these be governed by the rules of the Regents so that they can

be changed from time to time without the necessity of legislative enactment. Sentiment upon this recommendation was divided, a majority of those present being in favor of the proposition, a minority nearly as great in number against such an arrangement.

The third topic: "Unprofessional conduct" means and shall include the following acts or conduct by or on the part of a practitioner of medicine:

(a) Advertising fraudulently either in his own name or in the name of another person, firm, association or corporation in any newspaper, pamphlet, or other printed paper or document, or by writing letters or causing them to be written, wherein or whereby the medical practitioner holds himself or herself out to cure diseases or defects or for being employed by any person, firm or association. or corporation so advertising or announcing.

(b) Wilfully betraying a professional secret.

(c) Habitual drunkenness or addiction to drugs.

(d) The employment of any capper, solicitor, or drummer for securing patients, or the division of fees or promise of division of fees or the payment of money to any person or persons, or of any other valuable thing in return for service in securing patients.

An addition to the law that revocation of license be authorized by the Regents of a practitioner declared insane or confined in a State hospital for the insane. A vote being taken the amendment was favorably recommended.

The chairman of the committee announced that in consideration of the requests of some of the representatives present for further allowance of time be given for more thorough consideration of the proposed changes that no definite action would be taken until a special meeting of the Regents to be held early in January. In the meantime the committee would be pleased to consider any memoranda which might be submitted for the improvement of the recommendation as above outlined, so that they might fairly represent the opinions of the medical profession.

Original Articles

Duodenal Ulcer-Its Diagnosis and Treatment With Report of a Case.

BY EARL H. KING, M.D.

Read before the Saratoga Springs Medical Society, March 28, 1914. In presenting this subject to this society tonight I am moved to call your attention most decidedly to the frequent and apparently increasing existence of various forms of so-called chronic indiges

tion, with the tendency to acute exacerbations, and along with this the resort by so many of the laity to the widely advertised proprietary medicines for the relief of the distress incident to the above symptom (for the term 'indigestion' as usually used really is.)

We find patients floating from one medical man to another for treatment for these conditions and during the intermissions between such consultations trying all the recommendations of friends, and the glowing reports of cures by nostrums cause these sufferers to be ever adding to the profits of the nostrum venders. Perhaps no class of remedies enjoy such sale as those prepared for the relief of "stomach, intestinal and liver disorders."

Why is this and why are we often unable to give our patients more than temporary relief and then he seeks someone else or tries some or all of the many pathies that cater to chronic cases? I venture to say that the medical profession is often at fault for this. condition of affairs, not only in this class of cases, but also in other diseases ammenable to treatment and perhaps cure. I say at fault, for how many are in the habit of simply prescribing a stomach tonic, a digestive and caution as to diet-the latter too often not heededand usher the patient out without digging down to the fundamental cause of the digestive symptoms which are many times deep seated and of long standing, but may be in the incipiency or entirely reflex in the stomach from causes remote from it.

This is not said with the intention of sermonizing, but rather with the idea in view of urging the more thorough study of all chronic conditions or incipient ones before they become chronic. There is no reason why so many should be going to the larger cities to consult men following special branches if every man would endeavor to make a complete and thorough diagnosis of his cases. We all have at our disposal the modern methods of accomplishing this end and do we not often neglect to make use of them.

It is well known that there are four or five conditions which underlie these digestive derangements, namely-gastric ulcer, duodenal ulcer, chronic appendicitis, gall bladder troubles, and chronic constipation (which latter may be due to some organic disease or deflection of the intestinal tract.)

Indiscretion in eating and drinking is perhaps responsible for many of these symptoms, but it is also many times the cause of the more serious underlying disease. Then again the frequency with which malignancy is the sequlae of some of the above mentioned diseases, if not relieved, should be sufficient reason for a thorough study of all cases presenting themselves to ascertain whether we have a simple or some deep seated and perhaps serious trouble to deal with.

With this end in view I beg to bring before you a brief study

of duodenal ulcer which is perhaps of more frequent occurance than is generally believed.

Etiology: There are many cases of duodenal ulcer as well as gastric in which the cause is not determinable, but both present similar etiological factors; namely, conditions producing hyperchlohydria and the resulting erosion by the irritating gastric juice. When we remember that acid gastric contents pass into the alkaline medium in the duodenum and are there neutralized and finally made. alkaline it is evident that the more acid the former the more difficult and prolonged the accomplishment of the latter with the consequent irritation. The hyperacidity is so often due to indescretions in diet and the stimulation of gastric secretions by highly seasoned foods and the injuditious use of alcoholic beverages.

Burns of the abdomen, feezing, erysipelas and septicemia are among the etilogical factors. These conditions producing a lowered vitality predispose the mucous membrane to irritation from gastric juice. Direct local infection from acute infections elsewhere in the system seems also to be a plausible argument.

Pathology: The result, regardless of the cause, however, is the same-a punched out funnel shaped ulcer, usually single, though sometimes multiple or accompanied by gastric ulcer, extending down through the submucousa and muscular layer, and still more frequently than when in the stomach perforating, with the result of producing either adhesions to adjacent viscera or general peritonitis. Duodenal ulcer when it heals is likely to produce more serious results from scar formation than when situated in any part of the stomach, other than the pylorus, because the duodenum is of so much smaller calibre that obstruction of the lumen more certainly follows cicatricial contraction. This emphasises the possible continued gastric disturbances from motor causes even if the classical course of ulcer as formerly taught did not go on to hemorrhage, perforation and resulting infection of adjacent structures. With modern means of determining its course we are led to believe that many of the ulcers heal with resulting cicatriziation and more or less obstruction to the outlet of the stomach.

This resulting obstruction would seem to suggest the reason for so many dilated stomachs that are diagnosed and reported in literature as well as the many cases of so-called fermentative dyspepsia and numerous cases in which gaseous eructation is a prominent symptom, many of these conditions existing seemingly regardless of the form of diet.

This leads to the belief that duodenal ulcer or ulcer of the very proximal end of the pylorus is of more frequent occurance than is generally supposed. The classical symptoms are not always present, the ulcer having been of a simple type and having healed leaving a

cicatricial mechanical obstruction with the above mentioned resulting pathology.

Peptic or round ulcer of the duodenum is less frequent than gastric ulcer and is still more likely than the former to run a latent course until hemorrhage or even perforation and its sequences call attention to it. The general consensus of opinion seems to be that duodenal ulcer occurs about the proportion of one to ten of gastric ulcer, but as has been suggested with more improved methods of diagnosis and a careful study of these cases, it would seem that it is more frequent than this. Mayo recently states that it occurs in the proportion of one to three or four.

It occurs more frequently in men than in women and between the ages of 20 and 60 years. It not only tends to run a more latent course than gastric ulcer, but also is more refractory to treatment and has a greater tendency to perforate, and as has been outlined above to cause obstruction, and is in consequence of these tendencies a more dangerous disease. It may occur in infancy while gastric ulcer is seldom seen before the age of ten years.

Its site is most frequent at the upper end of the duodenum between the pylorus and the common bile duct. Generally it is quite close to the pylorus, though it sometimes appears lower down, and exceptionally may be found in any part of the duodenum, or even in the upper part of the jejunum. It varies in size from that of a pea to that of a twenty-five cent piece, or even larger in exceptional cases.

Symptoms: In this connection will be considered also the pathological findings in the blood, stomach contents and stools. which of course in addition to constituting the pathology of the disease are prominent symptoms in diagnosis.

Clinically there may be nothing of note until hemorrhage suddenly occurs which may be more or less severe, but by careful investigation it will very frequently be found that the patient has suffered more or less from so-called indigestion or discomfort sometime after eating which has not been of sufficient note to cause him to seek medical aid or else he has been using cathartics or digestives on his own initiative for its relief.

The symptoms may be similar to gastric ulcer, namely burning or boring pain with circumscribed tender spots.

The symptoms when present are a burning, boring pain in the epigastrium to the right of the median line about two fingers breadths below the free border of the ribs, and may radiate upward or downward and not usually through to the back. This pain and discomfort does not usually occur immediately after taking food, but rather some two to four hours afterward, and sometimes even six hours; that is, until the contents of the stomach at the termination

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