Peptic ulcer

Peptic ulcer

PEPTIC ULCER* By T~OMAS DOUGLAS ROSS, M.B., Ch.B.(Glas.), F.F.Hom. THIS is a vast subject and I shall not be able to do much more than summarize pre...

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By T~OMAS DOUGLAS ROSS, M.B., Ch.B.(Glas.), F.F.Hom. THIS is a vast subject and I shall not be able to do much more than summarize present knowledge of causal factors, pathology, diagnosis and treatment. My chief aim is to plead for more medical treatment and therein I give an honoured place to the homceopathic remedy which I consider to be of paramount importance even if surgery is often necessary. One need not emphasize to an audience of homceopathic doctors the importance of a full and careful history in the investigation of a dyspepsia. Details of the patient's curriculum vitse often throw much light on environmental factors in the breakdown and also on the victim's reaction. We all know the predisposed types: those inwardly worrying, conscientious folk who appear to be tackling a big job successfully, but at a price. They m a y be plagued b y restless driving ambition, often there is disharmony in their personal relationships: someone with whom the patient can't get on yet must conciliate, like a difficult boss, business partner, or wife, or mother-in-law. Financial worry is another big factor leading to m a n y secondary frustrations. Behind all this tension very often is tobacco; taken for its initial soothing effect and also perhaps to make the patient feel more at one with his fellows (the herd instinct), but leading to greater vagal irritability and vase-constriction and I think making ulcers more difficult to heal. While the classical duodenal type does occur frequently: the lean restless impatient individual with lined face and deep naso-labial folds--it is important to remember t h a t peptic ulcer afflicts all types and all ages from infancy to old age. I have seen boys whose ulcers started at 7, 9, 1 l, and quite a few at puberty. I don't remember any girls starting so young, but peptic ulcers in young women are nowadays quite common, e.g. Mrs. B., aged 25, who couldn't stand her mother-in-law, and who smoked cigarettes heavily. She relapsed twice after medical treatment with rest in hospital, and at operation there was found a deep chronic duodenal ulcer. The fattest patient I remember with a duodenal ulcer weighed 17 stone and I have several heavyweights with proved ulcers under treatment now. In fact almost any ordinary citizen can develop a peptic ulcer, given enough environmental stress and some innate predisposition, and the disease is a very common one today. Even in such a small hospital as Glasgow Homceopathic Hospital with only 30 adult beds, we have had 229 cases of peptic ulcer since 1945 and seldom are without one or two cases in the wards. Regarding pathology, the two big factors are: the acidity of the gastric juice, and the integrity of the mucous membrane of stomach and duodenum. Oesophageal, gastric, duodenal, jejunal, and Meckel's diverticulum ulcers all have in common the presence of HC1 in gastric juice, more or less concentrated. In duodenal ulcers the gastric juice is usually abundant and of high acidity, less so in gastric ulcers. But the two conditions have so m a n y points in common that there is every reason for regarding them as variants of one disease while admitting differences in extremes of classical type affected, geographical incidence, social class, etc. Moreover, gastric and duodenal ulcers are quite frequently found together or * A paper read to the Faculty of tIomceopathy on March 31st, 1960. 227

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following each other, the gastric ulcers usually secondary to the duodenal. I t is doubtful whether simple non-maligant peptic ulcer ever develops in complete achlorhydria. Some cases without acid in the first test meal can develop abundant acid after two weeks' treatment of gastritis--the thick mucus being washed aw%v with hydrogen peroxide in daily lavage. The secretion of acid is a complicated business into which I am not competent to go very deeply, but there are several things we should know. The parietal oxyntie acid-secreting cells in the fundic glands secrete when stimulated a fairly constant strength of hydrochloric acid (about 0.5 per cent.). This is a remarkably corrosive fluid for a natural secretion. The total number of acid bearing cells varies from person to person and gastric acidity appears to depend on how many parietal cells are brought into action at one time. People endowed with a very large number of acid secreting cells (and this may be a family tendency) will be more likely to have a high degree of acidity in the gastric juice. Illingworth states that the proportion of total parietal cells engaged actively in secreting acid also varies from time to time, e.g. 20-30 per cent. in resting conditions, 70 per cent. or more after food, and possibly nearly 100 per cent. after large doses of histamine. The cells secrete acid firstly from nervous stimuli down the vagus nerve liberating acetyl choline which acts via histamine. This is the appetite juice caused by taste or smell of food or chemically by hypoglycsemia. Pavlov who pioneered the nervous factor in acid secretion observed that wolves in Russia when starving in winter developed a higher gastric acidity enabling them to eat bark, and recent work on rats has also shown an increase of acid under conditions of fear. May not fear increase similarly human gastric acid? Secondly comes the gastric or humoral phase. Many foods contain secretagogues and all food coming in contact with the pylorie antrum of the stomach activates, it is thought, the secretion of a hypothetical hormone, gastrin: Secretagogues and gastrin acting through the blood stream stimulate the oxyntic cells, again probably via histamine. The pyloric antrum can also, it seems, influence acid secretion even when excluded from the food passage, and greatly increase it when transplanted into the colon, showing that the faeces contain either a powerful secretagogue or some substance which stimulates the antral mucosa to produce its hormone. Thirdly there is the intestinal phase of gastric secretion about which little seems to be known. Some foods when they reach the small intestine stimulate the flow of gastric juice, probably by a humoral mechanism. Dragstedt, working with dogs in 1951, estimated that the nervous and gastric phases each accounted for 45 per cent. and the intestinal phase for 10 per cent. of the gastric acid, but the proportions in humans are, I believe, unknown. Kay's work in the Western Infirmary, Glasgow, using large doses of histamine while protecting the patient b y anti-histamine drugs, to bring all the acid secreting cells simultaneously into action, has shown that in duodenal ulcer subjects the response to maximum stimulation is much greater than usual. This suggests an actual increase in the total population of parietal cells and hence a constitutional predisposition to high acidity. I t is obvious that histamine has a great deal to do with acid secretion but attempts to restrain its gastric action by anti-histaminics fail in peptic ulcer. Recent work by Irvine, Duthie and others shows that efficient histamine destruction by the liver may be necessary to protect the gastric mucosa from continuous stimulation by histamine absorbed from the bowel (hence possibly the alimentary bleeding tendency in cirrhosis). (Lancet, 23/5/59).

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The acid factor must then rank high, but there are others. Increased susceptibility to nervous stimuli leading to vasomotor congestion of the gastric or duodenal mucous membrane; motility disorders, reversed peristalsis, may all play a part. Hurst stressed the infective factor and vascular irregularities. He postulated infective minute emboli or thrombosis of small vessels in the mucous membrane. Miller observed a tendency to spasm alternating with atony of arterioles, in the lips and mucous membrane of ulcer subjects. It would seem that such vasospasm could be increased by cold, emotions and infections, all known factors in peptic ulcer. Recently Barclay and Bentley have shown a direct arteriovenous shunt mechanism in the gastric mucosa which can blanch the mucous membrane. Most authorities explain the fluctuating pain in peptic ulcer by variations in local inflammation and congestion. Acid per se is not the cause. Jacques Spira holds that it is the mixture of bile salts with gastric HC1 that damages the mucous membrane. He states that regurgitation of bile is caused b y fat in the stomach, and claims good results simply by eliminating fat from the diet and giving small doses of alkali. This emphasizes the importance of deranged gastric motility and would explain pylorospasm as a protective reflex leading to delay in emptying but to further damage of the gastric mucous membrane by the acid-bile-salt mixture acting much longer than normal. Spira explains the predilection for ulcers to affect the lesser curvature of stomach and corresponding area of duodenum by the fact that the food bolus travelling forward along the greater curvature is joined by regurgitated bile as it circles back along the lesser curvature. Although it has not apparently been officially blessed by the authorities I must say Spira's theory appeals to me and for many years I have told ulcer patients to avoid greasy and fatty foods. But olive oil I think should not be included in this restriction. I t seems to have a beneficial effect on those who can take it and is said to act by causing the production of a hormone, enterogastrone, when it enters the duodenum. This hormone inhibits the flow of acid. I t is reasonable to restrict coffee, strong alcohol, curries, highly spiced foods and coarse irritants as damaging to the mucous membrane, but provided food is chewed to a fine pulp there seems to be no harm in a generous ordinary diet. There are many other factors in the ~etiology of peptic ulceration--for instance the endocrine one. Biggart and Willis (Lancet, 28/11/59} found the parathyroids to be abnormal more frequently in male duodenal ulcer patients and the adrenal glands five times more commonly involved in peptic ulcer. They link the adrenal changes with emotional stress and mention also the occurrence of gastric hypersecretion and peptic ulceration in Cushing's syndrome and following steroid therapy. Alvarez in his fascinating book gives many instances of the effects of emotion on digestive processes, e.g. "blushing" inside stomach or sigmoid, and cessation of all gastric movement and digestion for as long as six hours after a meal and the colon filling with gas from emotional causes. He also suggests that various secretions, e.g. those into the duodenum can be arrested by excitement while gastric acid continues to flow not now buffered by the alkaline juices, and he gives instances of recurrence of hsemorrhage from the stomach following anger or worry. In Alvarez's opinion some people can't switch off their mental activity at bed-time and this leads to gastric hypersecretion from stimuli down the vagi. Every practising doctor knows the importance of those nervous factors but we have now to deal with the results, which can persist for a long time after the victim is "storm free" and can themselves, in the shape of painful ulcers, keep up nervous tension and anxiety.

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ACUTE PEPTIC ULCER W e think of peptic ulcer as the chronic relapsing variety but acute ulcers must firstbe considered as the precursors of the chronic type, and because they occasionally cause tragedies in their own right. Acute peptic ulcers can occur anywhere exposed to peptic juice. They have been produced experimentally in many ways: by injection of gastric mucous membrane extracts (Bolton's gastro-toxic serum) by injections of streptococci (Rosenow), by injecting typhoid vaccine, by merely raising the acidity of the gastric juice. They are well known to occur clinically during burns; (less so nowadays probably because sepsis is less); various tox~emias even in infants; during severe stress; from A.C.T.H. and cortisone; and, very important, from various forms of aspirin. Aspirin is responsible for many cases of quite severe bleeding. We had a young woman in G. H. Hospital recently who required a transfusion for bleeding after taking aspirin. And these cases are now quite common. Apart from the irritation of the aspirin there is usually some general tox~emia, influenza, headache, etc. for which the drug was taken and which may predispose to the formation of an ulcer. The majority of acute ulcers, however, just appear out of the blue in a patient apparently well and may be symptomless; or may perforate or bleed. Most acute ulcers are multiple, develop and heal quickly, but a few go on to a subacute stage and then become chronic due to some of the factors I have already mentioned. Here is the explanation of many sudden perforations and h~emorrhages without any previous warning symptoms. These acute ulcers would not show up with X-rays and even at autopsy might be missed. They can co-exist with chronic ulcers. DIAGNOSIS OF CHRONIC PEPTIC ULCER Ulcers may present atypically. Many quite chronic ones cause no symptoms beyond trivial dyspepsia, yet may bleed one day. Some patients with a posterior duodenal ulcer or large lesser curvature ulcer complain of nothing but a pain in the back: a persistent boring pain worse when tired and leading to much investigation of spine, etc., before the cause is discovered. In others the pain is unusually high, really in the chest (often prmcordial) and in some it may be felt quite 10w in the abdomen. Most peptic ulcer patients feel chronically tired and many use the word "miserable" to describe their plight; not surprisingly they are often dubbed neurotic. The case history is always important and may be almost diagnostic. The duodenal ulcer patient tells of the episodes of epigastric or right hypochrondriac pain lasting for a few weeks, worse when empty, relieved after food, and often waking him in the night. But pain in the morning before breakfast is not a feature of duodenal ulcer although some Natrum carb. cases have an empty feeling then. Heartburn, acidity, waterbrash are common and the last is especially diagnostic. Later the picture becomes more blurred. Fullness quite soon after eating, a feeling of bursting tension, flatulence, bad tasting eructation and occasionally vomiting become more marked but there may still be the pain in the night and also day pain which is ameliorated by a little more food. Vomiting always gives great relief, and as pyloric stenosis advances it becomes the prominent symptom but it can occur quite early in some cases, especially of gastric ulcer. Nausea is not common in early cases but there is the fear to eat. Illingworth recognizes three kinds of ulcer pain. 1. A diffuse epigastric pain, which extends to the back.and is relieved by

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food and alkali. He regards this as a visceral pain due t o hyper~emia from the acid. 2. A fingertip spot of pain in the epigastrium superimposed on (1), due to irritation of the parietal peritoneum; situated to the left of mid-line in gastric and to right in duodenal ulcer, sometimes with tenderness. The first two types of pain are relieved after hmmorrhage suggesting their hyper~emic cause. 3. A tension or bursting type of pain when pyloric stenosis is threatening, aggravated b y coarse foods, relieved b y emptying the stomach. SIGNS OF ACTIVE ULCERATION I lay a good deal of stress on a succussion splash in the stomach occurring two hours or more after food. Even in quite early ulcers this m a y be present, probably due to pylorospasm, and I think it is a valuable sign, in the absence of gross visceroptosis or ileus. In late cases with pylorie stenosis it is, of course, invariable along with visible peristaltic waves passing from left to right, and sometimes a palpable tumour at the pylorus. Tenderness on palpation is often absent, and would not be expected in posterior ulcers. The children with peptic ulcers had usually been diagnosed as having acidosis, or bilious attacks, and the succussion splash led me to the correct diagnosis. Acetone in a young person's urine is a very common occurrence in vomiting from any cause including acute appendicitis, and acidosis is a risky diagnosis, to be made only after careful elimination of more serious causes of vomiting. To clinch the diagnosis an X-ray by an experienced radiologist is essential. Occasionally even the expert will miss an active ulcer, but not often nowadays, and he can usually state whether the ulcer is active from the presence of spasm, local tenderness, irregular mucosal pattern in the vicinity, irritability leading to transient fleeting filling of the niche. A definite ulcer crater at times m a y not show up radiologically if it is filled with clot or debris, and (edema sometimes gives a smoothing out of the mucosal pattern round a gastric ulcer with quite a large filling defect which m a y simulate neoplasm (Dr. S. D. Scott Park, personal communication). The history, signs and symptoms in carcinoma of stomach are usually quite different from those of peptic ulcer, but an X - r a y diagnosis of gastric ulcer or antral ulcer always leaves one a little dubious. There is no worry with duodenal ulcers as carcinoma does not occur in this site. I n doubtful cases the presence of free HC1 in the gastric juice is reassuring, its absence worrying; but one must remember t h a t carcinomatous change in a gastric ulcer can occur with acid present, and a peptic ulcer with apparent achlorhydria. Length of history is in favour of peptic ulcer but again the carcinomatous change in old ulcers m a y deceive. A short history and anorexia in an older person are very suspicious of carcinoma. I f the gastric ulcer is not much smaller radiologically after a month's medicM treatment, and particularly if the HC1 is low, one should not hesitate to advise operation. No gastric ulcer, even in a young person, should be lost sight of till really healed. I had a lesson from this tragic case a woman of 25 whom we treated medically in Glasgow Hom(eopathic Hospital was anxious to get home for domestic reasons. The gastric ulcer crater was much smaller oll discharge. She did not report again until too late and laparotomy revealed a carcinoma of stomach with liver involvement. Now that f~ecal occult blood can be so easily tested for b y H~ematest tablets, this test should be used freely in practice to screen suspected cases and to assess progress of ulcers. This tablet test is not very sensitive and if positive

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it really means something. The F.O.B. should become negative quite quickly, say in the first two weeks. A persisting positive test in the absence of piles or bleeding gums and on a meat free diet always arouses the suspicion of carcinoma. But one other common disease can cause it: cirrhosis of the liver, besides rarer medical conditions such as blood dyscrasias and pseudo xanthomatosis elastieum. We had a woman in Glasgow Homceopathic Hospital recently who was very ansemic on admission and required a transfusion. She had quite severe dyspepsia and abdominal pain which responded to Stannum 30--the slow increase and diminution of the pain being typical. Barium meal was negative but the gall bladder was non-functioning. I n view of the persistently positive F.O.B. tests a laparotomy was done, to reveal not gallstones or carcinoma but cirrhosis and a big spleen which none of us could feel before operation even under anmsthesia. I t is fair to add t h a t the patient was very obese and the spleen enlarged down in the left abdomen and not across as it usually does! I am glad to say she is very well now. I retain an old-fashioned belief in the value of the test meal as showing: the total fasting secretions, the type of acid curve: (high climbing in duodenal ulcer) blood in active ulcers or carcinoma, offensiveness in carcinoma and pylorie stenosis, especially carcinoma; much mucus in gastritis; absence of acid in cancer or gastritis. Where this lack of acid occurs a histamine test meal is required after gastric lavage for a week to get rid of excess viscid mucus in gastritis and so reveal either genuine anacidity, or the presence of acid, which m a y now be abundant. TREATMENT

The surgeons, as we well know, are pessimistic about medical treatment and not too h a p p y about surgery as the final answer either. I t is a pity they don't know the value of Homceopathy either in curing the condition completely or in giving much quicker and longer lasting relief. Even when the patient must come to surgery I consider homceopathic treatment before and after operation to be of vital importance. The types admitted to hospital are usually long standing, deep indurated ulcers, penetrating to pancreas and gall bladder or transverse colon. Illingworth probably had this type in mind when he wrote that "the long term progress of ulcer patients treated in hospital is influenced little or not at all by the medical treatment they have received". I must admit that I have frequently advised such cases to have surgery and when one sees the condition at operation one is not too ashamed of a medical failure to heal this sort o f ulcer, especially when duodenal. Where the ulcer is gastric it often heals surprisingly quickly if put to rest and given medical treatment. X-rays are reliable to show healing of a gastric but not of a duodenal ulcer, and it must also be remembered t h a t spells of freedom from pain and bleeding occur in quiet phases of duodenal ulcers which are not really healed. Hurst's indications for operation in peptic ulcer are valid still. These were: 1. Where a chronic ulcer does not heal after eight weeks' thorough medical treatment as shown by persisting pain, tenderness and l~ositive F.O.B. tests. Gastric ulcers particularly must not b e left long unoperated owing to the possibility of carcinoma. 9 2. Where ulcers keep recurring in spite of medical care. 3. Hour-glass constriction of stomach; pyloric or duodenal stenosis. 4. Perforation. 5. Rarely h~emorrhage. . . . . . . . . . . . . . . .

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IN MAKING UP OUR MINDS ABOUT ADVISING SURGERY. Each case requires individualization and consideration of factors such as: 1. The type of work the patient has to do. 2. The economic status and opportunity for rest and spells off work; future prospects; is the person likely to reach a less stressful life soon? Would medical treatment get a fair chance? 3. The age of the patient. Young people d o n ' t do so well with surgery a n d also, as Ogilvie says, "We know t h a t a gastrectomy well performed is good for t w e n t y years of trouble free service; we do not know that it will last for t h e forty-five'years it will be called on to serve a man of twenty." 4. But length of history comes in here and a deep chronic fibrosed ulcer can occur nowadays in quite a young person. I f medicine fails we must give them their surgical chance. Wide extension of pain, e.g. to back, suggests a big penetrating ulcer. 5. Frequent vomiting usually means pyloric stenosis is threatening. 6. Women seem to do better with medical treatment or less radical surgery t h a n men, and are more liable to have severe nutritional anaemia after a gastrectomy. 7. Some people obviously will not discipline themselves enough to give medical treatment a fair chance. Unfortunately this inability makes them more liable to relapse after surgery. As to the choice of operation one can only choose a good surgeon and leave it to him. Gastro-enterostomy has gone out of fashion because of the 23 per cent. long-term development of stomal ulcer leading to severe dyspepsias and h~emorrhages, and possibly gastro-colic fistula with persistent diarrhcea, or perforation. Vagotomy with gastrojejunostomy is said to be better. Severing the vagus fibres to the stomach blocks the nervous stimuli to acid juice but not t h e acid response to the hormonal or intestinal phases of digestion. Vagotomy also stills excess gastric motility. But these effects persist only for a year after the fibres are divided. Partial gastrectomy is now the popular operation but even surgeons cavil at such a multilation where so much work is thrown on the jejunum which might later stenose or ulcerate. I n expert hands gastrectomy can give near-perfect results to date, but when things go wrong it is a bad business and the immediate mortality due to leakage from the duodenal stump, h~emorrhage, injury to the pancreas, kinks or intestinal ileus is quite considerable. I t is of great importance not to operate if possible in an active phase when the ulcer and tissues around it are swollen and congested. Rest in bed for a week or two before operation with lavage, blood grouping and the indicated remedy is well worth while. Even if well performed a gastrectomy can be followed by various disagreeable syndromes such as anastomotic ulcer, with possibly fistula; dumping syndrome, afferent loop syndrome (persistent bilious vomiting), anaemia, and nutritional failure from rapid transit of chyme through the jejunum. I n duodenal ulcer I usually encourage the surgeon to do a gastro-enterostomy only. After all, it is followed as a rule by healing of the ulcer and I rely on Homceopathy to prevent stomal ulcer. The difficulty is to get people to keep at treatment when apparently well and I must admit to some stomal ulcers from this cause. I shall not weary you with figures but I have put the findings after a r e c e n t postal follow-up in an appendix to this paper. Of the 54 cases who had had gastro-jejunostomy, 34 reported complete success from the operation, 14 moderate success, and 6 failures. This is apparently higher than the average s u c c e s s

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rate and it m a y be connected with the fact t h a t I have always stressed the importance of continuing after-care and Homceopathy for some years. The most outstanding success is a man who is now 65 who had a severe ulcer after the first W a r and was finally operated on in 1926, the floor of the ulcer being in the pancreas. After a gastro-jejunostomy he rapidly gained weight and has never looked back although he is completely edentulous and refuses to wear his false teeth! At the worst gastro-enterostomy can be followed b y a gastreetomy but after the latter nothing surgical can be done except anastomosis between the two jejunal loops for the afferent loop syndrome. So there is a lot to be said for medical treatment getting a good trial before the surgeon is called in! Hurst claimed cure in a great m a n y cases and I think we should be quite optimistic where Homceopathy is also available. The regime I advise for severe attacks is the usual. Rest in bed and warmth for a month; attention to the teeth and mouth, a generous bland diet with avoid: ance of irritants like strong coffee, bovril, neat alcohol, tobacco, fats; frequent milky feeds between main meals if milk is tolerated, olive oil half-an-hour before meals if it can be taken, and a drink of milk and hot water in the night if pain awakens the patient. I have not much use for regular alkalies but would allow a little baking soda occasionally to relieve severe pain. Some people find Roter tablets suit them well, in others they do no good. I n pyloric stenosis daily aspiration of stomach contents is required and dehyration if present must be treated by generous intravenous infusions of 5 per cent. glucose and saline in proportions and amounts as advised b y the biochemists even to ten pints daily. I am not very h a p p y about giving potassium intravenously but might give it orally if the figures were very low. The blood urea should be estimated and renal failure watched for. Medical treatment in such severe conditions is usually just a preliminary to surgery. Most ulcer cases, however, are less severe and can be treated while going about at work and hope for a cure. These I enjoin to take relatively dry meals and liquids between meals, and always to rest for ten minutes after eating, preferably lying down. I got these two rules from Gibson Miller and find them invaluable. (Hurst showed t h a t on lying down during digestion the full duodenal bulb emptied.) And now to what is probably the best thing we can do for these sufferers-find the indicated homceopathic remedy for the whole individual. This will smooth out their motility disorders and nervous over stimulation better than a vagotomy, and more permanently. Even if the ulcer is too extensive and fibrosed to cure without operation the homceopathic remedy will make post-operative progress much smoother and greatly help towards a good final result. I t is obvious t h a t we have to treat the whole m a n and that almost any homceopathie remedy might be indicated, especially one of the big polychrests, prescribed on the general reactions of the individual. But the pathology requires consideration too and in practice some remedies turn up oftener than others. The best essays on digestive drugs that I have read have been Borland's published in Homeeopathy during 1940, 1941 and early 1942. Unfortunately these are hard to come by today but we hope they m a y soon be reprinted. Today time permits mention of only a few remedies t h a t have served me well. 1. Arsenic. alb. is often required when acute gastritis with vomiting and burning pain are prominent and the 12-2 a.m. aggravation time marked. The mouth is hot with thirst for cold sips but the burning in stomach is ameliorated b y warm fluids though milk does not always agree. The generals: fear, restlessness and chilliness and great weakness confirm our choice. When Arsenic has controlled the acute phase very often the bowel nosode.

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2. Dysentery co. does valuable work on a deeper plane. The relief from eating and vasomotor instability are marked and pylorospasm. 3. Few of us would care to treat stomachs without Nux vomica. The irritable, tense, impatient mentality gives the clue, and there is much reversed peristalsis and colicky pain with difficult vomiting and delineation, and relief from vomiting and after stool. The patient will note a close connection between his indigestion and stress, anger, worry, loss of sleep or indiscretions in diet. He wakes about 3 a.m. and lies worrying till nearly 7 a.m. when he will fall into uneasy sleep. He loves all the things he shouldn't take and after a night out will have a horrible "hangover". These people are oversensitive to everything especially pain. They are intensely chilly but feel faint in a warm room. Borland praises Nux for its power to revive quickly a person who having wined and dined too well in a stuffy room, gets acute gastric distension with colic and urging to vomit and to stool, and a sensation of extreme faintness. I n these circumstances Nux will restore peace very quickly and perhaps prevent a catastrophe. The Nux indigestion and distension is usually worse two or three hours after eating but the face flushes during a meal and sleepiness often comes on soon after. ~Vux vomica when well indicated will carry a patient a long w a y and m a y be repeated as required. Here is a letter from a doctor friend dated J a n u a r y 12th, 1960. "Regarding remedies which helped me most for peptic ulcer: Sepia did help but the next remedy you prescribed, Nux vomica 30, was really the only one which proved to hit a 'bull's eye'. I have scarcely had any pain or even discomfort for four years and three months and t h a t after some 35 years of pain almost every day. The ulcer was confirmed by radiological examination." 4. The Sulphur case has an excellent appetite and is usually cheerful in spite of his pain. He will feel the gnawing emptiness in the forenoon especially, heartburn will be prominent, and often early morning diarrhcea. A history of an itchy skin eruption of some sort is common. 5. Lycopodium comes in very often, particularly in Scotland, because of our starchy diet. I n fact, I think it is the commonest remedy I use for duodenal ulcer. I am chary of starting it too high and prefer not to give it during a spell of acute congestion in the ulcer which Nux vomica or Chelidonium or China or Carbo reg. or Arsenic might smooth over more safely. Lycopodium cases h a v e tremendous flatulence and feel the distension affecting the whole body even to the head. Pylorospasm is obvious and stenosis threatening. The focal pain, an acute burning, is well to the right and extends through to the right inferior scapula like a gallstone pain. There is m u c h waterbrash, sourness, hiccup and hunger, also "hungry headaches". Though hungry they feel full after a few mouthfuls and then eructations begin. The flatulent pains affect the abdomen also, in knots which the patient rubs, and there is constipation with painful anal spasm like Nux. All the symptoms are worse from 4 p.m. and the stomach pains also waken a t 2 a.m. like Arsenic, Kali carb. and Medorrhinum. W a r m t h internally comforts the pain and there is aversion to coffee and tobacco which aggravate, and to meat. The patient has usually a sweet tooth and has increased flatulence after sweets (like Arg. nit. which, however prefers cold drinks and is worse lying on the right side). The Lycopodium appearance is often typical: anxious frown, thin sallow lined face looking older than his age, fibrillary facial twitchings, yellow teeth, arcus senilis, grey hair, full hairless abdomen, often hernia. The Lycopodium woman is more obese as a rule. Loss of confidence is the chief mental symptom. I have seen long relief in ulcers follow a 6 or 12c of Lycopodium after an initial aggravation. I t is one of the remedies which often carry the patient through to a cure without the need to use other remedies. As the potency scale is

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ascended I find that high and highest potencies (10m to c+n) do longer and deeper work till repetitions are needed very infrequently--say once a year or even less. An example is the case of J.B., now managing director of a big firm. When I first saw him at the age of 30 in 1931 he had typical duodenal ulcer pain and also rather violent hiccups after eating, the symptoms having been present in bouts for 189 years. X-ray in 1952 showed a chronic duodenal ulcer with an active niche close to pylorus. He has had very little else but Lycopodium and the last doses, in 50m potency, were given in December, 1956, September, 1958, and January, 1959, and after the doses an old impetigo of his chin came out for a bit. Lycopodium always clears up any pain and flatulence he has without loss of a day's work. 6. Natrum carb. patients have a great deal of flatulence and acidity and the relief from eating is marked but short-lived. There is great emptiness in the early morning and late evening. The patient is tired, sad, weepy, jumpy and oversensitive to people, to sun, and to thunder, and can't tolerate milk. There may be herpes on lips or face, oral thrush, and a dry skin. Nat. carb. cured for me a woman who had rheumatoid arthritis and peptic ulcer. I t was striking because the cure followed the failure of several remedies previously given and both conditions cleared up On the one remedy. 7. Medorrhinum has somewhat similar mentals: the patient is weepy, jumpy, hurried, forgetful and also sensitive to storms. Sweets, salt, oranges and ice are craved. This nosode of the gonococcus has helped a great many peptic ulcers for me and also gallbladder cases. It can cause quite severe aggravation with sharp pains as of pins sticking in, violent retching and vomiting, and abdominal distension. The epigastric region is very sensitive to touch. The tender hot feet sometimes draw attention to Medorrhinum. 8. Sepia again is similar but more irritable and sullen as though she had a chronic grudge against fate. She may weep on telling the story like Kali carb., Medorrhinum, and Pulsatilla, and she hates being cross-questioned or contradicted. The nausea is prominent, much worse from cooking smells, and associated with emptiness; there is constipation with jelly-like mucus and a lump sensation remaining in rectum. I have found Sepia more useful in pregnancy sickness, visceroptosis and carcinoma than in ulcer but it might well be needed in gastric ulcer. It has helped me in bilious vomiting following gastrectomy. It is a mistake to reserve Sepia for females; in spite of its strong menstrual symptomatology the remedy has helped many men, often sallow and asthenie types with a history of bed-wetting in their childhood. Ptelea is similar to Sepia but with more liver congestion; marked aversion to meat, fats, and general relief from eating. The liver discomfort is worse lying on the left side. Aristolochia clematis should also be considered. Whitmont regards it as having the mentals of Sepia and the physical features of Pulsatilla. 9. One can't consider weepy remedies without reference to Pulsatilla. I have several patients with peptic ulcer, both men and women, who do very well on it. Gentle souls with dry tongues and slimy bitter t a s t e - - y e t no thirst; eructation greasy and tasting of the food eaten, who can't tolerate the least fat and want their environment both external and internal as cool as possible, although they may feel chilly when sick. Like Nux vomica they have desires for tasty indigestible foods and the constipation is somewhat similar but the temperaments are poles apart. Pulsatilla people like to walk up and down quietly to relieve their gastric distension. One bright little boy with a duodenal ulcer is doing well on this remedy at present. Anthony, aged 989 was brought first in January, 1959, because of spells of nausea, malaise, abdominal tenderness and vomiting which had been going on

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for a year. Shortly before I saw him he had had diarrhoea with the vomiting and had been given an antibiotic by a p~ediatrican; sprouts eaten two days previously were noticed in the vomit. He was a bright affectionate little boy weighing only 4 stone 3 lb., and liking ice cream and cold milk and t a s t y foods. There was an undercurrent of anxiety and restlessness and he did not like to be alone. His mother is healthy but his father had had pulmonary tuberculosis, now healed, and is rheumatic. An elder brother is eupeptic. During the year he has had Dysentery co., Pulsatilla, Tub. Bov., Medorrhinum, Sulphur, Lachesis, and in the last four months Pulsatilla 200, repeated three times, since when he has been very well and has gained half a stone. Vomiting stopped after the first dose of Pulsatilla and splashing is now seldom present. The X-ray taken a year ago showed a large but normal stomach, spasm and deformity of the duodenal cap with an almost constant spasmodic constriction round it about halfway between its base and apex--appearances most suggestive of active duodenal ulceration. The family are most impressed with the improvement in this boy's health---even examinations don't upset him n o w - and I think we can be hopeful of a very good result. On the whole I think the prognosis of peptic ulcer in children is very good, much better than in young adult life. I would like to mention one other case where rapid relief to a long-standing marginal ulcer followed Pulsatilla helped by its complementary remedy

Stannum. Mrs. W. G., aged 52, a small bright woman weighing only 789 stones but the mother of four large children, had had a posterior gastro-enterostomy twenty years ago for a " p r e t t y bad" duodenal ulcer. The appendix was also removed. This cured her ulcer symptoms but for some years prior to consulting me in 1957 she had been troubled with abdominal pain of three different kinds. 1. Severe colic with distension relieved by vomiting (at fairly long intervals). 2. Low central pain worse after being up from noon onwards, relieved by resting and sometimes b y eating. 3. A more recent colicky pain in the right hypochrondrium extending round the right lower ribs. There was at times distension with nausea and she occasionally wakened with abdominal pain which forced her to get up and walk about. The pain came on slowly and departed gradually and was relieved by doubling up and by pressure. The lower abdominal pain (not the colics) worried her most and it seemed to be better or worse during the whole of a monthly menstrual cycle. She easily got the sensation of fullness after eating and if she ate more t h a n usual and then exerted, she felt faint. Gynaecological examination was negative. There was distension of the upper abdomen with visible peristalsis, and a careful X - r a y examination after a barium meal by Dr. Scott Park clearly showed a fairly large marginal ulcer, and a large tender calcified gland in the lower abdomen. The patient wanted coolness and air, enjoyed cream, cheese and butter, but hated other fats and was very depressed and upset before each menstrual period. She improved at once after Pulsatilla 30 as to the nausea and upper abdominal pain, but the colics became severe and frequent until I gave her Stannum 30, since when they have hardly troubled her at all. I t was necessary to give the Stannum fairly frequently at first--every time there was an attack. Thereafter she has kept very well on doses of Pulsatilla 10m at long intervals given when nausea and distension begins. The last doses were in May and then December, 1959. Variability has been a feature, no two menstrual periods a l i k e - - a n d she is a classical Pul~atilla type.

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10. Thuja has a stomach rather like Pulsatilla; the symptoms suggest gastritis, with much heartburn on stooping. The patient craves chocolate and drinks too much tea and is upset b y anticipation, and from eating onions. Obese hirsute pituitary types with warts and moles and greasy face. 11. Phosphorus has controlled quite a number of ulcers for me. The keynotes are the thirst for big cold drinks and desire for and relief from ice cream and cold things, though unlike P'tdsatilla the patient wants to be warmly clad. Food is vomited in mouthfuls and the patient is weak, trembly and nervous about being alone and much comforted by someone being near, and worse from the dark and thunder. Less acute cases will crave salt and tasty things and stimulants and have an aversion to sweets and tea. Phosphorus people bleed easily, so give it fairly low in acute gastritis where it is often indicated, or acute exacerbation of chronic ulcer. 12. Borland praises Phosphoric acid for dyspepsia in adolescents with brain fag, styes, students' headaches with the right pupil larger than the left, and a sensation of pressing distension anywhere in the body. There is a great deal of abdominal rumbling and acute gastric discomfort half an hour after eating with crampy pains and regurgitation of food. But in contrast with Phosphorus, Phosphoric acid cases want warm drinks. 13. Carbo veg. comes in often in association with Phosphorus, Arsenic and Kali carb., and gives wonderful relief in acute gastritis with burning pain and great flatulence both up and down. Eructations and flatus ameliorate greatly. The basic pathology m a y be (esophageal ulcer, or gastric ulcer or carcinoma. The burning comes on soon after eating and is much worse from wine, heavy iced or spicy foods to which these people are addicted. Acute distension with air hunger and collapse may occur after a dinner party and Carbo veg. may earn, once again, i t s nickname--"corpse reviver". Carbo sulph, is similar in more chronic cases. I think of it as a Carbo veg. with features of Sulphur and like it in alcoholics and poor arterial risks, often chesty. 14. Another friend of broken down poor risk peptic ulcer cases is Kali carb.--one of the very best. The cases are often complicated with bronchitis, poor myocardium, anaemia, and pyloric stenosis, hepatitis with spells of fever, and old age. The face is puffy, anxious, and irritable and there are pouches of upper eyelids and below the eyes. There is a great deal of flatulence and bloating and throbbing of the epigastrium soon after eating but an unpleasant empty feeling if long without food. Kali carb. patients often have much pain in the back or chest and there may be a tender spot over the mid-dorsal spine. Food sticks in the mid-(esophagus with choking and coughing. They wake about 3 a.m. and have a very bad time for two hours or so with pain and sickness. The patient is very nervous and fearful, worse if alone but irritable and very sensitive to noise or touch. Any fright is felt in the stomach and the patient puts his hand on the epigastrium in a characteristic gesture. The patient desires sugar and hates meat. Now that we know about the importance of potassium loss in severe vomiting and its effect on the myocardium, we have a new reason for the use of this welltried homceopathic remedy in appropriate cases of peptic ulcer. Here is a typical case; note the long action of a low potency. Mr. A.M., aged 6189 an engineer foreman, consulted me in January, 1959, because of frequent spells of stomach pain, nausea and waterbrash. The pain extended downwards and into his back--where it seemed to explode, was worse 189 hours after eating, and also at times almost all night. There was distension but not usually vomiting. Pain was worse cold, noise, jar, slight exertion; ameliorated by milk. Bouts lasting two or three weeks recurred every six weeks or so. He had had his first h~ematemesis thirty years ago and thereafter attacks of mel~ena every two or

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three years; there had been one in 1958 and again shortly before I saw him. He also had winter bronchitis with violent coughing bouts, and a recent angina of effort, with chest pains extending down the left arm, bleeding prolapsing piles and quite severe prostatism; also sharp sudden headaches behind the right eye, often waking him in the early morning. His indigestion and chest pain frequer~tly wakened him at 2 a.m. He was liable to sudden anger and easy weeping but continued at his job as a rule and also had to cope with a good deal of worry at home. Blood pressure on the first examination was 180/120 with regular cardiac r h y t h m but a ringing aortic second sound. The epigastric area was very tender. The prostate was hard but symmetrical, urine normal, the retinal arteries narrow, no obvious glaucoma. He was obviously a poor surgical risk but I did not feel very hopeful either about medical treatment of such an old ulcer in an arteriosclerotic man so liable to bleed. However, encouraged by the patient to try, I gave him Kali carb. 6c, six powders, with some trepidation. He had quite a severe aggravation of spasmodic abdominal pain for the first ten days after it but reported feeling very well a month later when blood pressure was 150/100 and epigastric area much less tender. He did not return till April and then reported no stomach pain but headaches of sudden onset and gradual relief for which Pulsatilla 30 was given. Blood pressure 155/110. The headaches cleared after Pulsatilla, but a month later stomach relapsed and I repeated Kali carb 6c. Thereafter he kept very well all summer and did not require another dose of Kali carb 6 till November 6th. Splashing in the stomach over three hours after food was present on the February consultation but not thereafter. The urinary frequency and slow stream persists but within the limits of his cardiovascular degeneration he has improved enormously under spaced doses of quite a low potency of Kali carb., and has lost practically no working time in the year he has been under treatment which is a record for him. 15. Kali bichromate is similar to Kali carb. in m a n y respects and is well suited to the pathology of acute gastric ulcers and gastritis, and (esophageal ulcer. The sharp substernal pain extending to the back and stomach pain which can be covered by a finger point are keynotes. The pain is burning, worse 2-3 hours after eating and at 2 a.m. and accompanied by vomiting of very r o p y mucus. I n beer drinkers' gastritis it also helps the fullness and heaviness t h a t come soon after eating l there is no appetite but faintness and nausea if long without food. I f there is also viscid greenish nasal catarrh with crusting, migraine headaches preceded by blurred vision, and a tendency for stomach and rheumatic pains to alternate--we have a sure thing in Kali bichromate. (But note t h a t Iris versicolor has a similar headache and burning stomach pains but here the vomitus is very acid; and Pulsatilla has the same alternating gastric and rheumatic symptoms.) 16. I t is becoming a little difficult to decide which remedies to include in this lengthy list--there are so m a n y we have not yet considered. But Graphites must not be left out in duodenal ulcer although I don't use it so often as some of those already mentioned. The Graphites stomach pain is a burning heavy distension, ameliorated by warm milk, eating, eructation and lying down and accompanied by congestion to the head, bitter or rotten egg tastes, and aversion from sweets, salt, meat and fish. There is constipation: big k n o t t y stools with mucus, or offensive diarrh(ea with undigested food. The Graphites patient is chilly and eczematons with cracks at sides of mouth and anus, blepharitis, crippled naris, and often a poor circulation to the lower limbs. The mood is sad, anxmns, weepy, forgetful and notably irresolute. 17. Petroleum touches Graphites at certain p o i n t s - - t h e eczema and the need to eat frequently, but in Petroleum it is the nausea which is ameliorated b y

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eating; the pain comes soon after eating hence one thinks of it more for gastric ulcer. There can be abdominal colic as severe as in Colocynth and violent offensive diarrhoea worse during the day. The patients are thin, with dry rough cracked itchy skin, chilblains, offensive foot and axillary sweat, and catarrh. They are rather muddled and confused, and m a y have notions of duality, with occipital headache, and general tired aching. The feet and hands can burn like Sulphur but the patient is worse in cold and there m a y be a strange coldness in certain areas. 18. A nacardium has stomach pain like a plug or ball, passing off with gurgling; pain worse tw~o hours after eating and ameliorated b y eating again and worse from cold drinks a n d excitement, and with salivation. There is a strong impulse to swear or break out in some way and the patient is too timid or so situated t h a t he can't express this frustration. This remedy has greatly helped for me several such people with duodenal ulcer. The memory is very poor in Anacardium cases, and writer's cramp m a y occur. The chief mental s y m p t o m resembles t h a t of Staphisagria but the latter does not correspond so well to peptic ulcer. 19. China is an indispensable remedy in peptic ulcer, especially in hospital where so m a n y come in after hmmorrhage. I t is the most common remedy for severe aneemia due to blood loss with rushing in the ears, coldness and profuse sweating, and I usually find it indicated on the second or third day, after Carbo veg. or Arsenic or Cadmium sulph, or Ipecacuanha have dealt with the initial bleeding. But China is also curative in more chronic states of peptic ulcer where ~erophagy is extreme and the patient emaciated, with very sensitive abdomen which strangely does not mind firmer pressure. China cases are sensitive to everything: noise, touch, odours, tastes and have a slimy mouth with hatred of fats and desire for tasty things. There m a y be diarrhoea, worse after eating and at night, and the stools contain undigested food and mucus. I t is obviously a remedy to consider in gastro colic fistula. The patient is depressed and m a y even feel suicidal and often has never properly recovered from a hmmorrhage or some severe illness. 20. ~Vatrum sulph, has resemblances to China in the depression, slimy mouth with bitter taste, diarrhoea and liver involvement. But the Nat. sulph, diarrhoea is mostly first thing in the morning and the patient is sensitive to heat and to damp, and to light, and better when moving about. This valuable remedy is more often needed in cholecystitis and septic appendicitis with abscess extending up to liver, but it has also the stomach pain relieved b y eating. 21. Natrum tour. is so frequently needed for all sorts of ills t h a t it must not be forgotten in peptic ulcer. I n addition to the well-known general indications, the mapped tongue, dry lips and mouth, forenoon sinking hunger, cravings for salt, fish and milk and sensation of a lump in throat or stomach are prominent. Borland praises it for gastric ulcer and states he has not found it indicated in duodenal cases. But just to show that one can't exclude it in duodenal ulcer let me quote this case of J . R . where a duodenal ulcer has been cured with Natrum tour. as the principal remedy. I t was quite a bad ulcer with severe pylorospasm and gave me a good deal of worry at first. J.R., a boy of nearly 14, was brought to me in February, 1947, with a story of attacks of upper abdominal pain and vomiting since age 11 when he went away to school, where he had to eat badly cooked food. Acetone was found in the urine and the condition diagnosed as acidosis but he got no better, in fact steadily worse, and was only 589 stone when first I saw him. The boy was nervous, weepy and rather spoiled and noticed his stomach pain to be worse in warm weather. He had a desire for salt and m e a t y things and an aversion

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from fat and eggs and appetite generally was very poor. Although chilly he hated to wear a coat or underwear. I noticed visible gastric peristalsis and X-ray after a barium meal revealed a duodenal ulcer with slight ileus. My first prescription was Natrum tour. 30, after which he was worse for a month with quite projectile vomiting every second or third day requiring Pulsatilla 30 to palliate. Thereafter I gave at intervals of one to three months Dysentery co., Lycopodium, and Sepia and Sulphur and Tub. boy. He responded well to Sepia and Sulphur, but got much deeper and longer relief from Natrum tour., to which I always returned from time to time. He had a long run of relief from repeated doses of Argentum nit. and again from Sulphur but since 1954 when I gave Natrum tour. 30 in the plus method for a week on two occasions he has had no serious stomach trouble at all. An X - r a y in 1957 showed a scarred narrow duodenum but no delay and no signs of activity. I gave him Natrum tour. lm in 1957 and he has required nothing since and says he eats anything now. Admittedly other remedies were needed but I think IVatrum tour. deserves the main credit. Although this patient had a proved duodenal ulcer with night pain and relief from alkalies, his symptoms were rather more like those of gastric ulcer than usual. I gave him Natrum sulph, once only, in 1956 for headaches after a car accident, but his stomach was well by this time. I have another case of duodenal ulcer in a woman of 45 proved by X-ray, where diarrhoea and loss of flesh were prominent symptoms, also breaking backache. She got much better and rapidly gained weight after !Vatrum tour. 30. 22. Finally Ornithogalum whose pathogenesy closely resembles the picture of pylorie stenosis with extension of the stomach pain to back and down arms, worse at night and better from warm drinks. There are sensations of tense pressure throughout the whole body, and a creepy tingling in the lower limbs with cedema. I have never been able to convince myself that Ornithogalum did much good in extreme pyloric stenosis either in tincture or potency, but others have praised it. I would prefer surgery in stenosis from ulcer. The remedy, however, should be considered as a palliative in inoperable carcinoma along with Carbo veg., Arsenic, Cadmium, etc. And I have recently had two very good results from the Ornithogalum 200 in men with attacks of acute distension. Neither had any X-ray sign of duodenal ulcer, but one had had an operation for Meckel's diverticulum and the other had had the duodenum opened for an impacted gallstone. The former case also had unexplained cedema in attacks. I t remains to thank you, Mr. Chairman, Ladies and Gentlemen for your patient reception of this long paper. I f it engenders a more hopeful attitude and encourages some to t r y harder to cure peptic ulcers medically I shall be happy. I regret that I could deal with so few drugs and these not fully. The resources of our homceopathic materia medica are far richer than I have been able to indicate in the time. The treatment of ulcers medically is admittedly a long difficult business requiring usually quite a few remedies and a good deal of skill and experience, but that makes it all the more interesting.

REFERENCES

Hurst and Stewart, Gastric and Duodenal Ulcer (1929), Oxford Medical Publications. J-Jaques Spira, The Causation of Chronic Gastric and Duodenal Ulcers (a new theory, 1931). Oxford Medical Publications. Ibid., Gastro-Duodenal Ulcer (1956), Oxford Medical Publications. Walter C. Alvarez, Nervousness, Indigestion and Pain, Heinemann. 1943. C. F. W. Illingworth, Peptic Ulcer (1953), E. & S. Livingstone Ltd. Sir H. Ogilvie, Surgical Judgement from No Miravles Among Friends, Max Parrish, 1959. D. Borland, "Digestive Drugs", Homceopathy, 1940, 1941, and 1942.

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APPENDIX A postal follow-up of cases of peptic ulcer admitted to Glasgow H o m e o p a t h i c Hospital since 1945 shows the following figures. Duodenal ulcer males 135 females 63 Gastric ulcer males 13 Total peptic ulcers 229. females 18 Of these duodenal ulcers 65 males and 25 females underwent gastro-jejunostomy ~nd 12 males and 4 females gastrectomy. Of the totals there were 20 cases of hmmorrhage and 5 of the gastric ulcers were malignant. 120 patients replied to a postal questionary and 109 patients could not be traced. Some who were quite old at the time of operation or hospital treatment were known to have died, others had left the area. Of the 120 who replied 103 were duodenal and 17 gastric ulcers. Duodenal Ulcer. Of 54 gastro-jejunostomies, 34 reported complete success from the operation, 14 moderate success, and 6 failure. Of 9 gastrectomies, 6 reported complete success, 1 moderate success, and 2 failure. Of 41 treated medically, 14 reported complete success, 14 moderate success, and 13 failure. Gastric Ulcer. Two females had gastro-enterostomy with moderate success, 3 male and 3 females had gastrectomy, 5 with complete success, l failure, 9 were treated medically; 5 with complete and 1 with moderate success; 3 failures. DISCU SSION

Dr. L. R. Twentyman, in opening the discussion, said it was always a very great pleasure when Dr. Ross came "south of the Border" and was able to deliver to them the fruits of his experience and wisdom, with a soundness and earnestness which made an excellent basis for a discussion. There had recently been published a very interesting text-book of medicine, edited b y Garland and Phillips, the first text-book of medicine published for students and general doctors which aimed at cutting through the old textbook pattern, and included the psychological and social aspect. Reading the sections having to do with this particular subject, one could not help feeling the inadequacy of the present position. The introduction to the study of stomachs, duodenums, and the alimentary tract pointed out that in regard to the h u m a n digestion practically nothing was known. Practically everything in the courses on physiology referred to experiments on animals--things which had not been proved or verified in the human. Almost every detail of the h u m a n digestion was wrapped in total uncertainty, and the theories put forward to account for any details were untenable. I t was an interesting fact that gastric and duodenal ulcers were unknown in animals, except under extreme experimental conditions. They were an exclusively human phenomenon. Nobody knew why they did not occur in animals. Another fact which might be a clue to the setiology was that after the first world war, when people had been subjected to extreme and ghastly experiences, there was a flood of gastric and duodenal ulcers. Might not today, at the back of m a n y of these ulcers be the undigested experiences of modern life--the colossal amount of impacts on people which they do not have time to digest. We gobbled our food and did not sit down to digest it, or lie down for the ten minutes Dr. Ross mentioned. I t was eaten under the most unmsthetic conditions in coffee houses, cafes, and help-yourself bars, rushed down and no time taken to digest it. But there was also impact after impact from the newspapers and the

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rest of modern life, none of which was ever digested, but simply taken in as a poison into the h u m a n organism. The great increase in peptic ulceration in this century was not confined to a certain type of person, angry, aggressive, or anxious--these things happened to quite differing types of people. In a long-term follow-up of people with high acid curves there was no greater incidence 20 years later of those who developed ulcers than would be expected in any other section of the population. It might be that it was not nearly so much the type of person, or amount of acid, as how much courage a person had in facing life and overcoming the bitterness of modern life with all its shocks and fears. The problem of peptic ulcers was claimed as one of the great unsolved problems of modern medicine. Incidentally, their orthodox colleagues never mentioned what were the great solved problems of modern medicine. Acute epidemic diseases and tuberculosis were vanishing in the course of nature, but was it a fact that anybody had solved them. I n the health of the nation peptic ulcers were one of the largest causes of ill health, misery, and distress today. Turning to the homceopathic side, Dr. Twentyman said that in listening to the remedies given by Dr. Ross, he felt all he had to say was eminently sound and in line with his own experience. The vast majority of his remedies were remedies known to act very strongly on the liver. I t would seem that apart from all those factors of hyper-secretion and the rest, there was the problem of the liver, and he thought the experience with these remedies would go to prove that hypothesis. Whether duodenal and gastric ulcers constituted two different diseases was another most fascinating subject which would be worth while studying more from the homceopathic angle. He did not know whether he was just trying to "play" one of the things which interested him when he said that the remedies which acted largely on the duodenal cases were right-sided and the remedies which acted on gastric cases were left-sided remedies. That, too, might be inquired into. Most of the research at present went into the cause of peptic ulcers, or the cause of other diseases. I t would be most interesting to know what prevented every stomach and every duodenum getting ulcerated, to know what the defences were against the acid digestive juices, and what, in the normal person, continually prevented ulceration taking place. What was behind the production of mucus in the stomach, what determined its amount and quality. He again thanked Dr. Ross for the enormous pains he had taken in the preparation of his paper and he hoped by drawing attention to this problem it would encourage the profession to attack it more vigorously, and to develop the science of Homceopathy, which would help the patients and save them from the, statistically at any rate, unsatisfactory solution of surgery. Admittedly surgery was useful at times, but the experts were swinging against it. Dr. Ross thanked Dr. Twentyman for his kind words. His theories and ideas about origins were most interesting; he was sure the psychosomatic angle was the right one. But they had to deal with the results further on, and the presence of an ulcer did make a patient anxious and nervous. There was one part of his paper which he had not read which was relevant to Dr. Twentyman's remarks about the role of the liver. Therein it was suggested that the liver might in health have a function in destroying excess histamine absorbed from the bowel. The secretion of mucin was the natural protection for the gastric mucous membrane and in gastritis this was deficient. A gastric ulcer was almost always secondary to a duodenal ulcer, because the food stayed longer in the stomach, with accumulating acid which eroded the mucous membrane.

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Dr. Foubister said he would also like to thank Dr. Ross for coming and giving them of his vast experience. Regarding the general management of the patient, some years ago in the Royal Infirmary in Edinburgh a number of men with peptic ulcers were admitted and fed on beer, fish and chips, and everything t h a t was "wrong", but they were all rested and the results were excellent. Smoking was generally bad, but it was well worth while, if it was impossible to get a patient to stop smoking altogether, to forbid smoking before breakfast. H e wished to ask Dr. Ross what he thought about the use of aluminium cooking utensils, as aluminium had a very definite effect on the alimentary tract. Regarding the question of acetonuria, about half the children who suffered from the periodic syndrome were found to be tense, nervous children, who responded to Dysentery co. and one wondered if the s y m p t o m s were not the result of a pylorospasm rather t h a n actual ulceration as Dr. Ross suggested. The older homceopaths used to use low potencies of pathological homceop athic remedies such as Uranium nitrate and Ornithogalum. These remedies obviously had some place in the treatment of peptic ulceration and it would be interesting to hear what Dr. Ross had to say about such remedies. Regarding nosodes, Dysentery co. was often useful, as Dr. Ross said, for the arsenical type of patient, when "mental tension" was the keynote. Ulceration affected the gut, and dysentery was often followed by duodenum ulceration. He wondered what Dr. Ross thought of the bowel nosodcs in peptic ulceration. Another nosode which might be important was Diphtherinum. The late Dr. W a t t s of Edgware was very keen on the use of Diphtherinum, almost as a universal remedy in cases not doing well; and Dr. Illingworth-Law said he used Diphtherinum as an inter-current remedy in pathological states in regions supplied by the vagus and other nerves coming from the tractus solitarius. Dr. Foubister recalled the case of a policeman invalided out of the a r m y on account of duodenal ulceration at the beginning of the last war. I-Ie was performing a policeman's duties during the blitz and attended the Out-Patients' Departm e n t of the R . L . H . H . The symptoms appeared to call for Graphites which helped to some extent, but he kept on relapsing. The only childish illness from which he suffered was diphtheria which he had badly. Radiologically there was evidence of commencing duodenal stenosis. Diphtherinum 200 was given. I t had to be repeated six months later, and eighteen months later the radiologist reported normal findings. He had seen this man since the war and he had had no recurrence of indigestion. Another nosode which might be worthy of greater consideration in peptic ulceration was Influenzinum, especially as peptic ulceration was a feature of "gastric 'fin" and influenza was such a common and often serious illness. Dr. Ross agreed t h a t often patients did well on a ridiculous diet; probably the mental relief from strict dieting had a lot to do with it. Regarding the question of aluminium cooking utensils, he was not quite h a p p y about aluminium, and if patients could afford it he would rather get them to do without aluminium. I n chronic cases the odd symptom of Alumina turned up far too frequently to be ignored. As to the periodic syndrome cases, in his experience they were often rather cheating. Two of the boys mentioned in his p a p e r had deceived quite an eminent p~ediatrician. H e had found splashing very reliable--more so t h a n the books admitted. I t was very common not only in pyloric stenosis but also in early cases of ulceration. I t was necessary to be sure there was not a hot-water bottle next the patient when testing for splash! Regarding pathological remedies, he did not use them at all. He agreed

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with Dr. Twentyman that the causes of ulcer were way back in the brain somewhere, and the remedies, fundamentally, should be those covering the whole person. He agreed there was a place for a low potency remedy in acute cases, but he was very pleased with Ornithogalum 200 and preferred it to the tincture. Regarding bowel nosodes, he agreed with Dr. Foubister as to their value, especially Dysentery ca. and Morgan (Bach). He was grateful for Dr. Foubister's suggestions of Diphtherinum, which could affect the vagus, and Influenzinum. Dr. McCready said first he would like to thank Dr. Ross for his very erudite paper. Concerning diagnosis, he did not know if it was just a diagnostic point, but some years ago a man of about 50 came to him complaining of symptoms very much suggesting duodenal ulcer, but it was quite impossible to confirm this. Before coming to him the man had seen an eminent radiologist who took a lot of pictures, but nothing confirmed this. I t was decided he was a neurotic. He was treated for two or three months successfully, but then slowly began to get worse. More X-rays were taken, but they were very doubtful. I n the end, very reluctantly, the surgeon was called in. He was reluctant to operate, but as the man was getting worse the surgeon was pressed to open him up and discovered a very advanced duodenal ulcer, which turned out to be a bad bleeding ulcer, which indicated that X-rays sometimes could be completely uninformative. On the subject of setiology, when he was a medical student a man had come in who had a perforated gastric ulcer, and between bouts of hideous pain he tried to be as helpful as possible. He confessed it might be helpful if it was known he was a heavy drinker and when asked how much he drank he said, "Never less than 30 pints a day". That sounded rather exaggerated, but on consulting the Senior Pathologist he said that was a reasonable amount because brewers' draymen before the war had competitions as to how much they could drink and he knew a man who had drunk 49 pints a day. Dr. Nicholson asked if he might mention two cases which had interested him recently. Dr. Ross had mentioned the need to be careful with Phosphorus, because phosphorus patients tended to bleed. He thought Dr. Ross would be interested to hear of a case treated with a single dose of Phosphorus while he was still bleeding. As this was in an orthodox hospital he was able to give only one dose. The patient was very shocked and had lost a lot of blood and was very sick. A few hours after a dose of Phosphorus 12 there was an amazing improvement; the patient never looked back and had no more symptoms. A blood transfusion planned for the evening was not given for technical reasons, which was possibly a good thing. Ansemia was treated later with ordinary iron. The second case concerned Ornithogalum. Traditionally, this remedy was given in the unit doses of mother tincture, following the teaching of Dr. Cooper. Dr. Borland advised high potencies. Regarding the choice of this remedy, to avoid disappointment, certain indications should be looked for, but they were rather difficult to separate from the ordinary symptoms of pyloric spasm. Dr. Nicholson met with this case only the previous week. The man was convalescing well from a bleeding duodenal ulcer, but got a relapse of slight vomiting and distension. The symptoms seemed to be those of pyloric spasm. He was given two doses of Ornithogalum 30 at an interval of 12 hours which cleared the trouble up completely. I n fact he said he felt better than he had done for years, which was an interesting point, commonly seen in homceopathie treatment. Literature about Ornithogalum referred to its use mainly for cancer, but it

246

THE

BRITISH

HOM(EOPATHIC

.IOUR~AL

was possible that a wider scope should be found for this remedy in less serious conditions, particularly affecting the pyloric region. Dr. McCrae asked to be allowed to pay his congratulations to Dr. Ross for his most interesting paper. As a personal exponent of duodenal and gastric ulcers he had a tot of experience in the treatment of this condition, personally as well as through other people. He said it seemed to have been his lot to attract this condition to his practice. I t was often said that doctors who treated a certain condition were rather liable to develop the condition themselves. Whether that was true or not, it might be one of the reasons why he became so personally acquainted with it. I t was interesting to notice that study from the electro-physical point of view showed that remedies for the treatment of gastric conditions fell into three rather big groups, and that in the other groups there were remarkably few remedies. Dr. Ross had mentioned about 25 medicines, and he would not go into any details of the 50 remedies he had found classified, but would like to run through them for the benefit of those who might care to study them in particular with relation t o gastric conditions. GRovP 1

GRouP 6

GROUP 10

A garicus Bovista Ptelia Sepia

A nacardium Antimoniu~n tart. Argentum nitricum Arsen. alb. Baptisia Capsicum Causticum Graphites ~Titric acid

Comocladia

GROUP 2

Lachesis GRovP 4

Ignatia Kali bichrom. Kali carb. GRouP 5

Collinsonia Cuprum m.et. Dioscorea villosa Leptandra Lycopodium iVatrum carb. Natrum tour. Ornithogalum Phosphorus Plumbum met. Selenium Silicea

GRovP 8

G]~ouP 11

Chenopodium Cina Natrum sulph. Naphthalum Pceonia T abacum Tellurium Thuya

Carbo reg. Chelidonium Colocinthis Hydrastis Ipecacuanha Kali sulph. Magnesium carb. Magnesium sulph. Mere. cot. Mere. dulc. Mere. sol. N u x vomica Opium Stannum Sulphur Triosteum perfoliatum

Dr. Ross said that Dr. McCrae's was a very interesting list of remedies, and if a sequel could be written to this paper it would make the symposium on the treatment of ulcer much more valuable. He hoped the tremendous amount of ground Dr. McCrae had covered could be put down on paper at some time. Dr. Foubister asked if he might add one comment to his previous remarks. Dr. Ross mentioned the danger of Lycopodium. Some years ago Dr. Foubister had a patient with typical symptoms of Lycopodium. He had had a duodenal ulcer for twenty years. He was given Lycopodium cm and the ulcer ruptured within a week. However, he was much better aider an operation. Dr. Foubister said it only needed one case of that sort to suggest that one must be careful. The President said he would like to thank the members present for the splendid discussion, and more particularly once again to thank Dr. Ross for his delightful paper. He was sure the members would wish to join with him in a very hearty vote of thanks.