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Annotations

NOBEL PRIZE

Prof. Selman Waksman, director of the RutgersUniversity institute of microbiology, New Brunswick, hasbeen awarded the Nobel prize for medicine and physiologyfor the discovery of streptomycin. This discovery, in1943, was the outcome of work begun in 1915, whenProfessor Waksman found in soil the actinomycete laternamed Streptomyçes griseus. He has since developedneomycin from Streptomyces fradim.

1. Forsell, G. Amer. J. Roentgenol. 1923, 10, 87.2. Eliason, E. L., Pendergrass, E. P., Wright, V. W. M. Ibid, 1926,

15, 295.3. Rees, C. E. Surg. Gynec. Obstet, 1937, 64, 689.4. Scott, W. G. Radiology, 1946, 46, 547.5. Ferguson, I. A. Ann. Surg. 1948, 127, 879.6. Rappaport, E. M., Rappaport, E. O., Alper, A. J. Amer.

med. Ass. 1952, 150, 182.7. New, P. F.J. Brit. J. Radiol. 1951, 24, 441.8. Wellens, P., Spyckerelle, G. J. beige Radiol. 1949, 32, 157.9. Manning, I. H. Gunther, J. U. Amer. J. Path. 1950, 26, 57.

10. Norgore, M., Schuler, I. J. D. Surgery, 1945, 18, 452.11. Levin, E. J., Felson, B. Radiology, 1951, 57, 514.

TRANSPYLORIC PROLAPSE OF THE GASTRICMUCOSA

RADIOLOGICAL examination sometimes shows an

inconstant Riling defect in the base of the duodenal

cap, resembling a mushroom, cauliflower, or umbrella,due to linear folds of gastric mucosa passing throughthe pylorus and, as it were, pouting into the duodenum.This pouting is inconstant in shape and it may be presentonly during antral contraction ; serial radiographsshow a continually changing pattern that can be furthermodified by pressure over the antrum or duodenal capand by altering the position of the patient.As long ago as 1923 Forsell drew attention to the

mobility of the mucosa on the muscular wall of thestomach and to its independent changes i:p. shape. Soonafterwards it was shown that prolapse of the gastricmucosa through the pyloric sphincter into the duodenumcould be- recognised radiologically and confirmed at

operation. As ofteD happens with radiological appear-ances, increasing familiarity has been followed byreports showing an increasing proportion of positivefindings. Thus, Rees 3 found 4 instances in 3000 patients,Scott 4 just over 1% in 1000 patients, Ferguson 5 7%in nearly 300 patients, and Rappaport et al. 15-5%in 1000 patients. In this country New has reportedthis change in nearly 3% of 1700 patients, while inBelgium Wellens and Spyckerelle s found it in 5% oftheir patients. Rappaport et al. cite a case in whichcharacteristic appearances were seen in only one offtfteen radiographs of the pyloric antrum and duodenum ;and such inconstancy suggests that sometimes the normalis being confused with the abnormal.Manning and Gunther 9 described six cases of mucosal

prolapse examined post mortem. In none of these didthis disorder account for death, though in 1 gastrichaemorrhage was a contributory factor. In 5 cases theantral rugse were thickened, hypermobile, and redundant,with microscopic evidence of mild to severe chronicinflammation in the mucosa or submucosa. In 1 case

congestion and multiple small superficial ulcerations werepresent on the prolapsed folds. Thickening of the pyloricmuscular ring with apparent narrowing of the pyloriccanal was seen in 4 of the 5 cases examined micro-

scopically. In 4, the entire circumference of the pyloricinucosa was involved in the prolapse ; the other 2 showedonly tongue-like projections.Norgore and Schuler,lO described 2 cases treated by

partial gastrectomy on account of vomiting and epi-gastric pain made worse by solid foods. Levin andFelson 11 found 18 cases of prolapse in 100 patients withno digestive complaint. Of the 1000 patients examinedby Rappaport et al., only 28 had no gastro-intestinalsymptoms, and of these 3 showed mucosal prolapse ;

of 118 with lower abdominal -symptoms only 16 hadmucosal prolapse ; while of 854 with upper abdominalsymptoms 136 had prolapse. The proportional differencesbetween the three groups are small. Of the 155

patients with mucosal prolapse 91 showed one or morefurther definite abnormalities in the gastro-intestinaltract ; hiatus hernia, cholecystitis or gall-stones, andpeptic ulcers were the most common. Of the remainder39 had chronic recurrent dyspepsia consisting of periodicepigastric fullness, generally after heavy or spicy food,flatulent discomfort, and heartburn ; discomfort was feltsoon after a meal and actual pain was rare. Bicarbonateof soda gave much relief, but aluminium hydroxidegel gave little. Gain of weight before the onset of

symptoms was not uncommon. All these 39 patientshad notable evidence of neurosis, and said that theirsymptoms were often induced by emotional disturbance.4 patients (not all in this series) were treated surgically,but relapsed afterwards. A further 25 patients in theseries with positive radiological findings had only transientepigastric discomfort or no upper abdominal symptomsat all. Gastric analysis and gastroscopy gave no definiteinformation. As in New’s 7 series the appearanceswere more often seen in men than in women, and weremost usual in the fourth and fifth decades.

It thus seems that prolapse of the gastric mucosainto the duodenum may give rise to either no symptomsat all or to mild symptoms, especially in the neurotic.There is no evidence that this disorder is a hazard to thepatient’s life.

12. See Lancet, Oct 11, 1952, p. 729.

GENERAL PRACTICE IN SCOTLANDTHE Scottish Medical Practices Committee issued its

fourth report this week. The committee welcomes asubstantial increase in the number of principals in

practice : on July 1, 1952, there were 2379 doctors

providing general medical services in Scotland, comparedwith 2328 a year before ; and of this year’s total 2127also provided maternity medical services, as against2063 in 1951. The latest figures show that the averagenumber of patients per doctor in Scotland is about 2150 ;the corresponding figures for England and Wales at thebeginning of this year give an average of about 24COper doctor, but, as the annual report of the Ministry ofHealth 12 points out, the total number of patients ondoctors’ lists is still inflated by duplicated and out-of-dateentries. Moreover the Scottish average is reduced by thefigures for the isolated areas where a doctor is neededeven though his list is very small ; the doctor on theisland of Coll, for example, has a list of only 209. Thereare many places, chiefly in the industrial areas, wheredoctors still have more patients than the committee thinksdesirable, and the report hopes that when the proposedchanges in the distribution of the central pool come intoeffect, new doctors will find it easier to gain entry intoestablished practices in these areas.On the question of ways into general practice, the

evidence before the committee in the past year hasstrengthened its view that "the likeliest method for ayoung doctor to establish himself in general practice isto be assumed into partnership, preferably after aninitial period of assistantship." Doctors who have set upnew and independent practices (even in districts whichhad been included in the list of underdoctored areas)have often, in the committee’s experience, had a hardtime of it, and the proportion of doctors who apply tostart practice on their own account is decreasing. Thecommittee granted 148 applications for admission toexecutive councils’ lists during the year under review,and only 31 of these were from doctors going into inde-pendent practice, whereas in the previous year the

proportion was 20 out of 74.Scottish executive councils advertised 25 practice

vacancies during the year, and they received over 500