about draft defects are not confined nor even predominant in the large cities. It has been here mentioned that the larger cities of the state do provide both health supervision and physical education for their children. What is needed is the care of all of the children in the state, not the least those in the smaller places and the country. This can only be effected by state laws dealing with physical education of all the children. New York has had such a law in operation for several years. The Federal Government is making an effort to have such laws passed in all the several states.

In 1918 the Federal Commissioner of Education called a national conference on physical education. This body considered ways and means by which physical education laws should be enacted in the several states. It finally deputized a well-organized body, The American Playground and Recreation Association, the association that has had the War Camp Community Service so successfully in hand, to introduce physical education laws in the legislatures of the several states and to carry on a propaganda for their adoption. This body has been successful so far to have laws on physical education enacted in thirteen states. It was too late to introduce the draft of such a law in the Connecticut Legislature at the last session. The next session, however, will be approached with a law to introduce physical education on a broad basis in this state.

I wish to bespeak for the efforts of that body your coöperation and help so that Connecticut may have for its children the benefit of an efficient law in that respect.

DR. OVERLOOK (Pomfret): What I have to say has nothing to do with the question. I know nothing about the public schools but I have under my care a private school of 125 to 150 boys of eleven to eighteen years of age, hardly any over eighteen, and my experience might be of interest to you who are working in the public schools, on one or two points. The school is fitted with a rowing course, baseball, football, tennis, etc. A point that may be of especial interest to you is the number of boys that come to this school who are deficient in some way. They are all the sons of wealthy people and their medical attendants are the best men in the profession. It would surprise you to know the number of boys who come with bad hearts, with flat feet, with spinal curvatures, having ill-fitting shoes, and various other defects. Twenty years ago many of these boys came with enlarged tonsils, deviated septums, etc., and in those respects they have very much improved. Very few in recent years have not had these attended to. Evidently the work in the public schools has aroused interest in the parents or their physicians and has led them to look after these things in boys who attend the private schools.

DR. FOOTE: It has been stated that it is extremely important to look after the children under school age. Unquestionably much of the trouble in children below that age has to do with improper food. The troubles

of childhood are so closely associated with industrial conditions, cost of milk, etc., that very likely the state will have to look after the nutrition of children under school age. A card catalogue ought to be kept of these, stating their weight and measurement, particularly in the class of children that are not well cared for. In New Haven we have some 26,000 school children, we have had three school physicians, one of these absent in the service,—so that we have only two physicians to look after these 26,000 children; and they can only give five hours a day, which is almost valueless. Dr. Goodenough spoke about stripping the children. I understand there is a law in some cities (and I am not sure the state law does not require it) that each child should be examined, but I understand the state law prohibits stripping to make the examination. If that law is followed, many physical defects will not be discovered.

DR. DONALDSON (Fairfield): We have all been highly edified by Dr. Foote's paper which is of such importance to the public, and many who are not here to-day will like to read the paper when published in our Proceedings; and I was very much gratified when Dr. Rogers made the suggestion that the Committee on Publication be requested to furnish a copy of Dr. Foote's paper, with an abstract of the discussion, for publication in the public press.

Observations on Gastric Surgery.

DR. EDWARD R. LAMPSON, Hartford.

As one reviews the medical literature on the subject of gastric surgery and reads the articles which have come forth from the great clinics of this and other countries, he realizes the impossibility of producing anything new or original along this line of work. Notwithstanding, I have decided to report, for what it may be worth, my experience in this line of surgery during the past three years. Most of these cases, however, have been operated upon during the past two years or since my appointment as full attending surgeon at the Hartford Hospital. It is by studying our cases and records that we are stimulated to do better work and make more careful histories because in so doing we appreciate many shortcomings and see where improvement can be made.

I have operated on 41 patients for various gastric conditions and have done 43 operations, 2 of the patients being operated upon the second time.

There were among these-26 with non-perforated duodenal or gastric ulcers; 6 perforated ulcer cases; 3 children having congenital pyloric stenosis; 3 patients with carcinoma of stomach; 3 operations of gastrostomy for stricture of the esophagus. Of the non-perforated ulcer cases the oldest patient was 68 and the youngest 17, the average age being 41.5 years. There were among these 22 duodenal and 6 gastric ulcers, 2 having both gastric and duodenal. Seventeen or 65.4% were males and 9 or 34.6% were females. Six of these cases gave a history of melena or hematemesis, 3 of them of severe type and they were operated upon after they had sufficiently recovered from their hemorrhages. One of these cases was of such severity that transfusion was resorted to to save his life, as he was completely exsanguinated, having had a previous hemorrhage one week before.

A Roentgenological examination was made of every case except two. The reason it was not made in these was in the first one the diagnosis of "gall stones" had been erroneously made and so sure did we feel of our diagnosis that an X-ray examination was omitted. Upon operating, no gall stones were found but a well-marked duodenal ulcer. In the second case, the operation was done as an emergency, a perforated duodenal ulcer being suspected. This patient, five weeks before, had had a severe hemorrhage from a duodenal ulcer and was convalescing, having been on a Lenhartz diet for that period of time. In the early morning he was seized with a sudden severe pain in the upper abdomen. When I saw him his abdomen was rigid, his pain so intense that great beads of perspiration stood out on his forehead. I rushed him to the hospital and had Dr. Steiner see him in consultation. He agreed to the diagnosis of probable perforated duodenal ulcer. I operated at six-thirty in the morning and was pleased to find our diagnosis incorrect as to perforation but a large indurated duodenal ulcer was found and a gastroenterostomy was done. I have never been able to understand the cause of the excruciating pain but probably it was simply an extraordinarily severe pylorospasm.

Of the 24 cases reported upon, one patient could not retain the barium and, therefore, the report was incomplete, leaving 23 cases for consideration. In 17 of these, the operative findings agreed with the recorded X-ray examinations. In 6 cases, the Roentgenological reports and the operative findings did not agree. This gives us an error of 26%. The 3 cases of carcinoma of the stomach were not included in this list but a correct diagnosis was made in each case. I am sure that with the greater experience of our Roentgenologists we are not now making as large a percentage of errors.

The gastric contents were not analyzed in as many cases as should have been done, 8 such examinations only having been made. In 6 there was a hyperacidity and in two the acid content was about normal. I am afraid that it must be confessed that with the advent of fluoroscopic and Roentgenological exam

inations we are thinking less of the importance of the analysis of the gastric contents and in some of these cases where the diagnosis made from the serial plates seemed positive, the gastric analyses were omitted. This is not as it should be as every aid to diagnosis should be used to enable us to arrive at as correct and accurate diagnosis as possible. And one result of looking through these series of cases is that I am personally resolved in every instance in future to have, except in those cases where the emergency is great or where there has been a recent hemorrhage, gastric analyses made.

Eleven patients showed no loss of weight, 15 patients lost an average of 19 lbs., the greatest loss being 50 lbs. and the least recorded weight 10 lbs. Vomiting did not seem to be a prominent symptom as it was absent in 14 cases, present in 12.

Pain or gastric distress came on from one to three hours after eating and was relieved by food or alkalis and was present in all cases except 2 and these 2 cases complained of no pain. In the gastric cases the pain seemed to come on sooner after the ingestion of food than the duodenal and to be a marked symptom. As one Italian expressed it-"No food, no pain," and therefore he was starving himself.

Eusterman of Rochester says that the nearer the ulcer is to the cardiac end of the stomach, the sooner the pain occurs after eating and it was interesting to find that in my small series of cases the same thing seemed to hold good, but unfortunately this is not constantly true. The periodicity of the attacks was noticeable in the histories, the time being covered from twenty to two years with recurring attacks and intervals of freedom from pain from years to months.

Six of the patients had had previous operations including appendectomy, removal of ovarium cysts and separation of adhesions.

Type of Operations Performed.

Where the patient was suffering from an uncomplicated duodenal ulcer a posterior short loop anti-peristaltic gastroenterostomy was performed without any attempt at pyloric