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Moynihan tended to blame the suture material or the presence of oral sepsis for the stomal ulcers he encountered but he did note that in the majority of those who developed stomal ulcers a high level of gastric acidity had been recorded. It was noted that stomal ulcers rarely, if ever, followed operations for cancer. They were more common in men than in women, more common in operations for duodenal ulcers than for gastric ulcers, and more common after gastro-enterostomy than after gastrectomy, except in those cases where a Roux en-y anastomosis had been performed. From this it was rightly inferred that the acid secretion of the stomach was the major factor in initiating a stomal ulcer and this was confirmed by the work of Mann and Williamson (1923), who demonstrated conclusively by experiments on dogs that ulceration followed any operative procedure which prevented the neutralization of the acid gastric secretions.Moynihan, who may be considered the doyen of gastric surgeons, continued to practise the operation of posterior gastro-enterostomy throughout his surgical career and claimed a recurrence rate of 1-6 %, (1926). Ogilvie (1938) assessed the incidence of stomal ulcer at 20% and it became increasingly obvious in the 1930s that even in the most skilled hands gastro-enterostomy was followed by a 30 % incidence of stomal ulceration (Berg, 1930) which was more difficult to control than the original ulcer. Surgeons then turned their attention to gastric resection as a primary operation for duodenal as well as gastric ulcer, but even a two-thirds gastrectomy, while effective in the case of a gastric ulcer, still carried a 5 % to 7 % recurrence rate in cases of duodenal ulcer (Smithwick, Harrower, and Farmer, 1961). Higher and more radical procedures were devised till Visick in 1948 published his results for 'measured gastrectomy'. By this was meant a resection of the first part of the duodenum and the entire stomach except for a small pouch at the cardia supplied by the uppermost short gastric artery. This operation was eminently successful in relieving the patient of ulcer symptoms and in protecting him against a recurrence, but it brought in its train a whole series of post-gastrectomy symptoms, which in themselves were incapacitating. Capper and Butler (1951) estimated that 12% of gastrectomy operations were followed by the early or immediate post-gastrectomy syndrome. Tanner (1954) put the figure as high as 28.5%, 7.6% of these being described as severe. The more radical the gastrectomy the more troublesome the syndrome became. A not inconsiderable death rate, estimated at 4 %, shook the faith of many in these more radical procedures.With the introduction of vagotomy by Dragstedt and Owens (1943) a new approach to the problem opened up. Dragstedt held that the most important single factor in the pathogenesis of duodenal ulcer was hypersecretion of acid during the hours of sleep and that this could be abolished by vagotomy. The 97 on 7 May 2018 by guest. Protected by copyright.

Infiltration of various organs, notably the lung, has been recognized as an allergic manifestation since Loeffler (1932) One of the most complete and recently recorded cases is that of a male patient aged 55, described by Ruzic, Dorsey, Huber and Armstrong (I952). This patient suffered from a pyrexial illness associated with asthma. He complained of lower abdominal tenderness and his blood picture revealed eosinophilia. A barium meal examination revealed a filling defect of the lesser curvature of the stomach. Chest X-rays showed apical thickening suggestive of tubercle but Koch's bacilli were never found. At operation the stomach wall was found thickened from cardia to pylorus. No other organs were involved. Inspection of the interior of the stomach revealed no lesion of the mucosa. Histologically the biopsy specimen showed a chronic inflammatory process around the vascular channels in the submucosa, muscularis and serosa. The inflammatory reaction was most marked in the serosal zone and consisted of perivascular infiltration of lymphocytes, macrophages, giant cells and a fairly large number of eosinophils.We have had the opportunity of investigating two such cases by laparotomy, biopsy, blood examination and skin sensitivity tests. One of these is of special interest in that four abdominal explorations were carried out over a period of as many years. On each occasion the area of involvement differed and on the final exploration the condition was found to be completely quiescent. Case Reports Case i. Mrs. J.R. The patient, a strongly built active farmer's wife, first attended hospital in 1940 when she was 38 years of age. She complained of intermittent attacks of abdominal pain

hope and faith to believe that some other Fellow, of the College, perhaps some young doctor in this Hall, may be stimulated by what I have said to attempt to solve the problems which still remain.