831

Medical Societies

LIVERPOOL MEDICAL INSTITUTION

IN his inaugural address at the opening of the 110thsession, Dr. G. F. RAwDON SMITH, the president, tracedthe history of anaesthesia from the day that Adam’srib was removed. At first psychical methods, such ashypnotism, magnetism, and mesmerism, held the field.There were also primitive oral anodynes ; and physicaldevices, variously attributed to the Egyptians, Assyrians,Greeks, and Romans, were introduced and persisted intomedieval times. The first mention of inhalation anaes-thesia is to be found in Pliny, though some claim that itoriginated in China. Continuing the record down tothe present day, Dr. Rawdon Smith emphasised theimprovements during his lifetime, and suggested that thepresent tendency was to attach overmuch importanceto anaesthesia compared with surgery.At a meeting of the institution on Nov. 7, with Mr.

J. B. OLDHAM, vice-president, in the chair, a discussionon the late results of

Partial Gastrectomy for Peptic Ulcerwas opened by Mr. A. KIRK WILSON, who describeda personal and consecutive series of 148 patients who hadundergone partial gastrectomy for -simple peptic ulcera-tion between 1934 and 1939. Of these, 104 had gastric,40 duodenal, and 4 jejunal ulceration. Of the patientswith a jejunal ulcer, 3 had a gastrocolic fistula, and in4 of the patients with a gastric ulcer a gastrojejunostomyhad first to be undone. Analysis of the patients by age-groups showed that over 50 % of the patients withduodenal ulcers were under forty years of age, while65 % of those with gastric ulcers were over forty. Inthe same period, 117 cases of carcinoma of the stomachwere explored, and among these a partial or total gastrec-tomy was done 48 times.Before deciding on operation for a high gastric ulcer,

the size of the crater, the degree of penetration andfixation, and the response to medical treatment mustfirst be considered. Ulcers of the pyloric antrum andcanal were operated on fairly early because of theirtendency to malignant metaplasia. With duodenal ulcersthe main indications for operation were repeated perfora-tion and recurrence of symptoms after several coursesof intensive medical treatment in hospital.The Polya-Moynihan operation was done for 44

patients, the Hofmeister operation for 45, and the"physiological" " for 59. The over-all mortality was8 % ; in exactly half of these deaths, necropsy showedthat the cause of death was pneumonia and that healinghad occurred without infection in the peritoneal cavity.One pulmonary embolus was recorded, and in 3 cases,where permission for necropsy was unobtainable, a leakfrom the duodenal stump was suspected.In more recent series the mortality and morbidity

had been much reduced by : (1) more intensivepreoperative preparation, to correct minor degrees ofanaemia and hypoproteinsemia, and (2) improved anaes-thesia. With d-tubocurarine the relaxation comparedvery favourably with that produced by a perfect spinalanaesthetic, and chest complications had not caused anyanxiety.

Dr. ROBERT KEMP said it must be remembered thatthe surgeon operated only on medical failures, andthat the physician saw only the bad results of surgery.This paradoxical situation took no account of the goodresults of both methods. The physician had three dutiesto his patient in regard to surgerv : he must have clear-cut indications in his own mind ; he must know therisks and drawbacks of operation ; and he must followup the late results of his advice. With most complicatedulcers and with many gastric ulcers the indicationsfor partial gastrectomy were clear. But with duodenalulcers each case must be considered individually ; andthe decision as to when the lesion was beyond permanenthelp from medical treatment should not be delayed.Apart from the immediate postoperative risks, therewere those of later stomal ulcer and, it seemed, anincreased liability to pulmonary tuberculosis. Afteroperation the patient might also be handicapped byanaemia, small stomach, dumping, lassitude, malnutrition,

gastritis in the stump, and the need for further dieting.Of the 148 patients on whom Mr. Kirk Wilson hadperformed partial gastrectomy 108 had been followedup ; of these, 71 were still alive. No less than 55 %of these 71 were in excellent health, doing full workand taking a full diet, with no significant symptoms.In another 28 % the patients were in good health andcapable of full work, but needed a modified diet. Inthe remaining 17 % the result was only fair ; despitedieting these patients still had some symptoms and lostsome time from work. In every patient seen the conditionwas better than before operation. There had been adramatic change from the miserable life of the man withan intractable ulcer to that of the fit active man withoutpain and full of gratitude to the surgeon even so longafter the operation. The results in duodenal ulcercases were particularly good. Nevertheless, it was stillthe physician’s duty to keep his patient on a regimestrict enough to obviate the need for surgery. If he failedin this the operation should be done under optimumconditions, with full preparation and convalescence inthe medical wards. The best permanent results wouldbe obtained by giving patients a simple postoperativeregime to follow indefinitely, and by seeing them fromtime to time to ensure that they did so.

Mr. G. C. E. SIMPSON still felt that there were manycases where gastroenterostomy with ligature of thepylorus was the operation of choice. Before 1939 hewould have said first choice, but since deprivation offats now often prevented satisfactory dieting, he madeit the exception. Towards the end of 1942 peptic ulcerhad increased in frequency, and he had begun to meetnumerous patients with gastrojejunal ulceration, oftenwith colic involvement ; in several the gastroenterostomyhad been done as long as twenty years before, and theyhad been able to dispense with dieting. But in 1944their number had again diminished ; the change in theflour might possibly have had an influence. For manyyears all cases of peptic disorder had been seen on a_jointward round with a physician, and referred afterwards toa dietetic clinic.

Mr. CosBiB Ross said that in 160 consecutive gastrec-tomies 8 patients had died as a-result of the operation,making a mortality-rate of 5 %. Of these 8 deaths,3 had been from myocardial failure, 3 from lobar pneu-monia, and 1 from a pulmonary embolus ; and 1 patienthad died during the operation. A further 3 patients haddied later, 1 from carcinoma of the oesophagus, 1 fromcarcinoma of the stomach sac, and the third -from aperforated stomal ulcer. This last case was interestingsince the ulcer had occurred a year after gastrectomy,previous to which there had been two perforations.With these persistent perforations it might be advisableto prevent further trouble by carrying out an almostcomplete gastrectomy. Of the patients followed up,55 had been interviewed and examined, 22 havinghad the operation for a duodenal ulcer and the remaining33 for a gastric ulcer. It was a sobering thought thatover 75 % had had symptoms for over five years and thatmany of these cases had been in and out of hospitalfor medical treatment.

Of these 55, not one expressed dissatisfaction withthe result of the operation ; in fact, 47 were extremelygrateful. Of the remaining 8, 2 were ill from otherconditions, 1 having advanced phthisis and the secondsyringomyelia. The other 6, though stating that theywere much improved, admitted to mild dyspepticsymptoms, such as heartburn, inability to eat greasy foods,occasional vomiting bouts, or discomfort after heavymeals. None complained of even moderate pain. Exceptthe 2 patients ill from other causes, all were workingregularly, though some had changed from their normaloccupation to some less arduous work. In this con-

nexion it was interesting that 11 out of the 55 com-plained of a diminution of strength and energy. Theshort afferent loop was important in making the anasto-mosis. Recent experiments had shown that the dailyintramuscular injection of 30 mg. of histamine-base inbeeswax in laboratory animals caused a torrent of acidsecretion, which broke down the capacity of tissue incontact with the acid to defend itself. In a series ofgastrectomised dogs the histamine-beeswax’ techniquealways produced a stomal ulcer when a long afferent loopwas used, and never when a short loop was devised.

832

In view of this, the anastomosis should be a retrocolicone close to the duodenojejunal junction.

Mr. A. CLIFFORD BREWER had recently collected dataon some 362 partial gastrectomies for duodenal ulcera-tion. This analysis was being conducted in the depart-ment of surgery of the University of Liverpool. Thepredominant fact was that where a subtotal gastrectomywas done, with removal of the whole pylorus combinedwith a Hofmeister stoma, the results were excellent.Where any procedure less than this was performed,and particularly where the pylorus was left behind,results were by no means so good. Where difficultywas encountered from activity of duodenal ulceration,a two-stage operation appeared very satisfactory so

long as the second stage was performed within sometwelve weeks of the first. It seemed that subtotalgastrectomy was the operation of choice for duodenalulceration, and in the cases analysed the results hadproved eminently satisfactory.

Dr. T. CECIL GRAY said that spinal anaesthesia probablygave rise to more postoperative chest complicationsthan did general anaesthesia. The improvement todaywas due not only to a special agent and technique but

also, and very largely, to correct preoperative andpostoperative care. The importance of good nursing,dental treatment, breathing exercises before and afteroperation, and active and passive movements to aidthe circulation in the recovery period was emphasised.Undoubtedly the use of the barbiturates as the mainanaesthetic agent, aided by curare, had enormouslyimproved the prognosis. By exacting criteria theincidence of chest complications in upper abdominaloperations was now below 10 %.

Dr. H. FuLD thought Dr. Kemp had no reason tobe gloomy about his figure of 30 % for postoperativeanaemias. American figures for anaemia following sub-total gastrectomy were 10 % ; the difference was probablydue to the low-grade nutritional anaemia prevalentamong hospital patients in this country. Haemoglobinestimations in 500 unselected patients seen in the surgeryduring the last twelve months revealed levels of lessthan 11-5 g. per 100 ml. in more than 20 % of patients.In view of the progressive lowering of the operativemortality, it might prove worth while in future to referpatients who developed an ulcer syndrome after the ageof forty-five to the surgical expert without much delay.

Reviews of Books

Year Book of Eye, Ear, Nose, and Throat, 1945Editors : LOUIS BOTHMAN, M.D. ; S. J. CROWE, M.D. ;with the collaboration of E. W. HAGENS, M.D. Chicago :Year Book Publishers. London : H. K. Lewis. Pp. 540.188.

THAT the fenestration operation has a place in thetreatment of the deaf is now incontestable, but a keenlycritical approach is still essential. These abstracts showthat good results are obtainable in younger patients andin those where bone-conduction is still unimpaired. Casesof so-called catarrhal deafness may be more suitablethan otosclerotics, but the differential diagnosis mayvary from difficult to impossible. Technique is evidentlybecoming standardised, and the endaural approach isfavoured by American surgeons. Deafness and cataractassociated with maternal rubella in early pregnancy havebeen established as developmental deformities. A largenumber of abstracts deal with the use of chemotherapeuticsubstances in different areas of the eye and upper respi-ratory tract, and some good results obtained withpenicillin in cases of intrinsic bacterial allergy are

specially interesting. Both surgery and irradiation forlaryngeal carcinoma receive support, though both arestill crude. Fresh work on the surgical treatment oflaryngeal or tracheal stenosis is reported. Treatmentof disorders of the ocular muscles is still being revised.Again the bulk of the abstracts are from Americanliterature, and again the high editorial standard ismaintained.

Juvenile Delinquency in New ZealandA Pl’eliminary Study. EILEEN PgzLZPP. New Zealand :Council for Educational Research. London : OxfordUniversity Press. Pp. 140. 7s. 6d.

THE need for up-to-date and reliable facts about theunderlying causes of juvenile delinquency is widelyrecognised. A valuable contribution to the subject ispromised by this book which provides a preliminarystudy of the nature and extent of juvenile delinquencyin New Zealand during the years 1938-45. The writerwas trained in the social-science department of an Englishuniversity and has had wide experience in variousbranches of social case-work. The figures analysedreveal a striking difference in the proportion of cases oftheft to other offences in New Zealand compared withother countries, the proportion being roughly 30 % lowerthan, for example, in England, U.S.A., or Australia.This is thought to be attributable to the very much moreuniform social and economic conditions prevalent inNew Zealand. The information available also suggestsa relatively heavy incidence of delinquency among Maoriboys, in all probability associated with- the lamentablehousing conditions, although it is thought that uninten-tional discrimination, and readiness to bring a Maorichild before the court, may have some bearing on thesefigures. The main body of the book is concerned with

an attempt to draft a form on which a summary of thesocial history can be recorded for the information ofthe children’s court. A novel feature is the fact that thepersonal social histories are obtained from the delinquentsthemselves. The summaries, of which five examplesare given, illustrate the complexity of the influences towhich delinquency has been a response, and, as the writersays, should help " to correct the over-simplified ideason causation still widely current." Although emphasisis laid on environmental influences as shown by a tendencyto recommend removal from the home as an essentialpart of treatment, the fact that similar circumstancesmay have very different effects upon the behaviour ofindividual children is not overlooked. Useful suggestionsare made regarding the lines along which further studyof delinquents might be pursued.

Manual of Diagnosis and Management of PeripheralNerve InjuriesROBERT A. GROFF, M.D., lieut.-colonel, M.C.A.U.S.,

formerly assistant professor of surgery, Jefferson MedicalCollege ; SARA JANE HouTZ, B.S., first lieutenant (P.T.)a.u.s. London : J. B. Lippincott. Pp. 188. 36s.

Tms little book, written primarily for physiotherapists,deals shortly with the anatomy, injuries, symptomatology,and treatment of peripheral nerve injuries. A full accountof the tests of muscle function, including line drawingsillustrating every test described, is followed by a seriesof beautiful anatomical drawings of the regions of thebody most susceptible to nerve injury. The physio-therapist will find the first section easily read, and itssubject matter should be sufficiently comprehensive forexamination purposes. The section on muscle testingis detailed and useful for- reference. The anatomicaldiagrams are no doubt of use to a student who is onlyconcerned with the anatomy of the nerve and muscle,but have less to recommend them to doctors, to whomthe book is also dedicated.

Heredopathia Atactica PolyneuritiformisA Familial Syndrome Not Hitherto Described. 8IGVALDREFSUM. Oslo : Johan Grundt Tanum. Pp. 303.

Tms book deals with an intensive study of twounrelated Norwegian families in which the author findsevidence of a disease not previously recognised, andwhich he has named heredopathia atactica polyneuriti-formis. One or more of the five persons in these twofamilies presented signs of hemeralopia, atypical retinitispigmentosa, chronic polyneuritis, ataxia, and othercerebellar phenomena. Three patients showed electro-cardiographic signs of sinus tachycardia. Lumbarpuncture showed albumino-cytological dissociation witha normal cell count and a great increase of the albuminand globulin content. He thinks the syndrome heredi-tary, and promises further light on it when pathological-anatomical studies by his colleague, Dr. Cammermeyer,on the patients coming to post-mortem examination havebeen completed.