379BRITISH MEDICAL ASSOCIATION: SURGERY.

BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING AT BATH.

SECTION OF SURGERY.WEDNESDAY, JULY 22ND.

CARCINOMA OF THE STOMACH.IN opening a discussion on this subject Sir ’,

William I. de Courcy Wheeler reminded the meetingthat 10,000 people died annually in the British Isles Ifrom this condition. He proceeded with a destructivecriticism of the method of diagnosis by analysis of thegastric contents which, in his opinion, did not leadto any definite goal, nor did he consider the fractionaltest-meal productive of encouraging results. Thegreatest advance in diagnosis lay, he said, in accurateX ray examinations ; though even here one must notexpect the miraculous. He referred to the occurrenceof venous thrombosis as a valuable sign of earlycarcinoma of the stomach (Prof. T. G. Moorhead),and cited four cases where its value was illustrated.The speaker was of the opinion that if there was nogain in weight, or at least maintenance of weight,after efficient medical treatment, malignant diseaseshould be suspected and exploration was then morethan justified. He recognised a definite " perniciousansemia type " of carcinoma of the stomach, andheld that should such cases not respond very rapidlyto treatment by arsenic, malignant disease should besuspected. In dealing with the differential diagnosis,syphilis and. gastric disturbances in pulmonarytuberculosis, diabetes and actinomycosis, were

described as conditions likely to be confused withmalignant disease of the stomach.Proceeding to the question as to whether gastric

ulcer was or was not a precursor of carcinoma, thespeaker instanced several cases of undoubted implanta-tion of carcinoma on a chronic ulcer, but admittedthat most cases of carcinoma on which he had operatedarose without symptoms which would suggest thepresence of a previous ulcer. He did not believe thatpalliative operations were of much value. The valueof radium in the treatment of carcinoma was

undoubted. The two-stage operation for removal ofthe carcinoma was seldom, if ever, necessary, andhe found the shock from gastrectomy of the Mayo-Moynihan-Polya type to be surprisingly small. SirWilliam Wheeler then described a very interestingcase, in which he had removed, apparently, the wholestcmach for a non-malignant ulcer. His address wasillustrated by slides and X ray photographs.

Dr. E. I. Spriggs spoke of theClinical Manifestations and Early Diagnosis

of cancer of the stomach, excluding the use oflaboratory methods. He first gave an account ofthe classical symptoms-vague discomfort occurringin elderly men, with gastric flatulence and loss ofappetite gradually developing into nausea, eructationmerging into vomiting, pain either in the pit of thestomach, the small of the back, or between theshoulders; then later, a tumour, loss of weight,colour, and vigour; and finally, ulceration, coffee-ground vomit, mild irregular fever, involvement ofother structures, and death in two years. He com-pared these symptoms with those described in25 chosen cases, in which a very full history wasobtained. In 17 the history was recent; in four itwas long. The history of old indigestion, he pointedout, must not be allowed to obscure the diagnosis.Dr. Spriggs compared the symptoms according tothe part of the stomach involved. In cases wherethe carcinoma was situated at the cardiac end,eructation was more common than in other types.After a time the symptoms gradually merged intothose of cesophageal obstruction. In cases of the" leather bottle " type, the patient early complainedof an aversion to food. When the neoplasm wassituated at the pyloric end cf the stomach, therewas always pain after food, which might, or mightnot, be relieved by more food. The history was never

clear-cut. Vomiting of large quantities of food atintervals of two or three days, he considered, was a veryrare sign in cases of malignant disease. In three ofhis cases hasmatemesis was the first evidence of thepresence of malignant disease. An anxious expressionwas sometimes present, and, if present, was sufficientlycharacteristic to be an aid to diagnosis. Finally, thespeaker expressed his opinion that the first mostvital step towards a diagnosis of carcinoma was not,the clinical study of the patient. He believed thatinvestigation should be carried out at once-thatthere should be no " watching "-and that carcinomashould be excluded at the earliest possible moment.X ray examination he considered the most important.All examinations should be very complete, and if thediagnosis was still in doubt an exploratory operationshould be performed.

Dr. A. F. Hurst dealt mainly with the methods ofinvestigation of the patient. He strongly urged thatdoctors should send their pat’ents early to the

radiographer, and that patients should be encouragedto come early to their doctors, even for vague pain.He discussed the methods of examination of thestomach content, chemical and microscopical. Withreference to the examination for pus, he recom-

mended routine examination of the " spittle." He-considered that the presence of blood in every partof a fractional test-meal was evidence of malignantdisease unless there had been a recent haemorrhagefrom an ulcer. He was of the opinion that a skilledradiographer could show an abnormality of thestomach in 100 per cent. of cases of malignant disease.A fallacy was present if the stomach was not emptywhen the examination was made, for the bariummight then appear low down, because it had sunk tothe bottom of a full stomach. Occult blood waspresent in 100 per cent. of cases and the examinationfor its presence was of the utmost importance. Itwas never present in normal people, and although itwas found in patients suffering from a gastric ulcerthat condition could be distinguished by X rayexamination. Examination of the blood for megalo-cytosis was important in the differential diagnosis ofpernicious anaemia. Dr. Hurst showed slides illus-trating this point and described a method of measuringthe cells.

Pathology of Gastric Carcinoma.Prof. M. J. Stewart dealt with the pathology of

carcinoma of the stomach, the relation of ulcer tocarcinoma, the mode of spread of the carcinoma,and the frequency of secondary deposits in the liver.He presented an analysis of 165 cases examined in thepost-mortem room. Of these, 82 per cent. were betweenthe ages of 40 and 70, and the proportion of malesto females was 2 to 1. His address was illustrated bya series of microscopical specimens showing sectionsof chronic ulcer and of malignant disease. In a seriesof 216 clinical specimens of gastric ulcer and carcinoma9-5 per cent. showed carcinoma implanted on a chroniculcer.

Dr. Gregory Cole (New York) said that five yearsago it was taught in America that 68 per cent. ofcases of gastric ulcer became malignant. In one-tenth of the ulcer cases he had seen in the last tenyears he could not say whether they were malignantor not, in the remaining 90 per cent. he had onlyseen one in which carcinoma developed in theneighbourhood of a chronic ulcer.

Mr. John Morley, although he considered the ideathat carcinoma was often implanted on a chroniculcer attractive and that it would lend point to theadvice to patients to be investigated early, neverthe-less doubted its truth. He drew attention to thepossibility of a mistake in microscopical diagnosisin those cases where, as had been pointed out bySir Bernard Spilsbury, there might be proliferation ofcells at the edge of an ulcer. Where the history ofindigestion was recent-under 12 months’ duration-there was a strong likelihood of the presence ofmalignant disease. He was of the opinion thatcarcinoma originating in a chronic ulcer was rare.

380

Dr. W. D. Haggard (Tennessee) said that in. dealingwith ulcers the operation of wide excision with thecautery and subsequent examination was of greatvalue. He believed in the two-stage operation inlate cases. He said that in America they were stilllooking " like the wise men towards the East forinspiration."

Mr. A. H. Burgess (Manchester) considered earlydiagnosis of penultimate importance. Surgical treat-ment must, as always, aim at radical extirpation. Heinstanced ascites, secondary deposits in the liver orthe peritoneum (which might be felt in Douglas’spouch by rectal examination) as contra-indicationsto radical operation. Fixity to the liver or to thepancreas were not necessarily contra-indications. Ifthe middle colic artery was certain to be damaged,owing to extent of growth to be removed, he thoughtthe case should be left alone. He considered palliativegastro-jejunostomy was indicated only if there wasobstruction. He then dealt with the operativedetails and demonstrated a stomach clamp.

Dr. C. L. Starr (Toronto) emphasised the importanceoi not " watching." If glands were enlarged, curewas impossible. He did not believe in exploratoryoperations, except in a limited number of cases.

Mr. Garnet Wright considered that clinical evidencewas mainly against the probability of the developmentof carcinoma on top of a chronic ulcer.

Mr. R. P. Rowlands described a case of primarytuberculous ulcer, which he had treated by resection.He did not consider exploration dangerous in earlycases, nor did he think that damage to the middle.colic artery was a serious matter.

Mr. H. S. Souttar described two " ludicrouslyinoperable cases with which he had dealt, doinga gastro-jejunostomy in the one and a resection in-the other, and had succeeded in giving both of themseveral months of comfortable life. He described- and eulogised Schumacher’s clamp.

Sir Berkeley Moynihan (President of the Section)stated that surgery had out-paced medicine in thetreatment of carcinoma of the stomach. There wasvery little chance of improvement under medicaltreatment, but there must always be a certainmortality in cases operated upon. He did not considerthat the omentum need be removed-in fact, he leftit and used it as a cover for the field of operation.Operations of the type Billroth No. I were onlysuitable for ulcer cases. Examination should bemade as often and as fully as possible. There weremany methods of operation-each useful. Patientsmust always be made fit for their operation ; therewas no great hurry and time spent in transfusion ofblood, glucose injections, artificial and real sunlightwas time well spent indeed. The President con-

sidered that the profession should teach the publicabout carcinoma, and he put forward the suggestionthat the Ministry of Health should send out doctorsto preach the gospel of health. If it was suspected

Ithat a patient was threatened with carcinoma, the Iexperts should be gathered around him at once.

IThe openers then briefly replied.

THURSDAY, JULY 23RD.Treatment of Primary Acute Intestinal Obstruction.A discussion on this subject was opened by Sir

William Taylor (Regius Professor of Surgery, DublinUniversity). He stated that the surgery of the acuteabdomen had advanced so satisfactorily during thepast 25 years, with the sole exception of acuteintestinal obstruction, that one was compelled toask why the mortality from that condition was

to-day no better than it was at the beginning ofthe century.. He attributed this appalling state ofaffairs to the ignorance and carelessness, both inex-cusable and nothing short of criminal, of the generalpractitioners and physicians, who see these unfor-tunate patients in the earlierst ages of their illness.Instead of realising that purgatives and enematacould do no good, but, on the other hand, might doinfinite harm-apart from the delay in surgical

treatment their administration entailed-these prac-titioners were continually laying themselves open toan action at law for malpractice or, worse still, theyran the risk of being placed in the dock formanslaughter. The speaker estimated the truemortality of acute intestinal obstruction as nearer60 per cent. than the figure usually given (35-40 percent. )-an alarming state of affairs. It was a mysteryto him, he said, that general practitioners andphysicians, all of whom had come to recognise thatthe only satisfactory treatment for all other acuteintra-abdominal conditions was early surgical inter-ference, could not come to the same conclusion withregard to acute intestinal obstruction. Apart fromacute intussusception, the speaker recognised threestages of obstruction : (1) Where (within 24 hours ofonset) the patient’s general condition was good andthere was little or no distension ; (2) where (withinthe second, third, or fourth day) the patient’s generalcondition was still good, but there was considerabledistension and the vomiting was severe ; and(3) where the general condition was bad: pulsefeeble, vomiting continuous and stercoraceous,abdomen distended, and the patient profoundlypoisoned. Treatment in the first stage consisted inwashing out the stomach with sodium bicarbonatesolution and free opening of the abdomen under ageneral anaesthetic. When the obstruction had beendealt with the stomach was again washed out. In thesecond stage, the obstruction was similarly dealtwith and removed, but, in addition to this, a separateincision was made through the left rectus above theumbilicus and a high loop of jejunum was broughtout. A tube of 7 or 8 mm. diameter was fastened intothis, after the method of Senn’s gastrostomy, and bymeans of which the jejunum was drained and irrigatedwith sodium bicarbonate solution. Later the patientmight be supplied with sodium bicarbonate andglucose by the same means. In the third stage, SirWilliam Taylor advised local infiltration of theabdominal wall and withdrawal of a loop of jejunumas above. Should the patient survive, the obstructionmight be dealt with later. The washing out of thestomach in these cases is of paramount importance.In obstruction of the large bowel, caecostomy afterthe manner of Sir Harold Stiles gave the best resultsso far as tiding the patient over his immediatedangers was concerned. The speaker then dealt withthe condition of acute intussusception, and stated thatin his practice it was the most common cause of acuteintestinal obstruction. In these cases there couldbe no excuse for failing to make a diagnosis. Hehimself had had a total of 81 cases with only threedeaths. In cases of obstruction of the adynamictype, Mr. Sampson Handley’s method left little tobe said on the subject, but Sir William Taylor was ofopinion that in very severe cases jejunostomy withsiphonage and gastric lavage, combined with morphia,might help the patient for a few days. Finally, hesaid, until physicians and general practitionersrealised that there was only one legitimate treatmentfor acute intestinal obstruction-namely, early opera-tion-we could not hope to improve our results.

Mr. Sampson Handley considered that the highmortality in obstruction cases was, at least in part,due to the fact that these operations were frequentlydone by medical men whose skill and training didnot justify them in undertaking such a seriousresponsibility. He also blamed the authors ofsurgical text-books, whose description of the signsand symptoms of acute intestinal obstruction wasoften lamentably vague and confused. Mr. Handleyinsisted on the great value of the " two-enema "

test-on the failure of the second enema the diagnosismight be considered as settled. He then dealt atlength with the operation of precautionary lateralanastomosis and illustrated his points with diagrams.Death in general peritonitis was usually due to obstruc-tion and not to the peritonitis as such, and the speakerbelieved that the recovery-rate, even in cases afterobstruction had supervened, amounted to 75 percent., if treatment was prompt.