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case distension of the organ was recognisable by percussionor succussion. Paroxysmal tachycardia also depended fre-quently on gastric disorder. Mackenzie had pointed outthat in palpitation the rhythm of the heart was normalthough hurried, whereas in paroxysmal tachycardia thenodal rhythm occurred, the pulse being irregular and aventricular wave only being apparent. A case in support ofthis contention was quoted which was immediately relievedby liq. pepsin. c. bismuth. et nuc. vom. Intermittency ofthe pulse was often associated with stomach disorder, thecommonest type being that due to extrasystoles, whose

pulse wave did not reach the wrist. An instance of this

temporary condition induced by imprudence in diet wascited, in which the phenomenon and dilated stomach subsidedin a few days on treatment directed solely to the gastricdisorder. Pseudo angina pectoris with pain spreading downthe arm was a fourth manifestation usually attributableto flatulent distension of the stomach. It came on an hourafter meals or during the night and not with exertion as a rule.In most cases the heart did not appear sufficiently diseasedfor true angina, and with suitable treatment of the digestiveorgans the attacks ceased to occur. A very striking exampleof this form of cardiac distress was described in which

recovery immediately followed on the adoption of strict milkdiet. It should not be forgotten, however, that true anginamight be brought on by stomach over-distension, and

subjects of valvular disease suffered acute distress, sometimesending fatally, through this cause of embarrassment of theheart’s action. Fatty degeneration of the heart renderedpatients peculiarly liable to distress and danger to life fromstomach disturbance, and the management of digestion wasquite as important as treatment of the heart.

Dr. PRESTON KlXG read a paper on

niffe’J’entiation in Chronic Joint Afections.The present nomenclature of chronic arthritis, he said, wasmost unsatisfactory. The disease which was at presentknown as rheumatoid arthritis was called by so many namesand included so many really different forms of ill-healthin which the only common connecting link was thatin each there was some joint trouble that it was not

surprising if confusion and misunderstanding occurred whenit was discussed. Rheumatoid arthritis was a poly-articular affection with marked debility, occurring mostlyamong women in earlier life, in which the joint troublewas often quite overshadowed by the more importantgeneral constitutional symptoms. It should be differentiatedfrom the osteo-arthritis of later life, in which the joint con-dition formed the most important feature. The use ofX rays in differentiating between these cases of chronicarthritis was disappointing. It showed little more in osteo-arthritis than could be either seen or felt, and the greatertranslucency of the bones which was said to occur in rheumatoidarthritis did not accord with his (the speaker’s) experience.There were so many variable factors in the production of anX ray photograph that evidence of extra-translucency hadto be taken with caution. Osteo-arthritis and rheumatoidarthritis were not to be looked upon as separate diseases.It was a question whether either of these should be regardedas a disease at all. A distinct disease should have a specificcause, which produced results which were fairly constant.No one specific cause had been shown for either and in eachthe symptoms varied with the nature of the evil. Bothosteo-arthritis and rheumatoid arthritis were often the resultof many and quite different infections. These were easier totrace in rheumatoid arthritis than in osteo-arthritis, and it wasalso easier and more hopeful to treat with vaccines the formerthan the latter. Among the sources of infection pyorrhoeaalveolaris, leucorrhoea, and gonorrhoea were the most common.In differentiating in chronic arthritis, and in suggesting abetter nomenclature, it would be well if the term infectivearthritis " were adopted to distinguish these cases from therest. It was in the infective case that the involvement ofthe temporo-maxillary joint and spondylitis deformans werechiefly seen, and there is that group to which he wished tokeep the name rheumatoid arthritis. In osteo-arthritisspondylitis deformans was often present, but not in associa-tion with an affection of the temporo-maxillary joint, and ina much more chronic and quiet form. Plaster casts wereshown to illustrate points in the differentiation of chronicarthritis.

SURGERY.

WEDNESDAY, JULY 23RD.

President, Mr. W. THELWALL THOMAS (Liverpool).Mr. G. H. MAKINS (London) opened a discussion on

The Diagnosis and Treatiizeitt of Pi-iniar?j Carcinonca of theStomaelt.

He said that though the first operation for the removal of amalignant growth of the stomach had been performed morethan 30 years ago, he considered that it had not gained thepopularity it deserved, in spite of the fact that it had beenmuch advocated by some surgeons. Carcinoma of thestomach was very common-in fact, it constituted 21 percent. of all cases of carcinoma, yet malignant disease of’thebowel was more frequently operated on than was cancer ofthe stomach. There were different reasons for this. In thefirst place, the diagnosis of cancer of the stomach at an earlystage was very difficult ; and, in the second place, the-

general practitioner did not recognise how successful theoperation for removal of gastric growths was ; and he feltthat an obstruction of the intestine must be relieved andcolotomy was a very successful operation and was easilyperformed. An operation for cancer of the stomach wasthe more likely to be successful the earlier the operationwas performed, but at this early stage the diagnosiswas extremely difficult. There were no characteristic.symptoms, though a very sudden onset might be suggestive.Test meals might be of some value, but the informationobtained was by no means conclusive. The absence of freehydrochloric acid was sometimes striking, but very little

weight could be laid on that, and it appeared to be certainthat the situation of a lesion in the stomach had moreinfluence on this sign than had the nature of the lesion.Skiagraphy was useful, but it gave little information in theearly stages ; it could distinguish between a tumour of thestomach and one of the colon, and it could also show clearlythe existence of a gastro-colic fistula. An exploratoryincision was made for two purposes ; one purpose was t(}

diagnose. This operation was generally almost free fromdanger, but an exploratory incision might be performed tosee whether a growth was removable. In such a case therewas definitely some danger. It must not be forgotten thateven when an exploratory incision had been made it was notalways possible to diagnose between an inflammatory massand a tumour. When a diagnosis of cancer of the stomachhad been made, the treatment to be adopted must dependon the position and extent of the growth. Growths situatedin the cardiac region offered no inducement for operation ;those in the body of the organ might be suitable for

gastrectomy, but the growths involving the pylorus werebest suited for operation ; and as these formed some60 per cent. of the whole number of cancers of the stomachhe would chiefly consider these cases. When the growthextended along the lesser curvature the case was of the moreunfavourable kind. The extent of the lymphatic invasiondid not depend on the size of the primary growth or thelength of the history of symptoms. The obvious involve-ment of the glands did to a certain extent render the

prognosis unfavourable, but slight glandular affection neednot deter the surgeon from attempting removal. In about5 per cent. of the cases the growth had extended into theduodenum, and it was not rare for the growth to involve thetransverse colon and transverse meso-colon. These casesmight be dealt with, but necessarily the operation was pro-longed. On the whole, if the pancreas was involved it wasbetter not to operate, but this rule was not absolute. Themain contraindications to operation were visible metastases,ascites, and involvement of the abdominal wall. As to themethod of operation, some modification of Billroth’s pylor-ectomy seemed to be the best operation, and as a rule abouta hand’s breadth of the stomach at the cardiac end should bequite free from disease. Some ingenious operations hadbeen performed, and a recently introduced operationseemed to be very good ; in this the upper end ofthe duodenum was closed, and the jejunum was unitedto the cut surface of the stomach, thus doing awaywith the necessity for a posterior gastro-jejunostomy.He found it difficult to express numerically the resultsafter operations for the removal of malignant diseaseof the stomach, but he was inclined to think that from 15 to.20 per cent. might represent the average mortality. The

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duration of life after the operation varied greatly, but it wascertain that in a number of cases there was no return of thedisease, even after several years.

Mr. E. W. HEY GROVES (Bristol) thought that muchvaluable time might be lost by the many diagnostic methodswhich had been put forward for the recognition of malignantdisease of the stomach. One difficulty in diagnosis arosefrom the fact that in some 50 per cent. of the cases cancerwas preceded by some inflammatory condition. In anydoubtful case an exploratory incision was required, but evenafter the abdomen was opened it might be impossible to bequite sure. At one time he considered that the presence ofa metastatic growth was conclusive evidence of a malignantgrowth, but he had seen a case in which there were two verydefinite nodules in the liver, and yet though no operationfor removal was done, the patient had recovered and wasstill well. In all cases he was in favour of removal of the

great omentum, for it was not at all rare for the growth toextend into it.

Dr. T. K. DALZIEL (Glasgow) held that a certain diagnosiswas quite impossible in an early stage, and when the diagnosiswas certain it was generally too late. He was inclined inall cases to remove as much of the stomach as possible, butit was necessary to leave a portion of the cardiac end aswide as a finger. Fear of sepsis in these operations couldbe put aside, but it was essential that there should be notension.

Mr. R. F. JowERS (Brighton) laid stress on the difficultyof deciding on the malignancy of a mass in the stomach.

Mr. A. H. BUCK (Brighton) considered that there weremany very doubtful cases even after the abdomen had been

opened. He was strongly in favour of early exploratoryoperations. He believed that even very extensive operationson the stomach were very safe if the patient were in goodcondition.

Mr. D. P. D. WILITIE (Edinburgh) drew attention to therisk of leaking when the cut end of the duodenum wasclosed ; and a series of experiments had led him to the con-clusion that this was due to interference with the superiorduodenal artery.

Mr. W. McADAM ECCLES (London) urged that an explora-tory operation was needed even before any tumour could befelt, and he was in favour of incising the stomach to examinethe mucous membrane when the diagnosis was in doubt.

Mr. H. B. ROBINSON (London) was in favour of openingthe abdomen whenever there was any difficulty in diagnosis,but this was not always sufficient to clear it up.

The PRESIDENT considered that the hydrochloric acid testwas absolutely useless, and he related a case which appearedto be malignant by all the usual tests, the glands beingaffected also, but the patient recovered and remained well,even though the growth was not removed. He thought thatthe public was realising that many cases of indigestion weresurgical. The best treatment of a gastric ulcer was excision.

Mr. MAKINS, in reply, said that he was opposed to makingan incision into a stomach merely for diagnostic purposes.

Mr. WILKIE read a paper on

Experimental Observations on the Caitse of Death in ÂrmteIntestinal Obstruction.

Dealing first with simple obstruction of the intestinal lumen,he showed that when the occlusion was situated high up inthe small intestine in the region where secretion was veryactive the great loss of fluid by vomiting accounted in greatmeasure for the symptoms ; when, on the other hand, theocclusion was low down in the small intestine the copioussecretions of the upper reaches were reabsorbed and symptomswere consequently delayed. He had found that the contentof obstructed intestine was not acutely toxic when absorbedthrough the intestinal mucosa, and that toxic absorptioncould not account for the symptoms of acute ileus. Wherethe intestine was strangulated and infarction of its walltook place his researches indicated that the acute symptomsand early fatal issue were due mainly to shock and

splanchnic paresis, and but slightly, if at all, to absorptionof poisonous products from the strangulated loop. The

practical conclusions drawn were : (1) That the surgery ofintestinal obstruction should be as conservative as possibleand that only on imperative indications should the lumen ofthe bowel be opened, the danger of peritonitis being greaterthan that of absorptive toxagmia ; and (2) that in all formsof intestinal obstruction great improvement follows copioussubcutaneous infusions of saline and dextrose solutions.

Dr. A. A. WARDEN (Paris) read a paper onRadium and Inoperable Cancer.

He ’showed from cases which he had treated that it wasworth while to employ radium in all cases which were notoperable or in which the patients refused operation. Heheld that some cases of cancer were really curable by radium,for in several under his care no recurrence had occurred evenafter some years.

THURSDAY, JULY 24TH.Mr. A. M. MARTIN (Newcastle-on-Tyne) opened a dis-

cussion on

The Diagnosis and 1’recct-ment ot I)ti?tries of the Knee-jointother than Fractitres and -Dislocations.

He stated that he did not intend to include perforatingwounds of the joint. He drew attention to the anatomy ofthe knee, pointing out that it was not simply a hinge-joint,for at the end of extension there was rotation due to thelength of the inner condyle ; and, again, the flexed knee wascapable of rotation. If when the knee was in the flexed

position excessive rotation should occur the internal semi-lunar fibrocartilage might be dragged towards the middle ofthe joint, and so it might be injured. In acute synovitis ofthe joint there was no instability of the joint, and the con-dition quickly improved with rest and elastic pressure.Rupture of ligaments was chiefly due to over-extension, whenthe posterior ligament, the hinder part of the internallateral ligament, and the anterior crucial ligament gave way ;this lesion was seen chiefly in those who played football.The treatment would consist in complete rest in the extendedposition for three months, followed by massage. Some caseshad been able to return to football. When lateral movement

had caused the breaking of a lateral ligament mere rest wasinsufficient, and the best treatment was to suture the torn liga-ment. When the anterior ligament was torn primary suturewas best, but it should be followed by rest for several weeks.When one or both crucial ligaments were torn it was by nomeans certain what was the best treatment; probably itwould be best to order a firm knee-cap which would supportthe joint. For haemophilia rest was the best treatmentcombined with the use of horse serum ; it was importantthat no incision should be made, and that not even aspira-tion should be performed. Occasionally loose bodies mightbe due to injury ; in one case he had seen portions of thearticular cartilage, and in another case he had found theloose body was composed of a blood-clot, while in a thirdcase he had seen small flakes which had no doubt beenderived from a semilunar fibro-cartilage. The symptoms ofloose bodies might be very obscure, but sooner or later thebody could be felt ; it was always advisable to fix the loosebody by means of a needle before incising the joint, and alocal anaesthetic was best. Traumatic osteo-arthritis was

probably always the result of injury to a joint which wasalready affected with osteo-arthritis. Operations were

generally useless. The most important condition about whichhe would speak was injury to one of the semilunar fibro-carti-lages. This injury was very common in the north of England ;in mining the knees were flexed when the seam of coal wasnot thick ; and while the knee was flexed there was powerfulrotation, as the miner swung round to throw the coal intothe tub." In this movement the fibro-cartilage was liableto be torn. The internal fibro-cartilage was most commonlyaffected-in over 92 per cent.-and this was probably due tothe fact that the internal cartilage was more firmly attachedand therefore was more liable to be torn when pulled on. Theinjury was most often in the anterior part; the cartilage mightbe torn or ruptured, or it might even be split horizontally.Sometimes a portion of the ruptured piece might project onthe inner side of the joint, and it might give rise to apalpable swelling, and this was the only way in which aninjured fibro-cartilage could give rise to a prominence.After the injury had once occurred very slight causes mightreproduce it. When the lesion occurred in footballers thefixation on one foot on the ground by the studs on the solewas a great factor in the production of the injury. A directblow could never cause injury of a fibro-cartilage. The

symptoms were simple; the knee was fixed in the flexed

position ; there was great pain, and the patient felt

perfectly helpless. Soon swelling came on, which slowlysubsided. After a number of attacks the signs might

1 THE LANCET, Oct. 19th, 1912, p. 1067.