Medical Review of Reviews

SOCIETY PROCEEDINGS.

American Surgical Association.Meeting held at Richmond, Va., May 46, 1908. Mr. B. G. A. Moynihan, Leeds, England, read a paper upon the "Late Results After Operations for Benign Diseases of the Stomach and Duodenum." In estimating the value of surgery in nonmalignant diseases of the stomach he reviewed the records of his operations to the end of 1905. They are 281 in numbers and are classified as follows: 1. Perforating ulcer of the stomach or duodenum. 2. Cases for which hæmorrhage has been the immediate cause of urgent interference. 3. Cases of chronic ulcer, etc. 4. Cases of hour-glass stomach. Of the 281 patients recent information is at hand in reference to 265. In Class 1, in 27 cases of perforating ulcer operated on 18 patients recovered. In Class 2, 27 patients submitted to operation for acute hæmorrhage, 23 of whom recovered. In Class 3, among 205 patients, there were 2 fatal cases and 214 operations. In Class 4 there were 22 cases, made up of 7 males and 15 females. The total mortality in this group is 3.

A summary of the number of cases in all the groups gives the following results:

no better; 9 are doubtful; 6 are not recently reported. Thirty-four patients are dead-18 as a result of the operation, 7 of carcinoma of the stomach, 9 from other causes unconnected with the disease of the stomach or the operation performed for its relief. Among the lessons to be drawn from the history the following points are submitted: The operative treatment of stomach disorders should be confined exclusively to cases in which an organic lesion is present. In acute perforating ulcer the perforation should be closed or the ulcer excised. When a nonmalignant lesion is discovered the treatment depends on its position in the stomach. If the ulcer be prepyloric, pyloric or duodenal, gastroenterostomy should be performed. It is desirable also to infold an ulcer whenever possible. The most satisfactory method of gastroesterostomy is the posterior no-loop operation, with the almost vertical application of the bowel to the stomach. Regurgitant vomiting occurs as a result of the "loop" operation, whether anterior or posterior; it is relieved almost certainly by an enteroanastomosis. In hour-glass stomach the surgical treatment presents special difficulties on account of the frequency of a dual lesion, one in the body of the stomach, one at the pylorus, and consequently double operations have to be performed.

STUDY OF GASTRIC AND DUODENAL ULCERS. WITH ESPECIAL REFERENCE TO THEIR

SURGICAL CURE.

Dr. William J. Mayo, Rochester, Minn... discussed gastric and duodenal ulcers. In

the series reported the average duration of the symptoms was over 12 years, and medical treatment had failed to effect permanent cure. Only cases failing to yield to reasonable medical treatment, he said, should be considered surgically. The opinion as to cure is based on the condition of the patient two years or more after the operation. All the patients with ulcer and kindred diseases of the stomach and duodenum operated on by Drs. C. H. and W. J. Mayo since 1893 to April 20. 1908, are classified. Total number of operations was 824; the total number of patients operated on, 765. Of 543 cases of ulcer operated on, 27 were acute perforations. All the patients of acute perforation treated by simple suture, with one exception, recovered and remained well. Twice in chronic cases the base of the ulcer had been cut out, producing an effect similar to acute perforation. The defect was closed, good results following. In more than 300 posterior no-loop gastrojejunostomies, with the intestine sutured to the stomach in its normal position downward and to the left, performed for ulcer of the stomach and duodenum there is reported a mortality of less than I per cent., and but three patients have required secondary operation on the stomach for any cause. In all loop operations, anterior or posterior, the intestine is applied to the stomach downward and to the right, but in the no-loop method this sometimes caused angulation, turning the jejunum at the duodenojejunal angle rather sharply from its normal position, and occasionally caused chronic bile regurgitation. Excision, the Finney operation, and the operation of Rodman, he remarked, each has a field of usefulness

Three hundred and

in suitable cases. seventy-nine patients with ulcer of the stomach and duodenum were operated on previous to June 1, 1906, covering a period of from 2 to 15 years since operation, have been traced. In 318 actually demonstrated ulcers, 80.7 per cent. of the patients were cured, 9 per cent. were improved and 4.2 per cent. were unimproved; 6 per cent. died in the years following operation from various causes, only two of which were connected with the stomach. After operation for ulcer patients require medical supervision until cure is established.

END RESULTS FOLLOWING OPERATION FOR BENIGN DISEASES OF THE STOMACH AND DUODENUM.

Dr. John B. Deaver, Philadelphia, asserted that reliance on direct experience and observation rather than on theory must be condemned in the scientific surgery of today. He has traced 66 of the patients on whom he has performed stomach operations for benign disease. Of this number, 44 are free from all gastric symptoms, 9 are greatly improved, 5 are unimproved and 8 have died. These figures give a percentage of cures of 66.6; of patients greatly improved, 80.3. A division of the patients is made from the operative viewpoint and the percentages of cures and improvements given. An analysis of the various diseases of the stomach and duodenum for which operations were performed and a list of the cases traced, in more or less detail, are included in the paper. Dr. Deaver concludes: The operation of choice should always be performed when feasible; when not feasible, the operation of necessity.

All cases of stenosis of the pylorus, whether due to a neoplasm, cicatricial contraction, hyperplasia, pyloroplasm, or what not, should be treated by operative interference, preferably by posterior gastrojejunostomy. All ulcers of the stomach which do not respond to medical treatment promptly, and the various sequelæ of this disease, should be treated. by operation. All ulcers of the duodenum which do not respond promptly to medical treatment should be treated by operation. His preference in performing gastroenterostomy is by the posterior gastrojejunostomy, no-loop, clamp route.

HOW FREQUENTLY DO GASTRIC ULCERS BECOME CARCINOMATA?

Dr. William L. Rodman, Philadelphia, believes gastric carcinomata due in at least 50 per cent. of the cases to a previous ulcer. Though statistics vary concerning the frequency of the occurrence, the latest studies give the highest percentage. Within two years he has had nine cases of cancer in which there was

an unmistakable history of ulcer. In some cases the classical symptoms of chronic ulcer are so marked that there is no suspicion of carcinoma, and even when the abdomen is opened mistakes have been made by those most experienced in gastric diseases. In other cases after two or more years the symptoms change so that malignant degeneration is suspected. Little is to be learned from gastric analysis, as the chemical characteristics may be the same as in simple ulcer. Rapid and regular diminution or disappearance of hyperacidity at intervals is the most important sign. This phenomenon probably indicates that cancer is developing. The difficulty of diagnosis is the strongest plea that can be made for early exploratory operation in all gastric cases of doubtful nature failing to yield to medical treatment within a reasonable time. Dr. Rodman advocates removal of all suspicious lesions by simple excision, pylorectomy or partial gastrectomy, according to the conditions in the individual cases. Jour. A. M. A.

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