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CARCINOMA OF THE STOMACH
52
CORRESPONDENCE CARCINOMA OF THE STOMACH
To the Editor
of
THE LANCET
Sm,—I hope that the correspondence
on this will not come to an end before definite steps are taken to settle the question in dispute. I write as an ignoramus, but I am very anxious to know whether cancer is often a sequel of peptic ulcer. It is said that cancer can follow chronic gastritis. It is also said that peptic ulcer may originate in inflammation. Perhaps there is more support for the second statement than the first. But does a peptic ulcer often become cancerous ? Who shall answer this question and on what grounds°l The surgeon may be able to diagnose a cancer at operation but he will have difficulty in saying whether it started from a peptic ulcer. He sometimes cannot be certain whether an ulcer is cancerous or not. The radiologist can give an opinion but he is not likely to be dogmatic about doubtful cases. The gastroscopist may recognise the nature of an obvious cancer, but he is not likely to be able to give an opinion with certainty about the less obvious. The morbid anatomist has the best chance and his opinion is the one that should be most seriously considered. There are certain criteria which the morbid anatomist can apply and on the basis of his opinion trustworthy statistics would be built. In his capacity as a histologist he would be able to gather further evidence. But it is to be remembered that on this question even
subject
histologists
can err.
No amount of theorising nor quoting of authorities is going to settle the question. Let us have the matter thoroughly investigated by physicians, surgeons, radiologists and above all by morbid anatomists of our teaching, schools. Let them take time so that they can produce statements that cannot be disputed. I am, Sir, yours faithfully, CHARLES MILLER. H
TREATMENT OF SHOCK
To the Editor
of
THE LANCET
much interested in Dr. Walker Tomb’s shock in your issue of Dec. 18th, having myself put forward similar arguments in favour of the sympathetic theory (Bgham med. Rev. 1936, 11, 131 ; Lancet, 1935, 2, 1412 ; Brit. med. J. 1935, 2, 1227). I think it might be dangerous, however, to pass unchallenged the view suggested that spinal anaesthesia is always a good treatment for shock. There is no doubt that under the influence of a spinal anaesthetic the signs of shock will sometimes vanish, but in others they are made worse. I believe the explanation is as follows : In early cases where the amount of plasma lost from the circulation is relatively small, cutting off the painful impulses does good, and there is enough blood in currency in spite of the loss of tone produced in the vessels of the lower part of the body. Where, however, the plasma-loss is more severe the vasoconstriction present is absolutely necessary to carry on the circulation, and it can only be overcome gradually if the patient’s life is not to be endangered. In such a case the sudden paralysis of a large part of the sympathetic system increases the collapse and may produce death. Even in the prevention of shock the protection of spinal anaesthesia is not complete. If we accept the evidence of a rising blood-sugar, sympathetic hyperactivity goes on even in an analgesia to the nipple plane, which means that all sympathetic
SIR,-I
article
on
was
impulses to the cut off, contrary
liver and adrenal glands are not, to the teaching of the late Howard Jones. In the cat sympathetic fibres to the splanchnic area have been shown to emerge from as high as the second thoracic nerves. Local reflexes confined tothe splanchnic area may also play a part in abdominal operations but these can be stopped by splanchnic block. In " high spinal," therefore, anxiety on the part of the patient will cause a continued secretion of adrenaline, and will also cause sympathetic impulses to be conveyed to those parts of the body unaffected by the analgesic. The patient’s anxiety can be reduced by a basal hypnotic, and its effects can be stopped completely by the use of gas-and-oxygen, which apparently has an inhibitory effect on the sympathetic system, as no rise in blood-sugar occurs. Dr. Tomb’s suggestion of treatment with ergotoxine is logical, though like him I have not tried it. A simple method of treatment, however, is to give insulin, which is antagonistic to the sympathetic, in small doses repeated as often as required and controlled if necessary by blood-sugar estimations. Fluids of course should be given to replace loss by sweating and otherwise. I am, Sir, yours faithfully, J. W. RIDDOCH. 1937
APLASTIC AND ACHRESTIC ANÆMIAS To the Editor of THE LANCET
SIR,-In your issue of Dec. llth, Dr. A. F. Zanaty describes the results of sternal puncture in a number of cases which he calls achrestic anaemia ; from his findings and certain other points he arrives at the conclusion that achrestic ansemia is a variety of pseudo-aplastic anaemia, and disagrees with our suggestion that it may be related to pernicious anaemia. But Dr. Zanaty’s cases present many differences from our published description of achrestic anaemia. The points he quotes in support of his theory are that the cases he examined showed : (1) a macroblastic hyperplasia of the bone-marrow; (2) a marrow less cellular than in pernicious anaemia with many nucleated red cells in small groups ; (3) more or less hypoplastic white-cell elements ; (4) anisoof the red cells " cytosis rarely extreme " ; (5) a, count than in pernicious anaemia; higher reticulocyte (6) the occasional presence of immature leucocytes ; (7) usually a negative van den Bergh reaction; (8) occurrence at a younger age than in pernicious anaemia ; (9) absence of nervous complications ; and (10) a remarkable tendency to haemorrhage. Taking these points seriatim, the cases quoted in our final description of achrestic anaemia showed : (1) a type of hyperplasia of the bone-marrow resemthat of pernicious anaemia—i.e., megaloblastic ; (2) marrow equally, if not more, cellular than in pernicious anaemia with groups of haemocytoblasts (megaloblasts) the prominent feature ; (3) white-
bling
cell elements sometimes hyperplastic and sometimes hypoplastic, as in pernicious anaemia (see Muir 2) ; (4) anisocytosis severe when the anaemia was severe ; (5) a low reticulocyte count, in the absence of intensive liver therapy-as in pernicious ansemia ; (6) immature leucocytes occur occasionally in typical pernicious none of our cases of achrestic anaemia to show any; (7) the van den Bergh happened reaction varied from negative to indirect or direct
anaemia;
1 Israëls, M. C. G., and Wilkinson, J. F., Quart. J. Med. 1936, n.s. 5, 69. 2 Muir, R., Text-book of Pathology, 3rd ed., Edinburgh, 1933.
CORRESPONDENCE CARCINOMA OF THE STOMACH
To the Editor
of
THE LANCET
Sm,—I hope that the correspondence
on this will not come to an end before definite steps are taken to settle the question in dispute. I write as an ignoramus, but I am very anxious to know whether cancer is often a sequel of peptic ulcer. It is said that cancer can follow chronic gastritis. It is also said that peptic ulcer may originate in inflammation. Perhaps there is more support for the second statement than the first. But does a peptic ulcer often become cancerous ? Who shall answer this question and on what grounds°l The surgeon may be able to diagnose a cancer at operation but he will have difficulty in saying whether it started from a peptic ulcer. He sometimes cannot be certain whether an ulcer is cancerous or not. The radiologist can give an opinion but he is not likely to be dogmatic about doubtful cases. The gastroscopist may recognise the nature of an obvious cancer, but he is not likely to be able to give an opinion with certainty about the less obvious. The morbid anatomist has the best chance and his opinion is the one that should be most seriously considered. There are certain criteria which the morbid anatomist can apply and on the basis of his opinion trustworthy statistics would be built. In his capacity as a histologist he would be able to gather further evidence. But it is to be remembered that on this question even
subject
histologists
can err.
No amount of theorising nor quoting of authorities is going to settle the question. Let us have the matter thoroughly investigated by physicians, surgeons, radiologists and above all by morbid anatomists of our teaching, schools. Let them take time so that they can produce statements that cannot be disputed. I am, Sir, yours faithfully, CHARLES MILLER. H
TREATMENT OF SHOCK
To the Editor
of
THE LANCET
much interested in Dr. Walker Tomb’s shock in your issue of Dec. 18th, having myself put forward similar arguments in favour of the sympathetic theory (Bgham med. Rev. 1936, 11, 131 ; Lancet, 1935, 2, 1412 ; Brit. med. J. 1935, 2, 1227). I think it might be dangerous, however, to pass unchallenged the view suggested that spinal anaesthesia is always a good treatment for shock. There is no doubt that under the influence of a spinal anaesthetic the signs of shock will sometimes vanish, but in others they are made worse. I believe the explanation is as follows : In early cases where the amount of plasma lost from the circulation is relatively small, cutting off the painful impulses does good, and there is enough blood in currency in spite of the loss of tone produced in the vessels of the lower part of the body. Where, however, the plasma-loss is more severe the vasoconstriction present is absolutely necessary to carry on the circulation, and it can only be overcome gradually if the patient’s life is not to be endangered. In such a case the sudden paralysis of a large part of the sympathetic system increases the collapse and may produce death. Even in the prevention of shock the protection of spinal anaesthesia is not complete. If we accept the evidence of a rising blood-sugar, sympathetic hyperactivity goes on even in an analgesia to the nipple plane, which means that all sympathetic
SIR,-I
article
on
was
impulses to the cut off, contrary
liver and adrenal glands are not, to the teaching of the late Howard Jones. In the cat sympathetic fibres to the splanchnic area have been shown to emerge from as high as the second thoracic nerves. Local reflexes confined tothe splanchnic area may also play a part in abdominal operations but these can be stopped by splanchnic block. In " high spinal," therefore, anxiety on the part of the patient will cause a continued secretion of adrenaline, and will also cause sympathetic impulses to be conveyed to those parts of the body unaffected by the analgesic. The patient’s anxiety can be reduced by a basal hypnotic, and its effects can be stopped completely by the use of gas-and-oxygen, which apparently has an inhibitory effect on the sympathetic system, as no rise in blood-sugar occurs. Dr. Tomb’s suggestion of treatment with ergotoxine is logical, though like him I have not tried it. A simple method of treatment, however, is to give insulin, which is antagonistic to the sympathetic, in small doses repeated as often as required and controlled if necessary by blood-sugar estimations. Fluids of course should be given to replace loss by sweating and otherwise. I am, Sir, yours faithfully, J. W. RIDDOCH. 1937
APLASTIC AND ACHRESTIC ANÆMIAS To the Editor of THE LANCET
SIR,-In your issue of Dec. llth, Dr. A. F. Zanaty describes the results of sternal puncture in a number of cases which he calls achrestic anaemia ; from his findings and certain other points he arrives at the conclusion that achrestic ansemia is a variety of pseudo-aplastic anaemia, and disagrees with our suggestion that it may be related to pernicious anaemia. But Dr. Zanaty’s cases present many differences from our published description of achrestic anaemia. The points he quotes in support of his theory are that the cases he examined showed : (1) a macroblastic hyperplasia of the bone-marrow; (2) a marrow less cellular than in pernicious anaemia with many nucleated red cells in small groups ; (3) more or less hypoplastic white-cell elements ; (4) anisoof the red cells " cytosis rarely extreme " ; (5) a, count than in pernicious anaemia; higher reticulocyte (6) the occasional presence of immature leucocytes ; (7) usually a negative van den Bergh reaction; (8) occurrence at a younger age than in pernicious anaemia ; (9) absence of nervous complications ; and (10) a remarkable tendency to haemorrhage. Taking these points seriatim, the cases quoted in our final description of achrestic anaemia showed : (1) a type of hyperplasia of the bone-marrow resemthat of pernicious anaemia—i.e., megaloblastic ; (2) marrow equally, if not more, cellular than in pernicious anaemia with groups of haemocytoblasts (megaloblasts) the prominent feature ; (3) white-
bling
cell elements sometimes hyperplastic and sometimes hypoplastic, as in pernicious anaemia (see Muir 2) ; (4) anisocytosis severe when the anaemia was severe ; (5) a low reticulocyte count, in the absence of intensive liver therapy-as in pernicious ansemia ; (6) immature leucocytes occur occasionally in typical pernicious none of our cases of achrestic anaemia to show any; (7) the van den Bergh happened reaction varied from negative to indirect or direct
anaemia;
1 Israëls, M. C. G., and Wilkinson, J. F., Quart. J. Med. 1936, n.s. 5, 69. 2 Muir, R., Text-book of Pathology, 3rd ed., Edinburgh, 1933.