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FOURTH ANNUAL MEETING OF CLINICAL CONGRESS OF SURGEONS OF NORTH AMERICA.
130 of the most striking features of recent statistica: history. Some conception of the life-saving thus secured may be gathered from the following illus. tration. In the seven years 1906-12 the deaths oj 736,682 infants occurred in England and Wales equivalent to an average rate of 115 per 1000 births Had the infant death-rate been 144 per 1000, as it had been in the seven years 1899-1905, there would have perished 922,454 infants in the years 1906-12 The improved conditions imply a saving of 185,772 lives during these seven years. Defective Sanitation, Poverty, and Intemperance
affecting Infant Mortality. Among the domestic forms of insanitation overcrowding and lack of cleanliness are the most detrimental to child life, and these fall most heavily on the poor. This usually means for the bottle-fed child unsatisfactory arrangements foi the storage of food and the consumption of contaminated or partially decomposed milk. Among
,
.
Medical Association, and by Professor KRÖNIG and Dr. C. J. GAUSS, of Freiburg, Dr. BREWER gave The Presidential Address:A Preliminary Report on a Simple and Rapid Method of Pyloric Closure in Gastro-enterostomy. Dr. Brewer referred to the defects, as pointed out by Tappliner, of all simple methods of pyloric closure, and after reviewing the various methods suggested in the past, described his method. This consists in constriction of the pylorus by an aluminium band, which is easily passed round the tube at this point and is quickly rolled with the
fingers into
an
unyielding ring
with sufficient
to obliterate the lumen of the tube, but not to compromise the vitality of the compressed tissues. Experiments upon dogs, he said, had shown that this method of closure produced a complete occlusion of the pylorus, as evidenced by the fact that water would not pass the constricted point when the stomach was distended, and also that sections through the pylorus and aluminium ring showed, on both gross and microscopic exami. nation, not only that the pylorus was closed, but that the vitality of the tissues was not impaired. Another series of experiments showed that the same method could be applied to the pyloric antrum, and, further, that the pylorus, which had been closed for some months, could have its function restored by a second laparotomy and removal of the aluminium band. Although the method had not yet been used on the human subject, Dr. Brewer held that the animal experi. ments had been so conclusive that he beiieved it to be the simplest and safest method yet proposed for such cases. Operation on the Gasserian Ganglion. Dr. HARVEY CUSHING, of Boston, reported a series of 156 cases with only two fatalities. On Nov. 11th Dr. JOHN B. DEAVER, of Philadelphia, read a paper on
compression
the defects of sanitation for which the local authorities are responsible the most injurious to infants are unsatisfactory methods of scavenging. defective paving of streets and passages, and insufficiency of water-supply. Respecting the effect of poverty on’infant mortality, Dr. Newsholme observes that when poverty involves malnutrition of either the expectant or the nursing mother it is only reasonable to assume that injury to the offspring will occur. Statistics are quoted from the Registrar-General’s report for 1911 which show that infant mortality increases with declining social position. The rate does not exceed 77 per 1000 births among families of the upper and middle class, whilst it is equal to 148 per 1000 among textile operatives and 160 among miners. But that these excessive death-rates are not necessarily connected with poverty is proved by the fact that the rate among agricultural labourers is only 97 per 1000. We cordially recommend the two volumes of the series already published, as practically indispensable Gastric Hœmorrhage. to students of modern vital statistics. As such they will doubtless be regarded, and probably acquired He said that operation might be indicated in for reference by those who are responsible for the gastric carcinoma when haemorrhage chanced and there was still guardianship of the public health ; they may also be to be ofan earlyor symptom in or otherwise incure, advanced, profitably studied by those who contemplate future hope cancer when was so profuse operable, haemorrhage enrolment in the public health department of our and persistent as to shorten even the period of profession. prognosis. In this case the measures to be adopted ______________
were excision, gastro-enterostomy, or jejunostomy, FOURTH ANNUAL MEETING OF CLINICAL according to the pathological condition found at But four most essential questions CONGRESS OF SURGEONS OF operation. to remained be settled: 1. The recognition of NORTH AMERICA.
AT the annual meeting of Clinical Congress, which was held in Chicago between Nov. 10th and 15th, 1913, the attendance numbered about 4000. As on previous occasions the holding of clinics was a special feature for which the wealth of material and the numerous
hospitals and institutions of Chicago proved especially favourable. The opening meeting took place on Monday evening, Nov. 10th, under the presidency of Dr. GEORGE EMERSON BREWER, of New York. Dr. E. W. ANDREWS, chairman of the committee of arrangements, introduced Sir RICKMAN GODLEE, President
suitable cases. 2. The time to operate. 3. The type of operation. 4. The proof of our position by mortality statistics. Dr. A. J. OscHNER, of Chicago, said that one must not look upon gastric haemorrhage primarily as a surgical emergency. As a result of the surgical possibilities established during the past few decades, a feeling had arisen that every serious condition must be attacked surgically. But this was justifiable only when the good judgment of the surgeon indicated that the patient was in such good condition that surgical treatment would offer the greatest possibility of cure. A careful and accurate diagnosis, based upon a thorough knowledge of the history of such cases, was the foundation for this judgment. Mr. HERBERT J. PATERSON, of London, read a
of the Royal College of Surgeons of England, who said that he had been impressed with the enormous amount of clinical material he had seen at all the hospitals visited, and had been much struck with the methodical manner in which instruction was paper on The Operation of Gastro-jejunostomy and the carried on at these institutions. After some congratulatory remarks Dr. Principles that should Determine its Use. by MURRAY McLAREN, President of the Canadian He thought that there was little doubt that the
131 immediate results of the posterior operation wero fter extensive operation, radium was used. In better than those of the anterior. Convalescence hese three cases there had been no recurrence and ran more smoothly and vomiting was less common. iealth had been fully restored. He had also had Moreover, the anterior operation might necessitate ’our cases inoperable on account of the patients’ washing out the stomach during the first few days. general condition, where apparently a cure had As to remote results, he thought the advantage ’esulted. Dr. Kelly thought ,that with an abundant rested with the anterior operation. Mr. Paterson iupply of radium its use for superficial cancer devoted the greater part of his paper to arguments would yield better results than surgery. showing that the operation of gastro-jejunostomy is (To be contin2sed.) a physiological one, notwithstanding Sir Berkeley " Moynihan’s expressed belief that the physiological explanation of gastro-jejunostomy is rot." The MEDICINE AND THE LAW. four practical lessons, he said, were: 1. That the type of gastro-jejunostomy employed is of less Post-mortem Examinations and the Consent of importance than the manner in which it is performed. 2. That if gastro-jejunostomy be a Relatives. physiological operation its use for the treatment of A,TUDGMENT delivered recently by Lord Anderson gastric haemorrhage is correct and explicable. in the Court of Session, Scotland, is of interest to 3. That occlusion of the pylorus is an unnecessary those called upon to make post-mortem examinations. complication of gastro-jejunostomy, and is based on In the case in question an action for damages (we use erroneous pathology. 4. That if gastro-jejunostomy English phraseology rather than the less familiar be a physiological operation, then it is as efficient Scottish legal terms) was brought by Mrs. Hughes, a treatment for ulcers of the body of the stomach the widow of a deceased miner, against Dr. R, C. as for ulcers near the pylorus ; in other words, Robertson on the ground that he had made a postgastro-jejunostomy is preferable to excision. mortem examination of her husband’s body Dr. CARL BECK, of Chicago, said that Mr. without authority, and that he had destroyed Paterson’s remarks in regard to the anterior and certain of the body instead of replacparts posterior operations, as well as the relative merits ing them for burial with the rest of it. of each, were important and suggestive. As to The action was successfully defended for Dr. whether pyloric exclusion was practically useless, Robertson the Medical and Dental Defence by further experimentation was needed. Union of Scotland, Lord Anderson being of the ’ On Nov. 12th Professor KR6NIG read a paper on opinion upon the evidence that the defendant had The Radiot7ae°apeutic Treatment of Benig7z and sufficient authority for what he did, and that he Tnmoll1’s. in fact restored the heart to the body, although had Malignant He said that they had treated 254 cases of he had burnt portions of the intestines, a course It is not cancer with Roentgen rays and radium, 150 of justified by their decomposed condition. them on purely therapeutic lines and without necessary to recite the facts upon which this decision operation. Of these 150, 140 were treated with was based and which amply justified it, but it may Roentgen rays and mesothorium; in 10 the be mentioned that there had been, or was alleged Roentgen ray alone was used. Of 64 cases of to have been, an accident, injuring the abdomen carcinoma 43 cases had been treated for the pre- of the deceased, that after a day or two he had vention of secondary growth almost exclusively gone to the infirmary at Kilmarnock, that an exwith unfiltered Roentgen rays, while 21 cases were ploratory examination had been made by the treated partly with filtered and partly with un- defendant who is one of the surgeons of that filtered rays. The difference was striking. While institution, that the patient’s condition had proved 32 out of the 43 cases died of carcinoma, they had to be very serious, and that two days later he died. been able to follow the subsequent history of 20 out To this it may be added that there was evidence of -the 21 cases and found that 60 per cent. of the that a suggestion was at some time made by the recurrences occurred the first year after operation. deceased both to Dr. Robertson and to Dr. A. Revie, Recurrent cancer had been treated with radioactive the medical officer of the colliery, that the deceased substances. The 140 cases treated with Roentgen had made an indiscreet meal of whelks and chip rays and mesothorium should be differentiated into potatoes, and that the widow and dependents aftertwo groups: 1. Those in which carcinoma had wards made a successful claim before the sheriff not spread beyond the primary focus into the substitute under the Workmen’s Compensation Act. neighbouring tissue, and in cancer of the cervix It will readily be understood that in these cirwhere the carcinomatous growth had spread into cumstances the probability of a post-mortem the parametrium and glands, so that operation was examination being required by the relatives was out of the question. 2. Those carcinomas in which taken into consideration, together with direct additional metastases were already present. While evidence as to some of them (but not the widow) it had been found possible to produce remarkable having asked Dr. Robertson to make one. It is of retrogressions and checking of the carcinomatous more general interest, however, to note the points metastases by intense radiation of Roentgen rays of law referred to by Lord Anderson, not because and radium, in all cases the carcinoma had spread they have any element of novelty, but because his later on. They could not say they had saved a lordship’s judgment show.3 that principles established single patient. In the second group the majority in such matters are not likely to be departed from. of cases were at the present time impossible of With regard to this Lord Anderson said emphaticure. cally, "It is quite well settled by the cases of Dr. HOWARD A. KELLY, of Baltimore, said he had Pollock v. Workman, 2 Fraser, and Conway v. employed radium in 188 cases of malignant growths. Dalziel, 3 Fraser, that an unauthorised postHe had treated 40 cases of cancer of the lower part mortem examination is a legal wrong." This, he of the uterus, where the disease was apt to spread explained, was on the principle that distress might rapidly, and the cases were considered hopelessly be caused to relatives by the dissection of the advanced and inoperable, and in three of these, body of one who in life was dear to them,
affecting Infant Mortality. Among the domestic forms of insanitation overcrowding and lack of cleanliness are the most detrimental to child life, and these fall most heavily on the poor. This usually means for the bottle-fed child unsatisfactory arrangements foi the storage of food and the consumption of contaminated or partially decomposed milk. Among
,
.
Medical Association, and by Professor KRÖNIG and Dr. C. J. GAUSS, of Freiburg, Dr. BREWER gave The Presidential Address:A Preliminary Report on a Simple and Rapid Method of Pyloric Closure in Gastro-enterostomy. Dr. Brewer referred to the defects, as pointed out by Tappliner, of all simple methods of pyloric closure, and after reviewing the various methods suggested in the past, described his method. This consists in constriction of the pylorus by an aluminium band, which is easily passed round the tube at this point and is quickly rolled with the
fingers into
an
unyielding ring
with sufficient
to obliterate the lumen of the tube, but not to compromise the vitality of the compressed tissues. Experiments upon dogs, he said, had shown that this method of closure produced a complete occlusion of the pylorus, as evidenced by the fact that water would not pass the constricted point when the stomach was distended, and also that sections through the pylorus and aluminium ring showed, on both gross and microscopic exami. nation, not only that the pylorus was closed, but that the vitality of the tissues was not impaired. Another series of experiments showed that the same method could be applied to the pyloric antrum, and, further, that the pylorus, which had been closed for some months, could have its function restored by a second laparotomy and removal of the aluminium band. Although the method had not yet been used on the human subject, Dr. Brewer held that the animal experi. ments had been so conclusive that he beiieved it to be the simplest and safest method yet proposed for such cases. Operation on the Gasserian Ganglion. Dr. HARVEY CUSHING, of Boston, reported a series of 156 cases with only two fatalities. On Nov. 11th Dr. JOHN B. DEAVER, of Philadelphia, read a paper on
compression
the defects of sanitation for which the local authorities are responsible the most injurious to infants are unsatisfactory methods of scavenging. defective paving of streets and passages, and insufficiency of water-supply. Respecting the effect of poverty on’infant mortality, Dr. Newsholme observes that when poverty involves malnutrition of either the expectant or the nursing mother it is only reasonable to assume that injury to the offspring will occur. Statistics are quoted from the Registrar-General’s report for 1911 which show that infant mortality increases with declining social position. The rate does not exceed 77 per 1000 births among families of the upper and middle class, whilst it is equal to 148 per 1000 among textile operatives and 160 among miners. But that these excessive death-rates are not necessarily connected with poverty is proved by the fact that the rate among agricultural labourers is only 97 per 1000. We cordially recommend the two volumes of the series already published, as practically indispensable Gastric Hœmorrhage. to students of modern vital statistics. As such they will doubtless be regarded, and probably acquired He said that operation might be indicated in for reference by those who are responsible for the gastric carcinoma when haemorrhage chanced and there was still guardianship of the public health ; they may also be to be ofan earlyor symptom in or otherwise incure, advanced, profitably studied by those who contemplate future hope cancer when was so profuse operable, haemorrhage enrolment in the public health department of our and persistent as to shorten even the period of profession. prognosis. In this case the measures to be adopted ______________
were excision, gastro-enterostomy, or jejunostomy, FOURTH ANNUAL MEETING OF CLINICAL according to the pathological condition found at But four most essential questions CONGRESS OF SURGEONS OF operation. to remained be settled: 1. The recognition of NORTH AMERICA.
AT the annual meeting of Clinical Congress, which was held in Chicago between Nov. 10th and 15th, 1913, the attendance numbered about 4000. As on previous occasions the holding of clinics was a special feature for which the wealth of material and the numerous
hospitals and institutions of Chicago proved especially favourable. The opening meeting took place on Monday evening, Nov. 10th, under the presidency of Dr. GEORGE EMERSON BREWER, of New York. Dr. E. W. ANDREWS, chairman of the committee of arrangements, introduced Sir RICKMAN GODLEE, President
suitable cases. 2. The time to operate. 3. The type of operation. 4. The proof of our position by mortality statistics. Dr. A. J. OscHNER, of Chicago, said that one must not look upon gastric haemorrhage primarily as a surgical emergency. As a result of the surgical possibilities established during the past few decades, a feeling had arisen that every serious condition must be attacked surgically. But this was justifiable only when the good judgment of the surgeon indicated that the patient was in such good condition that surgical treatment would offer the greatest possibility of cure. A careful and accurate diagnosis, based upon a thorough knowledge of the history of such cases, was the foundation for this judgment. Mr. HERBERT J. PATERSON, of London, read a
of the Royal College of Surgeons of England, who said that he had been impressed with the enormous amount of clinical material he had seen at all the hospitals visited, and had been much struck with the methodical manner in which instruction was paper on The Operation of Gastro-jejunostomy and the carried on at these institutions. After some congratulatory remarks Dr. Principles that should Determine its Use. by MURRAY McLAREN, President of the Canadian He thought that there was little doubt that the
131 immediate results of the posterior operation wero fter extensive operation, radium was used. In better than those of the anterior. Convalescence hese three cases there had been no recurrence and ran more smoothly and vomiting was less common. iealth had been fully restored. He had also had Moreover, the anterior operation might necessitate ’our cases inoperable on account of the patients’ washing out the stomach during the first few days. general condition, where apparently a cure had As to remote results, he thought the advantage ’esulted. Dr. Kelly thought ,that with an abundant rested with the anterior operation. Mr. Paterson iupply of radium its use for superficial cancer devoted the greater part of his paper to arguments would yield better results than surgery. showing that the operation of gastro-jejunostomy is (To be contin2sed.) a physiological one, notwithstanding Sir Berkeley " Moynihan’s expressed belief that the physiological explanation of gastro-jejunostomy is rot." The MEDICINE AND THE LAW. four practical lessons, he said, were: 1. That the type of gastro-jejunostomy employed is of less Post-mortem Examinations and the Consent of importance than the manner in which it is performed. 2. That if gastro-jejunostomy be a Relatives. physiological operation its use for the treatment of A,TUDGMENT delivered recently by Lord Anderson gastric haemorrhage is correct and explicable. in the Court of Session, Scotland, is of interest to 3. That occlusion of the pylorus is an unnecessary those called upon to make post-mortem examinations. complication of gastro-jejunostomy, and is based on In the case in question an action for damages (we use erroneous pathology. 4. That if gastro-jejunostomy English phraseology rather than the less familiar be a physiological operation, then it is as efficient Scottish legal terms) was brought by Mrs. Hughes, a treatment for ulcers of the body of the stomach the widow of a deceased miner, against Dr. R, C. as for ulcers near the pylorus ; in other words, Robertson on the ground that he had made a postgastro-jejunostomy is preferable to excision. mortem examination of her husband’s body Dr. CARL BECK, of Chicago, said that Mr. without authority, and that he had destroyed Paterson’s remarks in regard to the anterior and certain of the body instead of replacparts posterior operations, as well as the relative merits ing them for burial with the rest of it. of each, were important and suggestive. As to The action was successfully defended for Dr. whether pyloric exclusion was practically useless, Robertson the Medical and Dental Defence by further experimentation was needed. Union of Scotland, Lord Anderson being of the ’ On Nov. 12th Professor KR6NIG read a paper on opinion upon the evidence that the defendant had The Radiot7ae°apeutic Treatment of Benig7z and sufficient authority for what he did, and that he Tnmoll1’s. in fact restored the heart to the body, although had Malignant He said that they had treated 254 cases of he had burnt portions of the intestines, a course It is not cancer with Roentgen rays and radium, 150 of justified by their decomposed condition. them on purely therapeutic lines and without necessary to recite the facts upon which this decision operation. Of these 150, 140 were treated with was based and which amply justified it, but it may Roentgen rays and mesothorium; in 10 the be mentioned that there had been, or was alleged Roentgen ray alone was used. Of 64 cases of to have been, an accident, injuring the abdomen carcinoma 43 cases had been treated for the pre- of the deceased, that after a day or two he had vention of secondary growth almost exclusively gone to the infirmary at Kilmarnock, that an exwith unfiltered Roentgen rays, while 21 cases were ploratory examination had been made by the treated partly with filtered and partly with un- defendant who is one of the surgeons of that filtered rays. The difference was striking. While institution, that the patient’s condition had proved 32 out of the 43 cases died of carcinoma, they had to be very serious, and that two days later he died. been able to follow the subsequent history of 20 out To this it may be added that there was evidence of -the 21 cases and found that 60 per cent. of the that a suggestion was at some time made by the recurrences occurred the first year after operation. deceased both to Dr. Robertson and to Dr. A. Revie, Recurrent cancer had been treated with radioactive the medical officer of the colliery, that the deceased substances. The 140 cases treated with Roentgen had made an indiscreet meal of whelks and chip rays and mesothorium should be differentiated into potatoes, and that the widow and dependents aftertwo groups: 1. Those in which carcinoma had wards made a successful claim before the sheriff not spread beyond the primary focus into the substitute under the Workmen’s Compensation Act. neighbouring tissue, and in cancer of the cervix It will readily be understood that in these cirwhere the carcinomatous growth had spread into cumstances the probability of a post-mortem the parametrium and glands, so that operation was examination being required by the relatives was out of the question. 2. Those carcinomas in which taken into consideration, together with direct additional metastases were already present. While evidence as to some of them (but not the widow) it had been found possible to produce remarkable having asked Dr. Robertson to make one. It is of retrogressions and checking of the carcinomatous more general interest, however, to note the points metastases by intense radiation of Roentgen rays of law referred to by Lord Anderson, not because and radium, in all cases the carcinoma had spread they have any element of novelty, but because his later on. They could not say they had saved a lordship’s judgment show.3 that principles established single patient. In the second group the majority in such matters are not likely to be departed from. of cases were at the present time impossible of With regard to this Lord Anderson said emphaticure. cally, "It is quite well settled by the cases of Dr. HOWARD A. KELLY, of Baltimore, said he had Pollock v. Workman, 2 Fraser, and Conway v. employed radium in 188 cases of malignant growths. Dalziel, 3 Fraser, that an unauthorised postHe had treated 40 cases of cancer of the lower part mortem examination is a legal wrong." This, he of the uterus, where the disease was apt to spread explained, was on the principle that distress might rapidly, and the cases were considered hopelessly be caused to relatives by the dissection of the advanced and inoperable, and in three of these, body of one who in life was dear to them,