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Medical Societies.

MEDICAL SOCIETY OF LONDON.

Malignant St’l’iotu’l’e of the (]iJsophag1ts.A MEETING of this society was held on Feb. 13th,

Mr. CHARTERS J. SYMONDS, the President, being in thechair. ’

Dr. G. WILLIAM HILL demonstrated on patients the treat- z’

ment of Malignant Stricture of the (Esophagus, with specialreference to the employment of intubation and of radium.He said that the treatment of primary gullet cancer waspractically nearly always merely palliative for the relief of

dysphagia and pain. The only cases in which operation hadhitherto been successful were in all probability not instancesof primary disease in the oesophagus, but of invasion, cancerfrom the pharynx, and in these instances Solis Cohen’s andGluck’s types of operation-viz., total laryngectomy, togetherwith partial excision of the deep pharynx and of a smallsegment of the adjacent cervical oesophagus—had often beensuccessful. (Esophagectomy alone, whether of the cervicaloesophagus as first practised by Czerny, or of the thoracic, orof theabdomino-thoracic oesophagus by thoracicotomy after themethods of Sauerbruch, von Hacker, W. Meyer, and others,had no permanent or even temporary cure to its credit.With early recognition by means of the more generaladoption of exact endoscopic methods of diagnosis, togetherwith improvements in operative technique, an occasionalsuccessful cesophagectomy might be regarded as a matter oftime, but that time was not yet. Killian had claimed tohave diagnosed and successfully removed a small sarcomaof the gullet by endo-oesopbageal measures through the

cesophagoscope, but it would probably be long beforeanother such cure was recorded. The only externaloperative treatment which had been, and was still, ex-

tensively practised was the strictly palliative operation ofgastrostomy, but Dr. Hill thought he would be able to showthat the endo-cesophageal palliative measures mentioned inthe title of his paper-viz., intubation and radium-would inthe near future render the necessity of the resorting togastrostomy a much more exceptional event than it was to-day.Before dealing in detail with these special procedures withradium and intubation he passed under rapid review suchpalliative measures as treatment by drugs-e.g., iodides,iodipin, fibrolysin, which, like serum therapy, were notoften even of temporary value. Of drugs acting locallyspirit of ether broke up frothy mucus in the gullet byreducing surface tension; astringents, like adrenalin, cocaine,and turpentine, were of little use; local anodynes, like

morphia, chloretone, and orthoform, were sometimes usefulfor pain in cancer high up; they rarely, however, enabledone to dispense with hypodermic injections of morphia,atropine, &c., in very painful cases. Lavage of the gullet incases of dilatation above a stricture was the best means ofremoving decomposing substances, but glycerine of boricacid and of carbolic acid, sanitas, and similar preparationswere also useful as disinfectants and deodorants. Peroxideof hydrogen was contra-indicated. Caustics were generallyinadvisable, even when applied endoscopically to tightstrictures ; and electrolysis, ionisation, and carbon-dioxidesnow had not as yet had any extensive trial. Relief of

dysphagia by the X rays had been claimed in a few instances <where the disease was high up. The question of diet was of igreat importance, but time did not admit of its proper dis- 1cussion on this occasion. Blind bougieing undoubtedly gave 1relief to dysphagia, but was not free from danger even inexpert hands, and should be abandoned in favour of endo- 1scopic bougieing which was a much safer and more efficientprocedure in every way; but with intubation periodical t

bougieing was unnecessary. The permanent retention of asmall gum elastic oro-aesophageal catheter or feeding tube fhad been advocated by Krishaber at the International Medical E

Congress in London in 1881. Mackenzie was the firstto use an entirely intra-oesophageal permanent intubation- r

tube of gum elastic held in position by strings. This was a

later superseded by Symonds’s gum elastic intracesophageal D

funnel, an appliance of great utility which could, by the aidof the oesophagoscope, be much more easily inserted thanformerly. When the stricture could not be sufficiently dilatedby endoscopic graduated bougies or when it was near eitherend of the gullet, Symonds’s funnels were impracticable.James Berry was the first to employ permanent soft redrubber oro-aesophageal tubes of small calibre, which were,however, difficult of introduction. Symonds improved onBerry’s method by introducing a red rubber oro-cesophagealcatheter shaped like a Jacques urethral catheter, which wasmore easily introduced by a whalebone guide inserted intothe eye near the distal extremity. This method had provedmost useful in his (Dr. Hill’s) hands, but the pliant tube wasliable either to be vomited or coughed up, and could onlybe reintroduced by one skilled in its use without the aid ofthe cesophagoscope. Dr. Hill had therefore been led to devisea styletted red rubber oro-cesophageal catheter for eitherpermanent or temporary retention, which by reason of itshaving a backbone of soft silver or of whalebone fastenedto the teeth was not easily ejected by the severest coughingor vomiting. Patients could be fed with liquids through thetube, and after this intubation apparatus had been worn aweek or two the dilating bougie effect often enabled thepatient to swallow fluids, soft food, and often some solids bythe side of the tube. Although in advanced cases thestyletted tube had to be retained in situ permanently, inothers it could be left in for a week or two until from thebougie effect the patient swallowed well by the side of thetube when it could be removed until the dysphagia againbecame troublesome. He had treated a large number ofcases by either the permanent or the temporary wearing ofthis styletted oro-cesophageal intubation tube with the mostgratifying results ; the tube was well borne and Dr. Hillregarded gastrostomy as nearly a thing of the past in hispractice. The styletted tube was not only more efficient’than other intubation tubes, but it was more easily intro-duced than any other with or without endoscopic bougieing.Moreover, feeding entirely through an oro-aesophageal intu-bation tube was specially indicated for permanent use wherethere was a communication between the malignant gullet andthe air passages, so that liquid nourishment could be poureddirectly into the stomach. Several eonfreres had adoptedthat method of treating dysphagia for stricture with

complete satisfaction. It was indicated in cases whichwere unsuitable for the employment of Symonds’s funnel.The life of the styletted tube was from five to tenweeks. Dr. Hill then spoke of the employment of radium.Impressed by the results claimed abroad by Exner, Einhorn,Goisey, and others in gullet cancer, he stated that he wasthe first to apply radium to the gullet in this country, andwas probably the only one who had done much work onthat viscus with large quantities of radium. He worked in

cooperation with Dr. N. S. Finzi, who possessed 205 milli-grammes of radium (costing .63300). They had treated 22cases in all, using from 50 to 20 milligrammes on the gulletfor periods varying from 12 to 28 hours on end, repeated insome instances as many as six times. They claimed fourtemporary cures ; in six other cases there was quite remark-able improvement ; in seven further cases there was sub.stantial improvement ; and in five cases only was there noimprovement whatever, radium being only used once, and itwas doubtful whether two of these cases (advanced ones)were not worse after the one application. The techniquewas explained and the subject generally was illustrated by alarge number of X ray photographs and original drawingswith the aid of the epidiascope ; six patients were examinedwith the cesophagoscope, and the interior of the stomach in:me instance was demonstrated by the new Hill-Herschellmethod of cesophago-gastroscopy, nearly everyone presentaeing given an opportunity of seeing the region of theylorus.Dr. STCLAIR THOMSON gave details of the cases of two

patients who had been much relieved by Dr. Hill’s treatment.Mr. L. B. RAWMNG gave his reasons for preferring gastros-

iomy to other methods of treatment.Mr. H. TILLEY said that when an ansesthetic was required

’or endoscopy of the oesophagus chloroform was better thanither.Dr. FINzI said the dose of radium for healthy mucous

nembrane was 100 milligrammes for six or seven hours with, platinum shield 1-2L millimetres thick, and for diseasedaembrane three or four times longer.