suffering from severe pain in left iliac
region at a point lower than McBurney's
point on oppsite side. There was marked
tenderness at this point but no evidence of
tumor. Her temperature ranged from 102
to 103. There was some nausea with
occasional vomiting. After a day or two
there was slight pain on pressure at same
point on opposite side. I gave anodynes
to relieve pain, and salines until bowels
were thoroughly evacuated, hot water bags
were applied, hot vaginal douches and
other symptomatic treatment as the case
demanded. The pain and fever continued
for a week, when she began to menstruate
and all unfavorable symptoms abated and
the patient regained her usual health. My
diagnosis at this time was salpingitis.
About a month later she had a similar
attack but not so severe, which passed off
with a menstruation.

No physician attended her during th's



*Read before the North Carolina Medical Society, at
Tarboro, N. C, May, 1900.



568



THE CHARLOTTE MEDICAL JOURNAL.



attack. With her subsequent menstruation
she had no trouble. I did not see her again
professionally until November, when I
obtained the following history : That
while playing at school she had a fall,
which caused a very sharp pain for a while
in left side. After the accuteness of the
pain subsided, she still continued to feel
uncomfortable, this condition remained un-
changed for about four days, when she had
an attack resembling colic, bowels moved
three or four times freely. This was Friday
morning. I saw her in the afternoon 1
found her suffering with the same train of
symptoms that characterized the first
attack. I treated her as before, giving her
saline purgatives repeatedly the next day,
(Saturday) but could get no action from
the bowels. So gave injections with rectal
tube with negative result. The vomiting
became incessant, nothing could be retained
by the stomach.

Sunday morning she began to develop
symptoms of peritonitis, and abdomen be-
came swollen, the tenderness more general,
and the temperature dropped to normal.
At this time I called my friend Dr. A. S
Pendleton, of Warrenton, N. C. in consul-
tation. He agreed with me in the opinion
that nothing but an early operation could
save my patient. I took her to Richmond
by an early train Monday morning. .She
was taken at once to Dr. McGuire's Hospi-
tal and prepared for operation. At about
three o'clock p. m. she was placed on the
table. The operation was neatly and quick-
ly done by Drs. Hunter and Stuart Mc-
Guire, disclosing the following condition :
The whole peritoneal cavity was filled
with offensive pus, the appendix was found
in a sloughing condition, imbedded low
down on the left side, and it was with
difliculty released from its malposition and
brought up through the wound of incision,
the omentum had sloughed about two
inches, the bowels were in a semigangren-
ous condition, the tubes and ovaries were
normal. Patient reacted from the opera-
tion but succumbed six hours later.



Pylorectomy for Adeno Carcinoma, with
Report of a Case.*

By Dr. Jos. H. Branham, M.D., Professor

of Surgery and Abdominal Surgery

Md. Medical College.

J. R., white male came under my charge
about September ist, 1899.



♦Read before the North Carolina Medical Society, at
Tarboro, N. C, May, 1900.



His family history was good, no cases of
malignant disease being noted. His gene-
ral health had been good until about i8
months before, when he had a severe attack
of malaria. This was followed by recur-
rent gastric attacks characterized by cramps
and vomiting, the vomit containing bile.
During this time he had to be careful as to
food, coarse articles causing distress and a
sense of distention in the upper region of
the abdomen.

EXAMINATION.

Patient tall and spare, skin sallow and
muddy, pulse weak and rapid on exertion.
Mucous membranes pale.

Physical examination of abdomen shows
thin walls, tenderness over region of
stomach, which organ was slightly dilated,
and the spleen was much enlarged.

Under large doses of quinia the splenic
enlargement rapidly disappeared, but the
gastric symptoms grew worse.

Gastric lavage gave little relief.

September 26th, he was admitted to the
National Temperance Hospital and shortly
afterward Prof. C. Urban Smith was able
to make out a small mass at the right of
the median line above the umbilicus.

This could only be felt when the patient
sat with his legs well apart and stooped
well forward.

The following notes by Prof. Smith
elucidate the points of diagnosis.

Contents of stomach Acid.

Acid Hydrochloric .09%

Acid Lactic Free.

Acid Butric Free.

Pepsin and rennet normal, contained ex-
cess of mucus, yeast cells and a few cells
resembling cancer. Salol test showed good
motor functions.

Kali iodide test showed delayed absorp-
tion. Indican in urine.

Diagnosis, cancer of pylorus.

Preparation for operation.

Patient was put on a strictly liquid diet
and for two days was given three grains of
salol and 1-30 gr. of nitrate of strychnia
three times per day.

The night before he was given a purge
immediately before taking the anaesthetic
his stomach was carefully washed out with
sterile salt solution.

The usual preparations of the parts to
secure surgical cleanliness were made.

OPERATION Oct. I2th.

A median incision about four inches in
length enabled us to examine the organs in
situ. The pylorus was slightly lower than
normal and was freely movable. A small
growth about two inches in length and an
inch broad was found occupying the an-



THE CHARLOTTE MEDICAL JOURNAL,



569



terior and inferior aspect of the pylorus
encroaching on the duodenum. The length
corresponding to the circumference of the
gut.

This growth extended about two thirds
around the organ, and was firm but not
hard. No other abnormality was tound in
the neighboring parts.

The attachment of the omentum to this
part of the organ was tied off and severed.
The diseased part was now drawn well
forward into the abdominal wound and
surrounded by sterile gauze sponges. The
attachments divided and the duodenum
severved about an inch below the neoplasm
and the stomach the same distance above.

An end to end anastomosis was next
made by means of a Murphy button which
was reinforced by peritoneal sutures. The
abdominal wound was closed after carefully
cleansing the parts with salt solution, part
of which was left in the peritoneal cavity.
All the sutures used were cat gut hardened
in a solution of bichloride of mercury in
alcohol one part to a thousand.

The patient was very weak and had
several subcutaneous infusions of salt solu-
tion during the first twenty-four houis after
the operation. He was also given about
i-io grain of strynchnia nitrate during
and after the operation. He rallied slowly.
For the first five days he had nothing by
the stomach and was nourished entirely by
the rectum. On the 14th, he had his high-
est temperature loi deg. He was allowed
to wash his mouth with cold water.

On the 17th. he was given small quant-
ities of albumen and panpeptone. This
collected in his stomach and caused great
distress and was washed out on the 19th.
by the stomach tube. This gave great
relief and was continued about every
second day for two weeks. Most of the
food taken apparently remained in the
stomach, the rectal feeding was continued
during this period. On the 29th., seventeen
days after the operation, the Murphy button
was removed from his rectum by the resid-
ent physician. He gradually became able
to digest food and gain strength slowly.

His temperature was nearly always sub-
normal, both before and after the opera-
tion ; this I attributed to the bad nutrition
due to insufficient assimmilation.

He left the hospital, Nov. 30th. and
returned to his home in N. C, weighing at
this time, 84 lbs. He reported by letter
from time to time to me and gradually
gained strength and weight until April
1900, he had reached the very respectable
figure of 147 pounds.



PATHOLOGICAL REPORT.

Prof. R. L. Mc Mur.— "The growth is
a carcinoma. Showing at points sufficient
glandular arrangement to justify the name
Adeno Carcinoma. Beside tl.e principal
mass a number of small points of invasion
of the surrounding tissue is noted.

The growth seems to have encroached on
the mucous membrane of the duodenum to
a great extent."

general considerations.

The recent great improvement in opera-
tion technique and in means of diagnosis
giving better results have aroused much
interest in the surgical treatment of disease
of the stomach.

Pylorectomy was first done in man by
Pean in 1879, ^"'^ the first successful case
was by Billroth, 18S1.

The mortality was high in the early cases,
but recently it has been much diminis^hed.

The following table is probably not
nearly complete, but will give a general
idea of the mortality and also of the im-
proved results of recent operations.

cases recovered died
Winslow 60 16 44

Mikulicz 33 8 24

Billroth 19 8 11

Guinard 399 194 105

Czerny 39 18 11

Kronlein 34 19 5

Carle 14 3 11

Milkulicz 30 15 5

Hartmann 10 6 4

Wilmott Evans 13 13 i

Morison 5 5 o

Kocher 57 50 7

Mayni 35 3i 4

Roux 12 9 3

Tuffier 963

Lambotte 541

Van Kleef 413

Leeds Infirmary staff 7 3 4

Karg 440

Guessenbaur 13 7 6

Mayo 330

American Journal Medical Science. 18S5,

Wemi Med. Nov. No. 34.

Referring to the above table we find that
the cases collected by Winslow and Mikul-
icz (i and 11) were the early cases done
before 1SS5. They are probably duplicated
to an extent, but as they give almost the
same results this does not impair their value
for comparison.

Taken together they show a mortality of
74 per cent. While ^ihe rest of the table
taken from an article by Mayo Robson,
which shows the combined mortality of
both the old and new cases. Shows 572
cases, recovered 399, deaths 174. Mortali



570



THE CHARLOTTE MEDICAK JOURNAL.



30.4 per cent. Could the old cases be
eliminated, this mortality would be much
further reduced.

Lancet, March 24, 1900.

This remarkable result shown by Kocher
57 cases with a mortality of less than 9 per
cent, gives hope that we will soon be able
to class this as one of the operations, not
excessively dangerous.

The remote result of the operation un-
fortunately have not been so good. Most
of the cases being relieved for only a short
time, and later showing recurrences. Fifty
successes of Kocher showed one woman
living 10 years without recurrence, one five
years, one three years and one two years.
Four died of other troubles without recur-
rences after three or more years, so we may
claim these eight cases as permanent cures
out of the fifty-seven cases operated on.
The other cases of the fifty-two who sur-
vived the operation were made more com-
fortable and in the aggregated had many
years of useful life added to their existence.

I think that we may now consider some
of the general facts, bearing on the cases
and influencing the results of the operation.

CAUSATION.

Unfortunately we are still in the dark as
regard to the etiology of malignant dis-
ease. True, much recent work has been
done along this line and reports of the same
have been make. This will no doubt be of
great value in the future, as yet however,
we have nothing accepted by the profession
as proven. We have good reason to hope
that we shall soon have light on the cause
of this terrible scourge, and that this may
lead to improved methods of treatment.

DIAGNOSIS.

Great advance has been made along this
line. Some points in the natural history of
the disease will help us in coming to a cor-
rect conclusion. Cancer occurs usually
after middle life but there are many excep-
tions to this rule.

*A paper by Prof. Wm. Osier and Dr.
McCrae gives the proportion under 30
years in a collected table of 3257 cases 2.5
per cent. In 150 cases from the Johns
Hopkins Hospital 4 per cent, were under
30. Men are more often the subject of
gastric cancer than women. The position
of the growth is most frequently the pylor-
us, over 60 per cent, of cases being found
here. Among the symptoms pointing to
this disease we note briefly pain, dull,
often continuous, and increased after eat-
ing ; belching of gases, often foul ; vomit-
ing of partly digested food, later, mixed



*New York Medical Journal, April 21, 1900.



with decomposed blood ; (coffee grounds)
loss of weight and energy, temperature not
infrequently sub-normal, but may be elevat-
ed in rapid cases near the end.

PHYSICAL SIGNS.

Usually some dilation of stomach when
growth is at the pylorus. The presence
of a mass can usually be made out by ex-
amining patient frequently and in various
positions, (the value of change of position
was well illustrated in my case.) The
stomach should be examined empty and
distended both by gas and fluid. Great
assistance can be obtained by careful ex-
amination of the contents of the organ.
Absence of HCl. while not a positive
sign points strongly to the cancer. Excess
of lactic acid is suggestive of cancer, the
finding of parts of growth in the wash
water may enable us to make a positive
diagnosis ; unfortunately, this is possible
only late in t"he disease, and often after the
time for radical operation has past. The
X ray may help us make out a mass.

Finally the exploratory incision should
be considered as ^almost harmless as they
are in other parts of the abdomen, and
should be employed early, as soon as we
have strong suspicion of cancer, this will
enable the surgeon to attack the growth
while it is still small.

When a neoplasm is found after open-
ing the abdomen the selection of the pro-
per operation for the case is of great im-
portance.

If the lymphatic glands are involved aud
many adhesions are present the operation
should be abandoned, or in case there are
symptoms of stenosis present a gastro
enterostomy should be done. Pylorectomy
is indicated when the growth is in the
pylorus, and when the glands are free and
the organ not much adherent.

Partial or complete gastrectomy is to be
done when the tumor occupies other situa-
tions and the organ is free from adhesions.

When adhesions are present the opera-
tions becomes excessively dangerous and
even when successful recurrence soon takes
place.

The method of operating differs much
with surgeons, Kocher first does a gastro-
jejunostomy and some weeks latter excises
the mass, closing the two ends of gut.

His results have been better than any
other surgeon who has had a very large
number of cases. He does not like the
Murphy button as he says it often fails to
pass, and he reports one case where it was
found in the stomach fourteen months after
the operation. Dr. Mayo of Rochester,
Minn., who has had five successful cases



THE CHARLOTTE MEDICAL JOURNAL



571



and no failures always uses the button. Its
advantages are the ease and rapidity with
whicn it enables us to close the bowels.

The slough which it causes is probably
advantageous as it removes tissues which is
near the growth and are possibly infiltrated.
It is not necessary to draw on the organ to
so great an extent when it is used, thus
dragging on the nerves and other important
parts is avoided, which, together with the
saving of time lessens the shock and the
other bad results of long exposure and
manipulation of the parts.

The case before you illustrates some im-
portant principles, to which before closing
we will call your attention. The marvelous
improvement in our patient's general con-
dition and the small extent and the slow
growth of the tumor lead us to hope that
this will be one of permanent cure. The
repeated washing out of his stomach after
the operation relieved the patient of great
distress and probably saved his life.

The rapid increase of cancer during the
last few years makes the report of every
operation more important than formerly.

Too many physicians and surgeons tend
to despair the unfortunates who are attack-
ed by this dreaded disease. Many, like
Micawber, are waiting for something to
turn up from the labratory workers. That
some other means of destroying or prevent-
ing this one of our worst enemies may be
discovered, we all hope, but it would be the
height of folly to fold our arms and wait for
such a consummation, let us rather try to
improve our known methods of attack.

Nothing will help us so much in this
direction as early diagnosis and operation.
Much is due to the stomach specialist in
helping to perfect means of diagnosis; but
often he treats these cases until the disease
has advanced too far. Careful lavage and
diet not infrequently lead to temporary im-
provement ; both physician and patient are
soothed into a fatal sense of false hope, and
procrastinate until the time for radical
operation has passed. The exploratory
ooeration will probably do more to save
these unfortunates than anything else, and
should be more frequent employed. Practi-
cally all these cases are operable at some
period of their existence, and we have
reason to hope that in future they will be
referred to the surgeon at a time when the
tumor can be succefsfully attacked, and not
only temporary relief is possibly but when
a large proportion can be permently cured.
The cases of absolute cure of cancer in other
organs is becoming more and more common,
surely we can hope for this same advance in
cancer of the stomach where glandular in-
volvement comes late in the disease.



DISCUSSION.

Dr. Chas. J. O'Hagan. — I can only
say that I think the Society is indebted to
Dr. Branham for the remarkably lucid and
interesting description of a very remarkable
operation. I was in Baltimore at the time
and saw the patient there, and he looked in
the last stages of existence and I thought
the operation could not be successful. The
doctor has been kind enough to give us
some information about the operation and
I think he deserves a vote of thanks, and I
move that he be given it. The motion was
seconded and adopted unanimously.



Shall we use Anodynes and Anesthetics
in Midwifery.*

By N. P. Boddie, M. D., Durham, N. C.

This is a question of very great impor-
tance, and perhaps a good many of you
may think it has been answered long ago
in the affirmative. But if you refer to the
rank and file of the profession, you are
very much mistaken.

A good many good physicians, and a
majority of the laity, are bitterly opposed
to and prejudiced against their use — so
much so that those who would use them are
afraid to do so and use them at their own
peril.

Now, if I can provoke a free and open
discussion of this important subject and
thereby break down some of this opposition
I will feel like I have done a good deed and
won the good will and approval of the suf-
fering mothers of our times, as well as the
more sympathetic of our profession.

The first duty of any physician is to re-
store his patient to his or her normal con-
dition, and to do this with as little pain and
suffering as possible. Therefore, we con-
clude, if by using anodynes and anesthetics
in our obstetric practice we can relieve our
patients of pain and suffering without
damage to them, it is our sacred duty to
do so.

I do not say we can use these pain re
lievers indiscriminately and in all cases,
but I do say, so far as my experience goes,
there are very few cases, if any, in which
we cannot use to advantage one or the other.

One of the greatest difficulties in the way
of their use, as I have already said, is pre-
judice in both doctors and laity, and con-
sequently if used at all, so little is used, or
so unintelligently given, they do no good
and possibly harm. I will try from expe-



*Read before the North Caroli;
Tarboro, N. C, May, 1900,



Medical Society at



572



THE CHARLOTTE MEDICAL JOURNAL.



rience to give some practical suggestions
on this subject.

Chloral hydrat, I think, is one of, if not
the best anodyne and relaxant we have.
We must have time, say two to four hours
to get our patient under its influence, and
it must be given in full doses, twenty to
thirty grains every hour or two till one to
two drams are taken. It takes more for
some patients than others, usually about
ninety grains are sufficient. You must give
it until you get the physiological effects —
patient semi-conscious and sleeping, awak-
ing only during the contraction. Chloro-
form, say Squibb's, (only the best to be
used) to be given during the contractions,
anticipating them a little. Beginning the
latter part of the first or dilating stage and
continuing until the presenting part is de-
livered. And thus your patient passes this
terrible ordeal without pain or knowl-
edge of the transaction. It is hardly neces
sary to say our patient requires our closest
attention.

But it pays in more ways than one. We
win the love and esteem of our grateful
patient, we have the approval of our own
conscience of having relieved suffering hu-
manity, and the commendation of all good
people, by largely removing the incentive
to commit possibly the most prevalent crime
of our times, criminal abortion and preven-
tion of child-bearing.

Are not all physicians largely responsible
for this state of affairs, in paying so little
attention to the intense suffering of obstet-
ric patients.

Morphine deserves a large place in this
subject. Who would try to practice medi-
cine without a hypodermic syringe and mor-
phine? None, I dare say, and they are as
indispensable in obstetrics as in general
medicine. A hyperdermic of a half grain
of morphine, given when your patient is
tired and worn out with nagging pains and
rigid OS, gives her one to three hours of
sweet and refreshing sleep, and when she
awakes rested, os relaxed and contractions
normal, and with the aid of chloroform,
completes labor in comparative comfort and
in a few minutes.

When you have exhausted your skill in
trying to stop abortion or miscarriage, tam-
pon the vagina with antiseptic gauze or
cotton, give a full dose of morphia, leave
your patient to rest and when you return in
a few hours, say from five to twenty-four,
you will find the os dilated, and often the
foetus and membranes lying loose in the
vagina and so have very little trouble or
pain in clearing the parts.

I do not say as routine practice, we should
give a hyperdermic of morphine after de-



livery, but I do say that most of our multi-
para will be relieved of a good deal of suf-
fering thereby.

It is barbarous to let patients suffer from
those agonizing "after pains" as some do,
when they can be relieved so easily and
promptly. I find the coal tar preparations
with Dover's powder and mono-bromate of
camphor act nicely in these cases, but must
be given in full doses. In some cases
nothing acts so well or seems to do at all
but morphine given hyperdermically.

I think we all will use more morphine in
our obstetric practize in the future, if we
will give it a fair trial, especially in rigid
OS and crampy contractions. One objec-
tion that is usually given to anesthetics and
anodynes in midwifery is increased danger
of post-partem hemorrhage, and this may
be true. So "forewarned is forearmed,"
I take no risk but give a full dose of ergot
on completion of second stage, and I also
keep my hand on the uterus, gently but
firmly pressing and kneading till the pla-
centa is expelled, gently pulling on the cord
and so avoid infecting the vagina after de-
livery. Watch closely the uterus for some
time, to be sure that it is firmly contracted.
If there seems to be any tendency to bleed-
ing, I give a hot antiseptic douche at once.
So I have never had any bleeding to bother.
Another objection given to the use of anes-
thetics and anodynes is prolonged labor,
and some times this seems true, but I have
seen just as tardy labors when none were
nsed. But agreeing that it is the case, is
it not far better to deliver our patients in
comparative comfort and with least possible
danger of lacerations, with a slow labor,
than to deliver them with a quick labor
and have torn parts, intense agony and an
exhausted and disgusted patient.^

Let's all resolve we will do more to re-
lieve the sufTering motherhood of our coun-
try. None are more deserving and none
who suffer more or have so little done to
relieve them.



Symposium on the Biology, Pathology and
Treatment of Tuberculosis.*

By Paul Paquin, M. D,, Asheville, N. C.

Tuberculosis depends on three factors :
1st. Predisposition of a complex physical
nature.

2nd. General and special feebleness and