Medical Society of the State of North Carolina. An.

Transactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) online

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iBehan, R. J. Interst. M. J., 1914, sxi-965.

=Kochei- ; "Uber Ileus," Mitt. a. d. Grenzgeb. d. Med. u Cliig., Jena, 1908, iv, 195-230.

"Whipple, Stone, and Bei-nheim. Annals Surg.. Mav, 1914.

^Hartwell, J. A. J. Exp. Med.. 1913, xviii, 139.

^McLean. A. Ann. Surg., 1914, lix, 407.

«Peiser, Beii. Klin. Wchnschr., 1914, lix, 996.



SOME GASTEO-INTESTINxiL CASES, WITH CLD^ICAL

EEPORT.



C. S. Lawrence, M.D., Wixston-Salem.



In studying the mass of literature written upon tlie gastro-intestinal
tract, it would seem that nothing of importance could be added at this
time, and in my short paper I shall not try to put forth any new ideas,
but simply report two clinical cases of gastric .surgery that have come
under my observation recently.

As we go over the work of the leading men of this country and of
Europe, one finds ideas in common with all of them, and other princi-
ples in which some of them quite differ. Coffees' work on gastro-inter-
optosis is epoch-making, but we find a great many men AA^ho disagree
with him. Lane says that the colon is the case of all ills except cleft-
palate. Moynihan says that the cause of a great many gastric symptoms
may be found in the right lower quadrant, and has called attention to
the gall bladder and appendix being simultaneously affected.

While there is much written and much work being done, we must not
stop, but continue on to the goal idea, for, as I heard Moynihan in his
London address on intestinal stases say in reference to the great amount
of work being done along this line, out of much that is dross there is a
nugget of pure gold. In my own exj^erience, and in observing the clinics



SUKGERY. 15"

of others, I have been impressed Avith the tardiness with which cases of
gastric and duodenal ulcers come to operation. I believe that these cases
should be given a chance to be cured medicinally; but after a month or
so of such treatment, if they are not cured, I believe they should be re-
ferred to the surgeon. The recurrence of the so-called cured cases, I
believe, should also be referred to the surgeon for treatment. How often
is it that we have cases of epigastric trouble come to us saying that they
had been cured three or four times by as many stomach specialists !
Let me report a case here :

Case 1. — Male, white, age 38; by occupation a merchant; born in North
Carolina and has always lived in the State. Fifteen years ago he began to
have pain in the epigastrium two hours after eating. The pain was not so
severe at first, but grew worse within a year or two. He did not vomit, but
had sour stomach ; eructations of hot burning fluid. He grew better and
worse until five years ago, when he was treated by a stomach specialist, who
said he was cured, and he was much better for a time, but soon got worse
with the pain after eating, which was relieved by certain kinds of food which
he carried with him. The sour stomach and hot fluid was more troublesome,
and he often resorted to the stomach tube for relief, and says that he has
often removed food material from the stomach that he had eaten twenty-four
hours previously. Patient is very nervous, constipated, and has lost consid-
erable weight within the past year or two.

Physical examination: Expression pinched and anxious; teeth are bad,
mild form of pyorrhea ; tongue large and indented by the teeth and coated
with thick mucus ; chest well formed, lungs negative, heart normal in size.
apex murmui", systolic in time, not transmitted. Abdomen scaphoid, tender
over entire abdomen ; more so on I'ight side from brim of pelvis to costal mar-
gin ; great deal of gas in the intestines.

X-ray examination: Stomach large, extending to promontory of sacrum
constriction grater-curvitures, giving hour-glass appearance. Twelve-hour res-
idue ; diagnosis, ulcer lesser curvature.

Operation February 11, 1915: Laparotomy through right rectus incision
above umbilicus. The stomach was found to be quite large, the pars pylorica
in the left iliac fossa ; all the intestines were in the pelvis ; the ciecum was
large and very movable ; had a hard, chronically inflamed appendix attached to
it; on the anterior wall of the stomach near the lesser curvature was found
two large ulcers, each of which had a tag of omentum adherent to it. The
ulcers were turned in with linen thread and a gastro-enterostomy retro calica
performed, the appendix removed and the ctecum plicated.

Patient left the table in good condition ; post-operative history uneventful :
did not vomit but one time ; the morning after the operation he vomited small
quantity of bile stain fluid.

May 20, 1915. Patient has gained 15 pounds in weight and feels well, at-
tending to business, and X-ray examination shows gastro-enterostomy opening
patulous and functionating properly.



158 NORTH CAROLINA MEDICAL SOCIETY.

Think what it would have meant to this man's life had he been saved
all these years of suffering and loss of time from his business, and hoAv
much more pleasant his home life would have been had he been able to
enjoy his supper and romp with the kiddies instead of a pain in the
belly and a nervous feeling as though he would tear their heads off every
time one dared to make a noise. A gastro-enterostomy has relieved
him now. Why could it not have done so fifteen years ago? I say it
would and should have been done. He has been a neglected case up to
this time.

Let me report a case at the other end of the line.

Case 2. — Male, white, age 31 ; by occupation, bookkeeper. In July, 1914, he
had an attack of general abdominal pain, followed by nau.sea and vomit, with
rise of temperature; his attack did not keep him in bed. but he suffered pain
four or five days and got better. One month later he hud another attack.
This time the pain was in the epigastrium. Since July he has had pain every
day, coming on four hours after eating. Pain is relieved by taking food. He
has eructations of sour fluid which burns his throat ; he has lost weight,
grown very nervous, and is constipated.

Family history: Negative; previous health good up to last July.

Physical examination: Teeth in good condition ; tongue slightly swollen,
indented by the teeth, coated with tenacious mucus ; chest negative. Abdo-
men rigid all over, more on right side than on left ; just below the costal
margin near the median line is a tender spot ; with the slightest pressure the
patient yells witli pain. The region of the appendix is also quite tender and
the muscles are very rigid.

X-ray examination: Stomach normal in size and position; slight constric-
tion first portion duodenum hyperperistalsis ; six-hour residue in duodenal cap.
Diagnosis, duodenal ulcer.

Operation on May 1, IDl.'): Laparotomy right rectus incision above umbili-
cus. A large duodenal ulcer was found, involving the top and anterior wall of
the duodenum. A tag of omentum was adherent to the ulcer. These adhesions
were freed and the ulcer turned in with linen thread and a posterior gastro-
enterostomy performed. The appendix was adherent and contained an entero-
lith, the caput coli covered with a Jackson membrane : the appendix was
removed.

The patient was on the table one hour and fifteen minutes and left it in
good shape. Three hours after the operation patient vomited large quantity
of blood ; one hour later vomited blood again ; five hours later vomited four
ounces of dark blood. At this time tlie patient began to show signs of hemor-
rhage in the pulse and pallor of the skin, and I was quite anxious about him,
knowing that I had placed three rows of linen sutures in the posterior layer
and two I'ows in the anterior layer. I felt confident that the hemorrhage was
coming from the ulcer that I had turned in. While thinking of the best course
to pursue in order to save my patient. I happened to think that I had a sample
of "Coaguline Ciba" that an agent had left me. and I dissolved the contents
of the sample bottle in a glass of water and let him drink half of it. He I'e-



SUEGERY. 159

tained the mixture thirty minutes aud vomited five ounces of bloody fluid con-
taining two large clots. At this time tlie pulse was 143, temperature 99,
patient very restless. Normal salt drop method by rectum was started with
the remainder of the Coaguline Ciba in the salt solution. This was kept up
until 500 c.c. had been taken. From this time the patient did not vomit again
and within six hours the pulse came down to 118, and the patient made a
rapid recovery and is feeling fine at this writing.*

Had this man gone ou many months longer, there is no doubt that he
would have been the same physical wreck that Case ]^o. 1 was.

As to the diagnosis of gastric and duodenal ulcer, it is simple, and
with the instruments of precision at our command, combined with the
clinical symptoms, diagnosis should be made with great accuracy. These
cases complain of actual pain in the epigastrium, occurring always at
the same hour after eating in each case — may be one hour in Case A
and three hours in Case B, but will always occur at the respective hour
in the given case. The pain is usually relieved by taking food in the
way of milk cracker, hard-boiled egg, or by taking bicarbonate of soda.
In the ulcer of the duodenum the pain does not occui*, as a rule, for
some time after eating, say, three to five liours; sour stomach, hot fluid
in the mouth, etc.

Hemorrhage is less constant and less reliable as a diagnostic sign, as
is also the test meal, as many cases of gastric aud duodenal ulcer show
a normal acidity.

The tender point over the seat of ulcer, with jaundice at times, loss
of w^eight (for a great number of these patients are afraid to eat because
of pain), constipation, and nervousness.

X-RAY EXAMINATION.

The necessity of a standard method of examination has been urged by
Carman of the Mayo clinic, which Dr. Whittington and myself have
followed in our work, w^hose technic may be defined as the combined
fluoroscopic and skiagraphic examination with double opaque meal.
Barium sulphate is used in the six-hour meal, and at the time of the
examination the patient is given bismuth subcarbonate in buttermilk.

"As seen at operation, four classes of gastric ulcer may be distinguished :
(1) Small, exceeding .shallow mucous erosions aud slit-like ulcers; (2) Pene-
trating or callous ulcers, with relatively deep craters; (3) Perforating ulcers
with or without accessory cavity formation; and (4) Very early carcinoma-
tous idcers.

"Of these four classes, the first, the small shallow erosions, offer the greatest
difficulty of rontgenologic detection. They are either superficial denudations



*X-ray examination June 2. 1915, shows gastro-enterostomy oponing patulous and
functionating properly.



160 NORTH CAKOLINA MEDICAL SOCIETY.

or mere slits in tlie mucosa, incapable of holding enough bismuth to make a
visible niche. Unless accompanied by an incisura or a six-hour rest, their
presence will hardly be even suspected, much less positively determined.

"The penetrating ulcers which have burrowed more or less deeply into the
gastric wall show a definite crater, which may be either quite round, oval, or
irregular. The degree of the facility with which the crater can be seen by
the Rontgen ray as a niche depends upon its size and location.

"Perforation of an ulcer and a continuation of tlie destructive process into
an organ or tissue results in the formation of an accessory cavity. Perfora-
tion may, of course, occur without the production of a pocket. In this event
the radiologic signs are like those of callous ulcer, plus, in some instances, the
distorting effect of adhesions.

"The very early carcinomatous ulcers are not, as a rule, distinguishable
microscopically from nonmaliguant ulcers. Their Rontgenologic signs are not
different from those penetrating or perforating ulcers.

"The positive radiologic diagnosis of gastric ulcer can only be based upon
presence of one of two signs, namely, the niche or the accessory pocket.

"Other signs which are corroborative but not diagnostic of themselves are :
(1) the incisura, (2) hour-glass stomach, (.3) residue in stomach after six
hours, (4) lessened mobility, (5) localized pressure-tender point, (6) delayed
opening of the pylorus, (7) acute fish-hook form of the stomach with displace-
ments to the left and down, (8) gastric hypotonus, and (9) anti-peristalsis.

"A distinct residue from the six-hour meal amounting to an eighth or more
of the quantity taken is a relatively common accompaniment of gastric ulcer.
Its most common cause is the pylorospasm which frequently accompanies
ulcer, but in the case of an ulcer at or near the pyloric region obstruction
from scar contraction may be responsible.

"A six-hour rest is by no means an exclusive indication of ulcer, since it may
occur in any obstructive condition, including carcinoma, duodenal ulcer, and
pericholecystic adhesions, as well as reflex from conditions outside the
stomach.

"The Rontgenologic signs of ulcer differ so much from those of carcinoma
in the vast majority of cases that differentiation requires no effort at all.
For example, a callous ulcer with niche and incisura, or a perforating ulcer
with pocket formation, has no radiologic resemblance whatever to a well
developed carcinoma, either scirrhous or medullary, and such cases make up
the bulk of those patients coming for Rontgen ray examination. In a general
way ulcer defects always project from the gastric contour, while in carcinoma
the growth with its resultant irregularity extends into or encroaches upon
gastric lumen. Between the typical cases and the typical carcinoma, however,
there is a small percentage of cases in which rontgenologic differentiation is
impossible. These are the border-line cases, in which carcinoma cells are
found in the ulcer. In such instances the Rontgen signs are chiefly those of
the ulcer, and the lesion is usually not determinable macroscopically.

"Extreme size of an ulcer-crater as shown by a large niche should make
one suspicious of malignancy, a fact which Carman has had impressed upon
him by experience. He says a niche three or more centimeters in diameter is
apt to show microscopic signs of carcinoma.



SURGERY. 161

"Differentiation of pyloric ulcer from pyloric carcinoma is most difficult.
Here, in either event, the only radiologic signs may be a six-hour rest and a
typical irregularity of contour, and the rontgenologist can only say ^yith cer-
tainty- that a lesion exists."

DUODENAL ULCER.

Superficial acute ulceration of the duodenum may give no definite
evidence rontgenologicallj. Even at laparotomy these superficial lesions
of the mucous membrane may not be felt, and may be overlooked unless
the duodenum is incised and inspected. Cases of fatal hemorrhage have
been reported soon after laparotomy which failed to reveal duodenal,
ulcer diagnosed clinically or radiographically.

Chronic ulceration of the duodenum may be diagnosed with extreme
accuracy by several methods, as follows :

According to Carman's experience at the Mayo clinic :

"The rontgenologic indications of duodenal ulcer, which have been fre-
quently catalogued by various observers during the past two years, may be
divided into major and minor signs :

"The major signs are :

"1. Gastric hyperperistalsis.

"2. A residue in the stomach (sometimes in the duodenum) after six hours,
if there be obstruction from scar contraction.

"3. A divericulum of r)erforating ulcer.

"The minor signs are :

"1. The gastric hypermotility with early free opening of the pylorus and
speedy clearing of the stomach.

"2. Gastric hypertonus.

"3. Irregularities on the outline of the cap or bulb, or of the duodenum.

"4. Lagging of bismuth in the duodenum.

"5. Pressure of tender point over the duodenum.

"6. Spasm of the stomach, such as hour-glass or slowly traveling incisura.

"Of all the radiologic signs of lesion of the digestive tract, the presence, after
six hours, of distinct residue from the barium or bismuth meal is perhaps the
most important. The radiologist feels assured that almost without exception
such residue signifies an organic lesion, whether or not all his diagnostic
deductions be confirmed. Theoretically, a residue may remain in simple atony,
but of the cases in the Mayo clinic with residue which came to operation,
every one was found to have some condition requiring surgical intervention.

"A residue in the stomach from the barium or bismuth meal six hours after
its ingestion occurs in a large proportion of cases of duodenal ulcer. T-his
is often loosely spoken of as being due to pyloric obstruction, whereas the
obstruction is actually in the duodenum and is produced by ulcer scar con-
tractions. Occasionally there will be found not only six-hour residue in the
stomach, but also a six-hour residue in the duodenum above the stenosis, thus
enhancing its diagnostic value. A six-hour residue may, however, also be
11



162 NORTH CAROLINA MEDICAL SOCIETY.

found in the stomach as a result of gastric ulcer or carcinoma, or thickening
of the pyloric ring. A six-hour residue in the duodenum may result from
bands of adhesions, or from the pylorospsasm incident to gall-bladder disease.

"Hyperperistalsis in conjunction with six-hour residue is worth more than
95 per cent in diagnosis.

"The exaggerated peristalsis of duodenal ulcer does not appear to be related
to the degree of hyperacidity. The average total acidity in eighty cases with
hyperperistalsis was 67.7 per cent, while in seventy-two cases without hyper-
peristalsis the average total acidity was 74.8 per cent. The highest acidity
noted, 120 per cent, occurred in a case with normal peristalsis.

"Though the Rontgen ray often fails in the positive diagnosis of duodenal
.ulcer, its findings have an exclusion value : that is to say, the chance of some
other lesion existing is minimized in proportion as the latter is radiologically
detei-minable.

"Hypermotility, hypertouus, deformity of the cap or bulb, lagging bismuth
in the bulb, pressure tender over the duodenum and spasm of stomach are
minor contributory radiologic signs of duodenal ulcer. The combination of
hyperperistalsis and six-hour residue or a diverticulum, when found in an
otherwise normal stomach, constitute about the only evidence on which a
purely radiologic diagnosis of duodenal ulcer may safely be advanced."

According to Case :

"Defects in the duodenal bulb constitute one of the chief rontgenographic
means of recognition of duodenal ulcer and its complications. Filling defects
in the duodenal shadow, to be interpreted as ulcer, should be differentiated
from the normal defects due to hepaticoduodenal ligament and the deformities
of the bulb, due to exti'aduodenal pressure, as. for instance, gall bladder,
blood vessels, second portion of the duodenum, etc. The defects due to gall-
bladder region adhesions are very characteristic : the defect occurs on the
gall-bladder side of the bulb shadow, but the bulb is otherwise anatomically
normal."

In conclusion, let me say that with the diagnostic methods that I have
outlined, at our command, one is not justified in allowing his patient
to go on from year to year suffering with gastric trouble without finding
the facts in the case and the proper treatment advised.

Seventy-two per cent of the cases of gastric carcinoma operated at
the Mayo clinic have their origin in gastric ulcer. Early diagnosis and
the proper treatment would save these cases. Let us be more considerate
of the nervous dyspeptic, and instead of dismissing him with a prescrip-
tion, let us give him a bismuth meal and take a look at the movies, that
we may see something of interest to us and of great value to the patient.

Dr. H. S. Lott, Winston-Salem : Duodenal ulcer is a matter of a great
deal of importance, chiefly because it attacks so often young men in the
prime of life. A case impressing this fact upon me very forcefully was



SURGERY. 163

one ill "which a .young man was attacked Avith violent pain soon after a
hearty breakfast. The previous attacks had been mild, though the indi-
gestion had been constant. My diagnosis was of an acute appendix, with
a likely perforation ; and after a great deal of persuasion the patient was
taken to the hospital. After much delay, and a constant increase of
alarming symptoms, the usual appendix incision was made, the caecum
found fixed by many strong bands, and the appendix containing an en-
terolith, much distorted and fastened to its wall. The absence of active
inflammation at this point, and the evidence of some leakage from some
other, caused me to enlarge my incision and continue the search ; but the
distention was such, and condition of the patient such, that it Avas not
found.

The case ended fatally, and in reviewing the entire history as it has
since come to my knowledge I feel very sure that there was a duodenal
ulcer which had existed for some time, and that the perforation of the
onset had occurred at that point.

This also emphasizes, to me, the importance of the blend of ''right-
sided pain" in men, as Avell as in Avomen. We may consider in them the
appendix, gallstones, perforating duodenal ulcer, and a failure of re-
sorption of the A^essels passing from the umbilicus to the liA'er, and
other structures, thus forming permanent and painful guy-ropes, which
may persist throughout a lifetime.

Dr. Lawrence (closing discussion) : I thank you for the discussion.
I haA^e been impressed in my brief experience Avith the eagerness Avitli
w^hieli a great many surgeons go after certain conditions ; for instance, a
chronic appendix comes into a surgeon's office, and he cannot get it out
too quick. A chronic ulcer comes, and he refers it to the stomach
specialist. N^oaa', my first case that I reported Avas a A^ery pitiful one,
a Avell educated, cultured man, who lost out in life simply because
liis fire-box had burned out. He couldn't get up steam. He was running
a little second-hand furniture store, trying to make a living for his wife
and six children. This fellow carried a stomach tube with him all the
time. He would let things stay in a little while, then pump them out.
x\.n old doctor told me, "His stomach is like a Scotch bagpipe; he can
press on it and make all kinds of music." His stomach Avas very large
and right down in the pelvis, and he had constriction just above the
pylorus, giving an hour-glass contraction. This is due to the ulcer in
the lesser curvature, causing contraction of the muscle bands around the
stomach.

I made a A'ery large gastro-enterostomy opening, and the man got along
beautifully from the very start, and went home and Avent to Avork. He



164 NORTH CAROLINA MEDICAL SOCIETY.

eats well now and seems to enjoy it. He lias gained fifteen pounds in
weight. I think it is the duty of surgery to pay as much attention to one
patient as to another. Why should we grab a chronic appendix simply
because it is easy to take it out ?

Gastro-enterostomy does not always cure gastric and duodenal ulcers,
but I believe it is up to the surgeon to work out the cure for these cases,
just as it is up to the surgeon to work out the cure for metastatic
arthritis.



SYMPOSIUM ON GANGER.



THE PEECY CAUTERY IN TEEATMENT OF CAECINOMA
OF THE UTEEUS.



Dr. Everett A. Lockett, Winston-Salem.



It is taken for granted that carcinoma of the uterus is admittedly
a surgical condition only. This paper is not intended to be exhaustive,
but to bring before you for consideration a comparatively ncAV technique
for treatment of carcinoma of the uterus.

I will not take up your time by picturing to you the horribleness of
carcinoma of the uterus — ^both to the patient herself and, in the later
stages, to the members of the family; this all of us can recall only too
well. Neither do I come before you to exploit an absolute panacea for
cancer of the uterus ; but to give you what is considered by many eminent
men to be the last work in the treatment of uterine carcinoma, in the
technique which gives promise of being thus far the nearest approach
to the successful treatment of this condition.

Frankly, I confess to you that the first time I heard of the Percy
Cautery was during the past fall while taking a post-graduate course.
and as the rationale of the treatment appealed to me I began to investi-
gate, and was greatly pleased to find it so well thought of, and so widely
used, particularly by Crile at Cleveland and at that most wonderful
surgical proving ground, the Mayo clinic. Just here I want to add
that it is so well thought of by the Mayos that several members of the



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