REPORTS OF CASES.

PARTIAL GASTRECTOMY FOR CARCINOMA.

DOCTOR JOSEPH I. EDGERTON: I wish to present this patient, a male, forty-one years of age. His father is living and in good health at seventy-eight; mother died of stomach trouble, probably cancer, at fifty-eight years of age. Patient had malaria severely twenty-five years ago, but has had no recurrences. He indulges moderately in tea, coffee, and alcohol, and smokes regularly from fifteen to twenty cigarettes daily. For the past thirteen years he suffered with heartburn, which has been more constant during the past two years, during which time he also suffered from nausea and pain in the epigastrium after eating. During the last few months he had burning pains after eating; was hungry all the time, but afraid to satisfy his hunger, for when he took solid food it remained in the stomach for an hour or so, and then was vomited. On one occasion last winter he vomited some mucus streaked with blood. He began washing out the stomach twice a day on October 4, and brought up greenish clumps of mucus resembling There was no vertigo. His bowels were constipated, and he lost about twenty-five pounds in weight during the last few months.

moss.

On November 27, 1905, the stomach contents contained free hydrochloric acid; moderate reaction; odor butyric. A mass could be felt. over the region of the pylorus, and operation was advised and accepted by the patient. The usual preparation of cleansing the stomach by lavage was performed, and in the operation Mayo's technic was followed. The abdomen was opened near the median line and the gastric artery was doubled, ligated and divided near the cardia. The gastrohepatic omentum was also doubled and ligated close to the liver, leaving most of its structure attached to the stomach. The superior pyloric artery was treated in the same manner, and the upper inch or more of the duodenum was freed. With the fingers as a guide beneath the pylorus in the lesser cavity of the peritoneum, the right gastroduodenal artery was ligated. The gastrocolic omentum was cut distal to the glands and vessels up, to an appropriate point on the greater curvature and the left gastroepiploic vessels were ligated. With a running suture of catgut through the seared stump the end of the duodenum was closed. The proximal end of the stomach was double-clamped along the Miculicz-Hartman line, and divided with a cautery, leaving onequarter inch projection. Then gastrojejunostomy was done. The tumor was found to occupy the pyloric end of the stomach, extending around the whole circumference. No adhesions were present. There was a delay in finding the nearest point of the jejunum that could be brought to the stomach wall and in taking great pains to suture the opening in the mesocolon so as to prevent hernia into the lesser cavity of the peritoneum.

His temperature at no time following the operation was above 99.6° Fahrenheit, and there has been no vomiting since operation. He took water in eight hours and liquid nourishment in twenty-four. His

bowels were moved by enemas during the first week, but there was no distention; in fact, no more discomfort than from an ordinary exploratory laparotomy alone. The man has gained about twenty-five pounds in weight and is at his regular employment again with no discomfort whatever referred to his stomach.

CASE OF MORPHINE POISONING.

DOCTOR DANIEL A. SINCLAIR: I wish to report the case of a patient. who is sixty-three years of age, weighs one hundred eighty pounds, is five feet six inches in height, full blooded, with marked organic heart disease. He has been coming to my office for the past two or three years suffering from alcoholism. He is a periodic drinker, and when first seen, two or three years ago, had been treated along the regular lines for such a condition. He freely informed me that he had been in the habit of receiving injections of morphine from previous doctors. and that was the only treatment that did him any good. Accordingly one-quarter of a grain of morphine was injected, which the patient reported at the next visit was of no benefit whatever, stating that it was, he knew, a very small amount-nothing like what he had been used to getting. The dose of morphine was very carefully increased to one-half grain without any effect, and finally, at the earnest solicitation of the patient and his assurances that he could stand the morphine, the dose was increased to one grain. This injection bore out his statements as to his previous experiences and "just about steadied him," without producing anything but a very short sleep. His subsequent periodic sprees were treated along the same lines, from three-quarters to one grain being used at an injection. It became so much a matter of course to inject this patient and see no untoward effects whatsoever that there was no hesitation about giving him a grain of morphine two or three times a day, according to the exigencies of the occasion. Between the sprees the man, who was of more than average intelligence, not only abstained from alcohol, but did not have the slightest desire for morphine or any other drug.

The treatment detailed above was carried out until the last spree, about a month ago. On this occasion he presented himself, intoxicated, but retaining all his faculties, and begged for an injection of morphine, saying that he would only be put "on the ragged edge," as he expressed it, if he received the usual dose. He stated that he had taken as many as three grains of morphine without any bad effects, but this statement he afterward denied. He had a very important meeting for the next day, and therefore was desirous of securing a good night's rest. One and one-half grains of morphine sulphate were injected into his left arm. In about half an hour I was called to him hurriedly, and found him in a much stupified condition. This was about 8 P. M.; a small dose of cocain was injected and I left, returning about 9 o'clock, when the patient was breathing slowly, about five or six a minute. He was walked up and down until about II o'clock, at which time his respirations had diminished to one in two minutes. Up to this time there had

been injected hypodermatically 3/5 of a grain of cocain, 4/150 of atropine sulphate, 4/30 of strychnine and 4/100 of nitroglycerine. He had also been given about a quart of strong, black coffee. The situation being desperate, at the request of the man's family 1/12 of apomorphine sulphate was injected as an emetic and was effectual in about one-half minute. The patient went steadily into a deep coma, became very blue and was apparently dying. Artificial respiration and the administration of oxygen were then resorted to and the tongue pulled forward with artery forceps. At 1:30 P. M. he began breathing at the rate of about four a minute. About a quart of black coffee was given as an enema and about 3 A. M. he was breathing about ten times a minute and was conscious.

The oxygen and artificial respiration, together with the cocain, probably saved the man's life. Two lessons should be learned from this case: (1) Not to be importuned into giving any patient a large dose of morphine, even though he is used to it; and, (2) not to abandon hope or relax one's efforts, even when the patient is apparently beyond hope, as this case shows that even in apparently fatal cases life may be saved.

DISCUSSION.

DOCTOR ROBERT H. M. DAWBARN: This case recalls to my mind a case of morphine poisoning which occurred when I was interne at the Nursery and Child's Hospital. I placed the patient on his back and administered atropine (the first dose of which dilated the tubes) until, from morphine poisoning, the patient developed a case of atropine poisoning. Life was saved by artificial respiration, which was kept up for eight hours by myself and assistant, each taking two-minute turns. Walking the patient up and down was tried, but the exertion seemed only to make the heart weaker. If I were to criticise the treatment of the case under discussion, it would be the giving of depressing narcotics, as after vomiting from an overdose of morphine the patient usually collapses.

DOCTOR MAURICE PACKARD: In a series of experiments, in which I have been interested, which were being conducted by Doctors Bodine and Jeffries, they were trying to find out from guinea pigs how much morphine would act as an antidote for a given injection of cocain, acting upon the principle that cocain is a physiological antidote for morphine. Previously atropine had been used for this purpose, but atropine and morphine acted similarly, in that both have a tendency to depress the smooth muscle fibres as well as secretion, while, on the other hand, cocain stimulates the smooth muscle fibres and increases secretion, as is shown by the druling at the mouth and the frequency of urination. The best possible treatment, I think, is the stomach tube. After using it once, however, it must be used every half hour, for the mucous membrane of the stomach repeatedly secretes morphine. With the stomach tube and the proper use of cocain, most of these cases will end in recovery.

ORIGINAL ABSTRACTS.

MEDICINE.

BY GEORGE DOCK, A. M., M. D., D. Sc., ANN ARBOR, MICHIGAN.

PROFESSOR OF MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN,

HYPERTROPHIC STENOSIS OF THE PYLORUS.

ROGERS (Archives of Pediatrics, March, 1906) reports a case of hypertrophic stenosis of the pylorus in an infant of three weeks. Medical treatment was persisted in until the third month, when operation by posterior gastro-jejunostomy was performed. Patient recovered. The symptoms of nearly complete stenosis of the pylorus in children. are very stereotyped, and in the beginning of the gastric disturbance. they are always suggestive. Any considerable amount of food in the stomach nine hours after the last meal, as was observed in the author's case, especially if present on more than one occasion and accompanied by other symptoms of obstruction, should always determine the advisability of immediate surgical interference. This case well illustrates the hopelessness of medical treatment. Improvement from time to time will raise the hope that operative measures may not be necessary. Such improvement is usually deceptive. Rogers' case is the third successful operative case reported from this country. The operation was performed under ether and occupied twenty-five minutes.

SURGERY.

D. M. C.

BY FRANK BANGHART WALKER, PH. B., M. D., DETROIT, MICHIGAN.

PROFESSOR of surgeRY AND OPERATIVE SURGERY IN THE DETROIT POSTGRADUATE SCHOOL OF MEDICINE; ADJUNCT PRofessor of operative suRGERY IN THE DETROIT COLLEGE OF MEDICINE.

AND

CYRENUS GARRITT DARLING, M. D., ANN ARBOR, MICHIGAN.

CLINICAL PROFESSOR of SURGERY IN THE UNIVERSITY OF MICHIGAN,

THE DIAGNOSTIC SIGNIFICANCE OF COLIC.

In the New York Medical Journal, Volume LXXXIII, Number XII, La Roque brings out the characteristic features of colic from different sources and contrasts it with peritonitis.

He refers to the common inclusion of most manifestations of abdominal pain under the term colic but thinks it should be limited to designate spasmodic involuntary muscular contraction of the walls of an intraabdominal viscus or canal. The commonest causes he states are found in the gastrointestinal tract, biliary and pancreatic passages,

urinary apparatus and female generative organs. They may be incident to irritative lesions as inflammation or fermentation and their products, including gaseous distention, to obstructive lesions as foreign bodies, invagination, torsion and constriction from without, and to nervomuscular incoordination as in lead poisoning and certain other intoxications.

Certain symptoms are common to all varieties of colic, as the paroxysmal pain, its sudden onset and griping character, restlessness, et cetera. Certain other symptoms are referable to functional or anatomic alterations in the structure involved. In affections involving principally the stomach the pain is referred chiefly to the epigastrium. Colicky pain of the intestine is often most severe in the region about the umbilicus. Diarrhea generally indicates intestinal disease, and the intensity of it is greatest in diffuse colonic disease. In general the darker and more intimately mixed is the blood in the feces, the higher is its origin. The false diarrhea incident to mechanical obstruction about the ileocecal junction is scanty, mucoid, often bloody in character, with little fecal matter and often associated with tenesmus. The spasmodic vomiting of colic is expulsive, often violent, and in general it may be said that the intensity of vomiting varies directly with the height of the lesion and inversely with the severity of the diarrhea. Except in intestinal obstruction, however, vomiting is never stercoraceous. Colic is usually the first symptom of plumbism. The chief diagnostic features are: Constipation, flat or retracted rigid belly, associated cramps in other muscles, slow, wiry pulse and the absence of all signs of intraabdominal inflammation. In connection with tabes colic may be gastrointestinal, renal, ureteral, vesical, and even rectal, bronchial, laryngeal and other affections are not unheard of. Biliary colic begins and is most severe in the region of the gall-bladder, from which it radiates along the course of the intercostal nerves to the right scapula. Pancreatic colic is not frequent. Renal or ureteral colic begins over the region of the kidney and radiates downward and anteriorly. Uterine, tubal and ovarian colic are commonly combined and often indistinguishable. Pelvic examination generally detects the

cause.

In every case of abdominal pain the phenomena of colic must be immediately differentiated from those of peritonitis. The author has presented the following table:

Colic.

Less sudden onset.

Gradually rising to maximum.
Waxing and waning in intensity.
Paroxysmal.

Less positively localized to a point of
greatest intensity.

PAIN.

Peritonitis.

More sudden onset.

May be preceded by the pain of the primary lesion.

No spontaneous waning in intensity, persistently severe, often positively localized, and unless diffuse, there is always a point of greatest intensity.