VOLUME XXII. JULY, 1902. NUMBER 1. 125553 REPORT OF A CASE OF REMOVAL OF STOMACH By CHAS. S. WRIGHT, M.D., Salt Lake City, Utah. Operations for removal of the stomach are still sufficiently rare to justify reporting cases when they do occur, even though they may terminate unfavorably. It may impress some of you as a peculiar proceeding to report a case like the one I have selected, as my patient died. This is a remote reason for reporting the case. It is not so fascinating to report unsuccessful cases, though this, after all, is only a relative term, as I consider it better to take a chance on life in an effort to be benefited rather than suffer without cessation. It takes some courage to report in detail our fatal cases, although I believe if the rule prevailed to so report them, many times more real information would be the result than we obtain at present. In fact I would like to be a member of a very secret society composed only of persons who would honestly report their mistakes and badly terminating cases. Literature pertaining to cancer of the stomach and its removal for the same is as yet somewhat meager. The somewhat noted case of the German physician who recently removed the stomach successfully is still fresh in our minds and has doubtless stirred some surgeons to emulate his example. This is not exactly my case, but like the boy who took hold of a live wire, I could not let go from an innocent procedure when I most desired. The case in brief is as follows: Mr. B., aged 57, a farmer with no particular family history bearing upon this subject, came to me June 1 for a stomach disorder for which he had been treated with confidence by a number of physicians for dyspepsia. The patient said that for four years past he had been a. cted with digestive disturbances and for the last year more especially he had been a sufferer with pain in the region of his stomach. His general appearance was dishearten * Read before the Rocky Mountain Inter-State Medical Association, Denver, Colorado. September 3 and 4, 1901. ing, being emaciated to rather an extreme degree. He could not retain his food no matter how carefully it was prepared at home. A feature which troubled him greatly was the tendency of all food to ferment or sour and cause him unusual distress until relieved by vomiting. A physical examination of the region of the abdomen occupied by the stomach showed a somewhat distended condition, and upon palpation a hard mass was located about the pyloric end of the stomach, suggesting that I had a cancerous condition with which to deal. At my request, the lady with whom the patient came also easily felt this hardened mass. My advice to send him to the hospital was accepted, with a view to more closely watch the case, also with the intention of making an incision to determine more definitely what hope might be given in an effort to remove the diseased tissuee, believing at that time it was pyloric alone. He reached the hospital in about a week, and strange to say, with the most careful efforts, no lump or swelling could be outlined, leaving the impression with some physicians who saw the case at this time that there was not sufficient evidence to justify an exploratory incision. The other symptoms, vomiting and pain, continued, though the latter was nearly relieved on a carefully prepared diet at the hospital. The vomited matter consisted principally of fermented food products, and at no time contained any trace of blood or broken down tissue. I experienced no difficulty in washing his stomach out, though no particular benefit seemed to follow this treatment. A test breakfast was given about ten days after the patient had been in the hospital, consisting of a pint of weak tea and a slice of toast, after which the stomach was washed out and an examination made of its contents, showing a very large quantity of lactic acid which required 10 c.c. deci-normal solution of sodium hydroxide to neutralize 10 c.c. of the filtered stomach contents. A report which was confirmed in this case and referred to in the Medical Review of Reviews by Dr. Ehret of Strasburg may be of interest. In speaking of the fermentation in these cases, he says: "There is one bacillus of special interest in connection with gastric fermentation. All observers who have studied the contents of the cancerous stomach have doubtless seen a long, thin, filiform bacillus which may be present in great abundance. Accompanying the bacillus we usually see the yeast plant (sarcina) and various bacteria, both bacilli and cocci." Boas, who first described this filiform bacillus about four years ago, noted that it was usually present in the cancerous stomach. Among many other findings it was learned that this bacillus was capable of producing lactic acid in large quantities. The author firmly believes that cancer of the stomach may be diagnosticated by the presence of this bacillus in large quantities, when the general health is as yet unimpaired. Out of twenty-nine cases in which this germ occurred in abundance in the stomach, twentyfive were examples of cancer of the stomach. In the remaining cases cancer could not be diagnosticated. After observing this case for a period of about ten days, I concluded we were justified in making an exploratory incision to determine the actual condition of things. Accordingly an incision was made in a median line, and we found the lesser omentum involved in an extensive inflammation and was adherent to the surrounding intestines, full of nodules, and necessitated great care in freeing it from adhesions. After it had been freed, we were able to explore the stomach a little better, though not easily, as the left lobe of the liver had become involved on its under surface to the stomach generally, but particularly the cardiac end of the stomach. In gently freeing these adhesions, the stomach was entered, and much of its contents gushed out through the incision, although carefully washed out before operating. We were now a little further than desired, and owing to the nature of the stomach being in a soft, cheesy, degenerated and sloughy condition, we could not close it up, as no sutures would hold and the whole lesser curvature, including an inch and a half of the esophagus, was involved. So to complete as much as possible the work, we were compelled to remove the entire stomach, and hoped to be able to unite with a button the duodenum with the esophagus. This task was too difficult to do owing to the friable nature of the esophagus and inability to bring it out far enough to unite them. After several unsuccessful efforts, we abandoned this idea, and to make as finished a piece of work as possible, tied off the lower end of the esophagus and brought the pylorus into the wound and stitched it there, leaving an artificial opening. The patient stood the rather lengthy operation exceedingly well under chloroform and ether anesthesia and rallied to consciousness promptly. He lived about twentyfour hours afterwards, dying from what appeared to be shock produced by the operation. Since writing the above, I noticed a recent article in American Medicine by MacDonald of San Francisco, bearing upon the subject, entitled, "Indications for and Against Total Removal of the Human Stomach." This writer makes the following classification regarding this operation: Ist. The diagnosis and age of the patient. 2nd. The state of the blood. 3rd. The heart. 4th. Pre-existing conditions as environment, habits, food, 6th. The proper preparation of the patient. The difficulty of a diagnosis is discussed under the first heading. Any case over forty years exhibiting marked emaciation, lassitude, anorexia with absence of normal leucocytosis, together with the presence of filiform bacillus of Boas, contraindicates operation. As to the blood, it is stated leucocytosis is not present in uncomplicated cancer and when marked shows a metastatic condition exists. The heart, nervous and muscular system must be intact. As in other conditions, drinking, syphilis, drug users, etc., contraindicate an operation. Evidences of a metastatic condition are decidedly unfavorable to an operation. Preparation of patient should include, among other things, rest for a week or two with care in diet and daily lavage of stomach. DISCUSSION OF DR. WRIGHT'S PAPER. DR. FREEMAN.-I think such an important contribution to surgery should not pass without something being said upon the question. It is a great pleasure to know that we have surgeons in the West who have been able to perform this operation upon the stomach. It has been done in the East, and it has been done by Dr. Wright here. The question of cancer has received great attention from time immemorial down to the present, and everything has failed; even the injection of medicines of various kinds into the tissue of the cancer itself has failed to produce those results we would like to see. Coley's antitoxine has but very little if any effect upon it, and hence the only thing we have to depend on is the knife, and however objectionable that may be, it is our duty to carry its use as far as we can possibly carry it and preserve the life of the patient. It is the only chance the patient has and hence we are justified in doing extreme things. Whether we are justified in making the entire removal of the stomach with the hope of trying to cure the patient is still a very questionable consideration, but judging from the cases already reported we are not justified in this. Dr. Wright, however, found himself in a position where it was necessary to do a certain thing, and he had the nerve to do it, instead of closing up his patient and waiting for him to die, which he would have done without some attempt to save his life, and I think he is entitled to great credit for his action. DR. PARKHILL.-Mr. President: I did not hear all of Dr. Wright's paper, but I am very glad to congratulate the doctor for his boldness under the circumstances. I have performed the operation myself once. My patient was a woman about forty years of age. She had a large cancerous growth of the stomach, involving almost the entire organ. I performed the operation, and the patient died the following day, and in my opinion, died of shock from the operation. I believe, however, that the patient would have recovered had it not been for the fact that she was simply starved to death when I saw her and operated on her. She had vomited almost continuously for about two weeks, and it was as a last resort that I operated. I believe if she had not been in the starved condition in which she was, she would have recovered. In such a case I would again remove the stomach. SUPPURATION OF THE MIDDLE EAR.* Salt Lake City, Utah. Suppuration of the middle ear, or purulent otitis media, may be either acute or chronic in its course, and each form of the disease presents certain features and characteristics peculiar to itself. The former frequently merges into the latter, however, with no definite line of separation, and each has not a few symptoms in common. Acute suppuration of the middle ear often results from a cold in the head and may be caused by an inflammation of * Read before the Salt Lake County Medical Society, March 10, 1902. |