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Les cartaa. planchaa. tableaux, etc.. peuvent Atre filmte i dee taux da reduction diffArants. Lorsquo la document est trop grand pour itre reproduit en un seul clichA. il est filmi k partir da Tangle sup^rieur gauche, de gauche A droite, et de haut an baa. an prenant le nombre d'imeges nAcessaire. Les diagrammes suivants illustrent la mAthoda. 2 3 5 6 MKMOopr mouinoN ran ouun {Mat and IsO TEST CHART No. 2) 1.0 1.1 U 112 II* 12.0 1.25 iu ^ /1PPUEO MHGE Inc IU3 Com IWn SbMl Mochwtw, Nm rorfc 14609 USA (711) 4«-0]00-mion> (716) 2« - M86 - rn <® Chronic Ulceration of Stomach Simulating Cancerous Disease RELATION OF A CASE OF QASTROENTEROSTOMY WITH MURPHY BUTTON j» jtt j» j» RECOVERY ...BV... JAHES F. W. ROSS. n.D.. TORONTO. ONT. AND E. B. O'REILLY, n.D., HAHILTON, ONT. Reprintad from THE CANADIAN JOURNAL OF MEDICINE AND BUROCRV, Toronto, Fobruary, 1902. 'I V ^ CHRONIC ULCERATION OF STOMACH SIMULATING CAN. CEROUS DISEASE-RELATION OF A CASE OF QASTROdNTEROSTOMY WITH HURPHY BUTTON -RECOVERY. MY JAMES K. W. KOSS, M.D., TORONTO, OXT., AKI) E. «. (»KEILI.V, M.D., HAMILTON, OXT. Ix the short paper presented an effort will be made to impress tipon the profession the fact that even after the abdomen has been opened it is diffieult, if not impossible, to make a differential diag- nosis between chronic ulceration and cancerous disease of the stomach. Our methods of diagnosis are very faulty and insuffi- cient. Early diagnosis in either of these conditions is as yet almost out of the question. Faggo says: "A case in which well narked symptoms have eiieted for eighteen months, or longer, may generally be pro- nounced to be one of simple ulcer of the stomach, and not a case of malignant disease. On the other hand, cancer of the stomach may, for the most part, be diagnosed whenever the characteristic tumor is discovered accompanying the usual symptoms met with in these cases. Cases of simple ulcer affecting the pylorus have now been placed on record, in which this part has been so thick- ened and indurated that the presence of a scirrhous mass has been simulated." Miss D. W., aged 28. From the patient's own statement it appears that she consulted a doctor regarding the condition of her stomach, with which she had been troubled for about three years. At times she felt perfectly well, and then again suffered from considerable discomfort after eating food. This discomfort fre- quently ended in vomiting. The vomited material was very sour and had an unpleasant odor. She found that raw fruits and any acids disagreed with her. She craved for sweet things. Her skin felt dry; ,iie bowels were constipated. She entered tlie training-school of a hospital in April, 1899, and the gastric con- dition grew worse. In August, 1899, she found it necessary to go home. She was then treated until December, but without benefit, in fact she seemed to be steadily growing worse. The abdomen became dis- tended and pains set in in the back, and there was a great deal of soreness about the waist. Shortness of breath came on, and she found it necessary to sit up in order to get her breath. The pa- \l lient then came under the care of Dr. E. B. O'Reilly, Hamilton, Ontario, whose notes are now given. . . _, u i aoa " The patient first came under observation in December, !»»«». It was found that she had been, for some months, under treatment for dyspepsia. She was emaciated, and complained of suffering and pain whenever food was taken. Opium had been adminisr tered to relieve the pain, and the opium habit was already formed. Physical examination revealed aothing. Food was peptonized. In spite of this and the careful medication the symptoms again became ggravated. . , -r^ n -a: *v. " In January, 1900, after consultation with Dr. Griffin, the patient was sent to the Hamilton Hospital. Efforts were made to prevent fermentation of the stomach contente; rectal alimenta- tion was persevered in with considerable benefit. The pain sub- sided and the patient gradually gained in weight. On March 24tii, 1900, she was discharged from tiie hospital, and remained fairly well for two weeks, but as soon as food was passed into the stomach tiie symptoms again became aggravated, the pam returned, and tiie flatulence and nausea became troublesome. Great rigidity of tiie right rectus muscle was noticed. There were several pro- fuse hemorrhages from the stomach and bowels. Exploratory incision was strongly urged. There were five severe hemorrhages ^° " In April the patient grew worse daily. About the middle of May, 1900, as Dr. Ross was in own, I asked him to see th- case witii me. He also advised exploratory operation.^ ihe m. aiy- sis showed the urine to be pale in color; sp.gr. ..018; aucaiine reaction; no sugar or albumen; slight mucoid sediment, with a few pus cells." . . j • Dr. Ross' notes are as follows: "The patient was found, m May, 1900, extremely emaciated, rigidity of the right rectus muscle was noticed, and an indefinite thickening could be felt m the epigastric region. As the patient was only twenty-eight years of age, and as malignant disease of the stomach is rather rare at this period of life, there appeared to be good ground for hesitating before making an exact diagnosis. Diagnosis of ulcer of the stomach had been made when the patient was in the Hamilton Hospital in January. j r *i, "The symptoms pointed to obstruction of the pyloric end ot the stomach, and it was not possible to say whether this obstruction was due to the pro once of cancerous growth or to some other cause. The symptoms had extended over such a period that they pointed to the presence of an ulcer, but the thickening that could be distinctiy made out led to the belief that, in all probabiUty, malignant disease had been grafted on to the former condition of ulceration. • xi. x -i- " There was no history of cancerous disease m the lamiiy. w Some dilatation of the Btomach could bo made out, but there waa not the enormous dilatation so frequently found in cases of can- carous obstruction of the pylorus. The rhythmic muscle waves, so characteristic of pyloric obstruction, wore not observed." On the 5th of Juno, 1900, operation was performed by Dr. Ross, assisted by Dr. White. The abdomen was opened above the umbilicus and the stomach drawn out. A large growth was found at the pyloric end. The perigastric lymphatic glands were en- larged and the whole Btomach wall looked exactly as it does in cases of cancer. The case was looked upon as hopeless, and a decision was arrived at not to attempt to remove the growth, but to give temporary relief bv moans of n gastroenterostom.v. The operation was rapidly performed by means oi .i large ' Murphy button and an anastftmo.-iis eflFected betwwn the stoxitach and duodenum. The patient was not in a good aidition "wing to the previous starvation. The opern'ion hm' to be pei ,./rmc<1 rapidly to prevent collapse. Great care \vas taken, iiowever, notwithstanding the necessity for haste, to carefully supply sup- porting sutures to prevent leakage. After the operation there u «• not much elevation of temperature or pulse. Patient made ac uninterrupted iA)nvale8cence. On the 2nd of May, 1901, eleven months after operation, th patient weighed 140 pounds, looked the picture of health, and wab just returning to complete her training as a nurse. On examina- tion of the abdomen no mass could be felt. The patient was not suffering from any gastric symptoms. Fagge says further : " That even when the symptoms point clearly to the existence of serious organic disease of the stomach there always remnins the question whether this disease is simple chronic ulcer or cancer. Between these affections the diagnosis is often perfectly easy." And he might have added that it is some- times extremely difficult. In the case recorded there was no perforation with the foi-- mation of abscess cavity, such as is occasionally found to simulate cancer very closely. An extremely interesting case is recorded by Sidney Martin and Eilton Pollard, of hour-glass contraction of the stomach with pyloric stenosis. This case helps to throw considerable light on the condition under discussion. The stomach was completely divided so that there was a larger right pouch and a somewhat smaller left pouch, formed as a consequence of the constriction across from the greater to the lesser curvature about its middle. A careful examination, post mortem, showed the presence of a chronic ulcer at the hour-glass constriction that apparently had excited I'ersistent contraction of the circular muscular fibres, and led, with the formation of fibrous tissue, to permanent stricture similar to those strictures of the rectum produced by small ulcers. \ The pyloric stenosis thut was also present seemed to result ftor the presence of a small duodenal ulcer with perforation, and the consequent formation of a small abectes and a largo amount of cicatricial tissue betwcon the pylorus, the duodenum, and the transverse colon. The symptoms in this cose lasted over a period of ten vears. In the case of Hiss D. W, the stomach was drawn out and was not adherent. . In a very interesting article, Moynahan sayB : " The mduni- tion in some cases of ulcer may be of such density that the appear- ance and characteristics of the malignant growth may bo inim- icked with reuiarkable intensity. In one case of my o\vn, which I submitted to the operation of gastroenterostomy, believing the pyloric mass to be malignant and not removable, the patient gained so rapidly in health, and has so stoutly maintained his im- provement for a period extending over two years, that I am skep- tical as to the accuracy of my diagnosis." Thayer, Hirsch, Lirdstrom, Kammerer and others have men- tioned examples precisely similar, and Mayo Robson l'»i8 recorded a case of pvlorectomy for supposed malignant diset-o- whiclj, on minute examination, proved to be chronic inflammatory thick- ening. In an interesting article liy Satterthwaite, a description of the ulcers is given. He says : " A large number of gastric ulcers have rounded contour, sharply cut edges, surrounded by a zone of tough fibrous tissue. A puckering of the gastric walls about them is present, and bands of fibro\is tissue radiate outwards." This variety has been called the acute. In contradistinction to this is the chronic variety, which has greatly infiltrated walls ami ragged, shelving edges, forming a sort of inverted cone, the apex being at the peritoneal covering of the stomach. When exposed lo the eye there can scarcely be much mistaking such an ulcer, thoiigh it might be taken for a cancer or sarcoma. A microscopic section of such a mass might be taken for a round-celled sarcoma, because in both sarcoma and gastric ulcer there is a great similarity of the character of the round cells. But, if the non-malignant ulcer is brought into view the peculiar excavated centre should indicate its true character." Satterthwaite's observation in this connection may t)c quite correct, but it must l)e difficult for a surgeon to get such a view at the time of operation unless a very large opening is made into the stomach wall. , Symptoms.— The ordinary symptoms of ulcer of the stomach ure localized pain after eating, vomiting, hematemesis or raelena, or both. • * • J- I Pain.— The pain at fust is often only an epigastric ?. "^tt'" "P^"-.^]^"?' ^t has never regretted doing the op»-ation 1 self. He considers that the indications for operftion ^ ^-f t !• ''^'^ T "Peated hemorrhages, even if small, especially If dilatation of the stomach is present; secondly, for violent pain ^^i"'.- ^^T^?"",*'°P' "^hen caused by retention from pyloric obs^ction; thirdly, for perforation; and fourthly, for the Mssi- bih^ of the condition being not simple, but cancerous It would be well to add " for the possibility of the condition f / , being not cancerous but simple." Surely this is a more important indication for operative interference. Guinard holds that, under two conditions, exploratory opera- tion is justifiable: first, when there is distinct «^«difi<=f l^^ ?f ^ trie chmistry, especially apepsia and the presence ofla^'t^^ *«"| after a test-meal fnnd, secondly, complete failure after careful dietary and medical treatment to keep up the weight of the pa- tient's body to its normal standard, or to restore l?st weight. The indication for operation, given by some « that it shou d be performed in the absence of hydrochloric acid ^^f l/^*;;^ J is present, and when there is reduction in the amount of altumen ^'^tlems to be apparent that.before long the P^acti^ J^^ ^. to perform an exploratory operation in all cases of doubtful stom *'^SpSn:-Chronic ulcers, with thickening simulating mali^ant disease, are cured by a simple gastroenterostomy^ ihe removal of cancerous growths is a very ^ ?7f ^e pr^^"J^' ^f. not a very satisfactory one. To be satisfactory it P^^* »« P" formed very early in the disease before lyniphatic infection has *^Bari?ng condemns the proposal to excise gastric ulcer which '" SustY/l^n'^d the stomach in two cases and applied the ac^al cauterv to the ulcer, and then performed ga«t«>«'^*".°^*°^y- .^ ^rfomance of gastroenterostomy, without the ^l^cat^^^ «* |^^ Sautery, would no doubt have been sufficient to effect a cure His o^rations were performed for what I. J'^-« d«««'?^„^ as the acute ul«r, and not for the form under consideration, cb'-o^^^.^^^f' ™ Smor mass. The excision of such a mass is an unjustifiable pro- It would be well to attempt to cure this simple acute ulcer by plication of the stomach wall. In this way the irritation of the food would cease to be a factor, and the ulcer would be given an opportunity to heal. The operation would be an extremely simple one, and would be accompanied by very little danger. After Results of Gastroenterostomy. After gastroenterostomy the stomach, if Previously lar^ly ci^ lated, reduces in size in a very short time. There may be difficulty produced by a narrowing of the new orifice, but if the operation is properly performed this is not likely to occur. As a cons^ quence of the operation both bile and pancreatic juice must find their WAV into the stomach, but they evidently do no harm. Pyloric spasm is produced as a consequence of the presence of a gastric ulcer. After gastroenterostomy the hyperacidity of the stomach disappears, and the ulcer heals as a consequence of the rp«t obtained by the organ and the cessation of the spasm. Ji