ST. BARNABAS HOSPITAL

MINNEAPOLIS

THREE CASES OF DUODENAL ULCER AND ONE CASE OF GASTRIC CARCINOMA

The following cases were practically contemporaneous, and since each offered considerable diagnostic interest, they are reported here together as valuable for comparison. In not one of the first three could a positive diagnosis be made. In the fourth the diagnosis of ulcer was thought to be fairly definite, but at operation it proved to be carcinoma.

CASE I.-Mr. P, a laborer, aged 40, entered the hospital in the service of Dr. G. G. Eitel. He complained of having had stomach trouble for twenty years, which of late had grown so severe as to make him desire surgical interference. He suffered with constant pain about the umbilicus, the pain apparently uninfluenced by food in the stomach. He had had no severe attacks of gastralgia. He was annoyed by frequent acid eructations; his appetite was extremely variable. He rarely vomited and had never vomited blood. He had never been jaundiced, and had had no bowel disturbances. On physical examination he was seen to be thin, but not markedly emaciated. There was marked pallor. No tumor could be made out, but there was considerable tenderness in the epigastrium and to the right extending from the gall-bladder region to the region of the appendix.

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Gastric ulcer, gall-stones, and appendicitis were all possibilities, and an exploratory operation was determined upon. The incision was made to the right of the rectus muscle over the gall-bladder. No gall-stones were found. The appendix, however, showed signs of chronic inflammation, and it was removed. The stomach and duodeum were next examined. A small ulcer was found just above the biliary papilla. It had perforated, but by a process so gradual that the peritoneum was entirely protected by tough fibrous adhesions. The edges of the ulcer having been rolled in, the serous surfaces were brought together with

silk sutures, and a gastro-enterostomy performed by means of a large Murphy button whereby the jejunum immediately below the duodenum was attached to the posterior aspect of the greater curvature of the stomach. The convalescence was uneventful. The button was not passed until the twenty-eighth day.

In this case the tenderness and pains were probably due in part to the old appendicitis. Had operation not been performed this ulcer might very possibly have healed spontaneously in time, nature having already started the healing process.

siderable tenderness.

CASE II. Mr. A-, a farmer, aged 63, was also in the service of Dr. G. G. Eitel. He had been in excellent health until three years ago, when he began to have stomach trouble. He continued working, however, until three weeks before entering the hospital. At that time his symptoms intensified. He had almost constant pain in the region of the gall-bladder and conThe pain was not influenced by food in the stomach. His abdomen became gradually distended. He rarely vomited, and had never vomited blood. When he entered the hospital his condition had become very serious. His temperature was 103°, the pulse scarcely perceptible, and the abdomen enormously distended. He was suffering considerable pain, the pain extending well down from the gall bladder region into the right iliac region, decreasing in intensity from above down. Intestinal perforation was suspected, but the patient's condition did not warrant operation. He died two days after entrance. The autopsy which was performed by Dr. S. M. White was incomplete, and only parts of the kidney, spleen, duodenum, stomach, and abdominal aorta were obtained.

number of small grayish areas, the largest about 2 m.m. in diameter. The microscope showed inflammatory areas throughout, including capsule, glomeruli and uriniferous tubules. Many tubules beneath the capsule atrophied. Caseous areas with giant cells found among the uriniferous tubules and near the capsule.

LIVER.-Gross appearance showed no changes. Microscopic examination not allowed.

PANCREAS. Apparently normal in size and shape, but adherent to the duodenum to an abnormal extent. Microscope showed several caseating areas with giant cells found within the lobules and the connective-tissue area near the duodenum.

STOMACH.-Walls thin and smooth, few folds. When opened contained a black fluid. At the pylorus thick edematous folds.

APPENDIX.-Normal.

LARGE INTESTINES.-Adherent in places to the peritoneum.

DUODENUM.-Contained two ulcers; one in the lower and posterior wall near the pylorus extended down into the adherent pancreas. This ulcer, deeply situated between the folds of the duodenum, was about 3/4 in. in diameter, and narrowed down at the base, the base consisting entirely of pancreatic tissue. The edges were slightly undermined, the border irregular, and the walls stained by pigment from old hemorrhages.

The second ulcer was about 1⁄2 in. from the first and in line transversely to the long axis of the intestine. This ulcer was 14 in. in diameter, and broadest at the inner side. The muscularis and serosa were perforated at the center and base, the opening being about 1-16 in. in diameter. The walls smooth, the margin slightly thickened, the thickening being in the submucosa. The perforation was surrounded on its peritoneal surface by fibrinous adhesions binding it to the wall of and adjacent portion of the intestine.

Microscopically: Mucous membrane destroyed, submucosa greatly infiltrated and necrotic, muscular coats greatly infiltrated and bundles separated. The cellular infiltration consisted of round cells, and gave no evidence of tuberculous or other specific granulometous process.

CASE III-Entered the hospital Dec. 3, 1904, in the service of Dr. D. C. Cowles, who had been

first called to see the patient, a man 55 years of age, that morning, and found him vomiting a greenish fluid and complaining of intense pain, which radiated all over the abdomen. He had the typical Hippocratic facies. There was no temperature, and the pulse was 120. On examination a mass, the size of a fist, was noted in the right groin, in the region of the right femoral ring. The mass protruded markedly, and was very tender; a slight impulse on coughing could be obtained, and it was very evidently a typical femoral hernia. It resisted all efforts at reduction.

Dr. Rochford was called in consultation, and the patient was sent to the hospital.

FAMILY HISTORY.-This is unimportant except for the fact that several members of the family have been afflicted with femoral hernia.

PAST HISTORY.-Has been well and strong except for a constant "sour stomach" and "heart burn," which has troubled him all his life, and for the relief of which he says he has taken "enough soda to sink a ship." In August, 1902, he had a very severe attack of stomach trouble, which was then diagnosed as either ulcer or cancer of the stomach.

The patient was operated upon immediately upon entering the hospital. Upon opening the hernial sac a turbid fluid with a few fibrinous flakes escaped from the abdominal cavity. The hernia was easily reduced, and the patient recovered nicely from the anesthetic. He refused all nourishment, however, saying that "it gave him so much pain in the stomach." Thirty-six hours after the operation he began to hiccough, then to vomit, the vomitus finally taking on a fecal odor. The abdomen became markedly tympanitic and tender. There was complete obstipation, the pulse became very rapid, and the temperature subnormal. He died at 7:30 p. m., December 6th.

POST-MORTEM FINDINGS

Patient was a fairly well nourished man, and weighed about 156 pounds. Abdomen tympanitic. Scar of operation in right femoral region. Autopsy confined to abdominal cavity. On opening the abdomen a large amount of milky-looking, sour-smelling fluid gushed out; coils of intestines were adherent and matted together, and covered by fibrinous flakes (the evidence of an acute peritonitis). There was no intestinal ob

struction. The site of operation at the internal ring looked clean and free from any infection.

On turning back the stomach, fluid gushed out from an opening as large as a lead pencil, which seemed to be located at pyloric end of stomach. When, however, the stomach and duodenum were opened the perforation was found to be at the base of a round ulcer, which was situated in the duodenum on the posterior wall just beyond the pyloric ring. There were many adhesions between the duodenum at the base of the ulcer, and the gall-bladder, liver, and omentum.

The walls of the ulcer were not markedly thickened, and gave no evidence of carcinomatous infiltration. No enlargement of lymph glands in neighborhood of the ulcer.

In the right kidney a cyst, the size of a hen's egg, connected to lower pole of the kidney by a narrow pedicle. The cyst was filled with a clear fluid. The left kidney also contained a small cyst buried in its substance. From the appearance of the ulcer it would be difficult to say whether the perforation had been produced by the vomiting brought on by the incarcerated. hernia or not.

CASE IV.-Mr. L-, aged 54, in the service of Dr. T. F. Quinby.

The patient first experienced gastric pain last June, and his trouble was considered to be severe dyspepsia. The pain became very severe, and he was not able to endure solid food. He never vomited, and as long as he confined himself to liquids he had little or no discomfort. As he grew steadily more thin and anemic, in October a test-breakfast was given. When a tube was passed an hour later the stomach was found to be almost empty. Free hydrochloric acid was found, however, and lactic acid was absent. There was no difficulty in passing the tube, but when withdrawn a little blood was observed in the eyelet. When examined microscopically this showed neither tissue nor cells.

Repeated physical examinations were always negative for tumor, although there was considerable tenderness in the epigastrium. Owing to the negative nature of both signs and symptoms, and the long duration of the trouble, the diagnosis was thought to be that of gastric ulcer, and Dr. Eitel was asked to perform an operation. At the cardiac end of the stomach a large hard nodular mass was found. It lay at one side of the

cardia, and thus produced no stenosis. The glands along the lesser curvature were all extensively involved. The location of the tumor was such that the ribs prevented its being discovered by palpation.

REMARKS

The question of the diagnosis of gastric from duodenal ulcers by clinical symptoms is a very nice one. In the cases given above only one of the three distinguishing characteristics given by Bucquoy was present, i. e., the location of the pain to the right rather than to the left as is usually the case in the gastric variety. In none of the cases was there intestinal hemorrhage or the violent gastric crises. The dorsal pain point, which is so common in the stomach, was also absent in these cases.

In relation to Case III, in which ulcer was not suspected, it is interesting to note that scars of healed ulcers are more frequently found at post-mortem than one would suspect from clinical observations. Welch makes the statement that such scars are found in about five per cent of persons dying from all causes.

The condition of the aorta in Case II is interesting in view of the embolic theory of ulcer etiology.

The miliary tuberculosis, which has been found, was also interesting as having been entirely overshadowed by the symptoms of peritonitis.

It is not at all uncommon for carcinomata to become implanted upon an old ulcer scar, and the long duration of Case IV might lead one to suspect that condition here. The position of the growth, however, was such as to safely preclude such origin in this instance.

DR. ABBOTT'S PRIVATE HOSPITAL

MINNEAPOLIS

THREE NEPHRECTOMIES PRESENTING

UNUSUAL CONDITIONS*

IN THE SERVICE OF DR. V. A. ABBOTT
CASE I.

July 27, 1904. Mrs., married, tripara. For six years pain and dragging in right kidney region. Pain absent for long periods; more fre

*Presented before the Minneapolis Pathological Society at its October meeting.

quent of late, and constant last two weeks. Worse during last pregnancy three years ago. No cancer, tuberculosis, or rheumatism in family. Right kidney large and tender. Temperature 102°. Urine sp. gr. 1010; pus 17 to 14 inch field; albumen and sugar negative; no tubercle bacilli.

Segregator: Right kidney no urine; left kidney 7 c.c. in 15 minutes.

Cystoscope: Bladder and ureteral orifices normal. Catheter passes only 134 in right ureter.

OPERATION.-Perirenal tissues one-fourth to one-third inches thick; dense adhesions. Kidney on exposure showed yellow spots elevated and scattered over surface. Kidney considered tubercular, and removed. On opening the kidney the yellow spots seemed to lie in the kidney substance mostly at the base of the pyramids, and to project above the general surface as though they were more soin the re.' of the tissues.

On microscopic section the yellow areas seem to be inflamed in rather small areas; in others there is a marked fibroid degeneration. The arteries are sclerosed and there are large areas without glomeruli or tubules. There is a marked hyalin degeneration of the glomeruli. The yellow spots are not so evident microscopically as macroscopically.

In the lower pole of the kidney there were no yellow spots, and no appearance of cortex or pyramids. The microscopic section of this part shows the same areas of round-celled infiltrations, obliteration of the arteries, but not so much. fibroid degeneration. In this part of the kidney the epithelium of the tubules and glomeruli has much the appearance of the analogous cells in the fetal kidney; i. e., there is apparently a lack of full development.

What gives the color to the spots at the base of the pyramids? It is not fat nor do there appear to have been hemorrhages. There is no appearance of tuberculosis.

If this is a case of chronic interstitial nephritis it probably represents a unilateral disease because since the kidney was removed the patient has rapidly improved and the urine is normal. Did the nephritis arise from the obstruction of the ureter?

CASE II

Sept. 23, 1904. Miss F, aged 40, single,. always thin. General health has been good. Appetite fair, and bowels regular. Menses regular; now menstruating. One year ago she first noticed a lump in the left ovarian region; was never movable or tender, and did not vary in size. Never had cystitis or vaginal discharge. On Wednesday, Sept. 21, 1904, she was well as usual. Did the washing for the family the next day. About noon the tumor began to swell rapidly, and became painful. Called physician Friday a. m., and Friday noon she was brought to the city, 100 miles. Pulse, 130; temperature, 103°; W. B. C. 8400, Hb. 80 per cent.

PHYSICAL EXAMINATION.-Patient thin, abdomen not distended. Projecting two inches above abdominal surface was a fluctuating tumor 7x4 inches, extending obliquely to the right from a line joining the umbilicus and left anterior superior spinous process and midway between and into the left pelvis as low as a point opposite the internal os of the uterus. The uterus small and pushed to the right, and movable in relation to the tumor. Right kidney movable one inch, and made out with certainty. Left kidney not felt in normal position. Urine contained large amount of albumen, pus, and casts.

Segregation not attempted, as the bladder was distorted by the tumor.

DIAGNOSIS.-Pyonephrosis with misplaced kidney or ovarian cyst and twisted pedicle. Operation 24 hours after the first symptom was noticed. Temperature, 103; pulse 146 and very weak. Gave strychnine and saline enema.

Local anethesia. Small median incision; no adhesions. Tumor felt like an intraligamentous cyst. Ether then given, and incision extended to above umbilicus. Tumor exposed with great difficulty. Tumor seemed to project under outer layer of mesosigmoid, the veins of which were much distended. Uterus re-examined, and again. found distinct from tumor. Kidney regions again palpated through incision. Right found; left negative. Left ovary could not be examined on account of size and position of tumor.

The diagnosis was congenitally misplaced kidney, with pyonephrosis, or hydronephrosis more probable. Peritoneum over tumor incised, and

enucleation begun. A true capsule was soon found, and enucleation was then easy. The vessels were about one and one-half inches long, and seemed to come from the external iliac region close to the bifurcation of the common iliac. The ureter was about three inches long. These were tied off, and the tumor removed. There was no bleeding of consequence. The peritoneum and capsule were drawn up and stitched to the lower part of the abdominal wound, and an iodoform gauze inserted. This left the end of the tied ureter inside the sac, but close to bladder and very short. Rest of abdominal wall closed.

Kidney contained 40 ounces of old pus yielding staphylococci and colon bacilli on culture. There was only a small thin island of kidney tissue remaining in the under part. The ureter is closed where it enters the kidney. One or two dilated calices can be made out, but there is no indication of a kidney pelvis. There is a strip of calcareous deposit beginning near the urethral opening, and running downwards for about two inches.

The peculiar features of this case are:

I. That the pyonephrosis, which must have existed for a long time, gave her no perceptible trouble until the drainage suddenly ceased from absolute closing of the ureter.

2. The point of origin of the renal vein and artery.

3. The point of origin of the ureter.

4. The rapid convalescence of the right kidney, the pus, albumen, and casts disappearing in about a week.

The microscopic examination shows necrotic areas. The parenchyma is almost entirely destroyed, and the glomeruli few and distended. The epithelium of the few tubules is much altered where present.

Section of the uterer shows the same areas of round-celled infiltration and fibroid degenertion.

CASE III

May 25, 1901. Miss F, aged 27, single. Alexander operation three years ago. Cystitis followed use of catheter, and has continued since. Pus and albumen in urine.

Cystoscope shows ulcer three-fourths by onethird of an inch surrounding the right ureteral

orifice. No tubercle bacilli in urine or from floor of ulcer. Argentum nitrate to ulcer and irrigation of bladder.

May, 1902, small ulcer at left urethral opening, right ulcer healed.

Right ureter admitted catheter casily. Left ureter admitted small catheter with difficulty. Argentum nitrate to ulcer and urotropin internally.

June 21, 1902.

Cystoscope; no ulceration. Trigone red and velvety. Examination made at this time through incision made for an ovariotomy revealed no calculus in ureter, and no tubercle bacilli in urine.

December 8, 1902. Cystoscope shows left ureteral opening red, pus exudes. Right normal.

Left kidney large, tender and painful. Temperature 100° to 103. Pus and albumen increased.

Left kidney was at this time incised. Several pus pockets. Pus fi. Colon bacilli on culture. No tubercle bacilli.

July 22, 1904. Constant temperature 99° to 100° for the last year. Sinus never healed. No tubercle bacilli in urine or sinus. Left nephrectomy. Perirenal tissue thick and indurated. Kidneys a mass of pus sacs; sinus removed with kidney. Ureter not removed, the patient being too weak.

Oct. 16, 1904. Patient is gaining in flesh and strength. Has had no temperature since the operation. Wound closed.

The microscopic examination of the kidney shows unmistakable tuberculosis, fibroid degeneration, parenchyma destroyed, and necrotic

areas.

The points to be noted in this case are

1. Although between twenty and thirty careful examinations of the sedimented urine were made during the three years the patient was under observation, no tubercle bacilli were found. 2. No tubercle bacilli were found in the

curetting from the bladder ulcer.

3. Colon bacilli were found in the pus at the nephrotomy, but no tubercle bacilli.

4. Tubercle bacilli were never found in the unclosed sinus after the nephrotomy.