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life may not be placed in jeopardy by de- ever in 1888 by one of the greatest surgical lay or disastrous treatment be instituted. geniuses of his age-Lawson Tait (1845-1900).

X. (a) Determine, if possible, the location of the initial pain; (b) enquire if the

Heat (hot, moist cornmeal poultice, hot paid was at first diffuse in the central abdo.

water bag, hot bath) aids to relieve pain. men for a while; (c) later and final observe

No oathartics-cathartios stimulate peris. whether the pain localizes itself in the region

talsis, increases pain and distribution of sepof the affected organ (peritonitis).

sis. They induce vomiting. A rectal enema XI. The location of the pain may be su.

(or two) may be efnployed—the composition perficial (hyperesthesia of the skin) or deep may be equal parts of molasses and milk, soap

Rec. in the muscularis (rigidity). McBurney's

suds, glycerine, magnesium sulphate. point is a skin hyperesthesia (from the cutane

tal injections of air. ous branches of the twelfth dorsal and first lumbar nerve-the ileo-hypogastric).

XII. The location of the sudden abdom. inal pain is indicated by the segment (so- it may be remarked that there is a

THE REASON FOR “PATENTS.”—And here matic) of the spinal nerves in adjacent ab.

for the patent-medicine fake.” Many dominal muscles (rigidity), skin (byperes

patent and proprietary' compounds are disthesia). The diseased abdominal viscus is

) protected, fixed by muscular and nerve mech

tinctly useful. · Sometimes they fill a void

in wbat we are wont to term "legitimate" anism similar to the muscular protection

therapeutics. Most of those that are fixation of an inflamed joint.

XIII. The topographic anatomy of the worthy of confidence have been manufactured abdominal viscera should be mastered, for, it

in the first instance, from the prescriptions

of physicians. is the solid ground of nature on which rests

Many patent compounds rational diagnosis.

have become distinct evils, whatever they This can be accomplished by study in the cadaver and at au

may have been originally:-M. F. Cupp,

American Jour. of Clinical Medicine. topsy.

XIV. Remember the major regions of peri- CONCERNING THE DIAGNOSIS.—Joseph N. tonitis-appendicular, pelvic and that of the Study declares that upon the correct diaggall-bladder.

nosis depends the intelligent administration XV. Remember the major regions of vio- of therapeutic agents, the proper use of surlent peristalsis, colic (calculus), biliary, gical appliances, and the all-important quesureteral, oriductal and pancreatic.

tion of the necessity of operative surgical pro. XVI. Call the most available and compe- cedure. After reviewing the history of tent abdominal surgeon early in consultation. some of the modern aids to diagnosis, he

XVII. Remember that operations do not concludes that we are justified in saying kill-it is disease that tolls the funeral bell. that it is unwise to declare that an indi.

XVIII. Operations on the dying are unsat- vidual is suffering from some disease simisfactory.

ply because the specifio bacillus is found in

the body, that the Widal or diazo methods in. GENERAL TREATMENT OF SUDDEN ABDOMINAL

dicate typhoid fever, or that the tuberculin PAIN.

test indicates tuberculosis. These helpful First and foremost, should be introduced: methods of diagnosis the writer believes to be -(a), anatomic rest which is maximum somewhat limited in value, and too much dequietude of skeletal or voluntary muscles. pendence should not be placed in them as a Retire to bed not to rise for defecation or class unless they are accompanied by the urination; (b), physiologic rest which is clinical phenomena which are characteristio minimum function of viscera. Food and fluid of the disease. The microscopical examinaare prohibited per mouth.

tion of diseased structures, secretions and ex

. No anodynes or in minimuin repeated doses ceptions has often cleared up a doubtful diag

nosis. The writer concludes by saying it until clinical history and the diagnosis is completed (maximum doses of anodynes ob

would perhaps be fair to say at the present scures the diagnosis).

time that there are many cases both of a med.

ical and surgical nature, in which the diag(NOTE.-The method of treatment for ab- nosis must be somewhat limited.

The pbydominal pain by anatomic and physiologic sician who would serve his patient best must rest was especially advocated by the distin. use all methods for correctly interpreting disguished English physician, Wilkes, in 1865 ease and other abnormal conditions of the (living at present), continued hy the cele. body, not relying upon any one procedure to brated American Alonzo Clark (1807-1887) the exclusion of others which have been by the "opium splint” and established for- proven to be meritorious.--Medical Record.

The Medical Society of City Hospital Alumni

President, LOUIS H. BEHRENS, 3742 Olive Street
Vice-Pres., WALTER C. G. KIRCHNER, City Hospital

Secretary, FRED. J. TAUSSIG, 2318 Lafayette Ave.
Treasurer, JULES M. BRADY, 1467 Union Avenue


Scientific Communication, Wm. S. Deutsch, 3135 Washington Ave. Executive. A. Ravold, Century Building

Publication, W. E. Sauer. Humboldt Building Entertainment, Frank Hinchey, 1011 Delmar Ave.

Public Health, R. B. H. Gradwohl, 522 Washington Ave

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A CASE DIAGNOSED CARCINOMA VEN- says about a teaspoonful-of blood and muTRICULI WITH RARE AND UNEX

This relieved his pain considerably, PECTED FINDINGS.

and deglutition became much easier.

I saw the patient for the first time the next mornJEROME E. COOK, M. D.

ing. He then told me that he had just "choked up"—this is the expression be used

-about half an ounce of light red blood. I wish very briefly to present the history This I saw; it was partially clotted with a and course of a case which to me at least was small amount of mucus not intimately both interesting and instructive.

The case

mixed, which on microscopical examination was seen by several more experienced tban I was seen to consist mainly of red blood cells without suspecting the correct diagnosis; in good condition with a number of non. the history, with the exception of the one fact degenerated leucocytes and a few bacteria. which would have made the diangosis, was On the same day patient had a very large, fairly complete and accurate as substantiated tar-like passage from the bowels. With the by the patient's daughter. Following is an exception of this local trouble patient has abbreviation of the history and clinical nota- no pain or discomfort, but he feels very weak. tions:

He says that during the past three months White, male, age about 70, and a brick- he has lost considerable weight, even as layer by occupation; entered the City Hospi. much as 25 or 30 pounds. (His sister also tal November 15th, 1905, with the diagnosis says that in the past half year he has lost of debility. Habits were good; takes beer greatly in weight and strength.) occasionally, no whiskey. Family history Physical examination shows a fairly well shows no hereditary taint, no tuberculosis, built man of large frame, somewhat emaciated, canoer or neurotio tendencies.

skin loose, cheeks sunken, clavicles promi. Previous History.-Had measles, scarlet nent, sallow complexion, mucous membranes fever and varioloid in childhood. Has had very pale, only one or two teeth remain in the several attacks of rheumatic fever, the last mouth, tongue dry and swollen, pupils equal

, one occurring a year ago. Has been subject and react. The breath has a peculiar foul, to attacks of sore throat.

fishy odor. The swelling which the patient Present Trouble.- Patient says he has had says is at the base of his neck is not evident. an attack "just like this" before. This is Chest is quite well formed, eto., no rales, no corroborated by his sister, who says that abnormal dullness, area of cardiac and hepa. about ten years ago he was taken with the tic dullness not increased. Second aortio same kind of sickness, and the doctors did sound is slightly accentuated. Abdomen flat, not think he would live. His present illness epigastrio pulsation, muscles fubby, no tenbegan a week before the patient entered the derness, no palpable masses, no ascites, no vis. hospital when he noticed that his throat was ible bernia. No general glandular enlargegetting sore, swallowing was very painful, ment, no edema, arteries very markedly and he became very hoarse. He did not take sclerosed. Pulse 96, respiration 24, tem persolid food, because it gave him too much ature 98.4. The temperature remained about pain, but liquids he was able to take without this point, or was a little subnormal during so much discomfort, and they passed readily bis illness. The urine shows a low specific enough to the stomach. Two or three days gravity, a trace of albumin, and some casts. after the beginning of the trouble patient The trouble is evidently about the upper says a diffuse swelling appeared at the base part of the digestive tract. The tongue is of bis neck-he indicates the suprasternal re- dry, swollen and glazed, the under surface is gion.

congested and shows dark blue dilated veins; On the day he was admitted to the hospi. the mouth and pharynx are dry. The laryntal he expectorated a small amount-patient goscope shows the lower pharynx and the larynx dry, and containing considerable dry, symptoms that the condition is readily recog. stringy mucus. I could note no other ab- nized.' The present case is the only one of normality.

foreign body in the esophagus that I have On the morning of the 18th the patient seen, but knowing the great variety of objects again brought up blood to the mouth, and that might enter this tube with different also had a snjall tarry stool; he is very weak size, shape and other physical properties I and somewhat restless and complains of epi- believe that there is some exaggeration in gastrio tenderness for the first time. He does the statement. Some might cause total obnot vomit. Leucucytes number 25,000, struction with very little bemorrhage, others hemoglobin 30-40%. Smear shows nothing little bemorrhage or obstruction with considof special significance. Patient is getting erable pain, or as in the present case consid. nothing by mouth, is fed reotally. In ac' erable initial pain, excessive hemorrhage and count of his age and weakness, but most es- partial obstruction, pecially because of a possibility of renewed A few points were brought home very forhemorrhage I do not feel justified in using cibly by the case: Firstly, in all cases of the stomach tube for diagnosis.

hemorrhage from the upper part of the digesNovember 19, 1905.-Rectal feeding, saline tive tract the possibility at least of foreign enemata with whiskey hypodermoclyses; body in the esophagus must be considered. nothing given by mouth except tannin. Pa- Again, an article which appeared in a retient very weak. Small turry stools

cent Johns Hopkins Bulletin is recalled in November 20, 1905.–Stools show no evi. which the routine use of the X-ray in all ob. dence of hemorrhage today, same treatment soure cases about the thorax is advocated. continued, enemata not well retained.

This latter seems a very rational and practi. November 21, 1905. --Small amounts of cal suggestion, at least in hospital work. fluid by mouth with no apparent bad results, the article reported its value is demonstrated patient growing weaker.

and several very peculiar and obscure cases Patient showed no improvement and died diagnosed, mostly aneurism. In the present on the 23d. No new symtoms bearing on case its use would have settled the diagnosis the local trouble developed. We were much

and given opportunity for surgioal interferat a loss for a diangosis. The history and ence. picture were not typical to us of any special

DISCUSSION. condition. After thinking over the matter pro and con, and considering ulcus, caroin

Dr. William Rush.--This is an extremely oma, varicose esophageal veins, and aneur- rare and interesting case.

I do not see how ism, in view of the history of steady loss of a correct diagnosis was possible without the weight, the cachexia, passage of a little fresh use of the X-ray and this omission was exblood from the mouth with large tarry stools, cusable under the circumstances. This man epigastric tenderness, pain and difficulty in was passing blood from the bowels and gulp. swallowing I ventured a diagnosis of carcin. ing up fresh blood, and you therefore, naturoma of the stomach involving at least to some ally, would not introduce the stomach tube extent the cardia, and that some large vessel or a sound for fear of doing barm. I should bad been eroded.

have been inclined to consider this a case of The post-mortem findings were startling. ulcer, rather than carcinoma, owing to the Besides a fatty degeneration of the heart, freshness of the blood and the acute beginsmall white kidney, etc., the following con- ning of the trouble. However, the treatment dition existed. Opposite the cricoid carti. the loan received was correct, the withdrawal lage a piece of sharp triangular shaped tin of food by the mouth, and the avoidance of measuring about an inch on each side had sounding. Possibly the introduction of a lodged in the esophagus perforating the walls hard or a soft sound would have detected the on both sides into the posterior mediastinum, resistance, but one would not intrcduce a and causing a gangrenous abscess behind sound in the case of a patient losing blood the esophagus, extending from the first to from the stomach or esopbagus, apparently the fourth dorsal vertebra.

from ulcer. I have never seen an ulcer of . As to the reasons and justification for the the esophagus, but I know of a case with diagnosis of carcinoma about the cardia I do many features similar to those related this not care to enter. No doubt I should have evening, in which the diagnosis of ulcer of done like Allen Ramsay's dial, “gladly own the esophagus was finally made and the paI dinna ken."

tient recovered under the method of treatI came across the following statement in a ment used by Dr. Cook in this case. A text-book, “The presence of a perforating case presenting such symptoms as painful foreign body, cancer, or aneurism, about the swallowing, blood not vomited but gulped up, esophagus is indicated by such characteristic should lead us after this experience to make

use of the X-ray. Tbis case is a great lesson means of the fluoroscope was enabled to see to us. Had i bad such a case, not knowing when the little bag which was tied with catof such an occurrence, I should bave thought gut opened. I observed a similar case to this of an ulcer, and should have attempted to one at the City Hospital, though the foreign relieve the symptoms by the ulcus treatment, body was in a different situation. A patient and of course the patient wculd have died. was brought to the hospital in a comatose

state; he was sent to the nervous ward, of Dr. W. E. Sauer.-The proper thing to which I had charge. After observing the have done here would have been to examine

case twenty-four hours, not being able to ar. the esophagus. The sudden onset and the rive at a diagnosis, patient was transferred to difficutly in swallowing would have led to a

a medical ward. Every possible condition supicion that the trouble was in the esopha.. was thought of until on digital examination gus. The patient could have been cocainized

of the rectum a thickened bone was found, and an examination easily made. The fact extending across the rectum penetrating the that the pain came on suddenly and that it urethra. Operation was performed, but failed continued on swallowing pointed to some

to save the patient. condition in the throat or esophagus, and if the esophagoscope bad been used in the Dr. William S. Deutsch.-It is interesting examination I think the diagnosis could to get as complete a history as bas been given have cleared up the case.

us in this case. There are a few points in

which I differ from Dr. Rush: first, that the Dr. J. M. Pfeiffenberger.—This reminds patient was very likely mistaken in having me of a case that occurred when I was in the

had a similar attack twenty years ago. There hospital. That was a carcinoma of the might have been some loosening of the piece esophagus. The patient complained muoh of tin; it might have been partly dislodged as this one did and had hemorrhages. We

and given many of the symptoms he had. It introduced a sound and found there was a

would be very rational to believe that he had thickening about midway between the

swallowed this when a child. The other mouth and the cardiac end of the stom- point in which I disagree with Dr. Rush is ach. We were able to pass the stomach tube that the surgeon being called upon to operate and found there was no trouble in the stom

for something when the internist could not ach, so a diagnosis of caroinoma of the

make a diagnosis, would not have had to make esophagus was made. But the patient was a gastroenterostomy, but might have given the not in a condition for operation. He died in

man a fistula through which he could be fed. the hospital, and we found this thickened por. He would not necessarily feel that because he tion of the esophagus at post-mortem, a thick- could not find an ulcer he must make a gasening to such an extent that it explained the

trastroenterostomy, but he would have made feeling of fullness in the throat that the pa

a fistula by which the patient could have tient had complained of. It was practically been kept comfortable and these hemour bages the same picture that Dr. Cook's case pre- avoided. A point that may be of interest to sented. There were also the tarry stools and

Dr. Brady is that in a recent visit to the the vomiting of fresh blood. The breath was Mayos I found they were doing much of that very offensive.

work there. They have made a great many Dr. Jules M. Brady. The recent work of experiments in the past year, especially good Holzknecht published in the Berliner Klin.

results have been obtained by them in X-ray ische Wochenschrift, would seem to justify work showing dilations in the esophague. . the use of the X-ray as a routine procedure

Dr. B. H. Gradwohl.-I would ask whether in all obscure abdominal and thoracic condi.

the failure to make a chemical analysis of tions. It is all very well to theorize after we

the stomach contents wus due to fear of doing know the result of a case, but from the his

damage by the introduction of the tube. tory and objective examination the diagnosis of carcinoma at the lower portion of esopha- Dr. Wells.-I wish to inform those who gus or of the cardia, seemed very probable. have spoken of the X-ray in connection with The correct diagnosis could have hardly been this paper, and who seem to have erroneous arrived at by any other means except by the views as to the scope of utility of the ray, that use of the X-ray. Holzknecht claims to have its field of usefulness is by no means limited been able to palpate abdominal tumors which to the detection of the denser substances, norprevious to the use of the rays he was unable mally or otherwise encountered in the body. to feel; some palpable tumors which were Recently at this society I showed in connecsupposed to belong to the stomach he was tion with a paper by Dr. Clopton on Paget's able to make out had a different seat, He ex- disease of the bone, some plates in which perimented with Sahli's desmoid test and by minute changes in the periosteum were plainly

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shown. It is quite common to observe cer. point and never lose sight of the end of the tain adventitious muscle changes in making tube. In all cases of bleeding from the radiographs for other lesions or suspected esophagus or trachea these tubes are introbone affections; and such changes in the soft duced, but always absolutely under the diparts may be neither calcareous ncr osseous rection of the eye. There is absolutely no deposits, but merely relative thickening, due danger. to more transient conditions, such for instance

Dr. Wells.-As to the possibility of this as simple congestion or the more enduring cellular hyperplasia. For the whole scheme

piece of tin having been swallowed in inof radio photography is based on the princi. fanoy, while I see plenty of reason for to


tally discrediting such view in this case, I ple of relative density, and there is almost no limit to the possibilities in showing con

recall a case sent to me for X-ray in which trast between substances of varying pene

I located a tin whistle lodged in the esophatrability to the rays. The difficulty is in the

gus of a child about one year old, the child matter of technique. The X-ray has been

having presented no alarming symptoms and

took its milk without difficulty. This whistle before the world for nearly a decade, and in spite of the fact that office instalment and

would bave gone down and been passed in hospital equipments are getting to be as com

the expected manner because of its shape and

smoothness, but had it been otherwise and of mon almost as any of the other essentials to an up-to-date armamentarium, there is a woe

a shape to engage itself in the membranes of ful lack of anything like the technical

the gullet, it migbt have done so, and produced knowledge that is absolutely necessary in the

no more serious symptoms; for a time, at

least, until inflammatory changes were inoperating of an X-ray outfit to the desired ends. I have frequently come across in.

duced, when, of course, the presence, of a

serious condition must have become evi. stances of men trying to make radiographs

dent. without paying attention to the requirement of backing the plate with some highly ab

Dr. Rusb, in closing.-1 did not really sorbing substance, such as sheet lead, with

suppose any surgeon would operate on this the result, of course, that their plate was

stomach, but Dr. Deutsch says they would. fogged, unless, the exposure happened to be

Of course a gastrostomy would have done no a very short one. The reason for this fog.

good for a man bleeding to death from the ging being the responsive or retro-radioactiv

esophagus. Not having in mind a foreign ity of the table or chair upon which the body the picture was of an ulous and where plate happened to be placed in making the

you suspect an ulcus the use of sounds and exposure. When we have learned to use to the

stomach tubes are entirely contraindicated. very best advantage our apparatus, no mat

Of course there are instruments, such as the ter how modest and


may be,

we esopbagoscope, that would have revealed the will very much broaden the field of the X-ray trouble, but we must consider the case as the and the hopes of its champions and those

picture was presented to Dr. Cook. who see a promising future based on the ac. the picture of a bleeding ulcer. Many cases complishments of the past, will be realized. have been caused to bleed profusely by the Dr. L. H. Hemplemann.-There was no

introduction of the tube, even fatal hemor.

rhage resulting. No one would think of an attention attracted to the esophagus, and had

obstruoting foreign body in such a case withthe X-ray been used it would have been di

out such an experience as this. rected to the stomach, wbich would not bave shown anything in the esophagus. Pa- Dr. W. C. Mardorf said that the paper was tients with thickening in the esophagus most interesting and instructive one, and bring blood up in a different manner from thought Dr. Cook should be commended for those who vomit the blood, and this might his courage and frankness in reporting the have led to a consideration of the esopha- case. The failures were not heard from as gus. Had one sounded and met an obstruo- much as the successful cases, but in this intion at the cricoid cartilage it would have stance the essayist showed the true scienti. been thought that it was a hardening of the fio spirit. The speaker differed with the cricoid which is common in old people rather statement which had been made that the rethan a foreign body.

port was the picture of gastrio ulcer. The Dr. Brady. Would it not have been dan. typical form of gastric ulcer, as he con

Might gerous to pass a tube down there?

ceived it, was that of a more or less chronic

condition of indigestion, with pain and tennot a perforation have resulted ?

derness over the stomach, vomiting, and the Dr. Sauer.--No, not if done carefully. You vomiting of blood. In this case the onset could use a short tube, one with a conical was sudden, with no previous digestive dis.

It was

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