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practically confirm the diagnosis. The repeated detection of occult or invisible blood in the feces, if the proper precautions are taken in the tests, is a valuable diagnostic sign, and especially so in cases in which blood has not been otherwise observed.

Inability to pass a stomach tube more than 15 to 16 inches indicates an obstruction at the lower end of the esophagus or at the cardia; this condition with other signs may point strongly to a malignant disease.

Much delay or complete absence of the "deglutition sound" after taking a swallow of water also has the same significance. Simple palpation of the stomach, if skillfully carried out, will at times reveal the presence of very small tumors, even merely indurated areas on the anterior wall. And should doubt exist regarding the presence of a tumor, inflation and palpation may decide the question. Inflation and palpation is also one of the best means of locating certain gastric tumors, and of distinguishing between tumors of the stomach and of other organs.

Since the subjective symptoms of this disease are so closely simulated by those of other gastric disorders, they are of but little diagnostic value. Pain, however, of some variety is a very constant and fairly early symptom; so also is anorexia.

Numerous other tests of more or less value are sometimes employed in the diagnosis of this disease. However, the proper application of all the methods of diagnosis here mentioned will enable one to arrive at a reasonable certainty of the presence of gastric cancer, when present, much earlier than the diagnosis was formerly made; and in other nonmalignant cases by the same means, one may exclude cancer in a reasonably

short time.

Please remember that it is quite as important to exclude cancer in its absence as it is to make a positive diagnosis when present. The above methods are equally valuable in either case.

And, furthermore, let it be remembered that the medical man's full duty to his suspected cancer patient has not been done until all of the medical means of diagnosis, if required, have been applied. The old cardinal symptoms of gastric cancer have been purposely omitted because if we are not to see patients until after the appearance of these symptoms, then there is little need of making a diagnosis.

If there are still some physicians who believe that a positive or negative diagnosis of cancer, as the case may be, can be made, simply by a chemical examination of the gastric juice, then the sooner they relieve themselves of this idea, the better it will be for all concerned.

There should no longer be occasion for the utterance of such laments as the following, recently made by one of our prominent surgeons: "It has been pathetic, in some cases, to have patients withheld from operation by supposed absence of cancer, because of the presence of HCI" (in the gastric juice).

'Munro: Transactions, Mass. Med. Soc., 1904.

The value of the laboratory methods of diagnosis has at times been overestimated by physicians, and underestimated by some surgeons. It should be remembered by both physicians and surgeons that of our medical means of diagnosis, the laboratory tests constitute but a part. As is well known, most surgeons advocate surgical exploration as the best means of making an early diagnosis of cancer

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There may be some surgeons who believe, even as John B. Deaver does, that "no patient who presents symptoms of chronic gastric dyspepsia should be allowed to go on his way without operation, as a preventive of malignant disease." But William J. Mayo," who advocates and is as prompt in carrying out early exploration as are most surgeons, says of the diagnosis of cancer: "The most careful and painstaking methods of examination, including laboratory tests, should be insisted upon, but they should not be unduly prolonged."

It can be most truthfully stated that if Mayo's advice is heeded, there will be much less needless gastric surgery, and far more cancer patients will be forthcoming, at a stage of the disease warranting a greater number of radical operations. But in this work there must be intelligent and prompt co-operation on the part of the general physician, for it is he whom the patient first consults, and it is during these early visits that the true condition must be suspected, and determined by some means within a very short time.

We are now confronted with the highly important question, How much time may be allowed for the carrying out of the medical means of diagnosis? Of course, no rule can be established for all cases, except the general one, that it must be as short as possible. In advanced conditions the diagnosis may often be made with much certainty at the first or second visit. At this time a radical, in fact any, operation is usually out of the question. In selected cases a palliative operation may prove of some benefit. In earlier cases, two or three examinations in as many days or a week's time may be necessary. At this stage of the disease occasionally a condition will be found which warrants a radical operation, or, failing in this, if the lesion is at the pylorus, a gastro-enterostomy may prolong the patient's life several months.

In a still earlier class of cases, two or three weeks' time may be required to reach a probable diagnosis, or to learn that the patient needs surgical attention. In quite a number of these cases, if the lesion is favorably located, that is, in the pyloric end, and metastases are not too extensive, resection may be done, or, with adverse conditions for resection, the physician should know at least, and prior to the incision, that a gastro-enterostomy is probably indicated. The chief points to be observed in these various classes of cancer patients regarding operations are: (1) that the physician should be reasonably certain of the presence of cancer; (2) he should

Deaver: BoST. MED. AND SURG. JOUR., Oct. 11, 1906.
Mayo: Jour. Am. Med. Asso., April 7, 1906.

usually know when the case is beyond surgi- sulted from one chief cause, lack of sufficiently cal relief; (3) in cases which he considers oper- close and long observation of the patients. In able, he should have a pretty good idea that the private practice this lack of observation has conditions warrant at least a palliative, perhaps occurred only in those cases in which it was a radical, operation. Ulcer cases with stasis felt that the physician, referring the case, exmay be included here. Some of them cannot be pected a positive or negative diagnosis from a differentiated from cancer by medical means. single examination. This source of error in diag(4) In certain cases, either early or late, he should nosis has now been eliminated. know if the cancer is located at the cardia, or lower end of the esophagus, and be aware that no operation, except a gastrotomy as a last resort, should be attempted. In advising regarding operation, the patient's age and his physical condition are features which should be duly considered.

The above classes of patients' (and Hoffmann figures it that the disease has then been present ten and three-tenths months) constitute the vast majority, perhaps 95%, of all gastric cancers as seen by the consultant.

If a physician desires a tolerably accurate diagnosis and the best advice from the consultant, he should turn over his patient absolutely, until such time as is required for the final report. Sometimes three days, at other times three weeks, might be required for this report, but not a longer period. A reasonable length of time must be granted for the carrying out of the various tests. In some cases more time may be required to exclude cancer than is needed in other cases to make a positive diagnosis.

For example, at the first visit an absence of In the remaining small portion of cancer cases, HCl, and other symptoms may point to cancer, the true conditions perhaps cannot be learned yet one or two weeks' observation and proper by medical means within three weeks' time. In treatment may show, by a return of the HCl, that most of these cases, perhaps all, a surgical ex- the case was one of chronic gastritis or simple ploration should certainly be made, and the achlorhydria. Had the case proven to be cancer operation carried out which seems indicated. the diagnosis might have been made in shorter But even in these cases a radical operation cannot time.

be done, unless the lesion is favorably located. In concluding, it may well be stated that Sometimes the surgical diagnosis will be negative cancer of the stomach should more often be and sometimes mistakes will be made. Mistakes thought of by the physician in his diagnosis of are also made by the medical man. Thus far gastric disorders, and at an earlier stage of the those of the writer have been in the nature of com- disease. It is to him that the choice of methods missions rather than omissions. They have re- of diagnosis is necessarily left.

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17th pylorectomy

This table of 10 cancer cases may give one a general idea of loss of weight during observation, time required to make diagnosis, etc.

Case A is included on account of early age, etc.

A PORTABLE TRACTION AND RETENTIVE of the ends of the fractured bone, and at the same
APPARATUS FOR USE IN FRACTURE OF AND
OPERATIONS ON THE LOWER EXTREMITY.

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time maintain a good relation of the femur to the pelvis as well as a perfect alignment of the leg.

The proper relations must be maintained while considerable traction is employed. Where manual traction is all that is necessary, even this is hard to maintain with uniformity for any length of time.

Moreover, it is difficult to obtain good counter traction. It is difficult to keep the patient steady retentive appliances, whether this be plaster of during manipulation or during the application of

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s or ordinary splints and bandages. At best, | vised for and used in adult cases it is also applirovised methods of holding the shoulders, cable to children. e and pelvis, with or without traction, are It is so arranged that traction can be applied ult when a good position is desired. or let up instantly; and during traction the leg any of you are familiar with other forms of manipulated or moved in any position. The ion apparatus, some of which may be seen shoulders, the spine, the pelvis and the legs are e Children's Hospital. These are very per- held in position for any length of time, and the n mechanism and are all that may be desired apparatus cannot be upset during forcible movehospital, but they are not easily transported. ment or while a plaster of Paris bandage is applied one before you has proved useful in opera- from the axillæ to the ankles. It is fastened to where a strong, efficient and portable an ordinary operating table or to a broad or atus is necessary. While it has been de- narrow wooden table.

By removing the cross steels and placing a small stand, made for the purpose, between the pelvic and shoulder pieces, the apparatus may be used for certain forms of simple jackets in curvature of the spine or in Pott's disease. It can be carried in a dress suit case and considering the strength and power of the machine, it is not heavy.

In fractures of the femur, absence of shortening depends probably more than anything else on the length obtained at the first application of apparatus and maintained afterward by pull and splint.

During the wiring of old fractures of the neck of the femur, in congenital hip manipulation for traction and maintaining position after subtrochanteric osteotomy, for osteotomy in deformities from badly united fractures and in some other instances, this apparatus is useful.

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I. Position without the brace-lateral displacement of the shoulders to the right.

placement of the shoulders and the postural part of a rotation of the shoulders on the hips.

It consists of a curved pad for pressure on the

III. Side view of the brace in position.

chest bone behind and laterally, and another on the opposite pelvis above the trochanter, the two connected by peculiarly curved steels, one anterior, one posterior. They do not rest on the body to make pressure. The anterior steel is disconnected from the hip pad by a self-retaining catch. The pelvic pad has an arm jointed at the hip which extends down to the thigh band. This arm stands out from the thigh when the thigh band is loose. By the shape of the body steels the leverage is transferred so as to throw the chest forward as well as laterally.

This brace will not take the place of complicated braces and jackets. It will be found efficient for certain postural cases when it is undesirable to weaken the muscles by cumbersome and more extensive apparatus. It does not show through the clothing, remains in place and is adapted for active cases with postural lateral deformities.

Clinical Department.

REPORT OF A CASE OF DISSECTING ANEURISM
WITH RUPTURE OF THE AORTA; AUTOPSY.

BY W. E. PAUL, M.D.,
AND

W. A. BROOKS, M.D., BOSTON.

the patient was then sitting in a chair, moving to and
fro, and complaining of nausea. The pain continued
and was dull, steady and boring in character. There
was a sense of anxiety in the patient's look and manner.
It was considered probable that acute indigestion
accounted for the condition of the patient, and efforts
to relieve the stomach (drinking warm water) were
rewarded with fairly free vomiting of sour-smelling
stomach contents. The pain, though somewhat less,
remained in the back, and the patient could not lie
down, as that position was uncomfortable. Later
there were two or three attacks of vomiting, with con-
siderable vomitus. A glass of Hunjadi water was
taken, but was vomited in a short time. As the pain
continued severe in the back, about three quarters of
an hour after he was first seen a quarter grain of mor-
phia was given subcutaneously. The patient then felt
as though a movement of the bowels was imminent, but
two or three enemata gave little result and no gas was
passed. A half hour after the first dose of morphia,
a second like dose was given and in the course of ten
minutes the pain was much relieved. About two hours
after the onset he was able to go down stairs and drive
home in a cab.

During all this time he was pale and his pulse did not
change.

At his home he vomited once or twice and expressed himself as feeling more comfortable than at any time since the onset of the attack. He vomited occasionally, and two or three times considerable amounts were regurgitated.

THE textbooks fail to give a good description Seven hours after the onset the pain, never entirely of the clinical features of dissecting aneurism. absent, had moved up higher in his back, between the Our record of one case may, we hope, be of value shoulder blades, and was more a discomfort and burnif an attempt is made sometime to depict the ing feeling than a decided pain. A hot water bag made symptomatology which must necessarily be based it bearable. on a number of complete histories and post-there was an access of most severe, dull, steady, conTwo hours later and nine hours after the first pain mortems. Up to the present time both Allbutt's stant pain in the lumbar region at the site of the first statement that "it is known only after death" pain. He groaned with every breath and sat up in a and Stimpson's that "it cannot be recognized chair by preference. A gr. hypodermic of morphia with certainty during life," seem to hold good. was given as soon as possible, and relief was most marked in the course of ten minutes. It was found then that no gas had been passed, that vomiting had continued at intervals, that the pulse was 100, that there was evidence of shock with marked pallor; and it seemed that instead of a simple case of indigestion, some more serious trouble existed which was obstructing the bowel.

The patient was a hard-working merchant, fiftyseven years old, of a rugged type, who up to five years ago drank alcohol freely and continuously. He was an inveterate cigarette smoker and used much coffee. Twenty years ago he contracted specific disease. Ten years ago he had pneumonia. Three years ago he had a severe appendicitis and delayed consent to operation till it was most urgent. A fetid. gangrenous, sloughing remnant of appendix in a purulent cavity, walled off by adherent intestines, was found by Dr. Brooks and successfully removed. A large hernia has occupied the ite of operation on the right side of the abdomen since, but has been controlled fairly well by a belt.

For a few weeks previous to his fatal attack the atient had complained of being below par, and had frontal sinus infection treated by Dr. F. C. Cobb. lis digestion was not so good as usual, and he thought e was drinking too much coffee.

Dr. Brooks was summoned in consultation, and agreed that the case was a serious one and that the trouble might be due to the bowel being caught under some band. Physical examination of the abdomen revealed absolutely nothing abnormal, however, and the limitation of the pain to the back was confusing to our diagnosis in considerable measure. Laparotomy was most seriously considered, but was deemed unwise by Dr. Brooks.

Five hours later a saline cathartic was given, but was promptly vomited.

Eighteen hours after the first pain the pulse was 120 The day on which the final sickness began he was to 140 after going to stool; there was decided pallor eling very well and ate a hearty lunch of oyster crabs, and some pain persisted in the back. For the first ricot pie and coffee. He then took part in a game time there was a slight pain in the abdomen over the cards, and at the end of an hour's play got up to take descending colon. It was slightly tender, but did not other chair, when he was suddenly seized with severe cause the patient to shrink on palpation. Two high in across the lumbar region, not more marked on one enemata brought away a moderate amount of fecal e than the other, and extending upwards and out-matter, but there was little gas escaping at the same rds toward the scapulæ, but not going toward the time. The temperature was normal continuously from domen. He described it as a "red pain." It was the onset of the pain. During the morning (some severe that he could not go on with his game and s taken to a bedroom and attended by Dr. Buck. Paul saw him about fifteen minutes after the onset;

twenty hours after the initial pain) hiccough lasting a
few moments at a time had recurred. Also there had
been some spells of dyspnea lasting for a half dozen

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