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 RECAP 
 
 IN HONOR 
 
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 DR. LEWIS STEPHEN PILCHER 
 
 1917 
 
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IN HONOR 
 
 OF 
 
 DR. LEWIS STEPHEN PILCHER 
 
SURGICAL CLINICS 
 
 AND 
 
 CLINICAL REPORTS 
 
 IN HONOR OF 
 
 LEWIS STEPHEN PILCHER 
 
 Being the Reports of Surgical Clinics at the Hospitals 
 and Clinical Monographs by Surgeons in Brooklyn, 
 New York, to commemorate the completion of his 
 fifty years of service as a doctor of medicine. 
 
 PUBLISHED BY THE MEDICAL SOCIETY OF THE COUNTY 
 OF KINGS, NEW YORK. 
 
 1917 
 

 -KJ>\ 
 
 i-1 
 
PREFACE 
 
 On the 28th of March, 1866, Lewis Stephen Pilcher received the 
 degree of Doctor of Medicine from the University of Michigan, and 
 entered upon a career, which now for fifty years has been charac- 
 terized by devotion to the high ideals which have won for him the 
 esteem of his profession and the honor and respect of the public. 
 
 On the eve of the fiftieth anniversary of his entering the medical 
 profession, the Medical Society of the County of Kings, in New 
 York, appointed a committee to arrange for a suitable celebration of 
 the event. A banquet was held on the 12th of May, and on the 11th, 
 12th and 13th of May, Surgical Clinics were held in the hospitals of 
 Brooklyn and surgical addresses were delivered by Brooklyn sur- 
 geons in his honor. 
 
 It was to Brooklyn in 1866 that Dr. Pilcher came to begin his 
 medical career. It was at the Naval Hospital in Brooklyn that he en- 
 tered upon the duties of the physician. In this community he has 
 practiced his profession for forty-two years, and for the past twenty- 
 seven years has devoted himself exclusively to surgical work. 
 
 This volume is a simple expression of the alifection and respect of 
 his surgical colleagues who are his neighbors. The great world of 
 surgery outside of his own community has been glad to do him 
 honor. The surgeons who are his neighbors have been the chief re- 
 cipients of his benefactions because they have enjoyed the privilege of 
 living and working within the close circle of his inspiring influence. 
 
 This volume contains the reports of the surgical clinics and 
 surgical addresses given in honor of the man and the occasion. 
 
 James P. Warbasse, 
 Rai^ph H. Pomkroy. 
 
 Committee. 
 
UNITED STATES NAVAL HOSPITAL OF BROOKLYN. 
 
 NEW YORK 
 
SURGICAL CLINICS, HELD AT THE U. S. NAVAL HOS- 
 PITAL, BROOKLYN, NEW YORK. 
 
 Philip Leach, M.D., Medical Director, U. S. N. 
 
 C. M. Oman, M.D., Executive Surgeon, U. S. N. 
 
 E. P. Halton, M.D., Passed Assistant Surgeon, U. S. N. 
 
 H. F. Lawrence, M.D., Passed Assistant Surgeon, U. S. N. 
 
 Disi,oCATioN OF Intra- Articular Cartilage of Knee-Joint. 
 
 N , C.S., Ordinary Seaman ; age 19 ; white. 
 
 This man was admitted from the U.S.S. Nevada, April 15, 1916, 
 with a diagnosis of dislocation of an intra-articular cartilage of the 
 right knee joint. 
 
 History. — While exercising in the gymnasium in November, 
 1915, he fell from parallel bars and struck on the inner right knee. 
 He states that he got up and walked immediately but that the knee 
 felt sore and painful. It was not "locked." He was put to bed at 
 this time and remained in bed for three weeks, receiving the usual 
 hot applications and liniments. At the end of this time he felt much 
 relieved and according to his statement, the pain and stiffness had 
 practically disappeared. However, on resuming his duties he noticed 
 that this knee was distinctly troublesome and that he continually had a 
 sensation of uncertainty as to the manner in which this joint was 
 going to act. Eight times since November, 1915, the joint has be- 
 come "locked" in a semi-flexed position, but he has always been 
 able to straighten it out himself by manipulation. The last time 
 "locking" occurred was one week ago. 
 
 During the past two weeks he has occasionally complained of 
 pain and stiffness in the joint. 
 
 Physical Examination. — Examination shows very little difference 
 in the contour of the two knee joints; and there are no signs of 
 effusion. There is distinct tenderness over the position of the right 
 internal cartilage. X-ray examination is negative. 
 
 Operation by Surgeon C. M. Oman, U.S. Navy. — Ether anes- 
 thesia. A 3''' longitudinal incision is made over internal cartilage : and 
 what hemorrhage there is is controlled by ligatures. Capsule of 
 joint opened and immediately the internal cartilage is seen detached 
 from its normal position and hanging in joint, detached at both ends. 
 Care is taken to use instruments alone in the joint, not touching with 
 fingers. The cartilage is cut at each end and removed. Knee joint 
 flexed and extended to observe condition and to see that no loose 
 bodies are present. Capsule closed accurately with fine catgut and a 
 curved needle. External wound closed by interrupted silk-worm gut 
 sutures. Dry sterile dressing applied and joint supported by a long 
 posterior splint. 
 
 The splint will remain on for three weeks. Then the patient 
 will be allowed to walk on crutches for two weeks, and at the end 
 
of five weeks from the time of operation he will be allowed to bear 
 his weight gradually on this leg. 
 
 Comments by Operating Surgeon. — The above is a typical history 
 of many cases which are being treated for "sprains," "rheumatism," 
 etc., which really are dislocated cartilages. It is a well-known fact 
 that the internal cartilage is usually the one dislocated, due to the 
 anatomical arrangement of the joint. 
 
 It has been very rare in my experience to feel any projection on 
 the surface and never have I been able to fix a cartilage before 
 operating, as is mentioned in some works on surgery. 
 
 Of course it is needless to say that strict asepsis should be fol- 
 lowed. We have operated on a number of these cases and have never 
 seen any ill results. In fact, all the patients have resumed their 
 active duty on board of seagoing vessels without any discomfort. I 
 have been able to follow up a number of my operations on this condi- 
 tion for a period of six or seven years, and all the results have been 
 satisfactory. 
 
 It seems to me that a great many surgeons are a little shy in 
 opening the knee joint for this disabling condition; they seem to 
 retain the extreme fear and dread which were formerly felt when the 
 knee joint was operated upon. 
 
 Adenoma of Male Breast. 
 
 S , S., Machinist's Mate 2nd class ; age 23 ; white. 
 
 This man was admitted from the U.S.S. Ontario, April 20, 1916, 
 with a diagnosis of adenoma, left breast. 
 
 History. — In 191 2 he first noticed a swelling in the left breast 
 which seemed to him as an enlargement of the whole breast. The 
 next day the swelling had disappeared. Six months later the swelling 
 again appeared, and has been present ever since. At times, after 
 working hard, the breast became red and painful. Usually it caused 
 him only slight discomfort, and this was more or less imaginary. 
 There never has been any discharge from the nipple and no ex- 
 coriation about the breast. 
 
 Physical Examination. — Physical examination shows a firm mov- 
 able mass, regular in outline and rather firm in consistency, about the 
 size of an orange and not adherent to the skin or muscles. No secre- 
 tion can be expressed from the nipple. It is tender on manipulation. 
 The diagnosis of adeno-fibroma is made. 
 
 Operation by Surgeon C. M. Oman, U.S. Navy. — Ether anesthe- 
 sia. The whole breast was amputated by the usual incisions. Very 
 little hemorrhage. Wound closed by interrupted silk worm gut and 
 arm bandaged to side after dressings were applied. 
 
 Varicocele. - 
 
 S , R. T., Chief Machinist's Mate ; age 28 ; white. 
 
 This man was admitted from the U.S.S. Winslow, April 29, 1916, 
 with a diagnosis of varicocele, left. 
 
 History. — He gives the usual signs and symptoms of a moderate 
 varicocele and recently it has caused him considerable pain and the 
 usual mental worry. 
 
 Physical Examination. — Examination shows moderately enlarged 
 veins in left scrotum. 
 
 10 
 
operation by Surgeon C. M. Oman, US. Navy. — Ether anes- 
 thesia. High operation. A 2'' incision made over external ring; 
 testicle dislocated into wound ; the vas, a couple of small veins, and 
 the cremasteric muscle separated; veins ligated and transfixed; about 
 2^" removed and ends brought together by a double ligature of cat- 
 gut. The tunica vaginalis cut with scissors and everted. The 
 testicle returned to scrotum and the wound closed by deep fascial 
 catgut sutures, and three superficial silk worm gut sutures. Dry 
 dressings and support of testicle. Patient will be in bed for one 
 week. 
 
 Comments by Operating Surgeon. — We have found that this 
 method of doing this operation gives very satisfactory results. The 
 dislocation of the testicle permits one to get at the diseased veins, and 
 the cutting of the tunica vaginalis not only does away with swelling 
 of the testicle after the operation but absolutely prevents the forming 
 of a hydrocele some weeks or months later. It is a very quick opera- 
 tion, usually taking about seven to eight minutes. 
 
 Depressed Scar, FoIvI/)wing Maxillary Sinus. 
 
 B , J. H., Chief Electrician; age 39; white. 
 
 This man was admitted from the U.S.S. Florida, October 15, 
 
 1915, with a diagnosis of depressed maxillary scar. 
 
 History. — He has had a chronic sinus of the right lower jaw 
 about seven years. During the past few months he has had the wound 
 opened and the lower maxilla scraped. No dead bone found. The 
 roots of two teeth had been removed. The sinus ceased discharging 
 some weeks ago and the external wound is entirely healed, leaving a 
 depressed scar attached to the jaw bone. 
 
 Operation by Passed Assistant Surgeon H. F. Lawrence, U.S. 
 Navy. — Novocaine anesthesia. A 2.5 cm. (i inch) linear incision 
 made down to jaw bone. All the tissues were freely separated and 
 the wound closed by three silk-worm gut sutures in such a way as to 
 lift up the depressed portion of the scar and leave a wound in which 
 the scar should be level with the adjacent surface. 
 
 Deflected Nasal Septum. 
 
 Case I. S , G. H., Chief Carpenter's Mate ; age 30 ; 
 
 white. 
 
 This man was admitted from the U.S.S. Prometheus, April 8, 
 
 1916, with a diagnosis of deflected nasal septum. 
 
 History. — He has complained of nasal obstruction for some years, 
 and has had the usual disagreeable symptoms on catching a fresh cold. 
 
 Physical Examination. — A marked deflection of septum to the 
 right is discovered. 
 
 Operation by Passed Assistant Surgeon B. P. Helton, U.S. Navy, 
 Retired. — Cocaine anesthesia. Submucus resection of septum per- 
 formed. 
 
 Case n. W , H. C, Seaman ; age 22 ; white. 
 
 This man was admitted from the U.S.S. Wyoming, May 5, 1916, 
 with a diagnosis of deflected nasal septum. 
 
 History. — He has complained of the usual symptoms resulting 
 from obstruction of the nasal cavities. 
 
 Physical Examination. — There was a marked deflection of the 
 nasal septum with an old chronic ulceration on the septum. 
 
 11 
 
operation by Passed Assistant Surgeon B. P. Halton, U.S. Navy, 
 Retired. — Cocaine anesthesia. Submucus resection of septum per- 
 formed. 
 
 Deviation o^ Nasal Septum. 
 
 K , S. G., Seaman; age 21; white. 
 
 This man was admitted from the U. S. S. Wyoming, May 2, 19 16, 
 with a diagnosis of irregular deviation of nasal septum. 
 
 History. — He complains of the usual obstructive symptoms and 
 mouth breathing at night. 
 
 Examination. — Shows a markedly deviated septum to left. 
 
 Operation by Passed Assistant Surgeon E. P. Halton, U. S. Navy, 
 Retired. — Cocaine anesthesia. Submucus resection of septum per- 
 formed. 
 
 Hypertrophibd Tonsils and Adenoids. 
 
 M , N., Female; age 9^; white. 
 
 This child is a daughter of a Marine Officer. Diagnosis: Hyper- 
 trophy of tonsils and adenoids. 
 
 Operation by Passed Assistant Surgeon E. P. Halton, U. S. Navy, 
 Retired. — Ether anesthesia. Tonsils removed by dissection and cold 
 wire snare. Curettement of masses of adenoids. 
 
 Double Inguinal Hernia. 
 
 L , M. G., Gunner's Mate 2d class ; age 24; white. 
 
 • This man was admitted from the U.S.S. Arkansas, May 10, 1916, 
 with a diagnosis of a left inguinal hernia. 
 
 History. — Patient had been operated on for a left inguinal hernia 
 in August, 1913. One month ago he noticed a swelling at the site 
 of the old scar. 
 
 Physical Examination. — Examination reveals a small reducible 
 indirect left hernia at the site of the previous operation. Examina- 
 tion also shows a small indirect reducible right inguinal hernia. He 
 has not been aware of the presence of this hernia. 
 
 Operation by Surgeon C. M. Oman, U. S. Navy. — Ether anes- 
 thesia. A Bassini operation performed on each side with the Kocher 
 modification. A small sac containing omentum present on left side 
 and a small sac found on right side. 
 
 Comments by Operating Surgeon. — This patient will be kept in 
 bed for two weeks. 
 
 Chronic Bursitis of Toe. 
 
 C , J. D., Bugler; age 30; white. 
 
 This man was admitted from the U. S. S. Maine, May 2, 1916, with 
 a diagnosis of bursitis, chronic, metatarsophalangeal joint, left foot. 
 
 History. — For the past year the patient has been troubled with 
 pain, redness and swelling over this region. The pain becomes much 
 worse on standing for any length of time or upon taking the usual 
 "hike." 
 
 Physical Examination. — Shows swelling, redness and tenderness 
 over the inner side of joint. Practically no deformity of joint. 
 
 Operation by Passed Assistant Surgeon H. F. Lawrence, U. S. 
 Navy. — Ether anesthesia. Excision of bursa. 
 
 12 
 
Hemorrhoids. 
 
 Case I. W , F. J., Gunner's Mate 3rd class; age 26; 
 
 white. 
 
 This man was admitted from the U. S. S. Wyoming, May 9, 1916, 
 with a diagnosis of hemorrhoids. 
 
 History. — Five years ago this patient was operated upon for a 
 similar condition. One week ago the hemorrhoids again became 
 prominent. There is some protrusion and they bleed. 
 
 Physical Examination. — Shows two large bleeding internal hem- 
 orrhoids that cannot be replaced. 
 
 Operation by Passed Assistant Surgeon H. F. Lawrence, U. S. 
 Navy. — Ether anaesthesia. Sphincter dilated for 5 minutes. Clamp 
 and cautery applied to two sections. One mass ligated by catgut 
 ligature and removed by scissors. Iodoform and opium suppositories. 
 
 Comment by Operating Surgeon. — Bowels will be kept bound up 
 for four days. Patient will be allowed up after one week and advised 
 as to regularity to prevent future trouble. 
 
 Case II. — S , C. G., Boatswain's Mate 2nd class; age 
 
 26; white. 
 
 This man was admitted from the U. S. S. Utah, May 9, 19 16, with 
 a diagnosis of hemorrhoids. 
 
 History. — About one week ago patient first noticed small bleed- 
 ing, protruding mass. 
 
 Physical Examination. — Shows a small external pile and two 
 small internal piles. 
 
 Operation by Surgeon C. M. Oman, U. S. Navy. — Ether anes- 
 thesia. Sphincter dilated for 5 minutes. Clamp and cautery applied 
 to two sections. 
 
 Acute Appendicitis. 
 
 H , F. A., Ordinary Seaman; age 20; white. 
 
 This man was admitted from the U. S. S. Wyoming today, with 
 a diagnosis of acute appendicitis. 
 
 History. — Gives a history of having had acute appendicitis two 
 months ago. Last night he was taken with pain in right iliac region, 
 vomiting and fever. 
 
 Physical Examination. — Temperature 98.8, respiration 20, 
 leucocytes 30,000, polymorpho-nuclears 90 per cent, urine normal. 
 There is tenderness and rigidity. 
 
 Operation by Surgeon C. M. Oman, U. S. Navy. — Ether anes- 
 thesia. Gridiron incision, below and external to classical McBurney 
 incision. There is a marked increase in peritoneal fluid. Appendix 
 acutely inflamed, large, and surrounded by plastic lymph. Ligated. 
 Stump cauterized and returned to abdominal cavity. Wound closed 
 in usual manner. 
 
 Comment by Operating Surgeon. — This man will be kept in bed 
 for ten days. 
 
 Acute Appendicitis. 
 
 C , N., Private Marine; age 33; white. 
 
 This man was admitted from this hospital. May 12, 19 16. He 
 is a member of our marine guard. 
 
 13 
 
History. — He was taken sick three days ago with a pain in the 
 region of gall bladder. He was slightly jaundiced at the time. No 
 symptoms referable to the appendix at that time. He was given the 
 usual purgatives. He felt fairly well until last night when he began 
 to have violent pains in the abdomen which became locaHzed in the 
 right iliac region this morning. He vomited. 
 
 Physical Examination. — There was tenderness over region of 
 appendix, some rigidity. He states he has had a similar trouble once 
 before. Skin jaundiced. No tenderness over gall bladder. 
 
 Operation by Passed Assistant Surgeon H. F. Lawrence, U.S. 
 Mavy. — Ether anesthesia. Gridiron incision. Peritoneal fluid in- 
 creased; appendix bound closely to cecum and enlarged meso-appen- 
 dix, short and very thick. Appendix removed by dissection. Stump 
 cauterized and gut returned to abdomen. 
 
 14 
 
II 
 
 SAINT CATHARINE'S HOSPITAL. 
 
CLINIC AT SAINT CATHARINE'S HOSPITAL. 
 James C. Kennedy, M.D., F.A.C.S. 
 
 Gentlemen: This clinic is held in honor of Dr. Lewis Stephen 
 Pilcher, one of our most distinguished confreres. He has now reached 
 his fiftieth anniversary as a practicing surgeon. 
 
 His useful life as a highly respected citizen, an earnest and 
 competent surgeon, and as editor of a widely circulated surgical journal, 
 has given him a high place in the esteem of the people of our city 
 and of his medical and surgical colleagues. By his teaching and 
 example, always the true surgeon and gentleman, the distinguished 
 editor and scholar, he has justly earned his place among the great 
 men of modem times. This clinic, comparatively insignificant, will 
 evidence the gratitude of myself and my colleagues of Saint Cathar- 
 ine's Hospital for the great work Dr. Pilcher has done throughout a 
 long and honorable career. 
 
 Chronic Appendicitis: Gali* Stones. 
 
 The first patient for operation this morning is this slenderly built 
 woman, whose age is thirty-nine years. She was born in this country, 
 and is the mother of two children ; she has menstruated regularly and 
 has never had any miscarriages. Her previous history is negative, 
 except for the diseases of childhood. She states that two years ago 
 she began to have attacks of pain in the right iliac fossa, and that, 
 in addition she has had almost a constant feeling of fullness and 
 heaviness in the right hypochondrium, accompanied by a dragging 
 sensation over the hepatic area. This patient was sent into the hospital 
 with a diagnosis of chronic appendicitis which we believed to be cor- 
 rect; still we do not believe that all the symptoms stated are due to 
 appendicitis. Laboratory findings together with the x-ray examina- 
 tion, are negative. However, in the prone position, palpation over 
 the region of the gall bladder elicits soreness, but not sharp pain ; the 
 same is found in that portion of the liver, bounding the gall bladder. 
 These are two symptoms that I hold in high regard in gall bladder 
 disease. She has never had biliary colic or jaundice, but when the 
 abdomen is open we must not forget to examine the gall bladder. 
 
 Our incision is made below the umbilicus, through the right rectus 
 muscle. We are now in the peritoneal cavity, and find a chronically 
 inflamed appendix which we will remove; the stump is inverted ac- 
 cording to the Dawbarn method. I now place my right gloved hand 
 into the peritoneal cavity; the uterus and ovary are correct, — now 
 upward, and I find everything normal, with the exception of the gall 
 bladder which is filled with calculi. We will now close our appendiceal 
 wound, and, using the Mayo Robson incision, do a cholecystostomy 
 for cholelithiasis. On opening the gall bladder in the usual way I am 
 able to remove these stones with the forceps. Each stone, as you see, 
 is about the size of a small bird's egg. 'This is the last one, making 
 
 17 
 
thirty-two calculi in all. With the duets now freed, we will drain 
 the gall bladder as it is done ordinarily. 
 
 We all know that calculi may exist in the gall bladder or in some 
 portions of the bile ducts without giving rise to any symptoms, or at 
 least so few that it is almost impossible to make a diagnosis of their 
 existence. This statement is borne out, in some degree, by this case. 
 
 GaIvI. Stonr Disease. 
 
 Here is another operation for gall bladder disease, but it differs 
 materially from the case we have just concluded. The patient is a 
 stout lady, and on referring to the History we find her weight to be 
 l8o pounds, her age is fifty years, she was born in this country, and 
 is the mother of four children. There is a scar in the lower abdomen, 
 but the patient was unable to state the reason for the operation which 
 it marks. She has had paroxysms of pain, chills and jaundice for 
 four years. From the time of her arrival at the hospital she has had 
 all the classical symptoms of obstructed gall bladder disease. 
 
 On opening the abdomen, we find, with the exception of the 
 hepatic ducts, that the biliary canal is filled with calculi. Since this 
 is so, the obstruction to the flow of bile into the intestinal canal must 
 be in the common duct — here is a large stone lodged at the ampulla 
 of Vater. This was surmised because of her jaundice. As you know, 
 jaundice is produced by the passage of bile and its coloring matter 
 from the liver into the lymphatic vessels and the blood. Its essential 
 cause is obstruction of the outflow of bile into the intestines. The 
 obstruction does not prevent the secretion of bile by the liver, hence 
 there is a consequent dilatation of the biliary ducts and canals, stagna- 
 tion of their contents, and absorption by the lymphatics of the biliary 
 coloring matter and acids which reach the general circulation by way 
 of the thoracic duct. The biliary acids have the power of destroying 
 red blood cells, thus setting free hemoglobin — the free hemoglobin 
 increases the formation of bilirubin by the liver and so may serve to 
 intensify the jaundice. The characteristic lemon-colored appearance 
 of the skin and conjunctiva and urine are noted at this stage. The 
 feces become clay colored, owing to the absence of coloring matter, 
 and we often have constipation accompanying these cases, with alter- 
 nating attacks of mucous diarrhea, as a prominent symptom. 
 
 We will now open the gall bladder, and we find many small stones 
 floating in the dark colored fluid. These are removed with the scoop. 
 The calculi in the cystic duct are easily milked up into the gall bladder 
 and removed. Here in the common duct, however, is quite a large 
 stone which we can neither push upwards nor down into the duodenum. 
 I am unable to crush the stone with my fingers — and I never use a 
 forceps for that purpose lest the walls of the duct be damaged per- 
 manently, — so we will do a choledochotorhy ; here is the stone. You 
 will note the free discharge of bile which flows into our laparotomy 
 pads and which we will continue to sponge away until it stops. Two 
 catgut sutures are placed through the edges of the cut into the com- 
 mon duct, and passed around a long, dressed, rubber tube, fenestrated 
 at its lower end. These sutures will hold the end of the tube in place 
 for about ten days. Two heavy strips of iodoform gauze are placed 
 on either side of this tube, and will be left in place several days 
 after the tube is removed. The gall bladder is also drained with 
 rubber tubing, and the abdomen closed in the usual way. 
 
 18 
 
Chronic Appendicitis. 
 
 This is a case of chronic appendicitis. Our patient is a young 
 girl of seventeen years, born in this country. For the last year she 
 has had variable symptoms, paroxysmal pains being the most constant ; 
 these were confined to the right iliac fossa. Associated with this 
 there has been intestinal indigestion, alternating with mucous diarrhea 
 and constipation. The patient is extremely nervous — a symptom very 
 prevalent in chronic appendicitis. 
 
 The right rectus incision is the one we will use, pulling aside the 
 muscle after dividing its anterior sheath, and incising the posterior 
 sheath and peritoneum which leads us into the peritoneal cavity. With 
 the finger we endeavor to hook up the cecum, but we are prevented 
 from doing so, with the freedom we usually experience, because of 
 the adhesions. We find the appendix somewhat chronically inflamed 
 and enclosed in a well formed pocket. Bands running from the ileum 
 to th-e cecum constitute this ; here in the cecal wall I find a hard 
 mass snugly imbedded. We will remove this. It is, as you see, a 
 calcified body, about the size of a ten cent piece. It is white and hard, 
 and may be a calcified gland or a small ruptured blood vessel which 
 has undergone calcification. Perhaps it was this which caused the 
 adhesions, through irritation and the resultant inflammation. We will 
 send the specimen to the laboratory and perhaps the pathologist will 
 be able to help us out. The appendix is somewhat thickened ; we will 
 remove it, and invert the stump according to the Dawbarn method. 
 
 Fracture oe Pelvis; Rupture of Bladder. 
 
 The last case for operation today is this small boy who was 
 brought in by the ambulance this morning. He is twelve years old. 
 Several hours ago, he climbed upon the seat of an automobile truck 
 while the driver was delivering goods. He started the machine, and 
 then becoming frightened, jumped from the truck and fell under the 
 wheels. The rear wheel passed over him, causing a comminuted frac- 
 ture of the pelvis and rupture of the bladder. We thought that he 
 would die, soon after his arrival in the hospital, from shock, but he is 
 still alive and has some pulse. We bring him to the operating room 
 because it is impossible to pass a catheter into his urethra, and because, 
 as you see, his pernieum is bulging to an alarming extent from extra- 
 vasated urine. We will make a single incision into the perineum, and 
 you see the large amount of bloody urine which escapes. We believe 
 this to be a humane thing to do, notwithstanding the fact that we do 
 not believe the boy will live. By passing the finger through the wound 
 we find the pubic bone torn from its mooring, and lying on the rectum. 
 The ileum is fractured in several places. We will do nothing further 
 now, except to place a drain in position to carry ofif the extravasated 
 urine. We must await developments. 
 
 19 
 
THE TREATMENT OF GALL-STONE DISEASE. 
 Mathias Figueira, M.D., F.A.C.S. 
 
 Case L This patient came to the hospital with the history of stom- 
 ach trouble and more or less pain for a number of years. She 
 remembers suffering severe pains at intervals, several years ago. She 
 had no severe pain lately but has suffered from stomach and intestinal 
 trouble in the form of indigestion and constipation. At admission 
 to hospital besides the above symptoms she did not present anything 
 noticeable except a quite marked tumor under the right costal border 
 moving with respiration and continuous with liver. It was not very 
 tender and abdomen did not show any marked signs except moderate 
 distension. At operation the tumor was found to be caused by a 
 very much enlarged gall bladder, containing fifteen stones, one of 
 them as large as a pigeon's egg. It weighed 130 grams. The length 
 was 15 centimeters and the greatest width 6 centimeters. The walls 
 were 5 millimeters in thickness. On section it showed the lesions of 
 chronic inflammation. Patient made a good recovery and is now 
 well. 
 
 Case; II. The second case I report, came under by care two years 
 ago. A young woman was taken with abdominal pain that soon 
 centered under the costal border on right side and required hypo- 
 dermic injections of morphine for relief. After pain subsided her 
 stomach was so irritable that rectal alimentation had to be resorted 
 to for several days. Under the most careful dieting and care she 
 recovered but was soon taken with a similar attack and that followed 
 by another at such close intervals in spite of the best care and advice 
 that operation had to be done to save her from grave complications. 
 She is now well. 
 
 Comment. — That once the diagnosis of gall stones is made, opera- 
 tion is the best treatment, all surgeons are agreed. The internists, 
 many of them, still claim that a good many cases of gall stones can 
 be cured by medicine and proper dietetic treatment. It is certainly 
 possible for gall stones under rare conditions to pass into the intes- 
 tines and be eliminated that way, and anyone who has seen much of 
 gall stone disease knows that under medical treatment many cases will 
 very much improve. The attacks of pain will disappear, the diges- 
 tion will improve, the appetite return and such patients seem to re- 
 cover and remain comparatively well for months, sometimes for 
 years, and the doctor who treated them will enter them in his records 
 as cures. Months or years afterward when the patient has passed 
 out of the doctor's memory, probably out of his neighborhood, as 
 such cases often do, another doctor will get the case and will have 
 to operate on it to save life. 
 
 The first case reported in this paper is probably such a case 
 and is down in somebody's book as a cure of gall stones by medicine. 
 
 I have no doubt that if the history of cases that come to the 
 operating table with such grave complications as adhesions, per- 
 foration, involvement of neighboring organs, stricture of duct — if the 
 
 20 
 
history of such cases were carefully traced, the history of gall stones 
 "cured" by medicine would be elicited. 
 
 Medical treatment bears the same relation to these cases as the 
 ice bag does to complicated appendicitis cases. 
 
 As for those corresponding to the second case here reported, 
 even the internists will admit the urgent indication for surgical inter- 
 ference. 
 
 It is very important, I believe, to bear in mind that of all organs 
 the stomach oftener presents symptoms caused by disease in other 
 parts, and the gall bladder, in many cases of obscure and insistent 
 stomach trouble, is the organ at fault. Appendicitis and gastric ulcer 
 have often been operated upon when the gall bladder was affected 
 and gall stones were the cause of the trouble. 
 
 The statement of Dr. Mayo of Rochester in a recent publication 
 that, of 375 cases of gall stone disease coming to his clinic for opera- 
 tion, 13 per cent had been previously operated upon for the wrong 
 disease, should be a warning and a lesson to all of us. And the 
 practice of exploring the gall bladder in all abdominal operations 
 is a wise one as gall stones are often present with other abdominal 
 diseases. 
 
 I know of a case in which the surgeon operated for salpingitis with 
 abscess. He was wise enough to explore the gall bladder which he 
 found was full of gall stones. He did not remove them as the 
 patient's condition did not permit, but afterward informed her of the 
 condition. Within a few months symptoms of gall stones developed 
 and he operated with success and credit. Had he neglected to examine 
 the gall bladder and inform his patient when symptoms of gall stone 
 developed afterward, the chances are he would have been accused of 
 operating for the wrong disease. 
 
 When the diagnosis of gall stone disease is once made what 
 operation is the best to perform ? Keen's Surgery, the latest standard 
 work, published only a few years ago, contains the following state- 
 ment by the leading surgeons of the country on gall bladder surgery: 
 "Cholecystostomy we consider the normal operation for gall stones." 
 In 1,600 cases of gall stones reported cholecystostomy was performed 
 in 1,200 cases (just three-fourths of all cases) with a mortality of 
 less than 2 per cent. 
 
 Since the above statement and statistics were published quite a 
 change has taken place in the practice and teaching of some leading 
 clinics in this country, and cholecystectomy is now considered the 
 best operation for gall stones with a mortality a little less than 
 cholecystostomy. Statistics, published last year from the Mayo Clinic 
 at Rochester, show a total of 763 operations for gall stones. Of this 
 number 589 were cholecystectomies and 74 cholecystostomies. This 
 is a complete reversal of the practice and results of a few years before. 
 
 There is no doubt that the above results can only be attained with 
 the unusual skill and experience of the surgeons at the head of that 
 clinic. Cholecystectomy requires more skill in its technic and greater 
 care to avoid injury to the bowel, the vessels and main duct. This is 
 the statement made by Dr. Mayo in comparing the two operations. 
 
 I believe statistics from other clinics and from the general practice 
 of surgeons will give different figures corresponding rather to the 
 figures in Keen's Surgery. The statement of Crile, that the cases 
 of cholecystostomy that came back to the surgeon are the cases in 
 
 21 
 
which the gall bladder was diseased or the mucous membrane in- 
 flamed or the cystic duct closed or some other lesion present besides 
 the gall stones, is certainly true. 
 
 If at operation the gall bladder has a normal appearance, the 
 mucous membrane is not markedly altered, the bile flows freely and 
 looks natural, I believe cholecystostomy is the best operation in the 
 hands of the general surgeon. Maybe it does not speak for so much 
 surgical skill but the curing of disease and saving of life is the main 
 thing. 
 
 When on the other hand if the gall bladder is changed by in- 
 flammation or disease, when the mucous membrane is altered or 
 degenerated, when there is empyema or obstruction of duct, then 
 cholecystectomy is the operation and the surgeon not equal to it 
 should pass the case to better hands. 
 
 There are, however, cases in which the indications are not so 
 clear and distinct, border cases as it were. If I am permitted an 
 opinion I would say that in general surgical practise, with the skill 
 of the general surgeon at hand, the patient should be given the benefit 
 of the doubt and cholecystostomy performed. 
 
 If perchance he should be one of the cases that come back then 
 cholecystectomy can be done. 
 
 Quoting again from a noted surgeon, "the drainage operation may 
 be chosen for primary safety with later cholecystectomy recom- 
 mended as a probable necessity in the future, a two stage operation." 
 
 I will conclude by saying that when the deep sea captains follow 
 such opposite routes, it behooves the skippers of smaller craft to 
 sail by 'the dead reckoning of judgment and prudence, rather than 
 by the sun and stars. 
 
 22 
 
Ill 
 
 ST. JOHN'S HOSPITAL. 
 
SURGICAL CLINIC AT ST. JOHN'S HOSPITAL. 
 
 Warren L. Duffield, M.D. 
 
 Probable Fracture of Base oe Skull, Immediate Decompression. 
 
 Clinical History. — A male 60 years of age was brought to the 
 hospital about midnight with the history of having been struck by an 
 automobile. When admitted he talked in an irrational manner, was 
 actively delirious, requiring restraint, and his pupils were said to have 
 been unequal. When seen about one-half hour later he was in a 
 deep coma and could not be aroused. 
 
 Examination revealed four wounds of the head and a fractured 
 nose. One wound directly over the sagittal suture was incised and 
 a small portion of the bone had been gouged away but there was no 
 demonstrable linear fracture. The other wounds were not complicated 
 by any traumatism to the bone. The pupils were now equal, contracted 
 and slowly responded to light; the pulse was 90 and of good quality. 
 Slight patellar reflexes could be elicited after some effort. There was 
 tonic muscular spasm of all extremities but slightly less pronounced 
 in the left forearm. During the course of the examination there had 
 been no active movements of the extremities. Upon exploring the 
 scalp wounds all extremities with the exception of the left arm were 
 moved by the patient, but with no apparent return of consciousness. 
 Upon further examination of the left arm it was found to be flaccid 
 with the exception of the adductors which were in a condition of tonic 
 muscular spasm. A right temporal decompression was decided upon. 
 
 Operation. — Without any anaesthesia and through an inverted 
 U incision over the right temporal region the fibres of the muscle 
 were separated and the skull opened with a Hudson drill and the 
 opening enlarged with rongeur. There was no bulging of the dura but 
 upon opening it cerebrospinal fluid escaped in large quantity and with 
 considerable force. At first the fluid was perfectly clear but as it con- 
 tinued to flow it became markedly blood stained. Up to the time 
 of opening the dura the patient had been quiescent but as soon as the 
 fluid began to escape he commenced to talk in an incoherent manner 
 and began moving his extremities. The brain substance was dark in 
 color but there was no tendency to hernia. A rubber tissue drain was 
 introduced to the dura, the muscles sutured over and the flap accu- 
 rately restored. 
 
 Post-Operative History. — The average pulse, temperature and 
 respiration for several days were respectively 100, loi 1-5 and 30. 
 His blood-pressure six days later was 90 and 120; and twelve days 
 after operation no and 135. For about ten days there was an active 
 delirium almost every night and a mild delirium during the day, 
 though when spoken to he would answer in a rational manner and as 
 a test was able to read a newspaper. At present his pulse and tem- 
 
 25 
 
perature are normal and only occasionally is he slightly irrational at 
 night. All bodily functions are apparently normal and there is no 
 paralysis. 
 
 Comments. — Dr. William Browning made an examination sev- 
 eral days after the operation and expressed the opinion that the 
 delirium was due to an old and chronic alcoholism. 
 
 It is of course an open question whether this patient would not 
 have recovered under expectant treatment but as all symptoms of 
 intracranial injury had apparently increased during the first hour 
 and a half of observation an exploratory craniotomy was decided 
 upon and the results would seem to justify the decision. 
 
 Gastro-Enterostomy for Duodi;nai, Ulce;r. 
 
 Clinical History. — The patient is a married woman, 38 years of 
 age, whose family history is negative except for the death of one 
 sister from tuberculosis. The patient had an attack of pneumonia 
 seven and one-half years ago, had puerperal peritonitis eight years 
 ago, and has given birth to seven children. Twice during each of 
 the past six years she has had attacks of profuse hemoptysis with 
 severe pain in the epigastrium. Her most severe attack was in Sep- 
 tember, 1914, when in the course of two weeks she had fourteen 
 hemorrhages. 
 
 Her present illness began one week ago and during that time she 
 has had eight hemorrhages each lasting about five minutes. Repeated 
 doses of coagulose were given by her physician, Dr. C. B. Cortright, 
 to control the bleeding, as at this time she would not consent to 
 operation. Her epigastric pain is somewhat relieved by vomiting. 
 There is macroscopic evidence of blood in the stools. She is the sub- 
 ject of a mild pulmonary tuberculosis, though at present tubercle 
 bacilli cannot be demonstrated in the sputum. In May, 191 5, she was 
 twice operated upon, once for the removal of a diseased ovary and 
 later for the removal of the appendix. 
 
 Examination is practically negative except for a small point of 
 considerable tenderness in the epigastrium. The stomach contents 
 are acid, free HCl 15, combined acid 27, total acidity 46. No lactic, 
 acetic nor butyric acid present. Maltose and pepsin and a large 
 amount of mucus present. Microscopically a trace of blood, many 
 fungi and many starch granules can be found. Her blood count is 
 red-cells 3,950,000; leucocytes 6,800; hemoglobin 90 per cent, and 
 polymorphoneuclear cells 69 per cent. Examination of feces reveals 
 a small amount of blood. X-ray plates show a filling defect of the 
 pyloric end of the greater curvature and the duodenum immobilized 
 to the left of its normal position. There is an overlapping of the 
 duodenum and pylorus and a consequent blurring of the picture. 
 
 Operation. — Through a vertical right rectus incision an ulcer 
 about one and one-half cm. in diameter can be distinctly palpated 
 in the inferior wall of the duodeno-pyloric junction and at this point 
 there are numerous thin but firm adhesions. The duodenum and 
 pylorus are drawn upward and to the right by thin but firm perigastric 
 adhesions which extend downward across the duodenum and pylorus. 
 A typical Mayo posterior gastro-enterostomy is now performed with- 
 out difficulty except for posterior perigastric adhesions, similar to 
 those above noted and which require division before the stomach wall 
 can be drawn through the meso-colon. 
 
 26 
 
Comments. — After the abdomen was opened and before perform- 
 ing a gastro-enterostomy a Finney pyloroplasty with resection of the 
 ulcer, or a simple resection of the ulcer followed by a posterior gastro- 
 enterostomy were both considered but abandoned because of the im- 
 mobility of the pylorus due to the perigastric adhesions which would 
 have required considerable time for their dissection. With the patient's 
 history of pulmonary tuberculosis it was considered wisest to do the 
 simplest and quickest operation which would give relief, and this 
 seemed to be a posterior gastro-enterostomy. 
 
 Post-Operative History. — For seven days her recovery was smooth 
 and uninterrupted and all sutures were removed. On the eighth day 
 vomiting began and became more constant, the vomitus consisting 
 mainly of bile. On the tenth day the abdomen was again opened 
 and the second operation revealed the meso-colon folded on itself and 
 firmly adherent over the anastomosis producing an obstruction. Fol- 
 lowing the second operation there was slight and diminishing vomit- 
 ing. At this time her convalescence is well established. 
 
 Comments. — There are two features of interest in this case. Be- 
 fore operation the hemoptysis had been so pronounced that she was 
 quite exsanguinated, yet seven days post-operative, though the vomit- 
 ing was constant and persistent for about forty-eight hours, there 
 was not the slightest evidence of blood. A fair assumption would 
 seem to be that the ulcer had become quite firmly healed in the' 
 interval. 
 
 The second point of interest is that in spite of a very easy gastro- 
 enterostomy, excepting for a few posterior perigastric adhesions, and 
 with but little handling of the intestines very dense adhesions were 
 found across the entire meso-colon on the tenth day. These adhesions 
 were out of all proportion to the traumatism inflicted and were more 
 extensive and greater than we have ever seen under the same condi- 
 tions. Can it be that the repeated doses of coagulose had increased 
 the viscosity of the peritoneal fluid and thus favored the formation 
 of early and dense adhesions? 
 
 Stab Wound of the Abdomen Involving the Liver, Stomach and 
 
 Omentum. 
 
 A colored boy of nineteen was brought into St. John's Hospital 
 by the ambulance, suffering with an incised wound of the abdomen 
 and stating that about one-half hour before admission he had been 
 stabbed. 
 
 Examination reveals a well developed muscular youth with an 
 incised wound 2 cm. long slightly to the left of the median line at a 
 point midway between the ensiform and the umbilicus, and protruding 
 from the wound is a mass of omentum 2 cm. wide and 7 cm. long. 
 The pulse is 76, regular and of excellent quality, the temperature is 
 normal and there is no vomiting, abdominal rigidity nor complaint 
 of pain, and no evidence of shock. 
 
 Operation. — A vertical incision is made 2 cm. to the right of 
 the wound and reveals an incision passing through the edge of the 
 liver. The liver is sutured on both surfaces. There is also a wound 
 2 cm. long in the anterior wall of the stomach through which gas can 
 be seen bubbling. A double row of Lembert sutures are here intro- 
 duced. No further injury can be detected on the right side but on the 
 
 27 
 
left two severed omental vessels which are bleedjng briskly axe 
 ligated. The base of the protruding omental mass is now 
 ligated and sectioned within the abdomen, a cigarette drain introduced 
 to the neighborhood of the opening into the stomach, the operative 
 wound closed in layers, the protruding omentum removed and a small 
 drain superficially introduced into the stab wound. In order to pre- 
 vent all further infection of the abdomen the protruding omentum was 
 carefully excluded from the operative field before beginning the opera- 
 tion and was not touched until after the laparotomy wound was 
 closed. 
 
 Post-Operative History and Comments. — Following operation 
 there was no vomiting, fluids by mouth being withheld for forty-eight 
 hours, during which period Murphy drip was administered. At no 
 time was there evidence of peritonitis and the drains were removed 
 on the fourth day. A satisfactory and prompt recovery was made, 
 and the patient was discharged fourteen days from the receipt of the 
 injury. 
 
 This case serves well to illustrate the absolute necessity of ab- 
 dominal exploration in all cases of penetrating or suspected penetrat- 
 ing wounds of the abdomen, a practice which is or should be universal. 
 Assuming that there had been no protruding omentum one might have 
 felt almost justified in awaiting the development of symptoms for 
 there were certainly none present to indicate serious injury. To have 
 delayed, with actively bleeding omental vessels and a penetrating 
 wound of the stomach wall, would have been to have waited too long. 
 
 Acute Intejstinai, Obstruction Due to Procidentia Uteri. 
 
 This case is reported because of its apparent rarity. The index 
 of the first sixty volumes of the Annals of Surgery does not record 
 a case. 
 
 Clinical History. — A Hebrew woman of 57 years was admitted to 
 the hospital and the only history that could be obtained was that 
 twenty-four hours previously vomiting had begun and had increased 
 in frequency until at the time of admission it was constant. 
 
 Examination revealed a woman who appeared very much older 
 than the age given. She was very poorly nourished, her pulse was 
 weak and thready and the abdomen markedly distended. She was 
 constantly vomiting small quantities of fluid almost black in color. 
 Protruding from the vulva was a mass under considerable tension 
 which consisted of uterus, bladder and rectal wall — a complete pro- 
 cidentia uteri. All hernial openings were carefully examined but 
 nothing abnormal found. 
 
 We were unable to determine from her how long she had suflFered 
 with a procidentia or whether it had increased in size or had changed 
 in consistency coincident with the onset of vomiting, but received the 
 impression that there had been some change in it at this time. 
 
 Feeling that the cause of her obstruction was a strangulation 
 of bowel in the everted vagina, but not being able to exclude other 
 possible causes, it was decided to reduce the mass and wait for an 
 hour, as her condition did not seem to warrant any greater delay. 
 She was placed in a slightly exaggerated Sim's position, the mass re- 
 duced without great difficulty and the vagina tamponed. 
 
 One hour later, the vomiting still persisting, her abdomen was 
 
 28 
 
opened through a right rectus incision. Upon passing the hand down 
 into the pelvis a large mass of small intestine could readily be dis- 
 lodged. The intestine was dilated to about three times its normal size 
 and was of a deep bluish color. The large intestine from the rectum 
 back to the cecum was thoroughly but quickly inspected and found to 
 be collapsed. The ileum was found to be collapsed back to a point 
 about 45cm. from the cecum and at this point there were no definite 
 signs of obstruction. Proximal to this point the intestine was found 
 distended and congested and distal to it collapsed and light in color. 
 Upon handling the bowel the fecal current passed on and into the 
 cecum. The uterus was drawn up and rapidly fixed to the anterior 
 abdominal wall and the abdomen closed as quickly as possible. 
 
 It was doubtful whether she would live through the operation; 
 but under stimulation the operation was completed. She died about 
 five hours later. 
 
 Though no definite point of obstruction was demonstrable it is 
 our opinion that the obstruction was due to the gut being forced into 
 the sac formed by the everted vagina — a form of intestinal obstruc- 
 tion which we have not seen recorded. 
 
 29 
 
IV 
 THE LONG ISLAND COLLEGE HOSPITAL. 
 
CLINIC AT THE LONG ISLAND COLLEGE HOSPITAL, 
 
 MAY 12, 1916. 
 
 Wm. B. Brinsmade, M.D. and James Watt, M.D. 
 
 Inguinai, He:rnia. 
 
 THE patient is a man, thirty-five years of age, who three months 
 ago first noticed pain in his right inguinal region. This was 
 not brought on by any particular muscular effort, although his 
 ordinary vocation is one that entails hard work. Since its inception 
 the pain has gradually increased and is now fairly constant. Six 
 weeks ago he first noticed some protrusion in the painful region. This 
 protrusion has gradually increased in size, is now a constant annoy- 
 ance and hinders his work. 
 
 On examination, the patient standing, a protrusion the size of an 
 egg is visible emerging from the inguinal canal. On percussion this 
 tumor gives a resonant note and on manipulation disappears within 
 the abdomen with a gurgle. The history and results of the examina- 
 tion indicate the presence of a complete inguinal hernia. The ques- 
 tion arises whether such a case is one for which an operation should 
 be done or not. All operations are operations of either necessity or 
 election. When an operation is necessary a considerable risk to the 
 patient must often be assumed by the operator, whereas in opera- 
 tions of election a surgeon should not assume any risk that can possi- 
 bly be avoided. A hernia such as the one under consideration might 
 be held in place by a truss, but a truss is a very inconvenient and 
 troublesome implement to wear, if one is to earn his living by hard 
 work. We know also that a truss will not cure such a hernia as 
 this, and notwithstanding that a truss may suffice to retain the hernia 
 under ordinary circumstances, it not infrequently happens that in 
 spite of the presence of a truss the hernia escapes under special con- 
 ditions of exertion and is strangulated, the very presence of the truss 
 adding to the dangers of strangulation. In this particular patient the 
 records show that his kidneys, heart and lungs are all in good condi- 
 tion and we have therefore advised an operation, since in more than 
 95 per cent of the cases done in this clinic a permanent cure has been 
 secured by operation. 
 
 The surgeon has at times been called upon to give an opinion 
 as to whether a certain hernia was caused by an accident. The 
 teaching in this clinic is that there must be two causes for hernia ; 
 first, a predisposition by way of weakness in the abdominal wall and 
 second, increased abdominal pressure. Without both these factors 
 at work it is doubtful if a hernia would ever occur. 
 
 The method of operating adopted by us is that known as the 
 Bassini operation ; so far it has given in our hands perfect satis- 
 faction. In m.ost cases the person has but little ether, he seldom vomits 
 and there is no shock. Our rule is to keep these cases in bed for 
 
 33 
 
eight days. Upon the ninth day he is allowed to sit up in a chair, and 
 thereafter to walk around as strength returns. The cases are dis- 
 missed on the fourteenth day after operation with definite instruc- 
 tion to have the bowels move daily, and to engage only in moderate 
 exercise ; to avoid lifting of heavy articles for six weeks, after which 
 time they are permitted to take up their former method of living. 
 
 Fracture of the Patella. 
 
 A man forty years old, while walking in the street, caught his 
 foot against an obstacle and, in an effort to save himself, threw his 
 body backward. As he did this a snapping was fell in his right knee; 
 he sank to the ground and found to his surprise he could not lift his 
 right leg. He was taken home and an evaporating lotion was applied 
 to the knee for two days when he was sent to the hospital. When ad- 
 mitted the right knee was swollen and the patella was found to be the 
 subject of a transverse fracture, with separation of the two fragments 
 so that a finger could be placed easily between the two. He has now 
 been three days in the hospital, five days have passed since the occur- 
 rence of the accident. There is considerable redness and swelling 
 about the injured knee, and it is evident that the knee joint is filled 
 with bloody fluid. What is the best thing to do for this man? 
 The prime necessity is for him to get back to his work with a 
 sound limb in the shortest time possible. An absolute bony union 
 of a broken patella is not essential to excellent function. There- 
 fore, if operation is done upon this man simply for bony union, the 
 operation would be one of election and not of necessity. The patient 
 is advised to have the knee joint opened, the blood removed, and the 
 broken and lacerated tissues restored to their normal positions, and 
 we feel safe in promising him that he will have a more perfect result 
 in a shorter period of time by such procedure than by waiting for 
 healing to take place without operative interference. We had in- 
 tended to perform this operation this morning, but we find that there 
 is still present much evidence of reaction in the tissues with consider- 
 able infiltration of blood. Realizing that the knee joint is the largest 
 joint in the body, and that the slightest infection may lead to the loss 
 of the joint, or even of the leg, we think it better to postpone surgical 
 interference until the tissues are restored to a more normal condition. 
 When we do open this joint with a curved transverse incision we shall 
 find that not only the patella is broken, but that both lateral ligaments 
 are torn well down on either side of the joint. We wih also observe 
 that when the lacerations of the lateral ligaments have been repaired, 
 the broken fragments of the patella will have almost restored them- 
 selves to their proper position. The dense fibrous fascia, covering the 
 anterior surface of the patella, will have been torn across and its 
 lacerated edges will have dropped down like a fringe between the 
 fragments. These fibers are lifted out and the fascia sutured with 
 a few fine catgut sutures. After the operation the extended leg will 
 be put in a plaster case, and the patient confined to bed for seven 
 days, at the expiration of which time the case will be taken off and 
 the skin sutures removed. A lighter case is then applied and cut into 
 anterior and posterior sections. The patient is allowed to get out of 
 bed and sit in a chair for the next five days, at the expiration of which 
 time the case is left off while the patient is in bed and reapplied every 
 time he gets up. After eighteen days passive motion and massage 
 
 34 
 
are practiced and the patient is encouraged to bend the knee. This 
 method of treatment is kept up until the patient is able to flex his 
 knee to a right angle, after which he is discharged with instructions 
 to carry a cane in the streets constantly for the next two months. 
 Such care and help is important to avoid dangers of refracture. 
 
 The functional results from the closed method of treatment are 
 often so excellent that a surgeon is not justified in urging an opera- 
 tion in all cases of fracture of the patella. Such an operation should 
 never be performed except under the most rigid asepsis. In this 
 clinic we never put anything into a wound which has not been boiled ; 
 the operator and assistant should leave an operation with their gloves 
 as clean as when they commenced ; the blood clot being removed with 
 toothed forceps and a spoon curette. If there is any question about 
 the desirability of doing an open operation, always decide in the nega- 
 tive. One should be perfectly sure that the tissues have a normal 
 amount of resistance, and that the surroundings are surgically perfect. 
 It is for this reason, therefore, that operation on this patient is post- 
 poned until a future date. 
 
 Choi,e;cyste;ctomy for Chronic Ini^lammatign of thf Gai^i, 
 Bladder with Gali, Stonfs. 
 
 The patient is a woman forty-two years of age who was brought 
 to the hospital six days ago, suffering acutely with pain in the upper 
 right quadrant of the abdomen and over a small area in the back close 
 to the spine. She had been vomiting for two days and had a tem- 
 perature of 1023^ and was jaundiced. During the past six years she 
 has had from time to time attacks similar to the present one, but 
 never so severe. She has had two pregnancies during this period and 
 during each pregnancy has had several attacks similar to the first one. 
 There was bile in her urine and her stools were clay colored. She 
 commenced to improve as soon as she entered the hospital and her 
 jaundice has almost disappeared. We never operate upon any cases 
 of pronounced jaundice where it is possible to postpone operation. 
 The patient describes so-called bilious attacks as occurring from time 
 to time and not associated, in her mind at least, with the ingestion 
 of or abstinence from food. She is a well developed women of good 
 frame. It is fair to assume an obstruction to the flow of bile. I 
 want to call particular attention to Boas' sign which is pain over a 
 restricted area in the back, directly behind the region of the gall 
 bladder. I have never failed to find stones in any case in which this 
 symptom was distinctly present, but on the other hand I have often 
 found stones where the symptom was not present. With such a his- 
 tory and condition as has been described one is justified in urging 
 an operative procedure because it is certain that she will never be 
 well of these attacks until the cause is removed, and that she may 
 develop conditions which might become rapidly fatal. Mere pres- 
 ence of gall stones alone does not demand operation, since statistics 
 show that in a large percentage of all adult cadavers gall stones are 
 found. 
 
 The patient has accepted our advice and is ready for operation. 
 As the ciher is administered it is noticeable that she takes it well. A 
 pad placed under her back brings the liver well to the front. A trans- 
 verse incision is made through the right rectus muscle, about I inch 
 below the border of the ribs, because it seems to give a wider field 
 
 35 
 
for easy operative manipulation, and also because it is easier to close. 
 I do not know who first suggested this incision, but I saw it used in 
 Germany many times several years ago, and more recently it has been 
 brought to the attention of American surgeons by Dr. Moschcowitz of 
 Mt. Sinai Hospital, New York. After the abdomen has been opened 
 a large sheet of gum rubber is placed so as to cover the exposed 
 intestines, and on this rubber the gauze sponges that are used are 
 placed. Thus these sporgcs absorb whatever discharge there may be 
 without coming in co'iiact with the intestines. I believe this pro- 
 cedure to be of considerable value in prevention of that abomination 
 of abdominal surgery, adhesions. The region having been oriented 
 we discover a small gall bladder with thickened walls, within which 
 just as it narrows down to the cystic duct a stone can be felt. The 
 neck of the gall bladder is tightly contracted on it so that it cannot 
 be pushed up into the fundus of the gall bladder. The entire gall 
 bladder and cystic duct are hard and thickened. Nothing is discovered 
 in the common duct by palpation. We have then to deal with a diseased 
 gall bladder and duct containing a stone. In our opinion this gall 
 bladder is diseased beyond repair and must be removed. If left 
 behind and drained it will merely become a foreign body. The cystic 
 duct is therefore caught in a right angle clamp, by blunt dissection the 
 cystic artery is separated and tied. The duct is then cut across be- 
 tween tv/o clamps and the gall bladder removed from behind forwards, 
 leaving the surface of the liver which oozes very slightly. A long 
 probe is then passed through the duct into the common duct and the 
 ampulla of Vater for exploration. No obstruction is discovered. The 
 duct is then ligated. A long cigarette drain is fastened to the duct 
 and another drain, containing a split, soft rubber catheter, packed with 
 gauze, is placed beside it. Notice that both these drains are covered 
 with gutta percha tissue so as to prevent any irritation which might 
 set up adhesions. All sponges are now removed and counted. There 
 is no moisture at the bottom of the wound or around the liver so 
 the rubber dam is removed. 
 
 We are sure that this woman will be restored to her family in 
 three weeks in better health and with a better disposition than she 
 has had for a long time. Whenever you find either a man or woman 
 who is cranky and disagreeable to live with, do not put it down to 
 disposition or cussedness until every effort has been used to find a 
 local or pathological cause. In this connection I Vv^ould impress upon 
 you once more the necessity of arriving at a diagnosis first, by the 
 history ; next by examination ; and finally as an addendum to these, 
 the use of the laboratory. Do not learn to depend entirely upon the 
 X-ray for diagnoses ; valuable as it is, it is sometimes deceptive and 
 sometimes also it fails to reveal the condition which is present. 
 
 36 
 
ArtificiaIv Anus. 
 
 In certain cases of cancer of the rectum when the entire rectum 
 can be removed by the combined abdominal and either perineal, sacral 
 or vaginal operation, it becomes necessary to create an artificial anus. 
 The comfort and effectiveness of the new opening determines the 
 well-being of the individual. For the satisfactory control of an artifi- 
 cial anus we have found that the following method gives the best 
 results : A transverse incision is made above the pubes, and the 
 sigmoid isolated. The gut is then cut across well above the growth 
 and a second small incision is then made through the skin about 2^^ 
 inches above the transverse incision and to the left of the median line. 
 This brings the opening well above the pubic hairs. By blunt dis- 
 section through the fibres of the rectus, keeping well in front of the 
 peritoneum a passage about 2^ inches long is created down to the 
 transverse incision. The proximal cut end of the gut is drawn through 
 this passage and fastened to the peritoneum at this point of entrance 
 in the abdominal wall and to the skin at its exit. The operation for 
 the removal of the cancer may be performed at this or subsequent 
 sitting. The effect of this procedure is to create a loop or segment in 
 which fecal contents may collect beyond which there is a perpendicular 
 passage through the rectus muscle which seems to compress the bowel 
 and control its contents to a mild degree. I have used this method six 
 times, and my friend. Dr. Fiske, has used it four times, and the re- 
 sults have been satisfactory in all these cases, both to ourselves and 
 to the patients. 
 
 I now present a patient who is the subject of an artificial anus 
 thus made. A woman, who was operated upon eighteen months ago 
 on account of a growth in the rectum. The operation was performed 
 as described. The after course was hard for several months owing 
 to a large amount of tissue-sloughing through the peritoneal vaginal 
 wound. She has now gained weight and recovered full strength and 
 considers herself a well woman again. The artificial anus functionates 
 in a very satisfactory manner; by using a small syringe each morning 
 she is able to empty her bowel of the fecal contents. It takes her 
 about one-half hour each morning to perform her toilet for the day. 
 She wears no cup and only a simple compress made of a few layers 
 of gauze and cotton, which is pinned to her undervest. I believe this 
 is far better than any other form of artificial anus. As far as I 
 know this particular procedure has not been described. I have re- 
 served any description of this procedure until it had been performed 
 several times, and am now glad to present it to Dr. Pilcher on the 
 occasion of our celebration of his fifty years of devotion to humanity 
 and science. 
 
 37 
 
THE DIAGNOSIS OF FRACTURE OF THE NECK OF THE 
 
 FEMUR. 
 
 John D. Rushmore, M.D. 
 
 THE following remarks apply to the diagnosis of fracture of the 
 narrow part of the neck of the femur, or intra capsular fracture. 
 In the large majority of patients with suspected fracture of the 
 femoral neck the diagnosis is not difficult ; in a few cases one may feel 
 uncertain whether a fracture exists or not, without the evidence fur- 
 nished by a satisfactory skiagraph. On the other hand, before the use 
 of the x-ray, cases have been reported as fractures when a post mortem 
 has failed to show the fracture ; and even experts may differ in the in- 
 terpretation of a clear skiagraph, as to whether a fracture exists or 
 not. And inasmuch as the x-ray apparatus cannot be used in a large per- 
 centage of cases, for various reasons, one is obliged to fall back on the 
 long list of symptoms that are, singly, uncertain, but taken in their 
 totality, render mistakes in diagnosis very exceptional. 
 
 Considering then the symptom on which we base a diagnosis of 
 fracture of the neck of the femur, the most positive evidence for or 
 against the existence of a fracture is furnished by a good skiagraph, 
 when it can be obtained. 
 
 Next to a skiagraph I have depended on a symptom or sign which 
 is as evident to the eye as Allis's sign is to the touch. 
 
 Place one end of a tape measure over the anterior superior spine 
 of the ilium under firm pressure of the finger or thumb ; have an as- 
 sistant draw, by traction on the foot, the limb downward to its utmost 
 length without inflicting pain ; place the taut tape where it comes op- 
 posite to the inner malleolus over that bony point under firm pressure 
 with the thumb of the other hand, and then, being careful that the 
 knee of the patient is kept rigid, have the assistant shove the unbent 
 limb forcibly but slowly up toward the pelvis, and if there is relaxation 
 of the taut tape visible to the eye, a fracture of the neck of the femur 
 exists. If the same procedure is used on the opposite limb there is no 
 relaxation of the tape. The amount of relaxation that takes place will 
 depend upon the presence or absence of impaction. This sign has 
 nothing to do with mensuration ; any flexible and inelastic material can 
 be substituted for a tape measure ; even the edge of the sheet covering 
 the patient may be used; it is as useful in a one-legged man as a two- 
 legged man ; and probably could be employed where the patient had lost 
 the leg of the affected limb. It can be used in every case of suspected 
 fracture of the femoral neck ; and it is not necessary that pressure 
 should be made exactly over the top of the iliac spine or exactly over 
 the edge of the inner malleolus. The two important points to be ob- 
 served in this procedure are that the examiner should use forcible pres- 
 sure over the two bony points, and that the patient's knee should be 
 kept rigid. At the same time the assistant should make the utmost 
 
 38 
 
justifiable traction downward and pressure upward during the manipu- 
 lation. I at first thought that the relaxation visible in the tape indicated 
 that the fracture was ununited, and that the sign would be of little or 
 no value when there was impaction ; but from the inspection of ski- 
 agraphs which seemed to show impaction, and where the relaxation of 
 the tape was evident, I am led to think impaction does not lessen the 
 value of the sign. It is surprising how little approximation (less than 
 a quarter of an inch) of the points of pressure will show a marked 
 sagging of the tape. In differentiating a fracture from a dislocation of 
 the hip joint, I have had no experience in the use of the above sign. I 
 imagine the same relaxation occurs as in a fracture; but the signs of 
 each of these conditions are so different as not to give us trouble in 
 differentiating them. At the bedside the question is almost always 
 whether the patient is suffering from a fracture or not, and not whether 
 he has a fracture or a dislocation. 
 
 Taking up the question of the value of mensuration in the 
 diagnosis of this fracture, it is common experience that two surgeons 
 will not only differ in their measurement, but each one may obtain 
 different results in his own measurements, even though he has the 
 patient lying on a table and with the line of the body perfectly straight. 
 The usual reason given for these differences is doubtless valid, that 
 while the inner malleolus is easily made out, the anterior spine is not 
 a spine, and it is difficult or sometimes impossible to be sure that 
 one is pressing over the exact centre of it. More important still is the 
 inequality of the limbs demonstrated by the late Dr. A. T. Bristow in a 
 very careful set of measurements of the femora and humeri (Transac- 
 tions of the American Surgical Association, Vol. XXVII. Page 429). 
 These measurements confirm the conclusions arrived at by the late 
 Dr. J. S. Wight from measurements in the living subject. These tables 
 prove that an inequality, varying from 1-8 to i 3-8 inches may exist 
 in the length of the lower extremities, the difference not depending on 
 any previous lesion in the bones or limbs measured. This asymmetry 
 demonstrated to exist in such a large percentage of persons (78 per 
 cent in femoral lengths according to Bristow's figures) makes any con- 
 clusions as to shortening in suspected fracture of the neck of the 
 femur, based on measurements from the anterior superior illiac spine, 
 a source of error. 
 
 It is interesting, but not important, in this connection, to note 
 the asymmetry that exists in other parts of the body — in the head as 
 shown by comparing the two sides of hatters' patterns that are used 
 in the custom-made silk hats ; in tailors' measurements for custom-made 
 clothes ; in shoemakers' measurements for custom-made shoes ; and 
 sometimes, though rarely, in comparing the two sides of a face or the 
 length of fingers in the two hands. 
 
 It is, however, very important, in using the anterior superior spine 
 of the ilium in measuring the comparative length of the lower ex- 
 tremities of a patient to ascertain if there is or is not an asymmetry 
 in the pelvis similar to those mentioned above. It has been taken for 
 granted that in using the anterior spine for measurements of this char- 
 acter that symmetry of the pelvis exists in spite of the fact that de- 
 formity of the pelvis is a subject that the obstetrician has been lecturing 
 on for more years than the oldest of us have lived. This deformity 
 is no doubt due in most cases to rachitic or other disease. But the 
 other instances of asymmetry mentioned suggests that there may be a 
 
 39 
 
pelvic asymmetry short of actual deformity that would make the an- 
 terior superior spine of the ilium an unsafe point from which to meas- 
 ure the comparative length of the lower extremities. 
 
 Just here it may be mentioned that it is unsafe, when there is ap- 
 parent shortening in suspected fracture to draw the limb downward 
 sufficiently to have the malleoli on a line. The downward traction 
 should be accompanied by actual measurement from some fixed 
 point on the anterior spine, otherwise the apparent lengthening of the 
 afifected limb may be due to tilting of the pelvis, unless counter ex- 
 tension is used and both limbs drawn down with equal extension. To 
 prove whether there is asymmetry of the normal pelvis, set a normal 
 pelvis thoroughly cleansed of soft parts, on a flat surface, the pelvis 
 resting on the point of the coccyx and the tuberosities of the ischium; 
 lay a ruler across the anterior spines, and in a few cases the distance 
 between the ruler and the surface on which the pelvis rests will differ 
 on the two sides. Lack of ante-mortem knowledge of the history of 
 the patient and a possible inequality of the tuberosities render uncertain 
 any inference as to the asymmetry of the spine. 
 
 A better method is furnished by cadavers in the dissecting room. 
 Drive a pin into the top of the middle of the sternum through a tape 
 measure in order to avoid any slipping of the tape, and measure the 
 distance from this point to the anterior superior spines of the ilium 
 (and this can be exactly located in a cadaver) ; and it will be found that 
 the distance between the two points on the right and left side will differ 
 in many cases. In one body that I measured it amounted to a half inch. 
 Lack of knowledge of ante-mortem injury or disease, in spite of evi- 
 dence to the contrary in the cadaver, holds here as well as in pelvic 
 measurements. The best and most reliable evidence is furnished at the 
 bedside, in living patients who can testify to any ailment or injury that 
 might render the same measurements as in the cadaver uncertain. The 
 anterior spine is more difficult to locate with exactness in the living 
 person than in the cadaver, and one must be careful in the fixation of 
 the upper end of the tape in the sternal notch, and also be careful to 
 allow for differences produced by respiration. In spite of these causes 
 of uncertainty, I found the measurements in forty patients confirmed 
 the results of the cadaver measurements. In four cases the difference 
 in the measurements was one-half inch (the maximum). It varied 
 from this to equality in length. 
 
 There is still a possibility that there may be an asymmetry in the 
 malleoli of which I have no measurements to show whether it does or 
 does not exist. With reference to the method of holding the upper 
 end of the tape between the patient's teeth, it may be said that it im- 
 plies the teeth to hold the tape, also a sterile tape before use, and a re- 
 sterilization before employing it in the same way again. If mensura- 
 tion is employed at all — and it certainly should be — I think with Dr. 
 Bristow, "that the measurement taken from -the supra-sternal notch to 
 the plane of the heel, as indicated by a plane surface in apposition 
 therewith, will prove to be a method least open to error. The follow- 
 ing precaution, however, must be adopted : The measurement must 
 be made at the same period of respiration. The plane surface in ap- 
 position with the heel must be parallel in each case, as a slight inclina- 
 tion in either direction would mean an error in the measurements." 
 
 The method employed in Dr. Bristow's bone measurements — a 
 modified shoemaker's rule— would allow one to neglect the respiration 
 as a cause of error. I have preferred, however, to use the "relaxation" 
 
 40 
 
sign described above, as it enables one to neglect the respiration, asym- 
 metry, mensuration, and even pelvic deformity in the diagnosis. 
 
 Outward rotation of the foot is a well-known and often a striking 
 symptom of fracture usually marked, sometimes excessive and at times 
 absent. In a few cases inward rotation is present and difficult to ex- 
 plain. Limitation of voluntary inward rotation of the outward rotated 
 foot is also of some significance. This outward rotation of the foot gets 
 its importance only as associated with other signs of fracture, for it is 
 well known that it exists with contusion of the hip at times, and even 
 when there is no question of fracture, as in general anaesthesia, in 
 natural sleep, in debilitating disease, especially where the knee is even 
 slightly flexed, and in the cadaver. I once saw it in an old lady suffer- 
 ing from senile dementia who fell out of a low bed; the outward rota- 
 tion was marked with no other signs of fracture except difficulty in 
 standing for a few days. The rotation disappeared promptly, and after 
 a few weeks the patient fell out of the other side of the bed producing 
 a less marked outward rotation than on the other foot and with some 
 lameness and with the same prompt recovery as before. 
 
 The inability to lift the extended leg from the bed is a very marked 
 symptom in almost all cases ; and some authorities have gone so far 
 as to advise, even when other symptoms were absent, that such a 
 patient should be treated as a case of fracture. I have seen certainly 
 six cases where this symptom alone was present and a clear skiagraph 
 has negatived the possibility of a fracture. One case recently was an 
 elderly female who fell on her left hip and who presented this symptom 
 of fracture alone. The skiagraph showed no fracture. At the same 
 time the patient sitting on the edge of the bed had good though not 
 quite normal power in extending the leg on the thigh and flexing the 
 thigh on the abdomen. Another case with this symptom, beside out- 
 ward rotation of the foot, shortening and the ability to have the limb 
 lengthened by traction, and a positive skiagraph, after six weeks' 
 treatment by Buck's extension, could lift the extended leg while the 
 other symptoms of fracture were as evident as when she entered the 
 hospital. This symptom is present in fracture of the patella; and I 
 have seen it in acute synovitis of the knee joint, explained perhaps in 
 this instance by the patient's timidity or fear of inflicting pain in any 
 effort at lifting the limb. 
 
 More importance should be attached to Hennequin's symptom 
 than is usually done. The tenseness and swelling in the upper part of 
 Scarpa's space, which is described as Hennequin's symptom, are quite 
 characteristic of a fracture, and should be sought for in all cases. This 
 sign is accompanied by the helpless look of the thigh if the foot is 
 markedly rotated. In a few cases of very thin patients I have been 
 confident that I could feel the deformity produced by the fracture by 
 pressing deeply into the upper part of Scarpa's space, in spite of the 
 increased tension. 
 
 The so-called excursion of the trochanter is an unreliable sign at 
 best, especially so if the patient is not under a general anaesthetic. 
 
 Excursion of the anterior part of the foot with the patient 
 anaesthetized, when the trochanter is seized between the fingers and 
 thumb and forcibly lifted and depressed vertically, is of more value 
 than the trochanteric excursion. Allis' symptom (relaxation of the 
 fascia lata) has, theoretically, much to commend it, but personally I 
 have not felt sure of its presence iniless there were more than the usual 
 amount of shortening. I may make the same statement with regard 
 
 41 
 
to use of Nelaton's line and Bryant's triangle, as I have had difficulty in 
 being certain about the exact position of the top of the trochanter. 
 Tenderness on pressure in the upper part of Scarpa's space, tenderness 
 on pressure from behind forward at the suspected seat of fracture and 
 pain complained of when a short stroke is made over the trochanter 
 are signs usually present. 
 
 Crepitus, false (or new) point of motion and deformity which are 
 relied upon in diagnosticating fractures of the long bones are largely 
 neglected in the diagnosis of the fracture under consideration, partly 
 from an unreasonable fear of breaking up impaction by manipulating 
 the limb to elicit crepitus and partly on account of the impossibility of 
 recognizing the other two signs. 
 
 The age of the patient is to be considered in fracture of the neck 
 of the femur. A large proportion of these fractures occur in elderly 
 persons with sometimes very slight injury ; and yet not a few fractures 
 occur in the femoral neck of children although they are not disabled 
 to the same extent as old persons. 
 
 Let me in closing add one or two observations that seem not in- 
 appropriate in this connection. With the exact knowledge furnished 
 by a clear skiagraph the interne of a hospital, unless he is on his guard, 
 will be tempted to neglect the search for the well established signs and 
 symptoms on which reliance for so many years has been placed in 
 making a diagnosis of fracture of the neck of the femur; and when 
 he has finished his term of service, and gone into practice, and not 
 having the facilities for the taking the skiagraph, he will feel keenly 
 the lack of that aid and realize that he has been lax in the use of other 
 and quite reliable methods of diagnosis. And on the other hand he 
 will feel the unreliability of not a few of these signs that have been 
 depended on in former years. For instance, a malingerer might sue 
 another for causing a fracture of the neck of the femur and assume, 
 as a result of injury, pain, inability to stand or flex the thigh, outward 
 rotation of the foot, inability to lift the extended limb from the bed; 
 and the surgeon might find a shortening of a half inch ; and if he could 
 not find a deformity at the seat of fracture or a false or new point of 
 motion and feared to examine for crepitus in the interest of the patient, 
 and did not, or could not, confirm or correct his diagnosis by a ski- 
 agraph, the patient would be treated for a fracture that did not exist 
 and a jury might, within reason, render a verdict for damages to which 
 the patient was not entitled. 
 
 42 
 
V 
 THE GERMAN HOSPITAL OF BROOKLYN. 
 
ECHINOCOCCUS CYST OF THE LEFT LOBE OF THE 
 
 LIVER DISCHARGING INTO THE LEFT 
 
 HEPATIC DUCT. 
 
 Russell S. Fowler, M.D., F.A.C.S. 
 
 Chief Surgeon, 1st Division, German Hospital of Brooklyn. 
 
 Cases of echinococcus cyst involving the biliary passages upon 
 which operation has been done are very rare. Cases have been re- 
 ported by Duval, Langenbuch, Sasse, Lejeuntel (Alencon), Borchard 
 (Bean), Page, Rossi, von Ruber, v. Mosetig-Moorhof, Korte and 
 Kehr. 
 
 Rupture of such cysts into the biliary passages is very uncommon. 
 Rupture causes sudden blockage of the common duct and is the 
 occasion of very severe biliary colic. There is profound collapse and 
 death has been known to immediately follow. Frequently the block- 
 age is diagnosed as calculus obstruction. A correct diagnosis is only 
 possible if echinococcus elements are found in the stool. In some 
 cases there have been reported recurring colicky attacks and inter- 
 mittent common duct obstruction ; this occurs when the communication 
 between the cyst and bile passages is small and closes from time to 
 time. In other reported cases there were no colicky attacks but symp- 
 toms of cholangitis. One fatal case presented the appearance of acute 
 yellow atrophy of the liver. In cases in which the cyst does not 
 present as tumor the differential diagnosis is between liver abscess, 
 cholangitis with chronic stone or tumor blockage of the common duct; 
 the diagnosis is only possible when cyst elements are recognized in the 
 feces. 
 
 Occasionally rupture occurs without symptoms ; then also the con- 
 dition can only be recognized by the appearance of echinococcic ele- 
 ments in the stools. In some cases there has been rupture into the 
 veins of the liver or inferior vena cava followed by the carrying of 
 embolic cyst elements to the heart and pulmonary arteries occasion- 
 ing immediate death. The usual symptoms of rupture of an echino- 
 coccic cyst into the biliary passages are severe pain, chills and fever. 
 The obstruction in the common duct accompanying the rupture may be 
 by impaction of cyst contents or by inflammatory swelling caused by 
 the intense irritation. 
 
 The case herewith presented gave the following history: N. R., 
 female, age 21, married. No. 33205, seen in consultation with Dr. 
 Calogero Giovinco Nov. 12, 191 5. About four months before the 
 patient had noticed that her urine was high colored and she became 
 jaundiced; after three days this jaundice disappeared. Two weeks 
 ago she had pain in the epigastrium, diarrhea and vomiting. This 
 pain continued and she vomiteid from time to time. Examination 
 showed the abdomen extremely tender below the right costal border 
 and over the right lobe of the liver. There was rigidity of the right 
 rectus muscle. Moderate jaundice. 
 
 45 
 
Immediate operation was done. The liver was found enlarged 
 and acutely congested; the edges rounded. Intense inflammation of 
 gall bladder and ducts with all the glands along the cystic, hepatic 
 and common ducts acutely enlarged. Locally intense peritonitis. Gall 
 bladder opened and found packed with fine brilliant yellow sand. 
 Walls thickened and acutely inflamed. Gall bladder cleansed. Chole- 
 cystostomy. Two split tube drains. It was not thought wise to ex- 
 plore the ducts on account of the extreme and unusual acute inflam- 
 mation. It was thought in all probability the same yellow sand would 
 be found throughout the ducts and that it would be impossible to 
 cleanse the ducts with the existing inflammation. 
 
 After course: The jaundice slowly subsided Dut never entirely 
 disappeared, a little yellow tinge persisting in the eyes. Pain sub- 
 sided. Bile flowed from the tube and appeared in the feces. It was 
 deemed advisable to continue gall bladder drainage for a consider- 
 able period but unfortunately the tube became displaced on the tenth 
 day and this fact was not discovered until the day following. An 
 attempt to replace the tube was unsuccessful. The patient continued 
 free from pain except slight epigastric cramps from time to time; 
 gradually gained strength though a slight degree of jaundice per- 
 sisted. The wound healed slowly. There was but slight discharge 
 of bile from the wound. 
 
 Dec. 8, 191 5. Discharged. Wound healed. Very slight jaundice. 
 
 Dec. 22. Severe epigastric cramps and slight increase in jaundice. 
 
 Deo. 26. More severe cramps and pain over the gall bladder 
 and liver. Readmitted to hospital. Slight jaundice. Liver enlarged, 
 two fingers breadth below free border of ribs. Gall bladder region 
 sensitive. Wound firmly healed. Operation was delayed on account 
 of the difficulty which it was felt would be experienced in cleansing 
 the ducts. However, pain increased and jaundice deepened slightly 
 so that operation could no longer be delayed. 
 
 Operation. Jan. 6, 1916. Incision through previous scar. Many 
 dense adhesions. Gall bladder adherent to scar; acutely distended; 
 opened. Contents, thin bile ; mucous membrane intensely congested ; 
 hour glass type of gall bladder. Colon, omentum, duodenum, liver 
 and stomach densely adherent to gall bladder and neighborhood. 
 Adhesions separated carefully and normal anatomical relationship of 
 parts restored. Cystic duct dilated to twice normal. Common duct 
 dilated to the size of the duodenum or even larger. Bile aspirated 
 from common duct by suction apparatus. Duct incised, walls two to 
 three times normal thickness ; escape of bile and bile stained mem- 
 branous detritus. This membranous detritus varied in size from pin 
 point to the size of the last joint of the ring finger. Metal catheter in- 
 troduced into common duct and duct washed out with saline, the 
 opening into the duct having been enlarged sufficiently to permit of 
 the ready escape of the saline alongside the catheter. Over a pint of 
 detritus, stringy, glutinous, stained black with bile, was washed out 
 in this manner or removed by a long curved blunt curet introduced 
 for several inches, ten inches at times, into what was taken to be the 
 left hepatic duct. In the detritus were numerous pieces of thick green 
 membrane, recognizable as probable echinococcus cyst lining. Two 
 gallons of saline were used. A large probe passed freely into the dun- 
 denum. 
 
 Some saline, about a pint in all, was allowed to run into the duo- 
 denum from time to time. When the saline from the duct returned 
 
 46 
 
clear the curet was passed up and fresh membrane removed and the 
 flow again started. This was repeated until so far as could be as- 
 certained the ducts were clean. The curet passed ten inches into the 
 left hepatic duct without meeting resistance. There was no bleeding 
 from the irrigation. Digital exploration revealed a large opening of 
 the common bile duct into the duodenum, an opening large enough to 
 admit the tip of the finger into the duodenum; the common duct 
 itself was enormous, the finger was lost in it ; toward the liver the 
 finger felt an opening about twice the normal size, taken to be the 
 right hepatic duct opening and a continuation of the common duct 
 taken to be the left hepatic duct which freely admitted the finger. 
 The latter was fully as large as the enlarged common duct, the size 
 of the duodenum (Fig. i.) 
 
 The cystic duct opening could be demonstrated and was twice 
 the normal size. The lining of the common duct and the left hepatic 
 duct was smooth. The lining of the common duct so far as could be 
 seen presented no evidence of inflammation. The patient was thin, 
 worn out by long illness and bore the operation very badly. The 
 pulse, while the beats were distinct, was extremely rapid, rising to 
 over 200 per minute during the irrigation of the hepatic duct. It 
 was felt, however, that the patient stood very little chance of recovery 
 unless this duct could be freed entirely of its impacted detritus. When 
 the ducts were apparently clean and the irrigation discontinued, the 
 pulse fell to 180 but of very poor quality. Continuous hypodermic 
 whiskey stimulation was given from the time the pulse became weak 
 and saline and whiskey were administered by rectum. A rubber tube, 
 with a fenestrum cut in the side was placed in the left hepatic duct 
 through the common duct incision in such a manner as to place the 
 fenestrum facing toward the duodenum. This was used to take the 
 place of a T tube which was not available. A large calibre tube was 
 used not only for the purpose of freer drainage and to avoid block- 
 age but also with the idea of allowing of irrigation of the hepatic 
 duct and common duct should blockage occur, or should some of the 
 detritus show in the discharge from the tube. The incision in the 
 duct was sutured around and to the tube. A split tube was placed 
 in the foramen of Winslow ; a second split tube in relation to the 
 junction of the cystic duct with the common duct (which juncture was 
 higher than usual) ; a rubber tube was placed in the gall bladder and 
 the gall bladder edge inverted. The condition of the patient did not 
 allow of cholecystectomy although otherwise this was indicated. A 
 rapid layer closure of the abdomen was effected. The patient left 
 the table with a pulse of 180, very weak. 
 
 After-course: General treatment of shock (heat, posture and 
 saline by rectum) in addition to direct cardiac stimulation with half 
 strength whiskey by hypodermic, continuous at first, then every two 
 minutes, later every five minutes and so gradually stopped, succeeded 
 in accomplishing restoration to a fairly good condition in twelve 
 hours; at the end of twenty-four hours the bed was leveled and the 
 patient out of danger so far as the operative procedure was concerned. 
 The jaundice was less marked. At no time had it been severe. For 
 the first forty-eight hours the discharge through the duct tube con- 
 nected with a subaqueous drain was free and consisted of clear bile. 
 
 Jan. 8, 1916. Detritus began to pass through the duct tube and 
 it was feared that blockage might take place. Eight ounces of saline 
 were slowly introduced into the common duct, the subaqueous drain 
 
 47 
 
being also disconnected and cleaned. The introduction of saline pro- 
 duced no pain. The patient noticed a sensation of warmth in the 
 epigastrium. There was a return of about one ounce of saline through 
 the gall bladder tube. The return flow through the duct tube con- 
 tained mucus and thick stringy material, blood streaked. About two 
 ounces of the saline was not returned. Following this flushing of 
 the common and hepatic ducts the discharge from the duct tube again 
 became free and clear bile. As much as ten ounces of bile was col- 
 lected in the bottle in twelve hours. 
 
 Jan. 9, 1916. The flushing was repeated there having appeared 
 some detritus in the discharge. This detritus consisted of echino- 
 coccus cyst lining. At this irrigation seven ounces of saline was used, 
 two ounces at a time being slowly introduced and then a wait of a 
 few minutes. The return flow again contained mucus and thick, 
 stringy reddish material. About two ounces of saline returned through 
 the gall bladder tube. Practically all of the saline returned. The 
 patient complained of slight pain during the irrigation. 
 
 Jan. 10. The common duct was irrigated, seven ounces of 
 saline being used. Return flow as before ; two ounces were returned 
 through the gall bladder tube. Practically all the saline returned. 
 
 Jan. II. Common duct irrigated; return flow about the same; 
 some saline, about two ounces, returned through the gall bladder tube. 
 Patient noticed scarcely any pain. A small amount of saline escaped 
 through the wound alongside the tubes. 
 
 Jan. 12. Return flow the same. Saline returned through the 
 gall bladder tube and a considerable amount escaped through the 
 wound alongside the tubes. This irrigation occasioned no pain. 
 
 Jan. 13. Sutures removed ; good wound union except at emer- 
 gence of tubes. Split tube removed. 
 
 From this time on the patient was comfortable. Free biliary 
 drainage continued from the gall bladder tube and from the duct tube. 
 The tubes were removed on the seventeenth day. Further convales- 
 cence uneventful. The wound discharged a good quality of bile and 
 the stools became normal. 
 
 Feb. 5. Discharged. Wound reduced to a small sinus. No 
 biliary discharge. Patient strong. 
 
 Pathological Examination : The detritus removed at operation 
 showed everywhere echinococcus cyst wall and hooldets. No daughter 
 cysts could be demonstrated. Examination of the detritus passed 
 through the common duct tube post-operatively showed characteristic 
 booklets. Repeated examination of the stools failed to show echino- 
 coccus elements. 
 
 Feb. 23. Wound firmly healed. Patient has remained free from 
 symptoms and is rapidly regaining her strength. 
 
 May 21. Patient has remained well. 
 
 48 
 
EXTENSIVE AND RECURRENT CARCINOMA OF THE 
 BREAST AXILLA, NECK AND THORAX. 
 
 James Peter Warbasse, M.D., 
 
 CASES of carcinoma of the breast, which have or have not been 
 operated upon, which show symptoms of extension along the 
 course of the axillary vessels and nerves, giving rise to swelling, 
 pain, and numbness in the arm, have customarily been regarded as in- 
 operable, and condemned to morphine, x-rays, serums, bacterins, or 
 quackery until the inevitable end. The suffering of these patients is 
 very great, and death is welcomed as a rehef. Has surgery nothing 
 to offer these unfortunates? I think it has. The mistake made by 
 the older surgeons has been to think of carcinoma of the breast as 
 carcinoma of the breast, when as a matter of fact it soon is carcinoma 
 of the axilla, neck, and thorax, and should be thought of from the 
 beginning, either in fact or potentially, as such. 
 
 In these desperate cases the surgeon must put out of his mind 
 the idea that he is considering a disease of the breast, lest the psychol- 
 ogy of timidity be stimulated by the observation of the great distance 
 from its origin which the disease has traversed. When vs^e think of 
 disease of the axillary vessels, brachial plexus, scapula, humerus, clavi- 
 cle, lymphatics of the neck, ribs, pleurae or lungs, we are aware 
 that any of these structures may be removed, and are every day being 
 attacked with impunity by surgery. Primary cancer of these struc- 
 tures is unhesitatingly extirpated. Why should the surgeon withhold 
 his skill from such disease, if perchance it were preceded by a can- 
 cer of the breast? 
 
 These patients can be made more comJortable, and life in a cer- 
 tain number prolonged, and in some the disease cured by such radi- 
 cal operations. I have no hesitation in saying that such operations 
 have more to offer and will show more cures, than the simple am- 
 putation of the breast for primary carcinoma which was commonly 
 practiced thirty or forty years ago. 
 
 When the disease involves the axillary vessels and nerves and has 
 palsied the arm, the operation begins with amputation of the shoulder. 
 A flap is made from such tissues as are farthest from the disease. The 
 scapula and clavicle should be removed without hesitation in order to 
 remove disease or to uncover the vessels and nerves which are involved. 
 The axillary and sub-clavian vessels should be followed up into the 
 neck and thorax, and the vessels together with all surrounding tissues 
 removed. This dissection and excision may be carried as far as is 
 necessary to reach the limit of the disease. At the same time the 
 cords of the brachial plexus should be followed up and removed with 
 their surrounding tissues. Before cutting the nerve-trunks they should 
 be injected with novocain to block impulses and prevent shock. 
 
 49 
 
This dissection and excision of vessels and nerves may be carried 
 as far as is necessary. If it is discovered that a rib or ribs are in- 
 volved in the disease, they may be removed. Ribs are removed for 
 other conditions; why not to save a patient from cancer? Involve- 
 ment of the pleura calls for resection. Involvement of the lung de- 
 mands removal at least of the affected lobe. A lobe or the whole lung 
 is excised for other disease, why not for carcinoma . 
 
 There is no structure in the side of the neck which may not be 
 sacrificed. Vessels, including the internal juglar and carotids, may 
 be resected. The brachial plexus, vagus, and phrenic nerves may all be 
 removed. In the chest the only structures which must be preserved on 
 one side are the heart, aorta, and vena cava. The whole of one lung, 
 the ribs which cover it, clavicle, scapula, arm, all the vessels and nerves 
 of one side of the neck, and the neighboring and involved connective 
 tissue, muscles, and lymphatics may be extirpated. This means that 
 everything, practically on one or the other side of the spinal column 
 from the base of the skull to the diaphragm may be removed (Figs, i 
 and 2). 
 
 No operation, of course, would involve all of these structures; can- 
 cer would not involve them all. They are enumerated, however, to 
 show the possibilities of radical operations. Such procedures should be 
 carried out with due regard for the possibilities of shock. Blood should 
 be saved; and nerve trunks should be desensitized. Operations 
 of this sort may be done in several stages, with intervals of several days 
 for recuperation. In the hands of the experienced surgeon who knows 
 how to save blood and minimize shock, these operations have much 
 to offer. 
 
 The experience of surgeons is showing that many patients, other- 
 wise doomed to a painful exodus, may be made comfortable, may 
 have life prolonged, or may be cured by such radical procedures. The 
 literature of surgery is growing rich in the reports of these triumphs. 
 Presumedly hopeless cases have been cured. Many cases have been 
 operated upon repeatedly for recurrences and life prolonged, or the 
 disease ultimately cured. No patient should be regarded as beyond the 
 hope of relief unless the general toxemia and inanition indicate an 
 early conclusion. 
 
 50 
 
™ nS 
 
EPITHELIOMA OF NOSE. 
 James Peter Warbasse, M.D. 
 
 THIS patient, a man now seventy-two years of age, was operated 
 upon by me twenty-two years ago for epithelioma of the nose. 
 At the place where the nose-clip of his eye-glasses pressed 
 against the skin on the side of the nose, an indurated area had de- 
 veloped. Discontinuation of the pressure by changing the position of 
 the clip and modifying the character of the glasses was not followed 
 by healing. The area was small, and the induration but slight, still 
 the suspicion of epithelioma was sufi&cient to call for its removal. Ac- 
 cordingly, under cocaine anaesthesia, an eliptical incision was made 
 about the area of the disease, which was removed, together with a 
 small zone of apparently normal skin around it. As large a wound was 
 made as could be closed by simple suturing. The closure of the wound 
 was accomplished by interrupted silk sutures. The removed piece was 
 subjected to microscopic examination by Dr. Eugene Hodenpyle and 
 Professor T. Mitchell Prudden, of the College of Physicians and Sur- 
 geons, New York, both of whom reported that the growth was epi- 
 thelioma. Most probably enough tissue had been removed to eradi- 
 cate the growth. The incision had been placed about 2 m. m. away from 
 the apparent disease. Still the operation had been done for two pur- 
 poses: (i) diagnosis and (2) therapy. Had a positive diagnosis of 
 epithelioma been made before the operation, the therapy would have 
 been expressed in a wider operation. 
 
 Plastic on Nose 
 
 (a) The lines of 
 skin incision. 
 
 (b) Tumor ex- 
 cised and wounds 
 
 sutured 
 
 The diagnosis now being at hand, it was determined to apply the 
 therapeutic measure of choice. The wound had healed and the sutures 
 had been removed. Under local cocaine anaesthesia, the scar of the 
 first operation and the skin about it for a distance of 4 m. m. were ex- 
 cised by an elliptical incision. This left a wound too large to close 
 by simple apposition sutures. A curved incision was carried from 
 either end of the elliptical wound, marking out a flap on either 
 side, the length of the wound, and having a width at their bases 
 equal to the widest width of the wound (Fig. i). One of the lateral 
 flaps was made by carrying the incision to the median line of the nose, 
 the other by carrying the incision to the inner canthus of the 
 eye. These flaps were dissected free, and united in a straight line over 
 the denuded area. The two lateral wounds were then closed by in- 
 terrupted sutures. Fine interrupted silk sutures were used (Fig. 2). 
 Primary healing followed. 
 
 Now after twenty-two years the patient is here free from any 
 suggestion of disease, and with a scarcely discernible scar. It is ob- 
 served that he still, as a matter of precaution and habit, wears his 
 glasses low down on the nose, thus giving expression to the surgical 
 sense which prompts avoidance of further irritation of a once vulner- 
 able area. 
 
 51 
 
ON IMPENDING PERFORATION OF GASTRIC AND 
 DUODENAL ULCERS. 
 
 Carl Fulda, M.D. 
 
 IT must have been noted, even by those only superficially acquainted 
 with the Hterature of perforated gastric duodenal ulcers, that 
 the mortality in this class of cases is higher than it should be in 
 view of the advances made in other acute abdominal conditions. A 
 mortality of 73 per cent ^ or even of 40 per cent - does not compare 
 favorably with the death rate of appendicitis or cholecystitis. And 
 yet these latter conditions frequently present, at operation at least, 
 far greater technical difficulties than do those cases now under dis- 
 cussion. 
 
 Aside from those determining factors, as age and general condi- 
 tion of the patient, which are common to all surgical procedures, there 
 are two which decide what shall be the issue, once a perforation has 
 taken place. They are : 
 
 1. The age of the perforation. 
 
 2. The operation performed. 
 
 Considering the second factor first, we find that it has received 
 the greater attention. We will grant at once that a decided difference 
 in the outcome is to be noted between those cases in which closure 
 could be performed and those in which closure could not be done.^'^ 
 Failure to close the ulcer may be due to inability to find the perfora- 
 tion, to technical difiiculties presented by extensive induration, or by 
 its position. 
 
 This is admitted even by the most skillful and "from the char- 
 acter of the condition and its urgency it must happen that these cases 
 will be operated upon by those not of long experience in emergency 
 abdominal operations." ^ Petren's table shows, that while 9 per cent 
 were saved where suture could not be done, that even where closure 
 was possible there was still a mortality of 46 per cent. 
 
 The most attention has been given to the question as to whether or 
 not a gastro-enterostomy should be added to the closure. The sugges- 
 tion of von Eiselsberg to perform jejunostomy in certain cases of this 
 type, has only very rarely been followed, in this country at least. As to 
 gastro-jejunostomy, it is advocated: (i) When the infolding of 
 large indurated ulcers has resulted in obstruction at the pylorus; (2) 
 for the reason that closure alone does not cure the ulcer or a second 
 ulcer present; (3) it is maintained that closure does nothing to pre- 
 vent subsequent ulcer formation ; and finally (4) because gastro- 
 enterostomy will, in addition to its other advantages, allow earlier 
 feeding and laxative medication. ° 
 
 As to the question of obstruction, it will be acknowledged that 
 it is difficult to obstruct the pylorus unless elaborate operative pro- 
 cedures are undertaken. ^-^ \\'"e have never seen it occur even where 
 the infolding was very extensive. As to late results, such as obstruction 
 and cicatricial distortion, it has been shown that this does not occur.''' 
 In regard to the second point of advantage, enough cases have been 
 reported to show that within a short time after perforation and 
 
 52 
 
Fig. 1. Chronic nicer of stomach. Microscopic section from Case 11. 
 All layers except serosa are destroyed and perforation is imminent. 
 
 Fig. 2. Removed pylorus from Case II, with portion of stomach and duo- 
 denum. Mucosa aspect ulcer directly at pylorus about to perforate. 
 
closure, the ulcers have healed absolutely. As objection to the third 
 advantage, that of preventing subsequent occurrence of ulcers, enough 
 evidence has been presented to show that subsequent ulcers do 
 occur.2'8'^ Lastly, these patients can be fed as early without gastro- 
 enterostomy as with it ; and as to the administration of laxatives, that 
 will not generally be accepted as desirable. 
 
 We object to the performance of gastro-enterostomy in these 
 cases of perforation because we are not convinced that it is a safe 
 procedure in the presence of a peritonitis. Granted that the infection 
 is of a low grade, it must also be allowed then that the escape of 
 an acid gastric contents has lowered the resistance of the peritoneum. 
 Further, its performance must add to the length of time of operation 
 and so to the shock of the perforation in a patient whose resistance 
 is low from prolonged gastric disturbance and who still has to look 
 forward to a struggle with a peritonitis. We have never performed 
 a gastro-enterostomy in "five or at the outside seven minutes." ^ 
 Thirty-five to forty minutes, the time stated by Eliot ^ is more nearly 
 like the length of time required by most operators. 
 
 The danger of a jejunal ulcer following gastro-enterostomy, 
 though slight, must be added to the total of evidence against it. 
 When we consider the question of cancer formation on an ulcer 
 base ^^ excision would be of greater value than gastro-enterostomy. 
 
 More important, however, than all this, is the fact that it has 
 not been shown that adding gastro-enterostomy to closure of the ulcer 
 has in the slightest degree lowered the mortality of perforated gastric 
 or duodenal ulcer. Its advocates claim for it some value in the 
 patient's future; but the present events in his life are those with 
 which we are most concerned. If there were no other valid reasons 
 against its being done, it should be omitted for the reason that it 
 adds nothing to the chances of recovery. 
 
 Of vastly greater importance is the question of the time of 
 operation. On this point there is, and can be, no dispute. The 
 longer the interval between perforation and operation, the higher is 
 the mortality; the further the peritonitis has advanced, the less is 
 the chance of recovery. 
 
 Perhaps because it is generally accepted, little has been said on 
 this point in comparison with the amount of discussion on "gastro- 
 enterostomy or not." Now, one might suppose that from the ability 
 to recognize a perforation early to the ability to recognize a threat- 
 ened perforation would be a natural progression of events. And yet, 
 with one or two exceptions, nothing has been said on this point. 
 We beheve that the important reduction in the mortality of these 
 cases will come when an imminent perforation is recognized, and the 
 necessary surgical steps taken ; and not before that time. It must be 
 remembered that early recognition and operation of a perforation, 
 though important, are not alone sufficient. 
 
 Similar symptoms, of a perforated ulcer, may accompany 
 vastly different pathologic conditions, as discovered at operation. In 
 one case the perforation may be small with little leakage. In others 
 there may be a wide opening with the escape of large quantities of 
 gastric juice and even an entire meal. So that, even if operated upon 
 early after prompt recognition, there will still be factors present 
 beyond our control and variable in determining the end results. 
 Again, these acute abdominal conditions do not always occur when 
 time and place are convenient for patient and operator. 
 
 As a matter of fact it is doubtful whether the exact time of 
 
 53 
 
perforation is ever recognized. In the great majority of cases it is 
 the spreading of the peritonitis that produces the alarming symptoms. 
 The erosion has gone on slowly, approaching the serosa little by little. 
 The inflammatory process spreads to the peritoneum which thickens 
 in its attempt to prevent the perforation. The threatened point is 
 further protected by omentum, sometimes by the under surface of the 
 liver, by spleen, or even by the anterior abdominal wall. As the 
 erosion goes on, one of several events may happen. Either the de- 
 structive process goes on faster than the protective process without, 
 or the force within the stomach may become too great, and there 
 results more or less profuse leakage, and a rapidly spreading periton- 
 itis. It is not denied that there are cases in which little or no effort 
 at a protective process can be seen, but in the greater number of 
 cases the sequence of events occurs as described. 
 
 Epigastric pain and epigastric tenderness are the most important 
 symptoms of impending perforation of gastric or duodenal ulcer. 
 Other symptoms of ulcer may or may not be present, or have been 
 present. The pain varies in severity a good deal with the patient's 
 temperament, but it is decidedly epigastric, and, if present in the 
 patient's past history, increased markedly. The tenderness is severe 
 and localized, the maximum point thereof corresponding to the site 
 of the ulcer. Rigidity of the abdominal wall, though present, is of a 
 lesser degree than when the peritonitis is well under way. It is true 
 that these, symptoms are present in most cases of ulcers, but it is 
 their increase, their comparison with previous conditions that is 
 important. 
 
 It must not be forgotten that chemical, thermal and mechanical 
 stimuli are felt only in the upper and lower ends of the alimentary 
 tract. They are lost in the upper esophagus, and only perceived in 
 the lower rectum. Ulcerative processes in the stomach and duo- 
 denum do not in themselves cause pain except when the inflamma- 
 tory condition extends to the neighboring peritoneum. According 
 to the direction in which the lymphatics carry the inflammation, the 
 pain, by irritation of the lumbar and intercostal nerves, may be re- 
 ferred to organs that also send lymphatics to these nerves. ^^ These 
 anatomic relations explain the frequency with which less acute ulcer- 
 ative conditions in the stomach and duodenum are confused with 
 lesions of the gall-bladder, kidney, appendix or pancreas. ^^ 
 
 Increased epigastric pain and increased epigastric tenderness 
 then, in cases with a history of gastric or duodenal ulcer, are to be 
 interpreted as meaning that the peritoneum over the lesion is taking 
 part in the inflammatory process. Whether or not the necrosis also 
 will extend to the serosa, that too, is beyond our control. The im- 
 portant fact is that the perforation is imminent and prompt surgi- 
 cal interference is indicated. 
 
 Brentano^ obser\^ed that cases of perforated gastric and duo- 
 denal ulcer gave in their histories prehminary symptoms of perfora- 
 tion, such as cramps and stabbing pains and called them "Heralds 
 (Vorboten) of perforation." MitchelP^ observed that rigidity and 
 tenderness are signs that the peritoneum is already involved, and are 
 danger signals of perforation. McGuire^* noted an increase in pain 
 and tenderness just before perforation. Noetzel^^ hoped that the 
 mortality of the perforated cases would be reduced by prophylactic 
 means, that is, by early operation of painful ulcers. That is what 
 
 54 
 
Fig. 3. Removed pylorus with portion of stomach and duodenum, 
 tense inflammation of peritoneum. Perforation imminent. 
 
 In- 
 
 FiG. 4. Removed pylorus. Mucosa side of Fig. 3, showing part of stomach 
 and duodenum, ulcer about to perforate. Second ulcer is seen. 
 
we wish to emphasize and indorse, operation before, not after, per- 
 foration. 
 
 In the following seven cases the diagnosis of impending perfora- 
 tion was made and operation urged. Case I refused operation for the 
 reason that several months before, he had recovered from a similar 
 attack under medical treatment. His refusal was given in much the 
 same manner that patients with appendicitis, in their second or third 
 attack, beg for another trial of the ice-bag. And this we point out 
 as an objection to the medical treatment of painful ulcers, that if the 
 patient recovers for the time, as they do, in later attacks much valu- 
 able time may be lost trying the same treatment again. As a further 
 objection to this plan of treatment we may add that many of these 
 cases, for economic reasons can ill afford to undergo these long terms 
 of rest. They must be returned to work as promptly as possible. ^^ 
 
 Case I. — German Hospital. No. 31546. O. B. 27. Admitted to hospital 
 April 24, 1915- History of stomach trouble for several years. Pain and 
 epigastric tenderness. Worse two months ago. Recovered under care of 
 physician, rest in bed, milk diet, etc. On readmission, symptoms again worse 
 for several days. Operation advised by physician and refused. Twelve hoiurs 
 after admission symptoms alarming. Operation April 24, 1915. Large indu- 
 rated ulcer high up on lesser ctuvatiu-e. Considerable free blood in epi- 
 gastrium. Perforation only made out by noting point of escape of gastric con- 
 tents. Infolding with one deep suture and gauze tampon. 
 
 In this case the perforation took place while the patient was in 
 bed in a hospital. Recovery uneventful, discharged thirty-ninth day 
 after operation. 
 
 Case II. — German Hospital. No. 3031 1. L. I/. 49. History of stomach 
 trouble for years. Periodic pain, vomiting and epigastric tenderness. Food 
 increases pain. Recently all symptoms worse. Retracts epigastrimn in walking. 
 Tenderness in epigastrimn over area midway between umbilicus and ensiform. 
 Diagnosis, impending perforation of gastric ulcer. Operation November 12, 
 1 9 14. Large indiu-ated ulcer on lesser curvature. Peritonemn red and thick 
 over lesion. ]Bxcission of ulcer and posterior gastroenterostomy. Recovery 
 uneventful. Discharged twenty-first day after operation. 
 
 From the illustration (Fig. i.) it will be seen that only the 
 thinnest layer of tissue separates the stomach and peritoneal cavities. 
 There is little doubt in our mind as to the probability of perforation 
 in this case. 
 
 Case III. — German Hospital. No. 30903. W. D. 22. Attacks of pain 
 in stomach for two years, lasting weeks at a time. Pain came on soon after eat- 
 ing. Present attack began three weeks before admission. Artificial vomit- 
 ing brings relief. Entire epigastrimn tender, most marked to right of point half 
 way between umbilicus and ensiform. Operation, February 5, 1915. Ulcer, 
 indurated, of anterior siuface of stomach near pylorus. Peritonetmi red and 
 thickened. Posterior gastroenterostomy. Recovery imeventful, discharged nine- 
 teenth day after operation. 
 
 In this case gastroenterostomy was deemed sufl&cient. The man 
 has been well since. 
 
 Case IV. — German Hospital. No. 33090. H. P. 48. Had stomach trouble 
 for five years. Sharp pains in epigastrimn radiating to back. At first twice a 
 year, attacks are now once a month and more severe Ln character. Artificial vomit- 
 ing brings relief. Four days before admission pain is continuous. Eat- 
 ing does not influence pain! Diagnosis, Impending perforation of gastric ulcer. 
 Operation, November 11, 1915. Ulcer high up on lesser curvature, adherent 
 behind and boimd down. Much induration. Peritonemn thickened and red. 
 
 55 
 
Posterior gastroenterostomy. Discharged cured twenty-seventh day after 
 operation. 
 
 As in Case III, gastroenterostomy was sufficient to bring about 
 a cure. Patient has been free from pain since. 
 
 Case V. — German Hospital. No. 33257. C. G. 34. One week before ad- 
 mission patient had pain in epigastritim, stabbing in character, vomited blood. 
 Pain relieved by eating! Had tarrystools. Kpigastrium rigid and very tender 
 over area to right of point half way between umbilicus and ensiform. Diag- 
 nosis, impending perforation of ulcer at pylorus. Operation November 22, 
 1915. Large induration of duodenvmi pylorus and pyloric part of stomach. 
 Peritoneum very red and ulcer can plainly be felt, especially its thin base. 
 Resection of pylorus and indurated area either side thereof. Posterior gastro- 
 enterostomy. Discharged on thirty-second day, cured. 
 
 Aside from the extensive induration the case presented the inter- 
 esting feature of a second ulcer on the gastric side of the pylorus (Fig. 
 II.). On searching for this patient to ascertain his present con- 
 dition we learned that he had contracted pulmonary tuberculosis 
 and had gone to some country sanitarium for treatment. 
 
 Case VI. — German Hospital. No. 33278. F. S. 38. Four years history 
 of stomach trouble. Boring pain in epigastrium. Food aggravated pain! 
 Vomited no blood. Pain severe for last year. Starved on account of fear 
 of food. Even milk caused excruciating pain. Same pain day and night. 
 Entire epigastrium very tender but not rigid. Diagnosis, ulcer at or near 
 pylorus. Operation November 23, 1915. Entire pylorus for 2.5 cm. (i inch), 
 both ways red, indurated and hard. Ulcer felt in pylorus with thin base. 
 Under surface of liver adherent over ulcer but easily freed. Resection of 
 pylorus and posterior gastroenterostomy. Discharged one hundred and sixty- 
 ninth day after operation. (Figs. Ill and IV.) 
 
 It will be noted that in this case also, a second ulcer was found. 
 The peritoneum was intensely inflamed and the ulcer base thin. On 
 the twenty-eighth day after operation a gastric fistula appeared 
 which failed to close until the hundred sixty-ninth day after opera- 
 tion. 
 
 Case VII. — German Hospital. No. 34408. P. S. 25 Denies any previous 
 history of gastric disturbance. About an hour before admission he experienced 
 sudden epigastric pain. Epigastrium is tender and rigid. Maximum point of 
 tenderness over duodenum. Diagnosis, impending perforation of duodenal 
 ulcer. Operation March 30, 1916. One and one-half hours after admission 
 pylorus and first part of duodenum adherent to anterior abdominal wall. Only 
 very slight leakage from ulcer at pylorus which may have been started by 
 separating gut from abdominal wall. Entire pyloric portion of stomach, 
 pylorus and first part of duodenum indurated. Adhesions freed and ulcer 
 found in pylorus with base the size of a dime. Whole indurated area infolded 
 without regard to occlusion of pylorus. Gauze strip to point of infolding. 
 Discharged seventy-nineth day after operation, cured. 
 
 Dismissal in this case was delayed by a suppurative parotitis and 
 by repeated x-ray examinations. The last report made May 22, 1916, 
 six weeks after operation, is : Plate of stomach shows good tone, 
 regular peristalic wave and perfectly normal contour (Report Num- 
 ber 406). On the fifth day this patient was taking all the fluids he 
 wanted and in the twenty-seventh day was eating regular mixed diet. 
 He vomited only once, an hour after operation. This case is added 
 because, though there was infolding of a greater amount of gut wall 
 than usual, there was no ill effects noted and six weeks after opera- 
 tion no distortion of the stomach was observed. It must be noted 
 here, that the infolding is done in the long axis of the stomach and 
 duodenum which probably occludes less than if the folds were made 
 across the gut, 
 
 56 
 
Tabi,e I. 
 
 Durati®n Tender- 
 
 No. 
 I 
 
 2 
 
 3 
 
 4 
 
 5 
 6 
 7 
 In 
 
 Vomit- 
 Pain ing 
 + + o 
 
 + 
 
 Rel. 
 
 of Food to Pain 
 worse 
 worse 
 worse 
 none 
 relief 
 worse 
 
 Age Loc. of Sym. ness 
 
 2^ Gast. 2 years 4- 
 
 49 Gast. 5 years -}-+ + 
 
 22 Gast. 5 years + + Induced 
 
 43 Gast. 5 years + + Induced 
 
 34 Duod. 1 week -f- ++ + 
 
 38 Duod. 4 years ++ ++ + 
 
 25 Duod. o + + + _ — 
 
 the table given, the symptoms are arranged in the order of 
 their value to us. It will be noted that those considered most import- 
 ant are also the most constant. It may be added that the same relative 
 value is placed on these symptoms in dealing with less acute ulcers 
 or ulcers already perforated. 
 
 In conclusion we may state that gastroenterostomy, of whatever 
 value in other types of ulcers, does not, when added to closure of a 
 perforated gastric or duodenal ulcer, improve the patient's chances of 
 recovery. Though early recognition and operation have given the 
 best results, we submit, nevertheless, that the hope for improvement 
 in the situation Hes in operation before perforation. 
 
 REFERENCES. 
 
 1. Brentano, Langenbeck's Archiv. Bd. 81, No. i. 
 
 2. Petren, Surg. Gyn. & Obst. Vol. XIV, p. 555. 
 
 3. Eliot, E. Annals of Surgery. Vol. LV, p. 557. 
 
 4. von Eiselberg, Deutsche Med. Wchnschft. 1906, No. 30. 
 
 5. Patterson, Surgery of the Stomach, p. 170. 
 
 6. Lewisohn, Surg. Gyn. & Obst. Vol. XXII, p. 379. 
 
 7. Gibson, Surg. Gyn. & Obst. Vol. XXII, p. 388. 
 
 8. Jaboulay, Archiv. Prov. de Chir. 1906, No. 9. 
 
 9. Cuff, Brit. Med. Journal. 1907, Feb. 2. 
 
 10. MacCarty, W. C, Surg. Gyn. & Obst. 1910, p. 447. 
 
 11. Seyffarth, Deutsche Med. Wchnschft. 1911, p. 731. 
 
 12. Lennander, Centralbl. f. Chir. 1901. 
 
 13. Mitchell, Annals of Surgery. 1911, Dec. 
 
 14. McGuire, E., Buffalo Med. Journal.^ Vol. 67, No. 11. 
 
 15. Noetzel, von Bruns Beitr. z. Kl. Chir. Bd. 51, No. 2. 
 
 16. Schwarz, Centralbl. f. Chir. 1912, p. 26. 
 
 57 
 
VI 
 THE JEWISH HOSPITAL OF BROOKLYN. 
 
CLINIC AT THE JEWISH HOSPITAL. 
 William Linder, M.D. 
 
 SPLENECTOMY FOR TUBERCULOSIS OF SPLEEN. 
 
 Case; I. The patient is a woman twenty-nine years of age, who 
 for three years has been suffering from symptoms referred to her 
 stomach. She has lost twenty pounds in weight and is the subject 
 of progressive weakness. She is the mother of three children, of 
 whom the youngest is one year of age. She was admitted to the 
 hospital on March 27, 1916, complaining of a lump in the left side 
 of her abdomen, which was not painful or tender, she is the subject 
 of occasional chilly feelings. 
 
 Examination shows an emaciated woman, with clear conjunc- 
 tivae, no petechia, no enlargement of glands, with diffuse signs of 
 tuberculosis in both lungs. The left half of the abdomen is promi- 
 nent. There is a marked diastasis of the recti muscles. The promi- 
 nence of the abdomen is due to an enlargement of the spleen which 
 by percussion is found to extend from the ninth rib above to the 
 brim of the pelvis below. The liver is enlarged and extends from the 
 fifth costal interspace above to i inch below the umbilicus. Blood : 
 hemoglobin 57 per cent; R.B.C. 3,520,000; W.B.C. 4,200; Polys. 66 
 per cent ; slight poikilocytosis and anisocytosis. Wassermann negative. 
 Urine normal except presence of some colon bacilli. Temperature 
 upon admission, for the first three days varied from 100 to 102, then 
 sank to from 99 to 100. Pulse from 100 to 120. Respiration 24. 
 
 Remarks upon the diagnosis : The hemolytic function of the 
 spleen has been determined by experimentation in Banti's disease 
 when we find excessive hemolysis occurring. The removal of the 
 spleen in the early stages of Banti's disease is attended by great 
 benefit, before secondary cirrhosis of the liver with its associated 
 jaundice, ascites and gastro-intestinal hemorrhages occur. In this 
 connection the Gaucher type of splenomegaly must be considered for 
 purpose of differentiating. The Gaucher spleen occasionally runs in 
 families, has no associated cirrhosis of the liver, no hemorrhages, no 
 jaundice, no ascites. In this particular case the blood picture, the 
 leukopenia, the secondary anemia, the associated enlargement of the 
 liver and the absence of any glandular enlargement suggests Banti's 
 disease. On the other hand, the possibility of tuberculosis of the 
 spleen must not be overlooked. Miliary tuberculosis of the spleen 
 usually produce only a moderate enlargement. The largest spleen 
 recorded with tuberculosis is the amyloid which accompanies chronic 
 ulcerative phthisis. In this case the diffuse lung signs together with 
 the X-ray findings, the dyspepsia, the temperature that subsided with 
 rest bespeaks a possible tuberculosis. In either event a spleen, such 
 as this, is a menace to the continued life and well-being of the patient, 
 was made on the left side extending from the ninth costochondral 
 and indication for removal is clear. 
 
 Ether was then administered by Dr. I. D. Kruskal. An incision 
 junction to the outer third of Poupart's ligament along the outer side 
 
 61 
 
of the left rectus muscle. The peritoneum having been opened and 
 the spleen exposed, it was found to have a very short pedicle with 
 several large bands of adhesions attaching it to the diaphragm. A 
 better exposure was now obtained by dividing the eighth and ninth 
 costal cartilages and fracturing the corresponding ribs making an 
 osteo-plastic flap, which when retracted brought the diaphragm and 
 upper pole of the spleen into clear view. The esophagus going into 
 the stomach was plainly seen. The operator remarked that an ulcer 
 of the cardiac end of the stomach could be removed with ease by 
 this method of exposure. He stated that he had done a complete gas- 
 trectomy using this incision with the recovery of the patient. The 
 diaphragmatic adhesions were doubly ligated and divided between the 
 ligatures. Only the upper pole of the spleen was freed. The gastro- 
 splenic pedicle was then exposed and divided between ligatures until 
 the entire blood supply of the spleen was controlled. This was ac- 
 complished without disturbing the spleen from its bed. The spleen 
 was then lifted from its bed; inspection of the wound showed com- 
 plete hemostasis. The abdominal wound was then sutured in layers 
 and closed without drainage. 
 
 Pathological report of specimen: gross weight 1,266 grams; size 
 26 by 14 by 7 cm. Capsule very thick, marked increase in consistency 
 of parenchyma. Surface granular pinkish with areas here and there 
 of bluish colored tissue. Tendency to fasicular arrangement of por- 
 tion of the splenic pulp. Many blood vessels with patent mouths. 
 Microscopic section showed tuberculosis of the spleen. 
 
 CYSTIC GOITRE; THYROIDECTOMY. 
 
 Cass II. The patient was a girl twenty-three years of age who 
 had been the subject of a small swelling of the neck, noticeable for 
 ten years. Six years ago it began to increase in size and has become 
 steadily larger until the present time. Now there is a large swelling 
 occupying the left side of the neck and extending from the left angle 
 of the jaw to one and one-half inches to the right of the median line, 
 and from the clavicle to the lower edge of the jaw. The patient 
 suffers from cardiac palpitation only after much exertion, there is 
 slight exopthalmia. Face is flushed; tonsils not enlarged. Blood 
 count: W.B.C. 13,200; polymorphonuclears 81 per cent; monoculears 
 and transitional i per cent; lymphocytes 18 per cent. Pulse from 
 72 to 88; temperature normal. Dr. Linder remarked that this patient 
 has as yet manifested but slight symptoms of thyroid toxemia from 
 a result of increased thyroid secretions, although she is very excitable. 
 Her real motive for applying for operation is on account of the dis- 
 figurement from the growth and some pressure symptoms. She has a 
 simple cystic goitre, but such a goitre can produce secondary hyper- 
 thyroidism, by pressure upon that part of the thyroid which is still 
 active and so stimulating increased production of secretion. It may 
 easily be converted into a simple goitre of the Basedow's type. In 
 the removal of a goitre of this kind special care is to be observed to 
 avoid removal of the parathyroid bodies producing myxedema. The 
 patient was then anesthetised by ether oxygen by the endopharyn- 
 geal method by Dr. I. D. Kruskal. A transverse collar incision extend- 
 ing through the skin and platysma myoides was made and the flaps 
 dissected up sufficient to fully expose the seat of operation. These 
 flaps were then protected with towels secured by clamps and by gauze 
 
 62 
 
sponges, after which an incision was made in the median line expos- 
 ing the sterna-hyoid muscles which were retracted exposing the cap- 
 sule of the thyroid gland. After two parallel clamps had been placed 
 upon the muscles at right angles to their fibres, at about i inch below 
 the hyoid bone, the muscles were severed between the clamps and re- 
 tracted. The large venous trunks on the surface of the thyroid were 
 carefully doubly ligated and cut between ligatures, and enucleation of 
 the gland was started at the upper pole, the cyst being carefully lifted 
 up as freed, the blood supply being identified and controlled. The 
 recurrent laryngeal nerve was identified. The lower pole extended 
 about one and one-half inches below the upper margin of the clavicle. 
 It was carefully lifted up and rolled out toward the median line, 
 and finally the isthmus was divided. 
 
 In the course of this procedure the operator remarked that if the 
 surgeon carefully worked outside of the capsule and ligated all blood 
 vessels as they were met with, the lymphatic vessels would also be 
 enucleated and a dry wound would result, and there would be no 
 necessity of painting the raw surfaces with such an antiseptic solu- 
 tion as Harrington's, and drainage would be avoided for the removal 
 of the excess of thyroid juice spilt in the field of operation for future 
 absorption and the production of subsequent post operative hyperthy- 
 roidism. By the method of operating which he followed he left his 
 wound so absolutely dry that he was able to close it and have no 
 trouble thereafter. He was careful to avoid injury to the nerve or 
 to the parathyroid bodies. If he met with any difficulty it was his 
 custom to divide the isthmus first and study the region of the parathy- 
 roids and the blood vessels. At the completion of the neucleation, 
 the trachea exposed at the bottom of the wound was found to be 
 compressed and flattened and displaced to the right of the median 
 line. After final careful hemostasis the muscles that had been divided 
 were resutured. A few interrupted subcuticular catgut sutures co- 
 apted the skin. The skin wound itself was closed by special metal 
 clips which were to be left in place for five days. The use of these 
 clips was resorted to because of the less danger of skin infection 
 that attends such use. No drain was put in place. The operator 
 said that most cases of this kind were allowed to sit up at the end of 
 twenty-four hours. The subsequent history of this case was an un- 
 eventful recovery. 
 
 ACUTE HEMORRHAGIC PANCREATITIS; EXPLORATORY 
 INCISION; DRAINAGE. 
 
 Case III. Woman thirty years of age; mother of two children, 
 who gave history that six years ago she first experienced a severe 
 pain over the entire abdomen, which came on suddenly. Was at- 
 tended with repeated vomiting with chills and fever and marked 
 perspiration over the entire body. The attack lasted eight hours, at 
 the end of which time relief was experienced. It occurred during 
 her first pregnancy. One and one-half years later, during a second 
 pregnancy, second month, she then went through with a similar at- 
 tack, almost identical in its features. Eight months later a third 
 attack occurred and for the next five months these attacks occurred 
 every week or two but of less severity than at first. They were re- 
 lieved by enemata. Nine months ago these attacks again began, 
 although not so severe as formerly. They were attended with pain 
 
 63 
 
which extended throughout the abdomen and at times radiated to the 
 right shoulder. They were attended with vomiting, chills and fever 
 and her abdomen would become moderately swollen so that it was 
 difficult for her to assume a sitting posture. Four days previous to 
 admission to hospital she was again seized with severe epigastric pain, 
 which radiated to the left lumbar region, attended with vomiting. The 
 attack lasted for twenty-four hours, but the vomiting continued and 
 the abdomen began to swell. She was constipated. No urinary 
 disturbance. In this condition she was admitted to the hospital. Upon 
 admission the abdomen was distended, the abdominal walls were 
 slightly rigid, the epigastric region was doughy to the touch and very 
 tender. The tenderness was present over the entire abdomen ; no 
 abdominal organs could be palpated. Also tender in the left lumbar 
 region, especially at the right costovertebral angle. Right trapezius 
 tenderness also obtained. 
 
 Blood count: Total 23,500; polymorphonuclears 75; mononu- 
 clears I ; lymphocytes 24. Temperature from loo to 100.4. Pulse 
 72 to 80. Respiration is normal. Urine negative. 
 
 Dr. Linder remarked that the previous history of this patient 
 indicated typical attacks of gall stone colic. The last attack started 
 four days ago which differed from her previous attacks for these 
 reasons : The pain was referred to the mid abdomen which radiated 
 to the left of the median line around to the lumbar region. Upon 
 inspection both the abdomen and face showed a slight cyanosis. Pal- 
 pation revealed a distended, soft, doughy abdomen with a sense of 
 fullness in the mid epigastrium and tenderness extending to the left 
 of the median line with special tenderness at the costo-vertebral angle. 
 No special tenderness over the gall bladder and no palpable gall blad- 
 der could be found. The diagnosis of chronic cholelithiasis and acute 
 hemorrhagic pancreatitis was probable, and an exploratory abdominal 
 incision is called for. 
 
 Ether was then administered by Dr. Kruskal, and the abdomen 
 was opened through a right rectus incision ; coils of distended bluish 
 small intestines appeared in the wound. The gall bladder Avhen ex- 
 posed was found to contain numerous gall stones. It was thin walled 
 and bluish, no obstruction of the cystic duct. Palpation with the 
 finger in the foramen of Winslow showed no stones either in the 
 Ampulla of Vater or in the common duct. Through the gastro- 
 hepatic omentum an opening was bluntly made by the finger to ex- 
 pose and explore the pancreas. Some serosanguinous fluid escaped 
 from the opening. After carefully sponging the cavity exposed, the 
 pancreas was seen to be chocolate colored, containing numerous patches 
 of fat necrosis. The pancreas was punctured in four or five places 
 with a blunt instrument, and a split rubber tube containing gauze was 
 placed down in the retro-peritoneal space. The gall bladder was 
 opened and its contained stones were removed. 
 
 Dr. Linder remarked that primary hemorrhage into the pan- 
 creas does occur producing the typical lesion of fat necrosis. If this 
 hemorrhage is not too great, these attacks may not be recognized, and 
 the patient may get well from a slight hemorrhage, but such hemor- 
 rhages have a tendency to recur and unless recognized and operated 
 upon usually ultimately terminate fatally. The old conception that 
 diagnosis of acute pancreatitis cannot be made except at an autopsy 
 table, or if made the cases end fatally, does not hold today. In his 
 own service at the Jewish Hospital they have records of at least 
 
 64 
 
twenty-four cases of acute hemorrhagic pancreatitis during the past 
 six years and fully 75 per cent had been diagnosed or suspected be- 
 fore operation. It is important that in all operations upon the upper 
 abdomen, where the pathology is not clear, that the pancreas should 
 be exposed and inspected. If this routine was followed a great 
 many more cases would be diagnosed, at least on the operating table. 
 The history of the case just operated upon is typical of acute hemor- 
 rhagic pancreatitis in its early and mild stage. When the pancreas 
 was exposed, however, extensive hemorrhages were found. One of 
 the most frequent conditions that acute hemorrhagic pancreatitis is 
 mistaken for is acute intestinal obstruction. Pain, vomiting, abdominal 
 distention and obstipation occur in both conditions, but the pain in 
 acute hemorrhagic pancreatitis is more severe. It is so great often 
 that a half grain of morphine does not relieve it. In intestinal ob- 
 struction vomiting is more profuse. The differentiating from gastric 
 or duodenal perforation is to be made by the absence of the scaphoid 
 abdomen and the boardlike rigidity and also the absence of any 
 previous history of gastric or duodenal ulcer. 
 
 The after history of the patient operated upon was an uneventful 
 recovery. 
 
 65 
 
VII 
 THE BROOKLYN HOSPITAL. 
 
THE ORIGIN AND COURSE OF CHRONIC PERITYPHIL- 
 
 ITIS 
 
 John Edward Jennings, M. D. 
 Surgeon Brooklyn Hospital; Surgeon-in-Chief Greenpoint Hospital. 
 
 THERE is a group of cases in which the symptoms, which had been 
 attributed to the irritation caused by a chronically inflamed ap- 
 pendix, persist, after the removal of that organ to the annoy- 
 ance of the surgeon and patient alike. Forced upon the attention by 
 the fact that the symptoms are unrelieved by operation, it is evident 
 that conditions exist in the right iliac fossa which resemble chronic 
 appendicitis in symptomatology but are due to other causes. The 
 situation is complicated by the fact that almost all removed appendices 
 are declared somewhat abnormal by the sympathetic pathologist and 
 that complete relief of symptoms occasionally follows the excision of 
 organs very slightly changed in gross appearance from the normal. 
 This has led to increased interest in this region with the recognition 
 and study of various pathological conditions associated with pain, 
 constipation and digestive disorders. 
 
 The French recognized, nearly twenty years ago, a clinical picture 
 which has been described under the term "Typhlo-colite" or "Typh- 
 lite ptosique." Dieulafoy pointed out that there were attacks of 
 pain in the ileo-cecal region which had, he thought, nothing to do 
 with the appendix but which signified the localization of a muco 
 membranous colitis in the cecum. The attack resolves itself into a 
 severe seizure of pain about the cecum which lasts only a few hours 
 and disappears quite suddenly. If the patient is examined during the 
 attack it will be found that tenderness exists on pressure in the illiac 
 fossa but that there is no rigidity. In many cases an elastic body can 
 be felt which may vanish under pressure and appears to be the 
 distended cecum. Vomiting may be present with a slight rise of 
 temperature and a spontaneous diarrhea often ends the attack: more 
 or less tenderness sometimes presists. 
 
 More recently the same condition has been described in Germany 
 under the name of "Cecum mobile," or "Typhlatonie," etc. 
 
 In this country, Jackson, Flint and others have described the 
 fine vascularized membranes found upon the ascending colon or 
 cecum. "The membrane," Jackson says, "does not resemble the 
 ordinary conception of an adhesion. It is never adherent to the ab- 
 dominal wall nor to any contiguous portion of the small intestine. 
 Instead it resembles more closely than anything a thin pterygium. 
 In recent cases the membrane is quite free and produces but limited 
 restriction of the underlying colon. In more advanced and character- 
 istic cases it seems to bind the colon close to the posterior abdominal 
 wall and produces such marked angulations and convolutions of the 
 colon as to practically produce a stricture of its lumen." 
 
 The Theories as to Etiology are three: 
 
 69 
 
I — That it is congenital, 
 
 2 — That it is mechanical — a physiological response to trac- 
 tion. 
 3 — That it is inflammatory, either from a spreading peri- 
 tonitis from pomts of original infection without or 
 from infections within the contiguous gut. 
 The studies of Flint and of Eisendrath and Schnoor may be 
 accepted as determining the congenital origin of these structures. 
 "They originate," to quote from Flint, "after the rotation of the 
 gut from the secondary fusions of the peritoneum when the cecum 
 becomes attached to the posterior abdominal wall just over the kid- 
 ney and under the liver. In some instances these attachments, 
 usually confined to the posterior aspect of the cecum and colon, 
 are excessive and extend out over the ventral surface of the first 
 part of the large intestine resulting, with the subsequent descent of 
 the cecum, in their being drawn in the form of a thin veil or mem- 
 brane. In this process the blood vessels take part, a fact which ex- 
 plains the long unbranching course from their origin on the parietal 
 peritoneum downward and forward onto the cecum or colon where 
 they communicate with those of the intestinal wall." 
 
 Eastman called attention to "the striking similarity of the foetal 
 peritoneal fold described by Jonesco and Juvara and designated by 
 them the parieto-colic fold to the adult peritoneal anomaly described 
 by Jackson as membranous pericolitis and generally known as "Jack- 
 son's veil," and also to the probable casual relationship between the 
 bloodless fold described by Treves and a pocket-like anomalous peri- 
 toneal reflection which is not rare in the adult and which passes from 
 the mural peritoneum upon the right side quite low down, extending 
 upward and inward over the caput coli and vermiform appendix, to 
 be attached to the last two or three inches of the ileum and to the 
 peritoneum of the caput coli. It forms the boundary of a pre-colic 
 fossa in which the cecal head and the appendix may rest, as in a 
 pocket. It is likely that the caput coli with the appendix are not 
 rarely, during operations for appendicitis, shelled out of this peritoneal 
 fold, that is the bloodless fold of Treves, which forms the pocket, 
 being looked upon by the operator as an affair of adhesion forma- 
 tion." He also at the same time called attention to the fact that, 
 "Douglas Reid has described under the name Genito-Mesenteric 
 Fold, a rather common foetal fold of peritoneum which passes from 
 the terminal portions of the ileum into the pelvis" and connected it 
 with the formation of the so-called Lane's kink, and frequent as- 
 sociation of appendicitis and oophoritis. 
 
 We distinguish the following anatomical forms of these veils 
 or membranes : 
 
 I — The parieto-colic, in which the veil stretches from the 
 parietal peritoneum at the hepatic flexure over the 
 lateral and ventral surfaces of the ascending colon 
 and cecum. 
 2 — The parieto-cecal, which extends from the parietal peri- 
 toneum lower down, passes over the head of the ce- 
 cum and may merge with the first type above. 
 3 — ^The parieto-ileo appendicular, or fold of Treves. 
 4 — The genito-mesenteric or ileo-pelvic. 
 
 5 — The omento-colic, of Flint, which passes over the ven- 
 tral aspect of the colon and is continuous with the 
 omentum. 
 
 70 
 
Eisendrath and Schnoor from observations during operations 
 and from examination of ten foetuses, confirmed the position of East- 
 man and drew attention to the similar parieto-colic and genito-mesen- 
 teric folds on the left side. They reported a case which affords 
 proof of the role which the Jackson's veil may play in the produc- 
 tion of acute and chronic obstruction of the ascending colon and 
 cecum. "We are not prepared to state at the present time," they 
 write, "what causes this change in the peri-colic membrane from 
 an innocent persistent foetal structure to the production of a distinct 
 pathological entity." We may then consider the normal anatomy 
 of the peri-colic folds as sufficiently established for us to advance 
 their gross pathology and the nature of the process which brings 
 it about. In a number of cases of acute appendicitis operated on 
 during the attack the condition of the peri-colic membranes, which 
 were present, have been observed. In many of these the veil was found 
 edematous, somewhat thickened, pearly grey in color; and in several, 
 small portions were removed for section and culture. The sections 
 show round cell infiltration; and the cultures, a pure growth of colon 
 bacillus. In all of these cases the peritoneum itself was not in- 
 volved, and the process seemed to be a distinguishing symptom. 
 Localized areas of injection and thickening were made out and from 
 one of these the colon bacillus was isolated. It seems fair to assume 
 that the contraction and band formation, which is found in later 
 cases, are direct sequelae of this infectious process. I have 
 also observed four cases in which the process of veil con- 
 traction on the right side has been recognized at operation and 
 at a later date symptoms have arisen which have been due to a 
 similar process initiated on the left. These cases have also had 
 more or less colitis. I think we may safely say that just as we know 
 how acute infection spreads from the appendix behind the peritoneum, 
 so it may be recognized that a more chronic inflammation in certain 
 cases follows the same paths. This inflammation may be of short 
 duration and followed by resolution, as may be seen if one notes 
 conditions at operation in many catarrhal cases. It may be slowly 
 progressive with remissions and exaccerbations and it may leave in 
 its wake contractures and adhesions. There are cases in which a 
 definitely progressive history is obtainable, beginning as a larvate 
 appendicitis, advancing through the stage of ileocecal disablement to 
 the beginning of a chronic colitis with involvement of the splenic 
 flexure and sigmoid in the peri-colic process. It seems fair, to 
 some authors, to consider these cases examples of a descending colitis, 
 and to charge the peri-colitic bands to infection through the epiploic 
 appendages. 
 
 The disease may then be defined as follows : Chronic perityphlitis 
 is a process characterized by the presence of areas of subperitoneal 
 congestion, inflammation and cicatrical retraction accompanied by 
 disturbances of ileo-colonic function, by catarrhal and croupous in- 
 flammation of the cecum and ascending colon and sometimes initiat- 
 ing a descending colitis and peri-colitis. The fact that these areas 
 may be seen inflamed during an acute attack of appendicitis, that 
 one or more of them are often seen inflamed, an exacerbation of 
 chronic right iliac pain and that most of them recovered completely 
 after the appendix had been removed render it probable that the 
 infection takes its rise most often in the appendix. The fact that 
 
 71 
 
some of them continue to give symptoms after the appendix has 
 been removed calls for explanation. Is the continuation of trouble 
 due to irritation from the scars of contractures unrelieved by opera- 
 tion or is it due to recurrent attacks of inflammation set up by in- 
 fection in the terminal ileum, in the cecum, or in the ileo-colic glands ? 
 I am persuaded that each of these situations may furnish a nidus 
 from which recurrent spreading infections may arise. 
 
 The terminal ileum is rich in lymphatic tissue, it is the site of 
 ulceration in typhoid, in tuberculosis and perhaps more often than we 
 now admit, of infections not yet recognized as specific. In a recent 
 case a well defined ulcer with edges as indurated as the usual duodenal 
 type, involved two-thirds of the circumference of the ileum from 
 the ileo-cecal valve backward about two inches. It would seem, how- 
 ever, that this type of disease must be rare. 
 
 The ileo-colic glands are not infrequently found quite distinctly 
 involved in a definite group of cases of appendicitis, most often ob- 
 served in children and adolescents. These cases occur as an immed- 
 iate sequel of a tonsillitis. On the second, third or even the fourth 
 day of throat infection abdominal pains and vomiting begin. The 
 temperature is usually rather high, 103 to 104° F, and as the 
 general abdominal pain and tenderness becomes localized it is often 
 possible to recognize that it is somewhat higher and nearer the navel 
 than the usual site of appendicular distress. Some of these cases 
 go on to suppuration or gangrene, but most of them subside with rest. 
 If such' a case be opened in the catarrhal stage one finds that the 
 glands in the ileocolic angle are much enlarged and that this is much 
 more noticeable than the involvement of the appendix which may 
 even appear nearly normal. There will be found, however, the same 
 retroperitoneal injection and edema that has been mentioned before. 
 
 The relation of stercoral typhilitis to peri-typhilitis is doubtful 
 It has been noted that the disease has a tendency to progress and to 
 involve the left side and this appears in two different ways : In the 
 first, a catarrhal colitis is followed by the appearance of pain and 
 sensation of gas lodged on the left side. These "gas balloons," as 
 some of the patients call them, are high on the left side — this may 
 be called the diverticular type. In the second, after signs of right 
 ovarian irritation, constipation increases and the sensation of "gas 
 balloons" appears low on the left side. 
 
 The first variety seems to be due to an extension within the colon 
 and its dissemination in the region in which diverticulae are most often 
 found. 
 
 The second is due to a spread of the subperitoneal process 
 around the pelvic brim, apparently advancing with the congestion 
 of each menstrual period. These patchy areas of injection and 
 edema may be seen in cases not too far advanced, in which proper 
 search is made. 
 
 There is a variety of peri-colic's which apparently originates in 
 the gall bladder and descends involving the parieto-colic and omento- 
 colis folds and causing, in its later stages, a rather confused picture of 
 upper and lower disease on the right side. 
 
 The condition is to be suspected in cases of long standing, inter- 
 mittent right iliac pain and tenderness, in dyspepsia with tenderness 
 in the right iliac fossa, although no complaint of pain is often made. 
 These are typically ileal cases rather than cecal. 
 
 It should also be suspected in dysmemorrhea of young, unmarried 
 
 72 
 
women, especially if right sided ache persists between periods and 
 the digestion is affected. The signs are: tenderness and pain in the 
 same spot or spots at different times, often increased by exercise; 
 delay of bismuth meal ; tenderness and pain on inflation of the colon. 
 These cases should be carefully distinguished from those in which 
 atony and dilatation of the cecum exist without inflammation or ob- 
 structive retraction in the neighborhood. Such cases constitute quite 
 another group, probably to be dealt with in the same chapter with 
 local vagotonia, certainly not here. 
 
 Treatment: A liberal incision through the middle or around the 
 outer edge of the right rectus should be made so as to reveal the 
 terminal ileum, the cecum and the ascending colon and give access, 
 if necessary, to the right side of the pelvis. The appendix, the 
 cecum and its neighborhood, the situations in which inflamed veils 
 are to be found, are all investigated, as is the gall bladder region. 
 The appendix is removed and if no perityphlitis is found nothing else 
 is done. If there is present also a dilated and prolapsed cecum with 
 evidence of inflamed parieto-colic veils, the veils are severed with 
 a knife, not torn, bleeding points caught and tied, and the dragging 
 cecum suspended in a slit in the parietal peritoneum. If the process 
 involves the pelvis and the terminal ileum, this is taken care of by 
 slitting the ligament, binding down the ileum, and covering the raw 
 area either by folds of the broad ligament or by unrolling the mesen- 
 tery or by rotating the cecum inward as circumstances may suggest. 
 If the ileo-cecal glands are much enlarged they may be removed by 
 careful dissection. If the disease is of long standing and the cecum 
 and ascending colon are bound down by retracted bands, especially 
 if colitis has begun to be evident, it is better and safer to remove 
 the cecum and ascending colon and anastomose the ileum into the 
 beginning of the transverse colon. In the cases of the longest stand- 
 ing in which the muco-membranous colitis has set up toxic symp- 
 toms and in which the patients are much reduced, the surgical treat- 
 ment should be done in several stages. The appendix should be re- 
 moved if this has not already been done, a cecostomy or appendicos- 
 tomy made for irrigation and an ileo-sigmoidostomy performed. At 
 a later date, if necessary, the colon may be removed or as much 
 of it as seems desirable. Such measures will only be necessary in 
 cases in which the colitis has progressed so far as to make simpler 
 measures hopeless. It is desirable that the cases should be recognized 
 early and taken care of at that time. 
 
 73 
 
SURGICAL CONSIDERATIONS OF ACUTE DIFFUSE 
 PHLEGMONOUS GASTRITIS. 
 
 Richard Ward Westbrook, M. D. 
 
 Surgeon to the Brooklyn Hospital. 
 
 MONG the less well-known surgical diseases of the stomach 
 is the so-called acute diffuse phlegmonous gastritis. The dis- 
 ease will never attract wide discussion as it is fortunately rare. 
 It is at the same time so fatal that it is unlikely that the most skillful 
 diagnosis and the best surgical treatment will ever save more than 
 an extremely small percentage of cases. It is, however, neces- 
 sary that the unsatisfactory condition of our surgical knowledge 
 of this disease should be cleared up. Suggestions made by certain 
 well-known abdominal surgeons as to treatment are, I am sure, 
 quite inadequate. Some years ago it was my good fortune to ob- 
 serve and operate upon a case of true acute diffuse phlegmon of 
 the stomach which forms the basis of this article. This case, 
 like all the other authentic cases, was fatal in the outcome, but 
 showed clearly the conditions which must be met, if surgery may 
 ultimately be successful in its treatment. 
 
 Historical. It is stated that the first mention of this rare disease 
 was made by Varandaeus in 1620. In the same century further data 
 were furnished by Borel (1656) and Sand (1695). Occasional ref- 
 erences to the condition are found until 1874 when an important paper 
 by Lowenstein appeared, and another in 1896 by Leith, of Edinburgh. 
 At the present time some 100 cases have been reported. 
 
 There are two distinctly marked varieties of phlegmon of the 
 stomach: the circumscribed form, or abscess of the stomach wall, of 
 which but few cases are reported; and the diffuse form — with which 
 we have to do chiefly in this paper — known as acute diffuse phlegmon- 
 ous gastritis. A case of the circumscribed variety has been operated 
 upon by Dr. J. Wesley Bovee, of Washington, who recognized an 
 abscess of the stomach wall after abdominal section, opened and 
 drained the same, and was rewarded with a recovery. A second 
 case of this variety was treated by partial gastrectomy, six months 
 after the onset of acute symptoms, by F. Koenig, with recovery. 
 No authentic case of the diffuse form has ever been known to recover, 
 and in only two authentic cases — my own and a later one of J. E. 
 Adams of London — has the diagnosis been made previous to autopsy. 
 
 Pathology. The diffuse form of phlegmon of the stomach has 
 been likened to a virulent erysipelas. The parallel is striking, the 
 streptococcus being responsible for both conditions, the deeper form 
 of erysipelas spreading in the subcutaneous tissues and often form- 
 ing pus, very much as the phlegmon of the stomach wall extends into 
 the submucous area, also with the formation of pus. 
 
 The stomach wall is much thickened, sometimes eight or nine 
 times greater than the normal. The thickening is greater in the 
 pyloric portion, where the disease commences and from which it 
 may spread to the whole of the stomach. The thickening lies chiefly 
 in the submucous coat. This is white, or grayish-white, in color, 
 and pus may often be squeezed from small openings in it. Micro- 
 
 74 
 
scopically it is seen to be crowded with immense numbers of round 
 cells, in the later recorded cases, the streptococcus has been the 
 organism found most abundantly. The lining mucous coat is usually 
 intact, but in the later stages may be ulcerated through by the 
 underlying suppurative process. The muscular coat is intact at the 
 start, but may also later be destroyed in part, allowing pus to pene- 
 trate it to the peritoneal coat. The peritoneal coat very rarely is per- 
 forated, but usually becomes involved in local peritonitis. 
 
 The so-caUed circumscribed form of phlegmonous gastritis is 
 due to bacterial invasion of the submucous coat, but of a milder nature. 
 The staphylococcus is probably the infective organism. The mucous 
 and muscular coats are thinned and pushed away from the abscess in 
 the submucous layer. The localized abscess which forms may 
 vary from the size of a bean to three times the size of the closed 
 fist. It may rupture into the lumen of the stomach, or into the per- 
 itoneal cavity. The rest of the stomach may show little or no change. 
 This form has been supposed to go on to spontaneous cure in a num- 
 ber of instances, where pus has been vomited. Vomiting of pus, how- 
 ever, may be secondary to any perigastric abscess wherever arising. 
 Early operation in abscess should be productive of good results. 
 
 Etiology. The etiology of diffuse phlegmonous gastritis is as 
 yet obscure. It is far more common in men than in women, at 
 least in a proportion of 5 to i. It is chiefly a disease of early adult 
 or middle life. A large proportion of the cases reported have been 
 addicted to alcholic excess. All but a few of the cases are primary 
 or "idiopathic" in their origin, and but a few are secondary to 
 pus-infections elsewhere. A few cases followed operation on the 
 stomach, such as gastroenterostomy, and a few were secondary to 
 the presence of gastric cancer. Gastric ulcer has been antecedent 
 in only a few cases. 
 
 It is probable that the infectious organisms gain entrance to 
 the stomach wall through the blood current rather than through any 
 abrasion of the mucous lining, as evidence of the latter is rarely 
 found. If the latter were the case, we should expect it to more often 
 accompany gastric ulcer and cancer. 
 
 Symptomatology. The symptomatology in the early stages of the 
 disease, before the onset of peritonitis, I believe may be considered 
 fairly characteristic, although authorities state that we can hardly 
 do more than guess at the diagnosis. I am strongly of the opinion 
 that I should be able to make the diagnosis in a second case so 
 characteristic as my own. 
 
 It is a violent disease from the start, and its abrupt onset may 
 suggest corrosive poisoning. The earliest and perhaps most per- 
 sistent symptom is vomiting. This is repeated at short intervals and 
 is so continuous as to be a very distressing feature. It is said to 
 cease in some cases a day or two after the onset, and later to recur 
 as peritonitis advances. The vomited material is watery, becoming 
 bile-stained, and later darkish as it contains more material from the 
 upper bowel. 
 
 Pain soon follows the sudden onset of the vomiting, and becomes 
 the most prominent symptom. It is localized in the epigastrium, 
 and is severe and continuous. In some cases it is said to be delayed, 
 or absent. 
 
 Pressure over the epigastrium elicits marked tenderness. Rigid- 
 ity is not of high degree before peritonitis has advanced, but there 
 
 75 
 
is present a very distinct sense of increased resistance in the epi- 
 gastrium, over an area which the hand may cover. 
 
 The pulse at first is full, but acquires fairly early a weak and 
 rapid character. The temperature may range from ioo° to 105°. 
 Chills often occur. Constipation, or constipation preceded by diar- 
 rhoea, is apt to be the rule. Diarrhoea sometimes exists. The thirst 
 is extreme as a result of the inflammation and the constant vomiting. 
 Hiccough is commonly present. The patient's mental anxiety and 
 restlessness are very pronounced, and he has the appearance of being 
 very gravely ill. 
 
 Leith states that the average duration of the cases analyzed by 
 him was six and a half days before death occurred. It may occur 
 much earlier. Death is produced by septicemia with general peri- 
 tonitis. 
 
 
 Acute 
 Pancreatitis. 
 
 Perforated Gastric 
 
 or 
 
 Duodenal Ulcer. 
 
 PhlegmonouB 
 Gastritis. 
 
 Previous 
 history 
 
 Healthy, or occas- 
 ional attacks of indi- 
 gestion. May have had 
 gall-stone history. 
 
 Periodic or persist- 
 ent indigestion. 
 
 Healthy ; alcoholism, 
 with or without gastri- 
 ns. Gall-stone historr 
 
 negative. 
 
 ^e 
 
 Chiefly middle age. 
 
 Early adult and 
 middle age. 
 
 Chiefly middle age, 
 but may occur from 11 
 to 76. 
 
 Bex 
 
 Male, in large pro- 
 portion. 
 
 Male, chiefly. 
 
 Male, In large pro- 
 portion. 
 
 Chill at onset 
 
 Usually lacking. 
 
 Usually lacking. 
 
 Frequently present. 
 
 Vomiting 
 
 Follows the pain. 
 Becomes bile-stained, 
 later black from al- 
 tered blood. 
 
 Follows the onset of 
 pain. Blood may be 
 vomited. 
 
 Commences at once 
 and is usually con- 
 stant. Becomes bile- 
 stained and dark. No 
 blood present. No pus 
 in early stages. 
 
 Thirst 
 
 Usually extreme. 
 
 Less marked. 
 
 Very marked and 
 often intolerable. 
 
 Pain 
 
 Is the first symp- 
 tom, accompanied with 
 falntness or collapse. 
 
 Is the first symptom, 
 accompanied with falnt- 
 ness or collapse. 
 
 Appears after the 
 vomiting, and often 
 after a chill. 
 
 Temperature 
 
 Irregular, usually 
 low, but may be high. 
 
 May be subnormal 
 early. Later high. 
 
 Likely to be high 
 102° to 105°. 
 
 Pulse 
 
 Rapid and small. 
 
 Rapid and small at 
 the onset. 
 
 From 100 to 110 
 early ; later very rapid 
 and thready. 
 
 Hiccough 
 
 May be present. 
 
 Not prominent. 
 
 Frequently present. 
 
 Bowels 
 
 Constipation, usu- 
 ally extreme. 
 
 Usually constipation. 
 
 Either constipation 
 or diarrhoea. 
 
 Tenderness 
 
 Extreme in epigas- 
 trium. 
 
 Extreme in epigas- 
 trium. 
 
 Very marked, but not 
 extreme. 
 
 Tumor 
 
 Rarely palpable tu- 
 mor. Increased sense 
 of resistance with dis- 
 tention. 
 
 None. 
 
 None. But Increas- 
 ed sense of tissue re- 
 sistance. 
 
 Rigidity in up- 
 per abdomen 
 
 Apt to be extreme. 
 
 Extreme. 
 
 Not extreme, but 
 well marked. 
 
 Leucocytosis 
 
 8000 to 39000. 
 
 Averaging 20,000 to 
 30,000. 
 
 30,000 to 40,000 In 
 cases observed. 
 
 Urine 
 
 Sugar may be pres- 
 ent. 
 
 Negative. 
 
 Negative. 
 
 Jaundice 
 
 Slight jaundice usu- 
 ally present. 
 
 Usually absent. 
 
 Slight, In 16% of 
 cases. 
 
 76 
 
Differential Diagnosis. The diagnosis must be made chiefly with 
 regard to differentiation from acute pancreatitis and perforated gas- 
 tric ulcer. At the very onset it may simulate acute ptomain or other 
 poisoning, but on the second day it would require differentiation 
 from the conditions mentioned. The accompanying parallel col- 
 umns will show the distinguishing symptoms most readily. 
 
 It will be seen that it is possible to make the diagnosis in the 
 earlier stages of the disease, although it is but a narrow shading off 
 from the picture of acute pancreatitis. An accurate history of the 
 onset, combined with a careful observation of the several points of 
 variation will throw the weight of evidence towards the correct 
 diagnosis. At any rate, the diagnosis of an intra-abdominal surgical 
 calamity requiring laparotomy should ordinarily be possible within 
 some hours after the onset of the disease. 
 
 Report of Writer's Case. My own case was that of H. A., age 
 51, captain of harbor Hghter, married. Previous history negative. 
 Denies syphilis. No history of gall-stones. Has had no pus infec- 
 tion of any kind for months past. Has bad teeth, but there is no 
 trace of pyorrhoea alveolaris. Is an habitual drinker, chiefly whiskey 
 and beer, but is rarely intoxicated. Has always had a good stomach 
 up to six months ago, since when he has been inclined to vomit his 
 breakfast. 
 
 Present History. Was well on Sunday, Jan. 27, 1908, eating 
 as usual, and having cod-fish for supper. Went to work on Monday, 
 and felt well until the afternoon, about 3 o'clock. Was then seized 
 with chilly sensations. Went to bed on board his boat, was given hot 
 coffee and whiskey and became warm. At 5 o'clock began to vomit 
 greenish material. At 6 o'clock reached home by means of the 
 street cars, without assistance, and at this time pain commenced in 
 the epigastrium, and continued steady and severe. The pain was not 
 relieved by pressure, but he received some relief by steadying the 
 epigastrium with his hand. Vomited continuously all that (Monday) 
 night, and on Tuesday, also hiccoughed steadily. Thirst was extreme ; 
 he had no sleep at all and chills returned. At noon was seen by his 
 family physician. Dr. W. G. Hirseman, who found him with thighs 
 flexed upon abdomen, with anxious countenance, heavily coated 
 tongue, temperature 1005^°, respiration 35, pulse 85, good quality. 
 The abdomen was not distended, but palpation revealed marked ten- 
 derness of the epigastrium most intense to the right of the middle 
 line. Below the umbilicus deep pressure did not elicit tenderness. 
 There was no icterus. The patient was given one-fourth grain of 
 morphine by hypodermic injection, and a powder for the vomiting. 
 On the return of the physician at 8 p. m. the patient's symptoms were 
 increasing, the abdomen showed slight distention below the umbilicus, 
 and marked distention in the epigastrium. The temperature was 
 ioi^°, respiration shallow, and pulse 100, small, and intermittent. 
 On consultation with Dr. L. W. Pearson, the patient was sent to the 
 Brooklyn Hospital, as probably requiring surgical treatment. 
 
 I examined the patient at 1 130 a. m., Wednesday, less than thirty- 
 six hours from the time of onset of the illness. The patient was seen 
 to be a man of large frame, with every indication of severe suffering, 
 complaining of constant epigastric pain, worse in paroxysms, vomit- 
 ing slightly every minute or two, and hiccoughing. Pulse averaged a 
 little over 100 and was regular. Examination showed a moderately 
 distended abdomen, soft, and not tender below the umbilicus, but 
 
 77 
 
very tender above. The whole epigastrium was tender, but the 
 greatest tenderness was to the right of the middle line, at the point 
 over the head of the pancreas where greatest tenderness is also 
 shown in acute pancreatitis. The flat hand laid upon the epigastric 
 area received a sensation of resistance or tumor, nearly the size of 
 the palm, but not of a high degree of rigidity. Percussion gave 
 a tympanic note, extending well up into the left hypochondrium. The 
 combined findings suggested to my mind a distended stomach over- 
 lying a pancreatic tumefaction, or of tumefaction or pus collection 
 in the lesser omental cavity. A few rales were heard at 
 the base of the left chest. The blood test showed a leucocytosis 
 of 40,000. A diagnosis of an intra-abdominal calamity was made, 
 strongly suggesting acute pancreatitis or a perforation of the pos- 
 terior stomach wall, and operation advised. Examination under ether 
 gave the same impression to the hand. 
 
 Operation. Vertical incision through rectus muscle, four inches 
 long, one-half inch to right of middle line. Preperitoneal fat and 
 peritoneum seen to be slightly edematous. Sero-pus escaped on 
 incising peritoneum. Immediately, the stomach wall presented it- 
 self in the wound, thickened and boggy, with highly reddened but 
 smooth peritoneal coat, showing no evidence of ulcer or perfora- 
 tion. Further examination showed a segment of the stomach wall 
 about 3>4 inches in breadth to be involved, the thickening apparently 
 extending around the circumference of the stomach, although the 
 thickest part lay in the anterior wall. This thickened segment com- 
 menced with a well-defined border about i^ inches from the pylorus, 
 and the normal wall of the pyloric area could be invaginated with 
 the finger into the thickened segment, and the thickened wall palpated 
 in that manner. The border of the thickened segment extending to- 
 ward the cardia of the stomach was less well defined, and there 
 was some thickening shading off towards the cardia. 
 
 The abdominal incision was increased to 53^ inches, and an 
 exploration was made through the meso-colon into the lesser sac, 
 but revealed only a smooth, thickened posterior stomach wall, gently 
 adherent. The meso-colon and lesser omentum were both very 
 edematous and thickened, and a few enlarged lymphatic glands could 
 be felt along the greater curvature of the stomach. Pancreas and 
 gall-bladder were both found to be normal. It was decided to incise 
 the stomach wall in the thickened area and a longitudinal incision, 
 three inches in length, was gradually made down through the thick- 
 ened coats. When the submucous layer was reached, drops of pus 
 oozed freely out of small openings the size of a canary seed. Similar 
 small cavities, near the pyloric margin of the thickened area were 
 seen to be filled with opaque coagulum, not yet broken down into 
 pus. The stomach wall was over half an inch in total thickness at 
 this point. As far as the interior of the stomach could be seen and 
 felt with the finger through the opening, the mucous lining was deeply 
 congested and smooth, no evidence of erosion or ulcer being found. 
 The condition was then recognized as a diffuse phlegmon of the 
 stomach wall, and the question of drainage became the important 
 one. The transverse colon was completely collapsed, but the jejunum 
 was moderately distended, and dark bile-stained fluid welled freely 
 up into the stomach from the duodenum. It was decided to trust 
 to a gastrostomy for drainage, leaving the incisions in the stomach and 
 abdominal wall as freely open as possible. The drainage tube was a 
 
 78 
 
large sized stomach tube and was passed through the pylorus six 
 inches into the duodenum. The incision in the stomach wall was 
 loosely sutured with a catgut guy-rope suture at each end pene- 
 trating only to the submucous layer and left long and the stomach 
 lifted up into the abdominal incision and held there by tacking the 
 catgut guy-rope to the abdominal wall on each side of the incision. 
 Two wicking drains were passed into the lesser peritoneal sac, and 
 three large gauze tampons were packed freely about the involved area 
 of the stomach to isolate it in some measure, and to drain the peri- 
 toneal cavity. The abdominal incision was closed to two-thirds its 
 extent with through and through silk-worm gut sutures. The drain- 
 age tube was sutured to the skin incision. Drainage made its way 
 up freely through the tube from the duodenum, and the patient was 
 taken back to his bed in fairly good condition. 
 
 All vomiting ceased at once and the bile-stained fluid which 
 passed from the duodenum by siphonage into the bottle attached, 
 amounted to many ounces in the next twenty-four hours. The 
 patient was allowed to suck ice wrapped in gauze to relieve his ex- 
 treme thirst. He retained large quantities of saline infusion by slow 
 absorption from the rectum after the method of Murphy. The gauze 
 tampons in the abdominal incision drained very freely. There was 
 no leakage from the stomach about the tube. The stomach area was 
 no longer tympanic to percussion. The patient passed good amounts 
 of urine, and seemed generally improved, talking freely. He still 
 complained of the epigastric pain, however, which was but partially 
 relieved by the operation. The pain came in marked paroxysms, 
 emanating from the stomach area, and not due to general periton- 
 itis. 
 
 Thirty-six hours after operation, the upper abdomen was very 
 sensitive, and the skin hyperesthetic. Abdomen was still but moder- 
 ately distended, and but moderately tender below the umbilicus. Much 
 drainage persisted from the wound. Several stitches were removed, 
 and the stomach inspected as far as possible, and could be seen to be 
 purplish in color along the greater curvature. Pulse 120. Patient 
 not so clear headed, but he asked if condition was serious. On the 
 third day after operation, patient was still suffering the paroxysmal 
 pain; conscious, but unable to speak connectedly. Kidneys had 
 ceased to secrete. Death ensued 3^ days after operation and 5 days 
 after onset of attack. 
 
 Report of Autopsy. Body well nourished. The peritoneum is 
 everywhere somewhat injected and bathed with sero-pus, covered in 
 spots with fresh lymph. The intestines are slightly adherent with 
 lymph. The appendix is normal. The mesentery is very friable. 
 The meso-colon is inflamed, thickened and covered with lymph. The 
 gastric-colic omentum, more particularly at lower curve of stomach, 
 is inflamed and edematous. The pancreas is normally located and 
 apparently normal in size and consistency. Anterior aspect 
 of the stomach is intensely hyperemic, studded everywhere with 
 petechiae, covered with fresh lymph over the anterior duodenal half. 
 The mesentery contains a great deal of fat and is somewhat edema- 
 tous. The mucous membrane of the small intestine is everywhere 
 cyanosed, somewhat edematous, excepting in the upper part of the 
 jejunum which is pale and edematous. It is intact. The caput coli 
 is normal. The mucous membrane of the larger gut is moderately 
 congested and edematous. 
 
 79 
 
The anterior mediastinum is normal. The superficial area of 
 cardiac dullness is considerably increased. There is a total synechia 
 of the left pleural cavity. Also a total synechia of the right pleural 
 cavity, the adhesions being very ancient and firm. The heart is 
 much enlarged; the epicardium thickened and opaque and studded 
 with petechiae at the base. The left auricle is somewhat dilated and 
 hypertrophied. The auriculo-ventricular orifice is large. The valve 
 shows a moderate amount of atheroma anteriorly, in an early stage 
 apparently; otherwise normal. The tricuspid orifice is very large; 
 admits of four fingers separated. The valve seems to be normal. 
 The myocardium is considerably thickened in both ventricles, firm in 
 consistency, a trifle brownish on section. All of the cavities of the 
 heart are markedly enlarged: eccentric hypertrophy and dilatation. 
 
 Lungs. — The left lung is about normal in size ; somewhat heavy, 
 crepitates feebly on pressure. On cross-section the cut surface is 
 very dark and moist. The entire organ is intensely congested and 
 edematous. The right lung is somewhat enlarged, heavy, crepi- 
 tates feebly on pressure. On cross-section the cut surface is very 
 dark and moist. The organ is intensely congested and edematous. 
 The liver and the diaphragm on its under surface are united by old 
 firm connective tissue. The sub-diaphragmatic lymph nodes are 
 glued together. Diaphragm contains a large calcareous mass. 
 
 Spl,EEn. — The spleen is large. The capsule is thick. On cross- 
 section the surface is dark mahogany, moist; the pulp easily scrapes 
 away; the trabeculae are somewhat hyperplastic. 
 
 Pancrkas. — No edema or pus in pancreas. 
 
 The lower surface of the gall-bladder is covered with plastic 
 lymph. Organ is intact. No calculi. 
 
 Liver. — The liver is large, somewhat firm in consistency, surface 
 is smooth below and covered with old inflammatory tissue above. 
 On cross-section the cut surface is smooth and presents no further 
 distinguishing features. 
 
 Kidneys : — The left kidney is very large ; the capsule is adherent 
 in spots. Areas of depression on the surface of the organ, which is 
 otherwise finely granular. On cross-section the cut surface is dark 
 and cyanosed; cortex everywhere swollen; markings distinct. The 
 right kidney is small. The capsule is everywhere adherent. It con- 
 tains three cystic cavities filled with serum and fibrim. What remains 
 of the cortex is moderately swollen. The markings are somewhat 
 indistinct. 
 
 Stomach. — The stomach is greatly enlarged, the mucous mem- 
 brane is everywhere thickened, congested in spots, showing many 
 petechial hemorrhages. The pylorus is normal as far as the mucous 
 membrane is concerned. The submucosa and muscularis of the 
 stomach are phlegmonous. The whole stomach wall in the pyloric 
 region is very thick, perhaps more than half an inch. This condition 
 involves all of the lower aspect of the stomach, only a small area 
 at the cardiac end being free. No evidence whatever of ulceration. 
 The duodenum is moderately congested, edematous; otherwise free 
 from change. The stomach is free from pus. 
 
 Microscopic and bacteriological examinations showed the pres- 
 ence of the streptococcus. The streptococcus was also obtained from 
 one of the kidney cysts. 
 
 For the report of the autopsy, I am indebted to Dr. J. M. Van 
 Cott. 
 
 80 
 
Analysis of Operative Cases Reported. 
 
 There are but five -authentic reported cases, in addition to my 
 own, where surgery has been employed in acute phlegmonous gas- 
 tritis. Of these, two have already been referred to as being of the 
 circumscribed variety. 
 
 Of the acute diffuse variety, but three authentic cases have been 
 reported as having been operated upon, and in two of these the true 
 condition was not recognized until the autopsy. The first case was of 
 Leith, of Edinburgh, who in 1895, operated several days after 
 the onset under the diagnosis of general peritonitis, supposed to be 
 secondary to typhlitis, making an incision below the umbilicus and 
 washing out and draining the abdomen. The patient died in collapse 
 several hours after operation. Autopsy showed a typical acute 
 phlegmon of the stomach. The second case reported was that of 
 lycnnander, who, in 1898, operated on a woman of 29, with a history 
 of gastric symptoms dating back two or three years, who gave evi- 
 dence of a beginning general peritonitis following a supposed per- 
 foration of the stomach or duodenum. No perforation was dis- 
 covered, the abdomen was merely drained, and the patient died sixty 
 hours after operation. Autopsy disclosed a diffuse phlegmonous gas- 
 tritis involving the entire organ, the portal of infection probably hav- 
 ing been through two non-perforating ulcers of the lesser curvature. 
 The third case was a girl, aged 13 years, operated on by J. E. 
 Adams, St. Thomas's Hospital, London, under the diagnosis of per- 
 forative peritonitis with general peritonitis, four days after the on- 
 set. No lesion being found at the appendix, exploration of the 
 stomach showed no adhesions or perforation, but stomach walls an 
 inch in thickness when held between the fingers. The condition was 
 present throughout the stomach, but more noticeable in the pyloric 
 half. By exclusion, the diagnosis of acute primary phlegmonous 
 gastritis was made. Beyond drainage of the peritoneum, no further 
 operative attempt was made. The child lived four days after the 
 operation. Peritoneal fluid removed at operation gave pure cultures 
 of the pneumococcus, and cultures made at autopsy gave the pneu- 
 mococcus from the submucous and serous coats of the stomach. 
 
 Included in the list of reported cases of phlegmonous gastritis 
 in Robson and Moynihan's "Surgical Diseases of the Stomach" are 
 three cases which should have no place under that heading. One 
 of these (Case 84) is an instance of perigastric abscess following 
 an eroding gastric ulcer of the posterior wall, where posterior gastro- 
 enterostomy was done by Robson and recovery ensured. In another 
 chapter, this case is not claimed as one of phlegmonous gastritis, but 
 its incorporation with the list of cases has caused misleading quota- 
 tions of the case as a cure of phlegmonous gastritis by gastro-en- 
 terostomy. Another case (No. 85) was an instance of prolonged 
 gastritis, the mucous lining only being involved, the patient dying 
 after gastro-enterostomy, by the same operator. 
 
 A case which has been much quoted as a recovery from acute 
 phlegmonous gastritis by mere abdominal drainage was that oper- 
 ated upon by Mickulicz, and reported (1902) by Lengemann. The 
 patient was a young woman of 18, with prolonged history of anemia 
 and gastric ulcer. Operation was done with expectation of finding a 
 perforation. Bloody serum and gas-bubbles were present in the 
 abdominal cavity, but no perforation was located. The stomach 
 was thickened on its anterior wall, and two yellowish-gray maculae 
 
 81 
 
presented there, each about the size of a silver quarter. No incision 
 was made into the stomach wall, and the operator is said to have 
 made his diagnosis on the symptom-complex. Gauze drainage of the 
 abdominal cavity and over the inflamed area of the stomach brought 
 about a prompt recovery. From my own experience with an un- 
 doubted case of diffuse phlegmonous gastritis, I cannot believe that 
 this case was correctly diagnosed. 
 
 I cannot find, therefore, that there is any reliable proof of the 
 cure of diffuse phlegmonous gastritis by medical or surgical means 
 to the present date. 
 
 Possibilities of Surgical Cure. 
 
 One must admit that the chance of a surgical cure is extremely 
 small. The object of this paper is to establish the lines along which 
 surgery must proceed if there is to be any hope of cure. Robson and 
 Moynihan suggest that benefit may accrue from drainage and rest 
 of the stomach by gastro-enterostomy or gastrostomy. Gastro-en- 
 terostomy, I am sure, would be an entirely unfit procedure, and would 
 only defeat the end sought by adding additional traumatism to the 
 stomach wall and further the spread of the infection. Gastrostomy 
 would be also inadequate as shown by my own case, where a free 
 incision into the heart of the phlegmonous area, and rest to the 
 stomach, had no noticeable effect in staying the spread of the in- 
 flammation. The claim made by Lengemann, who reported the case 
 of supposed cure by Mickulicz, is altogether without appeal to surgical 
 judgment. He states that the free drainage of the peritoneal cavity 
 by gauze tamponade must have been sufficient in that case to limit 
 peritonitis and at the same time to bring about a cure of the early 
 require either the most complete drainage of the tissues involved, by 
 multiple incisions, or wide excision of the same. In my own case, 
 case can surgery hope to cure. Such treatment would seem to 
 drainage. This might be accomplished by whipping over the cut 
 phlegmon of the stomach wall. There is no reason whatever why a 
 phlegmon confined within the walls of any abdominal viscus should 
 be cured by simple drainage of the peritoneal cavity. Mickulicz's 
 case, in the light of my own case, strongly suggests an induration 
 of the stomach wall secondary to ulcer. 
 
 My belief is that only in the most radical treatment of an early 
 the thickened area, though not broad, extended from the anterior wall 
 through both greater and lesser curvatures, around nearly a complete 
 segment of the stomach, the posterior wall immediately behind be- 
 ing also thickened. Multiple incisions down to the mucosa would 
 manifestly have been very difficult in adequate degree in my case. 
 It is possible that a still earlier or more limited case than mine might 
 be adequately treated by free multiple incisions combined with gas- 
 trostomy. The possibility of having present a developing circum- 
 scribed abscess should be kept in mind in deciding the treatment, 
 as incision should there suffice. My own case showed plainly in 
 the submucous tissues the spreading gray lines of a streptococcus 
 infection with little ous. 
 
 I believe that nothing short of a partial gastrectomy was indi- 
 cated in my case. The risks of such a step would have been ex- 
 treme, but not entirely beyond hope. The condition being absolutely 
 hopeless otherwise, one would be justified in taking extreme opera- 
 
 82 
 
tive risk. In a similar case, I would do partial gastrectomy, adopt- 
 ing at the start the usual technique. At the cardiac end, the clamps 
 should be applied two or three inches beyond the marked thickening 
 if possible. At the duodenal end, less distance beyond the involved 
 area will suffice, as the inflammation does not tend to attack the 
 duodenum. After cutting away the stomach with knife or scissors, 
 a large-sized, moderately stiff drainage tube or catheter should be 
 passed several inches into the open end of the duodenum, and the 
 latter closed about it with purse-string suture. This tube will an- 
 swer the double purpose of drainage of the duodenum, from which, 
 in my case, a large quantity of dark fluid constantly welled up, and 
 also for feeding later on, as in ordinary duodenostomy or jejunostomy. 
 The treatment of the stump of the stomach remaining would be 
 simply that of staying of hemorrhage from the cut surface, and 
 drainage. These might be accomplished by whipping over the cut 
 edges with catgut, and leaving the cavity unclosed, to be surrounded 
 with a gauze pack; or the walls might be quickly sutured together 
 with catgut for the most part of the opening, and a large soft 
 rubber drainage tube left in the cardia. A large, free pack of 
 simple gauze left in the stomach area might provide sufficient drain- 
 age of that space and the peritoneal cavity. If the patient recovered, 
 and were in fit condition, an anastomosis of the jejunum with the 
 retracted cardiac end of the stomach, through a left rectus incision, 
 might be done some weeks later. If this were not feasible, life 
 might be prolonged by the duodenostomy. 
 
 Conclusions. 
 
 1. Acute diffuse phlegmonous gastritis is a rare form of inflam- 
 mation of the wall of the stomach, involving chiefly the submucous 
 layer, and produced usually by streptococcus invasion, locally, or 
 through the blood current. It is to be distinguished from local abscess 
 of the stomach wall, which is still more rare. 
 
 2. It occurs chiefly in middle and late-middle life, but may 
 occur at any period. 
 
 3. It is to be distinguished principally from acute pancreatitis 
 and perforated gastric ulcer, an important difference being the on- 
 set of vomiting before pain. 
 
 4. The prognosis is an absolutely fatal one unless surgery may 
 ultimately produce a cure. 
 
 5. Simple gauze drainage about the stomach, gastrostomy, and 
 gastro-enterostomy, as suggested by various surgeons, do not form 
 adequate methods of surgical treatment. 
 
 6. Partial excision of the stomach in early cases with duodenal 
 feeding and gastro-enterostomy at a later stage is a possible curative 
 surgical procedure in early cases. 
 
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 84 
 
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 85 
 
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 86 
 
RHINOPHYMA 
 
 Walter A. Sherwood, M.D., F.A.C.S., 
 
 Surgeon to the Brooklyn Hospital. 
 
 When acne rasacea becomes exaggerated to what may be called 
 its third or extreme stage, an increase in connective tissue takes place, 
 the tip and sides of the nose become converted into a lobulated mass, 
 so great as to form one or more pendulous tumors which overhang the 
 lip. The condition is known as Rhinophyma. 
 
 Digestive disturbance from whatever cause, producing reflex 
 dilatation of the nasal blood vessels and capillaries, is the basic etiolog- 
 ical factor. 
 
 Rhinophyma occurs after middle life, most often in males and 
 usually in subjects who are accustomed to rich food and a free in- 
 dulgence in alcoholic stimulants. The extreme cases which require 
 surgical measures for their relief are comparatively rare. 
 
 The following pathological note has been kindly supplied by Dr. 
 Nathan T. Beers : 
 
 "As the result of hypemutrition and chronic hyperemia of the 
 skin of the affected parts, the blood vessels and capillaries become 
 permanently enlarged. The sebaceous glands are involved and enorm- 
 ously distended. There is pronounced hyperplasia of the dermic 
 connective tissue elements. Nodules, at first gelatinous and later 
 fibrous in character, gradually develop. The increased vascular 
 dilatation is due not only to arterial engorgement but also to a 
 blocking off of the venous return as the result of follicular suppura- 
 tion and consequent formation of cicatrices." 
 
 The cartilage in some cases becomes hypertrophied. In a few of 
 the cases reported the growth of the tumor-like formations has been 
 rapid. Most of them, however, are of slow growth usually covering 
 a long period of years. 
 
 The condition must not be confused with Rhinoscleroma, a 
 chronic granulomatous process affecting the lip, nares and adjacent 
 structures and resulting in sclerosis and nasal deformity. This 
 disease was first described by Hebra. It exists in the south-eastern 
 countries of Europe and is exceedingly rare in the United States. 
 
 The treatment of Rhinophyma is surgical and the operative method 
 employed will depend on the characteristics of the individual case. 
 
 Report of Cass 
 
 W. L., aged 63, was recently referred to the writer by Drs. N. T. 
 Beers and Raymond Clark, under whose care he had been for the 
 correction of other conditions and for the purpose of attaining a 
 proper degree of physical fitness in order that he might submit 
 himself to the risk of a general anesthetic and operation. 
 
 He had been the subject of an increasing nasal deformity which 
 had started as an acne rasacea about twenty-five years ago. During 
 the last year the size and unsightliness of the condition had increased 
 
 87 
 
so rapidly as to be a matter of extreme embarrassment to himself, 
 his family and his friends. The appearance of the man when he pre- 
 sented himslf is well shown in the accompanying photographs (Figs. 
 1, 2 and 3). 
 
 The enormous enlargement, the overhanging lobulated masses 
 and the wide-open crypts of the sebaceous glands are well illustrated. 
 The entire organ presented a deep, purplish red appearance with 
 enormously engorged blood vessels. 
 
 After careful consideration of the several methods of attacking 
 such a condition it was decided to remove completely the diseased 
 tissues and cover in the resulting raw surface with suitable skin grafts 
 at one sitting. The method employed was practically the same as 
 that described by Binnie in his work on operative surgery. 
 
 The patient was referred to the service of the writer at the 
 Brooklyn Hospital where the following procedure was carried out : 
 
 Warmed ether vapor by Dr. Gwathmey administered through a 
 mouth canula under pressure of a motor-driven pump. 
 
 Step 1. — Gauze tampons introduced through nares to prevent 
 inflow of blood into the naso-pharynx. 
 
 Step 2. — With the forefinger of the left hand in the nostril as a 
 guide, an incision was made all around the growth from the middle 
 line outward. A straight incision was then made through the mid- 
 line from above downward. These were carried down to but not 
 into the cartiliage (Fig. 4). 
 
 Step 3. — The edge of the tumor mass was grasped with forceps 
 and all the diseased tissues within the line of incision were cut away 
 first on one side and then on the other (Fig. 5). Care was taken to 
 preserve the normal outline of the nostril and to prevent the knife 
 from entering the cavity of the nares. The hypertrophied cartilage 
 was shaved off with a knife until it assumed normal proportions. 
 
 Step 4. — Hemorrhage, which of course was very profuse and 
 continuous, was controlled by pressure, hot pads and the ligation of 
 the larger vessels. 
 
 Step 5. — The raw surface was then covered with good-sized 
 Thiersch grafts (Fig. 6) taken from the outer side of the patient's 
 arm. The principal steps of the operation will be readily understood 
 from the accompanying drawings. 
 
 The grafts were covered with silver foil, a dry gauze com- 
 press applied and the parts protected from injury by the application 
 of a rubber nose guard such as is used by football players. 
 
 All dressings were removed on the fifth day, the grafted area was 
 dusted with aristol and left exposed to the air and sunlight. Serous 
 exudate was considerable and as the result of it a hard dry crust 
 formed and covered the entire nose. This was in no way disturbed 
 until two weeks had elapsed when it was softened with cold cream and 
 gradually and carefully peeled off with forceps. It was found that all 
 grafts had retained their vitality. The process of epithelial repair was 
 very rapid, and at the end of three weeks the entire nose was com- 
 pletely covered with a new healthy skin of a color corresponding to 
 the rest of the face. The parts were smooth, the contour of the nose 
 was normal, and there was very little scar formation (Fig. 7). 
 
 The appearance of the nose has steadily improved and now ap- 
 pears as in Fig. 8. 
 
 The chief difficulties of such an operation are as follows: 
 
 1. The proper choice of an anesthetic and method of administer- 
 
 88 
 
Fig. 1. — Rhinophyma. Condition before operation. Front view. 
 
Fig. 2. — Rhinophma. Condition before operation. Side view. 
 
Fig. 3. — Rhinophyma. Condition before operation. Anterolateral view. 
 
Fig. 4. — Rhinophyma. Incisions of operation. 
 
Fig. S. — Rhinophyma. Method of removing tissue. 
 
Fig. 6. — Rhinophyma. Wound covered with skin — grafts after removed 
 
 of diseased tissue. 
 
Fig. 7. — Result after operat.ion for rhinophyma. 
 
Fig. 8. — Result after operation for rhinophyma. 
 
ing it. Rectal anesthesia is ideal for such operations but was not 
 deemed advisable in this case. 
 
 2. The danger of hemorrhage and difficulty of controlling it dur- 
 ing the dissection of the tissues. 
 
 3. The density of the tissues and absence of any line of cleavage 
 makes dissection tedious and favors wounding the cavity of the 
 nares. 
 
 4. The uncertainty of the healing process. 
 
 The result obtained was so satisfactory and gratifying to all 
 concerned, that it would seem to warrant the brief report herewith 
 presented. 
 
 The photographs are published by permission. 
 
 89 
 
VIII 
 THE NORV^EGIAN HOSPITAL. 
 
CANCER OF THE RECTUM. 
 
 H. Beeckman Delatour, M.D., F.A.C.S., 
 
 Surgeon-in-Chief to the Norwegian Hospital. 
 
 URGERY of the abdominal viscera through improvements of 
 technique and added experience of operators has been deprived 
 of many of its former complications and is attended by a con- 
 stantly diminishing mortality. Operations on the pelvic organs and the 
 appendix have long since become commonplace. Within the past 
 few years surgery of the upper abdomen, the stomach, liver, and gall 
 bladder has been extended and perfected, and today is approached 
 with much more confidence than formerly. 
 
 Malignant disease of the intestine, however, has been much neg- 
 lected and operations have been postponed until acute symptoms, such 
 as obstruction, have developed and forced interference. During the 
 past three or four years these Cctses have been diagnosed in the earlier 
 stages and more radical operations are being undertaken with a marked 
 reduction of operative mortality and a very decided gain in permanent 
 cures. 
 
 Cancer of the rectum has been the subject of operative attack for 
 many years, but the methods employed were such that many cases 
 were passed over as inoperable or were so operated that not suffi- 
 cient bowel was removed to insure a permanent result. The hesitancy 
 of the surgeon to produce an artificial anus has passed many a case 
 on to a period of prolonged suffering and ultimate death. "I would 
 rather die than have an artificial anus," is a statement we have fre- 
 quently heard and given expression to ourselves. The very idea of 
 it is repugnant. This feeling has delayed our progress in the treat- 
 ment of malignant disease of the sigmoid and rectum and been re- 
 sponsible for the infliction of prolonged suffering on many. 
 
 Inexperience, tending to high operative mortality, has also been 
 a factor in leading one to pass upon a given case as inoperable. Very 
 interesting in this connection is the paper of Mayo in which he com- 
 pares the percentage of operable cases at their clinic at different 
 periods and also the operative mortality of the same. 
 
 During the period from 1893 to 1910, there was an operative mor- 
 tality of 17.8 per cent.; from 1910 to 1913, it was 17.17 per cent, 
 with an operability of 51 per cent. During this period only about 
 one-half the cases examined were considered subjects for a radical 
 operation. 
 
 For the years 1913, 1914 and 1915, the mortality averaged 12.5 
 per cent, and the operability 71.8 per cent., while the operations were 
 made more radical. During this period nearly three-quarters of the 
 cases examined were operated, upon. With further experience and 
 due care in selecting cases the mortality will be lowered and the per- 
 centage of cures increased. 
 
 Early diagnosis is the keynote of success, but we must con- 
 stantly bear in mind that cancer of the bowel is slower of metastasis 
 
 93 
 
than cancer in other portions of the body, and that many apparently 
 advanced growths can be successfully removed with a long period of 
 immunity from recurrence and possibility of permanent cure. In 
 doubtful cases exploratory operation is certamly justifiable, and 
 should be performed in cases of persistent intestinal conditions m 
 patients beyond thirty-five years of age, when other means have failed 
 to reveal the cause of the symptoms. 
 
 We must not wait for emaciation and cachexia to develop, for in 
 these cases they appear late and the patient is then quite likely in the 
 inoperable stage. 
 
 Having made the diagnosis of cancer of the lower bowel, what 
 shall be our method of attack? Shall it be from the perineum, 
 through sacral section, by the abdominal route or by a combination 
 of these? This must depend somewhat on the individual case, but no 
 operation should be undertaken unless it is sufficiently radical to elimin- 
 ate the disease. The frequency of recurrence in the past has been 
 due to a too great desire to retain the anus in its normal position, 
 and the sooner the surgeon can realize that this should be the last 
 consideration the quicker shall we see an increased percentage of last- 
 ing cures. 
 
 It is our belief that very few cases can be satisfactorily operated 
 by either the perineal or sacral routes alone ; and, further, the ab- 
 dominal part of the operation is of immense importance in permitting 
 a thorough exploration of lymph glands and liver to determine the 
 amount of extension of the disease. If there is positive evidence of 
 involvement of the liver, no radical excision should be undertaken. 
 Enlargement of the lymph glands does not contraindicate operation, 
 for in many cases these glands are found to be the seat of a simple 
 inflammatory process and not due to extension of the growth. 
 
 If an artifical anus has to be produced, should we endeavor to 
 place this in the perineum or on the abdomen? Careful watching of 
 several cases has convinced us that the abdominal anus is the more 
 easily cared for by the patient. The perfection of the technique of 
 producing the abdominal anus, and teaching the patient its proper 
 care together with the application of a correctly fitted apparatus have 
 so reduced the disagreeable features of this condition that we no longer 
 hesitate to advise our patients to accept the operation. 
 
 The abdominal-perineal operation in either one or two stages is 
 our preference, and of late we have been better satisfied with the 
 one stage operation in those patients in whom a sufiicient time could 
 be given to preliminary preparation. In cases of obstruction, either 
 complete or nearly so, a preliminary colostomy should be done in 
 order that the bowel may be properly emptied and cleansed, for the 
 mortahty is largely due to sepsis from escape of feces during opera- 
 tion. 
 
 The method of procedure varies with different operators, but a 
 careful study fails to reveal any very radical differences. The most 
 recent descriptions are those of Jones of Boston, and Cofifey of Port- 
 land. The method of Coffey we have never attempted as it does not 
 seem practicable. 
 
 The operation which we have followed during the past four years 
 in eight cases without any operative mortality and so far no recurrence, 
 is similar to that described in the text books. 
 
 Operation: With the patient well elevated in the Trendelenburg 
 position, the abdomen is opened in the median line and an exam- 
 
 94 
 
ination of the extent and location of the growth is made ; the liver 
 is also examined for evidences of involvement. The intestines, ex- 
 cept the sigmoid, are then carefully placed in the upper abdomen and 
 protected by a large gauze pad, thus leaving the pelvis clear for our 
 manipulations. 
 
 The sigmoid is now lifted out and its mesentery traced to the 
 promontory of the sacrum where the inferior mesenteric artery can 
 be felt. The peritoneum is then incised and the vessel ligated in 
 two places, between the upper and middle sigmoid branches, and the 
 artery divided. This insures proper blood supply to the proximal 
 sigmoid which is to be used for the colostomy. By further separation 
 of the peritoneum to the left, the left ureter is exposed. The mesen- 
 tery is then divided from behind forward up to the edge of the 
 bowel. The incision through the peritoneum is now carried down- 
 ward parallel to the bowel and about one inch from it to the bottom 
 of the pelvic pouch and then these incisions are joined across the front 
 of the bowel. By blunt dissection with the fingers the rectum, to- 
 gether with the mass of fat, is separated from the hollow of the sac- 
 rum, down to and, if possible, beyond the coccyx. If the vessels have 
 been ligated above, this is accompanied by very little bleeding. The 
 next step is to free the bowel from the bladder and prostate, and in 
 doing this great care has to be exercised not to injure the ureters. 
 The dissection from above is carried down as far as possible for this 
 simplifies greatly the second stage of the operation. The division of 
 the bowel is not made until all dissection has been completed. A large 
 gauze sponge is now packed in the pelvis and soon stops any oozing 
 that may be taking place. 
 
 Two clamps are now placed on the bowel at the point selected 
 for division, the bowel is severed by the actual cautery and both ends 
 inverted and closed by silk suture. The gauze pack is next removed 
 from the pelvis, and the distal portion of the sigmoid and rectum 
 placed in the pelvis and covered with a small gauze pad. The edges of 
 the divided peritoneum are next sutured by continuous chromic suture 
 over the pelvis, thus excluding it from the general peritoneal cavity. 
 
 Where the amount of bowel to be removed was too large to pack 
 into the pelvis and permit suture of the peritoneum over it, we have 
 removed a large segment of the freed portion, after properly closing 
 the lumen by heavy silk ligature and then dividing with the cautery. 
 
 We next proceed to the production of the colostomy as follows: 
 A sufficient amount of bowel is brought forward so that about two 
 inches will project beyond the skin, the bowel is then sutured to the 
 peritoneum in the upper portion of the wound, the fibres of the rectus 
 muscle are separated and the anterior sheath divided and through this 
 the end of the intestine is passed and brought out beyond the skin 
 where it is fastened by several silk sutures. After final cleansing of 
 the abdominal cavity the wound is closed in layers and a gauze dressing 
 applied. The sutures closing the lumen of the bowel are left in place 
 and the bowel is not opened until from the third to the fifth day. The 
 method of producing a colostomy described by Brinsmade has given 
 very satisfactory results; as yet we have not used it. 
 
 The further steps of the operation may now be carried out if the 
 patient's condition will permit, or may be delayed for several days. 
 As this procedure rarely takes more than eight to ten minutes it can 
 usually be carried out at once. The patient is put in the lithotomy posi- 
 tion with the pelvis well elevated, the anus is surrounded by an incision 
 
 95 
 
through the skin and then closed by a strong silk suture. The levator 
 ani is next divided and the rectum separated from the prostate or 
 uterus in front and the remaining tissues attaching it to the COCC30C 
 divided. The free end of the sigmoid can now usually be seized and 
 brought through the wound and the remainder of the section be done 
 from above downward. There is usually very little hemorrhage, the 
 only vessels of importance being those near the skin and easily 
 reached. In this way from fifteen to twenty inches of the bowel are 
 removed. The gauze pack is now removed, the wound dried out and 
 the large cavity remaining is lightly packed with zinc oxide gauze and 
 the anterior portion of the perineal wound closed by interrupted silk 
 sutures. If thought best the uterus and adnexa, or portion of prostate 
 can be rem.oved as a part of the procedure. 
 
 The after-care consists in irrigation and repacking of the lower 
 wound as is necessary. The opening of the bowel is delayed for sev- 
 eral days so as to avoid infection of the abdominal wound. In cases, 
 where necessary, a large drainage tube may be sewn into the bowel 
 and the free end placed in a bottle so that the discharge is collected 
 without soiling the wound. 
 
 The extra portion of bowel, one and a half to two inches, project- 
 ing above the skin can be cut down to the level of the skin at any time 
 without anaesthesia. We believe the leaving of this for several 
 days to be an excellent plan because sloughing of some of the bowel 
 occasionally takes place and then the opening is brought too close to 
 the skin line. 
 
 After recovery the patient is fitted with our permanent colostomy 
 cup which enables him to go about his business without fear of soil- 
 ing his clothing and without the presence of disagreeable odors. 
 
 This operation, which has given in our hands an immunity of 
 over eight years in one case, and others still free of recurrence at vari- 
 ous periods over two years, with no mortality in the last eight cases 
 and with comparative comfort to all during those years, strongly 
 appeals to us when we recall the sufferers we have seen in the later 
 stages of the disease. These poor sufferers are in a deplorable con- 
 dition, reduced to mere skeletons, suffering intense agony, with con- 
 stant tenesmus and a continuous foul rectal discharge. The odor is so 
 offensive that they are avoided by their families. Their condition is 
 worse than death. Let us make every effort to reach these people early 
 and save them this miserable existence. 
 
 96 
 
IX 
 
 SAINT MARY'S HOSPITAL. 
 
GASTROJEJUNOSTOMY WITH CLOSURE OF THE DUO- 
 DENUM AND CHOLECYSTOSTOMY. 
 
 Onslow A. Gordon, M.D., F.A.C.S., 
 
 THE case here reported is considered worthy of record because 
 of the fact that the pylorus having been closed by a simple 
 method remains impervious at the end of sixteen months. 
 The patient, thirty-nine years old, referred to me by Dr. M. L. 
 Bodkin, had suffered from "indigestion" for about two years. She 
 complained of pain in the epigastric region often associated with nausea 
 and vomiting. The pain was usually relieved by taking food and 
 alkalies. Her vomiting usually occurred about two hours after meals 
 and was as a rule sour and burning. She had on two occasions vomited 
 almost clear blood and had noticed blood in her stools. Dur- 
 ing the past year she had lost forty pounds. With this classical his- 
 tory and physical and laboratory findings substantiating it, the 
 diagnosis was apparent. She was operated on June 4, 19 15. The 
 patihiology found at operation was an indurated ulcer just to the gas- 
 tric side of the pylorus and a gall-bladder containing several calculi. 
 The ulcer was treated by a posterior gastrojejunostomy with exclusion 
 of the pylorus. The gall-bladder was drained after the usual manner. 
 The interest in this case of course centers in the subject of exclusion of 
 the pylorus. The advisability of closure of the duodenum has not been 
 definitely established and advocates of this procedure are not at all 
 agreed as to the most desirable method. In this case the pylorus was 
 closed by the simple method advocated by Berg. A heavy linen purse- 
 string suture was carried around the posterior stomach wall at the 
 pylorus and then tied, thus closing off the duodenum. This closure 
 has remained permanent up to the present time, a period of six- 
 teen months, as shown by radiographs. 
 
 The patient made an uneventful and complete recovery and since 
 operation has gained about fifty pounds in weight and apparently is 
 in perfect health. 
 
 99 
 
X 
 
 THE PILCHER PRIVATE HOSPITAL. 
 
PAIN DUE TO ANATOMICAL DEVIATION OF THE 
 
 URETER. 
 
 Paul Monroe Pilcher, A.M., M.D. 
 
 TO determine the cause of pain referred to the abdomen or to 
 the back is often a difficult problem. When the pain comes on 
 unexpectedly in the night without a previous history of some 
 definite disorder, we think of many lesions which might give rise 
 to it. The occurrence of nausea, vomiting and frequency of urina- 
 tion is so common an accompaniment of most attacks of colicky 
 pain that they often simply tend to confuse the picture. 
 
 In our search for evidence we palpate the abdomen; we examine 
 the urine and blood ; we take the temperature ; we examine 
 the pelvis ; we take radiographs, and when all is done we may be still 
 in doubt. However, there are still more delicate tests which may 
 be employed. They consist of a combination of special methods and 
 instruments. I refer to the stomach tube, the Bismuth meal, the Bis- 
 muth enema and the x-ray in stomach and intestinal lesions ; the 
 blood test for cholesterol, urinary analysis, and the x-ray for gall 
 stones; and the cystoscope, the ureter catheter, the x-ray and pyelog- 
 raphy in obscure lesions of the kidney, kidney pelvis and ureter. Add 
 to these a mind trained to interpret these combined findings and a 
 correct diagnosis is the result, where fonnerly an exploratory opera- 
 tion was resorted to, and only too often failed to reveal the lesion. 
 
 During the past year several cases have been referred to our 
 clinic complaining of recurring pain in the hypochondrium and lum- 
 bar region, often extending downward to the lower right or left 
 abdominal region. Those patients in whom pus or macroscopic blood, 
 or tubercle bacilli have been found in the urine coming from the 
 ureter of the affected side, have been relatively easy of diagnosis, es- 
 pecially when a radiograph has shown the presence of a calculus at 
 the pelvo-ureter junction, or in the ureter. 
 
 In most of the remaining cases, gall bladder disease, ulcers of 
 the stomach and intestines — aneurysms — spinal disease — and tubo 
 ovarian and uterine lesions can be excluded as the cause of the pain. 
 
 There remain chiefly the chronic lesions arising from the ap- 
 pendix and a condition frequently mistaken for appendicitis, namely 
 intermittent dilatation of the renal pelvis due to anatomical deviation 
 of the ureter, and a small class of cases due to stricture of the ureter 
 and perinephritis. The acute inflammatory lesions are not easily con- 
 fused with any of these disorders. 
 
 The cases of anatomical deviation of the ureter include chiefly 
 those due to high implantation of the ureter into the renal pelvis, 
 twists and kinks of the ureter due to undue mobility of the kidney and 
 the first portion of the ureter, and the very important class of cases in 
 which a set of aberrant blood vessels cross the ureter and enter the 
 lower pole of the kidney and form a loop over which the ureter bends 
 and becomes obstructed. 
 
 103 
 
The diagnosis of such a condition can be made before operation 
 with considerable exactness ; but oftentimes it involves an extended 
 study of the case, and even when it is suspected after taking the his- 
 tory, examination may lead to the discovery of other lesions as a 
 cause of the pain. 
 
 The possibilities of diagnosis and the means employed to establish 
 the same are well shown in the following case reports : 
 
 Ii^i^usTRATivE Cases. 
 
 Case I. Clinic No. 1,976. Referred by Dr. H. M. LowenthaL 
 Diagnosis: Intermittent hydro-pelvo-nephrosis ; obstruction of ureter 
 due to aberrant blood vessels with kink and twist of ureter. 
 
 Chief Symptoms: Recurrent pain in right hypochondrium and the 
 right lower quadrant of the abdomen. 
 
 Patient is a young nervous girl, aged 23, who seven years ago 
 began to have pain in the right side coming on in the evening and 
 lasting for about two hours. If she worked too hard, or was very 
 nervous, pain would appear in the right hypochondrium. It would 
 come on sharply and would disappear suddenly. Latterly the pain 
 has been more severe and she has needed some morphine to control 
 it. There has been no disturbance of any of the essential systems of 
 the body. Her nutrition is good and the bowels are regular. There 
 are no symptoms referable to the stomach or lungs. No bladder 
 symptoms. Pain always starts in the same spot in the right hypo- 
 chondrium with severe colic-like pain which passes through to the 
 back, very similar to that observed in gall stone colic. After the sever- 
 ity of the pain has passed, the soreness remains and feels like a sore 
 tooth. Pain is more apt to come on when she is tired, but does not seem 
 to have direct connection with exercise, and no connection with eating, 
 gas formation in the bowels, or her menstrual periods. After awhile 
 the pain goes away and she passes an increased amount of water, or 
 at least she goes more frequently to pass her water. 
 
 Lately the pain has been more severe. She has an attack every 
 two or three weeks. Two weeks ago had an attack which lasted all 
 day and into the next day. At first there is a gnawing feeling in the 
 right side and sense of pressure, then developes severe colic, and 
 now there is a continual sense of distress in that side. 
 
 The condition has repeatedly been diagnosed as appendicitis and 
 she has repeatedly been advised to have her appendix removed but 
 the operation has been refused. 
 
 Physical examination showed no abnormahties with the exception 
 that the right upper quadrant of the abdomen examined during the 
 time the patient was having pain, showed the presence of a fairly 
 large mass in the region of the kidney and gall bladder presenting 
 beneath the free border of the ribs. There is some tenderness over 
 the cecum. 
 
 Examination of the urine — acid, 1020, no albumin, no sugar and 
 no abnormal microscopical findings. 
 
 From the history of the case, the age of the patient, the peculiar 
 character of the attacks, the long duration of the attacks, the ab- 
 sence of urinary findings, the absence of any gastro-intestinal dis- 
 of various types, the most probable diagnosis in this case is an inter- 
 turbance, such as excessive fermentation, constipation and indigestion 
 mittent hydro pelvo renalis, due to anatomical deviation of the ureter 
 
 104 
 
1 
 
 Fig 1. Uretero-pyelogram in Case 1. Showing de- 
 formity of ureter and "egg shaped" dilatation of renal 
 pelvis. Pilcher Clinic. 
 
Fig. 2. Outlines of kidney and ureter in Case 
 1. Note oblique axis of kidne}^ Uretero-pyelo- 
 gram. 
 
 Fig. 3. Artist's interpretation of the pyelograph in 
 Case 1. Pilcher Clinic. 
 
Fig. 4. Dilated renal pelvis due to 
 anatomical deviation of ureter (aber- 
 rant blood vessel). Incision exposing 
 kidney showing dilated pelvis present- 
 ing in w^ound. Case 1. 
 
 Fig. 5. Dilated renal pelvis showing 
 aberrant blood vessels crossing ureter 
 causing constriction. Showing position 
 of hand grasping kidney to accentuate 
 deformity. Aberrant vessels (Ab) have 
 already been cut — consisting of an ar- 
 tery and two veins entering lower pole 
 of kidney. Case 1. 
 
Fig. 6. Dilated renal pelvis due to 
 anatomical deviation of ureter. Later 
 step in operation after blood vessels 
 have been divided and dissected free 
 from ureter. In 'cases of long standing 
 a permanent impression has been made 
 upon the ureter with thickening. The 
 probe should be passed from above 
 downv/ard beyond point of obstruction 
 and a suitable size soft bougie passed 
 from above into the bladder. 
 
 Fig. 7. Pyelograph of the ureter and renal 
 pelvis in Case 2. 
 
caused either by an aberrant blood vessel or a fixed portion of the ure- 
 ter kinked by prolapse of the kidney. In a case of this kind we can 
 exclude chronic appendicitis and prolapsed or enlarged twisted cecum, 
 on account of a definite lack of intestinal symptoms. Stone in the 
 kidney is also possible, but may be excluded by x-ray examination. 
 But a stone present in the pelvis or right ureter for a period of seven 
 years would give absolute changes in the urine, which we did not 
 find in this case. 
 
 The indications for the examination are — first, an x-ray of the kid- 
 ney and second, a pyelograph of the pelvis of the kidney. 
 
 Further examination was made on October 21, 1915. 
 
 Radiograph taken by Dr. James Pilcher showed right kidney to 
 be normal in size, but its axis was oblique. There was no stone present 
 in the kidney, or its pelvis, or its ureter. 
 
 Argentide picture of the right ureter and kidney showed the 
 right ureter to be normal in size until it reached a point opposite the 
 transverse process of the first lumbar vertebra, where it is constricted 
 and twisted about. The argentide, hov/ever, passes by the obstruc- 
 tion and dilates the kidney so that the picture is that of a typical egg- 
 shaped pelvis which is pathognomonic of an intermittent hydro-pelvo- 
 renalis, due to constriction or aberrant blood vessels. (Figs. 1, 2, 3.) 
 
 In examining the pyelographs it will be seen that none of the 
 calyces are visible and this is so because the relaxed walls of the 
 hydronephrotic sac are not distended to their full capacity. The kid- 
 ney itself lies between the free border of the ribs and the crest of the 
 ilium. 
 
 Cysioscopic examination revealed the fact that the left kidney was 
 present and secreting normal urine. 
 
 Operation, exposing right kidney (Fig. 4). It was found pro- 
 lapsed and in an oblique position wnth a dilated pelvis. A set of aber- 
 rant vessels was found crossing the ureter, as indicated in the radio- 
 gram, consisting of a fairly large artery and two veins, as in the 
 accompanying drawings. The artery was ligated and divided and in 
 addition was dissected away from the ureter. (Fig. 5) It was found 
 that there was some constriction of the ureter beneath this attached 
 vessel. The pelvis which was greatly dilated was separated, a large 
 probe passed down through the ureter dilating it. (Fig. 6) A plastic 
 operation on the pelvis of kidney was done; the kidney fixed in 
 normal position and the wound sutured. 
 
 Patient made an uneventful recovery and has never had any re- 
 currence of symptoms since that time. 
 
 Cask II. Male. Referred by Dr. Warren L,. Duffield. Diagnosis: 
 Intermittent hydro-pelvo-nephrosis ; obstruction of ureter due to aber- 
 rant blood vessels causing kinking of ureter. 
 
 Abstract of History: Patient nineteen years of age. Six years 
 ago began to have attacks of pain in region of right kidney, not very- 
 severe, radiating to testicle and bladder. Lasting about two days. 
 Attack comes on gradually, becomes more severe, dull ache and then 
 disappears. These spells come on at least every two weeks, and are 
 described as attacks of severe cramplike pain in the right side beneath 
 the free border of the ribs, frequently brought on by violent exercise, 
 riding on trains, etc. Generally comes on in the middle of the night. 
 
 His urine has been examined by several physicians who stated that 
 he had pyelitis. Aside from the pain there have been no symptoms of 
 
 105 
 
renal disease. Bowels regular ; no indigestion ; sleeps well, but nervous. 
 This is practically all of his history. 
 
 In other words, he has recurrent attacks of pain in the right 
 hypochondrium referred to the right lumbar region, extending down 
 toward the bladder. The region of the kidney is tender during these 
 attacks. The patient is becoming more and more limited in his 
 activities. 
 
 Urine Acid; 1018; trace of albumin; small amount of blood; 
 many large round epithelial cells and crystals. 
 
 Cystoscopy: Urine collected from right kidney showed many blood 
 cells, probably traumatic ; large number of granular and renal epithelia. 
 
 X-ray of kidney negative. 
 
 Argument: By exclusion, all of the more common lesions were 
 eliminated. Our only positive signs were the few blood cells in the 
 urine and pain in the region of the right kidney, for the x-ray picture 
 was negative. Therefore, a pyelograph of the right kidney and ureter 
 was taken and showed that the right ureter was very markedly kinked, 
 forming a hairpin curve opposite the pelvis of the kidney, and that it 
 entered the pelvis of the kidney abruptly. A second picture showed 
 an egg-shaped dilatation of the pelvis of the kidney (Fig. 7). On this 
 evidence a diagnosis was made of intermittent dilatation of the renal 
 pelvis due to obstruction of the ureter caused by aberrant renal blood 
 vessels. 
 
 Operation was advised and undertaken by Dr. Duffield. The 
 exact anatomical conditions as outlined in the argument were found 
 by him at operation. The blood vessels were divided and the ureter 
 which had been very markedly kinked immediately straightened out. 
 The kidney was fixed in a high position and the patient made a good 
 recovery. 
 
 Cass III. Male. Referred by Dr. Arthur H. Bogart. Diagnosis: 
 Intermittent hydro-pelvo-renalis due to anatomical deviation of the 
 ureter. 
 
 Patient twenty-two years of age. Main points in history were 
 that the patient had suffered from attacks of pain referred to the right 
 side of the abdomen mostly in the lumbar region. First attack came 
 on suddenly in the middle of the night, in February, 1914, very severe 
 and suggestive of renal origin. There was frequency of urination. 
 Second attack ten months later came on during the day. Pain started 
 in the back and radiated to the front. At first the pain was severe, 
 then moderated. There was increasing frequency of urination. X-ray 
 examination negative. Several attacks followed. Was in hospital for 
 three weeks under observation, as the result of which he was oper- 
 ated upon for possible appendicitis, and a kinked, diseased appendix 
 was removed. However, attacks recurred immediately. Further 
 x-rays, wax tipped catheters and many examinations at another clinic 
 failed to reveal the cause of his symptoms. A study, however, of the 
 x-ray plates demonstrated that the kidney occupied an oblique posi- 
 tion; that its axis was not perpendicular which it should be in the 
 normal state; also that the kidney descended through an arc of fully 
 two inches and that the hepatic flexure of the colon was prolapsed. 
 Further, that there occurred regularly a spasm at the hepatic flexure 
 (Fig. 8), which would account for pain in the region of the cecum. 
 
 A pyelogram of the right kidney (Fig. 9), was taken under 
 anesthesia and it revealed an irregular dilatation of the pelvis of the 
 
 106 
 
Fig. 8. Radiogram of cecum and hepatic flexure 
 in Case 3. Showing spasm of section of gut 
 at flexure. Appearing on several plates. 
 
 Fig. 9. Outlined pyelogram of kidney in Case 
 
Fig. 10. (2096j Reproduction 
 of x-ray taken in Case 3 at Dr. 
 Eastmond's Clinic showing pro- 
 lapse of hepatic flexure, pro- 
 lapse of right kidney and change 
 in the kidney axis. Dotted line 
 A is the normal axis of the kid- 
 ney. Dotted line B is the axis 
 of the kidney shown in the x-ra3\ 
 
 [^liH^^^ 
 
 Fig. 11. Pyelogram in Case 5. Showing normal 
 ureter and kidney pelvis. 
 
right kidney with the calyces of the kidney moderately dilated. A 
 positive diagnosis of intermittent dilatation of the pelvis of the kidney 
 with anatomical deviation of the ureter was made. Previous to this 
 time pain had centered more over the region of the appendix and low 
 down in the pelvis. 
 
 Argument: The symptoms in this case were very severe first, pain 
 in the region of the kidney, later most marked over the cecum; some 
 frequency of urination during attacks; a few blood cells in the urine; 
 some rigidity of the right rectus muscle during these attacks. 
 
 The patient was operated upon by Dr. Bogart. A moderate 
 dilatation of the pelvis of the kidne ywas found. The kidney was 
 sutured in a high position. No aberrant blood vessel demonstrated. 
 Patient made a good recovery and has been well since that time. 
 
 Case IV. Female. Referred by Dr. Walter D. L,udlum. 
 
 Diagnosis: Intermittent dilatation of pelvis of kidney due to kink- 
 ing of ureter in a case of ren mobilis. Partial volvulus of ascending 
 colon. 
 
 Some cases are complicated by intestinal lesions. It is very im- 
 portant to search these out in order to do complete surgery when any- 
 thing is attempted. This patient complained of pain in the right hypo- 
 chondrium and the right lumber region, quite typical of renal disturb- 
 ance. These attacks were severe and recurrent, passing down to the 
 region of the cecum. The attacks of pain in the right side came on at 
 intervals of months, but there were no evidences of disease demonstra- 
 ble in the urine. In addition, she gave a very distinct history of in- 
 digestion supposed to be due to gastric ulcer; was persistently con- 
 stipated. 
 
 Radiogram showed the presence of a rudimentary rib, a prolapse 
 of the hepatic flexure and prolapse of the right kidney. 
 
 A pyelograin showed a very slight dilatation of the pelvis of the 
 right kidney, but no change in the calyces of the kidney. Negative 
 for stone. 
 
 Cystoscopic examination showed an accumulation of urine in the 
 pelvis of the right kidney. 
 
 Argument: A case with such a history demands more than a 
 diagnosis of intermittent dilatation of the renal pelvis, and further 
 examination revealed a prolapsed dilated cecum. 
 
 Operation was undertaken. The kidney was found to be prolapsed 
 and freely movable. It was raised up and fixed in good position. Then 
 the abdomen was opened through a right rectus incision. A prolapsed 
 and partially rotated cecum was found together with a markedly 
 dilated caput with a long appendix. A plastic operation was done on 
 the cecum, and the ascending colon was brought up into its normal 
 position and sutured there. As a result, the patient made a good 
 recovery and was relieved of her lumbar and lower abdominal pain. 
 There are now no symptoms of her original indigestion and her bowels 
 move regularly without cathartics. 
 
 Case; V. Patient presenting symptoms similar to those found in 
 cases of intermittent dilatation of the renal pelvis due to anatomical 
 deviation of the ureter, hut really due to conditions of the colon and 
 pelvic organs. A woman, twenty-four years of age, whose chief symp- 
 tom had been persistent pain in the left hypochondrium passing 
 around to the back and down toward the bladder. She stated that the 
 
 107 
 
pain came on suddenly and v/as described as a general abdominal 
 pain which later resolved itself into a colicky pain referred to the left 
 hypochondrium and left lumbar region. She usually vomited with 
 these attacks and demanded morphin to control the pain. The attacks 
 recurred with increasing frequency. Was sent to another clinic and 
 remained there for two months without diagnosis and returned home 
 still suffering from the pain. The chief features of her illness while 
 in the hospital were vomiting and pain. 
 
 The diagnosis first suggested by the symptom complex was an ob- 
 struction of the ureter with pain originating in the kidney. 
 
 Urinalysis showed an acid reaction, sp. gr. 1.020, trace of albumin, 
 no sediment. 
 
 Radiographs of the kidney were negative. 
 
 Vaginal examination showed tenderness in the left fornix. Trac- 
 tion on the cervix caused pain referred to left hypochondrium. 
 
 Radiographs of the colon demonstrated a deformity of the cecum 
 and transverse colon, confining a fecal mass in the cecum; also show- 
 ing the presence of adhesive bands binding together a portion of the 
 transverse colon and ascending colon. 
 
 A pyelogram of the left kidney and ureter was taken and no ab- 
 normality was found. (Fig. 11.) 
 
 Evidently the kidney must be excluded as the cause of the pain. 
 
 With the definite lesions known to exist in' the first portions of the 
 large intestine, the patient was again questioned as to her early his- 
 tory, and it developed that at first she had suffered entirely from 
 pain on the right side. This pain had come on suddenly, was accom- 
 panied by vomiting and fever and was very suggestive of acute ap- 
 pendicitis. The left sided pain evidently originated in the left tube and 
 ovary. 
 
 The abdomen was opened and a chronically deformed appendix 
 was removed. The ascending and transverse colon v^^ere freed from 
 the adhesions which bound them together. A plastic operation was per- 
 formed on the left uterine adnexa and some adhesions extending to 
 the sigmoid colon were divided. 
 
 The patient made a good recovery and has been entirely relieved 
 of her symptoms. 
 
 In concluding this brief clinical report the writer wishes to em- 
 phasize the fact that the diagnosis of pain due to anatomical deviation 
 of the ureter can rarely be made from a consideration of the clinical 
 symptoms alone, or by the aid of examinations made in the laboratory. 
 One must depend more upon the various mechanical aids, such as 
 the pyelograph and the cystoscope, basing our final judgment, how- 
 ever, on the combined evidence collected from interrogation of the 
 patient, a personal examination of the patient, the laboratory reports, 
 and the interpretation of the scientific aids to our special senses, the 
 cystoscope and the x-ray. 
 
 108 
 
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