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CLINICAL SURGERY 
BY CASE HISTORIES 

VOL. II 



CLINICAL SURGEEY 

BY 

CASE HISTORIES 



BY 



ARTHUR E. HERTZLER, M.D., Ph.D, F.A.C.S. 

Professor of Surgery in the University of Kansas; Surgeon to the 

Halstead Hospital, Halstead, Kansas, and to St. Luke's 

AND to St. Mary's Hospitals, Kansas City, Mo. 



VOL. II 

DISEASES OF THE ABDOMINAL AND 
GENITOURINARY ORGANS 



WITH ONE HUNDRED NINETY-NINE ORIGINAL 
ILLUSTRATIONS 



ST. LOUIS 

C. V. MOSBY COMPANY 

1921 



Copyright, 1921, By C. V. Mosby Company 

(All rights reserved) 



Press of 

C. V. Mosby Company 

St. Louis, U. S. A. 



Biomedical 
Library 

\h 

\i\^\\St. CONTENTS 

fUl 

'^ ^ VOL. II 

CHAPTER XI 

PAGE 

Severe Abdominal Crises 547 

Upper Abdomen, 547; Lower Abdomen, 577; General Abdomen, 593. 

CHAPTEE XII 

Severe Intermittent Pain 613 

Epigastric, 613; Hepatic, 621; Renal, 642; Appendiceal, 650; Supra- 
pubic, 669. 

CHAPTER XIII 

Abdominal Distress 679 

Epigastric, 679; Hepatic, 690; Renal, 705; Ileocecal, 710; Supra- 
pubic, 719. 

CHAPTER XIV 

Nutritional Disturbance 729 

With Pain, 729; Without Pain, 743; Loss of Weight, 759; Jaundice, 
767; Hematemesis, 778. 

CHAPTER XV 

Tumors of the Abdomen 788 

Epigastric, 788; Hepatic, 805; Renal, 818; Inguinal, 829; Supra- 
pubic, 841, 

CHAPTER XVI 

Disturbances of Uterine Function 870 

Menstrual Pain, 870; Hemorrhage, 891; Postmenopause Hemorrhage, 
925. 

CHAPTER XVII 

Diseases of the Abdominal Wall 942 

Tumors in the Region of the Abdominal Ring, 942; Tumors of the Ab- 
dominal Wall Proper, Including Fistula, 955; Inflammatory Infections 
Involving the Abdominal Wall, 962. 



V 



'^'06087 



VI CONTENTS 

CHAPTER XVIII 

PAGE 

Bladder 974 

Bladder Irritation, 974; Hematuria, 992; Obstruction, 1003 

CHAPTER XIX 

Rectum 1023 

Hemorrhage and Pain, 1023; Fistula, 1039; Perianal Diseases, 1044 

CHAPTER XX 

External Genitals 1053 

Affections of the Vulvar Region, 1053; Diseases of the Penis, 1068; 
Diseases of the Scrotum and Its Contents, 1075. 



ILLUSTRATIONS 



FIG. PAGE 

285. Fat necrosis in the upper part of the omentum from a case of necrosis 

of the pancreas 550 

286. Fat necrosis of the omentum in a case of acute pancreatitis .... 551 

287. A necrotic pancreas nodule on the left and one nearly normal on the 

right 551 

288. Subdiaphragmatic abscess containing gas 552 

289. Subdiaphragmatic abscess drained after the pleural space had been 

obliterated by packing it a week with gauze 553 

290. Schematic drawing of a neglected case of perforated ulcer 555 

291. Schematic presentation of the direction of escape of duodenal contents 

over the watershed provided by the great omentum 560 

292. Ulcerating duodenum in which perforation was prevented by the forma- 

tion of omental adhesions 561 

293. Loops of collapsed intestine lie below an opening in the mesentery 

through which they have slipped 568 

294. Gallstones removed from the intestine following death from intestinal 

obstruction 570 

295. Head of the pancreas in acute pancreatic necrosis 572 

296. The two puckered openings in the gut are surrounded by granulation 

tissue 575 

297. Emaciation due to intestinal fistulae and sepsis 576 

298. Meckel 's diverticulum with its tip adhering to the mesentery, showing 

the loop through which the intestinal coils had slipped .... 579 

299. Drainage of subdiaphragmatic abscess below the costal margin . . . 582 

300. Perforating hemorrhagic myoma of the uterus 587 

301. Fetus and blood clots from an extrauterine pregnancy 592 

302. (A) Appearance of the diverticulum after it was restored to its normal 

position. (B) Diagram of the position of the diverticulum when 

it was causing the obstruction 597 

303. Enterolith formed of pawpaw seeds 600 

304. Small abscess within the gut wall covered with plastic exudate . . . 606 

305. Appendix in an advanced stage of necrosis 611 

306. Appendix after it had been shelled out of the muscle coat 624 

307. Strawberry gall bladder 629 

308. The appendix located lateral to the ascending colon is surrounded by 

indurated tissue in which there was a small abscess 639 

309. Chronic inflammation of the gall bladder 641 

310. Hyperplasia of the mucosa of the gall bladder 641 

311. Stones removed from the left kidney 643 

vii 



Viii ILLUSTRATIONS 

FIG. PACK 

312. Kidney stone filling the pelvis of the kidney 645 

313. Shaded area indicates the extent of the adhesions 653 

314. Acute miliary tuberculosis of the ileocecal region, young man aged 

nineteen 656 

315. Enterolith protruding after the wall of the gut was cut 657 

316. Acute necrosis of the appendix 659 

317. An Acutely inflamed appendix entirely surrounded by the indurated 

omentum 661 

318. Periappendiceal abscess from bubo 667 

319. Papillary cystoma of the ovaries 670 

320. Loop of small intestine adherent to malignant gut causing closure of 

the lumen 673 

321. Carcinoma of the pelvic colon producing stenosis of the gut .... 673 

322. Localized periappendiceal abscess 677 

323. Hernia of the linea alba 681 

324. Enormous dilatation of the common duct due to a stone 684 

325. Gall bladder with corrugations of the mucosa 692 

326. Dilatation of the vessels in the hepatocolic ligament in a patient who 

had had many attacks of cholecystitis, but at the time of operation 

was free from symptoms 699 

327. Fistulous gall bladder containing a stone in the cystic duct .... 702 

328. Carcinoma of the cervix 704 

329. So-called carcinoma of the appendix 707 

330. Luteal cyst of the ovary 708 

331. Hemorrhagic ovary 709 

332. Ovarian cyst with hemorrhage 709 

333. Abscess within the broad ligament drained through the vagina . . . 719 

334. Interstitial myoma of the uterus 721 

335. Luteal cyst of the ovary 724 

336. Broad ligament abscess 726 

337. Abscess situated far laterally in the broad ligament drained by an in- 

cision above Poupart 's ligament 727 

338. Hernia of the linea alba 731 

339. Esophagus and stomach showing site of strictui-e, the greatly dilated 

esophagus and the marked dilatation of the cardiac end of the 

stomach 745 

340. Interior of the esophagus showing the atheromatous degeneration of 

the mucosa 746 

341. Slide of an atheromatous plaque of the preceding 747 

342. X-ray picture of the filling defect in sarcoma of the ileocecal junction 750 

343. Sarcoma of the ilocecal junction 752 

344. Sarcoma of the ilocecal region 753 

345. Esophageal dilatation due to a cicatrix of the cardia 756 

346. Carcinoma of the esophagus 766 

347. Stone from common duct 776 



ILLUSTRATIONS IX 

FIG. PAGE 

348. Large broad ligament abscess pointing both in the vagina and over Pou- 

part 's ligament 785 

349. Bilateral broad ligament abscess 786 

350. Adenocarcinoma of the stomach 789 

351. Diagrammatic presentation of a supposed pancreatic cyst 792 

352. Polycystic disease of the lesser omentum 794 

353. Cross section of a polycystic tumor of the lesser omentum showing the 

numerous smooth-walled cysts 795 

354. Slide of Fig. 353 796 

355. Ulcerating carcinoma of the stomach 798 

356. Pseudocyst of the pancreas 802 

357. Malignant cystoma of the ovary 804 

358. Ovarian cyst with twisted pedicle filled with blood clot 807 

359. Enlarged thick-Avalled gall bladder 817 

360. Ehabdomyosarcoma of the right kidney 819 

361. Ehabdomyosarcoma of the right kidney 820 

362. Dilated veins in the abdominal wall due to obstruction of the venous 

return 821 

363. Aneurysm of the left renal artery 823 

364. Hypernephrosis showing the dilated pelvis and thin cortex of kidney 

remaining 825 

365. Hypernephroma of the kidney 827 

366. Hypernephroma of the kidney 828 

367. Pendulous fibrosarcoma of the external surface of the stomach . . . 830 

368. Fibrosarcoma of the stomach 831 

369. Carcinoma of the cecum with lymph gland involvement 833 

370. Pelvic hematoma 835 

371. Colloid degeneration of a myoma of the uterus 840 

372. Schematic presentation of a subperitoneal postoperative liematoma . . 841 

373. Myxedema before treatment 843 

374. Patient after ten days' treatment with thyroid extract 843 

375. Before onset of the disease 843 

376. Myoma of the uterus with an infected focus in its interior .... 846 

377. Schematic differentiation between an enlargement of the uterus due 

(A) to a pregnancy and (B) to tumor 848 

378. Hemorrhagic myoma which simulated pregnancy 849 

379. Fibrosarcoma of the ovary 862 

380. Perithelioma of the ovary 864 

381. Hemorrhagic myoma 866 

382. Adenocarcinoma of the ovary 868 

383. Endocervicitis with mucus discharge 871 

384. Early carcinoma of the rectum 873 

385. Huge fallopian tubes possibly tuberculous in nature 875 

386. (A) Beginning malignancy in adenomyoma of the uterus. (B) Met- 

astasis in the ovary 881 



X ILLUSTRATIONS 

FIG. PAGE 

387. (A) Metastatic malignant adenoma of the ovary. (B) ' Adenocarcin- 

oma of the fundus 881 

388. Papillary cystadenoma of the ovary 883 

389. Pedunculated myoma protruding into a hematometrium 886 

390. Technie for removal of pedunculated myoma of the uterus 888 

391. Diagram showing relation of the tumor to the uterus in the preceding 

figure 889 

392. Pedunculated myoma of the uterus 889 

393. Technie for resection of a persistent corpus luteum 891 

394. Carcinoma of the vagina 895 

395. Polypoid degeneration of the cervical mucosa 896 

396. Carcinoma of the cervix 898 

397. Carcinoma of the cervix 901 

398. Carcinoma of the cervix after myomectomy 903 

399. Fungus carcinoma of the uterus 904 

400. Adenomyoma of the uterus 905 

401. Hyperplastic endometrium in adenomyoma of the uterus 906 

402. Adenomyoma of the uterus 908 

403A. Myosarcoma of the uterus 909 

403B. Myosarcoma of the uterus 910 

404. Pedunculated intrauterine myoma 912 

405. Technie of vaginal hysterotomy 913 

406. Myosarcoma of the fundus of the uterus 915 

407. Myoma of the uterus showing lymph sinuses, some of which are filled 

with blood clot 917 

408. Fundus carcinoma of the uterus 919 

409. Fundus carcinoma of the uterus 920 

410. Carcinoma of the fundus of the uterus 922 

411. Ketained placenta resembling deciduoma maligna 924 

412. Small mucus polyp of the endometrium 925 

413. Carcinoma of the l)ody of the uterus 928 

414. Carcinoma of the body of the uterus 929 

415. Carcinoma of the fundus of the uterus 932 

416. Beginning carcinoma of the fundus 933 

417. Carcinoma of the body of the uterus 935 

418. Temperature curve during the period of parotid suppuration .... 936 

419. Granulomatous endometrium in a case of pyometriimi 939 

420. Lipoma of the femoral ring 943 

421. Femoral hernia masked by lipoma 943 

422. Cyst of the canal of Nuck 945 

423. Abscess in a lipoma of the femoral ring 947 

424. Inguinal hernia masked by lipoma 949 

425. Femoral and interstitial hernias 951 

426. Schematic presentation of the traction produced by the deposition of 

fat about the umbilicus 952 



ILLUSTRATIONS XI 

FIG. PAGE 

427. Diagrammatic presentation of a cross section of the abdominal wall 

in the region of a beginning umbilical hernia 953 

428. Bald-headed endothelioma of the abdominal wall 957 

429. Accessory mammary gland in male 958 

430. Fibrosarcoma of the inguinal region 959 

431. Bald-headed sarcoma 960 

432. Spindle-celled sarcoma of the groin 961 

433. Necrosis .of a loop of ileum in a case of strangulated femoral hernia . 963 

434. Torsion of the great omentum 965 

435. X-ray of sinuses filled with bismuth paste 972 

436. Large stone in pelvis of kidney 976 

437. Two large bladder stones 978 

438. Papillary cystadenoma of the ovary 980 

439. Early tuberculosis of the kidney 993 

440. Carcinoma of the base of the bladder 996 

441. Papilloma at base of bladder 998 

442. Hypernephroma of the kidney 1002 

443. Bar across the base of the bladder after prostatectomy 1004 

444. Sarcoma of the posterior wall of the bladder 1005 

445. Diverticulum of the bladder everted showing the structure of the lining 

wall ' 1008 

446. Diverticulum of the bladder 1018 

447. Keloid of the prostatic capsule after prostatectomy 1020 

448. Diagrammatic presentation of stricture of the rectum 1024 

449. Deep ulcerous carcinoma of the rectum 1027 

450. Catheter with a silk suture protruding out of the suprapubic wound 1028 

451. Carcinoma of the rectum 1034 

452. Carcinoma of the rectum beginning just above the sphincter . . . 1036 

453. Fungating carcinoma of the anus 1038 

454. Tuberculous pararectal fistula 1043 

455. Tuberculosis of the pararectal tissue 1044 

456. Tuberculous ulcer of the anal margin 1046 

457. Condyloma of the anal region 1048 

458. Condyloma of the anal region 1048 

459. Strangulated hemorrhoid 1050 

460. Prolapse of the rectum in a child 1051 

461. Carcinoma of the vulva 1054 

462. Hernia in the perineum 1055 

463. Carcinoma of the clitoris 1056 

464. Submucous myoma protriuling from the vagina 1058 

465. Supravaginal amputation of the uterus when inverted by a tumor . . 1058 

466. Pedunculated tumor of the uterus 1060 

467. Cyst of the vagina 1063 

468. Esthiomene 1064 

469. Slide from Fig. 468 • . . . 1065 

470. Lipoma of the labium majus 1067 



Xll ILLUSTRATIONS 

FIG. PAGE 

471. Lipoma of the labium majus after excision 1067 

472. Diagrammatic presentation of episijadias 1068 

473. Chronic induration of the penis 1070 

474. Chronic induration of the penis 1070 

475. "Washboard" prepuce 1071 

476. Cauliflower carcinoma of the glans 1073 

477. Squamous-celled carcinoma of glans 1074 

478. Benign papillomas of the prepuce 1075 

479. Hematocele removed for mixed tumor of the testicle 1076 

480. Sloughing testicle after operation for retained testis 1078 

481. Mixed tumor of the testicle 1080 

482. Mixed tumor of the testicle 1082 

483. Mixed tumor of the testicle 1083 



CLINICAL SURGERY 

BY CASE HISTORIES 



VOL. II 



CHAPTER XI 

SEVERE ABDOMINAL CRISES 

Under this head are included those conditions which if unaided 
by surgical means are prone to end in death. They include intra- 
abdominal hemorrhages, perforations into the unprotected peri- 
toneal cavity and obstructions to the gut current or conditions that 
impair the integrity of its walls. This group of diseases demands 
immediate action and does not admit of detailed study but must be 
attacked on the basis of the intuition of the surgeon, backed by 
experience in similar conditions. 

These conditions must be distinguished from painful affections 
that are in themselves important but do not tend to destroy life. 

UPPER ABDOMEN 

Crises arising in the upper abdomen have to do with perforations 
of the stomach and duodenum and necroses of the pancreas. Rarely 
a necrosis of the wall of the gall bladder may result in an immedi- 
ately serious condition. The diagnosis of perforation is dependent 
on a sudden atrocious pain in the pyloric region sometimes ante- 
dated by mild symptoms of gastric disorder. The cardinal symp- 
toms of pancreatic disease are pain, collapse, distention and rapid 
pulse. 

This group must be differentiated from the spasmodic affections 
in the upper abdomen, notably gall bladder and renal colics. The 
notable difference in these is that there is no collapse in propor- 

547 



548 CLINICAL SURGERY BY CASE HISTORIES 

tion to the severity of the pain and when they have existed for 
some time there is less tendency to general disturbances ; notably 
those of the pulse and temperature. Often history can be of help. 

CASE 1. — A fanner aged fifty was visited because of some affec- 
tion of the upper abdomen. 

History. — His illness began two months ago. He had been working 
hard all day on the farm but complaining a little of a feeling of 
fullness across the epigastrium. He ate a hearty supper and that 
night about 10:30 he was seized with a sudden and very severe epi- 
gastric pain. This was accompanied by vomiting and followed by 
distention and extreme abdominal rigidity. The physician who 
was called at that time said that his pulse was about 120 and his 
temperature normal. A surgeon was called, who made a diagnosis 
of intestinal obstruction. He was removed to a hospital that night 
and operated on the next morning. The vomiting had stopped 
some time during the night, but the rigidity and distention remained 
at the time of the operation. At operation a right rectus incision 
was made. It was said that an obstruction was found at the hepatic 
flexure of the colon. The character of the obstruction or the 
method of its relief could not be ascertained. The appendix was 
then removed and the wound closed Avithout drainage. The pa- 
tient was relieved for the time being but one and a half weeks after 
the operation and while still in bed at the hospital he had an at- 
tack much like the one he had the day before he was brought in 
for operation. The pain, as before, was across the epigastric re- 
gion and was accompanied by vomiting, distention and rigidity. 
The pulse rate and temperature could not be ascertained. The 
pain was attributed to gas and treated as" such. It gradually passed 
away in twenty-four hours. 

The wound healed, but the patient did not improve. He became 
emaciated and weak, and took on a lemon-yellow color. A diagnosis 
of pulmonary tuberculosis was made while still in the hospital. It 
was claimed that organisms were found in the sputum. Four 
weeks after operation the patient was carried home on a stretcher, 
and he has been in bed since that time. His physical condition 
did not improve, and he has gradually grown weaker. Three 
weeks after he came home he was seen again by the operating 
surgeon who examined the blood and made a diagnosis of perni- 
cious anemia. The hemoglobin was reported as 65 and the red 



SEVERE ABDa:MIXAL CRISES 549 

count as 1,500,000 with microcytes, poikilocytes and nucleated red 
cells. 

Yesterday, three weeks after his return from the hospital, he 
had an attack of acute abdominal pain wdth some rigidity, but no 
vomiting. His temperature was 102° and the pulse 110 the attend- 
ing physician says. 

Examinaiion. — The patient is emaciated, weak, approaching col- 
lapse. He has a temperature of 101.5° and a pulse around 100, very 
weak, scarcely palpable. The respiration is not markedly acceler- 
ated but labored. There is very little abdominal rigidity, but he 
complains of pain in the upper abdomen. Examination of the chest 
shows flatness and bronchial breathing over the whole lower right 
lobe of the lung. No flatness but crepitant rales over the lower 
left lobe. Blood examination at this time showed a hemoglobin of 
60 per cent (Tallquist), a red count of 2,100,000 with the red cells 
normal and a white count of 6,000. 

Diagnosis. — A vigorous farmer after eating a hearty meal had 
severe epigastric pain with a rapid pulse and distention but wdthout 
fever. One thinks of perforation of an ulcer or pancreatitis. There 
is no history of gastric disturbance and the pain remained local- 
ized in the epigastric region. A perforated ulcer would have caused 
pain down along the right side unless indeed it had become local- 
ized. The operation excludes this. An account is given of an ob- 
struction at the hepatic flexure. The onset is wholly unlike an ob- 
struction in this region. Had the surgeon had a definite obstruc- 
tion to deal with he would scarcely have bothered about an inno- 
cent appendix. We may conclude, therefore, that he was not 
clear in his own mind as to the presence of obstruction. The find- 
ing of tubercle bacilli does not require serious consideration. No 
mention w-as made of epigastric exploration at the time of the 
operation. There remains a consideration of pancreatitis. The 
progressive emaciation is in line with this, as is the anemia. The 
present examination indicates a secondary and not a pernicious 
anemia. His primary afl'ection was probably a pancreatitis. The 
present state of the lungs, flatness and bronchial breathing on 
the right side and crepitant rales on the left suggests a hypostatic 
pneumonia. The state of the circulation and the general enfeebled 
condition are quite in harmony with the physical findings. 

Treatment. — Stimulants were suggested. 



550 



CLINICAL SURGERY BY CASE HISTORIES 



After-course. — He died the next day. 

Autopsy. — Only the abdomen was examined. Adhesions of the 
omentum were found along the under surface of the operative scar. 

The omentum and mesentery were found studded with raised 
yellowish patches of various sizes, the largest about the size of a 
finger nail (Fig. 285). These were taken to be fat necroses. The 
intestines, including the hepatic flexure of the colon, were normal in 
appearance. There were no stones in the gall bladder. The pan- 




Fig-. 285. — Fat necrosis in the upper part of the omentum from a case of necrosis of 
the pancreas. The white necrotic areas are set into the unchanged fat of the great omen- 
tum hke tiles in a floor. 



creas was mottled in appearance, but the larger pancreatic ducts 
were all stained with bile. The slide showed fat necrosis of the 
mesentery (Fig. 286). Many of the fat cells near the periphery of 
the necrotic area showed round-celled infiltration indicating that 
the necrosis had existed for some time. The pancreas itself showed 
islands of old necrosis (Fig. 287). 

Comment. — It is important in operating for a grave abdominal cri- 
sis to search until a lesion is found capable of producing the 



SEVERE ABDOMINAL CRISES 



551 



sjTnptoms present whether the hypothetical lesion is found or not. 
This search is much facilitated if the operator has clearly in mind 







A 












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Fig. 286 — Fat necrosis of the omentum in a case of acute pancreatitis. Note the opaque 
degeneration of the fat cells. Some of these have moderate cellular infiltrations about 
them. 



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Fig. 287. — A necrotic pancreas nodule on the left and one nearly normal on the right. 

all the conditions that might be responsible for a condition such 
as he has in hand. 



552 



CLINICAL SURGERY BY CASE HISTORIES 



CASE 2. — I was asked to see a boy aged four because of pus in the 
right side. 

History. — The child has a markedly distended abdomen which is 
not tender. The patient has been sick five weeks. An adequate his- 
tory of the onset is not obtainable. There was fever and digestive 
disturbance. 




Fig. 288. — Subdiaphragmatic abscess containing gas. 

Examination. — The liver is palpable below the costal margin, about 
two inches breadth. The dullness extends to the fourth rib. Above 
this is tympany. The x-ray shows a light shadow with a marked 
oval curve above (Fig. 288). This extends to the third rib. The 
leucocytosis is high, around 20,000, and the temperature ranges 
from 101-103°. 



SEVERE ABDOMINAL CRISES 



553 



Diagnosis. — Because of the increased area of liver dullness, the 
leucocytosis and fever, the diagnosis of an abscess in the region of 
the liver advanced by his physician was accepted. The question 
at issue was what was the relation it bore to the diaphragm. Be- 
cause it extended so high, to the third rib, it was my opinion that 
it was above the diaphragm, that is, that it was an empyema. My 
consultant insisted it was subdiaphragmatic. Above or below the 
diaphragm it seemed best to drain transpleurally. If it is pleural, 
the problem will be easily solved. If it is subdiaphragmatic, it will 
best be drained transpleurally. 



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Stlfe^rr,, 



Fig. 



289. — Subdiaphragmatic abscess drained transpleurally after the pleural space had 
been obliterated by packing it a week with gauze. 



Treatment. — A rib was resected and the pleural cavity was found 
free from pus, but the bulging abscess was felt beneath the diaphragm. 
A pack was placed against the diaphragm in order that a walled-off 
tract might form between the abscess and the external wall. After 
four days the pack was removed and the abscess opened (Fig. 289). 
Much gas and foul smelling pus escaped. A rubber tube was placed 
in the abscess. 

Pathology. — A pure culture of colon bacilli was obtained. 

After-course. — The child died in twenty-four hours. 

Comment. — The oval curve of the shadow in the plate should have 
made the diagnosis early. It seemed to me that the diaphragm could 
not be forced so high. In empyema confined between the lung and 



554 CLINICAL SURGERY BY CASE HISTORIES 

diaphragm the border of the lung must needs be fixed, which it was 
not. In empyema there would most likely be some involvement of the 
lung adjacent to the pleura involved, which there was not. The child 
died evidently from a too early opening of the abscess before the 
pleura had had time to effectually wall off a tract. It was rec- 
ognized that four days was too short a time to be sure that much 
walling off had occurred, but the drainage of the abscess seemed to 
my consultant to be urgently necessary. The patient was becoming 
rapidly more distended and he began to vomit. In draining a sub- 
diaphragmatic abscess transpleurally, as in draining a lung abscess, 
it is necessary that a walled-off tract be secured before the abscess 
is drained. If this precaution is not taken a suppurative pleuritis 
is almost certain to result. The light area seen in the x-ray plate 
at the dome of the diaphragm was obviously due to the pressure of 
gas. 

CASE 3. — I was called to see a farmer aged fifty-six because of 
severe abdominal pain. 

History. — The patient has not complained of gastric symptoms, 
other than occasional distention and eructation. Two days ago while 
driving a team about 5:30 p. m. he had a severe pain in the upper 
abdomen. He finished his journey, unhitched his team, and went to 
the house and lay down on the sofa. The pain increased in intensity 
and he called a physician some six hours later. The attendant found 
him with a pulse of 86 and a temperature of 100°. There was marked 
muscular rigidity along the whole length of the rectus. The chief 
point of tenderness was located three inches to the right of the um- 
bilicus. The following day the pain extended across the lower ab- 
domen and became much more intense and he began to become dis- 
tended. 

Examination. — Now two days after the onset of the disease he has 
a sensitive and distended abdomen. The temperature is 100.2°, the 
pulse 136, small and thready in character, and there is marked disten- 
tion. The tenderness is marked, particularly across the lower abdo- 
men. By placing him on the right side, a large amount of fluid can 
be demonstrated by percussion. The features are pinched, the ex- 
tremities cooling. 

Diagnosis. — The fact that he states that the onset was at 5:30 at 
once suggests a perforation. The beginning of the pain at the right 
upper abdomen, the extension downward and finally the invasion of 



SEVERE ABDOMINAL CRISES 



555 



the whole pelvis is confirmatory of this suspicion. The demonstration 
of free fluid likewise is quite in harmony with this view. The perfora- 
tion of an appendix lying high and lateral to the colon as his physi- 
cian suggests is unlikely, because appendices lying in this position 
do not blow out. It is only appendices lying at the pelvic brim that 
perforate with these hyperacute phenomena. Obviously the man 
is moribund. 

Treatment.— An incision was made over the right rectus between 
the costal border and umbilicus. A considerable amount of fluid es- 
caped. When this field was cleared a perforation of the pyloric end 
of the stomach was found. By raising up the abdominal wall a large 




Fig. 290. — Schematic drawing of a neglected case of perforated ulcer showing the accu- 
mulation of the fluid in the pelvis. 



quantity of fluid could be seen occupying the lower abdomen and 
pelvis. The amount of fluid was so great that the omentum was floated 
toward the left side (Fig. 290) . 

After-course. — The patient died in twenty-four hours. 

Comment. — There w^ere no protective adhesions about the perfora- 
tion and it is a question why the initial pain w^as not so great as 
usually is the case in such large free openings. Possibly there was 
little to escape, for the patient had taken nothing into his stomach 
for five and a half hours. The fluid found in the abdomen was a 
peritoneal exudate and not fluid that had escaped from the stomach. 



556 CLINICAL SURGERY BY CASE HISTORIES 

CASE 4. — A fanner aged fifty-four was brought to the hospital 
because of a severe abdominal pain. 

History. — At 5 :30 in the evening he was attacked by a severe pain 
in the region of the nmbilicus. He took some liniment to relieve the 
pain. He vomited. He then took some whiskey and vomited again. 
His physician, who arrived at eight o'clock, gave him four quarters 
of morphine before the pain subsided sufficiently to make it possible 
to remove him to the hospital. At this time his temperature was 97° 
and the pulse 90. His physician savs the upper abdomen was rigid 
while the lower was only moderately so. During the night the 
greatest pain was complained of in the hepatic region and in the back. 
He received two more quarters of morphine during the night. He 
passed urine once during the night. It was not attended by pain. 
His wife states that he has had some digestive disturbance during 
the recent past and has taken some tablets for it. 

Examination. — The patient's appearance is that of acute distress. 
His temperature is 98°, pulse 80, full, just a little quick. The res- 
piration is 48. The region of the gall bladder is tender and rigid 
and he seeks to halt the examiner by the interposition of his hands. 
The lungs are negative save for a few large bubbling rales at the 
level of the angle of the left scapula behind. The lower abdomen is 
but little tender, but there is dullness over the pelvis. It moves on 
change of position. There is no tenderness in the back. 

Diagnosis. — The sudden onset of severe pain located in the begin- 
ning, at the umbilicus, later concentrating in the hepatic triangle, 
in an individual the subject of chronic indigestion, suggests a per- 
forated ulcer. Against this assumption was the first appearance of 
pain at or below the umbilicus and the absence of deep tenderness 
and rigidity over the ascending colon. The initial pain in ulcer is 
usually over the site of the escaping fluid. He is a moderately thin 
man and the attack came on before supper, both points counting 
against a pancreatic necrosis. Besides, the pulse was slow, whereas 
in pancreatic disease, it is usually rapid from the beginning. Gall 
bladder colic was ruled out because of the very intensity of the pain 
associated with a subnormal temperature. He has vomited only 
after taking the liniment and whiskey, and the tympany was not 
marked, hence intestinal obstruction was not seriously considered. 
Taking all things into account, a grave abdominal crisis demanding 
immediate operation was diagnosticated. A perforated ulcer seemed 
the probable diagnosis. 



SEVERE ABDOMINAL CRISES 557 

Treatnieiit. — An incision was made through the right rectus mus- 
cle, the midpoint of the incision being on the level of the umbilicus. 
As soon as the abdomen Avas opened a quantity of blood-stained 
serum escaped. Ulcer was therefore excluded. The transverse 
colon appeared blue-black and a mesenteric thrombosis w^as sus- 
pected. Close inspection showed this suspicion to be unfounded. 
The hand was passed into the pelvis and a mass of distended in- 
testines was found here Avhich could not be dislodged. The incision 
was enlarged downward Avhen the fingers could be hooked under 
a band and by making traction the whole mass was brought out 
of the wound. A blackened area of gut was delivered, having as 
its midpoint a blackened and erectile Meckel's diverticulum. The 
diverticulum was adherent to the mesentery and a half dozen loops 
of gut had slipped through the loop so formed. After an interval 
the gut did not change color, therefore, the necrotic loop was fas- 
tened within the incision and a rubber tube placed in the proximal 
loop of gut. 

After-course. — The patient rallied well after the operation, but 
died the following day. 

Comment. — The cause of the crisis was not correctly diagnosticated, 
but the fact that immediate operation was demanded was correctly 
recognized. That was the essential point. The uncertainty of the 
diagnosis was recognized and the incision so placed that it could 
be easily lengthened in the direction of the offending area. In such 
cases even when it is recognized that the gut is hopelessly lost, it 
is best to open the gut. Immediate attempt at anastomosis, while 
inviting, usually ends in disaster either from shock or from sec- 
ondary perforation because the gut has become necrotic beyond 
the region of resection from extension of the thrombosis in the 
mesenteric vessels. Why the pain was referred to the upper ab- 
domen does not appear quite clear. The distended loops lay in 
the true pelvis, putting the mesentery on the stretch. It is this 
tension on the mesenteric root, likely, that determined the location 
of the pain. The presence of a fluid exudate in the pelvis was not 
taken sufficiently into account. Fluid in the pelvis in the absence 
of pain along the ascending colon should have located the lesion 
independent of the upper abdomen. While the upper abdomen was 
sensitive to pressure, there was no evidence of reaction sufficient 
to account for the symptoms. However, listening to boiling in- 
struments is not conducive to accurate thinking. 



558 CLINICAL SURGERY BY CASE HISTORIES 

CASE 5. — A fanner aged thirty-six wels brought to the hospital 
because of severe abdominal pains. 

History. — At six o'clock, while unhitching his team, he was seized 
with sudden severe abdominal pain. He fell to the ground and was 
carried into the house. He vomited once at this time. A doctor was 
called, w^ho refused temporary treatment, but hurried him to the 
hospital. On arrival at the hospital he was given 14 grain of 
morphine. The patient had an attack of severe epigastric pain 
eighteen years ago. He was in bed tAvo weeks at that time and he 
has had stomach symptoms ever since. The distress is worse in 
spring and fall. About three hours after meals he has a burning in 
the epigastrium, -with, nausea, but no vomiting. This pain is relieved 
by eating. The attacks last for two months or more and then 
they gradually disappear. Recently for a number of weeks he has 
had a return of the above symptoms. Tw^o days before the pres- 
ent attack the symptoms were exaggerated. There was little pain, 
but shaking while driving on a w^agon made him feel bad. He 
worked right along. 

Examination. — The pulse is slow, there is no fever, but there is 
a board-like rigidity over the entire abdomen. There is very severe 
pain all over the abdomen which is not relieved by morphine gr. 14. 

Diagnosis. — The very severe pain coming on at a time so definite 
that the patient is able to recall the act he was performing when he 
was struck down spells only one thing — perforation. The previous 
long history of serious epigastric disorder is interesting and con- 
firmatory evidence. 

Treatment. — Operation was performed six hours after the attack 
began. A perforated gastric ulcer the size of the end of a lead pencil 
on the anterior surface of the stomach was found. There was an 
induration about it the size of a dollar. The perforation was sewed 
up and the abdomen drained. 

After-course. — The patient made an uneventful recovery and with 
the aid of antacid treatment has remained free from his former symp- 
toms, until two years after the operation. He now has renewed 
trouble with his stomach. Antacids and diet control the pain, but 
when the treatment is discontinued, the difficulty returns. 

Comment. — The history of this case is classic. The diagnosis was 
promptly made by his physician, and he very properly refused pal- 
liative treatment until immediate operation was agreed upon and 



SEVERE ABDOMINAL CRISES 559 

preparations for the departure to the hospital begun. These are 
emergencies and it is the attendant's duty to point out the need of 
immediate operation at his command. With an overwhelming pain 
in the abdomen it is much easier for the patient to perceive the 
need than after he has been eased by morphine. Such strategy is 
wholly in the interest of the patient. With the persistence of the 
symptoms at the present time it is my opinion that operative treat- 
ment of the ulcer should be undertaken. 

CASE 6. — I was called to see a jeweler aged twenty-eight because 
of severe abdominal pain. 

History. — At 5 :30 at the close of a Sunday evening meal the pa- 
tient was seized by a sharp, lancinating pain in the epigastrium, 
just to the right of the median line. This pain was described as 
excruciating. After existing at its greatest intensity for some ten 
minutes, it began to subside somewhat. When I saw him at the 
end of twenty minutes he lay on the couch, trousers open, shirt 
drawn up, vainly holding a hot-water bottle to his right side. This 
position was chosen because the weight of the bottle w^as too 
great to be borne over the site of the most intense pain. His res- 
pirations were superficial and cautious. He began to moan loudly 
and lament that the awful pains were approaching again. The 
increased pain was marked by a horrified expression of the face 
and a beady brow. His general attitude was that of an agonizing 
serpentine movement wath a general spasticity of the muscles. 
Every manifestation of human suffering both physical and mental 
found expression here in the most emphatic degree. It w'ell de- 
served the French term "brutal." He has had some epigastric 
distress for some months, and three weeks before the attack he 
got an antacid mixture from his doctor w^hich gave him some relief. 

Examination. — The small, rapid pulse, the cold, beaded brow, and 
the history of preceding gastric hyperacidity left no question as to 
the diagnosis. The site of initial pain, well to the right of the me- 
dian line, made the probable site of the lesion to be the duodenum. 
He was taken to the hospital and transported directly to the operating 
room. 

Treatment. — Laparotomy was done. The incision was made at the 
lateral border of the rectus above the level of the umbilicus. The 
moment the peritoneum was opened, a flaky w^hey-like fluid es- 
caped. This fluid contained a few flocculi like clabbered milk. A 



560 



CLINICAL SURGERY BY CASE HISTORIES 



fine stream of this flowed over the omentum directly to the pelvis 
(Fig. 291). When this was sponged away the opening in the duo- 
denum appeared in the wound. The opening about 5 mm. in diam- 
eter occupied the center of an indurated area the size of half a 
dollar. The thickness of the indurated area seemed to be 5 to 6 
mm. Because of the indurated, fragile condition of the gut wall 
about the opening, closure was imperfect. The sutures were re- 
enforced by a tag of omentum. Drainage was placed about the 
wound. Since the escape of fluid was slight, no deeper drains were 
placed. 




Fig. 291. — Schematic presentation of the direction of escape of duodenal contents over 
the watershed provided by the great omentum. 



After-course. — There was considerable pain in the epigastrium for 
a few days, but the recovery was uneventful. He was placed on 
ulcer treatment and general improvement was rapid. For six 
months or more he had attacks of hyperacidity and had to have 
antacids. For some two years now he has been free from pain. 

Comment. — This is the only patient I have ever seen in' the throes 
of the first pains from perforation. It did much to impress on me 
the importance of the history of intense pain, and to appreciate 
how . diabolical a peritoneal irritation may be. This early pain 



SEVERE ABDOMINAL CRISES 561 

must be due to the irritation of the peritoneal nerve endings by 
the action of the acid fluid from the gut. It can not be due to 
inflammation, for at the time of operation none of the phenomena of 
inflammation had been initiated, and when the fluid had been re- 
moved, the intense pains did not return though the phenomena of 
inflammation about the drain obviously increased and gave rise to 
pains of its own, but they were of a different character and of a 
lesser intensity than those which marked the onset of the disease. 
The fragile nature of the gut wall at the site of the ulcer made 
reinforcement by means of the omentum imperative. It is an open 
question as to whether or not a gastroenterostomy should have 
been done at once. Deaver advocates this measure as a routine 
procedure, and when it is necessary to greatly narrow the lumen 
of the gut in order to close the perforation, this means of reestab- 
lishing the circulation may be the only way out. As a routine pro- 
cedure it can hardly be commended for the great omentum fur- 
nishes a means of protection of the peritoneum of the intestines, 
and if this organ is lifted to make anastomosis possible, this pro- 
tection is largely negated. The mere existence of an ulcer can not 
be regarded as a routine indication for gastroenterostomy. Nar- 
rowing of the lumen alone can present such an indication. Dea- 
ver 's experience merely proves that a great surgeon can do almost 
anything within the abdomen under almost any condition and meet 
but a small mortality. For the great bulk of lesser lights, more 
conservative measures are in order. The work of Deaver should 
excite our admiration, even our astonishment, but it should not 
excite our emulation. 

CASE 7. — A clerk ag-ed forty was brought to the hospital be- 
cause of abdominal pain and distention. 

History. — For the past eighteen years the patient has had gastric 
trouble. This took the form of an epigastric distress, coming on 
one or two hours after each meal. Only distress was felt in the 
epigastrium, but straight through to the back she felt a sharp, se- 
vere pain. This distress and pain were relieved by food, alkalies, 
and often even by a drink of water. She was often nauseated 
during these spells, but she never did vomit. The pain was made 
worse by sour foods. She often was troubled with ''heart burn" 
and acid eructations. The attacks of pain after eating would 
last from six weeks to three months and then she would have a 



562 CLINICAL SURGERY BY CASE HISTORIES 

free interval of several months. It was so during the eighteen 
years. Hard work during an attack always made the attacks worse, 
in fact hard work would often start the gastric trouble while a 
vacation sometimes made it disappear. She has been obstinately 
constipated during the eighteen years. The attacks continued 
so up to tAvo weeks preceding the trouble that brought her into 
the hospital. For the last two weeks the old gastric distress which 
she has had for so long has been especially severe. The epigastric 
distress and pain in the back have been coming on a short time 
after eating and lasting until the next meal was taken. She has 
been very much nauseated after meals, but has not vomited. 

Three days ago she ate a lunch about 1 p. m, and returned to work 
in the store. She had a great deal of epigastric distress that after- 
noon. About 4 o'clock she Avas just thinking of going out to get 
something to eat in the hope that it would relieve the distress, when 
she felt a sudden, sharp pain in the right epigastric region. This 
was immediately followed by severe pain straight through to the 
back and down in the lower abdomen in the bladder region. She 
staggered backward into a chair. She felt very weak and felt as 
though she could not get her breath. The pain became general 
all over the abdomen, but she did not vomit. She sat in a chair 
doubled over forward. A doctor was called, who took her home 
in his car. She could not straighten up on account of the pain. The 
doctor said her heart action was very weak and gave her strophan- 
thus tr. by mouth (dose not known). This was about 5:30 p.m. 
This medicine apparently started her to vomiting. She vomited 
once then and once about 5 :45. The vomitus looked like recently 
eaten food and contained no visible blood. At 6 p. m. the patient 
had a pulse of 80, of good force, and a temperature of 98°. She 
had general abdominal pain and soreness to pressure anywhere in 
the abdomen. Toward morning the pain settled in the epigastrium 
and right side of the abdomen. It extended across the epigastrium 
and down the right side of the abdomen, but not to the groin. It 
remained so until her entrance into the hospital three days after 
the attack. In the time between the onset of the attack and enter- 
ing the hospital she had not eaten anything and her bowels had 
not moved, thought her physician had given her quantities of 
purges. Her pulse had run from 80 to 90, and the temperature 
from subnormal in the beginning to 100°. The abdomen gradually 
became distended. 



SEVERE ABDOMINAL CRISES 563 

Examination. — The patient is a thin, anemic-looking woman ap- 
pearing to be about 40 years of age. She looks acutelj' ill. Her 
color is salloAv and the facial expression is one of anxiety. The 
heart and lungs are negative. The abdomen is considerably dis- 
tended and tympanitic. There is no palpable mass and no dullness 
in the flanks. There is tenderness to pressure all over the abdomen, 
l)ut this is especially marked in the right epigastric region and 
down the right side of the abdomen about on a level with the iliac 
crest. The pelvis was not examined. The reflexes were all some- 
what exaggerated ; no Babinski. 

Diagnosis. — The history of long endured gastric disease, indicat- 
ing hyperacidity or ulcer, the sudden advent of pain, the vom- 
iting, the pain in the subhepatic region and along the right lateral 
walls makes the perforation of a peptic ulcer certain. Gallstone 
colics sometimes first appear after years of hyperacidity due to 
referred irritation from the gall bladder. Gallstone colics are not 
attended by collapse. Kenal colics, too, may at first refer their 
pain to the subhepatic region. There is usually pain in the back 
and down the ureter. In neither gall bladder disease nor renal 
colic is there board-like rigidity as there is in perforated ulcer. 
Pericholecystitis may produce rigidity, but it does not come on at 
once, neither is it as intense as in ulcer. That she is alive three 
days after being treated with purges indicates the perforation is 
slight, incomplete, or well walled off. Inspection only can show 
which it is. 

Treatment. — Incision was made in the epigastric region in the 
right rectus just below the costal margin. The pyloric end of the 
stomach and the duodenum were found walled off by adhesions. 
A tongue of omentum was attached to the pyloric end of the stom- 
ach (Fig. 292). Some of the adhesions were recent, as much newly 
formed fibrin was found. The walled-off portion contained a some- 
Avhat cloudy, pale, serous exudate which did not contain any de- 
monstrable gastric contents. The exact site of the perforation 
seemed to be at the site of the omental adhesion. The adhesions 
were disturbed as little as possible. A rubber tube and gauze drain 
were inserted and the abdomen partly closed. 

After-course. — The pulse was 130 when the patient was taken from 
the operating room. This gradually became less rapid. She suf- 
fered very little if any from shock. There was no postoperative 



564 



CLINICAL SURGERY BY CASE HISTORIES 



vomiting, and the patient complained very little of nausea. The 
second day the temperature went to 101°, pulse 100. No nausea 
or vomiting. General abdominal pain and distention were relieved 
by gas enemas. The first food was given on the fourth day after 
operation, a milk diet only was allowed. The gauze drain was re- 
moved from the wound. A large amount of greenish-yellow drain- 




W^ 




/ 



Figr. 292. — Ulcerating duodenum in which perforation was prevented by the formation of 

omental adhesions. 

age followed the removal of the gauze. The drainage had a dis- 
tinct acid reaction. It was not tested for digestive ferments. The 
patient felt well except for soreness in epigastrium and right side. 
The rubber drain w^as removed three days later, there was much 
yellowish drainage. On the ninth day the patient was given soft, 



SEVERE ABDOMINAL CRISES obO 

nonirritating food. The drainage continued quite free and the 
patient complained of pain in the right upper abdomen. The drain- 
age grew less in amount, the pain gradually lessened, and by the 
eighteenth postoperative day the drainage had practically ceased. 
All abdominal pain and soreness was gone. The patient was put 
on a Sippey gastric ulcer treatment. In spite of the large amount 
of heavy magnesia taken daily, the patient was somewhat consti- 
pated and had abdominal distention which had to be relieved by 
enemas. Otherwise the patient felt fine and continued to gain in 
strength and at the time of dismissal, five weeks after entering 
the hospital, the wound was entirely healed except for the drainage 
opening which was crusted over. The patient had been free from 
abdominal pain for two weeks. 

Comment. — In a case so clear as this, in which the opening is ob- 
viously closed by nature's efforts it becomes a matter of grave con- 
cern if one should allow her handiwork to remain unmolested or 
whether one should destroy this effort and apply therapeutics of his 
own. To have done so would have much prolonged the operation 
in a patient always frail and now reduced by three days of suffer- 
ing and starvation. The adhesion bore every evidence of efficiency, 
consequently it was allowed to remain. 

CASE 8. — A merchant of thirty-six came to the hospital because 
of persistent vomiting. 

History. — Three or four months ago he began to have pain in the 
epigastrium. The pains at first were gnawing, but recently they have 
become darting in character. The pains at first were general in the 
upper abdomen but now they are more localized in the pyloric re- 
gion. The digestion and appetite at first were unimpaired and 
there was no loss of weight. A month ago vomiting set in and 
loss of weight has been rapid, he having lost some twenty pounds in 
this interval. In the last week he has vomited nearly everything 
he has eaten and there is marked loss of strength in consequence. 
There has been no blood in the vomitus or in the stool. The bowel 
movements were but little constipated until the last few weeks, 
the constipation now is due, his doctor thinks, to the small amount 
of food retained. He had previously had good health without di- 
gestive disturbance of any sort. 

Examination. — The patient is weak, is near collapse, the pulse 
120, small and weak. He is emaciated and gives the appearance 



566 CLINICAL SURGERY BY CASE HISTORIES 

of acute starvation. In the pyloric region there is a tumor the size 
of a lemon, — dense, fairly smooth, but somewhat nodulated at its 
upper pole. It is not movable in any direction. There is marked 
tympany due apparently to dilatation of the stomach and small 
intestines. Because of the extreme condition, no attempt at de- 
tailed analysis seems warranted. 

Diagnosis. — The location and character of the tumor with the evi- 
dent pyloric obstruction makes the diagnosis of carcinoma reason- 
ably certain despite the early age of the patient, since there were 
no symptoms indicating an ulcer or inflammatory lesion. Further- 
more neither of these conditions should have produced such a prom- 
inent tumor. An extragastric tumor should not cause such pronounced 
vomiting. Its density and nodular surface is typical of carci- 
noma. The probability, because of the fixity, is that it can not be 
removed. Yet starvation is imminent unless some sort of relief is 
obtained. A gastroenterostomy, therefore, it seems should be at- 
tempted. 

Treatment. — After the abdomen was opened a tumor the size of 
a small fist occupied the transverse colon just below the pylorus. 
It was a dense nodular mass. The upper border of this tumor had 
infiltrated the second part of the duodenum obstructing its lumen. 
The lumen of the colon w^as partly but apparently not completely 
obstructed. The colon was adherent to the posterior parietal wall, 
therefore, an anterior gastroenterostomy was done. It appeared 
that a colostomy would scon be necessary, but this was left to 
be done at a later date under local anesthesia. The release of the 
obstruction to the outlet of the stomach seemed to be the one 
important need. When the lesion was first exposed, I was under 
the impression that the duodenum was the primary seat and that 
an ulcer lay at the base. 

After-course. — The patient rallied from the operation but vomited 
a moderate amount of blood during the first twenty-four hours. 
Subsequently he was able to retain fluids, but in spite of this he 
died on the third day, apparently from progressive weakness. 

Comment. — The error in diagnosis was made because of the pre- 
ponderance of gastric symptoms and because of the size and loca- 
tion of the tumor. Carcinoma of the colon was not considered. The 
site is unusual and usually neighboring structures are not involved 
so early. The operation was a poor, hopeless attempt. It would 



SEVERE ABDOMINAL CRISES 567 

have been better to have closed the abdomen without making any 
attempt at operative relief. 

CASE 9.— A widow aged fifty-four was brought to the hospital 
because of abdominal pain and vomiting. 

History. — The patient has always enjoyed good health. Twenty 
hours ago she had a sudden abdominal pain followed by vomiting. 
This subsided after an anodyne, but her abdomen began to distend, 
Enemas were given without result. There were spasmodic attacks 
of moderate pain despite the morphine given. 

Examination. — The patient appears much older than the age given. 
Her face is serene and she appears an interested spectator of the 
activities surrounding her. There is moderate distention of the 
abdomen which is everywhere tympanitic. The walls are tense 
from distention, but nowhere is there rigidity, and only just below 
the umbilicus is there tenderness and even here it is not very marked. 
The nurse was able to introduce but little more than a pint of soap 
suds solution. Waves of peristalsis are seen at intervals beginning 
just to the left and above the umbilicus and travel downward and 
to the right. The pulse is 78, temperature 98.2, respiration 20. 

Diagnosis. — The initial pain followed by vomiting and progres- 
sive tympany suggests some accident which produced an occlusion 
of the bowels. The failure of the enema to produce results strength- 
ens this supposition. The absence of vomiting in the presence of 
a considerable distention and the small amount of enema retained 
suggests a low obstruction. A volvulus of the sigmoid would ac- 
count for it. A sudden infection producing an adhesion or a bowel 
paralysis may produce a like picture. Usually a disturbance in 
pulse and temperature would be produced, but these may be absent. 
Chronic causes such as tumor or fecal impaction do not begin 
with pain, but may develop it later when tympany becomes pro- 
nounced. 

Treatment. — Exploratory laparotomy. As soon as the abdomen 
was opened, loops of distended gut were encountered. By pushing 
them aside collapsed loops were found, by lifting on these a loop 
of moderately distended gut came into sight. It was easily dis- 
cerned that the obstruction was due to the slipping of loops of 
gut through an opening in the mesentery (Fig. 293). By enlarging 
this opening, the imprisoned loops were easily loosened. The open- 
ing was then closed by suture. 



568 



CLINICAL SURGERY BY CASE HISTORIES 



After-course. — Eecovery was undisturbed, 

Comme7it. — The diagnosis of obstruction was not certain. The pa- 
tient's condition was but little disturbed. If there had been a per- 
foration with no reaction, early operation in the face of the ab- 
sence of reaction was urgently demanded. In obstruction opera- 
tion, when performed before the pulse becomes rapid and before 
there is vomiting, is a safe procedure. By following this plan there 
are few regrets, though occasionally one may operate needlessly. 
This is particularly true of flabby old women. In them the onset is 




Fir. 



293. — Loops of collapsed intestine lie below an opening in the mesentery through 
which they have slipped. 



not so definite. If their pain is as acute they do not express it. 
Possibly the flabby state of their whole musculature is incapable 
of producing so much pain as in the case of husky young males. 

CASE 10. — I was called to see a matron of fifty-six because of ob- 
struction of the bowels. 

History. — For some years previous to this trouble the patient has 
had pain at irregular intervals in the right upper quadrant of 
the abdomen. I saw her six years ago in one of these attacks. 
There was then severe pain in the upper right abdomen which re- 



SEVERE ABDOMINAL CRISES 569 

quired morphine for relief. Following a period of lesser pain in 
the hepatic region, she developed a smooth globular sensitive tu- 
mor in the hepatic triangle. This subsided after a few months. She 
had a similar attack a month ago Avhich persisted more or less 
until the beginning of the present trouble. She had fever in the 
earlier period of the attack. After ten days the temperature was 
not determined. Six days ago she began to vomit at intervals 
with a few hours intermission. Two days ago she had severe pain 
and distention became marked and vomiting has been persistent 
since that time. It was announced by the attending physician 
ttat the patient had been much easier for the past four or five hours. 
The patient had ceased to vomit and she has no pain. He believed 
the crisis had passed though she had passed neither stool nor flatus. 

Examination. — The patient lies indifferent, almost stuporous, but 
replies intelligently to questions put to her. The abdomen is mod- 
erately distended, not markedly tender. The chief site of tender- 
ness is in the hepatic triangle. Pulse 120, temperature 100°, res- 
piration 36. 

Diagnosis. — Previous knowledge of the patient makes it possible to 
start with the premise that she has gallstones. Obviously there 
has been something superadded. There evidently is an intestinal 
obstruction; whether due to adhesions about the gall bladder it- 
self or to a stone which has ulcerated into the gut is problematic. 
Most likely it is the latter. In cholecystitis there may be violent 
vomiting with distention which may suggest a grave abdominal 
crisis, but such events should not last a week, and above all, should 
not bring the patient to impending dissolution. That there is a 
surgical lesion is apparent. That she is a surgical patient was not 
nearly so obvious. My assistant (Wuttke) made an observation 
worth remembering: ''When in a case of intestinal obstruction, a 
patient seems better without the passage of stool or gas, he is 
worse." It was obvious here that the seeming betterment in the 
past few hours, which her physician hailed as a good omen, was 
a precursor of disaster. Paresis of the intestinal walls has obviously 
supervened. The soft running pulse and quickening respiration 
confirmed this. 

Treatment. — Stimulants. 

After-course. — The patient died in four hours with a progressive 
enfeebling circulation. 



570 CLINICAL SURGERY BY CASE HISTORIES 

Autopsy. — The small intestines in the upper abdomen were bine- 
green covered with a grayish exudate. They were but moderately 
distended. The mesenteric vessels supplying the proximal four 
feet of the jejunum were everywhere filled with a clot. About 
20 inches from the duodenojejunal angle was a gallstone somewhat 
larger than a hulled walnut (Fig. 294). It could not be moved 
about in the gut because of the infiltrated, thickened state of 
the wall. The gall bladder was adherent to the duodenum and there 
was an opening uniting the two which showed a necrosis of all 
the layers with hemorrhagic infiltration of the mucosa. 

Comment. — The autopsy findings raise the question as to whether 
or not we have to do with a mesenteric thrombosis, possibly due 




Fig. 294. — Gallstones removed from the intestine following death from intestinal 

obstruction. 

to the ulcerous process, the foreign body being but an incident, 
or whether the stone was an active participant in the production 
of the symptoms. The progressive character of the symptoms in the 
beginning indicate that it was the stone which made the disturb- 
ance and that the mesenteric thrombosis w-as a secondary factor 
coming on, likely, from the history, two days before. The necrotic 
state of the gut wall made it easy to understand why pain and 
peristalsis had ceased. The size of stone which is able to pass 
is dependent on factors other than mere volume. Smaller stones 
than this may cause obstruction and larger ones may pass. Ulcer- 
ation with subsequent thrombosis with consequent laming of the 
gut wall is capable of causing obstruction with a relatively small 



SEVERE ABDOMINAL CRISES 571 

stone. The primary inflammation of the gall bladder is transmitted 
to the surrounding gut, which, in becoming attached, loses its 
power of peristalsis. The loss of the power of peristalsis at a time 
Avhen peristalsis should be active no doubt adds to the mechanical 
difficulties. The reaction due to the adhesion no doubt tends 
mechanically to narrow the lumen of the gut. 

CASE 11. — A matron of thirty-four called medical aid because of 
severe abdominal pain. 

History. — For many years the patient has been treated by various 
members of the hospital staff for recurring attacks of pain in the 
upper abdomen. The pains were located in the right upper quad- 
rant and radiated to the right shoulder blade. She was jaundiced at 
several different times. A diagnosis of gallstones was made and 
operation advised. The last attack was particularly severe. This 
morning her husband found her lying on the floor vomiting and 
suffering intense pain. 

Examination. — There is marked tenderness over the whole epi- 
gastric area and there is marked rigidity. The vomitus is clear 
and contains flakes of mucus. The temperature is 102°, pulse 80, 
respiration 26. The patient seems much collapsed. 

Diagnosis. — It is obvious that the scene has changed. In the pre- 
vious attacks the pains were confined to the right side. Now they 
extend across the Avhole upper abdomen. The rigidity and sensi- 
tiveness indicates peritoneal irritation. One thinks first of all of 
an accident to the previously diseased gall bladder, or that the 
previous diagnosis was wrong and an ulcer existed instead which 
has now ruptured. The general constitutional effect is that of some 
such grave accident or perforation but there is too much involve- 
ment in the left side to permit a diagnosis of either a grave acci- 
dent to the gall bladder or perforated ulcer. Necrosis or perfora- 
tion of the gall bladder are usually preceded by premonitory signs. 
This patient has been free from pain since the last gall bladder 
attack three months ago. An ulcer lying in the middle of the curva- 
tures of the stomach or which ruptures into the lesser peritoneal cav- 
ity may give rise to such symptoms, particularly if there is a par- 
tial walling off by adhesions before rupture. The onset resembles 
pancreatic hemorrhage except that the pulse is slow and there is 
little abdominal tympany. 

Treatment. — She was given a preliminary injection of morphine. 



572 



CLINICAL SURGERY BY CASE HISTORIES 



After-course. — ^Vomiting continued and on the third day became 
dark brown with greenish streaks. She vomited from two to 
eight ounces at short intervals. The temperature remained about 
102°, the pulse between 70 and 80. Repeated enemas failed to 
produce more than a few scybala. Abdominal distention became 
progressively worse. She died three days after the onset under the 
general symptom of weakness. 

Autopsy. — The peritoneum is everywhere smooth and glistening, 
but there is a small amount of bloody serum between the coils of 
the intestines. There are numerous, "small, white opaque patches 
in the omentum and mesentery. The pancreas is large, soft, and 
portions of it appear as a black, bloody mass shimmering through 




Fig. 295. — Head of the pancreas in acute pancreatic necrosis. A, stone in the pancreatic 
duct; B, edge of the duct retracted. 

the peritoneum. On section the greater part of the gland is ne- 
crotic except a small part near the head drained by the duct of 
Santorini. The interlobular spaces are filled with black blood. 
The gall bladder is of average size and contains many stones. The 
stones were small and closely packed together. The orifice of the 
cystic duct was blocked by a stone 1 cm. in diameter. The common 
duct was free from stones, save for two at the papilla of Vater. 
One stone lay in the diverticulum between the duodenal opening and 
the orifice of the duct of Wirsung blocking the orifice of the papilla of 
Vater and converting the common duct and the duct of Wirsung into 
one continuous closed channel (Fig. 295). The stone was 0.4 cm. 



SEVERE ABDOMINAL CRISES 573 

in diameter. The common bile duct was greatly distended with 
bile. The duct of Wirsung also was distended and its orifice at 
the diverticulum was widely open and the terminal portion was 
bile stained. The remaining organs were without notable change, 
save that the spleen was large and tense. The slides show the 
usual picture of pancreatic necrosis. 

Comment. — The associate who attended this patient was unfamil- 
iar with the clinical picture of acute necrosis of the pancreas. A 
finer example of the truth of the observation of Fitz can hardly be 
imagined. "The onset of sudden and severe pain in the epigastrium 
associated with low fever, weak pulse, constipation, collapse and 
persistent vomiting, occurring apparently without cause in a pa- 
tient previously in good health except for an occasional attack of 
gastric disorder." In the majority of cases the pulse is rapid as 
well as weak while in this case it was slow. Usually the distention 
becomes marked early in the course of the disease. This case pre- 
sents as its chief point of interest the lodgment of a stone in the pap- 
illa in such a way as to convert the common bile duct and the chief 
pancreatic duct into one continuous channel fully confirming Opie's 
opinion that the entrance of bile into the pancreatic ducts is an 
important factor in the production of pancreatic necrosis. 

CASE 12. — A fanner aged twenty was brought to the hospital be- 
cause of persistent vomiting. 

History. — Past history negative. Seven years ago he began to 
have attacks of severe general abdominal pain practically always 
accompanied by vomiting. He does not know whether he had fe- 
ver or not. When the attacks subsided he was left with general 
abdominal soreness, the soreness persisting in the right side longer 
than in the left. He had these attacks at intervals of a very few 
months, but there was one period of two years in the seven when 
he was free from attacks. His last attack was five days ago when he 
was suddenly taken with severe epigastric cramps. Four or five 
hours later he began to vomit. The cramps subsided in five or 
six hours, but a soreness across the upper abdomen persisted until 
two days ago when he was relieved by an enema. His bowels have 
not moved without an enema since the onset of the trouble. He 
passed considerable flatus with one of the injections. He vomited 
some blood, about two teaspoonfuls he thinks, at one time. He has 
not vomited blood at any other time. In the last two days the pain 



574 CLINICAL SURGERY BY CASE HISTORIES 

and soreness have subsided almost entirely, but the vomiting has 
persisted. Everything is vomited now. He has vomited once only 
a small amount from 1 :30 a. m. to 8 :30 a. m. today, however. 

Examination. — The patient is sparsely built but fairly well nour- 
ished. Head and neck negative. Lung expansion good, equal on both 
sides, normal resonance over both lungs. No rales or increased 
fremitus. Lower end of sternum deeply sunken. Heart not en- 
larged, no murmurs. Dullness from midsternal line to 7 cm, to 
left. Apex beat in 5th interspace. Abdomen distended, no evidence 
of peristalsis, distention not extreme. Tympanitis to percussion. 
No palpable masses in abdomen; abdominal organs not palpable. 
Some tenderness to pressure all over the abdomen, but the greatest 
tenderness is just below the umbilicus and towards the right side. 
W.b.c. 9,800; R.b.c. 5,824,000. Hg. 70. 

Diagnosis. — The history of repeated attacks of pain during the 
past seven years suggests an inflammatory lesion or some congenital 
rest producing recurrent occlusion. The latter seems the most 
likely, for there is no evidence of there ever having been any 
fever. At any rate an obstruction exists now. The persistence of 
vomiting after the cessation of pain indicates impending paralysis 
of the gut wall. There is not yet a break in the pulse rate, hence 
prospect from operation is fairly good despite the five days that 
have intervened since the onset. 

Treatment. — Removal of two adhesive bands extending from the as- 
cending colon to the omentum under which the small intestine was im- 
prisoned. Drainage of the dilated intestine was done in order to rid 
the patient of the enormous accumulation and to facilitate the re- 
turn of the coils to the abdominal cavity. The small intestines 
were found dark red in color and dilated larger than a normal 
large intestine. The abdominal cavity was filled with a straw-col- 
ored fluid and contained flakes and strings of fibrin. Two bands 
of adhesions of the omentum to the small intestine were found, 
A loop of intestine around these adhesions caused the obstruction. 
The cecum was examined and the appendix had apparently sloughed 
away at a previous attack. The intestines could not be replaced 
after removal of the obstruction so the contents were allowed to 
drain through a puncture of the intestine. A rubber drain was 
sutured through the abdominal wall. Pulse 100 and fairly good at 
the close of the operation. 



SEVERE ABDOMINAL CRISES 



575 



After-course. — The patient vomited at intervals a greenish-black 
fluid, for the first five days following operation. Temperature 
ranged from 98° to 100.5°, pulse 90 to 110. Continuous procto- 
clysis was given and no food bj' mouth until the sixth day when a 
small amount of broth was allowed. There was much oozing through 
several places in the line of incision. Two days later the suture 
line opened its entire length. Drainage was profuse. At the lower 
end of the wound was seen a mass of necrotic tissue that looked 
like a loop of intestine. This necrotic tissue sloughed away at the 




Fig. 296. — The two puckered openings in the gut are surrounded by granulation tissue. 



upper end of wound, exposing the Avhole diameter of the intestine 
(Fig. 296) which was discharging its contents of partially digested 
food. At the end of two weeks the patient said he felt well and had 
a good appetite. Some food seemed to be passing through the in- 
testinal tract as the nightly enema showed feces. There was no tend- 
ency of the wound to heal. Fistulas discharged a great deal. 
Condition seemed to remain about the same for several days. At 
the end of four weeks the wound was drawn as closely together 
as possible with adhesive straps. Small hemorrhagic spots appeared 



576 



CLINICAL SURGERY BY CASE HISTORIES 



in the skin on chest and abdomen and the patient was rapidly losing 
weight. No good results seem to come from strapping the wound, 
the skin became very irritated and the adhesive straps were dis- 
continued. Four weeks after the operation a large drainage tube 
was inserted into the intestine with the idea of carrying the food 
past the fistulous opening. This failed by the tube becoming plugged 
with the contents. The patient became very weak and for some 
time he had spells in which his mind was not at all clear. Arti- 
ficial feeding with pepsonized foods through the fistulas was tried 
and proctoclysis resumed, but the patient continued to grow weaker 
and the periods of delirium increased in frequency. He developed 
a purulent discharge from the left ear. Death came from exhaus- 




Fig. 297. — Emaciation due to intestinal fistulae and sepsis. 



tion at the end of seven weeks after operation. Emaciation was 
extreme (Fig. 297). 

Postmortem. — Abdominal wall very thin, no omentum observed, in- 
testines all matted down and connected to each other by adhesion 
bands. At upper end of abdomen on left of midline, stomach and 
omentum adhered to parietal peritoneum, forming a small pocket 
containing about 20 c.c. of pus, thick, yellow, and offensive. In- 
testines hard to loosen from each other because of adhesions. Many 
of the coils extending and matted down in pelvis, occasional small, 
necrotic, pus-like areas of adhesions scattered throughout. Appen- 
dix about 7 cm. long entirely retrocecal — distal end tapering. Duo- 
denum for about 4 inches beyond pylorus distended with gas and 



SEVERE ABDOMINAL CRISES 577 

fluid. Stomach containing gas and fluid. First opening of intes- 
tine (operative) to abdominal wall is about 5 feet below pylorus, 
second about 1 foot below this. Intestines inside appear quite nor- 
mal, external peritoneal surface everywhere ragged, dull appearance. 
Liver rather large, on section little blood, hepatic lobules rather 
distinct. Spleen about 12 x 7 x 2 cm., somewhat enlarged. On 
section little blood. Kidneys both apparently normal, very little 
fatty capsule. On section cortex 5 mm. thick, medulla normal, 
also pelvis. 

Comment. — The interest in this case centers in the starvation ap- 
parently from the opening into the gut so near the stomach. At 
least it so appeared before the autopsy. The drainage opening 
was made about five feet from the duodenum. The gut was so much 
distended that when it burst out of the opening into the abdominal 
wall the peritoneum split. The drainage opening was made at this 
point instead of seeking a point more distal. After the autopsy it 
appeared as though death really was due to sepsis rather than 
starvation. The petechial hemorrhages should have emphasized 
the importance of sepsis. These spots were recognized as dependent 
on a septicemia but all this was deemed of secondary importance 
to the indifferent nutrition. The adhesions were so extensive that 
even had we known all the autopsy revealed, further operating 
would have been of little avail. Nevertheless, in operating for ob- 
struction in the upper abdomen a point as far as possible from the 
duodenum should be selected for the formation of an enterostomy 
wound. 

LOWER ABDOMEN 

Severe crises in the lower abdomen have to do with perforation 
of the appendix and interruptions of tubal pregnancies, ruptures of 
preexisting abscesses, intestinal obstructions and irritations trans- 
mitted from elsewhere. Crises in this region, save in some cases of 
obstruction are seldom immediately dangerous and the indications 
for surgical operations are rarely absolute. When intestinal ob- 
struction is due to a lesion in the lower abdomen the symptoms are 
usually referred to the upper abdomen or the pain is generalized. 
The general tendency in crises in the lower abdomen is to act 
too quickly for very frequently the disease is less dangerous than 
the operator. 



578 CLINICAL SURGERY BY CASE HISTORIES 

CASE 1. — A laborer aged seventeen was brought in because of 
acute abdominal pain and retention. 

History. — For several years he has had abdominal pains at inter- 
vals. These attacks lasted from a few to fifteen minutes. He vom- 
ited several times, which relieved the pain. For the last three 
months the pains have been more frequent and more severe. They 
often come on after he has begun to eat, interrupting his meal. 
Forty-eight hours ago, while turning a heavy windlass, he was 
seized with a sudden pain, so acute was it that he was compelled 
to seek medical aid at once. The pain was continuous with periods 
of exacerbation. Morphine was required to relieve the pain. Twelve 
hours later, when he had been unable to urinate and distention of 
the lower abdomen took place, an attempt to catheterize him was 
made but failed. A trocar was introduced suprapubically and a 
quantity of fluid was drawn off. His physician believed that this 
was urine obtained from the free peritoneal cavity and he accord- 
ingly diagnosticated a ruptured urinary bladder. This puncture 
was repeated at two additional occasions. Within the past six 
hours, however, he passed several ounces of urine spontaneously. 
Twenty-four hours ago the pulse was 80, temperature 98°. He has 
not vomited since the beginning of the attack, but the pain persists, 
though of less intensity. 

Examination. — The patient's features are expressive of extreme 
pain and impending collapse. The pulse is 120, of good quality. 
The entire abdomen is board hard and tender all over, though not 
extremely so. He indicates the whole lower abdomen as the site 
of his greatest pain. The extreme upper ends of the recti muscles 
are perceptibly less tense than the lower portions. The extreme 
pain he suffers makes a satisfactory examination impossible. 

Diagnosis. — The recurrent pain indicates a disease antedating the 
present attack. The pain coming on after the meal has been partly 
eaten suggests an ulcer of the stomach. The appearance of the 
present acute symptoms while doing heavy labor is in harmony 
with this view. A single initial emesis likewise points the same 
way. The pain is in the region of and below the navel. A ruptured 
duodenal ulcer should have the site of greatest pain near the cos- 
tal arch. There should be some rise of temperature within twenty- 
four hours of the attack. The retention may have been due to the 
escape of stomach contents to the pelvis producing a reflex spasm 
of the bladder neck. A ruptured appendix is a possibility, though 



Severe abdominal crises 



std 



the history is not that of a perforation of that organ. The recur- 
rent attacks complained of were too frequent for appendicular 
colic, and they are not attended by after-soreness; yet this is a 
possibility. The frequent pains were not those of intestinal ob- 
struction, particularly the advent of pain during the meal does 
not seem to fit with the theory of intestinal obstruction. An acute 
abdominal crisis is present, and since the chief pain was located 
below the umbilicus and the most marked rigidity is here, a supra- 
pubic incision seems advisable. If there is a perforated duodenal 
ulcer, the suprapubic opening will be needed for the drain, for this, 




Fig. 298. — Meckel's diverticulum with its tip adhering to the mesentery, showing the loop 
through which the intestinal coils had slipped. 

no doubt, is the site of the greatest conflict, irrespective of its 
source. 

Treatment. — A 4 inch suprapubic incision was made. Coils of 
black gut presented. An investigation of the mesentery showed 
extensive thrombosis. The history precluding primary thrombosis, 
a further search was made. To the right of the conglomerate mass 
the gut was collapsed and of normal color. A rapid search proxi- 
mally from the ileocecal valve showed a mass the size of a thumb 
compressing the gut (Fig. 298). This arose from the gut and was 



580 CLINICAL SURGERY BY CASE HISTORIES 

attached to the mesentery. It was evident that we had to deal 
with a Meckel's diverticulum. The necrotic mass was lifted out 
of the wound, clamps placed on healthy gut and the whole resected. 
The severed ends were fastened outside of the abdomen and the 
remainder of the wound partly closed. Two gavize drains were 
placed about the ends and a double rubber drain into the pelvis. 

Pathology. — The severed loops are blue-black in color. The lumen is 
filled with hemorrhagic exudate. The mesenteric veins are filled 
with blood clots. There are two small puncture openings in the 
wall of the gut from which bloody fluid was seen to escape during 
the operation. The slides shoAv total necrosis of the gut wall 
with beginning loosening of some of the gland cells. 

After-course. — The patient stood the operation without notable 
shock and the general condition continued favorable for the first 
twelve hours. Following this the pulse became more rapid and he 
died eight hours later. 

Comment. — Intestinal obstruction by a Meckel's diverticulum 
should have been diagnosticated. It is the recurrent pain below the 
navel preceding a disaster that is characteristic of diverticulum 
trouble. This is particularly true when the recurrent pains extend 
over several years. The fact that he had pain during the meal 
is what misled me. Even the fact that the initial pain of the last 
attack was low and that the muscles of the upper abdomen were 
not wholly rigid was not sufficient to correct the delusion. The 
fact that the pains extended over several years in a seventeen- 
year-old husky boy should have made ulcer unlikely. However, an 
acute condition was promptly diagnosed and the incision was rightly 
placed and the lesion located promptly. This is all that concerned 
the patient. A more exact diagnosis would have been a matter 
of personal satisfaction and academic interest. 

CASE 2. — A student aged seventeen was brought to the hospital 
because of chill and high fever following an operation for appen- 
dicitis. 

History. — The patient was operated on two weeks ago for acute 
suppurative appendicitis. The wound still contains a drain. The 
appendix was normally located and contained pus. It was ruptured 
during removal. His progress until two days ago seemed favorable. 
At this time he began to have generalized abdominal pain most 
marked over the whole right side. In the evening he had a chill and 



SEVERE ABDOMINAL CRISES 581 

the temperature went to 104° following it. The operative w^ound was 
explored, but nothing to account for the exacerbation was found. 

Examination. — The patient seems seriously sick. The abdomen is 
moderately distended but nowhere sensitive save near the appen- 
dix operation wound. There is some pain on deep breathing. The 
respirations are 32 per minute and superficial. The lung examina- 
tion save for the increase in rate is negative. Pressure over the 
lower costal margin causes acute pain as does deep breathing com- 
bined wdth deep hepatic palpation. The area of liver dullness is 
not increased and the lower border of the lung is movable. There 
is no sensitiveness in the region of the kidney. The urine is nega- 
tive. W.b.c. 22,000; 92 per cent polynuclear leucocytes. 

Diagnosis. — Chill with rapid respiration following a surgical op- 
eration suggests pneumonia. The pain in the right side may well be 
compatible with a pneumonia involving the diaphragm. The lung 
signs are, however, negative. A metastatic lung abscess may be pres- 
ent. Metastatic abscess within the liver may produce such symptoms, 
but this accident is often attended by early jaundice. The pain caused 
by pressure over the lower rib border indica:tes an involvement of the 
diaphragm and liver. The onset is unusually stormy for an invasion 
of this region. Usually the liver dullness is extended upward in 
this affection but being early it may be assumed there has not yet been 
time for a fluid accumulation to take place. Should the abscess be 
intrahepatic, exploration may be a valuable first step in its drain- 
age. At any rate the infection is pronounced and the lower costal 
and the subhepatic region alone give positive findings and an ex- 
ploration of this region seems warranted. 

Treatment. — An incision was made along the costal border from 
the outer border of the rectus to the anterior edge of the quadriceps 
muscle. Between the liver and diaphragm a quantity of seropuru- 
lent fluid was found. This was drained by tube and gauze wicks. 

After-course. — Improvement was prompt. After a week he again 
got a rising temperature. Exploring the wound more deeply an en- 
capsulated abscess was found. This was drained and improvement 
again followed. A third time the temperature rose and exploration 
again disclosed a pocket of pus. This time the entire subdiaphrag- 
matic area as far as the falciform ligament was drained (Fig. 299). 
Following this no further disturbance took place. He was operated 
on some years later for a hernia in the site of the appendix opera- 
tion. The liver was found not to be attached to the diaphragm. 



582 



CLINICAL SURGERY BY CASE HISTORIES 



Comment. — In draining a subdiaphragmatic abscess it is well to 
drain the entire space as far as the falciform ligament at the first 
sitting. The capacity of the liver to form adhesions to the diaphragm 
is very limited, and the abscess is likely to spread over the entire 
surface sooner or later. A generous packing of this space is followed 
by less pain than the placing of a few drains only. 




J,arii: dratnagt 
and 6auie pcLcK in ab 
cess cavity- ' 



Fig. 299. — Drainage of subdiaphragmatic abscess below the costal margin. 

CASE 3. — I was called to see a widow aged forty-six who was 
suffering with severe abdominal pain. 

History. — The patient has three children, the youngest being four- 
teen years of age. The patient had had what her physician regarded 
as typical gallstone attacks. These were painful attacks in which 
the chief pain was located in the epigastrium and to the right of 
the msdian line. Six years ago she had a severe hemorrhage from 
the stomach. Since that time she has been reasonably free from 
epigastric disturbance, there being merely slight discomfort re- 
curring at long intervals. Menstruation has been irregular during 
the past year. For a year, particularly during the past few months, 
she has noticed an increase in the size of her abdomen so that she 
has had repeatedly to enlarge the girth of her clothes. Five days 
ago at 2 A. M. she had severe abdominal pains not located in any 
particular region, but most intense at the lower portion. Since that 
time there has not been any severe pain, but soreness particularly 



SEVERE ABDOMINAL CRISES 583 

in the lower abdomen with bladder irritability. The menses came 
on after the severe pain above mentioned. She vomited once the 
second day after the severe pain and again on the day following. 
Bile only was vomited. The temperature during this period was 
around 99 degrees and the pulse less than a hundred. She had 
taken considerable fluid during the past several days and seemed 
in other ways well on the road to recovery. At 11 a. m. today she 
was struck with sudden excruciating pain which half a grain of 
morphine failed to relieve. Morphine has been repeated several 
times in the five hours now intervened, but she has continued to 
complain bitterly of the pain. In the past two hours she has vom- 
ited large amounts of greenish-yellow fluids. 

Exmnination. — The patient is so restless, because of the pain, that 
an adequate physical examination can not be made. The abdomen 
is distended, contains free fluid, is everywhere moderately rigid 
and below the umbilicus, particularly on the right side, there seems 
to be a definite tumor outline. The constant movements of the pa- 
tient prevent a satisfactory examination, however. The uterus is 
fixed, the culdesac is bulging, particularly on the right side, and 
there is a definite resistance on this side. The resistance is increased 
by firm pressure above the pubes. There seems to be a mass fill- 
ing the pelvis and protruding over the pubes. The patient has a 
thick abdominal wall and the outlines can not be made out with 
certainty. The pulse is 120, temperature 99.4, respiration 36. 

Diagnosis. — The prevailing symptoms point to trouble in the 
lower abdomen. The great pain points to intense irritation of a 
large area of peritoneum. The girth of the patient has been in- 
creasing noticeably during the past year according to the patient's 
statement, indicating the possible existence of an abdominal tumor. 
The uterus is fixed and there is resistance above the pubes. Sudden 
pain in a soft pelvic tumor suggests ovarian cyst with twisted 
pedicle. This is substantiated by the fixed uterus and by the ap- 
pearance of menstruation at the beginning of the attack. There have 
been no marked upper abdominal symptoms for six years. From 
the history of hematemesis one is disposed to believe there has 
been an ulcer. The physician in attendance believes she has had 
gallstone attacks and the account he gives of the attacks makes 
it likely that he is correct. Neither ulcer nor gall bladder trouble 
seem to account for the dominating trouble in the lower abdomen. 



584 CLINICAL SURGERY BY CASE HISTORIES 

Appendicitis also was considered, but there was no account war- 
ranting one in locating the trouble in this region. The pelvic symp- 
toms did not seem to measure up with an affection of the appendix. 
A tentative diagnosis of an ovarian cyst with twisted pedicle was 
made. 

Treatment. — Exploration was agreed to. As the patient was being 
anesthetized she began to vomit large amounts of yellowish green 
fluid. The anesthetist, an inexperienced man, was warned of the 
danger. In the act of vomiting she suddenly ceased to breathe. A 
gauze sponge passed deeply in the trachea brought up a quantity 
of bile-stained mucus. Death was probably due to the aspiration of 
stomach contents. 

Autopsy. — A partial autopsy was permitted. The abdomen con- 
tained much straw-colored, cloudy fluid. The much thickened omen- 
tum lay in the pelvis. The w^alls of the intestines including the 
cecum and sigmoid were very much thickened, forming a conglom- 
erate mass which filled the pelvis and extended over the rim of 
the true pelvis. The omentum over the ascending colon was simi- 
larly affected. The small intestines in the upper abdomen under 
the great omentum were distended but not thickened or inflamed. 
In front of the pyloric end of the stomach was an indurated ulcer 
as large as a watch, in the center of which was a perforation ad- 
mitting the tip of the finger. This ulcer was partially covered by 
the adherent transverse colon. It appears that the entire ulcerated 
area had been covered by fresh adhesions, but recently had given 
way at one point. 

Comment. — Evidently the first pain at 2 a. m. five days ago was 
caused by a small perforation, which being partly protected by ad- 
hesions, permitted the escape of a small amount of stomach con- 
tents. This having occurred at 2 a. m. the stomach contained little 
else than acid stomach contents. This fluid gravitating down the 
watershed of the great omentum to the pelvis, wrought its chief 
havoc in the lower abdomen, producing a conglomerate mass consist- 
ing of intestines and omentum. These are what I felt on examination. 
At 11 A. M. of the day of observation, evidently the larger perfora- 
tion took place, throwing a large amount of stomach contents into 
the peritoneal cavity, causing the excruciating pains above men- 
tioned. I have never seen such severe pains except in perforated 
gastric or duodenal ulcer, but I imagined it might be caused by an 



SEVERE ABDOMINAL CRISES 585 

inflamed cyst wall becoming simultaneously necrotic and irritating 
the peritoneum over a large area. I pictured in my mind a partial 
twist five days ago and a complete twist when the patient was 
visited. This case shows once again that a patient with ulcer 
symptoms who has sudden atrocious pain has a perforation. It 
takes all the adjectives indicating the superlative degree of human 
suffering, hitched tandem, to express the agonies caused by a per- 
forating ulcer. When such a pain is present, an ulcer had best be 
diagnosticated. 

CASE 4. — A matron aged fifty-six was brought to the hospital be- 
cause of severe abdominal pain. 

History. — The patient is the mother of five children. She passed 
the menopause nine years ago. Two years previous to this time 
she had been examined by me because of frequency of urination, 
constipation, and general pelvic discomfort. The urine contained 
some pus cells. A firm tumor attached to the uterus filled the pel- 
vis. Its removal was recommended but the advice was not heeded. 
Two days before entering the hospital she had a sudden abdominal 
pain during the night. When examined by her doctor some hours 
later she had a temperature of 103.5° and a pulse of 140. Mor- 
phine was given for the pain and she was brought to the hospital. 

Exmnination. — Her temperature now is 102° and the pulse 120. 
The face is pale and anxious and the abdomen tender. Fluid can 
be made out in the flanks. The leucocyte count is 12,000. There 
is pronounced abdominal tympany. The abdomen is very flaccid 
and muscular rigidity is not marked but a reflex contraction takes 
place whenever the right upper pole of the tumor is palpated. The 
tumor occupies the region above the pubes and appears to be about 
the size of an adult head. Combined examination shows a globu- 
lar tumor riding on the pelvic brim. The cervix is continuous with 
the tumor. So far as can be made out the tumor is semifluctuating, 
though because of the tenderness its consistency can not be made 
out with certainty. 

Diagnosis. — Knowing that the patient has a myoma and consider- 
ing the onset of the stormy symptoms, temperature and rapid pulse, 
a septic infection of the myoma seems most likely. 

If it were an infection, its escape beyond the tumor seems probable 
because there is fluid in the abdomen and evident tenderness, and an 
operation under an extremely grave prognosis seems the best course. 



586 



CLINICAL SURGERY BY CASE HISTORIES 



The other possibilities are that there was an intramyomatoiis hemor- 
rhage or that the previous diagnosis was wrong and that an ovarian 
cyst is present, the pedicle of which has become twisted. 

Operation. — A large congested myoma was delivered. At its up- 
per right pole was an opening through the uterine shell in which was 
a hemorrhagic mass the size of a small lemon. There was a quart or 




Fig. 300.— Perforating hemorrhagic myoma of the uterus. The area of perforation is shown 
in the left upper quadrant of the tumor. 

two of hemorrhagic fluid in the free peritoneal cavity which was 
sponged out. The peritoneum was everywhere intensely congested 
and the guts markedly dilated. Because of experience in a previous 
ease a pan-hysterectomy was done. 

Pathology. — On section of the tumor, a large hemorrhagic mass 
surrounded by a shell of uterine tissue intact except at the upper 
right pole above noted was found (Fig. 300). Sections of the tu- 



SEVERE ABDOMINAL CRISES 587 

mor show thickened vessel walls. The hemorrhagic areas show fibrin 
network with abundant red corpuscles and a few small round cells. 
In much of the tumor the myomatous tissue remains intact being 
merely discolored by the infiltration. 

After-course. — The wound healed without trouble though the pa- 
tient was slow in recovering her strength. A year later the patient 
returned with a large scar hernia. This she choose to retain. 

Comment. — The fact that the temperature rapidly subsided should 
have indicated that it was toxic and not infectious in origin. Faith 
in my previous diagnosis of myoma should have been strong enough 
to have precluded the consideration of a ovarian cyst with twisted 
pedicle. The occurrence of a hernia throughout the extent of the 
wound without there having been any obvious infection following the 
operation shows the influence of the hemorrhagic exudate from the 
tumor in preventing the normal course in wound healing. This 
acts by preventing the organization of the fibrin in the new wound 
into fibrous tissue. This influence is seen in the interior of all of 
these hemorrhagic myomas. 

CASE 5. — I was called to see a married woman aged fifty-six be- 
cause of severe abdominal pain and vomiting. 

History. — The patient has never been pregnant. She has had 
flooding at intervals in late years. She is not certain when she passed 
the menopause, since she has been free from flow for long intervals for 
some years. She has had no flow for several years. She had been 
examined a number of years ago and was told she had a pelvic 
tumor. The tumor, the patient asserts, has become much larger in 
the past two weeks. She has been incapacitated now ten days with 
intense abdominal pain, vomiting and distention. She has had fever 
and rapid pulse. 

Examination. — The lower abdomen was occupied by a tumor gen- 
erally tender, but the outline could be well made out. No muscular 
rigidity. The tumor was dense and continuous with the cervix. No 
fluid could be demonstrated in the peritoneal cavity. Temperature 
101°, pulse 120, respiration 24. 

Diagnosis. — The presence of a large, hard tumor continuous with 
the uterus makes the diagnosis of myoma easy. The present storm, 
because of the general disturbance and the tenderness of the alleged 
sudden enlargement, most likely is due to a hemorrhage into its sub- 
stance. Its removal is in order. 



588 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The patient was examined in her country home. She 
was advised to go to the hospital for operation. She promised to do 
so within the week. 

After-course. — Five days after the examination while she was pre- 
paring to go to the hospital she was seized with a sudden severe 
pain and collapsed at once. Her physician found her pale and pulse- 
less "like a ruptured extrauterine pregnancy." Stimulants were 
administered but she died in eight hours. Autopsy showed a hemor- 
rhagic myoma which had necrosed through the uterine wall. A con- 
siderable amount of bloody fluid was free in the peritoneal cavity. 
There was no evidence of infection and the amount of blood lost was 
not suflficient to have in itself caused death. The assumption, there- 
fore, must be that death was due to shock, or in other words to the 
absorption of the toxic blood escaping from the degenerated myoma. 

Comments. — The outcome of this case is of interest from a patho- 
logic rather than in a clinical sense. The reason the blood in these 
myomas does not coagulate must be due to the absence of those ele- 
ments which institute coagulation since the blood in the general cir- 
culatory system coagulates normally. This absence of coagulability 
must be due to the slowly developing degenerative changes common 
to a greater or less degree to many myomas. That blood in other 
situations which does not coagulate is prone to cause constitutional 
symptoms is seen, for instance, in subcutaneous hemorrhages after 
blunt trauma and in extrauterine hemorrhage. 

CASE 6. — A matron of thirty-one was brought to the hospital be- 
cause of severe abdominal pain and collapse. 

History. — When first seen by her physician a week ago the patient 
was in bed and said that she had just started to flow after having 
missed her menstrual periods for the two preceding months. She com- 
plained of some pelvic cramps, especially on the right side. She had 
no rise of temperature but the pulse was 100. A diagnosis of 
threatened abortion was made and no pelvic examination was made. 
The patient was kept in bed and given codeine by mouth. In twen- 
ty-four hours the flow stopped and the pain subsided. During the 
week following the patient was not seen by her physician, but it 
was reported that at times she had pain in different parts of the 
abdomen but principally in the pelvis. 

Four hours ago she got out of bed to go to the toilet when she was 
seized with a sudden acute abdominal pain from Avhich she fainted. 



SEVERE ABDOMINAL CRISES 589 

"When seen by her physician two hours later she was still prostrate 
where she fell. Her face and lips were pale to the extreme and 
she was pulseless at the wrist. She complained of great thirst. 
Her pulse counted by stethoscope was 160. The abdomen was quite 
rigid. The pain was not very severe, was mostly on the right side. 
A diagnosis of ruptured tubal pregnancy was made and the patient 
taken to the hospital. She gave a history of having had a uterine 
suspension thirteen years ago before the birth of any of her chil- 
dren. She has three living children, the eldest eight and the 
youngest three. Her menses have always been regular and painless. 

Examination. — By the time the patient reached the hospital the 
pulse had become perceptible at the wrist (taken four hours after the 
acute attack) and was 150. The abdomen was rigid and there was 
dullness above the pubes. The extremities were cold. 

Diagnosis. — The diagnosis is undoubtedly a ruptured tubal preg- 
nancy. A tubal abortion would not likely produce such a profound 
shock. Hemorrhage evidently has ceased and she is on her way to 
recovery from the shock. Any other diagnosis is hardly possible. A 
ruptured ovarian cyst sometimes produces a profound shock, but 
not so great as this and there is the history of missed menstrual pe- 
riods. A necrotic appendix sometimes produces severe pain, but 
never such pallor or air hunger. 

Treatment. — She had been given stimulants of caffeine before she 
came to the hospital. She was given a fourth grain of morphine, and 
hot-water bottles were applied. She took so much water by mouth 
that none was given in any other way. The patient's condition was 
gradually improved during the week following. The pulse came 
down to 120 and was fairly good. A laparotomy was done. The 
pelvis was found to be filled with much dark blackish fluid blood and 
many large clots. A right-sided ruptured tubal pregnancy was found 
and removed. The body of a two months' fetus protruded through the 
ruptured tube. Nothing else was done. The patient left the operat- 
ing table in good condition. Pulse 138 and good quality. Proctoclysis 
was started and heat applied to the extremities. 

Pathology. — The distal end of the tube was filled with a clot dis- 
tending it. At the site of rupture the villi had penetrated deeply 
into the tube facilitating rupture at that point. Fatal hemorrhage 
is less apt to occur if this is the case than when wide rupture takes 
place the result of greatly increased intratubal pressure. 



590 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — The pulse gradually improved and came down to 
the 80 's during the following week. Recovery was uneventful. 

Comment. — To have operated when she was first brought to the 
hospital would most certainly have resulted fatally. Usually tubal 
ruptures bleed to death before medical aid can be summoned. Tubal 
abortions rarely bleed to death. The ideal method is to discover 
them and operate before rupture. Once the pregnancy has ter- 
minated, the surgeon's chief function is to operate after it is safe 
and expedite recovery by removing the fetus and the blood clots. 
It is rarely a life-saving procedure. Much mischief has no doubt 
been done by precipitous and ill-advised operations for extrauterine 
abortions. The general impression seems to be that unless the at- 
tendant operates at once, regardless of his qualifications or the 
environment, he is derelict in his duty. Procrastination loses pa- 
tients, but bad operating loses more. It must be determined 
whether the state of the patient is due to shock or hemorrhage. If 
it is due to shock, a good operator in a good environment had best 
stand to ; if due to loss of blood, he must choose the hazardous risk and 
operate. Determination of the amount of free fluid in 'the abdomen 
is the best guide. Because of the state of the capillary circulation, 
blood counts and hemoglobin estimates are useless. 

CASE 7. — A matron aged thirty-five was brought to the hospital 
because of severe abdominal pains. 

History. — The patient has been married fifteen years. A year and 
a half after marriage she had an abortion at five months. Two years 
later she had a normal labor, and two years later had another abor- 
tion "at five months. Seven years ago her last child was born. The 
menses have been regular since that time until the onset of present 
illness. Her last regular menstruation began March 24. She is 
positive conception occurred March 28. April 6 she had a sudden 
sharp, severe pain in the rectum. This pain was so severe that she 
had to go to bed and summon medical aid. She has had more or 
less pain at times ever since then. It is always Avorse w^hen bowels 
move. On April 28 the patient passed some clots per vaginam. A 
slight pink flow which was not like menstrual blood followed, last- 
ing until May 8. On this day there was a sudden severe pain in 
the lower abdomen and rectum. She vomited several times and 
felt very faint, but was never unconscious. She was kept under 
the influence of morphine all day. At 7 :50 the same day she was 



SEVERE ABDOMINAL CRISES 591 

curetted by her home phj^sician, who said he removed a six week 
fetus that had been dead two weeks. The uterus was packed for 
thirty-six to forty hours. During this time vomiting was con- 
tinuous, but ceased as soon as the pack was removed. There has 
been no hemorrhage since pack was removed, now two weeks ago. 
There is still pain but not so severe as before the operation. 

Examination. — The cervix is behind the symphysis pubis and is 
soft and patulous. Uterus is enlarged, tender, turned sharply to 
the right, and is fixed. There is a mass to the left of the uterus 
filling half of the pelvis, pressing the culdesac down in the vault of 
the vagina. The mass is dense, resilient and any pressure on it 
causes pain. Abdominal palpation elicits tenderness in the right 
lower abdomen from McBurney's point to the pubes. There is no 
muscular rigidity. 

Diagnosis. — The sudden severe pain deep in the pelvis accompanied 
by irritation of the rectum with nausea and collapse spells on the 
face of it a disturbance of an extrauterine pregnancy. There are 
a number of interesting factors which enter. The patient is cer- 
tain that the fruitful coitus took place just nine days before the 
onset of the illness. It is my experience that when a woman is so 
sure of the exact date on which conception took place, it most 
certainly did not take place on that date and that it is none of 
the surgeon's business why she fixed this date. The fact that there 
were two distinct attacks of pain indicates that there are two 
stages in the process. This stamps the lesion as a tubal abortion. 
The fact that the uterine flow followed some weeks after the first 
onset indicates that the first dislodgment was only partial. The 
second attack was much more severe and was probably attended 
by the expulsion of a fetus from the tube. We are confronted 
by the fact that her physician stated that he secured a six weeks' 
fetus as the reward of his curettage. Pregnancies have been re- 
ported both intrauterine and intratubal, but physicians also some- 
times remove imaginary fetuses. The pelvic mass fixes the uterus 
and is painful to the touch. This might lead one to suppose that the 
mass is caused by an inflammatory exudate the result of the curet- 
tage. The peculiar resistance and resilience is characteristic of 
a blood clot and does not have the more suffused feel of an inflam- 
matory exudate. Furthermore there is no fever and a leucocyte 
count of 10,000, just Avhat one would expect in a blood clot. There- 



592 



CLINICAL SURGERY BY CASE HISTORIES 



fore, a diagnosis of a left tubal abortion seems justified. It is 
not certain that abortion is complete. There may be a possibility 
that a renewed attack of pain may occur. The later the date of preg- 
nancy the more serious is tubal abortion. From the feel of the mass 
in the pelvis it is likely that abortion is complete and that the pa- 
tient is safe from renewed attacks. However, the patient is in good 
condition and operation is safe and will expedite recovery. 




Fig. 301. — Fetus and blood clots from an extrauterine pregnancy. 

Treatment. — The culdesac is filled with blood clots. There is a 
fetus 21/2 inches long lying free in the clots. The tube is thickened 
and the fimbriated end is ragged. The right tube is normal. The 
left tube and ovary were removed. 

Pathology. — The blood clots seem old and partly organized. The 
fimbriated end of the tube is split as if it had been torn when the 
tubal abortion occurred. The clots immediately about the fetus 



SEVERE ABDOMINAL CRISES 593 

seem partly organized (Fig. 301) as if this part of the hemorrhage 
had occurred at the first attack and that the whole mass was extruded 
at the last and more severe attack. 

After-course. — Recovery was uneventful and she has remained well 
since. 

Comment. — It is quite usual to find patients with extrauterine 
pregnancy who have been curetted. This always adds to the responsi- 
bility of the surgeon. Generally speaking, when a tubal abortion is com- 
plete as indicated by a period of quiescence and a curettement has 
been done it is well to defer operation long enough to determine 
whether or not the curettement may have produced an infection. 
Should the surgeon operate under such conditions without such pre- 
cautions, he makes himself responsible for the acts committed during 
the curettement. 

Generalized abdominal pains that do not tend to become local- 
ized, as is made evident by local tenderness and muscle rigidity 
or produce constitutional disturbances, are usually due to intestinal 
obstruction. Hemorrhage from visceral rupture or injury to the 
spinal nerves may do so. Vomiting is a valuable but late sign of 
intestinal obstruction and stercoraceous vomiting is the bridge be- 
tween the clinical manifestation and the autopsy findings. 

GENERAL ABDOMEN 

CASE 1. — A farmer aged 26 came to the hospital because of a post- 
operative hernia. 

History. — About seven years ago he had an attack of typhoid fever 
complicated by intestinal perforation. He was operated at his 
home and the hole in the intestine closed. The sutures gave way 
and the abdominal wound gaped open. It healed by granulation 
and was four months in closing up. A weak place was left in the 
abdominal wall which bulged when lifting and often gave some pain. 
Has worn a bandage over it ever since it first appeared. 

Examination. — There is a scar four inches long over the right rec- 
tus. It bulges perceptibly when he attempts to raise his head and 
trunk from the table. When he is lax, the tips of four fingers can be 
placed in an opening between the two parts of the muscle. 

Diagnosis. — His diagnosis of postoperative hernia is evidently cor- 
rect. His belief that it can be repaired is likewise correct. 



594 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The hernia was reopened. The omentum was adherent 
to the medial and upper borders of the hernial opening. These were 
tied off and the edges inverted. The appendix came into the wound. 
It was a large, long appendix and looked slightly inflamed, therefore 
it was removed. 

After-course. — Healing was uneventful and he returned home in 
two weeks. After being home only three days he was awakened at 
3 o'clock in the morning with a severe cramping pain in the left 
side of the abdomen. Heat was applied w^hich seemed to relieve 
him for a short time, but the pains soon became worse than before. 
They were paroxysmal in character, quieting down for a few min- 
utes and then returning again. Vomiting began about one hour af- 
ter the onset of the pain and continued up to the time of readmis- 
sion, two days after the onset of the pain. He has taken practically 
nothing by mouth since the onset of the attack. Several enemas 
were given during the past two days. Part of these were expelled 
and part retained. Turpentine stupes were repeatedly tried, but 
with no relief. The abdomen became distended and hard early in 
the attack and has remained so. Last night he was given morphine 
gr. 1/4 3^nd slept all night. This morning the pain and vomiting 
returned worse than before. He was therefore brought back to the 
hospital. 

The patient lies on his back and is bathed in perspiration. The 
face is anxious and the patient complains constantly of great 
pain in the left side of the abdomen. Pulse 120, temperature 99.5°. 
The abdomen is distended and rigid, particularly over the left rec- 
tus. The sensitiveness is most marked over the left lower quad- 
rant. A diagnosis of intestinal obstruction was made. Because 
of the sudden onset and the remittent character of the pain, the 
early appearance and persistent character of the distention with the 
absence of fever and increase of leucocytes, the diagnosis of intestinal 
obstruction was made. A laparatomy was immediately done. A 
loop of small intestine 11/2 feet in length was found which had slipped 
through a hole in the great omentum, the band of omentum tightly 
constricting the intestine. They were much distended and of a 
dark red color. The omental vessels were filled with thrombi. 
The peritoneal cavity contained much serosanguineous fluid. The 
intestines were released a portion of the omentum removed and the 
wound closed without drainage. 



SEVERE ABDOMINAL CRISES 595 

After-course. — As soon as the patient awakened from the anes- 
thetic he said his pains were gone. The subsequent recovery was rapid 
and uneventful and he has remained well. 

Comment. — Evidently an opening was made in the omentum or 
one already present was overlooked at the time of the repair of the 
hernia. In cases of omental adhesions at hernial openings, that 
part proximal to the point of adhesion is usually exceedingly thin and 
a hole may be inadvertently made in it unless great care is exer- 
cised. They should always be sought for, and if found, carefully 
repaired. 

CASE 2. — A school boy aged nineteen was brougfht to the hospital 
because of vomiting and abdominal pain. 

History. — Two years ago the patient had a severe attack of ab- 
dominal cramps. He attributed it to eating raisins. The attending 
physician at his first visit found nothing, but an examination made 
a day later revealed a tumor immediately below the umbilicus. 
This was supposed by his physician to be a mass of raisins, and he 
manipulated it with his fingers in order to break up the lump. The 
cramps subsided and flatus and stool passed on the next day. The 
patient was free from any complaint from that time until four days 
ago when he became chilly and nauseated while loading a wagon. 
The two days following he felt much improved. On the third 
day he ate a hearty breakfast and later a ham sandwich, and took 
a small drink of whiskey, to which he was not accustomed. He im- 
mediately began to have cramps and walked about to lessen the 
pain. After a few hours he vomited freely. The pains increased 
during the afternoon and he rolled about from pain. A doctor 
was summoned. Morphine was administered hypodermically and 
Avas repeated the following day. Many enemas w^ere employed dur- 
ing the following days, but pain and vomiting continued. During 
this period the physician was able to palpate a tumor to the right 
of the median line. On Friday the enema brought away a piece of 
the meat eaten on the Sunday previous. This gave some relief 
and a little supper was eaten. Thirty-six hours ago he began to 
have more pain and has vomited persistently since. He has had 
two hypodermics of 1/4 grain of morphine during the day. 

Examination. — The abdomen is but little sensitive and there is no 
rigidity. There is moderate distention ; no dullness in either flank ; 



596 CLINICAL SURGERY BY CASE HISTORIES 

the tongue is dry and coated and there is evidence of impending 
collapse. The pulse is 144, temperature 97°, respiration 24. 

Diagnosis. — The recurrent attacks of pain with obstipation suggest 
a recurrent partial obstruction. The history of palpable tumor which 
disappeared suggested transient intussusception as a possible cause. 
The duration of a week without collapse indicated that the ob- 
struction was not complete until within the past day or two. The 
absence of stercoraceous vomiting suggests that the obstruction 
must be near the ileocecal valve. The location of the alleged tumor 
is in harmony with this assumption. The absence of tenderness 
excludes peritonitis unless the repeated injections of morphine mask 
the symptoms. An intussusception at the ileocecal valve seems the 
best diagnosis. At any rate immediate action is demanded. 

Treatment. — The abdomen was opened in the right semilunar line 
below the level of the umbilicus. When the peritoneum was opened, 
about a quart of straw-colored fluid escaped. The intestinal coils 
appearing in the incision were injected and much distended. The 
ileocecal portion of the intestine was at once sought and was found 
lying over the kidney. It presented a tumor. When the tumor 
was drawn into the Avound, it was seen to be an intussusception 
through the ileocecal valve, about twelve inches long, with a dis- 
tinct tumor at its upper extremity. The tumor was thought to be 
a polj'p which had produced the inversion of the gut. When the 
intussusception was reduced by traction and pressure on the tu- 
mor, a dimple remained over the base of the supposed polyp (Fig. 
302, B). This made it obvious that the tumor mass was an inverted 
Meckel's diverticulum, with a thickened apex. By careful pressure 
the diverticulum was restored to its former position (Fig. 302, A). 
The diverticulum was nearly the diameter of the gut from which it 
sprang and was about two and a half inches long. The mass in its 
apex w-as about the size of a hulled w^alnut. The diverticulum was 
clamped just below the solid mass and a mattress suture passed 
the ileal side of the clamp. The clamp was removed and the gut 
severed, the edge being cauterized with carbolic acid and iodine. 
This raw end was then inverted into the lumen of the gut. The 
contracture of the walls of the intestine after the suture line had 
been inverted resulted in narrowing the lumen of the gut more 
than had been intended. No evil resulted, however, as the lumen 
remaining was the size of a finger, but looked small in contrast 



SEVERE ABDOMINAL CRISES 



597 



to the adjoining dilated gut. The cecum was replaced and the 
loop of ileum containing the stump of the diverticulum was pulled 





B. 



Fig. 302. — A. Appearance of the diverticulum after it was restored to its normal position. 
B. Diagram of the position of the diverticulum when it was causing the obstruction. 



over above and distal to the cecum. An inch stab drain opening was 
made in the abdominal wall just above the crest of the ileum. A 



598 CLINICAL SURGERY BY CASE HISTORIES 

small, flat gauze pack was placed over the ileum and a drainage 
tube below it. The original incision was closed completely. 

Pathology. — The part removed consisted of a mass about the size 
of a hulled walnut, with a flange of diverticular wall below it in which 
the muscular and mucous coats could be readily made out. On 
section the mass was seen to be composed in part of blood clot, giv- 
ing the appearance of a submucous accumulation of blood of some 
days' duration. At the apex of the tumor immediately beneath 
the peritoneum was a cap 3 or 4 mm. thick, which was pearly white 
and resembled when cut the section of a skin papilloma. Micro- 
scopic examination showed the submucous thickening Avas due to 
an old blood clot. Toward the opening of the diverticulum the mu- 
cosa was normal, but at the apex it was continuous with the white 
thickened cap. The latter proved to be composed of glandular 
tissue arranged in two distinct layers; an inner, made up of Brun- 
ner's glands somewhat irregularly disposed; and an outer, which 
resembled the benign adenomas so often found in the intestines. 
This arrangement suggested strongly the aberrant masses of pan- 
creatic tissue, which have often been reported present in Meckel's 
diverticulum, and particularly the case in which Kiittner observed 
both Brunner's glands and aberrant pancreatic tissue. The fact 
that in our case some of the misshapen Brunner's glands termi- 
nated in the adenomatous portion, raises the question whether the 
so-called pancreatic tissue may not in reality have been aberrant 
intestinal glands. 

After-course. — Following the operation the patient awoke quickly, 
and at 6 p. m. his chart showed pulse, 132 ; temperature 101° ; res- 
piration, 28. He attempted to vomit and his stomach was emptied 
by lavage of a large amount of greenish fluid. Flatus was expelled 
late in the evening following an enema. There were emesis and 
repeated gastric lavages in the days following. On Tuesday, the 
third day, there was free bowel movement, with much flatus, and 
the patient complained of hunger. On the fifth day, Friday, the 
chart showed pulse 92; temperature 99.2°; respiration 24. Satur- 
day : pulse 78 ; temperature 99.4° ; respiration 24. On the seventh 
day: pulse 68; temperature 98.4°; respiration 20. During the first 
two days there was a profuse drainage of cloudy serum from the 
drainage opening; this became reduced at the end of the second 
day, and the drains were removed. The skin of the entire central 



SEVERE ABDOMINAL CRISES 599 

incision opened on the sixth day, and a considerable amount of pus 
was expelled. Healing was complete in three weeks. He has re- 
mained well since. 

Comment. — The recurrent attacks of obstructions, particularly in 
children, should suggest strangulation by some fetal remain. Invag- 
ination of a diverticulum is less common than looping about an ad- 
ventitial band. The fluid exuded because of the strangulation of the 
gut, though itself free from bacteria, was likely the cause of the 
failure of the wound to heal. The development of a scar hernia 
was to be expected, but did not occur. 

CASE 3. — ^A fanner ag-ed twenty-six was brought to the hospital 
because of an acute abdominal pain. 

History. — Thirty-six hours ago the patient was seized with severe 
pain in the right lower quadrant of the abdomen. It was not pre- 
ceded by nausea. The temperature when taken by his physician 
an hour or two later was subnormal. He was given a hypodermic 
injection but was only partly relieved. After a few hours the 
pains became more intense and he was nauseated. The hypodermics 
had been repeated six times by the time he reached the hospital. On 
entering the hospital he still had severe pains and clamored loudly 
for relief. He had no previous attacks of a similar nature neither 
had he ever suffered from stomach disturbances. He had passed 
neither stool nor flatus since the beginning of the pain. 

Examination. — The patient is restless and requests that he receive 
relief at once. His restlessness makes examination unsatisfactory. 
The abdomen is much distended, everywhere tympanitic but no- 
where markedly sensitive to pressure. Deep pressure in the ileo- 
cecal region is responded to by expressions of active resistance. 
The temperature is 99°, pulse 120, respiration 32. A blood count 
Avas not made because of the apparent urgency of the need of treat- 
ment. 

Diagnosis. — A sudden pain with subnormal temperature usually 
indicates an accident not primarily inflammatory, usually a perfora- 
tion or obstruction. The very sudden onset suggested a perforation 
but the initial pain was lower than that usually seen in gastric or 
duodenal perforation. There w^as no history of previous stomach 
disease. A sudden perforation of an appendix was suggested by the 
location. The obstruction might be accounted for by an inflamma- 
tory paralysis. The pronounced tympany particularly at a distance 



600 



CLINICAL SURGERY BY CASE HISTORIES 



from the site of initial pain suggested an obstruction. A more 
definite diagnosis was not attempted. 

Treatment. — An incision was made along the right semilunar line 
which had its midpoint at the level of the umbilicus. A large 
amount of cloudy serum escaped when the peritoneum was opened. 
The cecum was collapsed as was the terminal portion of the ileum. 
Many widely distended loops of small gut forced their way into 
the field of operation, while these preliminary surveys were being 
made. At the junction of the collapsed and distended portions 
was a mass the size of an unhulled walnut. The gall bladder re- 
gion was free from adhesions. The mass was free from attachment 
to the gut wall hence must be a foreign body. An incision over it 




Fig. 303. — Enterolith formed of pawpaw seeds. 



along the convex surface was made and the foreign body extracted. 
The cut was closed by a Czerny-Lembert suture. A stab drain was 
made in the flank and the original wound closed completely. 

Pathology. — The mass removed was a rounded lump with here and 
there unimportant irregularities (Fig. 303). The surface is covered 
by calcareous flakes. From the lightness it obviously is not solidly 
calcareous. A section shows that the bulk of the tumor is made up of 
a conglomerate of pawpaw seeds with a thin calcareous covering. 

After-course. — The patient recovered from the immediate effects 
of the operation but after a week he had renewed evidences of 



SEVERE ABDOMINAL CRISES 601 

obstruction. Exploration showed a mass of closely adherent in- 
testinal coils Avith thick, indurated walls. An attempt to separate 
all of them seemed futile and to resect the whole mass was obviously 
out of the question. A proximal distended loop was drained in the 
hope of reaching a point above the obstruction. This was partly 
successful, but he died in three days. The autopsy showed a mass of 
closely adherent intestinal loops, the obstruction being due to the 
close attachment with the added edematous thickening of the gut 
walls. A slide of the gut Avail showed edema and fibrinous exudate. 
Comment. — This case presents a number of factors of fundamental 
importance. It was formerly held that intestinal stones when lighter 
than water were derived from the gall bladder and when heavier 
were primarily of the gut lumen. This stone had as nucleus seeds 
of fruit. In many of the recorded cases this has been the ease. 
Why this foreign body caused such a sudden stoppage of the lu- 
men is not quite clear. It must have taxed the lumen for a con- 
siderable period. A reactive change in the gut wall may have 
been responsible. The irritation Avith the formation of a large exu- 
date still able to undergo coagulation furnished an ideal field for 
the formation of extensive and persistent adhesions. This state 
is the common cause of postoperative adhesions. So far as could 
be determined, the patient had eaten freely of paAvpaws six Aveeks 
or two months before. This is ample time for a calcareous deposit 
to form, as we knoAV from the study of foreign bodies in the blad- 
der. Each season, hoAvever, he was in the habit of eating this 
fruit, and we can not be sure but that these seeds represented fruits 
of previous seasons. 

CASE 4. — A fanner aged thirty-six came to the hospital because 
of pain in the lower abdomen. 

History. — The patient has had good health until the present attack 
AA'hich began two days ago. He thinks he ate something at dinner 
that disagreed Avith his stomach. He had general abdominal pain 
all the afternoon. He took castor oil to relieve it, but he vomited 
at once after taking the oil. The symptoms were the same the 
next day, but the patient did not go to bed. At the end of twenty- 
four hours he noticed a localized tenderness over the appendix 
in the right lower part of the abdomen which caused him to suspect 
the nature of his trouble and he presented himself for examination. 



602 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — There was distinct tenderness over the appendiceal 
region with rigidity of the right rectus muscle. Temperature 100.6°, 
pulse 110. 

Diagnosis. — Acute appendicitis. The attack was wholly typical. 

Treatment. — Appendectomy with drainage was done. A small 
gauze drain was placed medial to the cecum. 

PatJiology. — The appendix was large, blue black with a partial rup- 
ture near its base. 

After-course. — The wound closed in three weeks and the patient 
was free from disturbance for four months. 

Re-entry and Second Operation. — After a hard day's work the pa- 
tient ate a heavy supper, felt perfectly well until about 10 p. m. 
At this time he had general abdominal pain and vomited once. These 
symptoms grew worse and he called a doctor who at once brought him 
to the hospital. It was then about 2 :30 a. m. Morphine gr. l^ was 
given before he was started on the journey. 

Examination. — Pulse is slow and regular, there is no rise of tem- 
perature. There is abdominal tenderness at a well localized point 
to the left of umbilicus Avith some rigidity. He vomits whenever any- 
thing is taken. The pain is very severe and is more on the left side 
than on the right. Urine negative. He was relieved for a time by 
the morphine, but after a few hours the symptoms began to return 
with increasing severity. 

Diagnosis. — Severe abdominal pain without rise of temperature or 
increase in pulse rate in one who has recently been operated on for 
a suppurative lesion always suggests obstruction from bands or ad- 
hesions at the site of the previous operation. The persistent tendency 
to vomit strengthens this assumption. The increasing tympany must 
be interpreted in the same light. 

Treatment. — Laparotomy was done at noon. The probability was 
that the obstruction was near the site of the appendectomy scar, but 
since the chief pain has been located at the left of the umbilicus, it 
seemed wisest to make a midline incision. As soon as the peri- 
toneum was opened a blood-stained fluid escaped. A band extend- 
ing from the cecum to a v-shaped transverse colon had a loop of 
gut thrown over it. This band was removed. A loop of gut proxi- 
mal to the site of obstruction had become adherent to the ascending 
colon. In liberating it the peritoneal surface w^as injured. This 
area was carefully repaired with silk. The intestines were dis- 
tended. The abdomen was closed without drainage. 



SEVERE ABDOMINAL CRISES 603 

Pathology. — The band which caused the obstruction is as large as 
a slate pencil. It is covered with a layer of endothelial cells. The 
body of it is made up of parallel bundles of fibrous tissue interspersed 
by many blood vessels. 

After-course. — The patient did well following the operation so 
that he seemed recovered by the end of the week. During this time, 
however, the patient had several times complained of a pain that 
would come on for a few minutes then leave when he felt something 
like gas pass through the intestines where his old pain used to be. 
This in no sense disturbed his well-being. 

Third Attack. — Eight days after the operation he was taken with an 
attack like the first one. The pain was very severe and there was 
vomiting. There was a definitely localized tenderness to the right 
and above the umbilicus. The pain rapidly grew worse. 

Examination. — The patient seemed markedly collapsed, the features 
were drawn, and the face wore an extremely anxious expression, 
not approached in either of his preceding attacks. There was sensi- 
tiveness and rigidity to the right and above the umbilicus. 

Diagnosis. — The point of tenderness is over the site of the adhesion 
found at the first operation. Because of the thickness of the gut wall 
found at that time, showing a universal tendency to the formation of 
a plastic exudate, it must be considered likely that adhesions have 
formed which are responsible for the renewed trouble. This is con- 
firmed by the slight attacks of pain noted at intervals during his 
convalescence from the operation for obstruction. Some disaster 
obviously must have been added to it to produce the marked change 
in the general appearance of the patient. 

Treatment. — An operation was performed at once. The incision was 
made through the right rectus over the site of maximum tenderness. 
Adhesions were found. Loops of small intestine were adherent to 
each other and to the omentum. It was noted that the intestines 
making up the mass were unusually blue as compared to neighbor- 
ing coils. Because of the involved arrangement of these coils and 
the unfavorable condition of the patient the adhesions were mo- 
lested only enough to permit the selection of the proximal loop. 
A rubber tube was inserted into the intestine at a point well above 
the conglutinated coils. The stomach was washed before the pa- 
tient left the table. 

After-course. — The patient was much shocked following the opera- 
tion and it was two days before the pulse became easily detectable 



604 CLINICAL SURGERY BY CASE HISTORIES 

at the wrist. He rallied considerably, but despite frequent washing 
of the stomach, he vomited frequently. The pulse became markedly 
full, wave-like, and about 120 to the minute. At the fourth day, 
save for the increased amount of the vomitus, he seemed better. 
The pulse became small and running, and at ten in the evening the 
extremities began to cool. At 2 :30 a. m he asked for an orangeade, 
but before it could be prepared he suddenly died. 

Autopsy. — The loops of gut that had made up the conglomerate 
mass were found to have loosed themselves for the most part. A 
hard firm clot occupied the mesenteric vein which drained the dis- 
colored loops of gut. 

Comment. — The original attack of appendicitis was classical. The 
cause of the obstruction was a band extending from the cecum to 
the colon. The formation of this adhesion was fostered by the 
drain that was placed medial to the cecum at the time of the ap- 
pendix operation. The operation for obstruction was done early, 
but notwithstanding this, there was evidence of a pronounced tend- 
ency to the formation of the plastic exudate. The extension of 
this process to the vein must be looked upon as the cause of the mes- 
enteric thrombosis which formed the basis of the final disaster. 
The presence of a thrombosis was not recognized at the time of the 
operation. Had it been a resection or even a delivery of the affected 
loops it would have been a hazardous undertaking and in the light 
of the pronounced depression following what little was done would 
most certainly have terminated fatally. This case shows the simi- 
larity between the initial symptoms of obstruction and mesenteric 
thrombosis. Marked was the added degree of systemic disturbance 
in the latter, expressive no doubt of the absorption of toxines from 
the injured tissues. 

CASE 5. — A boy aged four years wa,s brought to the hospital be- 
cause of a strangfulated hernia. 

History. — The patient has had a tumor in the right inguinal region 
at intervals since he was eighteen months old. At that time it 
came down and strangulated and had to be replaced under ether 
anesthesia. In March, 1917, six months ago, it again strangulated 
and was replaced without anesthesia. On the morning of October 
5, 1917, it strangulated again and could not be replaced under 
ether. Patient came into the hospital at 8 :30 p. m. The tumor was 
soft, slightly tender to the touch, but the patient appeared comfort- 



SEVERE ABDOMINAL CRISES 605 

able, was without temperature, and not vomiting. During the night 
the tumor became hard and the patient vomited twice. In the morn- 
ing it was larger and harder. 

Examination. — The lad's face looks pinched and he is restless. In 
the right inguinal region is a tumor as large as the end of the 
thumb. It is fairly firm to the touch and its manipulation causes 
pain. The testicles are in the scrotum. 

Diagnosis. — The location of the tumor corresponds to the inguinal 
canal. The history of the preexistence of the hernia may be regarded 
as accurate. The only problem to be considered is that of irreduci- 
bility or strangulation, since quite frequently in children a hernia 
remains for a time irreducible and after a time it returns into the 
abdomen without aid. On the other hand strangulation in children 
is rare. In this case the patient has vomited and his features seem 
drawn and he is restless and the reaction shows a disturbance in the 
circulation of the gut. 

Treatment. — Operation showed a strangulated loop of intestine of 
a very dark red color. A peristaltic wave could be made to traverse 
the strangulated portion and there was no constriction ring cutting 
the muscle layer. The viability of the gut therefore, was doubtful. 
Inasmuch as the patient is a child, it was deemed best to return it to 
the abdominal cavity. The loop was, therefore, replaced and the 
hernia repaired. 

After-course. — For a number of days following the operation the 
abdomen was greatly distended and tympanitic and the patient 
vomited occasionally. No food was given. Water was given per 
rectum. The temperature and pulse were never high. After six 
days the tympanites gradually disappeared and improvement fol- 
lowed. He went home October 20, fifteen days after operation. 

October 22, after being home but two days he became tympanitic 
to a marked degree. At intervals he had pain in the abdomen 
which was alwaj's accompanied by a very marked intestinal peri- 
stalsis. He became some better the next day, but October 26 was 
more tympanitic again. He vomited several times. On the next 
day vomiting continued and became of a fecal odor. Tympanites 
and peristalsis were marked and he was returned to the hospital. 

Operation October 28. — On opening the belly two loops of intes- 
tine were found permanently adhered to the strangulated loop, form- 
ing a partial stenosis (Fig. 304). These were dissected off and the 



606 



CLINICAL SURGERY BY CASE HISTORIES 



strangulated loop sutured into the abdominal incision and a fistula 
formed. A catheter was inserted into the lumen of the intestine. 
Flatus and some brownish fluid immediately drained off. Improve- 
ment began immediately. 

On November 5 he complained of severe abdominal pain. That 
night he passed bloody urine. No casts were found and the daily 
output was not decreased. On the night of November 6 he passed 
a small gravel. On November 7 the urine was practically free 
from blood. 

November 19 — intestinal fistula closed, peristalsis increased and 
became visible. Pain became intense and he vomited once. The fis- 




Fig. 304. — Small abscess within the gut wall covered with plastic exudate. A probe has 
partly separated this exudate. From a case of irreducible inguinal hernia. 

tula was opened with a pointed hemostat, and gas and feces were 
at once expelled. The patient was relieved but remained very 
toxic. A catheter was introduced and the bowels were washed 
out. The patient became comfortable at once. He was now dis- 
missed with both ends of the loop projecting from the abdominal 
scar. After recuperating several weeks he returned to the hospital 
and a Murphy circumcision clamp was placed one blade in each 
loop. In ten days this had separated by pressure necrosis and 
an opening between the two loops resulted. After this the open- 
ing in the abdominal wall nearly closed. The fistula being lined 



SEVERE ABDOMINAL CRISES 607 

with gut mucosa, the cuff had to be separated and turned back 
before closure could take place. This was done and the opening 
closed permanently. Since then he has occasionally had bellyache 
but he is developing normally. 

Comment. — In this instance the gut was too much strangulated 
to make its return into the abdominal cavity safe. While the 
gut did not perforate, it was so badly injured that protective ad- 
hesions formed about producing obstructive strangulation. The 
only alternative would have been section of the formation of fis- 
tula. Since a fistula had to be done later it would have been bet- 
ter to have done it at once. The formation of a fistula is always 
safer than immediate anastomosis. It is interesting to specu- 
late now as to the ultimate fate of the loop of gut now attached to 
the abdominal wall. A loop of gut is less apt to fall about this 
and produce strangulation than if a small strand were present. In 
as much as strands often exist in the abdomen without resulting 
in mischief, it seems best to allow conditions to exist as they now 
are rather than loosen the loop as a prophylactic measure. To 
loosen it would require a resection — a procedure not altogether 
without danger. 

CASE 6. — I was called to see a fanner aged forty-four who was 
suffering from an acute abdominal distention. 

History. — Two days ago he was attacked by severe pain in the epi- 
gastrium. There was no griping, but when most intense the pain ra- 
diated all over the abdomen. In the evening he vomited. His phy- 
sician found him in great pain and gave him a fourth of a grain 
of morphine. His temperature was then 98 degrees and his pulse 
70 per minute. One day ago his pulse was 84 and his temperature 
100.2. He then had severe pain in the ileocecal region and was rigid 
chiefly in this region. In the evening the pain was most intense 
on the left side and the rigidity was equal to that on the right side. 
He now had frequent urination and complained of marked stinging 
and pounding in the glans penis during the act. He has had in- 
tense thirst during the day, but all fluids had been withheld. He 
has previously had good health. 

Examination. — The patient lies in bed with the thighs flexed and 
his hands to either side of the trunk. His expression is one of 
deep alert thought, free from pallor or pinching of the features. 
"When he was approached for examination, his hands met those of 



608 CLINICAL SURGERY BY CASE HISTORIES 

the examiner as if to ward off danger. The abdomen is moderately 
distended, the muscles are fixed and the respiration is preeminently 
thoracic. There is general rigidity, marked along the whole of the 
right rectus and the lower half of the left. He complains everj-- 
where of pain, particularly above Poupart's ligament on the right 
side. He will not permit percussion except over the left upper 
quadrant, and it is markedly tympanitic here. His tongue is red, 
small, not dry, or yet normally moist. There is a marked absence 
of saliva in the mouth. The pulse is 120, hard, and there is just 
a suggestion of a running pulse. The temperature in the mouth is 
98; that of the axilla was 100.2. He had taken nothing by the 
mouth for many hours. 

Diagnosis. — The triad of pain, rigidity and vomiting appeared 
early here, at first diffuse, it later became localized in the right 
iliac fossa. It remained localized here but for a short time, then 
proceeded across to the left side, as evidenced by the bladder ir- 
ritation and the pain in the left side. The low temperature and 
gradually ascending pulse indicates an advancing sepsis. The lower 
mouth than axillary temperature indicates a change in the whole 
digestive apparatus. The process in two days spread across the 
lower abdomen involving both fossae and the true pelvis. From the 
degree of pain it is evident that a considerable degree of reaction 
is present. The diagnosis therefore must include an unlimited 
peritonitis starting from the appendix and now involving the whole 
lower half of the abdomen without any evidence of a tendency 
to walling off. The differentiation between appendicitis and per- 
forated ulcer in this case is easy. The initial pain while severe 
did not have the awful intensity which characterizes perforations 
which lead to a generalized peritonitis in two days. Ulcers some- 
times perforate without the intense pain usually characteristic, 
but in these cases there is a more or less perfect walling orf and 
the lower abdominal cavity is not affected. After a day or two one 
may have the right and lower abdomen chiefly involved as in this 
case, but in those the initial symptoms are more severe. Naming 
the disease is less difficult than determining the course to pursue. 
To open and drain will hasten absorption, perhaps lessen the 
resistance against a spreading of the infection. Considering the 
unfavorable surroundings in which he is placed, conservative treat- 
ment was decided on. 



SEVERE ABDOMINAL CRISES 609 

Treatment. — Salt water by rectum and morphine hypodermically to 
control the pain and secure quiet. Nothing by mouth. 

After-course. — Much to my surprise he recovered. I removed his 
appendix three months later. There was evidence of a perforation 
near the base of the appendix. 

Comment. — When there is evidence of spreading peritonitis from 
a perforation with marked tympany, operation does little good, in 
fact it seems rather to hasten than to slow the progress of the disease. 
This is particularly true in patients of his age. In young adults the 
tendency to limit the process is much greater. Once cases have 
reached this stage, in patients in middle life, operation is futile and 
a conservative course seems to offer more than operation. 

CASE 7. — A baby girl aged five months was brought to the hospi- 
tal because of a bloody stool. 

History. — At 10 o'clock yesterday morning her mother noticed 
when she awoke that she seemed very pale and seemed to be sick. 
Shortly afterward she began straining to stool and began screaming. 
The bowels moved during the morning previous to this. At 1 :20 
A. M. today she passed blood by the rectum which the mother esti- 
mated at several ounces. At 6 a. m. she passed a considerable amount 
of bloody slime. During the day she passed the same material eight 
times. At 8 p. m. she vomited clotted milk and a few hours after 
vomited some greenish fluid. She has refused to nurse since the 
vomiting occurred. This morning her doctor suspected there was 
a tumor in the midabdomen. At another visit a few hours later the 
presence of a tumor was unmistakable. He started for the hospital 
without delay. 

Examination. — The child is well developed and well nourished. 
There is no evidence of collapse. The abdomen is normally rounded. 
Above and to the left of the navel a prominence is visible as though 
an object the size of a walnut were lifting up the abdominal wall. 
On palpation the abdomen is everywhere soft. The tumor mass is 
easily palpable and is felt to project downward and to the left and can 
be followed until it disappears into the pelvis. 

Diagnosis. — This is a classical picture of intussusception. The 
bloody stool, sj'mptoms of obstruction and tumor make the diagnosis 
unmistakable. 

Treatment. — An incision just to the right of the median line was 
made. A sausage-like mass an inch in diameter extended from above 



610 CLINICAL SURGERY BY CASE HISTORIES 

the umbilicus in a curve to the left and downward as far as the 
bottom of the true pelvis. A loop of ileum disappeared into the 
end of the tumor mass. Traction on this loop failed to dislodge 
the gut, therefore the lower end of the tumor mass Avas grasped 
and its contents "milked" toward its proximal end. By this 
means the contents were made to escape. As the contents began to 
emerge it became evident that the cecum had become inverted into 
the transverse and descending colon. When reduction had become 
nearly complete the cecum could not become everted without com- 
bined pressure on tumor and traction on the gut. The appendix 
much inflamed appeared and by gently separating the adhesions, 
the entire cecum became unfolded. After reduction the appendix 
and the segment of the cecum below the valve alone were indurated; 
the ileum was free from induration. 

After-course. — The baby continued to vomit for some hours after 
operation. Enemas were expelled and a hypodermoclysis was given. 
After this recovery was rapid. 

Comment. — Obviously the cecum and appendix became inverted 
and traveled up the ascending colon, carrying the ileum with it. 
Whether inflammation preceded or followed this inversion is not 
known. The induration was of that solid, fragile type that ordinarily 
requires more than the time which elapsed since the symptoms began, 
in which to develop. 

CASE 8. — A fanner aged thirty-two was brought to the hospital 
because of pain in the chest and abdomen. 

History. — Thirty-six hours ago the patient had a violent chill. He 
soon developed a pain below the tip of his right shoulder blade. 
When his physician examined him he had a temperature of 104° 
and a respiration of 34. By that time there was pronounced ab- 
dominal pain, most marked on the right side. He was brought at 
once to the hospital. He has had some abdominal pain in times 
past but never any spells that incapacitated him. 

Examination. — The patient on entrance has temperature 103.6°, 
respiration 30, pulse 110. There is no dullness in the lung but some 
crepitant rales at the base of the right lung. There is some pain 
on deep respiration. The abdomen is tympanitic, generally sensitive, 
but most marked on the right side. There is some rigidity of the 
right rectus in the ileocecal region. There is no expectoration. 
W.b.c. 11,800; 90 per cent polymorphonuclears. 



SEVERE ABDOMINAL CRISES 



611 



Diagnosis. — The sudden onset with chill and high fever certainly- 
suggested a beginning pneumonia. In the intervening time dull- 
ness should have appeared in such a husky man, but there are but 
a few crackling rales to indicate any lung trouble. The abdominal 
distention is such as to make the determination difficult, but the 
pain is too diffuse to be a referred pain from a diaphragmatic 
pleurisy, which taken together with the probable lower right 
rectus rigidity indicates an appendicitis. Besides, the physician, 




Fig. 305. — Appendix in an advanced stage of necrosis. 



a very wide awake practitioner, evidently is convinced of the 
surgical character of the attack or he would not have sent the pa- 
tient to the hospital. It seems wisest to see. 

Treatment. — A large grayish-black appendix was found at opera- 
tion. The wall was fragile and smeary. The base was ligated with- 
out any attempt at inversion. 

PatJiology. — The entire appendix had undergone necrosis (Fig. 
305). 



612 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — A fecal fistula formed and a rather extensive infec- 
tion of the wound followed. Healing took place without further 
treatment. A hernia developed and was repaired a year later. 

Comment. — The cause of the chill is not apparent. If the entire 
process originated in the appendix, there must have been a bacter- 
iemia with some involvement of the lung. There was no complicat- 
ing pneumonia. The cases of appendicitis which I have seen in 
which there was an initial chill were all cases of gangrene of the ap- 
pendix. In such cases prompt operation is imperative. 



CHAPTER XII 

SEVEEE INTERMITTENT PAIN 

Under this head may be included those cases which either menace 
the life of the patient, and may require surgical aid to intercept them, 
either in the individual attack or to prevent a future attack, or the 
condition is of such a nature that they must be differentiated from 
the severe cases already discussed. This group includes lesions which 
require the immediate earnest attention of the surgeon, but which 
usually permit a degree of careful study, 

EPIGASTRIC 

Epigastric pains are sometimes due to ulcer, sometimes to impend- 
ing perforation, less often to visceral crises and pancreatic affections. 
Most commonly the epigastric pains are due to disturbances referred 
from other regions, notably the gall bladder, kidney, and appendix. 
Cardiac disease and the associated visceral congestions and tabes 
mesenterica must not be forgotten. 

CASE 1. — A retired farmer aged sixty-eight came to the hospital 
because of digestive disturbance and loss of weight. 

History. — Since three months he has suffered from loss of appetite 
and epigastric distress and distention. This distress was not par- 
ticularly influenced by the small amount of food he was able to take. 
He had lost some twenty or thirty pounds. He had never had marked 
epigastric pain but for some years had been subject to brief spells 
of loss of appetite. So far as he knows he has never had chills 
or fever. Three months ago he became jaundiced. This jaundice 
has gradually increased. 

Examination. — The patient is sallow, the abdomen is flat but there 
is epigastric tympany. The muscles in the upper abdomen are 
tense and pressure produces discomfort, but no actual pain. The 
discomfort is not located at any definite point. There was no op- 
portunity to make a gastric analysis. The urine contains much bile 
and the stool is clay colored. 

613 



614 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The loss of weight with gastric disturbance in an old 
man suggests carcinoma in the absence of definite symptoms. This 
is particularly true when the onset is sudden and the decline rapid. 
The gradually progressive jaundice suggests an involvement of 
the pancreas and with it the common duct, either primarily or sec- 
ondarily. The history seems to leave but little doubt as to malig- 
nancy, but the patient does not seem as feeble as the historj^ of the 
case would seem to indicate ; therefore, an exploration may be 
suggested. 

Treatment. — Under local anesthesia a gall bladder the size of a 
finger with very thick walls was discovered. The common duct was 
thick but no stones could be felt, neither were any enlarged glands 
to be found. There must be a stone in the duct, however. A drain 
was kept in the gall bladder for four months. 

After-course. — He began to improve rapidly and soon regained his 
weight. Now ten years later he is still in fair health but he has a 
slight recurrence of his former trouble. These attacks come on with- 
out known cause. 

Comment. — The course precludes the existence of carcinoma and a 
definite answer as to the cause remains obscure. The other most ob- 
vious cause is a cholecystitis with or without stones. The previous 
slight attacks and the subsequent mild disturbance strengthens this 
belief. Why such relief should have come from simple drainage is 
a mystery not yet solved. The most reasonable explanation is that 
there was a duct stone and that it escaped into the gut. 

CASE 2. — A farmer ag-ed fifty-six came because of stomach 
trouble and loss of weight. 

History. — He has always lead a vigorous business life and had 
enjoyed good health until the beginning of his present trouble. Last 
September he began to suffer general abdominal distress, loss of 
appetite and loss of weight. There were with it long periods of 
insomnia. He has a report from a stomach specialist who diagnoses 
carcinoma and advises operation. Aside from a reduced acid con- 
tent the report does not look impressive. The patient regards this 
report as final and expresses a desire to go to the hospital at once 
"and have it out." 

Examination. — Examination shows a supple skin, the tongue is clean 
and the abdomen is nowhere sensitive or rigid. It presents merely 
the emptiness of fasting. The patient seems extremely nervous, but 
not depressed or irritable. 



SEVERE INTERMITTENT PAIN 615 

Diagnosis. — The physical signs were not those of carcinoma. I 
learned on further questioning that his wife had died three months 
before and that his disability dated from that time. It is not unusual 
to find nutritional disturbance and actual digestive disorders follow- 
ing emotional disturbances. This may result in total anacidity. These 
cases are unattended by pain and they are sleepless from nervousness, 
while a carcinomatous patient loses sleep only because of pain. It may 
be put down as a general rule that if a patient loses sleep because of 
apprehension he does not have what he thinks he has. If a patient who 
thinks he has cancer does not sleep, it is important to know why he 
does not sleep. If because of pain, cancer is indicated, if because of 
"nervousness" he likely has not cancer. Even the neurotic may 
complain of pain, but he locates it in the cardiac or sternal region 
and it is likely to be most marked in the fore part of the night, while 
the organic disease causes most trouble in the after part of the 
night. 

Treatment. — I directed his son to take the patient to a hotel and 
order a porterhouse steak for him, to take him to see the sights each 
day and repeat the porterhouse steak. He was given potassium bro- 
mide 20 grains four times a day. He was ordered to return in five 
days. At the end of this time and as soon as he hove in sight he 
exclaimed "Set some high furniture in the room and watch me step 
over it." The treatment was continued. 

After-course. — The patient rapidly regained his weight and has re- 
mained well now many years. 

Comment. — Young specialists who have seen much of chemistry 
and little of human nature are apt to get the surgeon into an em- 
barrassing position. It is particularly true in complaints of the 
stomach. Laboratory diagnosis in gastric complaints is of less im- 
portance than a carefully obtained history. 

CASE 3. — A merchant aged fifty-two came because of pain in the 
stomach. 

History. — The patient's father died of a tumor of the stomach and 
a brother has been operated on for gastric ulcer. The patient had 
malaria at intervals from the age of one j-ear to eleven years while 
living in southern Illinois. Typhoid at fourteen and twenty-three. 
Last attack was followed by severe night sweats for several months. 
About twenty years ago he had some stomach trouble which lasted 
about five years. He had a continual severe soreness in the stomach 



616 CLINICAL SURGERY BY CASE HISTORIES 

which was not aggravated by meals. He took medicine given him 
by doctors and from this time up to four or five years ago he was 
very well. He was in a motor car accident eight j^ears ago and 
suffered what he says was a dislocation of the cervical vertebrae. 
This was reduced. He has been troubled with hemorrhoids as long 
as he can remember. For the last four or five years he has noticed 
a fullness in the stomach after eating even a small amount of food. 
There was no real pain. Last September 4th, at one o 'clock p. m. 
immediately after a meal he was seized with severe pain in the 
stomach, which was not relieved even by hypodermic of morphine. 
Since that time he has had pain after eating solid food. He has 
vomited but once after eating, and the vomitus consisted of rice 
and milk with no sign of blood or discoloration. He says the stom- 
ach fills with gas after each meal and pain begins in from 30 to 60 
minutes after, but his greatest pain is at night. His bowels have 
been irregular, tending to constipation, but there has been diarrhea 
at intervals recently. His appetite is poor. No tarry stools. He 
has lost sixteen pounds in weight during the past three months. 

Examination. — The patient looks thin and depressed and all move- 
ments show a bodily weariness. The abdomen is flat, retracted, rigid 
in its upper portion and there is sensitiveness in the epigastric region 
and to the right of it. The x-ray shows a normal motility and 
emptying time. The gastric analysis shows an absence of free 
hydrochloric acid and a trace of lactic acid. The benzadine reaction 
is positive for blood, and microscopic examination shows many red 
cells and many yeast cells. The feces are positive to the benzadine 
and Meyers tests. The blood examination showed a general anemia. 
The urine was without interest. 

Diagnosis. — The general appearance of the patient suggests car- 
cinoma. His statement that at one o'clock on September 4th he 
had a severe pain, looks like an impending perforation. His symp- 
toms have increased markedly in severity since that time. If a 
partial rupture occurred, his marked trouble now may be due to 
perigastric adhesions resulting from it. The pain comes on in one- 
half to one hour which suggests ulcer. If there is malignancy, it 
must have become implanted on an ulcer. Because of the uncertain 
diagnosis an exploration seems warranted for if it is cancer, there 
may be a prospect of a cure. 



SEVERE INTERMITTENT PAIN 617 

Treatment. — An indurated mass was found at the pylorus which 
was thought to be nonmalignant. The induration lay just below the 
pylorus beneath the meson and gave the impression of a perigastric 
mass. Its density was equal to that of a carcinoma, but its relation 
made it appear as a perigastric induration, probably excited by 
an impending perforation of an ulcer. A simple posterior gastroen- 
terostomy was done. 

After-course. — A few days after operation the patient started to 
vomit large quantities of bile. This continued without abatement 
and interfered with giving of nournishment to such an extent that 
the incision was reopened in order to determine whether an ob- 
struction was present. The tissues around the gastroenterostomy 
wound were found so indurated as to block this opening and per- 
haps the intestines. A drainage tube was placed in the stomach and 
gut in the hope of preventing so much absorption. The patient 
died on the tenth day. 

Comment. — Notwithstanding the mass about the pylorus the open- 
ing was patent and a gastroenterostomy was not needed. The 
indurated mass I feel certain would have disappeared with ulcer 
treatment. We knew from the x-ray that the stomach was emp- 
tying, therefore the only indication for operation was to remove a 
malignant grow^th if one were present. I forgot the evidence the 
x-ray furnished. I have a number of times encountered the post- 
operative complications here encountered. It is due to a tremendous 
thickening of all the coats of the walls of both the intestine 
and stomach. The slide in such cases shows an enormous edema 
with some cellular infiltration but the preponderant bulk is an 
edema or a fibrinous exudate. The cause of it I do not know. I 
have been able to produce an imitation of it by injecting gastric 
fluid into the gut walls of animals. It is possible that the con- 
tact of the gastric fluid with the new wound is responsible for it. 
Silk sutures seem to further it, perhaps because the permanence of 
them seems to induct the acid into the interior of the gut wall. If this 
be true, catgut would be better, for in a few days it disappears. 
This unpleasant complication evidently has not occurred to any 
one else. At least the literature is silent. The futile attempt to 
lessen the trouble by drainage was about as effective as yelling 
at a runaway horse — it but expedites what we can not control. 



618 CLINICAL SURGERY BY CASE HISTORIES 

CASE 4. — A fanner aged forty-one came because of pain in the 
epigastrium, the left side and back. 

History. — His father is well at sixty-four, the mother died of con- 
vulsions at forty-five after an illness of some years. Two brothers 
and one sister are living. One brother died in infancy. The patient 
married seventeen years ago and has two children, both in good 
health, two dead, the cause of death being diarrhea, and measles and 
pneumonia, respectively. His wife is in fairly good health ; no preg- 
nancies for nine years; no miscarriages. He denies all venereal dis- 
eases. When he was twenty years of age he fell eighteen feet from 
a tree and struck on his neck and shoulders. He retained consciousness 
but could not get up, and had to be carried home. Paralysis was com- 
plete below the neck. He could move his head and neck but not his 
arms, body or legs. In a week or two slight movements of toes and 
hands began to return. Gradual improvement followed, but he was 
in bed for four weeks. After being up a few days he learned to walk 
again, but for two months more he dragged the left foot. Later he 
was able to walk apparently as well as before the injury. There were 
some contractions of both hands, the left worse than the right at first. 
Passive motion was used all the time. The right hand was strapped 
to a board for three months to prevent contracture. Now he can 
not straighten second, third, and fourth fingers of the right hand. He 
had obstinate constipation with the paralysis and following it for 
some time. 

His present trouble began one and one-half years ago with slight 
pain in the epigastrium. There was no relation to meals and it 
was not affected by eating. This gradually grew worse. He was 
treated by his physician with little relief. The pain extended 
to the left under the ribs and to the back and somewhat to the right, 
but not so severe at this point. Pain became very severe, some- 
times occurring in attacks but very seldom leaving altogether. He 
often had to be given hypodermics for pain. He received three hy- 
podermics a week for two weeks before operation. There was 
no nausea or vomiting but some constipation. A surgeon diag- 
nosed gall bladder disease and operated on him four months ago. 
He said he found a "knuckle" on the gall bladder but no stones. 
The gall bladder was removed and the incision was closed without 
drainage. The patient was in the hospital sixteen days. After 
he went home, he felt well for five weeks; then the symptoms re- 
turned and were just the same as before the operation. Three 



SEVERE INTERMITTENT PAIN 619 

months after this while drilling in the field the patient became 
dizzy and fell unconscious from the drill he was riding. He re- 
gained consciousness in ten or fifteen minutes but felt weak and 
dizzy and went to the house. Pain soon started in the epigastrium 
and became severe. A doctor was called who gave a hypodermic 
injection. He has had these same pains, often in severe attacks, 
ever since. He is never really free from pain for long at a time. 
He gets relief from the attacks best by lying on the floor with legs 
drawn up, especially the left leg. He averages two hypodermics 
a week for pain. The attacks often last several hours. No pain 
elsewhere. No fever, no headache, and no urinary trouble. 

Examination. — Heart and lungs negative, abdomen negative. Eyes 
react to light but doubtful if they are as brisk as normal. There 
is evidence of injury to the spines of vertebras of the 7th cervical 
and 1st dorsal. Reflexes, patellar and Achilles, markedly increased 
on both sides. Deep reflexes in arms also brisk. There is contrac- 
ture of 2nd, 3rd, and 4th fingers of right hand. Wassermann, blood 
negative, spinal fluid is positive. 

Diagnosis. — The injury twenty j'cars ago left the spinal process 
of two vertebra displaced laterally. The rapid recovery of the le- 
sion indicates that the disability must have been due to a hemorrhage. 
The long free interval bespeaks perfect recovery. The pains now 
sharp and intense as they are indicate irritation of the sensory 
roots. They are tj^pically lancinating, girdle-like. The increased 
reflexes indicate a compression of the cord. The feebly positive cord 
Wassermann is an excuse for antisyphilitic treatment only because the 
pains are so typically lancinating. The x-ray of the spine showed 
nothing capable of compressing the cord. 

Treatment. — He received the regulation salvarsan treatment. 

After-course. — His symptoms responded promptly but in a year he 
returned with renewed symptoms. Further treatment caused them to 
disappear again and he has now been free from pain for three years. 

Comment. — The symptoms indicate a cord syphilis rather than 
an incipient tabes. If the symptoms were due to delayed results 
from the injury they should not have disappeared after specific 
treatment. 

Case 5. — A school boy aged seventeen came to the hospital be- 
cause of pain in the stomach. 

History. — Eight months ago he began to have pains in the stom- 
ach, especially before meals. The x-ray showed a narrowing of 



620 CLINICAL SURGERY BY CASE HISTORIES 

the outlet of the stomach he was told. A laparotomy was done by 
a young operator and a tumor of the stomach demonstrated. This 
being too big a job evidently, he allowed the tumor to remain un- 
molested and removed the appendix through a separate incision. 
The patient has grown gradually worse during the past four 
months and now is in constant pain located in the stomach region. 
He is relieved by vomiting residual food. He now has severe pain 
reaching to the left scapula. Distention has become progressively 
worse. He has lost 20 pounds in weight. For the past four days 
emesis has failed to secure results and distention has increased. 

Examination. — The tongue is white and serrated. The abdomen 
is greatly distended but not sensitive. Despite the distention, there 
is a palpable mass in the epigastrium. X-ray examination showed 
an hour-glass stomach with pyloric obstruction. W.b.c. 7,700. R.b.c. 
5,500,000. 

Diagnosis. — The epigastric pain worse before meals and relieved 
by food suggests a hyperacidity. The reference of the pain to the 
back and the x-ray findings showing a narrowing of the outlet, suggest 
an ulcer. The mass palpable probably is an indurated area about an 
ulcer without abscess formation since there is no leucocytosis or fever. 
The marked distention must be due to involvement of the surround- 
ing guts by this mass. The immediate requirement is relief from 
the marked distention. 

Treatment. — A midline incision was made. An irregular mass the 
size of a small fist occupied the greater curvature of the stomach 
and mesocolon and involved the transverse colon as well. The 
colon w-as completely occluded. The mass was adherent to the 
duodenum but there were no glands palpable. The distention of the 
small intestines and the proximal end of the colon was enormous. 
Because of the age of the patient a diagnosis of carcinoma was made 
with reluctance. There was a small subperitoneal nodule, oblong 
in shape, on the surface of the stomach at some distance from the 
mass. This was believed to be carcinomatous and it was excised for 
examination. The mass being inoperable, an artificial anus Avas 
made in the cecum. 

Pathology. — The nodule removed showed typical carcinoma. 

After-course. — There was relief from the abdominal distention, but 
the general condition did not improve. The advice of another sur- 
geon was sought who because of the age of the patient denied the 



SEVERE INTERMITTENT PAIN 621 

possibility of malignancy. He did a relaparotomy which was fol- 
lowed by a constant oozing until the patient died two days after 
operation. 

Comment. — The symptoms in this case were intermittent and were 
relieved by eating. Subsequently they became constant and loss of 
weight began. This is typical for the implantation of carcinoma on 
an nicer. At operation the history and character of the mass in- 
clined me to a diagnosis of infiltrative perigastritis from ulcer until 
the small subperitoneal nodule above mentioned was sighted. When 
in doubt of the nature of a lesion, it is of importance to search for 
such nodules. Their gross appearance is characteristic. They are 
subperitoneal, oblong, flat. They differ from tubercles in being flat- 
ter and less rounded. They have the appearance of being lymph 
borne. 

HEPATIC 

The common cause of pain in the hepatic region is, of course, gall 
bladder disease, usually stone or inflammations, generally both. Not 
infrequently there are typical attacks without stone and but minimal 
anatomic changes. These may recur even after the gall bladder has 
been removed. Pain in the hepatic region may be due to diaphrag- 
matic pleurisy and to sudden loss of cardiac compensation. Kid- 
ney crises may be referred to this region and an appendix lying high 
up may simulate hepatic colic and cholecystitis. 

CASE 1. — A fanner aged sixty-two came to the hospital because 
of pain in the abdomen. 

History. — Five months ago his trouble began with a sudden pain 
in the right side. There has been constant pain since. Now the 
pain radiates upward in the region of the right nipple, to the back 
and to the left side under the short ribs. There has never been any 
jaundice. His appetite became poor at the onset of the pain and he 
has lost 40 pounds in four months. 

Examination. — The patient is a large, portly man bearing evidence 
that he has been a powerful man. There is evident emaciation, the 
trouser band is half a foot too large: mute evidence of loss of weight 
during the lifetime of the trouserfe in spite of the still generous ab- 
domen. There is deep tenderness over the upper end of the right 
rectus, and there is well-marked muscle rigidity. There are 12,000 
leucocytes. The temperature and pulse are not disturbed. 



622 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The sudden onset, the peculiar radiation of the pain, 
the marked local tenderness and muscular rigidity make it seem 
likely that there is a gall bladder infection. The loss of weight 
is unusual and the radiation of the pain to the left costal margin 
makes one suspicious of carcinoma. The sudden severe pain speaks 
for gallstones. The leucocytosis might be produced either by an 
infected gall bladder or a carcinoma. Since relief would be likely 
if the gall bladder be at fault, operation seems Avarranted. 

Treatment. — Exploratory operation was undertaken. A hard nodu- 
lar mass as large as an apple occupied the pyloric region and the 
lesser curvature. There was a packet of glands above the stomach 
and one below in the region of the head of the pancreas. The gall 
bladder was free. 

After-course. — The progress downward, apparently accelerated by 
the confinement in bed, was rapid, and he died in three months. 

Comment. — I have repeatedly had patients with gastric cancer 
name the day on which their symptoms began. What accident 
to the tumor marks the advent of these phenomena is not known. 
Surely the tumor must have attained a considerable size before 
these symptoms appear, for I have operated on patients within 
a month after such sudden onset and found large tumors. It is 
my opinion that the onset is caused by a breaking down of masses 
of tumor tissue, perhaps attended by more or less loss of blood. 
Whether or not such ulcerative processes expose nerves to irrita- 
tion is not known, but it is the ulcerous carcinomas that are 
attended by such sudden advent of symptoms. What caused the 
acute pain in this case was not apparent unless there was a hemor- 
rhage in some part of the tumor. 

CASE 2. — A fanner aged twenty-nine came for consultation be- 
cause of epigastric pain. 

History. — Ten days ago the patient had severe pain in the upper 
part of the abdomen and was unconscious for a time. There was no 
vomiting or fever. The severe pain left rather suddenly but there 
has been some soreness since then. Since that attack the appetite 
has been good. For several years he has had epigastric pains but 
he does not know whether it is worse after eating. He has had 
spells similar to the above before, but not so severe and not at- 
tended by loss of consciousness. Bowel movements usually are 
regular, sometimes he has diarrhea, and sometimes he is consti- 



SEVERE INTERMITTENT PAIN 623 

pated. Following the above attacks, he was better for a year, but 
has now been sick all summer. He feels pressure in the epigastrium 
which extends to the back in the midline. Sometimes the pains 
are more severe in the back than in front. Sometimes when the 
pains are very severe he is relieved by vomiting. He thinks the 
pain comes on soon after eating, 

Feb. 20, 1916 : The patient has had severe pains chieiiy in the 
epigastrium, but the chief point of tenderness is along the right 
costal border. 

Feb. 26, 1916 : One attack this week lasting the whole afternoon. 
No vomiting, appetite not so good. Half hour after meals the pains 
begin with lesser pain at night. 

April 1, 1916: He had severe pain yesterday, lasting all day and 
most of the night. He thinks he was yellow after the pain. The 
pains now extend through to the back and sometimes they are 
worse in the back than in the region of the stomach. 

March 17, 1918: He has been fairly free from pain, but had a 
slight spell two months ago. He feels pain in the back when he 
first gets up in the morning. His pain is increased when jarred 
in a wagon. It now bears no relation to meal times. During the 
past few days he has had pain lower down in the right side and 
the tenderness has extended lower than in previous attacks. He had 
some fever but no vomiting. 

Examination. — During the previous attacks his pain has been most 
pronounced in the region of the gall-bladder. Now he has distinct 
tenderness over the right side of the right rectus and there is marked 
rigidity. There is marked deep tenderness. The urine was negative 
and the x-ray showed no stone. 

Diagnosis. — Because of the relation to the time of maximum pain 
and the distribution, he was thought to have an ulcer despite nega- 
tive laboratory findings. The severe pain with loss of consciousness 
was thought to be an impending perforation. He was treated for 
four years with antacids and diet under the impression that he had 
an ulcer. He usually improved under the treatment, but would re- 
lapse in spite of treatment. The site of the tenderness and the ra- 
diation to the right along the short ribs suggested a duodenal in- 
volvement. Later the pain in the back was located lower down 
and finally was exaggerated by being jolted over the roads. This 
suggested a kidney trouble, but the urine showed nothing and the 
x-ray was negative. His last attack was distinctly appendiceal. 



624 



CLINICAL SURGERY BY CASE HISTORIES 



Treatment. — A long indurated appendix lay lateral to the cecum and 
colon extending to beneath the gall-bladder. The stomach and duo- 
denum were explored but no sign of trouble past or present was dis- 
covered. The base of the appendix was friable and an area of the 
cecum the size of a quarter had to be inverted because of the fria- 
bility of the tissue in the immediate vicinity of the appendix stump. 
The appendix was adherent to the lateral wall of the colon. The 




Fig. 306. — Appendix after it had been shelled out of the muscle coat. The clubbed 
extremity represents the tip with its indurated walls covered with a plastic exudate. 



curved tip was much indurated. The remainder was shelled from the 
muscular coat (Fig. 306). Closure without drainage. 

Pathology. — The appendix shows extensive recent induration and 
connective tissue proliferation of an earlier inflammation. The ter- 
minal three centimeters were much thickened by a partly organized 
exudate. 



SEVERE INTERMITTENT PAIN ^ 625 

After-course. — He had a temperature of 101° the day following the 
operation and it remained near this level for a week and then per- 
manently subsided with the drainage of a subcutaneous abscess. He 
was troubled with gas pains during the first few days following the 
operation. These were treated with starvation, stupes and a colon 
tube. After a few days he was given magnesia and bismuth. 

Comment. — From the appearance of the specimen I am disposed 
to think there must have been a perforation at the very tip when 
he had his severe attack of pain four years ago. In those cases in 
Avhich epigastric pains precede a frank appendix attack there has 
always been a chronic duration. The reason for these symptoms 
I believe is that there is a low grade proliferative process inside 
the peritoneum. This process keeps the nerves of the appendix 
more or less in a state of irritation with the consequent disturb- 
ance in the stomach. "When finally the infection reaches the surface of 
the appendix and a periappendicitis is produced, the typical ap- 
pendicitis symptoms result. I believe one should diagnosticate these 
cases early when the pains radiate around the short ribs when the 
other signs point to ulcer. In a young male gallstones are un- 
likeh'. Closer questioning in his native tongue indicates that what 
he meant by stating that he became unconscious was that he felt 
weak as though he w^ould collapse. 

CASE 3. — A farmer's wife aged forty-one came to the hospital 
because of pain in the right side. 

History.— Her present trouble began a year ago with pain in the 
right side. The attacks began with a severe pain under the short 
ribs just below the right breast. They are very severe, requiring 
hypodermics for their relief. They cause nausea but she has vom- 
ited only once. The pain passes around the right border of the 
ribs margin and extends to the right shoulder blade. This severe 
pain lasts from one to one and one-half hours and is followed by 
a great tenderness under the right side under the short ribs. Some- 
times the pain starts in the pit of the stomach. The attacks came 
on three weeks apart at first but kept coming closer together until now 
they come every few days and there is a constant tenderness. She 
has had fever up to 100° several times during these attacks. She 
was jaundiced once when she had had no pain of any kind for some 
weeks. She is troubled with gas a great deal since the beginning 
of these pains and bloats after every attack. The appetite is not 



G26 CLINICAL SURGERY BY CASE HISTORIES 

good but the bowels are regular. She gets up once a night to 
urinate. There is much sediment in the urine. She has no pain 
on urination except at intervals when she has some burning. Her 
Aveight remains about stationary. The menses have been irregular 
for a year, coming on at three-, seven- and nine-week intervals. 
There is always a good deal of cramping. She used ta have very 
severe occipital and parietal headaches. They were very severe 
up to the last few months when they have subsided somewhat. She 
has two children living and well, the youngest seven years of age. 
She has always been well, Avith the exception of the severe head- 
aches at the menstrual periods which began soon after puberty. 
They are very severe over the right eye and over the top head. 
She is often nauseated at these times. Her mother had severe 
headaches which disappeared when she passed the menopause. She 
passed some small stones from the bladder eight years ago. The 
description of the attacks and of the materials passed is unsatisfac- 
tory. 

Examination. — The patient is of the adipose type. The skin is 
clear, without jaundice. There is tenderness to pressure over the gall 
bladder region and along the right subcostal margin, as well as over 
the appendix and right and left iliac regions. It is difficult to de- 
termine the relative intensity of superficial and deep palpation, though 
there seems to be a definite deep tenderness over the gall bladder 
region particularly in deep inspiration. The perineum is lacerated 
to the second degree. The cervix has a deep stellate laceration with- 
out erosion. The fundus is in position and is somewhat enlarged. 

Diagnosis. — The patient has been treated for her headaches with 
cannabis indica in the out-patient department, for several years, 
without any very definite results. The impression was gained that 
they are migrainous in character, a supposition corroborated by the 
fact that her mother had similar headaches. The patient is very 
stout and the dysmenorrhea suggests a premature ovarian atrophy. 
The physical findings seem insufficient to account for them because 
of the absence of erosions, the usual accompaniment when uterine 
disturbances are responsible for headaches. The attacks of subcostal 
pain of sufficient degree to require morphine for their relief, extend- 
ing to the right subscapular region attended by a slight rise in tem- 
perature and followed by definite subcostal soreness seemed to in- 
criminate the gall bladder. The intermittent character suggested 



SEVERE INTERMITTENT PAIN 627 

stone rather than simple inflammation. The fact that there is a his- 
tory of having passed gravel causes one to hesitate before making 
this diagnosis, though the urine and x-ray examination do not sug- 
gest stone. The stoutness of the patient makes the x-ray examination 
less certain than is ordinarily the case. Ureteral catheterization was 
considered, but the clinical history did not seem to warrant this ad- 
ditional traumatism. Because of the increasing suffering of the pa- 
tient, a diagnosis of gallstones was made to serve as a basis of treat- 
ment. 

Treatment. — The gall bladder seemed normal inside and out, but 
it was drained and the appendix was removed. The appendix seemed 
normal but it was attached laterally to the cecum in a way to sug- 
gest a past inflammation. The common duct seemed normal in size 
and pliability and could be palpated throughout its extent. The 
pylorus of the stomach was examined and was found normal. 

After-course. — The patient made an entirely normal recovery. She 
suffered from no pain after the first few days. The drainage had al- 
ways the appearance of normal bile. Since dismissal from the hospi- 
tal she has remained free from pain, but the headaches and menstrual 
disorders continue as before. 

Comment. — The type of patient, the history of the attacks and 
the phj'sical findings seemed typical of gallstones, j^et exploration 
failed to show anything abnormal. The removal of the appendix 
and the drainage of the gall bladder were done in the hope that 
changes too minute to admit of gross detection might have taken 
place. Possibly the appendix had something to do with the attacks. 
A stone in the kidney or other renal disease may have been a cause, 
though the presence of jaundice at one time hardly fits in with an 
uncomplicated renal disease. The attack of jaundice at a time when 
the patient was having pain might have been accepted as a sufficient 
cause for exploring the common duct, but the actual presence of 
jaundice was not sufficiently established to warrant this hazard, par- 
ticularly since the anesthetist was relatively new at his work. On 
the whole this ease must be marked up as unfinished business. 

CASE 4. — Attacks of pain in the right side brought this man of 
sixty-three to the hospital. 

History. — He has been troubled for two years with periodic at- 
tacks of pain which start under the right short ribs and is also 
felt in the epigastrium. He has vomited only three times with the 



628 CLINICAL SURGERY BY CASE HISTORIES 

attacks. He has not had any fever of which he knows. At first 
the attacks were every few months but they are getting closer to- 
gether until the last few weeks he has had them every few days. 
During the last few weeks he has had a constant tenderness under 
the right costal margin. His attacks usually last about an hour and 
then gradually wear off. His worst attack was in Colorado a year 
ago. It lasted two hours and he vomited continually. Opiates were 
given twice, but they did not stop the pain. He became deeply 
jaundiced after this attack and the urine was highly colored. He 
did not notice the character of the stools. This was the only time 
he noticed a jaundice. He has had no stomach symptoms in the 
interval between attacks. He is always constipated. There is no 
urinary disturbance. 

Examination. — The patient is a portly, thick-necked individual. 
His blood pressure is 140-90. He is pale and anemic looking. The 
blood picture is that of a mild general anemia. Head, neck, heart, 
and lungs negative. The abdomen is very sensitive to pressure 
along right margin of the ribs and epigastrium. No mass is felt. 

Diagnosis. — The history is typical of gall bladder colic with a 
cholecystitis during the last few Aveeks. The fact that he had no 
disturbance between the attacks suggests that there was no cho- 
lecystitis during the earlier period of his disease. This may be 
of importance in deciding the type of operation to be performed. 

Treatment. — The gall bladder was found to show much evidence of 
acute inflammation. The omentum was attached all over the gall 
bladder. It was filled with grass green fluid and many flocculi. It 
contained one large stone the size of a hickory nut down at the cystic 
duct and many smaller ones above it. These were removed and a 
large rubber drain inserted in the gall bladder. Because of his gen- 
eral appearance it seemed best to play safe and do a simple drain- 
age. 

After-course. — For about ten days after operation the drainage 
from the gall bladder was a dark blackish green. This gradually 
changed after ten days to a normal yellowish-green color. The post- 
operative course was normal. The wound healed by primary union 
with the exception of the drainage opening. His temperature never 
went over 100.5° or pulse over 90. The drainage was maintained 
three weeks because of the pronounced inflammation. A week after 
he returned home he had an acute pain similar to his former at- 



SEVERE INTERMITTENT PAIN 



629 



tacks. His family phj^sician called another surgeon who reestab- 
lished drainage, and a month later removed the gall bladder. 

Comment. — Obviously the duct was not yet patent and the gall 
bladder filled up and caused pain. I hoped I had circumvented 
just this thing by maintaining drainage three weeks. This evi- 
dently was not adequate. Had I removed the gall bladder I might 
have avoided the unpleasant sequence. I do not like to remove 
inflamed gall bladders from portly old men whose antecedents I 
do not know. 

CASE 5. — A matron of forty-one came to the hospital because of 
pain in the pit of the stomach and back. 

History. — For several years she has had periodic pain in the pit 




Fig. 307. — Strawberry gall bladder. 

of the stomach and back. There is soreness and indigestion between 
the attacks. Solid food disagrees, but the attacks are not related 



630 CLINICAL SURGERY BY CASE HISTORIES 

to the meals. The attacks come on without warning and last an 
hour or so. She has to go to bed and has had to have hypoder- 
mics on several occasions for the relief of pain. She feels tired and 
worn out, and there is a constant aching under the right shoulder 
blade. Dieting used to help but it does not now. She now has 
a constant fullness and queer feeling high in the epigastrium. She 
has had six severe attacks during the past year, one a month ago and 
one five days ago. She now has a marked soreness under the short 
ribs on the right side. She has no fever with her attacks and is 
never jaundiced. She has never had rugged health. She has one 
child seventeen years old and has had no miscarriages. She had 
dysmenorrhea before pregnancy. 

Examination. — There is marked tenderness over the hepatic re- 
gion which is increased on deep respiration. Other examinations 
are negative save a pronounced laceration of the cervix. 

Diagnosis. — This is a classic history of gallstones, well told. With 
such a history stones are rarely wanting. 

Treatment. — The gall bladder was thickened, moderately distended, 
and contains many small stones. Therefore, the gall bladder was 
removed. 

Pathology. — Many of the gallstones were friable, others very small. 
The gall bladder itself was studded with fine elevations, giving a 
perfect imitation of a strawberry (Fig. 307). The slide shows the 
glands prominent and pronounced about the vessel walls and in the 
submucosa. 

After-course. — She was troubled with cystitis for somfe months fol- 
lowing operation. She was given potassium citrate for this and 
gradually improved. Otherwise she was well. 

Comment. — This case is remarkable because it is so typical ; scarcely 
anything is lacking. 

CASE 6. — A matron of thirty-five came to the hospital because 
of pain in the upper part of the abdomen. 

History. — Her present trouble started five years ago during the 
first pregnancy. She had a sharp pain under the right costal margin 
which was not colicky in character and did not double her up and 
was not followed by jaundice, but she did have pain which extended 
straight through to the back at that time. It lasted for about 
six weeks and disappeared before the termination of pregnancy. 



SEVERE INTERMITTENT PAIN 631 

She had no pain then for two years. Then pains began again in the 
epigastrium which she describes as grinding. They would last 
for several weeks and then she would be free for from four to eight 
weeks. Since last April 1 the pain has been almost constant. In the 
epigastrium and under the right costal margin the pain is not con- 
stant, but under the inner margin of the right scapula it is, and it 
gets w^orse towards evening. It is more a feeling of soreness than 
real pain. She says that breakfast seems to relieve the pain in the 
epigastrium, but that following a hearty meal the pain and gaseous 
distention is much worse. She never vomits, and has no acid eruc- 
tations, the appetite is good, bowels are regular, weight remains 
constant. The patient had measles in childhood and tonsillitis one 
year ago. She has been subject to severe headaches as long as she 
can remember. When between sixteen and seventeen years of age, 
she had a spell of unconsciousness which she said lasted three 
days. The right arm and leg were partially paralyzed when she 
regained consciousness, but she quickly recovered. • 

Examination. — The patient is extremely nervous, complaining of 
pain wherever touched, but soon settles down when pressure is main- 
tained. The site of spontaneous pain is not more sensitive to pressure 
than other parts of the abdomen. The uterus is in position, no spe- 
cial tenderness. She has large hemorrhoids which bleed on examina- 
tion. The urine is negative, the Hg. is 80 points, an Ewald meal 
gives total acidity 42 points, free HCl 13 points, and combined 
29 points, and no blood. The nervous system shows no changes. 
The pharyngeal reflexes are absent. 

Diagnosis. — The patient does not tell her story consistently and the 
tale told various members of the staff does not tally. She probably 
has had a nervous hyperacidity, possibly ulcer. The type of pain is not 
that characteristic of gall bladder disease. The fact that it came 
on during pregnancy suggests this possibility, however. She is ex- 
tremely nervous, in fact typically neurasthenic. The paralysis she 
describes as having occurred during her seventeenth year was un- 
doubtedly hysterical. The only lesion capable of objective demonstra- 
tion was the hemorrhoids. 

Treatment. — -Inasmuch as the hemorrhoids demanded treatment, 
the removal of these was done in order that we might retain the pa- 
tient for further observation. 



632 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — She improved considerably during her stay in the 
hospital, but after she returned home she was soon as bad as before. 
Another surgeon explored the gall bladder a few months later but 
found nothing. Her condition remains unchanged. 

Comment. — It is difficult to determine to what extent such nervous 
conditions are based on organic lesions, particularly of the genital 
tract, and how much on functional nervous conditions. Even when 
there is some obvious lesion of the genital tract its correction must 
be undertaken with much circumspection in neurotic persons, lest 
the operation be made the object of renewed nervous manifestation 
and the activities of the surgeon be made the subject of unfavorable 
comment. This is particularly true of patients who are not able to 
repeat their story, when the history is taken by different doctors at 
different times. In such cases it is often advantageous to have the 
history retaken by one who knows nothing of the patient or of the 
previous history. They sometimes dilate on their story to an il- 
luminating degree when they believe they have a credulous examiner. 

CASE 7. — A farmer aged fifty-one came because of abdominal 
pain. 

History. — His general health was good until a year ago. Since 
then he has had much headache but no severe illness. The pain in 
the head has always been worse on the right side. Hemorrhoids 
operated on fifteen years ago and again two years ago by a rectal 
specialist. He had pleurisy twelve years ago. No chronic cough 
or pleurisy recently. His chief complaint now is a burning in the 
stomach and at times a bloating. No vomiting. At intervals 
there is a distinct pain in the region of the gall bladder which 
radiates to the back, which his physician describes as being typical 
of biliary colics. The patient describes the pains as continuous, 
dragging, and gnawing. He has never had a hypodermic for his 
pain. While describing his stomach symptoms he complains of pain 
in the right leg, in the tibia and also in the hip. Pain in the hip 
is not increased by walking; burning in right foot and leg. Pain 
in shoulders, pains would frequently shift from one place to another. 
These pains often make him nervous and irritable. He adds also that 
he has had domestic trouble twelve years. 

Diagnosis. — On the assurance of his physician, the diagnosis of 
gall-bladder trouble was accepted. While he describes a fairly typical 



SEVERE INTERMITTENT PAIN 633 

attack of gall bladder colic he at once augments his account by ir- 
relevant symptoms. 

Treatment. — Nothing was found in the abdomen, but the gall blad- 
der was drained. 

After-course.— The patient was not influenced in any way. He 
declared himself cured but at once started to relate a long train of 
symptoms. Curiously enough he is satisfied that the operation was 
of great benefit to him. He becomes progressively more neurasthenic. 

Comment. — I should have known better than to operate on this pa- 
tient. While describing his supposed gall bladder symptoms he 
switched at once to vague scattered pains. If a patient has actually 
had gall bladder colic he keeps his mind on the subject and does not 
allow it to wander after minor symptoms. His volunteering the 
fact that he had had domestic trouble for many years should have 
deterred me. Digestive troubles may be both the cause and result of 
domestic infelicity, but the condition is not remediable by surgical 
means, at least not by drainage of the gall bladder. 

CASE 8. — A housewife of thirty-three came to the hospital be- 
cause of attacks of pain in the abdomen and in the bladder. 

History. — Her trouble began four years ago with pain over the hip 
bone extending to the bladder. There was bloody urine for a few 
days following the attack and during the height of the pain she 
was unable to empty the bladder at all. There has been no recur- 
rence of these attacks. She now has pain low in the back and there 
is a constant feeling of heaviness and some soreness under the 
right costal margin. She has had sudden severe attacks of cramping 
pain beginning along the right costal margin and extending across 
the abdomen to the left side. They often come on as frequently 
as one or two a week and sometimes remain away a month. Of 
late they are becoming more severe and require morphine to stop 
them. During this time she is nauseated but does not vomit. Stom- 
ach symptoms betAveen attacks are mainly those of bloating and 
heaviness, if certain foods like cabbage are taken. Appetite is 
fair, bowels regular most of the time. She has had five children, 
the youngest two years of age. She has had no miscarriages. Men- 
struation started at twelve years of age, is regular, and lasts three 
days. The thighs and legs ache at the beginning of the flow but 
no great degree of pain. No discharge betw^een periods. When the 



634 CLINICAL SURGERY BY CASE HISTORIES 

pains in the side come near the menstrual time the flow begins a 
few days early. 

Examination. — The patient has marked tenderness over the gall 
bladder, the uterus is retroverted so that the cervix impinges on the 
bladder. There is a second degree perineal laceration. 

Diagnosis. — The beginning of this patient's complaints sound very 
much like a renal colic, but no trace of stone can be found and the 
urine was normal. 

Treatment. — A number of gallstones were removed and the gall 
bladder was drained. The perineum also was repaired and a sus- 
pension of the uterus was done. 

After-course. — Recovery was uneventful. 

Comment. — I have several times been led to make a provisional 
diagnosis of renal colic when pain radiating to the bladder with 
blood in the urine was present, only to fail to demonstrate a renal 
disease and to be confronted later by typical gallstone attacks. 
The relation is not clear. The disposition of the advent of the 
menstrual flow to be expected when the gall bladder colic comes 
near the time for the flow is of interest. Gall bladder colics are 
prone to come at the conclusion of labor. This association in this 
case seemed to warrant a correction of the pelvic topography 
though there were no other symptoms to urge it. 

CASE 9. — A school girl of seventeen came to the hospital because 
of abdominal cramps. 

History. — Her general health has always been good. She has not 
had typhoid, but had severe tonsillitis at 11 years of age, which ended 
in a discharging right ear. One year and a half ago she had a sudden 
severe pain in the epigastrium, lasting one hour. When the pain in 
the epigastrium was most severe, she vomited and was somewhat re- 
lieved. She had another attack six months later which lasted two 
hours. After the attack she had a little pain accompanied by local 
tenderness in the region of the gall bladder. Another attack two 
months later ended in a series of light attacks which lasted for two 
or three months. In the intervals she felt sick at times and frequently 
had gas on the stomach. At this time she had a severe attack with 
vomiting which lasted 18 hours. There was some jaundice. She 
had another severe attack in the latter part of July, one week before 
entering the hospital. This attack also started with gas on the stom- 
ach and pain in the region of the gall bladder, but this time the pain 
radiated toward the back under the right shoulder blade. 



SEVERE INTERMITTENT PAIN 635 

Examination. — The examination is negative except for deep ten- 
derness over the gall bladder, most marked at the height of inspira- 
tion. 

Diagnosis. — As the attacks recurred, they became more typical of 
gall bladder disease. The age of the patient and the relief from 
vomiting suggested ulcer. The jaundice was not incompatible with 
this theory. The deep tenderness was most pronounced over the gall 
bladder and the direction of radiation spoke strongly for gallstones, 
hence this opinion was rendered. 

Treatment. — Cholecj'stectomy with drainage was done. The gall 
bladder contained four stones. 

After-course. — The recovery was uneventful and she has remained 
well. 

Comment. — Probably in more cases than we suspect the gallstones 
are present early in life. Many patients who present gallstones in 
later life have epigastric pains early in life and many of them have 
distinct histories of septic infection. 

CASE 10. — A matron of sixty came because of cramping pains 
in the upper abdomen with jaundice. 

History.- — The patient's illness began fifteen years ago when she 
first noticed a heaviness in the stomach after eating and a great 
accumulation of gas in the stomach and bowels. Two or three 
times each year she has had severe attacks of cramping pain in the 
pit of the stomach and along the rib border which doubled her 
up. These were ahvays followed by jaundice. Two weeks ago she 
had one of these attacks and is now extremely jaundiced. She 
has had much tenderness over the gall bladder most of the time 
during the last year. She has been very constipated the last fif- 
teen or twenty years. She has frequency of urination, especially 
at night, and a burning in the bladder region. 

Examination. — Physical examination shows the patient deeply jaun- 
diced, the sclera deeply tinted. There is marked tenderness to pres- 
sure over the whole epigastric and right subcostal regions. The urine 
contains much bile. 

Diagnosis. — The pain preceding the appearance of jaundice many 
years, and the absence of chills suggests that the common duct obstruc- 
tion may be due to inflammation rather than stone. The tenderness in 
the hepatic triangle indicates a cholecystitis. The deep state of jaun- 
dice Avould make a duct drainage hazardous. A simple gall bladder 



636 CLINICAL SURGERY BY CASE HISTORIES 

drainage seems the operation of choice. If the jaundice is due to in- 
flammation, this may subside if the causative factors are removed. 

Treatment. — The gall bladder was drained and four stones were re- 
moved. Common duct was not examined at this time because of ex- 
tensive adhesions about it. I did not care to invite hemorrhage by 
breaking them up. Because of the intense jaundice, a simple drain- 
age was done. 

After-course. — The patient drained profusely for a month and the 
jaundice cleared up. Four months later there was still a sinus. Ex- 
ploration located a small stone in the gall bladder. After this was 
removed the sinus closed and she had no further trouble. Jaundice 
never reappeared after it once cleared up. She has remained well 
now many years. 

Comment. — The patient was advised that after the jaundice 
cleared up a second operation should be done in order to explore 
the common duct. She feels too well to submit to this. Inflamma- 
tory occlusion with jaundice which occurs with cholecystitis may 
entirely recover when the inflammation subsides. In such cases the 
jaundice comes on some times after the acute onset, occurring only 
after the gall bladder inflammation has reached some degree. When 
the jaundice is due to stone, it begins with the onset of pain and is 
intense from the start. The prompt exploration of the common duct 
in such cases as this is theoretically correct but the course here 
followed makes for a lower mortality, particularly in the hands of 
the beginner. In many cases time proves that duct exploration 
was not necessary. So it proved in this case. 

CASE 11. — A matron of forty-three came to the hospital because 
of epigastric pain. 

History. — One child, menses always painful. Well otherwise until 
four years ago when she had a cramp in right side extending toward 
the pit of the stomach and backwards to below the shoulder blade 
lasting twelve hours. After a week the attack w^as renewed. These 
attacks were repeated several times during the past four years. 
In the attack-free interval she suffered much from epigastric pain 
and gas. These pains bore no relation to mealtime and were not in- 
fluenced by the taking of food. These epigastric pains have been 
increasing in the past year. Recently these pains have been attended 
by vomiting. Vomiting at first gave some relief, but recently it 
has had no influence. There was jaundice following an attack three 
months ago and there was bile in the urine for a month. 



SEVERE INTERMITTENT PAIN 637 

Examination. — She is a plump woman presenting the general ap- 
pearance of good health. There is pain over the hepatic region on 
deep pressure which radiates toward the epigastrium. There is 
greater resistance over the right than over the left rectus muscle. 
Gastric analysis shows no blood. 

Diagnosis. — The attacks of pain were typical of gallstone colic. 
The continued epigastric disturbance, vomiting without relief, jaun- 
dice without other evidence of common duct obstruction point to 
a chronic inflammation of the gall tract likely with stone. Ulcer 
does not have such a typical radiation to the scapular region and 
vomiting should give temporary relief from pain. The absence of 
blood also favored the diagnosis of gall bladder disease. 

Treatment. — A large number of gallstones were removed. The gall 
bladder was thickened but the common duct seemed free. Drainage. 

Pathology. — The gall bladder was thickened, apparently due to 
an edema. The slide showed some round-celled infiltration but no 
changes in the glands. 

After-course. — A normal recovery from the operation followed. 
There was complete relief from the attacks of pain and from the di- 
gestive disturbance. Four years later the patient again complained 
of epigastric distress. There were no colicky pains. There was 
greater loss of appetite than in the previous trouble. Treatment 
failed to secure any relief. A cholecystitis was diagnosticated in 
spite of a beginning jaundice. The removal of the gall bladder 
seemed indicated. Before the patient could resolve to undergo 
operation there was loss of flesh and a hard nodular mass was dis- 
covered in the region of the gall bladder. A diagnosis of carcinoma 
of the gall bladder was made and operation was refused. Lan- 
cinating pains radiating to the epigastrium and back appeared. The 
mass increased in size steadily, jaundice deepened, and emaciation 
grew apace. The patient died from exhaustion five years after 
cholecystotomy. 

Comment. — There was no evidence of malignant change at the time 
of the operation. With the history of cholecystitis the gall bladder 
should have been removed. This might have prevented the occur- 
rence of the carcinoma. As a preventive against carcinoma, chole- 
cystotomy can hardl}' be recommended as a general proposition, for 
carcinoma is of rarer occurrence than the increased mortality of the 
cholecystectomy over cholecystotomy. This is true of the operation 



638 CLINICAL SURGERY BY CASE HISTORIES 

in the hands of the average operator but with the expert the preven- 
tion of malignancy is a matter worthy of consideration. 

CASE 12. — Pain in the upper abdomen brought a business man of 
fifty-two to the hospital. 

History. — Six years ago this patient was operated upon at this 
hospital for the cure of inguinal hernia and two years ago for the 
removal of his prostate. Both these operations were for typical af- 
fections of their type and the recovery was without incident. The 
present trouble has manifested itself in slight degree for several 
years. Two years ago, while he was in the mountains recuperating 
from his prostatic operation he was attacked by a severe pain in 
the right upper quadrant of his abdomen. He vomited several times 
and after the relief of pain by opiates he had to lie abed a week be- 
cause of soreness in the upper abdomen. He had had similar though 
less severe attacks some years before. He was attended by an able 
internist in a western city who diagnosed gall stones and advised 
operation. He has had several slight spells in the intervening time. 
Recently while at a summer resort he had a similar attack which 
was again diagnosed gallstones by his attendant. There has been 
no jaundice. 

Examination. — It is now three weeks after the last attack above 
noted took place. He has lost some twenty pounds in weight and 
has a considerable general anemia, having 2,800,000 reds and 75 
per cent Hg. The whites are 7,700. There is deep tenderness over 
the gall bladder region extending well outside the lateral border of 
the right rectus. No tumor can be palpated. There is deep tender- 
ness in the flank. This is aggravated by deep respiration. No pain 
is caused by pressure over the epigastrium or along the ascending 
colon. The urine contains a trace of albumin, but his blood pres- 
sure is only 145. 

Diagnosis. — The history of the attacks he had had, particularly 
the last one, seems typical of cholecystitis, especially of the type in 
which large, crumbly stones are found. There never has been 
any reason to suspect a kidney lesion during the frequent examina- 
tions that have been made in his previous sojourns in the hospital. 
There has never been any pain in the ileocecal region. It is sus- 
picious that there should be so much peritonitis in the early days of 
the attacks. The deep tenderness in the flank likewise causes one 



SEVERE INTERMITTENT PAIN 



639 



to hesitate but both these conditions may be associated with chole- 
C3'stitis if the gall bladder be large and pendulous. 

Treatment. — An incision was made along the lateral border of 
the right rectus muscle extending from the costal margin to below 
the level of the umbilicus. The gall bladder and duodenal region 
were free from any disease. Lateral to the hepatic region, reaching 




Fig 



308.^ — The appendix located lateral to the ascending colon is surrounded by indurated 
tissue in which there was a small abscess. 



quite to the liver, was an appendix as large as a finger and four inches 
long. The tissues about it were deeply infiltrated and in the greater 
part of its length it was covered by fragile adhesions. When it 
was lifted from its bed, a small abscess was found lying between it 
and the colon. (Fig. 308.) The original incision was closed com- 
pletely after a stab drain had been made in the flank. 



640 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The appendix was made up for the most part of 
edematous tissue infiltrated with round cells. 

After-course. — The wound drained for six weeks and there was 
some subcutaneous infection of the primary incision. Despite the free 
discharge of pus, the pulse and temperature did not greatly exceed 
the normal. The patient seemed to recover from the operation com- 
pletely, but within a year he began manifesting the Stokes-Adams 
syndrome and died in one of the attacks some six months after the 
appearance of the first one. 

Comment. — The tenderness more laterally than the usual seat of 
pain and the ability to cause pain by deep pressure over the kidney 
region caused me to consider the kidney as the possible source of 
the pain, but the appendix as the offending organ was not seriously 
considered. Cardiac affections as sequence to chronic infections are 
by no means rare and constitute one of the chief secondary indica- 
tions for the eradication of local foci. 

CASE 13. — A matron of forty-one came to the hospital because 
of severe pain in the upper right quadrant. 

History. — Eleven years ago, following childbirth, she had a severe 
pain in the region indicated. It was very severe and cramp-like but 
did not radiate and was not followed by soreness. After repeated at- 
tacks over a period of two years gallstones were diagnosticated and 
operation performed. No stones were found, but the gall bladder 
was filled with a black, ropy substance the operator reported. Drain- 
age was left in three weeks. She was free from pain four years. 
For the past five years she has suffered an increasingly severe at- 
tack of pain of the same character. For the past year and a half 
these pains have radiated to the right shoulder and the past sev- 
eral attacks have been followed by soreness under the ribs. Her 
health otherwise has been good. 

Examination. — The patient is well nourished and bears no evi- 
dence of the suffering she relates. There is tenderness and a sense of 
resistance in the hepatic triangle. Otherwise examination is negative. 
There is no jaundice and the urine is free from bile. 

Diagnosis. — Relief following previous drainage of the gall bladder 
indicates that this was the source of pain. The return of the pain 
may be accepted as a recrudescence of the disease. The attacks now 



SEVERE INTERMITTENT PAIN 



641 




Fig. 309. — Chronic inflammation of the gall hladder. The mucosa is thickened and 

in part defective. 




Fig. 310. — Hyperplasia of the mucosa of the gall bladder. 



radiate to the scapula and are followed by local soreness, both factors 
indicating that there now is a stone present and a pericholecystitis. 
There is no evidence of duct stone. 



642 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The gall bladder is attached to the abdominal wound, 
the result of the previous drainage. The colon is attached to the gall 
bladder, the result of a recent inflammation. The gall bladder con- 
tains a single stone the size of a walnut. The gall bladder is edem- 
atous and much thickened. It was removed. 

Pathology. — The stone is irregular and the surface scales off on 
slight pressure. The gall bladder besides the edema is corrugated 
(Fig. 309) and there is a marked proliferation of the gland suggest- 
ing malignancy at first glance (Fig. 310), but closer examination 
shows it to be a simple hypertrophy. 

After-course. — Recovery was delayed by suppuration of the wound, 
but since it has healed, the patient has been free from complaint. 

Comment. — In this case cramps and black, ropy mucus antedated 
the development of stone. True to rule when there was no stone the 
pain did not radiate and there was no local soreness, while when 
stone was present, radiation and local tenderness were both present. 
This case again shows that a gall bladder with a definite history of 
a trouble had best be removed. 

RENAL 

The classical cause of kidney crises is, of course, stone. There may 
be crises which disappear never to return again due probably to acute 
congestion. Renal colic may be referred to the epigastric region, but 
not higher, and the common direction is downward to the genital, 
organs and bladder. Spondylitis may cause pain in the loin and the 
pain may be referred to the bladder and genital organs but not to the 
glans. Pain may occur in tumor, tuberculosis and in nephritis. 

CASE 1. — A farmer aged forty-six cajne to the hospital because 
of pain in the left loin. 

History. — Twenty-five years ago he first had a sharp cutting pain 
below the short ribs on the left side. This extended downward to 
the left testicle. While this attack was on, he passed small amounts 
of urine at frequent intervals. The attack lasted several hours. 
He did not notice any blood in the urine. Following that attack 
he had similar ones at intervals of a month to a year. During the 
past year the attacks come every three or four weeks and in the 
intervals between attacks he has a dull pain beneath the ribs. This 
pain is made worse by jolting and sometimes it starts an acute at- 



SEVERE INTERMITTENT PAIN 



643 



tack. During the past year he has vomited with the acute at- 
tacks. He has much gas in the bowels during the acute stage, which 
adds to his pain. He has had some dribbling after urination, but 
no retention. 

Examination. — Save for tenderness, 4 em. to the left and 2 cm. 
above the umbilicus and in the lumbar region, examination is neg- 
ative. The prostate is somewhat enlarged but it is smooth. The 




Fig. 311. — Stones removed from the left kidney. 

X-ray shows a trilateral shadow in the region of the left kidney. A 
confirmatory plate showed an additional smaller shadow lateral to 
the main one. The urine contains no blood, but all of five examinations 
showed many crystals and two of them showed pus. Those which 
contained pus were alkaline in reaction. 

Diagnosis.— The finding of a definite shadow in both plates makes 
the diagnosis of stone in the kidney certain when taken along with 
the long and definite history. 



644 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The kidney was large and the pelvis dilated to hold 
several ounces. The large stone (Fig. 311) shown on the x-ray lay in 
the pelvis. A smaller one was embedded in one of the ealices. Many 
smaller ones were scattered throughout the kidnej'. About a dozen 
were removed. The presence of the dilated pelvis together with the 
many small stones made it appear wise to remove the kidney lest 
some of the small stones be overlooked. 

Pathology. — The kidney showed some chronic interstitial changes 
and some cloudy swelling. The character of the stones is well shown 
in the illustration. 

After-course. — Recovery was uneventful. He passed a normal 
amount of urine at once after the operation and seemed in no wise 
the worse off for the loss of his kidney. 

Comment. — This case is unusual in the number and shape of the 
stones removed. The question of a justification of the removal of a kid- 
ney for stone is a vital one. Many good surgeons have done it, but it 
has always appeared to me to be poor surgery. I feel more convinced 
of it now than ever before. 

CASE 2. — A fanner aged forty came because of pain in his left 
side. 

History. — The patient had rheumatism for two weeks two years 
ago. One sister died of pulmonary tuberculosis. Patient's pres- 
ent illness began gradually four or five years ago with pain in the 
back and left loin. This pain grew gradually worse and soon it 
was nearly constantly present. Later spells of vomiting and general 
abdominal pain began. He was constipated at these times. Three 
years ago he was operated on in one of these attacks and he was 
told a kink in the bowel was corrected. The appendix was removed, 
and umbilical rupture was repaired at the same time. After the 
operation he felt w^ell for about three months, when his old trouble 
returned. Then pain was most severe in the left lumbar region and 
in the abdomen usually two inches below and to the left of the 
navel. Sometimes the pains extended over the entire abdomen. 
The attacks of pain were often so severe that he would have to 
be carried home. The pain becomes less severe if he lies down 
and keeps quiet with external heat applied. 

Examination. — There is deep tenderness in the left renal triangle. 
The urine shows some red cells and a goodly number of white ones. 
The x-ray shows a large stone in the left kidney (Fig. 312). 



SEVERE INTERMITTENT PAIN 



645 



Diagnosis. — The x-ray makes the diagnosis. There is room for 
speculation as to the findings at the previous operation. A midline 
incision was made extending from the umbilicus to the pubes. This 
indicates that the appendix was not the original object of attack. 
An umbilical hernia was not mentioned before the operation. To say 
the least, such a hernia is unusual in a husky young male. Consider- 




Fig. 312. — Kidney stone filling the pelvis of the kidney. 



ing all these factors, it seems likely the operator was misled by the 
general abdominal pain. 

Treatment. — A left nephrolithotomy was done. 

After-course. — The wound healed in three weeks and save for 
bladder irritation which existed for some months he has been well. 
He was given five grains each of salol and boric acid for this blad- 



646 CLINICAL SURGERY BY CASE HISTORIES 

der irritation. After this he was well for two years when he 
returned with renewed symptoms. The x-raj' showed another stone. 
This was removed as before. It was exceedingly fragile and was 
much broken up in extraction. He was advised to drink only 
boiled water after this operation. He remained free from pain nine 
months when he returned with renewed pains and a stone was again 
demonstrated with the x-ray. He Avas advised to have a nephrec- 
tomy done. He hesitates to consent to this and I can not urge it. If 
he will bear the pains until he forms a firm hard stone its removal 
may be justified. 

C omment. ^The majority of patients on whom I have operated for 
kidney stone have been previously operated on for some condition 
of the gastrointestinal tract. The profession seems to be slow in 
learning that pain arising in the kidney may radiate or be trans- 
mitted to almost any region of the body, but that pain arising in some 
disease of the gastrointestinal tract can not be transmitted to the 
kidney region. Pain from kinks happily have about ceased to be heard 
from except from a few extra-credulous persons. Once a stone 
has been removed, a patient should drink only distilled water or if 
this is not available the water should at least be boiled. If there 
is one recurrence, there are apt to be more following a second 
nephrolithotomy. Obviously a nephrectomy" will stop this tendency, 
but if the patient exhibits such a stone-building capacity he is apt 
to develop one in the remaining kidney. In such an event, ob- 
viously, the surgeon is in a very embarrassing position. In my ex- 
perience, young stones, particularly those that are fractured in re- 
moval, are particularly apt to be followed by recurrence. Likely 
fragments are left which form foci for new stones. The surgeon 
does well, in my opinion, to open the kidney wide enough to per- 
mit removal of the stone without fracturing it. A kidney stone 
should never be grasped with forceps unless it be a large, hard 
one Ij'ing free in the pelvis of the kidney. A stone is never so large 
as to justify nephrectomy. A stone found in a pus pocket does not 
indicate nephrectomy but prolonged drainage. 

Case 3. — A housewife aged thirty-two came to the hospital with 
a complaint of attacks of pain in her back passing around to the 
bladder. 

History. — For eight years the patient has had a soreness in the left 
lumbar region. Up until last May, 1919, it was only a soreness. At 



SEVERE INTERMITTENT PAIN 647 

that time she had suddenly a severe pain in the lumbar region which 
passed around the ribs and radiated down to the bladder. The 
pain came in paroxysms and was severe and cutting. The attack 
was accompanied by vomiting and a constant desire to urinate. 
The urine Avas scanty but she never noticed that it was bloody. 
She had no fever. The attack lasted an hour and ceased gradually. 
Since that time she has had many similar attacks. She has never 
gone three weeks without one, and they have come as often as 
every three days. They are all exactly alike, except differing in 
severity, and some stopped suddenly while others tapered off. The 
attacks have been getting worse ever since her miscarriage four 
months ago. Her last attack was one week ago. A week ago she 
had a severe pain start in the left groin just inside the anterior su- 
perior spine of the ileum. This pain passed into the bladder. It did 
not make her vomit but nauseated her. It made her urinate fre- 
quently, but nothing like the pain on the other side did. She has 
had several attacks of this pain every day since. The attacks last 
a few hours. All her attacks have been stopped by hypodermics 
of morphine. Her appetite is good. Digestion fair. Bowels regu- 
lar. She has headache in temples and occipital region frequently. 
Xo cough. In 1914 she had an attack of pain in the right side ac- 
companied by nausea, vomiting, and temperature. A diagnosis of 
appendicitis was made. The side was sore for three to four days. 
The attack had no relation to menstrual period. A year ago she 
had influenza. Since that time her menses have been irregular. 
They were regular previous to that time. She had a miscarriage 
four months ago. Has had three children ; oldest aged eight years, is 
living; second died at two years of age of enteritis, the third 
one, born tAvo years ago, lived only four hours after birth. She has 
always had severe cramps with menses and has to go to bed. The 
pain is most severe a day before the flow and right after. The pains 
have been worse since an attack of influenza a j'ear ago. Cramps 
more severe and flow is offensive. 

Examination. — Patient is well nourished, is pale but does not look 
acutely ill. Pupils equal, regular, and react to light and accommoda- 
tion. No ptosis or nystagmus. Teeth good. Tonsils moderately 
large. Thyroid palpable. Lungs normal. Heart negative. Abdo- 
men soft, no rigiditj' or distention. Point of extreme tenderness just 
above a line running from umbilicus to anterior superior spine on 



648 CLINICAL SURGERY BY CASE HISTORIES 

right side. Much tenderness in right flank. Point of tenderness over 
left kidney both anteriorly and posteriorly. Some tenderness over 
right kidney. Perineum lacerated, second degree. Cervix bilaterally 
lacerated, thick mucopurulent discharge from cervix; fundus of 
uterus retroflexed and bound down on the left side of the pelvis. 
Tenderness on both sides of uterus. Extremely tender to left. X-ray 
examination of urinary tract negative. No shadows seen. Blood 
count, W.b.c. 11,400. Urine 1.004, negative. 

Diagnosis. — The early attacks w^ere typical of kidney colic. The 
later ones indicated a pelvic lesion. Pelvic infections may cause 
pains simulating a kidney colic but a kidney stone colic can not imi- 
tate pelvic disease. The physical findings indicate tubal infection. 
The presence of a moderate leucocytosis indicates a mildly active 
state. 

Treatment. — Double salpingectomy. Anterior fixation of the uterus. 
The uterus and tubes were bound posteriorly by plastic adhesions 
which looked recent. Tubes were filled with pus, but the fimbriated 
ends were not closed. Both ovaries were partially destroyed by the 
abscess, but a portion of each was allowed to remain. The appendix 
was not examined. 

After-course. — There was no postoperative shock, no vomiting. 
Temperature 99.6°, pulse 108 evening of first day. The following 
three days the temperature gradually rose, reaching 101° the fourth 
postoperative day, after which it gradually subsided and she felt well. 
A week after operation the lower end of the wound looked red and 
swollen, a small amount of pus was evacuated. Subsequent course 
uneventful. At the end of second week the patient passed a long 
mulberry calculus from the bladder. She had no attacks simulating 
renal crisis while in the hospital. 

Comment. — Evidently both conditions were present. After the 
acutely inflamed tubes were removed, the patient seemed relieved 
of her trouble. The passing of the ureteral stone, therefore, came 
as a complete surprise. The stone was of such a size and character 
that its presence should have show^n in the x-ray plate. 

Case 4. — A lady aged twenty-five came to the hospital because 
of pain in the left side and back. 

History. — She has a pain which appears in the back, at irregular 
intervals in the left side and extends to the back. It does not radiate 



SEVERE INTERMITTENT PAIN 649 

and is never cramp-like in character. It sometimes lasts from a day 
or two, to a week. When they last so long, it is more of a soreness 
than an acute pain. Pain has been present nearly constantly during 
the past three weeks. For the first time, a week or so ago, the 
pain radiated into the groin while she was passing urine. She 
has never noticed blood in the urine, and riding in a vehicle did 
not seem to make it Morse until just recently. Working now makes 
it worse. She thinks the side swells when the pain is most severe. 
She gets up three times during the night to urinate. She has 
passed some blood in the stool. Her father now has a kidney stone 
and a sister died from an operation for the removal of one. 

Examination. — There is marked tenderness below the twelfth rib 
behind. Pressure in front also causes pain to be felt behind. The 
urine shows much epithelium and leucocytes, but no red cells in 
any of several examinations. There is some albumin. The x-ray 
shows a shadow in the region of the kidney. Hg. 60 ; R.b.c. 3,800,000 ; 
W.b.c. 12,000. 

Diagnosis. — The shadow on the plate makes the diagnosis. The 
sense of a tumor she feels when the pains are severe suggests a 
hydronephrosis. This may account for a failure of blood to appear 
in the urine. 

Treatment .—^hQ kidney was delivered with difficulty because of 
a hydronephrosis the size of two fists. When this was opened, a small 
stone was found in the beginning of the ureter. The redundant hy- 
dronephrotic sac was resected and sutured with twenty-day chromic 
catgut. 

After-course. — The recovery proceeded uneventfully until the six- 
teenth day, when she had an elevation of temperature to 102°. Urine 
was draining from the wound. Two days later a quantity of pus 
escaped from the wound and she was at once relieved. She has been 
well since. 

Comment. — The patient's sense of tumor at the height of the pain 
was correct. The hydronephrosis was formed chiefly by a bulging of 
the anterior wall. This made resection easy, and the prospect of ul- 
timate results good. The farther the beginning of the ureter is from 
the kidney, the more difficult it is to reconstruct a pelvis that will 
empty itself. This patient's general condition was not good, and 
a nephrotomy was to be avoided at all hazards. 



650 CLINICAL SURGERY BY CASE HISTORIES 

APPENDICEAL 

The all important disease of this region is of course appendicitis. 
Other affections may occur, notably tuberculosis and tumors. 

Case 1. — A young- farmer came to the hospital because of pain 
in the lower abdomen following traumatism. 

History. — Ten days ago the patient was thrown against the horn 
of a saddle, striking the lower abdomen. Pain came on the next 
day and gradually increased for several days. Two days ago he 
lifted a calf into a wagon and the pain became worse at once. There 
has been no nausea or vomiting and no bladder trouble. The tempera- 
ture has ranged around 101 degrees since he has been under medical 
observation, now three days. Aside from gas at times, he has had 
no previous abdominal disturbance. 

Examination. — There is sensitiveness and rigidity in the region 
of the appendix. The abdomen is moderately distended, but without 
general sensitiveness. The inguinal ring admits the tip of the finger 
but there is no protrusion. The temperature is 101°, pulse 84, res- 
piration 20. 

Diagnosis. — There is evidently some acute inflammatory process 
having its seat in the ileocecal region. Were it not for the history of 
definite trauma, one would make a diagnosis of appendicitis without 
hesitation. Being thrown against a saddle horn by a bucking horse 
is no gentle manipulation and is quite capable of producing a lesion 
of a hollow viscus. He does not know just the point of impact of the 
saddle horn, being too busy at the time trying to keep in anatomic con- 
tact with the pony, to conduct any topographic anatomic studies, 
and following there was general soreness without a localized contusion. 
Pain came on the day following the injury and gradually increased 
until two days ago when he had a sudden sharp pain following 
heavy lifting. It is possible that the injury so bruised an area of 
gut wall that it necrosed and a perforation followed a week later. 
The symptoms since that time have not been severe enough, however, 
for a free perforation, but a previous adhesion may have formed. 
The physical findings do not seem to be extensive enough for such 
a condition. An appendicitis may be present either causatively re- 
lated or independent of the trauma. The uncertainties of the con- 
dition warrant exploration. The temperature precludes an uncom- 
plicated hernia, and, besides, there is nothing in the inguinal canal. 
The temperature, pain and rigidity indicate an acute process. 



SEVERE INTERMITTENT PAIN 651 

Treatment. — The appendix was removed through a right rectus in- 
cision ; the appendix was long and hung over the brim of the pelvis. 

Pathology. — The appendix was brownish black, considerably in- 
durated but without gross perforation. There was considerable exu- 
date, but there was no part which showed changes indicative of 
trauma. 

After-course. — There was some superficial infection of the wound 
but he has remained without a hernia. 

Comment. — In order that trauma shall be considered as a causative 
agent, the injury must be such that the contusion may reach the site 
of the appendix and that the symptoms shall begin within 48 hours 
after the receipt of the injury. This case seems to meet both re- 
quirements. The position of the appendix was such that it would 
have been exposed to a trauma. This question is apt to come up in 
cases in which indemnity is claimed from accident insurance. 

Case 2. — A child aged seven was brought to the hospital because 
of abdominal distention and obstipation. 

History. — Ten days ago she complained somewhat of sore throat 
but played about as usual. The two days following she complained 
of feeling bad without definite pain. Six days ago she complained 
of pain in the abdomen. At this time rubbing the painful area gave 
relief. The pain was most pronounced at the level of, and to the 
right of the navel. The physician in charge diagnosed appendicitis. 
She coughed a little but raised nothing. In the three days following, 
the abdomen became distended and laxatives produced no bowel 
movements and seemed to increase the tj'mpany. Intestinal ob- 
struction was feared and she was brought to the hospital. The child 
has always had good health never having had either bowel or lung 
diseases. 

Examination. — The patient lies in a semistupor. The abdomen 
is soft everywhere, not tympanitic, and not retracted. Deep pres- 
sure on the right side brings forth a slight protest. The respiration 
is 38, the pulse 110, and the temperature 101°. The breath sounds 
are distinct over both lungs in front, somewhat diminished in the 
back above, and the bases of both lungs are flat and there is an 
absence of breath sounds. The patient protests vigorously w^hen 
the right side of the chest is percussed. Gentle pressure over the 
short ribs causes pain. There are many subcrepitant and medium- 
sized rales over the bases of the lungs, more marked on the right. 



652 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The fact that the abdominal pain was relieved by rub- 
bing is sufficient to exclude the peritoneum as the site of its origin. 
The patient's mentality was in a state of hebetude, quite the opposite 
to what obtains in peritoneal inflammations. The absence of mus- 
cular rigidity is another important negative point for peritoneal 
pain. The attendant had not examined the lungs, hence the duration 
of lung changes is not knoMai. Evidently the associated involvement 
of the diaphragmatic pleura is the cause of the abdominal pain. 
This occurred during the influenza epidemic and the lung changes 
likely were those common to that disease. 

Treatment. — The lung condition was treated expectantly. 

After-course. — The patient gradualh'' recovered in the course of 
two weeks. 

Comment. — The vast majority of cases in which I am called to 
operate for appendicitis in children have pneumonia instead of ap- 
pendicitis. When a child complains of pain in the abdomen, this is 
too often accepted as topographically correct. There may be ten- 
derness over the abdomen, but quite often slight pressure brings 
relief. Very early pressure may be acceptable in peritonitis when 
the pain is due to spasm, but when peritonitis begins, pressure is 
no longer acceptable. Muscular rigidity is absent in pneumonia. 
This may be difficult to determine if the child cries, but if it can 
be examined w^hen asleep, the muscle is not rigid. Even in a cry- 
ing child, if gentle pressure is made on several points of the abdomen 
at the same time when it draws its breath, less relaxation Avill be 
noted if there is an area of appendicitis (peritonitis). A muscle, 
when it guards an inflammatory lesion, never sleeps, but main- 
tains its rigidity while the patient slumbers. Lung findings gen- 
erally clear up all doubt, but early the lung findings may be ob- 
scure. Possibly hyperresonance with increased breath sounds is 
the only clue. The lesion is a diaphragmatic pleurisy, and when 
localized, lung findings may be absent ; sometimes pressure over the 
ribs at the site of the attachment may elicit pain on the affected 
side. In rare instances a lung lesion may coexist with an appendi- 
citis. Then the diagnosis is very confusing. 

Case 3. — A minister aged forty came because of abdominal pain. 

History. — The patient had an acute abdominal affection six weeks 
ago which began with pain and vomiting. The pain was diffuse 
and very severe, so severe that he became quite collapsed. It did 



SEVERE INTERMITTENT PAIN 



653 



not at any time localize. Abdominal distention was pronounced 
and continued so for several weeks. He still has considerable trou- 
ble with gas and distention. He had fever for two weeks, but 
it was never over 102°, the pulse was as high as 140. His physician 
made a diagnosis of appendicitis and advised that the organ be re- 
moved in order to prevent a recurrence of an attack. He is ob- 
stinately constipated. 

Examination. — The patient looks sick. He is evidently anemic and 




Fig. 313. — Shaded area indicates the extent of adhesions. 



undernourished. The abdomen is rounded and generally tympa- 
nitic, particularly at the lower portion. There is no fluid demon- 
strable, no sensitiveness, and no rigidity. General examination is 
negative as are the blood and urine examinations. 

Diagnosis. — From the history it seems fair to assume that the at- 
tending physician was correct in ascribing the disturbance to an 
affection of the appendix. The only argument in favor of this 



654 CLINICAL SURGERY BY CASE HISTORIES 

diagnosis is that it is the most frequent cause of acute abdominal 
affections. There was no localized pain at any time. Any of the 
rarer causes of infection may as well have been active. A partial 
leak from an ulcer may have caused it, despite there is no history 
of previous epigastric distress. The preponderance of tj'mpany in 
the lower abdomen argues against this. Occasionally an acute sem- 
inal vesiculitis gives rise to such a history, but the seminal vesicles 
are not involved. The continued impairment of health is not 
explained by any of the findings. There is no abscess that is 
being absorbed, at least it gives no evidence in the pulse and tem- 
perature. The presence of tympany indicates that the intestinal 
walls have not yet fully recovered from the inflammation they 
had undergone. It seems best, therefore, to attack the problem 
on the theory of the most probable cause — appendicitis. 

Treatment. — A right rectus incision was made. It was seen that 
there were still extensive adhesions between intestinal coils through- 
out a wide area (Fig. 313). The cecum was covered with omentum 
and adherent intestinal coils. After much dilftculty the cecum 
was loosened but careful search failed to disclose an appendix. 
By following a strand of tissue downward from the cecal band a 
nodule the size of a bean was found 3 inches from the cecum. This 
was believed to be the remains of the appendix. It was removed. 
Considerable bleeding was caused by the separation of the ad- 
hesions and the gut was torn in one place and had to be sutured. 

Pathology. — The small object removed proved to be the terminal 
half of the appendix. 

After-course. — The patient was much shocked following the opera- 
tion but recovered fully. He remained in fair health for ten years 
although he never regained his former vigor. He was easily sub- 
jected to colds and had an irregular and indefinite cough. Ten 
years after the operation the cough became much worse and he had 
rales over both lungs without dullness but with some dyspnea. 
There was irregular fever and a pulse of increased rate and soft. 
The blood count was not changed. He returned home and after 
some months suffered some acute lung trouble and died. His physi- 
cian diagnosed pneumonia. 

Comment. — After a severe abdominal infection a secondary opera- 
tion should not have been done so early. At least three months 
are required for the reaction to subside and for the adhesions to 



SEVERE INTERMITTENT PAIN 655 

loosen as much as they will. After severe attacks of appendicitis, 
especially those which began with severe pain and were followed 
by evidence of a diffuse inflammation, it is questionable whether 
removal of the appendix is necessary. Once the appendix has per- 
forated, a spontaneous cure results. In this case operation six 
weeks after the beginning of the acute attack was particularly ill- 
advised. There was no evidence of a localized affection that sur- 
gery could relieve. The patient was in no condition for a young 
surgeon to make a joy ride among his abdominal viscera. As I 
recall this case I am reminded of the ubiquitous young man with a 
new automobile and with no place to go. The obvious thing in 
either case is to do nothing. Neither the stump of the appendix 
nor the adhesions were responsible for his continued ill health 
and it is quite possible that he had a metastatic lung infection. 
Small foci there may cause prolonged ill health without giving 
evidence of any definite sort. Even if this be assumed, no direct 
connection could be traced between such an infection and the 
final termination in lung disease. The last illness resembled an 
acute miliarv tuberculosis, and it is indeed possible that a post- 
infection may have had an influence on the development of such 
a disease. An empyema or lung abscess not infrequently ends as 
an acute tuberculosis. 

Case 4. — A schoolboy aged nineteen presents himself because of 
pain in the lower abdomen. 

History. — His father died of tuberculosis and a sister now has tu- 
berculosis of the spine. The patient has had fair health. Six months 
ago he was in bed ten days with a slight attack of pneumonia. Two 
months later he had an attack of pain in the right lower quadrant 
of the abdomen. He remained in bed for a few days and the sore- 
ness subsided soon after. Recently he has felt a return of the sore- 
ness, but no severe pain, no nausea or rise of temperature. 

Examination. — Negative except for deep tenderness in the region 
of the appendix. The area of tenderness is as large as a hand and 
seems quite pronounced in spite of the lack of muscular rigidity. 
The laboratory examinations are all without interest. He looks 
pale and distressed as though he had lost weight, but he does not 
show any blood changes. 

Diagnosis. — The trouble which kept him in bed six months ago is 
not clear. A study of his record made at another hospital indicates 



656 



CLINICAL SURGERY BY CASE HISTORIES 



an indefinite pulmonary affection. The attack two months ago has 
all the earmarks of a mild acute appendicitis. The cause of so wide 
an area of tenderness without muscular rigidity is not apparent. 
The removal of the appendix seems advisable. 

Treatment. — ^When the cecum was exposed, it was seen to be cov- 
ered closely with submiliary tubercles. These covered the last 




Fig. 314.- — Acute miliary tuberculosis of the ileocecal region, young man aged nineteen. 
The great omentum is being drawn out of the wound. Save for a number of mesenteric 
lymph glands, the entire disease is exposed to view. 

six inches of the ileum and a portion of the omentum. The re- 
mainder of the omentum was free (Fig. 314). All the affected 
omentum and the appendix were removed. 

Pathology. — The tissue removed showed typical miliary and sub- 
miliary tubercles. There was no caseation in any of them. 



SEVERE INTERMITTENT PAIN 



657 



After-course. — Recovery from the operation was uneventful ex- 
cept for a low temperature, slow pulse, and a diffuse weak apex 
beat. He returned for examination in fifteen months and seemed 
to be perfectly w^ell and shows a marked gain in weight. 

Comment. — The persistence of the pain in the abdomen, its dif- 
fuse extent and the history should have led to a correct diagnosis, even 
though physical findings failed to show any lesion of the lungs. The 
fact that he was in a hospital ten days because of an undiagnosed 
lung attack was in itself extremely suggestive. At the time of the 
supposed attack of appendicitis two months ago he probably received 
the first dissemination of bacilli in the cecum and appendix. 

Case 5. — A gentleman of leisure came to the hospital because of 
pain in the abdomen. 

History. — Two days ago he began to have pain in the lower part 
of his abdomen more pronounced in his right side. It was not at- 
tended by vomiting or nausea. He gives a history of previous 
attacks of pain, one many years ago which was attended by vomit- 




Fig. 315. — Enterolith protruding after the wall of the gut was cut. 

ing and fever and pain in the right side which lasted a week or two. 
More recent attacks were not attended by nausea and likely not 
by fever. 

Examination. — There is tenderness on deep pressure and some 
rigidity in the ileoceal region. The pulse is 84, the temperature 99. 
In other respects he seemed without interest. 



658 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The local tenderness and muscular rigidity seemed 
sufficient to warrant a diagnosis of a mild appendicitis. 

Treatment. — The abdomen was opened by a right rectus incision. 
An indurated mass the size of the finger ending in a clubbed ex- 
tremity was at once palpated. This was readily determined to be 
the appendix with much thickened walls and hard and clubbed end of 
indetermined nature. 

Pathology. — The clubbed extremity is due to the presence of a stone. 
When the wall over it was cut retraction of the circular fibers 
forced it from the lumen of the appendix (Fig. 315). The gut 
wall was thickened and showed only moderate round-celled in- 
filtration. There was some periappendicitis. The surface of the 
mass was covered with calcareous material. The interior was in 
part made up of flaky material resembling oat chaff. 

After-course. — Recovery has been complete. The digestion has been 
remarkably improved. 

Comment. — There are a number of cases recorded in which stones 
found in the gut have begun in the appendix. What the central 
material may have been is problematical. Being a theologian, he 
more than likely had at some time or other indulged in foods calcu- 
lated to combat constipation. 

Case 6. — A farmer a.ged twenty-four came to the hospital because 
of pain in the abdomen. 

History. — The patient complains of recurrent pain in the right 
side. He has had "indigestion" for six or seven years. He often 
has pains in the stomach in the morning, and sometimes vomits. His 
appetite is good and the bowels are regular. He has had numerous 
attacks of tonsillitis, the last three weeks ago. The patient has 
had pain in the right side frequently, six or seven times in the 
last year. He has soreness in the right side for two or three days, 
which then subsides. Sometimes it is accompanied by diarrhea, 
sometimes not. No urinary disturbance. The last attack of this 
character occurred two months ago. Four days ago while he Avas 
still not feeling very well, because of the attack of tonsillitis, he 
became very warm, and drank a great deal of water before dinner. 
He ate a little dinner, but vomited it fifteen minutes later. The 
following afternoon he had a diarrhea but no abdominal pain. 



SEVERE INTERMITTENT PAIN 659 

The following morning he had pain in the right lower abdomen, but 
ate a little dinner. He felt badly all afternoon and the pain con- 
tinued, although he was up and about his work. He slept well 
during the following night and had no boAvel movements. The 
following day he had a formed stool but the pain continued all 
day, and got much worse toward night. The pain became very se- 
vere and he vomited six times during the night. At the time of 
entering the hospital the next morning he still was nauseated and 
complained of pain in the right lower abdomen. 

Examination. — There is marked rigidity of both recti below the 
umbilicus and very definite tenderness over the ileocecal region. The 
pulse is 88, temperature 100.4°, respiration 24, W.b.c. 17,000. 





Fig. 316. — Acute necrosis of the appendix. A, microscopic. B, gross. 

Diagnosis. — The gradual onset following a tonsillitis first with nau- 
sea and vomiting for three days before a definite localized pain be- 
gan indicates a progressive endo-appendicitis with a toxic peri- 
appendicitis following. The Ioav temperature and slow pulse in- 
dicate but little suppuration. One sometimes sees low tempera- 
ture and slow pulse in gangrenous appendices but these begin with 
sudden severe pain. 

Treatment. — Appendectomy. A muscle-splitting operation was 
done because from the history and phj'sical findings it was not an- 
ticipated that drainage would be necessary. 



660 CLINICAL SURGERY BY CASE HISTORIES 

Patliology. — The appendix is red, kinked upon itself, and is covered 
with a plastic exudate which attaches the folds of the loop of the 
appendix to each other (Fig. 316A). There is intense injection of 
the vessels and edema of the entire vessel M'all. The microscopic 
changes are confined to proliferation of the endothelial cells in the 
lymph nodules, likely the product of previous attacks, and round- 
celled infiltration from this one (Fig. 316jB). There are few 
changes in the muscle and subserous layers save the edema. The 
infective processes therefore played their game in the submucosa' 
and the irritation of the outer layers was caused by toxic products 
and not by the invasion of bacteria. The irritation of the parietal 
peritoneum, which gave rise to the muscular rigidity, is due to the 
irritation of the toxic periappendicitis. 

After-course. — The temperature went up to 101° for three days 
following the operation then rapidly descended to normal. At the 
end of the fifth day the temperature rose to 102.5° and remained so 
two days. A subcutaneous abscess was drained following which the 
temperature returned to normal. The pulse did not go above 70. 

Comment. — Exudates at a distance from seats of bacterial activ- 
ity may keep up a temperature for some days following the removal 
of the focus, just as a blood clot may keep up a temperature though 
entirely aseptic. These may be viewed as protein reactions. Fre- 
quently in such cases the reaction must be differentiated from 
subcutaneous suppurations due not to an infection from below but 
from the skin, for these infections present staphylococcus epider- 
midis albus which are not found about the appendix. Of course 
subcutaneous abscesses may occur from infections of the appendix, 
but the two can usually be distinguished on clinical grounds alone. 
Whenever the skin is irritated by abdominal exudates it is a sig- 
nal for the staphylococcus epidermidis albus to get busy. Drain- 
age of the skin wound for a few days following the operation may 
obviate this complication. In this case the first rise of temperature 
evidently was due to the toxic absorption, the last rise to the sub- 
cutaneous infection. 

Case 7. — A banker aged forty-eight was brought to the hospi- 
tal because of severe abdominal pain. 

History. — Two weeks ago while walking he was seized with pain 
under the tip of the sternum, which grew steadily worse and radi- 
ated to the right costal margin. The pain was severe, cramp-like, 



SEVERE INTERMITTENT PAIN 



661 



and lancinating in character. By morning a doctor had to be called. 
The patient's temperature was 102.4°. The next day the pain 
was less but he never has been entirely free from pain since the 
onset. He was able to be about the house, but unable to attend 
to any business. He has had no previous attacks of abdominal pain. 
There was no pain in the back with the present attack. 

Examination. — Two weeks after the onset there was a mass in the 
ileocecal region the size of a lemon. There was some muscular rigid- 
ity and marked deep tenderness. There was neither tenderness 
nor rigidity in the hepatic region. The white count was 12,000. 




Fig. 317. — An acutely inflamed appendix entirely surrounded by the indurated omen- 
tum. The omentum was severed, allowinar the appendix to show. 

Diagnosis. — The onset was quite like a gallstone attack, but the 
pain was less intense. He did not send for his doctor until the 
next morning. In gallstone attacks relief is usually summoned 
at once. The mass in the side lies in the region of the appendix 
but the fundus of the gall bladder not infrequently attaches 
here and may simulate an appendicitis. While it is most likely 
an appendicitis, it is wise to so place the incision that either region 
may be attacked. 

Treatment. — The great omentum was wound about a much thick- 
ened appendix (Fig. 317). It lay over the pelvic brim. The omental 
mass was removed along with the appendix. 



662 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The appendix was hyperplastic, the process evidently 
having existed longer than the case history reads. 

After-course. — Aside from some skin infection, recovery was 
prompt. 

Comment. — Differentiation between gall bladder and appendix at- 
tacks is not easy always. It is unusual for a normally located ap- 
pendix to give pain along the costal margin, as in this case. 

Case 8. — A fanner aged thirty-five came to the hospital be- 
cause of pain in the lower abdomen. 

History. — The patient's trouble began a week ago with epigas- 
tric pain with vomiting. After a day he was practically free from 
pain and worked during the day; he came to the hospital on the 
eighth day. His physician found no muscular rigidity at the time 
of onset but some deep tenderness. The temperature was 99 and 
the pulse 80. Since that time there is a gradually increasing ten- 
derness and the pulse and temperature have kept pace. 

Examination. — Abdomen is soft everywhere except above the an- 
terior superior spine. There is a mass the size of a turkey's egg, 
tender to pressure and well circumscribed. The chief point of ten- 
derness lies lateral to the main mass. The temperature is 102°, pulse 
90, respiration 19. 

Diagnosis. — Epigastric pain with vomiting and with subsequent 
deep pain in the ileocecal region without muscular rigidity indi- 
cates an affection of the appendix which does not reach the parietal 
peritoneum, either because it is retrocecal or lateral to the cecum. 
The localized mass indicates a periappendiceal abscess well walled 
off. The well-defined tumor with gradually ascending temperature 
and pulse indicates that the infection has escaped its original con- 
fines and has become a spreading process demanding relief. 

Treatment. — Incision above the spine extending II/2 inches each way. 
I split the fibers of the external rectus and cut the fibers of the 
internal rectus. The parietal peritoneum was free from the mass. 
Some pus was escaping from below the cecum. An abdominal pad 
was placed over the cecum and one downward toward the pelvic 
brim, walling off the free peritoneal cavity. The appendix lay 
under the head of the cecum. After loosening the adhesions, it was 
found lying parallel with the incision. The appendix was soft, 
semifluid and of a greenish-gray color. It was ligated and cut off 
without any attempt to cover the stump. Several ounces of pus 



SEVERE INTERMITTENT PAIN 663 

were contained in the abscess about the appendix, the abscess being 
covered by the cecum and the tip of the great omentum. There 
Avas no reaction on the part of the peritoneum of the small gut 
or of the omentum beyond the tip actually involved in the walling 
off of the appendix. I noted this with apprehension. A large tube 
Avas placed in the pelvis and gauze drains both above and median 
to the head of the cecum. The abdominal wound was partly 
closed with silkworm gut suture. 

Pathology. — Appendix is soft, semifluid and tears at the slightest 
grab of the forceps, but is less fragile near its base where it was 
ligated and cut. 

After-course. — The patient reacted well, but a spreading peritoni- 
tis began at once and the patient died of a generalized peritonitis on 
the seventh day. 

Comment. — The early history of pain corresponds to the period of 
beginning necrosis. The period free from pain indicates that the 
appendix was too dead to feel pain and the surrounding tissue 
had not yet reacted. The gradually increasing pain represents the 
period of reaction of the surrounding peritoneum. The return of 
the temperature represents the period of pus formation. The flaccid 
muscle wall in the presence of a distinct temperature showed the ab- 
scess to be walled off and free from the parietal peritoneum. Being 
walled off with a constantly ascending pulse and temperature indi- 
cated that the abscess was enlarging and unless drained would 
likely continue to enlarge until it ruptured spontaneously. The 
fact that the appendix had literally melted down made it evident 
that virulent bacteria likely were loosed, and to combat this, lib- 
eral drainage was used. It is possible that if an opening had been 
made into the abscess and simple drainage employed, Avithout an 
attempt at the removal of the appendix, the issue might have been 
different. Transperitoneal drainage of an abscess is always a pre- 
carious proposition. Had I known what I know now, I should have 
done so. Had the abdominal wall been adherent to the inflammatory 
mass, I should have done so as a matter of principle. 

Case 9. — A fanner was brought to the hospital because of pain 
in the abdomen. 

History. — He has had several attacks of abdominal pain with nausea 
in years past. Seven days ago he had a more severe attack with nau- 
sea, fever and distinct pain in the right iliac fossa. The fever reached 



664 CLINICAL SURGERY BY CASE HISTORIES 

the height of 102.5° but subsided by the third day, but pain persisted 
and he remained in bed. Operation advised by his physician was 
refused. Yesterday the pain became more severe and extended far- 
ther toward the median line and the fever reached 102.5 again and the 
pulse 108. He now expressed a willingness to undergo operation. 

Examination. — The patient lies with the thighs drawn up ; he seems 
apprehensive yet stoical. The abdomen is flat and moderately 
hard, particularly in the low^er part. He makes no comment dur- 
ing the course of examination but admits pronounced pain when 
he is asked. 

Diagnosis. — The history of repeated attacks together with the phys- 
ical findings admit of no doubt as to the seat of the disease. The 
late recrudescence of pain and temperature make it clear that a 
localized appendiceal abscess has crept into the pelvis. His general 
attitude indicates a spreading condition. The flatness and hardness 
of the abdomen indicates an induration of the walls of the gut in the 
region of the infection. Such organs are not capable of further 
defense because they can not dilate and form barriers and their 
indurated areas do not admit of renewed formation of exudate -and 
new adhesions. Therefore, help, if there be any, must come from 
outside. 

Treatment. — The appendix is removed from its indurated environ- 
ment with some difficulty. There is some pus about the appendix 
wdthout a definite abscess, but there is a large amount of floccular 
exudate free in the pelvis. There seems to be no walling off toward 
the left. The intestinal walls are thickened, nonadherent, and are 
not responding to the rencAved stimulus. 

Pathology. — The lower portion of the appendix opposite the meson 
presents a necrotic area the size of a bean. A leak occurs at this 
place. This seems to be the source of the renewed infection rather 
than the extension of the periappendiceal abscess. It is interest- 
ing to note that just at this place there were no adhesions, indicat- 
ing that this area was necrotic early in the disease, preventing ad- 
hesions at this point, and that a leak occurred as soon as the dead 
area became separated. 

After-course. — The patient died on the second day from a general- 
ized peritonitis. 

Comment. — Secondary recrudescence of symptoms with a distinctly 
walled off abscess results from the giving way of the wall at some 



SEVERE INTERMITTENT PAIN 665 

point. In the flat, hard abdomen there is usually a creeping along 
of the infection between partly adherent coils of gut. The disease 
here is progressive. The secondary perforation from a necrotic area, 
as in this case, is unusual so long after the beginning of the disease. 

Case 10. — A fanner aged forty came to the hospital seeking re- 
lief from abdominal pain. 

History. — The patient has had epigastric distention and distress 
for two years. He has had several attacks in w'hich the pains were 
severe under the short ribs and epigastrium and extended to the 
right shoulder. The last attack of this sort was six months ago. 
There has never been any jaundice. Six days ago he had renew^ed 
pain with a pronounced aggravation of the digestive disturbance. 
Two days after this an area of localized pain presented above the 
superior spine extending nearly to the level of the umbilicus. The 
bowels have been loose for ten or twelve years until the present at- 
tack, during which there has been no movement. 

Examination. — The abdomen was everywhere soft except over the 
point of maximum pain where a definite moderately sensitive tumor 
mass the size of a walnut could be felt. The muscles between this 
mass and the liver border were soft, nonresistant to pressure. The 
tumor mass did not move on pressure or with respiration. 

Diagnosis. — The early history of diarrhea, epigastric distress with 
periodic distinct pain wath radiation to the right shoulder suggested 
gall bladder disease. It was not until the mass appeared that the 
affection could be definitely separated from the gall bladder. Even 
with this evidence gall bladder disease could not be put wholly out 
of mind for elongated, pedunculated gall bladders sometimes pre- 
sent low down and if they become adherent become independent of 
the movements of the liver. Because of the firm character of the 
tumor and the absence of muscular rigidity, a diagnosis of a subacute 
indurative appendicitis lying lateral to the cecum could be made. 
With the acceptance of such a diagnosis the possibility of an asso- 
ciated gall bladder disease must be kept in mind and the incision 
so made that the upper abdomen can be explored. When there is 
likely to be an abscess the fear of spread of infection negates this 
desideratum. 

Treatment. — An oblique incision just anterior to the quadratus 
muscle exposed the mass. The appendix, as thick as the little finger, 
lay lateral to the cecum and was embedded in a complete new 



666 CLINICAL SURGERY BY CASE HISTORIES 

membrane. This covering was incised and the appendix enucleated. 
The whole wall of the cecum was thickened so that inversion was 
not possible. Hence flaps were made of the peritoneal covering of 
the base of the appendix and the mucosa alone ligated. The serosa 
flaps as well as the new membrane which had covered the appendix 
were coapted with a running catgut suture. The abdomen was 
closed without drainage. 

Pathology. — The walls of the appendix were much thickened owing 
to an extensive plasma cell infiltration. The mucosa was markedly 
thinned and the lymph follicles reduced in size. 

After-course.- — Recovery was uneventful save for a stitch abscess 
in the skin. The digestive disturbance including the chronic diar- 
rhea has disappeared. It is by no means certain, however, that 
the gall bladder is unaffected, for chronic diarrhea with subcostal 
pain radiating to the shoulder suggests gall bladder disturbance. 
Possibly the great induration of the cecum may have been responsi- 
ble indirectly for the symptoms. At any rate the patient has been 
well several years and does not share the apprehension of his 
surgeon. 

Comment. — AVhen the appendix is responsible for chronic gastric 
disturbance there is usually marked thickening of the walls. In the 
absence of such thickening the appendix should be assumed to be 
the cause of the digestive disturbance only after the most painstaking 
examination of the stomach and gall bladder. In such cases if con- 
ditions are favorable and the operator experienced, the removal of 
the gall bladder is advisable, particularly in women. 

Case 11. — A hardware merchant aged thirty-two came to the 
hospital because of a painful swelling in the right groin. 

History. — The patient is stated to be a prominent business man of 
exemplary habits. Two weeks ago a pain developed in the right groin 
which made walking difficult. It came on suddenly while working with 
a stalled car. When seen by his doctor the following day, he had 
temperature 101°, pulse 90, and was tender in the region of McBur- 
ney's point. He had no previous attack. During the past ten days 
the temperature has fluctuated between 100° and 102°. Several 
days ago a tumor appeared, and his physician made the diagnosis of 
irreducible inguinal hernia. 

Examination. — The patient has an apprehensive look but is of good 
color. Two inches above the midpoint of Poupart's ligament he in- 



SEVERE INTERMITTENT PAIN 667 

dicates the seat of his trouble. He holds the thigh moderately flexed. 
At the point indicated is a deep mass quite tender to the touch. It 
extends from this point to the region of the external ring and is a 
sausage-shaped swelling, the largest part of which is at the level of the 
termination of the canal. (Fig. 318.) So far as he knows he has 
had no hernia. There is no definite rectus rigidity, but the appre- 
hensiveness of the patient makes a careful examination impossible. 
Diagnosis. — The mass is obviously inflammatory and because of 
the duration of the fever and its tendency to increase, the process 
likely has reached a suppurative stage. There is obviously irri- 
tation of the ileopsoas muscle. The inguinal canal appears to be 
the site of the mass in the groin. There is no muscular rigidity 




t \f 

Fig. 318. — Periappendiceal abscess from bubo. 

which would exclude a low lying appendicitis. An irreducible her- 
nia is not likely because the tumor was not present at the beginning 
and was of gradual onset. An inguinal suppuration was therefore 
diagnosticated. 

Treatment. — As soon as the rectus fascia was severed a small amount 
of pus was encountered apparently about the vas deferens. The 
right testicle was brought into view and presented a small area of 
epididymitis. The revised diagnosis was a retroperitoneal abscess 
extending from a subacute epididymitis. The inguinal canal was 
now more freely opened and an abscess lying between the perito- 
neum and the psoas muscle was discovered. The deep abscess was 
drained at the lateral end of the incision and the lower abscess at 



668 CLINICAL SURGERY BY CASE HISTORIES 

the medial end and the remainder of the incision was closed with 
a figure-of-eight silkAvorm gut suture. It was hoped in this way to 
avoid a hernia. 

After-course. — The drains were removed in a week. Up to date, 
now seven years after operation, a hernia has not developed, so it 
is safe to say none will appear. 

Comment. — Had the epididymis been carefully examined before 
operation it would not have been necessary to make a diagnosis that 
required revision. The patient seemed excessively modest, supporting 
the bed sheet with his hands during the course of the examination 
lest he be unduly exposed. I should have known that excessive mod- 
esty usually has more than the genitals to conceal. The history 
of a sudden onset likely was a fiction. 

Case 12. — A farmer aged thirty-two came because of pain in the 
abdomen. 

History. — The patient complained of pain in the right iliac fossa 
for some days and for the past two days has had some rise of tem- 
perature, 100° to 102° according to his physician. The pain is in- 
creased by flexing the thigh. He had no radiating pain, neither was 
there nausea or vomiting. There has been no previous attacks. He 
has always been well and has not previously consulted a physician in 
many years. 

Examination. — The patient lies in bed with the right thigh slighth' 
flexed and rotated outwards. His pulse is 85 and temperature 
102.5°. The abdomen is soft, nowhere tympanitic and there is no 
rigidity. On deep pressure below McBurney's point there is 
marked tenderness. The right inguinal lymph glands are enlarged 
and tender. There is no tenderness in the lumbar region. The white 
count is 17,000. 

Diagnosis. — The obvious diagnosis was appendicitis, as his physi- 
cian had surmised. However, the absence of muscular rigidity in 
the presence of marked deep tenderness made such a diagnosis 
questionable. The gradual onset of soreness was not that com- 
mon for appendicitis, and the leucocyte count was too high for the 
degree of abdominal disturbance. The history as to other pain being 
unsatisfactory, I set out to explore. I found a large right testicle, 
evidently an acute epididymitis. There was a point of fluctuation. 
I concluded, therefore, that the abdominal pain was due to an in- 
fection of the lymph node situated in the iliac fossa near the ex- 
ternal iliac veins below the crossing of the ureter. 



SEVERE IXTERMITTEXT PAIN 669 

Treatment. — A drainage of the epididymal abscess was done. 

Pathology. — The pus which escaped was thick, dirty, greenish 
white. The bacteria present were not identified. 

After-course. — The testicular and abdominal pain rapidly subsided. 
There had been no recurrence when last heard from some three years 
after. 

Comment. — Whenever there is deep abdominal tenderness without 
muscular rigidity, the lesion likely does not involve the peritoneum. 
The disease then is likely to be extraperitoneal, a retrocecal appen- 
dix, and endoappendicitis and endosalpingitis, or an inflammation 
so far distant from the anterior parietal peritoneum that it is not 
excited to reaction. Sometimes in a gangrenous appendix there 
,is no rigidity because the dead tissue does not excite the peri- 
toneum to reaction. Here the history of sudden severe pain is 
nearly alwajs to be elicited. The nature of the testicular trouble 
was undoubtedly gonorrheal. No questions were asked, but it may 
be taken for granted that had his testicular trouble been acquired 
through legitimate channels, its presence would have been an- 
nounced in the anamnesis. I have found that patients are always 
grateful if one does not discuss problems which both understand 
equally well, 

SUPRAPUBIC 

The acute lesions in the pelvis are most commonly due to inflam- 
mations of the tubes or a deeply lying appendix. Any affection 
capable of irritating the peritoneum may simulate these. 

CASE 1. — A matron of thirty-two cajne to the hospital because 
of pain in the lower abdomen. 

History. — The patient has had pain over her bladder for nine 
months. She has had some uneasiness before that time, but it never 
amounted to actual pain. The pain has been a dull heavy pain but 
recently has been more severe. On several occasions an anodyne was 
required. In the past two months she has had to get up at night to 
urinate. She is becoming more constipated each month. The menses 
are regular and last from four to six days. Her menses began at six- 
teen and have always been painful. She has been married eight 
years but has never been pregnant. She has never had any vaginal 
discharge. 



670 



CLINICAL SURGERY BY CASE HISTORIES 



Examination. — The patient is tall, thin, of the intellectual sort, 
and her general expression is that of good health. The abdomen, 
save for some rigidity just above the pubes and some sensitiveness, is 
negative. The pelvic examination shows a mass filling the pelvis, 
completely anchoring the uterus. She complains somewhat of pain 
during the examinations. The laboratory examinations show noth- 
ing of interest. 




Fig. 319. — Papillary cystoma of the ovaries. 

Diagnosis. — The large mass in the pelvis comes as a surprise after 
the mild history. One thinks first of pus tubes. The patient's bear- 
ing indicates that she is telling the truth. The masses are more elastic 
than indurated tubes, giving the feel more of cystic tumor, but no 
definite outline of tumor can be made out. There is no fluid in the 
abdomen to suggest malignancy. Her condition is becoming pro- 
gressively more pronounced and relief is demanded. 



SEVERE INTERMITTENT PAIN 671 

Treatment. — After the abdomen was opened, cauliflower masses 
were seen to fill the space about the pelvic organs, evidently papil- 
lary carcinomas of the ovary (Fig. 319). The peritoneum of the 
pelvis, and to a lesser extent the gut walls, were studded with minute 
tumors. The masses and as many of the nodules as could readily be 
reached were removed. 

Pathology. — The tissue removed presents the usual picture of a 
serous ovarian tumor that has become malignant. 

After-course. — Recovery from the operation was uneventful. She 
has been free from trouble now eight years. 

Comment. — It is a curious oncological fact that a permanent cure is 
possible in these tumors even after metastases in the peritoneum 
have formed. Eelieved of the major mass the system is said to be 
able successfully to combat the remaining nodules. The explana- 
tion seems to be that the nodules are formed of cells mechanically 
detached from the tumor mass and have become encapsulated by 
the peritoneum. They are therefore dead masses which the peri- 
toneum has interred. They do not represent developing metastases 
that regress. In no other way can this phenomena be fitted into 
the general scheme of tumor growth and development. Slides made 
of these little nodules bear this out. 

Case 2. — A merchant aged fifty-five came to the hospital for re- 
lief of a fistula in the ri^ht side. 

History. — Six months ago he had an attack of acute abdominal 
pain lasting about three hours. It was located in the lower abdo- 
men. He did not vomit. He does not know Avhether there was any 
rise of temperature. He was unable to secure a bowel movement 
though several enemas were given. After some hours the trouble 
subsided and he had no further trouble for a month. The bowels 
moved without trouble or pain. At the end of a month he had 
another attack exactly duplicating the first in every detail. It 
failed to subside and after eleven days an opening was made into 
the bowels on his right side. Relief followed the operation. Six 
days later he again passed feces through natural passages with 
the aid of enemas. Some stool still escapes from the opening in 
the side and he wants to be rid of the opening. His general health 
has improved since the opening in the side was made and he has 
nearly regained his normal weight. There never has been blood in 
the stool. 



672 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — If he has regained his normal health as he states, 
he was before far from being a well man. He is sallow, looks haggard, 
and the skin is inelastic and hangs in folds. In the ileocecal region 
is an opening large enough to admit the tip of a finger; much feces 
is escaping from this. The skin about it is much excoriated. Rectal 
examination shows a hard mass in the culdesac just beyond the reach 
of the finger. 

Diagnosis. — An obstruction recurrent and that opened again spon- 
taneously following a colostomy can not have been wholly organic. 
If due to a temporary compression as in slipping through a diverticu- 
lum, the relief should be complete. The conclusion seems warranted 
that the situation must be represented by a half and half condi- 
tion; that is, an organic state partly narrowing the lumen making 
the temporary occlusion by foreign substances more easily possible. 
Rectal palpation indicates that this is most likely a malignancy of 
the sigmoid, though a perisigmoiditis from a diverticulitis can not be 
excluded. His general appearance indicates malignancy. 

Treatment. — A left rectus incision was made. A hard elongated 
mass occupies a loop of sigmoid and extends to within several inches 
of the floor of the culdesac. To the right of this mass a loop of 
ileum is adherent. This loop is firmly adherent and its walls are 
thickened, giving the impression that the malignancy has invaded 
its walls. Therefore a loop of ileum was resected and since it was 
found that the distal limb was severed too close to the ileocecal valve 
to admit of a lateral anastomosis and the whole ascending colon was 
involved in dense adhesions, the proximal limb was anastomosed 
to the descending colon. The tumor was cut close to the bottom of 
the culdesac, and a permanent artificial anus made after the redun- 
dant sigmoid had been removed. A gauze drain was conducted down 
to the pubis. 

Pathology. — It was found that the loop of ileum was adherent to 
the tumorous gut only by inflammatory adhesions and might have 
been separated (Fig. 320). The tumor involving this side of the 
gut had ulcerated, leaving but a thin wall between it and the loop 
of ileus. The adhesion was, therefore, an anticipatory one. The 
opposite wall was as thick as the finger and showed an involvement 
for about three inches (Fig. 321). In structure it was an adenocar- 
cinoma. 

After-course. — There was much pus from the pelvic floor. Feces es- 
caped at once from the stump of colon and the primary colostomy 



SEVERE INTERMITTENT PAIN 



673 




Fig. 320. — Loop of small intestine adherent to malignant gut causing closure of the lumen. 




Fig. 321. — Carcinoma of the pelvic colon producing stenosis of the gut. 



674 CLINICAL SURGERY BY CASE HISTORIES 

wound closed spontaneously. He was annoyed much by a persistent 
singultus. The wound from which the pelvic drain had protruded was 
very slow to heal. After he had been at home some months he 
had a spell of vomiting and distention following a dietary adventure. 
He never recovered fully from this and following it he had difficulty 
in securing a passage through his new anus. He returned after he 
had lost much weight and strength. Exploration showed that the 
gut wall about the ileocolic anastomosis was so thickened that the 
lumen was nearly occluded. Loops of ileum in the pelvis near the 
site of the preliminary gauze drain were matted together. The result 
of this conglomerate mass was to materially lessen the available 
lumen. He died of exhaustion soon after. 

Comment. — A loop of gut attached to a malignancy most likely is 
not itself involved in the malignant growth and it should 
not be so regarded until definitely proved so. A gauze drain is 
a poor thing to place near a lot of guts not the site of a preexisting 
infection. The amount of irritation produced is more extensive and 
more lasting than when a suppuration has preceded the advent of the 
gauze. Many things, if anticipated strongly enough, are apt to 
happen. Infections belong to this category. 

CASE 3. — A married woman of twenty-one was brought to the 
hospital because of acute pains low in the abdomen. 

History. — The patient has been married eighteen months. The 
menses have always been regular since the age of thirteen years. She 
has passed her menstrual period about twenty days. Last night she 
had a sudden stabbing pain in the right side just above and to the 
right of the pubic bone. The temperature when first taken was 97° 
and the pulse 90. There was no marked collapse, no menstrual flow, 
and no rectal tenesmus. She had a similar attack in July. 

Examination. — Two days after the onset the patient looks com- 
fortable, the pulse is 90 and the temperature 101°. There is marked 
rigidity of the lower right rectus and tenderness over the brim of the 
true pelvis. Vaginal examination shows a uterus slightly enlarged 
and softened, slightly sensitive to lateral movement. There is some 
tenderness but no bulging in the right culdesac. The tubes are not 
palpable. 

Diagnosis.- — The delayed menstruation and the slight enlargement 
of the uterus speaks strongly in favor of a pregnancy. The his- 
tory of a previous attack, the unilateral muscular rigidity, the sensi- 



SEVERE INTERMITTENT PAIN 675 

tive but empty ciildesac speak strongly for an acute appendicitis. 
The blood count of 11,000 is a figure in harmony with either acute 
appendicitis or tubal rupture. The history of stabbing pain is sug- 
gestive of tubal pregnancy and the temperature 101° with a pulse of 
90 is even more so. She may have had a previous attack of appen- 
dicitis and still this may be a tubal rupture. The patient's condition 
is favorable and the safer plan seems to be exploration. 

Treatment. — Appendectomy. The appendix hung over the rim of 
the pelvis. The pelvic organs were not notably involved. The uterus 
was enlarged and soft, obviously pregnant. 

Pathology. — The appendix was much thickened and pronouncedly 
erectile. 

After-course. — Recovery was uneventful. 

Comment. — When there is marked local reaction in an appendix 
extending into the pelvis, a mass may be formed beside the uterus. 
This mass is more confined, more edematous than when there is a 
hemorrhage in the culdesac from a ruptured extrauterine pregnancy, 
but when there is a moderate hemorrhage, the characteristic bilateral 
bulging of the culdesac is lacking. In such instances the leucocyte 
count may be of value. If they number more than 15,000 a suppura- 
tion is present for the leucocytosis of the hematoma of extrauterine 
hemorrhage rarely exceeds 13,000. In this case the tenderness was 
more acute than is normally the case in hemorrhage. Her designa- 
tion of the pain as stabbing seems to have been due to the fact that 
persistent inquiry as to the character of the pain had been made by 
her physician. The subsequent questioning produced a less dramatic 
story. The history of previous attack was of great aid in arriving 
at a diagnosis. 

CASE 4. — A waitress aged twenty-six came to the hospital be- 
cause of periodic pain in the right side. 

History. — She has had several attacks of pain in the right side in 
the last year or two. The pain at the first attack was very severe, 
after that was dull, and now is gradually becoming worse. She 
gets some relief from a hot-w^ater bottle. The pain seems related 
somewhat to the menstrual period. Pain radiates down in the 
pelvis and down into the hip bone. This pain Avas first noticed 
about three years ago or one year before the last baby was born. 
She also complained of headaches which some time ago were occipital 
though now mostly frontal in type. She has had a small goiter for 



676 CLINICAL SURGERY BY CASE HISTORIES 

the last three years. There is some choking sensation at times. Appe- 
tite and sleep are good. The bowels are constipated. She has 
had four pregnancies ; one seven years ago, the second died at three 
months, the third was a miscarriage at three months, the fourth re- 
sulted in a normal child. Her menses began at seventeen, were 
regular and without much pain until first baby was born. Since 
then they are irregular and painful. She has been separated from 
her husband sixteen months. 

Examination. — There is a small, uniform goiter, slightly more 
marked on the right side. Abdomen is sensitive over both lower 
quadrants. The right ovary is the size of an egg and when it 
slips from beneath the hand she complains of acute pain. The 
uterus is in position and the cervix is lacerated. The left tube is 
enlarged and adherent to surrounding structures. The left ovary 
is soft and enlarged. Perineum lax, probably a second degree 
laceration. 

Diagnosis. — The location of the pain in the pubes radiating to the 
hip indicates that it is of ovarian origin. The sudden onset would 
suggest a pyosalpinx and the findings on the left side bear out this 
suggestion. However, she has had pregnancies since the onset of the 
pains and there are no adhesions about the right ovary which is ap- 
parently the chief offender. The sudden onset, together with the 
continued soreness, worse at the menstrual period and relieved by the 
hot -water bottle, suggests a hemorrhage into the ovary. The physical 
findings are in accord with such a suggestion. 

Treatment. — The ovaries and tubes were found adherent to each 
other and to their broad ligaments. Both tubes were closed at the 
fimbriated extremities, swollen, thickened, but contained no pus. They 
were removed. There was a large hemorrhagic cyst the size of a hen's 
egg in the right ovary. This was removed. 

Pathology. — The tubes show a thickening of the walls with much 
round-celled infiltration. The ovary is composed of a large blood 
clot with a thin layer of cortical substance remaining. 

After-course. — The recovery was complete and permanent. 

Comment. — The time of the development of the tubal inflammation 
is not clear. It must have developed after the last pregnancy. There 
is no history of there having been any increase in the leucorrhea at 
any time. It is significant, however, that she was divorced sixteen 
months ago. It is quite possible that a foreign gonococcus completed 



SEVERE INTERMITTENT PAIN 



677 



the domestic triangle. At any rate the histopathology indicates such 
a pathogenesis. 

CASE 5. — A fanner lad was brought to the hospital because of an 
acute abdominal pain. 

History. — Ten days ago he was seized by an acute pain in the ab- 
domen. It was general at first, but after a few hours it localized 
in the right side. He had fever and he vomited twice. The soreness 
has nearly disappeared, but he still feels it when he walks. He had 
frequent urination for a number of days but that too has subsided. 
He is now free from pain and has had no fever for a week. 




Fig. 322. — Localized periappendiceal abscess. 



Examination. — There is slight tenderness over the ileocecal region 
and there is slight rigidity. There is a painful mass back to the blad- 
der demonstrable on rectal examination (Fig. 322). There are 15,000 
leucocytes. 

Diagnosis. — The bladder irritation early in the attack together with 
the painful mass now palpable makes it certain that the offending 
appendix hangs into the pelvis. From the subsidence of the symp- 
toms it is evident that the process is well walled off, but that there 
is still an active process going on is evidenced by the leucocyte count. 



678 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The patient was advised to wait a month before sub- 
mitting to operation. Circumstances were such, however, that he 
desired to get it over with. A right rectus incision was made. The 
appendix at its base and the cecum were free. The end of the ap- 
pendix lay embedded in a mass of adhesions in the floor of the pelvis 
(Fig. 322). It was carefully dissected out. There was about a 
dram of free pus about the tip of the appendix and a good deal of 
bleeding was caused by the enucleation. A drain was placed in the 
infected area. 

After-course. — Despite the drain he developed a violent peritonitis 
and it looked as though he would die. He recovered after a month and 
has had no trouble of any sort now in fifteen years. 

Comment. — This patient should not have been operated on at 
that time. The surrounding peritoneum had regressed from its 
preliminary state of reaction and was unprepared to control the 
infection. On the other hand, the bacteria were still in a relatively 
virulent state. It was too late, therefore, for an early operation 
(because the preliminary hyperemia had subsided) and too early 
for a late operation (because the bacteria w^ere still virulent). Most 
likely the abscess present would have been absorbed. If not, an ascend- 
ing temperature would have announced the development of an im- 
portant abscess. In that event, drainage in front of the peritoneum 
would have been sufficient, or it could have been drained into the 
rectum. There is an unwarranted prejudice against drainage into 
the rectum. Nature does it this way and gets away with it. When 
an abscess can be felt by rectal examination this is the easiest and 
safest way to drain it. Usually a single puncture is sufficient. I have 
never attempted to introduce a drain. Why surgeons should feel 
free to drain through the vagina and eschew the rectum is difficult 
to understand. The bacterial content is not so different and an 
appendiceal abscess is usually able to match flora with either. 



CHAPTER XIII 

ABDOMINAL DISTRESS 

The simple complaint of abdominal distress is the most indefinite 
of the entire phraseology of disease. It may signify a too liberal 
diet, or an incipient malignancy, or any malady between these wide 
extremes. It indicates nothing more than that it will require a 
careful analysis of the patient in order to arrive at a diagnosis. 

EPIGASTRIC 

Epigastric distress usually implies some disturbance with the 
function of digestion, whether this be due to referred causes or to 
changes in structure. The search for possible referred causes and 
the analysis of the functions of the stomach must be invoked. Most 
commonly overlooked are the constitutional diseases and no patient 
may be convicted of having a stomach disease who has not been put 
on trial for evidence of general disease. 

CASE 1. — A farmer aged sixty-four came to the hospital because 
of pain, abdominal distention, and obstinate constipation. 

History. — For ten years he has had attacks of abdominal flatulence. 
These attacks have grown worse in the past four years. He has had 
attacks of pain in the midabdomen which radiate to the lower ab- 
domen. The pains have never been so severe as to require an anodyne. 
They were never influenced by eating and bore no relation to meal 
time. Two daj^s before being brought to the hospital he had a severe 
attack, and in spite of pills and salts, the bowels did not move. There 
was marked pain extending to the lower abdomen. The abdomen was 
distended and everj-where sensitive. Since being in the hospital he 
has improved on diet and the bowels moved with oxgall and now move 
with mineral oil only. His appetite has become better and there has 
been marked general improvement. He has had a gradually increas- 
ing difficulty in urination. He gets up six to eight times a night. 
Sometimes there is some pain and difficulty in starting the flow. He 
has had hemorrhoids which sometimes cause pain but little or no 

679 



680 CLINICAL SURGERY BY CASE HISTORIES 

bleeding. His pulse on entrance was 80, temperature 96°, respiration 
18. Since then there has been a variation, pulse 60 to 96, temperature 
96° to 100.2°, respiration 18. His former weight was 140, a year 
ago it was 120, now it is 119. 

Examination. — The patient is a small man who carries his age 
badly. There is evidence of emaciation. One would think from his 
appearance that it was recent. The abdomen is flat, sensitive, and 
rigid, particularly the upper part. In the midline, halfway between 
the umbilicus and the sternum, is a soft lobulated tumor which is 
unattached to the skin but is intimately connected with the fascia. 
There are small mucocutaneous hemorrhoids. The prostate is large, 
smooth, but rather firm. The blood pressure is 110-70. Urine is with- 
out interest. 

Diagnosis. — The general appearance is that of one suffering from 
carcinoma. The long duration makes that questionable. He has 
lost but two pounds in a year and in the three weeks he has been 
under treatment he has improved so much that a malignancy is 
unlikely. His appetite has become good and he relishes his food 
and his bowels now move with the aid of only a little mineral oil. 
The obstinate constipation, the general collapse, and the distention 
suggested pancreatic disease. However, the disease has been too 
constant for any acute disease of the pancreas. The pulse was 
only 75 to 90 which is not so fast as that usually observed in pan- 
creatitis. Yet now that he has improved his pulse has dropped to 
60. He has had a temperature as high as 100.2° which indicates a 
reaction of some sort. The small tumor of the midline is obviously 
a hernia of the linea alba. These often produce marked disturbance 
of the digestion, often marked pain. A rise of temperature and 
pulse is not a part of the symptoms usully produced by it. The 
prostate annoys him but there is nothing in the urine to indicate any- 
thing capable of producing a constitutional disturbance ; as much 
may be said of the hemorrhoids. In view of the prominence of 
the hernia and the lack of any other definite source of trouble one 
seems warranted in removing this possible source and at the same 
time searching for other lesions. 

Treatment. — The hernia was isolated under local anesthesia. As it 
was raised up, a distinct pedicle the size of a pencil Avas attached 
at either pole, evidently the round ligament of the liver (Fig. 323). 
A hard nodule the size of a grain of corn w^as found in the great 



ABDOMINAL DISTRESS 



681 



omentum just below the transverse colon. A hard nodular mass 
was then found along the lesser curvature of the stomach. Glands 
were palpable along the vertebral column on the right side. The 
midportion of the pancreas was hard, board-like, with nodulations. 

Pathology. — The tumor removed is composed wholly of fatty tis- 
sue. The nodule removed from the great omentum is irregular in 
outline, very dense and on section is lobulated and greyish white 
in color. Pin point areas can not be distinguished. The slide shows 
the entire area to be composed of round cells with very sparse inter- 
cellular tissue. 

After-course. — He recovered from the operation and to date has 
constantly improved. 



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HH 



Fig. 323. — Hernia of the linea alba. The ends of the round ligament of the liver involved 
in the hernia are indicated by X. 

Comment. — Both diagnoses were wrong. A differentiation between 
hernia linea alba and carcinoma was gone into but the now obvious 
ulcer was not considered. Yet the long duration of the marked 
complaint, four years, and the loss of weight should have suggested 
ulcer. In view of the history of an acute abdominal attack be- 
fore he was brought to the hospital, together with the increased 
pulse rate relative to the temperature, with the subsequent rise of 
temperature might have meant an impending perforation. At the 
time of operation it was thought the hard pancreas was secondary to 
the supposed carcinoma of the stomach. The nodule removed from 
the omentum bears every evidence of being an area of fat necrosis 
which has become infiltrated with round cells. If so, then the pan- 
creatic trouble obviously developed in an individual who already had 



682 CLINICAL SURGERY BY CASE HISTORIES 

a stomach ulcer and a hernia linea alba. A somewhat complicated 
picture, one must admit, yet one capable of logical analysis had the 
history been properly interpreted. 

CASE 2. — A married woman of thirty-two caane for consultation 
because of pain in the stomach. 

History. — The patient was married four years ago and has never 
been pregnant. Her trouble started seven or eight years ago. She 
had pain in the epigastrium, which was present practically all 
the time but was more of a soreness than real pain. It approached 
a real pain after eating. She would often fast on this account 
and was free from pain during that time. Vomiting occurred at 
irregular intervals, with no seeming relation to meals. There never 
was blood in the vomitus, but just watery fluid. She has always 
had a dragging, weak feeling in the lumbar region, especially when 
on the feet a great deal, and she is dizzy when she stoops. Her 
stomach trouble is worse at menstruation and she is nervous at 
these times. She flows three or four days and has some pain in 
the beginning. She becomes restive when details are sought rela- 
tive to the pelvic troubles at the beginning of her complaint. 

ExamiTmtion. — The stomach empties very rapidly showing no ab- 
normalities. The uterus is retroverted and fixed toward the left 
side. There is resistance on each side of the uterus but no mass can 
be made out. 

Diagnosis. — The patient gives a history which corresponds with 
gastric ulcer. The fact that the symptoms are worse at the menstrual 
period does not necessarily associate the stomach trouble wath 
pelvic disease. On the other hand pelvic symptoms often are asso- 
ciated with hyperacidity and a chain of symptoms closely resem- 
bling ulcer. If the pelvic trouble is relieved the gastric symptoms 
may disappear. The nature of the pelvic trouble can not be made 
out. The fact that her composure was disturbed when she feared 
she would be questioned gives a possible clew. Whenever a mar- 
ried woman becomes restive when possible pelvic disease is hinted 
at I suspect she may have had some trouble before marriage. Of- 
ten they relieve the situation by hypothecating a previous marriage. 
At any rate the uterus is fixed in retroversion. 

Treatment. — There was a bilateral chronic salpingitis, both tubes 
were firmly bound down. The uterus was brought forward and the 
tubes removed. The appendix seemed normal. 



ABDOMINAL DISTRESS 683 

After-course. — Healing was prompt. She gradually improved and 
after the first year had little complaint save for slight pain at the 
beginning of menstruation. 

Comment. — In neurotic women with pelvic and gastric symptoms 
it is extremely difficult to differentiate between them. In fact 
the nervous state may result from both and any sort of treatment 
may be of no avail. If there is actual anatomic disease in the 
pelvis it may be corrected. Often one can determine the rest by 
trying alternately ulcer and neuropathic treatment. Often gastric 
disturbances due to pelvic disorders are relieved by rest in bed 
and diet. They recur when the patient is again on her feet. Too 
much dependence, therefore, must not be placed on the diagnostic 
value of ulcer treatment. In this case most likely the trouble was 
due to the salpingitis. 

CASE 3. — A matron aged fifty-six entered the hospital because 
of epigastric cramps and jaundice. 

History. — The patient has had repeated attacks of typical gallstone 
colic extending over a period of ten years. During the first few years 
they were not followed by jaundice but during recent years they 
are attended by jaundice lasting from three weeks to two months. 
Her last attack occurred three months ago and was followed by jaun- 
dice which has lasted to date. She has lost 30 pounds in weight, but 
during the past three weeks she has gained a few pounds and she 
has a better appetite and feels stronger. The jaundice varies in in- 
tensity. 

Examination. — All that remains of the last attack is deep tender- 
ness over the hepatic region and a moderate jaundice. The pulse 
is 60, the blood pressure 190 — 90. The urine contains a trace of al- 
bumin and a few casts but the specific gravity is 1.021. 

Di-agnosis. — The typical colics preceding the jaundice suggest blad- 
der stones, while the prompt appearance of jaundice with the attacks 
suggests a common duct stone. The long duration of the jaundice 
likewise suggests a stone rather than an inflammatory occlusion. On 
the other hand, malignancy is unlikely, for she has gained a little 
weight. A gain of even a few pounds is very uncommon in malig- 
nancy; besides the jaundice varies in intensity. This last fact is 
strongly suggestive of a ball-valve stone. The long duration of the 
jaundice suggests that the obstruction is maintained by the simple 
ball-valve mechanism. If this is so, less can be expected by waiting 



684 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 324. — Knormous dilatation of the common duct due to a stone. 

than if an inflammatory thickening played a part. Since the patient 
is now gaining a little, operation seems not all too hazardous. 

Treatment. — When the abdomen was opened there appeared in the 
bottom of the wound a huge sausage-shaped body which at first ap- 
peared to be the colon (Fig. 324), but it lacked indentations and was 
deep blue in color. Exploration proved it to terminate in the duo- 



ABDOMINAL DISTRESS 685 

denum and liver, respectively, and to receive the cystic duct. A 
large quantity of bile escaped when it was cut into and a stone as 
large as a hickory nut was extracted. The gall bladder itself con- 
tained no stones and was not molested. 

After-course. — The patient has remained free from symptoms ref- 
erable to the hepatic region, but has since suffered a cerebral hemor- 
rhage. 

Comment. — The interest in this case centers in the huge dilatation 
of the common hepatic duct. Despite the typical gall bladder colics 
there were no stones in the gall bladder. "We may assume that this 
stone was at first in the gall bladder and escaped into the common 
duct. There is the additional evidence that the gall bladder was di- 
lated. Had the stone been in the common duct from the beginning, 
the gall bladder should have been contracted according to an ancient 
and respected, though obsolete, theory. This is a logical explanation 
and is in harmony with the anatomic findings. However, the cystic 
duct was small and bore evidence of having given passage to a 
stone. The old saw of the contracted gall bladder being indicative 
of common duct stone is not in harmony with modern experience. 
A contracted gall bladder means a more or less ancient hyperplastic 
cholecystitis, stone or no stone, in the common duct or elsewhere. 

CASE 4. — A housewife of sixty came to the hospital because of 
pain in the upper abdomen. 

History. — Thirteen years ago she had an attack of severe pain in the 
right side and in the epigastric region. A doctor was called and 
gave her a hypodermic injection. She had a number of attacks 
after this, which were always worse in winter. Five years ago an 
attack was attended by jaundice. Recently she has vomited a number 
of times and is seldom free from pain. There is no pain in the back. 
She has had six children and has always been well except for attacks 
above recorded. 

Examination. — Her general condition is negative. The abdomen is 
soft and flabby. There is deep tenderness over the gall bladder and 
over the epigastrium. Pressure in this region causes pain under 
the costal margin on the left side. Pressure directly over the left 
side causes no pain. 

Diagnosis. — The definite initial attack thirteen years ago requiring 
morphine, the jaundice attending the attack five years ago and the 
deep tenderness over the hepatic region, and the age and general 
habitus of the patient seem to make the diagnosis of gallstones certain. 



686 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — Laparotomy showed a large saddle ulcer on the lesser 
curvature extending well over the pylorus. The gall bladder was 
free from disease. The pylorus was not obstructed and there was 
no dilatation of the stomach. Hence the abdomen was closed and an 
ulcer treatment begun. 

After-course. — The patient improved under treatment and save for 
bronchitis passed the next five years in comparative comfort. After 
this the digestive disturbance became aggravated but remained sta- 
tionary for a time, then the symptoms became much increased. Ema- 
ciation set in and she died in five months from the time of the begin- 
ning of the last illness, having in the meantime developed a hard 
nodular tumor in the pyloric region. 

Comment. — ^When pressure over the hepatic duodenal region causes 
pain on the left side of the abdomen, the lesion is most certainly gas- 
tric. I had not learned this point at the time the patient was exam- 
ined. The jaundice most likely was caused by the ulcer. Evidently 
this is one instance in which carcinoma developed on an ulcer. The 
question arises whether or not the development of carcinoma would 
have been prevented had I excised the ulcer. Probably not. She 
might have died from the operation. The mortality from excision 
of ulcers in my hands is greater than the danger of transformance of 
benign into malignant ulcers. 

CASE 5. — A wagon manufacturer aged fifty-four sought relief 
from abdominal pain. 

History. — For three or four months he has had general abdominal 
discomfort, chiefly in the region of the umbilicus, with eructations 
of gas. It is most pronounced at 2 to 3 o'clock a. m. He has lost 
15 pounds in the last three months. The appetite has been good 
until just recently, when he vomited once. His father died of car- 
cinoma, his grandfather with stomach tumor, and his grandmother of 
gastric hemorrhage. 

Examination. — The red count is 5,000,000, white blood count 4,000, 
hemoglobin 70 per cent. The gastric analysis shows a reduced acidity. 
The patient appears apprehensive and even more anemic than his 
hemoglobin showed. There is moderate abdominal tympany and 
general soreness over the epigastric triangle. On deep palpation a 
mass can be felt in the region of the pylorus. There is no retention 
of food as measured bv the raisin test meal. 



ABDOMINAL DISTRESS 687 

Diagnosis.— The chief disturbance being in the early morning hours 
suggests ulcer, but the pain is not that of ulcer neither is the meal 
sequence in harmony with such a suggestion. Ulcer is attended by 
loss of weight only when there is serious disturbance with the food 
intake. The presence of a palpable mass is unusual in ulcer and 
its presence together with the general appearance speak strongly 
for malignancy. A carcinoma that has advanced to a stage of a pal- 
pable mass is rarely operable. There is no indication here for a 
palliative operation and the only excuse for exploration is the hope 
that the condition is still operable. 

Treatment. — Exploratory laparotomy was undertaken. The py- 
loric region and the lesser curvature were involved in a thick nodular 
tumor covering the entire circumference of the gut near the pylorus. 
The regional lymph glands were enlarged and very hard. 

After-course. — Despite the extent of the disease, the patient began 
to improve at once after the operation and regained his normal weight. 
He engaged actively in business for a year. At the end of this time 
the old symptoms returned with increased intensity and the decline 
was rapid, death occurring in about three months. Vomiting per- 
sisted for the last month of his life. 

Comment. — Such marked improvement after simple incision is un- 
usual, though briefer cessations are not so uncommon. The reason 
for such occurrences -is not known, neither can such be predicted 
from findings at the operation. The cause of such improvement is 
unknown. 

CASE 6. — A farmer aged fifty-six came to the hospital because of 
pain in the stomach. 

History. — The patient had never had digestive disturbance before 
the onset of the present trouble. Beginning two years ago he has 
had periodic attacks of epigastric pain. He says they came on at 
no regular periods and did not seem to be closely related to meals. 
They were sometimes worse when the stomach was empty and some- 
times worse just after eating. They were always relieved by soda. 
For the past year he has had but little trouble. The present attack 
began about two weeks ago. It is worse than any of the previous 
attacks. He has vomited about every other day one or more times 
since the attack began. He has never noticed blood. He has lost 
fifteen pounds in two weeks; his appetite is poor and the bowels are 
very constipated. There have been no urinary symptoms and he has 
never been jaundiced. 



688 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — The patient's statement is the only evidence of his 
plight. There is no anemia, the abdomen is soft, and no points of 
tenderness can be discovered. The x-ray shows a normal empty- 
ing time and there are no filling defects. 

Diagnosis. — A provisional diagnosis of gastric ulcer was made and 
the patient advised to stay in the hospital. The fact that he had an 
attack two years ago confirms the ulcer hypothesis. If he has carci- 
noma now it must have been implanted on an ulcer. If he has car- 
cinoma, operation has little to offer. The patient wished to go home, 
and the following prescription was given ; Magnes. oxid. Pond, oz. 
ss, Bismuth subnitrate oz. ss. Soda Bicarb, oz. iii, half teaspoonful 
after meals and repeat in two hours. 

After-course. — He improved on this treatment and rapidly regained 
his weight. He is still well four years later. 

Comment. — This case represents a type of old men's stomach trou- 
ble. I do not presume an ulcer was cured. Either he had none or 
has it yet. In such cases one can follow one of three courses ; operate, 
find no ulcer, remove an appendix or gall bladder and ascribe the 
cure to this, or find some dilated vessels and call it an ulcer, do a gas- 
troenterostomy and ascribe the cure to that ; or give him antacids or 
regulate his diet and confess you do not understand the condition. 
I have tried each in turn. One may argue that by removing the 
gall bladder or appendix the recurrence is prevented, that this cure 
is permanent while the antacid cure is only temporary or may be 
so. If one follows these cases many years this is not always, even 
usually, borne out. One is obliged to ascribe recrudescence to ad- 
hesions or something else. I have observed this fact in those who 
have been operated on by surgeons of the highest skill. I have 
rarely seen patients return with a carcinoma. The gastric analy- 
sis of these cases varies, sometimes there is much acid, sometimes it 
is diminished, there may even be none. 

CASE 7. — A farmer of fifty-six came to the hospital because of 
pain in his stomach. 

History. — Fourteen months ago he began without known cause to 
have diarrhea. There was much mucus in the stool and the move- 
ments were attended by cramping pain. There has been no blood in 
the stools. The pains Avere at first low in the abdomen but now 
are located in the upper abdomen. The symptoms improved at first 
under treatment but soon returned with increased intensity. His 



ABDOMINAL DISTRESS 689 

usual weight has been 130 but now is 107, most of this loss of 
weight has occurred in the last three months. At the present time 
pain is nearly constant and opiates are required to control it and 
despite them sleep is much interfered with. Eecently vomiting has 
set in. There never has been any jaundice. 

Examination. — The patient is sallow and has the worried look of 
a constant sufferer. The abdomen is flat and the walls are rigid. On 
palpation a hard, nodular mass the size of an orange is felt to the 
right of the median line in the hepatic triangle. The mass is fixed 
to the surrounding tissue. Inflation of the colon causes it to dis- 
tend below this mass. Inflation of the stomach causes this organ to 
distend to the left of the mass. The examination of the colon and 
sigmoid is negative. 

Diagnosis. — The onset with diarrhea and tenesmus with the loss 
of weight would suggest malignancy in the large bowel. The ulti- 
mate spontaneous disappearance of this symptom in a measure re- 
lieves this suspicion. The appearance of vomiting points to the 
stomach. The distention of the colon below the mass and the dila- 
tation of the stomach together with the typical site of the tumor fixes 
the growth near the pylorus. The size of the tumor would speak against 
its location on the large gut since the tumors in this situation are usu- 
ally annular and do not attain a large size. The subsequent ab- 
sence of constipation likewise speaks against a tumor in this situa- 
tion. The cause of the early diarrhea and tenesmus likely was 
reflex possibly when the peripherj" of the colon was first involved 
in the growth of the tumor. 

Treatment. — None. The tumor likely was inoperable and the pa- 
tient did not care to consider exploration with the possible gastro- 
enterostomy. 

After-course. — Vomiting increased and the patient died in about 
two months from starvation. 

Comment. — Usually when the initial symptoms of carcinoma have 
to do with carcinoma of the stomach one has not long to wait before 
the gastric preponderance declares itself. The characteristic of the 
colon symptoms secondary to carcinoma of the stomach in such cases 
is a sudden onset. When colon symptoms are due to disease of the 
colon itself, the onset is gradual. 



690 CLINICAL SURGERY BY CASE HISTORIES 

HEPATIC 

The common cause of discomfort in the hepatic triangle is a dis- 
turbed gall bladder, either from simple inflammation or "quiescent" 
gallstones. Yet evidence of organic changes should always be 
sought. Cardiac and lung diseases are prone to cause distress in 
this region. Organs in the lower abdomen not infrequently find the 
hepatic triangle a sympathetic sounding board. 

CASE 1. — A matron of fifty-six came to the hospital because of 
dig-estive disturbance, loss of weight, and heart trouble. 

History. — Menopause six months ago. Since then she has had a 
weak heart and periods of fainty feeling. She had jaundice four 
years ago which lasted six months. She lost 30 pounds during 
this period and has not regained her normal weight of 170 pounds. 
The chief complaint now is that she has no appetite and much of 
the time feels half nauseated. This is associated with shortness 
of breath and an irritable heart. This tendency is aggravated by 
any indiscretion in diet or overeating. She had some trouble with 
her heart eight years ago after taking a quantity of aspirin for 
headache. She never has had any trouble in lying down. Too 
much excitement tends to bring on the heart trouble. There never 
has been any actual pain in the region of the heart. Recently she 
has had a good deal of pain under the right shoulder blade and 
some under the right breast but never any tenderness. There has 
never been any bladder trouble but she gets up one or more times 
every night. 

Examination. — Large, well-nourished woman with a slight waxy 
pallor. Blood pressure 200, pulse 70 ; there is a sharp click at the sec- 
ond aortic sound and there is some extension of the transverse diam- 
eter of the heart. The abdomen is soft and flaccid. There is slight 
but definite tenderness over the gall bladder region. The urine and 
blood examinations are without interest. 

Diagnosis. — The attack of jaundice, the stomach disturbance, and 
the pain under the shoulder blades and under the breast indicated 
a gall bladder disturbance. The persistence of the symptoms without 
colic indicated inflammation rather than stone. This inflammation 
must have been severe at one time in order to produce jaundice. 
However, not infrequently a stone when fixed to the walls of the gall 
bladder produces prolonged irritation without colic. The results in 
the two conditions are the same. 



ABDOMINAL DISTRESS 691 

Treatment. — The gall bladder is distended and of a deep blue color. 
It empties partly on pressure and no stone is palpable. The gall 
bladder was removed. 

Pathology. — There are no obvious macroscopic changes in the gall 
bladder save a general granular appearance of the surface of the mu- 
cosa but no thickening of its walls. The slide shows round cells 
sparsely distributed throughout the mucosa and some hyaline degen- 
eration of connective tissue nearest the glands. 

After-course. — The relief from all the symptoms was prompt and 
complete. Six months later she had regained her weight and had no 
more heart attacks. She has remained well since. 

Comment. — This is a typical case of chronic cholecystitis, so-called, 
in which a chain of symptoms is removed, yet the tissue shows so little 
change when studied in the laboratory that the manner in which the 
changes are brought about is not clear. There must be a certain degree 
of irritation exerted on the nerves supplying the gall bladder that 
they exert a deleterious effect on tli£ surrounding organs. When the 
history points to the gall bladder as the source of irritation, if no 
stones are found its removal is more necessary than if stone is found. 
Drainage of the gall bladder is merely a subterfuge. 

CASE 2. — A housewife aged forty-six came to the hospital because 
of repeated attacks of pain in the region of the liver. 

History. — She has had repeated attacks of severe pain in the re- 
gion of the liver during the last eight years. At first they came 
on about once in three months. They were relieved by hypodermic 
injections. Following an attack five years ago she had pain in her 
side for a month. During the past year she has had frequent 
light attacks, the last one a week ago. She has lost some 40 pounds 
in weight. She has had much digestive disturbance and backache 
and some bladder irritation. 

Examination. — The patient is a small apprehensive woman who 
shows the effect of toil. The abdomen is lax, permitting palpation 
of the abdominal contents in an exceptional degree. There is deep 
tenderness in the hepatic triangle. The uterus is retroflexed, large, 
somewhat sensitive and the cervix is eroded. The perineum is lacer- 
ated to the second degree and there is a pronounced cystocele and rec- 
tocele. The urine is 1.010, contains pus cells. 

Diagnosis. — The diagnosis of gallstones may be made with a degree 
of certainty from the history. Likely the attack of jaundice five 



692 



CLINICAL SURGERY BY CASE HISTORIES 



years ago was due to an inflammation and not to a common duet 
stone. The gall bladder trouble probably accounts for the loss in 
weight. Obviously the pelvic lesions should likewise be repaired, but 
considering the general condition of the patient, operation on the 
gall bladder will be quite enough for one sitting. 

Treatment. — The gall bladder was found large and very long and 




Fig. 335. — Gall bladder with corrugations of the mucosa. There is a stone in 

the cystic duct. 

contained a quantity of stones. The easily accessible ones were re- 
moved, but one was firmly fixed in the cystic duct. The interior of the 
gall bladder was much congested and contained some strands of fi- 
brin. It was deemed best, therefore, to remove it. This was ex- 
ceedingly easy because of the laxity of the abdominal walls and the 
emaciated state of the patient. 



ABDOMINAL DISTRESS 693 

Pathology. — The interior of the gall bladder shows an unusual 
degree of corrugation (Fig. 325). Long bands of fibrin are attached 
to the papillary projections of the mucosa. The wall is thick and 
firm. The slide shows extensive round-celled infiltration and some 
loss of substance of the mucosa. 

After-course. — The patient waked up from the anesthesia promptly 
but the pulse was small and rapid. She took much fluid by mouth 
and received salt solution by the large bowel. The pulse became 
smaller and more rapid and on the third day her tongue became dry, 
she became delirious and died a day later. During the period follow- 
ing the operation she passed only eight ounces of urine which contained 
a little albumin and a few casts. The autopsy showed nothing ab- 
normal in the field of operation, and save for some cloudy swelling 
of the kidneys, some fatty degeneration of the liver and hypostatic 
pneumonia, there were no findings. 

Comment. — The findings were not those of a nephritis. Most like- 
ly death was caused by an acidosis, whatever that is. Patients who 
have become much emaciated from unknown causes are apt to die 
when operated on; it makes no difference how the operation is done. 
Perhaps a simple drainage would have been better surgery, but I 
have seen patients die in just the same way after simple drainage. 
Such patients should be put to bed and kept there until their nutri- 
tion improves. Whenever a patient has becomes emaciated from an 
unknown cause or from a cause not directly removable by the opera- 
tion, the surgeon will save himself embarrassment by deferring oper- 
ation. Chemical tests of the blood and urine for acetone will not 
give him a clue before operation or help him out once the process 
is started. Such tests are fine science, but a degree of perfection to 
the point where the studies are capable of materially helping the 
surgeon has not yet been reached. 

CASE 3. — A housewife of thirty-eight entered the hospital be- 
cause of cramping pains in the upper abdomen. 

History. — The patient has had four spells of severe pain under the 
short ribs on the right side. These pains begin in the back under the 
shoulder blade and extend to the front, then across to the left side, 
and finally they settle over the right side. There is tenderness for a 
week or two following the attack. She had her last one two weeks 
ago. It lasted twelve hours and she still has abdominal tenderness. 



694 CLINICAL SURGERY BY CASE HISTORIES 

Her general health is good. She has had ten children, the youngest 
two years old. There are no menstrual disturbances. 

Examination. — The patient is markedly tender over the gall blad- 
der and there is some muscular rigidity. The uterus is in position, is 
movable, and there is a slight laceration of the cervix with erosion. 

Diagnosis. — The location of the pain followed by tenderness gives 
the typical picture of gallstones. There is evidently a cholecystitis 
following the attacks as expressed by the tenderness, but since they 
only follow the attack, the removal of the cause should break the 
chain. Simple drainage appears the operation of choice. 

Treatment. — Cholecystectomy with the removal of three large gall 
stones was done. The gall bladder is free from adhesions, there is 
no thickening of the gall bladder or apparent change. 

After-course. — Recovery was uneventful and she remained well 
for a year, when she returned complaining of epigastric distention 
after eating, pain under the right shoulder blade, dizziness and con- 
stipation. She now complains of pain at menstruation. The onset 
is painful and after flowing a few days the flow ceases and then 
starts again with renewed pain. Her epigastric troubles are markedly 
worse at the menstrual periods. She was given antacids. She re- 
turned in a month complaining of shortness of breath and pains ex- 
tending to her heels. She is constipated and passed some blood from 
the bowel during the week. She has frequent urination, particularly 
during the periods, sometimes passing urine as often as three times 
in an hour. She has pain in the intermenstrual period like that 
she usually has at the menstrual period with augmentation of the 
epigastric distress. The patient now has a large and sensitive uterus. 
The cervical erosion is more pronounced. Her symptoms were relieved 
by taking hyoscyamus and bromides for three months. The epigastric 
symptoms likewise were relieved. The perineum and cervix were 
repaired and the hemorrhoids removed. She was freed from her 
symptoms. 

Comment. — When this patient returned after a year complaining 
of epigastric distress, I felt sure she had a recrudescence of the gall 
bladder condition. It was not until her second visit that the pelvic 
symptoms came to the fore. Uterine antispasmodics were given as 
a test and seemed to give the desired relief. Operation made this 
permanent. After the last operation she admitted that the pelvic 
symptoms had troubled her before and that she minimized them in 



ABDOMINAL DISTRESS 695 

order not to detract attention from the main trouble, the cramps. 
When questioned about the alleged pain under the shoulder blade 
she stated she probably was mistaken, that she so feared its recur- 
rence that she included it in her complaints. In suspected recurrences 
in any well defined disease that has been remedied it is often of im- 
portance to re-examine the whole picture lest what appears to be 
a recurrence may be an antecedent or a wholly disassociated disease. 

CASE 4. — A matron ag-ed thirty-four came to the hospital because 
of pain in the upper abdomen and nervousness. 

History. — The patient had two children aged six and eight years. 
No miscarriages. She has not been well for several years. She has 
had some pain in the right side under the short ribs, but it has 
never been severe enough to compel her to call a doctor. Her Avorst 
attack was a month ago. Sometimes the pains come on as often as 
two or three a week. She has vomited but once, but is often nauseated. 
When the pain is most severe, there is a griping, but at other times 
there is only a fullness in the gall bladder region. She has some 
gas but the appetite is good, and digestion is not affected by the pain. 
The patient has also a raised place in the right groin. It is not pain- 
ful, but makes her feel weak. Menses are slight and come on too soon. 
She has now menstruated three times in forty-five days. She has 
always had some leucorrhea. She has been nervous several years, 
subject to hot flashes, and palpitation. 

Examination. — Pulse is 100, full, bounding. The apex beat is 
diffuse but there is no tremor, goiter, or eye symptoms. She is nerv- 
ous and the epinephrine reaction suggests hyperthyroidism. There 
is tenderness over the gall bladder. The uterus is retroverted, and 
right ovary is behind the uterus and is very sensitive. Perineum is 
lacerated to the second degree. 

Diagnosis. — Because of the nervous state and the obvious pelvic dis- 
turbance, a repair of these is important for the preservation of the 
nervous equilibrium. The symptoms referred to the upper abdomen 
seem strongly indicative of gallstones. These may be a subject for 
exploration. 

Treatment. — The perineum was repaired, the round ligaments pli- 
cated and one gallstone removed and the gall bladder drained. 

After-course.— ^he was unusually distressed by gas after the oper- 
ation. After this was expelled the improvement was rapid. Four 
months after operation she had a sharp pain in the region of the 



696 CLINICAL SURGERY BY CASE HISTORIES 

gall bladder during the menstrual period, but not at other times. 
There is no pelvic distress during the menstruation and she now goes 
the regular length of time. The general nervous state has improved 
markedly and the symptoms referable to the upper abdomen have been 
absent for several years. 

Comment. — It was my impression that the one attack of subcostal 
pain indicated that the gall bladder should have been removed. From 
later developments it is possible that the attack was due to reactive 
processes which had not yet subsided after the operation. This was a 
hope rather than a prediction but events seem to have warranted it. 
The raised place in the right side, of which the patient spoke, evi- 
dently was a muscle contraction indicative of protection of a pain- 
ful ovary. 

CASE 5. — A matron of forty-nine entered the hospital because 
of abdominal pain. 

History. — The patient complains of recurrent pain in the hepatic 
region and epigastric distention. For a dozen years she has had 
periodic epigastric pains which radiate to the side along the costal 
margin to the back under the shoulder blade. She has never been 
jaundiced. Between the spells she feels quite well save that in recent 
years she has had severe indigestion. She has one child twenty-four 
years old. She has menstrual pain during the first few days. 

Examination. — She is a small, slight woman, with flaccid abdominal 
walls. There is distinct deep tenderness in the hepatic region. Be- 
low the costal arch is an ovoid tumor which glides freely between the 
hands in bimanual palpation and can be fixed between the hands and 
prevented from moving with the liver. 

Diagnosis. — The history and the tenderness indicates gallstones. 
The mass which glides under the costal margin is regarded as a mova- 
ble kidney. It seems surprisingly superficial but the thin, flaccid 
abdominal walls seem to account for this. 

Treatment. — Resorcin bismuth mixture. Advised operation. 

After-course. — After continued attacks for a year the patient con- 
sulted a surgeon who made a diagnosis of ovarian cyst and operated 
under this diagnosis. When the abdomen was opened no cyst was 
found but both ovaries were removed anyway. She continued to 
have pain and became weaker. I examined her again and found a 
globular tumor the size of a goose egg lying in the ileocecal region. 
The kidney could be palpated above it. The tumor could be pushed 



ABDOMINAL DISTRESS 697 

to the midline and up under the liver. The diagnosis now was cystic 
gall bladder. After the abdomen was opened, this was found to be 
correct. When the gall bladder was delivered, it reached nearly to 
Poupart's ligament and contained about a quart of clear mucid 
fluid. A single stone lay in the cystic duet. Cholecystectomy was 
done. She died some years later of carcinoma of the stomach. 

Comment. — Had I been more careful at the first examination I could 
no doubt have felt the kidney independent of the tumor. The failure 
of the previous operator to find the "ovarian cyst" after the abdo- 
men was opened is explained by the fact that he operated in the 
Trendelenburg position and the tumor gravitated up under the liver. 

CASE 6. — A matron of thirty-fi.ve came in with the complaint of 
pain in the shoulder and in the region of the liver. 

History. — The patient has two children, the youngest twelve years 
of age. Menstruation is regular and lasts four or five days. She 
had an appendectomy and cervical repair seveji years ago. She now 
complains of pain in the right shoulder and neck so severe that she 
can not do her work. The pain is worse at the menses, at which 
time the arm aches all the way to the fingers. These pains are worse 
in damp weather. She has pain under the right short ribs as well 
as back at times, which extend back under the shoulder blade. These 
pains are never severe. She has some pain before and after menstrua- 
tion, none during the flow. 

Examination. — The uterus is in position. It is somewhat sensitive 
on bimanual examination. X-ray of the right kidney region is neg- 
ative. The cervix is extensively eroded. There is pronounced deep 
tenderness over the gall bladder. The 10th intercostal nerve is sen- 
sitive along its course. 

Diagnosis. — The pain in the neck and the backache are reflex from 
the cervical erosion. The constant soreness under the shoulder and 
the occasional pains under the costal margin may be of the same 
origin, though the deep pain in the hepatic triangle is suggestive of 
gall bladder disease. 

Treatment. — The gall bladder was found adherent to the great 
omentum which was separated from it with some difficulty. The 
gall bladder contained stones which were removed and a drain in- 
serted. The cervix and perineum were repaired. 

After-course. — Combinations of pelvic and gall bladder symptoms 
are frequently encountered and their separation may be difiicult. 



698 CLINICAL SURGERY BY CASE HISTORIES 

In this instance there is nothing in the history to indicate when 
sufficient reaction took place about the gall bladder to invite omental 
adhesions. The patient had eclampsia during her last confinement 
and since gall bladder troubles are prone to light up at such times, the 
adhesions may have taken place then without exciting attention and 
the reaction resulting may have been masked by the graver malady. 

CASE 7. — A professional man aged forty-two came because of 
pain in the right upper abdomen. 

History. — He has had several attacks of cramping in the upper 
abdomen. They lasted a few hours or less, and after a period of 
soreness, would subside. The present attack began four days ago 
with severe pain. This has persisted until the present time. He 
has had fever from the beginning and it still persists. 

Examination. — There is marked sensitiveness in the hepatic trian- 
gle. The whole area is marked by muscular rigidity. The remainder 
of the abdomen is free from pain and rigidity. Pulse 90, temperature 
102°, respiration 22. 

Diagnosis. — This evidently is an acute cholecystitis and perichole- 
cystitis. Evidently his previous attacks were colic without note- 
worthy inflammation. Likely, therefore, there are stones present. 
The attack probably will subside, but having persisted four days, 
grave changes may be taking place. At any rate he is suffering 
acute pain, and being a professional man, this is a matter of great 
importance. At least a drainage seems demanded, possibly a re- 
moval of the gall bladder. The details of this must be determined 
at operation. 

Treatment. — After the gall bladder was exposed, it was found that 
it was wholly surrounded by adhesions, leaving but its summit ex- 
posed (Fig. 326). In view of this fact it seemed best to do a sim- 
ple drainage rather than run the risks involved in a removal of the 
gall bladder. The gall bladder was, therefore, opened, and a quantity 
of stones with dark bile above and whitish pus at the bottom was 
found. A drainage tube was inserted and a small gauze drain was 
placed about it. 

After-course. — He got up on the fourth day and in a week or so 
went about his business. He remained well for seven years, when 
he began to have pains again. At first they were not severe, but sub- 
sequent attacks became more pronounced. One attack lasted a week 
and he suggested a removal of the gall bladder. This was under- 



ABDOMINAL DISTRESS 



699 



taken. The gall bladder was of medium size, the walls thickened 
but there was not a sign of the adhesions present at the first operation. 
The common duct likewise was large, hard and thick. The anesthetic 
was given in an abominable fashion and I feared to open the common 
duct under such conditions and a simple cholecystectomy was done. 
The pains continued and five days later he passed a stone per anus. 
Following this he was completely relieved and has remained so. 



A V 


\ 






^' ^^m .. 




m^^E^^^uE^^^ -' , »• • t-^ ,~ ' 


^ 


^St^^lUliiilUf^fSlSSSSt^^^^ 


jj^H^^^^^^^^I 



Fig. 326. — Dilatation of the vessels in the hepatocolic ligament in a patient who had had 
many attacks of cholecystitis, but at the time of operation was free from symptoms. 

Comment. — There is a question as to what should have been done 
at the first operation. Undoubtedly the safest plan was chosen. To 
have removed the gall bladder then would not have insured against 
leaving a stone in the common duct. To open the duct in the face of 
pronounced infection is to invite a cholangitis. The time of the sec- 
ond operation was ill chosen. It should have been done earlier, when 
the first recurrence was noted. Even with a good anesthetic the open- 
ing of the common duct would have increased the risk, but leaving 



700 CLINICAL SURGERY BY CASE HISTORIES 

it untouched was poor surgery and was so recognized. That the 
stone passed spontaneously was a fortuitous circumstance and came 
to relieve a bad situation. Had it not done so, a third operation 
would have been demanded before a tinal cure could have been ex- 
pected. When operations are done in the acute stage and adhesions 
can be separated without producing too much bleeding, and the 
common duct can be readily palpated and declared free from stone, 
then the removal of the gall bladder is the ideal procedure. If the 
duct is thick, the only way one can be sure it does not harbor a stone 
is to open and explore it. "When jaundice is present, this is a hazard- 
ous procedure, and in such cases simple drainage alone is permissible. 

CASE 8. — A housewife of fifty-two came to the hospital because 
of pain in the abdomen and indigestion. 

History. — The patient had typhoid fever twenty-six years ago. Her 
general health has never been good since that time. She has always 
been constipated and her appetite is always poor. She had attacks 
of pain in the right side under the short ribs at intervals for twenty 
years. They were often associated with vomiting. During the past 
few years she has had only two or three attacks a year. They were 
so severe that a doctor had to be called. She has not been jaundiced 
in any of these attacks. Two weeks ago she had her last attack. 
There was pain in the right side and in the back under the shoulder 
blade and she was "sick all over." She had fever for some days and 
has felt weak ever since. 

Examination. — The patient is weak and emaciated — with a sallow 
complexion. She has temperature 100, pulse 80, respiration 22. 
There is marked tenderness in the hepatic triangle and some rigidity. 
Urine 1.008, a trace of albumin, no casts. 

Diagnosis. — The history of gall bladder infection from the time of 
the typhoid fever stands out with unusual clearness. The generally 
impaired health speaks for a continued infection. The acute attacks 
of pain suggest a stone. There has been no jaundice and no chills. 
The slight fever observed from time to time is quite compatible with 
an infection associated with gallstones. The general impairment 
of the health of the patient suggests a continued intoxication. In 
such instances a removal of the gall bladder is indicated, whether 
stones are present or not. Whether or not the operation shall be 
done now or wait a fever-free period must be decided. There seems 
but little prospect of a much more favorable time, and since it is more 



ABDOMINAL DISTRESS 701 

convenient to do the operation at once, it shall be done. There is 
no evidence pointing to a common duct stone. 

Treatment. — A mass of adhesions exist between the liver, duode- 
num, and colon. Though the separation was carefully conducted, 
the duodenum was opened into. The opening was closed at once. 
Great difficulty was experienced in finding the gall bladder. It was 
finally found as an object as thick as a finger and about two inches 
long. There was a stone in the bottom of it. The common duct was 
not opened, though its walls were so thick that palpation was of little 
value. The gall bladder was removed. The cystic duct was much 
thickened down to the common duct. A drain was placed to the 
site of operation. 

Pathology. — The nub of gall bladder obtained had very much 
thickened w^alls so that scarcely any cavity remained except below 
where a stone as large as a hazelnut lay. The walls were made up 
of dense fibrous tissue with much round-celled infiltration. The epi- 
thelial lining was reduced to patches of low epithelium. 

After-course. — A duodenal fistula formed which closed after seven 
weeks. Fortunately the opening was small. She gradually gained 
in health and after a year was in good health, better than for many 
years. 

Comment. — The common duct was not explored because the opera- 
tion already was severe, due to the extent and character of the adhe- 
sions. There was good reason from the history to feel that the duct 
was free from stone, though the conditions were such that no trust- 
worthy information could be gained from palpation. Since the cys- 
tic duct was thickened down to the common duct it seemed likely 
that the thickening of the common duct was a continuation from above. 
If such were the case, with the removal of the source of infection 
the thickening should subside. From the findings at operation it 
is a bit surprising that such acute exacerbations should have appeared 
so late in the stage of development. 

CASE 9. — A school teacher aged fifty-two came to the hospital for 
relief from a discharging- fistula of the abdominal wall. 

History. — A year ago the patient had an attack of abdominal pain 
which was diagnosed appendicitis and an operation was performed. 
When the incision was made, the appendix was found normal, but 
there was an abscess of the gall bladder, the surgeon explained. The 
gall bladder was drained through the appendix incision. A fistula 



702 



CLINICAL SURGERY BY CASE HISTORIES 



has remained ever since the operation. It requires about two dress- 
ings a day because of the escape of a pale green fluid. When the fis- 
tula closes, pain begins, which is relieved when it opens again. The 
drainage is nonirritating to the skin. 

Examination. — -There is a fistula leading to the gall bladder region. 
At the bottom of this the probe impinges on a stone. 

Diagnosis. — Fistula of the gall bladder with an impacted stone in 
the cystic duct. 



I 


i. 




I 






1 


mt 

^ 





Fig. 327. — Fistulous gall bladder containing a stone in the cystic duct. 



Treatment. — The mouth of the fistulous opening was circumscribed 
and the contracted gall bladder freed from above downward. At the 
lower part of the cystic duct a stone as large as a hazelnut was 
found. The cholecystectomy was completed. 

Pathology. — A stone the size of a marble lay deep in the gall blad- 
der (Fig. 327). The gall bladder wall is thickened and microscopic 



ABDOMINAL DISTRESS 703 

examination shows a considerable round-cell infiltration of the wall 
with a colloid degeneration of the submucosa. 

After-course. — Recovery was prompt and complete. 

Comment. — The operator who did the first operation was of lim- 
ited experience and he did well to limit his efforts to simple drainage. 
This relieved the patient from her immediate trouble. Had jie been 
an expert operator he would have done well to have removed the 
gall bladder, since there were no adhesions to make such a procedure 
extra hazardous. 

CASE 10. — A matron of forty-two came because of pain in her 
right side. 

History. — The patient began menstruating at the age of thirteen; 
periods were always regular, not painful. She has had three chil- 
dren, the second child dying soon after birth. The others are 
living and well, the youngest being eleven years old. The patient's 
father died of hemorrhage of the stomach, at the age of seventy- 
three; her mother, with congestion of the stomach at the age of 
seventy-eight; and a sister, with a tumor of the uterus. Thirteen 
years ago, while working, the patient was seized with severe cramp- 
like pain in the epigastrium. The pain soon spread over the en- 
tire abdomen. She said it felt as though something had burst in 
the right side. The attack lasted about two days, though she was 
not confined to bed. Since then the attacks have recurred two to 
three times a year and last from one to five days. The pain is 
always in the right upper quadrant of the abdomen, with tender- 
ness two fingers below the right costal margin and three fingers from 
the median line. The pain also radiates to the inferior angle of 
the right scapula. The present attack began seven days ago fol- 
lowing a two weeks' siege of la grippe. The cramp-like pain 
came on suddenly, was more intense over the region of the gall 
bladder, and radiated to the inferior angle of the right scapula. 
There was vomiting when anything was taken by mouth, the vomi- 
tus was greenish-yellow in color but contained no blood. Two to 
three hypodermic injections daily were required to control the 
pain. Menstruation is painless and regular, lasting usually five 
days. There has been a tendency to an increased flow during the 
past six months. 

Exami7iation. — The patient is poorly nourished. Lungs negative; 
heart irregular in rate and rhythm, apex visible at the fifth inter- 



704 CLINICAL SURGERY BY CASE HISTORIES 

space. Two inches to the left of the midsternal line there is a loud 
systolic murmur replacing the second sound, and ending in a loud 
first sound, best heard at the apex. There is slight tenderness over 
the gall bladder and also over McBurney's point. She has had clay 
colored stools during the last week. The perineum is lax and there 
is a marked cystocele. The cervix is eroded, presenting a mass the 
size of a small hickory nut at the posterior part of the cervical canal 
(Fig. 328). It is fairly sharply defined from the surrounding tis- 
sue but it bleeds readily when touched. The urine is cloudy, con- 
tains some albumin, but no casts. 

Diagnosis. — The various elements that go to make up this symptom- 
complex are simple enough, but their association makes them of 
interest. There is evidently a mitral stenosis. The gall bladder 




Fig. 328. — Carcinoma of the cervix. 



attacks likewise are typical enough. Sometimes heart disorders 
are characterized by pain in the hepatic region. These do not 
extend over such a long period of years and there are usually other 
evidences of decompensation. Hepatic pain due to cardiac dis- 
turbances does not require such large doses of morphine for its 
relief. The accidental discovery of the cervical tumor is of especial 
interest. The location of the tumor in one quadrant of the cervix 
makes it suspicious. Its density and tendency to bleed is sufficiently 
characteristic of carcinoma. 

Treatment. — Despite the discomfort of the gall bladder condition 
the cervical disease was regarded as the more important. Therefore 
the cap of the vagina, the basis of the broad ligament and the en- 
tire cervix were removed. Because of the patient's poor general con- 



ABDOMINAL DISTRESS 705 

dition and the heart lesion, the operation was done under local anes- 
thesia. 

Pathology. — Section shows an early adenocarcinoma. 

After-course. — The recovery from the operation was satisfactory. 
Two months after the first operation the gall bladder was relieved of 
a number of stones, likewise under local anesthesia. After the re- 
covery from these operations, there was considerable improvement in 
the general health. She is still in good health five years after opera- 
tion. 

Comment. — Had I to operate on this cervix now, I should do it 
under spinal instead of local anesthesia. This case shows the ad- 
vantage to be gained by a thorough general examination. 

RENAL 

Simple distress in the renal region is prone to be due to circulator}' 
disturbance in the kidney itself or referred pains from the germinal 
glands. Static disturbances in the spine and its attached structures 
often are at the bottom of such disturbances. 

CASE 1. — A professional man a-ged thirty-five came because of 
pain in the rig-ht upper abdomen. 

History. — Eighteen years ago the patient was kicked in the abdo- 
men in a football game. He was unconscious twelve hours but was 
able to be about the next day. He has never been well since. Dur- 
ing the next two years he had attacks of obstruction at intervals. 
He was operated on by a competent surgeon who found "mesenteric 
hernia" and removed the appendix. During the next twelve years 
he had stomach symptoms, some sourness, with pain and soreness in 
the right upper abdomen. He finally became incapacitated and went 
to a distinguished diagnostician who diagnosed neurasthenia. He 
was later explored by a distinguished surgeon who found a very 
large cecum and ascending colon with adhesions. The adhesions 
were removed. Improvement folloAved this procedure. It did not 
last, however, and a year and a half later the ascending colon, 
a fourth of the transverse colon, and ten inches of ileum were 
resected. He had a stormy convalescence having a fever of 102° 
to 103° for two weeks with pain in the hepatic triangle, and rusty 
sputum and a leucocytosis of 23,000. A clear effusion developed 
in the chest. Later a phlebitis of the left leg developed. After 
a time he improved and did pretty well for a year. During the 



706 CLINICAL SURGERY BY CASE HISTORIES 

past year he has again had attacks of pain in the hepatic triangle. It 
conies on sometimes once a month, sometimes two or three times a 
month. It seems to come on after exhaustion and lasts several 
days. It comes on gradually with pain and vomiting. The bowels 
are regular during these attacks but there is some dizziness. He 
began a course of rest six months ago with forced feeding. He 
has gained 30 pounds since then. He was able to work for a time 
but had to take a protracted rest recently. His chief complaint now 
is pain in the gall bladder region with hyperacidity and eructations. 

Examination. — The patient is obviously on a high nervous tension, 
but seems well nourished. Physical examination is negative save for 
extensive abdominal scars the result of his numerous operations. 
There is possibly a slight general sensitiveness and a little tympany. 
The x-ray shows a delay of the barium current in the colon and the 
descending colon is much contracted. 

Diagnosis. — Symptoms of obstruction which are associated with 
hyperacidity are usually spastic in character and when these symp- 
toms coexist there is usually a preformed nervous substratum back of 
it. Unfortunately when these cases are once operated on, adhesions 
often form which give a real organic basis for subsequent complaints. 
The multitude of complications after the last operation seems to have 
left no trace. The fact that he has been in fair health at intervals 
but suddenly becomes exhausted indicates a nervous disturbance 
rather than an organic disease. The best guide to such nervous spastic 
states is usually a hurrying of the barium meal through the stomach 
and small intestines only to linger in the large bowel. In such cases 
operation is never indicated. 

• Treatment. — He was placed on hyoscyamus and bromides in suffi- 
cient doses to control nervousness and insure reasonable sleep. 

After-course. — He began to improve at once and has continued in 
good health. 

Comment. — It is a mistake to operate on such patients. The nervous 
exhaustion is but increased by the burden of the operation. Happily 
these extensive operations on the colon are now things of the past. 

CASE 2. — A school girl of fifteen came because of pain in the 
right side. 

History. — Her general health has always been good save that she 
has had three attacks of pain in the right side at intervals of six 



ABDOMINAL DISTRESS 707 

months. The last, two months ago, was associated with local ten- 
derness, fever, and vomiting. 

Examination. — Nothing abnormal could be discovered on examina- 
tion. 

Diagnosis. — The diagnosis of appendicitis made by her physician 
had to be accepted from the history. 

Treatment. — Appendectomy. 

Pathology. — The appendix feels hard at its lower extremity. On 
section it is solid below near the tip but further up contains a lumen. 
The microscopic picture shows many groups of epithelial cells scat- 
tered throughout the mucosa and submucosa. (Fig. 329.) 




carcinoma of the appendix. A, gross. B, microscopic. 



Comment. — This is a typical so-called carcinoma of the appendix. 
It bears no clinical or anatomic relation to carcinoma. One sees the 
counterpart in the tips of Meckel's diverticula and it should be re- 
garded as congenital peculiarities and not as proliferating cell proc- 
esses tending to destroy life, as carcinomas do. 

CASE 3. — A matron aged thirty-seven came because of pain just 
inside the anterior superior spine of the ilium. 

History. — Her present trouble began about three. years ago. The 
first two years she had attacks of pain in the right side at intervals 
of six weeks to two months. This was not severe and she did nothing 



708 CLINICAL SURGERY BY CASE HISTORIES 

for it. It lasted a day or two and was gone. During the last year 
they have come on every two or three weeks and were very severe. 
They sometimes came on very suddenly and radiated to the vulva. 
The spasm would last 10 to 15 minutes and then develop into a dull 
pain which lasted for several days. She never vomited with the 
pain but felt slightly nauseated at times. She thinks she has some 
fever. The pain was made worse by lifting, and was worse before 
the menstrual period. The pain was not accompanied by urinary 
symptoms. Appetite good. She is always very constipated and has 
headache occasionally. She used to have much cramping pain at the 




Fig. 330. — Luteal cyst of the ovary. 

menstrual periods but these have been less during the past year. She 
has never been pregnant. 

Examination. — The heart, lungs, and abdomen are negative. The 
uterus is slightly retroverted. There is a mass the size of a small 
orange to the right of the uterus. The mass and the uterus are in- 
dependently movable. The mass is firm, elastic, somewhat irregular, 
and not sensitive to pressure. 

Diagnosis. — The history sounds like appendicular colic during the 
first two years, but during the past year were evidently ovarian, a 
supposition confirmed by finding a tumor beside the uterus. The 
fact that they are now worse before the menstrual period and worse 
on lifting indicates the same thing. The tumor is firm but not solid, 



ABDOMINAL DISTRESS 



709 



which together with its form would suggest a dermoid but it is causing 
too much pain to be a dermoid. If it is a dermoid, there must be secon- 
dary changes. It is too large to be an ovarian hematoma. 

Treatment. — Resection of the cyst of the right ovary the size of an 
orange. Resection of hematoma of left ovary size of a walnut. The 
appendix was small, hard, white in appearance, and was removed. 

Pathology. — The section of the right ovary (Fig. 330) shows a thick- 




Fig. 331. — Hemorrhagic ovary. 




Fig. 332. — Ovarian cyst with hemorrhage. 

ened cortex with a large cyst in the center. The cyst contains a whit- 
ish mass lining it, which has retracted from a part of the wall. The 
slide shows this to be a luteal wall. The left shows a hematoma the 
size of a walnut (Fig. 331) with a portion of the medullary portion 
of the ovary at. one pole, and a recent hematoma between this pole 
and the larger and older hematoma (Fig. 332). The appendix is 
sclerotic, the mucous membrane having almost entirely disappeared. 



710 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — She was much improved but has ovarian pains at 
times. 

Comment. — The question is the relation of the appendix to the 
attacks earlier in the complaint. One might suppose that the changes 
took place earlier in the attack and were responsible for them. 
However, we know nothing about the genesis of these uniformly 
sclerosed appendices. The ovaries show sufficient changes to ac- 
count for the symptoms complained of. The alleged conservative 
surgery of ovarian resection is usually greater meddlesomeness but 
in cases like this in which there are definite pathologic changes re- 
section is the only means of removing the disease and retaining the 
menstrual function. Likely sclerotic changes in the remaining por- 
tions of the ovaries are responsible for her occasional pelvic pains. 

ILEOCECAL 

The common cause of continuous distress in the inguinal and 
ileocecal regions is ovarian in origin, much less commonly to dis- 
ease of the appendix. Tumors and low grade infections in the broad 
ligament not infrequently are the exciting factors. 

Case 1. — A housewife aged thirty-seven sought relief from pain 
in the lower abdomen. 

History. — She has never been real strong ; she had a nervous break- 
down thirteen years ago. She had earache as a child, and a discharge 
followed. The right ear still discharges at intervals. Her menses 
began at 11, regular, free flow, five-day type. Used to have dysmen- 
orrhea but has none now. Was married at twenty-three; has never 
been pregnant. She has a little leucorrhea sometimes before periods 
but not sufficient to wear a pad for it. Some backache for years, 
not worse at periods. 

The present trouble came on with attacks of pain in the right 
side low down, lasting several days, at intervals of a month or six 
weeks or longer. They bear no relation to the periods. They are 
now occurring further apart but are more severe than formerly. She 
has about one attack a year now, but they last several weeks. With 
the pain in the right side she has gas and bloating. She does not 
know whether she has fever or not, but she has to go to bed. There 
are some urinary symptoms, notably difficulty in voiding with burn- 
ing at times. Sometimes she has palpitation. The last spell began six 



ABDOMINAL DISTRESS 711 

weeks ago. The family doctor diagnosticated appendicitis and ad- 
vised operation. 

Examination. — There is sensitiveness over the sixth space and 
some over the lower abdomen. There is no muscular rigidity. The 
pelvis is filled by a hard nodular mass apparently attached to the 
uterus. Uterus feels as though it were pushed against the pubes. 
There is a nodule above the left border of the pelvis the size of an 
egg, apparently attached to main tumor. 

Treatment. — A mass the size of a double fist occupying the fundus 
of the uterus Avas found, also a nodule the size of a hen's egg in the 
left cornua of the uterus. A supravaginal hysterectomy was done. 

After-course. — Recovery was entirely uneventful. The abdominal 
wound healed by first intention and the patient made a good recovery. 
On dismissal the abdominal wound was entirely healed. Vaginal ex- 
amination showed the stump of the cervix down low against the an- 
terior vaginal wall. Some thickening and tenderness on each side of 
the cervical stump in the broad ligaments. Cervical stump rather 
fixed. She gradually improved and has remained well. 

Comment. — There evidently had been considerable exudation about 
the field of operation. This delays recovery but does not prevent 
it. Her complaints were obviously due to the growing tumor. Had 
her physician examined her pelvic organs he would not have thought 
of the appendix. He did urge the need of a pelvic examination, 
but the patient refused to submit. 

Case 2. — A lady aged thirty-three, a bookkeeper, came to the 
hospital because of pain in the right side. 

History. — Ten years ago she had a sudden pain in the right side 
low down with some bladder irritation. Within a few days the right 
breast became very painful and sensitive and it was enlarged. At 
the end of a week the pain extended to the left side of the pelvis 
and a few days following this the left breast enlarged and became 
sensitive as the right had done. At this time she began to have a 
discharge from the vagina. She has had more or less leucorrhea since 
that time. Six years ago she had nausea and pain in the stomach 
and some fever. This continued several weeks and the doctor called 
it walking typhoid. Two months ago she was seized with pain in 
the stomach and vomited at intervals for three days. She could not 
eat, and ptomain poisoning was diagnosticated. She was in bed a 
week. Two weeks ago there was a renewal of this attack and in 



712 CLINICAL SURGERY BY CASE HISTORIES 

addition she had a pain in the right side above the hip bone. She 
was unable to straighten her leg. She had a severe pain in the back 
just below the ribs, which was more severe than the pain in the ab- 
domen. She had frequent urination and the urine was highly colored. 
Her doctor reported a temperature up to 103°. She has lost 10 
pounds in weight and has not slept well, though she is not nervous. 
She had various diseases of childhood and has had from one to 
three attacks of tonsillitis every winter. Her menses are regular, 
are painful the first two days, and last three or four days. 

Examination. — Save for deep tenderness in the lower abdomen, more 
marked on the right side than on the left, the physical examination 
is negative. The urine contains a few leucocytes. There was no blood 
on a number of examinations. W.b.c. 5,200, Hg. and E.b.c. normal. 

Diagnosis. — Recurrent epigastric pains with nausea and vomiting 
suggest appendicitis. This suspicion is strengthened by the recent 
localization of pain in the right inguinal region. At the first attack, 
too, there was pain low down first on the right then on the left side. 
This may be interpreted as having been an infection of the pelvis 
from an overhanging appendix which gradually crept across the pel- 
vis. She had a vaginal discharge following the pelvic irritation. A 
rural lass of thirteen would not likely have an ascending infection. 
This charitable view is substantiated by the fact that the leucorrhea 
followed the pelvic inflammation. Had the infection been of extra- 
neous origin, the leucorrhea would have preceded the pelvic irri- 
tation. The recent pain in the region of the right kidney likely 
is due to a ureteritis. That the inflammation about the appendix 
extends deeply is shown by the unusual degree of involvement of 
the psoas muscles. The absence of fever and leucocytosis indicates 
that the infection has subsided or that it is fully encapsulated. 

Treatment. — Since there was an early history of involvement of 
both sides of the pelvis a midline incision was made. The omen- 
tum and several loops of intestine were adherent to the tubes. The 
right tube and a tongue of omentum were attached to the appendix 
at its tip. The base of the appendix was firmly attached to the 
parietal peritoneum just above the brim of the pelvis. The appendix 
was removed and the adhesions separated. 

Pathology. — The appendix showed an extensive sclerosis near its 
base with more recent edema and round-celled infiltration in its 
more distal parts. 



ABDOMINAL DISTRESS 713 

After-course. — The recovery was uneventful until the ninth day, 
when she had a severe pain in the right renal region. This was so 
great as to require an anodyne. She had a trace of albumin and a 
considerable number of red cells in the urine. These elements les- 
sened and in a few days disappeared, never to return. The close 
proximity of the appendix to the ureter requiring violent separation 
may have accounted for this pain. There were no bacteria in the 
urine. 

Comment. — Obviously this patient had an early attack of appendici- 
tis which extended across the pelvis producing adhesions which en- 
dured. The subsequent attacks were confined to the appendix and 
its immediate environs. Many adhesions discovered later in life, and 
too often ascribed to unholy sources, find their origin in a past appen- 
dicitis. One is convinced of this if he systematically explores the pel- 
vis in appendix operations done on girls and young women. 

Case 3. — A housewife aged thirty-two came to the hospital seek- 
ing relief from pain in the left side and backache. 

History. — Her trouble began with the birth of her last child, seven 
years ago, when she was badly lacerated. The lacerations were not 
repaired then, but were repaired five years ago. The trouble began 
with a numbness which started in the left hand and passed over 
the body. The hands and feet got very cold and she vomited a slimy 
mucus and has continued to have spells up to the present time. Af- 
ter the attack is over, she gets a dull, steady pain low down in the 
left side of the abdomen. These spells always come on from one to 
three days before the period and continue until stopped by hypo- 
dermics or sedative medication. The pain sometimes stops with the 
period but often stays for two or three weeks. This experience is 
repeated every month. She says she has only about 10 good days be- 
tween the periods. When the trouble began the spells did not come 
every month, but they have come regularly for the past eighteen 
months. She can do no work without getting a backache. She has 
frequency of urination with small amounts of urine and uncomfort- 
able feeling without actual pain. The frequency is most marked 
at night. After her monthly nervous spells, the frequency is much 
worse. She has three living children and has had four miscarriages. 
Her appetite is good but the bowels are habitually constipated. She 
has very little headache. Very little discharge between periods. 



714 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — There is abdominal tenderness to pressure over 
both iliac regions and over the bladder. The perineum is lax, the 
uterus is in position and movable. Left ovary is the size of an egg and 
is sensitive; the right ovary is not palpable. There are three large 
hemorrhoids. 

Diagnosis. — The physical findings do not account for her multi- 
tudinous pains, neither does the appearance and attitude of the hus- 
band account for it. A small fibroma near the horn may be present. 
The most obvious cause is the large and sensitive ovary. The pros- 
pect for relief rests on the assumption that the ovary is the cause, 
or that something will be found to account for it, or finally if there 
is an important neurotic element that this can be controlled by after 
management. 

Treatment. — The three hemorrhoids were removed. The left cystic 
ovary, about three times normal size, was removed. The veins of 
the pampiniform plexus were varicosed and were ligated and resected. 
There was no tumor of the uterus. 

Pathology. — The ovary was polycystic. 

After-course. — She complained much of pain for some months 
but with sedatives and general encouragement she is now free from 
complaints and most likely free from suffering. 

Comment. — It is still not clear how much the operation and how 
much the general treatment had to do with restoring the patient's 
equilibrium. The pampiniform plexus was removed and with it I 
hope the nerves supplying the uterus. This may have been a factor. 
Symptoms usually due to pampiniform varicocele, namely heavy 
dragging especially when on the feet, was lacking here. The ovary 
must have been the chief cause. This is the more easily acceptable 
since the complaints are sometimes duplicated in males who have had 
unskillful operations done on their cords — a condition denomi- 
nated "irritable testis" by Sir Astlay Cooper. Patients with com- 
plaints not in harmony with the anatomic findings must be followed 
after they leave the hospital. 

Case 4. — ^A matron aged thirty-seven came complaining of pains 
in the left groin, bloating, and frequent urination. 

History. — The patient has one child twelve years old. She had 
dysmenorrhea as a girl ; at sixteen had an attack of anemia last- 
ing six months. About five years ago she began to have pain in the 
left groin. At first it came on at intervals of two or three weeks 



ABDOMINAL DISTRESS 715 

and lasted two or three days only, but in the last six months it has 
been nearly constant. During the past three years she has had a 
severe pain in the back. This pain is below the small of the back 
and is steady. When she is on her feet much during the day her 
ankles become puffy. It disappears during the night. She has se- 
vere pains in the back of the bead and some in the temples. These 
come on at intervals of a few days to several weeks. She becomes 
nauseated in these attacks and sometimes vomits. She has bloating 
at times, but her appetite is good and she suffers no notable indi- 
gestion. She is obstinately constipated. Urination is frequent, small 
in amount, and causes burning. Three years ago she had a severe at- 
tack of epigastric pain with vomiting, which lasted an hour. She 
describes the pain as agonizing. The next day she passed several 
stones, about the size of grape seeds, per rectum. 

Examination. — There is tenderness in the left groin, none elsewhere 
over the abdomen. The hepatic region is not tender. The perineum 
is lax, the cervix lacerated and the fundus retroflexed. There is 
a mass to the right of the fundus. The urine, save for a pronounced 
acidity and high specific gravity, is normal. 

Diagnosis. — This patient seems to fulfill all the requirements for 
entrance into the *' pelvic case" league. The backache, and groin 
pain sometimes extending down the legs, and the headaches, all point 
to the same thing. The cause of the intense groin pains probably in- 
dicates some special trouble with the left ovary. The epigastric pain 
described has all the earmarks of a gallstone colic. The statement 
that she passed several stones the size of grape seeds may have been 
aided by the excitement of anticipation. The bladder irritation 
is probably a part of the pelvic congestion as are also the leg pains 
and evening edema. 

Treatment. — A trachelorrhaphy was done. The mass lying to the 
right of the uterus proved to be due to an adhesion between the ap- 
pendix and ovary. The appendix was removed. A large solitary 
stone was found in the gall bladder. The stone was held in the 
grasp of the gall bladder, causing the whole to look like a segment 
of a snake which has recently swallowed a bird. 

After-course. — Recovery was uninterrupted. The final result can 
not yet be determined. 

Comment. — Such cases are common among the simple folk, who 
labor hard and do not dissipate. The difficulty in management is 



716 CLINICAL SURGERY BY CASE HISTORIES 

that the repair of the tangible organic lesions is but a small part of 
the treatment that should be applied. Usually they have borne a 
lot of children and often the condition is aggravated by marital ex- 
cesses or by measures used to prevent conception. The pain down 
the legs and the swelling, usually limited to the region above the 
ankles, are all but phenomena referred from the congested organs 
in the pelvis. Such cases must be followed after they leave the 
hospital. 

Case 5. — A retired fanner aged 70 years came to the hospital be- 
cause of pain in the lower abdomen and obstipation. 

History. — The patient's past history is negative. His present 
trouble began about two months ago when he was taken rather sud- 
denly with a griping pain in the lower abdomen. He felt as though 
the bowels wished to move. They did move a little and then sud- 
denly shut off. The griping then began worse than before and was 
accompanied by vomiting. The local doctor gave him an enema, got 
his bowels to act, and he felt relieved. His bowels then moved 
fairly well after that and he felt all right. Since that time he has 
never had an exactly similar spell, but he has had to take cathar- 
tics all the time or he becomes constipated, and when the bowels 
stopped acting he could only get them started again with great diffi- 
culty after three or four days. During all this time he felt gener- 
ally bad all over and had some griping in the lower abdomen. His 
general health is good. His appetite is very poor. He sleeps well. 
His urine is slow in starting but he says it has always been so. He 
passes a normal stream. There is no pain or burning or frequency. 
He has no headaches or dizziness. He has lost 40 pounds in the last 
two months. He has never been jaundiced. 

He has had a great deal of trouble with his stomach since his 
trouble began. The food has never tasted good. He has eructa- 
tions of a sour substance. He has no pain after eating. In the last 
two months he has had several vomiting spells. The quantity has 
been large and he thinks it was caused by too much food. The 
vomitus is green. Never contains any* blood. 

Examination. — Blood pressure 160-70. No marked degree of ar- 
teriosclerosis, no discoloration of the skin. Marked arcus senilis, scar 
in front of right pupil. Chest markedly emphysematous. Heart 
outline hard to determine on account of hyperresonance due to em- 
physema. Apex beat not discoverable, no murmurs, tones faint. 



ABDOMINAL DISTRESS 717 

Hyperresonance over both lungs. No areas of dullness or rales. No 
abdominal masses palpable. Some tenderness to deep pressure in 
right iliac region. Nothing palpable by digital reetal examination. 
Hb. 70, W.b.c. 8,600 ; R.b.c. 4,880,000. 

X-ray findings, first plate shows stomach shadow with stomach nor- 
mally filled and normal pylorus and duodenal cap; two hours later 
stomach completely empty and barium all in small intestine. Twenty- 
two hours after first plate barium is shown in the cecum, transverse 
and descending colon. The shadow is seen in the descending colon 
down to the left iliac region where it abruptly breaks oif as though a 
mass filled the lumen. Plate 4, taken after a barium enema, shows 
the rectum and part of the sigmoid partially filled with barium which 
cuts oif abruptly in the left iliac region. There is a large loop of 
the sigmoid filled with barium below the obstruction. 

Diagnosis. — Carcinoma of sigmoid colon. 

Treatment. — The abdomen was opened under local anesthesia and 
the obstruction located in the sigmoid colon. It was adherent to 
the peritoneum on the side and was adherent to a loop of small gut. 
The adhesions were both cut loose and the raw spot in the gut covered. 
A perforation in the colon was left. There was a long loop of sigmoid 
rather mobile below the tumor. A large loop containing the tumor 
was pulled up into the abdominal wound and sutured to the peri- 
toneum all around. The loop of sigmoid was then covered with moist 
dressings. 

After-course. — There was no postoperative shock. Pulse 96, respira- 
tion 22, temperature 99.5°, the evening of first day. There was se- 
vere pain in the region of the wound. No abdominal distention. 
Vomited but once. On the second day the patient vomited twice and 
suffered much from gaseous distention of the abdomen. This was 
relieved by use of the colon tube. There w^as some leakage around 
the hemostats which were closing the bowel perforation. Temper- 
ature 99.6°, pulse 100. On the fourth postoperative day the wound 
was dressed. There was considerable dark fecal discharge through 
the intestinal perforation, but it had not contaminated the wound 
to any great extent. Temperature Avas 98, pulse 76, strong and 
regular. 

Five days after the first operation, the carcinoma "was resected 
and an end-to-end anastomosis of the sigmoid made. A rubber 
tube was inserted in the sigmoid and pushed up above the anasto- 



718 CLINICAL SURGERY BY CASE HISTORIES 

mosis. The mass of intestines containing the anastomosis and drain- 
age tube were left adherent in the abdominal opening just as they 
were before the operation. Vaseline gauze packs were inserted 
around between the intestines and abdominal wall. 

After-course. — Second day after operation the wound was dressed. 
Gauze separating edges of wound from gut was contaminated 
with feces. These were removed and replaced. As there already 
Avas a fecal fistula, the rubber drain in the gut was removed. Tem- 
perature 99°, pulse 84 to 90. The patient continued in good con- 
dition, temperature ranging from normal to 99.6°. All of the bowel 
contents passed through opening in the gut, nothing passing by 
rectum. The wound had granulated in a great deal by the fourth 
week after operation, but it had not closed the opening in the bowel. 

Third Operation. — Four weeks after second operation a third one 
was performed to close the openings in the gut, the one in the sig- 
moid in which the rubber drain had been and the one made by 
cutting through some of the anastomosis sutures. Their edges 
were everted, the skin and fascia along the edges of the wound 
were dissected up and closed over the sigmoid. Tension sutures 
tied over small rubber tubes were used in pulling the skin and 
fascia together. 

After-course. — No apparent shock followed the operation. Tem- 
perature subnormal and pulse 84 the evening of the day of opera- 
tion. The second day the temperature went to 101.2°, pulse 110. 
The sutures holding and wound not draining. The third postopera- 
tive day the upper and lower end of the incision opened a little 
and fecal drainage came through. This continued almost three 
weeks. The first normal bowel movement occurred the third week 
after the third operation. On dismissal, ten weeks after admission 
to the hospital, the wound was almost entirely healed. Small sinus 
at each end of the incision was still draining a small amount of 
feces. The patient had a natural normal bowel movement each 
day, pulse and temperature were normal and there was no abdom- 
inal pain. 

Comment. — By doing a two step operation under local anesthesia 
one is able to work with perfect safety to the patient. This method 
is only applicable when the tumor is located in a portion of the gut 
which is sufficiently mobile to permit its dislocation outside of the 
abdomen. 



ABDOMINAL DISTRESS 



719 



SUPRAPUBIC 

Distress in the suprapubic region demands a search for menstrual 
disorders, pelvic tumors, bladder disturbances and less often, renal 
diseases. 

Case 1. — A widow aged thirty-six came to the hospital because 
of pain in the left side. 

History. — One child four years old. Four weeks ago she was cu- 
retted for reasons unknown, she being a widow. For ten days fol- 
lowing the operation she was comfortable and began to go about the 
house. At this time sudden pain developed in the left side of the 
pelvis, with chill, temperature of 103° and a pulse of 140. The tem- 




Fig. 333. — Abscess within the broad ligament drained through the vagina. 

perature has subsided, but there is still pain in the left pelvis. There 
is some pain on defecation and there was slight bladder irritation in 
the beginning. She has had no chill following the initial one, but 
is very sensitive to changes in temperature when the bed clothes 
are lifted. 

Examination. — The patient is pale and the cheeks are somewhat 
sunken, but the face is not expressive of suffering. The pulse is 
130. The lower abdomen is tender, particularly on the left side and 
the left rectus is rigid in the lower fourth. The perineum is lax, 
the cervix low, and the uterus large and retroverted. It is not 
movable and an attempt to move it causes acute pain. To the left 
of the uterus in the base of the broad ligament is a mass the size of a 
goose egg. It is hard, not movable, and but moderately painful. 



720 CLINICAL SURGERY BY CASE HISTORIES 

The mass seems to be just above the vault of the vaj?ina. Nothing is 
palpable above the pubes. 

Diagnosis. — The sudden onset of pain and fever following intra- 
uterine manipulation brands it as an infection extending from the 
uterine cavity. In these cases the site of infection is usually within 
the connective tissue of the broad ligament. That there is some peri- 
toneal involvement is indicated by the rectus rigidity and pain. The 
mass is low down, which precludes tubal infection or infection of 
the pampiniform veins. 

Treatment. — Expectant, with local douches not too frequently re- 
peated so that the general strength may not be reduced by them. 

After-course. — After this treatment had been continued fever and 
leucocytosis increased. The mass had not reduced, on the contrary, 
seemed semifluctuating. A drainage tube was, therefore, introduced 
into it (Fig. 333). (The artist has reversed the slide.) After a 
number of weeks of drainage, recovery was complete. 

Comment. — In pus accumulations following interrupted pregnan- 
cies extraperitoneal drainage should be done whenever possible. The 
more virulent forms of bacteria are usually found in these abscesses. 

Case 2. — A matron aged fifty comes because of general abdom- 
inal pains most marked in the epigastrium. 

History. — The patient has had four children, the youngest being 
twelve years old. She has had no miscarriages. The menses are still 
regular every three weeks and she flows profusely a week or longer. 
Her trouble began about two years ago with pain which was very 
indefinite as to locality. More recently the pains have been most 
marked in the pit of the stomach. She refers to them as biting pains. 
They are not influenced by the taking of food. All the pains are 
worse at night. All these troubles have increased lately. She now 
has palpitation which is noticed especially upon lying down at night. 
The appetite is fair, but the bowels are very constipated. She gets 
up sometimes at night to urinate. Just recently she has had pain in the 
left side of the abdomen which is felt through to the back. There is 
pain under the right costal margin. She has never been jaundiced. 
She has had several attacks of sudden pain in the epigastrium which 
lasts only about five minutes. This is attended by much bloating 
and palpitation of the heart. She has a rupture on the right side 
which comes down but has never been strangulated. A truss has 
not been worn. There is puffiness of the hands and feet, most marked 
in the morning. She has lost twenty pounds in a year and a half. 



ABDOMINAL DISTRESS 



721 



Examination. — The heart and lungs are normal. The right kidney 
is easily palpable. There is no sensitiveness in the hepatic triangle. 
The inguinal canal is wide and a soft mass comes to the labium on 
coughing. The uterus is retroverted and the size of a fist with a 
moderately distinct bosselation at the right cornu. The hemoglobin 
is 50 per cent. , 




Fig. 334. — Interstitial myoma of the uterus. 



Diagnosis. — There is a question whether or not the uterine trouble 
is responsible for all her symptoms or whether there is not some 
separate trouble in the upper abdomen. The fact that there is a 
distinct bosselation in the uterus makes it seem likely that this in- 
tramural tumor exciting the uterine fibers to contraction is responsi- 
ble for all her pains. The pains have increased as the uterine trouble 



722 CLINICAL SURGERY BY CASE HISTORIES 

increased. She speaks calmly of the extent of the flow but her marked 
anemia indicates that it must be excessive or that there is some added 
cause responsible for the anemia. There is no evidence of such and 
the anemia apparently is a secondary one. An unretained hernia 
sometimes causes marked epigastric disturbance, but in this case there 
seems to be no added disturbance in the epigastrium when the hernia 
protrudes. The symptoms in the upper abdomen are not definite 
enough to warrant one in diagnosticating a definite disease in this 
region. The diagnosis of myoma of the uterus is made. At any 
rate the uterus is the source of the bleeding which is the real menace. 
The upper abdomen can be explored at the same time. 

Treatment. — A supravaginal hysterectomy and a repair of the her- 
nia was done. There was no evidence of gastric disease and there 
were no gallstones. The hernia was an inguinal one extending well 
into the base of the labium major. The sac at the time of operation 
was empty. 

Pathology. — There is a myoma the size of a green walnut in the 
right eornu. It is a pure fibroma and is encapsulated by a thick 
layer of uterine tissue (Fig. 334). The tumor protrudes into the 
uterine cavity. Near the inner os the mucosa is thickened. This is 
evidently the source of the uterine hemorrhage. The endometrium 
shows an increase in the stroma cells. 

After-course. — Save for a prolapsus of the vagina the patient has 
been well. 

Comment. — The most difficult factor in myomas is to judge how 
nearly a given tumor may come to explaining all of the patient's 
symptoms. The interstitial ones are often responsible for the pres- 
ence of pain in the pelvis or upper abdomen. The test may sometimes 
be made by means of bromides. Large doses of this drug will calm 
a uterine pain, while it is likely to make organic diseases of the 
upper abdomen worse. The uterine condition likely was responsible 
for the upper abdominal pain. The hernial sac was empty. Had there 
been a part of the omentum adherent in the sac, one might have pre- 
ferred to ascribe the upper abdominal symptoms to that. 

Case 3. — A married woman of twenty-seven years comes with 
the complaint of pain in the lower abdomen. 

History. — The patient has had repeated attacks of pelvic pain, 
which have recurred at intervals during the seven years of her mar- 
ried life. The first attack began at the end of her first menstrual 



ABDOMINAL DISTRESS 723 

period after her marriage. She had a sudden severe pain in the lower 
abdomen accompanied by frequent and painful urination. She had 
a high fever which lasted several weeks. She has never felt well 
since. The menses have been irregular, prolonged, and painful. 
Some bladder irritation has remained and she is now constipated. The 
bowels were normal before the advent of this trouble. The present 
attack began several months ago and has continued until the present 
time. She now has less pain than in the beginning, but when much 
on her feet, the pain is much increased. She has no children. She 
has been much troubled with leucorrhea since her marriage. 

Examination. — The patient is much emaciated and is evidently 
septic. The uterus is fixed and there is a dense mass in the right 
side of the pelvis. Nowhere is there evidence of softening. She 
has a count of 12,000 leucocytes and her temperature varies from 97.6° 
to 101°, pulse 90 to 110. 

Diagnosis. — The patient had a gonorrheal infection soon after mar- 
riage. The frequently recurring attacks indicate a severe infec- 
tion and the prolonged course of this attack indicates a mixed in- 
fection. The presence of leucocytosis, fever, and rapid pulse indi- 
cates an active infection with a virulent organism. There is no point 
of softening which should make vaginal drainage definite of results. 
In such a mass without a guide one may open into a gut with a re- 
sulting fistula, a very embarrassing complication. "Watchful waiting 
has its dangers since she is becoming more emaciated as time goes on. 
It seems best to accept the risk of a radical operation. The patient 
is destitute and can not avail herself of prolonged efficient general 
care. 

Treatment. — A laparotomy was done. The adhesions were very ex- 
tensive and much hemorrhage was encountered which was controlled 
with difficulty. The left side showed a typical subacute pus tube, 
while the right side had a pus tube and a thick-walled cystic tu- 
mor not quite as large as a goose egg. The pelvis was drained supra- 
pubically with two large gauze drains and by a rubber drain through 
the vagina. 

Pathology. — The cyst was lined with a mass resembling sheeps' 
skin (Fig. 335). The section shows it to be composed of luteal cells. 
The pus contained streptococci. 

After-course. — There was intense local infection which continued 
to drain for several weeks. As soon as she was able she was moved 



724 



CLINICAL SURGERY BY CASE HISTORIES 



to the country. She improved for a time but retained a discharging 
suprapubic sinus. She consulted a local surgeon who explored the 
wound and found a piece of gauze. He presented this to the husband 
as exhibit A. The general condition of the patient was not improved 
by either procedure. Following the operation of the surgeon she 
rapidly declined and died six weeks later. 

Comment. — Drainage of the infected area through the vagina would 
have been the safer treatment. Even if one merely opens the culdesac 
the depletion hastens the process of resolution and often an abscess 




Fig. 335. — Luteal cyst of the ovary. 

previously hidden may reveal itself or rupture spontaneously. The 
pus tubes which have a variety of bacteria and are characterized by 
frequent exacerbations with never a complete remission are unsatis- 
factory at best. "With local drainage they often drag over years. If 
a radical operation is done, death may come from the operation itself 
or from secondary foci. In this case the after-care was entrusted 
to the family doctor. He removed the drains and inserted others 
from time to time. Whether the gauze which appeared as exhibit 
A was one of the original drains, one of those reintroduced as drains, 



ABDOMINAL DISTRESS 725 

or if a gauze pad was left during operation could not be determined. 
A gauze drain should be left until it lias served its purpose. Once 
removed, it should be left out. 

Case 4. — A matron aged thirty-six sought relief from dragging 
pain in the right side and thigh. 

History. — The patient's trouble started eleven years ago at the 
birth of the first baby. She was badly lacerated and the perineum 
was repaired at once, but the cervix was not. She says that the 
perineum broke down and the repair did no good. She had an eclamp- 
tic attack six hours after the birth of the first baby. She had no 
trouble at the birth of the second baby two years ago. Her chief 
complaint now is a dragging in the left side of the pelvis and a sting- 
ing pain extending down the left thigh. She has little appetite and 
is very nervous. She has a profuse vaginal discharge just before 
the period, which is scanty and lasts three days. She has pain in the 
temples, top head, and at the base of the neck. 

Examination. — The uterus is large, retroverted but movable. The 
cervix is not lacerated, but the perineum is torn to the sphincter. 

Diagnosis. — The large tender uterus without laceration, and the 
slight flow indicate that the chief trouble lies in the body of the uterus. 
The location of the headache, the pain in the pelvis, and nervousness 
are typical of metritis. 

Treatment. — The ovary was large and lay in the culdesac. The 
pampiniform plexus was enormously dilated. The uterus was fixed 
in place and the pampiniform plexus ligated and cut. The perineum 
was repaired. 

After-course. — Following the operation she had frequent urina- 
tion and some irritability of the bladder. It was never pronounced. 
She has pain in the stomach before meal time which was relieved 
by eating, but eating did not appease her hunger. She was given ant- 
acids for this. The bowels became regular soon after the operation. 
Some leucorrhea continued for some time and the rectum was irri- 
table for a time several months after operation. At the end of a 
year she had but little leucorrhea, she has but slight headache just 
before menstruation. The bladder irritation has disappeared and she 
sleeps well. 

Comment. — This case shows very well the need for following up 
these patients so that their recovery may be aided by medical means 
and to a degree by moral suasion. Tonics and sedatives as may be 



726 CLINICAL SURGERY BY CASE HISTORIES 

required may be necessary for a long time. Three months after 
operation she was quite sure she had not been benefited in the least 
by operation. She is the beautiful wife of an affluent and doting 
husband, a combination designed to delay recovery. The first result 
of replacing the uterus is often a bladder disturbance and that likely 
was the explanation in this case, though hemorrhage into the broad 
ligament after operation for varicocele of the broad ligament can 
not be excluded, but the advent was not sudden enough to be well 
accounted for on this explanation. 

Case 5. — A matron of forty-one was brought to the hospital be- 
cause of pain in the lower right side of the abdomen. 

History. — She has three children, aged fifteen, thirteen and seven 
years, and had two abortions before the birth of the last child. 




Fig. 336. — Broad ligament abscess. 

These were self-induced. She began last Wednesday with soreness 
across the lower abdomen, chiefly on the right side, low down. The 
pains at first were intermittent and reached the maximum twenty- 
four hours after the onset. The last menses was three weeks before 
the onset of the pain and she flowed three or four days. She 
had some pain in the right side during menstruation. When she 
was first married she had attacks in which there was soreness 
throughout the abdomen. During the present attack when ob- 
served she had a temperature of 101° or 102°. 

ExamiTvation. — There is tenderness over the lower abdomen, par- 
ticularly on the right side. There is a mass the size of an orange 
in the right broad ligament high up (Fig. 336). It is fixed and 
boggy, and pressure on it causes pain. 

Diagnosis. — The onset of the temperature following menses indi- 
cates a tubal infection. An appendix or a twisted cyst could not be 



ABDOMINAL DISTRESS 727 

excluded. The shape of the mass was not that of a cyst and the 
onset was not that of appendicitis. 

Treatment. — Exploratory incision. The mass is formed by a thick 
tube and adherent guts. The tube wall was thickened and there 
is pus about the tube. The left tube is not affected. The tube was 
removed and a drainage tube was introduced. 

Pathology. — The tubal M'all was infiltrated but the lumen contained 
no pus. The pus contained an unidentified coccus. 

After-course. — The drainage lessened and the temperature was 
soon reduced to nearly normal. At the end of three weeks there 
was a sharp rise of temperature and a mass was found over the 
body of the ischium. This was drained from above extraperito- 
neally. The disturbance subsided, and following a secondary infec- 




Fig. 337. — Abscess situated far laterally in the broad ligament drained by an incision above 
Poupart's ligament. (Drawing modified from Cullen.) 

tion in the abdominal wall recovery was complete. She remained in 
good health for six months and the second attack began. During men- 
struation she had a rise of temperature and felt badly, but after the 
menses she felt better again. General ill feeling and rise of tempera- 
ture came on at the next succeeding period and she had a temperature 
of 102°. The left side became extremely tender, A mass was formed 
in the left side and she was drained by another surgeon. The pus 
was said to have contained gonococci. She has had two other attacks 
requiring drainage. Following this she had another attack during 
which another surgeon attempted a radical operation and she died 
of peritonitis. 

Comment. — There was a historj' of abdominal pain soon after mar- 
riage, which is suspicious. She had three births at term, however, 



728 CLINICAL SURGERY BY CASE HISTORIES 

following this. The gonococci may have lived in the urethra of the 
husband rather than in the tubes. However, having admitted two 
induced abortions, there may have been such preceding this attack. 
The course has been distinctly that of infection by a pus coccus 
rather than a gonococcus. The infection evidently was intraligamen- 
tous, the tube being involved secondarily only. This should have been 
so identified and the ligament drained extraperitoneally as presented 
in Fig. 337. Had the exact condition been recognized, expectancy, 
for a time at least, would have been the wiser procedure. A radical 
operation in such cases is always a dangerous procedure. 



CHAPTER XIV 

NUTRITIONAL DISTURBANCE 

"When a patient loses weight he is sick. Loss of weight may be due 
to extraabdominal causes even if there is an associated intraabdominal 
disease. 

WITH PAIN 

When there is obvious disturbance of nutrition together with pain 
within the abdomen the possibility of malignancy must be the chief 
concern. Pain itself may disturb nutrition, by lessening the amount 
of food taken, when there are no lesions directly affecting the digestive 
tract itself. The relation of the two is of prime importance. 

CASE 1. — A laborer aged thirty-four came to the hospital because 
of a pain in his right side. 

History. — The present illness began four months ago with attacks 
of abdominal pain and some pain in the back. At first the attacks 
came on every week or so, but now they come on more often and 
he has been vomiting in the last few attacks. Now there is pain 
and soreness in the right side in the ileocecal region and it seems 
to go -from front to back. There has been frequent urination with 
the attacks for the last month. One week ago he had a sudden 
pain in the epigastrium followed by vomiting. In a few hours 
the pain became fixed in the right loAver region of the abdomen. 
He was in bed three days. When he did get up, he could hardly 
walk for the pain in the right side. He has had much pain in 
the back the last few days. In a few of the attacks he has felt 
hot as though he had a fever. 

Examination. — Temperature 97.8°, pulse 58, respiration 20. There 
is no rigidity. There is tenderness over the whole right half of the 
abdomen. Urine 1.008, no albumin or other foreign elements. 

Diagnosis. — The epigastric pain which finally settles in the ileo- 
cecal region seems indicative of appendicitis. 

Treatment. — The appendix was removed. 

Pathology. — There was apparently some round-celled infiltration 
in the submucosa. There were not enough changes to account for the 
symptoms complained of a week ago. 

729 



730 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — The temperature after operation did not rise above 
99.6°, pulse 58 to 70. The patient left the hospital two weeks after 
operation having run an entirely uneventful course. 

Three months later he returned with a complaint of stomach 
trouble. He gave a history, which was not elicited at the first con- 
sultation, of stomach trouble extending over a period of ten years. 
The attack would last a few weeks, then pass away. He would have 
epigastric pain two or three hours after meals; then the time of 
appearance of pain grew shorter and finally came on immediately 
after meals. At first eating would relieve the pain. After going 
home from the hospital, following his operation for appendicitis, 
the pain did not subside but was continuous. The worst pain was 
on the right side under the ribs and going from front to back. 
There were frequent attacks of vomiting. The vomitus had a sour 
taste. His appetite was good. Stomach analysis showed free HCl 
35 per cent, combined acidity 20 per cent, total acidity 55 per cent, 
and a trace of blood. An exploratory operation was done. A retro- 
peritoneal sarcoma was found. He died two months later. 

Comment. — Evidently his trouble from the beginning was due to 
his tumor. The history was too indefinite to have warranted such 
a diagnosis of appendicitis, but when one hears of epigastric pain 
which later "settles" in the ileocecal region, it is hard to think further. 

CASE 2. — A fanner aged fifty-six cajne because of pain in the 
stomach and loss of weight. 

History. — For twelve years the patient has had severe digestive 
disturbance. All foods distressed him, apparently without rhyme 
or reason. Foods that he seemed to tolerate for some months sud- 
denly seemed to cause distress and he had to work out a new diet 
list. He frequently vomited, but without any rule relative to meal- 
time or food eaten. The pain was never intensely severe, but fre- 
quently compelled him to lie down. He has lost some thirty pounds 
in weight. 

Examination. — The patient does not appear emaciated and there 
is no evidence of nutritional disturbance. Laboratory examination 
is without interest. There is a hernia of the linea alba three fin- 
gerbreadths below the ensiform cartilage (Fig. 338). It is not 
evident on inspection but is easily palpable. There is some abdominal 
tympany, but no sensitiveness. 



NUTRITIONAL DISTURBANCE 731 

Diagnosis. — The long duration of the illness and his apparent ex- 
cellent general state excludes any grave disease. The duration is 
too long for even an ulcer. Obviously the stomach suffers from 
its environment. The hernia of the linea alba comes as a welcome 
object upon which to fix the blame. 

Treatment. — The hernia was repaired under local anesthesia. 

After-course. — The recovery was prompt and lasting. 

Comment. — The careful search for hernias of the linea alba should 
always be made in all cases of chronic indigestion, particularly if 
the nutritional disturbances do not correspond with the degree of 
the complaint. I have seen patients lose as much as 50 pounds, but 




Fig. 338. — Hernia of the linea alba. 

even with this loss there was no evidence of secondary anemia. The 
findings of a hernia should not end the search, however, for these 
patients sometimes have other diseases. 

CASE 3.— A mechanic aged forty-eight came because of distress 
in the stomach and loss of weight. 

History. — He began to lose weight and strength three months ago. 
He has lost 40 pounds in these three months and has been obliged 
to give up work. He has never had any digestive disorders before. 
He is troubled with a sense of fullness which is made neither bet- 
ter nor worse by eating. He has a sense of fainting sometimes. 
There has never been actual pain or vomiting. He does not have 
aversion to any particular article of diet. He has been examined 
by a well-known stomach specialist whose report shows a near 
absence of hydrochloric acid, makes the diagnosis of carcinoma, 



732 CLINICAL SURGERY BY CASE HISTORIES 

and advises immediate operation. He is pessimistic and uncommu- 
nicative as to his symptoms, and contradictory replies were made 
when asked about his pain. He states that he slept enough, but 
his wife was of the opinion that he slept very little, and a man's 
wife generally knows better than he himself how much he sleeps. 
Therefore it is safe to say that this man did not sleep. 

Diagnosis. — The gradual loss of weight and sleeplessness were 
the outstanding features. He believed the gastroenterologist was 
correct in his diagnosis, but was reluctant to consent to an ex- 
ploratory operation, though urged to do so by his son who was a 
physician. He is merely an apathetic being ruled neither by fear 
nor hope. When a man is responsive to neither of these emotions, 
he hasn't any organic disease. Therefore, I asked him to be seated 
in my office where I could observe him unknown to himself. For 
twenty minutes he gazed fixedly into space. At the end of this 
time I put my hand on his shoulder and said, "Old top, tell me 
about it." With a startled look, he said that no one but himself 
suspected the cause of his trouble, that a trusted brother had 
cheated him out of his property. He did not want his own family 
to find it out. 

Treatment. — I advised him to leave his environment for a period of 
months. In addition bromides with nux vomica were given regularly. 
He was advised to eat anything that looked good, particularly cheese 
and iron wedges. 

After-course. — He returned in four months having regained his 
weight. He has worked at his trade some ten years now, without any 
impairment of health. 

Comment. — When depression accompanies cancer it is accompanied 
by fear. Depression with indifference does not associate with or- 
ganic disease, at least not within the realm of the operating surgeon. 

CASE 4. — A housewife aged forty-four came to the hospital be- 
cause of digestive disturbance and loss of weight. 

History. — ^When about twenty-four years old she had digestive 
disturbance for several years. She had epigastric pain relieved 
by vomiting, sometimes by taking food. Never vomited any blood. 
The pain was localized in the pit of the stomach, but sometimes 
it extended through to the back, particularly when severe. For 
a number of years following the birth of her only child eighteen 
years ago she had pelvic trouble, and wore a pessary with some re- 



NUTRITIONAL DISTURBANCE 733 

lief for a number of years. Four months ago she began to have epi- 
gastric pains again, some nausea, but no vomiting. She lost her 
appetite and began to lose weight rapidly, having lost some thirty 
pounds in the four months since the trouble began. 

Examination. — The patient looks worn but not cachectic. The ab- 
domen is somewhat rigid in the upper part and there is a general 
sensitiveness. There is nearly an entire absence of hydrochloric 
acid after an Ewald meal. The blood picture was not materially 
changed. 

Diagnosis. — Because of the marked epigastric disturbance and loss 
of weight, together with the change of the gastric secretions, a diag- 
nosis of carcinoma of the stomach was made. The history seemed 
to indicate that the patient had had a gastric ulcer twenty years 
before and this was looked on as the basis for the present complaint. 

Operation. — The stomach is free from any lesion. The gall bladder 
is as large as a hen 's egg and is completely filled by a single gallstone. 
The wall of the gall bladder is firmly fixed to the stone. Hence a 
cholecystectomy was done. 

Pathology. — The stone was composed of a dirty, brick-colored, 
brittle mass, to the surface of which the wall of the gall bladder 
was intimately united. There was an entire loss of mucosa and 
but the fibrous layer remained. 

After-course. — Recovery was uneventful and tlie digestive dis- 
turbance disappeared and her former weight was restored. She re- 
mained well for ten years, but now suffers from diabetes. 

Comment. — There had never been a typical gall bladder attack. 
At the time of operation the bladder wall was incompetent to react 
either by contraction or inflammation. What brought about the 
sudden gastric disturbance I am unable to say. There is no clue 
to the duration of the gallstone. Whether this had any relation 
to her trouble in early life is a speculation. 

Case 5. — A retired farmer aged sixty came to the hospital be- 
cause of stomach trouble. 

History. — The patient's general health has always been good, save 
that he had typhoid at twenty-one. He smoked a great many cig- 
arettes every day until 1895. He then quit for twelve years. His 
usual weight was 190 pounds, at forty years of age he gained 50 
pounds in three years, reaching a weight of 250. He then got short 
of breath, but was not incapacitated. As far back as he can remem- 



734 CLINICAL SURGERY BY CASE HISTORIES 

ber he has had to get up once each night to urinate. He has smoked 
two or three cigars a day until his present illness. A year and a 
half ago his appetite became poor, his food did not digest and he 
had diarrhea for several months, but no vomiting. He went to 
Texas last winter, w^here he improved. After four months he began 
to feel worse again. The diarrhea recurred, he could not eat, and 
he became very weak. At this time spots appeared on his wrists. 
He has no pain to speak of, but there is numbness in his fingers 
and toes. 

Examination. — The patient is very pale, but not particularly ema- 
ciated, the tongue is smooth, glazed and pale. There is a systolic 
murmur and some emphysema. The abdomen is soft, flat, and flabby. 
There is some edema of the scrotum and there are a number of pur- 
puric spots on each wrist. Red blood count 1,200,000 ; Hg. 35 to 40 
per cent Tallquist; the smear shows poikilocytosis and anocicytosis. 

Diagnosis. — Though this man was sent in with a diagnosis of 
carcinoma of the stomach, he clearly is suffering from pernicious 
anemia, though the digestive disturbances have dominated. In 
some instances when the digestive symptoms are pronounced early 
in the disease before the blood picture becomes typical, the anemia 
may be regarded as secondary to the gastric symptoms. Therefore, 
there was some cause for the early confusion in the diagnosis. "When 
such symptoms are great, malaise in proportion to the loss of 
weight, diarrhea, purpuric spots and possibly a history of remis- 
sions should have caused his physician to suspect pernicious anemia. 
The fact that he recuperated while in Texas should have been 
enough to exclude malignancy. 

Treatment. — Cacodylate of soda hypodermically. 

After-co\irse. — The patient returned home and died after a few 
months. 

Comment. — I once did an autopsy on a body in which a very good 
surgeon had done a gastroenterostomy. None of the signs of per- 
nicious anemia were lacking, though the blood picture indicated 
a secondary anemia. I also once did an autopsy in a case in which 
the author of a book on hematology had made the diagnosis of perni- 
cious anemia. There was a carcinoma of the cardia. 

CASE 6. — A widow of fifty-six came because of epigastric dis- 
tress and loss of weight. 

History. — The patient has had stomach trouble for thirty years. 
Ten years ago she had several hemorrhages. She had pains in the re- 



NUTRITIONAL DISTURBANCE 735 

gion of the stomach at this time, which was relieved by taking food. 
These pains ceased after the hemorrhages started. Two years ago 
the pains began again, and one year ago she had several hemor- 
rhages which compelled her to remain in bed for a number of months. 
She has free intervals from pain, lasting four or five days. The pains 
are most apt to occur in the afternoons and at night between mid- 
night and three in the morning. Recently she has vomited her food, 
but no blood. She now takes two to three grains of morphine for the 
pain. She weighs 76 pounds. Her regular weight is 110 pounds. 

Examination. — Abdominal examination is negative save for some 
muscular rigidity in the hepatic region. Stomach analysis fails to 
show blood. The x-ray shows a considerable portion of the test mass 
after seven hours. 

Diagnosis. — Pyloric stenosis from peptic ulcer. The history of pain 
relieved by eating, its occurrence in the early morning hours, the 
vomiting of blood with the subsequent vomiting of food, and the 
x-ray findings are distinctive. 

Treatment. — Gastroenterostomy. A mass occupies the pyloric re- 
gion, reducing the lumen of that gut to the size of a lead pencil. 

After-course. — The recovery was rapid and in a year had just ex- 
actly doubled her weight. Her appetite is good, and she eats every- 
thing. 

Comment. — The pronounced increase in weight is interesting, and 
shows well the benefits of gastroenterostomy when it is really in- 
dicated. 

CASE 7. — A matron of forty-nine came to the hospital because 
of digestive disturbance. 

History. — The patient has had fair health. Menopause occurred 
thirteen years ago. She has been disturbed for a number of years by 
indigestion, backache, and dragging pain in the pelvis when much 
on her feet. Present complaint began four months ago. It began 
with a chill followed by a rise of temperature of 104°. For some 
days following it would be below normal in the morning and reach 
a high degree at night. Following the onset of the fever she had 
pain in the stomach and right breast which extended to the back 
below the shoulder blade. Soon after the onset she was yellow 
and had intense itching of the skin. This lasted several weeks and 
subsided quite rapidly. The urine at times looked bloody. Since 
the disappearance of the jaundice she has been weak, and while the 



736 CLINICAL SURGERY BY CASE HISTORIES 

appetite has been good, she has not increased in strength. She has 
lost about 20 pounds in weight. She has not been jaundiced since 
the beginning of the attack. 

Examination. — Heart and lungs are normal. A mass appears in 
the right upper quadrant which slips beneath the fingers on deep 
respiration, similar mass palpable to the left but less plainly. These 
evidently are the kidney's. There is deep tenderness over the gall 
bladder region, no muscular rigidity, no tumor palpable and the 
liver is not enlarged. There is some jaundice apparent in the sclera 
and the skin is sallow and inelastic. There is a trace of bile in 
the urine. 

Diagnosis. — Chill, jaundice and subhepatic pain indicates infec- 
tion of the hepatic ducts, likely obstruction from stone. The pain 
in the chest in the beginning likely was a referred pain, since 
there was pain in the back at the lower angle of the scapula present 
at the same time. 

Treatment. — The gall bladder was the size of a thumb, no stones 
were palpable, but the walls seemed thickened. The common duct 
was thickened to the size of a finger. No stone was palpable. The 
pancreas was not changed. The common duct was opened and ex- 
plored. The little finger was barely admitted. No stone was felt. 
A probe detected a foreign body below the reach of the finger, evi- 
dently within the wall of the duodenum. This portion of the gut, 
therefore, was mobilized according to the method of Kocher, This 
accomplished, a stone the size of a hazelnut kernel could be pal- 
pated. The duct was opened over the stone, which made its extrac- 
tion easy. After it had been removed, the papilla was seen to be 
widely open, making an opening which communicated with the in- 
terior of the gut. The opening into the duct was carefully closed. 
The gall bladder was removed. Drainage was placed down near 
the duct. 

Pathology. — The gall bladder wall was much thickened. The slide 
showed edematous fibrous tissue with abundant round-celled infil- 
tration. 

After-course. — The after-course was uneventful until the fourth 
day when the temperature began to rise and the pulse became rapid. 
The patient died on the tenth day of paraduodenal sepsis. 

Comment. — This history is typical of duct stone. The fact that 
there was no stone palpable, of course, did not make me hesitate 



NUTRITIOXAL DISTURBANCE 737 

to open into the duct. The history and the thickened duct left 
only the question of size and location of the stone to be determined. 
With the stone located in the duodenal portion of the common duct, 
the raising up of the gut was anatomically the logical procedure, 
but physiologically it was foolhardy. By so opening an area 
of loose fibrous tissue, it was exposed to the infection of the 
duodenum. The gut here having no peritoneal covering does 
not readily unite, and being poor in blood supply, can offer but 
little resistance. The better way would have been to remove the 
stone by the transduodenal route. By this route no connective 
tissue space Avould have been opened and a surface of the gut 
covered by peritoneum would have been available for suture, insur- 
ing union. Should bacteria have escaped, as is almost unavoidable, 
the peritoneal surface would have been much better able to care 
for it than the loose retroperitoneal tissue. 

CASE 8. — A man aged sixty came to the hospital because of epi- 
gastric disturbance and loss of weight. 

History. — This patient had typhoid fever at twenty-seven. He has 
never had any stomach trouble even during the many years he was 
a traveling salesman, eating and sleeping when and where he could. 
His present illness dates back to one year ago. The first thing 
noted was epigastric soreness and pressure and a feeling of fatigue 
constantly present. There is not a real pain, but a soreness. It is 
present almost all of the time. It gets worse almost immediately 
upon eating. A large drink of water gives a sensation of increasing 
pressure. He eats almost everj'thing and no particular foods 
aggravate or relieve it. He has never taken anything to relieve 
it. The soreness extends around the rib margin on the right side 
and is often felt in the back. He never vomits after eating and 
is never nauseated. Bowels are obstinately constipated, would go 
three or four days without a bowel movement if he did not take 
cathartic. Never noticed blood in the stool, or tarry stools. His ap- 
petite has always been good. He has trouble starting the urine, 
there being a dribbling at first. He seldom arises at night to urinate. 
Has lost about 26 pounds of weight in the last year. 

Examination. — The abdomen is soft and compressible without ten- 
derness save in the upper abdomen and here at no definite point. 
There is not the resistance of a carcinoma or of a gallstone attack. 



738 CLINICAL SURGERY BY CASE HISTORIES 

The motility is normal and the emptying time not delayed. Labora- 
tory findings were negative. 

Diagnosis. — The history of a rather definite beginning digestive dis- 
order with a distinct loss in weight, and especially the marked loss of 
strength, suggested carcinoma. The disposition of the pain to ra- 
diate around the right costal margin suggested gall bladder disease. 
The prostate is moderately enlarged, smooth, and not tender. Ex- 
ploration alone seems likely to give a definite diagnosis. 

Treatment. — No disease of the stomach was found. The gall blad- 
der was thickened and of a deep blue color. It was drained. 

After-course. — The gall bladder drained for three weeks and the 
openi'ng promptly healed after the drainage was removed. He 
was much improved and regained his former weight. He returned 
two years later complaining of soreness across the epigastrium 
and in the region of the gall bladder. There has been pain in the 
back during the past week. He has difficulty in retaining his urine 
and gets up several times a night. His bowels are regular and the 
urine is negative. He improved on antacids. He returned again 
in six months with renewed epigastric distress and more pronounced 
difficulty in retaining his urine. He retains his normal weight. 
He reappears from time to time and is relieved by the same means. 

Comment. — This is rather a typical case of cholecystitis without 
stone. The temporary improvement from drainage with disposition 
to recurrence is characteristic. A cholecystectomy should have 
been done. This shows again that a patient with gall bladder 
symptoms without stone should have his gall bladder removed. 
He has with it a gradually enlarging prostate. As time goes on he 
likely will change from incontinence to retention and the catheter 
or prostatectomy. 

CASE 9. — A matron aged sixty entered the hospital because of 
epigastric disturbance and indigestion. 

History. — Beginning ten years ago the patient had gas and eruc- 
tations after meals. Seven years ago she had an attack of acute 
epigastric pain which radiated along the right costal margin. She 
was completely prostrated for an hour or two, but after that the 
trouble was all gone without leaving any tenderness. She had 
several attacks during the few years following, but they ceased four 
years ago, but her present symptoms appeared. She now has epi- 
gastric disturbances and causes herself to vomit in order to relieve 



NUTRITIONAL DISTURBANCE 739 

the epigastric distress. The material produced is watery, very- 
sour, and contains mucus, but no blood and no undigested food. Her 
appetite is poor and the bowels constipated. 

Examination. — There is some deep tenderness over the gall bladder 
region, but otherwise the examination is negative. 

Diagnosis. — The severe epigastric pain radiating along the costal 
margin and after a period of exhaustion ending in a sense of complete 
well-being is typical of gall bladder colic without infection, hater 
there is evidence of cholecystitis but no colic. Cases with such a 
history — typical cramps followed by cholecystitis or digestive dis- 
turbances — are candidates for removal rather than drainage of the 
gall bladder. 

Treatment. — The gall bladder contains many stones and the cystic 
duct and the common duet were thickened. The common duct was 
explored and the cystic duet ligated near the common duct and the 
gall bladder removed in the usual wa3^ A simple tube was placed 
in the common duct opening. 

Pathology. — The gall bladder walls are thickened and show the 
usual cellular changes. 

After-course. — She recovered from the operation but after a month 
complained of epigastric burning. This increased in the succeed- 
ing month, at the end of which time jaundice appeared. This in- 
creased until it became very intense. Four months later she was 
operated by a surgeon in a distant city who reports that the terminal 
portion of the common duct seemed completely obliterated and he 
united the hepatic duct to the duodenum. At this time a marked 
nephritis developed and she died. 

Comment. — Evidently the common duct was not injured by the 
ligature or jaundice would have appeared at once. Besides, the ar- 
tery and cystic duct were ligated separately so that the exact struc- 
tures ligated could be seen. Perhaps an inflammation set up which 
caused the obliteration of the duct said to be present. I have never 
encountered such a condition and am unable to visualize a pathologic 
process that could bring it about. I have overlooked stones, and 
have removed quite a few left by other operators which produced 
jaundice, but never have I seen an obliteration of the duct. Whether 
the exploration of the common duct had anything to do with it, I do not 
know. 



740 CLINICAL SURGERY BY CASE HISTORIES 

CASE 10. — A lumberman aged seventy came because of epigas- 
tric disturbance and loss of weight. 

History. — Except for rheumatism, he has always enjoj'ed good 
health. Two months ago he awoke one morning at 3 a. m. with a 
gnawing pain in the epigastrium. He was chilled for an hour, and 
a fever of 103° followed. He drank a large amount of warm water 
and vomited freely. He felt better after this. After a few days he 
ate a heavy New England boiled dinner, but soon vomited everything 
he had eaten. Observing some dietary discretion, he gradually im- 
proved, but in ten days the attack Avas renew^ed more severe than 
the first. The chills and fever abated, but he grew weak, vomit- 
ing at times, and he had some chilliness. He lost some 40 pounds. 
He was able to be up at short intervals only. The boAvels move 
with laxatives. 

Examination. — The patient presents the hulk of a once large power- 
ful man. The tongue is heavily coated. There is a marked jaundice, 
the stool is clay colored and the urine contains much bile and a few 
casts. There is no abdominal distention or rigidity anywhere. His 
heart is widely dilated and intermittent and there was some aortic 
regurgitation. The pulse is slow and full. 

Diagnosis. — The great loss of weight at once suggests malignancy, 
but the rise of temperature has no place in carcinoma. Furthermore, 
when a carcinomatous patient once vomits, he never again attacks 
a New England boiled dinner. The subsequent jaundice is of too 
sudden origin to belong to a malignancy. On the other hand, the fever 
and vomiting and jaundice correspond to a common duct obstruction. 
The physical findings give little evidence. There is no evidence of 
gall bladder stone, but the usual association of the two makes it 
wise to predict their concomitant existence. The lack of sensitiveness 
over the hepatic triangle makes it questionable whether there is any 
stone in the gall bladder, or, if so, that the stones are embedded, since 
there has been no colic. Pancreatic disease can be excluded because 
of the slow pulse and absence of distention. The patient is as easily 
diagnosed as his disease. The loss in weight finds expression in an 
enfeebled circulatory system. The initial chill suggests an infection 
which endangers the patient from an ascending infection whether 
he be operated on or not. If an attempt be made to drain the com- 
mon duct, to the danger of sending the ascending infection on its 
way must be added the danger of the operation itself, notably hemor- 



NUTRITIONAL DISTURBANCE 7-41 

rliage, either immediately following the operation or secondary hem- 
orrhage a week or more later. The less one can do and yet rid the 
patient of his intoxication, the better. 

Treatmeni. — Drainage of the gall bladder under local anesthesia 
was advised, but rejected. He desired a general anesthestic which 
I feared to use. 

After-course. — After trying a "cure" for three weeks he was op- 
erated upon by another surgeon who removed a number of stones, 
none, I understand, from the common duct. He died a few days after 
the operation. 

Comment. — The problem as to what treatment to advise may well 
give us pause. A once overfed man who has become feeble and ema- 
ciated is an undesirable risk at best. A large, vigorous body, always 
well fed, droops quickly when deprived of the daily nourishment. 
Impending feebleness was marked by feeble, distant, diffuse apex 
beat. I am reluctant to give such patients a general anesthetic. By 
draining the gall bladder under local anesthesia and securing a drain- 
age I had hoped to render him bile-free and thus secure a favorable 
condition for a curative operation. Aside from the immediate dan- 
ger from the operation, there are other considerations. It has been 
my misfortune to see patients with this association of symptoms de- 
velop an ascending cholecystitis following a radical operation such 
as opening the common duct or removing the gall bladder. I have 
not had this misfortune when I confined my efforts to the timid act 
of draining the gall bladder under local anesthesia. 

CASE 11. — A widow aged forty-four came because of pain in the 
stomach, eructation of gas, and general weakness. 

History. — Her trouble began two years ago. She first had a feeling 
of heat in the epigastrium running up under the sternum and followed 
by vomiting. She says she has had slight attacks for a period of 
twenty-five years, but they only lasted a short time each summer until 
two years ago when they became persistent. A year ago she began 
to have severe pains in the stomach after eating. They began im- 
mediately after eating or even before the meal was finished. She 
does not vomit often, but when she does, it is slimy, never dark 
colored, and it usually relieves the stomach. Up to two years ago 
she weighed 165 pounds. She now weighs about 115. Almost every 
meal is followed by pain. She has a great deal of gas in the stom- 
ach, chiefly in the afternoon and evening. She has grown very 



742 CLINICAL SURGERY BY CASE HISTORIES 

weak in the last two years. Appetite very poor. Bowels very much 
constipated. She had her last period two j^ears ago but now every 
two or three weeks she has a yellowish vaginal discharge. She has 
had ten children, the youngest five years old. 

Examination. — The patient is obviously much emaciated. The 
abdomen is soft, except in the epigastric triangle where the muscles 
are rigid and she complains of sensitiveness on pressure. There 
is no tumor palpable. The x-ray shows no filling defects and the 
emptying time is little if at all delayed. There is some delay in the 
excursion through the colon. There is some pain in the right renal 
triangle. 

Diagnosis. — The pain immediately after eating, relieved by vom- 
iting, suggests an ulcer. The great loss of weight without pyloric 
obstruction makes it likely that the ulcer is cancerous. Slimy vom- 
itus without obstruction usually means malignancy. If such is the 
case, it may be early enough to make operative removal possible. 
The urinary findings suggest a possible pyelitis. 

Treatment. — The patient refused operation. Urinary antiseptics 
and antacids with diet were prescribed. 

After-course. — She returned four months later stating that she 
felt much better. It was discovered, however, that she had lost an 
additional 15 pounds despite the fact that she felt better. The ex- 
amination failed to show any new findings. She was advised to sub- 
mit to exploration or nothing. She returned in two years and stated 
that she had tried internal treatment elsewhere, and receiving no 
benefit, she submitted to operation. A competent surgeon declared 
an inoperable malignancy to be present. Examination at this time 
showed a nodular mass in the midline. She had lost still an additional 
15 pounds in weight, weighing 85 pounds, just half her normal 
weight. 

Comment. — It is possible that at the time she was first examined 
she was just developing a malignancy on a preexisting ulcer. I 
have never yet to my knowledge succeeded in curing a definite car- 
cinoma of the stomach. A number from whom I have removed tumors 
believed to be malignant have remained well after operation, but 
after reexamination in the light of greater experience I doubt whether 
any of them were really malignant. This patient seemed to be 
in an early stage, possibly she might have been cured. Possibly she 
might have consented to operation, had she not been given antacids 
which apparently gave her some relief. 



NUTRITIONAL DISTURBANCE 743 

WITHOUT PAIN 

When there is marked disturbances of nutrition without pain, the 
surgeon meets his most difficult task. Here, more than in any other 
field, he must lean on his colleagues, for the condition implies a 
physiologic disturbance, without an anatomic basis in the surgical 
sense. History is often of little help and unless the surgeon is able 
to demonstrate a definite anatomic lesion, as a tumor, he will do well 
to retire in favor of the internist. The attempt to hypothecate a 
diagnosis from the history leads to much needless "exploration." 

CASE 1. — A farmer aged fifty-eight came to the hospital because 
he had vomited blood. 

History. — He never had any stomach trouble until the present 
attack began, which was two months ago. After feeling slightly 
nauseated all day he vomited his supper. He did not notice the 
character of the vomitus. He was still nauseated when he went 
to bed. He vomited again during the night and this time he no- 
ticed that there was blood in the vomitus. He vomited blood at 
intervals all night, clots as large as walnuts being expelled. Since 
this attack he has not vomited, but has had an aching pain in 
the region of the stomach, which comes on periodically and has no 
reference to meals. He has lost about 30 pounds since February 
and his appetite has been rather poor. He has an aversion to 
meats. 

Examination. — The skin is inelastic and sallow, general evidence 
of loss of weight. The lower part of the abdomen is soft, but above 
the umbilicus the muscles are somewhat fixed and there is a ten- 
derness on deep pressure. Because of the recent hemorrhage no 
gastric analysis w^as made. There are 11,800 leucocytes. There 
is no tumor or splenic enlargement and no fluid in the abdomen. 

Diagnosis. — There being no evidence of hepatic cirrhosis, some sort 
of ulcer must be responsible. Since he was well up to the time of 
the hematemesis, ulcer would seem most likely. His color is not 
that of secondary anemia but of cachexia. The loss of weight 
likewise suggests malignancy as does the dislike for meats. The 
location of malignant gro\\i;h which bleeds early before there are gen- 
eral symptoms is likely to be located at the cardia. There has been no 
difficulty in swallowing so that there is no tangible evidence in fixing 
the location. 



744 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — He was given antacids and ulcer diet. 

After-course. — Emaciation and weakness progressed, and when he 
came back for examination, a nodular mass could be felt in the epi- 
gastrium. He died in three months. 

Comment. — The interest in this case lies in the fact that the first 
symptom of which the patient took cognizance was hematemersis, 
though there had been a growing aversion to meats before this time. 
The question is as to what should have been the line of treatment at 
his first examination. If a patient has lost weight from a carcinoma 
without there being obstruction, the patient can rarely be operated 
successfully. As a matter of fact, the operative cure of gastric 
cancer is pretty much a delusion. The cases cured are usually indu- 
rated ulcers. This has been my experience. 

CASE 2. — A retired farmer aged eig^hty-three came to the hospital 
because of difficulty in swallowing-. 

History. — He has had trouble in swallowing for several years. It 
is only during the past few months that the difficulty has been 
pronounced. He complains that the difficulty is in swallowing, but 
that once it is down, it stays there. Kecently he has been having 
severe headaches, and for ten days there has been marlced swelling 
of the hands and feet. His general health has alwaj's been good ; 
he has never had any digestive disturbances. 

Examination. — He is an emaciated man with swollen hands and 
feet, with puffy face, and apprehensive look. His abdomen is re- 
tracted and hard. The apex is wide out of its position and diffuse, 
the pulse feeble but excited. The aortic second sound is accen- 
tuated. The urine contains both albumin and sugar and many pus 
cells. The x-ray shows the esophagus enormously dilated, a long 
fine line separating it from the stomach. 

Diagnosis. — The x-ray shows the constriction to be at the cardia 
while from the history one would have expected it to be high up. 
The general state, edema, severe headaches, and urinary findings 
show him to be but little removed from a uremic state. 

Treatment. — Expectant. His general condition did not seem to ad- 
mit of a gastrostomy even under local anesthesia. 

After-course. — He died of starvation after three weeks. 

Autopsy. — There was a narrow constriction 3 inches long between 
the esophagus and stomach (Fig. 339). There were no metastases or 



NUTRITIONAL DISTURBANCE 



745 




Fig. 339. — Esophagus and stomach showing site of stricture, the greatly dilated esophagus 
and the marked dilatation of the cardiac end of the stomach. 



any invasion into the surrounding tissue. The area of constriction 
was not hard but leathery. When the esophagus and stomach were 
opened, no new growth was found at the point of constriction, but 



746 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 340. — Interior of the esophagus showing the atheromatous degeneration of the mucosa. 



the mucosa is corrugated longitudinally. The mucosa of the 
esophagus was studded with yellowish-white plaques slightly raised 
above the surface (Fig. 340). The slide shows them to be made up of 



NUTRITIONAL DISTURBANCE 



747 



desquamating cells which do not stain (Fig. 341). There is no reac- 
tion in the submucosa or the muscularis. The stomach is thin and 
the mucosa atrophied. The kidneys showed but little change, save 
the cortex of the left one was markedly thinned in some areas. 
Other organs showed no changes. 

Comment. — He should have had a gastrostomy for which he 
begged, even in the face of the hazardous risk. From the findings 
of the autopsy it is impossible to determine the duration of the 
esophageal dilatation. The history of some dysphagia for two years 
is not definite, and it is only the last few months that the trouble 









Fig-. 341. — Slide of an atheromatous plaque of the preceding. The piling up of the struc- 
tureless cells are shown at the left of the cut. 



seemed to be definite. Considering the age of the patient and the 
general findings, no disease other than carcinoma was seriously 
considered. If time is a factor, evidently the dilatation must have 
existed for a long time. The plaques are supposed to be formed 
from prolonged irritation from retained contents, and since these 
are not found in dilatation from ordinary causes, the duration in 
this case must have been great. Likely other factors than long 
duration play a part. There was no history of any trouble in early 
life. 



748 CLINICAL SURGERY BY CASE HISTORIES 

CASE 3. — I was called to see a farmer of fifty-eight because of 
difficulty in swallowing. 

History. — ^He has always had good health, until four months ago 
when he noticed that he had difficulty in swallowing. Until then 
he was not conscious of any impairment in health. At first the 
dysphagia was periodic and he seemed to be free in the interval. 
Later it was constantly present for solids, while fluids passed un- 
hindered. He discovered at this time that the spells when food 
apparently swallowed would regurgitate increased in frequency and 
became greater in amount. He now began to lose weight rapidly. 
For the last week he has been able to swallow but little food and 
even water was regurgitated. 

Examination. — The patient was collapsed rather than emaciated. 
There were no physical signs and only the acetone breath corrobo- 
rated the all too definite history of acute starvation. Because of the 
clear indication, the esophagus was not . sounded. 

Diagnosis. — The gradually progressive difficulty in swallowing 
makes the presence of a carcinoma in the region of the cardia certain. 
The chief indication is to secure a means of feeding him. 

Treatment. — Gastrostomy by the Frank method under local anes- 
thesia was done. The operation was done at a private home and our 
armamentarium failed to include a scalpel. The entire operation 
was done with a pair of scissors ''gastrostomy without a knife" 
as my assistant facetiously remarked. 

Pathology. — He presented a hard, annular ring at the terminal 
end of the esophagus. It seemed to occlude the opening entirely. 

After-course. — The patient did not improve greatly following the op- 
eration, and he died in twelve weeks of gradually increasing inanition. 

Comment. — The intermittent obstruction in the beginning of the 
disease may be accounted for by spasm attending the ulcerous process. 
The gradual tightening of the ring made the intermittent process 
organic and permanent. I have noticed that when starvation is al- 
lowed to proceed to an extreme degree response to increased nutrition 
is not prompt. 

CASE 4. — A merchant aged thirty -three came to the hospital be- 
cause of a mass in the lower right side of the abdomen, and a general 
feeling of weakness. 

History. — The patient has felt perfectly well until nine months ago, 
at which time he commenced to have slight feeling of discomfort 



NUTRITIONAL DISTURBANCE - , 749 

and fullness in the epig-astrium. This distress usually came on one 
to two hours after eating and lasted for about thirty minutes. 
Belching seemed to relieve the distress. Vegetables, except pota- 
toes, seemed to increase the trouble ; no other foods seemed to have 
this effect. During the first two months of his illness he had three 
severe vomiting attacks after eating heavy meals, but has had no 
nausea or vomiting since. Later the distress in epigastric region 
seemed to improve, but he began to have a feeling of fullness and 
distress in the lower part of his abdomen which has gradually grown 
worse since the onset. This distress generally comes on two to 
four hours after eating and comes by periodic attacks, lasting only 
from a few seconds to three or four minutes. During these attacks 
there are rolling movements and rumbling in the region above noted. 
The bowels usually move tAvice each day. For the past week the 
bowels have been loose, moving three times each day. He has no- 
ticed no blood, mucus or dark discoloration of the stools. Three 
months ago he felt a small mass which was not tender in the right 
lower part of the abdomen in front of the hip bone. His doctor 
diagnosed a hernia and advised its repair. Since this time it has 
gradually increased. Since the onset of his sickness he has grad- 
ually become weaker and has lost 16 pounds during the nine 
months. There is no urinary frequency. Last December he began 
having rather frequent night sweats, not profuse, but marked. He 
would sweat while sleeping in a cold room. He had them up to three 
days ago. He has never had any fever that he was aware of, no 
cough. Other than the present trouble the patient has had good 
health save for several attacks of tonsillitis. He had scarlet fever at 
thirteen years of age. No history of tuberculosis. He has been mar- 
ried three months. 

Examination. — General appearance indicates a loss of weight. He 
is tall and looks emaciated. The skin is pale but mucous surfaces 
are red. Does not look acutely ill. Pupils equal and react to light 
and accommodation. Teeth good. Tonsils small. Thyroid not pal- 
pable. Chest rather long and of the iiat type and gives the ap- 
pearance of some atrophy of the scapular muscles. There is no 
muscle spasticity, and the expansion is fairly good on both sides. 
Right apex posteriorly not quite so resonant as left. Resonance 



750 



CLINICAL SURGERY BY CASE HISTORIES 



over rest of the chest is normal. There is bronchovascular breath- 
ing Avith accentuation of the expiratory sound over the right apex, 
but no rales. The spoken and whispered voice are a little more 




FiR. 342.- — X-ray picture of the filling defect in sarcoma of the ileocecal junction. The 
bulbous enlargement below is a cast of the lumen of the tumor. The fine line joining it 
below represents the narrowed portion of the tumor. 

marked over the right apex. The heart is not enlarged and there 
are no murmurs, thrills, or friction rub. Apex beat in 5th interspace. 
Heart dullness extends from right sternal border to 8 cm. to left 



NUTRITIONAL DISTUKCANCE . 751 

of left sternal border. The abdomen is slightly distended, but there 
is no visible paristalsis. In the right lower quadrant of the abdomen 
there is a rounded protrusion. It feels about the size of a, base- 
ball. It is smooth in outline with low bosselations. It may be 
moved around to a limited degree in any direction. It moves slightly 
with change of position. It is tender to rather firm pressure. There 
is no venous enlargement in the skin over it. Rectal examination 
is negative. External genitals negative. W.b.c. 8,800; R.b.c. 4,554,- 
000 ; Hg. 85. Urine negative. 

X-ray of gastrointestinal tract. Plate A. 8:50 a. m. Five minutes 
after taking barium meal stomach is filled, no distinct pyloric open- 
ing or duodenal cap. No filling defect. Plate B. 2 :45 p. m. Stom- 
ach is empty. Barium in small intestines and a rather large mass in 
the cecal region, but there is an appearance of a filling in the 
lower end of the cecum (Fig. 342). There is a fine line of barium 
which approaches the cecal mass in a curved line from the lateral 
side. Plate C. 8 p. m. Barium out of cecum, all in descending 
colon and rectum. Plate D. 8 a. m. Barium practically all in sig- 
moid and rectum but there is a small amount in the cecal region 
which shows as a narrow line far lateralward. 

Diagnosis. — The onset suggested a gastric lesion. Without cause 
the scenes shifted to the iliac region. When such a change occurs, 
one thinks of an appendiceal lesion as the primary factor. Indu- 
rated gut w^alls and an adherent omentum sometimes form tumors 
of considerable size and this must be kept in mind as one of the 
possibilities. Usually such tumors are more fixed and sensitive. The 
slowness of the process, together w'ith the build of the patient 
and his suspicious right apex, suggest an ileocecal tuberculosis. 
These two are usually more fixed than this mass is. Its large size 
and mobility resembles more closely a sarcoma than anything else. 
Sarcomas do not cause narrowing of the lumen, however, and this 
point alone is sufficient to exclude this disorder. The mass has 
the firm consistency of a carcinoma and the lumen is narroAved as 
in carcinoma, but these are usually not so large in so short a time 
and the patient is only thirty-three years of age. However, carci- 
nomas, when they do occur in young persons, are apt to grow rapidly 
and to form large tumors. Tuberculosis fits best with his general 
physical state, carcinoma with the physical appearance of the 
tumor itself, and induration about a subacutely inflamed appendix 



752 



CLINICAL SURGERY BY CASE HISTORIES 




I'lff. 343. — Sarcoma of the ileocecal junction. 



NUTRITIONAL DISTURBANCE 



753 



accounts best for the introductory epigastric disturbances. At 
any rate, the patient needs to be rid of it and we shall see what we 
shall see. 

Treatment. — A long right rectus incision disclosed a large, annular 
tumor involving the low^er end of the cecum. The sigmoid colon 
was adherent to the mesial surface of the tumor at this point. The 
terminal ileum was distended to above the size of a normal colon. 
There were enlarged lymph nodes in the meson in the region of the 
tumor. The whole mass was resected, taking about ten inches of 
ileum and half of the ascending colon going above into the normal 




Fig. 344. — Sarcoma of the ileocecal region. 



cecum. A lateral anastomosis was done. The wound was completely 
closed, but a rubber and gauze drain were put in a new opening 
through the flank. 

Pathology. — The specimen is irregularly globular in form and 
measures 4 x 41/2 inches. The much dilated ileum enters the lower 
border and the remains of the colon emerge from its upper border 
(Pig. 343). There is an irregular channel in the center measuring 
two inches in diameter except at the lower end where it is pro- 
nouncedly narrowed by bosselated outgrowths from the main tumor. 



754 CLINICAL SURGERY BY CASE HISTORIES 

The upper termination also is surrounded by a collar of projecting 
tumor but the lumen is not narrowed by it. The cut surface is pink- 
ish white near the border and whitish pink near the lumen. The 
mass is everywhere firm to the touch. The slides show a general 
cellular formation of small mononuclear cells interspersed by a 
limited amount of connective tissue (Fig. 344). The lymph nodes 
in addition show a few large lymphoid cells. The lymph glands 
show the same structure as the primary tumor. 

After-course. — The patient stood the operation well. He went 
back to his room with a pulse of 120 of good force. Six hundred 
c.c. of normal saline was given by hypodermoclysis. At 6 p. m. there 
was no evidence of shock, no nausea or vomiting. Temperature 100°, 
pulse 88, good and regular. General condition of the patient good. 
The second postoperative day found the patient in good condition, 
temperature 100.2°, pulse 84. Small amount of abdominal pain. 
Some pain in the back. No gastric disturbance. Following this, re- 
covery was uneventful. 

Com/ment. — The peculiarities of growth made this apparently an 
exception to the rule that sarcomas of the gut do not cause nar- 
rowing of the lumen. In view of the history, together with the 
type of tumor it seems fair to assume that the disease was originally 
an indurative appendicitis and that the cells once a part of a slug- 
gish inflammation went on to malignant development. The border- 
line between certain chronic inflammations, characterized by enor- 
mous round-celled infiltration, and sarcoma is exceedingly close. 

CASE 5. — A fanner aged thirty-two came to the hospital because 
of vomiting after taking either solids or liquids. 

History. — At the age of six the patient got some lye in his mouth. 
His parents did not think it got past his throat. They are not very 
certain as to the amount taken. Six years ago he suddenly began 
vomiting every time he ate or drank. He would vomit only a por- 
tion of the food or drink. The vomiting never occurred during a 
meal but ahvays followed immediately after. He noticed from 
the first that with each meal he had to take a great quantity of water 
in order to make swallowing easy. At first he took three glasses of 
water wdth his meals and this amount gradually increased until 
two weeks ago it required six glasses. The vomitus was always 
just the food or drink that he had recently taken. There was never 
any blood in the vomitus. During the first few months of his trouble 



NUTRITIONAL DISTURBANCE 755 

he would get a hiccough whenever he swallowed food. This was re- 
lieved by drinking much water. He never had any pain. He weighed 
145 pounds when the trouble commenced. He began to lose weight 
almost immediately, going to 118 pounds. He held this until the 
last two weeks. He now weighs 97 pounds. A year after the trouble 
began he had a tonsillectomy done, thinking it would give relief, 
but without results. On Feb. 3, 1920, he contracted influenza. He 
did not have a very serious attack. Temperature has been normal 
now about eight days. Immediately after his fever went down, he be- 
gan to vomit every time he took anything by mouth. There is no 
pain or distress accompanying the vomiting. He vomited water 
as well as solid food. He was much weakened by the influenza 
and has not gained any strength since. Hunger has never been 
great. He does not think he is any weaker than when he first re- 
covered from influenza. He has no cough, shortness of breath or 
swelling of the feet. His bowels have not moved without an enema 
since Feb. 3, 1920. 

Examination. — Patient is emaciated and has the appearance and 
action of being sick and weak. Head and neck negative. Chest is 
sunken above and below clavicle, equal on both sides. Normal resonance 
over both lungs. No rales or increased vocal fremitus. Heart 
not enlarged. No murmurs or friction rubs. Dullness from midster- 
nal line to 71/2 cm. to left. Apex beat in 5th interspace. Abdomen 
scaphoid; no palpable masses, no area of tenderness. Abdominal 
organs not palpable. Reflexes all exaggerated. No Babinski. 

X-ray plate taken of the esophagus immediately after the patient 
took xii ounces of barium mixture (all he could take) showed an ciior- 
mously dilated esophagus, the barium stopping at the cardia. The 
cardiac end of the shadow tapered to a point. Plate of the stomach 
region taken immediately after the above showed no barium in the 
stomach. Eighteen hours later more barium was given and after 
vomiting three hours, another plate was taken of the stomach. 
This showed only a trace of barium in the stomach. Plate taken 
six hours after the second barium meal showed most of the barium 
in esophagus, a little in stomach and small intestine. It also shows 
the barium given the day before in the cecum and ascending colon. 
(Fig. 345). 

Diagnosis. — Cicatricial stenosis of cardia. 



756 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 345. — Esophegeal dilatation due to a cicatrix at the caidia. 



NUTRITIONAL DISTURBANCE 757 

Treatment. — Feb. 22, 1920: Complains of much pain in left ear, 
no rise of temperature. Piece of impacted wax filling entire canal 
removed. Pain relieved by hot olive oil in ear and hot-water bottle 
to outside. Tympanum inflamed but not bulging. 

Feb. 23, 1920 : Plummer esophageal dilator inserted with smallest 
tip. Followed by stomach tube which entered the stomach. Swallow- 
ing ability not much improved. 

Feb. 24, 1920, 1 p. m. : Patient complained of much pain in side. 
Temperature 100, abdomen sunken. Complains of pain in right lower 
abdomen. No tenderness, no rigidity, cecum palpable. Patient's 
mouth very dry. He thinks the pain is due to having had no bowel 
movement. Hot-water bottle to side. Plummer esophageal dilator 
inserted. Could not be positive it went into stomach. Patient felt 
so weak and pulses became so rapid that this was not followed by stom- 
ach tube. Temperature up to 101.6° after insertion of dilator. Pulse 
80. There is tenderness over left mastoid. Ice cap applied. 

Feb. 25, 1920 : Patient feels better. Tenderness over mastoid gone. 
Still vomits after eating. Vomitus stained pink as with fresh blood. 
Dilator with smallest tip inserted and followed by stomach tube. 
Lavage given. Temperature went to 101°, pulse 96. 

Feb. 26, 1920, 11 a. m. : Temperature normal. Had vomited while 
taking breakfast. Dilator passed with next to smallest tip. Followed 
by stomach tube. Stomach lavage of sodium bicarbonate given. Some 
water left in stomach. One glass of milk with two beaten eggs given 
through stomach tube. No vomiting after lavage until 3 :50 p. m. 
Fluid watery and mucus blood stained. Temperature two hours 
later up to 100°. Complains of pain in right side along costal mar- 
gin. Lungs show a little decreased resonance and a few rales in 
lower right lobes. 

Feb. 27, 1920 : Pain along costal margin on right side. Dilator 
inserted in esophagus. It caused emesis of a great deal of food pre- 
viously taken. Had had no breakfast. Examination of lungs shows 
a marked dullness to percussion over lower right lobe with tubular 
breathing over this area. 

Pneumonia involving lower right lobe. In the evening the tempera- 
ture was 102°, pulse 96. Pain in right lower chest much better. Pa- 
tient feels better. 

Feb. 28, 1920 : Lungs examined. Tubular breathing in right 
lower lobe gone, somewhat more resonant to percussion. Tubular 



758 CLINICAL SURGERY BY CASE HISTORIES 

breathing changed to faintly heard breath sounds and rales. Higher 
up inside the right scapula is an area of dullness with distinct tubu- 
lar breathing. Left lung normal. Patient still has some pain in the 
right chest, but feels better generally. Has vomited less today on 
taking food and water. 

Feb. 29, 1920: Temperature 99.2° in the evening. Has been no 
higher today. Can take water in small amounts and keep it down. 

March 1, 1920, 10 a. m. : Stomach tube passed but would not enter 
the stomach until a dilator had been previously introduced. Eight 
ounces of water, sixteen ounces of milk and two raw eggs were 
put into the stomach through tube. The milk and eggs were retained 
all day. There was general abdominal pain all day ; temperature sub- 
normal. Lungs clearing up. 

March 2, 1920: Dilator and stomach tube passed. Two eggs and 
two glasses of milk left in stomach. 

March 3, 1920 : Tried to pass dilator with next to smallest tip but 
was unable to get it into stomach. Stomach tube also failed to enter 
stomach. Used smallest tip on dilator and it entered, after which 
stomach tube entered. Two eggs and sixteen ounces of milk left 
in stomach, 

March 4, 1920 : Dilator used, using all the tips successively, from 
smallest to the largest. Stomach tube then introduced and milk, 
sixteen ounces with two eggs and water left in the stomach. 

March 5, 1920: All sized dilator tips put through esophagus. 
Stomach tube introduced and usual milk and eggs given. Patient 
has been drinking milk at intervals all day and retains it. Is able 
to get liquids into stomach but not solids. 

March 6, 1920 : Dilator largest size used. Eggs and milk with two 
ounces of sugar given through stomach tube. 

Same treatment the three days following. Always kept down food 
given by gavage, but vomited solids taken at meal time. 

After-course. — His condition remained good and then there has 
been a rapid restoration of weight. He still has at times some diffi- 
culty in swallowing, and the barium meal shows that there is a wide 
dilatation of the esophagus persisting. 

Comment. — It is likely that the dilatation of the esophagus will 
persist and that the use of a sound will be necessary from time to time 
to maintain the patulency of the cardiac oritice. The history of the 
taking of lye in childhood is the only factor which makes a differentia- 
tion from spasmodic stricture possible. 



NUTRITIONAL DISTURBANCE 759 

LOSS OF WEIGHT 

Nutritional disturbances usually imply loss of weight. Digestive 
complaints, however, are borne without any loss of weight. When no 
loss of weight is present the disturbance is physiologic and does not 
involve anatomic change. Since no anatomic change is present they 
are usually not surgical. 

CASE 1. — A retired merchant aged seventy-one comes complain- 
ing of nausea and loss of strength. 

History. — He has not been well for a j-ear. Before that time he 
had bleeding piles for a number of years. The first symptom was 
sickness of the stomach. Sudden movements increase the nausea. 
He has no appetite but eats well when once started, and there is 
no disturbance from it. He vomits occasionally, several times 
a little blood. He is up part of the time but is kept in bed most of 
the time by his weakness. He weighs 140, this being nearly his 
normal weight. His feet have been swelling, particularly after 
being up for some time. 

Exaynination. — The face is puffy, the skin yellow, inelastic, the 
pulse is 80, but soft. The tongue is moist and coated, and the edge 
is taken up by a pronounced angioma. The abdomen is soft and 
flabby, nowhere is there sensitiveness. He has an appetite for pickles 
and eats cheese with impunity. Urine 1.011, negative. Hg 40, R.b.c. 
2,000.000, poikilocytosis and anicocytosis, no nucleated reds. 

Diagnosis. — The progressive weakness, the blood findings, the ab- 
sence of loss of weight, all speak for pernicious anemia. The soft 
heart sounds, the flabby abdomen, the relatively good digestion, all 
speak against carcinoma. The vomiting of blood might be ascribed 
to either carcinoma or pernicious anei^ia. The history is not clear. 
There may have been no blood. The several observers disagree. 

Treatment. — He was given arsenic. He improved somewhat on this, 
going to 60 per cent Hg and R.b.c. 3,000.000. 

After-course. — ^With the improved blood state the hemorrhoids again 
became troublesome, causing a considerable loss of blood. These were 
ligated. Following this he improved rapidly and apparently regained 
his health. He has remained so three years. 

Comment. — This was apparently a grave secondary anemia. Two 
important factors were overlooked in the diagnosis ; no nucleated red 
cells were found and the color index was not materially altered, being 
neither raised as in pernicious anemia nor lowered as in secondary 



760 CLINICAL SURGERY BY CASE HISTORIES 

anemia. The improvement has persisted too long to ascribe it to a 
free interval in pernicious anemia. These are ticklish jobs for the 
surgeon. Pernicious patients are disposed to bleed and not infre- 
quently a trivial operation is followed in a few days by the death 
of the patient. I have seen this disaster follow the pulling of a 
tooth, a gastroenterostomy under the impression that a vomiting of 
blood was from an ulcer, and once from ligation of supposititious 
hemorrhoids — all these happily in the hands of colleagues. 

CASE 2. — A widow of forty-seven came to the hospital because of 
persistent vomiting. 

History. — She began twelve weeks ago to have pain in the epigas- 
trium. This pain was dull, heavy in character. It was not trans- 
mitted. It was made somewhat worse by taking food. It remained 
the same all day and at night it was not so severe. The abdomen 
bloated a great deal at times after this pain came on. The pain 
disappeared in four weeks and she has not had it since. The first 
vomiting spell came on five weeks after the onset of the pain. This 
usually followed the ingestion of food. There was no regularity 
about the vomiting. She would often go several days without it. 
The vomitus is sour. It looks like liquid stool quite often, but it 
never has a fecal odor and it is often a clear acid water. The 
vomiting is getting more pronounced. It is especially bad the last 
few days. She now vomits everything she eats. Previous to this 
attack of stomach trouble she had felt very well. The only pre- 
vious gastric trouble she has ever had was gas after eating; this Avas 
several years ago. Her appetite continued good up to three weeks 
of the beginning of the trouble. Even now she can eat except 
for the fear of bloating arid vomiting afterw^ard. The bowels 
have been constipated ever since the trouble began. She has lost 
about 25 pounds of weight in the last three months. She has no 
other trouble and has always been Avell. 

Examination. — She is a small, very emaciated w^oman but does not 
have the appearance of being severely ill. The abdomen is scaphoid. 
The stomach is filled with gas and its outline can be plainly seen 
through the abdominal wall. It extends to just below the umbil- 
icus. Peristaltic waves can be readily seen traveling toward the 
pylorus ; often three distinct waves can be seen at one time. There 
are no points of tenderness. In the right of the median line a little 



NUTRITIONAL DISTURBANCE 761 

above the umbilicus is a distinctly palpable tumor. It is freely 
movable. 

Diagnosis. — The presence of a palpable tumor, rapid emaciation, 
and vomiting suggest a pyloric tumor. The location of the tumor 
is in harmony with this h^'pothesis. Whether or not it is an indu- 
rated ulcer or a carcinoma can not be determined. The rather 
definite onset twelve Aveeks ago is strongly suggestive of malig- 
nancy. The past history presents nothing but periods of slight 
flatulence — certainly not enough to diagnosticate ulcer. At any 
rate there is pyloric obstruction and relief is urgently needed. If 
it is a malignant tumor, as seems most likely, its mobility suggests 
there may be a possibility of a radical removal. 

Treatment. — An incision Avas made in the midline above the um- 
bilicus. The mass was readily found and delivered. It was a tu- 
mor extending from the lesser curvature of the stomach past the 
pylorus. It was hard and indurated and at the pyloric end there 
was considerable edema. There were no enlarged lymph nodes. 
A gastroenterostomy was done posteriorly. The condition of the 
patient made a resection of the mass an unjustifiable risk. 

After-course. — The patient suffered considerably from shock im- 
mediately following the operation. The pulse Avent to 135 and 
was very w^eak. Adrenalin chloride m.x was given by hypo and a 
sodium bicarbonate proctoclysis Avas started. She made a good re- 
covery from the shock and suffered very little thereafter. She 
was kept on liquid diet nine daj^s. During this time she suffered 
a little from gas and nausea and vomiting a little on several suc- 
cessive days. The A'omitus Avas ahvaj's small in amount and never 
showed that there AA^as much retention or hemorrhage. After tak- 
ing soft solids the nausea and vomiting became less, but both Avould 
reappear CA^ery time she Avas giA^en a cathartic. These Avere dis- 
continued and enemas used. She improved markedly in the next 
fcAv months folloAving, gaining a Aveight she had never attained 
before. She refused to return for radical removal of the mass. 

Comment. — She Avas right in refusing to return for removal. The 
removal of carcinoma of the stomach is a discouraging task. All of 
my own "cures" AA^ere either plain ulcers or conditions in Avhich a 
positive diagnosis could not be made. The certain eases of malig- 
nancy are either all dead or too recent to permit judgment to be 
passed. 



762 CLINICAL SURGERY BY CASE HISTORIES 

CASE 3. — An insurance agent aged forty came to the hospital 
because of pain in the stomach, and vomiting. 

History. — His trouble began eight years ago. At first he was 
sick after eating and had to vomit. At that time he worked on a 
farm but had to give this up on account of his trouble. He had his 
appendix removed four years ago, but derived no benefit from the 
operation. He has been obstinately constipated for a number of 
years. He now sometimes has vomiting spells in which he 
throws up a green bile. Sometimes he can not retain food, vomit- 
ing the food without bile. He lives on toast and eggs. The food he 
vomits is fresh food, never food eaten a long time before. He some- 
times has some pain in the morning. It is more of a gouging feeling 
than one of real pain. He has taken antacids prescribed by his 
family doctor. His stomach trouble was helped by this but a pain 
came in his back opposite his previous stomach pain. After tak- 
ing this medicine for a time the old gnawing pain returned and 
he began to vomit again. A few nights ago he had a severe stabbing 
pain which required a hypodermic injection for its relief. Since 
then he has been much collapsed, being too weak to walk more than 
a short distance. 

Examination. — He has a sallow putty-like skin. The skin is in- 
elastic and there seems to be just enough of it to encase his body. The 
abdomen is flat, without tympany and without sensitiveness except 
over the epigastric region which seems sensitive to superficial 
rather than deep pressure. It is reported that the bismuth meal is 
still largely retained after seven hours. General examination is with- 
out interest. 

Diagnosis. — The long history of pain with vomiting after eating 
followed by vomiting of food and the long retained bismuth meal 
indicate an ulcer with subsequent contraction. The severe pain at 
night suggests that an ulcer is still present. The pain so severe 
as to require a hypodermic is out of place but the patient is hy- 
peresthetie and his doctor unduly sympathetic. The vomiting at 
once after food indicates an active ulcer rather than a vomiting 
due to the pyloric stenosis. The relation may be due to a pyloric 
stenosis. This seems to be so because he obtained temporary relief 
from antacids. His condition evidently is getting worse and oper- 
ation is justified. 

Treatment. — The stomach is not dilated, neither is there an ulcer. 



NUTRITIONAL DISTURBANCE 763 

An area of dilated veins medial to the pylorus was regarded as 
evidence of an ulcer within. A posterior gastroenterostomy was 
done. 

After-course. — The operative recovery was without incident. 
While in bed he had a severe abdominal pain. It was clearly lan- 
cinating in character and morphine was given. It was noticed that 
his pupils were unequal and reacted to light not at all. No re- 
flexes could be elicited. A neurologist confirmed the diagnosis of 
tabes. 

Comment. — The prolonged history was misleading. It was after- 
ward learned that a previous examination had shown a normal motil- 
ity and emptying time. This not being in harmony with his doc- 
tor's findings it was ignored in the report given me. It was an er- 
ror to belittle the intensity of his night attack of pain. It was 
also an error to do a gastroenterostomy in the absence of definite 
evidence of pyloric obstruction. The findings of a petechial area 
in the walls of the stomach is poor salve when one needs a real ul- 
cer to justify his operative activities. 

Case 4. — A matron of thirty-eight came because of distress in the 
lower abdomen. 

History. — The patient complains of nausea, obstinate constipation, 
and pelvic fullness. She has had three children, the youngest of 
which is five years of age. She had an abortion at two months 
nineteen years ago and miscarriage at five months, thirteen years 
ago. Her periods have usually been regular. She had a severe 
pain in the right side three years ago. Since then she has had pains 
in this side at the period. Six months ago she had a severe uter- 
ine flow for three weeks. Since then she has been regular lasting a 
Aveek or more Avith pain in the right side. Her last period was a 
month before the attack. It was scant and lasted only a few days. 
Eight weeks ago she had a sudden severe pain in the right side. It 
seemed as if everything would fall out. There was rectal tenes- 
mus and she passed urine frequently with much pain. A physician 
gave five doses of morphine. The pulse was rapid and at the time 
there was half a degree of fever. She had morphine for two weeks. 
After this time the pain subsided. Nausea, obstinate constipation, 
and pelvic distress continued. She vomits much of the food taken. 

Examination. — Despite the two months of alleged nausea and vom- 
iting the patient is well nourished and save for acetonuria presents 



764 CLINICAL SURGERY BY CASE HISTORIES 

no evidence of starvation. Chest and upper abdomen are negative. 
There is marked tenderness above and to the right of the pubes. 
There is marked muscular rigidity here. Bimanual examination 
shows the uterus pushed to the left by a boggy mass to the right of 
the uterus. This is markedly tender but no fluctuation could be 
made out. The uterus is fixed, and attempts to move it cause 
pain. The mass is high up opposite the cornu of the uterus. The 
culdesac is somewhat thickened but presents no masses. The tem- 
perature since she is in the hospital varies from 97° to 100°, the 
pulse from 90 to llOv 

Diagnosis. — The sudden severe pain coming on at the time men- 
struation was due, after a previously atypical menstruation, at once 
suggests tubal abortion. The pain was severe, the pulse rapid with 
little temperature disturbance. The persistent pain requiring or at 
least receiving morphine for two weeks is longer than the usual 
duration of tubal abortion pains last. After two months there is 
muscular rigidity and tenderness to deep pressure. The absence 
of the mass in the pelvis usually formed by a blood clot is absent 
though the sensations complained of lead one to expect it. The 
boggy mass high up feels like an unruptured tube but it is un- 
usually sensitive. The whole picture seems best to fit a partial tubal 
rupture probably in the broad ligament. 

Treatment. — The somewhat thickened cord passes over a rounded 
mass the size of an orange. In seeking to determine the outline of this 
it ruptured at its base allowing a cupful of pus to escape. The pus 
is thick, greenish-white, of sickening odor. The sac of the abscess 
was easily shelled out and removed. The sigmoid was adherent 
to the left side of the uterus covering the ovary and tube on this 
side. The right tube was attached to the bottom of the culdesac 
by a clubbed extremity. All these structures were allowed to 
remain attached. 

Pathology. — The wall of the sac is made up of a homogeneous whit- 
ish tissue and is lined by a corrugated membrane. 

Comment. — Subsequent inquiry revealed that there had been no 
temperature observations in the early course of the disease. After 
two weeks when she came into the hands of the second physician 
the temperature ranged a little above normal. Pain from irrita- 
tion of the blood clot often persists for weeks. In these cases there 
is a mass going to the bottom of the culdesac. I explained the per- 



NUTRITIONAL DISTURBANCE 765 

sistenee of pain in a mass sitnated high up as being due to a clot 
surrounding a probable ruptured tube. This is where the error 
occurred. Whether a luteal cyst first became infected at the be- 
ginning of the attack or whether there has been an abscess before 
and it partly ruptured at this time I do not know. I suspect she 
had a mild tubal trouble since three years ago and at the time of 
the present attack a luteal cyst became infected. If this is true 
there must have been some escape from the tube for there no doubt 
Avas some general pelvic peritonitis. 

CASE 5. — A matron of thirty-four came to the hospital because 
of vomiting-. 

History. — She has had fairly good health vmtil six months ago 
when she suddenly began to have stomach trouble, with vomiting. 
There has not been much pain but there has been much gas. She 
has lost some weight, the husband estimates the amount at fifteen 
pounds. Recently she vomits as soon as food is eaten, there being 
almost immediate regurgitation. She never has noticed any blood. 

Examination. — She is tall, thin and narrow chested, but appears 
well nourished. Her Hg is 80 per cent with 4,000,000 reds and 
6,600 whites. The urine is negative. Physical examination is nega- 
tive. The stomach tube stops when the cardia is reached. A 20 F. 
bougie passes after a little manipulation. After being allowed to 
remain in position a few minutes it comes out easily. The x-ray 
showed a dilated esophagus, with a pointing like a cigar of the 
esophageal barium mass. A wide interval separates this from the 
mass contained in the stomach. (Fig. 346.) 

Diagnosis. — The sudden onset, the good general nutrition after six 
months, and the absence of any positive signs pointing to organic 
disease warrants a diagnosis of functional stricture. The fact 
that the bougie comes out easily after being in place for a time 
confirmed this. The feel of dense resistance as it is passed, however, 
gives one a feeling of apprehension. 

Treatment. — Attempts were made to increase the size of bogie 
passed but without result. Atropine was given but still without 
result. The patient lost little weight, but only liquid nourishment 
could be taken. 

After-course. — Treatment being without result, attempts were 
made to find an organic cause. Rather suddenly an ascites devel- 
oped which gave one the impression of a tuberculous exudation. 



766 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 3-16. — Carcinoma of the esophagus. 



The abdomen was tapped and the fluid found to be 1022. The exu- 
date must, therefore, come from a peritoneal irritation, though 
nothing was found on microscopic examination save a few lympho- 
cytes. After aspiration a roughened mass could be felt within the 



NUTRITIONAL DISTURBANCE 767 

abdomen. It was suspected that the mass might be a tuberculous 
conglomerate of intestines or omentum. The esophageal narrowing 
could not be explained on such a basis, however. A Wassermann 
was made and the report was positive. Antisyphilitics were given 
without result. Gradually the" esophageal stricture narrowed until 
fluids were expelled and the patient died of inanition. Autopsy 
showed carcinoma of the cardia and multiple carcinosis of the peri- 
toneum. 

Comment. — It was disconcerting to have such a sudden onset in 
so young a person. The Wassermann was misleading even if cor- 
rect. The need for a gastroenterostomy did not appear until the 
mass appeared in the epigastrium and it was then deemed to be 
too late. 

JAUNDICE 

Jaundice with bile in the urine usually implies occlusion of the 
common duct either due to stone or new growth. In diagnosis the 
important points are to determine its actual presence, if they must be 
obtained from the history, whether continuous and progressive, as 
in malignancy, or interrupted, as in stone and inflammation. 

CASE 1. — A matron of thirty-seven was brought to the hospital 
because of intense jaundice. 

History. — The patient has had four children, the youngest three 
Aveeks old. During the last labor she had five eclamptic convul- 
sions. These ceased after delivery. On the third postpuerperal 
day she had a violent pain in the right upper abdomen. Following 
this she became intensely jaundiced. 

Examination. — The patient is intensely jaundiced. There is deep 
tenderness in the hepatic triangle and the lower border of the liver 
is palpable. The urine is 1.020 sp.gr., contains albumin and many 
casts and much epithelium and bile. 

Diagnosis. — The nephritis is what one would expect after puer- 
peral eclampsia. The jaundice causes one to think of a possible 
yellow atrophy of the liver, but the history of onset with pain is 
reassuring, and besides, gallstone manifestations in the puerperal 
period are vastly more common. The palpable edge of the liver 
likewise is comforting as is the deep tenderness. The relation of 
the jaundice to the nephritis can not be determined because careful 
urine analyses are lacking. Since jaundice in itself may produce 



768 CLINICAL SURGERY BY CASE HISTORIES 

a nephritis or at least bring to the fore an existing one it seems 
highly desirable that the kidneys be relieved of the additional 
burden. Since a general anesthetic would add to the burden of the 
kidney, this seems best avoided. 

Treatment. — The gall bladder was drained under local anesthesia. 

After-course. — The jaundice rapidly cleared. The urine cleared 
slowly and not for six months was it deemed safe to give an anes- 
thetic for the purpose of freeing the common duct of its stone. She 
recovered from this operation also and now six years later has no 
evidence of kidney disease and no disturbance of the gall bladder. 

Comment. — The drainage of the gall bladder no doubt did much 
good by relieving the kidneys of the additional burden of eliminat- 
ing the bile. The duct was not opened at this time because of the 
fear of after-hemorrhage. The second operation was not under- 
taken under local anesthesia because, having once operated in 
this region, adhesions most likely would be present that Avould make 
the operation difficult. 

CASE 2. — A matron of sixty entered the hospital because of jaun- 
dice and progressive weakness. 

History. — For six months she has been feeling weak without pain 
or known cause and for three months has been becoming progressively 
more yellow. The bowels have been growing more sluggish. There 
has been no pain. The patient said she could hear the stones rattle 
when she turned from side to side. 

Examination. — The patient is intensely yellow and shows signs 
of emaciation. She has a tumor the size of a fetal head to the 
right of the rectus at the level of the umbilicus. It is smooth, firm 
and elastic. The edge of the liver can be felt above the tumor. It 
moves with the liver in respiration and can not be moved independ- 
ently of the liver but is movable from side to side. It can not be 
made to recede under the ribs or present in the flanks. The colon lies 
lateral to it. 

Diagnosis. — The association of the tumor with jaundice stamps 
the tumor as being derived from or involving the gall tract. This 
supposition is confirmed by its movement with the liver and not 
independent of it. On inspection one would think from the loca- 
tion that the tumor was renal, but the inability to make it appear 
in the flank excluded this supposition. The nature of the obstruc- 
tion is not apparent. The patient believes she can feel stones when 



I 



NUTRITIONAL DISTURBANCE 769 

she turns in bed. Such things are on record. The progressive ema- 
ciation and loss of strength antedating a slowly developing jaun- 
dice speak strongly for malignancy, however. Since the gall blad- 
der is so enormously dilated the cystic duct must be involved or in- 
vaded. If this is the case a drainage of the gall bladder will give 
no relief, for if the cystic duct is obstructed by the stone it can not 
get out of a drainage opening into the gall bladder. But the 
reasoning may be wrong, hence exploration seems advisable. 

Treatment. — An incision over the height of the tumor was made 
under local anesthesia. The tumor was aspirated and an opening 
made, when many stones were found. These were removed and the 
edge of the opening stitched into the abdominal incision. The an- 
terior superior spine could be palpated when the finger was in 
the gall bladder.' The gall bladder is much thickened, but a 
definite tumor could not be felt, either in the gall bladder or else- 
where. A section of the gall bladder was removed for examination. 

Pathology. — Slides made from the diagnostic section removed 
showed typical carcinoma. 

After-course.— TM\e did not drain. The patient lived, however, 
eight months after the operation. 

Comment. — The presence of jaundice was the welcome clue in this 
case. Without it the low position of the tumor and the large size 
would have made a tumor of other origin very probable. The fact 
that it could not be made to appear in the loin would have been the 
only point to differentiate it from a kidney tumor. The presence 
of a carcinomatous infiltration of the wall makes it likely that the 
tumor was primary in the gall bladder. Had the patient not been 
so enfeebled, a cholecystectomy would have been indicated. I have 
learned that she improved markedly for a few months after operation. 
The fact that jaundice continued makes it likely that the common duct 
likewise was involved and consequently inoperable. 

CASE 3. — A merchant aged thirty-four requested a consultation 
because he had an intense jaundice. 

History. — Three wrecks ago he became feverish and had nausea 
which he regarded as due to an indigestion. He says he could feel a 
lump in his stomach just below the ribs. Any food he ate caused dis- 
tress. After several days he noticed that the urine was very dark red 
in color. On disrobing he noticed that his skin was yellow. His family 
physician after a week or more called in a consultant. Bile was 



770 CLINICAL SURGERY BY CASE HISTORIES 

reported in the urine, but the blood was negative to all tests includ- 
ing the Wassermann, A diagnosis of obstructive jaundice was 
made and operation advised. There has been no pain at any time. 
Nothing in the past history was indicative of any definite etiology. 

Examination. — The patient is intensely jaundiced. The skin does 
not indicate any loss of weight. The abdominal walls are lax 
but not flabby. The urine is heavily loaded with bile, the stools 
clay-colored. There was a resistance deep in the hepatic triangle, but 
a definite tumor can not be made out. The edge of the liver is palpa- 
ble, rounded and a' soft protuberance can be indistinctly felt in the 
region of the gall bladder. Whether it is a part of the liver or a 
separate mass can not be determined. 

Diagnosis. — The rather sudden onset with feverishness and diges- 
tive disturbance without pain in a young man speaks strongly for 
catarrhal jaundice. This is substantiated by the palpable liver 
and the distended gall bladder if such there be. A duct stone in a 
young man is uncommon and jaundice is usually preceded by some 
other evidence of stone and the gall bladder is not palpable. A neo- 
plastic obstruction comes on more gradually, some little time being 
required before complete obstruction is reached. 

Treatment. — He had been taking sodium phosphate and he w^as 
allowed to continue. He had some bismuth for the nausea. 

After-course. — The nausea improved but the jaundice continued. 
He had lost some 30 pounds in w^eight and for a month he continued 
to lose though his appetite improved. The jaundice deepened. The 
skin took on a greenish hue and the stools became entirely bile- 
free. This status continued to eight and finally ten weeks. The 
duration seemed too long and the jaundice too intense for a catar- 
rhal jaundice. Yet nothing appeared to point to any more definite 
diagnosis. The internists urged operation but there seemed no 
clear indication and in the presence of such an intense jaundice op- 
eration would not be without danger. At the height of the per- 
plexity he began to have a good appetite and to gain in weight 
despite the fact that the jaundice had not cleared up. This gain 
in weight and the improvement was sufficient to exclude malignancy', 
for once patients go down from jaundice due to a malignant growth 
they never come up again. After he had regained half his lost 
weight the jaundice began to disappear. At this time he developed 
a troublesome cough and he had many large and medium sized rales 



NUTRITIONAL DISTURBANCE 771 

ill both sides of his chest without any consolidation. At this stage, 
now three months after the onset of his disease, his family physi- 
cian returned and developed from the history that the patient had 
had a chancre fourteen years before. A second Wassermann was 
made and a 4-plus was found. He was given salvarsan and rapid 
improvement followed. 

Comment. — Evidently a s^'philitic mass compressed the common 
duct. The sudden onset was unusual and the negative Wassermann 
was confusing. What, if anything, in the picture that would have 
warranted a persistent search for syphilis does not appear. The 
Wassermann reaction determinations were made by men of vast 
experience. Such experiences make agnostics. Jaundice from other 
causes, as duct stone, or positive carcinoma, not infrequently gives 
a positive Wassermann reaction even in the absence of syphilis. 
The long duration and the intensity of the jaundice should have 
prompted an abandonment of the catarrhal theory and a renewed 
search for a cause of obstruction. The diagnosis was in fact re- 
garded as unsatisfactory and was returned only for the want of 
a better one. The return of the appetite and the gain in weight 
at a time when he was given a series of rounds of calomel was 
significant, but the importance of this escaped both the internist 
and myself. There was the negative Wassermann ! Whether or 
not one would have been justified in operating, as I was requested 
to do, can be answered in the negative. It might have led to 
earlier diagnosis and might have lessened the disturbance from 
jaundice, but it would have added an element of risk. Besides, 
it is not pleasant to open the abdomen and find a syphilitic lesion, 
as I know from experience. It is still more unpleasant to open an 
abdomen and mistake the identity of such a lesion, as I also know. 
Internists should consider the sensibilities of the surgeon to a slight 
degree before they urge interference in wholly obscure cases. There 
are ways of determining the temperature of the bath besides throwing 
the baby in. 

CASE 4. — A matron was brought to the hospital because of ex- 
treme jaundice. 

History. — The patient has three children, the youngest eighteen 
months old. When she was eighteen years old she had severe pain 
in the region of the stomach with vomiting. The pains were con- 
fined to the epigastric region and did not radiate to the back. The 



772 CLINICAL SURGERY BY CASE HISTORIES 

first attack came on in the night and lasted several hours. She 
felt badly for a few days following but she had no pain. She was 
free from pains for several years when another attack occurred 
with vomiting of mucus and bile but no blood. After the birth of her 
first child, five years ago, she had much backache, which was partly 
relieved by a pessary. The last attack of pain occurred five weeks 
ago. This extended along the right costal margin and was not 
completely relieved by vomiting. Following this jaundice appeared 
for the first time. 

Examination. — The patient is much emaciated. There is pro- 
nounced jaundice. The pulse is 46, the temperature subnormal. 
The liver is not palpable and there is no tenderness over the gall 
bladder. The stool is clay colored. The urine is strongly acid 
and contains much bile. It contains no albumin but a few granular 
casts. 

Diagnosis. — The earlier attacks could not be distinguished from 
ulcer, but the last attack radiating as it did, together with the 
jaundice, seemed to implicate the biliary tract as the primary seat 
of the disease. The great emaciation suggested catarrhal jaundice. 
My observation has been that patients lose weight more rapidly in 
catarrhal jaundice than in obstruction from stone. 

Treatment. — The gastroduodenal region was free from disease. 
There were no stones in the gall bladder. The common duct was 
dilated and opened. There was a free passage into the duodenum. 

After-course. — The patient has been free from any symptoms rela- 
tive to the biliary tract now ten years. She has been, however, a 
chronic invalid more or less. She has had her cervix and perineum 
repaired. She is still thin, nervous, and undernourished. 

Comment. — From the appearance of the common duct I was of 
the opinion at that time that there was a duct stone that had but re- 
cently escaped through the papilla into the abdomen. It may have 
been so, but the probabilities are that it was a catarrhal jaun- 
dice. At any rate, opening into the common duct in a patient in- 
tensely jaundiced surely was tempting the wrath of the gods. 

CASE 5. — A widow aged seventy-five came to the hospital because 
of jaundice and weakness. 

History. — She has had six children, all living and well. She has 
had jaundice at intervals for ten years. The first spell came on 
after an attack of dysentery which lasted many months. She had 



NUTRITIONAL DISTURBAXCE 773 

some pain, but not very severe. A year ago during a spell of jaun- 
dice her speech began to be muddled. She was delirious part of 
the time and after recovery had some amnesia. She was able to 
write, but would repeat phrases often. Since then she has been able 
to transact business most of the time. She used to have pain in 
right shoulder blade but none lately. She never had chills but 
had fever at intervals, mostly when there was jaundice. She has 
had trouble with gas at times. Four months ago she had another 
attack of her speech trouble and was a little befuddled for a 
few days before, but there was no paralysis and no jaundice. She 
now has pain in the region of the umbilicus. It is not very severe 
but keeps her awake. She has pain in the front part of her thighs. 
Her usual weight was 221 but she now weighs 175. 

Examination. — The abdomen is not sensitive except in the right 
upper quadrant on superficial examination and some resistance and 
marked sensitiveness on deep pressure. The reflexes are a little 
exaggerated but sensation is normal. Her heart is a little dilated 
to left, apex a little diffuse, sounds a little muffled. Labora- 
tory findings are negative save a slight general anemia and bile 
in the urine. 

Diagnosis. — The historj^ of dysentery preceding the first attack 
of jaundice might suggest a metastatic abscess, but apparently the 
jaundice came simultaneously with the dysentery. Most likely the 
gall bladder was the cause of the diarrhea. The so-called dysen- 
teric attack seems to have been nothing more than a diarrhea. 
There was neither mucus, blood, nor tenesmus. The history indi- 
cates a common duct involvement without stone in the bladder. 
Evidently she has had two cerebral hemorrhages. The amnesic at- 
tacks seemed to be associated with the onset of the jaundice. It 
was suggested that relief from the jaundice might prevent recur- 
rence of the cerebral trouble. I refused operation, but after six 
weeks the patient returned somewhat improved and renewed her 
request for operation. I was reminded of the popular song, "Who 
Is Looney Now?" 

Treatment. — A drainage of the gall bladder under local anesthesia 
was done. 

After-course. — The wound drained freely for a week, when she had 
a renewed cerebral hemorrhage and died. 



774 CLINICAL SURGERY BY CASE HISTORIES 

Comment. — The prospect of securing any noteworthy relief was 
very remote and the operation was done under a grave prognosis. 
Trying to do anything in a surgical way to prevent cerebral com- 
plications of any sort is chasing a rainbow of a pale blue sort, corner 
side down. 

CASE 6. — A matron of fifty-nine came because of jaundice. 

History. — About 25 or 27 years ago the patient began having 
attacks of acute epigastric pain "\vith abdominal rigidity and vom- 
iting. These were relieved only by opiates. In some attacks she 
was slightly jaundiced and with others she was not. About a year 
ago her trouble was diagnosed gallstones and carcinoma of the 
stomach, and she was operated on. No carcinoma of the stomach 
was found, but the gall bladder was found to be full of stones, and 
a cholecystectomy was done. Two weeks after the operation -svhile 
she was still in bed she had an attack of acute epigastric pain with 
vomiting and muscle rigidity. She did not become jaundiced with 
this attack although the attack was just like the ones she had 
previous to the operation. She had these attacks one after another, 
often every day for a month at a time. During this last winter she 
became jaundiced and with every attack since w^ould become yellow 
and clear up between the attacks. She had these attacks at differ- 
ent times up to four months ago when they ceased and did not reap- 
pear until this last one. During this free interval her skin cleared 
up and she ate everything without discomfort. The present at- 
tack began ten days ago. She was first nauseated and vomited and 
the pain started shortly afterwards. The pain was cramp-like and 
extended across the epigastric region. She has had an attack or two 
every day since. The jaundice has gradually deepened. At the 
time of her operation she weighed about 140 pounds. She started 
to gain four months ago and weighed 160 pounds before the present 
attack. She had never noticed whether or not the stools were putty- 
colored. 

Examination. — The patient is intensely yellow and has marked 
tenderness over the hepatic triangle. The urine contains much bile 
and the stools are clay colored. The temperature is normal, and 
the pulse ranges at about 100. There is a long, transverse abdom- 
inal scar. 

Diagnosis. — Common duct obstruction, probably by a stone. This 
seems probable since she had many attacks of jaundice and from the 



nutr:t:oxal disturbance 775 

history of the operation the common duct Avas not drained. The in- 
termittent character of the jaundice indicated a stone, near the 
termination of the common duct capable of acting like a ball valve. 
Had she not had her gall bladder removed, a simple drainage as a 
temporary expedient should be seriously considered. Nothing but 
a drainage of the common duct will be of avail, however, since she 
has already had her gall bladder removed, and this in view of the 
fact that she was operated on by a surgeon who, in spite of the his- 
tory, did not explore the duct, makes one apprehensive of the pres- 
ence of many adhesions and in consequence an extra formidable 
operation must be anticipated. 

Treatment. — Expectant treatment was followed — sodium phosphate 
and laxatives. 

After-course. — The patient ran a septic temperature from the 
time she entered the hospital and had from one to two attacks of 
severe epigastric pain with rigidity which were relieved only by 
opiates. The jaundice gradually deepened. She vomited during 
the attacks very often. After ten days the temperature suddenly 
dropped to normal and remained so and the attacks of pain ceased. 
The jaundice gradually cleared up, and the patient was dismissed 
ten days later to go home and recuperate before any operative 
procedure should be attempted. 

The patient returned in three weeks, the jaundice completely 
gone and the general conditions vastly improved. The operation 
was now undertaken. A transverse incision was made along the 
scar of her previous operation. On entering the abdomen all 
the abdominal viscera in that region were found densely matted 
together by adhesions. The transverse colon actually was adherent 
between the edge of the liver and the anterior abdominal w-all. 
After breaking up dense adhesions about the common duct, it was 
exposed. The duct was carefully palpated throughout its length, 
but no stone could be felt. The duct itself was the size of the 
little finger w'ith very dense walls. The duct was opened midway 
in order that the interior could be better explored. When opened 
the duct admitted the little finger. A stone was now palpable 
at the terminal end of the duct. Failing to extract it through 
the duct, it was removed transduodenally. The opening through 
the wall of the duodenum was carefully closed w^ith silk. A T-tube 
was placed in the duct and a gauze drain passed to the bottom of 
Morrison's pouch. 



776 



CLINICAL SURGERY BY CASE HISTORIES 



Pathology. — The stone was a brittle one and was as large as a hick- 
ory nut (Fig. 347). 

After-course. — A part of the gauze drain was removed on the 
fourth day, and the remainder on the sixth day. Up to this time 
there has been very little drainage through the T-tube. There 
has been a great deal of bile drained through the rubber drain 
and around the T-tube. On the seventh day there w^as § viii drain- 
age through the T-tube. On the eighth day the drainage looks 
fecal in character and smells so. The T-tube was removed. The 
skin around the incision was much irritated. On the eleventh day 
the rubber drain was removed. The skin was excoriated by duo- 
denal drainage. On the thirteenth day the drainage was much de- 
creased and consisted mostly of bile. Therefore, it is concluded that 
the duodenal contents came from the opening in the common duct 




Fig. 347. — Stone from common duct. 



and not from a duodenal fistula coming from the place where the 
stone was removed from the duodenum. On the twenty-first day the 
patient went home feeling very well. The wound was healed with 
the exception of the place where the drainage tube had been. There 
W'as still a little drainage of bile. No duodenal drainage occurred. 
Since then she has been perfectly well. 

Comment. — It is my opinion that this was a good job. A logical 
interpretation of the history indicated that there was a stone in 
the common duct. It seems incredible, however, that a stone of 
this size should not have been palpable. The explanation is found 
in the presence of the pronounced induration of the walls. The 
difficulties to be encountered by judging the skill of the operator 
were properly estimated, waiting for an interval of freedom from 
jaundice before operating w^as good judgment. Had I waited 



NUTRITIONAL DISTURBANCE 777 

longer, the induration would have disappeared and the stone could 
have been palpated and most likely have been removed through the 
opening in the duct. Months are required for such ducts to become 
normal and from her history a renewed attack was to be feared be- 
fore this Avould take place. The transduodenal extraction brought 
with it the danger of a fistula, a distressing and dangerous complica- 
tion. For a time it seemed that just this had occurred but the rapid 
closure of the wound makes this unlikely. 

CASE 7. — A retired merchant aged seventy-five came because of 
jaundice and loss of weight. 

History. — The patient was always well until three months ago, 
when he felt sick at the stomach. In six weeks he became jaundiced 
and the stools became clay colored at first, but later some color 
returned to the stools without any lessening of the jaundice. At 
the beginning of the jaundice there was some diarrhea and a cer- 
tain degree of looseness continued amounting to two or three semi- 
fluid stools per day. Now he has an aversion to food but the small 
amount he is able to force down does not cause any great degree 
of distress. There is intense itching of the skin. Were it not for 
this, he thinks he would sleep well. He has lost much in weight. 

Examination. — He is a large man, who shows evidence of marked 
emaciation, the skin is loose and inelastic and everywhere shows 
scratch marks. All exposed surfaces are intensely jaundiced. The 
upper abdomen is prominent, somewhat tympanitic, but without 
rigidity. A globular mass the size of an apple is easily palpable in 
the hepatic triangle. It is smooth, elastic and moves with respira- 
tion. 

Diagnosis. — Malignant disease of the pyloric region, secondary 
dilatation of the gall bladder. The rather sudden onset of the 
jaundice speaks of carcinoma of the pjdorus rather than of the 
pancreas, though the complete occlusion of the common duct is 
quite in accord with a primary affection of the pancreas. 

Treatment. — General expectant treatment with Carlsbad salts and 
calomine carbolic solution for the skin in the following proportion: 
Carbolic acid, 5 iss, Zinc Oxide, Calomine, Starch aa § ii; Glycerine, 
o i ; Aq. ad q xvi. 

Subsequent Course. — The lotion above mentioned produced some 
relief from the intense itching and for a time his nausea was lessened. 



778 CLINICAL SURGERY BY CASE HISTORIES 

After a month he had a large hematemesis, followed in ten days by 
another and he died in a few days. 

Discussion. — The occurrence of the vomiting of blood speaks for 
the primary lesion being gastric rather than pancreatic. Relief 
from the jaundice and consequently from the itching may some- 
times be secured by a cholecystostomy when the jaundice is due 
to the obstruction low in the common duct. When the onset is 
sudden and the primary lesion is gastric this is less likely to be the 
case than when the onset is slow and progressive before there is 
much gastric disturbance, indicating a primary atfection of the 
stomach. When the gall bladder is so widely distended the oper- 
ation is very simply performed under local anesthesia Avithout 
marked inconvenience to the patient, and when urged to do so I 
frequently do it, though experience has shown that it more often 
fails than succeeds. 

HEMATEMESIS 

When nutritional disturbances are associated with loss of blood 
it means cancer or ulcer; if the loss of weight is marked it is likely 
the former. 

CASE 1. — I was called to see a married woman aged thirty-four 
because of a continued fever following childbirth. 

History. — She had her fifth child five weeks ago. At the fifth 
day postpartum she began to have fever. Two days following she 
had an eruption which the family doctor diagnosed smallpox. The 
fever continued after the eruption disappeared. A surgeon Avas 
called but found nothing of a surgical nature that could be made 
responsible for the fever. The fever has remained the same since the 
last consultation two weeks ago. It varies from 100° to 102.5° 
and the pulse from 90 to 110, the respiration about 20. She has 
no appetite but suffers no pain. 

Examination. — The patient does not seem seriously sick, but is 
pale and anemic. The lungs sIioav- no abnormalities. The abdomen 
is soft and there are no points of sensitiveness. The uterus shows 
a normal rate of involution, is in position and is moA'able. To the 
right of the uterus continuous with the body of the ischium is 
a mass nearly as large as an egg. It is very hard and is not 
sensitive to pressure. The left side is unaffected. 



XI'TRITIOXAL DISTL'RI5A::CE 779 

Diagnosis. — Though there are no positive lung findings, a fever 
whieh continues for weeks postpartum keeps the lungs under sus- 
picion so long as the fever lasts. The mass in the pelvis is suffi- 
cient to account for her difficulties, however. Since it is firm, the 
prospect for its ultimate resolution is good. The patient must 
be warned that subsequent abscess formation may take place. 

Treatment. — Expectant. 

After-course. — The patient improved for a time and the tempera- 
ture ceased to be taken. After some months she began to have a 
rise of temperature again and this had persisted some three weeks 
at the time of the second visit. At this time, four months after the 
first visit, there was a marked tumefaction above and to the right 
of the symphysis pubis. It was sensitive to pressure and gave 
a sense of fluctuation. Bimanual examination showed that the mass 
extended nearly to the uterus but did not come to the floor of 
the pelvis. An incision was made from the pubic eminence parallel 
with Poupart's ligament for 3 inches. An incision made here caused 
a large quantity of pus to escape. A gauze drain was placed into 
the bottom of the wound. Healing took place in a month and she 
has had no further trouble. 

Comment. — The dense mass noticed at the first examination was 
an infiltration of the cellular tissue of that region. This condition 
is pathognomonic of such cases. It resembles an exostosis when 
first palpated, so hard it is. 

CASE 2. — A housewife aged forty-nine came with a complaint of 
pain in the lower abdomen and progressive loss of strength. 

History. — Eight years ago she began to have attacks of severe 
pain in the epigastric region. They were so severe that a doc- 
tor had to be called. She usually vomited, which brought some 
relief. In some of the attacks she had some epigastric soreness. 
These attacks came on every two to six months. The last attack 
was three months ago. After this one she had fever for several 
weeks and had a pronounced soreness in the epigastrivim and along 
the costal margin. Two weeks after the beginning of the attack 
she became jaundiced. This has continued to increase in severity 
to the present time. Her appetite is indifferent and she bloats 
easily. The patient has two children aged eleven and seven years, 
respectively. She flows two or three days every three weeks. She 
has had pain in the sacral region worse at the menstrual period. 



780 CLINICAL SURGERY BY CASE HISTORIES 

She had some soreness and pain in the region of the stomach. 
The pains were sometimes relieved and were sometimes made worse 
by eating. This has troubled her but little for a number of years. 
She has had pain under the left shoulder blade for many years. 

Examination. — The patient is well nourished but is intensely 
jaundiced. There is sensitiveness in the hepatic region and a 
tumor is palpable even in quiet respiration. It is hard but rela- 
tively smooth and is tender. There is a pronounced retroflexion 
and a moderate perineal laceration. The urine contains much bile, 
some albumin and a few casts. 

Diagnosis. — The advent of jaundice following repeated attacks 
of epigastric pains with the subscapular pains leaves but little 
doubt but that there is trouble in the gall tract. The palpable 
tumor is evidently of the gall bladder. In spite of its great 
hardness, its smooth surface and the acute manner of its onset 
stamps it as inflammatory. There have been no chills, but the 
persistence of the trouble makes it seem likely that there is 
a stone in the common duct. The presence of an inflammatory 
tumor, most likely with adhesions and infection, completes the 
picture. The sacral pains likely were due to the retroflexion and 
the epigastric disturbance likely was the first expression of devel- 
oping gallstones. 

TreUtment. — The tumor felt on palpation is a mass of thickened 
omentum which entirely envelops the gall bladder. The shrunken 
gall bladder was found by exploring the extensive omental adhe- 
sions. These were separated sufficiently to expose the fundus 
of the gall bladder only. This was incised and a quantity of 
gall stones removed, most of them brittle. There was some 
pus in the gall bladder. A drain Avas placed in the gall bladder. 

After-course. — The jaundice cleared up within a few Aveeks and 
the patient regained her strength. She was advised to return af- 
ter a few weeks for a common duct drainage. 

Second Operation. — There were a few adhesions remaining about 
the gall bladder. The common duct was readily opened. It was 
free from stones. The hepatic duct was dilated. The ducts were 
drained with a tube and the gall bladder removed. She died in 
two days, without any cause being apparent except a suppression 
of urine. 



NUTRITIONAL DISTURBANCE 781 

Comment. — Evidently the obstruction was due to an inflam- 
matory thickening of the common duct or else the stone had es- 
caped before the second operation. The latter is not probable be- 
cause the common duct was not dilated as it would have been had 
the obstruction been due to a recent stone. The operation was not 
difficult and the resources of the patient were not taxed. As 
in so many of these cases, the kidneys were made vulnerable bj^ 
the prolonged jaundice. Had the second operation been omitted, 
the patient likely would have remained w^ell. There seems to 
be no certain way of telling in such cases whether there is a com- 
mon duct stone present or not except to look in and see. To 
do this requires a dangerous operation. That a shrunken gall 
bladder is a sign of common duct stone I do not believe. This 
alone can come from a proliferative inflammation of its walls. 
If no inflammation exists, the gall bladder does not shrink even 
if there is a stone in the common duct. It might have been bet- 
ter to have removed the gall bladder at the first operation. I 
hesitate to break up extensive adhesions when the patient has 
been jaundiced for a long time. 

CASE 3. — A fanner sixty-eight sought consultation because of 
loss of appetite and strength. 

History. — His health has always been good until the advent of • 
the present trouble. For three months he has been losing appetite. 
There has been no vomiting, but recently he has had some difficulty 
in swallowing solid foods. He has lost 20 pounds in weight. 

Examination. — He is a powerful man, but the skin is loose, non- 
elastic, and the abdomen flat. There is no tenderness anywhere. 
The tongue is large, foul, indented, and covered with a heavy fur. 
Red blood count 3,600,000, white blood count 11,800, Hg 70. Stom- 
ach tube stops suddenly 36 cm. from incisor teeth. 

Diagnosis. — This presents the classic picture of a well advanced 
carcinoma of the cardia Avhich has already advanced to the stage 
of occlusion of the esophagus. The tube was hardly needed to prove 
its presence. Attended by loss of w-eight, a moderate general ane- 
mia with a slight leucocytosis is sufficient to exclude cicatricial 
or spasmodic stricture of the esophagus. 

Treatment. — ^The occlusion was not great enough to exclude the 
taking of all foods, hence a careful dilatation by means of bougies 
was done in order to put off as long as possible the inevitable gas- 



782 CLINICAL SURGERY BY CASE HISTORIES 

trostomy. Following this treatment deglutition became quite free 
and treatment was discontinued. 

After-course. — A month after the soundings were discontinued 
the patient began again to experience greater difficulty in swal- 
lowing. Gastrostomy was advised, but the patient desired that the 
sounds be tried again. While the argument was going on, the pa- 
tient vomited a pint and a half of blood. Following this he was able 
to swallow more freely and he gained strength again. Vomiting of 
blood recurred at intervals and he died from hematemesis eight 
months after he was first examined. 

Comment. — The improvement in swallowing following the hemor 
rhage was due, no doubt, to the breaking down of the tumor. Had I 
sounded the esophagus just prior to the hemorrhage it would have 
set the effort in a bad light. Possibly the earlier soundings contrib- 
uted to its occurrence. Though at the time there was good author- 
ity for attempting to keep the esophagus patent by direct mechan- 
ical means, I never again repeated the attempt, fearing hemorrhage 
might be caused by it or occur simultaneously with it. Gastrostomy 
is safer and surer and does not invite a catastrophe. 

CASE 4. — A retired farmer aged sixty-five came because of loss 
of appetite. 

History. — He has never had an illness of any moment until now. 
This trouble began two months ago. After eating a hearty meal he 
says that he suddenly lost his appetite, and with the exception of 
one day, he has not been able to relish food since. He never 
has had any pain in the region of the stomach. He vomited a 
small amount at the onset of the trouble but has not vomited since. 
He has lost twenty pounds in weight and feels weak. He feels 
nauseated at the sight of food, particularly^ meats. 

Examination. — The patient seems weak and gives one the im- 
pression of having lost more in weight than his statement indicates. 
Hg 85, R.b.c. 4,500,000 ; W.b.c. 4,500. The urine is negative. There 
is no free hydrochloric acid, also no lactic. The abdomen is soft 
and there is no sensitiveness. 

Diagnosis. — The sudden onset of loss of appetite with loss of weight 
and anacidity strongly suggests beginning carcinoma, though there 
is nothing in the physical examination to support this view, save 
the lack of acid. 



NUTRITIONAL DISTURBANCE 783 

Treatment. — Exploration. An old scar near the pylorus was found, 
not appreciably narrowing the lumen, however. Nevertheless a gas- 
tric enterostomy was done. 

After-course. — The patient gained rapidly but showed distinct nerv- 
ousness requiring bromides. He has weak spells and loses his appe- 
tite at times but quickly recovers under the use of bromides. 

Comment. — Whether the heavy meal he speaks of gave him an acute 
gastritis or whether there was some underlying nervous state it is 
impossible to say. Since he improves under nerve sedatives he 
probably has some trouble all his own which he has not seen fit to con- 
fide. At any rate there is no evidence that the operation had any 
thing to do with his recovery. 

CASE 5. — A farmer aged thirty came because of pain in the right 
loin. 

History. — Four months ago he developed a number of boils on 
his arms. A few days after these appeared he began to feel tired 
and weak. He developed a diarrhea which lasted four days. Fol- 
lowing this he had a high fever. Because of this he was taken to 
a hospital where he remained eight weeks. During this entire time 
he had a general abdominal soreness most marked on the right side. 
During a part of this time he had night sweats regularly. The 
last tw^o wrecks of his stay in the hospital he had a severe blad- 
der irritation which was attended by frequent and painful urina- 
tion. He had to be catheterized several times. At the end of this 
time an abscess was opened beside his rectum. When this was done 
his bladder trouble ceased. Following this he developed pain in 
the lower right side of his abdomen. He was unable to straighten 
his right leg. A swelling now appeared in his back above the hip 
bone. He had a severe cough for a time but none' now. There w^as 
no pain or expectoration. His bowels move without aid. His ap- 
petite is poor and he has lost much w^eight. 

Examination. — The patient is pale and emaciated. He lies heav- 
ily in bed with the right thigh semifiexed. The chest expansion 
is poor but the two sides are equal. There is some prolongation 
of the respiratory sound over the right side. At the base there 
is diminished breathing and slight dullness. There is a faint 
systolic murmur at the apex which is not transmitted. The abdo- 
men is generally distended and there is tenderness on deep pressure. 
This is marked in the right groin. The inguinal lymph glands on 



784 CLINICAL SURGERY BY CASE HISTORIES 

the right side are enlarged. There is sensitiveness in the right 
lumbar region. The movements in the hip joint are free, except 
extension is limited. An attempt to force extension causes pain 
in the right groin. The blood pressure is 100-70. R.b.c. 3,000,000 ; 
W.b.c. 8,000 to 10,000; Hg 30; pulse 80, temperature 97°, respira- 
tion 22. Urine contained a few pus cells. 

Diagnosis. — The flexed thigh indicates irritation of the iliopsoas 
muscle. The general dullness of the right side of the abdomen 
suggests a collection of pus. The relatively low leucocyte count 
is accounted for because of the long existence of the trouble. There 
is no evidence as to the findings in his previous trip to a hos- 
pital, but the diagnosis of typhoid fever was made. The sudden on- 
set after the development of boils suggests a metastatic origin, 
particularly since the lungs seem likewise to have been infected, 
though this may have come secondary to the abdominal infection. 
The findings are those seen following a retrocecal appendix, though 
abscesses from this source usually cause a greater degree of dis- 
turbance. Its bulging in the groin seems now to suggest a peri- 
nephritic origin, but this phase seems to have been of late develop- 
ment, while it should have been primary if of renal origin. The 
general findings are those of a retroperitoneal abscess due to an 
appendix. 

Treatment. — An incision was made above the crest of the ilium. 
An abscess was found extending from above the kidney to Poupart's 
ligament and into the pelvis to the base of the bladder. In this 
entire extent it seems to have elevated the peritoneum. A rubber 
drain was placed into the pelvis and the large cavity packed loose- 
ly with gauze. 

Pathology. — The pus is yellowish in color and contains a Gram- 
positive coccus which could not be more closely identified. 

After-course. — Relief of pain followed the opening of the abscess 
and after a day the temperature remained normal. In a week the 
leg could be fully extended. 

Comment. — It is difficult to account for the genesis of this abscess. 
There is no history that would indicate its origin from any lesion of 
the gut tract. Retroperitoneal abscesses follow suppurations in other 
parts of the body not at all infrequently and it may perhaps not be 
too far fetched to assume that the infection reaches the retroperitoneal 
lymph glands by way of the lymphatic ducts. 



NUTRITIONAL DISTURBANCE 



785 



Case 6. — A matron of thirty-six was brought to the hospital be- 
cause of weakness following labor. 

History. — Mother of six children. Following labor she had a pro- 
tracted fever and an eruption. After six weeks the fever continued 
in a low form. There was some malaise but the general condition 
remained fair. 

Examination. — The uterus was not fixed firmly and was in posi- 
tion being large, corresponding to one which has not undergone nor- 
mal involution. At the lateral extremity of the broad ligament 
there was a dense indurated area of almost bony hardness. This 
mass seemed fixed to the body of the ischium as though it were a tumor 
going out from the bone itself. (Fig. 348). 




Fig. 3-)8. — Large broad ligament abscess pointing both in the vagrina and over Poupart's 

ligament. 



Diagnosis. — Postpartum infection in the broad ligament. 

Treatment. — Expectant. General measures to promote nutrition. 

Subsequent Course. — Condition remained the same for a number 
of months. At the expiration of this time a mass appeared to the 
right of the pubes and temperature began to ascend. Bimanual ex- 
amination showed a mass lying lateral to the bladder pointing to 
the surface above the medial termination of Poupart's ligament. 
Fluctuation could be made out. The mass was incised above Pou- 
part's under local anesthesia without removing the patient from the 
bed. Eecovery was rapid following this drainage. 

Comment. — The question of the propriety of vaginal drainage 
might be raised. When an abscess has one collapsible wall it 



786 



CLINICAL SURGERY BY CASE HISTORIES 



makes little difference at Avliich pole the incision is made. If con- 
ditions had been favorable this route would have been selected. Un- 
der the circumstances the site selected was at once more conven- 
ient to incise and the drainage opening was more easily cared for 
than if a vaginal opening had been made. 

Case 7. — A matron of forty-six was brought to the hospital be- 
cause of fever following childbirth. 

History. — Abortion at third month, curettage, A low fever con- 
tinued following an initial temperature of moderate degres — maxi- 
mum 102.5. Her general condition became much impaired and she 
was confined to her bed except for short intervals each day. 

Examination. — She showed the physical characters and general 
disposition of a prolonged septic process. There was some general 




rig. 349. — Bilateral bioad ligament abscess. 



tenderness over the pubes. The uterus was fixed and there was indu- 
ration in the base of each broad ligament. (Fig. 349.) Nothing 
could be felt by the abdominal hand. 

Diagnosis. — Streptococcic infection in the base of the broad liga- 
ment. 

Treatment. — Incision into the indurated areas, packed with gauze. 

Pathology. — The tissue was dense and edematous. No pus pockets 
could be found in either broad ligament. The culdesac was carefully 
avoided. 

After-course. — After some days the pockets occupied by the gauze 
began to exude a small amount of pus. The patient began to grad- 
ually improve and recovered completely in about four months. 



NUTRITIONAL DISTURBANCE 787 

It seemed likely that incision into the indurated areas hastens 
recover}' by depleting the tissue. Not infrequently folloAving such 
an incision, after the opening has closed, localized abscesses form. 
These generally are mixed infections. It seems quite likely that 
the mixed infection excites the tissues to reaction, which the 
streptococci do not and this reaction by forming a frank abscess 
accomplishes the destruction of the persistent streptococci. 



CHAPTER XV 

TUMORS OF THE ABDOMEN 

Tumors of the abdomen imply surgical activity in all save the 
pregnant uterus. The chief concern lies first in determining its 
point of origin and then its character. Usually where the first is 
determined the second also can be determined. 

EPIGASTRIC 

Tumors of this region are usually developed from the stomach, 
less often from the pancreas and retroperitoneal tissue, rarely from 
the liver. 

CASE 1. — A school teacher aged fifty-three came to the hospital 
complaining- of dull aching in epigastrium and a movable tumor in 
the region of the umbilicus. 

History. — A little more than a year ago he began having a dull 
heavy pain in the epigastrium after eating. He did not vomit and 
the pain was not sharp. He began to lose weight. A year ago his 
doctor was able to palpate a tumor in the abdomen just over the 
umbilicus. The type of tumor was not diagnosed. He was operated 
and nothing was done with the tumor, the abdomen being left as it 
was. He was told that the whole abdomen was filled with masses. 
He gained 12 pounds in the two months following operation, hav- 
ing previously lost 25. He began having the same epigastric dis- 
tress almost immediately after operation and this has steadily grown 
worse. He lost his appetite. He now produces vomiting every night 
by putting his finger in his throat and relieves the distress for the 
night. He never vomits any other way. Never noticed any bloody 
or coffee ground vomitus. He has lost 32 pounds of his original 
weight, weighing now just 100 pounds. He never has any real 
pain. He was never subject to stomach trouble prior to about 
14 months ago. He has never been jaundiced. He does not remem- 
ber childhood diseases. Has always been well until this trouble 
began. 

788 



TUMORS OF THE ABDOMEN 



789 



His mother died of cancer of stomach. One brother died in the 
late 50 's of an undiagnosed stomach trouble. 

Examination. — The patient looks older than his given age. He 
is extremely emaciated and has a cachectic appearance. He looks 





\ 



,v 



r 



.--J 



Fig. 350. — Adenocarcinoma of the stomach. 



to be acutely ill. Head and neck negative. Chest flat, lower end 
of sternum shrunken, ribs prominent. Expansion fairly good, equal 
on both sides. Normal resonance throughout. No rales, no in- 
creased fremitus. Heart not enlarged, no murmur or friction rubs. 



790 CLINICAL SURGERY BY CASE HISTORIES 

Dullness extends from midsternal line to 7I/2 cm. to left. Apex 
beat in 5th interspace. 

Abdomen scaphoid; walls extremely thin and hard. Liver and 
spleen not palpable. Left kidney palpable, not tender. Mass pal- 
pable just to right of, umbilicus, circular, fiat and hard. Feels 
about 4 inches across. It can be pushed around almost anywhere 
in upper half of abdomen. 

X-ray taken five minutes after barium meal shows an absence of 
pyloric opening and duodenal cap and a distinct filling defect in 
pyloric end of stomach. Stomach extremely large, extending almost 
to the pelvic brim. Another picture taken six hours later shows 
a retention of almost half the barium meal in the stomach. 

Diagnosis. — Carcinoma of the stomach. 

Treatment. — Pylorectomy under local anesthesia with removal of 
the pyloric tumor. Gastrojejunostomy. On opening the abdomen a 
tumor was found in the pyloric end of the stomach. This had a 
rounded fiat outline. 

Pathology. — The tumor projects above the surrounding mucosa of 
the stomach like a cauliflower. (Fig. 350.) Herein is the explana- 
tion of its slow growth. This type of growth, common in the rectum, 
is unusual in the stomach. 

After-course. — There was some postoperative shock. Temperature 
dropped to 96, pulse became very weak for a few hours but did 
not change in rate. Patient showed rather marked pallor. Did not 
perspire or change in respiration rate. No vomiting and no com- 
plaint of pain. Temperature remained subnormal the week follow- 
ing operation. He took soft food on the fifth day. The sutures 
were removed the ninth day. The wound was healed except for a 
small draining sinus at lower end of wound. On the tenth day the 
patient sat up in a chair. He continued to make an uneventful 
recovery and wa,s dismissed in three weeks after the operation. He 
had gained 10 pounds, was taking general diet and had no gastric 
discomfort. 

Comment. — It is strange that this tumor remained operable so long 
after the preliminary exploration.. The extreme mobility was the 
factor that lead to the conclusion that it was still operable. 

CASE 2. — A carpenter aged forty-six came because of pain and 
tumor in the region of his stomach. 

History. — He has enjoj'ed uniform good health until the begin- 
ning of the present trouble a year and a half ago. At that time 



TUMORS OF THE ABDOMEN 791 

while at Avork he was struck violently in the pit of the stomach by 
a scantling which had slid from a considerable height. It knocked 
his breath out, but after half an hour he was able to walk to his 
home. After lying about for a few days he returned to work, and 
after a Aveek the soreness disappeared. He never regained his for- 
mer vigor, however. Several months later he noted he was losing 
weight. This has continued until the present time. His former 
weight was 190, now it is 146. Four months ago he noticed a tumor 
developing in the pit of his stomach. He has had a sense of full- 
ness and some sensitiveness on pressure, but no actual pain. His 
appetite has been indifferent for some time past, and he has had loose 
stools at times. 

Examination. — He is a large-boned man who evidently once was 
powerful, but he looks weary and worried. Mouth and lungs are 
normal. The abdomen is somewhat distended but soft and flabby. 
Below the ensiform cartilage is a tumor the size of a large grape 
fruit. It is tense, elastic, evidently cystic. Quite firm pressure can 
be applied before it elicits his interest. It seems smooth and globu- 
lar. It can not be moved about either by manipulation or change 
in position. It can be tilted somewhat, but the base is not movable. 
There is a slight general anemia. The stools are negative. 

Diagnosis. — Injury of a pronounced nature, followed by the de- 
velopment of a cystic tumor and attended by emaciation is pathogno- 
monic of pancreatic cyst. It is a matter of academic interest to 
determine the relation it bears to the surrounding organs, notably 
the stomach and transverse colon. By inflating first the stomach 
and then the colon the tumor is proved to lie down between the two 
(Fig. 351^). The removal of as much as possible of the cyst wall, the 
attachment of the wall remaining to the edge of the incision in the ab- 
dominal wall seems to be the procedure indicated. 

Treatment. — The tumor was exposed through a mid-line incision. 
The omentum, studded with many tubercles appeared. In going 
through this, coils of intestines were found to be matted over the 
cyst. By separating these, a cavity containing near a quart of fluid 
was encountered. There was no cyst. The fluid was imprisoned 
by extensive adhesions of coils of thickened intestines. The walls of 
these were covered with fibrinous exudates. Adjoining coils, not 
directly concerned in the formation of the cavity, were studded with 



792 



CLINICAL SURGERY BY CASE HISTORIES 



tubercles. A section of the omentum containing a number of tuber- 
cles Avas removed for further study. The fluid was mopped out and 
the abdomen closed. 

Pathology. — The tissue removed showed typical tubercles with some 
small caseated centers. 

After-course. — The patient gained some twenty pounds in weight 
in the months following the operation. Following this he began 





Fig. 351. — Diagrammatic presentation of a supposed pancreatic cyst. A. As 
posed to be before operation. B. As it was found to be at operation 



It was sup- 



again to decline and it was reported he died of lung tuberculosis, 
the lesion being first demonstrated in the right apex. 

Comment. — The cyst was therefore a sacculated tuberculous exu- 
date. The trauma likely afforded a favorable nidus for an infec- 
tion already in the body, though the examination failed to reveal 
its presence. The perfunctory examination one usually makes when 
he has his eye on the surgical lesion is not calculated to discover 
incipient apical tuberculosis. This sacculated peritonitis was so 



TUMORS OF THE ABDOMEN 793 

well defined and its situation so typical for pancreatic cyst that 
even the discovery of a lung lesion Avould hardly have restrained 
me from diagnosing a pancreatic cyst since the triad of symptoms, 
severe trauma, development of cyst, and emaciation, supposedly 
pathognomonic of that lesion, were so clearly pronounced. It may be 
noted finally that at operation the cyst lay below the transverse 
colon (Fig. 351-jB) and not between it and the stomach as the physical 
examination had indicated. Had the x-ray been available, a barium 
meal and enema would have furnished a less fallible means of topo- 
graphic determination. 

CASE 3. — A matron aged twenty-nine came because of pain on 
each side of the navel. 

History. — A year and a half ago she noticed pain in the right 
side below the navel. Soon after this she had pain in the other side. 
FolloAving this the pain ascended until now it is most pronounced 
on the level of the navel. There has never been any acute pain, 
fever or vomiting. The soreness has been increasing. Exertion 
increases the pain and sometimes she is free from pain for a con- 
siderable interval. It has been continuous for the past two months. 
Eight months ago she felt a hardness above the navel, and two weeks 
ago her physician pronounced it a tumor. Her general health is 
good. She has two children, aged five and three years old. She has 
some eructations of gas, but no other stomach trouble. 

Examination. — A tumor occupies the midline of the abdomen ex- 
tending from the epigastrium to below the umbilicus. It extends 
lower on the right side than on the left. The surface is hard and 
seems intimately associated with the abdominal wall. It seems to 
be fixed to the abdominal wall. Firm pressure causes pain. The 
x-ray shows that the stomach is pressed upon, causing a constric- 
tion in its middle and dislocating the whole organ to the left side. 
Pelvic examination shows a stellate laceration of the cervix, and 
a high position of the uterus. Hg 80; R.b.c. 4,200,000; W.b.c. 
12,000. 

Diagnosis. — The impression the mass gives on first examination 
is a conglomeration of intestines Avhich have become attached to 
the stomach wall. Localized hyperplastic tuberculosis gives this 
feel, but should not displace the stomach outward. She does not 
look tuberculous and there are no findings that warrant such an 
assumption. A pancreatic cyst might displace the stomach so, but 



J94: 



CLINICAL SURGERY BY CASE HISTORIES 



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Fig. 352. — Polycystic disease of the lesser omentum. 



there is no history of injury, and there is no loss of weight. The 
mass extends too low for a tumor of the lesser peritoneal cavity. 
It extends too high for an omental tumor, and is not movable 



TUMORS OF THE ABDOMEN 



795 




Fig. 353. — Cross section of a polycystic tumor of the lesser omentum showing the numerous 

smooth-walled cysts. 



796 



CLINICAL SURGERY BY CASE HISTORIES 



enough. It resembles somewhat the feel of a desmoid but it crosses 
the midline which a desmoid should not do. Its density and fixity 
seem best to fit in with a chronic proliferative process within the ab- 
dominal wall. 

Treatment. — A midline incision showed the abdominal wall to be 
free. Beneath it was a polycystic mass lying wholly within the lesser 
omentum. It had inverted the lesser omentum so that a part of 
the tumor lay over and hung below the transverse colon. Lobules 
extended downward and lateralward toward each groin. The mass was 
removed and the lesser omentum reformed by the unaffected portions. 







Fig. 354. — Slide of Fig. 353. The cysts are lined with endothelium while the solid portion 
is made up o£ loose connective tissue. 

Pathology. — The tumor consists of a conglomerate mass of cyst six 
inches in breadth and nearly as long in the vertical diameter (Fig. 
352). On section the cysts are seen to vary from microscopic size 
to the size of an unhulled walnut (Fig. 353). The contents is clear 
fluid. The slide shows the cyst walls to be lined with flat endothelial- 
like cells. The tissue between the cysts is poor in cells of spindleform 
or stellate shape, while the intercellular tissue is fibrinous or struc- 
tureless. It resembles the tissue of certain slowly growing fibrosar- 
comas of the ovary or retroperitoneal tumors (Fig. 354). 



TUMORS OF THE ABDOMEN 797 

After-course. — Recovery was prompt and uneventful. She still 
complains of a pulling in the pit of the stomach after a full meal. 

Comment. — After seeing the tumor, it is easy to see how perfectly 
it accounts for the symptoms. However, polycystic tumors in this 
situation are exceedingly rare and exist only as pathologic re- 
ports. It is astonishing that the tumor felt so superficial despite the 
fact it had no attachment with the abdominal wall and was cystic. It 
occurred to me after seeing the tumor that a solid tumor of the ab- 
dominal wall was a ridiculous assumption, for it could not have dis- 
placed the stomach, but I had never felt anything so firm and 
immovable save a desmoid. It was wholly outside of my previous 
experience, and any diagnosis was better than none. 

CASE 4. — A farmer ag"ed fifty-six came because of sharp pains in 
the reg^ion of the stomach. 

History. — The patient had grip four months ago. Since that time 
he has not been well. Fifteen or twenty years ago he had spells 
of diarrhea which were cured by * ' pain killer. ' ' He now has a sense 
of pressure in the pit of the stomach with cutting pain under the 
short ribs on each side. The appetite has been good but he has 
had so much gas following eating that he has limited his diet. He 
lost 15 pounds in the last few years, the most of it during this at- 
tack. When the pain is severe in the left side of the epigastrium 
it extends to the back under the tip of the shoulder blade. He has 
never vomited. During the past two weeks the appetite is de- 
creasing. 

Examination. — The patient is thin, seems worried and emaciated 
and appears as though he had lost more than fifteen pounds. There 
is rigidity in the epigastrium and there is on deep respiration 
a tumor palpable in the midline above the umbilicus. W.b.c. 10,800 ; 
R.b.e. 4,700,000. The stomach contents give a strongly positive 
reaction for lactic acid, but HCl is absent. 

Diagnosis. — The rather rapid onset with the general appearance 
of the patient is strongly suggestive of carcinoma. The peculiar 
board-like rigidity of the upper ends of the recti muscles suggests 
the same thing, as does the presence of lactic acid and the absence of 
HCl. The presence of a tumor makes the diagnosis highly probable. 
There is no evidence of metastasis and operative removal may be 
possible. 



798 



CLINICAL SURGERY BY CASE HISTORIES 




]''ig. o55. — L'lcerating" carcinoma of the stomach. 



Treatment. — After the stomach was exposed an area of induration 
as large as the palm of the hand was found along the greater curva- 
ture and anterior surface. The stomach was movable and there were 
no palpable glands. Eesection was done by the second Billroth 
method. 



TUMORS OF THE ABDOMEN 799 

Pathology. — There is a large, indurated ulcer with a smooth base 
and sharply defined border with overhanging edges (Fig. 355). The 
border is bosselated and dense. The slide shows a typical carcinoma 
rather sharply circumscribed against the surrounding normal tis- 
sue. 

After-course. — He progressed favorably for a week. During the 
second week he complained of epigastric distress. He had no actual 
pain and he took a fair amount of nourishment. He stated there 
was a feeling as of a foreign body which should be removed. At 
the end of the second week while sitting in a chair he drank grape 
juice which he at once vomited. He immediately became dyspneic, 
with a respiration of 48, with cyanosis, and died soon after. The 
autopsy showed induration in the Avails of all the guts concerned 
in the operation. There was no peritonitis. The anastomosis open- 
ing was patent. The walls were edematous with much round-celled 
infiltration. There were no areas of abscess formation. There was 
a lung embolism. 

Comment. — So far as the type of tumor was concerned, a cure 
might have been hoped for in this case. The unfavorable state of 
the area of operation likely accounted for the formation of the 
thrombus and the act of vomiting probably dislodged it. I have 
repeatedly noticed the marked induration of the gut walls in pa- 
tients on whom a gastroenterostomy' was done. It produces a 
board-like state of the gut wall. The cause of it is not apparent. 
Either other surgeons do not have this misfortune, or, like myself, 
are baffled bj^ it. 

CASE 5. — A housewife aged fifty-six came to the hospital seek- 
ing relief from pain in the epigastrium and left upper quadrant of 
the abdomen. 

History. — The patient felt well until five months ago when her 
strength began to decline and she felt a heaviness in the epigas- 
trium after meals. Her doctor told her she had influenza. About 
a month later she began to have pain in the left of her stomach 
and along the left side of the abdomen. She had some pain in the 
lower chest. A little later she began to have a continuous dull 
pain in the stomach which at times would be cramp-like in char- 
acter and very severe. Eating did not affect it much either way, 
although at first eating seemed to relieve it a little but later to 
aggravate it. Two weeks ago she began vomiting. There was con- 



SCO CLINICAL SURGERY BY CASE HISTORIES 

siderable blood in the vomitus. She has been vomiting 5 or 6 times 
a day since. She brings up a sour substance and bloats a great 
deal. She has gradually become jaundiced the last two weeks and 
it is increasing. Her appetite is very poor and her bowels extremely 
constipated. She has lost 20 pounds since the beginning of her trouble. 

Examination. — Her sclera are icteric and the skin is jaundiced. 
There is a tumor in the epigastrium the size of tw^o fists. The 
x-ray findings are very indefinite and of no value. The patient 
can not swallow the smallest amount of bismuth without vomiting 
and the pyloric region can not be demonstrated. Hence it can not 
be determined whether the mass in the epigastrium is in the gall 
bladder. The condition is evidently utterly beyond relief. The 
attending physician is sure the tumor is a distended gall bladder 
and the patient and her friends desire an exploration. 

Treatment. — An exploratory laparotomy was done. A carcinoma 
involving the pylorus was found. Metastases had taken place in the 
liver and the surrounding structures were infiltrated. 

After-course. — The general weakness of the patient increased, the 
vomiting was persistent and frequent and the patient died two 
weeks later. 

Comment. — It is a mistake for the surgeon to operate in such cases 
just because he is urged to do so. Even if he states that the only 
responsibility he assumes is that of technic when the inevitable result 
comes it is charged against surgery. Any man who has a disposition 
to cut and sew on order should be a tailor. 

CASE 6. — A housewife of fifty came to the hospital for relief 
of an abdominal tumor. 

History. — Six years ago she was operated on for gallstones. For 
five years previous to this operation she had had gallstone colic 
and gastric disturbances. She had noticed slight if any jaundice 
and had never noticed putty-colored stools. She passed 7 stones 
in the feces that she knows of during the five years. Those taken 
at operation were small but numerous. About ten or twelve days 
after operation she had a severe attack of pain across the epigas- 
tric region accompanied with distention and a rapid pulse. At the 
same time she had a pain in the left kidney region. Some pain 
remained in these places for three months and then stopped for 
the most part and she was comparatively free from pain for two 
years. About that time she noticed an epigastric tumor. It was 



TUMORS OF THE ABDOMEN 801 

much smaller than now and remained stationary up to six months 
ago, when she noticed that it was growing larger. As it grew, the 
pains in the back and epigastrium increased in severity. About 
four years ago it was discovered that she had sugar in the urine. 
She has a large amount at the present time. She had no loss of 
weight, or excessive thirst, and the amount of urine voided was not 
greatly increased. Three weeks ago she had a sudden attack of se- 
vere pain in the left side of the back and in the epigastric region. 
She did not vomit or have rise of temperature. The attack recurred 
every day since. She has never had any urinary or gastric disturb- 
ance, since her gallstone operation and the pain in the back did not 
radiate to the bladder region. Her appetite has been good up to 
two weeks ago. Since then she has had none, and the bowels have 
been rather constipated. She has lost 40 pounds during the last 
year. She has one child living, twenty-seven years old. She men- 
struates about every five weeks. Four years ago she had three severe 
uterine hemorrhages and had to be packed. Aside from this and 
previous to her gallstone attacks she had had good health. 

Examination. — The patient is sallow and weak and shows the loss 
of weight of which she speaks. The heart and lungs are negative. 
In the epigastric region in the midline and to the left is a smooth, 
tense, globular tumor the size of a fetal head. It is immobile on 
respiration, and is immovable to manual effort. It is slightly sensi- 
tive to firm pressure. A barium meal shows it to occupy the lesser 
peritoneal cavity. (Fig. 356.) 

Diagnosis. — A severe epigastric pain attended by abdominal dis- 
tention and a rapid pulse following a gallstone operation suggests 
a pancreatic affection. The development of an abdominal tumor 
in the situation in which this one is located confirms the suspicion. 
Its form and contour, Avith the attendant glycosuria confirms it. 
It but remains to determine whether it is a true or pseudo cyst. 

Treatment. — The cyst was exposed under local anesthetic. The 
wall was thick and it was freed as far as possible and the fluid con- 
tents withdraA\Ti, As much as possible of the cyst wall was removed, 
the border of that remaining was sewn to the edges of the incision and 
the cavity packed. 

Pathology. — The fluid was slightly clouded and did not digest 
starches or albumin. The wall was made up of fibrous tissue with 
sparse nuclei, but an epithelial lining could not be demonstrated. 



802 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 356. 



-Pseudocyst of the pancreas. The stomach filled with barium appears as 
shadow at the left of the cyst. 



After-course. — On the fourth day following operation the patient 
began to show signs of acidosis. She was drowsy and had an 
acetone breath. The urine showed a strong positive test for dia- 
eetic acid and one drop of urine reduced Haine's solution. Twenty- 
four hours later the patient was in coma, but could be roused and took 



TUMORS OP THE ABDOMEN 803 

water by mouth in large quantities. She was starved, given water 
per rectum and by mouth and given sodium bicarbonate as much 
as 200 grains a day. Four days later she began to rouse, and by the 
next day came out of the coma. She seemed to improve for several 
days, but a week later the symptoms of acidosis became more 
pronounced again. The previous treatment was used again with 
spiritus frumenti (that was some years ago) added as a stimulant, 
but the coma gradually deepened and in two days she died. 

Comment. — In the presence of glycosuria it is important to avoid 
a general anesthetic. No doubt a more protracted treatment of the 
glycosuria should have been instituted before operation was at- 
tempted. I so little feared acidosis when operating under local 
anesthesia that I did not deem it necessary. What occurred follow- 
ing the operation for gallstones to excite the pancreatic affection 
can not be deduced from the evidence at hand. It may be categori- 
cally assumed, however, that the patency of the pancreatic duct 
was in some way interfered with. It was likely a mistake to starve 
the patient in such a state. A more liberal diet might have been 
less disastrous. In impending acidosis in surgical cases I have found 
large amounts of codeine the best agent. 

CASE 7. — A niatroii aged fifty came because of a lump in the 
lower abdomen. 

History. — The patient has had nine children. The menses stopped 
six months ago but two weeks ago she had a free flow for a week 
after being examined by a physician. For two years she has noticed 
a lump in the lower abdomen. As it grew in size, pain in the lumbar 
region developed with frequent and painful urination. 

Examination. — In the right lower quadrant of the abdomen is a 
tumor the size of a grape fruit. It is hard, nodular, free at its median 
surface, but fixed at the brim of the pelvis. The fundus of the uterus 
can not be defined from the mass. The inguinal glands are free and 
the vessels in the skin of the abdomen are not dilated. 

Diagnosis. — The appearance of a flooding six months after the 
menopause spells malignancy of some sort. A tumor that is still 
growing two years after the menopause is likewise likely malignanl. 
The tumor is hard and bosselated and the uterus seems to be con- 
tinuous with it. If the tumor is a malignant myoma, it should 
have developed more rapidly and the menopause would hardly 
have been established. "When a malignant myoma becomes at- 



804 



CLINICAL SURGERY BY CASE HISTORIES 



tached, it is in the floor of the pelvis and not at its rim. Neverthe- 
less, the hard bosselated mass it seems to be indicates that it can 
be nothing else than a myoma. Ovarian cystomas that have become 
malignant usually show softer areas. 

Treatment. — The uterus was of normal size. The tumor felt was 
of the right ovary. It was attached to the peritoneum of the brim 
of the pelvis. It neither was attached to the abdominal wall nor to 
the peritoneum in the culdesac. It was removed but the peritoneal 
involvement could not be removed. 




Fig. 357. — jMalignant cystoma of the ovary. 

Pathology. — The tumor was solid save near the lateral border where 
it had attachment to the peritoneum. Here there were papillary pro- 
jections which had extended to the peritoneum in the culdesac. The 
slide shows solid and glandular epithelial tissue (Fig. 357). There- 
fore it is a malignant cystoma. 

After-course. — The patient was considerably shocked and had much 
pain at the point where the tumor was attached, immediately after 
operation. When last heard from a year after operation, she had 
had no recurrence but it will inevitably return. 

Comment. — Papillary cystomas are semimalignant but once they 
form solid tumors, as in this case, the prognosis is bad. The attach- 



TUMORS OP THE ABDOMEN 805 

ment of the tumor did not involve the pelvic peritoneum to a suffi- 
cient depth to cause a damming back of the blood, and the tumor, 
not being attached to the abdominal wall, did not cause vascular 
dilatation by direct irritation. Therefore, there were no signs to 
indicate, positively, inoperability. When one has once exposed the 
field of operation it is as well to remove as much as can be removed. 
In this case a thin layer alone remained. Whenever a malignant 
tumor is forcibly separated from a peritoneal tumor, shock is likely 
to be very marked. There is no means of prevention. 

HEPATIC 

The liver is usually responsible for tumors in this region ; the gall 
bladder if cystic, often too, if nodular. Irregular enlargement of the 
liver may appear as bosselated masses. Teratoid tumors are rarities. 

Case 1. — A housewife aged thirty-two came to the hospital be- 
cause of pain in the right side and lower part of the abdomen. 

History. — Her trouble began early in her last pregnancy which 
terminated in a normal delivery eight weeks ago. She had bearing 
down pains in the right side of the abdomen extending along the 
hip bone towards the bladder. She had a severe pain the size of a 
dollar in her back. During the pregnancy she had several attacks 
of sudden severe pains accompanied by vomiting. She had to have 
hypodermics for the control of pain. After the baby was born she 
noticed a mass in the right side below the short ribs. She also 
had a severe backache and a dragging down sensation, particularly 
when she was on her feet. When she turns on her left side the 
mass sags toward the middle of the abdomen and causes severe 
pain. Her appetite is good, she is obstinately constipated, but has 
no bladder trouble. 

Examination. — The patient has a sallow complexion but seems 
well nourished. The abdomen is rounded and distended. Palpation 
shows a rounded tumor extending from the costal margin to the 
crest of the ileum. It does not move on respiration and can not 
be made to appear in the flank. Neither is there sensitiveness in the 
renal triangle. When she is turned on the left side the tumor 
does not move but she thinks it does. It is not tender on pressure 
and is smooth and elastic. The uterus is high and to the left, lying 
on the pelvic brim. The fundus seems to disappear in the tumor. 



806 CLINICAL SURGERY BY CASE HISTORIES 

The uterus can not be drawn down or pushed to the left. The 
urine contains a few leucocytes. Hg 60 per cent; W.b.c. 11,000; 
R.b.c. 4,000,000. 

Diagnosis. — The fact that the uterus is drawn upward and to the 
right indicates that it is attached to the tumor. The tumor is 
smooth and elastic, evidently cystic. The fact that she had severe 
pains with nausea during pregnancy indicates that it became fixed 
in this high position at a time when it was raised upward by the 
growing uterus. It is too soft, smooth and nonelastic to be a 
pedunculated myoma of the uterus or a solid tumor of the ovary. 
It does not appear in the flank as it would if it were a hyperneph- 
roma or a hydronephrosis, though the localized pain in the lumbar 
region suggests the possibility of a renal origin. An inflammatory 
lesion of the gut tract would not produce an abscess of this size 
of so long duration. An abscess in this situation would produce a 
profound sepsis. The W.b.c. of 11,000 indicates a mild absorption 
as of extravasated blood. A cystic tumor of the upper abdomen 
might have secured attachment to the fundus during pregnancy 
and have retained this attachment after labor. However, the pain 
in the beginning was low in the right side and extended upwards. 
Therefore, it can not be primarily of upper abdominal origin. 
Furthermore, nothing occurs in that region that attains this size 
and consistence. 

Treatment. — A right rectus incision was made. When the perito- 
neum was approached there was found to be a marked properitoneal 
edema. After the peritoneum was opened it was found firmly ad- 
herent to the tumor. This separated, the tumor was found firmly 
adherent to the under surface of the liver, and its nature being still 
doubtful, I feared to separate it. The omentum was adherent to 
the medial surface of the tumor. Following the tumor to the pelvis, 
a twisted pedicle was found to connect it with the horn of the 
uterus. The appendix was adherent at the point of torsion. The 
pedicle was severed and the appendix removed. The tumor could 
then be shelled out from beloAv upwards. The firmest point of at- 
tachment was to the lower surface of the liver. The veins of the 
pampiniform plexus were filled with clots. There was also a hema- 
tosalpinx. 

Pathology. — The tumor was 6x5x4 inches in size. On section 
after being hardened the interior was found to be a large blood clot 
(Fig-. 358). The wall is that of a multilocular ovarian cyst. 



TUMORS OF THE ABDOMEN 



807 



After-course. — Recovery was uneventful and permanent. 
Comment. — Her sallow complexion and the leucocyte count were 
exactly that likely to be caused by the absorption of a blood clot. 




Fig. 35S. — Ovarian cyst with twisted pedicle filled with blood clot. 

No doubt the tumor secured its attachment to the under surface of 
the liver during pregnancy. Since she had several attacks of severe 
pain requiring morphine during pregnancy it is impossible to say 



808 CLINICAL SURGERY BY CASE HISTORIES 

just in which one of the attacks the twist occurred, possibly partly 
in each. Perhaps the twist occurred in one and the hemorrhage at 
another time. At the time of the pain, the question of appendicitis 
or a hematogenous infection of the kidney would have been an im- 
portant one. Ruling out the kidney by the urinary findings, opera- 
tion would have been safer than to wait. The pain in the lumbar 
region may have been due to involvement of the kidney by the ir- 
ritating cyst. There is no knowledge as to the state of the urine 
at that time. 

CASE 2. — A laboring man aged thirty-three entered Bell Hospi- 
tal because of pain in his side and back. 

History. — His trouble started gradually about fifteen months ago. 
The first thing he noticed was that he had a chill every night for 
twenty nights. These were quite severe and following the chill 
he perspired freely. The chills came on usually about 8 or 9 o 'clock. 
He felt stiflf and tired in the morning following these chills but he 
continued to work. He had pain in the stomach and right side fol- 
lowing these chills and he had to stay in bed two days on several 
occasions. He Was nauseated but never vomited. He had a sharp 
shooting pain at the end of inspiration. He improved somewhat 
and went to work again and has worked up to the present time, but 
he has been nearly constantly in pain. Recently he has become 
quite stiff in the back and quite short of breath. He has no cough 
but has had fever ever since the trouble started and has lost 20 
pounds in weight. Nocturia 2 to 3 times. No edema. For the 
past week he has had some pain in right leg. Preceding the pres- 
ent illness he had never been sick in bed since childhood. He 
has never had gonorrhea, but had a sore on his penis two years ago, 
but it lasted only three or four days. 

Examination. — The patient is well built and has evidently been 
a strong man. He has the appearance of suffering pain. The right 
pupil is larger than the left, both are irregular and react but 
little to light. Postauricular and epitrochlear glands are pal- 
pable. There is a slight bulging of the lower part of the right 
side of the chest. The bulging becomes more marked with deep in- 
spiration. This bulging on palpation proves to be an irregular 
globular elastic mass, semifluctuating in character. The liver dull- 
ness reaches the 4th interspace, but the lower lung border is mov- 
able. The percussion note is clear and there are no rales. The 



TUMORS OF THE ABDOMEN 809 

lower border of the liver is not palpable. The heart is normal, but 
its rate is increased. The abdomen is moderately distended and 
somewhat rigid particularly on the right half. There is no defi- 
nite soreness but pressure increases the resistance. There is flat- 
ness in the right half and a faint percussion note can be made 
out; There is some bulging in front of the quadriceps muscle, none 
over the kidney. The area of maximum tenderness is over the outer 
border of the right rectus. It seems as though one could feel in- 
definitely sausage shaped coils beneath the abdominal wall on the 
left side. The dull area does not shift on change of position. The 
R.b.e. is 12,000. There is albumin and casts and a good deal of 
pus in the urine from both kidneys. There is some swelling of the 
right groin at the lower border of Scarpa's triangle. The legs are 
not swollen. The reflexes can not be demonstrated. The x-ray of 
the spine shows nothing. 

Diagnosis. — The gradual onset of pain in the abdomen with ema- 
ciation resulting in the accumulation of fluid filling the right 
side of the abdomen suggests tuberculosis of the peritoneum. The 
rounded masses on the left side probably are coils of jejunum thick- 
ened by a tuberculous process. The failure of the fluid accumulation 
to move, it seems likely, is due to a sacculation because of hyper- 
plastic tuberculosis. The exudate is of too long a duration and too 
widespread to make a perirenal abscess likely, and the leucocytosis is 
not high enough. The x-ray seems to exclude a tuberculosis of the 
spine. The fact that the liver is displaced upwards suggests an 
intraperitoneal exudate which is lifting the liver. A sacculated 
peritoneal tuberculosis of the right half of the body seems the 
best diagnosis. 

Treaiment. — A right rectus incision was made. The peritoneal 
cavity was free from fluid, the omentum and intestinal coils were 
unaffected. The thickened coils it was supposed that we felt were 
not in evidence. Beginning at the midline was a bulging, fluctuat- 
ing mass which lost itself behind the liver above and extended 
down into the iliac fossas. It showed no evidence of acute infec- 
tion. The colon rode on its surface apparently unobstructed, but 
its vessels were much enlarged. The incision was closed and sealed 
with collodion. An incision was made from the midline of the 
tAvelfth rib downwards and inwards. The endoabdominal fascia 
bulged and where this was opened great quantities of yellowish 



810 CLINICAL SURGERY BY CASE HISTORIES 

odorless pus rolled out. In this were many white flakes, some of 
which were as large as a bite of beefsteak. The cavity extended 
from behind the liver over to well in front of the spinal column, 
down to Poupart's ligament and into the pelvis as far as the mid- 
line. The wall was smooth for the most part. A portion of the 
kidney was found in fragments. The capsule of the kidney could 
be made out. At the lower portion of this was an opening admit- 
ting two fingers. 

Pathology. — A great variety of organisms were demonstrated in 
the pus. A section of the kidney fragments showed areas of degen- 
eration and round-celled infiltration but no positive evidence of tuber- 
culosis. 

After-course. — The wound closed rapidly down to a small sinus. 
This persisted and he is reported to have died nine months later 
of progressive weakness and cough. 

Comment. — Though no positive evidence of tuberculosis could be 
demonstrated, the flake-like character of the pus suggested its pres- 
ence. Likely it was a tuberculosis which later became complicated 
by a secondary infection. The almost complete obliteration of the 
huge cavity should have been followed by a degree of physical re- 
cuperation greater than that which actually took place. The op- 
posite kidney evidently also was affected. After the recovery 
from the operation the urine of the remaining kidney should have 
been searched more persistently for tubercle bacilli. All that is 
known is that there were no marked urinary disturbances during the 
terminal period of his illness. 

CASE 3. — A farmer's daughter aged nineteen came because of 
painful urination. 

History. — Aside from a dysmenorrhea which confines her to bed 
during the first day, the patient has always had good health. Two 
and a half years ago she fell from a wagon, striking the right side 
of her back on a hard object. She was not confined to bed at the 
time but about one month later she began to have pain in the lum- 
bar region, which was dull, aching in character, coming on period- 
ically and aggravated by walking. This was accompanied by pain- 
ful micturition, burning in character, being worse at the end of the 
act. The urine was cloudy, but no blood was noticed. The above 
condition has grown steadily worse and during the past month she 
has been entirely incapacitated. The patient is unable to lie down 



TUMORS OF THE ABDOMEN 811 

and has slept very little. Micturition is very frequent and only a few 
drops of urine are passed at a time. The pain is localized in the 
region of the bladder and does not radiate. It is sharp, stabbing, 
and sometimes cramp-like in character. 

Examination. — The lower abdomen is rigid and there is suprapubic 
tenderness. There is no pain in the groin. The region of the kid- 
ney is tender on deep palpation and on bimanual palpation a defi- 
nite tumor which does not glide under the fingers can be made out. 
No difference in the skin in the two sides is discernible on direct 
palpation, but when a large fold is picked up, that over the affected 
side is felt to be thicker than that of the unaffected side. This 
shows that there is a deep inflammatory process. The cystoscopic 
examination aside from a purulent urine escaping from the right 
ureter, is negative, save for a general cystitis. No tubercle bacilli 
were found in the urine. The white count is 10,800. 

Diagnosis. — The subjective symptoms suggested stone in the blad- 
der, but the history and the physical findings indicate an infection 
due likely to rupture or severe contusion of the kidney at the 
time of the accident. Most likely there was but a severe con- 
tusion which resulted in a pyelitis. Had there been a rupture 
with subsequent infection the course likely would have been much 
more stormy. No examination of the urine was made at the time 
of the accident. Therefore the degree of injury is not known. At the 
present time evidently there is a pyelitis. There is no evidence 
of tuberculosis, but this can not be ruled out with certainty. Cys- 
toscopy confirms this. The deep edema in the kidney region indi- 
cates that there is a perirenal induration. The low leucocyte 
count makes it doubtful whether there is actual abscess formation or 
not. Perirenal abscess usually gives a high white count. An 
ancient one, however, may give a normal count. At any rate the 
bladder affection does not account for her complaint and the kidney 
must be investigated. 

Treatment. — The kidney was exposed and found to be surrounded 
by an infiltrated capsule, but there was no free pus. The kidney 
gave evidence of a subcapsular rupture, or at least a contusion, 
because there was a scar extending from the pelvis over the lower 
pole. The pelvis was tense with pus. A drain was placed through 
the substance of the kidney into the pelvis. 



812 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — Drainage brought an amelioration of the symptoms, 
but when last heard from, the sinus in the back had not completely 
healed, neither had the bladder irritation completely disappeared. 

Comment. — In such a case, in a patient in such good condition, 
it would have been better to have removed the kidney. I believed 
by the plan follow'ed I would be able to save the kidney. The cause 
for the reference of the pain to the bladder was due to transmitted 
pain from the pyelitis rather than from the moderate grade of cys- 
titis present. In such cases one hesitates to do a nephrectomy 
without knowing the state of the other kidney. To pass a catheter 
through an infected bladder to the supposedly healthy kidney is 
like striking a match to see whether it will burn so that in case of 
need one will be assured of well tried material. 

CASE 3. — A fanner of fifty-seven came because of a mass and 
pain under the short ribs on the rig-ht side. 

History. — His present trouble began about three years ago with an 
attack of pain under the short ribs on the right side anteriorly. 
The attacks were not severe, they lasted a few hours and then 
stopped, leaving him sensitive under the costal margin for a week. 
He did not vomit or have any fever that he knows of. He took a 
course of olive oil and saline cathartics and was free from the 
attacks for a year. They then started again. They came on acutely, 
were very severe, and were accompanied by vomiting and fever of 
usually above 2 degrees. The spells left him acutely sensitive under 
the right costal margin and he has never been able to lie on that 
side at night on account of it. His last attack came on tw'o weeks 
ago while hard at work on the farm. Eight months ago during 
one of these acute attacks a mass appeared in the right side just 
under the short ribs and has remained. His general health other- 
wise is good, except that he has had some burning on urination 
for about two or three years. He has never been jaundiced and has 
lost little or no weight. 

Examination. — He is a large man, weighing about 220, of vigorous 
bearing and ruddy complexion. There is a palpable mass under the 
right costal margin in the gall bladder region. This does not move 
about on change of position. It seems to move slightly with respi- 
ration. It is definitely sensitive. There is no sensitiveness in 
the renal triangle and the urine is negative. The prostate is mod- 
erately enlarged. 



TUMORS OF THE ABDOMEN 813 

Diagnosis. — The history of feverless attacks of rather severe pain 
in the hepatic triangle is suggestive of gall-bladder colic. The mass 
is indicative of a pericholecystitis and its failure to move but 
slightly on deep respiration indicates that the mass has become 
adherent to the anterior abdominal wall. 

Treatment. — An incision was made in the gall bladder region. A 
mass of adhesions of colon and omentum were found just below the 
liver, this being the mass palpated on examination. They were 
separated in the expectation of finding the gall bladder beneath. On 
the contrary, the adhesions surrounded a subacutely inflamed appen- 
dix. The gall bladder was found to be normal and lay medial to the 
inflamed mass. The appendix was removed and the wound closed 
without drainage. 

After-course. — The patient left the operating table in good condi- 
tion and ran a normal course for about 24 hours. At the end of 
this time he became distended and began to vomit. The attacks 
of vomiting increased in frequency. The vomitus consisted of small 
amounts of brownish black fluid and it was regurgitated every few 
minutes. The distention also increased and the patient had attacks 
of singultus which were very exhausting. The temperature was just 
under 101° and the pulse 70. The patient was in no great pain. 
Stupes and colon tube helped get rid of some gas but afforded ver^^ 
little relief. A stomach tube Avas then passed; about two quarts 
of blackish-brown fluid was obtained. Gastric lavage was used with 
soda bicarbonate solution until the solution became clear. Much 
relief from vomiting and singultus was immediately experienced. 

The following day vomiting began again, not so severe as before, 
but he was much distended. Lavage with soda bicarbonate was 
again given. About a quart of black fluid was syphoned off. The 
next day vomiting again set in, but not nearly so much as before, 
and there was still much distention. Gastric lavage was repeated, 
but no fluid syphoned off from the stomach. From this day on the 
symptoms began to clear up, and the patient made an uneventful re- 
cover.y. During the latter part of his convalescence he developed 
some bladder irritation and some pus appeared in the urine. He was 
given salol and boric acid, 5 grains of each, every four hours, and 
the condition rapidly cleared up. He has remained well. 

Comment. — Usually when an appendix lies lateral to the colon 
and makes symptoms in the gall bladder region there is sensitive- 



814 CLINICAL SURGERY BY CASE HISTORIES 

ness in the renal triangle just anterior to the edge of the quad- 
ratus lumborum muscle. Likely there was such in the earlier at- 
tacks, but at the time of observation the appendix was so completely 
walled off that the parietal peritoneum was not irritated at this 
point. The nature of the pathologic process was correctly recog- 
nized, but the organ at fault was mistaken. It is of more importance 
to correctly evaluate the symptomatology in terms of pathologic 
anatomy than it is to name the organ from which the process orig- 
inated. Evidently there was a postoperative introgastric hemor- 
rhage causing distention of the stomach. The stomach likely pro- 
jected the contents out of the stomach tube as soon as it was intro- 
duced indicating that the tonus of the stomach wall was not impaired. 
Therefore, it was not a true postoperative gastric dilatation. Had 
it been a true dilatation lavage should have been repeated at least 
every six hours. It would have been well perhaps to have used 
irrigations of hotter water than was used. The cause of the intro- 
gastric hemorrhage may be best attributed to the traumatism 
inflicted on the great omentum in separating the rather firm ad- 
hesions. It would have been better to have ligated proximal to the 
point of adhesion and to have removed that portion of the omentum 
involved in the adhesions. 

CASE 4. — I was called to see a woman of twenty because of a 
tumor of the abdomen. 

History. — For several years she has had frequent urination with 
some pain. She began menstruating at 14, has been regular since,, 
but has had to lie abed the first day because of cramping pains. 
The urine, according to her doctor, has constantly contained pus 
during the period of his observation, now six months. During tliis 
period he has noted a tumor in the right side below the costal 
margin. This has varied in size from time to time. Its disappear- 
ance was followed by the discharge of large amounts of urine. 
He never searched for bacteria and never made a leucocyte count. 

Examination. — The patient is well nourished and gives no evi- 
dence of suffering. There is a tumor in the right upper abdomen 
disappearing under the costal margin. It extends downward to the 
level of the umbilicus. It does not move on respiration. It is 
markedly sensitive to light pressure, less so to firm pressure. The 
urine is 1.004, free from foreign elements except an occasional 
leucocyte and squamous epithelial cells. 



TUMORS OF THE ABDOMEN 815 

Diagnosis. — The patient is evidently neurotic. The history of 
recurrent tumor of the upper abdomen would suggest a hydroneph- 
rosis. The feel is not that of a hydronephrosis, being sensitive to 
pressure, and it can not be pressed into the flank. The urine is the 
thin urine of a neurotic, but is sometimes observed in pyelitis 
and hydronephrosis. This seems the best diagnosis. 

Treatment. — As the patient went under the anesthetic the tumor 
disappeared. The abdomen could be palpated but nothing could be 
found. The physician in charge believed the diagnosis of phantom 
tumor was an impeachment of his intelligence. A right rectus in- 
cision was made but the abdominal contents were normal. 

After-course. — The tumor was not present for three weeks after 
the operation. The family doctor incautiously told the mother that 
the patient's troubles were imaginary. The patient was vigorously 
upbraided by her mother. The tumor promptly reappeared. The 
patient married two years later and has since borne four children 
and has had good health now more than fifteen years. 

Comment. — I have since seen phantom tumors aplenty, but have 
never again cut into one. There is one sign of phantom tumor 
not commonly mentioned. Its upper or lower limit is always at one 
of the inscriptiones tendeniae of the rectus muscle. The confines are 
sharply marked at the inscription. The tumor also always ends in 
a fairly tense muscle above. The tumor is due to a segmental con- 
traction of the rectus muscle and the associated portion of the 
lateral abdominal muscles. When the patient goes under the anes- 
thetic these portions of the abdominal muscles not involved in 
the tumor loose the tension first, making it possible to follow the 
relaxation of .the muscles directly involved in the tumor. 

CASE 5. — A matron aged fifty-four came to the hospital because 
of pain in the right side of the abdomen. 

History. — Ten days ago she began to have a distress across the 
upper part of the abdomen, most marked in the pit of the stomach. 
There was no actual pain but a feeling of discomfort. There was 
neither nausea nor vomiting. Three days later a severe steady pain 
extending entirely across the abdomen, most marked in the region 
of the navel developed. She did not vomit until given medi- 
cine by her doctor. She continued to vomit every day after this. 
The vomitus was always greenish with a strong bile taste. Two 
days ago the pains became more intense in the right side. They 



816 CLINICAL SURGERY BY CASE HISTORIES 

have remained there since. At the present time there is a pro- 
nounced soreness but no sharp pains. A cathartic and an enema 
are required to move the bowels. She never has had a similar at- 
tack. One year ago she had a spell of colic lasting three hours at- 
tended by vomiting. It was not followed by any soreness. She has 
had some bloating since then, but her appetite has been uniformly 
good. 

Examination. — She is a plump, well preserved woman apparently 
not desperately sick, yet very uncomfortable and apprehensive of 
worse things to come. The abdomen is everywhere resistant, be- 
ing most marked on the right side. There is marked tenderness 
between the costal margin and the crest of the ilium. Careful pal- 
pation demonstrates a tumor of those dimensions. The point of 
most pronounced tenderness is at the right rectus border on the 
level with the umbilicus. The mass does not move with respiration. 
She has some pain in the back in the region of the tenth rib. This 
is increased by pressure on the mass in front. The tumor can not 
be made to appear in the renal triangle. The urine shows a few 
leucocytes, W.b.c. 12,800. 

Diagnosis. — An attack of colic a year ago in a woman of this type 
and weight suggests a gall bladder attack. The present attack is 
in harmony with that supposition, being a cholecystitis and not a 
colic. Usually a colic is the immediate forerunner of a cholecystitis. 
That is lacking here. The pain in the back made worse by pres- 
sure is in harmony with such a supposition. There is no fullness 
or edema in the renal region as there would be if it were a perineph- 
ritis, and the urine does not comport with such a supposition. An 
appendix lying lateral to the ascending colon would not make such 
a tumor, particularly not without showing pronounced septic symp- 
toms. The condition likely is a gall bladder. She has markedly 
improved in the past two days but is still sick. It seems an act 
of prudence to allow her still further to improve before proceeding 
to operation. 

Treatment. — Ten days later an incision was made along the right 
semilunar line. A blue-black cyst appeared which extended from 
near the crest of the ilium to under the rib border. The lower pole 
was delivered after separating the adhesions. It was followed 
to the liver and proved to be the gall bladder. It was cystic and no 
stone could be palpated. An incision was made and a large quan- 



TUMORS OF THE ABDOMEN 



817 



tity of liquid blood escaped. At the bottom two huge stones and 
two smaller ones were found. The gall bladder was removed. A 
drain was placed. 

Pathology. — The two large stones each measured 2i/2 inches long by 




Fig. 359. — Enlarged thick walled gall bladder. (Reduced one-half.) 



2 inches in diameter. The smaller ones are the size of a hickory 
nut. The wall of the gall bladder is necrotic and about 8 mm. 
thick (Fig. 359). The slide shows marked hemorrhagic infiltration. 
The epithelium is exfoliated for the most part. 



818 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — Recovery was uneventful. 

Comment. — It seems strange that such huge stones could be car- 
ried without causing more distress. Had I known that the gall blad- 
der was blue-black I should not have dared to wait a week before 
operating. In another week it might have perforated. There is no 
certainty of this for it is known ovarian cysts infiltrated to this extent 
recover their nutrition. This is particularly likely to occur if they 
have temporary aid by adhesions with neighboring organs. This gall 
bladder had this and likely would have weathered the storm unaided 
because there was no virulent infection present. The adhesions of 
the gall bladder were such as to make it stationary on deep respira- 
tion, thus obliterating one of the cardinal signs of enlargement of 
this organ. 

RENAL 

The renal region besides harboring tumors derived from the kidney 
may contain those from the gall bladder and perirenal space as well 
as wanderers from other regions of the abdomen. 

CASE 1. — A child aged fifteen months was brought to the hospi- 
tal because of a tumor in the right side. 

History. — The child was normal in every way as an infant. Six 
months ago the mother noticed a tumor in the right side. The child 
seemed perfectly well otherwise. 

Examination. — On the right side of the abdomen bulging from 
under the costal margin is a globular mass the size of a fist. It is 
easily palpable in the flank when pressed upon in front. It is smooth, 
dense, and pressure upon it does not inconvenience the child. 

Diagnosis. — Nearly all tumors in this region in young children 
are some form of mixed tumor. The only diagnostic point of interest 
is whether or not it is a tumor of the kidney at all, for tumors in this 
region, not associated with the kidney, are by no means rare. The 
distinction is not possible clinically and even during the course of 
the operation the surgeon may be so preoccupied with other things 
that this detail of determining if it represents the kidney or not es- 
capes his attention, and he puts the question to the pathologist. 

Treatment. — The tumor was removed without difficulty (Fig. 360). 

Pathology. — The structure was that of the usual mixed tumor, but 
was characterized by large bundles of perfectly striated muscle fibers, 
therefore it is a rhabdomyosarcoma (Fig. 361). 



TUMORS OF THE ABDOMEN 819 

After-course. — The child recovered well from the operation, but 
died after a few months of an enterocolitis. 

Comment. — Young children bear the removal of these large tumors 
very well and a considerable proportion remain free, at least for 
many years. 




Fig. 360. — Rhabdomyosarcoma of the right kidney. 



CASE 2. — A retired gentleman aged sixty-eight came for consul- 
tation because of a tumor in the right side of the abdomen. 

History. — He has always had good health until 9 years ago. Since 
that time he has had pain in the chest which several times has 
extended down the left arm. In several of these attacks the pain 
has been very severe, so that he felt his life would be crushed out. 



820 



CLINICAL SURGERY BY CASE HISTORIES 



In the interval his general health has been good. Six months ago, 
however, he noticed that his general health was not so good. His 
appetite has become less and he has felt weaker. There has been 
some difficulty in urinating and at intervals he has noted some 
blood in the urine. He has had some pain in the right flank ex- 
tending downward and forward but never to the bladder or tes- 
ticle. 




Fig. 361. 



-Rhabdomyosarcoma of the right kidney. The striated muscle fibers cannot be 
made to show in the photograph. 



Examination. — The heart is generally enlarged, and the aortic 
sounds are exaggerated. The abdomen is prominent, particularly 
on the right side. The lower abdomen is marked by dilated veins 
extending upward toward the costal margin (Fig. 362). The abdo- 
men for the most part is soft and flabby but the right upper quad- 
rant is occupied by a firm roundish tumor. When pressed upon by 



TUMORS OF THE ABDOMEN 



821 



the anterior hand a bulging can be felt in the renal space and 
when the posterior hand makes pressure the mass can be felt to 
roll over toward the midline as far as the right border of the 
vertebral column. It moves slightly with respiration and is con- 
tinuous with the lower dullness but at the medial border there is 
a deep angle of tympany between the liver and tumor. The 
prostate is but little enlarged and is smooth and not tender. 
Diagnosis. — The physical findings indicate a tumor of the renal 




Fig. 362. — Dilated veins in the abdominal wall due to obstruction of the venous return. 
The artist wrongfully made the most prominent veins on the left side. 

region. Other tumors of this region are excluded by the transient 
hematuria. Its large size makes a separation from it and the liver 
impossible. There is no evidence that the blood comes from the 
bladder. 

Treatment. — None. 

After-course. — He died rather suddenly three months later. The 
exact cause was not learned. 



822 CLINICAL SURGERY BY CASE HISTORIES 

Comment. — The tumor itself was movable and while it was large 
and the operation would have been difficult, the technical hazards 
would not have forbidden the attempt. The proneness of hyperneph- 
roma to grow into the renal veins is well known and the presence of 
the dilated veins in the abdominal wall indicates that in this 
case not only the renal vein but the vena cava as well has become 
plugged by the tumor growth. Therefore, even though the growth 
might have been removed, the chief menace would have remained. 
Aside from this the manipulations of the operator might have dis- 
lodged a part of the intravascular growth with immediate disas- 
trous results. The importance of the presence of dilated vessels in the 
abdominal walls over an intraabdominal tumor is not sufficiently rec- 
ognized. I have seen surgeons cut down upon tumors despite this 
warning sign, only of course to be compelled to close the abdomen, or 
worse still, to attempt a removal of the tumor with more or less im- 
mediate disastrous results. 

CASE 3. — A matron aged fifty-six came because of pain in the 
left side of the abdomen. 

History. — The patient has always had good health and has three 
healthy children. Four years ago she began to have pain in the 
left lower abdomen. At first these were merely annoying but later 
they became so severe that she had to lie down. Being much on 
her feet seemed to increase the pain. When asked to locate the 
pain she applied the palm of her hand across her abdomen from the 
splenic region to the pubes. 

Examination. — The patient is a large, strong woman with a slight 
general anemia. To the left of the median line just above the 
level of the umbilicus is a tumor the size of a goose egg. The aorta 
is palpable and the pulsations are unusually strong and can be fol- 
lowed well down the course of the external iliac arteries. The 
tumor seems to be independent of the aorta, but it pulsates with 
equal vigor. There is an area the breadth of two fingers where 
the pulsation of the tumor ends and that of the aorta begins. There 
is a trace of albumin in the urine and a few casts. The Wassermann 
reaction was strongly positive. 

Diagnosis. — A pulsating tvimor separate from the aorta in direct 
line with the renal artery suggested the rare renal aneurysm. Since 
there seemed to be a portion of the renal artery between the aneu- 
rysm and the aorta, it seemed that the tumor might be operable. 



TUMORS OF THE ABDOMEN 



823 



Treatment. — When the tumor was cut down upon, a tumor as out- 
lined in the cut was exposed. What remained of the kidney sat as 
a cap on the outer upper part of the aneurysm. The external iliac 
arteries were markedly dilated, the left forming a short loop upward. 
At the narrowed portion of the tumor where it approached the aorta 
there was a calcareous plaque as wide as a dime and as long as a quar- 
ter. This formed a calcareous wall and it seemed useless to attempt 
to ligate through such tissue, so the operation was abandoned (Fig. 
363). 



f?emo»n5 of Kidney 




Fig. 363. — Aneurysm of the left renal artery. 



After-course. — She was placed on antisyphilitic treatment which 
was followed by a marked amelioration of the pain and improvement 
of her general well being, but the tumor remains as before. 

Comment. — This would have been an ideal case to try out the ware 
method, but the material was not at hand. The ease is interesting 
from a diagnostic point of view because of its rarity. This in fact 
furnished the onh' element of doubt. The iliac arteries were mark- 
edly dilated and the left made a peculiar hump upward which 
gave the feel of a secondary pulsating tumor. 



824 CLINICAL SURGERY BY CASE HISTORIES 

CASE 4. — A housewife aged forty-six came to the hospital be- 
cause of a tumor in the left side. 

History. — The patient noticed a tumor in the left side about four 
years ago. It has grown steadily since. Up to four months ago 
it gave no trouble at all and she felt strong and well. Since 
that time she has had severe pain in the left side of the abdomen. 
This comes on at no special time and is not affected by anything. 
It usually gets some better if she lies down. The pain is often 
almost unbearable and radiates to the left shoulder and head. She 
also has had a pain during the last six weeks under the right cos- 
tal margin. It comes on at no special time and is not affected by 
eating. She is not troubled with general malaise and weakness. 
The appetite is not so good as formerly and the bowels are con- 
stipated. She gets up once each night to pass urine, usually, but 
sometimes has spells of marked bladder irritation. There is no 
shortness of breath on exertion but her feet swell towards evening 
at times. She has seven children living, and one, aged one year, 
died of pneumonia. Youngest living child ten years old. No 
miscarriages. Menstruation regular, somewhat painful, lasts four 
to five days. 

Examination. — Patient fairly well nourished but appears anemic. 
The skin is slightly yellow tinged. Heart and lungs negative. A 
large abdominal tumor, situated on the left side, is apparent by 
palpation. It extends to the level of the umbilicus and within an 
inch of the rectus margin. This tumor is hard and smooth and has 
several irregularities along its inner border. By pressing on the 
tumor abdominally it can be felt from the back below the 12th rib. 
She has a pronounced cystocele. Hg 65 Tallquist; W.b.c. 377,000; 
40 per cent polynuclears ; large lymphocytes, 10 per cent ; small 
lymphocytes, 15 per cent ; Path, myelocytes, 35 per cent ; R.b.c. 
2,400,000. The urine contains many pus cells and some albumin. 

Diagnosis. — The blood picture at once makes the diagnosis of myelog- 
enous leucemia. The physical findings suggested a kidney tumor 
as much as the spleen because it could be made to appear so promi- 
nently in the renal triangle. 

Treatment. — The patient returned home and her physician gave 
her arsenic. 

After-course. — She died eight months later. 

Comment. — In this case the blood examination was all important. 



TUMORS OF THE ABDOMEN 



825 



CASE 5. — A housewife ag-ed fifty-six came because of a tumor in 
her left side. 

History. — The patient had a severe sick spell sixteen years ago. 
She does not know its nature, but she was in bed all summer. There 
was pronounced digestive disturbance but there was no definite 
pain anywhere. Her Aveight was reduced to 85 pounds. After she 




Fiff. 364. — Hypernephrosis showing the dilated pelvis and thin cortex of kidney remaining. 

recovered it was discovered that she had a tumor in the left side 
below the costal border. This tumor would disappear and then after 
a lapse of some time, would reappear. Five years ago she was sick 
of an unnamed disease several months. Since then the tumor has 
been constantly present. She has some digestive disturbance but 



826 CLINICAL SURGERY BY CASE HISTORIES 

now weighs 100 pounds. Her stomach is sensitive to many foods 
and she thinks the tumor causes it by pressing on the stomach. 

Examination. — A globular tumor occupies the space between the 
lateral border of the left rectus, the short ribs above, and the 
crest of the ilium below. On palpation it is fluctuant, slightly 
movable, and pressure upon it causes bulging in the renal region. 
The urine is negative. There is a general anemia. No urine flows 
from the left ureter. 

Diagnosis. — The presence of a fluctuating tumor in this region 
is most likely a hypernephrosis. This assumption is made certain 
by the absence of the flow of urine from the orifice of this side. 

Treatment. — The tumor was removed transperitoneally and the 
patient promptly recovered. 

Pathology. — The tumor is the size of an adult head. A portion 
of the cortex of the kidney was well preserved and capable of per- 
forming some function. The pelvis was dilated to a thin parchment- 
like sack (B^ig. 364). The ureter is occluded at the point of in- 
sertion into the dilated pelvis. 

After-course. — The patient improved greatly in strength and weight 
and her stomach symptoms much improved, though she never ceased 
to have some digestive disturbance. She died of lobar pneumonia four 
years after operation. 

Comment. — The nature of the process which gave rise to the 
occlusion of the ureter is not clear. Such a tumor is no real men- 
ace and likely disturbs because of its size. There was some renal 
substance left and had an internal plastic been done some func- 
tion would no doubt have been performed. Since evidently she had 
relied on her right kidney for years a speedy termination of the 
operation was deemed more important than the preservation of the 
small amount of renal substance the afifected kidney represented. 
The reconstruction of a pelvis from such an enormous sac is not 
altogether a simple bit of surgery and the functioning of the 
product is not always ideal. 

CASE 6. — A widow aged sixty-two came to the hospital for relief 
of a tumor in her right side. 

History. — The patient has felt somewhat weakened and shaky 
for six months. Three months ago she accidentally found a tumor 
in the right side. It has not been sore or painful and she has 
been able to go around without pain or inconvenience. There has 



TUMORS OF THE ABDOMEN 



827 




Fig. 365. — Hypernephroma of the kidney. 



828 



CLINICAL SURGERY BY CASE HISTORIES 



never been any blood in the urine. She passed the menopause ten 
years ago and has had no discharge since. She is obstinately con- 
stipated but not more so than usual and she has no pain when the 
bowels move. She has had some palpitation. 

Examination. — A tumor the size of a fetal head occupies the 
right upper quadrant of the abdomen. The mass can be palpated 
from the renal triangle from behind. It can be made to disap- 
pear partly under the liver. It moves with respiration but it does 
not move with the whole respiratory act, but begins after the 
liver has already partly descended. When the patient turns on 




Kig. 366.- — Hypernephroma of the kidney. 

her left side the tumor falls toward that side. The urine is normal. 
The blood pressure is 160-120. 

Diagnosis. — The fact that it can be easily palpated from the renal 
triangle makes it seem likely that it has its primary seat in the 
kidney. That it is not connected with the liver is evident from the 
fact that it does not begin its descent when the liver begins. 
There never have been any urinary symptoms, which makes an in- 
fective tumor unlikely, and its firm consistence excludes a cystic 
tumor. The slight irregularity of the surface likewise speaks for 
a solid expansile tumor. The law of probability suggests a hyper- 



TUMORS OF THE ABDOMEN 829 

nephroma. This is supported by the fact that a carcinoma is sel- 
dom so large, and mixed tumors are products of early life. This 
tumor is more mobile than retroperitoneal tumors derived from the 
fibrous or fatty tissues. 

Treatment. — A nephrectomy was done through a semilunar line 
incision. 

Pathology. — The upper pole of the kidney is occupied by a large 
solid mass with here and there a cystic tumor (Fig. 365). It is fairly 
well encapsulated against the tumor. The renal vessels are not in- 
volved. The surface of the growth is grayish in color with yellow- 
ish areas. The tumor is made up of large cells with vacuolated 
protoplasm. The cells are arranged in columns or rows as in the cor- 
tex of the adrenals (Fig. 366). 

After-course. — Healing was prompt. After a few months a small 
abscess formed in the scar. 

Comment. — The insidious, painless onset with a great degree of 
encapsulation indicates a mild degree of malignancy. Inasmuch 
as the renal pelvis was not involved or invaded, there were no uri- 
nary disturbances. It was encapsulated against the large renal ves- 
sels, hence extension by this avenue is not likely. Whether these 
tumors are "hypernephromas" or not is open to question. Be this 
as it may, the term expresses a clinical entity surgeons have learned 
to understand and controversial matters may be left to the pathol- 
ogists. 

INGUINAL 

Tumors found in the ileocecal region are usually inflammatory, 
granulomatous or neoplastic. These need to be distinguished from 
abscesses either without the abdomen or in the retroperitoneal tissue. 

CASE 1. — A grocery man aged forty-eight came to the hospital be- 
cause of pain in the rig'ht side of the abdomen. 

History. — Two weeks ago he began having pain in the right lower 
part of the abdomen. The pain was most severe when he attempted 
to walk. A moderate degree of nausea was present, but no vomit- 
ing. He had some rise of temperature. Pain was continuous until 
four days ago. Since that time he has no pain when he is perfectly 
quiet. Pain returns if he walks or moves about. His general 
health has always been good. He has had no bowel movement for 
three days. 



830 



CLINICAL SURGERY BY CASE HISTORIES 



Examination. — The patient is thin and shows loss of weight. There 
is no abdominal distention and no rigidity of the abdominal wall. To 
the' right and below the umbilicus is a tumor as large as the palm of 
the hand. The point of maximum tenderness is exactly over the clas- 
sical McBurney's point. The mass is not movable, is sensitive to 




Fig. 367. — Pendulovis fibrosarcoma of the external surface of the stomach. 



the touch, but there is no surrounding muscular rigidity. It does 
not move with a change of position. He has 17,400 leucocytes, 86 
per cent are polynuclears. The urine has a trace of albumin and a 
few casts and an occasional red cell. 



TUMORS OP THE ABDOMEN 831 

Diagnosis. — The history and location of pain suggests an appen- 
dicitis. The point of maximum tenderness at the time of observa- 
tion bears this out. The tumefaction is surprisingly well defined 
for an inflammatory mass. However, omental adhesions about an 
appendix when not attached to the anterior abdominal wall give 
such findings. Since it seems to be of recent origin, this is the 
only available explanation. The increase in leucocytosis suggests 
the likelihood of a deeply seated abscess pretty well encapsulated. 

Treatment. — A right rectus incision discloses a tumor as large as 
the palm of the hand attached to the lower border of the stomach 
















Fig. 368. — Fibrosarcoma of the stomach. 

near the pylorus by a pedicle an inch wide and half as thick. At its 
lower outer pole is an area of attachment as big as a finger, apparently 
of recent origin. The pedicles were severed at the stomach and ab- 
dominal walls, respectively. 

Pathology. — The tumor measures 8x5x2 cm. It is dense to 
the feel and its surface is slightly corrugated. Its color is mottled 
by varying shades of red and gray. The cut surface bears out this 
color scheme. The slide shows a spindle-celled, fibrous structure. 
(Figs. 367 and 368.) 



832 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — The recovery was prompt and to date permanent. 

Comment. — The tumor obviously was of long duration, its anlage 
probably congenital. From the appearance of the attachment it is 
likely that owing to a partly twisted pedicle the lower portion ob- 
tained an attachment to the anterior parietal wall producing at once 
the pain and local tenderness. The leucocytosis can be explained on 
the ground of irritation of the whole tumor mass. 

CASE 2, — A merchant a^ed forty-two came to the hospital because 
of pain in the right flank and loss of weight. 

History. — Nine months ago he noticed a pain in the right side 
when he stooped over. At this time he had the pain only when he 
was working. He never had any sudden acute attacks of pain, 
neither did he ever vomit, feel nauseated, nor have fever. About 
two months ago he began to have pain clear across the lower abdo- 
men in addition to the one in the right side. This pain in the lower 
abdomen seems to be present usually just before the passage of gas, 
and is relieved as soon as the gas is passed. The pain in the 
right side is now almost constantly present. It is a dull, heavy 
pain. Eating seems to affect the pain very little if any at all. The 
bowels have been constipated of late. The taking of purgatives 
does not seem to increase the pain. There are no urinary symp- 
toms. The appetite is good, and there is no digestive disturbance. 
He has lost 20 pounds in weight in the last six months but feels 
pretty good except for the pain in the side and abdomen. 

Examination. — Patient has the appearance of a normal healthy 
individual, and does not bear evidence of having lost weight. There 
is a small movable tumor in the right side half way between the 
right costal margin and ilium. It is freely movable on change of 
position and "somewhat tender to pressure. It is hard and somewhat 
lobulated. 

Diagnosis. — The history of progressively increasing pain with the 
appearance later of obstructive symptoms is suggestive of car- 
cinoma or tuberculosis. The findings of a dense bosselated mass 
makes the former of these two possibilities the likely one. Sar- 
coma can be ruled out for these tumors do not produce obstruction. 
A low grade of inflammation sometimes produces a tumor with symp- 
toms of narrowing of the lumen of the gut, but these are usually 
not movable and are not so dense as this one. This is a possibility 
that can be excluded after the mass is in hand. 



TUMORS OF THE ABDOMEN 



833 



Treatment. — A right rectus incision was made. The mass was 
found to be white, hard, and nodular. The appendix was large and 
hard, but not nodular. As far as could be determined, there were 
no metastases in the mesenteric lymph nodes except just medial to 
the mass. The mass with the cecum, appendix and a couple of 
inches of the ileum were resected. A lateral anastomosis made 




Fig. 369. — Carcinoma of the cecum with lymph gland involvement. The larger lymph gland 

shows necrotic center. 



between the ileum and ascending colon. One gauze drain was in- 
serted in the right flank through a separate incision. 

Pathology. — The mass is 6 cm. in diameter and irregularly lobulated. 
It occupies chiefly the ileocecal junction which it narrows to the 
size of a lead pencil. The lumen of the cecum is reduced to a nar- 
row slit (Fig. 369) and the appendix is thickened. Just outside 



834 CLINICAL SURGERY BY CASE HISTORIES 

of the cecal Avail are a number of lymph glands which show fine 
white points within them. The larger of them shows a necrotic 
area the size of a pea. The slide shows a typical adenocarcinoma. 

After-course. — There was very little postoperative shock. The 
pulse did not go over 100 immediately following the operation. The 
temperature went as high as 102° by the fifth postoperative day, 
but then came down rapidly. There was a little vomiting every day 
which stopped Avhen food and fluid were withheld and proctoclysis 
given. There Avas considerable pus drainage from the flank wound. 
Food was withheld for a Aveek. On the tenth day a cathartic 
Avas giA'en by mouth folloAved by boAvel moA'cment the next day. 
On the twelfth day the main incision line was swollen. It was sepa- 
rated by hemostats and drained of a large amount of foul-smelling 
pus. The temperature immediately dropped to normal and re- 
mained so until dismissal on the tAventy-fifth day. When the pa- 
tient left the hospital the flank Avound Avas entirely healed. The 
incision still drained a little pus through a small sinus. The tem- 
perature and pulse Avere normal. The patient was on a general 
diet and A\'as feeling fine. The boAvels move normally without a 
cathartic. 

Comment. — There are glands affected about the cecum and while 
carcinoma of the cecum usually offers a relatively good prognosis, 
this makes it likely the groAA^th Avill appear in the retroperitoneal 
lymph glands. Once Ij^mph glands become involved in any malig- 
nant tumor prospects of a cure are not good. 

CASE 3. — A married Avoman aged tAventy-four Avas broug-ht be- 
cause of a tumor Ioav in the abdomen. 

History. — This patient passed a normal puerperium two and a 
half years ago. Three months ago she Avent through her second 
confinement. The labor Avas prolonged and difficult. She remained 
Aveak for a number of weeks and had much bladder irritation and 
Avas obstinately constipated. A month after labor she Avas examined 
by a surgeon AA^ho discovered a tumor in the pel\'is and advised 
operation. 

Examination. — The patient is pale and lies Avith the left thigh 
flexed on the abdomen. She declares she can not extend it. Ab- 
dominal palpation shows a tumor in the left iliac fossa reaching 
Avithin tAVO or three inches of the crest of the ilium and disappearing 
in the peU'is. Bimanual palpation shoAvs the tumor to extend to the 



TUMORS OF THE ABDOMEN 835 

base of the broad ligament and pushes the uterus to the right (Fig. 
370). The uterus is not tirmly fixed and the bottom of the culdesac 
is free. The tumor presses on the bladder, but does not irritate its 
walls. The tumor is but slightly movable in the pelvis and is quite 
firmly fixed over the brim of the pelvis. It is firm, elastic, and 
firm pressure and manipulation causes pain. The Hg is 75, with 
12,000 leucocytes. 

Diagnosis. — Obviously a tumor of such a size did not exist at 
the time of delivery or the birth of the child would not have been 
possible. The history is that the birth was difficult; this may be 
accounted for by the presence of a smaller tumor which has since 
grown. Such a tumor must have been a fibroid or an ovarian cyst. 
This evidently is neither, for it clearly lies in the fold of the broad 




Fig. 370. — Pelvic hematoma. 

ligament, and following this escapes to the iliac fossa extraperi- 
toneally. No solid tumor could have done this. Obviously, there- 
fore, the material of this tumor must have reached this situation 
when in the fluid state. It is solid now. There is but one fluid 
capable of doing this, namely, blood. We have, therefore, a blood 
clot located within the broad ligament and extending into the iliac 
fossa, irritating the psoas muscle, hence the thigh contraction. An 
inflammatory exudate may assume this form. If it were an acute 
suppuration, the reaction would be greater than in this case ; and 
if chronic, more dense. Blood clot has a feeling all its own, dense, 
elastic, not simulated by any other material. 

Treatment. — Rest in bed was advised until the contraction of the 
thigh subsides then as much exercise as she feels like taking. 



§36 cLiNiCAL SUfeGERY BY CASE HISTORIES 

After-course. — The patient was requested to appear for examina- 
tion in three months. When she presented herself, very slight thicken- 
ing only remained in the base of the broad ligament. The uterus was 
freely movable and but little pain was caused. The bladder irritation 
had disappeared and the bowels moved with mild laxatives. She had 
regained her normal strength. 

Comment. — Had this been a malignant tumor as my predecessor 
assumed, it would have been utterly inoperable. Blood clots regu- 
larly require from two to three months to become absorbed. The 
activity of the therapeutics may be inversely proportional to the 
intelligence of the patient. These clots should be w'atched. Occa- 
sionally they become infected and must then be drained through 
the vagina or in some instances extraperitoneally above Poupart's 
ligament. 

CASE 4. — A school boy aged fourteen cajne to the hospital be- 
cause of a painful tumor in his side. 

History. — For three years at intervals of several months, he has 
had attacks of abdominal pain sometimes attended by nausea but 
never by vomiting. The pains were cramp-like in character and 
lasted only a few hours and were followed by no tenderness. Some 
weeks ago he noticed a swelling in the right side above the hip 
bone. He had had no pain and he does not recall when he had the 
last attack of pain. The condition was diagnosed a hernia by an 
osteopath who administered treatments. Following this he had pains. 

Examination. — -A tumor the size of a small apple is located above 
and medial to the anterior superior spine. It is not movable and 
is sensitive to the touch. It seems quite superficial and the abdominal 
wall can not be moved over it. Temperature 101°, pulse 90. 

Diagnosis. — The history of repeated colics with the appearance of 
a mass suggests at first thought an obstructive rather than an 
inflammatory lesion. Carcinoma in a lad is rare and would not ex- 
tend over three years. Tuberculosis would not present such an 
intermittent history. The present sensation on palpation suggests 
an inflammatory lesion because of its relation to the abdominal 
Avail and to the sensitiveness and fever. Whatever may have been 
the initial lesion an infection now exists. 

Treatment. — A quantity of pus was drained. A smooth walled 
cavity the size of an egg containing an enterolith was found. No at- 
tempt was made to find the appendix. 



TUMORS OF THE ABDOMEN 837 

After-course. — The opening healed in three weeks. 

Comment. — Evidentl}- the lad developed an enterolith and at inter- 
vals the appendix made fruitless attempts to expel it. Probably it es- 
caped from the lumen of the appendix by gradually necrosing its 
walls. Adhesions had anticipated this process and a thoroughly 
Mailed off cavity resulted. The cure will be permanent, the appen- 
dix having been eliminated by the necrotic process. Unless a her- 
nia develops as a result of the drainage, he will not require any 
further operations. 

CASE 5. — A farmer aged forty-five came to the hospital because 
of pain and a lump in the right groin. 

History. — He has had pain in his right groin for the past six 
months. He had some tenderness on two occasions preceded by spon- 
taneous pain lasting for several days. During the past few weeks 
the pain has been constant. He has felt weak but has continued 
with his work. He has felt feverish at times. The bow^els have 
moved regularly. Previously to the onset of this trouble he had a 
chronic digestive disorder characterized by burning both before 
and after eating. 

Examination. — The patient is a long, lean, rawboned man who 
gives no evidence of having undergone suffering or disease. A 
nodulated mass the size of an egg lies internal to the anterior supe- 
rior spine. It is dense, bosselated, and but little movable. It is sen- 
sitive on deep pressure. The abdominal wall becomes tense over 
it when pressure is made. There seems to be an indefinite mass 
projecting from the tumor to the epigastrium but the more or less 
voluntary retraction of the muscles makes a satisfactory examina- 
tion impossible. Pulse 74, temperature 98.4°, respiration 16. The 
urine is negative. W.b.c. 11,000 ; R.b.c. 4,000,000. Polynuclears 72 ; 
large mononuclears 12 ; small mononuclears 16 ; Hg 80. 

Diagnosis. — The history of disability extending over six months 
with two periods of exacerbation suggests an inflammation of the 
appendix without complete resolution. However, such a long dura- 
tion would be very unusual without progressive improvement. Such 
a long duration could be counted on only if there was a chronic 
nonsuppurative inflammation of the great omentum. In six months 
that should have been more acute. The hard nodular feel is that 
of malignancy, but usually carcinomas early are more movable and 
less sensitive. The prolongation of the mass toward the epigastrium 



838 CLINICAL SURGERY BY CASE HISTORIES 

suggests an omental affection. Extension in this direction in car- 
cinoma so early and before obstruction appears would be unusual. 
The leucocyte count, both the absolute and the relative, might 
occur either in malignancy or induration of the omentum. If 
it is omental, time should remedy it; if malignant, early operation 
is urgent. On the other hand if there is an actual induration 
extending from the ileocecal region toward the epigastrium which 
is malignant in character, operation is wholly useless. Since the 
diagnosis is not certain, exploration may be advised. 

Treatment. — An incision was made along the anterior border of 
the right rectus. A nodular mass was situated at the ileocecal 
junction which was free from the great omentum. From this in the 
retroperitoneal tissue extending to the epigastrium was a hard 
nodular mass, evidently malignant lymph glands. This mass seemed 
movable. Resection with lateral anastomosis of the severed ileum 
to the remains of the ascending colon was done. The renal vessels 
and the cava were exposed in the enucleation. 

Pathology. — The tumor had narrowed the ileocecal orifice so that 
the tip of the little finger could hardly be forced through it. The 
retroperitoneal mass was composed of a conglomerate of lymph glands. 
The slides showed typical carcinoma. 

After-course. — There was a moderate degree of shock, the pulse 
varying between 110 and 120 during the first twelve hours, but then 
came down to 90. On the second day he began to vomit quantities 
of greenish fluid. Gastric lavage was done a number of times and 
he became comfortable. He progressed favorably the succeeding 
days, but on the seventh day he began to hiccough. This was fol- 
lowed by brownish-green vomitus in large amounts. Lavage was 
again done and the gauze drain was removed. The condition re- 
mained unchanged, the temperature began to descend, and he died 
on the tenth day with subnormal temperature. The autopsy showed 
a gangrene of the terminal foot or more of the small gut with ex- 
tensive thrombosis of the mesenteric vessels. There was no leak and 
no evidence of peritonitis. 

Comment. — After the fact of retroperitoneal metastasis was es- 
tablished, the abdomen should have been closed. Once the field of 
operation is exposed most surgeons find it hard to desist if the 
operation is technically possible even if there is no prospect of 
actual cure. This was such a case. Obviously the thrombosis took 



TUMORS OF THE ABDOMEN 839 

place some days after operation or separation of the necrotic por- 
tions of the gut would have occurred. Death was due likely to toxic 
absorption. 

CASE 6. — A matron aged thirty-five was brought to the hospital 
because of a tumor in the lower abdomen following an operation for 
myoma of the uterus. 

History. — For several years the patient has been suffering from the 
usual symptoms of myoma. This tumor, which was the size of a 
fetal head, was removed by supravaginal hysterectomy by a com- 
petent surgeon (Fig. 371). The tumor on section showed extensive 
colloid degeneration. Recovery was uneventful from the anesthetic 
and the immediate effects of the operation. In twelve hours the 
patient began to complain of bladder irritation and tenesmus was 
added in the two days following. This continued unabated for 
several weeks. There was moderate rise of temperature and in- 
crease of the pulse rate. At the end of three weeks she was ex- 
amined by her surgeon and a mass was found to fill the pelvis. 
After consultation the diagnosis of sarcoma was made and an un- 
favorable prognosis rendered. The same state continued for two 
or three weeks until the time she presented herself for examination. 

Examination. — The patient seems well nourished, without signs 
of anemia, but very apprehensive and scarcely able to walk with 
support. The abdominal walls seem firm, neither rigid or flaccid. 
Bimanual examination shows a firm tumor 3x5 inches lying trans- 
verse to the long axis of the pelvis (Fig. 372). It seems smooth in 
outline but firmly fixed in the tissue, lies close upon the bladder, 
and seems to surround the rectum. 

Diagnosis. — The onset of bladder irritation soon after the operation, 
with the fever, speaks for a blood clot. The physical findings corre- 
spond to this, being identical with that after tubal abortion. Sarcoma 
does sometimes follow myomectomy with frightful rapidity, but never 
so quickly as this, and only follows hemorrhagic myomas and not 
colloid degeneration as in this one. Sarcomatous recurrences are soft, 
semifluctuating masses much softer than a blood clot, and the course 
is progressive. 

Treatment. — None. 

After-course. — After the patient was told the condition was an inno- 
cent one and Avould clear up in a few months she lost her apprehen- 



840 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 371. — Colloid degeneration of a myoma of the uterus. 



sive appearance and left the office with a stride far too vigorous 
to permit her escort to render assistance. In three months the 
entire mass had disappeared and the pelvis has remained free from 
any disturbance. 



TUMORS OF THE ABDOMEN 



841 



Comment, — Hematomas following operation are far more common 
than is generally appreciated. They give rise to a low degree of 
temperature, ranging usually from 99.5° to 102° with a leucocytosis 
of about 12,000. This disturbance is often ascribed to a low degree 




Fig. 372. — Schematic presentation of a subperitoneal postoperative hematoma. • 

of infection. The onset is usually more prompt after operation than 
in the case of low grades of infection. After pelvic operations 
their presence can easily be detected by palpation. 



SUPRAPUBIC 

Tumors in this region may be the pregnant uterus or a distended 
bladder. Once these two possibilities are excluded the diagnostic 
problems are simple. The uterine tumors are myomas, the ovaries 
either cystic, sarcomatous, or carcinomas. 



842 CLINICAL SURGERY BY CASE HISTORIES 

CASE 1. — A farmer's wife aged twenty-six came to the hospital 
because of an increasing size of her abdomen. 

History. — The patient says that for several years she has been 
getting larger across the abdomen. She consulted a surgeon a 
year and a half ago who diagnosed an ovarian cyst and at opera- 
tion not finding one he removed both ovaries as a prophylactic meas- 
ure. She has continued to grow larger since the operation. The 
patient has much trouble in keeping herself warm, but is not con- 
scious of any other defect. She states she is over weight, but does 
not know how much. In fact she seems to have rather a hazy 
notion as to why she is seeking medical advice other than that she 
is growing so large. She has two children, the youngest three years 
old. She has had no menstruation since the operation a year and 
a half ago. 

Examination. — The patient walks with an elephantine gait, sits 
down with great deliberation, and answers questions deliberately 
Avith a drawling voice. The features are heavy, the thick fatty 
pads about the neck are at once apparent (Fig. 373). The skin 
is markedly dry and rough. The legs are thickened, elastic rather 
than edematous. Her abdomen is as large as a seven months preg- 
nancy. Fluid is demonstrable and the percussion note gives the im- 
pression of a confined fluid with a loose sac. Vaginal examination 
shows some bulging in the culdesac, but the uterus is small, mova- 
ble, and evidently atrophic. The thyroid is not palpable. The 
examination is made difficult by the thick pads of fat in the neck. 
The urine contains some albumin, but no casts. 

Diagnosis. — The heavy padded features, the deliberate gait, and the 
dry skin is enough to establish the diagnosis of myxedema. If the 
abdomen alone had been examined, it would have been quite easy 
to confuse the condition with a parovarian cyst. 

Treatment. — She was given 5 grains of thyroid extract three times 
a day. 

After-course. — She lost 16 pounds in ten days and her general 
appearance changed markedly (Fig. 374). The ascites had entirely 
disappeared at the end of this time. She regained her normal health 
and appearance in a few months, and has continued well now sixteen 
years, but she still takes 5 grains of thyroid extract a day. 

Comment. — The fact that the ascites led an experienced operator 
to diagnosticate an abdominal cyst is sufficient excuse for including 



TUMORS OF THE ABDOMEN 



843 




Fig. 373. — Myxedema before treatment. 




Fig. 374. — Patient after ten days' treatment with thyroid extract. 




Fig. 375. — Before onset of the disease. 



844 CLINICAL SURGERY BY CASE HISTORIES 

this case here. The patient favored me with a photograph of herself 
taken just before the onset of the trouble (Fig. 375), Comparison of 
these give an unusually good presentation of the marked change in 
features this disease produced and also the marked specificity of 
thj^roid therap3'. 

CASE 2. — A fanner's wife aged forty-six was brought to the hos- 
pital because of severe pain in the lower abdomen. 

History.— The present trouble started Avith sudden pain in the 
right and left iliac region. The pain was steady and quite severe. 
She felt sick and weak all over but was not nauseated and did not 
vomit. In twenty-four hours the pain settled down in the pelvis 
reaching all the w^ay across. There seemed to be a soreness in both 
hip bones. The temperature was not taken during the attack. The 
attack was not related to the menstrual period. After the acute 
pain passed off she had soreness in the pelvis and hip bones for about 
a week. She has had five or six attacks during the past six months. 
They are getting more severe. The last one from which she is now 
recovering has lasted a Aveek. The bow^els are fairly regular noAV 
but during the summer months she was troubled with a severe 
diarrhea and passed blood with the stool. She is troubled with a 
purulent watery irritating vaginal discharge all the time. She has 
been troubled with frequency of urination both day and night all 
winter. She says that it feels as though something were pressing 
on the bladder. There is burning sometimes. Appetite good, but 
she sleeps poorly. She is very nervous all the time. She is troubled 
a great deal w^ith occipital and frontal headaches. One year ago 
she had a severe uterine hemorrhage and again nine months ago. 
Both came just after a period. They w'ere very severe for twenty- 
four hours. Her periods have been irregular for a year and a 
half, the last being six weeks ago. She has four children, young- 
est fifteen years old. All the labors w^ere normal. She had asthma 
as a child and had a growth removed from the cervix thirteen j-ears 
ago. 

Examination. — There is marked tenderness' to pressure over the 
right iliac region. A smooth, hard, rounded mass is felt just over 
the pubes. There is a second degree laceration of the perineum. 
The uterus is the size of two fists. The fundus is felt in anterior 
flexion and a smooth, hard, rounded mass lies to the left of it. A 
nodule the size of an egg lies to the ri^ht of the midline. This is 



TUMORS OF THE ABDOMEN 845 

very dense. The cervix moves when the tumor moves. The whole 
mass, cervix plus tumor, is movable Avith but slight pain on manip- 
ulation. 

Diagnosis. — A pain in the pelvis coming on suddenly, subsiding 
after several weeks leaving a definitely circumscribed tumor be- 
hind after the subsidence of symptoms usually indicates the presence 
of an ovarian cyst with twisted pedicle. This is made still more 
likely when such attacks are repeated. The tumor here is very 
dense to the touch and there is a smaller one to the right which is 
unquestionably a myoma. Another common cause for recurrent 
pelvic pain, with a residual tumor, is myoma with pus tubes. Be- 
sides the patient had a small tumor removed thirteen years ago. 
The tubes undergo periodic inflammation, then subside again. Usu- 
ally the recurrences do not follow each other so closely as here 
and the period of defervescence is longer. Nevertheless the tumor 
mass is exceedingly hard and there is an associated small hard 
tumor. The surface of the tumor is smoother than is usual when 
pus tubes complicate fibroids. There should be masses beside the 
uterus if we had to do with pus tubes. Another possible source 
of irritation is Avithin the uterus and tumor itself. This would fit 
in with all the findings, but is relatively an uncommon disease, 
not associated with pregnancy. In this case sev-eral attacks came 
on just at the termination of a menstrual period. Therefore, the 
diagnosis is most likely to be an infected myoma producing a pelvic 
peritonitis; the next most likely possibility, an ovarian cyst or 
dermoid with a twisted pedicle together with small myomas of the 
uterus. 

Treatment. — On opening the abdomen all the coils of intestines 
occupying the pelvis Avere found adherent to each other by a thin 
translucent membrane of extreme delicacy. These loops Avere ad- 
herent to one another and many of them Avere adherent to the sur- 
face of a tumor Avhich filled the pelvis. The tumor AA^hen dislocated 
proA'cd to be a multilocular myoma of the uterus. A mass the size 
of a fist was found in the middle of the fundus and one the size 
of an egg was found in the anterior wall near the right horn. Both 
tubes and OA^aries Avere bound up in the mass of delicate adhesions 
which coA'ered not only the tumor, but broad ligaments anteriorly 
and posteriorly. The tubes were not thickened. The adhesions sep- 
arated rather easily, leaving fcAV shreds with very little hemor- 



846 CLINICAL SURGERY BY CASE HISTORIES 

rhage; when separated they disappeared. The coils of intestines 
were separated from the tumor, broad ligaments, ovaries, and 
tubes, and most of the coils separated from one another. The cecum 
and sigmoid were but little involved in the adhesions. A supravag- 
inal hysterectomy was then done, taking the left tube and ovary. 
In suturing through the top of the cervix a pocket of pus was 




Fig. 376. — Myoma of the uterus with an infected focus in its interior. 

opened. This was removed by reamputation lower down, the remain- 
ing ovary was removed, and the operation finished in the usual way. 
Pathology. — Both ovaries were normal, the tubes but little in- 
volved. The uterine cavity was dilated, due apparently to a stric- 
ture at the internal os (Fig. 376), possibly the result of the removal of 
the tumor thirteen years before. The uterine walls were much 
thickened. The interior of the larger- tumor showed a smooth 



TUMORS OF THE ABDOMEN 847 

walled cavity which did not communicate with the interior of the 
uterus. The walls collapsed after the contents escaped. It con- 
tained no epithelial lining. The tumor tissue about the cavity 
was abundantly filled with round cells. The uterine mucosa was 
low, containing few glands. 

After-course. — The patient suffered some from shock after the 
operation. The pulse went to about 115 and the temperature the 
next couple of days was 99.6°. She suffered considerably from gas- 
eous distention which was relieved by enemas and stupes. About 
seven days after the operation she was given a cathartic, Pulv. 
Glys. Comp. dr. 2. She began to vomit shortly afterwards and kept 
it up every hour or two for three days. It was stopped by withdraw- 
ing everything by mouth and giving soda bicarbonate solution by 
proctoclysis, and by using gastric lavage. After the vomiting 
ceased, recovery proceeded uninterruptedly, except that she com- 
plained of soreness across the lower abdomen until within a few days 
of leaving the hospital. She ran a rapid pulse, usually from 90-100, 
most of the time in the hospital. Final recovery was complete. 

Comment. — It is a matter of speculation as to how the interior 
of the tumor became infected; most likely by way of the uterus 
since there were no dense intestinal adhesions about it. Further- 
more, evidently the tumor discharged into the cavity of the uterus 
from time to time. When the tumor emptied itself, the peritoneal 
surface ceased to be irritating, and the pelvic pain quickly sub- 
sided. The delicate but extensive adhesions indicated a slight 
irritation not attended by bacterial invasion. 

CASE 3. — A matron of forty-six came to the hospital because of 
hemorrhage and a tumor. 

History. — The patient is the mother of five children, the youngest 
of whom is twelve years old. She has had no miscarriages. For 
a year she has noticed a gradual lengthening of the menstrual flow. 
Before this time she was conscious of the presence of a tumor. It 
has gradually enlarged. Three weeks ago she had a severe hemor- 
rhage with considerable pain in the lower abdomen. Since then 
the tumor has grown rapidly. She thinks she has lost some weight. 

Examination. —The patient is well nourished, not anemic. She 
has a tumor in the midline extending up to the umbilicus. It is 
smooth, globular, semifluctuating and it moves freely from side 
to side but only slightly vertically. It does not vary in consist- 



848 CLINICAL SURGERY BY CASE HISTORIES 

eney while under the pressure of the examining fingers. The 
patient answers questions clearly and definitely, yet her attitude 
is such that it appears to me the statements might not be reliable. 
The cervix is hard, the supravaginal portion not softened, but 
seems to extend into the tumor. The vaginal mucosa is not blue 
and there are no breast changes. 

Diagnosis. — The entirely negative signs as to pregnancy, the his- 
tory of duration of more than a year, the persistent menstrua- 
tion seemed to rule out pregnancy, for any except one who has 
cut down on a pregnant uterus. For him there always is a question 
mark as tall as Uriah Heap. The direct attachment of the cervix 
to the tumor seemed to favor a soft myoma rather than an ovarian 
cyst. 






A. 

Fig. 377. — Schematic differentiation between an enlargement of the uterus due (A) to a 
pregnancy and (B) to tumor. 

Treatment. — When the abdomen was opened a large, deep reddish 
blue tumor presented itself in the wound. It was perfectly sym- 
metrical, a round ligament and tube attached to either side at 
exactly corresponding heights. The tumor was freely fluctuating 
and by practicing ballottement a roundish tumor could be made out 
in the depth. These were tense moments. I observed that the tubes 
and ovaries were attached at some distance from the summit of the 
tumor, as they must do if there were a pregnant uterus (Fig. 377). 
To make sure, I cautiously cut into the tumor. I went through a 
layer of deep red muscle tissue, then suddenly a small amount of 
clear serum escaped and out came a reddish mass which I at once 
took to be placenta. Close examination proved the mass to be a 
blood clot. It occurred to me that hej discomfort three weeks 



TUMORS OF THE ABDOMEK 



849 




Fig. 378. — Hemorrhagic myoma which simulated pregnancy. 



850 CLINICAL SURGERY BY CASE HISTORIES 

before might have been due to a hemorrhage into the placenta. 
Further investigation disclosed an area of colloid material. I 
knew then that I had to do with a myoma which had undergone col- 
loid degeneration and in which a secondary hemorrhage had oc- 
curred. A supravaginal amputation was done. 

Pathology. — Even after having demonstrated the nature of the 
tumor my assistants were very unpopular with me while I retired 
alone to cut open the tumor. It was a colloid myoma with second- 
ary hemorrhage. In the center of the tumor (Pig. 378) was an area 
the size of a small fist which for some reason had not undergone 
degeneration and when the uterus was tapped the finger gave the 
sensation of a deeply lying head. The structure was that of a hem- 
orrhagic myoma. 

After-course. — The patient recovered more quickly than the sur- 
geon. 

Comment. — Conscience doth make cowards of us all. The patient 
was a widow, and as the examination was completed inquired 
whether the tumor might be a pregnancy. I did not know she was 
a widow, owing to an error of the admitting clerk, else I should not 
have placed any confidence in the statement of the duration of the 
tumor, nor of the date of the excessive flow, having once been 
placed in an embarrassing situation by accepting such statements. 
I had traveled a considerable distance to a strange environment. 
Under normal conditions I should have waited to see how rapidly 
the tumor would grow. I have often wondered what would have 
been the result had I found a pregnancy after cutting a hole in 
the uterus. It probably would have healed. Had a miscarriage 
followed, the suture line would most certainly have given way. This 
is the only instance I have ever seen in which the rule that only in 
pregnancy the round ligaments are attached symmetrically to each 
horn of the uterus (Fig. 377 B) did not hold. The explanation is 
that the tumor was primarily intramural located near the internal os. 
As it grew both cornua were carried on its summit. 

CASE 4. — A housewife aged sixty-one entered the hospital because 
of a mass in the abdomen, pain in the hips and lower abdomen, and 
frequency of urination. 

History. — She had had no children and was never pregnant. The 
menses started at thirteen, lasting three to four days. Had a se- 
vere attack of typhoid fever a few months after menses started 



TUMORS OF THE ABDOMEN 851 

which stopped the periods and they did not reappear until she was 
seventeen years old. At the age of twenty-eight she had a tumor 
removed from the vagina, a pedunculated, fibroid it was called. 
The menses stopped four months following this operation. She 
passed the menopause at forty-five. She was always regular before 
that time but flowed scantily for only one day since the attack of 
typhoid fever and the subsequent return of the menses at seventeen. 
She has never had any vaginal discharge between periods. The 
attack of typhoid fever at thirteen was complicated by a throm- 
bophlebitis of the left leg which kept her in bed four months. 
The fibroid which was removed from the vagina at twenty-eight 
protruded from the vagina. If was about the size of an egg with 
a pedicle the size of the little finger she was told by her doctor. 
She said she knew of the existence of the tumor five years before 
its removal, although it protruded from the vagina only a few 
months prior to removal. Five years ago she had a tumor the size 
of a hazelnut growing around the bone outside of the left incisor 
removed. It was removed by electric cautery. She had pneumonia 
a year ago. The present trouble began about sixteen months ago. 
She noticed a lump in the left lower abdomen. There were no symp- 
toms at that time. It grcAv steadily and a year later gave pain 
for the first time. It was in the nature of a soreness and heavi- 
ness, always worse when on her feet a great deal, and was relieved 
by lying down. 

She has pain in the hips and lower abdomen. It does not radiate. 
The bladder symptoms began eight months ago. The greatest dis- 
turbance is during the last half of the night and the forenoon. She 
gets up eight to ten times at night and can not control urine well 
when she first gets up in the morning. There is a burning on urina- 
tion. She has lost 15 to 20 pounds in weight in the past two years, 
the bowels have been very constipated, especially during the last 
six months. Sleep fair at first part of night but very poor after 
that on account of the frequency of urination. 

Examination. — A nodular tumor the size of a fetal head is felt 
above the symphysis. One large nodule projects to the left, an- 
other projecting down to the right towards Poupart's ligament. 
The tumor mass is rather firmly fixed, tender to pressure, and has 
an elastic feel. The superficial veins on both sides of the lower 
abdomen and upper part of both thighs are enlarged and promi- 



&52 CLINICAL SURGERY BY CASE HISTORIES 

nent. There is a small oval tumor mass in left inguinal region, 
about 2 inches in length, somewhat lobulated and elastic. It can 
not be made to disappear. Vaginal examination shows the whole 
pelvis filled with a dense hard mass. It seems to be slightly mova- 
ble, but can not be pushed out of the pelvis. Blood Hg 80 per 
cent, W.b.c. 9,500; R.b.c. 3,800,000. Differential count, polynu- 
clears 38 per cent. L.l 10 per cent, S.l. 52 per cent. The urine is 
without interest save that it contains many pus cells. 

Diagnosis. — The fixed tumor together with the dilated veins in the 
lower abdomen and the thighs disclose it to be a malignant tumor 
and inoperable. Sarcoma is suggested by the size of the tumor 
and by the fact that she had a pedunculated tumor removed many 
years ago. That she menstruated but a day rather precludes a 
submucous myoma. It is rare that myomatous tumors cause trouble 
so late after the menopause. The late malignancies are nearly al- 
ways epithelial in origin. This mass is in places too soft for an 
epithelial tumor. Sometimes ovarian cysts showing malignancy 
appear late in life and retain in places a cystic or colloid character 
and may give a pseudofluctuating or elastic feel. This tumor, 
however, has the peculiar feel of a rapidly growing sarcoma. 
There is a type of sarcoma springing from small submucous tumors 
which late in life show malignane3\ So far as the patient is con- 
cerned the exact diagnosis is of no interest. Despite the dilated 
veins the tumor feels as though it might be elevated out of the pel- 
vis by an operation. It seems worthy of trial. 

Treatment.- — After the tumor was exposed by incision it could be 
rolled out of the pelvis save for a nodule the size of an orange 
situated on the right side just below the pelvic brim. This por- 
tion was firmly fixed to the vessel walls and had to be abandoned. 

Pathology. — The tumor mass was made up of a brittle, friable 
mass which could be torn asunder by the fingers. In several places 
cysts the size of an egg containing clear fluid, were found. The 
slide showed carcinoma evidently of ovarian origin. 

After-course. — The trouble rapidly returned and she died four 
months later. 

Comment. — Pelvic tumors, particularly those springing up long 
after the menopause, are all malignant, and when they once fill 
the pelvis, are nearly always inoperable. When there is marked 
dilatation of the lower veins of the abdomen they most certainly 



TUMORS OP THE ABDOMEN 853 

are inoperable. Usually the vessel wall is invaded and if a too 
rash attempt is made to remove it, a large vein may be injured and 
the patient caused to bleed to death under the surgeon's eye. When- 
ever one attempts to go against the obvious fact, disaster follows. 

CASE 5. — A matron aged thirty-five came because of a mass in 
the abdomen, pain in the rig-ht and left iliac region, and pain and 
vomiting- after meals. 

History. — Four years ago she noticed a mass just below the navel. 
She had no symptoms of any kind and gave it no further thought. 
She did not notice that the mass was growing until a few weeks ago 
although she says that she has had to wear larger corsets the last 
few years than formerly. Two months ago she had a normal men- 
strual period, the flow stopping in three days. She then began to 
have an epigastric pain and a sensation as of bloating. The pain 
was constant and when she took food she vomited. The local doctor 
ordered turpentine stupes, after the use of which the flow started 
again. He then ordered hot lysol vaginal douches. After these were 
given she began to have severe pain in both iliac regions; this 
started suddenly and has continued since. She has had pain in the 
stomach and groins and there has been a bloody discharge from the 
vagina since then. The blood is now mixed with a yellowish, puru- 
lent discharge. The stomach disturbance is now her chief com- 
plaint. She feels bloated and she has pain and often vomiting 
soon after eating. In the last three days she has had a pain in the 
right side under the short ribs and under the right shoulder blade. 
For the last three days she has had a severe pain on urination but 
she has no frequency and does not get up at night. She is ex- 
tremely constipated. She has no headaches. Her menses have al- 
ways been regular, the flow lasting four to five days without pain, 
but has been very profuse the first two or three days during the 
last nine months. She has no children and has never been pregnant. 

Examination. — The general appearance is that of good health. The 
abdomen is large, having the appearance of a seven-month preg- 
nancy. Palpation shows a mass in the abdomen extending from 
above the pubes to a handbreadth above the umbilicus. It extends 
a little higher on the right than on the left. It is rounded in form 
and smooth in outline. It feels hard to the touch, does not fluc- 
tuate, and is nowhere tender on pressure. Pelvic examination 
showed cervix lacerated, perineum intact. A large, smooth, hard 



854 CLINICAL SURGERY BY CASE HISTORIES 

rounded mass fills the entire pelvis. It appears to be attached to 
the uterine fundus. There is marked tenderness on the left side 
of the pelvis. WTiite blood count 12,500, 65 per cent polynuclears. 

Diagnosis. — The tumor likely has not grown rapidly for she has 
noticed that she had constantly to loosen her clothes, the surest 
sign of increasing girth. The beginning was associated with men- 
strual disturbance, the flow having stopped and then started again. 
She had severe pain in the iliac regions, which, while coincident 
with the giving of lysol douches, probably had nothing to do with 
them. The stomach trouble came on with these conditions and like- 
ly is reflex because it was not present before. The density of 
the tumor, its slow growth, and its obvious connection with the 
uterus indicates that it is a myoma. Some change obviously 
has taken place. If it were in the uterus itself, the reaction 
would be greater. The local examination shows the chief point of 
tenderness to the left of the uterus. Since pus tubes are frequently 
associated with large myoma, such a condition may confidently be 
expected here. The reaction is not such as to constitute a contra- 
indication to immediate operation. The blood count corroborates 
this opinion inasmuch as the polynuclear count is low. 

Treatment. — The uterus is made up of a myoma as large as an 
adult head. It is adherent to almost everything in its environment 
by quite recent adhesions. On the left side was a large tuboovarian 
abscess, on the right side there is a cystic ovary with hemorrhage 
into the cyst. The uterus was removed by supravaginal amputation. 

Pathology. — Th« mass as large as an adult head is made up of 
a single large tumor and several smaller ones the size of a lemon. 
The section shows numerous small cavities filled with a clear fluid. 
The face is pale pink, showing a distinctly fibrous arrangement. 
The slide shows regions with deeply staining cells. They are ar- 
ranged in parallel bundles and the nuclei are arranged in a parallel 
fashion. The ovaries are polj-cystic and the one has a hematoma 
the size of a walnut. 

After-course. — There were no immediate postoperative complica- 
tions. Two days after operation she developed a cough, raising 
considerable phlegm. The principal discomfort was from the pull 
on the operative wound. Examination of the lungs was negative. 
Respiration and temperature were not increased. The cough sub- 
sided and the patient made an uneventful recovery. 



TUMORS OF THE ABDOMEN 855 

Comment. — When tumors are alleged to have suddenly increased 
in size sarcoma is usually suspected and seldom present. Usually 
there is some complication in the tumor itself or in its adnexa. 
The inflamed tumor evidently, like a sore thumb, seems many times 
larger than its recent state, though the actual increase in size 
is not great. A sarcomatous uterus does not increase as rapidly 
as an inflamed one seems to the patient to have increased. Generally 
speaking, the organism in the pus in salpingitis associated with 
myomas is not very violent. In fact, often bacteria can not be found 
and in yet more none can be grown. In abscess within the substance 
of a myoma the bacteria are numerous and virulent until long after 
the beginning of the trouble. 

CASE 6. — A matron aged forty-nine came to the hospital com- 
plaining of acute abdominal pain with gradual enlargement. 

History. — Her menses stopped ten months ago without any attend- 
ant disturbance. She has noticed a gradual enlargement of the ab- 
domen for seven months. Since that time she has had several at- 
tacks of acute abdominal pain which came on rather suddenly. 
They were of a cramping, colicy nature, and very severe. They 
have come on once a month on the average. Once she fainted from 
the pain. The last attack, three weeks ago, was the worst. This 
was the only one that was attended by vomiting. She has had no 
fever with any of the attacks. Following the attacks she becomes 
very much distended. Her general health is excellent. She sleeps 
well and her appetite is good, but she is extremely constipated. 
She has a goiter which she noticed first six years ago. She has two 
children, the youngest twenty-five years of age. She was operated 
on for hemorrhoids a year ago. 

Examination. — She has a small goiter of the left lobe of the thy- 
roid. There are no symptoms of intoxication. There is a fluctuat- 
ing tumor in the lower abdomen reaching almost to the umbilicus. 
The perineum is torn to the second degree and the cervix is bilat- 
erally lacerated. There is a large, rounded tumor filling the culde- 
sac. The cervix is hard and the body of the uterus seems to lie 
over the bladder. Owing to the presence of the tumor over the 
pubes this can not be confirmed by bimanual examination. The 
tumor in the culdesac is semifluctuating but seems somewhat firm. 
There are no blood changes. 



856 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The sudden cessation of menstruation with the appear- 
ance of a tumor three months later suggests pregnancy, but there 
are no signs. The cervix is hard and the unchanged uterus seems 
palpable continuous with it. However, one can not be sure unless 
the uterus can be demonstrated by bimanual examination. This 
point could have been demonstrated by fixing a tenaculum and 
making traction, or by the archaic method of passing a sound. The 
advent of sudden severe pain might mean some accident of preg- 
nancy, particularly if it were extrauterine. However, the first at- 
tack of pain came on after she had noticed a tumor above the pubes 
which would be very unlikely in an extrauterine pregnancy. An 
abdominal pregnancy might be suspected had the tumor appeared 
after the severe pain. If there Avere an extrauterine pregnancy the 
uterus should shoAV some changes. These can not be demonstrated. 
The tumor fills the culdesac and, though semifluctuating, it seems 
too hard to be a simple cyst. The advent of severe pains suggests 
the possibility of an ovarian cyst with twisted pedicle resulting in 
inflammation in the culdesac with thickening. In such a case one 
would expect the uterus to be; pushed to the opposite side. An 
ovarian cyst with twisted pedicle should have been attended by 
fever and symptoms of abdominal inflammation. The fainting might 
have been due to a hemorrhage into a cyst and the resistance in the 
culdesac might have been due to this if an inflammation of the wall 
had followed. The best diagnosis seems to be an ovarian cyst 
which has undergone some sort of accident. 

Treatme7it. — A serous ovarian cyst the size of an adult head was 
found on the right side. In one side lying in the culdesac was 
a hard mass the size of the fist. The larger of the cysts was drained 
to facilitate removal. After removal the smaller compartment was 
found to be a papillary cyst adenoma. The sigmoid colon was ad- 
herent to the cyst. On the other side Avas a cyst the size of the 
first in which papillary cystadenomatous development had started. 
There were several small papillary grow^ths on the outside of this 
tumor which Avere attached to the upper part of the pelvis. This 
with the tube was also remoA^ed. 

After-course. — Immediately on recovery from the anesthetic the 
right eye was noticed to be much inflamed and the patient com- 
plained of it more than of the wound. An ulcer of the cornea on the 
right side Avas located just in front of the pupil. The eye was 



TUMORS OF THE ABDOMEN 857 

kept bandaged, washed with boric acid solution and treated with 
yellow oxide and atropine ointment. Healing of the ulcer began 
immediately and was complete M'hen the patient left the hospital. 
No scar could be seen. The operative wound caused very little 
postoperative trouble and the recovery Avas normal as far as this 
was concerned. On dismissal the eye was healed but the patient 
saj's there is sometimes a little blurred vision on that side. She 
has remained free from any pelvic trouble. 

Comment. — The eye trouble probably was due to an ether burn. 
From the operative findings the cause of the attacks of preoperative 
pain were not definitely determined. The sigmoid was adherent to 
the adenomatous part of the right cjst. Some accident must have 
occurred to bring this about. There were some extracystic papil- 
lomas on the left side which were capable of producing an irrita- 
tion. Possibly these represent a cyst which ruptured, leaving the 
papillary portion exposed. None of these should be capable of 
producing a pain great enough to cause fainting. Possibly there 
was a temporary twist of the pedicle which untwisted again. There 
is a question whether such an event can happen, though clinicians 
hypothecate it. 

CASE 7. — A married woman of thirty-six came because of pain 
in the lower quadrant of the abdomen. 

History. — The patient began to have pain in the left lower quad- 
rant of the abdomen about four months ago. Other than hemor- 
rhoids the patient has never had any illness. Her menstrual periods 
began at seventeen and have been regular, with scanty flow and 
dysmenorrhea. There has been sacral backache for years but 
very little headache. She has had no children and has never been 
pregnant. Four months ago the present illness began with pain 
and tenderness in the left lower abdomen. The pain would some- 
times remit, but the tenderness was always present. The sacral 
backache became much more severe. Very often vomiting attacks 
would occur. The pain would radiate downward to the left thigh, 
also upward toward the costal margin. When the pain was severe, 
there would be painful urination. There was no leucorrhea, no 
history of rise of temperature. 

Examination. — A smooth firm tumor mass can be felt in the abdo- 
men extending a handbreadth above the symphysis and toward the 
left. It is large enough to be noticed on careful inspection of the 



858 CLINICAL SURGERY BY CASE HISTORIES 

abdomen. By vaginal examination a smooth, firm tumor mass is 
found entirely filling the culdesac. It can not be moved about and 
is semielastic on bimanual palpation. There seems to be a nodule 
low behind the uterus and attached to it. The large tumor is 
not closely attached to the uterus. Urine is negative; temperature 
98, pulse 64. 

Diagnosis. — The growth of the main tumor has been fairly rapid 
according to the patient's statement, which makes one think of 
an ovarian cyst. The physical examination is not incompatible 
with this notion. Myomas sometimes, when edematous or cystic, 
give the same physical characteristics, and when hemorrhage oc- 
curs in them there may be a rapid increase in size, and sometimes 
when a tumor comes suddenly to lie above the pelvic brim the patient 
believes a rapid growth has taken place. Furthermore, the pa- 
tient has never been pregnant and has had dysmenorrhea, which 
speaks for myoma. Since she did not begin menstruating until 
seventeen years old, it must be assumed that there was some congeni- 
tal defect, and the dysmenorrhea may be ascribed to this. The 
nodule behind the uterus furthermore is undoubtedly a myoma, and 
this may account for the more recent increase in pelvic pain. The 
dominant feature in the case seems to be the rapid growth of the 
larger tumor and the diagnosis of ovarian cyst is ventured. 

Treatment. — A large ovarian cyst and a small uterine myoma were 
removed. 

Pathology. — The tumor was a serous cystoma. 

After-course. — The recovery from the operation was uneventful 
and the symptoms have disappeared. 

Comment. — Ovarian cysts when uncomplicated do not cause pain. 
When pain exists usually there is a twisted pedicle or they have be- 
come malignant, or there may be some other condition responsible 
for the pain. In this case it was most likely the myoma that caused 
the pain. 

CASE 8. — A matron of forty-nine came because of an abdominal 
tumor. 

History. — The patient has had eight children, the youngest twelve 
years of age, and no miscarriages. She has repeated typical gall 
stone attacks. Her menses have been delayed from one to three 
weeks for several years and for the past year and a half she has 
had none. During the time her menses were irregular she was 



TUMORS OF THE ABDOMEN 859 

examined and told she had a tumor and was advised to have an 
operation. She was not told the nature of the tumor. The patient 
volunteers that she is not pregnant, for having gone through eight 
previous pregnancies she feels qualified to speak. Her general 
health is excellent and she has gained 20 pounds in weight during 
the past six months. 

Examination. — There is a tumor reaching well above the promon- 
tory. The cervix is soft and seems to be continuous with the tumor 
presenting above the pubes. The supravaginal portion of the cervix 
is not appreciably softened. It is not movable and is sensitive 
on bimanual examination. The tumor is smooth, semifluctuating 
and is pyriform in shape. There are no breast signs. No heart 
tones or souffle can be heard over the tumor. 

Diagnosis. — The year and a half of amenorrhea seems an argu- 
ment against pregnancy. She had been examined by her family doc- 
tor prior to the cessation of menstruation and a tumor was found. 
The tumor is pyriform and semifluctuating and the cervix is soft, 
very ominous positive findings, and, too, the vaginal mucosa is cy- 
anotic. Amenorrhea sometimes exists for long periods in tumors of 
the ovary and this tumor is of a size to just about represent the 
normal rate of growth of an ovarian cyst. It is possible that the 
tumor is an ovarian cyst which is causing an amenorrhea or she 
may have passed the menopause and have incidentally an ovarian 
cyst. However, there is a pyriform tumor and a soft cervix. That 
much is certain ; all the other factors are more or less speculation. 
Then, too, the patient is so certain that she is not pregnant, which 
is the best possible evidence that she fears that she is. At any 
rate, she is not suffering, and is in no danger and a period of wait- 
ing will do no harm. 

Treatment. — Delay in order to wait developments was advised. 

After-course. — A child at term was born four months later. She 
was operated on three years later and a number of gallstones were 
removed. The pelvic organs were examined at this time and no tumor 
was found. 

Comment. — It is unusual for pregnancy to occur so long after men- 
struation. Evidently ovulation may continue for a period after men- 
struation has ceased. It has been my experience in several instances 
to have a patient state that her physician had found a tumor, at a 
time too long antedating the examination to make possible a preg- 



860 CLINICAL SURGERY BY CASE HISTORIES 

nancy if the statement were true, who nevertheless were pregnant. In 
several such instances inquiry addressed to the physician failed to 
confirm such a report. At any rate wlien it comes to a question of 
pregnancy, one positive or even one suspicious sign is worth more than 
all the history that can be tabulated. 

CASE 9. — A matron a^ed forty-six came because of discomfort 
in the pelvis. 

History. — This patient related without questioning that she was 
the mother of nine children, that the youngest was fifteen months 
old and that she now had not menstruated for four months. She 
asserted with positiveness that she Avas not pregnant because the 
sensations now were entirely different than in pregnancy. She had 
no other complaint. 

Examination. — There is a round semifluctuant tumor apparently 
connected with the uterus. The cervix has a stellate laceration and 
is neither soft nor hard. 

Diagnosis. — A woman always regular who stops menstruating sud- 
denly when in good health very likely is pregnant. 

Treatment. — Delay was advised. 

After-course. — She returned in eighteen months with an enormously 
distended abdomen. An ovarian cyst which held ten gallons of fluid 
was removed. She has remained well since. 

Comment. — The examination was cursory and useless. Dependence 
was placed on a general proposition that absence of menstruation 
meant pregnancy. When a woman who has had many children says 
that she is or is not pregnant, her word should be weighed with due 
respect and her diagnosis disregarded wnth extreme caution. The 
statements of such women are not colored as are those of women who 
do not or have not regarded the function of motherhood with acclaim. 
An old soldier knows the roar of cannon, it is said. 

CASE 10. — Housewife aged thirty came to the hospital because 
of pain in the bladder region, along both sides anteriorly and across 
hips posteriorly. 

History. — Periods regular, five to six days, flows severely first three 
days. Pain not any worse at the periods. Backache worse at the 
periods. Never pregnant. 

Never sick excepting tonsillitis, measles, and mumps. All these 
in childhood. 



TUMORS OF THE ABDOMEN 861 

Present trouble started with the bladder pain fifteen months ago. 
It has been getting Avorse but has been especially severe the last 
six Aveeks. This pain is constant. It is much worse when the 
urine passes. She has had spells of great frequency of urination, 
four to five times at night and often in the daytime. No urethral 
pain. Ahvays a soreness across the lower abdomen. 

The pains in the sides, extending from doMni in the pelvis half 
way to the rib margin began a year ago and are getting worse. 
The backache started six months ago. Very little headache. Appe- 
tite good, bowels always constipated. 

Some leucorrhea between periods. Xo blood. She has a drag- 
ging sensation in the pelvis when on her feet a great deal. 

Examination. — Patient has the appearance of excellent health. 
Head and neck negative. Heart not enlarged, apex beat in 5th in- 
terspace. Soft blowing systolic murmur at the apex. Lungs neg- 
ative. 

Mass in the pelvis reaching almost to umbilicus. Hard, somewhat 
tender. No fluctuation. No pelvic examination was made. 

Diagnosis. — Uterine fibroid. 

Treatment. — April 26, 1919. On opening the belly a cauliflower-like 
mass was found on the left side entirely replacing the ovary. On 
the right side replacing the ovary was a cyst the size of a baby's 
head. This was thick walled, and on being opened its whole inner 
surface was found covered with caulifloAver-like growths. The large 
cyst was firmly adherent posteriorly and separated with difficulty. 
The tubes, broad ligaments and peritoneum were very edematous. 
Both masses and the tubes were removed. 

Pathology. — Papillary cystadenomas of both ovaries. 

After-course. — The patient made a perfectly normal recovery. 
The temperature and pulse were not affected by the operation 
to any abnormal extent and the postoperative shock was nil. The 
abdominal Avound healed by primary union and the patient only 
complained of pain in both iliac regions for a time. 

Comment. — The irritation of the bladder and the referred pains 
were wholly unlike myoma symptoms. This error could have res- 
suited only from incomplete examination. 

CASE 11. — A married Avoman of thirty-five came to the hospital 
because of pain and a tumor above the pubes. 

History. — Her trouble dates back to one year ago Avhen she began 
to have pain in her thighs and feet. It has gradually grown worse 



862 



CLINICAL SURGERY BY CASE HISTORIES 



and now the pain is constant. It is felt low in the back part of 
the pelvis and goes down the legs to the feet. It is much worse 
when the patient is obliged to stand a great deal and do hard 
work. She has noticed a fullness in the bladder region for a year 
and for the past two months she has noticed a tumor in the lower 
part of the abdomen. Her menses began at fourteen and have al- 
ways been regular and painless. They last four or five days. She 
has six children living and well and no miscarriages. 




Fig. 379. — Fibrosarcoma of the ovary. 

Examination. — An ovoid tumor is found protruding above the 
pubes and extends to the culdesac. It is freely movable, smooth, 
firm, and not tender to pressure. 

Diagnosis. — The ovoid shape at once suggests a dermoid, but it 
is firmer than dermoids usually are. Solid tumors of the ovary 
are usually more globular but this has the dense, elastic, smooth 
feel of fibrosarcoma of the ovary. It is" not attached to the uterus. 
At any rate it requires removal. 



TUMORS OF THE ABDOMEN 863 

Treatment. — The right ovary is represented by a large solid pedun- 
culated tumor. It was removed. 

Pathology. — The tumor is oblong, smooth, and fairly firm. The 
cut surface in some parts is .wavy with connective tissue fibers 
and at others it is homogeneous and glistening. The slide shows 
a sparse connective tissue containing spindle cells and some groups 
of round cells. (Fig. 379.) 

After-course. — Recovery was uneventful. 

Comment. — These tumors are of slow growth and if removed early 
do not tend to recur. Neglected they not infrequently invade the 
surrounding connective tissue. 

CASE 12. — A school girl of nineteen was brought to the hospital 
because of amenorrhea and abdominal tumor. 

The patient has always had good health. She began menstruating 
at thirteen and has always been regular and free from pain. Five 
months ago she ceased to menstruate and a globular tumor ap- 
peared above the pubes. The finger of scorn was pointed at her, 
a conclusion to which the mother acquiesced despite the vigorous 
protests of the patient. 

Examination. — A globular mass can be felt above the pubes. It 
is movable laterally and is entirely painless. Examination under 
ether showed an intact hymen, a firm, normal colored cervix, and 
a dense tumor croAvding the uterus to the left. There was no blue- 
ing of the vaginal mucosa and no breast changes. 

Diagnosis. — The most common solid tumors of the ovary in young 
girls are endotheliomas or fibrosarcomas. This tumor is firm, elastic 
and is oblong in shape corresponding to the usual shape of such 
tumors. There are no signs of pregnancy. The presence of amen- 
orrhea is unaccounted for. The menses failed to appear at the 
time the tumor was first noted above the pubes. It must have ex- 
isted a considerable time to have attained a size too large to per- 
mit it to occupy the pelvis. The only two events occurring at this 
time to account for the amenorrhea is the dislocation of the tumor 
and the false accusation of a sensitive and sensible girl. The grief 
probably was a more important factor than the change in position 
of the tumor. 

Treatment. — A solid tumor somewhat larger than a child's head 
was removed from the right broad ligament. It evidently represented 
the ovary. 



864 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 380. — Perithelioma of the ovary. 



TUMORS OF THE ABDOMEN 865 

Pathology. — The tumor was partly solid and partly cystic (Fig, 
380). The solid parts are typical perithelioma and the cystic parts 
contain a thin clear fluid. The tumor was distinctly oblong, sug- 
gesting a dermoid before it was cut into. Nothing to substantiate the 
suspicion was found. 

After-course. — The menses were resumed three months after opera- 
tion and remained normal. 

Comment. — The sudden cessation of menstruation in the presence 
of an ovarian tumor is unusual, but by no means unknown. The 
type of tumor also is unusual but there is no evidence that there is 
any relation between the structure and the amenorrhea. 

CASE 13. — A matron of fifty-three came to the hospital because of 
a tumor in the abdomen and general weakness. 

History. — The patient is the mother of seven children, the young- 
est twenty years old. Her menstruation has always been regular 
until three months ago. She flows seven days, always profusely. 
She urinates several times a night but has no other evidence of 
bladder irritation. The bowel movements are variable, usually 
constipated, but move with laxatives without trouble. She has had 
for the past few months some pelvic discomfort. Two weeks ago 
the abdomen suddenly began to enlarge and she thinks a tumor 
appeared overnight. Since that time she has had no appetite and 
feels generally exhausted. 

Examination. — The region above the pubes is occupied by a rounded 
tumor riding on the pelvic brim. It is smooth, soft, semifluctuat- 
ing, and does not change in density. It is slightly movable from 
side to side. Vaginal examination shows a smooth, rounded mass 
which when rocked, by bimanual examination, carries the uterus 
Avith it. The cervix shows an old laceration and is hard. It is 
reddened and congested. 

Diagnosis. — The form of the tumor and the history of its sudden 
appearance suggest that it is a tumor previously intrapelvic which 
has come to ride above the promontory because of its increased 
size. Tumors that do this are myomas and ovarian cysts. The sud- 
den appearance in the abdomen when accompanied by constitutional 
symptoms are due, if myomas, to edema or hemorrhage, if ovarian 
cysts, to some disturbance of nutrition, usually a twisted pedicle. 
In this case there was no peritoneal irritation which would have 
been present were it the latter. On the contrary the abdominal 



866 



CLINICAL SURGERY BY CASE HISTORIES 



muscles offered no resistance to the palpating finger, though firm 
pressure caused moderate pain. The consistency both on abdom- 
inal and combined examination was semifluctuating. Ovarian cysts 
which suffer disturbed circulation are more dense than those not 
so affected. The density did not vary and was greater than a preg- 
nant uterus. The size likewise was greater than a uterus which 
has recently come to occupy an abdominal position, though pregnant 




Hemorrhagic myoma. 



uteri which have been confined to the pelvis by impaction or by ad- 
hesion may not come to reach the abdomen until they are larger 
than is usually the case. The age of the patient argued against 
pregnancy, but she had been regular until three months ago. The 
long continuation of the menses suggests myoma, particularly as 
they had been increasing in duration- during recent years. The 
diagnosis because of the general malaise and loss of appetite seemed 



TUMORS OF THE ABDOMEN 867 

to favor a myoma wliieli had undergone some accident, most likely 
hemorrhage. 

Treatment. — A laparotomy was done. A large uniform tumor the 
size of an adult head, semifluctuating and bluish-red in color, rep- 
resented the uterus. The first look made me fear a pregnancy. 
Following the course of the tubes and round ligament they were 
noted to end in the sides of the tumor about midway of the tumor. 
If it had been a pregnant uterus they would have ended near the 
upper pole. Furthermore, the tumor was globular and not pear- 
shaped as is a pregnant uterus. Therefore, a supravaginal ampu- 
tation was done and the operation delayed while the tumor was cut 
into for further information. 

Pathology. — When cut into much blood flowed from the tumor and 
its size was reduced. A shell of uterine tissue, a centimeter in thick- 
ness surrounded a deep red semisolid mass (Fig. 381). The cap- 
sule everywhere seemed complete and the portion near the cervix 
seemed free. The primary tumor was a typical hemorrhagic myoma. 
Throughout it were areas of fibrin network w^ith many large mono- 
nuclear cells within the meshes. Other areas show^ed the same 
fibrin network with unchanging cells within its meshes. 

After-course. — The operative recovery was uneventful. In a week 
the patient was walking in the corridors and went home at the end 
of ten days. 

At the end of six weeks it was reported to me that the wound 
had broken open and a tumor had reappeared. This was interpreted 
as being evidence of a late infection with opening of an abscess. 
Another report at the end of eight weeks from the time of operation 
stated that the patient was growing weaker and that there was 
bladder disturbance. On examination two days later a soft, granu- 
lar mass the size of an orange Avas found occupying the site of the 
incision and the whole pelvis was filled Avith a soft, boggy mass. A 
diagnosis of small rovind-celled sarcoma Avas made. The patient 
died six weeks later. At autopsy the pelvis w^as filled with the 
hemorrhagic mass and the tumor OA'er the site of the incision had 
increased to half the size of a fetal head. 

The tissue obtained shoAved cells like those in the tumor tissue. 
NoAvhere did the interstitial tissue take the fibrin stain but took 
only the picric acid of the Van Giesen stain. 



868 



CLINICAL SURGERY BY CASE HISTORIES 



Comment. — These frightfully rapidly recurring tumors seem to 
occur only when hemorrhagic myomas become malignant. I have 
seen one other run an identical course. 

CASE 14. — A matron aged thirty-two came to the hospital because 
of a fullness above the bladder. 

History. — The patient has had three children. She has had fair 
health until some three or four months ago when she began to have 




Fig. 382. — Adenocarcinoma of the ovary. 

a sense of fullness in the pelvis and frequent urination. Her physi- 
cian discovered a pelvic tumor. 

Examination. — The patient has a b'osselated mass filling the pelvis. 
The right and left parts move independently of each other. The left 



TUMORS OF THE ABDOMEN 869 

part is palpable above the pubes. The bosselations are indefinitely 
fluctuating. 

Diagnosis. — The density of the tumors suggested cysts. 

Treatment.— When the tumor masses were exposed some of the 
nodules were found dense while others were cystic. Wide excision 
was therefore done. 

Pathology. — The solid portions were granular, the solid portion 
obviously extending from the walls of the cyst toAvard the inte- 
rior. Solid nodules and small cysts were often intermingled. On 
section the solid parts were seen to be epithelial, being formed of 
papillary outgrowths in some parts, and solid epithelial masses in 
others. (Fig. 382.) 

After-course. — In two years there were recurrences solidly fixed 
in the walls of the pelvis. The patient died three years after the 
operation. 

Comment. — -The hope of cure in these cases is a delusion. They 
seem to come out clean, but recurrences take place with sickening 
regularity. Papillary tumors are much more hopeful of a cure. 



CHAPTER XVI 

DISTUEBANCES OF UTERINE FUNCTION 

The disturbances of uterine function are as protean as the com- 
plaints of women. Whenever a woman complains, disturbances of 
the uterus must be sought for and affirmed as excluded. The func- 
tional and psychic factors also must be determined, affirmed or ex- 
cluded by careful examination. 

MENSTRUAL PAIN 

Painful menstruation in adolescents and the mature unmarried 
are enigmas. The cause in many, likely in most of them, is due 
to endocrine disturbance. In the parous there is commonly a tumor 
or the results of childbearing, particularly lacerations, displace- 
ments, and inflammations. In the first group the less the surgeon 
does the better. In the latter, careful search .for an anatomic defect 
is required. 

CASE 1. — A matron of thirty-three comes because of leucorrhea 
and backache. 

History. — The patient has three living children and has had one 
miscarriage at seven months five years ago. She has no dysmen- 
orrhea and is regular, the flow lasting generally three or four days. 
She has had a pronounced leucorrhea for tAvo or three years. 
She complains of a continuous backache in the small of the 
back and over the sacrum. Sometimes there is pain on the tophead 
particularly when she is much on her feet. Recently she has be- 
come pronouncedly nervous so that at times she can not sleep well. 
She passes her urine more frequently than formerly and sometimes 
gets up at night. Sometimes there is burning after urination. She 
sometimes feels bloated and has burning in the region of the 
stomach. 

Examination. — The patient presents a well-formed physique giv- 
ing little cause to anticipate her statement that she is nervous. 
There is marked epigastric tympany and pronounced diastasis 
• 870 



DISTURBANCES OF UTERINE FUNCTION 



871 



of the recti muscles. The perineum is lacerated to the second de- 
gree. Both the anterior and posterior vaginal walls can be seen 
in the vulva. The cervix is low, eroded, and the body of the 
uterus is large, boggy, and retroflexed. There is some tenderness 
on bimanual examination. The urine shows a greater number of 
pus cells than normal, but otherwise is negative. The erosion of 
the cervix is typical. The os is surrounded by reddened tissue 
which appears to have undergone proliferation. The border be- 
tween the normal and abnormal, however, is sharply defined and 




Fig. 383. — Endocervicitis with mucus discharge. 



the entire periphery of the cervix is equally involved (Fig. 383). 
There are small nodules palpable in the depth. Eather rough pal- 
pation does not cause bleeding. 

Diagnosis. — The location of the backache, the occipital and vertex 
headache, the leucorrhea and the epigastric disturbance all lead 
us to anticipate a cervical erosion associated with a large and boggy 
uterus. The bladder trouble is symptomatic of the sagging uterus. 
The constipation is due to splanchnic inhibition rather than to 
direct pressure on the gut. We must conclude this for constipa- 
tion as frequently attends an inflamed uterus that occupies the nor- 



872 CLINICAL SURGERY BY CASE HISTORIES 

mal position as it does those in retroflexion. The deep nodules noted 
on palpation are seen to be located outside the reddened area and 
when stuck with a needle permit the escape of a thick, glairy mucus. 

Treatment. — The eroded portion of the cervix areas was resected 
and the perineum repaired. The uterus was replaced and a Gilliam 
done. The diastasis was repaired by a wide lateral overlapping of 
the rectus faseias. 

After-course. — The recovery was prompt and the symptoms effec- 
tually relieved. 

Comment. — This is the type of cases that the old gynecologists 
relieved, but did not cure, by local treatment. When there are 
pronounced headaches, particularly in the occiput and vertex, it is 
important to resect the eroded area, particularly if the glandular 
secretion is active. This is even more important when there is 
no obvious laceration, as in this case, than when there is a lacera- 
tion. In fact often in laceration the reddened surface may be due 
to a displacement or rather a dislocation of the columnar epithe- 
lium of the cervical canal rather than a reactive proliferation. Dis- 
placement aggravates these conditions by disturbing the venous 
return. If there is excessive menstrual flow a curettage may be of 
use, but when there is no metrorrhagia a curettement is worse than 
useless. 

CASE 2. — A matron aged forty-three came because of painful and 
excessive menstruation. 

History. — For the past several years she has had excessive men- 
struation with some pain low in the back. There has been pro- 
nounced leucorrhea following menstruation. She formerly flowed 
three or four days but now flows six or more. She has severe 
occipital pains preceding menstruation. She has been constipated 
many years which state has become aggravated recently and she 
has some pain before the bowels move. She has had six children, 
the youngest of whom is seven years old. There have been no mis- 
carriages. Her general health has always been fair. 

Examination. — The patient is tall and angular and appears fa- 
tigued and older than the age given, but not cachectic or anemic. 
She has a small goiter on the right side. There is a systolic murmur 
heard best at the apex and is transmitted to the axilla, but is 
heard along the left border of the sternum. There is slight enlarge- 



DISTURBANCES OF UTERINE FUNCTION 



873 



ment of the heart in all diameters. The perineum is lacerated to 
the second degree. The cervix is large, lacerated, and presents 
angry surfaces to view. There is an abundant glairy discharge. 
Diagnosis. — The pronounced cervical erosion accounts for her corn- 




Fig. 384. — Early carcinoma of the rectum. 



plaints. The occipital headaches are typically of pelvic origin. The 
removal of the offending portion with a perineal repair should remedy 
the difficulty. 



874 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — A Seliroeder amputation of the cervix and a perineor- 
rhaphy was done. In casually examining the rectum after the com- 
pletion of the above, a carcinoma of the rectum was found. It was 
2 or 3' cm. in diameter and was located behind the cervix (Fig. 384.) 
Since there were fresh wounds in the vagina it was deemed best to 
allow them to heal. Tw^o weeks later the carcinoma was removed 
through the perineum, the gut being attached to the preserved 
external sphincter. 

Pathology. — The rectal growth was typically an early cancer. It 
measured about 2 cm. in diameter and invaded only the submucous 
tissue. The muscle layer contained some round-celled infiltration, 
but no tumor nests. 

After-course. — The patient recovered normally from both opera- 
tions. She reported at intervals during the succeeding years and 
nothing unfavorable was found. She had good control of her 
bowels unless the stool was very thin. There was noted a tendency 
of the anal scar to contract and this was gently dilated several times 
and once the scar was incised. Six years after the primary opera- 
tion she had a more marked stoppage. Two weeks ago she had 
complete stoppage with severe cramps in the lower bowels and she 
had a severe headache and became nervous. Recently she has had 
shortness of breath and palpitation. The scar was incised freslj' 
and the rectal mucosa were united to the skin in the depth of the 
incision. Since then there has been no recurrence of the stricture. 

Comment. — This tumor is unique in that it was accidentally dis- 
covered before it had given any symptoms whatever. The patient ap- 
parently is permanently relieved. 

CASE 3. — A stenographer aged twenty-six came because of pelvic 
pain and irregular menstruation. 

History. — She began menstruating at eighteen and had pain from 
the start. She came at first only several times a year, then for sev- 
eral years she was quite regular but in the past two years the pe- 
riods have come every six to eight weeks. The flow is scanty and 
lasts but two or three days. She has a good deal of pain during the first 
day and frequently stays abed. Her general health is not good 
without being able to cite any particular disturbance. Chief of the 
complaints are uncertain sleep and general malaise. 

Examination. — The patient is tall and slender and distinctly of 
the intellectual type. The lungs and heart show nothing abnormal. 



DISTURBANCES OF UTERINE FUNCTION 875 

The whole abdomen is sensitive. In the suprapubic region is a tu- 
mor the size of a small fist. It is oblong and extends over the 
brim of the true pelvis. It is slightly mobile and can be made 
partly to disappear in the true pelvis. It is smooth and firm and 
pressure upon it causes but little discomfort. Under anesthesia 
the hymen is found intact. The tumor above mentioned seems at- 
tached to the uterus, at least pressure on it causes the uterus to de- 




Fig. 385. — Huge fallopian tubes possibly tuberculous in nature. 

scend and move to the left. Behind and to the left is another 
tumor the size of a small fist. It is smooth and can not be raised 
up. It is less firm than the other, but is not fluctuating. Blood 
and urine show nothing of interest. 

Diagnosis. — The tumor on the right side extends up too high for 
anything other than a myoma riding on the fundus of the uterus. 



876 CLINICAL SURGERY BY CASE HISTORIES 

That on the left side lies in the culdesac or in the broad lig- 
ament. Neither tumor seems quite as firm as myomas usually do, 
and the diagnosis must rest partly on exclusion. There is no evi- 
dence that the endometrium is encroached on. Therefore most 
likely a myomectomy with preservation of most or all of the uterus 
will be possible. 

Treatment. — After the abdomen was opened the tumors were found 
to be enormously distended tubes. The left was kinked upon itself 
and was attached to the horn of the uterus. The right was firmly 
attached to the upper surface of the broad ligament. The tubes 
were removed leaving the ovaries and uterus. A good deal of hemor- 
rhage was encountered coming from broad surfaces. The anes- 
thetic was incomplete, which made the problem doubly difficult. 

Pathology. — The right tube was 10 inches long and measured 4 
inches in circumference. It was of nearly uniform diameter through- 
out its length (Fig. 385). The left tube measured 8 inches in 
length and 9 inches in circumference at its wildest point. It was 
exactly pear shaped, the uterine end being small resembling the 
stem of a pear. The consistence was firm without resilience. On 
section the wall was found to be thin, not more than 3 mm. and 
smooth within. The contents were dry and cheesy, of a gray-white 
color, resembling the contents of a firm wen. The slide made from 
the wall showed it to be fibrous with few muscle fibers. A lining 
epithelium could not be demonstrated. 

After-course.— The patient bore the operation well, but vomited 
persistently from the start. On the third day the vomiting persist- 
ed despite frequent washing of the stomach, and the abdomen be- 
came much distended. Examination showed a hard mass in the 
culdesac. Its nature was suspected, and an incision through the 
wall of the vagina brought forth a sponge. She improved for a 
day, then began to vomit more violently than before. She became 
distended and died on the sixth day. The autopsy showed the end 
of the omentum firmly adherent to the uterus and left broad liga- 
ment, Under it was imprisoned a loop of the small gut. 

Comment. — The sponge nurse reported the count correct before the 
abdomen was closed. This was many years ago, and I have never 
since put any dependence on any one's statement as to the presence 
or absence of sponges. If neither operator nor assistant ever lets 
go of a sponge while it is in the abdomen, a sponge will never be 



DISTURBANCES OF UTERINE FUNCTION 877 

lost, for either the operator or his assistant would be missed 
should he disappear. Had a laparotomy been done to recover the 
lost sponge instead of a vaginal section, the omental adhesion 
would have been discovered and disaster averted. The nature of 
the tubal trouble is obscure. Where all the cheesy material came 
from I do not know. A few similar, but less extensive cases, have 
been recorded in the literature as tuberculous. There was nothing 
in the walls of the tube to warrant such a diagnosis. The patient 
was of such a type, but further than this there was no evidence. 
One may take his choice of diagnosing it such or declaring it of 
an unknown nature. The range of one's misinformation is ever 
greater than the protean manifestation of tuberculosis. Therefore 
nothing is gained by forcing such a diagnosis. 

CASE 4. — A matron of thirty-three came because of pain in the 
right groin and leucorrhea. 

History. — Her general health was good until six years ago, a few 
months before marriage, when she began to have a profuse leucor- 
rhea. At first it was very profuse, but; after being treated with 
suppositories it improved. She had one child five years ago. De- 
livery was normal ; since then the leucorrhea has not been so severe. 
During the past few years when she is much on her feet she has pain 
in her right side just above the hip bone and in the. right shoulder. 
She has headache much of the time, most marked in the frontal 
region. No urinary symptoms. Appetite good. Sleeps very well. 
Very little backache. Menses regular now, four-day type. There is 
still pronounced leucorrhea. Her menses began at seventeen and 
were irregular at first. She had much pain at the periods, it was 
cramp-like and compelled her to go to bed. In the interval she had 
pain in the right hip and often in the thighs. This was most marked 
when she was much on her feet. 

Examination. — The patient is tall and slight of build. She is of 
the intellectual type and desires relief because her present state 
makes her inefficient. The abdomen is hyperesthetic in the lower 
quadrants. There are no distinct points of tenderness save a general 
sensitiveness. The perineum is lacerated and lax. The cervix is 
lacerated, eroded, and presents some cystic degeneration. The 
uterus is big, boggy, and markedly sensitive to bimanual exami- 
nation. The right ovary is as large as an egg and pronouncedly 
tender. 



•878 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The patient did not menstruate until she was seventeen 
years old, which together wnth her general physique indicates a 
somatic system below par. The profuse leucorrhea coming on sud- 
denly a few months before marriage causes one a certain degree 
of apprehension. However, she became pregnant three months after 
marriage, an unlikely occurrence if the leucorrhea had been due 
to an indiscretion and the gonococcus. Furthermore, she is of 
the type in which emotional disturbance of an unfamiliar sort is 
most apt to produce a congestive leucorrhea. The chief complaint 
now, the groin pain and pain in the back, has a sufficient excuse in 
the lax perineum and the low hanging cervix. The leucorrhea now 
may well be accounted for by the cervical erosion. The headache, 
being frontal, lacks the peculiar evidence of a pelvic relation of the 
more common vertex or occipital headache, and it must be ques- 
tioned if the general enfeeblement or a latent eye strain may now 
be an intermediary link. The objective lesions demand repair, but 
the large and sensitive ovary, probably responsible for some of her 
antenuptial ills, must be regarded as a still existent menace to 
health. If she is to be brought to a satisfactory state of health, 
a long existent lesion must be found. Such ovaries must be included 
in the projected treatment. Even if this was the cause of the ills 
of girlhood its removal now, together with the repair of the ob- 
stetric lesions, the prognosis must still be guarded. Her subse- 
quent health will be dependent on a fortunate environment, both 
economic and domestic. If she shall be able to remain within 
her strength in both these directions a satisfactory state may 
be attained and maintained. 

Treatment. — Amputation of the cervix, perineorrhaphy, appendec- 
tomy and right oophorectomy was done. 

Pathology. — The cervix on section shows extensive cystic degen- 
eration. The slide show^s much round-celled infiltration about the 
cervical glands. The ovary measures 5x3 cm,, is hard and polycys- 
tic. *The slide shows the capsule to be much thickened and the 
interstitial tissue shows much hyaline degeneration. The medulla 
is composed of a large number of vessels with very thick walls 
which show extensive hyaline degeneration. 

After-course. — Operative recovery w^as uneventful and she has been 
generally much improved and gained some 20 pounds in weight. 



DISTURBANCES OF UTERINE FUNCTION 879 

Comment. — The bogginess of the uterus likely will lessen, but the 
remaining ovary may undergo cystic changes. In that event no 
other operative treatment can be undertaken, for a cystic ovary is 
vastly better than none. 

CASE 5. — A matron of thirty-four came because of pelvic distress 
following- abortion. 

History. — Her general health has always been good. She has four 
living children, has had two premature births at seven months, 
eleven and five years ago. The youngest living child is six years 
old. She had a miscarriage, at two months, nine months ago. 
She was in bed three weeks at that time, and had fever. 
She has been in bed much of the time since then. When she is on 
her feet she has a dragging feeling with a pronounced pain low 
in the pelvis on the left side. This pain is much lessened as soon 
as she lies down. The menses have been fairly regular and last 
a week. She had a marked leucorrhea soon after the abortion, but it 
is less now. The appetite is poor and the sleep variable. 

Exmnination. — There is general abdominal sensitiveness. The peri- 
neum is lacerated to the second degree, there is a bilateral laceration 
of the cervix with much erosion. The body of the uterus is large, 
is in position and is sensitive to bimanual pressure. Blood and urine 
negative. 

Diagnosis. — The history of two premature labors, followed by a nor- 
mal one followed by an abortion at tw^o months five years later in- 
dicates a chronic disease of the endometrium. The pronouncedly 
acute onset of her symptoms following this abortion, attended by 
fever, indicates an actual inflammatory trouble in the endometrium. 
The two premature labors suggest the possible presence of syph- 
ilis. She bore a healthy child after these premature labors, however, 
and her blood count is normal, viz., Hg 90 per cent; W.b.c. 7,000; 
R.b.c. 5,050,000. If in such a case I received a report of a positive 
Wassermann, I would not believe it. The pelvic distress is due 
evidently to congestion of the pelvic organs as idnicated by the 
large, soft cervix. The perineum gives poor support w^hich adds 
to her discomfort. The lacerated cervix adds to the congestion. 
Such a definite history of onset after an abortion suggests strongly 
that there may be retained products though usually when that is 
the case there is a more definite metrorrhagia. At any rate ex- 
ploration seems justified. 



880 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — Curettage. Repair of the cervix and perineum. 

Pathology. — The material obtained by the curettage shows a hyper- 
plastic endometrium with large round interstitial cells evidently de- 
cidual cells. 

After-course. — Recovery was prompt and lasting. 

Comment. — This is the one condition in which a curettage is really 
indicated, for there remains after the abortion decidual rests which 
act as constant irritants to the endometrium. A uterus that has 
contributed four living children and has become so much diseased 
had best be sterilized. 

CASE 6. — A married woman ag-ed forty-two came because of pel- 
vic pain. 

History. — The patient has never been pregnant. She has had 
dysmenorrhea many years. The flow is erratic, sometimes lasting 
a few days only, sometimes as long as twenty-one days. There is 
usually much exhaustion attending menstruation. She had no flow 
from June to November, then none again until January. During the 
past six months she has flowed several times. She has had several 
attacks of sciatica, sleeps badly, and is irritable generally. 

Examination. — The patient does not exhibit evidence of irrita- 
bility. General examination is negative. The uterus is as large 
as a fist, the bulk of enlargement being to the left and backward. 
The uterus is not fully movable and indefinite resistance is felt 
on either side of the uterus. The os is wide and a small soft 
polyp can be felt protruding from it. 

Diagnosis. — The long history of menstrual irregularity, the steril- 
ity, the general increase in size of the uterus seems to make the 
diagnosis of adenomyoma reasonably certain. The periods of amen- 
orrhea speak against malignancy, since if a malignant process 
were present, the flow should progressively increase instead of 
lessen. The increased pelvic distress which was urging her to 
operation was unexplained unless an increased hypersensibility 
made her more responsive to ailments long existent or that tubal 
trouble has been superimposed. 

Treatment. — After the abdomen was opened a papillary tumor was 
discovered in each ovary. These growths were half the size of a 
normal ovary and were implanted upon the ovary, not arising from 
it. Therefore, the ovaries and tubes, together with the uterus, 
were removed, for it was obvious the ovarian tumors were exten- 
sions from the uterus. 



DISTURBANCES OF UTERINE FUNCTION 



881 




Fig. 386 — A. Beginning malignancy in adenomyoma of the uterus. B. Metastasis in the 

ovary. 




Fig. 387. — A. Metastatic malignant adenoma of the ovary. B. Adenocarcinoma of the fundus. 

Pathology. — The uterus was as large as a croquet ball. The uterine 
cavity was small but the endometrium was thickened and corru- 
gated. (Fig. 386 A.) The wall of the uterus was uniformly thickened. 



882 CLINICAL SURGERY BY CASE HISTORIES 

The endometrium of the fundus was converted into a malignant ade- 
noma (Fig. dSlA). This, aside from the metastasis on the ovary 
(Fig, 386B) constituted the exclusive pathologic changes. The papil- 
loma of the ovary was similar to the endometrium in structure (Fig. 
387B). 

After-course. — An intense infection followed both in the broad 
ligaments and in the subcutaneous tissue of the abdominal wall. A 
staphylococcus and an undetermined bacillus were recovered from 
the pns. In ten days the patient began to exhibit a delirium. It 
was noticed at this time that the right parotid gland was swollen, 
to be followed in three days by an enlargement of the other. A 
nurse employed in that part of the house had become affected Avith 
mumps and a consultant considered this a possible source of the 
parotid trouble. In a few days fluctuation was present, however, 
and the glands Avere drained. There was a general improvement fol- 
lowing this and after a long period the patient recovered. As 3 et 
no reappearance of the malignant disease has occurred. 

Comment. — The only two parotid suppurations I have had have 
both been in patients with malignant papillomas of the ovaries 
complicating carcinoma of the fundus. This patient was operated 
on after an infected gall bladder in another patient had been 
drained. The same organism was found in both cases. Obviously 
there was direct transportation of the infection. 

CASE 7. — A matron of forty-six came because of apprehension 
that all was not right with her pelvic organs. 

History. — The patient could recall no abnormality in her sexual 
life until recently when she had a sense of fullness in the pelvis 
with frequent urination and occasionally dull pain during the last 
three or four months. She had missed two periods and desired to 
know whether she had become pregnant or was entering the meno- 
pause. 

Examination. — The uterus lay to the left of the median line and 
the ri^ht pelvic cavity Avas occupied by a tumor as large as a co- 
coanut. It Avas oblong and soft, boggy, and rather fluctuating. 
The cervix Avas not softened and I w^as quite sure I could feel a 
distinct separation between the tumor and the uterus. In order to 
make certain, hoAVCA^er, a tenaculum Avas attached to the cervix and 
an assistant made traction on this Avhile I controlled the tumor by 



DISTURBANCI^S OF UTERINE FUNCTION 



883 



bimanual examination. The uterus moved freely while the tumor 
was fixed by the hands. 

Diagnosis. — A semisolid tumor of the ovary was diagnosticated. 
Because of its semisolid consistency and its oblong shape, a dermoid 
was suspected. 

Treatment. — The ovary is as large as the operator's fist. After 
being cut into an extensive papillary formation was seen inside it. 
The tube being thickened and abnormallj^ attached to the tumor, it 
was removed along with the tumor. The patient having missed two 




Fig. 388. — Papillary cystadenonia of the ovary. 

periods and being forty-six years of age and taking into account 
the likelihood of the other ovary undergoing a like change also, it 
was removed. 

Pathology. — The section of the tumor shows thick, fragile walls 
from Avhich papillary projections have sprung (Fig. 388). The fluid 
contained was serous. The slide shows the papillary portion of the 
tumor is due to active proliferation about the base. At no point 
was the wall invaded. The cyst wall had the structure of a pseudo- 
myxoma. The other ovary showed no signs of degeneration. 



884 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — There has been no evidence of a return of the trou- 
ble and she is well six years after the operation. 

Comment. — This tumor differs from the usual papillary cystomas 
in being unilateral and in the thickness of the wall. "When these 
tumors become malignant they fill the cyst with a solid mass and 
by invading the wall of the cyst reach the surrounding tissue in- 
stead of destroying the cyst wall by erosion and extension of the 
papillary processes themselves. The papillary tumors are nearly 
always bilateral, yet removing the other ovary on suspicion is 
a dangerous practice and is indefensible except when the patient 
is at or beyond the menopause. In case the associated ovary is al- 
lowed to remain in such cases it should be observed from time to 
time in order that any change may be detected early, 

CASE 8. — A matron aged twenty-five came because of painful 
menstruation. 

History. — The patient had excellent health until her only child 
was born two and a half years ago. She had a miscarriage at three 
months two years ago. Since then her menses have been irregular, 
with pain which is most severe just before the period. The head- 
aches are more severe when menstruation is delayed. The pain is 
most severe in the top of the head. Recently she flows a few days, 
stops a day, then flows a few days again. The last few periods 
she has had pain in the region of the heart. 

Examination. — The uterus is in position but the cervix is eroded. 
There is a sensitive mass in the left broad ligament. 

Diagnosis. — The fact that her menstrual periods were normal be- 
fore the birth of the child makes it possible to fix a point of origin. 
That she miscarried six months later indicates an abnormal endome- 
trium at that time if the abortion was spontaneous, and most cer- 
tainly since then if it was induced. The intermittent flow with 
headache and referred pains points to local disturbances in the 
uterus. The intermittent flow indicates the difficulty to be in the 
mucosa either as a primary affection or secondary to circulatory 
disturbance within the muscle itself. The mass at the side of 
the uterus suggests that the endometrium is not alone at fault. 
The mass beside the uterus feels like an inflammatory exudate. It 
is not likely it has existed since the abortion two years ago. It 
may represent terminal changes. It may be the judgment is erro- 
neous. Bearing a close relation with the abortion it seems justi- 



DISTURBANCES OF UTERINE FUNCTION 885 

fied to explore the interior of the uterus with a curette. The eroded 
cervix indicates an irritating discharge and not a laceration. 

Treatment. — Curettment. Iodine was used inside the uterus both 
before and after the curettage was done. 

Pathology. — The products of the curettage showed a so-called 
hyperplastic endometrium which is equivalent to saj'ing that for 
some reason the endometrium did not reduce or retrogress after 
menstruation, as it normally does. There were no decidual remains 
demonstrable. 

After-course. — Improvement followed at once and she was freed 
from the intermittent flow though she retained some pelvic sore- 
ness. At any rate she has borne several children since. 

Comment. — ^Whenever there is apparent a causal relation of the 
menstrual disturbance to some obstetric accident it is justifiable 
to explore the uterus. The touch of the curette should indicate to 
the operator whether or not the endometrium is hyperplastic, or 
whether there are nodulations as of retained placenta or decidua. 
If none exists, it is quite useless, to say the least, to denude the 
uterus. 

CASE 9. — A matron aged forty-six was sent to me because of 
painful menstruation and passage of blood through the bladder. 

History. — The patient has had dysmenorrhea for a number of years. 
Four years ago she was operated on and the lower portion of the 
uterus removed. Following this some months she had more pain 
than ever and she noticed that she passed blood from her bladder 
at those times. The pain is now intense for several days during the 
menstrual flow. Except for a feeling of exhaustion due to the 
pain she is in good health. 

Examination. — The site of the former cervix is represented by 
a mass of scar tissue. No cervical canal can be made out. The 
body of the uterus is as large as a croquet ball, is smooth and 
dense elastic and not painful on pressure. The cystoscope shows 
a small opening half an inch above the trigone. The bladder wall 
is unatfected. 

Diagnosis. — Obviously the traumatism inflicted by the cervical 
amputation effectually closed off the cervical canal and at the same 
time injured the bladder wall. The size of the uterine body sug- 
gests an adenofibroma because of its size and symmetry. The closure 
of the opening between the uterine cavity will demand the reestab- 



886 



CLINICAL SURGERY BY CASE HISTORIES 



lishment of the cervical canal and the loosening of the bladder wall 
from the uterus in order that the hole in the former may be closed. 
Because of the size of the uterus its removal may be demanded. 
It seems best to attack this by the vaginal route. 

Treatment. — In attempting to separate the bladder wall from the 
scarred remains of the cervix a gush of blood was encountered. 
In palpating through the opening a cavity deeper than the finger 
could reach was discovered. At the depth of this a pedunculated 




Fig. 389. — Pedunculated myoma protruding into a homatometrium. 

tumor could be felt but the base could not be reached. This made 
it evident that the uterus was too large for easy removal through 
the vagina without morselement, hence this route was abandoned 
and the hysterectomy was completed through an abdominal inci- 
sion. The hole in the bladder was located and closed by superim- 
posed plication. A permanent catheter was placed in the bladder. 
Pathology. — The body of the uterus is composed of a shell from the 
fundus of which a pedunculated fibroma the size of a hen's egg pro- 



DISTURBANCES OF UTERINE FUNCTION 887 

jects (Fig. 389). In structure this is composed of fibrous tissue cov- 
ered by a thinned mucosa. 

After-course. — Recovery was uneventful. 

Comment. — The thickness of the abdominal wall and the tenseness 
under which the fluid was held prevented me from recognizing 
the uterine enlargement as hematomatous. In fact the opening 
into the bladder so absorbed attention that the nature of the 
uterine enlargement was given only fleeting attention. Being unable 
to determine the nature of the polypoid tumor at the base, I feared 
it might have malignant tendencies. Otherwise the proper for- 
mation of a cervical opening with removal of the tumor would have 
been all that Avas required. 

CASE 10. — A married woman ag-ed thirty-four came to the hospi- 
tal because of painful menstruation. 

History. — The patient's menstrual history is unimportant save 
for dysmenorrhea which has increased in severity during the past 
year. The flow has increased considerably in duration recently. 
She formerly flowed three to four days, but now she flows double 
that time. She has been married tw^elve years, but has never con- 
ceived. She is more concerned because of her sterility than the 
discomfort she experiences. 

Examination. — The uterus is displaced to the left and the cervix 
points to the tuberosity of the sacrum. The fundus seems to lie 
in the culdesac. The right side of the pelvis is filled with a hard 
bosselated tumor which is not fixed but which is painful when an 
attempt is made to lift it out of the pelvis. 

Diagnosis. — Its density and form and its unilateral attachment 
stamp it as a myoma. Its position to the right and the failure 
to spontaneously rise or to permit elevation suggest that it is eon- 
fined to the right broad ligament. 

Treatment. — The tumor is not associated with the broad ligament 
but is attached by a fairly broad base to the fundus of the uterus. 
A cuff is made of the peritoneum covering its pedicle and the ves- 
sels supplying the tumor are isolated and ligated separately (Fig. 
390- A). All hemorrhage is controlled before the peritoneal flaps 
are brought together by Lembert sutures (Fig. S90-B). This technic 
is used in order to avoid placing deep sutures for the control of 
bleeding. 



888 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The tumor is a dense one formed chiefly of fibrous 
tissue. 

After-course. — The patient bore a living child fifteen months after 
the operation. 

Comment. — The situation and character of the tumor was not such 
as to in itself render the patient sterile. It must have been the dis- 




A. B. 

Fig. 390. — Technic for removal of pedunculated myoma of the uterus. 

placement caused by it that brought about that state. This hypothe- 
sis makes it necessary to assume a very long duration of the tumor 
near its present size. The great density of the tumor makes this 
assumption tenable. This patient is one of the iew in my experi- 
ence who have borne children after a conservative myomectomy. 

CASE 11. — A married woman aged thirty-six came because of 
painful menstruation and obstinate constipation. 

History. — The patient has had no children, but one abortion four- 
teen years ago and one six months ago. The menses are regular, the 
flow slight, lasting one-half to three days. The menses have always 
been painful. She has obstinate constipation, never has a bowel 
movement without medicine or an enema or both. She has attacks 
of palpitation and precordial distress. 

Examination. — A smooth, round tumor fills the pelvis, pressing the 
uterus against the pubes. Traction on the cervix seems to move the 
uterus independently from the tumor mass. It lies directly behind 
the uterus. The apex beat is diffuse without murmurs and the rate 
is 90. 



DISTURBANCES OF UTERINE FUNCTION 



889 




Fig. 391. — Diagram showing relation of the tumor to the uterus in the preceding figure. 




Fig. 392. — Pedunculated myoma of the uterus. 



Diagnosis. — A solid tumor in the pelvis probably going out from 
the right ovary since the uterus seems to move independently of it. 
These tumors in women of this age are usually fibrosarcomas. 

Treatment. — The tumor was attached to the fundus only by a long 
narrow pedicle (Fig. 391). The pedicle was divided and the tumor 
only was removed. 



890 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The tumor shows exterisivfe colloid degeneration (Fig. 
392), evidence perhaps that the narrow pedicle did not supply a 
sufficient nutrition to enable it to retain its integrity. 

After-course. — Recovery was complete. The menses became less 
painful and the cardiac irregularity disappeared. 

Comment. — Had the tumor been ovarian the uterus would most 
likely have been displaced in the opposite direction to a greater 
extent than was the case. The relation of myomas to cardiopathies 
is probably not direct through an intoxication from increase in 
muscle tissue in the body as once thought. Nevertheless, cardiac 
irregularities sometimes disappear when the myomas are removed. 

CASE 12. — A married woman aged thirty came to the hospital be- 
cause of amenorrhea. 

History. — The patient has neither borne children nor miscarried. 
Menstruation has always been irregular and painful. She has repeat- 
edly missed her periods for several months together and she has 
not menstruated at all during the last nine months. She has pain 
in the right side, particularly when much on her feet and at un- 
certain intervals a rather intense pain in the sacral region. 

Examination. — The uterus is in position, movable but somewhat 
sensitive on bimanual examination. The right ovary lies deep in 
the culdesac, is somewhat enlarged and very sensitive to the touch. 

Diagnosis. — The patient desires to have children and to be rid of 
the pelvic pain which is particularly distressing on Saturday nights, 
her husband being a traveling salesman. The patient is a picture 
of perfect physical womanhood, and her husband having established 
an alibi by having children by a previous marriage, it was deemed 
permissible to explore, and at least anchor the truant ovary. 

Treatment. — The right ovary was twice its normal size and con- 
tained no less than eight corpora lutea varying in size from a corpus 
luteum of pregnancy to that of a pea. There were several small 
ones in the left ovary. These bodies were resected and the defect 
repaired. A wedge-shaped section was removed. A running buried 
suture was placed to control the hemorrhage and then a second layer 
to coapt the cut edges (Fig. 393). 

Pathology. — The structure of the corpora lutea did not differ from 
those of normal history. In one of them there was a cavity contain- 
ing fluid, giving the appearance of a beginning luteal cyst. The tu- 



DISTURBANCES OF UTERINE FUNCTION 891 

nic of tlie ovary was not thickened. The uterus was in no wise 
changed. 

After-course. — The patient began menstruating some three months 
later and has continued to menstruate regularly, with slight devia- 
tions, for ten years. Her desire to bear children has not been ful- 
filled. 

Comment. — I have seen several corpora lutea present on several 
occasions but never to the number and size exhibited in this case. 
The results indicate that their presence had to do with the sustained 




Fig. 393. — Technic for resection of a jiersistent corpus luteum. 

amenorrhea. Why they failed to undergo the usual retrograde changes 
did not appear from the study of their structure. The observation of 
this case causes me to wonder whether the corpus luteum of preg- 
nancy may have the function of restraining the uterus from undergo- 
ing the periodic bleeding which has become its habit. This is one 
of the rare instances in which resection of the ovary seemed to do 
some good. Generally it is meddlesome surgery done on organs the 
pathology of which we are whollj'' ignorant. If one must resect, the 
operation should be executed with as much care as one would use 
in operating on an eye. 

HEMORRHAGE 

Accidents of gestation and conditions resulting from it and tumors 
encroaching on the endometrium are the innocent causes. Malig- 
nancies must be considered in every case. Last, but not least, con- 
stitutional diseases, notably pernicious anemia, may be the cause of 
bleeding. 

CASE 1. — A married woman aged thirty-eight entered the hospital 
complaining of nervousness, headache and uterine hemorrhage. 

History. — The patient was always well as a child and young -woman. 
She has had three children, all living and well, the youngest of whom 



892 CLINICAL SURGERY BY CASE HISTORIES 

is fifteen years old. Ten years ago she had amenorrhea for seven 
months. Retroversion was diagnosed at that time and the uterus 
was replaced bimanually, knee-chest positions and hot douches used 
and the flow started and continued for three weeks and then became 
regular, according to her physician. The patient had no notable 
illnesses until four years ago when she began to be troubled with 
headache, located chiefly in the back of the head and occurring usu- 
ally, but not exclusively at night. Since that time she has been very 
nervous and excitable. At that time she presented herself at this 
hospital for examination, and a diagnosis of hyperthj^roidism was 
made and she received medicinal treatment with some improvement. 
She had choking spells at that time but she herself noticed no en- 
largement until a year ago. During the past year the nervousness 
has increased markedly and is now more distressing than at any 
previous time. Six months ago she had influenza at the time for 
her period and the menses did not appear. At the time for her next 
period she had cramps, but did not flow. Her doctor started the 
flow, so he said, by tipping the displaced uterus into position. She 
then flowed for ten days, stopped three days and then started 
again and has been flowing most of the time since. Some days 
there is very little flow and on others the flow is profuse with clots. 
During the last two days she has been troubled with cramps and 
backache every day when she is on her feet. She sleeps but little 
because of nervousness. The appetite is good but the bowels are 
constipated. She has frequency of urination when she has nervous 
spells, otherwise she has no urinary symptoms. 

Examination, — There is an enlargement of right lobe of thyroid 
which is smooth and moderately firm. It does not pulsate. There 
are no eye signs and but little tremor. The pulse is 90. The peri- 
neum is lacerated to the second degree and the cervix has a bilat- 
eral laceration with some eversion. There is a bloody discharge 
from the cervix. The uterus is in position, normal in size, and but 
little tender. 

Diagnosis. — The history of the goiter as compared with the present 
symptoms indicates that there is a regression of the toxic symptoms. 
The nervousness and sleeplessness are the chief symptoms which 
might be referred to this cause. The chief factor now to be con- 
sidered obviously is the uterine hemorrhage. Ten years ago she 
had a period of amenorrhea lasting seven months which it is al- 



DISTURBANCES OF UTERINE FUNCTION 893 

leged was relieved by the replacing of a retroversion. The present 
illness was initiated by a similar train. The intermission of the 
menstrual periods during some illness is not unusual but in influ- 
enza there is a tendency to hemorrhages. The flow begins before 
the usual time or the normal flow is prolonged. The failure of 
the menses to appear can not be ascribed therefore to the attack 
of influenza. The most obvious cause for amenorrhea is pregnancy. 
The manual replacement, if we can accept the statement at full 
value, can not be regarded as having anything to do with the re- 
appearance of the menses. Since the uterus is now in position, it 
is fair to infer that there has at no time been a displacement. The 
manual replacement may have been designedly done with a probe. 
The flow started at once and has continued more or less constantly 
since that time. The cramps have been most severe during the 
past few days and following this a lessening of the floAV. This 
indicates that some factor responsible for the hemorrhage may 
have been expelled. A hyperplastic endometritis or a polyp should 
have been initiated by a gradual increase in flow, certainly not by 
missing a period. A long period of sterility, however, suggests 
some uterine trouble. Since both conditions are possible, the diag- 
nosis, therefore, is hyperplastic endometritis or incomplete abortion. 

Treatment. — Palpation with the curette failed to produce evidence 
of incomplete abortion, hence it was decided to explore the inte- 
rior of the uterus. The vaginal mucosa was separated from around 
the cervix. The bladder was dissected up and the cervix and fun- 
dus split longitudinally. The mucosa over an area of 1.5 cm. was 
much hypertrophied, therefore, this area and the cornu of the 
uterus containing the fallopian tubes were resected. The two halves 
of what remained of the uterus were brought together with chromic 
20-day gut and the vaginal mucosa sutured to the cervix. A peri- 
neorrhaphy was done. 

After-course. — Uneventful. There was considerable bloody dis- 
charge from the uterus for a few days. This discharge decreased, 
but some was still present when the patient left the hospital. 

Pathology. — The area noted at the operation on inspection proved 
to be sharply defined from the uterine muscle except at one point. 
At this point a pea-sized area seems to be invaded by glandular 
structures. This area on section shows a prolongation of the uterine 
glands but these shoAv no malignant tendencies. At a distance from 



894 CLINICAL SURGERY BY CASE HISTORIES 

the area above discussed the mucosa shows a cluster of well- 
defined chorionic villi. 

Cofiiment. — From the foregoing it is evident therefore that we 
had to do with an abortion. Whether or not the area above dis- 
cussed might have become the starting point for a malignant growth 
can not be stated, but in view of the other findings it is a source 
of satisfaction to contemplate this possibility. The hemorrhage was 
due to an abortion, probably induced, Avhether intentional or not, 
and the hyperplastic area was an accidental finding. The correction 
of the uterine difficult}^ may have a salutary effect on the goiter. 
It is in the by-products that the justification for the operation 
must be sought. 

CASE 2. — A married woman aged forty-two was brought to the 
hospital because of vaginal hemorrhage. 

History. — The patient has two children, the youngest eleven years 
old. Two years ago the patient began having vaginal discharge. She 
noticed soon after that when she used the douche pain was caused 
and sometimes bleeding resulted. Later spontaneous pain of an 
indefinite burning character began. Her menses were regular 
and lasted four or five days, but there was a bloody discharge 
at intervals throughout the intermenstrual period. She had fre- 
quent painful micturitions and she was obstinately constipated, 
enemas being required to secure a bowel movement. Recently 
the patient has had constant severe pain and she has been taking 
anodynes to relieve it. 

Examination. — The patient is extremely irritable and nervous, 
and gives the impression of a neurotic. She insists on having a 
general anesthetic before an examination be attempted. This given, 
the entire vulvar area from the caruncles up to the base of the 
clitoris on either side is seen to be ulcerated. Below a rectocele 
bulges between what is left of the labia minora. The entire vaginal 
surface is replaced by an ulcerating, bleeding granulous mass. 
The posterior wall is involved to within two inches of the vulvar 
margin and extends to the posterior vault but does not involve the 
cervix. The anterior wall is involved throughout its extent, but 
does not involve the cervix. The rectovaginal wall is much thick- 
ened, as is the anterior Avail. (Fig. 394.) 

Diagnosis. — Syncytiomas, by retrograde metastasis, sometimes pro- 
duce fungating bleeding masses in the vagina, but these are more 



DISTURBANCES OF UTERINE FUNCTION 



895 



lobulated, softer, and run a more rapid course. Tuberculosis is softer, 
tends to leave undermined edges and does not bleed so readily nor 
does it cover so wide an area. Syphilis maintains a uniform out- 
line Avith soft bases and overhanging edges. 

Treatment. — Morphine ad libitum. 

After-course. — The patient lived three months. A rectovaginal fis- 
tula formed some weeks prior to her death. 




Fig. 394. — Carcinoma of the vagina. 

Comment. — When vaginal carcinomas are seen early, a vigorous 
curettage followed by acetone gives surprisingly good results. This 
treatment is preferable to the cautery because a complete destruc- 
tion of the tissue forming openings into one of the neighboring 
hollow viscera is less apt to occur. 



896 



CLINICAL SURGERY BY CASE HISTORIES 



CASE 3, — A matron aged forty-two came because of a bloody 
vaginal discharge between periods. 

History. — Her menses have always been irregular and for the past 
year she has been flowing every two or three weeks, and there has 
been a profuse vaginal discharge at times between periods. Three 
months ago this intermenstrual discharge became tinged with blood. 
She has two children, ten and six years of age. Fourteen years ago 
she had a severe attack of pain in the bladder which kept her in 
bed for five weeks. 

Examination. — The cervix is eroded and bleeds on touch. The 
mucosa of the cervix is soft and thin and the dividing line between 
squamous and columnar epithelial surfaces is sharp (Fig. 395). The 
uterus is of normal size and is freely movable. 




Fig. 395. — Polypoid degeneration of the cervical mucosa. 



Diagnosis. — The only factor of significance is the tendency of the 
mucosa to bleed. It is soft and shows no proliferation, however. The 
bleeding is the only factor which might suggest malignancy. The 
size of the uterus and the character of the discharge precludes fun- 
dus carcinoma. As a matter of precaution cervical amputation seems 
warranted. 

Treatment. — A pyramid-shaped portion of the cervix was removed 
with the electric cautery. The cervical canal was dilated and the inte- 
rior of the uterine canal palpated with a curette. 

Pathology. — The cross-section shows the mucosa to be of normal 
thickness and the slide fails to show any epithelial displacement. Four 
separate areas were examined. 



DISTURBANCES OF UTERINE TUNCTION 897 

After-course. — The wound healed and the trouble seemed to be 
effectually eradicated. After six months she had a little colored 
discharge again. The cervical canal was explored, but nothing 
found. Iodine-carbolic acid was applied. After a month bloody 
discharge was again noticed. The same treatment was repeated. 
She remained free for a number of months. Then a little blood ap- 
peared again. Inspection now disclosed a polyp as large as a slate 
pencil and half an inch long having its attachment just within the 
inner os. This was cauterized thoroughly. After this all discharge 
bloody and otherwise ceased. 

Comment. — Likely this diminutive polyp was pressed against the 
wall of the cervix by the dilator so that it was overlooked at the 
time of the cervical amputation. I can not be sure whether the 
blood noticed at the time of the vaginal examination came from the 
mucosa of the cervix or whether it came from the polyp and over- 
flowed the mucosa. I am disposed to believe the whole trouble was 
due to the little polyp and that the amputation of the cervix was un- 
necessary. Small comfort may be obtained from the fact that this 
removal will prevent a possible cancer. 

CASE 4. — A matron aged forty-six came to the hospital because 
of a bloody vaginal discharge. 

History. — The patient has had three children, the youngest twenty- 
one years old, and no miscarriages. Ever since the birth of her last 
child the periods have come every three weeks instead of four as 
before that time. The flow has always been free and lasts about 
one week. She has had a great deal of headache, but very little 
backache. The patient's present illness began gradually about three 
years ago. A vaginal discharge was first noted. It was whitish at 
first but later became yellowish and thick. For the last six months 
the discharge has been bloody. She now has constant pain in the 
lower abdomen, but it is worse sometimes than at others. It 
now radiates to the back. Menses are regular every three weeks and 
her pains are somewhat worse at those times. The appetite is 
variable. At the present time it is not very good. She is obsti- 
nately constipated. There is burning and pain on urination. She 
weighs 120 pounds now, though her usual weight is 130. She does 
not feel sick but the bloody discharge makes her feel apprehen- 
sive. 



898 



CLINICAL SURGERY BY CASE HISTORIES 



Examination. — The left side of the cervix is occupied by a fun- 
goid mass which bleeds easily (Fig. 396). To the feel it is soft and 
velvety and the outlines of the eroded area are sharply defined and 
somewhat undermined. Tlie right side of the vault is free but the 
left side is retracted and has pulled the cervix to that side. The fix- 
ation seems inflammatory rather than neoplastic. 

Diagnosis. — The sharp border and the soft feel suggests tubercu- 
losis, though the readiness to bleed makes me feel that it may be car- 
cinoma. The fixation of the cervix to the left also suggests carci- 
noma. The fixation of the uterus to the left makes radical operation 
impossible if it is carcinoma and needless if it is not. It secnns best, 
therefore, to excise the cervix with the cautery and to destroy as much 
as possible of the broad ligament by the same means. 




Fig. 396. — Carcinoma of the cervix. 

Treatment. — ^Excision of the cervix with the electric cautery under 
local anesthesia was done. An hour was spent in the process. 

Pathology. — The eroded area is made up of fine papillae, like a 
small bladder tumor, but here and there are nests extending more 
deeply into the cervical tissue establishing it as a malignancy. 

After-course. — The condition was reviewed three months later and 
a small suspicious area on the left side of the scar was cauterized. 
There has been no reappearance in six months. 

Comment. — The feel of this erosion was wholly unlike any I have 
ever felt and having never observed a tuberculosis of the cervix, I 
presumed this might be one. I have since seen two other carcinomas of 



DISTURBANCES OF UTERINE FUNCTION 899 

the cervix like this one. They seem to be less malignant than the 
common form, though I have no doubt the final result will be the 
same. I have never cured a carcinoma of the cervix. 

CASE 5. — A married woman aged thirty-four came to the hospital 
because of a vaginal discharge. 

History. — She had a child six years ago which lived only three 
days. Though weak and nervous since then, she has had no spe- 
cial complaint until the onset of the present trouble. Beginning 
three months ago she had a continuous pain in the bladder region 
and a vaginal discharge. She was examined at this hospital at that 
time and the folloAving note made: "There is a marked erosion of 
the cervix. It is soft, does not bleed on touch and there is a sharp 
dividing line between the erosion and the unaffected part. Opera- 
tion advised." She was treated locally for this for some months 
by her family phj-sician. Following this she became pregnant and 
all during her pregnancy she had a copious mucous discharge which 
became bloody as the time of labor approached. After the birth 
of the baby the discharge very suddenly increased and has contin- 
ued to increase up to the present time. She has been very weak 
since delivery six months ago. 

Examination. — There is a large cauliflower mass occupying the 
cervix. It fills the whole vault of the vagina. It is hard and friable 
and bleeds profusely on manipulation. The cervix is fixed to the 
right and resistance is felt in the right broad ligament. 

Diagnosis. — The cauliflower form, the density and tendency to bleed 
leaves no doubt as to the malignant character of the growth. The 
fixation to the right and the resistance in the broad ligament indi- 
cate that radical operation is not possible. 

Treatment. — ^The carcinoma was removed with a cautery knife. 

Pathology. — The tumor is a squamous-celled papillary carcinoma. 

After-course. — The patient was asked to return after three months. 
She did not return for a year. There was a circumscribed growth in 
the scar in the right side of the vault w^hen she did return. This 
mass was excised with a cautery and two treatments of radium ap- 
plied. The pain was in no wise abated, there being most likely 
other secondary growths. She continued to grow* weaker and died 
eight months after the second operation. 

Comment. — At the time of the first examination the appearance 
was that of a simple laceration. If this was such, did the malig- 



900 CLINICAL SURGERY BY CASE HISTORIES 

nancy develop during pregnancy or very rapidly following this? 
When seen three months after labor the mass was large and cauli- 
flower-like. If it had attained this size before labor it would have 
proved a serious impediment to delivery. It is fair to assume 
therefore that at least a considerable part of the growth took 
place after labor. Besides, the obstetrician noted nothing during 
the labor. Possibly a removal of the erosion when first discovered 
would have prevented subsequent trouble. This is the only instance 
where I examined a condition which was, or later proved to be, car- 
cinoma. From the subsequent course of develojiment I am inclined 
to think that it really was a simple erosion when first examined. 

CASE 6. — A widow aged sixty-four came because of a bloody dis- 
charge. 

History. — The patient has a son aged thirty-two, her only concep- 
tion. During her menstrual life she flowed four days every three 
weeks without pain other than a dull backache. She passed the 
menopause at fifty-two without notable disturbance. She was free 
from discharge for six or seven years. About three years ago she 
began to have occasional discharges which a year ago became 
bloody. She consulted her family doctor who made a diagnosis of 
erosion and applied iodine. Despite this treatment, the discharge 
became more bloody. Otherwise her health is good. 

Examination. — The general examination is without interest. The 
vault of the vagina is taken up by a superficial ulcer, the center 
of which contains an opening, the remains of the cervical canal. 
The edge of the ulcer is irregular and the base fine, granular, hard 
and bleeds readily on touch. The uterus is small and firmly 
fixed to the right. 

Diagnosis. — The growth obviously is a carcinoma. The firm fixation 
to the right stamps it as incurable and virtually inoperable. This 
superficial type responds well to cauterization. Prolonged freedom 
sometimes follows this plan of treatment. The patient requests an 
attempt at operative removal and asks that any risk be taken to se- 
cure the uttermost chance at a cure. She states she understands 
what she is requesting. 

Treatment. — A cuff was made by the vaginal route circumscrib- 
ing the ulcer with a good half inch of healthy vaginal mucosa. The 
edges of the cuff so made were sewn together. The operation was 
completed by the abdominal route. There was a mass to the right 



DISTURBANCES OP UTERINE TUNCTION 



901 



of the uterus that firmly fixed it. The ureter was identified at 
the side of the pelvis and followed it to the growth. An attempt 
to separate it from the growth was unsuccessful and the terminal 
10 em. was cut off. The ureter was ligated with silk. No attempt 
was made to unite it with any hollow viscus. The left ureter was 
separated without trouble. A wide dissection of -the parauterine 
tissue followed. The abdominal wound was closed with through and 
through silkworm and catgut for the skin. 




Fig. 397. — Carcinoma of the cervix. 

Pathology. — The section shows but little invasion of the deep por- 
tions of the cervix. The relation of the proliferating epithelium 
to the underlying tissue resembled closely that of a basal-celled car- 
cinoma. It is only at the right side that any extensive invasion has 
taken place. (Fig. 397.) 

After-course. — The earlier days of the convalescence were with- 
out note. On the fifth day the physician under whose charge she 



902 CLINICAL SURGERY BY CASE HISTORIES 

was, removed the sutures. That night the Avhole wound opened 
and many loops of small intestine caught in the dressing. The 
wound was resutured with through and through catgut and no 
further trouble ensued. The right kidney remained with its ureter 
ligated with silk. Usually it is said such kidneys atrophy and give 
no further trouble. She had much pain in the side and desired 
that it be removed. This was done and she was relieved. When 
last heard from seven years after operation, she was in perfect 
health. She derived as much joy apparently in her triumph over 
the adverse opinion of her surgeon as over the disease itself. 

Comment. — It is quite remarkable how many things one may do 
that ought to remain undone, and yet secure favorable results. 
Evidently the disease had been many years in developing and was 
of low malignancy. 

CASE 7. — A housewife of thirty-six came to the hospital because 
of irregular menstruation. 

History. — The patient has had six children, the youngest six years 
old. She has had irregular menstruation since the birth of the 
last child. During the past six months she has had a flow much 
of the time. Three months ago she consulted a surgeon who diag- 
nosed fibroids and is said to have removed one the size of a goose 
egg. She recovered from the operation but she still had as much 
bloody discharge as before the operation. This has continued to 
the present time. 

Examinatio7i. — She has a recent scar over the pubes. The cervix 
is large and eroded (Fig. 398). The erosion is hard, papilliform 
and bleeds readily on touch. The cervix moves freely. Evidently 
a supravaginal amputation was done. 

Diagnosis. — The hardness of the erosion and its tendency to bleed 
stamps it as unquestionably malignant. Evidently a myomatous 
uterus was removed, the operator having overlooked the more im- 
portant condition of the cervix. 

Treatment. — The stump of the cervix was removed through the 
vagina. 

Pathology. — It is a squamous-celled carcinoma. It has an addi- 
tional interest in that the cancer mass extends along the entire 
length of the cervix, being apparently one of those cases in which the 
squamous cells extend far up the cervical canal. 



DISTURBANCES OF UTERINE FUNCTION 903 

After-course. — The recover}- was uneventful and she was free from 
a recurrence a year after. Since then she has not been heard from. 

Comment. — It is fortunate that the condition of the cervix was 
found so soon after the myomectomy. Otherwise, this case might 
have gone down in history as an instance in which a carcinoma de- 
veloped in the cervix after a supravaginal amputation and conse- 




Fig. 398. — Carcinoma of the cervix after myomectomy. 

quently serve as an argument in favor of a panhysterectomy in 
myoma. Obviously a myoma of the fundus is not a guarantee 
against carcinoma of the cervix. Evidently the surgeon after finding 
a possible course of the hemorrhage in the myoma failed to search 
for other causes. 

CASE 8. — A matron aged forty-eig-ht entered the hospital because 
of prolonged menstrual period. 

History. — The patient has had four children, the youngest of 
whom is twelve years old. She has always had good health. She 
has noticed in the last six months that the menstruation has been 
prolonged and that there is a sense of heaviness in the pelvis 
at the periods, which she had not previously experienced. Being 
a person of intelligence, she desires to know the significance of 
these phenomena. 

Examination. — The perineum is lacerated to the first degree, the 
uterus is in place, movable, a little large and sensitive. The cervix 
is large, nodular, and hard (Fig. 399) the nodules presenting a 
smooth elastic feel like a glandular endocervicitis rather than the 
hard graty feel of carcinoma. The glandules are more extensive 
than one sees in endocervicitis. The examination produces quite 
extensive bleeding. 



904 



CLINICAL SURGERY BY CASE HISTORIES 



Diagnosis. — The friability as expressed in bleeding from the or- 
dinary manipulations of the examination indicates malignancy. 
The regular smooth rounded nodules are unusual and their density 
is not that usually observed in carcinoma, yet the increase in 
size of the cervix and its disposition to bleed can be explained 
on no other basis. 

Treatment. — The vaginal mucosa was deflected from below and the 
operation then finished from above. 




Fig. 399. — Fungus carcinoma of the uterus. 

PatJiology. — The section shows an extension of the growth through 
the cervical canal, apparently having its origin in this situation. 
The slide shows the growth to be a carcinoma. 

After-course. — The recovery from the operation was uneventful. 
It has been but a year since the operation and there is as yet no evi- 
dence of recurrence. 

Comment. — It was probably the hyperemia produced by the grow- 
ing tumor that caused the increased duration of the flow and the 



DISTURBANCES OF UTERINE FUNCTION 



905 



general pelvic pain. The prolongation of flow was that of conges- 
tion rather than that of a breaking down tumor. This would indi- 
cate that the process has been developing more than the nine months 
she has experienced these symptoms. From the arrangement of the 
nodules and their wide distribution it is likely that she had a 
bilateral laceration with erosion or possibly a ''congested erosion" 
before the tumors developed. Usually the carcinomas developing 
from the glands are more friable than the squamous type. The gross 
appearance of this growth was that of an enormous congenital ero- 
sion. 

CASE 9. — A matron of forty-three sought consultation because of 
a prolonged menstrual flow. 

History. — Her menstruations were very painful until the jbirth 
of her first child. Since then she has had little pain. She has 




Fig. 400. — Adenomyoma of the uterus. 



906 



CLINICAL SURGERY BY CASE HISTORIES 



had five children and has had four miscarriages since the last 
child was born. Menstruation had been regular, until the beginning 
of the present trouble, and lasted five or six days. Her present 
trouble began three years ago when she noticed her regular periods 
getting longer and that they were coming more closely together. 
After two years of this irregularity the flow became nearly con- 
tinuous, there being only periods of from 3 to 6 days when there 
was no floAv. During the last three months she has had a tired 
feeling and has had an ache in the lower abdomen. Her appetite 
is good but as the bowels do not act very freely she takes cathar- 




Fig. 401. — Hyperplastic endometrium in adenomyoma of the uterus. 



tics. Her gall bladder was drained and the appendix removed 
three years ago when perineal lacerations also were repaired. 

Examination. — The cervix is irregularly lacerated and the uterus 
is enlarged and nodular. 

Diagnosis. — The gradual lengthening of the menstrual flow as the 
menopause is approached usually indicates a hyperplasia of the en- 
dometrium, particularly if attended by marked enlargement of the 
uterus. This enlargement of the uterus is usually due to an 
adenomyomatous condition, though often the glandular element 
may not be demonstrable. The clinical picture in each is the same. 



DISTURBANCES OF UTERINE FUNCTION 907 

Therefore the diagnosis may read adenomyoma of the uterus with 
hyperplasia of the endometrium. 

Treatment. — Supravaginal amputation. 

PatJioIogy. — The wall of the uterus is much thickened (Fig. 400) 
and the endometrium likewise is irregularly thickened (Fig. 401). 
At one point the endometrium forms a poh'p two centimeters long. 
The structure of this polyp is of interest. The interstitial cells are 
much increased and an ugly look is imparted to the field. The proc- 
ess is quite innocent, however, though I have known microscopists to 
call these sarcomatous. 

After-course. — Recovery was uneventful and the patient remains 
well. 

Comment. — The whole history of this case is in harmony. I have 
noted in a number of instances that patients with adenomyomas had 
a dysmenorrhea before bearing children. The frequent abortions 
in later years indicate a disturbance in the endometrium which 
did not find expression as a metrorrhagia until later. There is no 
treatment which avails anything in these cases except the removal 
of the uterus. 

CASE 10. — A housewife aged, forty-nine came to the hospital for 
relief from excessive and painful menstruation. 

History. — A year ago she noticed that her menstruations which 
formerly had lasted only five days and Avere but little painful were 
increasing in length and painfulness. The duration has gradually 
increased until the flow is now continuous and profuse. She has 
some headaches, the bowels are constipated, and she has a sense 
of pressure on the bladder which causes frequent urination. She 
has had four children and three miscarriages. 

Examination. — The patient is pale but otherwise rugged. The 
uterus is three times the normal size, hard, smooth, and movable. 
The cervix is hard and smooth. 

Diagnosis. — The profuse flow together with the enlarged symmetri- 
cal uterus indicates an adenomyoma. It is unusual only in the short 
duration of the history. The repeated abortions following four nor- 
mal deliveries suggest an earlier beginning than the history would in- 
dicate. 

Pathology. — The uterus when cut open shows uniformly thick walls 
with a relativelv thin endometrium. The vessel walls show an exten- 



908 



CLINICAL SURGERY BY CASE HISTORIES 



sive endometritis. There was a small polyp near the right tubal 
ostium. (Fig. 402.) 

After-course. — She had a mild phlebitis of the right thigh which 
kept up a temperature. Only the superficial veins were involved, 
apparently the result of the intrapelvic cutting. There was no 
swelling of the leg or involvement of the deep veins of the thigh. 
After recovering from this complication she remained well. 




Fig. 402. — Adenomyoma of the uterus. 

Comment. — This type of tumor, far from uncommon, presents one 
of the most satisfactory objects for operative relief. Often they 
have a much hypertrophied endometrium which gives the impres- 
sion of malignancy, but the muscle wall is not invaded and supra- 
vaginal amputation produces a permanent cure. 

CASE 11. — A matron aged forty-three came to the hospital be- 
cause of uterine hemorrhage. 

History. — She has had two children but no miscarriages. She 
was well until two years ago when she began to be annoyed by 
pressure on the bladder and frequent urination. She began at 
the same time to flow more freely than formerly. Usually the flow 



DISTURBANCES OF UTERINE FUNCTION 



909 



lasted a week. The last period lasted two weeks and was profuse. 
She had a pain in the lower abdomen and in the back. These pains 
were particularly severe at the last period. For some months she 
has noticed a tumor in the lower abdomen. Since the tumor ap- 
peared she has had less bladder trouble. 




Fig. 403-^.- — Myosarcoma of the uterus. 

Examination. — There is a globular, fairly dense tumor the size 
of a five-month pregnancy. On bimanual examination it is found 
to be connected with the cervix. It moves freely in all directions. 
The cervix is free from disease. 

Diagnosis. — The bladder trouble obviously was due to pressure 



910 



CLINICAL SURGERY BY CASE HISTORIES 



since this disturbance ceased when the tumor rose out of the pelvis. 
The tumor being globular, solitary, and not ver^' hard, some type of 
degeneration probably is present in the interior of a myoma. The 
increase in the menstrual flow and increased pain at the last period 
suggests that it may be hemorrhagic. 

Treatment. — After the tumor was delivered, the uterus was found 
to be globular, perfectly symmetrical, soft and elastic in consistency. 
Therefore the broad ligaments were removed as freely as convenient 
and the amputation was made through the vaginal junction. 

Pathology. — On section the uterus is pink and homogeneous and 




-■Vf' 




'•T^\y 









Wif^- 



Fig. 403-D. — Myosarcoma of the uterus. 

shows a hemorrhagic area the size of a walnut in its center (Fig. 
403-A). The left ovary has a cyst and a hematoma. A large number 
of cysts from pin head to pea size are found in the endometrium. 
Other portions of the cut surface show areas of colloidal degeneration. 
The slide of certain areas shows simple colloidal degeneration. Ad- 
joining areas are cellular, being formed of large cells with deeply 
staining nuclei and abundant cytoplasm (Fig. 403-B). This can not 
definitely be diagnosed as sarcoma but considering the hemorrhagic 
exudate and the character of the cells it must be regarded as a 
borderland condition. 



DISTURBANCES OF UTERINE FUNCTION 911 

After-course. — One year and a half has elapsed since the op- 
eration, not time enough to determine whether there will be a recur- 
rence. If it really is a sarcoma, it will recur. Sarcomas usually 
recur early and freedom for this length of time is a very favorable 
indication. 

Comment. — In solitary soft globular tumors, particularly if of 
rapid growth, as wide an operation as possible should be done. To 
anticipate any degenerative change eases the conscience of the sur- 
geon, but if they are really sarcoma, recurrence will take place 
whether a panhysterectomy or a simple supravaginal hysterectomy 
has been done. 

CASE 12. — A matron aged thirty-seven came because of prolonged 
menstruation. 

History. — The patient is the mother of three children, the youngest 
being ten years of age. Her menstruation had always been normal, 
of five day duration, until the beginning of the present trouble four 
years ago. She noticed that the periods were lengthening, lasting 
a week or ten days instead of the usual five. Some periods the 
flow was particularly strong. Three weeks ago she had a very 
severe flooding requiring special measures to control it. She never 
had any pain and aside from the loss of blood she has nothing to 
complain of. 

Exa/mination. — The physical examination shows nothing abnormal, 
despite the patient's account of alarming hemorrhage. The blood 
count show^s nothing abnormal. The uterus is in position, freely 
movable, the ligaments are somewhat lax and there is some tender- 
ness on bimanual pressure. The cervix shows nothing abnormal. 

Diagnosis. — The single symptom of hemorrhage from the uterus in 
a woman in the middle of the child-bearing period, after ten years 
sterility indicates some anatomic change in the endometrium or of 
the body of the uterus. In such cases retention of some product 
of conception is not to be expected. Placental rests sometimes cause 
hemorrhages a year or two later, but hardly after so long a period. 
Endovascular causes of hemorrhages are more common near or after 
the menopause, but may occur in women even younger than this 
patient, however. On the whole, we must anticipate in this case 
a polypoid degeneration of the endometrium or pedunculated fi- 
broid. 



912 



CLINICAL SURGERY BY CASE HISTORIES 



Treatment. — The curette might remove some structure that would 
permit a diagnosis, but a cure in such cases is not secured by this 
instrument. Hence it was concluded to inspect the interior of the 
uterus, locate the offending part, remove it and preserve the re- 
mainder. Accordingly the bladder was lifted from the uterus as in 
the first step of vaginal hysterectomy and then the uterus was split 
in the anterior median line. Above the internal os a polypoid 




Fig. 404. — Pedunculated intrauterine myoma. 

fibrous mass was encountered (Fig. 404). The entire uterus had 
to be split before its site of attachment at the fundus could be in- 
spected. In order to secure its base, it was circumscribed, the 
portion of the fundus giving attachment to it being removed along 
with the tumor. The uterus was then closed, beginning at the 
highest point and terminating at the point of beginning in the cer- 
vix. (Fig. 405.) 



DISTURBANCES OP UTERINE FUNCTION 

A. B. 



913 




Fig. 405. — Technic of vaginal hysterotomy. A. The anterior wall of the uterus is split 
open, showing the polypus attached at the fundus. B. The base of the tumor is being cir- 
cumscribed with a knife. C. The defect left after the removal of the tumor is being closed 
with sutures. D. The incisions in the anterior wall and in the vagina have been closed with 
sutures. 

Pathology. — The tumor was made up of fibrous tissue covered with 
a very much attenuated mucosa. 

After-course. — The patient ran a low temperature for two weeks, 
but recovered without other incidence. She returned to her normal 



914 CLINICAL SURGERY BY CASE HISTORIES 

menstruation without excessive flow and regained her former health. 
A year and a half after the operation I had a letter from her physi- 
cian stating that the patient was pregnant and expressing a de- 
sire to know the extent of the operation and asked to know my 
opinion as to the advisability of terminating the pregnancy. Hav- 
ing neither experience nor knowledge to guide me, I concluded that 
so much mutilation as I had inflicted would hardly leave a uterus 
capable of bearing a child. Abortion therefore was advised. This 
was done and the patient did not conceive again. The patient 
passed through the menopause without disturbance some three years 
ago, eight years after operation. 

Comment. — This is the first patient on whom I did a diagnostic 
and therapeutic hysterotomy through the vagina. She is the only 
one who subsequently became pregnant, for in subsequent opera- 
tions of this kind I have always taken the precaution to resect 
the tubes. In patients during the menstruating period of life this 
is the most rational procedure. By this means the surgeon is able 
to make a certain diagnosis and employ conservative therapeutic 
measures. It should not be employed unless the disturbance is of 
sufficient gravity to warrant one in terminating the fecundity of 
the patient. The operation makes some demands on the technical 
skill of the operator and the large wound connected with the vag- 
ina is apt to undergo a low grade of infection sufficient to keep 
up a low temperature longer than after most operations. Out of 
many dozens of these operations I have never had one proceed be- 
yond a stage of annoyance. The patients during this temperature 
have good appetites and experience a sense of well being, but the 
nurse is apt to inquire why the temperature does not come to 
normal. 

CASE 13. — A housewife of thirty-six came to the hospital because 
of profuse hemorrhages. 

History. — The patient has had several children, the last about ten 
years ago. She was well until four months ago when she began to 
flood. She has had no pain at any time. 

Examination. — The uterus is uniformly enlarged and dense, moves 
freely, and is not painful. 

Diagnosis. — The uniformly enlarged bleeding uterus seemed to be 
clearly an adenomyoma. It was too dense to harbor a fetus and too 
uniformly enlarged to be a simple myoma. 



DISTURBANCES OF UTERINE FUNCTION 



915 



Treatment. — Supravaginal amputation. 

Pathology. — After the uterus was split open it was seen not to be 
an adenomyoma but a pedunculated tumor with a base proportion- 
ately broader than most intrauterine pedunculated tumors (Fig. 406). 
It seemed to be made up of fiber bundles arranged more or less paral- 
lel to each other and continuous with the muscle bundles of the 




Fig. 406. — Myosarcoma of the fundus of the uterus. 

uterine wall. The section showed these to be composed of spindle 
cells generally uniform in size, with occasionally a few with much 
broader nuclei and less cytoplasm. These w^orried me, but did not 
prevent me from giving a good prognosis as to cure. 

After-course. — The patient returned a year and a half later with 
a tumor filling the pelvis. She died a few months later. The recur- 
rence was a sarcoma. 



916 CLINICAL SURGERY BY CASE HISTORIES 

Comment. — The broad base of the tumor and the large cells seen 
on microscopic examination should have excited me to caution of 
speech. This operation was done before I formed the habit of open- 
ing the uterus at the operating table when in doubt as to the cause 
of a hemorrhage serious enough to suggest a hysterectomy. Had 
I done so, I should have removed the entire uterus if the light 
had dawned. 

CASE 14. — A matron aged forty-seven was brought to the hospital 
because of bleeding from the uterus. 

History. — Soon after the birth of the last child, eight years ago, 
the patient noted an increase in the menstrual flow. Three years ago 
it became so severe that she had to remain in bed during the height 
of the flow. The flow at this time lasted from ten to thirteen days. 
She was curetted at this time without result. A year following 
she had renewed hemorrhages and a physician discovered a tumor. 
With these hemorrhages there was a discharge of large amounts 
of watery fluid after which the tumor would grow smaller and the 
hemorrhage would lessen for a few months. She has grown weaker 
as the hemorrhages continued. A month ago she had a furious 
hemorrhage which caused her to nearly faint. She had severe 
pain at the time which she had never had before. There Avas much 
soreness of the abdomen for two weeks following. She thinks there 
was some fever. 

Examination. — She is still flowing at the time of coming to the 
hospital. The patient is moderately well nourished but she has 
a lemon-yellow color and the mucosae are white. The abdomen is 
flat, soft and flabby. A smooth tumor can be felt over the pubes 
being about the size of the head of a newborn child. The cervix 
is free and is continuous with the mass filling the pelvis. The 
tumor is movable. There is still blood escaping from the cervix. 
The urine is negative. The Hg is 30 per cent; R.b.c. 1,500,000; 
there is no evidence of pernicious anemia, a possibility the color 
of the patient suggests. 

Diagnosis. — The history of hemorrhages and the form and con- 
sistency of the tumor left no doubt as to the diagnosis of myoma. 
The absence of signs of pernicious anemia makes it likely that the 
anemia is secondary to the hemorrhage. The severe pain she had a 
month ago suggests the possibility of some secondary change within 
the tumor. With a hemoglobin of 30 per cent she is not a desirable 



DISTURBANCES OF UTERINE FUNCTION 



917 



risk. Since she has been bleeding profusely for a number of years 
it is likely that she has been anemic for some time. This is corrob- 
erated by the statement of her husband that she has had much the 
same color for a number of years. Patients long anemic bear opera- 
tion better than those in whom the anemia is acute. Furthermore, 
the chronically anemic build up less rapidly than the acutely 
anemic. It seems best here, therefore, to operate with only a brief 
general treatment, lest renewed hemorrhage occur. 




Fig. 407. — Myoma of the uterus showing Ijmrh sinuses, some of which are filled with 

blood clot. 



Treatment. — Owing to the impoverished condition of the patient's 
blood the uterus was packed with gauze soaked in terchloride of 
iron, and arsenic was given. After a week, a supravaginal amputation 
was done. 

Pathology. — The myoma lay just beneath the mucosa, which ac- 
counted for the tendency to bleed. There were a number of cyst- 



918 CLINICAL, SURGERY BY CASE HISTORIES 

like sinuses which may have discharged into the uterus and pro- 
duced the escape of watery fluid above mentioned. A hemorrhage 
had taken place in a number of these sinuses and a considerable por- 
tion of the tumor was somewhat infiltrated with blood (Fig. 407). 
This hemorrhage probably took place a month ago at the time she 
had the pain in the lower abdomen. 

After-course. — The recovery was uneventful and the blood soon 
reached its normal state. She has remained well. 

Comment. — In case of extreme anemia with hemorrhage of the 
uterus it is well to remember that the bleeding may be due to a 
pernicious anemia whether a uterine lesion be present or not. In 
such a case a careful blood study as well as actual observation 
as to the amount of blood lost may be necessary to determine 
whether the anemia be primary or secondary. Excessive uterine 
hemorrhage is by no means a rare, sometimes even the earliest, sign 
of pernicious anemia. This is sometimes true of Avomen long past 
the menopause. 

CASE 15. — A matron of sixty-five came to the hospital because 
of hemorrhage and a mass projecting from the vagina. 

History. — She passed the menopause at fifty-two and for five 
years following had no vaginal discharge of any sort. About eight 
years ago she began to have uterine hemorrhages. Some blood ap- 
peared every two to four weeks. Sometimes the blood was bright 
red and sometimes only a bloody mucus. The amount was small at 
times and sometimes there were sudden gushes. At the present 
time she flows some every day. There was no pain until three 
months ago. Since then there has been a dull heavy pain in the pel- 
vis with some sharp shooting pains downward toward the vulva. 
There has been a mass protruding from the vulva for the past six 
weeks. Since that time she has had pain in the neck of the bladder 
and she has increased frequency of urination especially at night. 
Her general health is good. She was curetted some months ago 
without any improvement whatever resulting. 

Examination. — The patient is a large fleshy woman without evi- 
dence of loss of weight or suffering. The anterior vaginal wall 
appears in the vulva but there is no tumor apparent. A muco- 
bloody discharge fills the vagina. The uterus is as large as a cocoa- 
nut. Its surface is irregularly bosselated. It is movable, somewhat 
irregular in outline, and sensitive to firm pressure. Bp.140-80; 
the urine is 1.011 but free from abnormalities. 



DISTURBANCES OF UTERINE FUNCTION 



919 



Diagnosis. — Freedom from any flow for five years, then a reap- 
pearance with an enlarged uterus suggests at once a carcinoma 
of the body of the uterus. The duration of this for eight years 
without notable change until three months ago marks this as unu- 
sual if it is a carcinoma. The recent appearance of a dull pain with 
lancinating pains at intervals, however, is quite in harmony with the 




Fig. 408. — Fundus carcinoma of the uterus. 



theory of invading malignancy. A slowly proliferating endome- 
trium that developed malignant tendencies very slowly may be hy- 
pothecated. This can be accepted if the bosselations are accepted 
as small fibroids. If they are malignant nodules, as the lancinating 
pains would suggest, then the present excellent state of the patient 



920 



CLINICAL SURGERY BY CASE HISTORIES 



is difficult to understand. At any rate the uterus is movable and 
is bleeding. The uterus seems too large to remove by the vaginal 
route, so a laparotomy seems indicated. 

Treatment. — After the uterus was exposed it was found studded 
with small fibroids from the size of a hazelnut to that of a hickory 
nut. The body was hard and gave no evidence of being invaded 
by malignant nodules. Because of the depth of the operative field 
and the fixation of the broad ligaments, clamps were left on the 
uterine artery rather than consume time in ligating them. 




Fig. 409. — Fundus carcinoma of the uterus. 



Pathology. — The uterus is firm and carries numerous calcified 
fibroids. The interior presents an ulcerated appearance without 
much thickening of the mucosa (Fig. 408), but it is definitely ma- 
lignant (Fig. 409). 

After-course. — Recovery was uneventful. The clamps were removed 
on the third day. She continues well. 

Comment. — Evidently the hemorrhage was for years due to a pro- 
liferative endometritis rather than a malignancy. The fact that 
the nodules were palpable through so thick an abdominal wall 
should have identified them as fibromas, for the low bosselations 



DISTURBANCES OF UTERINE FUNCTION 921 

of malignancy -would not have been palpable at all. In discussing 
with the patient the character of the alleged lancinating pains 
it appears she has in mind throbbing pains which were translated 
into lancinating pains by a too enthusiastic clinical recorder. 

CASE 16. — A housewife aged forty-four came because of painful 
and excessive menstrual flow. 

History. — Her periods have always been regular, flowing four or 
five days without pain. Since the birth of her three children, the 
last eleven years ago, she has flowed every twenty-three days, but 
without pain, and the duration of the flow was not increased. She 
had one miscarriage nine years ago. Two years ago the flow became 
more prolonged and later became painful. For the most of this time 
she has flowed seven to ten days each twenty-three days. The last 
period was particularly painful and she has now been flowing for a 
month. She now has pain in both groins. For some years she had 
pain in the back of her head. She has had goiter fourteen years, but 
it has caused no trouble. 

Examination. — The patient has an enlargement of the right lobe 
of the thyroid as large as an orange. The uterus is in position, 
is somewhat large, fairly flrm and is movable. The cervix is soft, 
eroded, and bleeds on touch. The urine contains much pus and many 
bacteria. Pulse 60, Bp. 160-90. 

Diagnosis. — The goiter evidently has nothing to do with her pres- 
ent complaints. The beginning of excessive flow nine years after 
the miscarriage suggests some disturbance in the endometrium. The 
uterus is not large enough to suggest an adenomyoma. The erosion 
is soft, and regular, and while it does not in itself show malig- 
nancy, it does indicate a congestion of the uterus as a whole. Be- 
sides, even if the cervix were malignant, it would not occasion 
the pain and metrorrhagia of which the patient complains. The 
problem is to determine the state of the interior of the uterus. 
There is but one sure way of flnding out and that is to look and see. 

Treatment. — The uterus was split up its anterior surface after 
lifting off the vagina. When the interior of the body was exposed, 
it was found that the endometrium was thickened, felt granular 
and bled easily. A hysterectomy was done. In separating the 
uterus from the bladder an opening was made into the latter. The 
hole was closed with chromic sutures and a permanent catheter was 
placed in. 



922 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The wall is thick, fairly firm, and many of the ves- 
sels are prominent. The mucosa is as above noted. The slide shows 
an adenocarcinoma at the fundus. There is no sign of malignancy 
at the cervix. (Fig. 410.) 




Fig. 410. — Carcinoma of the fundus of the uterus. 

After-course. — The catheter was allowed to remain a week. There 
was no trouble from the accident. There has been no recurrence. 

Comment. — In such cases the curette is a useless instrument. While 
enough mucosa could have been secured to make possible a microscopic 



DISTURBANCES OF UTERINE FUNCTION 923 

diagnosis, a second operation would have been required. Besides, 
the slide is not so sure a means of diagnosis as is the organ in situ 
when exposed by the surgeon's knife. A vaginal hysterectomy 
as done here is preferable to an abdominal operation. The vaginal 
route makes it possible to view the entire interior of the uterus 
which the abdominal operation does not. The injury to the blad- 
der in this case was pure awkwardness and does not militate against 
the operation. In younger women with dysmenorrhea or metror- 
rhagia coming after childbirth or abortion the uterus should be 
explored with a curette. After the child-bearing period is passed 
the curette ceases to be a legitimate instrument. 

CASE 17. — A married woman aged thirty-seven came to the hos- 
pital because of bleeding from the uterus. 

History. — She has seven children living, one abortion at five months 
a year ago. Has always had menstrual disturbance. Has had sev- 
eral attacks of inflammatory rheumatism. She has epigastric pain 
and is short of breath often on lying down. She has had some vesi- 
cal disturbance for some years and a polyp was removed from the 
urethra at this hospital some years ago. She now has headache, es- 
pecially in the forehead and occiput. She has severe backache and 
pain in the lower abdomen, both of which are worse at the menstrual 
period which is prolonged two weeks sometimes. The flow is often 
clotted. There is constant leucorrhea. Appetite not good. She now 
has been flowing four weeks. 

Examination. — The patient has a pronounced mitral regurgitation 
with evidence of disturbed compensation. The uterus is enlarged, 
the size of a four-month pregnancy. The cervix is hard, lacerated, 
especially in the right side. The cervix is pendulous and a boggy 
mass may be felt within the uterus. The uterus is lightly packed and 
a three-month mummified fetus was expelled the following day. Fol- 
lowing this the uterus was still large and the flow continued. 

2>ia<7no5*s.— -Obviously the expulsion of the fetus was not the whole 
affair or else there is a retained membrane. There was flooding 
for a year and it is remarkable that a pregnancy should have oc- 
curred. Likely there was some disturbance resulting from the 
abortion a year ago for the profuse bleeding began at that time. 
It seems best to flnd out. 

Treatment. — The uterus being too large to make a vaginal hysterec- 
tomy convenient, it was opened from above. The lumen contained a 



924 



CLINICAL SURGERY BY CASE HISTORIES 



mass as big as an egg. It looked like a deciduoma, and a hysterec- 
tomy was done. 

Pathology. — The uterus is double the normal size. There is no 
sharp line of division between the uterine wall and mass. The 
mass itself is a mottled grayish red mass soft and fragile. It has 
the appearance of a deciduoma (Fig. 411) but the slide fails to 
show anything but placental tissue with some fibrinoid connective 
tissue. 

After-course. — Recovery was uneventful. 




Fig. 411. — Retained placenta resembling deciduoma maligna. 

Comment. — On further questioning it was discovered that at the 
time of the alleged miscarriage a year ago she had pains and 
flooded. Since she continued to flow afterwards and the uterus did 
not grow she concluded she had miscarried at, as she estimated, 
five months. At the time the history w^as taken her statement that 
she miscarried at five months was accepted at its face value. Had 
the details been gone into, an exact diagnosis might have been 
made and the proper treatment instituted — curettage. The fetus 
expelled while in the hospital evidently had lain dormant a year. 
Details in a history are sometimes tremendously important. 



DISTURBANCES OP UTERINE FUNCTION 



925 



POSTMENOPAUSE HEMORRHAGE 

There is but one cause for postmenopausal hemorrliage ; malignant 
disease. Once a woman has passed the menopause, and bleeds again 
only the most conclusive negative evidence warrants one in excluding 
malignancy. 

CASE 1. — A widow of fifty-six came because of a bloody discharge 
from the vagina. 

History. — The patient passed the menopause nine years ago with- 
out incident and remained free from any discharge until six months 
ago. Since that time she has had a bloody discharge at irregular in- 




Fig. 412. — Small mucus polyp of the endometrium. 



926 CLINICAL SURGERY BY CASE HISTORIES 

tervals. Save for the apprehension caused by this discharge she has 
nothing to complain of. She has had four children, the menstruation 
was normal in amount and painless until the menopause. 

Examination.- — The patient's general appearance confirms her esti- 
mate of general bodily health. The uterus is slightly larger than in 
the child-bearing age, the fundus is movable, very slightly irregular. 
Because of the fat abdominal walls the density can not be made out. 
The cervix is smooth and small. 

Diagnosis. — A uterus that has remained quiescent for nine years 
and then bleeds must be suspected of harboring a malignant process. 
The large size of the fundus confirms this. 

Treatment. — A vaginal hysterectomy was done. During the course 
of the operation several small intramural fibroids could be made out. 

Pathology. — When the uterus was split open, instead of a malig- 
nant process, three diminutive polyps were seen, one in the cervix, 
one at a midpoint, and one at the fundus (Fig. 412). They are soft 
and easily compressible. The slide shows a few atrophied glands. 
The vessels are much thickened. 

After-course. — She has remained well. 

Comment. — The removal of the polyps would have cured the pa- 
tient. The large size of the fundus was due to the small fibroids. 
In order to make an exact diagnosis it was necessary to inspect the 
interior of the uterus. In women during the child-bearing age ex- 
ploration can best be made by elevating the bladder and splitting 
the uterus. In women past the menopause the broad ligaments are 
so fibrous that it is exceedingly difficult, much more so than is a 
hysterectomy. Under such conditions a vaginal hysterectomy pre- 
sents the simplest way of determining why a uterus bleeds after 
once being quiescent for years. When such a state exists the best 
place to discuss etiology is in the laboratory. 

CASE 2. — A matron aged fifty-four came because of vaginal hem- 
orrhage. 

History. — The patient has had three children and one miscarriage 
before the birth of the last child sixteen years ago. She passed the 
menopause five years ago without incident. After the menopause 
she remained free from any vaginal discharge until one year ago 
when she had a sudden profuse hemorrhage. She has had four 
other hemorrhages, the last two weeks ago. These hemorrhages 
were all so severe that active measures, such as stypticin and pack- 



DISTURBANCES OP UTERINE FUNCTION 927 

ing were required for their control according to her physician. 
She has some d^-spnea on exertion. 

Examination. — The patient is very fleshy and shows but little 
if any signs of anemia. The cervix is low, dilated, presenting within 
the OS a friable mass the size of a walnut. The fundus is in the 
hollow of the sacrum the size of a two or three months pregnancy. 
The mobility of the uterus can not be determined. The apex beat 
is near the anterior axillary line, intermits occasionally, and the 
sounds are faint. 

Diagnosis. — The discovery of the large fundus and the mass within 
the unchanged os are sufficient to make the diagnosis of malignancy 
certain. The question of operability is another matter. The 
uterus is large and seems fixed. The patient has evidence of a fatty 
heart and is dyspneic on exertion. Considering the gravity of the 
disease the risk of the anesthetic seems justified. If the uterus 
is fixed it likely is inflammatory, for fundus carcinomas seldom fix 
the uterus to a degree which makes its removal impossible. Be- 
cause of the uncertainties of technical operability and her excessive 
adiposity, the vaginal route seems preferable. By this route if 
the tumor is inoperable it is easier to back out than when an ab- 
dominal incision has been made. 

Treatment. — The culdesac was opened and the fundus was found 
free from adhesions. The cervix was circumscribed and the uterine 
arteries ligated and cut. The fundus was too large to deliver and 
the broad ligaments too inelastic to permit the exposure of the 
upper part. These were clamped, therefore, and the uterus removed. 
The upper part of the broad ligament still was not readily accessi- 
ble, so the clamps were left in situ. 

Pathology. — The entire interior of the uterus was filled with a fria- 
ble fungoid mass (Fig. 413). On section some parts showed typical 
malignant adenoma, other parts carcinoma. 

After-course. — The forceps were removed the second day and the 
gauze pack on the fourth. Eecovery was uneventful. 

Comment. — Fundus carcinoma of even this extent gives a fairly good 
prognosis because they do not invade the loose tissue of the broad 
ligament. Vaginal hysterectomy is more quickly done and is less 
likely to cause infection. By leaving the clamps on the broad liga- 
ments the operating time is much reduced. The broad ligaments in 
these old patients are friable and if too much traction is made on 



928 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 413. — Carcinoma of the body of the uterus. 

them in the effort to place a ligature about them they may pull 
off and provide much embarrassment for the operator. In some 
such cases, in which ether anesthesia was much feared, I have done 
this operation under spinal anesthesia. If there is much trouble in 
delivering the fundus, traction pain may be produced. 



DISTURBANCES OF UTERINE FUNCTION 



929 



CASE 3. — A matron aged fifty-three came because of hemorrhage 
from the uterus. 

History. — The patient passed her menopause six years ago. She 
remained free from trouble for three years. At that time she had 
some irritating vaginal discharge which at times was blood streaked. 
She Avas examined at this hospital and the uterus was found to be 




Fig. 414. — Carcinoma of the body of the uterus. 

small, atrophic, and pointing slightly to the left. She returned a 
year and a half later with much the same story. She had a granular 
vaginitis due apparently to the irritating uterine discharge. She 
was given an anesthetic and the uterus explored. It was an inch 
and a half deep and the curette obtained only a little atrophic 



930 CLINICAL SURGERY BY CASE HISTORIES 

endometrium. It was regarded as a bleeding from an endarteritis. 
She had more or less discharge during the next year and a half, 
rarely a little blood. She returns now because of more pronounced 
symptoms. Recently there have been pronounced hemorrhages, last- 
ing five weeks at one time. For the past few months she has had 
pain in the left groin and in the left hip. The pain is now severe 
especially at night so that it interferes with her sleep. There is 
pain on urination. The vaginal discharge has been more profuse 
but never has had an offensive odor. She has always had good 
health. She has never been pregnant. 

Examination. — The patient is a vigorous, well-preserved woman, 
but with the evidence of a general anemia. There is a deep ten- 
derness in the region of the gall bladder. The cervix is eroded and 
granular and bleeds on touch. Blood is flowing from the cervix. 
The uterus is nearly as large as a fetal head. Low bosselations 
can be felt on the top and anterior surface. There are no ex- 
tensions into the broad ligament and the whole seems movable. 
During the first days in the hospital the temperature varied be- 
tween 97° and 99.8°. There is a moderate general anemia. The 
urine was negative save for many pus cells and occasional red cells. 

Diagnosis. — Naming the disease offers no difficulty. The under- 
standing as to how and why the marked change has come about dur- 
ing the past year and a half, is another matter; whether a malig- 
nancy in the diminutive uterus was overlooked; or whether the 
whole process has developed since that time; or whether an exten- 
sion occurred from some neighboring structure. It hitherto has 
been my belief that, if a uterus was atrophic, fundus carcinoma 
was thereby excluded, and if hemorrhage existed, a vascular disorder 
could be diagnosticated. One thing only is clear, a carcinoma of 
the fundus of rapid growth is present. 

Treatment. — A panhysterectomy by laparotomy was done. The 
disease does not seem to have involved other structures. 

Pathology. — The uterus is as large as a croquet ball. When pressed 
upon it feels soft and squashy (Fig. 414). When cut open the in- 
terior is found to be filled with a soft, brittle mass surrounded by 
shell of uterine muscle. All topographic evidence of endometrium 
is lost. The slides show an adenocarcinoma. 

After-course. — In three months she returned with complaint of 
frequent urination and dysentery, tenesmus and pain at stool. Ex- 



DISTURBANCES OF UTERINE FUNCTION 93 1 

amination showed a mass involving the perirectal tissue and the re- 
mains of the anterior vaginal wall. "When examined three weeks 
later the mass had materially increased and movements of the bowels 
were obtained with difficulty. She soon died of exhaustion. 

Comment. — I have never seen any other epithelial tumor grow so 
rapidly. I have seen sarcomas implanted on hemorrhagic myomas 
duplicate this for rapidity of growth but never a tumor derived from 
epithelial cells. The question is whether or not the curette in the 
presence of vessels with degenerated walls could have duplicated the 
condition found in hemorrhagic myomas. The vessel changes are the 
same and the environment is similar, but that epithelial cells are 
capable of such rapid development was new to me. One thing only 
is certain ; a uterus once past the menopause that bleeds again is 
not a matter for hair splitting diagnosis. It should be removed. 

CASE 4. — A woman a^ed sixty-two entered the hospital because 
of bloody vaginal discharge and uneasiness in the pelvis. 

History. — The patient has had three children, no abortions. The 
menopause occurred ten years ago and she was entirely free from 
any vaginal discharge until several months ago when she noticed a 
slight bloody discharge and some sense of uneasiness in the pel- 
vis. There was no actual pain. The hemorrhage ceases sponta- 
neously, only to reappear after a week or two. 

Examination. — The uterus is low in the pelvis, slightly larger than 
a postmenopausal uterus. There are no nodules but definite limi- 
tation of mobility. There is some general sensitiveness. The patient 
looks sick and has lost a little in weight. 

Diagnosis. — The slight hemorrhage after ten years of freedom in- 
dicates some pathologic process, either an endarteritis or a malig- 
nancy. The size of the uterus would indicate the less grave lesion. 
The apparent fixity is without significance after the menopaus« 
for the muscle tissue in the broad ligament disappears and the 
fibrous tissue loses its elasticity, the uterus becoming fixed between 
fibrous bands. The general disturbance in health is significant. 

Treatment. — An abdominal panhysterectomy was done. 

PatJiology. — A small fungoid mass occupies the fundus of the 
uterus (Fig. 415), not otherwise markedly enlarged. 

After-course. — Recovery was uneventful, and there has been no 
recurrence after several years. 



932 



CLINICAL SURGERY BY CASE HISTORIES 



Comment. — This patient had informed herself of the significance 
of the appearance of a bloody vaginal discharge after the menopause 
and presented herself for treatment, making early hysterectomy pos- 




Fig. 415. — Carcinoma of the fundus of the uterus. 



sible. It is unusual to see so small a uterus the site of a fundus car- 
cinoma. 

CASE 5. — A matron of fifty-six came for consultation because of 
hemorrhage. 

History. — Her menstruation began at the age of fourteen years 
and was regular from the beginning, lasting from four to six days. 
She has had four children, the youngest twenty-four years old. The 
menopause occurred seven years ago without noteworthy disturb- 
ance. Two years and three months ago the patient had a blood 
discharge from the vagina which came with a gush. There were 
large clots in the discharge. She was much weakened by the loss 
of blood. Since this first attack there has been a more or less steady 
whitish yellow discharge which is generally streaked with blood. 
There has been no severe hemorrhage since the first onset. Since 
July she has had pain in the hips and lumbar region. The pain is 
worse in the right side low down in the pelvis. Her general condi- 
tion has remained normal. 



DISTURBANCES OF UTERINE FUNCTION 933 

Examination. — The general condition is unaffected. The uterus 
is in position and is movable and the surface is smooth. There 
is a general uniform enlargement without nodulation of any sort. 
The consistency is dense but elastic. The cervix is small, and hard. 
Hg 70 per cent ; R.b.c. 2,212,000 ; W.b.c. 8,200. The urine contains 
a considerable number of leucocytes and a trace of albumin. 




Fig. 416. — Beginning carcinoma of the fundus. 

Diagnosis. — The general feel is that of an adenomyoma. Her pre- 
menopausal history does not bear this out. However, not all adeno- 
myomas bleed. The present symptoms indicate a destructive process 
in the endometrium. 

Treatment. — An abdominal panhysterectomy was done. 

Pathology. — The fundus was large, thick-walled, and the mucosa 
is replaced by a dense friable mass of reddish gray color (Fig. 416). 



934 CLINICAL SURGERY BY CASE HISTORIES 

The Avails of the uterus are 2 to 5 cm. thick. The slide shows an 
adenocarcinoma but there is little disposition of the glands to in- 
vade the muscle wall. Likely an adenomyoma preceded the present 
state. 

After-course. — Recovery was uneventful and the patient remains 
well, now three years after operation, and it is fair to predict that 
she will remain so. 

Comment. — The thick uterine wall indicates that the patient had 
an adenomyoma before the advent of the present trouble. This 
case is peculiar in that cases of malignancy implanted on adenomyomas 
usually do not give a period of amenorrhea, but a prolongation of 
the menstrual period which gradually emerges into the hemorrhage 
of the malignant process. Obviously the process was a slowly grow- 
ing one and it had advanced to a considerable degree before the ini- 
tial hemorrhage took place. Evidently a vessel of some importance 
ruptured at that time. Had the bleeding been due to a general ero- 
sion of the affected area, bleeding would have taken place more con- 
stant since that time. The course of these lesions is relatively benign. 

CASE 6. — A unmarried lady aged sixty-five came to the hospital 
because of hemorrhage. 

History. — The patient passed the menopause ten years ago. Her 
present trouble began a year and a half ago. She had some pain 
much like that formerly accompanying the menstrual period. It 
would be present for several days in succession and absent for 
several days. The pain has been increasing in intensity but still 
not present every day. Four months ago the discharge from the 
vagina began. On some days the flow looked like pure blood and 
on others it was serosanguineous. The discharge has never been of- 
fensive. Her weight decreased thirty pounds in five months. Her 
appetite is good and she sleeps well. The bowels are not very regu- 
lar. 

Examination. — The patient is a well preserved woman for her age. 
The uterus is as large as a parous one, in position and movable. 
There is a polyp as large as a lead pencil protruding from the 
cervix. It is attached near the inner os and gives evidence of 
having recently bled, there being an eroded area covered with a 
clot on the surface. Otherwise she is well. 

Diagnosis. — The polyp is vascular and, bearing evidence of recent 
hemorrhage, seems sufficient to explain the bleeding. The polyp is 
attached in the canal of the cervix near the internal os. 



DISTURBANCES OF UTERINE FUNCTION 



935 



Treatment. — The uterine canal was dilated sufficient to give access 
to the base of the polyp. It was then destroyed with the cautery. 

Pathology. — The tumor presents the usual structure of a glandular 
polyp. 

After-course. — After the removal of the polyp the pain decreased 
and the discharge stopped. Her general condition improved and 
she gained some in weight. Two months later the discharge re- 




Fig. 417. — Carcinoma of the body of the uterus. 



appeared and in addition to the recurrence of her old pain she 
now complained of pain in the right groin. Reexamination showed 
the cervix free from disease, but the fundus rather larger than be- 
fore. The diagnosis now was of course carcinoma of the body of 
the uterus. Therefore, hysterectomy was performed. There were 
metastases along the tubes, but none other were discovered. The 
interior of the uterus was made up of a large amount of friable 
tissue (Fig. 417) which the slide shows to be carcinoma, in part 



936 



CLINICAL SURGERY BY CASE HISTORIES 



necrotic. The postoperative course was without incident until the 
tenth day when she had a violent chill. No cause for it could be dis- 
covered, but she was stuporous and lost her appetite. On the eight- 
eenth day both parotids became swollen and hard. The tempera- 
ture became irregular (Fig 418). Delirium set in on the twenty- 
first day, and she died without regaining consciousness on the 
twenty-fourth day. 



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Fig. 418. — Temperature curve during the period of parotid suppuration. 

Comment. — This case shows the result of superficial thinking, to 
put it in a charitable way. When a woman starts to bleed after 
a period of amenorrhea lasting ten years, with a uterus as large 
or larger than that normal to the child-bearing age, it can mean 
only carcinoma of the body of the uterus. The finding of the 
little polyp of the cervix offset all previous knoAvledge and ex- 
perience. Why she should have had temporary improvement is as 



DISTURBANCES OF UTERINE FUNCTION 937 

mysterious as why improvement follows some of our other therapeu- 
tic endeavors. "What the association may have been between this 
disease and the infection of the parotids I do not know. The only 
other like affection of the parotids I have seen occurred also 
in a case with carcinoma of the body of the uterus and metastases 
in the tubes and ovaries. 

CASE 7. — A widow aged fifty-eight came because of a bloody 
vaginal discharge. 

History. — The patient has had three children, the last thirty years 
ago. She passed the menopause at thirty-eight. She was lacerated 
with the first child and had a pelvic inflammation following. Fol- 
lowing this, intercourse was always painful. She never had ex- 
cessive flowing except for a short period following the birth of her 
second child. For a year or more she has had a bloody discharge 
from the vagina at times. She has much pain in the right side of 
the pelvis but this is relieved following the periodic discharge of 
pus. The discharge for the past few months is so constant that she 
wears a napkin. She had urethral trouble eight years ago and had 
a growth cauterized. She improved following this, but she still 
gets up several times a night. She has some pain in the tophead 
and epigastric burning at times. 

Examination. — The patient is slight in build and anemic in ap- 
pearance. Her hands show a moderate arthritis deformans. No 
other joints are appreciably affected, though she has occasional 
pains in various joints. The heart is not affected. The perineum 
is lax and shows the old laceration. The os is hard and smooth. 
The uterus is retroflexed, fixed and its outline can not be definitely 
made out. The fundus seems to widen from a narrow supravaginal 
portion. There is an offensive uterine discharge, yellowish white 
in color and containing a variety of organisms. 

Diagnosis. — A uterus that has long been dormant which begins to 
discharge a bloody fiuid is nearly always the site of a malignant 
tumor. The cervix here is free and the body is not large as when 
a carcinoma of the body is present. The flow of pus from the cervix 
is unlike the discharge from a malignant uterus. The diagnosis 
seems to be covered by the designation of the condition present, 
namely, a pyometrium. 

Treatment. — The attempt to explore the interior of the uterus met 
with difficulty, for no instrument could be made to enter the uterus. 



938 CLINICAL SURGERY BY CASE HISTORIES 

After some effort a Kelly forceps was passed, followed by a com- 
plete dilatation by larger instruments. As soon as the small forceps 
entered the uterus, there was a gush of foul smelling pus, amounting 
to several ounces. After the pus had escaped the interior of the 
uterus was swabbed with iodine and the interior explored with a 
curette. Nothing but a small amount of granulation tissue was 
obtained. A gauze pack was left in the uterus for twenty-four 
hours. 

After-course. — The patient went home in a week and has not had 
a recurrence of her trouble after five j^ears. 

Comment. — I really only intended the above treatment to be pre- 
liminary to a hysterectomy when local and general conditions should 
become favorable. The subsequent course has made further treatment 
unnecessary. It is interesting to note that following the drainage 
of the uterus the arthritis subsided. 

CASE 8. — A housewife aged sixty-four came for consultation be- 
cause of vaginal discharge. 

History. — About four months ago the patient noticed a whitish dis- 
charge from the vagina of considerable amount, tinged with a little 
blood. Vaginal douches were prescribed by her physician. These 
lessened the amount of discharge for a time. In one month there 
was an increase in the amount again and she consulted another phy- 
sician who diagnosed a possible carcinoma of the uterus and advised 
operation. The patient has borne four children, the oldest is forty- 
eight, youngest forty-two. She had two miscarriages both at two 
months following the birth of her last child. Her general health 
has always been good. She passed the menopause without dis- 
turbance twelve years ago. There has been no flow of any kind 
since that time until the present illness. Her appetite is not very 
good but she sleeps very well. She has some fullness over the lower 
abdomen and some slight pain under the short ribs on either side. 

Examination. — The patient does not look acutely ill and seems 
to be fairly well nourished. The abdomen is somewhat distended 
and there is a tympanitic note over the entire abdominal viscera. 
There is some tenderness over the abdomen especially in the right 
and left lower quadrant. No masses can be felt. There is a whitish 
discharge from the cervix, opening speculum caused pain. On 
palpation the upper end of the vagina seems constricted, barely 
admitting entrance of two fingers. The uterus can be felt on bi- 



DISTURBANCES OF UTERINE FUNCTION 



939 



manual examination to be as large as an orange. It seems smooth 
and fairly soft. Adnexa negative. No tenderness in the culdesac. 
W.b.c. 9,600 ; R.b.c. 4,832,000 ; Hg 80. The urine is without note. 

Diagnosis. — To find the uterus so large twelve years after the meno- 
pause indicates unequivocally carcinoma of the fundus. 

Treatment. — Vaginal hysterectomy was done. The uterus was 
pulled down with difficulty. The fundus was half again as large 




Fig. 419. — Granulomatous endometrium in' a case of pyometrium. 

as a parous uterus. When the uterine canal was opened into it 
was found to contain pus. There was a stenosis just outside the 
inner os. There was a growth in the cervical canal resembling car- 
cinoma along the cervicofundal line. Gauze pack left in pelvis. 
Eight hemostats left on blood vessels. 

Pathology. — The interior of the uterus is lined with a soft nodular 
material (Fig. 419). What was regarded as a possible malignancy 



940 CLINICAL SURGERY BY CASE HISTORIES 

at operation proves now to be too soft. The slide confirms the gran- 
ulomatous character of the tissue. 

After-course. — The patient did not suffer from surgical shock 
but was extremely nauseated and vomited several times following 
the operation. The temperature the first day 99, pulse 90. The 
after-course was very little disturbed, the highest temperature 
w^as 101, pulse 90, of good quality. The gauze packs and hemostats 
were removed the fourth day. The patient continued to improve 
and was dismissed on the nineteenth postoperative day, feeling well. 
Vaginal tract drawing together at upper end, still a small amount 
of discharge. She has remained well. 

Comment. — The smoothness and softness of the fundus should 
have given a clue to the correct diagnosis. The bloody discharge 
is unusual in pyometrium and likely the diagnosis was subcon- 
sciously made before the diagnosis was undertaken. A dilatation 
and curettage would have cured the patient. 

CASE 9. — A matron aged thirty-four came because of prolapse of 
the uterus. 

History. — The patient has four children and had one miscarriage 
at three months eight years ago. She has had a prolapse since the 
birth of the first child twelve years ago, but it is much worse 
since the birth of the last child five months ago. She has a burning 
pain in the left side. The general health is good but for some 
years she has been nervous and has had difficulty in going to sleep. 
She is most nervous just before menstruation. The flow is regular 
and lasts four or five days. 

Examination. — The patient is a slightly built woman with a worn 
apprehensive look. The general examination is without note. The 
perineum is lacerated to the second degree and the cervix is lac- 
erated and lies just within the introitus. The fundus lies on the 
rectum, is large, movable and sensitive to pressure. 

Diagnosis. — The patient ascribes all her troubles to the displaced 
uterus, and, as a matter of fact, if a displacement is capable of pro- 
ducing trouble, then surely there is justification in her opinion. 
That there is need for correction is clear. Having four children 
and having had one miscarriage it seems justifiable to make cer- 
tain of correcting the difficulty by doing a ventrofixation. She 
seems below par and though there is no definite premarital com- 
plaint she is of the type that does not recover fully. 



DISTURBANCES OF UTERINE FUNCTION 941 

Treatment. — The perineum and cervix were repaired and then the 
uterus drawn through a Pfannenstiel incision. The upper portion 
of the fundus was excised and the remainder of the fundus fixed 
in the fascia. 

After-course. — The wound healed without event but when she be- 
gan to menstruate blood forced its way through the scar. For a 
period of months she passed a part of the menstrual flow through 
the abdominal sinus. She was relieved of her symptoms otherwise. 
In order to relieve the complication, the sinus was excised down 
into the cavity of the uterus and several deep sutures placed in 
the remainder of the body of the uterus. This relieved the condi- 
tion. She returned after eight years complaining of inability to 
sleep, pain in the back of the neck and constant nervousness. The 
menses are regular, last four days, are painless, and are not at- 
tended by an exacerbation of the nervous phenomena. The uterus 
was fixed in position, the fundus firmly fixed in the fascia but the 
lower portion freely movable. The bladder did not sag. There was 
no physical reason for her nervousness. She had nursed a member 
of her own family through a long illness and her increased nervous- 
ness followed this period of strenuous physical exertion and mental 
apprehension. 

Comment. — ^Ventral fixation is the most effective way of reme- 
dying a prolapse. If the insertions of the tubes are not resected 
in the course of the operation they must be obliterated so that 
pregnancy can not take place. I had one other patient that dis- 
charged menstrual blood through such a sinus. In both instances 
the cervical canal seemed to be perfectly free, and there was no 
reason why the blood should force itself upward. When it is nec- 
essary to open the uterine canal in such cases the fascia after 
being fixed into the fundus should be fastened together above. 
In this patient the pelvic condition was only a contributory cause 
to her general ailment. The care of the sick relative brought on 
the same train of symptoms that the pelvic disturbance did. In 
such cases the patient as well as the disease must be treated. 



CHAPTER XVII 

DISEASES OF THE ABDOMINAL WALL 

Diseases of the abdominal wall are numerous and aside from curi- 
osities are of minor importance. Many intraabdominal diseases 
simulate affections of the parietes, consequently the relationship 
must be determined. 

TUMORS IN THE REGION OF THE ABDOMINAL RING 

Usually when a tumor is discovered in the region of an abdominal 
ring a hernia is at once diagnosticated. Inflammatory affections 
and tumors may occur independent of hernias or may complicate 
them. When a hernia is demonstrated the possible existence of 
other affections must be remembered. 

CASE 1. — A widow aged fifty-six came because of a tumor in her 
groin which causes pain when she is on her feet. 

History. — The patient has had frequent attacks of gallstone colic 
according to her physician and periodic attacks of bronchitis with 
persistent cough. This trouble has nothing to do with the attacks 
in her groin according to her. For some years she has had a lump 
in her groin which never fully disappears. She has no trouble 
when lying down. When on her feet, particularly when doing work 
which requires standing, she has much pain and is often compelled 
to lie down. 

Examination. — The patient presents physical evidence that she 
is correct in the diagnosis of the accessory disease. In her right 
groin is a tumor the size of a turkey egg (Fig. 420). It lies below 
Poupart's ligament but partly overrides it. It is but little movable 
and obviously terminated in the foramen. It can not be reduced 
but attempts at reduction do not cause distress. 

Diagnosis. — Its location is that of femoral hernia. Its consistency 
and irreducibility suggests an irreducible femoral hernia. Against 
a lipoma is the story of increased pain when long on her feet and 
the relief afforded by assuming the recumbent position. Occasion- 

942 



DISEASES OF THE ABDOMINAL WALL 



943 



ally an imprisoned omental hernia is attended by jaundice and pe- 
riodic colic attacks which are relieved by the repair of the hernia. 
Its repair seems indicated. 




Fig. 421. — Femoral hernia masked by lipoma. 



944 CLINICAL SURGERY BY CASE HISTORIES 

Treatment. — The tumor was exposed under local anesthesia. It 
proved to be a mass of fatty tissue in the center of which was a small 
peritoneal sac (Fig. 421). This was ligated and the mass removed. 

Pathology. ^-The tissue removed is a pure lipoma containing in it 
a small peritoneal sac. 

After-course. — Healing w^as uneventful. The patient was allowed 
to get up on the tenth day. As soon as she was on her feet she 
exclaimed to the nurse that she had her trouble just as before. 
An examination in the standing position revealed an interstitial 
inguinal hernia. The tumor we removed she declared had been there 
many years and had never caused any trouble. The patient lived 
many years with her inguinal hernia. She had many attacks of typ- 
ical gallstone colics. Later she developed a diabetes, had several 
attacks of cerebral hemorrhage, and finally died in diabetic coma. 

Comment. — Had she been examined in the standing position or 
had the inguinal canal been examined during the operation the 
oversight would not have occurred. If femoral hernias are operated 
on through the inguinal canal such oversights are not possible. 
It seemed during the operation that the pulling of the lipoma on 
the peritoneal sac fully explained her pains when she was much on 
her feet. As an example of logic it was very good, but the conclu- 
sions were fallacious. This case shows the far-reaching results 
of error. She refused to have the inguinal hernia repaired because 
of the failure of the first operation to secure relief from her 
trouble. She refused to have the gall bladder removed for the 
same reason. The diabetes likely resulted because of the persist- 
ence of the gall bladder trouble, and as a result of the diabetes 
she died — albeit at the advanced age of seventy-eight years. 

CASE 2. — A seamstress aged forty-three came to the hospital be- 
cause of a mass in the left groin. 

History. — About six years ago the patient noticed a small mass 
in the left groin. This has gradually grown to about the size of 
a walnut. It is not reducible by pressure. It does not disappear 
or change in size on lying down. It causes no symptoms that she 
is aware of, is never painful or even tender. It feels the same 
whether she is on her feet a great deal or whether she sits in a 
chair all day to work. She has been very nervous the last few 
years and her physician attributed it to the tumor which he diag- 
nosed hernia, not specifying what type. She has no bladder dis- 



DISEASES OF THE ABDOMINAL WALL 



945 



turbance of any kind. Her appetite is good, but her bowels are in- 
clined to be constipated. She has no shortness of breath, or swell- 
ing of the face or extremities. No palpitation of the heart. Her 
menses are regular, flows four to five days, rather scanty, no pain. 
Has never been married. She had the usual diseases of childhood, 
not sick since but for many years she has had more or less difficulty 
breathing through her nose. She catches cold very easily and the 
left side of the nasal passage is occluded very easily. 

Examination. — The patient is emaciated but looks to be in fair 
health. She looks older than the age given. Pupils equal, regular, 
react to light and accommodation; no exophthalmos, ptosis or 




Fig. 422. — Cyst of the canal of Nuck. 

nystagmus. There is a large exostosis on the left side of the nasal 
septum. It is wedge-shaped extending back about II/2 cm. The 
lower turbinates on both sides are swollen and congested. Teeth 
are in good repair. The chest negative, the abdomen scaphoid, 
no palpable areas of tenderness. There is a mass the size of a wal- 
nut below Poupart's ligament just outside the external ring and 
extends down into the labia majora. It is movable, feels cystic, and 
it can not be reduced. 

Diagnosis. — The mass is evidently cystic. It occupies the terminal 
area of the round ligament and must, therefore, represent the 



946 CLINICAL SURGERY BY CASE HISTORIES 

canal of Nuck. Its contents are too evidently fluid to admit the 
question of irreducible omental hernia and it does not lie in the 
region of the femoral canal. The tumor is evidently innocent and 
its removal can not influence the general symptoms of which she 
complains. However, she is determined upon its removal and doing 
so may give her some mental comfort. The nasal obstruction ob- 
viously requires correction and this it may be hoped will aid her 
general well-being. 

Treatment. — A cyst the size of a hen's egg lay just outside the 
left external inguinal ring and was continuous with the round liga- 
ment. It was removed. The cyst was egg-shaped (Fig. 422) and 
was filled with a clear straw-colored fluid. The cyst wall is composed 
of a fibrous capsule lined by endothelial cells. 

After-course. — The recovery was normal, entirely uneventful. The 
wound healed by primary union and caused no disturbance of any 
kind. Ten days after the first operation the nasal exostosis on left 
side was resected. Recovery uneventful. On dismissal two weeks 
after the first operation the inguinal w^ound was entirely healed. 
Left nasal passage well open. 

Comment. — Lesions of small clinical significance in persons who 
are nervous should receive dignified and respectful consideration. 
Persons without outside interests are apt to magnify small defects 
and ailments. A small wart to the spinster is of more social impor- 
tance than the ninth son of a prolific mother and the belittling 
of it is more apt to produce resentment. 

CASE 3. — A housewife aged seventy-nine was broug-ht to the hos- 
pital because of a mass in the right groin and pain in the right groin 
and over the lower abdomen. 

History. — For many years she has had a small lump in the right 
groin. Several times in the last few years she has had sudden at- 
tacks of vomiting lasting from a few hours to a day, for w'hich 
there was no apparent cause. Three days before entering the hos- 
pital she took a cathartic and that evening she complained of a 
pain in the region of her hernia. She ate some supper and vomited 
once soon afterward. She has not vomited since. The pain in the 
region of the hernia became worse and she had general abdominal 
pain. The pain was quite severe. The next day her daughter, who 
is a trained nurse, noticed the mass was considerably enlarged and 
was tender to pressure. She developed a fever of 100 and had some 



DISEASES OF THE ABDOMINAL WALL 



947 



abdominal distention which was relieved by enemas. The above con- 
dition remained constant up to the time of entrance into the hos- 
pital. Her general health has always been good save for a pneu- 
monia twenty-two years ago and again four years ago. 

Examination. — The patient is well nourished and does not look 
acutely ill. The abdomen is markedly distended and tympanitic. 
There is no abdominal tumor or area of tenderness. In the right 
groin is a mass oval in shape extending below Poupart's ligament 
which is the size of a small egg. It feels extremely hard and is 
very tender to pressure. 



' 


^ 








J 



Fig. 423. — Abscess in a lipoma of the femoral ring. 



Diagnosis. — Right strangulated femoral hernia. 

Treatment. — Repair of right-sided strangulated femoral hernia. In 
addition a tumor the size of a hen's egg was removed. It appeared 
like a mass of omentum permanently adherent in sac. 

Pathology. — On cutting into the mass a pocket of pus the size of 
a hazelnut was found (Fig. 423). This pus yielded on culture a Gram- 
negative coccus and a bacillus. Surrounding this was a lipomatous 
mass much infiltrated with leucocytes. 

After-course. — The patient complained very little of pain, tem- 
perature not above 99.6°, pulse 88 for two days. On the third post- 



948 CLINICAL SURGERY BY CASE HISTORIES 

operative day the patient seemed irrational, tried to remove dress- 
ings from the Avound and to get out of bed. The temperature was 
normal and there was no abdominal distention or pain. This dis- 
turbance was only temporary, the patient became normal the fol- 
lowing day and made an uneventful recovery. There was no swell- 
ing or tenderness over scar when patient was dismissed nine days 
after operation. 

Comment. — Apparently the lipoma had existed many years. The 
partial obstruction probably yielded the bacteria that caused the 
infection. 

CASE 4. — A married woman aged thirty-five came because of pain 
in the right groin. 

History. — Three years ago the patient began having pain above 
and to the right of the pubis extending as far out as the hip 
bone. It was most pronounced at the menstrual period. She had 
a badly lacerated perineum with some prolapse of the uterus and 
a slight laceration of the cervix. The pains were regarded as of 
ovarian origin and her laceration and displacement were repaired 
but the pain in the side returned after she began to be about on 
her feet again. She felt better in general but the original pain per- 
sisted. She returned in two years complaining of a tumor in her 
groin which she had not noticed before. She stated that some 
months before the appearance of the tumor she had relief from her 
old pain. 

Examination. — There is a protuberant mass above and to the right 
of the mons extending over the lower end of Poupart's ligament. 
When lying down this disappears and an opening can be felt. 

Diagnosis. — It is very obviously a right inguinal hernia. 

Treatment.- — A herniotomy was done. A tag of omentum was 
firmly attached to the bottom of the sac. When this was pulled 
upon it proved to be the infundibulo-pelvic ligament. It so pulled 
upon the ovary that a plastic had to be made of the peritoneum in 
order to allow the ovary to recede from the internal ring. 

After-course. — The hernia is cured and the pains are gone. 

Comment. — The pain complained of was regarded as of ovarian 
origin. Most likely there was traction on the ovary by the sac 
and pain was thereby caused. At any rate a hernia was not sus- 
pected until the patient exhibited her tumor. It has been my 
experience that women suffer more pain in inguinal hernias than 



DISEASES OF THE ABDOMINAL WALL 



949 



men do. I have learned, in operating on inguinal hernias in women, 
to determine the location of the ovary and if it is near the hernial 
opening to so loosen the peritoneum that the ovary may recede to 
somewhere near its normal position. I have found the ovary high 
in so many cases of inguinal hernias that I have come to believe 
there is some developmental connection between the high position 
of the ovary and the persistence of the peritoneal tube in the in- 
guinal canal. Conversely, when doing operations within the pelvis 
and the ovary is found near the pelvic brim without obvious cause, 
it is well to inspect the internal ring for a possible hernia. 

CASE 5. — A business man aged thirty-two came because of pain 
and tumor of the groin. 

History. — For about nine months he has noticed a dragging pain 
in his right groin. It is particularly pronounced after strenuous 




Fig. 424. — Inguinal hernia masked by lipoma. 

exercise. There has never been fever or nausea. Ten days ago he 
was examined by his family doctor who found a small tumor and 
diagnosticated hernia and advised its repair. His general health 
is excellent. 



950 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — The general appearance of the patient is that of 
perfect health. Above Poupart's ligament is a small enlargement 
which is not painful neither is it reducible. The external ring easily 
admits a joint of a finger which receives a distinct pulse when 
the patient coughs. 

Diagnosis. — An enlargement within the inguinal canal which gives 
impulse on coughing must be an incomplete hernia. It is irreducible 
yet causes but little inconvenience and must therefore be omental. 

Treatment. — When the inguinal canal was opened, a fatty mass 
the size of an egg appeared (Fig. 424). It separated readily from 
the cord and could be followed with suspicious ease down to the 
internal ring. A search at the pedicle disclosed a teat of peri- 
toneum the size of a sharpened end of a lead pencil and had to 
be opened into before it could be positively identified as a peri- 
toneal sac. It Avas ligated and the tumor removed. 

Pathology. — The mass removed was a typical lipoma. 

After-course. — He was relieved of his symptoms. 

Comment. — This tumor must have attained some size before his 
troubles began. The small sac seemed to be due to traction by the 
lipoma. It is not at all uncommon to find lipomas alongside of 
hernial sacs, but usually they are relatively small in comparison 
to the size of the hernial sacs. The diagnosis of irreducible omental 
hernia was unnecessary. Early hernias do not have fixed omental 
contents. On the contrary, a dragging pain coming on early is 
particularly suggestive of a lipoma. Besides this young man was 
disposed to be rotund. These individuals are particularly likely 
to have lipomas. 

CASE 6. — A merchant aged thirty-six came because of discomfort 
from a lump in his groin. 

History. — For a number of years he has noticed a lump in his 
groin. It causes considerable discomfort at times but disappears 
when he lies down. For some months he has had some pain higher 
up in the groin and believes he is developing another hernia. His 
general health is good. 

Examination. — The patient is a large, powerful man. When he 
stands a bulging appears over the external ring and a bulging 
higher in the groin (Fig. 425). Both these give an impulse on 
coughing and can be easily reduced when he lies down. 



DISEASES OP THE ABDOMINAL WALL 



951 



Diagnosis. — The lower mass is evidently an indirect inguinal hernia. 
Most likely the upper one is a hernia which escapes from the internal 
ring and then passes upward and outward between the abdominal 
muscles. 

Treatment. — An incision was made parallel to and just above 
Poupart's ligament. The inguinal canal was opened and no sac 
found about the cord. The femoral ring was explored and a shallow 
pocket admitting the terminal phalanx was present. The sac could 
be made to ascend over Poupart's ligament. The mouth of the 
opening was unusually broad. The sac was pulled upward by mak- 
ing traction above Poupart's ligament. The cord was searched for 
a sac near the internal ring but none found. The peritoneum was 




Fig. 425. — Femoral and interstitial hernias. 



opened and above the entrance of the cord was a pouch lying be- 
tween the external and internal oblique muscles. It was as though 
nature had done a Koeher operation — and had not done it well. 
This sac Avas ligated and removed. 

After-course. — Healing was uninterrupted and there has been no 
recurrence, now seven years. 

Comment. — A femoral hernia in a young man is not common and 
an interstitial hernia likewise is uncommon. I came near overlooking 
the upper hernia despite the patient's protest that he felt a dis- 
tinct bulging. He could not produce it by coughing, however, dur- 
ing the operation (operating under local anesthesia). Care in study- 
ing the loAver one should have made its nature apparent. 



952 



CLINICAL SURGERY BY CASE HISTORIES 



CASE 7. — A housewife aged fifty-five entered the hospital be- 
cause of pain in the lower half of abdomen when lifting and the 
sense of falling- out of the pelvic contents. 

History. — The patient has two living children, two died in infancy. 
No miscarriages. She reached the menopause four years ago and 
has had no flow of any kind since that time. She complains of 
dragging down pain of dull aching character in whole lower half 





Fig. 426.- 



-Schematic presentation of the traction produced by the deposition of fat about 
the umbilicus. A. Cross section. B. As viewed from surface. 



of the abdomen. This pain is worse when she moves around or tries 
to lift anything. It has bothered her for about two years. She 
also had dull aching pain in left lumbar region during the same 
period. Two years ago she noticed a sense of fullness in the re- 
gion of the navel. This has gradually grown worse. For one year 
she has had difficulty in holding her urine and gets up two to three 



DISEASES OF THE ABDOMINAL WALL 



953 



times each night to urinate. She also has pain on urination and 
afterwards. The bowels move regularly but she has to strain con- 
siderably during defecation. She had severe laceration during the 
birth of her first child. At times she gets bloated considerably. 
She has sAvelling of her feet at times, especially if she is on her 
feet much. She has considerable shortness of breath when going 
upstairs. 

Examination. — She is a large, obese woman. Blood pressure 175- 
80. Head, neck, and lungs negative. The heart is not enlarged 
and there are no murmurs but the second aortic sound is accen- 
tuated. There is a bulging at the umbilicus, especially on coughing. 




Fig. 427. — Diagrammatic presentation of a cross section of the abdominal wall in the 
region of a beginning umbilical hernia. The increased layer of fat between the superficial 
fascia and the recti muscles seems capable of producing traction on the umbilicus, thereby 
inverting it and thus inviting a hernia. 



The umbilicus is deep and a finger placed therein perceives an im- 
pulse when she coughs. There is laceration of the perineum with 
extensive relaxation and a rectocele. There is an equally promi- 
nent cystocele and a urethral caruncle as large as a bean. The cer- 
vix is just within the introitus when she is in the recumbent pos- 
ture. The urine is 1.012, contains much pus with albumin corre- 
sponding, but no casts or blood. 

Diagnosis. — There is obviously an umbilical hernia. A lacerated 
perineum, a cystocele and rectocele and a urethral caruncle. The 
prolapse is sufficient to account for the discomfort in the lower 
abdomen. The urethral caruncle, as well as the cystocele, each 



954 CLINICAL SURGERY BY CASE HISTORIES 

might well account for the A-esical irritation. The albumin is nearly 
all removed by filtering out of pus cells, and since there is an ab- 
sence of formed elements in the urine it seems safe to assume that 
the albumin present is due to the presence of pus. The umbilical 
hernia does not seem to add much to the list of complaints. Inas- 
much as an abdominal fixation is required, its repair may be added. 

Treatment. — The urethral caruncle was resected. The perineum 
was repaired, and this, together with the abdominal fixation, was 
depended upon to hold up the bladder. The fixation was made 
through a vertical incision. This incision was extended upwards 
through the fat to the umbilicus. A cup-like depression was formed 
which admitted the terminal phalanx of the thumb (Fig. 427). It was 
empty. It was excised and the defect closed by lateral overlapping. 

After-course. — There was a normal postoperative recovery. At 
dismissal there was considerable induration in the scar line which 
was sensitive to pressure. The perineum was entirely healed and 
formed a good support for the bladder. 

Conirnent. — This seemed to present the earlier stages of an um- 
bilical hernia. The traction of the fatty layer seems capable of 
producing traction on the umbilicus producing a pit (Fig. 426). 
This is no doubt aided by the increased abdominal contents but 
there is no evidence to show that the intraabdominal pressure is in- 
creased in fat individuals. The relaxation of the abdominal walls 
seems to go apace with the increase in bulk of the intraabdominal 
organs due to the deposition of fat. The difficulty in reintroduc- 
ing the abdominal contents into the abdomen when closing the 
incision in the abdomen of fat folks seems to be due to the solid 
character of the contents rather than increase of pressure. In- 
crease of pressure during muscle contraction depends on the power 
and toxicity of the muscles. If intraabdominal pressure were the 
important factors in the production of umbilical hernia, the athlete, 
and not the fat, leisurely matron, should be most commonly af- 
flicted. Most assuredly pinning the shoulders of an opponent to the 
mat increases the intraabdominal pressure more than the calling 
for a second helping of cheese. Once omentum gains entrance in 
an umbilical hernia the irritation attaches it and then evidently 
an increased deposition of fat adds to the bulk of the omentum 
imprisoned in the umbilical ring. At any rate those afflicted with 
an excess of adiposity are the most likely victims of umbilical 
hernia. 



DISEASES OF THE ABDOMINAL WALL 955 

TUMORS OF THE ABDOMINAL WALL PROPER, INCLUDING 

FISTULA 

The abdominal wall harbors desmoids aiid certain types of sarcomas. 
Slowly developing inflammatory affections both in the wall and be- 
neath it may simulate tumors. 

CASE 1. — This patient aged fifty-one came because of prolapse of 
the uterus. 

History. — The patient has always had dysmenorrhea. She married 
at twenty and has had five children. She noticed a prolapsus after 
the birth of her last baby. She has always had headaches and back- 
aches which were more pronounced at her periods. These have been 
much worse since the last baby Avas born, sixteen years ago. She 
has always been constipated. The menses stopped one and a half 
years ago. Since then her headaches and backaches have been bet- 
ter, but are still present. She has worn a pessary for prolapse 
with some relief. Last August she had a sudden attack of abdom- 
inal pain in the right lower abdomen. She was in bed three weeks. 
The trouble was diagnosed appendicitis b}^ her physician. When 
she got up she felt a lump in the abdominal wall at the site of the 
pain. Six months later she had pain again in the same region and 
the spot looked inflamed. During March the patient felt pretty 
well. 

Examination. — To the right of the median line, above the anterior 
superior spine she has a tumor 1x2 inches in size. The mass is 
still palpable when the abdominal muscles are put on tension and 
can be lifted with the abdominal wall. There is a moderate recto- 
and cystocele. The uterus is retroverted and the cervix presents 
in the introitus. The pelvic condition requires no comment. The 
tumor in the abdominal wall is dense elastic, is free from the 
muscle walls, yet it is not encapsulated. It has the relation to 
environment and consistency of a desmoid, though the onset sug- 
gested an inflammatory origin. 

Treatment. — Fixation of the uterus and perineorrhaphy, together 
with excision of the abdominal wall tumor Avas done. The mass was 
not encapsulated and fused gradually with the surrounding tissue. 
In removing it a part of the external oblique muscle had to be 
sacrificed. One could not be certain that all the affected tissue 
was being removed. 



956 CLINICAI; SURGERY BY CASE HISTORIES 

Pathology. — The tumor is very hard to the touch and fairly grates 
when cut. The cut surface is pearly and presents irregular wavy 
lines. The slide shows the edge to be intimately attached to the 
external rectus muscle. The fibrous bundles present intimate inter- 
digitations into the muscle bundles. There are a small number of 
small and medium sized cells with ovoid nuclei. It is evidently 
a dermoid. 

After-course. — Healing was uneventful. After four years there is 
no disability save a slight bulging where a portion of the external 
oblique was removed with the tumor. 

Comment. — The origin of desmoids shows many of the features of 
a subchronic inflammation simulating certain types of woody phleg- 
mons and may very well, it seems to me, represent an organizing 
stage of such a process representing a midstage between inflammation 
and sarcoma. 

CASE 2. — A married woman aged thirty-six came because of curi- 
ous tumors at the edge of her arm pits. 

History. — Since puberty she has been annoyed by swellings at 
the anterior edge of the arm pits. She first noticed them at the 
beginning of menstruation and at a previous labor they secreted 
milk for a time and afterw^ards became painful. After this labor 
the same process was repeated, but instead of subsiding, the right 
one became red and excessively sensitive to touch. 

Examination. — At the anterior border of the right axilla, partly 
overhanging the edge of that muscle, is a flat mass carrying on the 
surface perfect little nipples with glandules of Montgomery and 
all. It is indurated and contains a small softened area. On the 
left side is a similar one but it is not inflamed. 

Diagnosis. — The history and appearance is typical of accessory 
mammae and the location is the most common for this anomaly. The 
right one evidently contains an abscess. 

Treatment. — The softened area was incised and drained. It con- 
tained a dram of pus. 

After-course. — Healing took place in a week. 

Comment. — There was no inflammatory disturbance of the normally 
situated mamma. The source of the infection above described was 
not determined. It must have taken place through its own little 
nipple. 



DISEASES OF THE ABDOMINAL WALL 957 

CASE 3. — A maiden lady of thirty-four came because of a tumor 
on her right side. 

History. — The patient has had a tumor on her side for some twelve 
years. It has never caused any pain but recently it has become larger 
and comes in contact with her elbow when engaged in the gentle 
art of hoeing potatoes. The corset has nothing to do with the ir- 
ritation of this tumor for the simple reason that she has never worn 
one. Her general health has always been good. 

Examination. — The tumor is the size of a base ball. The summit 
is covered by a thinned skin which is reddish brown in color. Half 




Fig. 428. — Bald-headed endothelioma of the abdominal wall. 

way down the side of the tumor this skin abruptly terminates in 
the normal skin of the abdomen. (Fig. 428.) On palpation this 
thinned skin is felt to be intimately attached to the tumor, while the 
normal skin is not attached, but glides freely over the tumor. The 
tumor itself is dense elastic and is wholly insensitive to any manipu- 
lation. The whole mass moves on the deep fascia. 

Diagnosis. — This is a representative of a type of tumor appar- 
ently not clearly defined in the literature. It is characterized by the 
thinned skin on the surface, slow growth and apparent encapsula- 



958 



CLINICAL SURGERY BY CASE HISTORIES 



tion. Because of the peculiarity of the skin covering the surface, I 
have called them "bald-headed" sarcomas. 

Treatment. — An elliptical incision was made half an inch below 
the junction of the thinned and normal skin. The capsule of the tu- 
mor was freely excised along with tlie tumor. 

PatJiology. — On section this tumor was pearly pinkish, showing 
areas of fine granulations. On section it was made up of strands 
of spindle cells for the most part, but certain areas were made up 
of a network of epithelioid cells giving the general structure of 
an endothelioma. The majority of these tumors are made up of either 
endothelioid or spindle cells. 

After-course. — The tumor did not return. 

Comment. — The apparent encapsulation of these tumors leads to 
their being simply shelled out. When so operated on, they invariably 
recur. They must be removed widely, capsule and all. 

CASE 4. — A professional man aged forty-eight came because of a 
tumor above Poupart's ligament. 

History. — Has had a tumor above his hip bone ever since he can 







Fig. 429. — Accessory mammary gland in male. 



remember. It has caused no trouble, but since his mind has been at- 
tracted to tumor possibilities because of malignancy in other mem- 
bers of the family, he desires to know its nature. 



DISEASES OF THE ABDOMINAL WALL 



959 



Examination. — A tumor 5x7 cm. is located directly above the an- 
terior superior spine (Fig. 429). It is 2 em. thick and is mounted 
by a small conical projection. A pigmented area surrounds this, about 
the periphery of which are large glands. The tumor mass is made 
up of soft fatty tissue with smaller, firmer nodules scattered here and 
there in its substance. 

Diagnosis. — The size and shape of this tumor is identical with that 
of a mammary gland just beginning to show signs of puberty. 

Treatment. — None. 

Comment. — The interest in these conditions is solely one of diag- 
nosis, since none of those yet observed has been the seat of a patho- 
logic process. 

CASE 5. — A woman of forty-two came to the hospital because of 
a tumor in her groin. 

History. — Three years ago she noticed a lump in her groin. It 
was as large as a Avalnut when she first discovered it. It caused 




430. — Fibrosarcoma of the inguinal region. 



no pain and she did not consult her physician until it had attained 
the size of an orange. He removed it by injecting a local anesthetic 
and shelling it out. She w^as free from disturbance for nine months 
when she noticed another tumor in the same site. It has grown in 



960 



CLINICAL SURGERY BY CASE HISTORIES 



the past year and a half to its present size. Three weeks ago the 
skin over the end of it became ulcerated and a bloody fluid has 
escaped from it. Her general health has been good. 

Examination. — An irregular tumor the size of a fist hangs from the 
iliopubic region (Fig. 430). It is attached at its base but the bulk 
of it can be moved from side to side. The greater portion of the tumor 
is firm elastic. The ulcerated nodule is soft, and pressure on it 




Fig. 431. — Bald-headed sarcoma. 



causes the escape of a black fluid. There are no lymph glands palpa- 
ble in this region or elsewhere. 

Diagnosis. — The history of a relatively encapsulated tumor in this 
region which has recurred after removal is indicative of a type of 
sarcoma indigenous to this region. The tendency of the surface 
to ulcerate is characteristic. 



DISEASES OP THE ABDOMINAL WALL 



961 



Treatment. — A wide dissection was made exposing the deep fascia 
in the entire region. A sliding flap was required to fill the defect. 
Drainage was used in the lower angle of the wound. 

Pathology. — On section the tumor is whitish pink and a wavy fi- 
brous arrangement can be made out (Fig. 431). Near the ulcerated 
area the tissue is degenerated and there has been a hemorrhage. The 
slide shows a fibro-sarcoma (Fig. 432). 

After-course. — The patient has been free from recurrence for two 
years. 




Fig. 432. — Spindle-celled sarcoma of the groin. 



Comment. — These tumors are by no means uncommon, and it is 
the common experience that some operators shell them out with 
inevitable recurrence. Complete reoperation sometimes secures per- 
manent results, but usually recurrence follows. On the other hand, 
if their importance is appreciated and an initial wide dissection as 
here indicated is made, permanent relief may confidently be ex- 
pected. There is no tumor that recurs in the groin that may prop- 
erly be ''shelled out." 



962 CLINICAL SURGERY BY CASE HISTORIES 

INFLAMMATORY INFECTIONS INVOLVING THE ABDOMINAL 

WALL 

Infections involving the abdominal wall are usually the product 
of disease beneath seeking exit. Their interpretation implies usually 
a search of the more important affections. 

CASE 1. — A widow of sixty-eight was brought to the hospital be- 
cause of a strangulated hernia. 

History. — She has had a femoral hernia for many years. It has 
been strangulated a number of times, but she has always been able 
to have it reduced by her physician. Ten days ago it came down, 
but after trying for some time, it could not be reduced. It gave her 
no particular trouble and she allowed it to remain. Two days 
ago it became more painful and she vomited repeatedly on the 
morning of the day of entrance and the pain was much increased. 

Examination. — The patient is a slight w^oman but seems to be in 
good general health. She gives no evidence of suffering or intox- 
ication. There is a general moderate tympany but the abdomen 
is everywhere soft and without tenderness. There is a mass below 
Poupart's ligament on the left side. The skin is somewhat reddened 
and is sensitive to pressure. 

Diagnosis. — The long duration of the imprisonment indicates that 
an irreducible condition rather than a strangulation existed until 
the past twenty-four hours. Events now indicate an infection or a 
necrosis which is irritating the surrounding tissues. The vomit- 
ing and tympany suggest an irritation of the gut wall rather than 
an obstruction of its lumen. At any rate intervention is indicated. 

Treatment. — The lesion was exposed under local anesthesia. A 
loop of gut some four inches long was imprisoned in the femoral 
ring. When first exposed, it appeared blue black (Fig. 433). 
When released, the circulation soon became established so that it 
became brownish pink. Pressure blanched it but the color at once 
returned. A ring a quarter of an inch wide did not show this res- 
toration. It seemed so narrow that some reinforcing Lembert su- 
tures were employed to cover it. The gut Avas then returned to 
the abdomen and a drain placed through the ring into the abdo- 
men. Should a leak occur it seemed likely the worst that might 
happen would be a fecal fistula. 



DISEASES OF THE ABDOMINAL WALL 



963 



After-course. — The operation did not inconvenience her. She 
seemed comfortable for a day or two, but after this time she devel- 
oped a temperature which ascended as high as 103.5°. She seemed 
perfectly comfortable and her appetite remained good. There was a 
local suppuration and the temperature was ascribed to this. The 
temperature continued and she showed evidence of sepsis. This con- 
dition progressed and she died on the eighth day. Examination 
showed a generalized infection involving some loops of gut and 
the adjoining tissue. There was no evident leak in the gut. Ob- 




Fig. 433. — Necrosis of a loop of ileum in a case of strangulated femoral hernia. 

viously there was a generalized infection by bacteria which escaped 
from the gut wall. 

Comment. — It would have been best to have left the loop of gut 
entirely outside the wound. A fecal fistula likely would have been 
formed but this could have been dealt with at the proper time. Im- 
mediate resection would have been technically easy, but the mor- 
tality following this procedure is too high to make it the opera- 
tion of choice. Where the gut is not viable the establishment of 
a fecal fistula with subsequent resection gives a less mortality than 



964 CLINICAL SUllGEtJY BY CASE filSTORIES 

immediate resection. The method employed in this case was the 
worst of all. Unless the circulation in an impaired gut is returned 
promptly the jeopardized loop should be fixed outside the wound. 

CASE 2. — A merchant aged forty was broug-ht to the hospital 
because of a strangiilated hernia. 

History. — The patient has had a hernia since boyhood. For many 
years it was retained by a truss but in recent years it has been 
indifferently held and much of the time he has abandoned the truss 
entirely. Ten days ago his hernia remained out and became very 
painful. Attempts at reduction failed. No symptoms of obstruc- 
tion developed but the area became more painful and he developed 
fever. He has had a severe nephritis for a number of years and 
his surgeon feared to give him a general anesthetic, but since the 
condition is increasing in severity, operation under local anesthesia 
seems imperative. 

Examination. — The patient is a slight person, as indicated by her 
presents a puffy face and slightly swollen ankles, despite a ten- 
day incumbency in bed. The apex is in the anterior axillary line, 
diffuse but faint. The left scrotum including the inguinal region 
is swollen and edematous. The affected area is sensitive to pres- 
sure. The induration extends a handbreadth above Poupart's liga- 
ment and medial to the anterior superior spine. The urine contains 
albumin and casts. Pulse 110, temperature 102.5°. 

Diagnosis. — The history of old hernia, recently neglected, and now 
inflamed and painful, suggests thrombosed, irreducible omental hernia. 
It requires operation and even under local anesthesia presents a 
problem of some gravity. 

Treatment. — An incision under local anesthesia was made from 
the midpoint of the scrotum to near the anterior superior spine. 
The root of the scrotum and the perineum was infiltrated in order 
to block the long perineal nerves as it was anticipated that the 
omentum would be adherent in the scrotum. When the hernial con- 
tents were exposed it was found to consist of a blue-black mass. 
This mass extended throughout the inguinal canal. It was dis- 
lodged and withdrawn through the internal abdominal ring. Within 
the abdomen was a twist in the omentum above which the omentum 
was normal save the vessels were much dilated (Fig. 434). It was 
ligated through the normal portion. The remainder was removed. 
The enormous wound was closed at its upper and lower portions, 
but the midportion was packed. 



DISEASES OF THE ABDOMINAL WALL 



965 




Fig. 434. — Torsion of the great omentum. The portion below the twist was black and 
dense while that above was unchanged save for the marked dilatation of the veins. 



966 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The twist of the omentum consisted of a complete 
turn below which the vessels were completely thrombosed. The 
thrombosis seemed to be complete. The interstitial tissue was in- 
durated with a hemorrhagic exudate. 

After-course. — There was some suppuration in the wound and heal- 
ing was not complete for three months. He lived a year and a half 
before succumbing to his nephritis. 

Comment. — The mass palpable within the abdomen above Poupart's 
ligament should have suggested a twist in the omentum. A simple 
strangulated omentum would not have made a mass extending so 
high in the abdomen. The prolonged rest in bed occasioned by the 
suppurating wound together with the loss of weight it entailed was 
likely an assistance in alleviating the nephritis. 

CASE 3. — A matron aged fifty-six was brought to the hospital 
because of a fecal fistula following a strangulated femoral hernia. 

History. — The patient has had a femoral hernia for several years. 
Two years ago it became strangulated but was reduced by her 
physician. Six weeks ago it became strangulated again and her 
physician, failing to reduce it, called a surgeon. The surgeon op- 
erated at once and finding the gut black, withdrew the loop from 
the wound and fastened it there. Two days later, the gut remain- 
ing black, he opened it, producing a fecal fistula. The gut eon- 
tents have drained from this opening since that time. Her general 
condition now is satisfactory, but she desires to be rid of the fecal 
discharge. 

Examination. — The patient seems in good health. From an opening 
in the groin two ends of the gut protrude from which intestinal 
contents are escaping. The skin about the opening is much exco- 
riated. 

Diagnosis. — The condition is easily ascertained at a glance. The 
plan of procedure alone requires solution. It seems best to open 
the abdomen aAvay from the infected wound, secure a lateral anas- 
tomosis and then remove the terminal ends of the gut from above 
downw^ard. In this way it will not be necessary to invade the in- 
fected area except in the final stage of the operation. 

Treatment. — The area about the exposed ends of the gut was dis- 
infected as well as possible and then covered with a formalin 
pack. A towel was then sutured over this. The noninvolved skin 
above Poupart's ligament w-as then sterilized with alcohol and 



DISEASES OF THE ABDOMINAL WALL 967 

iodine and an incision made. The terminal ends of the gut were 
identified within the abdomen ; these were clamped 10 inches from 
where they were imprisoned in the femoral ring. These were sev- 
ered and the ends turned outside the abdomen. The ends within 
the abdomen were united by a side to side anastomosis and dropped 
into the abdomen. The ends outside of the abdomen were pulled 
down, as far as Poupart's ligament. The abdomen above was 
then closed. Poupart's ligament was then cut across and the ter- 
minal ends of the guts removed together with the tissues to which 
they were attached. The ends of Poupart's ligaments were then 
fastened to each other and to the fascia beneath. The wound below 
was closed in part and in part packed with gauze. 

After-course. — The wound above closed by primary union. That 
below Poupart's ligament suppurated somewhat, but was closed 
by secondary suture in two weeks. She left the hospital in four 
weeks with the wound completely healed. I removed a bladder stone 
from her four years later. The hernia wound was noted at that 
time to be perfectly firm. 

Comment. — In strangulated hernia with necrotic gut, this plan 
of a two step operation is the procedure of choice. It invalided 
the patient for several months but is quite free from mortality. 
I have practiced it repeatedly since this patient, with equally good 
results in all. It requires a certain degree of courage to refuse to 
do an immediate resection and anastomosis. Logical as immediate 
resection seems to be, it causes too great a mortality to warrant its 
general adoption. 

CASE 4. — A married woman aged forty-eight entered the hospital 
because of occipital headache, going down the back of the neck. 

History. — Her headaches began about fifteen years ago. They 
were not severe at first ; they came on in the morning, she would be 
nauseated and by night be as well as ever. The headaches have 
become worse and their period longer. They now sometimes last 
a week. They are usually unilateral and are accompanied by nausea 
and often by vomiting. They are extremely severe. She rarely has 
had them when pregnant. She has them now every ten days to six 
weeks. Her menses are regular, last two to four days, flow scant. 
No pain or trouble at the time. Last period now on. Her appetite 
is fair, bowels regular except during the attacks of headache. No 
urinary symptoms. Does not get up nights. She has no cough or 



968 CLINICAL SURGERY BY CASE HISTORIES 

shortness of breath on exertion. Has had some swelling of the feet 
when working hard all day. Weight is stationary now, weighs 102, 
she weighed 125 twenty-five years ago. She has had eight children, 
six living and well ; two have died, one at three months of inanition 
and one at fifteen months of pneumonia. The youngest child is now 
five years old. She had pneumonia in childhood and had repeated 
attacks of tonsillitis when she was from eighteen to twenty-five years 
of age. Her father died of apoplexy. He had had sick headache 
at short intervals lasting part of one day for many years. Two sis- 
ters have headaches of the same character. Her mother died at 
seventy-seven from cancer of stomach and liver. 

Examination. — The patient is poorly nourished and appears much 
older than the age given. She does not look acutely ill. The pupils 
are equal, regular and react to light and accommodation. The 
thyroid is palpable, as are the lymph nodes in side and back of 
the neck. The chest is flat and the sternum sunken, but the lung 
expansion is good and equal on both sides. The heart dullness ex- 
tends from midsternal line to 7.5 em. to left. Apex beat in 5th inter- 
space. Abdominal wall lax and flat. The cecum, descending colon, 
and left kidney are palpable. There is tenderness to pressure all 
over the epigastrium and some tenderness across lower abdomen. 
Perineum lacerated and lax. Cervix deeply bilaterally lacerated and 
extensively eroded. The uterus somewhat enlarged and rather ten- 
der. The fundus is in position, freely movable. W.b.c. 9,800; R. 
b.c. 4,802,000, Hg 75. Urine turbid, acid, 1.014, albumin present. 

Diagnosis. — The patient has an endometritis, lacerated cervix and 
perineum. She desires to be relieved of her terrific headaches at 
any cost. The only clue as to their etiology is the fact that she 
did not have them during her numerous pregnancies. This together 
with the fact that migrainous headaches often disappear with the 
advent of menopause suggests the only hope of relief. The uterus 
is large, the periods regular, which does not give any evidence of 
an impending menopause. The laceration is pronounced, the ero- 
sions extensive and angry. This condition is a menace and the temp- 
tation to rid her of this by hysterectomy is great, doubly so be- 
cause of the hope that the cessation of the menses will relieve her 
of the headaches. The patient earnestly desires the operation if 
it presents any hope whatever of any such a happy sequel. 

Treatment. — A vaginal hysterectomy was done. 



DISEASES OF THE ABDOMINAL WALL 969 

PatJiologij. — -The uterus is above normal size, cervix deeply lac- 
erated and eroded. The right ovary is almost destroyed by a cyst. 
The uterine wall is somewhat sclerotic and the interstitial cells of 
the endometrium much increased. There is extensive degeneration 
of the cervix. 

After-course. — There was some postoperative shock. The patient 
perspired f reelj^, was nauseated, vomited frequently and felt weak. The 
temperature was 96.5°, pulse 102, and weak the entire first day. The 
nausea and vomiting continued in all for three days at intervals. 
There was much pain low in the abdomen. On the fifth day the 
vaginal discharge changed from a red to a dark, almost black color 
and was very offensive. The temperature was 101°, the pulse 70. 
A vaginal examination with speculum showed a slough at the 
upper end of the vaginal tract and a large quantity of black foul- 
smelling discharge. The black offensive discharge continued and 
the patient gained strength very slowly. On the fourteenth post- 
operative day the temperature went to 102° and the patient com- 
plained of severe pain in the left inguinal region. There were no 
positive findings except a tenderness and rigidity on the left side low 
down. The discharge changed from black to grayish and was very 
profuse. The next day the temperature dropped to 101° and the pa- 
tient felt better. The discharge was still profuse and of a green- 
ish color. Temperature the next few daj^s again went higher, up to 
101.8°, Patient complained of but little pain, but felt weak and 
listless. On the twenty-eighth postoperative day the temperature 
again went to 103°, pulse 113'. The patient had complained for 
several days of a pain in the left lumbar region coming around over 
the crest of the ilium to the left iliac region. Urinalysis showed an 
acid urine with much pus. W.b.c. 13,400. The temperature contin- 
ued high for the next two weeks, usually 103° in the afternoon. The 
patient complained of pain in left lumbar region radiating around 
along the crest of the ilium anteriorly. Urine showed much pus 
and an occasional granular east. The skin above the crest of the 
ilium as high as the twelfth rib became edematous and the whole 
area sensitive. The indurated area was incised and a quantity of 
pus escaped. The lower part of the abscess in this region commu- 
nicated with a larger one in the pelvis. A drainage tube was placed 
in the pelvis from the lumbar incision. The temperature then 
dropped, and rapid improvement took place. 



970 CLINICAL SURGERY BY CASE HISTORIES 

Comment. — The interest in this case centers in the postoperative 
complication and the interest is heightened because the abscess 
was so long unopened. This permitted the line of least resistance 
in these abscesses to be clearly demonstrated. The pain above 
Poupart's ligament indicated its development and an opening here 
would have cut short the process. In this stage an opening here 
would have been preferable to an attempt to open into the culdesac 
because of the danger of wounding important tissues. The old ad- 
vice to always open abscesses at the lowest point may well be ig- 
nored when one or more walls of the abscess are movable. The dis- 
position of these burrowing abscesses to glide along the iliac fossa 
often causes it to be mistaken for a disease of the bone, and once it 
arrives in the region of the kidney, it may well be mistaken for 
a perirenal abscess, all the more so since such abscesses are usually 
attended by pus in the urine, and not uncommonly a dysuria. Usu- 
ally the history of an antecedent pelvic disorder aids the diagnosis, 
or an early pain above Poupart's ligament sets the observer aright. 
In true perirenal abscess there is a bulging in the renal triangle 
in front and less disposition to spread downward. Low grade peri- 
renal infections, however, may burrow in various directions, partic- 
ularly downward. 

CASE 5. — A housewife aged fifty came to the hospital because 
of an abscess in left hip of several days' duration. 

History. — Five years ago the patient had an abscess on the left 
side above the hip bone margin following an abdominal operation 
performed a year earlier. She has had small abscesses and discharg- 
ing sinuses on the left side and back for the past five years. The 
last abscess developed three days ago. It has not discharged as yet. 
Older abscesses have been discharging at times. There has never 
been any bone discharged. The abscesses have all opened sponta- 
neously. Sometimes there was pus or watery fluid discharged for 
several weeks at a time. Her general health has been fairly good 
except for the abscesses in the past five years. She had typhoid 
fever twenty years ago and was in bed seven weeks. She formerly 
had sick headaches with nausea and vomiting with her menses. Her 
menopause occurred six years ago and she has had no flow since. She 
has been married twenty-nine years but was never pregnant. Six 
years ago she was operated for adhesions ; she had pain in the abdo- 
men, loss of weight. The diagnosis was made by x-ray. She has 



DISEASES OP THE ABDOMINAL WALL 971 

no urinary disturbance, no shortness of breath, no cough. The ap- 
petite is good, she sleeps well, and there is no loss of weight. 

Examination. — The patient seems fairly vigorous with fair nu- 
trition. She looks much older than the age given. The skin is soft 
and elastic. There is a median thyroid felt, soft, enlarged, not 
nodular. Chest symmetrical, respirations free and equal. Heart 
somewhat enlarged to left, 10 cm. out. Heart sounds clear. There 
is a large, red, swollen, fluctuating area 10 x 6 cm. over the crest 
of the ilium ; the skin is smooth, tense, and hot. Several discharging 
sinuses are seen on the side of her back and above the crest of the 
ilium. There is definite tenderness over the lateral border of the 
sacrum on the left side. There is a marked spasm of the abdominal 
muscles in the right upper quadrant, and the liver is palpable. Op- 
erative scar left rectus below umbilicus about 5 cm. long. W.b.c. 
17,800; R.b.c. 4,336,000; Hg 70 per cent. The x-ray shows no ne- 
crotic bone anywhere in pelvis, hip joint or lower spine. 

Diagnosis. — The history of the trouble for which she was operated 
six years ago is difficult to get. She describes the trouble as a 
continuous pain in the left lower quadrant of the abdomen which 
at times became generalized over the whole abdomen. The pain 
in the left lower quadrant was also felt in the back. She thinks 
she had fever. She was cystoscoped and a ureteral catheterization 
was done and many x-ray plates taken previous to operation. Fol- 
lowing this she had fever, frequent urination, and increased pain. 
These continued until the abscesses formed. Obviously the indica- 
tion is to drain the abscess present. After this has been done it 
may be possible to trace the source of infection by means of a bis- 
muth paste injection. 

Treatment. — The abscess over the crest of the ilium was opened. 
Much pus was discharged. Two draining sinuses followed into 
this abscess cavity and through and through drainage from incision 
in abscess cavity out through the two sinuses was established. 

Pathology. — Smears show leucocytes, no bacteria seen. Culture 
of pus showed no growth in twenty- four hours. 

After-course. — After the abscess over the crest of the left ilium was 
opened, the patient's temperature dropped and she became com- 
fortable. The acute inflammation subsided very rapidly. All the 
sinuses drained a thin yelloAv pus continuously. None of them closed 
up. The wounds made at operation healed out, but all left sinuses. 



972 CLINICAL SURGERY BY CASE HISTORIES 

The patient ran some temperature all the time, varying from 99° 
to 101°. After the drainage had lessened the sinuses were injected 
with Beck's paste, it being put in under considerable pressure. The 




Fig. 435. — X-ray of sinuses filled with bismuth paste. 

injection caused her considerable pain. After the bismuth injection, 
the x-ray showed a veritable network of sinuses in the soft tissues 



DISEASES OF THE ABDOMINAL WALL 973 

about the crest of the ilium (Fig. 435). From these, three passed 
upward and ended exactly in the kidney region. One went doAvn 
from the kidney region to about as far on the left sacroiliac joint. 
At dismissal the sinuses were discharging pus and pieces of Beck's 
paste. The temperature had been normal for eight days, pulse 
not above 80. The patient was examined four months later. She 
had had an acute illness with cough. There was a marked tubercu- 
losis of the left apex. 

Comment. — It was not possible to determine what was found at 
the operation six years ago. Usually when surgeons are noncommuni- 
cative after operation it is fair to assume they are busy thinking. 
It is clear that following the catheterization and operation she had 
a considerable and persistent fever. Since there was no wound in- 
fection it likely came from an infected kidney. The sinuses as 
shown by the Bismuth paste, extended to the kidney region. Likely 
the burrowing began there. The presence now of a lung tuberculosis 
raises the question of a possible tuberculous lesion of the kidney 
augmented by an infection by the urethral catheter. The extent 
of the burrowing and the length of time required for an opening 
to form indicate a low degree of infection. It was the intention 
to investigate the kidney, but the presence of a lung complication 
precludes that. 



CHAPTER XVIII 



BLADDER 



Affections of the bladder have to do chiefly with irritation within 
it or to its inability to empty — not infrequently the two form a vicious 
circle. After the condition of the bladder is determined the general 
condition of the patient must be determined. 

BLADDER IRRITATION 

The bladder may be irritated from processes outside the bladder as 
well as those within. The presence of painful urination does not 
necessarily incriminate the bladder. Diseases of the bladder wall 
itself in fact are among the least common of the causes of urinary 
complaints. The presumption is, therefore, that in a case of urinary 
irritation the trouble is not one affecting primarily the bladder wall. 

CASE 1. — A merchant aged twenty-eight was brought to the hos- 
pital because of pain in the rectum and bladder disturbance. 

History. — Three weeks ago he began to have bladder irritation. 
The bladder was irrigated a number of times without relief. On the 
contrary, urinating has become more painful. Now he is unable to 
pass his urine spontaneously. He has had fever from the beginning. 
Pain in the pelvis has grown progressively worse and he is unable 
to say whether the pain is in the bladder or rectum. He knows of 
no cause for his trouble. 

Examination. — A smooth, rounded tumor is felt above the pubes 
which is evidently the bladder. The catheter enters without difficulty, 
and more than a quart of urine flows out. Save for a few pus 
cells, it is negative. The prostate is normal in size. To the left 
side and anterior to it is a boggy swelling which is very painful 
to the touch. W.b.c. 22,000. 

Diagnosis. — The condition of the urine indicates that the trouble 
is extravesical. The presence of the sensitive mass and the increased 
leucocyte count indicates an abscess lateral to the rectum, therefore 
perivesical. 

974 



BLADDER 975 

Treatment. — An incision was made lateral to the anus and a large 
pus cavity was drained. 

After-course. — Relief was immediate and the hole filled in in three 
weeks. 

Comment. — The source of the infection is not known. Complete 
and apparently permanent healing took place. This would hardly be 
expected if the infection had come from the bowel. It is interesting to 
note that despite a normal urine his bladder was irrigated by his 
physician and it is of equal interest to know that the bladder remained 
normal in spite of the irrigation. Evidently the doctor's technic 
was better than his judgment. 

CASE 2. — A farmer aged thirty came because of pain in his side. 

History. — The patient's health was good as a boy. He had mea- 
sles and mumps, but no serious illness. Nine years ago he had pain 
in the right loin which extended around in front toward the blad- 
der. There was a recurrence of this with fever and vomiting and his 
appendix was removed. He felt feverish but does not know whether or 
not fever was present. He does not know the state of the appendix. 
He was free from pain for several years. Five years ago he began 
to have a pain in the right chest which extended from the shoulder 
blade to the front. He was in a hospital eight weeks with this 
pain. He developed fever, shortness of breath, and a little cough. 
The doctor called it typhoid fever. When the patient left the hos- 
pital he was no better than when he entered. He had a little non- 
productive cough, but it got better when the patient was up and 
around. Two weeks after this fluid was discovered in the right 
chest and one pint of fluid was removed. Aspiration was tried 
seven or eight times later but no fluid was obtained. Gradually 
pain, shortness of breath and fever left, and the appetite improved. 
Eighteen months ago he had a rather severe pain in the left lumbar 
region. It lasted two weeks and he had a little fever, but no uri- 
nary trouble at this time. The pain gradually ceased and there has 
been very little trouble until eight months ago, when severe pain 
in the same place set in and has been continuous since. For some 
months he has had pain and burning on urination. Sometimes 
"white chunks" are found in the urine. He passes urine only five 
or six times a day. He has passed no blood and does not know 
whether or not he has any fever. He caught cold three weeks ago 
and has coughed some since. 



976 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 436. — Large stone in pelvis of kidney. 



Examination. — The right chest is much reduced in size and the 
respiratory excursions are feeble. The breath sounds are faint. 
The left lung is hyperresonant but no rales. There is some tender- 



BLADDER 977 

ness on pressure over the left kidney, both in front and in the back. 
The urine contains many leucocytes and a few red cells. The x-ray 
shows a large irregular shadow in the region of the left kidney. 
(Fig. 436.) 

Diagnosis. — The cause of the pain in the left side is made plain 
by the x-ray picture. The shadow follows accurately the outline 
of the pelvis and ealices. The determination of the past condition 
offers greater difficulty. There evidently was a pleurisy of un- 
known character, which caused fibrosis and contracture. After the 
withdrawal of the fluid, dullness must have remained or the nu- 
merous fruitless attempts at aspiration would not have been made. 
This was probably nonpurulent or an infection of low virulence, 
since healing spontaneously of purulent exudations is uncommon. 
The nature of the pain for which the appendix was removed is not 
clear. The site and character of the pain corresponded to a urethral 
calculus, but the removal of the appendix was attended by relief 
from symptoms. If a stone, it must have passed spontaneously. 
We may conclude that both those affections are things of the past 
and we have but to deal w^ith the stone in the left kidney. The 
urine does not indicate any great degree of infection and the 
trouble amounts to the presence of a foreign body only. 

Treatment. — The stone was removed without difficulty. Because 
of the large size of the stone, a complete bisection of the kidney 
was required. Hemorrhage was controlled by making traction on 
the kidney and gently twisting its pedicle. 

After-course. — On the fourth day following operation a pneumonia 
developed in the left lung, from which he died on the tenth day. 

Comment. — Possibly his statement of acute cough was not suffi- 
ciently heeded. There were no objective signs of lung trouble 
and the administration of the anesthesia was proceeded with. This 
may have formed the starting point for the postoperative pneu- 
monia. The function of one lung being impaired made the in- 
volvement of the other of much greater consequence. Large stones 
may sometimes with advantage be removed through an incision 
in the pelvis. When there are so many branches as in this case, 
fragments are apt to be left behind if removal is attempted in this 
way. 



978 CLINICAL SURGERY BY CASE HISTORIES 

CASE 3. — A retired railway engineer of sixty-seven came be- 
cause of painful urination. 

History. — The patient says he noticed frequency of urination at 
first about eighteen years ago. A few years later he had difficulty 
in passing urine. When it did pass he was compelled to strain, 
which produced great pain in the bladder region. Difficulty, fre- 
quency, and pain have progressively increased and he has seldom 
been Avithout pain. He has had no symptoms other than the above. 
He has a double inguinal hernia. Now he has to press up on the 
perineum with the hand in order to urinate. Often he has to urinate 
every half hour at night, but not so often in daytime. The chief 
pain is in the glans and over the pubes. 




Fig. 437. — Two large bladder stones. 

Examination. — The prostate is moderately enlarged, smooth, and 
elastic. There is considerable tenderness. The urine contains some 
pus. 

Diagnosis. — The enlargement of the prostate, the dysuria, the noc- 
turnal frequency seemed to make the diagnosis of enlarged prostate 
evident. 

Treatment. — When the knife was plunged into the bladder wall 
it struck against a stone. After the bladder was sufficiently opened 
to permit exploration, two large stones were discovered. One was large 
as a turkey egg, the other as large as a bantam egg (Fig. 437). After 
they were removed, the prostate was found but moderately enlarged 
and no obstruction existed. It was noted that the prostate was pressed 
flat where the stone lay against it. A suprapubic drain was put in. 

After-course. — After the suprapubic wound healed he could not 
pass his urine. The catheter passed without hindrance but the urine 



BLADDER 979 

would not flow when the catheter was not in place. Thereupon a 
permanent catheter was put in for two weeks after which urination 
became spontaneous and progressively freer. The bladder was irri- 
table many months but this has gradually disappeared. 

Comment. — The suprapubic pain and the referred pain to the 
glans as well as the relief of the obstruction by pressing on the 
perineum pointed to stone and should have stimulated to further 
study. The relatively slight complaint of pain threw me off my 
guard. The obstruction to urination caused by the flattened pros- 
tate is also a matter of interest. Likely the pressing downward of 
the base of the bladder caused by pressure of the stone receded and 
aided in restoring spontaneous micturition. When obstruction fol- 
lowed removal of the stone, I proposed the removal of the pros- 
tate. From this he demurred, since he felt so much relief. 

CASE 4. — A matron aged thirty came to the hospital for bladder 
trouble. 

History. — Fifteen months ago she began to have frequent and pain- 
ful urination. It has been increasing in severity since then and 
has been particularly bad during the past six weeks. The pain is 
now constant but is much more severe w^hen the urine passes. The 
site of the most severe pain is across the lower abdomen. There 
is little pain at the outlet of the bladder. She gets up four or five 
times at night and during the day time she passes urine very fre- 
quently. For the past six months the pain in the abdomen extends 
upward and now reaches to the rib margin. The appetite is good, 
constipation obstinate. She has some leueorrhea between periods. 
It is never bloody. "When much on her feet she has the sensation of 
weight in her pelvis. 

Examination. — The general appearance is that of good health. The 
lower abdomen is occupied by a mass which reaches nearly to 
the umbilicus. It is hard, smooth and slightly sensitive to touch. 
The abdominal skin veins are not prominent. The pelvis is filled 
with a mass fixed to the uterus and forming lobulations to either 
side of it. General examination is negative. 

Diagnosis. — The bladder history is that of pressure. The pain 
is abdominal rather than vesical though the pain is increased dur- 
ing urination. The smoothness and density of the tumor is that 
of a myoma. Though there is no history of acute inflammation, there 
is too much pain for a simple fibroid. The increased tenderness 



980 



CLINICAL SURGERY BY CASE HISTORIES 



in the euldesac and the disposition of the pain to increase as the 
tumor grows larger suggests a pyosalpinx as a complication of the 
myoma. Though the tumor seems fixed in the pelvis the absence 
of dilated veins in the skin speaks against a fixation from malig- 
nancy. Whatever the condition, therefore, it is capable of operative 
removal. 

Treatment. — After the abdomen was opened a cauliflower mass was 
found filling the left side of the pelvis and a large, thick-walled 




Fig. 438. — Papillary cystadenoma of the ovary. 

cyst filled the other and projected above the pelvic brim. The cauli- 
flower mass was firmly adherent to the floor of the pelvis. Both 
masses and tubes were removed. No visible parts of the tumor were 
left behind. 

Pathology. — The cyst when opened was found to be lined with an 
irregular cauliflower mass (Fig. 438). This was dense and brittle 
to the touch. 

After-course.. — Operative recovery was uneventful and she has re- 
mained well at least two years. 



BLADDER 981 

Comment. — Whenever one is not sure about the diagnosis of a my- 
oma it most likely is something else. A myoma after it raises out of 
the pelvis usually has a quiescent period. When they just begin 
to raise out of the pelvis and are complicated by inflamed tubes 
they do produce just the symptoms found here. In papillary cyst 
adenomas once the wall breaks and the papules are exposed to the 
peritoneum there usually is a serous exudate into the peritoneal cav- 
ity of an amount sufficient for clinical demonstration. There was 
none in this ease. The essential thing, that the condition was tech- 
nically operable, was correct. Though these conditions are semi- 
malignant, a cure may confidently be expected because the perito- 
neum was nowhere injured. The fact that there was no exudate 
likewise is a favorable sign. 

CASE 5. — A farmer aged fifty-six came to the hospital for relief 
from a foreign body in the bladder. 

History.— His general health has always been good. He is the fa- 
ther of four children. He states that three weeks ago he passed a 
grain of corn down his urethra and it escaped into his bladder. He 
has since had some irritation on urination and some precordial pain. 

Examination. — No physical findings that would indicate a cause 
for the precordial pain and it may be regarded as a manifestation 
of the same neuropathic condition which induced him to introduce the 
foreign body into the bladder. His statements as to the introduction 
of the bladder are manifest by the presence of many leucocytes and a 
few red cells in the urine. 

Diagnosis. — The urinary findings above noted warrant the ac- 
ceptance of the patient's own diagnosis. 

Treatment. — Perineal cystotomy. Drainage for a day. A stone the 
size of a small hickorj^ nut was extracted with forceps. 

Pathology. — In the center of this stone was the grain of corn. 

After-course. — The patient was up and about in three days and 
down town on the fourth. The recovery was uninterrupted and com- 
plete. 

Comment. — The chief interest lies in the fact that a stone of this 
size developed in three weeks. It is unusual also for a man of a 
family to perform such stunts. The passing of foreign bodies into 
the bladder is usually the work of single persons. Ordinarily I 
should be loath to accept a patient's statement that he had passed 
a foreign body into the bladder, for persons of this class are apt to 



982 CLINICAL SURGERY BY CASE HISTORIES 

be the possessors of vivid imaginations, but this patient's brother, a 
physician of good judgment, urged its acceptance. Hence a cystos- 
copy was not done. 

CASE 6. — A fanner aged twenty-seven came to the hospital be- 
cause of severe pain in the left back and side. 

History. — His general health never has been good. He had throat 
trouble as a boy and had pneumonia three times. He had f)ain in 
the left side in childhood. In the past eight years he has had 
several attacks a year of sour stomach which terminated in severe 
pain in the left side. The attacks would last from two to five days 
and before they terminated would cause pain toward the bladder 
and over the hip. Hypodermics were usually required. Riding 
seemed at times to bring on an attack. He thinks there has been 
blood in the urine. He has had to be catheterized several times 
during the attacks, but during the intervals of freedom, urination 
has been painless and unhindered. The last attack was two weeks 
ago ; it lasted two days and recurred after only one week of freedom. 
During this attack some small gravel the size of bird shot was 
found. He has not recovered as usual from this spell and has had 
a temperature of 102° at one time. During this attack his doctor 
found a mass in the left abdomen. 

Examination. — He is a large, fleshy young man, and aside from 
distinct tenderness over the kidney in front and along the ureter, 
physical examination was negative. His urine is 1.015 and is other- 
wise entirely negative. W.b.c. 6,500. The x-ray failed to show any 
stone. 

Diagnosis. — The attacks of pain are obviously renal. The location 
of the pain and bloody urine made this plain. The temperature sug- 
gested an infection. The entirely negative urine showed at once that 
the ureter was occluded and that the opposite kidney was capable of 
carrying on the function. Having passed gravel, it seemed most 
likely that still another was obstructing the ureter. The failure 
of the x-ray to show it did not preclude its existence. The inability 
to pass urine during the attacks may have been due to a reflex 
spasm but more likely was due to the hypodermics which were 
given to relieve pain. The temperature and the marked local pain 
suggests a suppuration. 

Treatment. — An incision was made down to the kidney which was 
found markedly distended, being as large as a grapefruit. It was 



BLADDER 983 

not palpable before operation because of the fat abdominal wall. 
The kidney was incised and a huge amount of cloudy urine escaped. 
Drainage was introduced. A month later failing to secure an open- 
ing through the ureter, the kidney was removed. After removal 
a small stone M-as found embedded in the constriction at the be- 
ginning of the ureter. 

After-course. — The patient recovered rapidly from the operation 
and though he had some bladder irritation during the first months 
following operation, he made a good eventual recovery. 

Comment. — Under ordinary circumstances the stone should have 
been discovered and removed. Because of the stoutness of the in- 
dividual, which made the wound very deep and which caused the 
patient to take the anesthetic badly, it did not seem warranted to pro- 
long the operation. Failure to enter the ureter by retrograde cathe- 
terization caused me to believe there was a cicatricial narrowing at 
the outlet of the pelvis. The kidney had been distended so long that 
the cortical portion had been nearly destroyed. It seemed hardly 
worth a prolonged effort to save it. The question arose as to 
whether a nephrectomy should be done at the primary operation. 
Patients who have recently suffered severe pain to the point of 
collapse bear operations badly and it seemed wise to secure relief 
from pain and allow him to recuperate and to allow an interval for 
the discovery of the cause and possibly its elimination and thus 
probably save the kidney. The statement of the patient that he had 
passed gravel was not certain proof that he had done so. 

CASE 7. — A housewife aged fifty -four cajne to the hospital be- 
cause of painful urination. 

History. — There is no tuberculosis in the family, though one brother 
has a chronic cough. The patient was well until she was nineteen 
years old Avhen she had whooping cough. Since that time she has 
coughed more or less and catches cold easily. She has four chil- 
dren and has had one miscarriage. Menopause three years ago. 
Two years ago she began to have frequent urination with pain 
and burning. She lost from 101 to 74 pounds since then. Eight 
months after the trouble in the bladder began she began to have 
pain in the abdomen to the left of the umbilicus and in the back. 
This pain has been severe in the last four months. Six months ago 
she vomited frequently for a period of a month or two. At this 
time she discovered a lump in the side. Though the lump increased 



984 CLINICAL SURGERY BY CASE HISTORIES 

in size the vomiting ceased. She has never had chills and does not 
think she has had much fever. She has never seen blood in the 
urine, but it has often been milky, especially after standing. 

Examination. — The patient is a slight person, as indicated by her 
weight, but outside of the very obvious tumor the patient showed 
no other lesion. The tumor occupies the splenic region and is 
the size of a large orange. It is movable and when pressed upon 
is easily palpable in the renal space. The mass is not tender. The 
urine is cloudy, neutral, and the specific gravity is 1.005. The 
microscopic examination shows many pus cells, but no casts. The 
bladder is hyperemic, no ulceration but the left ureteral orifice 
is crater formed while the right is normal. 

Diagnosis. — The tumor can be none other than one attached to 
or formed hy the kidney. The pus in the urine as well as the phys- 
ical findings indicates as much. The onset three years ago with 
pain and vomiting following later suggests that the rather rapid 
enlargement of the kidney tends to nausea and vomiting. There was 
no chill and no notable fever which counts against a pus microbe in- 
fection. The appearance of the urethral opening speaks definitely 
for tuberculosis. 

Treatment. — The kidney when exposed was large and extensively 
degisnerated and the ureter was as thick as a finger and as hard. The 
diagnosis of tuberculosis is thereby confirmed. The kidney and ureter 
as far as over the brim of the pelvis was removed. 

After-course. — The patient improved markedly, but there still re- 
mains some bladder irritation which is troublesome at times. 

Comment. — There is a question how much time should be spent on 
refinements in diagnosis in such cases. That the left kidney was 
hopelessly damaged was very probable from the clinical signs. In 
old tuberculosis kidney tubercle bacilli are not always easy to find 
and the finding of acid-fast bacilli is often misleading. The 
guinea pig test is the only method that is wholly reliable, but in 
cases where action is demanded, the time requirement is for- 
bidding. The state of this kidney had already proved that the op- 
posite kidney was capable of performing the renal function for the 
body. The elimination tests bear somcAvhat on the strength of the 
patient, when the annoyance of prolonged catheterization is taken 
into account. In patients in whom a longer period for observation 
is permitted and where the diagnosis is less obvious, the finer re- 



BLADDER 985 

finements are desirable. Useful tests are not always applicable be- 
cause of other considerations. I was once called to see a man with a 
pyonephrosis as large as a child's head. The patient was septic, 
wdth a high temperature. The physician desired that the opposite 
kidney should be examined by color test to determine its function. 
"While the usual technic was being applied it appeared that the pa- 
tient's resistance was being sorely tried, so I hastily prepared his 
side, slipped in a large tube in front of the quadratus and by the 
time the patient was pronounced operable, the operation had been 
done and the operator was dressed and ready to go down town. 
Valuable as other tests may be, the advisability of using a urethral 
catheter when there is an infected bladder seems questionable. 

CASE 8. — A farmer aged seventy-two came to the hospital be- 
cause of painful urination. 

History. — After the usual prostate history, the patient had his 
prostate removed nine months ago by suprapubic route by a good 
operator. His wound healed after six weeks, but the bladder trouble 
continued. Recently he has had tenesmus of an extreme degree. 

Examination. — The urine contains much pus, some red cells, but 
no casts. A sound introduced into the urethra impinges against 
a hard object which prevents the sound from entering the bladder. 
Rectal examination shows a rounded mass the general size and form 
of a prostate but very hard. It is very sensitive to pressure. 

Diagnosis. — A mass of such a size nine months after the removal 
of a prostate suggests a possible recurrence. This mass is too well 
defined and is too sensitive to admit of such a diagnosis. The sound 
comes to a sudden stop but without a click indicative of stone and 
the body against which it impinges is somewhat elastic. Were it 
not that the operator is competent I would suspect that but the mid- 
dle lobe if any had been removed. Stone is suspected, but in the 
absence of an x-ray, it can not be proved or excluded. The ob- 
struction to the sound is not that of a stone. Despite the fact 
that every possibility can be logically excluded, the fact remains 
that the man has something that annoys him. An attempt must 
be made to exclude this geographically as well as logically. 

Treatment. — After the bladder was opened, a calcareous mass the 
size of an egg occupied the position formerly occupied by the pros- 
tate. When an attempt to dislodge the stone with forceps was 
made, it was found that the mass was made up of a gauze tampon 



986 CLINICAL SURGERY BY CASE HISTORIES 

infiltrated with calcareous material. After the mass was removed, 
it was found that a portion of the capsule had formed a shelf over 
the mass and there remained a bridge across the bladder. A V-shaped 
piece was cut from this. 

After-course. — When last heard from months later there was still 
some pyuria and tenesmus. 

Comment. — ^When tenesmus develops after a prostatectomy, there 
is nearly always a stone and no delay should be allowed in solving 
the problem. The x-ray usually shows the stone. The reason the 
sound did not detect the stone was that the portion of the tampon 
occupying the apex of the prostatic cavity was not infiltrated so 
that the sound impinged against the gauze. 

CASE 9. — A farmer aged thirty-nine cajne to the hospital because 
of pain in the bladder. 

History. — In November, 1917, he began to feel a general malaise 
with no other special symptoms. In December he began to notice 
frequency of urination by day and had to get up several times a 
night to urinate, something he had never done before. About 
the last of January, 1918, he began to have some pain across the 
lower abdomen and a short time after the urine started it would 
suddenly stop and he would have a severe pain in the neck of the 
bladder. He would jump up and down hard on his feet and the 
urine would sometimes start again. For awhile he noticed no blood, 
but in a few weeks the urine began to get very bloody and has 
continued so. The burning and pain has become steadily worse. 
Bowels have been constipated ever since the trouble started. Per- 
fectly well otherwise. Has lost 15 pounds since November. Has 
never had any previous sickness. 

Examination. — The x-ray showed a shadow in the bladder the 
size of a walnut. Urinalysis, bloody sediment, 1.030, albumin, 
and blood present. Pus cells present. The history in itself is 
so typical that the x-ray is needed merely to determine its size. 
The amount of albumin corresponds with the amount of blood in 
the urine. There being no casts, it is safe to say that the kidneys 
are unaffected. 

Treatment. — The stone was removed suprapubically. The incision 
was closed about a drainage tube half an inch across. 

After-course. — The bladder was irrigated with sterile boric acid 
solution from time to time and fiaky particles were removed. The 
tube was removed after three days. 



BLADDER 987 

The patient was dismissed on the twelfth day with the supra- 
pubic wound not quite closed. He was passing urine by urethra 
and draining some above. This opening closed soon after and he 
has remained well. 

Comment. — The bladder was not markedly inflamed, A primary 
closure of the bladder (Avith catgut) would have shortened the 
stay in the hospital. A permanent catheter would have been re- 
quired for a week. 

CASE 10. — A widower of fifty-three came to the hospital because 
of painful urination. 

History. — Three years ago he got up one chilly morning and dis- 
covered he could not pass his urine. He was catheterized twice dur- 
ing the day and once the day following. After this time he could 
urinate spontaneously. He had much pain for ten days but after 
that he had none. He continued with no trouble save frequency of 
urination until a year ago. For the past year he has had intense 
burning on urination, particularly^ after the completion of the act. 
He has some pain in the bladder at other times as well as during 
the past few months. Sometimes after the flow starts it stops 
suddenly attended by severe pain. To avoid this he now uses a 
catheter. The urine has been cloudy for a year. He has lost weight 
but his general health is good. 

Examination. — There is a mass the size of a croquet ball to the 
right of the median line above the pubes. It is smooth and fluctuat- 
ing. Pressure on it causes him to have a desire to urinate. The 
prostate is moderately enlarged, smooth, and but little sensitive 
to pressure. The x-ray shows a stone nearly as big as an egg. 

Diagnosis. — Evidently he has a bladder stone. The reason for 
the location of the fundus of the bladder to the right of the me- 
dian line is not clear. The failure to empty the bladder is evidently 
due to the presence of the stone. Obviously the removal of the stone 
is important. 

Treatment. — A suprapubic incision was made and the distended 
sac opened into; a quantity of cloudy fluid escaped. No stone was 
found neither could the urethral opening be palpated. Toward the 
midline an opening was found which just admitted the end of the fin- 
ger. (Fig. 441). In this cavity the stone was felt. The opening was 
enlarged anteriorly and the stone extracted. A large suprapubic 
drain was placed. 



988 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — It required five weeks for the suprapubic wound 
to heal, but since then he has had no difficulty. 

Comment. — Obviously the sac was a distended diverticulum and 
in enlarging the communicating opening, I opened into the bladder. 
After making the diagnosis, my plan was to extract the stone and to 
attack the diverticulum at a second sitting. By enlarging the com- 
municating opening, apparently the trouble w^as cured. On the 
other hand it is possible the diverticulum was an innocent com- 
plication and had he not developed the stone he would have had no 
trouble. On the contrary the diverticulum may have been the initial 
factor responsible for the development of the stone. At any rate, 
despite the fact that he already has sixteen children he has mar- 
ried again. 

CASE 11. — A matron aged forty came to the hospital because of 
pain in the bladder. 

History. — Three years ago, after a period of obstinate constipa- 
tion with abdominal distention, she developed a persistent pain in the 
bladder. With this there was a sense of dragging down low in the 
back. When she urinated she had a bearing down pain but she 
could not be sure whether it was in the bladder or rectum. She 
had frequent urination both day and night. There was some blood 
in the urine at one time a year ago. After some weeks she grew 
better but had other attacks. The last one came on ten weeks ago. 
A year ago and again six months ago she was cystoscoped and had 
the ureters catheterized. A diagnosis of tuberculosis w^as made 
and the bladder w^as irrigated. She got much relief after six 
weeks. She has had a persistent vaginal discharge. She has 
four living children ranging in age from seventeen to five years. 
She had an abortion at two months, before the first child was born. 
Her menses come on every three to six weeks. She has no pain. 
She flows profusely three days and then less for two days. 

Examination. — She has diastasis of the recti muscles and marked 
tenderness on deep pressure over the pubis. The kidneys are both 
palpable, are not enlarged, or tender. The perineum is lax, the 
cervix is low, bilaterally lacerated, extensive cystic degeneration 
and erosion. The fundus is in the culdesac, is large and boggy 
and sensitive to pressure. It is immovable. The urine is cloudy, 
contains much pus and some red cells. The bladder shows much 
congestion and a bulbous edema. There are no ulcers. 



BLADDER 989 

Diagnosis. — The nature of the initial pain and the difficulty of 
locating it either in the bladder or rectum suggests a uterine origin 
of the trouble. The irregularity of the menstruation shows at 
least an associated endometritis. The profuse discharge suggests 
the presence of cervical inflammation. The appearance of the in- 
terior of the bladder indicates an extravesical origin of the trouble. 
The persistent irrigation to which the bladder was subjected likely 
accounts for the large amount of pus. At any rate a definite 
surgical lesion of the uterus exists and demands treatment irre- 
spective of the question of renal tuberculosis. 

Treatment. — The cervix was amputated and the perineum repaired. 
The fundus was resected and fixed into the rectus fascia. The uterus 
was large, very fragile, and boggy. 

Pathology. — The tissue removed from the cervix shows extensive 
cystic degeneration. 

After-course. — The bladder pains rapidly improved after the oper- 
ation and at the time of dismissal from the hospital were much im- 
proved. In the succeeding months they subsided save for an occa- 
sional spell of irritation. The pus likewise subsided. 

Comment. — Most of the bladder troubles in women who have 
borne children are extravesical. The fact that this patient has 
a pronounced pelvic disease should have placed suspicion on this 
organ as the source of the difficulty. At most a cystoscopic exam- 
ination which showed no definite bladder lesion should have di- 
rected attention from the bladder. An early correction of the 
uterine trouble no doubt would have cut down the duration of the 
disease. Many persistent bladder troubles are engendered by a too 
persistent use of the cystoscope in the hands of the inexperienced. 
Pyelitis not infrequently follows ureteral catheterization. 

CASE 12. — A farmer ag:ed twenty-five came to the hospital because 
of painful urination. 

History. — Four years ago he began to notice pain on micturition, 
and the urine looked creamy at times. Later pain in the right side 
set in, lasting from half an hour to two or three days. The pains 
were so severe on several occasions that a doctor had to be called. 
The pain was most intense in the back below the short ribs and it ex- 
tended to his right testicle. During the height of his attacks 
he passed urine frequently, but at one time he was unable to pass 
his urine and had to be catheterized. Six months ago he passed 



990 CLINICAL SURGERY BY CASE HISTORIES 

a stone the size of a small pea. He was sick in bed tAvo weeks 
after this severe attack and passed much pus. This continued un- 
til the present time. He developed a fever at that time which has 
continued to date. 

Examination. — He has a temperature of 103°, a leueocytosis of 
18,500 and a pulse of 115. A large mass is felt in the right 
lumbar region, it is not sensitive but is semifluctuating. The mass is 
palpable in front of the quadratus lumborum muscle and can be 
made to bulge the renal triangle. The skin in the renal region is 
edematous as can be demonstrated by catching a fold between the 
thumb and fingers and then making comparison with the unaffected 
side. The urine shows abundant pus and many casts. 

Diagnosis. — The finding of a mass in the kidney region, together 
with the history and the urinary findings warranted the diagnosis 
of pyelonephritis with perinephritic abscess. 

Treatment. — The abscess was incised and a pint or more of pus 
escaped. The kidney showed softened areas and these were incised 
and a drain inserted into the pelvis of the kidney. No stone could 
be found. 

After-course. — Fluid could be passed through the kidney into 
the bladder, but an abundant discharge of urine and pus continued 
through the incision in the loin. The patient never gained sufficient 
strength to warrant an attempt at nephrectomy. 

Comment. — In case of pyelonephritis with perirenal abscess it is 
a question whether it is best to take the full risk and do a neph- 
rectomy at once. If drainage is done and a degree of healing 
is secured, secondary nephrectomy is apt to be attended by grave 
risks not only from the operation itself, but from danger of in- 
jury to the duodenum. In this instance it is not clear just why 
the patient died. There was continued albumin and casts. Whether 
these were from the drained kidney or from the opposite kidney 
could not be determined. He died from exhaustion without any 
signs of suspension of kidney involvement. An infected kidney is 
capable of surprising restitution if all the foci of infection are 
drained. 

CASE 13. — A fanner aged seventy-eig-ht entered the hospital com- 
plaining" of frequent urination and pain in the back and constipation. 

History. — His health has always been good until the onset of 
frequent urination and difficulty in voiding about three years ago. 



BLADDER 991 

When moving about he was unable to control urine. He passes very 
small amounts at each urination ; while he has better control of his 
bladder lateh% the pain is getting worse. He has severe pain on 
urination and for five to ten minutes after. He gets up about eight 
times each night. The urine is always cloudy and often contains 
blood. He has been having pain of a dull aching character in his back 
for the past three years; this has been relieved somewhat lately. He 
takes a laxative every day. There has been some swelling of his 
feet. Recently he has had difficulty on urination and has had to 
be catheterized several times. 

Examination. — The x-ray of the bladder is negative for stone. 
The prostate is enlarged and nodular, particularly on the right side. 
The urine contains much pus. 

Diagnosis. — The increased frequency of urination when on his 
feet suggests stone but the x-ray fails to disclose one. The nod- 
ulations in the prostate are not cancer hard but any nodulations are 
suggestive of malignancy. The disposition to bleed is in harmony 
with this. Considering his age and general condition, attempt at 
radical removal does not seem warranted. 

Treatment. — The patient was put on urinary antiseptics and the 
bladder irrigated daily with potassium permanganate solution. The 
pain on urination disappeared almost immediately. The frequency 
persisted. The urine when he was dismissed showed many pus cells 
and red cells but his general condition was much improved. 

After-course. — The difficulty soon returned more intense than ever. 
Urination became exceedingly painful. A permanent suprapubic 
drain was decided on. When the bladder was opened a stone as large 
as a bantam egg was found. This was removed and the patient re- 
covered. He had a hemiplegia while in the hospital. 

Comment. — After the stone was found the x-ray plates were re- 
examined and the faint outlines of the stone could be made out 
behind the pubic bone. A cystoscopy would readily have discovered 
the stone, but after the x-ray failed to indicate stone it was deemed 
certain that the nodulations were the clue to diagnosis. I might 
have known that when carcinoma is the cause of the trouble im- 
provement by rest in bed with irrigation is not so marked as it 
was in this case. 



992 CLINICAL SURGKRY BY CASE HISTORIES 

HEMATURIA 

Hemorrhages from the bladder may be caused by tumors, irritation, 
as by a foreign body or by an ulcer. Hemorrhages from above are 
due to like causes. Inspection differentiates the lesion within the 
bladder, but those from the kidney must be arrived at by inference 
or accessory evidence. 

CASE 1. — A lad of thirteen was brought because of painful uri- 
nation. 

History. — The patient has had painful urination for nine months. 
He gets up three or four times a night and goes frequently during 
the day. The pain is never severe. His doctor has found pus in the 
urine from time to time during this interval. His appetite has 
not been good and he tires easily, but he has continued in school. 
When three years old he had a lame hip which was diagnosed and 
treated as tuberculous and he was kept in a splint for two years. 
The leg finally healed, but has become shorter than the other. 

Examination. — The patient is pale and thin. The left leg has 
two inches of shortening and the head of the femur lies above the 
acetabulum. There is some contraction of the adductors and ilio- 
psoas muscles. Evidently the diagnosis of tuberculosis was cor- 
rect. The urine is straw colored, cloudy and neutral in reaction. 
It contains many pus cells, no casts. The filtered urine still shows 
a trace of albumin. The x-ray showed no stone. There is some 
sensitiveness in the right renal triangle. The cystoscope show^s 
an injected bladder but without ulcers. Clear urine is ejected 
out of the left ureteral orifice but from the right it is cloudy. A 
few acid-fast bacilli were found in the centrifuged and concentrated 
specimen. 

Diagnosis. — The fact that he once had tuberculosis suggests a 
possible diagnosis. The finding of acid-fast bacilli confirms it. The 
sensitiveness of the right renal region and the elimination of this 
side and the absence of both these abnormal factors in the other 
points to the right kidney as the chief offender. The probable locali- 
zation in this one kidney seems to make it a favorable case for ne- 
phrectomy. 

Treatment. — The right kidney was removed. The kidney was con- 
gested and there were a number of small white points on the surface. 
The ureter was as big as a lead pencil and was hard. This was fol- 
lowed over the pelvic brim when it became much smaller and soft. 



BLADDER 



993 



Pathology. — The kidney showed a few areas of round-celled infiltra- 
tion without definite caseous areas or giant cells (Fig. 439). The 
ureter, however, shows the typical lesions of tuberculosis. 

After-course. — The lad improved and rapidly took on weight. When 
examined eight years later he was in fair health and had no com- 
plaint save that he sometimes had to get up to urinate. 




Fig. 439. — Early tuberculosis of the kidney. 

Comment. — It may be questioned if a ureteral catheterization 
should have been done. I feared then, as I fear now, to pass a 
catheter through a bladder through a pool of infected urine to a 
supposedly normal kidney. The evidence here presented was enough 
to furnish a logical plan of procedure. The real error was in re- 



994 CLINICAL SURGERY BY CASE HISTORIES 

moving the kidney at all. When it was found to be but little af- 
fected it should have been put back. The thickened ureter was a 
menace, but the menace likely was not lessened by mussing it up 
and removing it. The complete removal of a tuberculosis by a 
surgical operation is probably an iridescent dream. The removal 
of a part will help the system to eradicate the- remainder, if in the 
eradication infection is not liberated and new foci formed. The 
operative removal of impaired organs essential to life and even 
to the pursuit of happiness should be approached with thought 
and circumspection. The removal of tuberculous lymph glands has 
been found to be too dangerous and it has taught also to what a 
degree the disease may heal under favorable conditions. 

CASE 2. — A matron of fifty came because of pain in the left side 
and blood in the urine. 

History. — For several years she has had pain in her back, more 
pronounced on the left side. During the period of fifteen to twenty- 
two years ago she had three spells of pain in left side of her back 
under the short ribs, which came around to front and ran down 
the thigh. She vomited at each of these attacks. The last attack 
was in the right side. She has had no urinary symptoms. Ten 
days ago while at work she had frequent urination; some burning 
and vesical tenesmus. During this time the urine was red with 
blood and some clots. This cleared up in a few days and four 
days later she began work again. The following few days she 
felt cold at times and once had a chill after going to bed. Blood 
again appeared in the urine. This w^as followed by some fever, 
and the next day she had a hard chill which lasted thirty minutes. 
She had pain in back and more or less all over the body, and 
the following day she was nauseated and vomited. Since that 
time she has felt better. 

Examination. — The patient presents a fairly vigorous appearance 
without evident anemia or the appearance of suffering. The x-ray 
of the kidney region was negative. Cystoscopy and functional 
kidney tests were without interest. The urine was strongly acid, 
the sp. gr. 1.011, albumin positive, sugar negative, blood positive with 
Meyers, and some red cells and many leucocytes but no casts on mi- 
croscopic examination. A second examination showed sp.gr, 1.008. 
The temperature was 100°, pulse 98 on entrance. Three days later 
both were normal. 



BLADDER 995 

Diagnosis. — This attack seems like those she had fifteen and twenty- 
two years ago. Pain in the region of the kidney with hematuria. 
The long duration precludes a tumor and makes tuberculosis unlike- 
ly. The x-ray does not show a stone. Some 25 per cent of ureteral 
stones are not shown by the x-ray, but the presence of such is un- 
likely because the pain is not intense enough for stone and the 
amount of blood lost too great. To explain conditions such as this 
a diagnosis of essential hematuria must be had or confess ignorance 
of the condition. 

Treatment. — The patient was given a dram of potassium citrate a 
day. 

After-course. — The patient became free from symptoms in a week 
and has remained so. 

Comment. — In order to satisfy the requirements of exact diag- 
nosis a ureteral-- catheterization should have been made in order 
to search for a stone too small to show in the x-ray. We know 
that the amount of blood is too great to come from an injury 
to the ureter and hence must come from the kidney. A kidney badly 
enough diseased to bleed is susceptible enough to be liable to be 
infected by catheterization. I have seen more disaster follow 
catheterization than I can find in the literature. This makes it 
likely that some urologists are suppressing interesting information. 
Such observations convince me that ureteral catheterization should 
not be done without a clear and definite reason, just as one would 
trephine or open a knee joint save that the latter are the safer pro- 
cedures. Reverting to the cause of hematuria, it is a pity that the 
congested kidneys once described by Harrison have been forgotten. 

CASE 3. — A retired farmer aged sixty-four came to the hospital 
because of blood in the urine and painful urination. 

History. — This patient had had obstruction to the outflow at in- 
tervals for some years before he noticed that his urine was bloody. 
The flow continued to be interfered with at times after the appearance 
of blood. There was no pain at first but recently there has been much 
tenesmus and at times complete retention for twelve hours, then the 
flow would start again. Recently the pain has become so intense that 
opiates were required. He had lost some twenty pounds in weight. 

Examination. — The prostate was but slightly enlarged and was 
smooth and elastic. There was no stone on x-ray examination and a 
soft catheter passed almost unhindered. The cystoscope impinged 



996 



CLINICAL SURGERY BY CASE HISTORIES 



against a mass but because of the bloody bladder contents a view of it 
could not be obtained. The bladder was freely irrigated and then 
several ounces of adrenalin solution fifteen minims to the ounce and 
after 10 minutes an air dilating cystoscope was passed. A large 
multilobulated mass was seen to be situated above the trigone. It oc- 




Fig. 440. — Carcinoma of the base of the bladder. 



cupied a broad base. Many small papilli-like nodules were situated 
between the large bosselations. The remainder of the blader wall was 
congested, but free from tumor infiltration. The tumor mass even 
with the mental picture obtained through the cystoscope could not 
be palpated by rectal examination. 



BLADDER 997 

Diagnosis. — Because the catheter passed readily and because the 
prostate was smooth and elastic it may be assumed that this is not 
at fault. However, there were periods of dysuria several years 
ago which requires the assumption that the prostate was at fault 
or that the tumor was of several years' duration. The form of 
the tumor suggests a primary cauliflower tumor which would most 
certainly have given rise to hemorrhage. The patient was not dis- 
posed to observe his condition carefully and the urine was not ex- 
amined. It is quite possible, therefore, that there may have been 
hematuria present. If the tumor has been present several years it 
would seem futile to attempt radical removal. Since, however, 
there seems no great degree of infiltration of the bladder wall and 
the ureteral orifices are free, operative removal is not excluded. 
Since his dysuria has passed beyond the point of tolerance, some 
sort of relief must be sought. 

Treatment. — After the bladder was opened a large dense bosse- 
lated mass was discovered. It had a broad base which encroached 
and included the right ureteral orifice. (Fig. 440.) The base was 
deeply infiltrating and because of this no attempt at removal was 
made. Instead a cupped permanent catheter was put in place. 

Pathology. — A bit of tissue removed presented spindle form cells 
radiating from a common center. 

After-course. — The patient lived nine months, dying from pro- 
gressive weakness, though during the last few months he had much 
pain in the pelvis. 

Comment. — A bold, or an enthusiastic, or an inexperienced opera- 
tor might be justified in attempting the removal of such a 
tumor for it appeared to be technically operable. Unless a broad- 
based bladder tumor can be removed completely, it had best be 
left alone for attempts at removal or cauterization but tend to has- 
ten its growth. When a tumor of this sort becomes large enough 
to produce obstruction, a suprapubic drainage is the best treatment. 
The suprapubic drain can be made water tight, making it possible 
for the patient to get about. These suprapubic drains are much 
more satisfactory than a perineal drain or a vesicovaginal fistula 
in females practiced by some surgeons. In such cases as this where 
obstruction long antedates hematuria the surgeon is apt to assume 
that the trouble is due to the prostate. Whether all prostatics 
should be subjected to cystoscopic examination may be a debated 



998 CLINICAL SURGERY BY CASE HISTORIES 

question but when there is hematuria there can be but little doubt 
as to the need of it. However, since prostates are now removed 
by almost all surgeons by the suprapubic route, the need is less 
urgent, for should a bladder tumor be encountered it may be at- 
tacked or left alone as the case may be and the patient is no worse 
off than if the surgeon had proceeded with full knowledge of the 
presence of the tumor, however much it may chagrin the surgeon. 
When perirenal prostatectomy is done and the tumor then dis- 
covered, it is quite another matter. 

CASE 4. — A young physician came because of hematuria. 

History. — The patient has been having bladder hemorrhages at in- 
tervals for a number of months. The hemorrhage is moderate in 




Fig. 441. — Papilloma at base of bladder. 

amount and is unattended by pain. Save for the bloody urine he 
considers himself normal. 

Examination. — The cystoscope shows a small papilloma (Fig. 441) 
the stalks of which wave like a fern in a breeze. The base is very 
narrow and the bladder wall is unchanged. 

Diagnosis. — Benign papilloma. Such a diagnosis is possible only 
after having observed the patient many years. The thinness of the 
stalks, the narrowness of the pedicle and the unchanged state of 
the bladder wall immediately surrounding the stalk speak for its 
benign character. 

Treatment. — Removal of the tumor with forceps and cauterization 
of the base with the Paquelin's cautery was done. The tissue was 



BLADDER 999 

destroyed for 1/4 cm. about the tumor and through the mucosa into 
the muscle coat. 

Pathology. — The bits of tumor remaining showed villi covered 
with a single layer of cells. 

After-course. — He has remained free from recurrence now fifteen 
years. 

Comment. — To treat such tumors through a cystoscope is not jus- 
tified. Complete destruction of the base of the tumor is demanded 
in all cases. These tumors, like papillary tumors of the ovaries, 
are always semimalignant and can be cured only when thoroughly 
removed in the beginning of their growth. 

CASE 5. — Fanner aged sixty-one came to the hospital complain- 
ing of attacks of pain in left lumbar region, coming around in the 
front above the ilium and passing down to the bladder. 

History. — The present trouble started ten years ago. At that time 
he had a sudden attack of pain in the left lumbar region radiating 
around to the front just above the iliac bone and passing down 
to the bladder. Never felt in testicle ks he remembers. It was ac- 
companied by a constant deSiire to urinate and a burning sensation 
in the urethra. He did not vomit and did not have over a degree 
of temperature. From that time until two weeks ago he had two 
more attacks. These were exactly like the first. A few weeks 
ago he was suddenly taken ill with an exactly similar attack, ex- 
cept that he thought the pain started just above the ilium and 
passed back to the lumbar region and down to the bladder. 
The next day he had exactly the same kind of an attack. He had 
none then for four days when he had another. Since then he has 
had attacks of greater or less severity about every day and has 
remained in bed all the time. He can not say as to the length of 
an attack because they w^ere all stopped by an opiate. He says it 
took a great deal to stop them. Appetite good, general health always 
good except for the above acute attacks. Has been rather constipated 
the last few years. Hardly ever gets up at night to urinate. Has no 
burning or pain on urination and passes it freely. Never any pain 
in the bladder region except when the acute attacks are on. 

Exmnination. — The patient does not look acutely ill but he is un- 
able to walk because of pain in the left side. There is marked tender- 
ness on pressure in the region of the left kidney. Two sets of x-ray 
plates were taken, after proper preliminary treatment, but no shadows 



1000 CLINICAL SURGERY BY CASE HISTORIES 

were found. The urine was cloudy, contained some pus cells and 
many phosphate crystals in all of many examinations. The leucocyte 
count varied between 7,000 and 14,000. Temperature 99.5-100. There 
were some red cells in one examination. 

Diagnosis. — The repeated attacks of pain typically located indi- 
cated stone in the ureter and this is probably the correct diagnosis, 
notwithstanding our inability to demonstrate one by the x-ray. The 
small amount of red cells speaks strongly for stone. On the other 
hand, 14,000 is too large a number to be accounted for from a simple 
urethral stone. If this count is correct the possibility of abscess must 
be considered. This is unlikely or the temperature would go higher. 

Treatment. — He was placed in bed and given urinary antiseptics. 

After-course. — He improved rapidly and was free from disturb- 
ance in a few days. He did not desire further treatment. He re- 
turned home and was free from pain for a year then he had a similar 
attack on the right side. He had to have hypodermics for their re- 
lief. He vomited during one attack of pain. There is some general 
abdominal distention and there is tenderness on pressure in the 
general direction of the ureter. The urine is cloudy and contains a 
considerable number of red and white blood corpuscles. The x-ray 
shows a shadow in the region of the right ureter near the bladder. 

Comment. — Nine out of ten ureteral stones pass unaided. Whether 
or not in cases of renal colic we should proceed to a scientific examina- 
tion or await the spontaneous passage of the stone is a question that 
must be answered. In cases where the colic is typical and the x-ray 
shows no stone I believe in watchful waiting. When there is stone 
repeated pictures should be taken in order to determine whether the 
stone moves or not. If the attacks are recurrent and there is no 
change in position, one should proceed with its removal. If there is 
persistent pus in the urine, the stone should be removed. If there is 
stone in the kidney it should be removed. Ureteral catheterization 
should be looked on as a major operation. Much damage has been 
done by promiscuous resort to this all too fascinating a procedure. 

CASE 6. — A retired farmer aged eighty-three came to the hospi- 
tal because of painful urination. 

History. — The patient had a bladder operation eight years ago for 
a growth in the bladder. He was entirely relieved of his symp- 
toms following the operation except for occasional spells of painful 
urination, until in the past summer. At this time he commenced to 



BLADDER 1001 

have frequent and painful urination and passed only a small amount 
each time. He says his symptoms are somewhat similar to symp- 
toms he had before his first operation. At the present time he 
sometimes has overflow of urine, and can not always control it. At 
other times he has almost complete stoppage of urinary flow and 
thought he would have to be catheterized, although this has not 
been necessary. He was catheterized for three months preceding 
his other operation. He has been passing blood and pus in his urine 
which has been worse the past three weeks. Lately severe dull 
aching pain in bladder region has developed. It is w^orse on urina- 
tion. He has lost some weight recently. 

Examination. — Well preserved man, muscles rather flabby and 
shows some evidence of loss of weight. Skin cool, dry. No ab- 
normal discolorations. Head and face negative. No cardiac en- 
largement ; systolic murmur at apex not transmitted to axilla. Some 
abdominal distention, no palpable masses; some tenderness on deep 
pressure in pubic region. Liver and spleen not enlarged. Slight en- 
largement felt in prostate region b}' rectal examination and there 
is distinct tenderness on pressure. Extremities and reflexes nega- 
tive. Blood pressure 130-75. Urine 1.020, cloudy, alkaline, albumin 
present, blood present, Avhite and red blood cells. Hg 85 ; W.b.c. 
8,000 ; R.b.c. 4,600,000. X-ray shows shadow in the bladder region 
a little to the right of the midline. 

Diagnosis. — Bladder stone. 

Treatment. — The bladder was opened suprapubically. No bladder 
stone was found, but a large papilloma was found in the base of the 
bladder. An attempt at resection Avas made and the base where 
it was removed was cauterized with the electric cautery. The bladder 
was drained. 

After-course. — There was no postoperative shock. The gauze 
drain was removed on the second postoperative day; its removal was 
followed by some bright red staining of the urine. Nausea developed 
the fourth day and gastric lavage was given. The bladder was 
irrigated daily with boric acid solution, removing large amounts 
of debris, blood clots, and the return fluid was stained a bright 
red. There was little attempt at W'Ound healing; the nausea con- 
tinued, the pulse became weak and irregular and the patient failed 
rapidly, death resulted 20 days after operation from ascending kid- 
ney infection. 



1002 



CLINICAL SURGERY BY CASE HISTORIES 



CASE 7. — A matron of sixty-four came for consultation because 
of painful and frequent urination and loss of strength. 

History. — For a year or more she has had an irritable bladder. 
There has been blood in the urine on several occasions. She has 
had some dull pain in her right side for some four months. Her 
son, a physician, has noted that she has had an irregular temper- 
ature varying from below normal to 102°. He has found microscopic 
blood in the urine on numerous occasions. Just recently he dis- 
covered a tumor in the right kidney. 

Examination. — The patient is tall, thin and anemic. The abdomen 




Fig. 442. — Hypernephroma of the kidney. 

is soft and flabby. In the right renal region is a tumor three 
times the size of a normal kidney. It moves on respiration and is 
firm and nodular. It is not sensitive to pressure. The urine con- 
tains a small number of red cells and many leucocytes. Two acid- 
fast bacilli were found after prolonged search — in the twentieth 
stained slide to be exact. 

Diagnosis. — The build of the patient, the irregular temperature 
and the acid-fast bacilli seem to warrant the diagnosis of tuber- 
culosis. The tumor seems too large and firm for tuberculosis, it 
may be noted. At any rate removal seems indicated. 



BLADDER 1003 

Treatment. — After the tumor was exposed it was seen to be a hyper- 
nephroma. 

Pathology. — The slide shows a typical hypernephroma (Fig. 442). 

After-course. — The wound healed slowly and a sinus persisted a 
long time, likely due to a ligature of silk which was used to ligate the 
vessels. 

Comment. — The baffling thing was the low irregular temperature. 
I have not noted it in any other patient with hypernephroma. The 
finding of acid-fast bacilli completed the deception. 

OBSTRUCTION 

Obstruction to the outflow of the urine is usually due to an enlarged 
prostate. A prostate may cause obstruction without being enlarged 
and central nervous lesions may cause retention with or without en- 
largement of the prostate. 

CASE 1. — A retired farmer aged sixty-one comes because of diffi- 
culty in urination following prostatectomy. 

History. — The patient had the usual history of enlarged prostate. 
He was operated on two years ago and a very large smooth prostate 
was removed by the suprapubic route. The prostate was very large, 
bulging into the bladder so that it overhung the urethral orifices. 
The incision was made through the mucosa over the top of the pros- 
tate. After the gland had been removed a large pocket remained. 
This was packed with gauze for two days. The abdominal wound 
closed in four weeks and he was free from disturbances for six 
months. After this he began to have difficulty again. 

Examination. — A 26 F. soft rubber catheter passes without much 
difficulty, and five ounces of residual urine was obtained. It con- 
tains a few pus cells, but no other abnormal constituents. The x-ray 
failed to show a stone. 

Diagnosis. — There being no stone, it was concluded that a portion 
of a lobe was left behind. The mind naturally travels along lines 
it has traversed before. It was supposed that the contracting scar 
had drawn the offending mass before the urethral orifice. 

Treatment. — The bladder was opened again, but instead of a por- 
tion of prostate which I had hypothecated, there was a ridge passing 
from side to side in front of the urethral orifice (Fig. 443). This 
could be pushed upward and the opening into the urethra readily 
palpated. This bar was cut across with the cautery, after which it 
retracted away from the opening. 



1004 



CLINICAL SURGERY BY CASE HISTORIES 



After-course. — After two and a half years there has been no re- 
currence. 

Comment. — Apparently too much of the mucosa covering the large 
prostate had been left behind. Since the above experience I have 
removed a part of the bladder mucosa covering large prostates. I 
believe in such cases the capsule could be pushed into the hole re- 
maining after the removal of the prostate rather than to put the 
gauze into the hole, thus holding the flap up. The difficulty comes 
in making the gauze stay in place if it is placed on top of the flap. 




Fig. 443. — Bar across the base of the bladder after prostatectomy. 



If there is not much bleeding it does not make much difference 
where the gauze stays; If the suture is left long it can be cut in two 
days and the pack removed. Suturing the gauze in place or sutur- 
ing the flap itself in place requires a larger abdominal incision than 
is ordinarily required, which in general is to be avoided. I have 
in several instances threaded each end of a silkworm gut with a 
straight needle and passed each of these through the perineum ty- 
ing the ends over a gauze pad at the base of the scrotum. This is 



BLADDER 



1005 



effective but usually unnecessarily elaborate, but when firm pack- 
ing is required it is a valuable means. It is most likely to be re- 
quired in small fibrous prostates where one is obliged to cut out the 
obstructing tissue. 

CASE 2. — A school boy aged fourteen was brought because of 
bladder trouble. 

History. — The patient has had a progressive bladder disturbance 
lasting now four months. At first he was annoyed only by frequent 




Fig. 444. — Sarcoma of the posterior wall of the bladder. 

urination without pain. Later pain developed with a constant 
desire to urinate. There was no cause assigned and there was no 
antecedent disease that might have affected the urinary apparatus. 



1006 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — Aside from a look of distress, the lad seems quite 
normal. Suprapubic palpation excites apprehension but no pain. 
Bimanual palpation shows a tumor in the midline of the pelvis the 
size and shape of a goose egg. It is tense elastic in consistency. 
Manipulation causes some pain. He explains it as a sense of urgent 
desire to urinate. The urine showed many leucocytes but no blood. 

Diagnosis. — The patient's age and the size of the tumor suggested 
sarcoma. Epithelial tumors large enough to be palpated bimanually 
are quite rare and practically unknown in patients of this age. They 
are attended by pain and hemorrhage. The absence of pain, and its 
elasticity, excluded stone. A stone so large as this would have a 
longer time for its formation. 

Treatment. — General measures only were advised. 

Pathology. — At autopsy a tumor quite filling the bladder was found 
(Fig. 444). It did not involve the ureteral orifices and admitted of 
removal without destroying the entire thickness of the bladder wall. 
On section it was uniform, being grayish pink, and on microscopic 
examination it was found to be a spindle-celled sarcoma. In struc- 
ture it resembled the retroperitoneal sarcomas save that it was more 
cellular than is the rule in these tumors. 

Comment. — This is the only sarcoma of the bladder I have met with. 
As viewed at autopsy, its enucleation would seem to have been possible. 
That relief could have been had for any length of time is unlikely. 

CASE 3. — A fanner aged forty-eight came because of difficulty in 
passing his urine. 

History. — During the past fifteen years his urine has not passed 
as freely as it should, and for four years there has been actual 
trouble in passing the stream. About this time he noticed that he 
was passing quantities of mucus with the urine. Eiding horseback 
and doing heavy work always increased the amount of mucus. 
During the past year he has had serious difficulty in passing the 
urine at times, and there was a severe burning along the urethra 
attending the act when it did start. Even during this time he had 
periods of several weeks free from disturbance. He has noticed 
that the act of defecation often gave relief and helped him to get 
the stream started. Seven weeks ago he had acute retention. He 
was catheterized without difficulty by his doctor, but the next day 
there was great difficulty in passing the catheter. Following these 
two catheterizations he was able to pass his urine with a fair degree 



BLADDER 1007 

of comfort. Four days ago he had another retention and has been 
catheterized two or three days since that time. He has been taking 
45 grains of urotropin per day for three weeks according to his 
physician. An attempt to catheterize a second time failed. 

Examination. — The general examination is negative save some sen- 
sitiveness in the suprapubic region. There is some flatness here but 
no tumor can be made out. The prostate is not enlarged, the seminal 
vessels can not be palpated, but there is a bulging mass the size of an 
orange above the prostate bulging into the rectum. A catheterized 
specimen of urine shows acid reaction, specific gravity 1.026, albu- 
min in moderate amount and blood and pus. 

Diagnosis. — The difficulty in urination beginning so long ago in the 
presence of a normal sized prostate suggests a chronic inflammation. 
This may be brought about by encysted stone though there is no his- 
tory of pain such as usually attends a stone. The failure to pass the 
catheter sometimes and the ease with which it is passed at others in- 
dicate a false pocket or some obstructive object. Since the catheter 
can not now be passed the cystoscope is useless, and a suprapubic 
opening offers the best means out of the difficulty. 

Treatment. — A suprapubic opening was made. The prostate was 
not enlarged and the beginning of the urethra was not obstructed. 
At the base of the bladder was an opening large enough to admit the 
tip of the finger. It led into a cavity the bottom of which can not be 
reached by the finger. This is evidently an opening into a divertic- 
ulum. A large amount of urine loaded with mucopus escaped from 
this opening. Following the operation the patient was comfortable. 
The temperature rose to 101.5° for a day then came down again. A 
week later the base of the bladder was exposed through an enlarged 
suprapubic wound. The opening lay just behind the trigone. The 
index finger could be forced through the opening, but the bottom of 
the diverticulum could not be reached. The mucosa of the diverticu- 
lum half an inch below the opening was seized with forceps and 
pulled into the opening. A point more deeply down was then 
grasped by a second forceps and this point pulled into the wound. 
By repeating this maneuver the entire diverticulum was inverted 
into the bladder. The left ureter lay in the point of juncture of the 
diverticulum and bladder, and despite care was cut into. The di- 
verticulum was cut off at the restricted neck and the defect in the 
bladder so remaining was closed with catgut. The bladder was 
drained with a large rubber drain through the suprapubic opening. 



1008 



CLINICAL SURGERY BY CASE HISTORIES 



Pathology. — The diverticulum after removal contained 6 or 8 
ounces. The wall was fairly smooth but with some irregularities 
of surface (Fig, 445). The wall was 3 or 4 mm. thick. 

After-course. — The progress was uninterrupted for a week, when 
he began to be troubled with hiccough and the pulse rose to 110-120. 
During the next few days abdominal distention began. This in- 
creased despite stupes and enemas and the hiccoughs increased de- 




Fig. 445. — Diverticulum of the bladder everted showing the structure of the lining wall. 



spite gastric lavage. On the twelfth day he vomited. Hypodermoc- 
lysis gave no relief and the pulse rose to 140, the temperature to 
102, He became delirious and died. 

Autopsy. — There was a paravesical abscess holding several ounces 
of pus. The veins in this region contained septic thrombi. Neither 
the peritoneum nor the parenchymatous organs showed any changes 
to account for the hiccough or distention. 



BLADDER 1009 

Comment. — The history of difficulty lasting over fifteen years with 
the passage of much mucus should have led straight to the diagnosis 
of diverticulum. Even the discovery of a boggy indefinite mass 
above the prostate failed to bring clarity in the mental picture. 
The need for relief was more impelling than an exact diagnosis 
was self-evident. Greater effort should have been made to steril- 
ize the diverticulum before the operation w^as attempted. This 
might have averted the death from sepsis. The attempt to close 
the top of so deep a hole which from the very nature of things must 
be or become infected, w^as poor surgery, though this is the technic 
usually employed. I should now drain such a large cavity through 
the peritoneum, even placing a tube to the bottom of it so as to ad- 
mit frequent drainage would be an improvement. Precedent rather 
than good surgical principles was followed. 

CASE 4. — A boy aged five was brought to the hospital because of 
dribbling of the urine. 

History. — The child has always had dribbling of the urine. He 
never has passed a stream. He never has complained of pain, but he 
never plays ; sits about all day. He weighs only 35 pounds but usu- 
ally has a fair appetite. The bladder was irrigated several times a 
week over a period of several months, because there was pus in the 
urine, but no improvement followed. 

Examination. — The child is thin and listless and observes the manip- 
ulations of the examiner in an indifferent sort of way. He prefers 
to lie on his back with the thighs slightly abducted and flexed. The 
lower abdomen seems prominent; on palpation it shows a cystic tu- 
mor. Pressure on this hastens the dripping of the urine. The urine 
is 1.006, contains a trace of albumin and a number of mobile bacilli 
and many pus cells. Hg is 60; W.b.c. 10,000. The catheter passes 
easily without hindrance. The interior of the bladder is smooth, shows 
some injection and some purulent debris at the base. An obstruction 
can not be found. 

Diagnosis. — The history of dribbling during childhood in the ab- 
sence of any nerve lesion suggests a partial obstruction existent since 
infancy. The obstruction can not be located. A genitourinary spe- 
cialist is equally unsuccessful. A diagnosis of chronic retention of 
childhood was made. 

Treatment. — Since no obstruction can be found he was given uri- 
nary antiseptics until further information' can be obtained. 



1010 CLINICAL SURGERY BY CASE HISTORIES 

After-course. — The patient died in ten days of diphtheria. 

Autopsy. — The bladder was very large and smooth walled. Just 
distal to the veru montanum was a fold of mucosa resembling very 
much the valve of a vein. It allowed an object to enter freely to- 
ward the bladder but unfolded and obstructed the passage of any ob- 
ject which sought to pass from the bladder. There was no thickening 
anywhere or any evidence of inflammation. 

Comment. — This affection is not so very uncommon. I have seen 
three of them, the other two in girls. I did not succeed in relieving 
any of them, and they all died of intercurrent affections. Could 
the obstruction be located its removal would be quite feasible. Usu- 
ally it is in the beginning of the urethra. Its discovery in girls 
at least would seem to be a simple problem, but it is not. 

CASE 5. — A retired physician ag^ed seventy-five came because of 
difficulty in urination and indigestion. 

History. — The patient has had trouble for six years in passing his 
urine. He has had pain and tenesmus at intervals, and used a cath- 
eter for some time two years ago. He had some blood in the urine 
at this time but none since. Now he gets on fairly well for con- 
siderable periods of time, when suddenly he will have tenesmus 
and stoppage of the urine. After a time the urine flows almost un- 
hindered again. He has noticed that he has difficulty when he be- 
comes chilled, particularly when circumstances have compelled him 
to use an outdoor closet. He gets relief by remaining in bed 
warmly covered. He has indigestion with much gas at times and 
is then very constipated. This condition is much aggravated when he 
has trouble with his bladder, but it is present at other times as well. 
His general health has always been good. 

Examination. — The general appearance is that of an individual in 
good health at least ten years younger than his actual age. His 
blood pressure is 140-90, and the heart outline is normal. The lungs 
show nothing more than a moderate emphysema. He has a double in- 
guinal hernia. The urine is 1.018, free from abnormalities. The 
catheter passes readily without causing pain. The prostate is uni- 
formly enlarged without a notable enlargement of the middle lobe. 
The residual urine is less than an ounce. The prostate is smooth and 
of moderate size. 

Diagnosis. — The presence of blood in prostatic enlargement is always 
suggestive of malignancy. Since in this instance it followed cathe- 



BLADDER 1011 

terization and none has appeared in two years, malignancy may be 
excluded. Because of the advent of retention under conditions of 
chilling the cause may be ascribed to congestion. The absence of a 
middle lobe and the negligible residual, harmonizes with this theory. 
The digestive disturbance is of minor importance and apparently is 
dependent largely on his dietary. It has remained stationary, con- 
sequently likely is neither ulcer nor carcinoma. 

Treatment. — He was directed to wear woolen underwear the year 
around. Measures were advised looking to the correction of his di- 
gestive disturbance and constipation (heavy magnesia, bismuth sub- 
nitrate and sodium bicarbonate) and he was given five grains each of 
salol and boric acid four times a day whenever there was any sign 
of urinary disturbance. 

After-course. — He improved in every way promptly on this advice 
and has kept himself comfortable now six years. During the past 
year he has had some trouble in controlling his urine, evidence of 
continued enlargement of the lateral lobe. 

Comment. — ^When prostatics have intermittent trouble only, com- 
fort may generally be secured by attention to the conditions as 
above indicated, antecedent to the onset of the urinary trouble. 
These are usuallj' digestive, or due to disregard of sudden changes 
of temperature. Had this man's trouble been persistent with a 
residual urine or with infected bladder, I should have operated. 
These conservative measures are particularly advisable in old men 
with nothing to do except to regulate the weather while awaiting 
an apoplexy or a sudden terminal pneumonia. The indications for 
operation in enlarged prostates are rather the sequelas present or 
threatened than the enlarged prostate itself. That must be re- 
garded as incident to advancing years and its consequences to the 
individual must be evaluated in each instance. 

CASE 6. — A merchant aged thirty-eight came because of difficulty 
in urination. 

History. — ^Four years ago following a gradually developing stricture 
he acquired a perineal urinary fistula after having a painful affection 
of the scrotum for three weeks. Since then he has urinated partly 
through the natural channel, and partly through the fistula. He had 
his gonorrhea eight years before. 

Examination. — The fistula admits a fine probe but the urethra is 
not passable for a filiform. 



1012 CLINICAL SURGERY BY CASE HISTORIES 

Diagnosis. — The extent of the stricture can not be determined since 
the stricture can not be passed. 

Treatment. — A sound is passed to the stricture and the point cut 
down upon. The scarred urethra is followed for a cm. when the 
urethra again becomes widened, wider than normal as a matter of 
fact, readily admitting the finger into the bladder. The strictured 
portion of the urethra was excised and the severed ends loosened for 
2 cm. and brought in apposition. A No. 22 catheter was passed and 
an end-to-end anastomosis was made about it. The catheter was fas- 
tened in place with a No. 2 pyoktanin catgut suture. The soft parts 
were then closed about the urethra without drainage. 

After-course. — The catheter came away in seven days, it being re- 
leased by the absorption of the catgut suture. There was some in- 
continence for a few days after the catheter was removed, but this 
soon disappeared. A sound was passed at intervals of a week for sev- 
eral months. After ten years the stricture has not re-formed. 

Comment. — This method secures the most speedy result. In some 
10 per cent primary healing is not secured and a perineal fistula 
develops. This heals spontaneously after three or four wrecks. The 
method has the advantage of getting rid of the scar tissue. When 
the strictured area is very long, more than an inch, the method can 
not be employed. The urethra may be separated from the sur- 
rounding tissue for a centimeter without endangering its nutrition. 
When primary healing does not take place secondary hemorrhage 
may follow, as I have seen in two cases, both of which were easily 
controlled by secondary suture. 

CASE 7. — A retired miner aged seventy-six came to the hospital 
because of difficulty in urination. 

History. — The patient has had difficulty in urination for a number 
of years. He first noticed that he was compelled to get up eight or 
ten times at night to urinate. During the last year he has had diffi- 
culty in starting the stream and the urine only dribbled away when 
he did get it started. This condition has grown progressively worse 
during the last year, and two days ago he had a complete retention 
of urine and has had to be catheterized since. 

Examination. — The patient is a decrepit old man who shows the 
effect of the use of alcohol. He has a double inguinal hernia, the 
right one coming clear down into the scrotum, the external ring is 
so large that scarcely any resistance is offered. The left extends into 



BLADDER 1013 

the base of the scrotum only. The patient has a distended bladder 
which when catheterized proves to be the extent of three pints. The 
urine is cloudy, contains many pus cells but no blood. The specific 
gravity is 1.011, it is neutral in reaction and contains some albumin 
and a few casts. The prostate is large, smooth and plastic. The apex 
beat is near the anterior axillary line. The heart tones are indistinct. 
The pulse is easily depressible, irregular in rate and volume. 

Treatment. — A suprapubic prostatectomy was done, the operation 
being completed in one step under local anesthesia. The prostate 
was large and quite hard to shell out. Considerable hemorrhage at- 
tended, and two gauze packs were placed in the prostatic capsule, 
and the bladder was drained with a large rubber drainage tube. 

After-course. — After six days the silkworm sutures in the skin cut 
through and the wound gapped widely with a bulging of the peri- 
toneum between the recti when the patient coughed. The wound was 
drawn together with adhesive strips, but the patient complained so 
bitterly of pain that they were taken off. His respirations became 
rapid at the end of the first week, and a dullness at the base of the 
lung developed. Later medium-sized rales were heard in the axilla. 
His temperature varied from 97.5° to 100°. He was given ammo- 
nium chloride internally and in inhalations. His lung trouble grad- 
ually cleared up. At the end of sixty days when the patient was 
about ready to leave the hospital, he complained of earache and 
a renewed temperature of from 99° to 99.6° occurred. Phenol in 
glycerine was dropped into the ear. There seemed to be no bulg- 
ing of the ear drum though it was opaque and scarred. Two days 
following this the drum ruptured, discharging a small amount of 
pus, and the temperature dropped to normal. The patient states 
that he has had attacks of earache with discharge at intervals since 
childhood. During the next two weeks he had periodic attacks of 
pain and rise of temperature. There was no evidence of mastoid 
involvement. The patient was sent home on the seventy-eighth day 
with a perforation in the drum membrane and a small sinus above 
the pubis which drained urine occasionally when he exerted himself. 

Comment. — This decrepit old man had consumed much "scotch" 
in his day and was un.suited for an operation completed in one 
sitting. Drainage for two weeks with a building up of his circula- 
tion would have given better results. The first evidence of an im- 
pending hypostatic pneumonia was seen in a mild delirium ob- 



1014 CLINICAL SURGERY BY CASE HISTORIES 

served by the night nurse. This naturally caused the suspicion of 
kidney involvement, either of uremia or multiple infection. Some- 
times some days elapse before a positive diagnosis can be arrived 
at. Sometimes several conditions coexist, as multiple abscesses of 
the kidneys with a terminal hypostasis. The most important safe- 
guards against such accidents are careful attention to the circula- 
tion, cardiac tonics, and the avoidance of the recumbent position. 
This case represents a stupenduous amount of labor to secure for 
a derelict a few additional years of comfort. 

CASE 8. — A fanner aged sixty-two was brought to the hospital be- 
cause of pain on urination. 

History. — For years he had to get up five or six times a night to 
pass urine. A year ago he suddenly had pain in passing urine. 
He has headache at intervals and usually vomits before he gets 
relief. He was operated on seven months ago, the prostate be- 
ing removed by the transvesical route by an operator who 
assured the patient that he had done hundreds. The operation was 
very difficult the operator told him and the conclusion was arrived 
at that because of this it was malignant. The urine flowed freely 
for a few weeks, then obstructive symptoms began again. Now he 
has constant pain and passes the urine with difficulty. He had a 
sore testicle following the operation and it is still enlarged and 
sore. 

Examination. — The patient's face bears the expression of a con- 
stant sufferer. His knees are flexed and his hands go involuntarily 
to his hip, evidently a sort of habit movement, but nevertheless a 
sure evidence of real and prolonged suffering. A broad, deep puck- 
ered scar marks the region about the pubes. The region of the pros- 
tate on rectal palpation is marked by a hard scar, but no enlargement 
or nodules can be made out. The urine contains pus but no red cells. 
A sound comes to an abrupt stop when the prostatic region is reached. 

Diagnosis. — The statement of the operator that he had done hun- 
dreds is a sure indication that it was his first case. This is further 
indicated by the fact that he found the job difficult and concluded 
that the gland must be malignant. This, together with the early 
return of obstruction, indicates an incompetent operation. The possi- 
ble presence of malignancy can not be ignored, but obstruction to a 
recurrent tumor would not take place in three weeks while obstruction 



BLADDER 1015 

due to an incomplete operation would be expected to appear at about 
this time. 

Treatment. — A nodule the size of a hickory nut was removed from 
the right side. The scar from the left side had drawn this over the 
outlet of the bladder producing an obstruction. 

Pathologij. — The nodule removed was not malignant. 

After-c&urse. — He had a free flow of urine following the operation 
but when last heard of, still had some pain with frequency of urina- 
tion and some pus in the urine. 

Comment. — Early renewed obstruction indicates the remains of a 
part of the prostate. I could have quoted cases in which I myself 
had overlooked a portion of a lobe, but it is more in keeping with 
professional practice to detail another man's shortcomings. Leaving 
a part of the gland is apt to occur unless the operator has an accu- 
rate knowledge of the size of the gland before he begins. It is par- 
ticularly apt to occur when the operator does not use a finger of 
the left hand as a guide. 

CASE 9. — A retired fanner a-ged sixty-two cajne to the hospital 
because of dribbling of urine. 

History. — The patient had had some trouble in passing urine sev- 
eral years ago but none recently. He now complains that he is unable 
to retain his urine or that he must urinate at frequent intervals when 
he can pass only small amounts. For some months he has noticed a 
tumor in the lower abdomen. He consulted his physician who ad- 
vised consultation. His general health has always been good until 
the past few months. Now he is weak, tires easily, has lost his ap- 
petite and thinks he has lost considerable weight. 

Examination. — The patient presents a globular tumor above the 
pubes and reaching to the umbilicus. It is fluctuating and elastic. 
This disappears on passing the catheter. The catheterization is ac- 
complished with some diflficulty. The prostate is large, smooth, and 
resilient. The urine is acid, 1.008, albumin positive, and contains 
much pus. There is a moderate general anemia. The nervous sys- 
tem is normal. 

Diagnosis. — The history of dysuria followed by the incontinence 
of retention indicates a gradually encroaching prostate. This is veri- 
fied on palpation by the enlarged prostate, and the resistance the 
catheter meets. We may diagnosticate, therefore, hypertrophy of 
the prostate, retention cystitic, likely pyelitis. In prostates with pale 



1016 CLINICAL SURGERY BY CASE HISTORIES 

urine of low specific gravity it is very difficult to gauge the condition 
of the kidneys. If the urine is acid often the release of the pressure 
quickly restores the state of the urine. If alkaline, the difficulty may 
be increased. 

Treatment. — Suprapubic drainage was done and in a week the 
prostate was removed, both operations being done under local anes- 
thesia. 

Pathology. — The prostate was characterized by unusual gland pro- 
liferation, but no definite area of malignancy was found. 

After-course. — Following the placing of the suprapubic drain the 
urine remained unusually bloody, though there was no excessive 
bleeding at the time of the operation and palpation of the prostate 
at that time did not reveal any signs of malignancy. It was four 
days before the urine ceased to be bloody, and even after that it 
was bloody at intervals. This fact gave the suspicion of malignancy 
though it could not be determined whether the blood came from the 
prostate or from the suprapubic wound. After the prostatectomy 
the urine ceased to be bloody after the second day. On the seventh 
day after the prostatectomy the patient complained of being cold, 
and examination showed that he was having a considerable bladder 
hemorrhage. He was given pituitrin 1 c.c. and adrenalin TTL x. 
The pulse became very weak but not rapid. Twenty-one days after 
the prostatectomy the patient had another severe hemorrhage. He 
received 2 c.c. of pituitrin and 1/6 grain of morphine. The supra- 
pubic wound had all but healed and blood escaped chiefly through 
the natural channel. Following this he slowly improved. The 
urine remained somewhat cloudy, but it always flowed freely with 
good control. 

Comment. — In this patient there was a twofold reason for doing 
a preliminary drainage; the chronically distended bladder and the 
infected urine. When either condition exists drainage should be 
done. This patient was unusual, in that he had a considerable hem- 
orrhage so late in the course of the convalescence. In cases of ma- 
lignancy there is more disposition to bleed after the operation, but 
save for this, there is no reason for suspecting it. There is a fur- 
ther reason for hemorrhage. It is not known how long he had 
a distended bladder. Patients who have become anemic from a 
chronically distended bladder bleed profusely and stand operation 
badly, I once lost a patient on the third day from hemorrhage who had 



BLADDER 1017 

become anemic from long distention. The degree of anemia and the 
coagulation time of the blood gave some index as to the degree of 
the risk. 

CASE 10. — A fanner ag:ed sixty-seven came to the hospital be- 
cause of difficult urination and dyspnea. 

History. — The patient says that serious trouble began about one 
year ago but that frequency of urination began some years earlier. 
He has intense scalding sensations which are most pronounced just 
before the urine starts to flow. After urination the urethra feels 
raw for some time. Sometimes he has difficulty in getting the urine 
started. He often noticed blood in the urine during the past year. 
He has passed urine ten to fifteen times a night during the last 
few months. During the day if he remained quiet he did not pass 
it so often. His bowels are regular and his appetite remained good 
up to the last couple of months. He has lost from 20 to 30 pounds in 
weight during the past year. For some months he has been trou- 
bled with a persistent cough -with expectoration. There is dysp- 
nea at times so that he can not lie down. He was treated by a 
distinguished urologist for a month by irrigations. He was told 
that there was a diverticulum of the bladder and that because 
of his general condition he could not be operated on. 

Examination. — The patient is emaciated and decrepit, and exertion 
brings on dyspnea and cough. The respiration is labored and there 
is bluing of the lips and finger^. The lungs are emphysematous and 
there are many medium-sized and large bubbling rales. About the 
bases of the lungs are many fine crepitant rales. The apex beat is 
diffuse and not easily made out. The rhythm of the pulse is irregular 
and the volume inconstant. The prostate is enlarged and tender but 
smooth and not hard. Urinalysis shows specific gravity 1.022, al- 
bumin present, no sugar, much pus, and many red cells. 

Diagnosis. — The bladder condition having been provided us by a 
written report from the Urologist, we had only to call the condition of 
the lungs. Obviously a bronchitis, at least in part capillary, is pres- 
ent. This precludes any operative interference which would make 
a dorsal decubitus necessary. 

Treatment. — He was, therefore, treated by inhalations of benzoin 
and ammonium chloride. Later on strophanthus was added. In three 
weeks the lung condition had cleared up notably and a suprapubic 
cystotomy was done. No diverticulum could be found. Three weeks 



1018 CLINICAL SURGERY BY CASE HISTORIES 

later the prostate was removed, both operations being done under 
local anesthesia. 

After-course. — The patient made an uneventful recovery, going 
home in ten weeks with the suprapubic drainage stopped and the 
urine passing freely per urethra with good control. His general health 
is improving slowly, with still pus and albumin in his urine. This 
condition has persisted to date. The urine flows freely and a catheter 




Fig. 446. — Diverticulum of the bladder. 

passes readily. He has pain in the hips and sacrum and has the feel- 
ing as though the bladder were not empty. The amount of urine he 
passes varies greatly. Often when he has emptied his bladder he has 
the feeling as though it were full and often is then able to pass a con- 
siderable additional amount of urine. 

Comment. — This patient seemed in such an extremely unfavorable 
condition that it seemed useless to attempt relief. By a judicious 



BLADDER 1019 

combination of internal medicine and surgery he has evidently been 
given a new lease on life. The persistence of his bladder trouble, the 
feeling as though the bladder were not emptied probably indicates 
that the urologist was correct in diagnosticating a diverticulum and 
that it was overlooked at operation and it was demonstrated by the 
x-ray (Fig. 446). One would not have dared to attack the divertic- 
ulum at that time. Now that his general condition seems to war- 
rant it, such an operation may be undertaken. In such cases some- 
thing may be learned from military tacticians — divide the enemy 
and beat them a part at a time. 

CASE 11. — ^I was called to see a merchant agfed fifty-four because 
of urinary retention following prostatectomy. 

History. — His surgeon relates the following history. A year ago 
he came to the hospital because of urinary disturbance recently 
much exaggerated. The prostate was smooth, hard, and very large. 
A primary drainage was done, and ten days later the prostate was 
removed. The operation was difficult, much of the circumference 
of the prostate requiring sharp dissection for its removal. The 
wound drained five weeks. Six weeks after this it was noted that 
there was renewed difficulty in urination. This increased until 
the present time when he has considerable difficulty in urination 
and has a residual urine of three or four ounces. His general health 
has been fair save for a severe and persistent asthma which has com- 
pelled him to seek a change of climate from time to time. 

Examination. — The site of the prostate is occupied by a very dense, 
hard mass longer than wide and ending in a pyramid form toward 
the urethra (Fig. 447). The abdominal sear is very much hypertro- 
phied. 

Diagnosis. — The mass obstructing the urethra evidently is newly 
formed scar tissue. It has the feel of a keloid, and the markedly 
hypertrophied state of the scar in the abdominal skin shows the 
individual is disposed to excessive scar tissue formation. If the 
obstruction were due to a bar, there would not be such a mass 
of dense tissue, but the findings would be that of complete absence 
of a prostatectomy. Furthermore the primary operation was done 
by a surgeon conversant with the precautions necessary to avoid 
such formation. If this is the true conception of the pathology its 
removal is apt to be followed by a reformation of a new scar if it 
plays true to the usual laws of keloids. The x-ray is often very ef- 



1020 



CLINICAL SURGERY BY CASE HISTORIES 



fective in the removal of keloids, and while the nature of this ail- 
ment does not admit of the delay incident to x-ray treatment, once 
the scar is removed, its reformation may be prevented by the use 
of the x-ray. 

Treatment. — After the bladder was opened under local anesthesia 
the bladder outlet was found to be surrounded by a dense wall of 
fibrous tissue and not by a simple bar as is usual in recurrent ob- 
struction following prostatectomy. The tissue was too dense to per- 
mit infiltration with the novocaine solution, which made it necessary 







^ 


1*" 


1 


■ 


^^^^^^^^^^/ 

vf 






( 


s 


1^, 




^y 








v^^ 

V 

\ 


III 


( 




K 








P^ 







Fig. 447. — Keloid of the prostatic capsule after prostatectomy. 



to infiltrate the soft parts surrounding. The tissue was so dense that 
the strength of the cutting instruments was tried to the utmost. After 
the scar tissue had been removed, a large catheter was passed, ex- 
tending out of the meatus and to the suprapubic wound. The intra- 
vesical portion was armed with a silk string so that the catheter could 
be moved to and fro. 

After-course. — The catheter was kept in situ five weeks. A week 
after the removal of the catheter the suprapubic wound had closed. 
He was repeatedly rayed during the healing of the wound. His sur- 



BLADDER 1021 

geon reports that now two years after the operation he is able to void 
urine with a residual of a few drams. There is a firm scar at the 
prostatic site which seems to draw the bladder much more closely 
to the pubic bone than normal. 

Comment. — This is an unusual cause for secondary constriction of 
the bladder outlet. It is very probable that the use of the x-ray de- 
serves the credit for preventing a recurrence of the scar mass. There 
is no way to anticipate such a formation, or one might make prophy- 
lactic use of the ray after the primary operation, 

CASE 12. — A banker a^ed fifty-five was brought to the hospital 
because of inability to empty his bladder. 

History. — The patient has had some difficulty in passing urine for 
several years, but he never had to be catheterized. Suddenly, without 
warning, twenty-four hours ago he was unable to pass his urine. At- 
tempts to catheterize by his physician failed. The cause of the 
retention could not be found in the history ; venereal disease was de- 
nied and there had been no trauma. 

Examination. — A rounded fluctuating tumor occupies the midline 
above the pubes. Pressure on it increases his already intense desire 
to urinate. Attempts at catheterization v/ith several kinds of in- 
struments all failed. The obstruction obviously is deep in the pros- 
tate. The prostate is small and hard. 

Diagnosis. — The fact that the catheter passed to within the prostate 
excludes urethral stricture. ■ The small size of the prostate does not 
exclude it as a possible source of obstruction. Some relief must be 
obtained at once, and incision is no more serious than a puncture. 
If the prostate proves to be the source of obstruction, the problem 
then arises whether a temporary drainage shall be done or the ob- 
struction at once removed. This must be decided after the operative 
diagnosis is made. 

Treatment. — After the interior of the bladder was exposed by su- 
prapubic incision, the prostate was found to form an elastic roll 
across the trigone etfectually shutting off the urethral opening. The 
urine was not infected and there was no evidence of cystitis. It was 
deemed best, therefore, to remove the prostate at once. Having had 
no notable previous disturbance and the patient being in excellent con- 
dition, this was deemed justifiable. Enucleation was not possible and 
the prostate had to be cut out with scissors. The loss of blood was 
considerable. It was controlled by a tampon. 



1022 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The prostate consisted almost wholly of fibrous tissue, 
the glandular elements being very sparse. 

After-course. — The suprapubic wound healed in three weeks and 
the retention was good. Within several months urination became pain- 
ful and frequent and he passed some calcareous flakes. Irrigation 
helped some, but the trouble became worse. Therefore, fifteen months 
after the first operation the bladder was again opened and a large 
number of stones removed. Improvement occurred, but recovery 
was not complete. Therefore four months following the second op- 
eration the bladder was opened a third time and five stones were 
removed. Recovery promptly followed, but the x-ray showed a stone 
still remaining. This was overlooked at the time of operation. A 
year and a half after the third operation a number of stones were 
found and these again were removed. Inquiry into the geology of his 
locality disclosed that it is a limestone country and that the water 
was very hard. He was directed to drink only cistern or distilled 
water. There has been no further trouble. 

Comment. — The formation of stones after prostatectomy occurs 
in a considerable percentage of cases, more often w^hen gauze packs 
are used to control hemorrhage. The process in this case was invited 
by a rather ragged operation and by the fact that the water he 
drank was heavily charged with lime salts. Perhaps attention to 
his drinking water might have prevented the recurrences. These 
prostates are better removed by the perineal route because it can 
be accomplished without laceration of the bladder mucosa. These 
lacerated bits of bladder wall always invite the reformation of 
stones. 



CHAPTER XIX 

RECTUM 

Rectal diseases are but few. They comprise anal affections, chiefly 
hemorrhoids and fissures, the granulomas and the more serious car- 
cinomas. 

HEMORRHAGE AND PAIN 

These symptoms are often present in the mild as well as the more 
serious affections. This fact makes it imperative that when either 
of these symptoms exist manual demonstration of the lesion be made. 

CASE 1. — A milliner aged thirty-two came to the hospital be- 
cause of difficulty in defecation. 

History. — Five years ago, without known cause, she began to ex- 
perience difficulty in securing a bowel movement. Various reme- 
dies, together with injections, were used with diminishing results. 
She finally consulted a surgeon who diagnosed a stricture of the 
rectum and proceeded to do a dilatation under an anesthetic. She 
remained in the hospital two weeks and when she left she was given 
a rubber dilator and was instructed to use it twice a week. She 
got along very well for nine months, after which time she was unable 
to pass the dilator fully. After a time she discontinued its use. 
The difficulties increased after this time until a week ago, when she 
again entered this hospital. Dilatation was again attempted but was 
unsuccessful and she was advised that some other procedure would 
be required. She denies any venereal infection. She had no rectal 
discharge before the beginning of this trouble. 

Examination. — The patient is a vigorous young woman whose ap- 
pearance gives no evidence of the suffering she relates. The examin- 
ing finger meets a resistance immediately above the external sphincter. 
A rubber catheter passes and the extent of the narrowing seems to 
be about four inches. The constriction seems to be firm. A bismuth 
meal shows a dilatation of the pelvic colon in the region above 
the coccyx (Fig. 448). The blood count is not altered and the Was- 
sermann reaction is reported negative. 

1023 



1024 



CLINICAL SURGERY BY CASE HISTORIES 



Diagnosis. — The patient brings her own diagnosis which the ex- 
amination confirms. The long duration and the extent of it excludes 
carcinoma. Having already been subjected to dilatation a more pos- 
itive line of treatment seems necessary. This may consist in the 
removal of the constricted area or in an artificial anus. Inci- 
sion is useless. The x-ray shows the extent to be not more than four 
inches, which makes a perineal resection feasible. 

Treatment. — The sphincter was preserved and the offending por- 
tion of the gut was brought down and removed. The remaining 
stump of gut was attached to the sphincter and to the skin by a sep- 
arate row of sutures. A large rubber tube was placed well up into the 
gut. 

Pathology. — The specimen is five inches long and is as thick as 
a fork handle. When it is cut open a tortuous canal the size of a 




Fig. 448. — Diagrammatic presentation of stricture of the rectum. 

lead pencil is found. The wall is thick and fibrous and grates under 
the knife. The slide shows only a solid mass of connective tissue com- 
posed of thick fibers and few very narrow cells. The structure is 
that of keloid. The submucosa was largely obliterated and the 
mucosa contains fewer than the normal number of glands and those 
that remain are misshapen and often defective. 

After-course. — There was a tendency to constriction at the muco- 
cutaneous junction and this had to be incised after about six months. 
Following this so long as the patient was under observation, about 
four years, she had no trouble. She had control of the bowels unless 
the stool was thin. 

Comment. — In these long benign structures excision is the only 
satisfactory method of dealing with them. When longer than five 



RECTUM ^ 1025 

or six inches the perineal operation is not feasible and a permanent 
colostomy with excision of the diseased portion is the best way out. 
In this case as in many others there is no clue as to the etiology. 
There is no evidence that it was syphilitic, and tuberculosis certainly 
had nothing to do with it. 

CASE 2. — A matron of fifty-three came to the hospital because of 
pressure and pain in the rectum. 

History. — The patient has one child twenty-eight years old. Her 
menses stopped a year ago. She has not felt well for two years, and 
nine months ago she began to feel a pressure in the rectum. It 
throbs and aches, and bothers her particularly when she sits on a 
hard chair. There is pain in both groins at times. There has been 
no vaginal discharge and she has no bladder trouble. She had radium 
treatment six months ago, but just where the radium was applied is 
not clear and she has had treatment for her piles at intervals. 

Examination. — The cervix is deeply lacerated. The uterus is large 
and nearly fills the pelvis. There is tenderness on pressure and the 
mass seems to be fixed. There are small marginal hemorrhoids. 

Diagnosis. — The pelvic mass with the pronounced and progressive 
disturbance of the rectum suggests, because of the groin pains, a 
myoma undergoing secondary changes of a reactive rather than a 
neoplastic character. Infection would be early transmitted in the 
inguinal glands if the inflammation involved the floor of the pelvis. 
The disturbance on sitting on a hard surface suggests a perirectal 
inflammation. An inoperable maligant tumor had been diagnosed by 
an able diagnostician which makes it probable that there was evi- 
dence available that is not apparent now. 

Treatment.— Instesidi of the myoma being as large as was supposed 
from physical examination, it proved to be about the size of a lemon, 
but there was a double infiltrative salpingitis on both sides. This 
made up the bulk of the mass felt. Both tubes and the uterus were 
removed. 

Pathology. — An infiltrative salpingitis and a simple myoma. 

After-course. — So far so good. 

Comment. — Myoma not infrequently is accompanied by a salpin- 
gitis of low degree. The bulk of the tubal infiltration is added to 
that of myoma and gives an exaggerated notion of the size of the 
tumor. I have made this error many times. Whenever a myoma is 
not distinctly outlined a tubal trouble should be suspected. Peri- 



1026 CLINICAL SURGERY BY CASE HISTORIES 

neal tenderness and infiltration of the lymph glands aid materially 
in the diagnosis. When a myoma actually suppurates the constitu- 
tional symptoms are considerable and usually there is an associated 
tubal inflammation. When a myoma has undergone malignant 
changes, a considerable induration of the pelvic connective tissue, 
which is difficult to distinguish from reactive changes, results. 
These tumor changes are less common than the salpingitis and one 
ought to think of the common ailment first. In this case my regard 
for my friend's opinion caused me to ignore the obvious. 

CASE 3. — A retired business man aged seventy-one came to the 
hospital because of bloody stools. 

History. — For several years the patient has had some pain in the 
rectum when the stool was hard. During this time the stools were 
often very dark. One year ago mucus and blood appeared in the 
stool. His physicians at this time informed him that he had hemor- 
rhoids and a malignant growth in the rectum. They tried to remove 
them by cauterization with a hot iron every third day for three 
months. The discharge did not cease but on the contrary it became 
worse. They then removed the hemorrhoids and since that time 
there has been a complete loss of sphincteric control and the dis- 
charge of blood and mucus is continous. There has been no urinary 
trouble. His health has always been good. 

Examination. — There is an ulcerated area with high rolled up 
edges beginning two inches above the internal sphincter and extending 
up about two and one-half inches. The prostate does not seem notably 
enlarged, but the growth seems attached to it. Otherwise it seems 
free. 

Diagnosis. — The disease is unquestionably carcinoma. Its close 
attachment to the prostate suggests an invasion of that organ. This 
point can be determined only after exposure of the parts. If at- 
tached only to the prostate and seminal vesicles, the disease is at least 
technically operable. The patient's excellent general condition war- 
rants an attempt. 

Treatment. — The resection of the rectum was proceeded with under 
local anesthesia. After the prostate was reached it was found at- 
tached to the growth and was removed along with the tumor. The 
prostate with the urethra was cut off flush with the neck of the blad- 
der. After the rectum had been cared for, an attempt to find the 
opening into the bladder failed and a large tube was placed at the 



RECTUM 



1027 



neck of the bladder and a pack placed about it. The patient was 
becoming restless and the search was not prolonged. I presumed 
the urine would find its way to the tube. 

Pathology. — Typical adenocarcinoma. Fig. 449.) 

After-course. — My expectation that the urine would find its way 
out of the normal opening was doomed to disappointment and I had 
to put in a suprapubic drain. Three weeks after the rectal wound had 




Fig. 449. — Deep ulcerous carcinoma of the rectum. 

partly healed I attempted a retrograde catheterization, but could 
find no opening. I looked in with a cystoscope and there was none. I 
waited four weeks longer until the perineal wound had entirely healed 
and then passed a nubbed sound through the urethra until the blad- 
der wall was reached. Through the suprapubic wound the end of 
the sound was cut down upon and the sound passed into the bladder. 
A silk string was looped over the sound and fastened to the eye 
end of a soft rubber catheter. The sound was then removed and the 



im 



CLINICAL StJIl6£!l'? BY CASE HISTORIES 



catheter pulled after it. A silk loop was attached to the bell end of 
the catheter remaining in the bladder (Fig. 450). The catheter was 
allowed to remain in position three weeks. Now, three and a half 
years after the operation there is no recurrence of the carcinoma, 
and he passes his urine without hindrance and he has good control 
over his bladder and of the rectum when the stool is not loose. 

Comment. — This case is of interest because of the prolonged free- 




Fig. 450. — Catheter with a silk suture protruding out of the suprapubic wound remains. 

dom from recurrence after the removal of the prostate along with the 
malignant gut. It does not seem possible that there should be diffi- 
culty in finding the opening into the bladder after the removal of the 
prostate. It seems even more surprising that the distended bladder 
did not force the opening. Likely in the ligation of vessels in the 
course of the rectal amputation the hole in the bladder was closed 
and dislocated. Possibly it was fortunate that the urine was kept 
from the fresh wound of the rectum. This accident might possibly 
be imitated with advantage when such extensive operations are 
required. 



RECTUM 1029 

CASE 4. — A farmer aged sixty-six came to the hospital because of 
passage of blood and a brownish mucus from the rectum. 

History. — About six months ago he noticed a little blood on 
the outside of the stool. He paid little attention to it, thinking 
it was caused by bleeding hemorrhoids. About a month later there 
was a brownish mucous discharge together with bright blood. The 
discharge has gradually become worse. Now he often has a move- 
ment consisting of thin brownish mucus alone. He has one to two 
movements consisting of feces and five to six consisting of the 
brownish mucus in each twenty-four hours. He has had no pain. 
In the last four months he noticed that the stool was long and rib- 
bon like, as though it had come through a small lumen. He has 
control of the stool, but the discharge of mucus is hard to control. 
There is no loss of weight. The appetite is good and he sleeps well. 
There is no urinary disturbance. He had had neuralgia of both 
sides of the face starting a year ago and lasting until a month or 
more ago. One week ago he had a sort of cerebral hemorrhage. 
The whole left side including the face was aifected. This lasted 
two to three hours. There was speech difficulty for a day. He had 
a similar attack about two years ago which lasted only a few min- 
utes. 

Examination. — Patient is a large robust man, ruddy complexion, 
looks younger than his age. Teeth very poor, molars decayed. One 
decayed tooth root in lower left jaw. Tongue furred, breath bad. 
Pharynx negative. Pupils small, equal, slightly irregular, react to 
light and accommodation. Barrel-sliaped chest. Heart tones faint, 
apex in 5th interspace. Left border of dullness 8 cm. to left. Eight 
at left sternal line. Soft systolic murmur at apex transmitted to 
axilla and sternum. Lung expansion is good on both sides. There 
are no rales and there is hyperresonance. The prostate is large, 
rounded, smooth. An annular mass felt in the rectum about 4 inches 
up just above the prostate. The edges are raised, hard, and ragged. 
The lumen barely admits the finger. The examining finger is blood 
streaked. 

Diagnosis. — The history together with the physical findings leave 
no doubt as to the nature of the disease. Diagnosing the patient is 
a more difficult matter. He evidently has had two cerebral hemor- 
rhages, the last one within the last two weeks. A patient who has 
had cerebral hemorrhage with a relatively low blood pressure is 



1030 CLINICAL SURGERY BY CASE HISTORIES 

a poorer risk than one in a like condition with a high blood pres- 
sure. 

Treatment. — The rectum was dissected out at its anal end and 
pulled down and amputated above the carcinoma. The carcinoma 
was five inches above the anus, annular in type, and ulcerating. The 
peritoneal cavity was broken into in dissecting out the sigmoid. 
The end of the sigmoid was sutured into the skin. The space pos- 
terior to the sigmoid was packed with gauze and a tube put in the 
gut. Three hemostats were left on the mesenteric vessels to be re- 
moved later. 

After-course. — There was no shock apparent and no postopera- 
tive vomiting. Highest pulse rate the first day of operation was 85 
and the temperature 100°. A free bloody fluid drained the first day. 
The second day the patient suffered greatly. The pain extended 
entirely up in the abdomen. Temperature 100.2 and pulse 80. He 
passed only one ounce of urine in the first 48 hours after opera- 
tion. There was a drainage of a fluid tinged with bright blood. 
This appears to be urine. No doubt the bladder was entered in dis- 
secting out the sigmoid. The fourth day after operation he com- 
plained of abdominal pain after having a fairly comfortable day pre- 
vious. Urine was draining entirely from the wound. He took much 
water. Examination of wound showed rectal mucosa still down in 
place. There was nausea at intervals throughout the day. The 
following day he vomited several times, a green colored Avatery 
emesis. Temperature normal, pulse 56 to 64. During the afternoon 
his arm jerked for ten minutes. Later in the evening his left arm 
and the left side of his face jerked spasmodically. On the sixth 
day a part of the gauze pack w^as removed. The urine drainage 
did not flow from the wound. The patient had several attacks 
of clonic convulsions of the left arm and left side of the face. He 
vomited almost all the water taken. The bladder became distended 
in the evening and on catheterization 15 ounces of urine were re- 
moved. It contained much albumin and many casts. The following 
day the remaining gauze pack w^as removed. The rectal tube loos- 
ened and came out. The patient had a better day, did not vomit, 
but had several spells of the clonic convulsions involving the left 
arm and left side of the face, but they were not so severe as the 
previous day. The patient became delirious on the ninth day. The 
convulsions continued to occur several times during the day, in- 



RECTUM 1031 

volving the left arm and left side of the face. The temperature 
which has been subnormal the previous day went to 100.5° and 
pulse 100. The delirium continued and the patient died the tenth 
postoperative day. It seemed certain that sepsis was the cause of 
death, although the patient had cerebral hemorrhages. The extent 
of involvement was small, hardly enough to cause death. 

Comment. — It is a question whether the fluid draining from the 
Avound was urine. The culdesac was opened during the operation 
and the drainage Avas likely peritoneal exudate. The withdraAving 
of 15 ounces of urine on the sixth day precludes a perforated blad- 
der. Furthermore, if the bladder had been entered during the 
operation the fact likely Avould have been noted. It seems quite 
likely that the actual cause of death Avas due to uremia. 

CASE 5. — A man aged sixty-seven came to the hospital because 
of a growth in the rectum, hemorrhage, and loss of weight. 

History. — The patient has had boAvel trouble for three months. 
At first he had constipation, but the bowels are now loose, moving 
five to six times a day and two to three times at night. He has an 
aching feeling in the rectum. The blood is more constant now than 
at first. Mucus is present in the bowel moA^ement. A year ago he 
Aveighed 152 pounds, now but 131. His appetite is good. One week 
ago he had some trouble passing urine, but he did not use a catheter. 
He has some pain on urinating now, but it passes freely. His general 
health has always been good. 

Examination. — The patient is of slender, wiry build, and appears 
to have lost weight. His skin is loose and inelastic. The chest 
is emphysematous, the heart without moment, and the urine 1.010 to 
1.012, but Avithout abnormal elements. There is an annular constric- 
tion three inches above the sphincter. It just admits the examining 
finger. The constricting ring is about as thick as a finger. The gut 
Avith the ring is movable on the surrounding tissue. The constriction is 
hard and granular and the trauma causes a slight hemorrhage. The 
prostate is very large, but elastic and smooth. 

Diagnosis. — The physical examination rcA^eals nothing of moment, 
but the patient has a forbidding look. He is apprehensive of the 
operation. He is the type of patient prone to develop acidosis. The 
growth is definitely malignant and it is of a papillary type. The 
gut is movable and the tumor in a relatively early stage. Operation, 



1032 CLINICAL SURGERY BY CASE HISTORIES 

therefore, can be urged with good grace. Local anesthesia seems to 
be the least objectionable. 

Treatment. — In order to accommodate the physician and friends 
the operation was done on the day of entrance to the hospital. The 
anus was circumscribed by an incision and the lumen of the gut 
closed. The gut to well above the tumor was mobilized, drawn down 
and cut off, the free edge sutured to the external sphincter and 
skin. About six inches of the rectum were removed. Gauze drains 
were placed on either side of the rectum. The operation was done 
under local anesthesia. 

Pathology. — ^The tumor was a typical fungating annular carcinoma. 
The perirectal tissues were not invaded. 

After-course. — There was considerable postoperative shock, but 
the patient rallied well. His chief complaint the first few days was 
of discomfort in the bladder. He was unable to void urine and 
had to be catheterized. On the third day his temperature went to 
101°, pulse 102; subsided to 99.6°, pulse 92 on the sixth day. On 
the sixth day he complained of cramping pain in the right leg. There 
was some swelling in the thigh. This swelling continued to increase 
and the leg became sensitive, red, and edematous. No fluctuation 
could be made out. The leucocyte count was 38,200, mostly polymor- 
phonuclears. On the sixth day after the swelling appeared in the 
thigh an incision was made along the inner side of the right thigh 
and a small amount of thin watery pus was evacuated. Another in- 
cision was made above Poupart's ligament on the right side extraperi- 
toneally, but no pus was encountered. Two days later the patient 
died. Examination of the pus showed pure smear of short-chained 
streptococci. 

Comment. — The tumor was so favorably situated for a simple op- 
eration that an adequate preparation was not made. The patient's 
resistance was not as great as anticipated. Such a tumor operated 
on under local anesthesia was looked on as not more than an in- 
convenience. It was a rude surprise when he was much shocked. 
The pulse remained slow but the temperature dropped to 96 and the 
pulse remained weak. After the temperature rose the pulse became 
more rapid. Though there was no extensive preparation, the opera- 
tion was clearly done, the gut was not torn into and the surround- 
ing tissues were not contaminated by gut contents. Nevertheless, 
he got a violent streptococcic infection. I have had this same 



RECTUM 1033 

thing happen after the most elaborate preparation. Though such 
preparation may not do much toward sterilizing the field, it is 
fine salve when things go wrong. This was obviously a phlebitis. 
While the pus examined showed the offending organism to be a 
short-chained streptococcus the leucocyte count was much higher 
than is usually seen in the infections by this organism. Possibly 
other organisms were present and were overlooked or were confined 
to other regions than that incised. The gauze drain used was plain 
gauze. Possibly an impregnated gauze might have done more to 
prevent infection. Of such gauzes iodoform is unquestionably the 
most efficient, and bismuth gauze the least objectionable. The lat- 
ter likely does little to prevent infection other than by aiding in 
the sealing up of tissue spaces. 

CASE 6. — A physician aged seventy-five called me because of 
difiiculty in passing urine and bloody stools. 

History. — The patient has had rectal trouble two years. For many 
years preceding this he had difficulty in urination, but not severe 
enough to require special treatment. It was held measurably in 
check with urinary sedatives. When the rectal trouble began he 
regarded it as due to irritation from the prostate because it man- 
ifested itself in pain at stool and the passage of mucus both with 
and without stool. When the passage of blood with tenesmus was 
added to his troubles, he consulted a surgeon. A carcinoma of the 
rectum was diagnosticated and pronounced inoperable. He resigned 
himself to his fate, and, besides the remedies he previously employed, 
he added opium suppositories for the relief of tenesmus. A year 
after this time the constriction of the rectum became so great that bowel 
movements were obtained with such difficulty that he felt compelled 
to seek more vigorous medical advice. Save for a progressively in- 
creasing dyspnea he feels reasonably well. 

Examination. — The patient is a large, portly, worn-out physician, 
who typifies the old family doctor who served all but himself, 
and who in spite of his too long service had to drag his heavy in- 
firmities about to visit lesser ones that he might secure his daily 
mite. There is a constriction which begins two and a half inches 
above the anus. The lumen is so small that it does not admit the 
finger, which makes it impossible to determine how high up the bowel 
it extends. The attempt to force the finger through the constriction 
produces a considerable hemorrhage. The prostate is large, smooth. 



1034 



CLINICAL SURGERY BY CASE HISTORIES 



and presents a soft bosselation on the right side. The rectal mass 
impinges against the enlarged prostate but does not seem to be at- 
tached to it. He has a marked arteriosclerosis and blood pressure con- 
stantly above 200. His apex is in the mammary line and the sounds 
are indistinct. 




Fig. 451. — Carcinoma of the rectum. 



Diagnosis. — The dense constricting mass in the rectum is typical 
of carcinoma. The question of operability can not be definitely de- 
termined because the lumen remaining does not permit the finger to 
reach above it so that its mobility can be established. There is 



RECTUM 1035 

no evidence of metastasis and none of the pains complained of can 
be ascribed to secondary nodules. His general appearance does not 
suggest cachexia. A preliminary laparotomy in order to determine 
the operability would be desirable, but his adiposity and dyspnea, 
evidently cardiac, make a general anesthetic undesirable. The patient 
elects an attempt at the perineal operation under local anesthesia. 

Treatment. — The rectum and tumor were carefully isolated under 
local anesthesia. He was given ether rausch while the mass was 
withdrawn out of the pelvis. The operation was then completed 
with the local anesthetic. 

Pathology. — The tumor was an annular affair deeply infiltrating 
the walls of the gut and into the perirectal tissue about. It began 
about one inch from the anus and involved more than four inches 
of its extent (Fig. 451). As the gut was being withdrawn it had the 
dense tubular feel of a benign stricture. The slide shows an abun- 
dant connective tissue proliferation with a few epithelial cells — 
a veritable scirrhus of the rectum. 

After-course. — Healing was prompt and after a few weeks he had 
less bladder, trouble than he had had in years. The end of the gut 
tore away from its anchorage to the skin at the end of a week and 
retracted some two inches. Nevertheless, a good anal canal formed 
in five weeks. He attended his practice for a year following recov- 
ery from the operation, when he became hemiplegic and died with- 
out regaining consciousness. 

Comment. — In very corpulent patients the combined operation is 
difficult to perform, the after-treatment because of the inevitable 
infection of the abundant fat is troublesome and the management 
of the artificial anus a source of constant annoyance. Therefore, 
when at all possible, I prefer to bring the bowel out below. Nor 
do I believe there is occasion for worry if one is not able to secure 
enough bowel that the end, after the tumor is cut off, does not 
withdraw itself within what is left of the anal skin after tension 
is taken off of it. If there is tension w^hen the gut is sewn to the 
skin the stitches will surely pull out and the gut will retract, leav- 
ing a granulating channel between the skin and the end of the gut. 
I have had this happen many times and it has ceased to worry me. 
The very fact that much scar tissue forms in this region is often 
salutary. This forms a support and patients usually have fecal con- 
tinence when the stool is at all formed, a condition that is by no 



1036 



CLINICAL SURGERY BY CASE HISTORIES 



means always true -when the gut remains well attached to the skin. 
True these fibrous channels may require attention at times for sev- 
eral years, but once the scar has fully formed they remain in staUi 
quo without further attention. 

CASE 7. — A widow of sixty-eight came to the hospital because of 
tenesmus and bloody stool. 

History. — For the past nine months she has had pain on defecation. 
The stool has contained much mucus and recently some blood. In 




Fig. 452. — Carcinoma of the rectum beginning just above the sphincter. 

the past two months the pain has increased markedly. She has al- 
ways been constipated, but the bowels move readily with a laxative. 



RECTUM 1037 

Examination. — The patient is tall and very thin, but save for a 
barrel chest, her general condition is without note. Just above the 
sphincter at the posterior quadrant of the rectum is an ulcerous area 
an inch wide and twice as long. It is deep red, hard and granular 
to the touch, and it bleeds readily on manipulation. At the anal ex- 
tremity it ends abruptly at the cutaneous border. At the remainder 
of the periphery it ends irregularly sending here and there nodules 
into the otherwise unaffected mucosa (Fig. 452). The deeper struc- 
tures of the gut do not seem to be affected. The urine is 1.008 and 
contains a few casts. There was no albumin in several tests. 

Diagnosis. — The density, the tendency to bleed, and the character 
of its border suggests carcinoma. The superficial character and its 
granular base look like tuberculosis, an impression dispelled by the 
evidence obtained by palpation. The low situation and the lack of 
invasion of the deaper tissues make it an ideal case for perineal am- 
putation. 

Treatment. — The offending portion was resected under local an- 
esthesia. The sphincter was removed along with the gut. After the 
gut was loosened it was turned on its axis before being sutured to the 
cutaneous border, the idea being to partly close the lumen of the 
bowel and thus aid in its control. 

Pathology. — The glands were invading the muscular laj'er of the 
gut but nowhere did it extend beyond. 

After-course. — Healing occurred quickly. She could control the 
bowels when the stool was hard. She died six years later of apoplexy. 

Comment. — The appearance of this condition was strikingly like 
that of tuberculosis and the microscope alone could give the final 
decision. 

CASE 8. — A retired blacksmith came for consultation because of 
frequent bowel movements. 

History. — The patient has had excellent health until the past few 
years when he began to have scanty urine and sometimes a little 
trouble in starting the flow. He has never had to be catheterized. 
About a year ago he noticed streaks of blood in the stool. This has 
gradually increased. Later bowels move at frequent intervals. He 
has had no pain to speak of. He has been treated for piles by his 
family physician for the past seven months. 

Examination. — A large fungoid mass can be felt in the rectum. 
The examining finger easily reaches the topmost border. It is hard 



1038 



CLINICAL SURGERY BY CASE HISTORIES 



and nodular and bleeds on manipulation. The prostate is moderately 
large but is smooth. 

Diagnosis. — The fungiform, hard, bleeding mass can be nothing 
other than a carcinoma. Its tendency to form a cauliflower mass 
indicates a relatively favorable prognosis and its low situation makes 
it readily accessible through a perineal incision. 




Fig. 453. — Fungating carcinoma of the anus. 

Treatment. — The tumor was removed from below under local an- 
esthesia. The external sphincter was preserved. 

Pathology. — The tumor is typically everting adenocarcinoma (Fig. 
453). 

After-course. — The patient had retention of urine for one or two 
days following the operation. He had to be catheterized, which 



RECTUM 1039 

resulted in a moderate cystitis. There was considerable infection 
in the field of operation which caused a partial loosening of the 
end of the gut from its anchorage in the external sphincter and 
skin. On leaving the hospital he still had some trouble in passing 
urine at times. After healing was complete, however, he was free 
from any trouble. There was a cicatricial narrowing of the anal 
opening a few months after operation. This had to be incised on 
three different occasions before a permanent efficient canal was estab- 
lished. He has no incontinence unless the stool is thin. He has re- 
mained free from recurrence many years and has had no trouble 
on urination. 

Comment. — Fungating carcinomas of the rectum, if done at all 
early, give a uniformly good prognosis. 

FISTULA 

Perianal fistulas are due to perirectal abscesses, abscesses draining 
from a distance, as in broad ligament infections or bone disease and 
to tubercular processes in the soft parts. Vestigial fests while 
usually pointing in the midline behind the anus may point in other 
directions. 

CASE 1. — A matron aged twenty-seven came to the hospital be- 
cause of feces passing through the vagina. 

History.- — The trouble dates back six years ago when the patient 
was delivered of her first child. Delivery was by forceps after the 
patient had been in labor fifteen hours with the head of the 
child visible for ten hours, according to the patient's story. She was 
repaired immediately after the delivery, but she noticed that feces 
were passing through the vagina three or four days after the sutures 
were applied. Three months after delivery an unsuccessful attempt 
was made to repair the fistula. 

Examination. — There is an opening from the vagina into the rec- 
tum which admits the end of a finger. It is situated just above the 
external anal sphincter. 

Diagnosis. — A recto-vaginal fistula is obvious. 

Treatment. — The rectum was loosened from the sphincter and 
vagina to a point an inch above the fistula. The gut was drawn 
down so that the opening through the rectal wall lay outside the 
sphincter. The gut distal to the fistula was then removed and the 



1040 CLINICAL SURGERY BY CASE HISTORIES 

gut sutured to the sphincter and to the skin about the anus. The 
opening in the vagina was pared and sutured. 

After-course. — The sutures promptly pulled out and the end of 
the gut pulled above the opening into the vagina and the fistula 
recurred larger than before. I at once loosened the rectum about 
its entire circumference and brought down the whole gut as one 
would do in removing a low lying carcinoma of the rectum. The 
whole circumference was sutured to the anal margin. The gut stayed 
sutured and the fistula was healed. 

Comment. — The important point in the performance of this oper- 
ation is that the entire circumference of the gut must be loosened. 
If only one segment is loosened, the sutures regularly tear out. I 
learned this from repairing rectovesical or rectourethral fistulas fol- 
lowing perineal prostatectomy, but I forgot it again before doing this 
operation. 

CASE 2. — A fanner aged twenty-three came because of a fistula 
near his tail bone. 

History. — A year and a half ago, while pulling on a post he lost 
his hold and sat down violently on a block of wood. Six months later 
pain and tenderness with swelling developed over the tail bone. It 
began to discharge and after a month or so it ceased. Ten months 
later, pain, tenderness, swelling as big as at first appeared, but 
after discharging for some time, it again healed. It soon reopened and 
has discharged constantly since. His general health has always 
been good. 

Examination. — There is an opening in the midline over the coccyx. 
From this opening a sinus extends downward in the midline to near 
the anal sphincter. No sinus can be found leading upwards over the 
sacrum or into the pelvis. 

Diagnosis. — A recurrent abscess formation following a trauma to 
the perineal region suggests ischiorectal abscess. However, the in- 
jury was sustained in March and the abscess did not form until 
October. Ischiorectal abscesses from trauma are usually due to mixed 
infection from the gut tract and develop violently soon after the re- 
ceipt of the trauma. Furthermore, they do not usually discharge in 
the midline over the sacrum, though they may do so. Hence a diag- 
nosis of sacral dermoid was made. 

Operation. — A grooved director was placed in the fistulous tract 
and the whole of the affected area excised en hloc. Extending up- 



RECTUM 1041 

wards from tlie opening was a tiny sinus not discovered at the time 
of the examination, lined with epidermoidal tissue bearing hair. A 
small drain was placed in the wound about midway. 

After-course. — There was some infection of the wound but healing 
was nearly complete in two weeks. He remained well for nearly a 
year, when an opening reappeared two inches higher than the original 
opening. A sinus passed to the right of the median line but did 
not reach the bone. On dissecting out this tract a small bit of skin 
bearing four hairs was discovered. Following this recovery was per- 
manent, now 13 years. 

Comment. — These affections, though congenital in origin, as a rule 
do not become troublesome until early adult life. They seldom pro- 
duce serious trouble. Their chief interest lies in the fact that the 
skin-bearing tract may extend much further than is at first ap- 
parent, and unless the entire tract is removed, recurrence will most 
surely follow. Here a miss is as good as a mile. Most cases re- 
quire excision from the base of the sacrum to the sphincter and all 
the tissue as deep as the periosteum requires removal. When they 
are complicated by extension into the hollow of the sacrum diffi- 
culty in removing them without removal of a part of the sacrum is 
encountered. 

CASE 3. — A fanner's boy of eighteen came to the hospital be- 
cause of a discharging sinus near his anus. 

History. — On January 18, 1917, the patient fell from a scaffold 
on an upright timber, a portion of the wood piercing the skin to 
the right of the anus. An abscess formed and was opened several 
days later. Pus discharged and a portion of the clothing came out 
with the pus. Early in February he again had severe pain in the 
perineum with swelling and fever. The doctor, probing in the old 
wound, opened into an abscess higher up, which was much larger 
than the first. He was then taken to the hospital and the abscess 
widely opened. He remained four days. The wound continued 
to drain and did not heal. It closed occasionally and then he 
had severe pain until it opened again. Pus decreased but a sinus 
remained. April 13 he went to some "rectal specialists" who 
opened up the sinus, put in a tube and irrigated every few days. 
May 24 they started to inject the sinus with bismuth paste. They 
injected this many times, the last being on the ninth of July. A 
week later he came here. 



1042 CLINICAL SURGERY BY CASE HISTORIES 

Examination. — A sinus exists on the right of the anus and extends 
upward some four inches. 

Diagnosis. — When a large abscess exists on one side of the rectum 
usually the opposite side of the rectum also is affected. Therefore 
a bilateral infection was diagnosticated in this case. 

Treatment. — The sinus was opened up and a large pocket of pus 
found posterior to the rectum. No communication with the rectum 
was found. The cavity was found filled with Beck's paste. Another 
opening was made in the cavity to the left of the sinus and the Beck's 
paste was curetted out of it also with a gallstone spoon. The cavity 
was found to be very large and extended up to the promontory of the 
sacrum. Two large rubber drains were put in on either side of the 
anus, together with two gauze drains. The gauze drains were left 
for three days and the rubber drains a week. 

After-course. — The wounds narrowed down to a small sinus. A year 
after there was still a small opening which exuded a few drops of clear 
fluid at intervals. 

Comment. — In the case of an open wound it is difficult to say 
whether there ever has been a communication with the rectum. The 
pus had burrowed throughout the pararectal connective tissue. 

CASE 4. — An electrician aged thirty came for consultation be- 
cause of a fistula in the buttocks. 

History. — The patient is a thin, spare man, but apparently in good 
general health. Recently he has had some pain in the right anus and 
some weeks ago a discharging sinus developed. 

Examination. — A cursory examination disclosed a discharging sinus 
two inches to the right of the anus. At the time of the examination 
I did not note that the opening instead of being scarred and puckered 
like the usual perineal scar, was wide open, craterform, exactly 
like the ureteral orifice in tuberculosis of the kidney. 

Diagnosis. — Having failed to note the peculiarities above noted, 
I diagnosticated fistula in ano. 

Treatment. — In infiltrating the affected tract with novocain I noted 
that the tissues were everywhere softer than usual in fistulas and I 
was unable to follow the main tract by the touch of the needle. I 
passed a grooved director into the opening and found not a sinus, 
but an undermined area (indicated by the dotted line in Fig. 454). 
I opened into this tract and found a granular area which made its 



RECTUM 



1043 



tuberculous nature clear enough. Notwithstanding the discovery of 
the nature of the disease, having started to dissect out the diseased 
area, dissect it out I did. 

Pathology.- — Many tubercles with typical giant cells were found. 
(Fig. 455.) 

After-course. — The large wound left by the dissection was closed 




Fig. 454. — Tuberculous pararectal fistula. 



in part by suture, but it did not remain so and a large granulating 
wound formed which required many months before it closed. 

Comment. — Having discovered the tuberculous nature of the trou- 
ble, I should have split the affected area open and applied the 
cautery instead of making a fresh -wound. But not being fore- 
warned, I was not forearmed, and hence no cautery was at hand. 



1044 CLINICAL SURGERY BY CASE HISTORIES 




l'"ig. 455. — Tiibciculnsis rarectal tissue. 

PERIANAL DISEASES 

Ulcerous lesions may result from irritating bowel discharges, 
usually specific in character. Papillary tumors are frequently, but 
not always, due to venereal infection. Melanotic tumors at the 
anal margin are not common, but may resemble cutaneous hemor- 
rhoids or prolapse of the bowel. 

CASE 1. — An unmarried woman a^ed eighteen entered the hospi- 
tal because of a fistula following an operation for appendicitis. 

History. — The patient had tonsillitis in childhood and typhoid 
fever a year ago. On November 23 she had a sudden severe pain 
in the right side with nausea and no vomiting. For two weeks 
she was in bed with severe nausea and pain in the right side at in- 
tervals. She was told she had no fever. No distention of the ab- 
domen was present. Patient was operated December 6, and the 
wound closed without drainage. The appendix was found to be 
adherent, but no pus present. She suffered from the operative 
shock on the table. On the third day following operation she de- 
veloped a temperature and had localized swelling in the region 
of the operative wound. The next day the abdominal swelling was 
general and the pain severe. Vomiting began at this time. The 



RECTUM 1045 

next day the abdomen was opened and a rubber drain inserted. 
No drainage followed. On the next day they put in a gauze drain, 
but still no drainage followed. The temperature, rapid pulse, dis- 
tention and vomiting continued and another tube was inserted. The 
condition continued to increase in severity until eleven days after 
operation. She then began to improve, and on the twelfth day a 
fecal fistula started, which is still discharging. 

Examination. — The patient is emaciated but not anemic. She has 
an opening in the center of a scar in the right iliac region, from 
which pus and intestinal contents are oozing. A probe passes inward 
and upward for a distance of three inches. 

Diagnosis. — Obviously a fecal fistula is present. The probable site 
of the opening is conjectural. The statement that there was no pus 
present at the time of operation makes it likely that infection was 
due to the technic and not to the disease. The attempts at drainage 
make it likely that the fistula is the result of these efforts. Therefore 
the particular region of the gut affected must be determined at op- 
eration. 

Treatment. — The opening was circumscribed by the incision and 
the fistula closed with a forceps. The fistula was then resected down 
to its attachment to the gut. It was found to communicate with a 
loop of small intestine. The fistula was ligated close to the gut and 
the stump invaginated. The wound was closed completely and a 
drainage opening was made in the flank. 

After-course. — There was subcutaneous infection for a week but 
otherwise healing was complete. The patient has remained well. 

Comment. — The history of this case shows the results obtained by 
the occasional operator. The repeated attempts at drainage indicate 
a planless procedure. These fistulas once they form should be al- 
lowed to thoroughly heal out before their excision is attempted. After 
they contract to a fibrous cord an aseptic operation can be done. 

CASE 2. — A school boy aged eighteen came because of an ulcer 
of the anus. 

History. — Two years ago he began to have a painful affection of 
the anus. It was treated for some months with salves and supposi- 
tories but the trouble increased. A fistula formed and a surgeon 
was consulted. The fistulous tract was cut across. This refused 
to heal and has continued to spread until the present time. It 
causes a continuous discharge but is only moderately painful. The 



1046 



CLINICAL SURGERY BY CASE HISTORIES 



lad has always had fair health and has had no sickness save some 
of the minor affections of childhood. Save for a maternal aunt 
there has been no lung trouble in the family. 

Examination. — The patient is slight of build, long and narrow 
chested. General examination discovers nothing of interest. At 
the left of the anal margin is an ulcer extending half an inch 
over the skin surface and about the same distance over the mucous 
surface (Fig. 456). The edge is slightly undermined but shows at 
some points a beginning at healing. At other points the margin is 




Fig. 456." — Tuberculous ulcer of the anal margin. 

more elevated and of a brown color. The base of the ulcer is soft 
and granular and some pressure is required to produce bleeding. 
The upper border passes almost imperceptibly into the normal mu- 
cosa above. 

Diagnosis. — The soft character of the base of the ulcer and the 
undermined but somewhat thickened border suggests tuberculosis. Car- 
cinoma of the mucocutaneous border does not occur. The base would 
be harder and the border less evenly undermined and not indurated. 



RECTUM 1047 

While the boy is slight, no evidence of preexisting tuberculosis can 
be discovered. He does not know much of his early life. Excision 
seems the treatment most suited to the condition. 

Treatment. — The ulcerous area was excised with a healthy margin. 
The denuded area was closed by sutures. 

Pathology. — Typical tubercles were found in abundance. 

After-course. — A number of the sutures failed to hold, but the 
defect healed over in about three months and he has remained well. 

Comment. — The cautery likely would have been a better treat- 
ment than excision. At least dissemination would be less likely to 
occur after the use of this agent than after excision. However, in 
this case healing took place. Carcinomas at the mucocutaneous 
junction have been reported. Many years ago I saw a distinguished 
surgeon remove an ulcerous lesion in this situation which he pro- 
nounced to be carcinoma. I obtained a piece of it surreptitiously as 
it passed on its journey to the incinerator. This proved to be 
tuberculosis. Unless diagnosed by the microscope the reports of 
carcinoma in this situation should be regarded with caution. Fis- 
tulous tracts lined with granulation tissue should be regarded wath 
suspicion and carefully excised. 

CASE 3. — A boy aged two was brought because of a warty growth 
about the anus. 

History. — Six months ago a warty growth was first noticed near 
the anus. This was followed by others until in two months the anus 
was completely encircled by them. The child cries while stooling 
sometimes and he refuses to sit fiat on both buttocks. When in- 
jured the warts bleed. He was treated for a month by a dermatol- 
ogist who applied a powder which caused the child pain and stimu- 
lated the growth to renewed activity. The child, as well as his 
parents, has always been in the best of general health. 

Examination. — The patient is a vigorous little lad presenting the 
picture of general good health. Surrounding the anus is a cauli- 
flower-like growth (Fig. 457) which completely excludes the orifice 
from view. When the mass is parted the anal mucosa can be seen 
to be unaffected. The growth is firm to the touch. When the growth 
is viewed from the side the base can be seen to be formed by stalks 
with healthy skin between. 

Diagnosis. — The narrow stalks with the healthy skin between in- 
dicate that the lesion is nonspecific. This is confirmed by the ex- 
cellent physical condition of the child. 



1048 



CLINICAL SURGERY BY CASE HISTORIES 




Fig. 457. — Condyloma of the anal region. 




Fig. 458. — Condyloma of the anal region. 



RECTUM 1049 

Treatment. — The growth was snipped off with the scissors and 
the bleeding points cauterized with the platinum loop. 
■ Pathology. — The slide shows the masses to be composed of epi- 
thelial cells, palely staining for the most part, with stalks of vessels 
bearing connective tissue between them (Fig. 458). 

After-course. — Healing was uneventful. He has remained well. 

Comment. — There was nothing in the previous state of the child 
to give anv clue to the causation of this condition. The impor- 
tants of different character or of different sources may produce 
in character. When it comes to indicating the difference between 
the syphilitic and the nonsyphilitic one soon gets in a quandary. 
The anatomic difference is not convincing and the histologic pic- 
tures are identical. It appears as though the easiest way out of the 
difficulty would be to speak of condylomas of the syphilitic instead 
of syphilitic condylomas, implying thereby that condylomas of 
the syphilitic are not necessarily of specific origin. Likely irri- 
tants of different character or of different sources may produce 
the lesion. 

CASE 4. — A physician aged fifty-four came because of prolapsed 
hemorrhoids. 

Historij. — The patient has had some trouble with hemorrhoids for 
a number of years and for a year or more they have occasionally 
protruded, but were readily replaced by manual pressure. Two days 
ago following an attack of diarrhea they came down and were too 
painful and large to replace. 

Examination. — Three large egg-shaped masses surround the anal 
opening (Fig. 459). They are tense, blue-black in color, and over- 
hang somewhat the surrounding cutaneous margin. The skin sur- 
rounding their base likewise is inflamed. 

Diagnosis. — The diagnosis is easily that of hemorrhoids. The in- 
tense reaction is obviously due to thrombosis within the vessels. 
The surrounding inflammation likewise is due to the irritation of 
the blood clot. The condition presents essentially the factors of 
a septic inflammation. The condition is such, however, that necrosis 
of the surface is imminent and then infection will most certainly 
take place. Since the veins contain clots it will be desirable to ligate 
them proximal to the clots if possible, lest the manipulation cause 
an embolus. 



1050 



CLINICAL SURGERY BY Cx\SE HISTORIES 



Treatment. — The site of attachment of each mass was isolated, 
deeply transfixed, and doubly ligated, and then cut off and the stumps 
replaced. Two opium suppositories were placed above them. 

Pathology. — The masses are made up for the most part of edemat- 
ous fibrous tissue. The veins are thrombosed and there is con- 
siderable perivascular exudation of leucocytes. The central fac- 
tor in the pathology is the venous thrombosis." 

After-course. — Immediate and permanent relief from pain followed. 
It required a week before he was able to be about, however. 




Fig. 4S9. — Strangulated hemorrhoid. 



Comment. — Since the dominant lesion in these tumors is a venous 
thrombosis, a ligation as deeply in the mucosa of the rectum as 
possible seems rational. The minimum of manipulation likewise 
seems desirable. The patient being a phj-sician desires to bear 
testimony to the fact that this is a very painful affection and worthy 
the prompt and careful attention of surgeons and should not be 
greeted with levity, even in corpulent persons. 



RECTUM 



1051 



CASE 5. — A child of four was brought to me because of prolapse 
of the bowel. 

History. — The patient has been obstinately constipated since a 
small child. She has had much colic and is bloated much of the time. 
The appetite is poor and fitful. At the age of a year and a half the 
mother noted that the rectum everted whenever the child had a stool. 
At first the protruding portion gradually replaced itself spontane- 
ously. As the disease progressed, manual replacement had to be 




Fig. 460. — Prolapse of the rectum in a child. 

resorted to. Bleeding rarely occurs now since the mother has learned 
to manipulate the protruding part. 

Examination. — After the child has stooled, fully two and a half 
inches of the rectum protrudes (Fig. 460) and the mother exhibits 
the art of replacement. When the parts have returned the sphincter 
contracts well over it so that nothing abnormal is noticed. The child 
is anemic and exhibits signs of rickets. The abdomen is prominent 
and everywhere tympanitic. 



1052 CLINICAI. SURGERY BY CASE HISTORIES 

Diagnosis. — Prolapse of the rectum is evident and there is good 
sphincteric control. The child has in addition an intelligent mother 
willing to follow medical advice. 

Treatmeiit. — Nothing was done directly with the offending gut. The 
patient's diet was regulated and she was given antacids and laxa- 
tives. She was also given strychnine at intervals. By these means 
the general health improved but the anal trouble showed no improve- 
ment for a year and a half, by the end of three years the trouble 
had wholly disappeared. 

After-course. — She is now a perfectly normal university student. 
She has not required a laxative for many years. 

Comment. — This treatment gives better ultimate results than op- 
erative measures but obviously it can be applied only to treatment 
of children of intelligent mothers. This treatment is of course ap- 
plicable to children below par. I have had no success with it in husky 
children, though I must add the husky children I have tried it on 
were the offspring of mothers of lower intelligence. 



CHAPTER XX 

EXTERNAL GENITALS 

Affections of the external genitalia while of many varieties but 
few of them offer any difficulty in diagnosis. 

AFFECTIONS OF THE VULVAR REGION 

Carcinoma and tuberculosis are the common ulcerous lesions, but 
the rarer estheomine must not be forgotten. Cysts, lipomas, and her- 
nial protrusions furnish the common tumorous affections. 

CASE 1. — A widow aged thirty-six came to the hospital because 
of a tumor of the vulva. 

History. — A year and a half ago she had a wart-like tumor of 
the right side of the vulva. This was cauterized with an acid by 
her physician and healing was complete after about a month. Some 
nine months later she began to have a tumor in the opposite side 
which was soon followed by a tumor in^the groin. Later another 
tumor developed on the side of the original tumor but above it. 
All these grew rapidly and two or three months ago they ulcerated. 
Since then they have remained so. She has no pain but the contin- 
ual discharge irritates and prevents sleep and recently she has lost 
her appetite. 

Examination. — At the lower end of the right labium is a scar 
which confirms her statement that the original lesion healed. The 
labia now form large ulcerous tumor masses (Fig. 461) which are 
hard but fragile and bleed readily on touch. The left groin pre- 
sents a large ulcerous mass equal to that of the vulva. The whole 
mass seems movable on the underlying fascia. 

Diagnosis. — The growth is of course malignant. The fact that 
the original growth was wart-like and healed after cauterization and 
that these masses seem to move on the underlying tissue gives slight 
hope that something radical may be done. The rapid growth, how- 
ever, makes the wisdom of such a course very dubious. It may at 
least remove the ulcerous mass for a time. 

Treatment. — The labia with the tumors were removed and the in- 
guinal region was completely dissected out. It was found that at 

1053 



1054 



CLINICAL SURGERY BY CASE HISTORIES 



one point just medial to the large vessels the growth extended 
deeply in and could not all be removed. The wound was partly 
closed by suture and the patient turned over to the x-ray department. 

Pathology. — The growth is a carcinoma. 

After-course. — The large wound healed for the most part but at 
the point where the growth extended deeply it refused to heal 
even under the most rigorous treatment. Extension took place in 
this direction and she died six months later. 

Comment. — Everting tumors in this region sometimes show good 
results from radical treatment. Had not deep extension already 




Fig. 461. — Carcinoma of tlie vulva. 



taken place, temporary favorable results might have been obtained 
in this case. This extension could not be detected until the opera- 
tion was well under way. 

CASE 2. — A matron aged fifty -four came to the hospital because 
of a protrusion from the vulva. 

History. — The patient is the mother of a number of children. She 
has always enjoyed good health and except for a protrusion from the 
vulva she has no complaints to offer. There has been little bladder 
disturbance. 



EXTERNAL GENITALS 1055 

Examination. — Anticipating from the history a uterine prolapse, 
I was astonished to find an enormous rectocele which quite overhung 
the anus. The cervix was but little low and there was no cystocele at 
all. The perineum was lacerated well into but not through the ex- 
ternal sphincter. The mass could be replaced by a little effort but 
the sensation received in doing so was new to me. 

Diagnosis. — Huge rectocele. 

Treatment. — At the operation when the mass was pushed into the 
vagina and the vaginal wall lifted up from in front of the sphincters, 
I encountered not rectal wall but a sac containing clear fluid. The 
fluid was not under tension but I thought it must be a vaginal cyst, 
but what it should be doing in that situation was not clear to me. 
I decided to look in. An ounce of straw-colored fluid escaped and 




Fig. 462. — Hernia in the perineum. 

much to my astonishment a loop of small gut presented at the open- 
ing (Fig. 462). The vaginal wall was now separated from the wall 
of the sac and then the sac separated from the rectal wall. The 
redundant vaginal wall resulted and then the edges of the vaginal 
wall were united to each other and to the rectal wall by one sweeping 
suture. A perineal repair completed the operation. 

After-course. — Recovery was uneventful. 

Comment. — The question is whether this represents a stretching 
of the culdesac because of a weakened vaginal wall, or an instance 
in which the culdesac extends down farther than the normal. The 
latter was the case, for the vaginal wall below the cervix pre- 
sented no thinning and it is at this point where the relaxation 
must have begun if the whole tract had developed after the lacera- 
tion. Besides, the mesentery of the intestine was enormously long. 



1056 



CLINICAL SURGERY BY CASE HISTORIES 



CASE 3. — A widow of fifty-two came because of an ulcer on her 
privates. 

History. — For the past nine months she has noticed an ulcer above 
the opening of the bladder. At first it caused annoyance only from 
contact with the clothing. Kecently she has had pain even when care- 
fully protected. She has had some irritation of the bladder for some 
years requiring her to get up four or five times a night. 

Examination. — Just above the clitoris is an irregular ulcer 2 cm. 
in diameter (Fig. 463). It obscures the clitoris but does not extend 
to the meatus. It is freely movable over the underlying structures. 
It is hard to the touch and bleeds when manipulated. The inguinal 
glands are not involved. 




Fig. 463. — Carcinoma of the clitoris. 



Diagnosis. — The density and tendency to bleed marks it as a malig- 
nant growth. It is free from important structures and its removal 
should be easy. 

Treatment. — Under local anesthesia the inguinal glands were 
blocked out and a wide area about the growth extending to the 
meatus was removed. 

Pathology. — The growth involves both the hood and the glans of 
the clitoris. It is impossible to determine from which structure it 
originated. The slide shows it to be a squamous-celled carcinoma. 



EXTERNAL GENITALS 1057 

After-course. — There has been no recurrence. 

Comment. — These are unusual growths. If the prognosis is anal- 
ogous to those of the male prototype, the prognosis should be good. 
Probably the removal of the inguinal glands was unnecessary but the 
operation as performed is theoretically correct. 

CASE 4. — A married woman of thirty-four was brought to the 
hospital because of hemorrhage. 

Historij. — The patient has been married twelve years but has never 
conceived. Menstruation had always been regular, though painful, 
until four years ago when they began to be prolonged. The flow 
seemed to be normal for four or five days, then a dribbling followed 
for a week or ten days. About two months ago she had a severe 
hemorrhage that caused her to go to bed. She has been weak since 
and has been in bed most of the time. For the past two weeks she 
has had fever and headache and a fetid brown vaginal discharge has 
been present for this time. 

Examination. — The patient's pulse is 120, temperature 101.6, res- 
piration 24. The blood count shows R.b.c. 2,400,000; W.b.c. 4,000; 
Hg 60 per cent. There is some suprapubic tenderness. The vagina 
is completely filled by a tumor nearly as large as a fetal head (Fig. 
464). The finger can be passed anteriorly between the tumor and 
the pubic arch and the cervix palpated. The tumor on inspection 
is mottled brown and black. 

Diagnosis. — Pedunculated fibroid in the act of extrusion. 

Treatment. — "When the perineum was retracted it was evident that 
a mechanical problem was present. A friend suggested the use of 
an obstetric forceps. These were applied and the tumor extracted. 
After it was withdrawn and hung in the vulva it looked very much 
like a child's occiput smeared heavily with meconium (Fig. 465-5). 
The cervix could be felt encircling the pedicle of the tumor (Fig. 
4:65- A). While making traction on the tumor to determine the at- 
tachment of the pedicle it was discovered that the uterus could be 
inverted through the widely dilated cervix. This was accomplished 
and the fundus of the uterus removed along with the tumor (dotted 
line B, Fig. 2). After the cut surface of the uterus had been sewn 
and the stump allowed to retract it looked to be a very pretty job. 
It was noted then that the perineum had been lacerated to the 
first obstetric degree in the act of extraction. This was closed by 
two sutures. 



1058 



ClilNICAL SURGERY BY CASE HISTORIES 



Pathology. — The tumor consisted of a very hard myoma. It was 
necrotic throughout and contained several cavities filled with greenish 




Fig. 464. — Submucous myoma protruding from the vagina. 




A. B. 

Fig. 465. — Supravaginal amputation of the uterus when inverted by a tumor. 

fluid. The degeneration therefore affected the entire tumor and not 
the surface only. 



EXTERNAL GENITALS 1059 

After-course. — The first few days following the operation found 
the patient very comfortable and in a cheerful mood. The tempera- 
ture remained slightly subnormal and the pulse low. The only un- 
favorable sign was a complete lack of appetite, even a positive ano- 
rexia and the patient appeared pale, even waxen. These phenomena 
excited my interest but not my apprehension. On the fifth day the 
nurse called my attention to the bad condition of the perineal wound. 
Much to my amazement the whole perineum was gangrenous. Any 
effort to alleviate the condition was without result and the patient 
died on the eighth day. 

Comment. — I have pondered on this case now nearly a score of 
years. The anemia before the operation and the pallor evidently 
was not due to the loss of blood, as I thought, but to the poisoning 
from the tumor. I did not once suspect during the period after 
the operation that the gangrenous process might extend to the 
laceration. Morcellement instead of removing the tumor intact 
probably would have obviated the disaster. 

CASE 5. — A matron aged thirty-seven came to the hospital be- 
cause of a tumor protruding from the vulva. 

History. — The patient has had five children and one miscarriage 
five years ago. She has always had leucorrhea and dysmenorrhea. 
Two months ago she had a severe pain in the small of the back. Soon 
after she noticed that when she had a bowel movement a tumor 
mass would come from the vagina. Her periods have been regular 
since the birth of the last child until nine weeks ago. Since then 
she has had no menstrual flow. She has had some bleeding since 
but it is irregular and much less than a normal flow. She is tired 
and weak and thinks she has lost some weight. Her appetite is good, 
she sleeps well and she has no abdominal pain or urinary disturbance. 

Examination. — There is a pedunculated tumor the size of a small 
Q^g and about three inches long in the vagina with its pedicle ex- 
tending into the uterus (Fig. 466-A). The uterus is as large as 
a three-month pregnancy and the fundus extends to the right. It 
is fairly firm, the cervix is not markedly softened, neither is the supra- 
vaginal portion thinned. 

Diagnosis. — The tumor in the vagina is obviously a fibroid polyp 
which has become extruded from the uterine cavity. The alleged 
amenorrhea may be accounted for by the size of the uterus but its con- 



1060 



CLINICAL SURGERY BY CASE HISTORIES 



sistency does not suggest pregnancy. It is likely that the size of 
the uterus is due to tumor development with associated edema from 
irritation from the protruding mass. At any rate the tumor must be 
taken away. 

Treatment. — The mass was withdrawn out of the vulva and the 




X //zc of ompuZatLon 
of polup 



Fig. 466. 



-Pedunculated tumor of the uterus. A. Relation of the pedicle to the wall of the 
uterus before traction was made. B. After traction was applied. 



pedicle cut across at the level of the internal os (Fig. 466-5). When 
the pedicle was examined it was found that the entire thickness of the 
uterine wall has been cut through. It now became necessary to 

"explore the interior of the uterus. It was in fact inhabited and the 

' uterus was cleaned. 



EXTERNAL GENITALS 1061 

Pathology. — The tumor was a simple fibrous polyp. 

After-course. — An infection in the broad ligament occurred and she 
had a large indurated mass to the left and behind the uterus for 
many months. It ultimately cleared up completely. 

Comment. — One can not be too careful in removing the peduncu- 
lated masses. Were it not for the fact that these tumors often come 
in rather young women a hysterectomy would be the operation of 
choice. These tumors are always infected, often gangrenous, factors 
which add hazard to such an operation. It seems curious that preg- 
nancy could take place in spite of such an obstruction. Had the 
uterus not been pregnant inversion from traction would not have 
taken place. The tumor was attached at the inner os, and even had 
conditions been fully understood a subsequent emptying of the uterus 
could not have been avoided. 

CASE 6. — A matron ag-ed fifty-seven came to the hospital because 
of a general loss of strength and prolapse of the uterus. 

History. — Four years ago while walking she had a feeling as if 
something popped within her. Since then she has had a prolapse 
of the uterus. She has had a bulging of the vagina and an irrita- 
tion of the bladder. Since that time she has been troubled with ob- 
stinate constipation. She has noted, too, a general impairment of 
health. The general indisposition has been greatly augmented in the 
past four or five months, and in the past two weeks she has "gone all 
to pieces." She has had three children, the last twenty-seven years 
ago, when she suffered a complete laceration. 

Examination. — The patient presents the appearance of one much 
exhausted but of good nutrition. General examination fails to dis- 
close anything of importance. There is a large varicocele and the 
cervix protrudes out of the vulva. There is a complete laceration 
of the perineum. The urine showed no abnormalities. 

Diagnosis. — The physical examination makes the anatomic prob- 
lems evident enough. Why she shows such a decline in recent months 
does not appear. She ascribes it unhesitatingly to the annoyance of 
the prolapse, and, in the absence of any tangible evidence to the 
contrary, this view is accepted. 

Treatment. — The uterus is drawn up through a transverse supra- 
pubic incision, a portion is excised and the stump fastened into the 
fascia. 



1062 CLINICAL SURGERY BY CASE HISTORIES 

Pathology. — The tissue removed shows the usual involutional 
changes. 

After-course. — The patient made a normal recovery for the tirst 
week. At the end of this time she became weaker and restless and 
complained of headache. The breath had a marked odor of acetone 
but none could be demonstr