In spite of this severe course, the condition persisted for a very long
time, and the patient finally succumbed on July 15, almost three
months after operation.
The autopsy revealed in the pelvis a large abscess, bounded by the
uterus below, above and laterally by intestines. In the mesentery
there was another large abscess cavity. Suppurating tracts led from
this cavity to the portal vein, which contained no pus, nor an obstruct-
ing thrombus, but there were on its walls firm yellow deposits, evi-
dently the remnants of purulent parietal thrombi. In the liver, along
the branches of the portal vein, there were to be seen some white
nodules of pinhead size, which the pathologist pronounced to be old
miliary abscesses.
Case v., 1901, vol. ii., page 34. Acute Gangrenous Appendicitis ;
Diffuse Purulent Peritonitis; Operation ; Death. — Hannah S., 9 years
old, was admitted January 16. 1901. with a typical history of a first
attack of appendicitis. Temperature 102°, pulse 136, respiration 28.
On examination there were found the usual physical signs, and in addi-
tion extreme tenderness over the entire abdomen.
Immediate operation. Pus was found in the free peritoneal cavity:
extirpation of a gangi'enous, perforated appendix.
Patient did not react well : her pulse gradually failed, and she died
about thirty-six hours after the operation.
Case VI., 1901, vol. ii., page 35. Aciite Gangrenous Appendicitis;
Diffuse Purulent Peritonitis; Operation; Death.— Jacob L., 16 years
of age. was admitted August 11. Temperature 103.6°, pulse 112, res-
piration 26.
328
MOUNT SINAI HOSPITAL REPORTS.
Immediate operation. Patient reacted well, but soon fell into a con-
dition of noisy delirium. The peritonitis became progressively worse^
and patient died about seventy-tAVO hours after the operation.
To avoid repetition the remaining cases are briefly referred to as
follows :
Case A''II., 1901. vol. ii., page 36. Acute Gangrenous Appendicitis
with Diffuse Purulent Peritonitis; Operation; DeatJi.— Morris B., aged
5, admitted July 21, died July 22.
Case A^III., 1901, vol. ii., page 37. Acute Gangrenous Appendicitis
with Diffuse Purulent Peritonitis; Operation; Death. — Harris S., aged
33, admitted August 9, died August 12.
Case IX., 1901, vol. ii., page &S. Acute Gangrenous Appendicitis
with Diffuse Purulent Peritonitis; Operation; Death from Blood
Sepsis.— Morris G., aged 11, admitted October 2, died October 6.
Case X., 1901, vol. ii., page 61. Acute Ulcerative Appendicitis;
Midtijjle Abscesses; Diffuse Seropurulent Peritonitis; Operation;
Secondary Abscess in Douglas' Cul-de-sac : Secondary Operation;
Death.— Jacob G., 31 years old, admitted January 27, died February 1.
DISEASES OF THE LIVER AND SUBPHRENIC SPACE. TOTAL, 15 ; DEATHS, 8.
Abscess of liver 5
" " '• ruptured, with purulent perito-
nitis 1
Abscess of subphrenic space 2
Atrophic cirrhosis of liver 1
Syphilitic hepatitis 2
Carcinoma of liver 2
Actinomycosis of liver 1
Echinococcus cyst of liver and lungs 1
3
Operations on the Liver and Subplwenic Space. Total, 16 : Deaths, 8.
Total. Died.
Transpleural hepatotomy for abscess of liver 4 2
Transperitoneal hepatotomy for abscess of liver 1 1
" " " ruptured abscess of liver and dif-
fuse peritonitis 1 1
Transperitoneal hepatotomy for actinomycosis of liver 1 1
" " (secondary) 2
Transpleural operation for subphrenic abscess 2
" " " echinococcus cyst of liver 1 1
Omentopexy for cirrhosis of liver 1 1
Exploratory laparotomy for syphilis of liver 2 1
" " " carcinoma of liver 1
gerster: report of the first surgical division— 1901. 129
The great majority of the patients of Mount Sinai Hospital are Rus-
sian Jews. Their habits, mode of living, and their occupations are
mainly of a sedentary character. Their confining work, usually
of long hours, often leads to disturbances of the intestinal tract. A
great number of them suffer from hemorrhoids. It seems probable
that the etiological factor of a certain number of our liver abscesses
is to be found in this disorder. It may suffice to refer to the frequent
traumatisms to hemorrhoids, to subsequent ulcerations and throm-
bosis, and to the intimate anatomical relation of the hemorrhoidal
veins with the portal system. Strict pathological proof of this theory
is lacking, but its assumption gains additional strength from the fact
that the causes brought forward as etiological factors in these cases
will all be found to be of a negative character. With one exception
(vol. iii., 1901, page 157), no ulcerative or amebic infection was ever
found ; nor have any of our patients ever resided under the tropics.
Operative Technique.— ^ome reference ha^ been inade to our opera-
tive technique in the annual report of last year. This point is again
alluded to because, in a number of cases, a new modification has been
devised and successfully employed.
As a general rule the abscess is attacked where its superficial loca-
tion is indicated by symptoms and exploratory puncture. This may
be in front, i.e., below the free costal margin, with or without re-
section of one or more ribs, M'ell guarding against an injury to the
pleura ; or laterally, or from behind, penetrating through thoracic
Avail and the diaphragm.
1. The anterior or abdontinal operation is so well known that it is
mentioned here merely for the sake of completeness ; nor is there any
need to further add that it is suitable only in that comparatively small
number of cases where the liver abscess is situated in front and has
produced a marked, palpable enlargement of the liver.
2. The posterior or lateral route. This is the method not only of
choice, but also of necessity, where the abscess is located in the more
inaccessible portions of the liver, i.e., in the dome or in the lateral
portions of the liver ; it might be said, also, that it is the most suitable
operation for abscesses involving the subdiaphragmatic space.
As is well known, the operation, in the main, consists of the follow-
ing steps :
{a) Resection of one or more ribs.
(&) Isolation of the pleural cavity.
(c) Isolation of the peritoneal cavity.
130 MOUNT SINAI HOSPITAL REPORTS.
(d) Incision and drainage of the abscess.
The succe&s of this operation depends upon the exactness with which
the second and third steps are carried out. The modification above
mentioned refers particularly to the second step.
(a) Eesectioi of o)ie or ))iore ribs. Pus having been aspirated by
puncture through an intercostal space, an incision, four to five inches
long, is made directly over this interspace parallel with the course of
the ribs. After retraction of the superficial structures, from three
and a half to four inches of the ribs adjoining are resected sub-
periosteally. To aid contraction, favoring rapid obliteration of the
abscess cavity, resection of more than one rib is preferable.
To render the field more accessible, the intercostal vessels are de-
ligated at both extremes of the wound by mass ligature ; the intercostal
nerves are divided, and the intervening intercostal muscles are" ex-
tirpated. On the completion of these preparatory steps, we shall
find before us an area extending about four inches by two inches, the
structure thus exposed being the external surface of the parietal
pleura.
(h) Isolation of ike pleural cavity. Various methods have been
used for attaining this purpose. Sometimes the operation was done
in two sittings; the object of the first sitting being the formation of
adhesions betw,een the two opposed pleural surfaces by suture or
â– caustics. Recently, to prevent infection of the pleural cavity, suf-
ficient reliance has been placed upon simple suture, followed by im-
mediate evacuation of the abscess. But, adopting this method, the
suture must be close and exact, otherwise pleural infection is surely
followed by empyema, a grave, and occasionally a fatal, complica-
tion.
Infection of the pleural cavity may occur through gaping places
"between the stitches, or, if the suture itself is tight, through the stitch
holes. This may happen either at the time of the primary evacuation
or later. To prevent these mishaps the writer has devised the follow-
ing modification of the technicjue :
The parietal pleura is rapidly stitched, with a small, strong, full-
curved needle, in a continuous catgut suture to the diaphragmatic
pleura. Each stitch should also include the diaphragm. When this
suture is finished, it will be seen that some of the stitch holes are gap-
ing, this being due to the lack of elasticity of the pleura. To prevent
the access of pus to these patulous stitch holes, from six to eight inter-
rupted catgut sutures are introduced along the course of the previous
GERSTER: REPORT OF TliE FIRST SURGICAL DIVISION — 1901. liU
suture line, each suture coniprisiny the costal and diaphragmatic pleurae,
together with the diaphragm. These sutures are not tied. A narrow
strip of iodoform gauze is now placed so as to cover the continuous
suture, this strip to lie at the same time within the open ends of the
interrupted sutures. The interrupted sutures are now closed over the
gauze strip, holding it tirndy down against the continuous suture,
which they will very effectually protect against soiling by pus.
(c) Isolation of the peritoneal cavity. The pleura and diaphragm
being incised within the circle of protective sutures, the abscess may be
immediately opened, provided that it be subdiaphragmatic. If it be a
hepatic abscess, it may also be incised at once, if the under surface of
the diaphragm is adherent to the dome of the liver. If not, the place
of incision must be isolated from the rest of the peritoneal cavity by a
circular packing of iodoform gauze.
(d) Incision and drainage of the abscess. This step is carried out
according to the well-known method of first aspirating, then entering
;he abscess with a grooved director passed in along the hollow needle.
The needle being withdrawn, a slender dressing forceps is passed
down the groove of the director, and, being well opened, is withdrawn,
thus dilating the channel ])y stretching. Through this wide channel
one or two large drainage tubes are introduced. It may be said that
the pleural cavity was admirably protected by this device in all of our
six cases.
A brief extract from the histories of the fatal cases is hereby ap-
pended :
1901, vol. iii., page 154. Diffuse Purulent Peritonitis, caused hy
Perforation of a Liver Abscess; Operation; Death.— 'Eli H., 50 years
of age, was admitted to the hospital on November 18 with the follow-
ing history : Previous history negative, Avith the exception of an attack
of jaundice which occurred about thirty years ago. Patient stated
that his present illness had lasted eleven days, beginning Avith
chilly sensations and fever; that he had had pain in the right iliac
fossa during the past seven days. Bowels have been constipated, but
responded to enemata.
On examination it was found that the abdomen was so much dis-
tended and tympanitic that an exact palpation was impossible. In
anesthesia a mass was felt on the right side below the border of the
ribs. Temperature 101°, pulse 112, respiration 28.
Operation November 15. The greatest tenderness being located over
the appendix, the incision was made in this region. Thick, creamy pus
in large quantities was found in the free peritoneal cavity, filling up
all recesses behind the colon, and in the pelvis, covering also the in-
132 MOUNT SINAI HOSPITAL REPORTS.
testines where they were not matted together. Search for the ap-
Ijendix was imsiiccessful ; lengthy and continued exploration of the
other viscera was contraindicated by the wretched condition of th<3
patient. A counter-incision for better drainage was made in the loin.
Patient reacted very poorly after the operation, and died about ten
hours later.
At autopsy there was found a diifuse purulent peritonitis-, in the
right hypochondrium a large abscess cavity, which comnninicated with
a perforated abscess of the liver substance.
1901, vol. iii., page 156. Multiple Abscesses of the Liver; Several
Transpleural and Transperitoneal Hepatotonies, the final one with
Resection of a Portion of the Liver: Death due to -S'epsis from Addi-
tional Undrained Ahscesses. — ^lendl S., 42 years of age, was admitted
to the medical service of the hospital. Past history: "A long time
ago" had an attack of jaundice accompanied by abdominal pain.
Present history: Patient has complained for eight days of weakness,
loss of appetite, constipation, and pain in the right half of the ab-
domen. Physical examination revealed an enlargement of the liver,
compression sj^mptoms of the lungs, and friction sounds of the pleura.
Examination of the blood showed a leucocytosis of 21,600. Tempera-
ture 10.3.8°, pulse 86. On aspiration pus was found, and patient was
transferred to the surgical service.
Operation on Autiust 18. following the method previously described.
About four and a half inches of the eighth and ninth ribs were re-
sected in the midaxillary line. The pus evacuated was exceedingly
thick, ropy, and tenacious, and on this account its evacuation Avas diffi-
cult.
Though there was no infection of the pleura, the temperature re-
mained high, and the pus so thick that it absolutely clogged the
drainage tubes. An attempt Avas made to withdraw the pus by the
suction of a siphonage apparatus according to Sprengl. This also
proved ineffectual.
A second operation was done August 31. Incision below the free
border of the ribs. The peritoneum was found to be adherent. After
dividing about one and a half inches of liver tissue with the Paqueliu
cautery, the abscess cavity was reached and through-and-through
drainage was established.
Following this operation there was considerable improvement in
the general condition of the patient, large amounts of thick, viscous
pus and necrotic tissue being east off. After a short-lived improve-
ment patient began to lose ground again and septic temperatures were
permanent. As a last resort it was decided to subject the patient
to another operation, its object being free exposure of the cavity. This
final operation was done September 20.
The anterior and posterior wounds were connected by an incision
which ran perpendicularly to the direction of the ribs. The eighth
and ninth costal cartilages were resected. All the tissues covering
GERSTER: REPORT OF THE FIRST SURGIC.VL DIVISION — 1901. 133
the liver were found to be adherent. The intervening liver tissue,
about one and a half inches square, was extirpated by means of the
thermocautery, and thus the abscess cavity was exposed. Much thick,
tenacious pus was found adherent to the necrotic surface of the cavity.
This having been washed and sponged away, the surface was found
to be pitted with small pockets of pus, some of which extended inward
to a depth of from a half to one inch. All these pockets were curetted.
At the upper portion of the wound a large amount of necrotic tissue
Avas found. On removing this a narrow sinus was laid bare. The
cutaneous incision being extended upward (better to expose this sinus),
the exploring finger entered into another pus cavity which was situated
in the uppermost region of the liver.' This cavity was emptied and
drained. The entire abscess wall was lightly cauterized with the
Pacjuelin. Drainage by a Mikulicz tampon.
In spite of this radical procedure patient continued to lose ground.
The symptoms of septic absorption remained unchanged, and patient
succumbed on September 30.
At autopsy two additional large and undrained aJ)scesses were found
in the liver.
1901, vol. iii., page 157. Multiple Abscesses of the Liver: Opera-
tion (Transpleural Hepatotomy) ; Death from Sepsis. — Jacob F., 30
years of age, was admitted to the medical service of the hospital on
August 2 with the following history: For the past year patient has
been complaining of i^ain in the abdomen and of general weakness.
For three weeks he has been confined to bed. On examination there
was found an extremely emaciated individual, with a much-enlarged
liver which was painful on pressure. (!)n aspiration pus was found,
and patient was transferred to the surgical service.
Operation on August 7. Incision in the axillary line according to
the method previously described. The abscess was situated at great
depth.
To tide him over the shock persisting during the first twenty-four
hours, the patient needed energetic stimulation. In spite of the pro-
fuse discharge, and of the castiug-off of large pieces of necrotic tissue,
the temperature continued high. A number of other abscesses formed
and were opened, drainage taking place through the primary incision.
However, the patient continued to lose ground, and died of sepsis
August 20. His three last days of life were marked by a profuse and
fetid diarrhea.
At autopsy there was found an uncountable number of small and
large abscesses scattered throughout the entire liver : one large ( prob-
ably amebic) ulcer in the cecum, and innumerable small ulcers of
recent origin were found distributed through the entire colon. The
pleura Avas absolutely clean at the site of the operation.
1901, vol. iii., page 158. Multiple Abscesses of the Liver: Operation
(Transperitoneal Hepatotomy) : Z)<:'af/«.— Hirsch H.. 47 years of age,
134 MOUNT SINAI HOSPITAL REPORTS.
A\as transferred from tlie medical to the surgical service on April 5
with the probable diagnosis of abscess of the liver. The past history,
"with the exception of moderate alcoholism, is negative. Five weeks
iago patient had an attack of influenza, and was apparently recovering
when he was seized with very sharp pains in the right side of the
chest; these pains continued with increased severity, and were accom-
panied by chills and fever.
On examination it was found that the right lobe of the liver was
very much enlarged and both painful and tender. Pleural and perito-
neal friction sounds were distinctly audible over this portion of the
liver. Aspiration yielded a chocolate-colored pus.
The operation consisted of a transperitoneal hepatotomy. This re-
vealed that the abscess occupied a very high position, requiring the
resection of the lowest ribs.
The post-operative course was similar to that of the preceding his-
tory. Other abscesses were evacuated through the abscess first opened.
Later on pleurisy developed, requiring aspiration, 37 ounces of a
bloody serum being withdrawn. No abatement of the high fever took
place. A subphrenic abscess was suspected, and repeatedly searched
for with the aspirator in vain. Patient died on ]May 19.
No autopsy was permitted.
SUBDIAPHRAGMATIC ABSCESS.
Two cases of subdiaphragmatic abscess required for their ultimate
cure repeated thoracoplastic operations, Avhich will be reported in the
l)art dealing with the surgery of the thorax.
SYPHILIS OF THE LIVER. TOTAL, 2 ; DEATH, 1.
CARCINOMA OF THE LIVER. TOTAL, 2 ; DEATHS, 0.
ACTINOMYCOSIS OF THE LIVER. TOTAL, 1 ; DEATH, 1.
ECHINOCOCCUS CYST OF LIVER AND LUNG. TOTAL, 1 ; DEATH, 1.
A brief extract of the histories of these cases is appended. It will
be seen that in the case of syphilitic disease of the liver, for which ex-
ploratory laparotomy was performed, death was caused by pulmonary
edema. The cases of actinomycosis and of echinococcus cyst of the
liver are of sufficient interest to deserve a detailed account.
1901, vol. iii., page 159. Syphilis of Liver; Operation (Exploratory
Laparotomy) ; Death from Pvlmonary Edema.— Max B., 42 years of
age, Avas admitted to the hospital on August 15 with the following
history: Patient had a chancre twenty-two years ago, but gave no
history of the secondary manifestations of syphilis. The onset of
present illness dates back about three weeks. It was very acute in
the beginning, causing vomiting, pain in the epigastrium, very obsti-
nate constipation, and general peritoneal irritation.. On examination
GERSTER : REPORT OF THE FIRST SURGICAL DIVISION — lOOl. 135
there was found in the ri^irht hypochondrinm a very firm, smooth mass
holding close relations with the liver, suggesting a distended gall
bladder.
At the exploratory laparotomy on August 16. the mass revealed
itself as a syphiloma of the liver. As already stated, the patient died
on the same day in an attack of pulmonary edema.
1901, vol. iii.. page 161. Actinomycosis of Liver and Lungs; Opera-
tion (Exploratory Laparotomy ; Hepatotomy) : Deaih. — Adolph G.,
34 years of age, was admitted to the hospital on ^March 19 with the
following history: Patient had had three attacks of appendicitis.
After the last attack, eight months ago, he Avas operated upon at one
of the hospitals of the city. One month later a rectal abscess was
incised and drained. Present illness dates back six months, and
manifested itself by irregular chills and fever, vomiting, and occa-
sional attacks of jaundice. On examination it was found that the
liver was uniformly enlarged. It was not particularly painful or
tender, except at a circumscribed spot between the anterior axillary
and mammary line, .iust below the free border of the ribs. Aspiration
gave a negative result. On admission the temperature was only 100.4°,
but within a tew hours patient had a chill, the temperature rising
to 104°. Similar chills followed daily at irregular intervals, the tem-
perature once rising to 106.2°. Repeated and careful blood examina-
tions for malarial plasmodia yielded no positive result. In view of
the desperate condition of the patient, an exploratory laparotomy was
decided upon, and performed on ]\Iarch 22.
On opening the peritoneum, and after separating numerous ad-
hesions, a very firm mass was found occupying the anterior and under
surface of the liver, close to the outer side of the gall bladder. This
mass was of a yellowish color, very friable, and was evidently under-
going necrobiosis. Part of the mass was excised for subsequent patho-
logical examination ; the rest was curetted aAvay. With suitable drain-
age, partial closure of the wound.
The operation had absolutely no effect in ameliorating the condition
of the patient. He continued in the same septic state as before the
operation, and died on April 1.
At autopsy two large actinomycotic areas were found in the liveb
and several small actinomycotic foci in both lungs.
1900. vol. i., page 28. Echinococcus Cyst of Liver and Lungs;
Operation (Transpleural Hepeitotomy and Drainage) : Deeitli.—'SloYYis
1\I.. 57 years of age, was admitted to the medical division of the hos-
pital on October 16. 1900. Past history is too indefinite to be of any
value. Present illness of four weeks' standing, beginning with pain
in the upper part of the abdomen, especially to the left of the um-
bilicus. This pain was so constant as to cause absolute insomnia.
Jaundice appeared three weeks ago, and was, according to the patient's
136 MOUNT SINAI HOSPITAL REPORTS.
Statement, on the increase. Bowels constipated, stools clay-colored.
Since the onset of the disease patient had had two chills.
On admission, physical examination showed the following points:
Lungs : Dnlness, extending from the spine of the left scapula to the
base: diminished voice, fremitus, and breathing. Liver extends three
fingers' breadth below the free border of the ribs; the left lobe extends
nearly to the umbilicus.
During his stay on the internal service the following facts were
noted :
October 18 : Echinococcus cysts found in the stools.
October 20 : Left pleural cavity aspirated, one drachm of an amber-
colored, viscid, highly albuminous fluid withdrawn.
October 31 : Liver has decreased materially in size.
November 1 : Development of a double otitis media, necessitating
paracentesis on the right side. Durina- all this time the temperature
has ranged between 98.4° and 102.6°.
November 7 : Patient was transferred to the surgical service.
Operation the same day. On account of the poor general condition,
eucaine anesthesia was employed. The incision was made over the
ninth rib, and three inches of it were resected in the posterior axillary
line. The costal pleura was opened, and found to be adherent to the
visceral pleura, but no free fluid was found. Aspiration directly
inward withdrew a turbid, straw-colored fluid containing flakes. The
course of the aspirating needle was then dilated with dressing forceps,
and about a pint of this fluid was withdrawn. It was found to ema-
nate from a large cavity, apparently in the lung itself, reaching a