considerable distance downward, also upward toward the apex. This
cavity was irrigated, and drained by tubes and gauze.
Subsequent to the operation there was no change in the general
condition, nor did the wound offer am'thing of note. Beginning
November 14, and until death, profuse diarrhea prevailed. For a
while the general condition improved so far that patient was up and
out of bed. December 6, patient complained unceasingly of chilliness ;
temperature rose to 101.4° and pulse to 112. On December 7, without
any warning, and without any exertion having preceded it, patient
No autopsy permitted.
CIRRHOSIS OF THE LIVER. TOTAL, 1 ; DEATH. 1.
1900, vol. i., page 27. Atrophic Cirrliosis of Liver: Operation
(Omento-Fixation) ; Death. — Joseph ^l., 49 years of age, was admitted
to the hospital on November 20, 1900. In the past history there was to
be noted an excessive use of alcohol, a moderate tobacco habit, and an ab-
sence of a syphilitic infection. Patient had had for a number of years
repeated attacks of gastritis, accompanied by nausea and vomiting.
His present illness dates back only about two weeks, and was acute
in its onset, beginning with a chill and accompanied by fever. It was
characterized hj vomiting, the vomitus containing blood. About this
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — liJDl. 137
time the abdomen began to be swollen, and patient began to have
dyspnea, even on slight exertion. The urine was diminished, and
contained albumin, lint no casts.
On examination physical signs and symptoms characteristic of an
advanced cirrhosis of the liver were found. The omentum was pale
and edematous. Hobnail liver, moderately enlarged. Its surface was
scarified with the scalpel, and then, with a continuous chromicized
catgut suture, the omentum was sutured to the anterior abdominal
wall. Closure of the abdominal incision, without drainage.
For a while the condition of the patient was satisfactory. The
amount of urine, though somewhat greater than before the operation,
was still scanty, and the dropsy began to reappear. On November 28,
five days after the operation, patient vomited about two quarts of
clotted blood. The temperature rose from the normal to 101.4°. One
hundred and fourteen ounces of a sanguineous fluid were withdrawn by
paracentesis. The following day bloody vomit and profuse diarrhea,
the stools being mixed with blood. December 1, patient became pro-
gressively weaker, suddenly went into collapse, and died.
At autopsy following condition was found: Lungs: Negative.
Heart: Negative. Kidneys: Chronic diffuse nephritis of slight de-
gree. Spleen enlarged to half again its normal size; firm, congested,
with marked increase in the connective tissue. Liver smaller than
normal, hobnail in character, very hard and firm ; parenchyma almost
entirely replaced by connective tissue. Intesti)ies: Small intestines
contained some fresh blood; vessels of ileum congested. Large intes-
tines also contained blood, but no erosions were visible anywhere.
Stomach.: Congested. Esophagus: Varicosities at cardiac end. Pan-
creas showed interstitial pancreatitis of slight degree. Peritoneum:
The omentum is sewed to the anterior abdominal wall by suture ; no
adhesions. Considerable ascites.
DISEASES OF THE GALL BLADDER AND BILE DUCTS. TOTAL, 22; DEATHS, 5.
" gangrenous 1
" with gangrenous cholecystitis.... 3
" stones in gall bladder 3
" " " " " and cystic
Cholelithiasis; stones in gall bladder and common
Cholelithiasis; stone impacted in common duct.. 2
Cholangitis, infectious; typhoid fever and para-
colon infection 1
Carcinoma of gall bladder 1
138 MOUNT SINAI HOSPITAL REPORTS.
Operations on the Gall Bladder and Biliary Ducts. Total, 14;
Cholecystostomy 10 3
Cholecystostomy and unilateral salpingo-oophorectomy 1 1
" " choledochotomy 1
Exploratory laparotomy for cholangitis 1 1
It is readily seen, in the above statistical table, that there exists a
Haw in the diagnosis of some of onr cases of gall-bladder disease ; refer-
ence is made here to such vague terms as cholecystitis or cholelithiasis.
This is due to the fact that while an exact anatomical diagnosis is
aimed at in most eas.es, and subsequently verified at the operation, this
verification has been impossible m. a certain number of cases, because
operative interference was declined either by the surgeon or by the
patient. In one instance only was no definite cause of cholecystitis
found at the time of the operation.
If we except the case of infectious cholangitis (1901, vol. iii., page
180) and the case of carcinoma of the gall bladder (1901, vol. iii.,
page 181), there remain 20 cases of gall-bladder disease, so-called,
which were under treatment during the year 1901. Of these 20 cases
4 cases ended fatally — a mortality of 20 per cent. While this repre-
sents a high rate of mortality, this will become still more unfavorable
by excluding those cases which received no surgical treatment. Of the
20 cases, 7 Avere not operated upon, and in justice these 7 cases must be
excluded from our operative statistics. After the correction we get
four deaths following thirteen operations, or a mortality of 30.76 per
cent. The question may be asked, why this high mortality"?
Competent writers have repeatedly called attention to the close
symptomatic resemblance existing in many respects between gall blad-
der and appendicular inflammation. Considering that both the ap-
pendix and the gall bladder represent blind sacs lined with mucous
membrane and covered Avith peritoneum, both being more or less freely
movable Avithin the peritoneal cavity, the cavities of both exposed to
infection proceeding from the gut — considering all these facts, the
symptomatic parallelism is very natural. But this parallelism may
be said to exist regarding the indications, prognosis, and rate of mor-
As repeatedly explained in previous reports, the high rate of mor-
tality in appendicitis Avas mainly due to the fact that the cases Avere
either unrecognized or neglected, and came too late to the hospital for
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1901. 13^
lieatnient, i.e., at a time Avheu the patients were suffering from fatai
complications. With advancing years, a better recognition of the
disease, and with a Avider knowledge of the malady, the patients were
referred to the hospital in mneh better condition. The outcome was an
improvement in the prognosis and a decidedly diminished rate of mor-
tality. "We express the firm conviction that when these facts come to
be more and more appreciated, the mortality of gall-bladder disease
will also be much diminished.
No change was made in the operative technique followed in the First
Surgical Division of the hospital.
BeloAV will be found a brief report of those cases which ended lethal -
ly; also the histories of some of the eases which terminated in re-
covery, this particular attention being accorded to them on account of
exceptionally interesting features or of complications of an unusual
1901, vol. iii., page 167. Cholecystitis: Openition (Cholecystos-
tomij); Death. — '^aWe R., 40 years of age, was admitted to the hos-
pital on October 1. Past history is negative, while the present
history is too indefinite to be of great value. Its principal points
are : Onset three months ago Avith vomiting, headache, and pain in
the right hypochondriac region; jaundice during the past three
months, and confinement to bed for the past month.
On examination, in addition to the .iaundice. there was found an
enlarged and painful liver: the gall bladder was not palpable, on
account of the distension of the abdomen. The urine contained
much bile. Temperature 97°, pulse 80, respiration 2-4.
Operation on October 4. In anesthesia, a tumor, the size of a
large fist, was to be palpated in the region of the gall bladder. In-
cision through the right rectus muscle. On opening the abdomen,
there presented in the wound an unusually long right lobe of the
liver, and a distended gall bladder about the size of a large fist.
After having protected the abdominal viscera by packings, the gal!
bladder was aspirated and its contents evacuated. No stones being
felt in the gall bladder, systematic exploration of the ducts was
proceeded with, but with a negative result. This step was exceed-
ingly 'difficult, on account of very dense adhesions. A number of
enlarged glands were palpated in close proximity to the common
duct, but no stone was found.
As it was impossible to deli gate, at the great depth, the numerous
bleeding points, these parts were packed Avith iodoform gauze.
Drainage of the gall bladder; partial closure of the abdominal Avound.
In the subsequent course there Avas not the slightest irritation of
the peritoneum noted. On the fourth day after the operation the
tampons Avere changed, but this Avas followed in the CA'ening by
140 MOUNT SINAI HOSPITAL REPORTS.
slight oozing, requiring firmer packing. A more alarming symptom,
however, arose in the form of copious hematemesis; this recurred
on the following day, after which occurrence the pulse began to fail.
In spite of active stimulation, patient expired on the same day.
Only a limited autopsy could be held. No trace of peritonitis, and
iio stones were found in either gall bladder or ducts.
' 1901, vol. iii., page 170. Gangrenous Cholecystitis; Chronic Ap
pendicitis; Diffuse Peritonitis; Operation (Cholecystostomy, Appen-
diceciomy); Death from Sepsis.— Jose])h. W., 25 years of age, was
admitted to the hospital on March 25 with following history: Pa-
tient, who had never been sick before, was suddenly taken ill three
days ago with general and severe pain in the right hypochondrium
and epigastrium. At present it had become localized in the right
iliac fossa. Enemata produced no movement of the bowels, while
all internal medication led to vomiting.
Physical examination showed considerable rigidity over the entirj
abdomen, and tenderness over the entire right side, particularly
below the free border of the ribs. Liver was enlarged. On account
of the rigidity of the abdomen, examination unsatisfactory. Tem-
perature 102°, pulse, 118, respiration 28.
Immediate operation. Incision along the outer border of the right
rectus. The appendix was found in a state of chronic inflammation.
It was removed. This, however, did not explain the serious condi-
tion of the patient. On further explorati6n another mass was found
in the region of the gall bladder. The incision was extended up-
ward, and thus the distended gall bladder was exposed. It was
isolated by packings and aspirated, several ounces of a bloody, biliary
fluid being withdrawn. A small incision was made into the gal]
bladder, but no stone was found ; a drainage tube was inserted, and
the wound was closed in its lower portion.
Patient took the anesthetic very badly; was continuously cyanotic;
pulse was very poor and very rapid, 150 to 170, and required con-
Patient left the table in a very bad condition, and never rallied
from the shock of the operation ; he died about four hours later.
At autopsy the following conditions were found : Lungs showed
edema. Liver: Somewhat enlarged. Spleen: Septic. Gall bladder:
"Walls much thickened ; mucous membrane gangrenous throughout ;
Epicrisis. — This is another of the cases which offer considerable
difficulty in making the differential diagnosis between appendicitis
1901. vol. iii., page 173a. Cholelithiasis ; Biliary Cirrhosis of
Liver; Operation (Cholecystostomy); Death from Pneumonia. —
Mary G., 70 years of age, was admitted to the hospital on March 31
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1901. 141
with the following history: Patient had her first attack of jaundice
tAventy years ago. She has been having, during the past seven years,
attacks of pain and jaundice every two to four weeks, the duration
of these attacks being about two Aveeks. Lately these attacks were
so frequent and severe as to make life unbearable.
On examination the folloAving status was found : Patient markedly
emaciated. Skin and conjunctivae deeply icteric. Lungs emphy-
sematous. The liver extending from the sixth rib doAvnward to
half an inch below the umbilicus. It was nodular and hard. At
the lower margin of the liver there was a hard mass which was both
painful to touch and tender. The urine contained a large amount
of bile, as Avell as albumin and casts.
Operation on April 1. Incision through the right rectus muscle,
extended much lower than usual. On opening the abdomen the
liver was found to be much enlarged, deeply bile-stained; its surface
nodular (hobnailed). It was very difficult to find the gall bladder.
Ver}^ deeply, and covered by omentum and a mass of adliesions, a
mass could be felt, of the size of a large fist, and literally of a stony
hardness. On separating tlie adhesions and resecting portions of
adherent omentum, the gall bladder was exposed, containing appa-
rently one huge stone. On incising the gall bladder the stone (fully
the size of a duck's egg) was exposed. To deliver it, it had to be
cut in two Avith bone forceps. Several smaller stones, up to the
size of a Avalnut, AA^ere also removed from the cystic duct. A probe
was passed into the common duct, Avhich Avas found to be free. In-
troduction of a drainage tube ; partial closure of the abdominal
The subsequent course, notAvithstanding the magnitude of the
operation, Avas at first very encouraging. Only once did the tem-
perature rise to 101°, on the second day. Dressings Avere changed
on the fifth day, and everything about the Avound Avas doing well.
On the seventh day, hoAvever, the temi)erature rose abruptly from
98.6° to 102.4° and" the pulse rate from 88 to 112 ; the cause of this
Avas a typical lobar pneumonia involving the loAver lobes of both
lungs ; and patient died tAA-enty-four hours later.
Autopsy.— Heart: Fatty infiltration. Left lung: LoAver lobe con-
solidated. Right lung: LoAver lobe in stage of gray hepatization.
Gall bladder: Enlarged, and thickened Avails; one stone found in a
diverticulum; common duct materially dilated. Liver: As previously
described. Kidneys: Chronic nephritis.
Epicrisis. — This patient Avas observed, by a member of the attend-
ing staff, for a very long time prior to her admission to the hospital.
Operation, Avhile considered. Avas continually deprecated on account of
the poor general condition of the patient. Finally her sufferings be-
came so severe that operative interference Avas consented to by the
142 MOUNT SINAI HOSPITAL REPORTS.
Another remarkable fact about the ease was the huge size of the
1901, vol. iii., page 174. Cholelithiasis; Cholecystitis; Carcinoma
of Right Ovary; Operation (Cholecystostomy, Salpingo-odphorec-
tomy) ; Deatli.—Qsivah. R., 40 years of age, was admitted to the hos-
pital on August 20 with following history: "With the exception of
a single attack of jaundice (six weeks) seven years ago, patient
v^as perfectly well up to eight weeks ago. Since that time she
has complained of increasing weakness, loss of appetite, of flesh and
strength ; in addition there is also continuous pain in the right
hypochondrium and right iliac region. Vomiting almost regular
after the ingestion of food, occasionally occurring also between meals.
On examination there was found an enlargement of the liver;
below the liver, in the right side of the alidomen. there was a mass
approximately two and one-half inches wide and three inches long;
the upper part of this mass was smooth, the low^r distinctly hard,
almost stony, and nodular. This mass moved freely with respira-
tion, and also had considerable lateral mobility; it was somewhat
tender on pressure, and could be I'eadily differentiated from the over-
hanging liver. Vaginally a globular, slightly tender, freely movable
mass was to be felt in the right fornix. Skin and sclerge were deeply
icteric. Urine contained large amounts of bile.
A preliminary diagnosis of a movable kidney and of an enlarged
Eiedel lobe was made. Patient was kept under careful observation,
and, none of the symptoms showing any amelioration, an obstructive
jaundice was assumed and patient operated upon.
Operation August 23. Incision on the outer border of the right
rectus, at the level of the previously described mass. On opening
the abdomen a pear-shaped tumor presented at once in the wound;
this tumor was recognized as the distended gall bladder containing
calculi. The gall bladder rested upon the enlarged and prolapsed
kidney. The hand was introduced into the pelvis, in order to ex-
amine the mass which was felt vaginally before operation. This
mass was brought into the wound, and, being taken for a cystic
ovary, was replaced. A cholecystostomy was performed in the usual
manner; two large calculi were removed. Before closing the w^ound
some hemorrhage was found to be going on in the pelvis ; the ovarian
tumor was consequently again brought to view, when an active hemor-
rhage was found to be going on from a rent in its peritoneal coat.
This tumor, after deligation with a stout silk ligature, was extir-
pated. Partial closure of the abdominal incision.
Microscopical examination showed the ovarian tumor to be a carci-
The subsequent course was marred by a pyocyaneus infection and
by an intercurrent pneumonia. These local infections were com-
bated, in time, by appropriate treatment. However, the general
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1901. 143
condition began to fail, and patient steadily lost ground, a condition
of chronic sepsis developing.
Patient died in this condition on September 14.
No autopsy was permitted.
The case about to be described is presented in detail on account of
the highly interesting condition found during the operation, which
presented unusual difficulties in the operative procedures undertaken.
1901, vol. iii., page 176. Cholelithiasis (stones i)i the gall hladder,
impacted stone in the common duct); Operation (Cholecystostomy,
Choledochotomy) ; Becovery.— 'Fannie L., 40 years of age, was ad-
mitted to the hospital on April 18 with following history : The onset
of the present illness is dated about eight months back, when she
began to have attacks of abdomiiial pain, localized in the epigastric
and right hypochondriac regions, accompanied by jaundice; these
attacks have occurred at intervals of five to six weeks; the more
recent attacks were also accompanied by chills and fever; last attack
six days ago. Considerable loss of flesh and strength.
On examination there was found a marked icterus of the skin and
sclerse. The abdomen was tender, particularly in the right hypo-
chondrium, where a very tender mass (gall bladder) could be felt.
Operation on April 19. An oblique incision, five inches long,
following the free border of the ribs, was made, exposing the slightly
€nlarge'd liver and distended gall bladder, which was felt to contain
a stone. A stone was also felt in the common duct. The fundus
of the gall bladder was thickened and contained a deposit of fat
in its wall. The kidney was enlarged and displaced downward.
The gall bladder was isolated from the rest of the abdominal
contents by means of packings, and its fundus incised. A small
MOUNT SINAI HOSPITAL REPORTS.
quantity of colorless mucus escaped, and there was also removed
from the cystic duct a faceted stone (Fig. 2). Another stone could
be felt in the common duct, in close proximity to an enlarged and
hard lymi^hatie gland, and Ij^ing surrounded by a vein, and very
close to an artery, which could be felt distinctly to pulsate. The
stone could not be manipulated into the gall bladder or duodenum,
hence a semicircular incision was carefully made into the common
duct, closely hugging the vein. This opening was dilated with dress-
ing forceps, liberating a quantity of limpid bile. Then the stone,
with facets similar to those on the stone from the cystic duct, was
removed with a scoop (Fig. 3).
An attempt was then made to close the common duct by sutures,
but the second suture perforated an artery, causing considerable
hemorrhage; in the attempts to pass a ligature around the artery
the hemorrhage started anew, so that the artery had to be pinched
on itself and deligated. Suture of the duct had to be abandoned.
The first suture was removed and a rubber drainage tube was in-
serted into the duct. It was retained in place by surrounding it
with iodoform gauze. Tube drainage of the gall bladder. Partial
closure of the abdominal incision.
The subsequent course was practically uneventful. Both drainage
tubes were removed on April 30, and patient was discharged, cured,
on May 12.
CHOLANGITIS ; TYPHOID AND PARACOLON INFECTION. TOTAL, 1 ; DEATH, 1.
1901, vol. iii., page 180. Cholangitis; Typhoid and Paracolon
Infection; Operation (Exploratory Laparotomy) ; Death from Bac-
teremia.— Charles I., 33 years of age, was admitted to the hospital
GERSTER : REPORT ()F THE FIRST SURGICAT. DIVISION — 1001. 145
on August 31 with following history: Family and past history is
negative. The onset of the present iihiess, ten days ago, was acute
in its beginning, and commenced with nausea, vomiting, and a feel-
ing of general malaise ; considerable abdominal distension and marked
epigastric pain. During the attack patient remained in bed for two
days, but even after the sul)sidence of the acuter symptoms patient
did not feel well. Three days ago patient was again seized with
severe pain, colicky in character, and distinctly localized in the
epigastrium, radiating to the back; has vomited twice and had a
mouth temperature of 104.2°. On the following morning the tem-
perature fell to 101". but in the evening it rose again to 103°.
On admission, following status, of bearing upon the ease, was
found: The skin subicterie. The abdomen rigid, particularly in the
right half; the liver was enlarged; in the right hypochondrium a
very tender and painful mass, about the size of a lemon, was found.
The spleen was not enlarged, nor were there any other symptoms
pointing to typboid fever present. The proba])le diagnosis of chole-
cystitis or abscess of the liver was made, and operation decided upon.
The urine contained albumin and hyaline and granular casts. Tem-
perature 105.4°. pulse 112, respiration 26.
Operation September 1. Incision about four inches long, begin*
ning at the ribs, made over the right rectus. On opening the perito-
neum no free fluid was found. The exploring finger discovered a
Riedel lobe of the liver, which was the mass felt before the operation.
The gall bladder was fairly distended, and its contents could not
be pressed out through the ducts into the duodenum; the cystic and
common ducts were palpated and found to be free from stones; no
other cause for the obstruction was found.
On the surface of the Riedel lobe there was some inflammatory
fibrin, and just above the middle of the free border of the liver
there was a small, white, round spot aliout 3 mm. in diameter; this
was neither elevated nor depressed, and was taken to be a tubercle:
it was excised, after passing a hemostatic suture around it, and
preserved for future examination. (On examination it was found
to be merely inflammatory exudate. )
The gall bladder was now isolated from the rest of the peritoneal
cavity and aspirated : normal bile was obtained ; the puncture was
closed by purse-string sutures. The liver substance was aspirated
in several directions, but no pus was obtained; nor were there any
areas of induration to be palpated in the liver. Partial closure of
the abdominal incision.
The subsequent course in the beginning was practically negative,
as far as it influenced the condition of the patient.
On September 3 the culture taken from the bile at the time of the
operation was reported as showing a colon bacillus. "\Yidal reaction
was negative. Temperature between 102.4° and 104.6°.
On September 4 following condition was noted : General condition
less good; apathy increasing; jaundice more marked; liver more
MOUNT SINAI HOSPITAL REPORTS.
enlarged. Temperature between 103.6° and 105°. Blood culture
On September 5 the liver Avas again aspirated in the ninth space,
axillary line, but Avith a negative result. The temperature rose to