perience that even in tlie latei- stages of the disease laparotomy is well
borne, and the patients rapidly react from the anesthetic. This factor
in the mortality can therefore be excluded. As regards the secona
point that has been raised — viz., does the perforation per se result in
the death of the patient? — this also can in the majority of cases be
considered of secondary inq:)ortance, for shock attending the per-
foration is in many instances very slight or even absent altogether.
The peritonitis resulting from the perforation varies in extent and
virulence in different cases, and, furthermore, bears no constant rela-
tion to the length of time the perforation has existed or the extent of
the extravasation. As a rule, however, if the cases are operated upon
early the infection of peritoneum ought not to be sufficient to cause
death.

The third factor to he considcMed in this connection is the typhoid
fever itself. It certainly is well known, and to the internists espe-
cially, that typhoid fever is not a constant (quantity ; that typhoid fever



GERSTEK : REPORT OK THE FIRST SIRiiKAE DIVISION — 11)02. 205

in New York C'ity is not the same as tliat in some other centre; that its
virulence during one summer is not the same as that during another
year. The occurrence of nine cases of perforation during one sum-
mer's service, when during other years there were at most one or tw'»
cases, points to a greater virulence of the disease during the past year.
Further, since we may assume it is usually the severest causes tliat
perforate, we are justified in concluding that of the nine cases some
would have succumbed even had no perforation taken place. This
varying virulence of the fever will explain the variations in the results
following the repair of perforated ulcers during dilferent visitations
of the disease. Thus in one season, in which the virulence of the fevei
is not very intense, the percentage of recovery after the repair of per-
forated ulcers may much exceed that of another summer in which the
fever itself is much more severe. In the statistics heretofore pub-
lished this varying intensity of the fever during its different visit-
ations has not been considered in estimating the results that follow
the surgeon's repair of perforating ulcers; nor has anj^ attempt been
made to explain why the same surgeon's mortality rate under similar
conditions during one year far exceeds that of the following year. Thus
in our own service during the year 1901 one case of typhoid perfor-
ation was admitted to the service ; the child was admitted with a dif-
fuse peritonitis and the perforation was several days old. Yet, after
suture of the ruptured ulcer and cleansing of the peritoneum, the child
made a smooth recovery; the typhoid itself gave rise to very few
symptoms and seemed to be of a mild type.

As regards the symptoms in our three cases: In none was a pre-
perforative stage observed, neither in the leucocyte count nor in the
abdominal symptoms. The first manifestation of the perforation was
a severe pain, localized, in two of the cases, to the right lower quadrant
of the abdomen, and general in one. Vomiting occurred in one pa-
tient. Collapse was not noted in any. The temperature continued
high in all. In t:vo the leucocytes gradually increased from the time
of perforation, reaching 13,000 and 12,000. respectively; in the third
the leucocytes did not go beyond 4,800.

Locally the rigidity of the abdominal nuiscles was very early in evi-
dence after the perforation had occurred. Obliteration or partial dis-
appearance of liver and splenic dulness was noted in all three cases.



206 MOUNT SINAI HOSPITAL REPORTS.

Before operation there was evidence of free fluid in the peritoneal
cavity (dulness in both flanks, shifting with change of position).

Diagnosis. — All the typhoid patients in the medical service were
very closely and minutel}^ observed. The abdomen was examined at
each visit; leucocyte counts were made as a routine procedure twice
daily. If the patient complained of abdominal pain, this was at once
reported to the house physician, who went immediately to see the pa-
tient. The diagnosis of a perforation was made from the following
facts: Severe abdominal pain, localized or general; rigidity of the
abdominal wall; complete or partial obliteration of liver flatness; in-
creasing leucocytosis. Collapse, fall of temperature, vomiting were
not looked upon as essential points in making the diagnosis; they
helped, when present, merely to substantiate the other findings.

Operation.— Operation was advised in all cases and performed as
soon as consent could be obtained. The advisability of surgical inter-
ference in cases in which the perforation and extravasation have taken
place into the free peritoneal cavity cannot be questioned ; for, if left
to their fate, these patients will all of them succumb from septic peri-
tonitis. Where, however, the ulcer before its perforation has formed
adhesions to neighboring parts, thus effectually shutting off and pro-
tecting the free peritoneal cavity from infection, it is probably wiser
to wait before proceeding to operation ; for some of these cases will not
need operation at all, in others it will only be necessary to drain a
localized abscess. It is, from our present data, very difficult to dif-
ferentiate those cases in which extravasation has taken place into the
free peritoneal cavity from those in which it is entirely localized;
probably the best point in their dift'erentiation will be the absence of
liver dulness in the former and its presence in the latter.

The operation consisted in opening the abdomen in the right iliac
fossa, under general anesthesia (gas and ether in two cases, chloroform
in one), rapidly finding the perforated ulcer, and closing it with two
I'ows of Lembert sutures. Toilet of the peritoneum, and closure of the
abdominal wound with drainage. In one case the peritoneum was
completely closed, and likewise the external wound. Death on the
fourth day enabled us to make an examination of the wound. The
peritoneal cavity was sweet and clean, but the outer wound was the
seat of an intense gaseous infection. Thus, while we may dispense



GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 207

with peritoneal drainage, it is essential to drain the outer fasciae and
muscles.

The histories of these three cases were as follows :

1902, vol. i., page 28. Typhoid Fever; Admitted to Hospital with
Intestinal Perforation of several hours' standing; Laparotomy ; Clos-
ure of Perforation; Death. — Charles K., 35 years old, admitted August
29, 1902, in second week of typhoid. Several hours before admission,
had abdominal pain, constant in character, but not severe. On ex-
amination, abdominal wall lax; tenderness in right iliac fossa; no dis-
tension. Spleen enlarged. Liver : No obliteration of flatness.
Leucocytes, 8,600 ; Ehrlich and Widal reactions positive.

August 30 : In early morning complained of abdominal pain, at first
localized to right lower quadrant, but became general. Abdomen dis-
tended. Abdominal wall very rigid. Some free fluid in abdomen.
Liver dulness obscured. Temperature 104.6°. Leucocytes, 13,400.
l^rine acid, 1020, albumin (trace), hyaline and granular casts.

Immediate operation. Median abdominal incision ; gas and ether.
Escape of free gas and feculent material from peritoneal cavity.
Small intestines discolored and covered with patches of fibrin. Per-
foration in lower coil of ileum. Suture by two rows of Lembert.
Drainage of peritoneal cavity. Partial closure of abdominal wound.
Patient did not react well ; pulse failed in spite of stimulation. Death
after fifteen hours. No autopsy.

1902, vol. i., page 26. Typhoid Fever; Relapse; Perforation during
the Relapse; Large Localized Abscess in Sacral Concavity; Incision
and Drainage of Abscess; Intestinal Fistula; Death. — Pauline M..
42 years old, tailoress, admitted August 31, 1902, in the third week of
a very severe typhoid fever. Passed through five weeks of fever ; by
September 26 temperature reached the normal. Then commenced a
relapse complicated by pneumonia at right base. Pneumonia cleared
up by seventh day.

October 6 : Patient complained of abdominal pain, not very severe ;
no collapse. Abdomen rigid ; exquisite tenderness in left side of hypo-
gastrium, corresponding to which is an area of dulness. Liver dulness
almost entirelv obliterated. Leucoc.vtes, 12,000. Temperature 102.6°,
pulse 108.

Immediate operation. Median laparotomy under gas and ether.
Omentum adherent to abscess in pelvis. Small abscess in omentum.
I^arge abscess in sacral concavity, well walled off from general peri-
toneal cavity, and containing malodorous pus. Evacuation and drain-
age of this abscess cavity. Partial closure of abdominal wound.

Patient reacted well. Temperature remained between 103° and
104° ; pulse regular, between 120 and 140. Vomited several times



2Ufe MOUNT SINAI HOSPITAL REPORTS.

during first day. For the next three days temperature between 103°
and 104^, pulse poor and rapid. Vomited repeatedly. An enema
was partly expelled into the abdominal wound through the perforated
ulcer. On the fifth day patient succumbed to peritonitis.

Postmortem. — Peritonitis in lower part of abdomen, with .saccu-
lations of pus and feces. In ileum, about 25 cm. from ileocecal valve,
a perforated ulcer, the opening in which is one-third cm. in diameter,
and partly closed by adherent omentum.

Comments. — In this case it might have been advisable to wait until
the abscess was better sacculated and then to have incised it per
rectum.

1902, vol. i., page 27. TypJioid Fever; Perforatioit : Diffuse Feri-
fonitis; Laparotomy witJt Closure of Perforation : Death. — Fanny 0.,
housewife, 42 years old, admitted October 5, 1902, in the second week
of severe typhoid fever. During the week of her stay in the medical
sprvice her temperatures were very high, 106 -|-°.

October 5: At 6:80 a.m. severe abdominal pain and chilly sensa-
tions. Abdomen tender but lax. At 10 a.m. temperature rose to 106°,
pulse 128; vomited once; abdomen lax; liver dulness not obliterated.
Leucocytes, 3,500. At 5 p.m. no change in symptoms. At 10 p.m.
l)ain in lower right side of abdomen. Slight dulness in right iliac
fossa ; over this area there is tendei-ness. Abdominal wall lax. Liver
dulness partially obliterated. Leucocytes, 4,800. Vomited nourish-
ment.

Operation 2 a.m. Laparotomy through right rectus muscle under
chloroform. Free gas and free feculent material in peritoneal cavity.
Perforated ulcer in lower coil of ileum. Closure by two rows of mat-
tress Lembei't silk sutures. Toilet of peritoneum. Closure of peri-
toneum and outer wound without drainage.

Patient reacted well. Temperature and pulse eonfinued high.
Some nephritis developed. Bowels moved on the thii'd day. (Jeneral
condition remained good until morning of fourth day, when patient
suddenly collapsed and died a few hours later.

Postmortem. — Peritoneum sweet and clean; no leakage from per-
foration. Outer abdominal wound the seat of severe gaseous in-
fection.

Comments. — The severe infection of the outer wound would indicate
that though the peritoneal cavity may be closed without drainage, the
outer fasciae and muscles must be provided with sufficient • gauze or
Tube drainage.

The histories of the other fatal cases were :

1902, vol. i., page 44. Gangrenous Colitis; Perforation of Colon :
Loealized Abscess; Incision and Drainage; Death. — Bella Y., 50 years



GERSTER: REPORT OP THE FIRST SURGICAJ^ DIVISION — 1902. 209

old, admitted to the medical service on August 22, 1902. Her illness
was of two weeks' duration. It began with very frequent diarrheal
movements. She had pain in upper part of abdomen. No chill or
fever or vomiting. Only twice was a little blood in the stools.

On admission she was very apathetic; temperature 102.4°, pulse 130
and regular. Liver enlarged three fingers below free border of ribs.
In lower right quadrant of abdomen was a tender mass, smooth and
hard, fixed to the posterior parietes, and dull to percussion. Leuco-
cytes, 12,000. Urine acid, 1018 ; trace of albumin ; bile and indican
present; no sugar; pus cells, red cells, and hyaline casts. Ehrlich
reaction positive.

The pulse under free stimulation improved in quality, and on
August 23 she was transferred to the surgical side for operation.
Laparotomy under gas and ether anesthesia. Longitudinal incision
over the mass. Exposure of the tumor showed it to contain feces and
what appeared to be gangrenous mucosa of the intestine. Evacuation
and drainage of cavity. Dry dressing. On August 24-25, fecal dis-
charge through dressings. Gradual failure of pulse. Death on
August 26. •

Wound examination. — The entire hepatic flexure adherent to neigh-
boring viscera and parietes, and gangrenous. The rest of the colon
showed gangrenous and ulcerating patches in the mucosa. The
mucosa of the hepatic flexure absent (probably represented the gan-
grenous material found at operation). Gall bladder enlarged; con-
tained pus and calculi ; adherent to colon and liver. Kidneys, marked
degeneration.

1902, vol. i., page 41. Acute Volvulus; Gangrene of Sigmoid Flex-
ure; Laparotomy ; Tube Drainage and Exclusion of Gangrenous In-
testine from the Peritoneal Cavity: Death. — Mendel B., 73 years old,
merchant, admitted to medical service March 10, 1902. Symptoms
were of four days' standing. During this period there was no move-
ment of the bowels ; no fever, chills ; no pain ; no spontaneous vomit-
ing, abdominal distension ; no prostration. Urine acid, 1036 ; trace of
albumin; many casts, few red cells. Temperature 99°, pulse 80.
Abdomen distended; free fluid in the flanks; tumefaction in lower
half of abdomen ; no marked tenderness or pain.

Attempts to move the bowels by castor oil and high oxgall enema
ineft'ectual. Transferred to the surgical side. Immediate laparotomy.
Left lateral incision. Considerable malodorous, brownish fluid in
peritoneal cavity. Sigmoid flexure gangrenous. The poor condition
of the patient forbade any prolonged procedure. Drainage and ex-
clusion of gangrenous intestine from the general peritoneal cavity by
gauze tamponade. Dressing. Death in collapse a few hours later.

Wound examination. — ^Sigmoid flexure gangrenous, twisted around
its axis; difl^use peritonitis.



210 MOUNT SINAI HOSPITAL REPORTS.

A second case of volvulus was admitted in moribund condition.
Operation was not deemed advisable. Death within twelve hours.
Postmortem showed the descending colon to be tw'ice twisted around
its longitudinal axis, completely gangrenous.

1902, vol. i., page 45. Diffuse Sai'coma of Intestines and Perito-
neum; Exploratory Laparotomy : Death five weeks later from Cach-
exia. — Abraham G., 29 years old. admitted November 24, 1901. Had
been operated upon for appendicitis five years before. No syphilitic
history. His present trouble was of seven months' duration; onset
with malaise, night sweats, repeated vomiting of food, and nausea.
Pain in epigastrium commenced two months later; it was worse after
vomiting. Jaundiced once, five months before admission, this lasting
two months. At first his bowels were constipated; latterly they had
become very loose, stools very black in color. No coffee-ground vom-
ilus.

On admission, dulness and bronchovesicular breatliing over right
apex. Liver enlarged one inch below costal margin. Spleen some-
what enlarged. No palpable tumor in abdomen. Enlarged glands in
neck and groin.

November 26 : Exploratory laparotomy. Clear serous fluid in peri-
toneal cavity. On convexity of liver several grayish-white nodules,
bleeding on slightest touch, varying from 3 mm. to II/2 inches in
diameter. Peritoneal surface of pylorus studded with similar nodules.
Retroperitoneal glands enlarged and hard. Omentum contained a
number of nodules, some having undergone cheesy degeneration; a
few were removed for examination. Intestinal loops adherent and
studded in places with small nodular masses. Layer suture of ab-
dominal wall, with drainage.

December 3: Protrusion of omentum and some loops of intestines
through the wound, which had burst open.

December 17 : Fecal fistula formed. Wound had very unhealthy
appearance.

Gradual emaciation and advancing cachexia and asthenia. Death
December 26.

1902, vol. i., page 38. Carcinoma of Splenic Flexure; Intestinal
Obstruction; Artificial Anus in the Right Iliac Region; Ileocolostomy
after Recovery from the first Operation; Death on the tenth clay from
Perforation of the S^nall Intestine at site of Anastomosis, due to Pres-
sure Necrosis from the Murphy Button. — Hannah H., 73 years old.
still a fairly vigorous woman, sutTered from intestinal obstruction, for
relief of which an artificial anus in the cecum had been made. Six
weeks after her recovery from this operation, at the urgent request of
the patient to rid her of the disagreeable feature of the artificial anus.



GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1902. 211

an ileocolostomy was done, end-to-side anastomosis, using the Murphy-
button. The patient made an excellent recovery from the operation.
She was up and about, and was to be discharged, when she suddenly
collapsed on the tenth day and died within six hours.

Postmortem. — No air or feces in peritoneal cavity. Considerable
fresh fibrin at site of anastomosis. Small intestine at site of anasto-
mosis showed marginal necrosis, permitting the button to show
through. Large, hard mass in splenic region, involving spleen, left
kidney, and splenic flexure, and kinking the latter. Kidneys, chronic
interstitial nephritis. Liver fatty and congested.

Comments. — In this case death was due to necrosis of the small in-
testine at the site of the anastomosis, from pressure of the button.
Whether we are to consider that this pressure necrosis was indirectly
owing to the old age of the patient (73) or to her chronic nephritis
is a question ; but the experience gained in this case will dispose us to
make use of the suture instead of the button in future cases of anasto-
mosis in nephritic or very aged subjects.

1902, vol. i., page 86. Carcinoma of Hepatic Flexitime of Colon;
Intestinal Obstruction; Side-to-side Anastorriosis; Nephritis; Death. —
Hilda L., 60 years old, had suffered from constipation for two years.
Acute obstructive symptoms commenced five days before her admis-
sion. On admission, December 8, 1901, she was in poor condition;
pulse irregular ; abdomen not much distended. In right iliac region^
about the level of the umbilicus, was a doughy mass the size of an
orange, not tender. L^rine acid, 1012 ; trace of albumin ; granular
casts.

Immediate celiotomy. Some clear serous fluid in abdomen. Small
intestines moderately distended and injected. Hard tumor at hepatic
flexure. Side-to-side anastomosis between small intestines and de-
scending colon. Closure of abdomen. Patient reacted poorly. Passed
no urine after operation. Succumbed twenty-four hours after opera-
tion from cardiac failure.

Comments. — In this case an anastomosis was decided upon because
the intestines were not much distended ; secondly, it would not con-
sume any more time than a colostomy, and the patient would be spared
the disagreeable accompaniments of an artificial anus in the cecal
region (and especially as the stools are usually fluid Avhen a colostomy
ip performed at this place).

The case of duodenal perforation will be reported in a special article
by Dr. Berg.



212



MOUNT SINAI HOSPITAL REPORTS.



DISEASES OF APPENDIX VERMIFORMIS^ 101 CASES; 10 DEATHS.



(Aj Appendix not perforated. ^

Acute catarrhal appendicitis- 11

Subacute " " 3

Chronic " " 18

Acute ulcerative appendicitis 3

" " with marked symp-
toms of septicemia 2

Acute empyema of appendix' 4

" " " with gangrene" 3

Acute gangrenous non-perforative appendicitis. ... 10
" " " " " with

periappendicular abscess 1

Acute gangrenous non-perforative appendicitis with

free exudate in peritoneal cavity 3

Acute gangrenous non-perforative appendicitis;

thrombosis of mesenteriolum 1

Carcinoma of appendix 1

(B) Appendix perforated; local or connplete gangrene.
(a) Circumscribed peritonitis; abscess:

(1) No free exudate in peritoneal cavity.... 21

" " " " " mul-
tiple omental abscesses 1

No free exudate in peritoneal cavity; sec-
ondary subphrenic abscess 1

(2) F"ree exudate in peritoneal cavity 4

" " " " " purulent

thrombosis of mesenteriolum 1

(h) Diffuse purulent peritonitis" 13



o
9
2

15
3

1

4

2

10



21

1

1
4

1
5



Operations — 9.') Operations on 94 Patients; 9 Deaths.



Appendicectomy for acute catarrhal appendicitis' 11 11

" " chronic " 15 15

" " acute ulcerative " 5 4



'Appendix removed in a number of other patients in whom the abdomen
was opened for diseases other than that of appendix vermiformis. These are
not included in the tabulation.

-One case with acute ulcerative endocarditis.

^These cases refused operation in the quiescent period. .

*One case had also chronic salpingo-oophoritis.

■•One case was complicated post-operatively with gangrene of six inches of
ileum, and resulted fatally.

'One case not operated; admitted moribund.

'In one case, in which the Kammerer incision had been employed, this was
followed on the tenth day (post operationem) by a ventral omental hernia that
was irreducible; this was owing to a violent straining effort on the patient's
part. A laparotomy for the cure of the hernia, undertaken some weeks later,
was followed by death of the patient. (See ventral hernia.)



GERSTER: REPORT OP THE FIRST SURGICAIj DIVISION — 1902. 21;?



E-i y ^

Appendicectomy for acute empyema of appendix' 7 6 1'

" " acute gangrenous, non-perforating ap-
pendicitis 13 13

Appendicectomy for acute gangrenous, non-perforating ap-
pendicitis; evacuation and drainage of periappendicular

abscess 1 1

Appendicectomy for acute gangrenous, non-perforating ap-
pendicitis; incision of thrombosis of mesenteriolum 1 1

Appendicectomy for carcinoma of appendix 1 1

For circumscribed peritonitis; abscess'":

Evacuation of abscess; drainage; no appendicectomy.... 1 1

" " " " appendicectomy" 26 26

" " " " " second-

ary drainage of subphrenic abscess; costal route.... 1 1

Evacuation of abscess; drainage; appendicectomy; in-
cision of purulent thrombosis of mesenteriolum.... 1 1
For diffuse peritonitis:

Evacuation of abscess; drainage; drainage of peritoneal

cavity 3 1 2

Evacuation of abscess; drainage; irrigation and drainage

of peritoneal cavity 2 1 1

Evacuation of abscess; drainage; no drainage of perito-
neal cavity 7 3 4

Evacuation of abscess; drainage; drainage of subphrenic

abscess; drainage by costal route 1 . . • 1

We had occasion in our last report to call attention to the im-
portance of the vascular and blood lesions that accompany acute in-
flammations of the "appendix vermiformis. As there pointed out, these
lesions bear no relation to the severity of the local changes — a fact that
is well illustrated by one of the fatal cases of the past year.

1902, vol. i., page 138. Acute Appendicitis; Foudroyant Septi-
cemia; Appendicectomy ; Death eighteen hours later. — Lena T., a ser-
vant-girl, single. 22 years of age, had never been sick until five days
before admission. Her present illness commenced with chilly sensa-
tions and headache; three days later she had severe pain in the right
iliac region, radiating down the legs. The day before admission she
vomited repeatedly a watery fluid matei-ial. Bowels moved daily.

On admission. February 4, 1902, she was in a poorly nourished con-
dition and very nnich prostrated. The heai't and lungs were normal.
There was marked tenderness in the right iliac region ; the right rectus
was exquisitely tender ; no definite mass was to be felt ; some abdominal
distension. Rectally a tender area was to he felt high up and to the

■"One case combined with right salpingo-oophorectomy.
■'Death due to post-operative gangrene of six inches of ileum.
"Two cases followed by fecal fistula.

"Median laparotomy was practised in two cases in which the abscess was in
the middle line in the sacral concavity.



214 MOUNT SINAI HOSPITAL REPORTS.

right. Genital organs normal. Temperature 104°, pulse 114. Diag-
nosis: Acute appendicitis.

Immediate laparotomy for removal of the appendix. Appendi.x lo-
cated below and to the outer side of the caput, embedded in thin lymph.
It was developed, deli gated, and removed. It was 2i/o inches long, its