peritoneal coat injected, and its nuicosa showed a few minute hemor-
rhagic areas. The cecum and part of the omentum were very much
injected.
The patient reacted poorly. The pulse, in spite of vigorous stimula-
tion, gradually failed, the temperature rose to 105.4°, vomiting was
incessant, and death occurred eighteen hours later, the clinical picture
being that of a foudroyant septicemia. No ant()])sy ])ei'mitti'd.
It has l)eeii our expei'ience that in these cases tiie general symi)toms
of poisoning are far more in evidence than the local manifestations
from the diseased apix'udix. .\s a rule a sevei'c chill ushci's in the at-
tack; the pulse rate rises rapidly, the tunpcraiuvv luiryiiifj, being either
sliijhtUi or etnisiderdbbi (U vai< (J. The ptitieuis look siek (iiid are very
)nueli proslrtih (I. With tlu' history of such an onset, irrespective of
the intensity of the local ahdnihinal syniptoms, we resort to inntiediale
operative in t erf ere nee.
In the last volume of our i-eports two fatal cases of septicopyemia,
with purulent thrombosis of the mesenteric and portal veins and
purulent infarctions in the liver, were reported. During the
year 1901 several more cases were encountered, all of which ended
fatally. In 1902 Ave had two cases of purulent thrombosis of the ves-
sels of the appendicular mesentery and of the cecum. Both these
eases recovered after removal of the appendix with its mesentery and
drainage of the throml)osed veins. Their histories were:
1902, vol. i., page 158. Aeute Gangrenous Appendieitis; lliromhosis
of Mesenteriolum of Appendix and Adjoining Veins of Cecum; Ap-
pendicectomy ; Drainage of Thrombosed Veiiis; Cured. — J. G., 24
years old, a canvasser, was never sick until thirty-six hours before his
admission. During the first twelve hours he felt chilly at intervals
and suffered with pains in the right iliac fossa. During the last
twenty-four houi's he had two severe chills and vomited repeatedly,
the pain in the right iliac region remaining constant.
On admission, April 26, 1902, temperature was 102.4°, pulse 108.
He was well nourished. His internal organs M^ere nonnal. The lower
half of the right rectus was slightly rigid. Exquisite tenderness from
McBurney's point downward and inv, ard to the pubes; no distinct
mass was to be felt Rectally nothing except distended intestines could
be palpated. Diagnosis: Acute appendicitis; pi-obably venous throm-
bosis.
GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1 002. 215
Immediate laparotomy was proceeded with. Just before taking the
anesthetic the patient had a very severe rigor. The appendix was
located anteriorly to the caput coli, lying free and surrounded by
omentum. It was 21/0 inches long, dusky in color, and completely
gangrenous. The vessels of the mesenteriolum contained purulent
thrombi. The vessels of the caput coli could be palpated as rigid
cords. This rigidity extended well up along the ascending colon.
The appendix was delivered from its omental bed, its mesenteriolum
deligated at as high a point as possible, and the appendix, after
li gating its base, removed. In the stump of the mesenteriolum could
be seen the purulent thrombi in the veins. The veins, in the stump and
iii the adjoining portion of the cecum were drained by gauze, and the
wound closed.
The patient reacted well. The temperature fell during the next
twenty-four hours to 99°, the pulse rate to 72; with chilly sensations
it rose suddenly in the next four hours to 103°, pulse rate 92; it then
declined rapidly to 97.8" on the third day, and thereafter fluctuated
between 99° and 100°. There was a profuse purulent discharge from
the drain opening for ten days; thereafter the wound healed rapidly
1902. vol. i., page 179. Perforated Empyeyna of Appendix; Puru-
lent Thromhosis of Vessels of Appendii and Neighhoring Cecum: Ap-
pendicectomy ; Removed of Mesenteriolum; Incision and Drainage of
Thrombosed Veins; Cured. — Isaac M., 27 years old, a presser, had
never been ill until the present time. Thirty-six hours before admis-
sion he began to suffer with severe abdominal cramps; vomited re-
peatedly; was chilly at onset. During his transportation to the hos-
jjital the abdominal pains subsided very materially.
On admission' December 19, 1901, he was in fair general condition,
but looked very sick; his temperature was 104°, pulse rate 82. The
internal organs were normal. The abdomen was rigid and tender all
over, but especially so in the right iliac fossa ; free fluid in both flanks.
Rectally a tender area high up could be palpated. Diagnosis : Acute
appendicitis ; peritonitis.
Immediate laparotomy. Fi-ee exudate in the peritoneal cavity.
1'here was a localized encapsulated exudate in the right iliac fossa be-
low and external to the caput coli. This was very thick and tenacious,
but odorless. The appendix was found internal and below the caput
coli, curled up in a semicircle. It was perforated, and from the hole
brownish pus exuded. The mesenteriolum was infiltrated with pus,
and the purulent infiltration extended up to the adjoining vessels of
the cecum. The appendix with its mesenteriolum was deligated and
removed. The purulent veins of the caput Avere incised and curetted
and drained. During this part of the manipulation the cecum was
punctured, and at once closed by I.embert suture. Drainage of stump
of mesentery and appendix and cecal region; closure of rest of the
wound. The temperature fell after operation to 100.8° and then rose
216 MOUNT SINAI HOSPITAL REPORTS.
to 102.2°, and continued for the next ten days between 100° and 101".
There was a profuse purulent discharge from the drainage opening
for a week ; thereafter rapid closure of the wound. The convalescence
was interrupted by a rather severe attack of tonsillitis. Discharged
cured February 2, 1902.
It is an interesting question how we shall explain the course and
final disposition of the infectious thrombi in these two eases. Are we
to consider that the thrombosis remained localized in the veins which
were found to be involved at the operation ; that these thrombi eventu-
ally broke down into fluid i)us and were discharged through the drain
opening; or are we to believe that some of the infectious material did
j»ass up into the mesentei-ic and portal vessels and liver and Avas finally
destroyed by the liver cells? In the fii'st of the two cases we have
reason to assume, on account of the chill tliirty-six hours after opera-
tion, with a sudden rise of temperature and a rapid decline to a sub-
normal point, that some infectious material did escape into the portal
system and was probabl}^ destroyed in the liver. In the last case the
absence of a chill and high fever subsequent to operation would lead
us to infer that the thrombosis i-emained entirely localized and that
the purulent thrombi broke down and were discharged in the secretions
from the wound. That the livei- is able to cope successfully with a
limited amount of infectious material is well known,^ and probably
explains why septic infarction of its substance from infections in the
portal system of veins is not always attended with the formation of
ahscesses in it.
In the past year there were admitted 13 eases of diffuse purulent
peritonitis secondary to appendicitis. Of these, one was in a mori-
bund condition and was not operated upon. In all but one of the
operated cases the appendix was i-emoved and an abscess cavity, when
it existed, was thoroughly drained. In 3 the peritonitis it.self was
treated by gauze drainage ; two died and one recovered. In 7 no peri-
toneal drainage was employed, the peritoneal cavity being mopped
dry of the exudate and the wound closed as far as the exit of the drain
passing into the abscess cavity; 4 died and 3 recovered. In 2 the
peritoneal cavity was cleansed by irrigation with hot normal saline
solution, and then drained with gauze; death followed in one. shortly
after the operation, from shock: the other was eured.
'Johns Hopkins Hospital Reports, vol. viii., Nos. 3-9.
GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1902. 217
The question of peritoneal drainage in cases of purulent peritonitis
is a most important one, and has engaged our attention for several
years past. In 1899 and 1900, with the consent of Dr. Gerster, Dr.
Berg treated 6 cases of diffuse purulent peritonitis without drainage ;
since then 8 other cases have been so handled. Of the 14 cases, 8 re-
covered and 6 died — a mortality of 44 per cent. During the same
period 24 cases were treated by extensive peritoneal drainage with
gauze and tubes ; of these, 8 recovered and 16 died — a mortality of 66
I)er cent. In 3 other cases the peritoneal cavity was cleansed by irri-
gation with hot normal saline solution and then drained; 2 died and
1 recovered, or 66 per cent, mortality.
Only those cases were treated without peritoneal drainage in which
at the time of operation the peritoneum was smooth and uncovered by
granulations ; otherwise the cases were not selected, and some of them
were indeed suffering with intensely virulent and extensive infections
of the peritoneum. (For a full discussion of this question and tech-
nique of operation see articles by Dr. Berg in Mount Sinai Reports.
1900, and Medical Record, June 30, 1900.) Dr. Berg will shortly pub-
lish these 14 cases in extcnso.
The fatal cases of the past year were as follows :
1902, vol. i., page 134. Acute Appendicitis; Diffuse Peritonitis;
Admitted Moribund: Died without Operation; No Postmortem Per-
mitted.
1902, vol. i., page 161. Acute Gangrenous Appendicitis; Diffuse
Purulent Peritonitis: Appcndicectomy ; Counter-incision: Peritoneal
Irrigation: Drainage; Death. — Samuel S., 7 years old, taken sick two
days before admission with pain in right side ; felt sick ; vomited ; no
chills.
On admission, February 7, 1902, temperature 103.6°, pulse rate 128.
Examination revealed healthy internal organs; abdomen rigid and
slightly distended ; right iliac fossa especially tender ; no mass to be
felt. Immediate laparotomy. Appendix gangrenous; diffuse puru-
lent peritonitis; appcndicectomy; irrigation of peritoneal cavity;
drainage; counter-incision in left iliac region for di-aiiiage. De:.ith
a few hours later from shock.
1902, vol. i., page 130. Acute Appendicitis; Diff'use Sacculated
Purident Peritonitis; Drainage of a Number of the Sacculations;
Death from Septicemia. — Frank S.. 22 years old. never had a previous
218 MOUNT SINAI HOSPITAL REPORTS.
attack of appendicitis. Four days before admission, began to have
general abdominal pain, which became localized to right iliac fossa.
Two days later had a severe chill.
On admission, April 16, 1902. temperature was 104.2°. pulse 120.
Abdomen w&s everywhere tender and distended; large mass could be
felt in right iliac fossa.
Immediate laparotomy. A number of large cavities containing
very fetid, foul pus were evacuated and drained. Appendix could
not be readily located. Continuance of high fever and inability to
secure a movement of the boM^els prompted a revision on the follow-
ing day. An acute kink of the small intestine from adhesion to a
gauze drain was found as the cause of the obstruction. Two other
large abscesses between the intestinal coils evacuated. Omentum gan-
grenous in patches. Drainage. Several hours after this revision,
bowels moved freely, but the severe intoxication continued, and death
occurred April 21.' 1902.
1902, vol. i., page 162. Acute Gangrenous Appendicitis; Diffuse
I'urulent Peritonitis; Appcndicectomy ; Peritoneal Drainage; Death. —
Edna W., 3 years old, commenced to complain, four and one-half days
before admission, of abdominal cramps and diarrhea. The next day
the child collapsed; temperature was 102 "" ; abdoiiuMi became tense;
vomited, and bowels did not move. The child became progressively
worse until her admission, July 25, 1902. At that time the tempera-
ture was 102°, pulse 144; Hippocratic facies; abdomen rigid and dis-
tended, markedly tender, and especially so in the right iliac fossa ;
shifting dulness in both flanks.
Immediate laparotomy. Appendix gangrenous, perforated at apex;
peritoneal cavity filled with foul, thick pus and fibrin. Appcndicec-
tomy; gauze drainage. Death from shock six hours latei'. No
autopsy.
1902, vol. i., page 165. Acute Gangrenous Appendicitis; Diffuse
Purulent Peritonitis ; Appendicectomy ; Peritoneal Drainage ; Death. —
Bertha K., J.3 years old, never had a previous attack of appendicitis.
The present attack was of five days' duration. No initial chill, but
two days after the onset had a severe chill, from which time the peri-
tonitis dates.
On admission temperature was 101°, pulse 135; abdomen rigid, very
tense, much distended; shifting dulness in both flanks; no mass to he
felt on account of extreme rigidity of the abdominal nniseles.
Immediate laparotomy. Appendix gangrenous and perforated ; dif-
fuse fibrino-purulent peritonitis; omentum necrotic in j)atches and its
vessels thrombosed. Appendicectomy ; peritoneal drainage ; injection
of 20 gm. of concentrated (50 per cent.) magnesium sulphate into the
GERSTER : REPORT OF THE FIRST SURGICAL DIVISION — 1902. 219
small intestine. Died tweiity-fdiu' lioiirs latei- of septicemia, tem-
perature rising to 107.8°.
1902, vol. i., page 163. Acute Gangrowus Appendicitis; Diffuse
Purulent Peritonitis : Chronic Nephritis; Appendicectomy ; No Peri-
toneal Drainage; Death. — Aaron W., 45 years old, had repeated at-
tacks of intestinal colic. The present illness was of thirty-six honrs'
ch^ration. marked ])y intense pain in abdomen and right iliac fossa,
vomiting, hiccoughing, and inability to move the bowels; considerable
fever. Urine, albumin and casts.
On admission, August 16, temperature Avas 100.4°, pulse 108. Ab-
domen was much distended and rigid; dulness in both flanks; marked
tenderness in right iliac fossa ; Hippocratic facies.
Immediate laparotomy. Appendix gangrenous and perforated;
localized abscess; dilfnse purulent peritonitis. Appendicectomy; drj'-
ing out of peritoneal exudate ; no peritoneal drainage ; drainage of
abscess. Did well for forty-eight hours, then ceased to pass urine,
and succumbed on the third day from septicemia.
1902, vol. i., page 164. Acute Gangrenous Appenelicitis; Diffuse
Purulent Peritonitis ; Extensive Collection of Pus in Right Suh-
plirenic Space; Appendiccctoniji ; Drainage; Death. — Simon "W., 15
years of age. First attack of appendicitis; four days' duration; peri-
tonitis of two days' duration.
On admission, ^lay 14. 1902. temperature 104.2°, pulse 150. Base
of right lung compressed, and signs of fluid beneath the diaphragm;
abdomen distended and rigid, very tender; palpation difficult on ac-
count of rigidity; no mass to be felt per rectum. A mitral stenosis
and insuffif'iency present. Aspiration of right subphrenic space
jnelded foul pus. Transpleural incision and drainage of large col-
lection of purulent material above and behind the liver. Exploration
showed entire peritoneal cavity to contain pus. Incision over ap-
pendix ; latter organ ' found retrocolic, gangrenous, and perforated ;
diffuse purulent peritonitis. Appendicectomy; drying of peritoneal
cavity. Death twelve hours later.
It is to be especially noted that the technique of closure of that
l^ortion of the incision which is not needed for drainage has be*n
changed. We formerly used through-and-through silk or silkworm-
gut sutures, and only too often did serious and extensive phlegmons
of the abdominal wall result from infection of the stitch canals. We
now sew the peritoneum with catgut, and the fascia or nuiscles with
chromic gut. strapping the skin with sterile zinc-oxide straps. The
infections have almost entirely ceased, the wounds healing kindly by
tirst intention.
220 MOUNT SINAI HOSPITAL REPORTS.
DISEASES OF THE LIVER — 12 CASES; 4 DEATHS.
Acute degeneration of the liver (during preg-
nancy)' 1 1
Liver abscess, traumatic 1 1
single, secondary to colitis 5 5
" amebic; amebic colitis 3 .. .. .. 3
Carcinoma of liver secondary to cholelithiasis'. . 1 .. .. 1
Periendothelioma of liver 1 . . . . 1
Oprnilioits iipoii Liver — 11 Op( ralioiis on JO I'atienls; 3 Deaths.
Exploratory laparotomy for new growth 1 . . . . 1
Laparotomy for liver abscess 1 1
Transpleural route for drainage of liver abscess. . 6 5 '.. .. 1
Subpleural •' " " .< « " . . 1 . . . . . . 1
Combined transpleural and transperitoneal opera-
tions for drainage of liver abscess 1 . . . . . . 1
Colostomy for amebic colitis with liver abscess. .1
The cases of liver abscess oecnrriiig in the First Surgical Division
of ]Monnt Sinai Hospital during the past three years, and those of the
entire surgical service during 1898-1899. will be made the subject of a
special article by Di-. Beig. and will appear shortly.
The fatal cases during tlie past year were all amebic abscesses of the
liver secondary to amebic colitis. Their histories were:
1902, vol. ii.. page 290. Aiiubic Absciss of the Tyivcr Secondary to
A77ichie Colitis; Si(hpl('itral Jlejxilotonnj and Drainafje; Died. — Ida
H., 52 years old, sulfei-ed with diarrhea for the past year. During
the past four weeks she had almost constant pain in right side of ab-
domen, not radiating; chills and fever; night sweats; no jaundice.
On admission. Se{)tem])ei' 9. 1902, liver was enlarged upward and
backward to angle of scapula and downward to one finger's breadth
below umbilicus. Marked tenderness over liver; crepitant rales over
its convexity. Temperature 99°-l()4.4°. pulse 100; leucocytes. 13.000.
[Jrine acid; trace of bile. Stools clay-colored. Aspiration of liver
yielded i)us.
September 10 : Subpleui-al hepatotomy ; evacuation and drainage
of large liver abscess. Kesection of tenth rib in post-axillary region.
Eeflection of pleura raised up from diaphragm and parietes. In-
cision of diaphragm. Hepatotomy. iMacuation of lai'ge amount of
pus. Tube drainage.
September 11 : Profuse (iisehai-gc of pus from abscess cavity con-
taining amebte. No evidences of pleural involvement. (Jeueral con-
dition good.
'Not operated. ^
GERSTEK : KEPORT OF THE FIRST SURGICAL DIVISION — 1902. 221
September 16 : The wound pale and necrotic ; no evidences of granu-
lation. Almost continuous diarrhea, stools containing ameba?. Tem-
perature between 100° and 102°.
September 18: Death from exhaustion. Diarrhea almost continu-
ously. No autopsy.
1902, vol. ii., page 292. Amebic Abscess of Liver; Amebic Colitis;
Transpleural Hepatotomy and Drainage of Abscess; Colostomy to Ex-
clude the Large Lntestinc; Death. — Solomon B., 17 years old. His
previous history was not obtainable. Had just arrived in this country-
from Roumania. For five days before admission, October 14, 1902, he
had chilly sensations; fever; no diarrhea; movements dark; no blood;
no jaundice.
On entrance to hospital temperature was 105.2°, pulse 100, small
and feeble; no jaundice; liver enlarged downward; tenderness in axil-
lary region over liver, friction sounds over convexity of liver. As-
piration of liver yielded thick i:)us.
Immediate operation. Transpleural hepatotomy; evacuation of
large liver abscess ; drainage. Abscess wall necrotic.
October 16 : Abscess cavity discharges moderately ; ameba? in the
pus. Profuse diarrhea commenced, stools containing mucus and
blood; amebffi in stools.
October 19: Diarrhea continued profuse; patient exhausted by con-
tinued stools. Temperatures between 101° and 103°.
October 20 : Colostomy under eucaine for exclusion of large intes-
tine from fecal current.
October 21 : Large hemorrhage from descending colon.
October 22 : Colon irrigated through colostomy wound. Three hem-
orrhages from colon, and patient died shortly after the last one.
Autopsy through tJic tcouud. — Entire colon, upper part of rectum,
and last ten inches of ileum studded with various sized ulcers; edges
of these undermined ; bases deep. The abscess in the liver had a
necrotic, ragged, honeycombed wall. Kidney, acute degeneration.
It was impossible to find the vessel that gave rise to hemorrhage.
1902. vol. ii., page 298. Avicbic Abscess of Liver; Amebic Colitis;
Laparotomy, Drainage, and Transpleural Counter-drainage ; Death. —
Abraham G., 55 years old, admitted ]\Iay 9. Sutfered for some time
prior to present illness with diarrhea. For six months he had severe,
sharp pains in right side of chest and abdomen, radiating to back, and
right shoulder; pain worse on coughing; no jaundice; frequent chills
and night sweats. Lost 48 pounds in this time.
On admission his general condition was poor; no jaundice; tem-
perature 101.6° ; liver enlarged downward one finger's breadth below
free border of i-ibs ; tenderness over liver ; rales over its convexity.
Connected with lowei* edge of liver a large mass reaching to level of
umbilicus. Aspiration anteriorly yielded pus.
Inmiediate operation. Laparotomy; hepatotomy; peritoneal cavity
I)i'otected by gauze packings; evacuation and drainage of large abscess
222
MOUNT SINAI HOSPITAL REPORTS.
in right lobe, which reached well back to the posterior surface of the
liver. To secure better .drainage, a 'counter-incision was made behind,
the pleural cavity shut off In- sutures, the diaphragm and liver incised,
and through-and-through drainage established. Temperatures de-
clined after operation to 98° to 100° ; at end of the first week they
fluctuated between 100° and 102°, though drainage of the abscess
cavity was excellent. Profuse and almost continuous diarrheal move-
ments commenced at end of first week, and continued in spite of every
kind of medication and local treatment. Ameba? in stools and in pus
from liver. The abscess cavity in the liver showed no tendency to
contract ; its walls remained necrotic and discharged a profuse secre-
tion mixed Avith bile. Quinine internally, and irrigations of the ab-
scess cavity and colon with solution of cjuinine 3 per cent., had no in-
fluence upon the disease process. The diarrhea continued, and grad-
ually the patient's strength became exhausted. Death July 7, 1902.
No autopsy.
DISEASES OF THE GAI.I, HI-.\nnEK AND DM.E DI'CTS — 21 PATIENTS; 5 DEATHS.
Cholelithiasis' 2
" biliary colic: jaundice^ 1
" peripyloritis and gastritis' 1
" empyema of gall bladder' 1
" subacute cholecystitis; calculi in
gall bladder 1 1
Cholelithiasis; contracted gall bladder; pyloric
stenosis 1 1
Cholelithiasis; acute cholecystitis; calculi in gall
bladder 4 3
Cholelithiasis; empyema of gall bladder; calculi
in gall bladder 1 1
Cholelithiasis; empyema of gall bladder; calculi
in gall bladder; myocarditis 1
Cholelithiasis; empyema of gall bladder; calculi
in gall bladder and cystic duct 1 1
Cholelithiasis; gangrenous cholecystitis; stones
in gall bladder and cysticus 1
Cholelithiasis; gangrenous cholecystitis; chole-
mia; calculi in gall bladder 1
Cholelithiasis; calculus in choledochus; ruptured
empyema of gall bladder- 1 1
Cholelithiasis; calculus in choledochus; con-
tracted gall bladder containing calculi; jaun-
dice' 4 2
'Not operated upon.
-Had been operated upon at a previous time for acute empyema of gall
bladder with cholelithiasis, and discharged with a sinus.
'One of these patients had been operated upon at a previous time for
empyema of gall bladder and cholelithiasis. The common duct was not
opened at primary operation, on account of the poor condition of the patient;
a secondary operation was deemed more advisable.
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 223
Operations upon Gall Bladder and Bile Ducts — 21 Operations on 16
Patients.
b^ '^ c Pi
Drainage of gall bladder for ruptured empyema 1^
Cholecystostomy and drainage 6 2 1° 3
Cholecystectomy 3 3
" extirpation of mucosa of gall bladder
(Mayo's operation) 1 1
Cholecystectomy and pyloroplasty (Heineke-Mikulicz) .1 1
Cysticotomy and drainage 1 1"
Choledochotomy and drainage 1* 1
" " cholecystostomy; drainage 2 .. .. 2
" " extirpation of mucosa of gall
bladder^ 2 2
The histories of the fatal cases during the past year were:
1902, vol. ii., page 277. Cholelithiasis; Empyema of Gall Bladder;
Cholecystostomy : Myocarditis ; Sudden Death eight weeks after Ope-
ration. — Fanny L., 56 years old, housewife. For past four years she
had suffered with repeated attacks of cholecystitic pain. Never was
jaundiced. The present attack was of two weeks' duration, -attended
with large, painful tumor in region of gall bladder, and fever. The