come tender and very rigid.

Patient's general condition was })oor. the face cyanotic; expression
anxious; the tongue was moist and coated; the respirations were shal-
low and rapid (42) ; pulse small and could not bo counted; tempera-
ture 102.6°. The abdomen, on percussion, dull in both Hanks. In the
left femoral region, just below Poupart's ligament, there was a soft,
rounded mass; it Avas not tender to the touch, and was irreducible.
Patient almost moribund.

In spite of all this, it Avas deemed a duty to relieve the strangulation
of the intestine. Schleich's intiltration anesthesia. A longitiulinal
incision was cari-ied over the prominen(*e of the tumor. Rapid dis-
section revealed a large, empty hernial sac, through the ring of which
a large amount of foul, brownish fluid leaked away. To expose the seat
of the trouble the abdominal cavity had to be invaded. Median incision.
Distended small intestine presented in the wound, and was traced
downwai-d until a collapsed ])ortion was reached. Here a knuckle of
intestine seemed to be constricted by a band. This being divided, how-
ever, it became evident that this could not have been the cause of the
trouble. The distended intestine was now followed up in the opposite
direction. High uj), near the duodenal fossa, a completely gangrenous
loop was reached. Its length was about eight inches. The gangren-
ous coil was attached to the external wound, the most of which was
closed by suture.

Vigorous hypodermatic and iiili-a venous stimulation did not succeed
in terminating the collapse, and the patient <lie(l three hours after the
operation.

No auto])sy was ])enuitted.

III. VENTRAI, UERXIA.

(1) Si)())il<ni( oils Viiilral lliniia.
In the two cases of spontaneous median ventral hernia, plastic pro-
cedures involving the fasciie of the recti were i-esorted to and yielded
satisfactory results for the time being.



GERSTER : REPORT OF THE KIRST SURGK'AE DIVISION —1902. 253

(:2) Po.sf -operative ¥( Html Hernia.

Of the seven patients suffering^ from post-operative ventral hernia
that presented themselves for treatment, one declined operation, and
another one died. The history of tliis ease Avill be found below. The
remaining number, mostly herniie contracted after operations for ap-
})endicitis. were dealt with in this manner: The various layers of the
abdominal wall were separatt^d by careful dissection, after which the
various planes were sutured in their anatomical order. In all of these
cases the innnediate result was good.

The history of the fatal case is as follows:

1902, vol. ii., page 256. Ventral Hernia Following an Operation for
Appendicitis (Kammerer Incision); Repair of the Abdominal Wall:
Death from Diffuse Peritonitis. — Henry B., 24 years of age, admitted
April 8. He had been operated upon at this hospital, during March
of this year, for appendicitis (interval). Ten days after this opera-
tion a small hernia appeared at the site of the incision. The scar be-
came very painful, which made him seek relief.

April -4 a longitudinal incision was carried over the centre of the
protnision. Directly after incising the skin and superficial fascia,
the omentum was reached, intimately adherent both to the superficial
fascia and to the structures through which it passed. The hernia haa
no peritoneal sac. The liberation of the adhesions was very difficult.
The anatomical relations had become so indistinguishable that the in-
cision had to be extended both upward and downward. Thus the nor-
mal peritoneum was reached. The intestines were intimately adherent
to the posterior surface of the omentum and to the abdominal parietes.
The separation of all adhesions having been accomplished, a large
section of the prolapsed omentum was resected. The wound was
closed by exact suturing.

The hernial protrusion had evidently occurred in consequence of
the giving Avay of the deep sutures, and the contents left the abdominal
cavity through a peritoneal aperture. This explains the absence of
a sac.

The day after the operation patient vomited repeatedly; tempera-
ture rose to 103.4°. pulse to 130; the abdomen became rigid, tender,
and painful. The tension became so extreme that it was deemed
proper, the following day, to remove the cutaneous sutures. Con-
siderable bloody purulent fluid escaped from the subcutaneous space.
The wound was packed and covered with a moist dressing. The
patient's condition becoming worse, the entire wound was opened. A
large amount of a grumous. ])loody, and purulent fluid escaped from
between the coils of intestine, especially from the pelvis and flanks.
The intestines w^ere coated with a fibrinous exudate; some coils were
completely collapsed, others moderately distended. The abdominal



254 MOUNT SINAI HOSPITAL REPORTS.

cavity was repeatedly flushed with saline solution until the fluid re-
turned clear. Multiple drainage of the peritoneal cavity.

First the condition of the patient seemed to improve. The vomiting
diminished in frequency (probably in consequence of repeated lavage).
In the evening of the 8th patient became restless and delirious, and
expired the same night.

IV. UMBILICAL HERNIA.

Two patients were operated upon. Omphalectomy, exposure of the
various layers of the abdominal wall, and layer suture Avere em-
ployed. The immediate result was satisfactory in both instances.

V. INTERNAL HERNIA.

One case of strangulated internal hernia was admitted. The ring and
hernial protrusion were situated in the anterior parietal peritoneum
just above the bladder. The patient had declined to be operated on
for three days, and consented only after fecal vomiting had set in.

1902, vol. ii., page 241. Stranyulaicd Internal Hernia: Relief of
Strangulation ; Ohliteration of Sac: Death. — Marcus D., 55 years of
age, admitted to the medical service on April 5. Had been complain-
ing for two years of digestive disturbances, eructation, abdominal dis-
tension, constipation, and loss of weight. For a number of years a
double inguinal hernia was present. One week before admission the
hernia of the left side suddenly became irreducible ; after two days,
however, it slipped back spontaneously. April 10 patient vomited
once, but the temperature and pulse were normal. April 11 he vom-
ited repeatedly foul fluid ; abdomen became tender and the signs of a
peritoneal exudate were found in the left flank. The distension in-
creased markedly, but the patient declined an operation. The follow-
ing day vomiting continued and became fecal. Finally the distension
became enormous and the patient consented to an operation.

Operation. Chloroform anesthesia. The abdomen was opened in
the median line below the umbilicus through a five-inch incision.
Distended and congested but viable small intestines, together with
coils of collapsed intestine, presented in the wound. The distended
coils were traced downward until the obstruction was reached. A
loop of small intestine was constricted by the firm fibrous neck of a
small sacculation of the anterior parietal peritoneum just above the
bladder. The incarcerated loop was easily withdrawn and was ap-
parently normal. The ring was split and the sac obliterated by sev-
eral tiers of sutures. Closure of the abdominal incision.

On the day following the operation the pulse became poor in quality,
but responded to stimulation. In the evening the abdomen became
considerably distended. Though the bowels moved, the distension
returned almost at once. The pulse became weaker, and while at-



GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 255

tempting to administer an intravenous infusion the patient suddenly
v^^ent into collapse and died.
No autopsy was permitted.

DISEASES OF THE KIDNEYS — 13 PATIENTS ; 10 OPERATIONS ; 3 DEATHS.



Nephroptosis; appendicitis 1 1

Ectopic kidney; acute nephritis 1 1

Cystic degeneration of kidneys 1 . . . . . . 1

Perinephritic abscess 1 1

Nephrolithiasis 1 . . . . . . 1

Suppurative nephritis; nephrolithiasis; cystitis^ 1 .. .. 1

Pyelitis^ 1 . . 1

Pyelonephritis^ 1 . . . . 1

Acute degeneration of kidneys, probably due to

chemical causes; anuria 1 . . . . . . 1

Urogenital tuberculosis 1 . . 1

Tuberculosis of kidney 1 1

Neoplasm of kidney; hematuria^ 1 .. .. 1

Sarcoma of right kidney; metastatic growth of

liver 1^ . . . . I''

Operations upon the Kidneys — 10 on 9 Patients; 3 Deaths.

Nephropexy and appendicectomy 1 1 ....

Splitting both kidney capsules (Harrison) for

anuria 1 . . . . . . 1

Nephrotomy for anuria (cystic kidneys) 2' . . . . . . 1

" " calculi in pelvis of kidney 1 .. .. .. 1

Nephrectomy; ectopic kidney 1 1

" tuberculous kidney 1 1

Double vasectomy for tuberculosis 1

Exploratory laparotomy; tumor of kidney and

liver 1

Incision and drainage of perinephritic abscess. . 1 1



1902, vol. ii., page 344. Nephroptosis; Chronic Appendicitis; Neph-
ropexy; Appe7idicectomy ; Cured. — Sophie S., 21 years old, fore-
woman. Three years ago had an attack of severe pain in right iliac
fossa, accompanied by chill, vomiting, and frequent urination. Kept
to bed for one week. It took three months for her to recover her
health. For ten months past has had intermittent pain in right side,
its intensity increasing toward evening. Micturates every fifteen
minutes during day; three to four times during night. Pain at be-
ginning and at end of micturition. Lost flesh and strength. Is very
nervous. Appetite good.

'Not operated upon.

^'Transferred to medical service, unimproved.

^Two operations in one patient.



256 MOUNT SIXAl HOSPITAL REPORTS.

On admission there was noted slight dulness at left apex, with few
coarse rales; faint systolic murmur at apex; liver and spleen normal.
Right kidney can be felt as freely movable, smooth mass which can
be readily replaced into the loin ; it is of normal size. Pressure over
McBvirney's point rather painful.

August 11, 1902: Nephropexy; appendicectomy through longitudi-
nal lumbar incision. Kidney delivered, capsule formed into two flaps,
and these attached to lumbar fascia. Appendix removed through
same incision; it was in a state of chronic inflammation. Uneventful
recovery.

January 31, 1908 : Kidney in good position ; nervous symptoms
much less marked; patient gained somewhat in weight.

1902, vol. ii., page 332. Ectopic Sacral Kidney the seat of Acute
Inflammation; Nephrectomy : Cured. — Joseph S., 29 years old, a cloak-
maker. Had an attack, similar to the one for which he came ^o
hospital, ten days before. His present illness conniienced twenty-four
hours before admission. It was marked by severe pain in both lumbar
regions, radiating into the groins. He had no chill, but some fever;
vomited several times. T^rination frequent and somewhat painful ;
no hematuria.

On admission, October 9, 1902, he was in fair general condition:
his lungs, livei-, and spleen normal. Heart: Disease of aortic and
mitral valves. Abdomen : Entire right side rigid, but the lower half
especially so ; no free tiuid : no tumor could be felt, on account of
muscular rigidity; per rectum, high up above the prostate, a large, in-
definite mass could be palpated. Temperature 103.4°, pulse 104.

Immediate operation was thought necessary, as an acute empyema
of the appendix could not be excluded. Abdomen opened on right
side by Kammerer incision. Appendix found free and normal in aj)-
pearance ; it was deligated and removed. Exploration revc^aled a
ma.ss in the median line, over the lumbosacral junction, covered by
peritoneum. By placing the patient in Trendelenburg's position
this mass was easily exposed; for further exploration its peritoneal
covering was split longitudinally. The mass was at once recognized
as a kidney; it was firmly lodged at the luml)()sacral junction; its
vessels came from the aorta in two large branches; it was cubical in
form, hilus to inner side; the veins ran lengthwise along the hilus; no
marked surface depressions. While examining the organ a large renal
vein was torn. The cortex was so friable that with the most gentle
manipulation a deep rent into it was made. The bleeding from thes(^
sources was very profuse, and could not be controlled by clamp or
tampons. After determining the presence and consistence of the re-
maining kidney by palpation through the abdominal wound, nephrec-
tomy was done. The pedicle was secured with heavy catgut. Some
aberrant arteries at upper pole were also ligated. Cigarette drain
to stinnp ; layer suture of abdominal wall. Uneventful convalescence.



GERSTER: REPORT OP THE FIRST SURGICAL DIVISION — 1902, 257

Pathologist's report of kidney: Acute degeneration and inflamma-
tion.

1902, vol. ii., page 333. Acute Degeneration of Kidneys; Total
Anuria; Splitting of Both Kidney Capsules (Harrison) ; Death.—
Samuel S., 33 years old, was operated upon for appendicitis one year
before. Three days ago he suddenly experienced a burning pain in
abdomen, followed by vomiting. The vomiting was frequently re-
peated. The bowels did not move. No fever, chills, or jaundice.

On admission, lungs, heart, and internal organs normal. He had
passed no urine in the last twenty-four hours. Catheterization yielded
one drachm of urine. Temperature 100.4°.

Hot packs, enemata, irrigations of intestines, medication, etc., did
not succeed in starting up the secretion of urine. As a dernier ressort
the splitting of both kidney capsules was done. Under local anes-
thesia the kidneys were exposed and capsules split. The kidneys both
showed markedly increased intracapsular tension and were very brittle.

June 19 : No urine was secreted during the next two days ; gradual
stupor; coma; death.

Autopsy through the ivound. — Bight kidney: Large, firm, not very
hard ; capsule not adherent ; cortex of normal thickness ; pyramids con-
gested and studded with punctate hemorrhages; calices and pelves
normal: ureter pervious. Left: Slightly larger than right; otherwise
the same conditions as in the right kidney. Other organs normal.
Microscopical examination of kidneys: Acute degeneration with granu-
lar changes in epithelium; marked congestion.

1902, vol. iii., page 335. Nephrolithiasis; Nephrolithotomy ; Drain-
age; Infection of Kidney; Death from Sepsis. —Sarah S., 26 years
old, a domestic, suffered from attacks of nephritic colic on right side
for three years. She passed small calculi at various times. Fever
during some of the attacks. Never had hematuria. Urine turbid
and contained pus.

On admission internal organs normal. X-ray examination of right
kidney showed shadow of stones corresponding to position of pelvis.
Right kidney palpable, but not enlarged. Urine acid, 1030 ; pus and
red blood cells ; no casts ; no tubercle bacilli. Temperature 100°, pulse
100.

June 4 : Nephrotomy under gas and ether. Development of kidney
somewhat difficult on account of perinephritic adhesions. Section
of kidney while an assistant compressed the vessels at the hilus.
Large number of stones removed from the pelvis and a few from the
parenchyma ; they varied in size from a split pea to a marble ; some
were lodged in the cortex near the periphery. Suture of kidney,
drainage of pelvis, anchoring of organ to quadratus lumborum muscles.
and partial closure of outer wound.

June 5: Temperature rose to 103.6°. Vomited repeatedly. Passed



258 MOUNT SINAI HOSPITAL REPORTS.

twelve ounces of urine which was acid, 1030 ; trace of albumin ; red and
white cells; no casts.

June 6: Temperature high' 103 4-°. pulse 120. Vomited several
times. Wound laid open; small collection of pus at lower end of
wound and wdthin the capsule ; the latter was necrotic. The cut
section of the kidney showed numerous scattered purulent areas. Free
drainage.

June 7 : Patient passed very little urine— nine ounces in twenty-
four hours. Temperature 103 -|-°, pulse 120. Wound showed exten-
sive necrosis. The onset of uremic symptoms, together with anuria,
prompted a splitting of the kidney capsule on the other side (Har-
rison). The uremic state became deeper, and death from sepsis oc-
curred June 8. No autopsy.

1902, vol. iii., page 337. Tuberculosis of Left Kidney; Nephrec-
tomy; Cured. — Henry B., a clerk, of Savannah, Ga., suffered for six
years from attacks of pain in the left lumbar region, at times radi-
ating downward into the bladder and thigh. The pain was severe,
and lasted one to two days. Did not recollect ever having passed
bloody urine. The latter was dark brown, malodorous, and cloudy.
He was told that he passed gravel four months before his admission.
His family history was tuberculous. He had lost weight and suffered
considerably, especially in last few months.

On his admission, April 19, his internal organs were normal. The
left kidney region was tender and painful; no tumor could be felt.
The urine was acid, 1024; faint trace of albumin; few pus cells:
mucus: no tubercle bacilli could be found on repeated examination;
total amount of urine, 35 to 40 ounces ; urea, 2 per cent.

April 21, 1902 : Exploration of left kidney under gas and ether.
Usual kidney incision. Development of the organ difficult on account
of numerous adhesions, especially around upper pole. The kidney
was enlarged, lobulated; at its upper pole was a fluctuating area
which contained pus. The ureter was much dilated. Nephrectomy
was decided upon and carried out. Vessels of pedicle separately tied
with heaw silk. The ureter was stripped out of its bed as far as its
pelvic portion, and then ligated and removed. Cigarette gauze drain-
age. Closure of outer wound in usual manner. Uneventful con-
valescence. Discharged cured May 17, 1902.

Autopsy of Kidney.— IjSirge abscess at upper pole; several small
cheesy foci in its vicinity. Ureter thickened and dilated, and con-
stricted near its pelvic portion. Tubercle bacilli found in kidney pus.

1902, vol. iii., pages 334 and 342. Bilateral Cystic Degeneration
of Kidneys; Oligurui: Double Nephrotomy: Death. —Joseph E., 42
years old, was first admitted on December 31. 1901. With the ex-
ception of slight gastrointestinal disturbances, his previous history
was negative. During the past eight weeks urination was difficult
and painful, and in the last week there was almost constant vesical



GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 259

tenesmus. No chills, sweating, or fever. Had pain in left lumbar
region; no uremic symptoms; edema of legs. During the last two
days he voided two giassfuls of urine.

On admission he was in fair condition; tongue moist and coated;
no edema of legs or feet; breath urinous; diminished breathing and
dulness at bases of both lungs. Liver, spleen, and heart normal; no
accentuation of basic cardiac sounds; pulse of slightly increased ten-
sion. Abdomen : A swelling in left lumbar and hjrpochondriac re-
gions, corresponding to left kidney. Prostate normal. Temperature
98.6°, pulse 100.

During the first six hours of his stay in the hospital he passed but
one and a half ounces of urine ; this contained some blood cells and
pus cells, no casts. The administration of diuretics and infusion
of digitalis, and rectal saline injections, rapidly restored the kidney
function. During the next twenty-four hours he passed 187 ounces
of urine, which was clear, acid, 1014, some albumin, no casts.

The kidneys continued to functionate well, and the tenderness of
the left kidney diminished. A small stone was passed per urethram
on January 2. The diagnosis of calculous pyelonephritis of left side
with oliguria was made, but, on account of a diphtheria epidemic in
the ward, operation was postponed ; the patient was discharged and
told to report at a subsequent time. On January 11, 1902, he re-
turned to the hospital. He had passed no urine in twenty-four hours,
and had severe pain in left kidney region. Pulse 108, temperature
102.6°.

Examination showed the presence of a large, globular, slightly
tender mass corresponding to left kidney. The administration of
saline enemata, diuretic mixtures, and cathartics did not restore the
kidney function. No urine was secreted during twelve hours. On
the basis of a calculous pyelonephritis being the cause of the anuria,
a nephrotomy of the left kidney was decided upon.

January 12, 5 a.m. : Under chloroform this was performed. The
fatty capsule was edematous; kidney was large, of soft consistence,
surface cystic. Aspiration Mdthdrew turbid, yellow fluid, odorless,
containing 0.8 per cent, of urea. The pelvis of the kidney was dis-
tended with the same sort, of fluid, and in it were lodged several cal-
culi. The organ was split, the stones removed, and free drainage
established; There was veiy little hemorrhage during the operation.
Following the operation the patient vomited a number of times and
hiccoughed almost incessantly. Kidney function could not be re-
established, in spite of the administration of saline enemata. saline
cathartics, diuretics, etc. Temperature 100° -102°, pulse 120. In the
late evening of January 12 the right kidney was also split and drained.
The organ was cystic, resembling a bunch of grapes, but there were
no calculi in its pelvis. A vomiting and incessant hiccough con-
tinued. A free urinous discharge soaked the dressings; no urine
passed into the bladder. Gradually the vsymptoms of uremia devel-
oped, and death occurred January 18, 1902.



260



MOUNT SINAI HOSPITAL REPORTS.



Autopsy through wounds. — Bight kidney: Eighteen cm. long; cap-
sule adherent. Entire organ studded with cysts varying in size from
a pea to a walnut; some of these contain bloody fluid, others clear,
serous fluid. Between the cysts is apparently normal cortical sub-
stance. The pelvis contained a small, soft stone. Right ureter: Much
thickened; lumen dilated, and contained several soft stones, which
seemed to completely stenose the canal. Left kidney: Same as on
right side ; no calculi in ureter or pelvis.

PERINEUM AND MALE GENITALS. TOTAL, 106; DEATHS, 5.



Vesical calculi 1

Cystitis, chronic 1

" tuberculous 2

Carcinoma of bladder 4

Tumor of bladder 1

Papilloma of bladder 1

Retrovesicular inflammatory exudate 1

Seminal vesiculitis, tuberculous 1

Hypertrophy of prostate 11

and vesical calculi 2

Tumor of prostate 1

Tuberculosis of prostate and seminal vesicle. ... 2

Gonorrheal prostatitis 1

Urethritis, acute, non-specific 1

" " gonorrheal 2

Periurethral abscess 2

Perineourethral fistula 2

Stricture of urethra 7

Redundant prepuce 1

Hematoma of corpus cavernosum 1

Varicocele 4

Hydrocele 1

Suppurating epididymo-orchitis, pelvic abscess. . 1

Thrombosis of spermatic vessels 1

Fissure of anus 2

Fistula in ano 11

Hemorrhoids 29

Ischiorectal abscess 4

Carcinoma of rectum 5

Pruritus ani 2

Proctalgia 1



1
1
1



2
1
5
1

3
1
1
1
2
11
29
4
1
1



HYPERTROPHY OF PROSTATE — 11 CASES; 4 DEATHS.

Eleven patients with hypertrophy of the prastate were admitted
during the past year. Upon these patients the following operations
were performed : perineal prostatectomy four times, with two deaths ;
suprapubic prostatectomy twice, with no deaths; Bottini's operation
twice, with one death ; suprapubic cystotomy, removal of calculus and



GERSTER: REPORT OF THE FIRST SURGICAL DIVISION — 1902. 261

drainage, twice, with no deaths; irrigation of the bladder, one ease,
with one death. The material is altogether too small to permit of onr
making definite deductions. It is to be noted that of the four cases
discharged as cured, in two the prostate was removed by the supra-
pubic and in tAvo by the perineal route ; in th*e two cases discharged as
improved, suprapubic cystotomy and drainage had been done, prin-
cipally for the removal of calculi from the bladder; the one case dis-
charged as unimproved refused treatment; and, finally, of the four
cases w^hich terminated fatally, in two the prostate had been removed
by the perineal route, in one Bottini 's operation had been done through
s. perineovesical fistula, and one case had received only vesical irriga-
tions. The histories of the cases with a fatal termination were as fol-
lows :

1902, vol. iii., page 365. Hypertrophy of Prostate; Operation,
Perineal Prostatectomy ; Death.— Louis K., 62 years of age, was ad-
mitted to the hospital September 7 with the following history : Patient
had gonorrhea twelve years ago. He had some difficulty with mic-
turition during the past eight or nine years; the more acute disturb-
ances date back only five days, since which time there is a more
marked frequency in urination, accompanied by severe pain in the
hypogastric region and in the glans penis. During the past three