stump besides, to control bleeding in case the clamp should slip. A
large cigar drain was applied to the pedicle, the old packings removed
and fresh ones inserted, and the wound partly closed with through-
and-through chromic catgut sutures. On June 21 the clamp Avas re-
moved Avithout hemorrhage. Thereafter there was a continuous pro-
fuse discharge of bile, together with attacks of pain in the region
of the wound, until July 29, when it Avas decided to again open the
abdomen. Incision was made through the old scar, and extensive
adhesions of omentum and stomach partly tied off and partly torn
through. At the depth of the Avound about the site of the stump of
the cystic duct a large inflammatory mass Avas found. OAving to the
poor condition of the patient nothing further could be done. A
cigar and a gauze drain were introduced to the depth of the Avound,
and the greater part of the Avound closed Avith through-and-through
silk sutures. The sutures became infected and had to be remo\^ed
early, and there Avas then a Avide, gaping Avound. There was a dis-
tressing hiccough for several days. Until August 13 there Avas a
profuse biliary discharge. Thereafter the biliary and the AVOund
discharge became steadily less. The large wound granulated slowly,
and the patient left the hospital completely recovered on October 15.

Empyema of Gall Bladder; Stones in Cystic Duct; Cholecystec-
tomy; Cysticotomy ; Cure. — Sarah W., 25 years old, admitted January
17, 1902. During Iavo months prior to operation patient had had
seA'eral severe attacks of biliary colic. During the Aveek prior to
operation there had been continuous pain and repeated vomiting.
There Avas tenderness and rigidity OA'er the upper part of the right
rectus; no mass could be felt. Temperature 102°, pulse 128. Opera-
tion January 18, 1902. Incision along outer border of right rectus
revealed an enormously distended gall bladder. The cystic duct Avas
also distended so as to form a distinct diverticulum, and contained
several stones. Aspiration of the bladder yielded a cloudy, bile-
stained fluid. The bladder Avas remoA'ed in the usual Avay. An
incision was then made into the dilated cystic duct and four small
stones removed. A cigarette drain Avas introduced against the under
surface of the li\'er. The Avound Avas closed Avith layer sutures.
Convalescence was uninterrupted, and the patient Avas discharged
cured on February 22.

Cholecystitis; Stoui nt Comymni Bile Duct; Cholecystectomy : Chole-
dochotomy ; Cure. — Mrs. Eva B., 28 years old, had been discharged
from the hospital on ^lay 5, 1902, after a choledochotomy. She had
remained perfectly Avell until June 15. Avhen she had been seized with
scA'ere pain in the right hypochondrium. Th(n-e was no vomiting nor
jaundice, but intense itching of the skin. Tho urine Avas deep broAA-n
in color and contained bile-stained epithelium, red blood cells, and
coarsely granular casts. The stools Avere very light in color. Tem-
perature and pulse Avere normal, and no mass Avas to be felt in the



360 MOUNT SINAI HOSPITAL REPORTS.

abdomen. On June 17 an incision was made in the line of the sear.
Stomach and omentum were found adherent to the scar. The gall
bladder was found buried in adhesions; it was extremely small. A
stone was felt in the common duct, but it slipped away from tlie
examining finger and its location could not again be ascertained.
The common duct was again incised at the site of the former opening,
but no stone was found. A probe entered readily in both directions.
A drainage tube was introduced through the incision in the common
duct into the hepatic duct. There was no free flow of bile. The
tube was sutured to the skin. The bladder was then removed in the
usual way and the abdomen closed. There was a profuse acid dis-
charge from the wound for two days. iMethylene blue given by
mouth appeared in the wound in three minutes. After a few days
the discharge in the wound was alkaline and biliary in character,
while that from the tube was a little bile-tinged and contained combined
HCl. There was probably an abnormal opening into the stomach
throilgh the old cicatrix in the common duct, which was adherent to the
stomach. On June 22 the stomach contents no longer came out of
the wound. On June 28 there was a fecal odor to the discharge.
On July 11 the sinus was curetted. Thereafter the discharge became
less, and the patient left the hospital with a very small sinus on
July 16. (Note — January, 1903: The wound closed soon after the
patient left, and she has remained perfectly well ever since.)

Cholelithiasis ; Cholecystitis: Choledochotomy cwd Suture; Choleeys-
totomy and Draiiiage; Death. — i^'arah B.. 52 years old, admitted No-
vember 17, 1902, had been having attacks of gallstone colic for twelve
years. Six years before admission, had had first attack of jaundice.
After this attack thirty stones had been passed, and patient Avas
free from pain for four years. During the year previous to operation
there had been several severe attacks. Jaundice had been present
five months when patient was admitted to the hospital. During this
time there had been chills accompanied by fever, and other symptoms
of cholangitis. The liver was palpable one and a half inches below
the free border of the ribs. On November 21 an incision was made
through the rectus muscle. The gall bladder was shrunken and con-
tained a single stone. In the common duct two stones were felt.
The stones were removed from the duct and the opening sutured.
The gall bladder was then opened and the stone removed therefrom.
The mucous membrane was swabbed with pure carbolic acid and a
drain introduced. The rest of the abdominal wound was sutured.
About three hours after operation patient went into a condition of
shock, and died six hours after operation. No autopsy.

Cholelithiasis; Cholecystitis: Cholecystotomy: Secondary Cholecys-
tectomy and Choledochotomy : Death from Cerebral Emholism. — Bar-
bara K., 46 years old, admitted September 19, 1902. There had been
an attack of biliary colic ""fourteen months before admission. One



LlLJENTllAL: REPORT OF THE SECOND SURGICAL DIVISION 1!H)2. ^^61

week before operation patient had a similar attack, with voniitin^;-,
janndiee, and clay-colored .stools. The liver was enlarged, the gall
bladder region tender, and the right rectus rigid. For two days
after admission the temperature rose daily to 105° F., the jaundice
was more marked and the general condition worse. Operation on
September 22, 1902. An incision through the right rectus revealed
an enlarged, congested liver and a distended gall bladder. Intestines
and omentum were adherent to the gall bladder by recent adhesions.
Aspiration of the bladder yielded four ounces of inodorous bile.
Several small stones were removed from the bladder and the organ
was sutured into the wound. No stones were felt in the ducts. Bile
drained freely from the wound, but the jaundice persisted. On
September 30 ten stones were removed from the sinus. On October 2
several more stones were removed. On October 6 six more stones
were found in the dressings. On October 12 the temperature, which
for ten days had not been above 100°, rose to 104.4°, accompanied by
a chill. The temperature then dropped to 100° again and remained
there until October 20, when it again rose to 103.2° and again there
was a chill. Stones were frequently found in the dressings. But
the biliary fistula and the jaundice persisted. Accordingly, on No-
vember 18, a secondary operation was performed. Two movable
stones were felt in the common duct. They were cut down upon and
removed. The gall bladder was then removed in the usual manner.
The raAv surface in the liver was sutured with catgut. The abdomen
was closed by layer sutures. Patient stood the operation fairly well,
although the pulse needed considerable stimulation at the end. On
the following evening, after a convulsion lasting about a minute, the
patient died. In the absence of an autopsy the cause of death was
taken to be a cerebral embolus.

Clioleliniiosis: Empyema of Gall Bladder: Peritonitis: Ctioh cys-
totomy ; Death. — Fanny B., 29 years old, admitted April 6, 1902. Pa-
tient had had several mild attacks of pain in the upper part of the
abdomen, slight jaundice, and constipation. Four days before ad-
mission she was seized with violent epigastric pain accompanied by
nausea. Slight jaundice developed and pei-sisted. The pain in-
creased in severity and constipation became marked. Pulse 134, tem-
perature 103.6°. Immediate operation was undertaken under local
anesthesia. Owing to the extreme rigidity of the alidominal nniscles
palpation Avas negative. On opening the abdomen through the right
rectus muscle, free turbid fluid escaped from the peritoneal cavity.
The liver was found enlarged, and the gall bladder much distended.
Four and a half ounces of cloudy, foul-smelling fluid were withdrawn
by aspiration. The bladder was then opened and thirty-eight stones
were removed. The bladder was sutured to the peritoneum and two
tubes introduced. The lower end of the wound was sutured. On
the following morning the temperature had dropped to 101° F. and
the pulse to 120. In the evening she became restless and vomited



362 MOUNT SINAI HOSPITAL REPORTS.

frequently. During the night she got out of bed and was very unruly.
On the following morning she went into collapse and died forty-five
hours after operation. No autopsy.

Stone in Common Duct; CholcdocJiotomy ; Cure. — Mrs. Eva B., 28
years old, admitted Api-il 11, 1902. During the eight months prior
to operation patient had had six attacks of biliary colic accompanied
by vomiting and jaundice. Two weeks before admission a severe
attack was ushered in with pain in the right hypochondrium, radi-
ating to the shoulder. There was vomiting and jaundice, the latter
persisting up to the time of operation. Patient had lost thirty-five
pounds in weight. The liver could be felt below the free border
of the ribs, but the gall bladder could not be palpated. On April 12
the abdomen was opened by an incision through the right rectus.
The gall bladder was markedly contracted, and in the common duct
a movable stone was felt. An incision was made into the duct between
two silk Lembert sutures and the stone removed. The sutures were
then tied, thus closing the opening in the duct. A drain was intro-
duced down to the sutured duct. The wound was closed with layer
sutures, and adhesive straps for the skin. Convalescence was rapid,
and the patient was able to leave the hospital on INIay 5.

LIVER — 13 ; 6 DEATHS.

Totals. Deaths.

Abscess of liver; incision and drainage 6 1

Multiple abscesses; incision and drainage 1 1

" " and portal phlebitis 1 1

Abscess of liver; exploratory celiotomy 1 1

Suppurating gumma; incision and drainage 1

Cholangitis; exploratory celiotomy 1 1

Cirrhosis of the liver; epiplopexy 1 1

Carcinoma of liver and omentum 1

The incision of choice in right-sided hepatic abscess of considerable
size has been the posterior one, transdiaphragmatic but not trans-
pleural, the pleura being pushed up out of the way. Our results
have been most satisfactory in this trying class of cases.

Abscess of Liver; Incision and Drainage; Death. — Jacob S., 29
years old, admitted June 14, 1902. The man had had a colitis of
fifteen months' duration. For three months before admission he
had had pain in the right hypochondrium, radiating to the back.
The liver reached two inches below the free border of the ribs. Tem-
perature 102.8°, pulse 128. On aspiration in the tenth space pus
was obtained. On June 14 an incision was made parallel to the
eleventh rib. Three inches of the rib were resected and the pleura



IJLIENTHAL: REPORT OP THE SECOND SURGICAL DIVISION — 1902. 363

stripped back. The liver was exposed through a longitudinal slit in
the diaphragm. The liver was aspirated and pus obtained deep down.
A grooved director and dressing forceps were then introduced and
about four ounces of pus evacuated. Numerous small abscesses were
found communicating with the main abscess. A drainage tube was
inserted and a dry dressing applied. On the following day the
general condition, in spite of free stinudatiou, was poor. On the
second day after operation the patient suddenly died. No autopsy.

Abscess of Liver; Exploratory Celiotomy; Death. — David C, 23
years old, admitted December 23, 1901. Five days before admission
the man had been seized with severe pain in the epigastrium accom-
panied by vomiting. On the day after the onset there had been a
chill. The general condition was poor. There was slight icterus and
distinct peritoneal facies. Pulse 130, temperature 104.8°. The liver
was somewhat enlarged downward. The abdomen was very rigidj
especially the upper part of the right rectus. An exploratory incision
along the upper part of the right rectus was made at once. The
liver was congested and extended two inches below the free border
of the ribs. It was aspirated several times, but only blood withdraw'n.
The gall bladder and appendix were normal. The spleen was a little
enlarged. Pancreas and stomach were normal. The right kidney
was larger than the left. The peritoneum of the entire right side
of the abdomen was congested. Flakes of fibrin were seen on the
lesser omentum. Owing to the poor condition of the patient further
interference was contraindicated. The wound was closed with silk
sutures. On the following day the abdomen was opened on the left
side. The intestines were congested and distended. An aspirating
needle was introduced into the large intestine and gas allowed to
escape. This was also done in several parts of the small intestine.
A small incision was made in the intestine and subsequently sutured.
The patient's condition was too poor to justify further procedure,
and the wound was closed. Death took place on the following day.
Autopsy revealed an abscess containing about two ounces of pus in
the most posterior portion of the right lobe of the liver.

MuUiple Abscesses of the Liver; Iiicisioji and Drainage; Death. —
Julius W., 43 years old, admitted August 31, 1902. Patient gave
a history of attacks of malai-ia and diarrhea. Two weeks before
admission he had* had an attack of diarrhea, which was followed by
vomiting and fever. 'I'lie liver reached two inches below the free
border of the ribs. The spleen wa.s pa]i)al)le. There was tenderness
over the liver. Leucocytosis, 14,400; AYidal negative. Temperature
103.6"". pulse 100, respiration 24. The urine contained a trace of
albumin and a trace of bile. Tliei-e was some conjunctival icterus.
On August 31 the abdomen was opened by a median incision. The
left lobe of the liver was much enlai-ged and soft. Aspiration yielded
thick, yellow, inodorous pus. The pus cavity was packed with gauze.



364 MOUNT SINAI HOSPITAL REPORTS.

Aspiration of the right lobe also yielded pus. It was then decided
to make an incision in the right flank and drain the right lobe. This
was done by resecting part of the tenth rib; the incision Avas trans-
peritoneal. A small abscess was opened and drained. The man
gradnally lost ground and died three days after operation. At the
autopsy a large abscess was found in the upper part of the left lobe
of the liver. In the right lobe there was a smaller abscess. In the
cecum and ascending colon there were several superficial ulcers.

Suppunitive Portal PliJebitis: Multiple Abscesses of Liver: Incision
and Drainage; Death. — Foster R., 40 years old, admitted August 20,
1902. Four weeks before admission the man had been operated on
for gangrenous appendicitis and an abscess. The appendix had ,
been removed. Following this operation there had been frequent
chills with fever, sweating, and loss of flesh and strength. The gen-
eral condition was pooi- and there was conjunctival icterus. The liver
was tender and much enlai'ged. The spleen was also enlarged. There
was a profuse purulent discharge from the appendicitis wound. As-
piration of the liver through the ninth interspace in the axillary line
yielded thick, reddish pus. The ninth and tenth ribs were resected
in the axillary line, whereby the pleura Avas injured. As the patient's
condition was poor, the pleura was opened widely, packings were
introduced; and, as aspiration through the pleura had pielded pus,
a grooved director was insei'ted and an attempt made to open the
abscess. The patient went into collapse and the operation had to be
stopped. Seven hours later the man died. Autopsy showed suppu-
rating phlebitis in the mesentery; suppurative portal phlebitis; mul-
tiple abscesses of the liver.

Abscess of Liver; Incision; Cnre. — Samuel F., 16 years old, ad-
mitted ]\rarch 29, 1902. Five weeks before admission patient had
begun to cough and expectorate. He had lost in weight, had daily
chilly feelings, and had to go to bed. Tliei'e had been pain in the
right hypochondrium, radiating into the shoulder. During the three
days prior to admission there had been severe hiccough. The liver
was a little enlarged downward. Aspiration in the ninth interspace
in the post-axillary line yielded pus. Temperature 101°, pulse 116.
On ]\Tarch 29 the patient was transferred from the medical side and
operation was at once performed. A longitudinal incision was made
over the eleventh rib in the post-axillary line and portions of the
eleventh and twelfth ribs were resected. The i)leural reflection was
stripped back into the upper part of the wound and the abscess opened
through the diaphragm. A large quantity of yellow, odorless pus
was evacuated, and two rubber tubes inserted. During the week fol-
lowing operation there were two small hemorrhages, which were readily
controlled by packing. Thereafter convalescence Avas uninterrupted,
and patient Avas able to leave the hospital on ^Fay 16 Avith a small
sinus about three inches deep.



LILIENTHAL : REPORT OF THE SECOND SURGICAL DIVISION — 1902. 365

Suppiimting Gumma of Liver; Incision and Drainage; Cure. —
Philip W., 39 years old, admitted December 22, 1901. There had
been several attacks of pain in the region of the liver during the
three years prior to operation. Tavo weeks before admission patient
was seized with severe pain in the right hypochondrium. There was
neither vomiting nor jaundice. Deep breathing caused pain, as did
also any motion forward or backward of the trunk from the waist up.
The latter symptom had existed for several months. There was some
tenderness over the liver, but no marked enlargement. On December
24 an exploratory incision was made through the right rectus. There,
were a few adhesions around the gall bladder. The ducts were
normal. On the anterior surface of the right lobe there was found
a hard, grajish-white mass as large as a hickory-nut. On incising
it a necrotic area was found at its centre. A drain was introduced,
after thorough curetting, and the rest of the Avound closed. The
pain had evidently been due to inflammatory adhesions between the
liver and the parietal peritoneum. The patient received mercurial in-
unctions and was given KI and Fowler's solution. The wound healed
rapidly, and the man left the hospital on January 16. fA^o^e— Jan-
uary. 1903: The patient is perfectly well.)

CJiohiitgitis; Exploratory Celiotomy: Death. — Leon 6., 47 years
old, admitted July 31, 1902. During five months prior to admission
the man had had several attacks of biliary colic. Ten days before
admission he had had an attack accompanied by chills, vomiting, and
icterus. Temperature 103.8°, pulse 110. The liver was neither en-
larged nor tender. The abdomen was rigid in the epigastrium and
left hypochondrium. On July 31 an exploratory celiotomy was done
along the right rectus. Considerable bloody fluid and some blood
clots escaped. The liver was found rotated so that the falciform
ligament pointed from left and above to the right and downwai'd.
Colon and stomach were adherent to the liver. Numerous distended
gall ducts were seen on the surface of the liver. The patient went
into collapse and the wound had to be rapidly closed. Death occurred
thirty-six hours later. No autopsy.

Cirrhosis of the Liver: Ascites: Epiplopexy : Death. — ^Mary C. 24
years old, admitted JNIarch 1, 1902. The patient had been married
two years and had had two abortions. There had been swelling of
the abdomen and edema of the feet for a year prior to admission.
The abdomen had steadily increased in size, and there had been
progressive loss of flesh and strength. There was a systolic murnuir
at the apex of the heart. The abdomen was distended with" fluid :
the girth at the umbilicus was 93 cm. There was edema of the lower
extremities. The abdomen was tapped three times and about 250
ounces withdrawn each time, but the fluid rapidly reaccunnilated.
Epiplopexy on April 12. A three-inch incision was made in the
median line above the navel. On opening the peritoneum considerable



366 MOUNT SINAI HOSPITAL REPORTS.

fluid was allowed to escape. There was no evidence of a tuberculous
peritonitis. The liver felt very hard. The omentum was sewed to
the parietal peritoneum with chromic gut. The wound was then
closed. An incision three inches long was then made below the um-
bilicus and a long Chamberlin tube, the lumen of which was packed
with gauze, introduced into the pelvis; this was left in place. The
patient died on the following day. Autopsy showed an advanced
cirrhosis of the liver.

ESOPHAGUS AND STOMACH — 5 OPERATIONS; 2 DEATHS.

Totals. Deaths.

Gastrostomy for carcinoma of esophagus 1

Gastroenterostomy for carcinoma of stomach 1 1

Exploratory celiotomy for carcinoma of stomach 1 1

Pylorectomy for carcinoma of stomach 1

Pyloroplasty, Finney's method 1

Under this heading some interesting cases are reported. One pylo-
roplasty by Finney's method demonstrated the value of this form
of the operation, and the result left nothing to be desired. A case of
exploratory operation followed by death, undoubtedly hastened by
such operation, once more exemplifies the saying of jManges that, so
far from being uniformly innocent, "exploratory laparotomy may
be one of the most dangerous of operations." To be sure, this patient
had an incurable cancer, but there is no doubt that the mere handling
of such tumors through a laparotomy wound is a serious, procedure.

Carcinoma of Esopliayus; Gastrostotny under Local Anesthesia;
Recovery. — ^Nlax R., 65 years old, admitted February 16, 1902. Two
months before admission patient had first experienced pain and diffi-
culty in swallowing solid food. For one month before admission
there was difficulty in swallowing fluids. Patient was much emaci-
ated. An esophageal bougie was arrested 13i^ inches from the teeth.
Gastrostomy under eucaine, 4 per cent. Incision three inches long
along outer border of left rectus. The stomach was drawn into the
wound and sutured to the parietal peritoneum \^dth silk. A tube
was inserted through a small opening into the stomach, and fastened
Avith a purse-string suture. The M'ound Avas packed witli gauze,
making a funnel-shaped inversion of the stomach wall. Before the
patient left the table he received an intravenous infusion of twenty
ounces, and three ounces of milk were injected into the stomach. Con-
valescence was uninterrupted. Patient got out of bed on the fifth
day; he left the hospital, much improved, on INIarch 12.

Carcinoma of Stomach; Anterior Gastroenterostomy ; Death. —
Marcus G., 50 years old, admitted March 24, 1902. Patient gave



LILIENTHAL : REPORT OF THE SECOND SURGICAL DIVISION — 1902. 367

the usual history of a pyloric tumor preceded by a history of chronic
gastritis. Patient was transferred from the medical division and
operated upon on April 11 under chloroform. A median incision four
and a half inches long was made partly above and partly below the
umbilicus. The pylorus, the seat of a tumor, was adherent to the
liver. There was considerable infiltration of the posterior wall of
the stomach. An anterior gastroenterostomy was done with a Murphy
button and the line of junction reinforced by two Lembert sutures.
The wound was closed without drainage. Two days after operation
the patient began to vomit a brown, feculent fluid. The temperature
remained normal, but the vomiting continued and the pulse became
more and more feeble until the patient's death one week after opera-
tion. At autopsy a colloid carcinoma was found in the anterior wall
of the stomach. The pylorus did not admit the tip of the little finger.
There was a carcinomatous mesenteric lymph node.