The time of operation was twenty minutes. The wound healed by
primary union. The patient got out of bed on the twelfth day and
left the hospital fifteen days after operation.
Ferity phlitic Ahscess; Celiotomy: I)cafJi.—i>\mon IT., 4 years old,
admitted June 27, 1902. Ten days before admission the child had
begun to vomit and the vomiting continued. The bowels could not
be made to move. The abdomen graduall.y became distended. On
admission the abdomen was markedly distended and tympanitic. No
mass could be felt. By rectmn a mass could be felt high up in the
pelvis. On June 27 the abdomen was opened by a median in-
cision. A loop of distended small intestines was punctured wath
the needle. An abscess in the region of the cecum was then opened.
Drainage of abscess cavity and partial closure of wound. Shortly after
the operation there developed signs of general peritonitis, which
caused the patient's death in twenty-foiu- hours.
376 MOUNT SINAI HOSPITAL REPORTS.
Appendicitis; Pyosalpinx; Intraligamenious Cyst; Appendicec-
tomy ; Eimclcation of Cyst; Salpingo-oopJiorectomy ; Cure. — Malvine
R., 45 years old, admitted December 2, 1901. Patient had had one
child twenty years before admission. There had been frequent at-
tacks of pelvic pain, and during the few months prior to admission
there had been several attacks of pain in the right iliac fossa. Four
days before admission the patient had been seized with severe pain
in the lower part of the abdomen ; she had vomited several times. The
bowels had not moved since the beginning of the attack. There was
rigidity over the lower half of the right rectus, and a very tender spot
just above Poupart's ligament on the right side, where, on deep pres-
sure, a mass could be indistinctly felt. By vagina a boggy mass could
be felt to the right of the uterus. Temperature 102.8°, pulse 135.
Diagnosis: Pyosalpinx and appendicitis. The abdomen was opened
through the rectus incision. Adherent omentum presented. A cyst
in the broad ligament, the size of a lemon, was found and enucleated.
The right tube was filled with pus and was likewise removed. The
appendix was found behind the cecum, embedded in a mass of ad-
hesions; it was also removed. A cigarette drain was led down to the
stump of the tube and the wound sutured. Recovery was uneventful,
and the patient was transferred to her home nine days after operation.
INTESTINAL OPERATIONS. TOTAL, 27 ; 19 DEATHS.
Totals. Deaths.
Appendicostomy, colostomy, and ileosigmoidostomy for ulcer-
ative colitis 1 1
Colostomy for ulcerative colitis 1 i
" " cancer of rectum 2 1
" " imperforate anus 1 1
Celiotomy for volvulus 2 2
" " tumor of cecum 1 l
" " " " colon 1 1
" and resection of tumor of colon 1 1
" " " " " " sigmoid flexure 1 1
for intussusception â– . . 5 4
" " papillomatous proctitis 1
" " typhoid perforation 4 3
" " tumor of small intestine 1
" and resection for acute intestinal obstruction 1 1
" for acute intestinal obstruction 1 1
" " fecal fistula 2
Colocolostomy for carcinoma of colon and stomach 1
Appendicostomy (Weir) was performed in one case of ulcerative
colitis. The operation failed to afford rest to the bowel, so colostomy
had to be done. While the apparently large mortality in the intestinal
operations is to be deplored, it was unavoidable from the veiy nature
of the cases, as will be seen by the following reports.
Four cases of perforation in typhoid were operated upon, with
only one recovery. Wliile it seems incontrovertible that this compli-
LIIJENTHAL: REPORT OF THE SECOND SURGICAL DIVISION — 1902. ."^TT
cation is a distinctly surgical one, the results must depend upon the
shortness of the period between perforation and operation and also
on the general condition of the patient.
Ulcerative Colitis; Colostomy; Death. — Solomon L., 49 years old,
admitted July 7, 1902. There had been bleeding from the rectum
for ten years, which for two years prior to admission had been pro-
fuse. During the five months prior to operation the bleeding had
been almost continuous. There had been a loss in weight of forty
pounds in a year. The stools were examined for tubercle bacilli and
for amebce, Avith negative results. Operation on July 12. A longi-
tudinal incision was made in the left lumbar region. The colon was
found much thickened. A right-sided colostomy was then done and
the appendix removed. Sections through the appendix showed glan-
dular hyperplasia. The bowels were irrigated daily with nitrate of
silver solution. There were five to seven stools a day, with blood
and mucus. The temperature rose daily to 101° or 102° F. On
August 24 the patient became comatose and had a general convulsion
lasting five minutes. Two hours later there was a similar convulsion.
On September 6 the patient complained of severe pain in the right
chest and had bloody sputum ; this was taken to be due to an embolus
in the lung. Thereafter there was profuse purulent expectoration,
vnth signs of an abscess in the right lung. The patient lost steadily
and died on October 4. At the autopsy the left upper lobe was
found consolidated. In the right upper lobe there was an abscess
9 cm. in diameter. The entire colon was the seat of a severe colitis
with polypoid formations, with abscesses and with undermined ulcers.
There were thrombi in the portal and mesenteric veins.
Chronic Ulcerative Colitis; Appendicostomy : Colostomy; Ileosig-
moidostomy ; Left Colostomy; Death. — Mollie F., 26 years old, ad-
mitted January 28, 1902. Patient had been married two years, had
had two children and no abortions. Two years before admission the
patient had begun to have frequent stools containing blood and mucus.
There had been some abdominal pain. A few dilated hemorrhoidal
vessels were cauterized with the Paquelin. In spite of this the stools
continued to contain blood. On February 22 an incision was made
through the right rectus. The tip of the appendix was cut off and
a catheter about 20 F. was passed into the bowel through the lumen
of the organ and left in place; cecum sewn into wound and Avound
packed. The colon was flushed out daily with 1 :5000 silver nitrate
solution. The frequent bloody stools continued as before. On INIarch
15 an exploratory celiotomy was done on the left side. Numerous
small glands were found in the mesosigmoid. One of these was re-
moved for examination. The right colostomy wound was then en-
larged and the caput coli draAvn into the Avound. A glass rod was
placed under the caput coli through its mesentery. Gauze packings
378 MOUNT SINAI HOSPITAL REPORTS.
were inserted and the wound left open. On March 17 the tempera-
ture was 103.4° and the pulse 112. The left wound had become
infected. The extruded portion of the colon was incised with the
Paquelin and a piece removed for examination. The colon was washed
out daily with warm water: a rectal tube was introduced for the
washings and the water allowed to run through until it came away
clear. In spite of the fact that all fecal dejections passed at the
colostomy wound, blood and mucus continued to be passed per
rectum and the general condition continued to get worse. The
temperature was continually elevated. During April for a short
time no blood was passed per rectum. But soon blood and mucus
were again passed per rectum. On May 10 the colon was excluded
by an ileosigmoidostomy. A median incision was made below the
umbilicus. A loop of ileum about five inches from the cecum was
isolated and severed. Both ends were clamped. The same Avas done
with the sigmoid. The proximal end of the small intestine was then
sutured to the distal end of the large intestine. On account of the
difference in size of the two loops, a longitudinal slit was made in
the small intestine. Interrupted sutures of heavy silk were used,
the knot being on the inner side of the gut. The suture line was
reinforced with Lembert sutures. The extruded portion of the colon
at the site of the previous colostomy wound was cut away. The
median abdominal incision was closed with sutures. From May 17
to ^Fay 29 there were daily irregular rises in temperature, at times
above 104° F. There were frequent watery movements, which were
somewhat controlled by opium. During this time there was no blood
in the stools. ^lay 27, general condition poor; frequent defecations
continue; discharge from colon is getting less; methylene blue irriga-
tions three times a day. On May 29 a left-sided colostomy was done.
An incision was made in the line of the former wound on the left
side. The transverse colon was brought into the wound and was sur-
rounded with packings. A silk purse-string suture was inserted, the
bowel incised, and a tube introduced and tied in place. Irrigation of
the bowel was continued daily. At times considerable mucus was
washed away. On June 7 there was dulness with bronchial voice
and breathing over the entire lower lobe of the right lung. No
tubercle bacilli were found in the sputum, but almost- pure culture
of the diplococcus. The temperature rose to 104.6° and the pulse
to 136. The consolidation of the lung remained unchanged, the tem-
perature remained high, and the pulse became more and more feeble,
until death took place on June 20. No autopsy.
Carcinoma of Rectum and Peritovenm : Colostomy ; Death. — Ben-
jamin R., 30 years old, admitted May 22, 1902. For five months prior
to admission patient had had attacks of pain in the left side of the
abdomen, with blood and mucus in the stools. There had been alter-
nating constipation and diarrhea, and a loss in weight of twenty
pounds. A large, nodular mass Avas felt in the rectum. On May 23
LTLIENTHAL : REPORT OF THE SECOND SURGICAL DIVISION — 1902. 379
a, right rectus incision was made. There was free fluid present.
Numerous tumors were found, some in the omentum and one large
one on the left side from which a piece was removed for examination.
The diagnosis was adenocarcinoma. As there were signs of perito-
nitis with distension an enterostomy was done, but the patient died on
the next day. The autopsy showed primary adenocarcinoma of the
rectum with metastases in the general peritoneal cavity.
€(!)■(■! noma of dAon and StoDuich; Colocolostoiny : Death. — Abra-
ham W., 68 years old, admitted April 8, 1902. During the four
months prior to admission patient had suffered from anorexia, con-
stipation, and epigastric oppression. Four days before admission
there was an attack of severe abdominal pain. Patient had lost
twenty-five pounds in four months. The alxlomen was distended,
tymppnitic, and increased peristalsis was visible over the lower por-
tion. There was a large, tender mass in the left hypochondrium and
epigastrium. Operation on April 11, 1902. The abdomen was opened
in the median line. There was some bloody fluid in the peritoneal
cavity. The tumor was found to involve the splenic flexure and the
stomach. An anastomosis was made with a Murphy button between
the transverse and the descending colon. The ascending colon had
so short a mesocolon that it could not be used for an anastomosis.
All attempts to move the bowels after opei-ation were unsuccessful
and death took place six days after operation. At autopsy a tumor
of the size of a fist was found in the greater curvature of the stomach.
The microscope showed it to be a carcinoma.
Carcinoma of Hepatic Flexure; Eesection: Death. — Annie (4., 31
years old. admitted November 16, 1902. Patient had had nausea, epi-
gastric pain, and constipation during four months prior to admission.
There was a nodular mass on the right side of the abdomen below the
free border of the ribs. IMaunsell resection of the tumor was done on
November 30 through a median incision. Gauze drains were led down
to the suture line. Many enlarged glands were felt near the tumor.
Death took place suddenly forty-eight hours after operation, ap-
parently from heart failure. There were no signs of peritonitis.
Carcinoma of Descending Ceiloii : Myocarditi.^; Resection of Colon:
Death. — INIeyer L., 45 years old, admitted January 7. 1902. Two
weeks before admission there had been an attack of abdominal pain,
which later became localized to the left iliac fossa. There had been
neither constipation nor vomiting. In the left iliac fossa there was
a tender tumor of the size of an apple. The tumor was not movable
and could not be felt by rectum. On Januai-y 7 the abdomen was
opened by a left rectus incision. The tumoi- Avas found adherent
to the pelvic wall. In se])nrating adhesions a few drops of pus were
found. The tumor was in the wall of the sigmoid. Adherent omen-
tum was removed and the gut resected. Silk sutures knotted in the
380 MOUNT SINAI HOSPITAL REPORTS.
interior of the gut Avere used for the anastomosis, reinforced by a
running Lembert suture. The line of suture was drained with strips
of gauze. Following the operation the abdomen became distended,
the pulse rapid, 138, and the bowels could not be made to move.
On January 9 it was decided to open the cecum. A four-inch in-
cision was made in the right iliac fossa, the cecum drawn into the
wound, and packings placed around it. A tube was inserted into
the cecum and held in place with two purse-string sutures. The
intestines were found injected and distended. The patient died a
few houi's later. No autopsy.
InfldtHHuiforij Tumor of Cecum: ('cUotomn : Death. — Morris G., 55
years old, admitted October 24, 1902. Twelve days before admission
the man had had an attack of pain in the right iliac region ; there Avas
nausea but no vomiting. In the right iliac fovssa there was a freely
moA'able tumor of the size of a lemon. On October 25 a rectus in-
cision Avas made over the tumor. The tumor Avas found to be \'ery
hard and surrounded the cecum. The appendix coukl not be found.
In trying to libei-ate the boAvel it Avas torn and the opening closed
Avith silk sutures. ScA'eral pieces Avere removed for examination,
and the abdomen closed Anth drainage. The pathologist reported
chronic inflannnation. The patient became septic and died four days
after operation. Wound autopsy shoAved a large, inflammatory exu-
date behind the cecum and on either side of it. There Avas a deep
ulcer inside of the cecum.
Tumor of Descending Colon: Iniestinul ()hsirucfio)i : Exploratory
Celiotomy: Death. — Sadie CI., 32 years old, admitted June 27, 1902.
There had been a sudden onset four days before admission Avith se\'er^
general abdominal pain and vomiting. The vomiting persisted, but
the bowels moA^ed after enemata. Temperature 102°, pulse 112. The
abdomen Avas somcAvhat distended, but it Avas lax, except during a
spasm of pain, AA^hen it became rigid. ^Median celiotomy on June 29.
There Avas some free fluid. The intestines Avere injected and dis-
tended. A firm tumor of the descending colon Avas found. The
patient coljapsed and the Avound had to be closed. Following the
operation there Avas fecal vomiting, and death took place in a few
hours. At autopsy a small constricting carcinoma Avas found in the
upper part of the descending colon.
Intra-ahdominal Abscess: Incision; Tumor of Small Intestine:
Fesection: Closure of Fecal Fistula: Cure. — AVilliam K., 29 years old,
admitted INIarch 1, 1902. Tavo Aveeks before admission the man had
been seized Avith general abdominal pain, Avhich, tAvo days later, had
become localized in the right iliac fossa. The boAvels had moA^ed
with cathartics. A large, tender, ovoid mass was felt on the right
side of the abdomen. An incision was made over the tumor and
several ounces of pus evacuated. The cavity Avas to the inner side
IJLIENTHAL: REPORT OP THE SECOND SURGICAL DIVISION — 1902. 381
of the colon and was well walled ofit'. Two tubes were introduced
for drainage. On March 11 a capsule of methylene blue was given
and twelve hours later the secretion of the wound was colored blue.
The discharge persisted, and the patient left the hospital on May 16
with a discharging sinus. He was told to return, which he did on
June 7, 1902. On June 14 an incision was made encircling the sinus.
On opening the abdomen a tumor of the small intestine was found.
The sinus led through the tumor into the gut. The tumor was in
the ileum about twelve inches from the cecum. Three inches of the
ileum were resected, silk sutures being used through-and-through,
reinforced by Lembert sutures. A drain was introduced down to
the suture line and the wound closed. The sutures became infected
and there was no union of the abdominal wound. Six days after
operation there was a profuse discharge of fecal matter from the
wound. Later on a second smaller fecal fistula developed. The fecal
discharge continued until August 14, when it was clecided to clos-'
the fistula?. The wound was curetted, the fistulfe packed with gauze
and roughly closed with sutures. Under Schleich's local anesthesia the
fistula? were dissected down to the peritoneal cavity. Adherent omen-
tum was tied off and removed. The general cavity was well walled
off' with gauze. The two ends of the affected loop of gut were caught
with intestinal clamps. The fistuln? were reopened, the edges fresh-
ened, and the openings closed with silk sutures. A drain was intro-
duced to the suture line and the wound closed. The patient stood
the operation well and experienced little pain. From August 21 to
August 26 there was a fecal discharge from the wound. Thereafter
the wound healed rapidly, and the man left the hospital with the
wound healed on September 16. The tumor proved to be a spindle -
celled sarcoma.
Acute Intussusception ; Celiotomy: Beduction: Cure. — Dora L., 3
years old, admitted December 5. Five days before admission the
child had been seized with severe abdominal pain, with vomiting
and passage of blood and mucus per rectum. The abdominal dis-
tension became progressively worse. The apex of the intussusception
could he felt per rectum. On December 5 the abdomen was opened
by a median incision below the umbilicus. There was some free
bloody fluid. The intussusception, eight inches long, was relieved
by traction and expression. It was found to be entirely colic in
type. The abdomen was filled with saline solution and the wound
closed. Six days after operation the child developed a broncho-
pneumonia. This soon cleared up and the child was able to leave
the hospital cured on December 30.
Acutf Ileocecal Intussuscei)fion: Celiotomy: 1\ eduction; Death. —
Abraham B., 5 months old, admitted April 20. 1902. During the
two days prior to admission the child had had blood and mucus in
the stools. During this time no fecal matter had passed. Rectal
382 MOUNT SINAI HOSPITAL REPORTS.
examination showed a tumor high up on the left side of the abdomen.
Temperature 104°, pulse 146, respiration 40. On opening the abdo-
men through a median incision an ileocolic intussusception was found.
It was readily reduced and the abdomen was closed. Death took place
in twelve hours. No autopsy.
Gangrenous Intussusception : Resection; Death. — Paul A., 9 months
old, admitted July 1, 1902. Four days before admission the child
had passed blood and mucus per rectum. The abdomen had become
distended and the bowels could not be made to move. The abdomen
was distended and rigid. By rectum a soft mass could be felt pro-
truding into tlie lumen of the bowel. A median abdominal incision
was made. The intussusception was found to be ileocecal and could
not be reduced. Eesection was done by end-to-end silk sutures. The
abdomen was closed. The resected loop of gut w^as gangrenous. The
child went into collapse and died four hours later. No autopsy.
Acute Ileocecal Intussusception; Resection; Death. — Solomon L.,
5 months old, admitted January 23, 1902. This case was almost
identical with the preceding one. The anastomosis was made with
a Murphy button and death took place nine hours after operation. At
the autopsy a small amount of bloody fluid was found in the right
side of the abdomen. There was no leakage at the site of the button.
Volvulus of Sigmoid and Descending Colon ; Celiotomy; Reduction;
Death.— ld£i K., 40 years old, admitted May 11, 1902. Sudden onset,
two days before admission, with pain in right iliac fossa and vomiting.
Constipation was absolute from the onset, and vomiting was repeated.
The abdomen was tympanitic and much distended. Median celiotomy
showed a volvulus of the sigmoid and ascending colon. The disten-
sion was relieved by three punctures, the openings being closed by
sutures. A rectal tube was then inserted and a large amount of fluid
feces and gas came away. It was then easy to untwist the volvulus.
All the obstructive symptoms Avere relieved by the operation, but the
patient died twenty- four hours later. No autopsy.
Volvulus of Sigmoid Flexure; Celiotomy; Reduction; Death. — Rose
J., 45 years old, admitted October 12, 1902. This case was almost
identical with the pi'eceding one and the patient died eighteen hours
after operation. No autopsy.
Imperforate Anus; Colostomy; Death. — Infant D., two days old,
admitted July 11, 1902. The child had vomited since birth and had
passed neither gas nor feces. The abdomen was distended and tympa-
nitic. On inserting the finger into the anus an absolute obstruction
was met with. Median celiotomy and opening of a loop of distended
large intestine. Meconium escaped and a tube was inserted into the
boAvel. Death took place thirty hours after operation. Autopsy
LILIENTHAL : REPORT OF TIJE SECOND SURGICAL DIVISION 1902. 383
showed a septum, one-eighth of an inch thick, about a half-inch from
the anus, by means of which the continuity of the bowel was inter-
rupted. There was no peritonitis. In the heart an open foramen
was found.
Acute Intestinal Obstruction; Resection and Anastomosis ; Death. —
Sarah D., 14 years old, admitted August 17, 1902. Three days before
admission patient had been seized with cramps in the upper part of
the abdomen, with repeated vomiting. The bowels had moved after
an enema. The abdomen was much distended, with dulness in the
flanks. Temperature 101.6°, pulse 150, respiration 24. Patient had
not passed urine for twelve hours and only one ounce was found in
the bladder. Operation was deferred on account of the bad general
condition. The condition did not improve and operation was under-
taken on August 19. A right rectus incision was made and consider-
able bloody fluid evacuated. Two knuckles of small intestine were
found compressed by a band extending from the abdominal wall to
the mesentery. On relieving the constriction one knuckle of gut was
found severelj^ injured, with a perforation at the site of constriction.
Resection of the gut Avas done with the aid of the Murphy button,
f!nd a drain led down to the suture line. The patient collapsed at
the end of the operation and died nine hours later. No autopsy.
Acute Intestinal Obstruction; Celiotomy; Death. — Mollie P.. 24
years old, admitted September 14, 1902. The patient had been
operated on in May, 1902, for an ovarian cyst, and had made an un-
eventful recovery. Four days before admission she had been sud-
denly seized with pain in the epigastrium, nausea, and vomiting.
During these four days neither stool nor gas had been passed. Vomit-
ing had continued. The abdomen was not distended and no mass was
present. Subcutaneous saline injections were given to increase the
amount of urine. On September 16 the abdomen was opened in the
median line. The intestines were matted together and injected ; the
upper coils of small intestine were distended. About three feet of
the ileum and the entire large intestine were collapsed. The collapsed
coils of small intestine were adherent throughout their entire extent
to one another. The adhesions were separated as much as possible.
The poor condition of the patient prevented further procedure. An
intravenous infusion was given on the operating table. On the fol-
lowing day vomiting persisted. A loop of intestine Avas drawn into
the wound, opened, and a tul)e inserted. Death took place a few
hours later. No autopsy.
TypJwid Perforation ; Purulent Peritonitis; Suture of Perforation:
Death.— Aavon Z., 23 years old, admitted August 13, 1902. On the
fifth day after admission to the medical division for typhoid fever
a perforation of the intestine was diagnosed and the case referred to
the surgical side. Operation was performed about thirty hours after
384 MOUNT SINAI HOSPITAL REPORTS.
the perforation had taken place. A median incision was made below
the umbilicns. There was a purulent peritonitis. A perforation was
found in the ileum, covered with fibrin. The opening in the gut