no improvement from antispecific treatment, we must dismiss syphilis
as a causative factor in producing the lesion. "With no tubercular
foci in the lungs or other organs, with the marked improvement from
simple tracheotomy, and from the appearance of the infiltrated tissues
(entirely unlike that of tuberculosis \ the disease cannot be ascribed
to the tubercle bacilli. Its long duration and subsequent improve-
ment would seem to exclude cancer. There remains only to be con-
sidered a chronic congestion and swelling of the laryngeal tissues,
due possibly to some general systemic poisoning, the nature of which
we do not know. The marked improvement resulting from trache-
otomy was a striking feature of the case.
1901, vol. i., page 51. Carcinoma of Lanjux; Laryiigectomy;
During Convalescence Tliromhosis of Transverse Cervical Veins;
Incision and Drainage: Cio-t.â€” AYilliam O'C, 60 years old, referred
to the hospital by Dr. Gleitsman. His previous and family histories
were negative. He never had syphilis or tuberculosis. Six years
iDefore, he had been waylaid by highwaymen who attempted to strangle
him. Five months before his admission he felt a sensation as though
a foreign body was lodged in his throat. He also occasionally felt a
gagging sensation at swallowing. He lost no flesh or strength. Ap-
On admission, November 2(3, 1900, examination revealed a small
tumor in front of the thyroid cartilage, in the median line. This
tumor was movable under the skin and upon the deeper tissues, was
hard and of the size of a pigeon's egg. No glandular enlargements
to be palpated. Laryngoscopy showed the vocal cords injected, left
aryteno-epigiottic fold occupied by two small nodular masses, size
of a pea ; no ulceration visible. No change in epiglottis or base of
tongue. Some huskiness of voice. A piece of the mass over the aryte-
noid fold had been excised by Dr. Gleitsman and reported by him to
be carcinoma. Urine normal. Heart's action good. Temperature
99.6Â°. Diagnosis: Carcinoma of the larynx with metastasis in front
of the thyroid cartilage.
November 30 : Under ChCL anesthesia a complete laryngectomy
was performed. By a longitudinal median incision the trachea was
opened and a cauula inserted. The larynx was then freed ou both
sides well back to the esophagus. The trachea being divided and
sewn into the lower angle of the wound by silk ligatures, the upper
90 MOUNT SINAI HOSPITAL REPORTS.
end of the trachea was drawn upward by a sharp retractor, and thus
the trachea and larynx separated from the esophag'us up to the reflec-
tion of the mucous membrane of the pharynx. The carcinoma was
here found to involve a part of the anterior esophageal wall, and this
had necessarily to be widely excised. The upper attachments of the
larynx were divided between the root of the epiglottis and the su-
perior aperture. The hemorrhage was moderate. The glands on
either side of the larynx were enlarged and hard, and were excised
along with the larynx. The most difficult part of the operation was
the closure of the gap in the esophagus and pharynx. Its upper
limit had retracted very much and was very inaccessible. Three roAVS
of catgut sutures securely closed the pharyugo-esophageal opening.
Closure of the external wound, drainage, and insertion of large
tracheal canula. It was necessary to administer a subcutaneous saline
infusion of 1,500 ccm. at the encl of the operation. Operation lasted
three hours and fifteen minutes, the greater part of which was em-
ployed in closing the gap in the esophagus. Post-operative reaction
good; pulse 92; highest temperature during the first week 101Â°.
Nourishment for the first three days was given by rectum.
December 3 : Swallowed fluids. No leakage from the esophagus.
December 4 : Took all nourishmejit by mouth ; during the day took
51 ounces of fluids.
December 5 : Leakage from the esophagus noticed ; this gave rise
to an ichorous discharge from the drainage openings.
December 7 : Leakage quite abundant, necessitating administration
of nourishment through a catheter passed through the mouth to below
the fistula in the esophagus. The wounds at once became cleaner and
the ichorous discharge ceased.
December 8 : Tracheal anchor sutures removed.
December 13 : Esophageal fistula appears to be closed and nourish-
ment is again commenced by mouth, without the tube. Swallowing
easy. Drainage wounds granulating nicely ; phonates audibly. In-
creasing in weight.
January 4: The patient was to be discharged on this day. In
the afternoon he had a severe chill, and the temperature, which had
been normal for three weeks, rose to 104.4Â°, pulse 128, respiration 28.
On January 7 he had another chill ; meantime the temperature had
fluctuated l>etween 100.4Â° and 104 -|-Â°. On January 9 a deep-seated-
area of induration with edema of the integument was detected, corre-
sponding to the origin of the left sterno-cleido-mastoid muscle. This
was tender, but not painful.
January 12 : Induration more marked. Superficial veins visibly
dilated. Temperature continued' high. No other cause for the tem-
perature and chills.
January 14 : Induration continued marked, with edema supra- and
infraclavicular. It was decided to explore this area of induration.
Under ChCl. anesthesia the inner third of the left clavicle was re-
sected, so as to afford good exposure. The transverse cervical and
GERSTKR : REPORT OF TJIK FIRST SURGICAL DIVISIONâ€” lOOl.
siiprascapnbir veins were found thrombosed. These veins were in-
cised and their chits evacuated. The deep lymphatics accompanying
the veins were infiltrated, dense, and yellowish in color. After evacu-
ation of the thrombi Avithin the veins, free bleeding from the veins
followed. Drainage of the veins and external Avound.
Reaction was again very good. The chills were not repeated. The
temperature ])eeame normal on the day following and remained so.
The external wound was closed by secondary suture a week later.
Uninterrupted convalescence and uradual oain in weight. Discharged
cured February 11, 1901.
Coninieiits. â€” Of especial interest in this case is the septic thrombosis
of the cervical veins six weeks after the operation. Was the cause
thereof a secondary late infection through the lymphatic vessels
accompanying the veins, or was it a direct infection from the drain-
age canals that for two weeks discharged an ichorous pus.' If the
former, it would be expected that the subclavian and jugular veins
would have been infected, for the lymphatic stream enters directly
into these trunks. If the infection came from the drainage openings,
it is difficult to understand why no symptoms were manifested until
several w^eeks after all ichorous discharge had ceased.
After-History. â€” A local relapse speedily followed the operation,
and the patient died suddenly about five months after his discharge.
DISEASES OF THE BREAST. TOTAL, 17 ; DIED, 1.
Acute mastitis; abscess 4 4
" femoral phlebitis 1
" toxic synovitis of knee. . . 1 1
Chronic " " 1 1
Lipoma of breast 1 1
Fibrocystic adenoma 4 4
Tumor in both breasts 1
Carcinoma of breast 1
Recurrent carcinoma of breast 1
Endothelial sarcoma 2 2
Operations on the Breast â€” 16 : 1 Death.
Incision of abscess 6 6
Excision of chronic abscess 1 1
" lipoma 1 1
'â– cystic adenoma 4 4
Amputation for carcinoma 1
Excision of recurrent carcinoma 1
Amputation for sarcoma 2 2
92 MOCNT SINAI HOSPITAL REPORTS.
The acute suppurative diseases of the breast are usually referred
to the out-patient department for incision and drainage. Retro-
mammary abscesses are excellently drained by making a curvilinear
incision at the margin of the breast in its lower quadrant, and then
freeing and raising the breast from its underlying tissues. Be-
sides affording the very best drainage, such an incision has an
additional advantage in that the disfigurement of the breast and the
mutilation of the gland tissues are avoided. A subacute mammary
abscess was completely excised through such an incision. Benign
tumors are by preference removed through a marginal incision.
For malignant neoplasms, the entire breast gland, with the under-
lying pectorals, and the lymphatics and glands of the axilla, are
removed in one piece.
One death after amputation of a very extensive carcinoma of the
breast and glands occurred. The patient, an elderly lady with
myocarditis, never reacted well from the anesthesia. The tempera-
ture commenced to rise at once, with corresponding increase in the
pulse rate, and death ensued from heart failure eighteen hours after
The patients with endothelial sarcoma were 55 and 60 years old
respectively. In one the disease had existed for three years and
had involved the glands in the supraclavicular and axillary spaces
of both sides. In the other the tumor was noticed six months before
admission, and the axillary glands of the same side were involved.
Amputation was performed in both eases. Nothing of their subse-
quent histories is known.
DISEASES OF THE PLEURA AND LUNGS. TOTAL. 6 ; DIED, 2.
Empyema 1 1
Persistent pleural sinus 1 . . 1
Unresolved pneumonia 1 1
Tuberculosis of lungs 1 â– â€¢ 1
Operations on Plenrce and Lungs. Total, 4: Died, 2.
Thoracotomy (rib resection) 1 1
" " " for pyopneumothorax.... 2
Thoracoplasty and Delorme 1 â€¢ â€¢ 1
GERSTER: REPORT OP THE FIRST SURGICAL DIVISION â€” 1901. 93
DISEASES OP THE CHEST WALL. TOTAL, 2; NO DEATHS.
o p g ^
Tuberculosis of the costal cartilages 1 1
Recurrent sarcoma of the serratus magnus 1 1
Operations on the Chest Wall. Total, 2; No Deaths.
Excision of costal cartilages for tuberculosis 1 1
" " recurrent sarcoma of serratus magnus. ... 1 1
The Deloriiie operation has been employed in several cases. Our
experience with it has not been entirely satisfactory. It is an
ideal operation for those cases in which the pyogenic membrane is
confined to the lower limits of the plenral cavity. "Where it extends
to the apex of the hmg, and has become intimately adherent to the
large venous structures at the base of the heart, its separation is very
difficult and attended with considerable risk. Especially difficult
is the removal of the pyogenic wall from the apex of the lung, as free
access to it can only be obtained by mobilization of the first rib.
In one of our cases, a very extensive pleural abscess cavity, the
Delorme operation failed to effect a closure. A subsequent com-
bination of the Delorme and Estla.nder operations speedily brought
about a perfect cure.
1901, vol. iv., page 305. Pelvic Abscess; P\jopneumotliorax ;
Thromhosis of Inferior Cava: Pulmonary Embolus: Thoracotomy;
Resection of Bib; DeatJi. â€” The patient, F. G., a houseAvife, 30 years
old, had been admitted to the gynecological service -January 8, 1901,
for pelvic abscess. On February 27 she was transferred to the medi-
cal service. At that time there Avere physical signs of fluid and air
in the left pleural cavity; temperature 102.8Â°.
March 4 : Aspiration yielded turbid serum and gas.
March 9: Thoracotomy; resection of rib. Evacuation of large
amount of pus and fibrin and gas.
IMarch 10: Continued high temperatures, up to 104Â°. Profuse
mucopurulent discharge from wound. No tubercle bacilli in sputum.
March 31 : Suddenly, while sitting up in bed, fell back collapsed
Postmortem. â€” Lungs: Emphysematous. Left lung compressed
against the spine: almost earnified ; covered with thick fibrin. INIod-
erate amount of pus in plenral cavity.
Heart and vessels: Pericarditis externa; parenchymatous myocar-
ditis. Thrombus in pulmonary artery and its main branches.
MOUNT SINAI HOSPITAL REPORTS.
Thrombus rolled up, and in main part decolorized and firm. At its
end there was a red thrombus (recent) not adherent. In vena cava,
extending almost to diaphragm, a large, firm, decolorized, adherent
thrombus : upper end larger and rounded. Thrombus extends into
left common iliac vein and left internal iliac, down to site of pelvic
Spleen: Enlarged; capsule adherent; diffuse amyloid degeneration.
Kidneys: Slight evidences of interstitial nephritis. Ureter double
on left side.
Liver: Nutmeg, large.
Adnexa: Large pus sac to left of uterus, containing inspissated pus.
Bacteriological exami)iation of thro)nhus: Streptococci, small and
DISEASES OF THE STOMACH. TOTAL, 18; DEATHS, 6.
Carcinoma of esophagus and cardiac end of
Carcinoma of stomacli 5
" " cardiac end of stomach 1
" " pylorus 5
Tumor (benign) of pylorus 1
Ulcer of stomach; acute anemia 1
" " " and perigastritis 1
Acute dilatation of stomach 1
Operations on the Stomach. Total, 14; Deaths, 5.
Gastrostomy ( Kader ) 2
Jejunostomy ( Witzel ) 2
Laparotomy and cauterization of gastric ulcer 1
Gastroenterostomy (anterior-antecolic) 2
" (posterior-retrocolic) 5
Gastrotomy, secondary, for removal of Murphy button 1
Exploratory laparotomy for carcinoma of stomach 1
CARCINOMA OF ESOPHAGUS AND OF CARDIAC END OF STOMACH. TOTAL, 2;
Both cases were operated upon by establishing a gastric fistula by
Kader 's methodâ€” a method which has in the past given us very satis-
factory results. Leakage did not occur after the removal of the tube.
^Operative treatment of carcinoma of the esophagus is at the present time
only a palliative one (gastrostomy). The consideration of these cases is
therefore included in this place.
GERSTEK: REPORT OF THE FIRST .SLIKGICAL DIVISION â€” litOl. 95
In one of these cases death folhjwcd the operation, its cause being ex-
treme debility and cachexia.
1901, vol. iii., page 140. Carcinoma of the EsopJiagus; Carcinoma
of the Cardiac End and of the Lesser Curvature of the Stomach;
Operation (Gastrostomy, Kader) ; Deatli. â€”hoius ]\I., 59 years of age,
was transferred from the medical service to the surgical division
January 5. There has been marked difficulty in swallowing since
a year and a half; the difficulty increased to such an extent during
the last four months that even liquids could not be readily swallowed,
most of them being regurgitated within fifteen minutes. Loss of
weight amounted to over fifty pounds.
Operation January 6. Gastrostomy l)y Kader 's method, preceded
by an intravenous saline infusion. Patient did not rallv after the
operation, and died, in spite of vigorous stimulation, the same day.
CARCINOMxV OF STOMACH AND PYLORUS. AND BENIGN TUMOR OF PYLORUS.
TOTAL. 10^ ; DEATHS, '-i.
As the operative treatment of these conditions is nearly identical, it
seems pro])er to group them all together. Of the eleven cases enu-
merated above, one case (1901, vol. i., page 25) declined operation; on
one case (1901, vol. iii., page 149) exploratory laparotomy only was
done, the tumor l)eing too extensive for extirpation, and there being, in
the absence of stenosis, no indication present f(n' anastomosis. Gastro-
enterostomy was performed seven times, five times posterior-retrocolic,
twice anterior-antecolic. Twice the growth was so extensive, and the
stomach so firmly fixed, that nothing remained to l)e done but jeju-
In all cases of gastroenterostomy the ^Murphy button was employed.
The method chosen was that originally described by ^Murphy. The re-
sults were not entirely satisfactory, inasmuch as the button failed to
pass in a number of cases. This must be attributed to these factors;
uneven pressure exercised by a defectively made flange of the button,
or uneven pressure caused by the irregular puckering of the stomach
wall included in IMurphy's purse-string sutui'(\ oi-, finally, to a com-
bination of both of these factors. But in no case did leakage occur.
That this defect of the button is not imaginary will be shown by the
f olloAving case :
1901, vol. iii., page 150. Carcinoma of Pylorus; Posterior-Retro-
â– colic Gastroenterostomy : Retoition of Button, causing symptoms
'One case entered the hospital twice.
96 MOUNT SINAI HOSPITAL REPORTS.
of Obstruction; Secondary Gastrotomij ; Eemoval of Button; Re-
covery. â€” Julius E., 56 years of age, was transferred from the medical
to the surgical service July 26. Past history was characteristic of
pyloric stenosis; the symptoms, physical signs, and the result of the
examination of the contents of the stomach being those of pj^loric
Operation on July 26 under local anesthesia, consisting of posterior-
retrocolic gastroenterostomy by means of Murphy's button. Things
went well for nine days, patient taking considerable nourishment.
The Avound healed by primary union. On the ninth day the sutures
were removed. The following night, during an attack of coughing, the
entire wound burst open and was resutured. On the morning of the
thirteenth day, though the feeding had been careful, patient began to
vomit persistently. The usual eft'orts to control the stomach were inef-
fectual. Toward evening patient collapsed, his expression being anx-
ious, the pulse wretched. He was removed to the operating room,
where, under eucaine anesthesia, the scar was reopened and the in-
cision extended downward to permit thorough and rapid explora-
tion. The small intestine was empty, and the button could be felt
where it had been placed at the time of the first operation. The
anterior wall of the stomach Avas incised; the button was freed from
the site of the anastomosis and was removed. The aperture of the
button Avas found to be clogged with partly digested food. Suture
of the gastric incision, folloAved by .suture of the external Avound,
terminated the operation.
The vomiting ceased at once.
The wound healed by primary union, and patient A\-as discharged
improA^ed September 1.
Note. â€” In February. 11)02, the patient Avas presented in an excellent
condition to the Surgical Section of the Xcaa- York Academy of ^Medi-
cine.^ He had gained seventy-fiA'e pounds in AA'eight.
In addition to the case just reported there AA-ere others in AA'hich the
button failed to pass. There Avas another case of obstruction caused
by a retained button AA-hich had to be removed by gastrotomy.
This patient, hoAveA'er, remaining under treatment beyond the time
embraced in this report, the history Avill have to appear in next year's
Of the 11 (respectively 10) cases of malignant disease of the
stomach, three ended lethally. A short extract of their histories is
1901, A^ol. iii., page 144. Extensive Carcinoma of Stomach with
Fixation of the Organ; Jejunostomy; Death. â€” Celia G., 56 years of
age, Avas admitted to the hospital January 15. For five months
IN. Y. Medical Record, March, 1902.
GERSTER: REPORT OF THE FIRST SURGICAL DIVISION â€” 1901. 97
symptoms of pyloi'ic obstrnction were extant. On examination a
large, hard, nodular tumor was found in the epigastrium. Patient
was extremely emaciated and cachectic.
Operation January 16. A carcinoma, was found, involving the
entire stomach and omentum, and forming a very large and im-
movable mass which occupied the space behind and below the liver.
Gastroenterostomy was impossible, and je.junostomy by AYitzel'v^
method was done.
Patient died six days later of exhaustion.
1901, vol. iii., page 1-17. Carcinoma of SfoinacJi ; Operation (An-
terior-Antecolic Gastroenterostomy) ; Death. â€” Wolf W., 50 years of
age, was admitted to the hospital September 18 with the following
history: Patient complained for four months of pain and a drag-
ging sensation in the region of the stomach, accompanied by a loss
of flesh and strength. On examination there was found in the
region of the epigastrium a mass, the size of two fists, very movable,
and changing its position freely with the position of the patient.
As there were no sjmiptoms of pyloric stenosis, gastroenterostomy
was not indicated. On account of the mobility of the tumor, its
extirpation Avas suggested to the patient, but was declined. Patient
was discharged unimproved.
He was readmitted November 5. During this time the gastric
symptoms became so pronounced that patient desired an operation.
While his general state was not much worse, the local condition
changed in so far that the previously movable tumor had become
Operation November 8, 1901, under chloroform. On opening the
abdomen an enormous tumor was found, involving the entire circum-
ference of the pylorus, about half of the anterior wall, two-thirds
of the jH)sterior wall, and contiguous portions of the greater and
lesser curvatures of the stomach. The operation consisted of an
anterior-antecolic gastroenterostomy by means of a Murphy button.
In the beginning everything went well. Primary union of the
abdominal wound. One week after the operation patient began to
fail, and died on the same day.
A limited autopsy revealed a faultless condition of the anastomosis,
button still in place.
1901, vol. iii., page 148. Carcinoma of Pylorus: Operation (Pos-
terior-Effrocolic Gastroenterostomy ) : Recovery: Reaclmission : Jeju-
nostomy : Death. â€” Julius B. was admitted to the medical service of
the hospital July 18 with the following history: Patient Avas com-
plaining for two months of pain in the epiga.strium after eating,
followed by vomiting two or three hours later. Considerable loss
of flesh and strength. On examination there was found a slight
tenderness in the region of the pyhn-us, but no distinct tumor could
be felt. Examination of the stomach contents after a test meal
98 MOUNT SINAI HOSPITAL REPORTS.
showed only a trace of hydrochloric acid. The vomited matter re-
sembled coffee-gTonnd material, and its examination demonstrated
the presence of hemiu crystals.
He Avas transferred to the surgical service and operated upon on
July 29. On opening the abdomen the pylorus was found to be
occupied by a hard, nodular tumor about the size of a lemon. It
was freely movable, but its extirpation was contraindicated by the
presence of extensive glandular infiltration. Posterior-retrocolic
gastroenterostomy was done. With the exception of a short post-
operative delirium lasting twenty-four hours, the course of healing
was uneventful. Primary union of the wound. Patient was dis-
charged August 19, the button not having passed. A radiographic
examination demonstrated the button one inch to the left and on a
level with the umbilicus.
Patient was readmitted Oetolier 1. Ever since his discharge patient
complained of pain and oppression felt in the epigastrium. During
the last few days vomiting has set in again. Patient was kept under
observation for ten days. In spite of a very cautious feeding the
vomiting persisted, with very rapid loss of flesh and strength.
Operation on October 11. On opening the abdomen the whole
stomach, with the exception of a small portion near the cardiac end,
was found to be infiltrated by a ma.ssive new growth. The con-
tiguous portions of the jejunum also had numerous small metastatic
deposits. The site of the former gastroenterostomy was carefully
explored, and found to be surrounded by new growth, within which
sat the button. As the uninvolved portion of the stomach was not
available for a second gastroenterostomy, jejunostomy was done by
The operation was well borne. Very soon, however, the patient
became apathetic, and, grooving weaker and weaker, died four days
after the operation.
ULCER OF THE STOMACH. TOTAL, 2 ; DEATH. 1.
Of the two cases of ulcer of the stomach, only one demanded ope-
rative interference, this becoming necessary on account of copious and
uncontrollable bloody vomiting. Though the resulting anemia was
very grave, as a last resort, operation was decided upon. Patient sur-
vived the operation only about twelve hours. Following is a brief ex-
tract from the history of the case :
1901, vol. iii., page 142. Gastric Ulcer; Hemat erne sis: Profound-
Anemia; Gastrotomy ; Cauterization of Gastric Ulcer, and Gastro-
enterostomy (Anterior-Antecolic); Death. â€” Fannie S., 18 years of
age, was admitted July 25 to the medical division of the hospital.
Present illness began two weeks prior to admission with severe pains
in the epigastrium, recurring every two or three hours, each parox-
GERSTER : REPORT OF THE FIRST SURGICAL DIVISION â€” 1901. 9!>
ysni lasting about half an hour. Up to three days before admis-
sion there was no vomiting. Then she vomited a large quantity
of bright-red blood (, according to her statement, about one quart).
The bloody vomiting recurred the following day: stools tarry. Ou
fidmission a blood count showed .'3,-199,000 red blood cells, 12,000