Medical Society of the State of North Carolina. An.

Transactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) online

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believed that I would have, and the reason I don't believe I would have
was just because of this one thing : when I used to operate on these cases
presenting a similar picture every one of them died, and this fellow lives.
And for that reason I believe it a better plan. I thank Dr. Payne for
even condescending to discuss my paper.

Dr. Lott speaks of the vomiting as due to the nerve reflexes. While
it is true that the reflex influence will produce pain and some vomiting,
yet I have never seen a case of appendicitis but what vomited something;
it was mucus, or it was foodstuff, or it was regurgitated intestinal sub-
stance ; and I have never washed a stomach but what I always got some-
thing back if my patient was vomiting incessantly. For the reason that
I get something back, I believe then that the stomach should be washed.
As to the normal salt solution, I don't believe it is wise to wash the
abdomen or to wash the cavity by pouring salt solution into the cavity,
because you distribute your infection and you doubtless force it into other
fields where it would not get. Those of you who have tried to pour a
dog's belly full of water and then turn that dog on its back and put a
wick down in the dog's belly and try to drain that fluid out, are sur-
prised to see that, if you will make another incision, the water has gotten
in there, and you have another pocket of fluid that has not been drained.



148 2^0RTH CAROLINA MEDICAL SOCIETY,

Dr. Graham's idea is speaking the truth as I see it better by far than
I could speak it myself, and I thank him very much for his remarks.

Dr. Lawrence, always in removing the appendix I think of it like this :
After I get in the abdomen it is rather like scrapping a fellow ; if I see
he is a big fellow and I think he is going to lick me, I don't scrap him ;
but if I think that I can get around him and head him off, and I don't
raise excitement sufficient to bring up his allies, then I will attack him.
If it presents itself in the field, and is not hard to remove, and not hard
to obtain, I think it is well to always remove it. In this connection I
wish to say that a number of cases (or just a few cases) have come to
me for a secondary operation, cases that had been drained, and they had
drained, but they wanted to have the appendix removed. Frequently we
will make the operation and find that that appendix had been beautifully
operated on by nature. Through the process of sloughing gangrenous
appendix had been removed through the pus, and there was no appendix
left to remove. I "wish to state that I thank you, also, doctor, for the
discussion of the paper. Dr. Griffith's idea in handling these cases is
exactly as has been my custom. I thank you.



PANCEEATIC CYSTS, WITH KEPOET OF CASE.



L. S. Booker, M.D., Durham.



The object of the following case report is to call attention to a condi-
tion Avhicli is not common, but of sufficient frequency to be borne in
mind when making a diagnosis in an obscure upper abdominal condition.
The first pancreatic cyst successfully operated was in 1882 by Gussen-
bauer. But the true father of this branch of surgery is Nicholas Senn,
Avho in 1886 published his experimental and clinical researches which
laid the foundation for rational surgical treatment of some of the dis-
eases of the pancreas. Since 1900 our inspiration and guidance has
come chiefly from the teaching and. example of Mayo Eobson.

The term "Pancreatic Cysts" has been used to describe any fluid tumor
in or associated with the pancreas, though such tumors differ widely
in causation, position, and clinical features. The following classifica-
tion is as precise as our present knowledge permits: (1) Eetention



SURGERY. 149

Cysts, (2) Proliferating Cysts, (3) Hydatid Cysts, (4) Congeuital
Cystic Disease, (5) Hemorrhagic Cysts, (6) Pseudocysts.

Of the hemorrhagic variety I wish to report the following case :

Miss N. P., age 20, admitted to Watts Hospital December 25, 1914. Chief
complaint, pain in epigastrium, nausea and vomiting. Previous personal and
family history negative.

Present illness: Present trouble began three j'ears ago, when patient fell
across a ditch, striliiug her stomach against a rocl^. She had to be helped
home and for several weelis complained of soreness in epigastrium ; then be-
gan to suffer with indigestion, flatulence and discomfort after eating. About
one year ago she first noticed a swelling in upper abdomen, which would dis-
appear on lying down. Her symptoms of indigestion increased, and in addi-
tion she suffered sharp attacks of pain, followed by nausea and vomiting.
She now vomits a great deal, and is more or less nauseated all the time, but
has never vomited blood. Pain is aggravated by eating, and is not relieved
by vomiting. Bowels constipated and appetite poor.

Physical examination: A fairly well nourished girl in great pain. Epigas-
trium very tender, slightly rigid, and presents a pulsating mass in middle line,
slightly movable and partially disappearing under left costal cartilages. Mass
feels symmetrical and is very tense. No bruit heard, not expansile. Stomach
contents, urine, and feces negative. Blood haemoglobin 80%. reds 4,500. whites
6,000.

Operation January 1, 1915: Upper right rectus incision, stomach, duodenum
and gall bladder found normal. Cystic mass presented between folds of
gastro-hepatic omentum. Lesser peritoneal cavity opened through gastro-
hepatic omentum and mass found to have its origin to head and body of pan-
creas. Cyst was aspirated and greater portion of its walls excised. Drainage
Inverted and held in position by cat-gut sutures. The remaining cyst wall was
Inverted around tube and held by purse-string suture. Lesser peritoneal cav-
ity closed around drain and abdomen closed to drainage in the usual way.
Patient made an uneventful recovery, and was discharged on fourteenth day.
cured.

Pathological report, by Dr. Kerns: The specimen consists of a symmetrical
cystic mass about the size of a quart cup, the walls of which are thick and
dense. The outer surface is smooth, with few adhesions. Inner surface
smooth, with few organized blood clots adherent. Contents of cyst consists
of a bloody fluid 500 c.c. in amount, with many blood clots in various stages
of organization. The fluid is alkaline in reaction Spg. 1,028 with feeble prop-
erty of digesting casein. Microscopically, the fluid contains many erythrocytes,
few leucocytes and epithelial cells. Section of wall shows it to be formed
of dense fil)rous tissue, the inner surface of which is lined with cylindrical
epithelia. Specimen belongs to the hemorrhagic variety of cyst of pancreas.

The fact that traumatism will give rise to pancreatic cysts receives
ample confirmation from both experimental and clinical observation.
Lazarus produced a cyst by crushing the pancreas of a dog, forming a
haemotoma which later became an encapsulated cyst, containing 100



150 NORTH CAROLINA MEDICAL SOCIETY.

c.c. of watery fluid. The same author reports eight cases arising appar-
ently as a result of traumatism. Korte reports one hundred and seven-
teen cases, 30% of which were preceded by abdominal injury. As to
age, most cases occur between twenty and forty, although Richardson
reports a case in a child of fourteen months. Sex. Robeson and Cam-
midge say that true cysts are more common in women and pseudocysts
more common in men. Korte statistics show almost equal incidence in
men and women. Retention cysts are the result of chronic pancreatitis,
so regarded by most authors. Calculi, tumors, chronic infections of
duodenum and bile passages, duodenal and gastric ulcers have been
mentioned as pathological lesions accompanying pancreatic cysts.
Whether they cause both the cyst and the pancreatitis or whether the
cyst results from pancreatitis is hard to determine. Robeson and Cam-
midge favor the latter supposition. Proliferating cysts are of two kinds,
benign and malignant. Benign cysts have much the same characteristics
as multilocular ovarian cyst adenomas. A few cases of malignant cysts
have been reported. They occur as epitheliomas. Hydatid and congeni-
tal cysts are extremely rare and have but little clinical significance.

Pseudocysts are those in close proximity to the pancreas, but do not
originate in the substance of the gland. They may involve the gland
secondarily, and an accurate distinction of a true pancreatic cyst from a
pseudocyst is not always possible. The majority of pseudocysts are, how-
ever, circumscribed collections of fluid in the lesser peritoneal cavity.

Diagnosis: From the description of this case it is evident that there
are no pathognomonic symptoms or physical signs of pancreatic cyst.
A history of injury is often an aid. Diagnosis depends largely on physi-
cal signs, and these may resemble those of growths of liver, kidney,
suprarenal spleen, mesentery, or ovary.

Treatment: The treatment is essentially surgical. Aspiration was
the treatment adoi^ted in some of the earlier cases. It is contraindicated
on account of the danger of peritonitis or perforation of one of the large
vessels in the wall of the cyst. Complete extirpation is only occasionally
possible. It is more diflicult and has a higher mortality than incision
and drainage, and is nearly always impossible on account of adhesions.
Incision and drainage (marsupialization) is the most siiitable operation
in the majority of cases. If the cyst is large, the greater part of its wall
should be excised and a rubber drainage tube inserted and held in place
by cat-gut sutures and leakage guarded against by a purse-string cat-gut
suture tied after inverting the walls of cyst around drainage tube. As a
rule, granulation tissue will soon obliterate the cavity, but occasionally
a small fistula will persist for years.



SURGERY. 151

Dr. E. a. Lockett, Winston-Salem : As regards pancreatic cysts, I
saw two cases in a clinic ; one of them w^as of tlie acute hemorrhagic type,
and the other was of the adenomatous type. Both were in women ; both
gave symptoms of acute attacks of nausea and vomiting. The first one
was followed by a state of collapse. Both of these cases were operated
upon ; both were diagnosed before operation, both appearing in Dr.
Deavers' clinic. In the first, the case of acute hemorrhage pancreatitis,
a portion of the peritoneum cov-ering the posterior wall of the duodenum
was pushed forward, giving a mass larger than my fists ; that was the
case in which only the gall bladder was drained. The other, of the
adenomatous type, had been previously operated on two years before.
This I may say without any exaggeration at all was as large as a 5-year-
old child's head, in a very thin Avoman. As in the other case, the exam-
ination of the urine and stomach and of the feces was negative. Dr.
Deavers emphasized the fact that there was a negative examination of
urine. He cut into the large cyst, which was just pushed right out from
the gastro-colic omentum, and in cutting into it this just laid open one
fold of the gastro-colic omentum. The numerous cysts were opened and
he did a marsupialization (connecting the cyst wall to the abdominal
wall), and draining the cyst. Both patients recovered.

Dr. Lockett : I move that Dr. Hanes of Richmond be accorded the
privileges of the floor.

The courtesy of the floor is extended to Dr. Hanes.

Dr. Frederick M. Hanes, Richmond, Ya. : It is possible, by the pas-
sage of an esophageal tube, to secure the contents of the duodenum. ISTow,
if the duodenal contents are examined by very simple methods for lipo-
lytic and starch-splitting ferments, one can frequently determine by
these tests the functioning of the pancreas. It seems to me that in cases
of cysts large enough to practically destroy the pancreas, examination of
the pancreatic ferments in the duodenal juices will throAV light on the
diagnosis. So far as I am aware, the method has not been used. A few
weeks ago I had a chance to use this method following an operation for
cyst of the pancreas. The surgeon who operated was anxious to know
the cause of a very severe post-operative diarrhea, and we made several
studies of the duodenal contents to test for the presence of pancreatic
ferments. They were present in normal amounts, so we decided the
diarrhea was not due to abnormal pancreatic secretion. Any method
which promises aid in the diagnosis of pancreatic disease is Avorthy of
extended usage.



152 NORTH CAROLINA MEDICAL SOCIETY.



POST-OPERATIVE INTESTINAL OBSTRUCTION, WITH
CASE REPORT.



A. deT. Valk, M.D., Winston-Salem.



To consider post-operative intestinal obstruction in all its phases is
almost too great an undertaking to cover in a brief article on the subject,
and it is the writer's desire to touch mainly upon the functional form of
this condition in connection with a rather interesting case report.

It happens to be not an infrequent complication following abdominal
operations, and so often we are at a total loss as to means of prevention.
It is rather amazing that we do not have to face it more often, all con-
sidered, and there remains no doubt that nature accomplishes wonders
when judiciously assisted.

Etiologically post-operative obstruction is generally divided into two
classes, namely, mechanical and functional; the latter implying the
adynamic and dynamic forms of ileus.

The mechanical form is not only an immediate complication, but oc-
curs weeks, months, and even years after operation. It might be brought
about in various ways, but probably the most potent factor here is the
result of a peritonitis with subsequent adhesions and constricting bands
or the plication of intestines due to abraded areas or raw surfaces.

Adynamic ileus, as the name implies, is a deficiency of the vital power
of the intestines themselves, and is caused by any condition interfering
with intestinal mobility, either local or reflex. Locally probably peri-
tonitis is the most common factor. Reflexly, of course, no definite cause
can be determined, but it is not uncommon as the result of trauma and
overexposure of the intestines at operation. Shock is also an important
factor.

In the dynamic or spastic type of ileus there is a spastic contracture
of a segment of intestine, giving rise to obstructive symptoms. In the
true reflex functional ileus the paralysis or spasm may be of peripheral
or central origin, and Behan^ believes that the spastic contracture is the
result of vagus stimulation or inhibition of the sympathetic nerves, while
the paralytic form is just the opposite, being due to inhibition of the
vagus or stimulation of the sympathetics.

Kocher- claims that in most cases of so-called dynamic ileus, meaning
the paralytic as well as spastic, the condition is by no means purely a
functional disturbance, and that there are practically always light me-
chanical hindrances which lie in the background.



SURGERY. 153

We see transitional stages of reflex paralysis of the gastro-intestinal
tract following operations from the mildest grade of distention to the
gravest form of ileus. Acute dilatation of the stomach is no doubt a
manifestation of this same reflex paralytic condition. That this state is
mainly a reflex jjaralysis is well shown in a certain group of cases in
which the peritoneum is not opened and we have an adynamic ileus fol-
lowing.

Here we are dealing Avith a condition, the cause of which is more or
less speculative, that makes it more than difficult to combat. However,
we realize that it frequently follows in certain cases, especially after
operations necessitating extensive handling of the intestines, and one
may reasonably anticipate its development and institute early treatment.

The mortality is rather high, one writer reporting 60 per cent in a
series of ninety cases.

Just Avhat brings about the so often rapid exitus in these j)atients is
not definitely understood, but probably the recent work of Whipple,
Stone, and Bernheini'^ throws more light on the subject than any other
work of late years. These authors tend to lead us to believe that death
in intestinal obstruction is due to an intoxication. They have shown in
dogs that ''isolation of a loop of duodenum or jejunum by double ligature
and reestablishment of the continuity of the alimentary tract is rapidly
fatal." "The toxin is supposed to be formed by the mucosa of the closed
loop, and absorption takes place, not only from the loop contents, but also
from the mucosa direct." Further : ''The fluid contents of the isolated
loop when injected into a normal animal produces a reaction similar to
that of the dog with closed loop." Drainage of loop in many cases will
relieve condition, but this is not constant.

Hartwell^ fails to find evidence to justify the claims made by the
above quoted authors, and believes that while there is no doubt a toxin
produced, this is brought about by altered condition of mucosa as the
result of circulatory disturbance. He further considers that marked loss
of body fluid with fall of blood pressure and its effect upon cerebral cir-
culation the main factor in producing death.

McLean^ agrees with Hartwell (after a series of animal experiments),
and is more in favor of the theory of disturbed cerebral pressure due to
loss of body fluids as cause of fatal termination.

All of these corroborate the general finding that disturbances are more
pronounced following the formation of loops in the duodenum and high
jejunum and become markedly less as one approaches the colon. These
experiments are, of course, dealing with mechanical obstruction, but are
readily applicable to a certain extent to the functional form.



154 NORTH CAROLINA MEDICAL SOCIETY.

The diagnosis in most cases is easily made, and from the character of
onset, symptoms, etc., one can generally differentiate betAveen the me-
chanical and adynamic form. As a rule, the latter comes on quickly —
within forty-eight hours after operation — but not always can it be dis-
tinguished from a beginning peritonitis. In the absence of sepsis, how-
ever, with a sudden onset, in an apparently favorable post-operative
course, distention, nausea, and vomiting and absolute cessation of peri-
stalsis, its nature can be suspected. Pain is not colicky in character and
collapse is likely to follow.

In the way of treatment, it seems to be generally unsatisfactory.
Immediate supportive measures should be instituted. Saline infusions
are no doubt helpful. Gastric lavage, hot applications to abdomen and
stimulating enemata should be tried. Strychnia, eserin, atropin, and
pituitrin are advocated as means of influencing peristalsis. Peiser'^
claims satisfactory results with use of harmonal.

Medical treatment should, of course, be instituted in all cases for a
certain time, and this is measured by the individual's response to such
treatment. Further measures should be surgical, and an enterostomy
quickly done will save, in many cases, what is apparently a hopeless con-
dition. This can be done through original incision by simply opening
the same and bringing up and opening the distended bowel. Many times
this procedure can be carried out under local anesthesia.

It is a question as to whether or not we too often prolong the expectant
treatment beyond all hopes of saving our patient.

The subsequent course, after enterostomy, is not without danger and
risks of skin digestion and starvation, but the immediate danger of rapid
toxic death is a more pressing consideration.

The pulse is probably the best criterion as to the condition of patient,
and where we find no amelioration of symptoms with medical treatment,
and a gradually increasing pulse rate, one should resort promptly to
enterostomy before serious toxemia intervenes.

In the evolution of medicine on the whole, especially the present era,
the greatest efforts that have been put forth have been those in the direc-
tion of prevention, and here we find a condition in which prophylactic
measures are to be most seriously considered. More careful consideration
of temperament of patient, because it is frequently in nervous, apprehen-
sive individuals that we see this complication. Emphasis may be laid
on the prevention of shock, and here may be mentioned the use of
novacaine and quinine and urea, in abdominal incisions, as well as the
choice of anesthetics. Proper preliminary preparation of the gastro-
intestinal tract before Operation ; more careful consideration of tissues,



SURGERY. 155

especially tlie peritoneuni and viscera, during operation, and early insti-
tution of supportive treatment during or immediately after operation
should be observed.

In connection with this brief consideration of post-operative obstruc-
tion, I want to report the folloAving rather interesting case :

T.. C. male, age 7. Operated upon on August 1. 1914, for acute perforated
gangrenous appendix, with localized peritonitis involving the entire right lower
quadrant. This was done through a lateral "muscle-splitting" incision, ap-
pendix removed, and free drainage instituted. He made a rather slow re-
covery and was discharged thirty days after operation.

Ten days after leaving hospital he returned with an acute intestinal obstruc-
tion. He was again operated upon and tlirough a right rectus incision a small
obstructing band of adhesions was located across the ileum (about %cm. from
the ileoca^cal junction) and relieved. The patient's bowels moved while on
the table, and he recovered almost immediately. Pulse dropped from 140 to
120, distention subsided, and there was marked improvement in general condi-
tion for about twenty-four hours. During this time there was one evacuation
of bowels by means of an enema. On the afternoon of the following day — that
is, about thirty hours after operation — he complained of distention of abdo-
men, nausea, and frequent eructation of gas. Pulse rate increased, reaching
140 in short time, and within a few hours there was marked intensification of
all symptoms. Abdomen became greatly distended, nausea and vomiting con-
stant, and there was no further movement of bowels. Temperature 97.5, pulse
150, quite restless, and there were signs of a pending collapse.

Under light anesthesia the lower angle of the right rectus incision was
opened, the first loop of distended bowel presenting brought up, attached to
peritoneum and immediately oi>ened, with the evacuation of a great deal of
gas and fecal material. Patient recovered on table. Pulse improved ; disten-
tion subsided, and there was marked relief of all distress. For the following
ten or twelve hours he was quite comfortable, and during this time there was
considerable drainage from enterostomy. This, however, became less as time-
went on, and at the end of twenty-four hours he ceased to drain through open-
ing. There was a rapid return of all the previous symptoms of ileus : tem-
perature 97, pulse 160, and weak, marked distention, nausea, and vomiting.
In fact, patient was apparently in worse condition than on former occasion
and markedly toxic. On both occasions every effort was made to relieve the
condition by means of gastric lavage, hot applications to abdomen, stimulating
enemata. eserin, strychnia, etc., but all apparently in vain ; so again, under
light anesthesia, a second enterostomy was done, this time oijening the upper
angle of the right rectus incision. A large amount of gas and intestinal con-
tents expelled. Consciousness was soon regained, but it was difficult to get
any response to stimulation for twenty-four to forty-eight hours following.
Temperature remaining subnormal and pulse ranging between 140 and 150.

After the second enterostomy there was free drainage of intestinal contents,
not only through the upper, but also through the lower openings after twenty-
four hours. It was s<ion found that the drainage from the enterostomies was



156 NORTH CAROLINA MEDICAL SOCIETY.

causing excoriation of the skin over the abdomen, so a continuous tub was
used during the day and dressings clianged frequently during night.

Ten daj's after second enterostomy a normal movement of bowel was ob-
tained by means of an enema and following this a normal evacuation every
other day.

The lower enterostomy gradually closed to small size, while upper remained
open and drained free. On November 10th, eight weeks after second opening
was made, patient was again operated upon and upper fistula closed with a
very happy result. The lower opening has gradually closed, and from all
reports he is doing well, with a normal bowel movement daily. Of course,
there is always the possibility of subsequent trouble in this case.



Online LibraryMedical Society of the State of North Carolina. AnTransactions of the Medical Society of the State of North Carolina [serial] (Volume 62 (1915)) → online text (page 18 of 58)