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A MON'l JW OF 

SURGICAL SCIENCE AND 

PRACTICE 



J. B. LIPPINCOTT COMPANY 



Ewms Gallouay 


I T’S a lucky break for the patient 
when the surgeon decides to oper- 
ate under NEOcatne 
NEOcaine is the Spinal Anesthetic 
which Labat used for 17 years without 
a death Jt is especially indicated for 
poor surgical risks because of its ex- 
tremely low toxicity 
Many^ important hospitals insist 
upon use of NEOcaine for Spinal 
Anesthesia This is due to the fact 
that Icadmg 'surgeons have discovered 
that this drug is not only the least toxic 
of any employed for the purpose, but 
also the simplest and safest 

^ Spinal Anesthesia with 
NEOcaine affords perfect 


abdominal relaxation resulting in a 
smoother operation In addition, it 
contributes to quicker recovery with 
minimum shock and nausea 
Technique is exceedingly simple 
assuring satisfactory ancstliesia The 
spinal fluid is allowed to drop directly 
into the NEOcaine ampoule, ^ssolving 
the, pure crystals, and then slowly in 
jectcd with or without barbotage 
Supplied in ampoules of 0 05, 0 08, 
0 10, 0 12, 0 J5, 0j20 and 0,30 Gm,, in 
boxes of 10 ampoules. 

“Write today for new pamphlet sum 
manzing recent valuable papers on 
Spinal Anesthesia 


NEO 


: A i N E ANGLO-FRENCH DRUG GO. (U. S A ) INC 


1270 Broadway 


New York, N y 


FOR SPINAL ANESTHESIA 


Please mention Annals of SuRCEm when writing ad\crtisers 


Annals of Surgery 
Tanuara lOSS 


VOL 107 


JANUARY, 1938 


NO 1 


ANNALS of 
SURGERY 


A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 

Aho the Official Publication of the Ameucan Smgical Association 
and the Southern Suigtcal Association 




EDITORIAL BOARD 


WALTER E LEE, MD ROY D McCLURE, MD 


Chairman, Philadelphia 


Deti oit, Mich 


TJAPNinv npnmvc T\/r GEORGE P MULLER, M D 

PhtlaMphm 

Nashville, lenn ^ 

H C NAFFZIGER, MD 

EDWARD D CHURCHILL, San Fiancisco,Cal 

MD DALLAS B PHEMISTER, 

Boston, Mass M D 

, Chicago, 111 

ROSCOER GRAHAM, MD „ orpMuripn rp n 

Tmonlo,Ca,mda W F. RIENHOFF JR , M D 

’ Baltimoie,Md 

SAMUEL C HARVEY, MD A O WHIPPLE, M D 


New Haven, Conn 


NewYoik 


JAMES TAFT PILCHER, B A , M D , Managing Editor 


J B 1 

PHILADELPHIA 


Fubhshers 


MONTREAL 


NEW TORK 


Entercl at the Post Office at Philadelphia and admitted for transmission through the mails at second class rates 
Price Sioooayear Copyright 1938, J B Lippincott Company, 227-231 South Sixth Street Printed m U S A 


1 



Vo] 107 


CONTENTS 

JANUARY, 1908 


No 1 


FURTHER CLINICAL EXPERIENCES WIIH NINEIY- 
FIVE PER CENT OXYGEN TOR THE ABSORPTION 
OF AIR FROM THE BODY 1 ISSUES Jacob Fine, M D 

Louis Hermanson, M D 
Stanley Frehling, M D 

Boston Miss 1 

RESULT SIN THE OPERATIVE IREATMENT OF MAJOR 

TRIGEMINAL NEURALGIA Francis C Grant, M D 

Phihdelphia Pa 14 

SPASMODIC TORTICOLLIS TREATED BY T HE PLASTIC 
REDUCTION OF MOTOR FIBERS OF THE SPINAL 

ACCESSORY NERVE Clement B Masson, M D 

New York N Y 20 

COMPLETE SYMPATHETIC DENERVATION OF THE 

UPPER EX 1 REMIT Y Albert Kuntz, M D , Ph D 

William F Alexander, M S 

St Louis Mo 

Charles L Furcolo, M D 

Springfield Mass 25 

T HE PROPHYLACTIC AND ACT IVE USE OF ZINC PER- 
OXIDE IN FOUL SMELLING MOUIH AND NECK 

INFECTIONS Frank L Meleney, M D 

New York N Y 32 

GLOSSITIS RHOMBICA MEDIANA Hayes E Martin, M D 

M Elizabeth Howe, M D 

New York NY 39 

PLASTIC RECONSTRUCTION OF THE ESOPHAGUS Carl Eggers, M D 

New York NY 50 

INFLAMMATORY TUMORS OF THE GASTRO-INTESTI- 


NAL TRACT 

Guilford S Dudley, M D 

Laurence Miscall, M D 



New \ ork N Y 

55 

NONSPECIFIC GRANULOMATA OF THE INTESTINE 

Ralph Colp, M D 



New York N Y 

74 

THE SO-CALLED HEPATO-RENAL SYNDROME 

John H Garlock, M D 

Samuel H Klein, M D 



New York N Y 

82 

TUMORS VENTRAL TO THE SACRUM 

Lonn D Whittaker, M D 

John dej Pemberton, M D 



Rochester Minn 

96 

INTRAMEDULLARY DERMOID CYST 

F Keith Bradford, M D 



Chicago III 

107 

TEARS OF THE SUPRASPINATUS TENDON 

Tom A Outland, M D 

Walter F Shepherd, M D 



Sayre Pa 

116 

2 {Contents continued on page 

4) 





Practically All 
Leading Roentgenologists 


NOW USE THE PATTERSON TYPE B 
FLUOROSCOPIC SCREEN 


T his screen has proved to be such 
a decided improvement over all 
previous fluoroscopic screens that it is 
now used by practically every leading 
roentgenologist In fact, every user with 
vhom we have been in contact has ex- 
pressed the opinion that from every 
standpoint the Patterson Type B is far 
ahead of all other fluoroscopic screens 
which they have used 

Much greater brilliancy, increased 
contrast, and operation at lover volt- 
ages are among the advantages of this 


screen It reduces exposure factors, 
which protects the patient as well as the 
tubes and equipment 

If you have not as yet experienced 
the advantages of this superior fluoro- 
scopic screen it would pay you to ask 
your dealer for a demonstiation 

NEW AND HELPFUL INFORMATION 
The following new Patterson Leaflets are now a\ail- 
able (1) Cassette Contact, (2) Care of Intensifying 
Screens, (3) Patterson Mounting Paste and Method 
of Mounting Intensifj ing Screens Send for anj in 
which j oil are interested 

THE PATTERSON SCREEN CO , TOWANDA PA 


Patterson 



INTINSiri ING Screens FLUOROSCOPIC 

screen specialists for more THAN TWENTY YEARS 


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Annals of Sureer> 
January 1938 


CONTENTS— 

DUPUYa REN’S CON J RAC J URE A Bruce Gill, M D 

PhtladcIpUfi Pa 122 

GLOMUS 1 UMOR Anatole Kolodny, M D 

York \ y 128 

INTERNAL FIXATION FOR RECEN I FRACTURES OF 

THE NECK OF HIE FEMUR Melvin S Henderson, M D 

Rochester Minn 132 

BRIEF COMMUNICATIONS AND CASE REPORTS 


A METHOD or RLDECING I ARGE DIAPHR \CMATIC HI RMA I ROM 
ABOVE 

ACLTE I^rLAMMATOR1 jrjLMTIS M ITII INTI STINAI OBSTRUCTION 

COLECTOM\ rOR CHRONIC H EOCOLITIS 

CHRONIC INTI AMMATOR\ TUMOR 01 Till MI SI NTI R\ 

OBSTRUCTION DUE TO \I>I*I NDICLS I Pill OICAI 


GUNSHOT MOUND OE RIGHT H lAC BONU 

MEMOIR 

FRANCIS AUFNANDER CARRON SCRIMGER 


Harry G Sloan, M D 

CIca eland Ohio 143 

147 

148 

Percy Klmgenstein, M D 

Nell York N \ 151 

Carl Baumeister, M D 

Council BIufTs Iona 

C W Horgens, M D 
C F Morsman, M D 

Hot Springs S Dak 153 
Sigmund Mage, M D 

Ncn ^ ork NY 155 
Edward W Archibald, M D 

159 


do you treat 

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B^own- Buerger Cbnv/ertilble Cy/stoscope 



The Brown Buerger Convertible Cysloscope cola 
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Annals of Sureery 
January ms 


TOPERATIVE COMFORT 



In the hollow of your hand 


pROSTiGMiN PROPHYLACTIC safeguards 
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Summarizing a report of 249 cases 
{Western Journalof Surgery, Qynecology, and 
Obstetrics, 45 458) the author 
said, in part, the following "The 
feeling of security which its use 
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PROSTIGMIN PROPHYLACTIC, ampuls, 1 CC 
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PROSTIGMIN REGULAR, ampuls, 

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1 to 2 ampuls p r n 


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J OHN HUNTER (1728-1 793) obt lin- 
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his “A Treatise on Blood Infl inim ition 
ind Gimsliot Wounds ’ w is b ised while 
scivmg IS stiff nivil suigeon during the 
war with Fi nice In 1776 he wis ip- 
pointed Surgeon Extraordinary to tiie 
King and in 1785 peiffoimed his hrst 
ligation of the femoral aitery in Hunter s 
Canal for popliteal aneurism The old 
operation h id proved unsatisf ictory and 
this improvement of Hunter s wis a 
siginfie int contribution to surgery 


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Intestinal Sutures 

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Small V2- Circle Needle 

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Celluloid- Linen 


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Black Silk 


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Si/cs 00 o I, except *00 0 onlj 

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B-l B- 4 . 



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lo-Da} Catgut 

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10-Day Catgut t 

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* 1 2 inches 

f 9 inches 



Package of 12 tubes of a kind ^4 20 

Cleft Palate and Harelip Sutures 


r-i r 2 » ; 

CUTTING tlTTIN( tl 1TIN< 



NO MATTKIAI SI7B NFEDLB 

1751 Kal-dcrmic 00 c-l 

1752 Aluniinuni-Bron/c Wire 00 c-i 

1753 Bhtk Bnidccl Silk 000 c-2 

1754 Alummum-BronzeWirc 00 c-4 

1755 Kal-dermic 00 c-3 

1758 Aluminum-Bron/eWire 00 c-3 

Suture length 1 S inches 

Package of 12 tubes of a kind ;;^4 20 


Thyroid Sutures 

T hermo-flex («o«-/<or//7Wf)orClaustro- 

Thermal (boilable) catgut, and black 
braided silk with half-circle, taper point 
Atraumatic needles Suture length 2 8 inches 


NO MATTRIAL SIZE Nrmi F 

1635 Non-Boihble Plain Catgut o t-i 

1625 Boihble Plain Catgut o t-i 

1624 Black Braided Silk 000 t -2 

Package of 12 tubes of a kind ^4 20 

Plastic Sutures 

F ine sizes of Kal-dermic, silk and silk- 
worm gut with small, cutting point 
Atraumatic needles Suture length 18 
inches Boilable 



NO 

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Kal-dermic 

SI/E 

8-0 

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B-I 

165 1 

Kal-dermic 

6-0 

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1 652 

Kal-dermic 

8 0 

B -5 

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B -5 

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4-0 

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Black Silkworm 

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1655 

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1 658 

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Package of 12 tubes of a 

kind 

20 


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S pecial needled sutures are also pre- 
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able materials 




DISCOUNTS ON QUANTITIES 

DAVIS & GECK, INC , 217 DUFFIELD STREET, BROOKLYN, NEW YORK 

Copyright 1938 Davis & Geck, Inc Printed in U S A 




“A balance of qualities...” 


NEW types and varieties of sutures arc 
constantly needed to meet advances in 
surgery, but the fundamentals of suture 
dependabilitj remain unchanged 
Sutures still should be not onlj easy to 
handle but correct in every phase of be- 
havior No single feature nor point of 
merit can accomplish this it demands 
a combitiation of various qualities 
Therefore, in everj new product and in 
every development by our scientific staff 


the first concern is a proper ratio of vital 
ch.iracteristics 

The special feature of each product is 
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This policy, which involves the annual 
consumption of more than 250,000 tubes 
in experimental work and tests, gives as- 
surance that D & G Sutures invanablv pos- 
sess the correct balance of qtiaMtes 


Cf S^utUAjii^ 


BROOKLYN, NEW YORK, USA 


DAVIS & GECK, INC 



Annals of Surgcrv 
January 1D3S 



Therapeutic pioducts have come and gone — but Uiotropin 
has suivived on meiit alone That is something to "ciovv 
about ” Today, Uiotiopm still letains the esteem of physicians 
as a uiinaiy antiseptic which, used propeily, is effective often 
wheie othei measuies have failed Urotropm is a biand of 
methenamine, its purity guaranteed by Scheimg & Glatz, Inc 
Supplied in sanitape piotection in 5-gram tablets, 30 m a box, 




7yj-giain tablets, 20 in a box Also m laigei packages, and 
in ciystals A trial supply may be obtained by physicians 


k. 



SCHERING & GLATZ, INC 

113 West 18th Street New York City 


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Annals of Surccrj 
Janiinr> 1018 


Actual Practice in Surgical Technique 









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Mclhotl of IIoI<Unt, ConnrI Slitrli From 
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Gynecology Surgical Anatomy Proctology 
Vititor‘1 always welcome 


CHICAGO POST-GRADUATE 
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3 Special instruction and practice in the lech 
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to surgeons who wish to renew the Anatonij 
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Personal Instruction Actual Practice Op 
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of Teaching Ideal and Unsurpassed For 
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A V PARTIPILO, MD , F A C S , Director, 19'0S Ogden A>c .Cliicngo III .Phone nn> market 70M 


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FARNSWORTH LAB ,159 N State St , Chicago 


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Incorporated not for profit 

ANNOUNCES CONTINUOUS COURSES 

MEDICINE — Informal Course Intensive Per- 
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GYNECOLOGY & OBSTETRICS— Diagnostic 
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FRACTURES & TRAUMATIC SURGERY— In- 
formal Practical Course Ten Day Intensive 
Course starting February 14 1938 
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UROLOGY — General Course Two Months Inten 
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CYSTOSCOPY — Ten Day Practical Course 
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CINE AND SURGERY 

TEACHING FACULTY 

Attending Staff of Cook County Hospital 

Address Registrar 427 South Honore Street 
Chicago, Illinois 


10 


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Annals of SuiRcn 
Tinnar% n"S 



'Discipline is the development of the fac- 
ulties by instruction and exercise " When 
functions such as habit time of bowel 
movement are neglected through lack of 
discipline or intelligence, they require care- 
ful training to restore them to a normal state 
Petrolagar has proved to be an agree- 
able and effective means of assisting in the 


establishment of bowel discipline Because 
Petrolagar mixes intimately with the bowel 
contents, it increases the bulk in the stool 
to a soft mass which is easily passed 
Petrolagar is prepared in five types — 
providing the doctor with a variation of 
treatment to suit the individual patient 
Petrolagar Laboratories, Inc , Chicago, 111 


Petrolagar is a mechanical emulsion of pure liquid petrolatum (65% by volume) and agar agar Accepted by 
the Council on Pharmacy and Chemistry of the American Medical Association for the treatment of constipation 



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Annals of Surcerj 
January 193S 




I ^ 


Armour Laboratories Assure Potency, Standardization, 
Dependability by Modern Scientific Techniques 

• Every glandular preparation must have three 
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iveness in your i\ork It must he of high potency. 

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The Armour Laboratories protect and assure 
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THE ARMOUR LABORATORIES 

Headquarters for Medicinals of Animal Origin 

ARMOUR AND COMPANY UNION STOCK YARDS • CHICAGO 


SOME ARMOUR 
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AKMOUR TinnOID tins 
been standardized on llie 
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AltMOUR PITUITA11\ I I 
QUID has been standard- 
ized on the Guinea Pig 
Uterus for its oxjtocic 
potency 

SOLUTION Lit ER EVTUACT 
(AIlMOUll) lias been ns 
sayed on the Red Cell 
Regeneration counts in 
true Pernicious Anaemia 
cases 


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Annals of SurKeir 
January 103S 



D 


To pro\ide the profession with medicinal prod- 
ucts of highest quality and unvarying potency 



To contribute to the progress of medicine by de- 
\ eloping new and superior agents through research. 


^ To issue information about the uses of the 
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channels e\clusively 



1 


ifve. GitenUofi a/ Sxvcgmnd 


• The Exacting Require- 
ment!, of Surgery are more than 
amply fulfilled by Tincture 'Mer- 
thiolate’ (Sodium Ethyl Mercuri 
Tlnosalicylate, Lilly) This anti- 
septic compares favorably with 
the best germicides m bactericidal 
and sustained bacteriostatic ef- 
fects It IS especially distinguished 


by Its low toMcity to tissues and 
its applicability for preoperative 
skin disinfection and surgical 
dressing 

* 5 ): * 

Tincture 'Merthiolate’ (Sodium 
Etbyl Mercuri Tlnosalicylate, 
Lilly) IS supplied in four-ounce 
and one-pint bottles 


ELI LILLY AYD COMPANY 

Principal Offices and Laboratories, Indianapolis, Indiana, USA 


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ANNALS OF SURGERY 

i IL ' i 

VOL 107 JANUARY, 1938 No 1 



FURTHER CLINICAL EXPERIENCES WITH NINETY-FIVE PER 
CENT OXYGEN FOR THE ABSORPTION OF AIR FROM 
THE BODY TISSUES'^ 

Jacob Fine, M D , Louis Hermanson, M D , and 
Stanley Frehling, M D 

Boston, M vss 

FROM THE SURGICAL DEPARTMENT, BETH ISRAEL HOSPITAL AND TIIF DEPARTMENT OF SURGFRY, 

IIAR\ARD MEDICAL SCHOOL BOSTON MASS 

When atmospheiic air accumulates in excessive quantities in body cavi- 
ties or tissue spaces, it may become a noxious foi eign body causing symptoms 
varying from a mild discomfort to alarming distress This is the situation 
m gaseous distention of the intestine, spontaneous pneumathorax, subcutane- 
ous emphysema, air embolism and the immediate postencephalographic state 
The oxygen fraction of the an is rapidly absorbed, but the nitiogen fi action 
lemains as the offending agent It disappears fiom the tissues very slowly 
because its diffusibility into the blood stream depends on the small difference 
between its partial piessuie m the tissues (627 Mm Hg ) and the blood^ 
(573 Mm Hg ) 

The simple expedient of withdrawing the mcarceiated nitrogen by needle 
and syi inge can he effectively applied only in the case of pneumathorax W e 
have, therefore, attempted to effect the removal of the nitrogen indirectly by 
lowering the tension of the nitrogen in the blood stieam This is readily 
accomplished by supplanting the ordinal y an which is breathed by 95 pei 
cent oxygen Shaw^ measured the fall m the paitial piessuie of nitrogen m 
the arteiial blood during the inhalation of puie oxygen and found that after 
one houi this pressure is 155 Mm Hg , aftei two hours 91 Mm Hg , aftei 
three hours 52 Mm Hg and after four hours 31 Mm Hg Therefore, when 
pure oxygenf is breathed, the diffusion pressure existing between nitrogen 
111 the tissues and that m the blood piogiessively increases, so that one should 
expect a corresponding mciease m the speed of absorption of nitiogen from 
the tissues into the blood stream, whence it escapes into the expired air 

In a pievious communication- experimental evidence was offered confirm- 
ing these theoretic consideiations Cats, whose ohstiucted intestines were in- 
flated with nitrogen, disposed of only 10 pei cent of the original volume of 
gas when atmospheric an was bieathed, wheieas about 60 per cent disap- 
peared m the same inteival of time when pure oxygen was breathed Similar, 

* The expenses of this investigation were defrayed by the DeLamar Mobile Research 
Fund, Harvard Medical School, Boston, Mass Submitted for publication March 25, 1937 
tFor practical purposes 95 per cent oxygen is adequate 

1 




FINE, IIERMANSON AND EREIILING .\ntnisof‘,uri,ci5 

Jftniinrj I'Hs 

though not accurately cjuantitatcd, results were observed in pueiimapentoneuin 
and subcutaneous cmphjseina ' It was pointed out fuithennoie that tlie 
tune requned to absorb a guen volume of nitiogen from any body space 
depends on the sui face area of the gas bubble, since only that fraction m 
contact \\ith an absoibmg surface can entci the sunounding tissues and from 
tlieie the blood capillaiies Foi example, 500 cc of nitrogen m the intestine, 
tlie pleural cavity 01 the peiitoneal ca\it} \\ill piesumabh requne a considei- 
ably greater intenal of time for absorption than an equal volume dispersed 
as tiny bubbles throughout the body, as in caisson disease ” 

These obser\ations have been applied to patients suffering from intestinal 
distention and from the sjmptoms immediately following encephalography 
The pieliminar) results were reiiorted 111 two recent jiapers' ^ together with a 
description of an appaiatus foi the clinical adinimstiation of 95 per cent oxy- 
gen * In this lepoit we are picsenting further clinical experiences with 95 
per cent ox}gen in order to define moic cleaih its advantages and its limita- 
tions for the absorption of air from the body eaMties and tissue spaces 

INTl'STIXAL DISH XTlON 

Case 1 — Mc^cntcuc Adciitlis Postopcializc DisIciUwn — A nnle, igc 12, two weeks 
before 'idinission to the liospitnl hul bad pcii-umbilical pam accompanied bj nausea and 
aoniiting, wbieb subsided in 24 hours Jbe same ssniptoms rccuired 11 da\s later, and 
tlic pain tins time radiated to the riglit lower quadrant At celiotom> the onb abnormal 
finding was acute mesenteric adenitis One node was remoied for biopsj and appen- 
dicectomj was performed From the second to the fifth postopcratiie da^ be aomitcd 
once or twice daih He passed a slight amount of flatus occasionallj but the abdomen 
became distended and be began to feel peri-umbihcal, colickj pain A duodenal tube was 
inserted, heat applied to the abdomen md cncmata were gnen, but without relief There 
had been onh one small bowel e\acuation since operation, which was obtained b> enema 
on the third poslopcratnc daj On the st%cnth postopcraluc da> a scout roentgenogram 
showed distended cods of small and large intestine Because of the persistence of colic 
and progrtssne distention, he was put into a 95 per cent oxjgcn tent for 21 hours wath 
the two one-half hour rest periods out of the tent for feeding The following obseraations 
were made during the oxjgen inlialation period 

Tadle I 

ABDOMINAL GIRTH IN CENTIMETERS AT VARIOUS LEVELS 
Midw'ay from 



Xiphoid 

Umbilicus 

Umbilicus 
to Pubis 

Remarks 

II 00 A M 

66 cm 

65 5 cm 

68 cm 

Put into 95% oxygen tent 

3 30 r M 

66 cm 

65 cm 

67 5 cm 

Out of tent for one-half hour 

7 30 P M 

65 cm 

64 5 cm 

67 cm 

Passed moderate amount of flatus 
and small amount of feces Out 
of tent one-half hour Abdomen 
softer 

8 00 A M 

62 5 cm 

62 cm 

64 cm 

Spontaneous and adequate bow'el 
movement Abdomen soft and 
collapsed 

All pain and vomiting ceased, the 
had normal evacuations thereafter 

abdomen remained soft, he passed gas freely and 


*Tliis has since been modified by Schwab,® and more recentlj by Burgess" Both 
modifications have the considerable advantage of dispensing with the motor unit for 

2 



Volume 107 
J»umbcr 1 


AIR IN THE BODY TISSUES 


Comment — The vomiting, colic, distention and failure to have bowel 
evacuations suggested mechanical obstiuction On the 7th postoperative day 
95 per cent oxygen was admimsteied as a final measure befoie resorting to 
entei ostomy The piompt and peimanent lelief of all symptoms, associated 
with the eftective deflation accomplished, aftei all othei measures were un- 
availing, lend clinical suppoit to the expeiimental obseivation that 95 per 
cent oxygen is an effective agent foi decompiessing the intestine distended 
with gas 

The smooth convalescence aftei the oxygen inhalations indicates that we 
weie not dealing with established mechanical obstiuction Piesumably the 
oxygen inhalations deci eased the mtialummal tension of the overstretched 
intestine sufficiently to allow the intestinal muscle to lecover enough tone to 
effect an adequate evacuation 

That deflation of the bowel can be accomplished even in the presence of 
an organic obstiuction is demonstrated by the following two cases 

Case 2 — Obsintciwg Carcinoma of the Sigmoid — A female, age 75, was re- 
ferred to the hospital for complete procidentia She gave a history of lower abdominal 
colickj’- pain of four weeks’ duration with increasing constipation and anorexia For four 
dajs preceding entry there had been no bowel evacuation 111 spite of enemata and purga- 
tives Vomiting occurred once Examination showed an emaciated, dehydrated elderly 
lady, complaining of occasional lower abdominal pain There were rales and suppressed 
breath sounds at the lung bases, artei losclerosis, and a blood pressure of 165/95 The 
abdomen was generally tender and markedly distended, particularly in the lower half 
There was moderate audible, but no visible, peristalsis A soap suds enema resulted in 
only a little flatus 

Because of her age and precarious condition, she was placed in a 95 per cent oxygen 
tent preliminary to performing cecostom}'- She was kept in the tent for a total of 34% 

Table II 



ABDOMINAL GIRTH 

IN CENTIMETERS 

AT VARIOUS LEVELS 


Xiphoid 

Umbilicus 

Midway from 
Umbilicus 
to Pubis 

Remarks 

5 00 P M 

78 cm 

82 cm 

81 cm 

95% oxygen started 

12 30 A M 

74 cm 

78 cm 

79 cm 

Abdomen much softer Passed i 

8 00 A M 

72 cm 

77 5 cm 

78 cm 

little flatus Out of tent for one- 
half hour 

Oil enema with gas and fecal returns 

9 00 A M 

9 45 A M 

72 cm 

77 5 cm 

78 cm 

Out of tent 

Back in tent 

12 00 NOON 

6 00 P M 

73 5 cm 

78 5 cm 

81 cm 

Out of tent for one-half hour 

8 00 P M 

72 cm 

76 5 cm 

77 5 cm 



circulating the air Schwab’s apparatus utilizes a face mask instead of a hood This 
makes it impractical for administration of oxygen over long periods of time but answers 
the purpose for the treatment of postencephalographic symptoms The new Burgess tent 
IS an excellent substitute for our original apparatus, but lacks the valuable feature of a 
washout valve which greatly shortens the time necessary to attain the desired concentration 
of oxygen 


3 



FINE, HERMANSON AND FREIILING A^^uary " 

hours, with occnsional interruptions for rest and to a\oicl the possible toxic effects of 
continuous, prolonged administration of 95 per cent owgen Within se\en and one-half 
hours after starting o\^gen there e\as a marked deciease in abdoniiinl girth After 
IS hours the abdomen was obeioush less prominent and the colick) pain had eamshed 
Enemata were then moderateh successful, especialK for flatus Although the inaxiinum 
decrease in girth was obtained at the end of 34}^ hours, the hulk of the effect was secured 
after the first 15 hours of oxygen adimnistration 

At the conclusion of the experiment the patient was entirelj comfortable and seemed, 
clinicallj, so much improacd that the apparent need for decompression at the time of ad- 
mission w'as obiiated and a more leisureb nnd adeiiiiate preoperatne stud\ and prepara- 
tion were made possible Enemata continued to be cffeetiee On the fourth daj after 
entry, a barium enema show'cd obstruction m the sigmoid, following which cecostoinj 
was performed for obstructing scirrhous carcmomi of the sigmoid 

Comment — This case is a clear clemonstiation of the efficacy of 95 per 
cent oxygen inhalations to deflate a bowel distended with gas The decrease 
in abdominal gnth was considcr.ihle before any siibstanti.il amount of flatus 
W'as expelled, indicating that the lesult was efTeeted laigcl)' hj the absoiption 
of nitiogen fiom the bowel into the blood 

Case 3 — Prrfoialcd Gatiqmtou^ Prnloiitin Poslo/'n alive Mechanical 

Ileus — A male, age 42, following excision of a gangrenous appendix and drainage of the 
accompaining peritonitis, hccaine distended m spite of passing small amounts of flatus 
during the first thicc postoiiciatne dass Eserme sulphate, heat to the abdomen and 
repeated enemata failed to preient increasing distention An intragastric tube discharged 
large amounts of green fluid and some gas On the fourth postoperatnc da> the in- 
halation of 95 per cent ox\gen was started and continued for 18 hours with interniptions, 
totaling one and one-hUf hours During this period of exposure to oxegen, no gas was 
passed bj rectum The following table shows the course of the abdominal distention 

Taiiil III 

ADDOMINAL GIKTII IN Cl NTIMI T1 RS AT aAUIOUS LCVTI S 
Midway from 



Costal 


Umbilicus 



Margin 

Umbilicus 

to Pubis 

Remarks 

4 20 P M 

90 5 cm 

89 5 cm 

89 8 cm 

Oxygen started Abdomen verj 





tense 

9 00 P M 

91 5 cm 

89 cm 

92 cm 


12 00 P M 

90 cm 

87 cm 

94 cm 


I 00 A M 

91 cm 

87 cm 

91 5 cm 

Abdomen softer 

2 30 A M 

91 cm 

88 cm 

91 5 cm 


6 00 A M 

90 cm 

86 cm 

88 5 cm 

Abdomen softer Patient more com- 





fortable 

9 00 A M 

88 cm 

85 cm 

88 5 cm 


10 30 A M 

88 5 cm 

85 5 cm 

88 5 cm 



The final measurements show a iiiaximum reduction in girth at the umbilicus of 4 cm , 
but the actual decrease in distention is not a'tcurately leflected in the figures The ab- 
domen during the first eight hours w'as very tense and although the measurements at 
I A M show no obvious reduction, the abdomen had become quite soft and the patient 
more comfortable At the close of the period of oxjgen inhalation, enterostomy was 
performed for acute intestinal obstiuction The small intestine was edematous but not 
distended with gas Large amounts of free fluid m tlie peritoneal cavity accounted in 
part for the degree of distention originally presented Following operation all symptoms 
rapidly subsided and an uncomplicated convalescence ensued 

4 



Volume 107 
Number 1 


AIR IN THE BODY TISSUES 


CoMMLNr — Duiing the peiiod of exposuie to oxygen no intestinal con- 
tents escaped by lectum, while some ten ounces of fluid and little or no gas 
weie lecovered from the stomach tube The decompi ession is, theiefore, at- 
tiibutable to absorption of at least part of the distending gases by the use 
of the oxygen tent 

The lesulting fall m mtialuminal tension may have leleased the intestinal 
cn dilation above the point of obstruction sufficiently to facilitate paitial ab- 
soiption of the accumulated fluids as well Although we have no direct 
clinical evidence foi this asseition, the expeiimental data at hand are ade- 
quate “ To a laige extent, theiefore, the 95 pei cent oxygen tent differs from 
an enterostomy tube only in that the late of decompi ession is slowei 

We do not wish to imply from the expeiience with the cases detailed so fai 
that the 95 pei cent oxygen tent should be utilized as a loutine preopeiative 
measure in all instances of mechanical ileus But it is pei haps not too bold 
to suggest that by its use an entei ostomy may be obviated altogether tn me- 
chanical obsti uction of a Uansitoiy natuie The evanescent chaiacter of the 
obstiuction in many cases of geneiahzed 01 localized peritonitis, in winch 
lelease of the inti a-mtestinal tension by enterostomy is fiequently all that is 
necessaiy, is famihai enough It is piecisely m this soit of situation that 
the oxygen method may provide a valuable substitute or at least seive as a 
palliative during the peiiod of indecision as to the mechanical or functional 
natuie of the distention By way of illustiation we cite the following two 
cases 

Case 4 — Pcifoiatinq Appendicitis -with Pcntonitis — A male, age 3, had complained, 
iix days previous to admission, of pen-umbilical pain and was given castor oil Pain 
and vomiting persisted until entry Physical examination showed a toxic, dehydrated, 
cjanotic child with generalized abdominal spasm and distention A gangrenous appendix 
was removed and an extensive pelvic peritonitis drained There was steady improve- 
ment with gradual decline in temperature and pulse rate until the sixth postoperative 
day, when marked distention recurred together with fever and tachycardia A bulging 
mass presented in Douglas’ pouch No gas could be passed by rectum with the aid of 
the usual measures After eight houis m the 95 per cent oxygen tent he suddenly passed 
a large amount of flatus and had a copious bowel evacuation, with immediate softening 
of the abdomen and a reduction of 6 cm in abdominal girfli Steady improvement fol- 
lowed and the pelvic mass resolved spontaneously 

Comment — The point of view that Uie deflation secured was not neces- 
sarily a result of the oxygen inhalations cannot be conti overted , but it loses 
plausibility 111 view of the fact that in piactically all cases in which the method 
has been tried, the same lesult has been uniformly obtained 

Case 5 — Bilateial Tiiho-Ovai lan Abscesses, Pelvic Pei itonitis, Bilatcial Bioncho- 
pneitmonia — A female, colored, age 39, entered the hospital with a chief complaint of 
abdominal pain and swelling Her past history was unimportant except that her first 
two children had died m infancy and her third pregnancy terminated m a miscarriage 
Two weeks before admission she contracted a cold, which was accompanied by a dr\, 
hacking cough Shortly thereafter she had severe epigastric pain which later shifted 
to the lower abdomen The abdomen became swollen and breathing increasingly diffi- 
cult Anorexia, constipation and dysuria followed and persisted for the week preceding 

5 



FINE, HERMANSON AND FREHLING 


Annal'Jof Surpen 
Tanuary 1938 


entry Although she took fluids during the 48 hours prcMOus to admission, she ■vomited 
several times and passed no gas or feces Phjsical e\amuntion showed an acutel} ill, 
obese Negro woman, markedly d3spneic, with evidence of bilateral bronchopneumonn and 
severe distention of the abdomen, which was rigid and tv mpanitic throughout Both 
lower quadrants were tender Pelvic examination showed diffuse tenderness and a pro- 
fuse vaginal discharge The white blood count was 23,000 Ihe temperature, pulse 
and respiration were elevated 

The clinical picture of bronchopneumonia, peritonitis and distention, due either to 
a functional or mechanical ileus, was rather desperate Immediate cehotomv seemed to 
involve too grave a risk An enema vielded no flatus or ftcal results An intragastric 
tube was introduced and fluids given parentcrallj She was put into a 95 per cent oxv'gen 
helmet for the relief of the distention as well as for the respiratorv distress Table IV 
summarizes the results 


Table IV 


ABDOMINAL GIRTH IN CENTIMETERS AT VVRIOUS LI V ELS 



Costal 


Midw ay from 
Umbilicus 



Margins 

Umbilicus 

to Pubis 

Remarks 

12 00 P M 

100 cm 

105 cm 

107 cm 

Oxj gen started 

8 00 A M 

105 cm 

105 cm 

106 cm 

Remov ed from tent for two hours 

6 00 P M 

103 cm 

106 cm 

108 cm 

Remov ed from tent for one and one- 
half hours 

7 00 A M 

99 cm 

102 cm 

104 cm 

Passed large amount of flatus for first 
time in p6 hours Abdomen quite 
soft Patient much more comfort 
able 


Following the period of oxjgen therapv, operative exploration of the pelvis dis- 
closed bilateral, acute and chronic tubo-ovarian abscesses with multiple fresh and old 
adhesions to surrounding structures Convalescence was marked bj a productive cough, 
but there was rapid decline of the fever and tachveardia, the djspnca abated, vomiting 
stopped, fluids and food were taken freclj and gas and feces were passed without diffi- 
culty Distention did not recur 

Comment — Although measui ements of abdominal giUh show a final de- 
ciease of 3 cm at the umbilicus after a total of 2/^4 hours of exposuie to 95 
per cent oxygen, theie was a notevv'orthy inciease m giith at various levels 
dm mg the fiist 18 houis This seems to contiadict our belief that oxygen 
was beneficial, at least foi that peiiod Howevei, as alieady suggested m 
connection with a similar experience m Case 3, the measurements of girth, 
when the abdomen is tense, do not accurately leflect the actual degree of 
intestinal distention As the restiicting effect of a tight musculature gives 
way, the viscera displaced upwaid into the thoracic cage and downwaid into 
the pelvis recede to their more usual positions and the compressed intestinal 
coils expand, so that for a time at least duimg the peiiod of effective oxygen 
theiapy the abdominal girth may actually mciease 

Discussion — We offer the foiegoing data as fuither support for the 
adoption of the 95 per cent oxygen tent method foi the treatment of mti ac- 
table gaseous distention of the intestine It is not possible to pi edict the 
percentage of successes or failuies involved by the use of this method with- 

6 



■\ olume 107 
Number 1 


AIR IN THE BODY TISSUES 


out a much more extensive expeiience The consistently satisfactory re- 
sults secuied m the patients referred to in the previous report,^ as well as 
those cited m the piesent communication, lead us to believe that a high 
aveiage of successes can be obtained if the proper technic is adhered to 
The feai of toxic effects fiom piolonged penods of bieathing pure oxygen, 
lepoited by Bingei'^ and a numbei of other investigators, does not constitute 
a valid objection to the method for seveial reasons (i) The nursing le- 
quiiements of patients make mteiiuptions m admimstiation of oxygen neces- 
saiy Such mteiiuptions, averaging one-half hour in eveiy four to eight 
hours,'" constitute a sufficient factoi of safety, as is amply demonstrated m 
experimental studies® and m oui expeiience with patients There has not 
been a single instance in which the faintest suggestion of oxygen poisoning 
appeared We have given 95 pei cent oxygen intermittently for as long as 
35 horns, but much shoitei penods will ordinal ily suffice for the desired 
result (2) Should futiiie expeiience fail to sustain oui belief that the method 
is without danger, the substitution of Baiach’s oxygen-helium mixtuie,® which 
IS likewise a lespiiable gas containing no nitrogen, would obviate this objection 
The simplest types of intractable distention for which the method may be 
utilized ai e the postoperative, functional types and those associated with pneu- 
monia or cardiac disease In addition, the distention of peritonitis is a pai- 
ticularly appiopiiate type for its application Brown^® aptly points out that 
the disturbed function of the gastro-intestinal tract in peritonitis may be as 
mimical to recovery as the peiitonitis itself If overdistention can be avoided 
01 minimized by an agent which is moie directly effective than those in cui- 
1 ent use, we may be in a position to treat peritonitis with more success than 
heretofoi e 

If the distention is due to established mechanical obstiuction, there is no 
choice but to perform an entei ostomy Aside from relieving the excessive 
tension 111 the blocked loop by enterostomy, operation provides the only cer- 
tain method of detei mining the nature of the obstruction The possible pies- 
ence of strangulation makes immediate surgery obligatoiy regardless of the 
surgical iisk When, however, theie is good leason to believe that sti angula- 
tion IS not present, the element of surgical risk may justify withholding imme- 
diate operation if a useful alternative exists which will, at least temporarily, 
efficiently decompress the bowel In these circumstances the inhalation of 95 
jier cent oxygen should find its place 

We have used the inti agastric catheter routinely during the administration 
of oxygen m order to prevent the entrance of air or oxygen into the duodenum 
In no instance was it possible to attribute any substantial portion of the defla- 
tion accomplished to the amount of gas discharged through the catheter 

The suction method of Wangensteen has its own important indications, 
but It IS doubtful if It can be confidently relied upon in low obstructions to 

* Periods of rest out of the tent, unless unavoidable, should ordinarily not exceed 
one-half hour because the longer the patient breathes atmospheric air the more nitrogen 
enters the blood from the lung and the longer is the subsequent interval in the tent m 
order to desaturate the blood of its nitrogen 

7 




riNE, HERMANSON AND EREHLING was 

deflate the bowel just above the block, \\hicb is the part in most urgent need 
of it Nor can a suction tube answer the needs of a case in wbicb more than 
one level of obstiuction exists, such as may occui in peritonitis In this in- 
stance, as 111 anv closed loop obstiuction, the commonest example of vhicb 
IS obstiuction of the colon, the choice rests bctiieen an enterostomy oi 95 
per cent oxygen administeied through a helmet To the extent to which a 
suction tube, like an entei ostoni)’’ tube, removes fluid directly, it is jirobabl) 
supeiioi to the oxygen method, which can onl) do so mdiiectly by improving 
the absoiptive capacity of the bowel aftei jiartial deflation A combination 
of both methods applied simullaneousl}' should piovide the maximum benefit 
wdiich each has to ofiei 

In long standing obstiuction the bowel musculatuic is occasionally so 
paialyzed fiom oveisti etching that enterostomy fails to result in prompt 
evacuation Cheever^^ and others ba\e theiefoie, been led to eviscerate the 
gut and expiess the letaincd fluids and gas at the time of enterostoim There 
are those wdio feel that this is a heioic piocedure fi aught with danger In 
the controveisy concerning the lelatne meiits of lapid Aersus slow decom- 
pression, a middle giound may be taken by performing the enterostonij and 
supplementing it wuth the administration of 95 per cent ox\gcn If the cn- 
tei ostomy fails to function, the oxygen tent will at once initiate gradual de- 
flation and permit a more lapid recover) of muscle tone than might occui 
spontaneously If the entei ostomy functions too well, according to those 
wdio fear the effects of too sudden decompression, the tube can be clamped, 
gradual deflation accomplished more giadually by the ox\gen tent and the 
tube opened at a less critical period theieafter 

SPONTAXEOUS PNEUMATHORAX MEDIASTINAL I MPHVSEMA 

Expansion of the lung aftei spontaneous pneumathorax can occur onl) 
after the point of lupture is healed Until then withdiaw'al of an by needle 
and syringe fiom the pleural cavity is the simplest and most eftectue way in 
wdiich to lelieve the piessuie effects of pneumathorax 

In a previous paper^ w'e stated that “in the case of ^alvular pneumothoiax 
or mediastinal emphysema, foi which the method (95 per cent ox)gen 
inhalation) might be utilized, w'e encountei a diffeient situation than in 
instances of completely closed spaces containing an, 111 that the volume of 
gas entei mg the pleural or mediastinal space is not a limited quantity, but 
continues to increase as long as the point of entrance of an lemains open 
Substituting pme oxygen foi an as the lespiiatoiy gas w'ould result in the 
absorption of the nitrogen, but its immediate replacement by the entrance of 
oxygen thiough the defect w'ould offer no advantage in countei acting the 
pressuie effects of the gas, unless the late of entrance of the oxygen thiough 
the defect weie no gi eater than its late of absoiption by the tissues ’ The 
following cases aie illustiations 111 point 

Case 6 — Ruptnied Emphysematous Blcb^ Vahulai Pnciimatlioi ai — A male, age 
56, with a history of chronic productne cough for 30 jears, was suddenh seized with 

S 



Yolume 107 
umber 1 


AIR IN THE BODY TISSUES 


severe dyspnea while climbing stairs, five months before admission He remained dyspneic 
and bedridden seven weeks Thereafter he was able to be up, but walking a block or two 
caused breathlessness He entered the hospital with the complaint of dj'spnea on exertion 
Phi sical examination showed a dyspneic and orthopneic patient with a right-sided pneuma- 
thorax This was confiimed roentgenographically, which showed collapse of the entire right 
lung The remainder of the history and phj sical examination was negative or irrelevant 
The cause of the pneumathorax was considered to be due either to an acid fast bacillus 
infection, for which there was insufficient evidence, or rupture of an emphysematous bleb 

The special feature of the case was the persistence of the pneumathorax for five 
nioiiths Failure of the lung to reexpand after such a long interval implies that the 
original point of lupture had not healed If this be true, the oxygen in the air of the 
pleural space should approximate the oxygen content of alveolar air, which is i6 
per cent A gas analvsis of a sample from the first 500 cc of air withdrawn gave the 
following results Oxygen 3 2 per cent, carbon dioxide 8 8 pei cent, nitrogen 88 per cent — 
proportions moie nearly those ordinarily found m tissue spaces or what might be ex- 
pected m a closed pneumathorax But a closed pneumathorax of this duration should 
have allowed sufficient readjustment of cardiorespiratory mechanics to banish the dvspnea 
Furthermore, even if the collapsed lung had become “hepatized” or resisted expansion 
because of a viscid mtrabroiichial secretion, collapse of the chest wall, elevation of the 
diaphragm or ipsolateral displacement of the mediastinum should have occurred, but 
none of these was present according to the roentgenographic evidence The apparent con- 
tradiction of facts could be reconciled only on the assumption that a leak, probably of a 
valvular tjpe, must still be present but too slow to reflect the highei oxygen content of 
aheolar air 

Roentgenographic examination iniinediately after the removal of the first 500 cc of an , 
and on the next day of 900 cc , failed to show any expansion of the lung The patient, 
nevertheless, experienced subjective relief from dyspnea In these circumstances further 
withdrawal of air seemed worth trying, but the immediate withdrawal of the air, or even 
a large fraction, might tear and enlarge the original hole causing the pneumathorax Pre- 
caution to avoid this hazard suggested the use of 95 per cent oxygen to facilitate a gradual 
and uniformly distributed expansion of the lung Accordingly, the patient was given 
seven hours of continuous inhalations of 95 per cent oxygen, but only a very slight ex- 
pansion of the middle lobe resulted The insignificant effect on the volume of air m the 
pleural space produced by seven hours of oxygen therapy was not surprising, for although 
such a period of exposure to oxygen should give a measurable result m the intestine or 
m the subarachnoid space, the pleural cavity, like the stomach, offers a comparatively 
poor surface area per unit volume of nitrogen for absorption * 

The oxygen content of the intrapleural air after the seven hour oxygen period lose 
from 3 2 to 4 3 per cent Such an increase m oxygen percentage is consistent with a very 
slow leak, but it might also be consistent with a rise m oxygen saturation of the tissues 
as a result of breathing pure oxygen for seven hours Lacking clinical data on this aspect 
of the problem of gas diffusion, we proceeded as follows With the patient breathing at- 
mospheric air, 2,000 cc of air were withdrawn b> needle and syringe from the pleural 
cavitv Gas samples were taken for analysis during withdiawal of the 2,000 cc of 
air, at one-half hour, one hour, and two hours afterward, with resulting oxvgen con- 
centrations of 3 3, 3 6, 6 78, and 7 5 per cent, respectively We should now have been 
convinced of the presence of a leak had not a hissing sound been heard near the occluded 
needle left m place during these observations That the leak, if present, was m fact a 

* In a previous paper" calculation of the relative surface areas of the stomach and 
small intestine showed that the latter has an absorbing surface ten times that of the 
stomach Consequently a seven hour effect from 95 per cent oxygen on gases m the 
intestine would theoretically require 70 hours for the same result on gases in the stomach 
In this respect the pleural cavity is analogous to the stomach 

q 



FINE, HERMANSON AND FREHLING 


\nnalsof SurKorj 
January 1038 


slow one was suggested by a roentgenogram wliicb showed, for the first time, a sub- 
stantial expansion of the right upper lobe 

Ninety-five per cent oxvgen was then administered for 17 hours, with a further, 
though negligible, increase in the expansion of the upper lobe The expansion persisted 
for the following 24 hours and the lelief of the dyspnea, at rest, was almost complete 
It was decided to attempt a gradual and evenh distributed additional inflation of the 
lung by withdrawing 2,000 cc of the residual air in increments of 500 cc , and simul- 
taneously replacing it with equal increments of pure oxvgen Complete expansion of the 
upper lobe and partial expansion of the middle lobe resulted, and the vital capacity in- 
creased from II to 18 liters Since the patient vv as free of dj spnea and vv as for the 
first time able to be up and about vvathout respiratorj discomfort, nothing further was done 
Should the last procedure have failed to improve the symptoms, we had intended repeating 
it after first desaturating the blood of its nitrogen bj administration of 95 per cent 
oxjgen for several hours The patient remained well with moderate activity out of 
bed for the next five davs, but roentgcnographic examination on tbe daj of discharge 
showed partial recollapse of the right upper lobe He ’•eniained active and free of dis- 
comfort for the next four weeks onlj to relapse to a state of d> spnea on mild exertion 
The evidence is therefore clear that this is a case of valvular pncumathorax with a verj 
slow leak 

Comment — The details of this case deinonsti ate the correctness of tlie 
argument presented 111 the introductoiy paragiaph of this section We vveic 
only paitially successful in expanding this patient’s lung because the leak was 
still piesent after five months The slowness of the leak made possible vvhat- 
ev'cr tempoiary improvement we did secure The ox}gen inhalations did not, 
and could not, be expected to produce a significant expansion of tbe lung 
In anothei case of recent spontaneous pneumathoiax, oxygen inhalations 
proved quite useless because the leak was fai too gieat Within 20 minutes 
aftei applying the oxygen helmet, a gas sample from the pleuial space showed 
88 per cent oxygen, indicating the futility of attempting reexpansion of the 
lung by oxygen Foi the same leason the method pioved futile in the fol- 
lowing case of mediastinal emphysema 

Case 7 — Mediastinal Eiiiplivscnia, Bilatcial Pneumathoiax Siibcutaneous Em- 
physema, Foteign Body in Bionehus Ruptiiied Bionchiis — A female, age 3, aspirated 
a nut into her trachea the night before admission At entrj into tlie hospital she had 
wheezing respirations, and a roentgenogram showed hyperventilation of the left lung 
Bronchoscopy for extraction of the nut from the left primary bronchus was followed bj 
normal respiratory function of the left lung, but several hours later subcutaneous 
emphysema of the head and neck, and shortly thereafter of the entire bodv, appeared 
The temperature rose to 102“ F, the respirations varied from 40 to 60 per minute and 
the pulse rose to 160 She became cyanotic and was placed in a 95 per cent oxjgen 
tent with prompt relief of the cvanosis but not of the dyspnea The following morning 
the temperature was 105° F and roentgcnographic examination showed extensive, bilateral 
pneumathorax The subcutaneous emphvsema involved tbe whole body and was extremely 
tense Immediate aspiration of the air from the left pleural space resulted in prompt 
relief of the dyspnea Another roentgenogram showed considerable reexpansion of both 
lungs The subcutaneous tissues, which up to this moment had remained very tense, 
immediately and dramatically softened It was obvious that the leakage of air from 
the presumably ruptured bronchus was far too great to make the oxygen inhalations 
of any value except for the relief of the ejanosis Excellent oxvgenation of the tissues 
was evident, so that the tent was continued m use To pi event leaccumulation of air 
m the pleural spaces a trocar was inserted into the light pleural cavity, through an inter- 

10 



A ohmic 107 
Ivumlier 1 


AIR IN THE BODY TISSUES 


costal space in the avillar}'^ line, and connected to a rubber tube, the end of which dipped 
slightly beneath the level of a column of water Within 12 hours the patient’s tempeia- 
tuie fell to 100° F and the pulse to 130 Careful attention to the one-way water valve 
resulted in satisfactorj’ clinical improvement for 24 hours, following which the trocar 
became obstructed and the temperature again rose to 105° F Readjustment of the 
trocar was followed by an immediate fall in temperature to 100° F , the pulse to 120, and 
the respirations to 30 She seemed to be doing extremely well thereafter taking food, 
talking, cic The temperatuie, pulse and respnations did not rise markedly She was 
taken out of the oxvgen tent at intetvals with no resulting discomfort On the third 
night the child became cyanotic ^^hlle out of the tent and died suddenly 

Comment — This is an instance of mediastinal emphysema so fulminating 
in chaiactei as to pieclude any possibility of help by 95 per cent oxygen 
There was no effect whatever on the pneumathoiax 01 the subcutaneous em- 
pltysema until a vent foi the steadily accumulating air was made The oxy- 
gen tent sei ved onl)’- to oxygenate the blood moi e effectively than might have 
been possible in the oidinaiy oxygen tent It had the additional advantage 
over the lattei , as ah eady described m a previous paper, that by enclosing the 
head and neck only, the chest was accessible for nursing and special proce- 
dures such as thoiacotomy without depriving the cyanotic patient of a con- 
stant supply of OX} gen 

The staking fall in temperatuie, aftei lelease of the incaiceiated air in 
the chest and subcutaneous tissues, suggests that the fever may have been 
caused by inability to dissipate heat (i) via the expned air, owing to the 
pneumathorax , and (2) via the skin, owing possibly to interfeience with the 
circulation of the skin and subcutaneous tissues by the high tension of the 
gases in the mteistitial spaces 

POSTENCEPHALOGRAPHIC SYMPTOMS 

Following encephalography most patients experience a variable degree of 
headache, nausea and general indisposition lasting from 24 to 72 hours The 
disability may be severe and even prostrating Such patients form ideal sub- 
jects for the clinical evaluation of the theoretic principles underlying the mech- 
anism of the action of 95 per cent oxygen for the absorption of air from tissue 
spaces The air consists of a fixed volume distributed over a surface area 
(the cortical subarachnoid space and ventricles) which is relatively large for 
the amount of an requiring disposal, as compared with such conditions as 
pneumathorax or even gaseous distention of the intestine 

Following IS the first instance in which 95 per cent oxygen w^as tried for 
postencephalographic headache 

Case 8 — Epilepsy Postencephaloqiaphic Headache — An epileptic girl, age 26, 
had an air injection into the spinal subarachnoid space for encephalography at 2 00 p m 
May 24, 1935 Sodium amytal effected sleep for three hours, then she awoke with severe 
headache which persisted in spite of opiates At ii 45 am the following day, while 
still suffering with violent headache, she was placed in a 95 per cent oxygen helmet 
Thirty minutes later she felt much relieved and two hours later the headache had com- 
pletely disappeared 


11 



FINE, HERMANSON AND FREHLING \nnaisorsuacn 

T a nu n r j 1" ^ 

CoMMLNi — After this expeiience Schwab, Fine and MixteF’ studied the 
results of oxj'gen theiapy in 37 cases Although not all patients weie uni- 
foimly and completely relieved of the distiessing symptoms caused by the an 
injection, the beneficial eflfects were sufficiently stiikmg to justify adoption 
of the proceduie as a loutine therajreutic measuie 

A maximum of thiee hours of exposure to 95 per cent oxygen inhalations 
suffices foi the absoiption of the bulk of the injected air, as shown by roent- 
genogiams before and aftei the administiation of the oxygen There is a 
simultaneous disajipeai ance of headache and nausea The prophylactic use of 
95 per cent oxygen lesults in either complete or paitial avoidance of these 
symptoms A slight headache and mild nausea may persist in some instances, 
hut, as a rule, the patient is fit and able to be up within 24 hours, which is 
distinctly shortei than is the case foi patients who aie not given oxygen 
This procedure has been consideied unnecessaiy by those utili/ing oxygen 
instead of an for encephalogi aphy It is unfoi tunately not always possible to 
avoid the jDOStencephalogi aphic sMidiome b}' the use of oxygen, because nitro- 
gen enters the subaiachnoid space and the ventiicles from the blood during 
the time required foi the absoiption of the oxygen ' Schwab ct al^ have 
demonstrated the value of bieathing oxygen even w'hen oxygen is employed 
as the visualizing medium It is possible, how'e\er, that the extremely rapid 
diffusibility of the anesthetic gases lecently advocated by Aiid,i2 
oxygen-helium mixture of Barach, may supplant puie oxygen or atmospheric 
air as the visualizing agent To the extent to wdiich these new'er agents may 
succeed in avoiding the postencephalogiaphic symptoms, inhalation of 95 pei 
cent oxygen wall lie lendeied unnecessary 

AIR CMBOLISM 

Death from an embolism is due either to obstruction of the pulmonary 
capillaries from air enteiing the great veins in the neck 01 chest, or to air 
entering the coronary or ceiebral arteries from pulmonary veins, severed or 
torn, during intrathoracic opeiations To avoid such a catastiophe the only 
available prophylactic measure is the routine use of the Trendelenburg posi- 
tion suggested by Lihenthal On theoretic grounds an appioach to the prob- 
lem might be made by prepai mg patients, m w horn the danger of air embolus 
exists, so that the nitiogen fi action of the an bubbles shall diffuse out of the 
blood wath the maximum possible speed This can be done by desatuiating 
the blood of its nitiogen content by the use of a general anesthetic containing 
no nitrogen, such as cyclopiopane and pure oxygen, 01 by the inhalation of 
pure oxygen if the operation is performed under local anesthesia We have, 
howevei, failed to prolong the life of cats, wdio weie given a minimal lethal 
dose of intravenous air, by the piehminaiy administration of puie oxygen for 
one hour Whether oxygen will avail in an embolus into the ceiebral or 
coronary arteries is the subject of a current expeiimental investigation We 
have had no clinical experience with the use of oxygen foi this purpose 

12 



Aolurac 107 
^ umber 1 


AIR IN THE BODY TISSUES 


CONCLUSIONS 

(1) The inhalation of 95 pet cent oxygen, according to a technic pie- 
viously desciibed, piovides an effective method for deflation of the distended 
intestine vhen othei nonopeiative measures fail Ninety-five per cent oxygen 
IS a valuable agent whethei the distention is of functional or mechanical 
ongm In mechanical ileus it may be used to advantage befoie or aftei entei- 
ostomy IS performed 

(2) Ninety-five pei cent oxygen is of little 01 no value for the treatment 
of valvular pneumathorax 01 mediastinal emphysema so long as the size of 
the point of luptuie is of any consequence 

(3) Ninety-five pei cent oxygen inhalations pi event 01 lelieve the symp- 
toms following encephalogi aphy 

(4) None of the patients who bieathed 95 pei cent oxygen, foi the 
length of time nccessaiy to obtain theiapeutic effects, showed any signs 01 
symptoms of o\3gen poisoning Toxicity was avoided by inteiiupting the 
administration of the gas eveiy foiii to eight houis foi one-half houi 01 
longer 

5) The length of time necessary to obtain theiapeutic benefit fiom the 
admh«stration of 95 pei cent oxygen cannot be predicted in any given case 
It will vai)f 111 accordance with the \olume of an to be absoibed and the 
1 dative extent of the surface area available for absorption 

BIBLIOGRAPHY 

'Shall, L A Pei sonal Communication 

' Fine, J , Sears, J B , and Banks, B M The Effect of Oxygen Inhalation on Gaseous 
Distention of the Stomach and Small Intestine Am J of Dig Dis and Nutrition, 
361, 1935 

® Fine, J , Frehhng, S , and Starr, A Experimental Observations on the Effect of 
Ninety-five Per Cent Ox>gen on the Absorption of Air from the Body Tissues 
J of Thor Surg , 4, 635, 193S 

* Fine, J , Banks, B M , Sears, J B , and Hermanson, L The Treatment of Gaseous 
Distention of the Intestine by the Inhalation of Ninety-five Per cent Oxjgen An- 
nals OF SURGERV , 103, 375, 1936 

“ Schwab, R S , Fine, J , and Mixter, W J The Reduction of Post-Encephalographic 
Symptoms by the Inhalation of Ninety-five Per Cent Oxygen Arch Neur and 
Psychiatry, 37, 1271, 1937 

" Burgess, A M Oxygen Therapy A Modification of the Box Method Giving Ninety- 
five Per Cent Oxygen New England J Med In press 
' Binger, CAL, Faulkner, J M , and Moore, R L Oxygen Poisoning in Mammals 
J Exper Med , 45, 849, 1927 

® Savres, R R Quoted by Evans, J H , and Dushordwe, C J Further Observations 
on Oxygen Therapv in the Treatment of Pneumonia Anesth and Anal , 2, 193, 1932 
“ Barach, A L Use of Helium in the Treatment of Asthma and Obstructive Lesions of 
the Larynx and Trachea Am Int Med, 9, 739, 1935 
“Brown, H P, Jr Peristalsis and Peritonitis Annals of Surgery, ioo, 167, 1934 
“ Cheever, D pperative Evacuation of the Small Intestine in Paralytic Stasis New 
England J Med, 207, 1125, 1932 

'■Aird, R B Experimental Encephalography with Anesthetic Cases Arch Surg, 32, 

193, 1936 

” Lihenthal, H Thoracic Surgery 2 vols Saunders, 1925 

13 



RESULTS IN THE OPERATIVE TREATMENT OF MAJOR 
TRIGEMINAL NEURALGIA 

Francis C Grant, MD 

Pini,\Dri.PinA, Pa 

Trigeminal neuralgia does not endanger life Intermittent attacks of 
seveie paioxysmal pain in cheek, lip oi tongue, however, mteifeie Mith eating 
or drinking and lesult in loss of weight and strength Although suffeiers from 
this condition have hoped that death might bring lehef from the pain, and 
suicide from this cause is not unknown, nevertheless, many persons ha.\ e en- 
joyed lelative comfoit for many yeais m spite of it The abiupt remissions 
of the pain, so charactei istic of the seizures, ah\ ays lead to the hope that they 
will not recui 

Relief of the pain by suigical inteivention becomes, therefore, a question 
of expediency The mortality of such an operation must be carefully con- 
sidered Following surgeiy, can the patient be assuied of complete relief of 
pain ^ What ai e the possible sequelae of an operation ^ 

In this series the transtempoi al approach to the sensory loot of the 
tiigeminal nerve has been employed The late Dr Charles H Fiaziei devel- 
oped and perfected the practical details of this technic and operated upon the 
majoiity of the cases herein recorded Since he saw no added advantage in 
the suboccipital approach to the sensory loot, the recoids from this Clinic 
do not contain a sufficient number of cases operated upon by that technic to 
permit an opinion relative to compaiative results 

The problems to be consideied m the surgical treatment of major trigeminal 
neuralgia are (i) The operative moitality, (2) the type of operation to 
be perfoimed, whether the sensory root should be completely or partially 
sectioned and the motor loot preseived or cut, (3) the percentage of post- 
operative complications, such as keratitis, facial paralysis 01 diplopia due to 
injury of the adjacent third or sixth cranial neives, and (4) the peicentage 
of complete relief of pain without the appeal ance of annoying paiesthesias 
(i) Moitality — In this senes the transtemporal, or appioach to the 
sensory root thiough the middle fossa, was employed m 949 operations upon 
925 patients with 13 deaths, an operative mortality of i 36 pei cent In the 
first 100 cases m which the sensory root was cut the moitality was 4 per cent 
In dividing the whole senes into groups of 100, m two of these groups no 
fatalities occurred, in three the mortality was i per cent, and in two, 2 pei 
cent No fatalities occtined m 286 consecutive cases In the latest group 
from 900 to 949, no deaths followed opeiation 

This operative mortality has been stiictly consideied Any patient dying 
m the hospital, no matter how long after operation, and regardless of the 

14 



^ olumo 107 
Ivumber 1 


MAJOR TRIGEMINAL NEURALGIA 


cause of death, has been included Seven cases died of cerebial embolism oi 
apoplexy, three within 24 houis of opeiation, one on the fifth, one on the sixth, 
one on the ninth, and one on the fourteenth day postopeiatively Three 
patients died of postopei ative hemonhage and clot, two from meningitis and 
one from pneumonia (Table I) 


Tablf I 

PERCCNTA.GE OF MORTALITY 

949 Operations 925 Patients 

13 Deaths i 36% Mortality 

CAUSES or DEATH 

Cerebral embolism 7 

Hemorrhage 3 

Meningitis 2 

Pneumonia i 

That moie than half of the operative moitalities were the result of ceiebial 
vasculai accidents is doubtless due to the fact that 83 per cent of these 
patients weie 50 or over at the tune of operation As we have stated, major 
trigeminal neuralgia is a condition appearing in the latei yeais of life 
How'ever, an operative moitahty of i 36 per cent is evidence that even m 
elderly people opei ative relief foi the pain should not be refused unless 
leally serious contiaindications exist 

(2) Type of Opeiafwn to Be Pei jointed — Whether the sensoiy root 
should be completely or incompletely severed and the motor loot pieserved or 
cut can best be determined when the operative complications are consideied 
If pain IS not refeired to the first division, a subtotal avulsion, preserving pait 
at least of the fibers to the ophthalmic bianch, is indicated Fiequently cases 
are encountered where the tugger zone exists in the second 01 third division 
of the sensoiy area but not in the fiist To be sure, irritation of this trigger 
zone causes pam over the eye, but touching the eyebi ow or forehead is not fol- 
lowed by pam m the maxillaiy or mandibular branches Undei such circum- 
stances a subtotal sensoiy root section will relieve the pain, although anesthesia 
will not be complete in the skin aieas supplied by the ophthalmic blanch The 
coineal reflex will be preserved 

(3) Incidence of Postopei ative Compbcafwns — The two most feaied 
sequlae are keiatitis m the ipsilateral eye and facial paralysis Injuiy to the 
adjacent third 01 sixth nerve can occur, although moie likely to follow com- 
plete or incomplete avulsion of the gasseiian ganglion than section of the 
sensoiy root The third and sixth neives were injured on 24 occasions, or 2 5 
pel cent In ten of these cases a complete avulsion of the ganglion was effected 
so that if the sensory root is attacked behind the ganglion, the percentage of 
third and sixth neive involvement falls to i i per cent 

A paitial facial paialysis resulted in 33 cases, 01 3 4 per cent The record- 
ing of paitial facial paralysis has been noted very carefully Any facial 
paralysis, no matter how slight, has been noted All of these cases recovered 

15 



FRANCIS C GRANT 


Annals of Surccry 
Tunuar> 19'’S 


completely withm a yeai, 19 of them withm thice months of operation Six 
cases of complete facial paialysis, without lecoveiy, have been ohseived, 01 
o 65 pel cent 

Two causes foi facial paialysis following loot section have been sug- 
gested ^ When avulsion of the whole loot was practiced, it was believed that 
either the seventh nerve was damaged at the time the sensory root of the 
fifth was torn away or that following avulsion a hemori hage m the pons with 
damage to the nucleus of the seventh neive might have occuried We now 
believe that stiippmg the dura from the flooi of the skull just in front of 
the ganglion damages the petrosal vein 01 nerve The petiosal vein urns 
with the facial nerve in its canal As the dm a is elevated to expose the 
ganglion sheath the vein is toin 111 the facial canal and hemorrhage occurs 
compressing the seventh nerve m its passage through the bone The observa- 
tion of Gardner and Babbitt- that in a laige percentage of these cases of facial 
paralysis a hemorrhage m the middle eai with blackening of the drum-head 
could be noticed, supports this impiession The petrosal nei\e connects with 
the geniculate ganglion of the facial nerve Avulsion of this nerve m elevating 
the dura damages this ganglion and inteirupts the function of the seventh 
nei ve 

Eighty-five instances of keratitis resulted from complete or incomplete 
section of the sensory root Fifty-nine instances occuried in 353 cases of 
complete loot section, 01 16 7 pei cent In 590 cases of subtotal section of the 
sensory root 26 instances of keratitis were observed, or 4 4 per cent In five 
of these a partial facial paralysis resulted from the operation, preventing 
closuie of the eyelids and rendering the development of keiatitis almost in- 
evitable That the keiatitis following complete sensory loot section is moie 
severe than when subtotal section is performed is borne out by the fact that m 
the 59 instances of keratitis following complete section, in 15, closure of the 
eyelids was necessary to control the ulceration and in six cases enucleation 
of the eye was necessary because of the extensive infection In the 26 cases 
subsequent to subtotal section of the root, no eyes were sacrificed, and m but 
five was the keiatitis sufficiently severe to demand sutuie of the eyelids These 
figures support Frazier’s'® contention that incomplete root section would go 
far toward eliminating keratitis 

Table II 

THE INCIDENCE OE KERATITIS AND RECURRENCE 
AFTER TOTAL AND SUBTOTAL RESECTION OF THE SENSOR'i ROOT 
No Seventh 



of 

Third 

Sixth 

Nerve 

Com 


Eyes 

Lids 

Recur 


Cases 

Nerve 

Nerve 

(Partial) 

plete 

Keratitis 

Lost 

Sutured 

rences 

Complete sensory section 

359 

5 

13 

6 

4 

59 

(2 with 7th N ) 

6 

15 

7 over 
7 H yrs 

Incomplete sensory section 

590 

3 

3 

27 

2 

26 

(S with 7th N ) 

0 

5 

44 over 
4 yrs 


(4) Relief of Pain Pai esthesias and Recwience of Pam — Complete relief 
of the original pain followed 942 of these 949 operations, 01 99 2 per cent 

16 



Volume 107 
l^umber 1 


MAJOR TRIGEMINAL NEURALGIA 


In seven patients no lelief followed complete oi incomplete section These 
patients had precisely the same pain postopei atively as they had had before 
opeiation although complete facial anesthesia had been produced Obviously, 
major tiigeminal neuialgia was not the cause of the pain Atypical or minoi 
neuralgia was pi esent and opei ation should never have been performed This 
erroi in diagnosis can be avoided by injection with alcohol of the appropriate 
branch of the fifth nerve before opeiation 

Tabit III 

RELATION or PARESTHESIAS TO TYPE OE OPERATION 



Total 

Sensory 

and 

Total 

Motor 

Subtotal 

Sensory 

and 

Motor 

Subtotal 

Sensory 

and 

Motor 

Avulsion 

Section 

Second 

and 

Third 


Motor 

Spared 

Spared 

Cut 

Ganglion 

Nerves 


271 

67 

470 

107 

15 

19 

No relief of pain 

2 

I 

0 

2 

I 

I 

Severe paresthesia 

16 

I 

20 

3 

I 

0 

Mild paresthesia 

23 

ir 

48 

12 

2 

0 


One hundred thiity cases complained of paresthesias, (138 pel cent) 
Ninety-eight of these paresthesias weie mild (103 per cent), of the type m 
which the patient was peifectly satisfied with the result of the operation and 
had complete relief of pain, but noticed the numbness of the face, had a sense 
of mild temperatuie distuibance, heat or cold, itching, or a sensation of 
formication in the anesthetic aiea Thirty -two (34 pei cent), had seveie 
paresthesias, developed a difterent type of pain 111 the anesthetic area, usually 
burning and dull, and weie almost as uncomfortable aftei opeiation as they 
weie before Fourteen of these patients developed this tiouble within six 
weeks of opeiation, 18 within the first yeai postopei atively This pain was 
entiiely unlike the foimei stabbing, lancinating tic pain, but was a faiily 
continuous burning ache deep in the anesthetic area Four of these patients 
weie subjected to leoperation upon the sensory root without relief Fifteen 
had various operations directed against the sympathetic neive supply of the 
face, with very indiffeient results Only one was leheved who had been sub- 
jected to a caiotid sympathectomy 

Fifty-one cases of recurrence (53 pei cent), of tiue major trigeminal 
pain occuiied in this series, seven m 359 cases of complete sensoiy loot abla- 
tion (2 pel cent), and 44 among 590 patients in whom partial section was 
accomplished (74 pei cent) Of the seven cases the lecurrence appeared 
on SIX occasions in the fiist and once in the thud division Obviously, re- 
curience of pain was due to the fact that the ojieiatoi failed to sever com- 
pletely all the fibeis of the loot In the 44 cases pain reappeaied in the 
fiist division in 40, in the third in thiee and in the fiist and thud in one In 
the 40 cases the fibeis i mining to the fiist division were deliberately spared 
to preserve the corneal leflex and pi event keiatitis Thiity of these cases 
were subsequently relieved by supra-orbital avulsion and five by reopera- 

17 



FRANCIS C GRANT 


Annals of Surecry 
Januarj 103S 


tioii and complete severance o£ the sensory loot Five weie not leoperated 
upon The foui cases having lecunence in the third or first and third divi- 
sions were cases in which the oiiginal pain occurred entirely in the second 
division, and in whom only the middle third of the loot was severed These 
were relieved by reoperation and complete lOOt section 

In the seven cases of lecurience following what was thought to be com- 
plete sensoiy loot section, the pain leappeaied on an average of seven and 
one-half yeais aftei operation In the 44 cases of incomplete sensory root 
ablation the lecurrence occurred on an average of four years postoperatively 
In 17 patients the pain appeared on the opposite side after it had been 
lelieved on the side on wdiich it commenced These cases aie not included 
as recuirences Five w^ere relieved b)' bilateral opeiation, two by bilateral 
alcohol injection of the trigeminal branches m\olved, ten were operated 
upon on the side w'here the pain originated and the pain wdien it leappeared 
on the opposite side w'as checked by alcohol block An average of four 
years and four months elapsed betw ecu the relief of pain upon one side and its 
onset upon the other, the shoitest period being nine months, and the longest 
12 years Nine patients w'ere seen wnth typical tiigeminal neuralgia on both 
sides All had a radical operation performed on one side and in seven an 
alcohol block stopped the pain on the othei No deaths occurred in this series 
This gioup of patients is paiticularly impoitant because it emphasizes the 
fact that bilateral trigeminal neuialgia can be easily and permanently lelievcd 
by bilateral operations if the indications arise The improved technic of 
subtotal section and pieseivation of the motor loot preser\es the integiity of 
the muscles of the low'ei jaw and greatly reduces the chances of ocular com- 
plications 

The question has been raised whether any sensory fibers might be cai- 
ried by the motor root If such fibers w^ere present the pieservation of this 
loot might account foi subsequent paiesthesias in the anesthetic area of the 
face In 392 cases in this senes, m wdiich the motor root w-as sacrificed, dis- 
regarding for the moment whether the sensoiy root w^as completely or incom- 
pletely sectioned, theie lesulted 22 severe and 46 mild paresthesias, 01 5 S 
and II 7 pel cent lespectively Among 537 cases in wdnch the motoi root 
was spared, again regaidless of whether the sensory loot w'as completely 
or partially sectioned, there w^ere 21 seveie and 50 mild paiesthesias, or 3 9 
and 9 3 per cent 1 espectively Apparently preservation of the motor 1 oot does 
not increase the frequency of postopeiative paresthesias Ceitamly for func- 
tional reasons eveiy effort should be made to preserve it 

Another impoitant, but unfoi tunately seldom used, indication for block 
of the fifth nerve fibers exists besides trigeminal neuralgia Malignant dis- 
ease of the face, mouth or paranasal sinuses may often be a source of sevei e 
and constant pain By an alcoholic injection of the proper branch, 01, if the 
pain be widespread, by section of the sensory root, this pain can be lelieved 
And if this constant pain be relieved it is amazing how^ the morale of these 
patients is improved They can eat and sleep m comfort , they gam weight and 

18 



Volume 107 
Number 1 


MAJOR TRIGEMINAL NEURALGIA 


stiength The insertion of radium needles oi fulguration of the cancer does 
not distress them and they are ready and willing to undergo much more 
radical treatment I am suie that several patients rendered fiee fiom suffer- 
ing by tiigeminal block owe then final cure to the fact that an extensive and 
ladical attack upon the malignancy was undei taken m an anesthetic area In 
41 cases, sensory root section oi mtracianial section of the second and thud 
divisions was pei formed One death occuired in this series This gioup 
of cases is not included m making up the statistics for the operative lesults 
m major trigeminal neuialgia They are mentioned simply because much 
unnecessary suffering can be avoided if this use of tiigemmal block be kept 
m mind 


CONCLUSIONS 

A leview of the operative treatment of majoi tiigemmal neuralgia stiongly 
lemforces the opinion that subtotal section of the sensoiy loot with pieserva- 
tion of the motoi root is the piocedure of choice It is true that recuiience 
of pain can and does occui But the piotection that sparing the ophthalmic 
fibeis affoids the coinea, the reduction m the numbei and seventy of post- 
operative pai esthesias, more than makes up foi this single disadvantage If 
recurrence is noted, it almost always involves the fiist division Supia-orbital 
avulsion is an easy and cosmetically unobjectionable means of lehef When 
the age and general health of the gioup of patients suffeiing fiom majoi 
tiigemmal neuialgia is considered, an opeiative mortality of i 36 pei cent is 
extremely satisfactory Little or no reason seems to exist foi a refusal to 
attempt to leheve the pain of even the most debilitated of these suffeiers 
Temporary relief may fiist be afforded through an alcohol injection, then, 
when the patient has been 1 estored to health, permanent relief can be effected 
by subtotal section of the sensoiy root 

REFERENCES 

^ Dixon, S F On the Course of the Taste Fibers Edinburgh M J , 1, 395, 1897 
- Gardner, W J , and Babbitt, J A The Occurrence of Tympanic Hemorrhage Following 
the Radical Operation for the Relief of Trigeminal Neuralgia Ann Otol Rhinol 
and Laryngol , 38, 1040, 1929 

“Frazier, C H Subtotal Resection of Sensory Root for Relief of Major Trigeminal 
Neuralgia Arch Neurol and Psychiat, 13, 378, March, 1925 
* Grant, F C Relief of Pain by Neive Section JAMA, 92, 116, January 12, 1929 


19 



SPASMODIC TORTICOLLIS TREATED BY THE PLVSTIC 
REDUCTION OF [MOTOR FIBERS OF THE 
SPINAL ACCESSOR-i' NEID E 

iim’our or two cvsis 
CLi.AirxT B M vssox, [M D 

Nlw 'ioiik >, Y 

Dogliotti,^ in 1934, published ihe icsults of Ins operative tieatment on 
the facial neive for spasmodic movements of the facial muscles often referied 
to as a facial tic It w'as Ins theon that if the facial nerv'e on the affected 
side Avere scA'eied, the cential poition caicfull) split m half, and only one-half 
of the cential end sutured to the entire peripheral end of the nerve, harmful 
neive impulses could he reduced hy at least 50 per cent In so doing the 
nen'e-muscle-thresliold would be laiscd and such inipulses that did arise 
Avould he enough to supply tone to the faci.il muscles, proAide innerAation 
for any of the foimci movements of cxpiession hut not enough to cause 
disfiguring spasmodic movements In 1935, he dcmonstiatcd that Ins theoiy 
AA'as correct If this Avere successful in dealing AAitli the scAcnth cranial iierAC 
the question arose Y'ould it he successful in the case of the clcAenth cianial 
nerve in the treatment of spasmodic torticollis^ 

The author is aa^cII aAvaie of the commonlj used opciation for torticollis, 
such as SCA ei mg the first tin ce antci 101 and postei 101 cervical roots together 
Avith the intradural section of one 01 both spinal accessor} neives This opera- 
tion IS quite a ladical proceduic and aaIiiIc it is successful in ridding the 
patient of the troublesome spasmodic moAcments of the head and neck, it 
does rob the patient of a laige amount of poAACi fiom head, neck and shoulder 
moA'^ements One patient subjected to this operation A\as cuied of Ins tor- 
ticollis but unable to letuin to his foimci woik of piessing clothes because of 
the loss of trapezius poAver in the right shoulder It is further proposed that 
a complete section of the eleA-^enth neiA^e on one 01 both sides folloAA-ed by a 
partial lesuture may not he adequate in caciv case of spasmodic torticollis, 
but should be used first since it is a less serious operation and more conserA^a- 
tive The anatomy and operatiA'e technic are shoAvn m Figs i and 2 

The eleA^enth, or spinal accessoiy neu'e, consists of tAvo paits, the acces- 
soiy part to the vagus and the spinal portion The foimei is much smallei 
and is distributed to the phaiyngeal and supeiioi laiyngeal branches of the 
A^agus to supply m part the azygos UA'ulae, IcA^atoi palati muscles, and possibly 
some feAV fibers continue on to be distributed Avith the recurrent laryngeal 
nerA^e to supply most of the laryngeal muscles The spinal portion takes its 
origin from rootlets as fai doAvn as the seA'enth cerAucal segment of the cord 
Avhich, in turn, come from the anteiior giay substance of the coid These 
rootlets join and form a tiunk AA'hich increases in size as it ascends betAveen 
Submitted for publication June 16, 1937 

20 



^ olumo 107 
Jsumber 1 


SPASMODIC lORTICOLLIS 


the dentate ligaments and the anterior roots of the spinal neives This por- 
tion then enters the posterior fossa of the skull by way of the foiamen mag- 
num and leaves by way of the jugular foramen, receiving here a few filaments 
from the vagal accessory portion of the eleventh nerve At its exit from the 
jugular foramen, it passes backward, either in front oi behind the internal 
jugular vein, and descends obliquely behind the digastiic and stylohyoid 
muscle to the uppei part of the sternocleidomastoid muscle It pierces that 
muscle, and passes obliquely acioss the posterioi triangle, to teiminate in 



Facial llcrve 


. Spill at 
Accsssorv L 

Sfernoclct ci, 
inas-fotdHusct 





Trap£7.tus /• 
■'Fluscla-->->- 


Wi i'i\ 
hW:l. --W.^ 


Fig I — Drawing illustrating the anatomic relations of the spinal accessoo nerie to 
the other stiuctnres in the neck (After Wahasse Surgical Treatment, i, 887 ) 

the deep surface of the tiapezius muscle “ The neive is exposed and operated 
upon along that pait of its couise after leaving the lower border of the digas- 
tric muscle and before it enters the, sternocleidomastoid muscle (Fig i) 

CASE REPORTS 

Case I — St Vincent’s Hospital, No 15922 A W, age 39, single, electrician, 
admitted October 6 , 1935, operated upon October 17, 1935, and discharged, improved, 
October 23, 1935 Diagnosis Bilateral intermittent spastic toiticollis 

The disease began seven years ago and has been progressive, so that it interfered 
with his work, which consisted of walking along subway tracks to inspect the installa- 
tion of electrical equipment There was nothing in his work that necessitated turning 
his head in any one diiection He used stimulants moderately, and suffered no phj'sical 
or mental traumata before the onset of the torticollis 

In 1926, two years before the onset of symptoms of torticollis, the patient suffered 
a severe infection in the left nasal passage which spread to the throat and to both ears 

21 



CLEMENT B MASSON 


AnnaUof Surgery 
January 10!^ 


and ejes He ^^as ill for five weeks llie tvpe of orRanism was not ascertained, but 
if it can be substantiated that the disease Ins an infectious onset then tins widespread 
infection might be considered a possible etiologic factor of his torticollis During 1928, 
slight spontaneous movements of the head to the left occurred dail> Thev were painless 
and casilj controlled but graduallv, after a lapse of three or four vears, the spasms 
became more severe, accompanied with pain in the left side of the neck, and were almost 
entirelj out of his control A resection of the right sternocleidomastoid muscle, in 1933, 
did not improve his condition 

Physical Eiamiiiatwii, October 6, 1936, showed a robust man Ivmg quictlv in bed 
without distress or pain 'Iherc were intermittent involuntarv contractions of all the 
muscles on the left side of the neck and, to a lesser extent, the deep muscles on the right 
side Espcciallv upon effort, such as sitting up, talking and walking, irregular move- 
ments of the left trapezius and sternocleidomastoid muscle and deeper groups would occur 
followed soon bv similar muscle groups on the right side Bilateral involvement was 
evadent with the left side affected first, and subseqiicntlv involuntarv contractions occurred 
111 muscles of the opposite side of the neck When in a spasm the occiput was directed 
toward the left shoulder and the cbm tipvvaid and to the right There was a noticeable 
hj'pertrophv of the left sternocleidomastoid and trapezius muscles, and a verv evident 
deformity was present on the right side as a result of a previous operation, at which 
the origin of the sternocleidomastoid muscle was severed No other neurologic signs 
were found A blood count, uranahsis and blood Kahn test were all negative 

A transection of the left, eleventh nerve was proposed with resection of one-half 
of the proximal end followed bv suture of the remaining onc-lialf into the entire periph- 
eral end (Fig 2B) 

Opel at toil — October 17, 1935 Local anesthesia Oblique incision on the left side, 
paralleling the anterior border of the sternocleidomastoid muscle, which was followed 
dovv'nvvard for a distance of 10 cm The eleventh nerve was found entering the mesial 
surface of this muscle It was traced upward for 3 to 4 cm and found to consist of 
the entire trunk of the nerve, determined because of the absence of branches and bv 
the effect of faradic stimulation The nerve was severed and a portion of the proximal 
end of the nerve stripped upward The remaining portion, approximatclj one-half, 
was sutured into the entire distal end with five black silk sutures Ibcrebj, the num- 
ber of functioning axoncs entering the peripheral end of the nerve was reduced bv 
one-half 

As a result there was a paraljsis of the left sternocleidomastoid, and an almost com- 
plete paralvsis of the left trapezius muscle It is to be noted that the trapezius muscle 
was not entirel} thrown out of function, since the upper cervical nerves also contribute 
to the innervation of this muscle According to the patient, after three months, these 
muscles began to function again 

Follow-up — ^July 18, 1936 It was noted that the head was held m a more normal 
position He stated that three months after operation there w'as a noticeable return of 
power in the left sternocleidomastoid muscle, and that “it would move indepcndentlv,” 
■te, rhythmic jerks took place at times but not powerful enough to move his head The 
trapezius movements are more powerful and tend to pull the head back a little, so that 
his chin is held higher than normal It was planned to canj out a similar operation on 
the right side to lessen the trapezius pull However, the patient did not return, as he 
felt so greatly improved 

Case 2 — Neurological Institute, No 16685 E J S , age 45, married, clerk, 
was first seen in the clinic, July 14, 1933, complaining of “spasm of the neck and pain 
in the left shoulder ” The onset in May, 1933, was gradual and the course progressive 
The contractions were especially noted when walking A year ago, he became greatly 
upset, emotionally, upon being discharged from an Insurance Companj, where he had 
been employed for 20 jears This episode certainly furnished a suitable mental back- 
ground for the development of a functional nervous disease At this time, while driving 

22 



Volume 107 
Number 1 


SPASMODIC TORTICOLLIS 


a car, he could control the movements of his head and neck by placing his hand on 
the left trapezius muscle There was no acute infection preceding the onset of the 
torticollis, but he was sick for a week, in 1919, with influenza During this illness 
his temperature reached ioi° F, but there was no diplopia or delirium He smokes 
half of a package of cigarettes a day and takes no other stimulants Frequently the 
patient’s sleep is distuibed by screaming Howevei, he is not conscious of his out- 
cries His family life is normal and he has one child, age 13 

Physical Examination — There were present irregular spasms of the left sternocleido- 
mastoid, platysma and trapezius muscles, most pronounced while walking and less evi- 
dent while lying down His occiput was drawn to the right, pointing the chin upward 
to the left Theie was hypertrophy of the right sternocleidomastoid and trapezius muscle 
All laboiatory tests w^ere negative Diagnosis Mild spasmodic torticollis, on an organic 
basis, which improved maikedly with baking, faradism and deep massage 

The patient w'as readmitted October 
3i> 1935. when it was found that the 
spasms of the right neck muscles had be- 
come more pronounced and, at times, very 
persistent Examination show'ed the oc- 
ciput rotated to the right and backward 
which pointed the chin to the left The 
right shoulder was arched during the 
spasms There w'as pronounced hyper- 
trophy of the right sternocleidomastoid 
and scapular division of the trapezius 
muscle With a little emotional activity, 
these muscles jerked violently, turning the 
head through 90° from right to left Dur- 
ing this period of hospitalization, a very 
thorough attack from a mental standpoint 
was made upon his torticollis, but with no 
more than a very temporary effect upon 
the spasmodic movements 

OpeiaUon — ^January 8, 1936 A sec- 
tion of the right spinal accessory nerve 
W'as accomplished The proximal end con- 
sisting of one-half of the total nerve w'as 
sutured into the entire distal end of the 
nerve (Fig 2B) Postoperatively, there 
was a paralysis of the right sternocleidomastoid and trapezius muscles The position of his 
head was more erect and he felt better He returned, February 20, 1936, to the surgical 
follow-up clinic and stated he was definitely improving On attempting to walk, there was 
a tendency for the former distorted position of the head and neck to recur It was thought 
advisable to operate, m addition, on the first, second, and third cervical roots, in order to 
accomplish a better result In June, 1936, the patient returned greatly improved, was able 
to hold his head erect, and power had returned m the right sternocleidomastoid and 
trapezius muscles There was a little increased tone in the sternocleidomastoid muscle 
but the irregular jerky movements were not present The involuntary movements in the 
right sternocleidomastoid and trapezius muscles when they did occur, induced by walking, 
were so weak that they did not affect the position of his head 

CONCLUSIONS 

A conservative method of ti eating spasmodic torticollis has been shown to 
give satisfactory results m two cases The method is similar to that used by 

23 



Oiis.iid.tf of cem- I 

vsftcAed And. \/f 
SutuiociTo ad" ^ 
fascia -> 


One half cF the' , 
Csntjbat end. SU- 
twi edto the sn- 
tiie yeriyhraat 


Tig 2 — Drawing showing the technic of the sui 
gical procedure emplo>ed in Cases i and 2 



CLEMENT B MASSON 


AnnaKof SurKcry 
January 19J8 


Doghotti in treating the facial neive foi facial spasms of an organic nature 
namely, by a plastic reduction of motor fibers The operation is less hazard- 
ous than cervical root and mtiadural, spinal accessoiy nerve section If, in 
any case, a satisfactory result is not obtained, one may always resort to the 
lattei proceduie which stops spasmodic movements, but deprives the patient 
of considerable motor poM ei in the neck and shoulders 

REFERENCES 

Doghotti, A M Guenson clu sinsme cssenticl du ncrf facial par reduction plastiquc dcs 
fibres niotices Extrait dcs Bulletins ct Menioires dc h Socictc Nationalc do Chiriigic 
Seance du ii Juillet, 1934, 'lome LX, No 25 
" Gray’s Anatomj Spitzka New American Edition, page 1009 


24 



COMPLETE SYMPATHETIC DENERVATION OF THE UPPER 

EXTREMITY 

Albert Kentz, M D , Ph D , William F Alexander, M S 

St Louis, Mo 

AND 

Cha-Rles L Furcolo, M D 

Springfield, Mass 

FHO\I THE DEP\RTMLNT OF MICRO IVVTOMF ST LOUIS UNI\ ERSITT SCHOOL OF MI DICIVF ST LOUIS MO 

Sympathetic denervation of the extiemities has become a lecognized 
theiapeutic measme m the suigical tieatment of peiipheral vascular disease 
The suigical pioceduies fot sympathetic deneivation of the upper extiemity 
which have been employed most commonly dm mg recent yeais involve ex- 
tiipation of a poition of the s)'’mpathetic trunk including the mfeiior ceivical 
ganglion and the fiist and second thoiacic segments These procedures aie 
based on cuiient knowledge legaiding the souices of the sympathetic fibeis 
which supply the upper extiemity These fibers leave the sympathetic tiunk 
mainly through gray communicating rami which aiise from the infeiior and 
middle ceivical sympathetic ganglia and join the neives which make up the 
biachial plexus In a laige peicentage of cases, sympathetic fibeis which 
arise below the infeiioi ceivical ganglion also join the biachial plexus, mainly 
via an mtrathoiacic ramus of the second thoiacic neive Avhich joins the 
fiist (Kuntz,^ 1927) All the nerves extending from the biachial plexus 
into the upper extiemity include sympathetic fibeis The pieganglionic neu- 
rons involved 111 the sympathetic innervation of the uppei extremity are 
located in the uppei thoracic region of the spinal cord, beginning with the 
first thoiacic segment and extending downwaid at least as fai as the third 
01 fourth 

The impoitance of complete sympathetic deneivation of the uppei ex- 
tiemity m the surgical tieatment of diseases in which marked peiipheial vaso- 
constiiction is a majoi factor has been emphasized lepeatedly Unsatis- 
factory clinical lesults due to incomplete sympathetic denervation of the 
extiemity have also been lepoited in several instances 

Extirpation of the portion of the sympathetic tiunk including the mfeiioi 
cervical ganglion and the first and second thoracic segments, commonly re- 
ferred to as cervicothoracic sympathectomy, effects complete functional elimi- 
nation of all sympathetic fibers which supply the upper extremity except 
possibly a few, in certain cases, which enter the veitebral canal below the 
second thoiacic segment, ascend m it and join the anterioi roots of neives 
which contiibute to the brachial plexus This has not been demonstrated ana- 
tomically m man, but has been demonstiated m cats by the use of experi- 

Submitted for publication March 2, 1937 

25 



KUNTZ, ALEXANDER AND FURCOLO 


Annals of Surgorj 
January 1938 


mental anatomic methods (Kuntz/ 1936) Observations reported following 
cei vicothoracic sympathectomy m certain clinical cases also suggest that m 
man sympathetic fibers may enter the upper extremity from sources othei 
than the ceivical and fiist and second thoracic segments of the sympathetic 
tiunk (Levy-Simpson, et al Telford,'' 1934) 

Cervicothoracic sympathectomy not only effects functional elimination of 
the sympathetic mneivation of the upper extiemity, but also of the correspond- 
ing side of the head and neck, due to interruption of the pi eganghonic fibers 
to the middle and superioi cervical ganglia, thus producing an unwanted 
Hoinei’s syndrome and abolishing perspiration in the area affected It also 
results in degeneration of the majority of the sympathetic fibers m the upper 
extiemity, due to lemoval of the ganglion cells from which they arise Fol- 
lowing degeneration of the vasomotor fibers, the vascular musculatuie becomes 
sensitized to adienm, consequently, its tonus is maikedly increased m re- 
sponse to adienm in the ciiculatmg blood (Smithwick, Freeman and White^) 
The clinical lesults of sympathetic denervation, m many cases in which the 
opei ative ti eatment has been applied to both the upper and lower exti emities, 
have been less satisfactoiy m the uppei extremities than in the lowei This 
probably can be explained most satisfactorily on the assumption that the 
vascular musculatui e m the upper extremity became hypersensitive to adrenin 
111 the circulating blood following degeneration of the vasomotoi fibeis Sym- 
pathetic denervation of the lower extremity by the surgical piocedure usually 
employed does not involve extiipation of the ganglion cells from which the 
vasomotor fibers to the extiemity arise, consequently, the vascular muscula- 
ture in the lower extremity does not become sensitized to adrenin 

In order to avoid the unwanted eflfects of extiipation of the inferior cer- 
vical and upper thoracic sympathetic ganglia, paiticularly Horner’s syndiome 
and sensitization of the vascular musculature to adrenin, but still secure func- 
tional sympathetic denervation of the uppei extremity, Telford," in 1935, 
advised section of the white communicating rami of the second and thud 
thoracic nerves and crushing and division of the sympathetic trunk belov 
the third thoracic ganglion, leaving the white communicating ramus of the 
fiist thoracic nerve, the sympathetic trunk ganglia and the gray communicat- 
ing rami which join the nerves making up the brachial plexus intact Smith- 
wick" has desciibed an operative procedure designed to effect functional 
sympathetic denervation of the upper extiemity which differs somewhat from 
that outlined by Telford In this operation, the roots of the second and 
thud thoiacic nerves aie divided pioximal to the communicating lami and a 
short segment of each nerve is resected The sympathetic trunk also is di- 
vided below the level of the third thoracic neive, but none of the sympathetic 
trunk ganglia are lemoved and the gray communicating rami joining the 
nerves which make up the brachial plexus remain intact This operation in- 
terrupts none of the preganglionic components of the first thoracic nerve 
Its early clinical results m ii patients, according to Smithwick, indicate that 

26 



Volume 107 
Number 1 


COMPLETE DENERVATION OF ARM 


few if any piegangliomc components of the first thoracic neive aie involved 
in the sympathetic innervation of the hand 

The assumption that preganglionic components of the first thoiacic neive 
play no significant part in the sympathetic innervation of the uppei extremity 
IS not m accord with curient teaching In view of this fact and the impoi- 
tance of complete functional sympathetic deneivation of the uppei extremity 
111 the suigical tieatment of peiipheial vascular disease, it has seemed desnable 
to obtain additional data regaiding the distribution of the piegangliomc 
components of the uppei thoracic neives by means of animal experimentation 

Methods and Results — Prepaiations for the anatomic study of the dis- 
tribution of piegangliomc fibers m the inferioi ceivical ganglion have been 
obtained from cats Some of these animals had been subjected to unilateral 
section of the loots of the second and thud thoracic neives proximal to 
the communicating rami, resection of a short segment of each of these nerves 
and division of the sympathetic trunk below the level of the third thoiacic 
nerve The otheis had been subjected to unilateral section of the loots of 
the first thoracic nerve and lesection of a short segment of this nerve, includ- 
ing the ongm of its white communicating ramus The sympathetic trunk 
lemamed intact These operations were carried out under aseptic condi- 
tions and the animals were allowed to live long enough (14 to 21 days) to 
insuie degeneiation of all interrupted preganglionic fibers The infeiior 
cervical ganglia weie then prepared for study by means of a modified Cajal 
silvei technic 

Pieparations of the inferior cervical ganglia taken from the animals which 
had been subjected to the first operative piocedure outlined above show com- 
plete degeneration of all the preganglionic fibers enteimg the ganglion at its 
inferioi pole The major portion of the intercellular fiber complex in the 
poition of the ganglion supplied by these fibers also has undergone degenera- 
tion, and the portion of the sympathetic trunk above the inferioi cervical 
ganglion shows many degenerated fibers, indicating that many preganglionic 
fibers which aiise below the level of the fiist thoracic segment continue up- 
ward in the cervical portion of the sjmipathetic trunk The portion of the 
inferior ceivical ganglion adjacent to the area through which the white ramus 
of the first thoracic nerve enteis it shows no evidence of fiber degeneration 
(Fig i) The mtercellulai fibei complex in this portion of the ganglion is 
entirely compaiable to that of the inferioi cervical ganglion on the unoperated 
side 

Preparations of the inferioi cervical ganglia taken from the animals which 
had been subjected to the second operative proceduie outlined above show 
complete degeneration of all the preganglionic fibers entering the ganglion 
through the white communicating ramus of the first thoracic nerve The 
major portion of the intercellular fiber complex m the portion of the ganglion 
adjacent to this ramus (Fig 2) and a large percentage of the fibers m the 
portion of the sympathetic trunk above the infeiior cervical ganglion also 
have undergone degeneiation At the inferior pole and in the adjacent por- 

27 



KUNTZ, ALEXANDER AND FURCOLO 


Annals of Surteo 
January 1DJ8 


tions of the ganglion the inteicellulai fiber complex is entirely comparable 
to that m the corresponding portions of the ganglion on the unoperated side 
The above observations support the cuirent view that the preganglionic 
fibeis which effect synaptic connections with ganglion cells m the inferioi 
cervical ganglion include components of the fiist thoracic as well as com- 
ponents of lower thoracic neives The portion of the ganglion in which the 
inteicellulai fiber complex undeigoes degeneration following section of the 
white ramus of the fiist thoracic nerve, fuithermoie, includes laige numbers 
of ganglion cells Some preganglionic fibeis of lowei origin piobably effect 



Tio I — Dn«ing fiom n section of tlic in 
ferior cenical ganglion of the cot adjocent to 
the area through tvhich the white communicit 
ing ramus of the first thoracic nerte enters it, 
following degeneration of all iireganglioiuc fibers 
arising below the first thoracic segment 



Tig 2 — Drawing from a section of the iii 
ferior cenical ganglion of the cat adjacent to 
the area through which the white commumcat 
iiig ramus of the first thoracic ner\e enters it 
following degeneration of onlj the pregangliomc 
fibers of the latter ramus 


S3mai3tic connections m this portion of the ganglion, but the numbei of 
ganglion cells with which pi eganghonic components of the fiist thoracic neive 
effect synaptic connections obviously is laige The distiibution within the 
ganglion of the axons arising fiom these ganglion cells, furthermoie, indi- 
cates that many of them enter gray lami which join the neives which make 
up the brachial plexus 

Physiologic expel iments m which the effects on the eye and the blood ves- 
sels and sweat glands of the uppei extremity of diiect stimulation of the pre- 
ganglionic fibeis in the first, second and third thoiacic neives weie observed 
have been carried out on both cats and dogs With the animal under anes- 
thesia, the uppei three or foui thoracic nerves were exposed by incision lateral 
to the vertebral column and resection of the coi responding ribs A galvanic 
cuirent of threshold strength for the preganglionic fibers was used as stimulus 
The electiode was applied at the cut surface of the distal portion of the divided 
ventral root In case of the second and third thoracic neives, it was some- 

28 



Volume lot 
>iumber 1 


COMPLETE DENERVATION OF ARM 


times applied at the cut surface of the distal poition of the ventral root and 
sometimes to the white communicating ramus 

Stimulation of the ventral root of either the first or the second thoracic 
nerve consistently resulted m dilatation of the pupil and retraction of the 
nictitating membiane Stimulation of the vential root of the thud thoracic 
nerve lesulted m letraction of the nictitating membiane but not m dilatation 
of the pupil Section of the loots of eithei the fiist oi the second thoiacic 
nerve alone or its white communicating lamus did not produce Hornei’s 
syndrome, but section of the loots oi white communicating lami of both 
these neives consistently lesulted in a complete Homer’s syndrome 

Stimulation of the ventral root of either the fiist, the second or the thud 
thoiacic neive lesulted in activation of sweat glands in the paw pads and 
constiiction of cutaneous vessels of the foot The exact distiibution of the 
sweat glands and cutaneous vessels affected by stimulation of each nerve sepa- 
rately has not been determined It is significant, however, that sweating 
elicited by stimulation of the preganglionic fibers of the fiist thoracic neive was 
apparent on all pai ts of the paw pads 

In ceitain expeiiments, using both cats and dogs, the distal poition of the 
ulnar aiteiy was exposed and its leactions to stimulation of the ventral roots 
of the fiist and second thoracic neives sepaiately were observed under low 
magnification Stimulation of either root resulted m maiked constriction of 
the aitery 

In one senes of expeiiments earned out on dogs, kymogiaphic lecoids 
weie made of the changes m blood pressure m the distal poition of the ulnai 
artery in response to stimulation of the vential root of the first thoiacic nerve 
Simultaneous lecoids of the geneial blood piessiire also weie made These 
recoids indicate an initial inciease followed by a deciease in piessure m the 
ulnar aiteiy, without any change in the geneial blood pressure The initial 
mciease m pressuie m the ulnai artery obviously is due to the conti action of 
its musculatuie in i espouse to stimulation of preganglionic components of 
the fiist thoiacic nerve, the deciease in pressure following the initial increase 
IS probably due to the reduction in the volume of the blood flowing through 
the constiicted artery 

Comment — The anatomic data set foith above shows clearly that pie- 
ganghonic components of the fiist and lowei thoiacic nerves effect synaptic 
connections m the inferior ceivical sympathetic ganglion and that the fibers 
which extend upward in the cervical sympathetic trunk include preganglionic 
components of the first and lower thoiacic nerves This is m accoid with cui- 
lent anatomic teaching The lesponses of the ins to stimulation of the ventral 
loots of the first and second thoracic neives indicate that both these nerves 
include preganglionic fibers involved in the sympathetic innervation of the 
eye This also is in accoid with current teaching The absence of Horner’s 
syndrome following section of the roots of either the fiist or the second 
thoracic neive alone indicates that the normal tonus of the dilator pupillae 
muscle may be maintained thiough the preganglionic components of either of 

29 



KUNTZ, ALEXANDER AND FURCOLO 


Annals of Surcen 
January 1033 


these nerves Both the anatomic and the physiologic findings indicate that 
preganglionic components of the first thoiacic nerve play an important role 
m the sympathetic innervation of the upper extremit}'' both with regard to 
the sweat glands and the vascular musculature 

Comparative anatomic and physiologic data, as far as such data ai e avail- 
able, indicate a close correspondence in the distribution of the preganglionic 
components of the thoiacic neives in the carmvoia and man If the distribu- 
tion of the preganglionic fibers of the first thoracic nerve in man corresponds 
to the distiibution of these fibers iii the cat and the dog, sympathetic denerva- 


^ympalhetic Irunk 

r\ 


Middle \Vi 
cervical 
ganglion- -j- 

f ' )’ 

Ansa frM 
subclovia-pf ■i 




-V,- Romus of Til 


M joining T I 

/ in 


re VC 

irc c'"! \< dnc "vfv , Sympolhelic frunk 

Communicoling romi 


Tig 3 — Dnwiiig from i Irannn dissection illustratiiiK the 
amtomic relationships of the sympathetic trunk and commiinicat 
ing rami to the nerves of the brachial plexus 

tion of the blood vessels of the upper extiemity m man obviously cannot be 
accomplished by any operative proceduie which leaves intact the first thoracic 
neive with its communicating ramus and the inferior cervical ganglion with 
the giay communicating rami which connect it with the neives which make 
up the biachial plexus (Fig 3) 

In view of the damaging effect of sensitization to adienm of the vasculai 
musculature following degeneiation of the postganglionic vasomotor fibers 
111 cases of vascular disease in the upper extremity, it must be legarded as 
advantageous to leave the sympathetic trunk ganglia vt situ m older to avoid 
interruption of the gray communicating rami which join the nerves making 
up the brachial plexus Interruption o,f the white communicating ramus of 
the fiist thoiacic nerve, m addition to interruption of the white communicating 
lamus of the second thoracic nerve and division of the sympathetic trunk 

30 



Volume 107 
Number 1 


COMPLETE DENERVATION OF ARM 


below the level of the second thoiacic ganglion, is essential to insure com- 
plete functional sympathetic denei vation of the upper exti emity If the sym- 
pathetic tiunk IS divided between the second and third thoracic ganglia, sec- 
tion of the communicating ramus of the third thoiacic neive, according to our 
piesent knowledge, can have no effect m the sympathetic denervation of the 
upper extremity unless fibeis aiising m the third thoracic ganglion ascend m 
the leitebral canal and join neives which contiibute to the brachial plexus 
Summary — The preganglionic fibeis which effect synaptic connections m 
the inferior ceivical sympathetic ganglion include components of the fiist 
and lowei thoracic nerves Preganglionic components of the fiist and lowei 
thoiacic nerves also extend upward in the cervical poition of the sympathetic 
trunk These findings are in agreement with curient teaching 

The axons of infeiior cervical ganglion cells with which preganglionic 
components of the first thoracic nerve effect synaptic connections are rela- 
tively widely distributed in the upper extremity, paiticularly its distal poitions, 
both to the vasculai musculature and the sweat glands If the inferior cervical 
sympathetic ganglion and the giay communicating lami connecting it with 
the brachial plexus are left intact, complete functional sympathetic denei vation 
of the uppei extremity cannot be effected without mteriuption of the white 
communicating ramus of the fiist thoracic nerve 

REFERENCES 

^Kuntz, A Distribution of the Sympathetic Rami to the Brachial Plexus Its Re- 
lation to Sympathectomy Affecting the Upper Extremity Arch Surg , 15, 871- 
877, 1927 

The Autonomic Nervous System, 2nd ed Lea and Febiger Co , Philadelphia, 

1934 

The Autonomic Nervous System, Essential Anatomy, JAMA, 106, 345- 

350, 1936 

- Levy-Simpson, S , Brown, G E , and Adson, A W Observations on the Etiologic 
Mechanism in Raynaud’s Disease Proc Staff Meet, Majo Chn , 5, 295-298, 1930 
“Smithwick, R H Modified Dorsal Sympathectomy for Vascular Spasm (Raynaud’s 
Disease of the Upper Extremity Annals or Surgery, 104, 339-350, 1936 
* Smithwick, R H , Freeman, N E , and White, J C Effect of Epinephrine on the 
Sympathectomized Human Extremity Arch Surg , 29, 759-767, 1934 
“ Telford, E D Sympathectomy A Review of One Hundred Operations Lancet, 444- 
446, 1934 

The Technique of Sympathectomy Brit Jour Surg, 23, 448-450, 1935 


31 



THE PROPHYLACTIC AND ACTIVE USE OF ZINC PEROXIDE IN 
FOUL SMELLING MOUTH AND NECK INFECTIONS’^ 

Frank L Melenea, M D 

New York N \ 

There aie ceitain infections of the mucous meinbiane of the mouth and 
thioat in whose pathogenesis anaejohic and mici o-aci opiulic oiganisnis play 
a piomment pait These organisms aie frequently found m mouths which 
aie not kept m good h3'gienic condition They may also be found m mouths 
which aie apparently normal, but are more often ohseived where there is 
dental caries, oi loot infection, or wheie there is persistent irritation of the 
gums from deposits upon the teeth These organisms frequently take part in 
the inflammatory process in the gums as m cases of pyoi rhea, oi in the ulcei - 
ated infections of the tongue and cheek, commonly called stomatitis Whether 
they aie primary invaders of normal tissue like the hemolytic streptococcus 
01 the diphtheria bacillus is not knoAvn, but thej" fiequentl^ invade the tissues 
when theie has been a break m the pi unary defenses of the mucous mem- 
brane, caused eithei by a foreign body such as a splinter, fish bone, tooth oi 
a fractured jaw, oi following an operative piocedure such as tonsillectomy or 
tooth extraction When such an invasion takes place they may simply pro- 
duce a diffuse inflammation of the submucous tissues oi they may cause 
necrotic ulcers wdiich desti oy large poi tions of the mucous membi ane, or they 
may course through the lymphatics to the cervical lymph nodes, or they may 
spread by direct extension through the tissues causing extensive necrosis either 
downward through the floor of the mouth and into the neck oi upw'ard into 
the face, not infrequently extending into the orbit or beneath the temporal 
muscle into the pericranial tissues 

If the infection manifests itself as a seveie cellulitis of the submucous tis- 
sues, either of the mouth or of the throat, it gives the typical pictui e described 
by PlauF and by Vincent,^ common^ knowui as “Vincent’s angina ’’ If the 
germs invade the floor of the mouth and burrow dowm into the tissues of the 
neck or invade the lymph nodes of the neck, they may tin eaten or produce a 
closure of the glottis which is called “Ludwig’s angina 

Diffeiential Diagnosis — Mild foims of inflammation of the mucous mem- 
brane of the mouth occui in patients aftei prolonged vomiting or prolonged 
staivation The digestive action of gastiic juice may produce ulcers in the 
mouth or on the lips which do not peisist long after the vomiting ceases 
In starvation cases the stomatitis has been attributed to lack of vitamins, and 
this IS confirmed by the favorable response following the administration of 
these substances in many cases Smeais and cultuies fiom these lesions usu- 
ally do not reveal the activity of aiiaeiobic oi mia o-aei ophihc oiganisnis 
* Read before the New York Surgical Society, February lO, 1937 Submitted for 
publication April 22, 1937 


32 



Volume 107 
Number 1 


ZINC PEROXIDE IN INFECTIONS 


The hemolytic sti eptococcus commonly produces a diffuse cellulitis of the 
tissues of the thioat and not mfiequently spreads to the neck By the 
rapid development of edema frequently tin eatens oi pi oduces a closure of the 
glottis, but there is usually no necrosis of the mucous membrane oi of the 
deep tissues of the neck, and the odoi of the exudate is not foul Infec- 
tions m which the auaeiohic o) ima o-aet opJnhc otgamsms are playing the 
dominant idle, lesult m both neciosis of the mucous membrane and necrosis 
of the deepei tissues, and the exudate has a rathei characteiistic and very 
offensive putrid odoi Usually the hemotytic sti eptococcus infections pioduce 
a high fever and a profound intoxication, while the infections due to the 
aiiaeiobic and mia o-aei ophilic o} gamsms produce less fever and less 
intoxication, and a more distiessing and extensive destiuction of tissue The 
hemolytic sti eptococcus infections are veiy apt to aiise acutely and lapidly 
subside, while the ima o-aei oplnhc and anaeiobic injections are more apt to 
develop slowly, spiead insidiously and lesolve less lapidly 

Bacteuology — Anaerobic as well as aeiobic cultures in the hemolytic 
sti eptococcus infections reveal laige numbers of those organisms The ordinary 
aerobic cultuies m the foul smelling infections usually yield the oidinary mouth 
01 gamsms with the nonhemolytic sti eptococcus predominating Howevei, if 
a daik field illumination is used for examination of the exudate, fusiform 
bacilli, spirilla, oi spiiochaetae may be seen Both Ti eponema niaci odentmni 
and Ti eponema mtci odentmm aie found The spirochaetae are almost always 
present m the severest cases, but may be absent fiom the mildest forms 
When anaerobic cultures aie made, nonhemolytic streptococci are usually 
found on the blood agar plates which are eithei stiictly anaerobic or micro- 
aerophihc With the special media lecommended by Smith^ and otheis, the 
fusiform bacilli, spirilla and spiiochaetae may be obtained The fusifoim 
bacilli glow out m 48 houis m plain cooked meat medium to which 10 pel 
cent ascitic fluid has been added The spirochaetae glow out m eight to ten 
days in 33 per cent sheep 01 beef seium in distilled watei to which a bit of 
sterile labbit kidney has been added These oi gamsms aie not pathogenic 
when injected into animals in pine cidtine, but when they aie combined they 
have a syiiei gistic action which pi oduces a 11101 e 01 less extensive lesion 

The odor of the lesion arises fiom the development of gases by the 
bacterial action on the tissues When these 01 gamsms are cultivated arti- 
ficially it IS found that the nonhemolytic anaerobic sti eptococcus is the onl} 
one which m pure culture will produce a foul odor The spirochaeta T niici 0- 
dentnnn produces an unpleasant odor but it is not foul When the stieptococci 
and the spirochaetae are combined, the odoi is veiy foul and lesembles that 
coming fiom the infected tissues 

Ti eatnient — When the aiiaeiobic and micio-aei ophilic 01 gamsms are pres- 
ent 111 the mouth unaccompanied by any inflammation, they may be minimized 
or eliminated by a number of oxidizing agents such as potassium chlorate, 
potassium peimanganate, or sodium perboiate, but they are more quickly and 
more effectively eliminated by the use of zinc peroxide When, however, there 

33 



FRANK L AIELENEY 


Annals of Surprrry 
3 n n u a rj JO'IS 


IS an infection eithei mild oi giavc with an nnasion of tlie subniutous tissues, 
and supeificial iilceiation of the mucous mcmbianc, 7inc jicroxide is much 
moie effective m treatment than the othei o\idi/ing sulistantts When the 
infection has spiead to tlie dcepci la)'eis either directly oi thiough the l}ni- 
phatics, suigeiy is lequiied and dioitUi be tadical, extending well heyond the 
aiea of indurated tissue and opening the iinohcd facial spaces It is frequently 
necessaiy to lemove masses of l3miph nodes oi the suhmaxillary salivary glands 
111 01 del to effect the pioper diainage If the incisions ha\c not been carried 
to the limit of the ncciosis, it will continue to spread and cause a great deal 
moie destiuction This has been illusti.ited over and ovei again ivhen con- 
seivative operations haie been attempted, m the dental clinic foi example, and 
the cases have had to be subsequently taken into the hosjiilal foi more extensn e 
suigeiy When the tissues have been opened b}' adequate surgerj, how- 
evei, the infection can be bi ought under contiol bj' tbe careful application of 
zinc peroxide suspended in stcidc distilled water, to ex cry pait of the infected 
surface If this is done, the foul odor will almost immediatel} disappeai , and 
smeais and cultuies of the exudate will show lapidl}' deci easing numbers of 
the spirochaetac, fusifoim bacilli and the anaeiobic streptococci 

The zinc pei oxide must be an eliective preparation as shown by prclimi- 
naiy tests® indicating its ability to liberate oxvgen w'hen susjiended in distilled 
w'atei It should be stciilized m small quantities at 140° F drj heat for four 
boms, and applied as follows The di) powdei is suspended m approximately 
an equal quantity of w atei so that it has the consistency of 40 per cent cream 
It can be suspended evenly with an “Asepto” syringe and ajiplied with the 
syringe to every pait of the wound surface If theie aic any sinuses, it should 
be delivered into them through a catheter, but if tbcie are anj paits of tbe 
infection wduch cannot be 1 cached, it wnll have to be opened up so as to permit 
contact, W'hich is essential When the whole suifacc of tbe wound has been 
coveied, fine meshed gauze soaked m zinc pei oxide should be placed over the 
surface, and the wdiole wound sealed w’lth several layers of Vaseline gauze so 
as to pi event evaporation The diessing should be changed dail}" Wdien the 
gauze is removed, at the end of 24 liours, the old zinc pei oxide and exudate 
should be w^ashed off wnth saline from an urigating can The zinc peroxide 
suspension is then applied as befoie This technique has been more fully 
described m pi evious papers o, c 7, s » 

The zinc pei oxide should also be used at tbe same time, as a mouth w'ash, 
about one pait pow'dei to fom paits Avatei One mouthful every three or 
foul houis coats the mucous membrane A^eiy ivell This should be thoioughly 
spread aiound the suiface of the mouth If theie are any lesions on the 
tonsillar Avails 01 phaiynx, it should be applied Avith a cotton sw ab Gargling 
or swishing the mateiial around in the mouth aviII usually not lesult in contact 
Avitli the tissues back of the antei 101 pillar of the fauces 

When the smeais and cultuies hai'e become entiiely negative foi patbo- 

* The only dependable product avadable at present is the "vtcdicinaJ giadc” of zinc 
peroxide made by the DuPont Chemical Companj, Niagara Falls, N Y 

34 



Volume 107 
^umbe^ 1 


ZINC PEROXIDE IN INFECTIONS 


genic oiganisms, simple dressings will be satisfactoiy Our expeiience ^^lth 
these cases during the past two yeais has demonstrated the superiority of this 
treatment over any pievious tieatment Fust, m the lapid subsidence of acute 
geneial symptoms, second, m the rapid lesolution of the local piocess, third, 
in the rapid disappeai ance of the foul odoi which is so offensive to the patient 
and to other patients in the neighborhood, and fouith, m the lapid healing 
of the wound 

We believe that zinc pei oxide should be used as a piophylactic mouth wash 
m all cases piehmmaiy to tonsillectomy oi dental extraction It is logical to 
believe that these seiious infections would be gieatly diminished if this weie 
employed extensively Piehmmaiy studies of the flora of the mouth should 
demonstrate the piesence of the offending organisms, and if they aie present, 
tieatment should be instituted a day oi two befoie the operative piocedure 
IS earned out, until the oiganisms have laigely or, if theie is time, until they 
have completely disappeared 

ILLUSTRATIVE CASE REPORTS 

Case I — No 502485 J S , female, niai ned, age 20, was admitted to the hospital 
with symptoms and signs simulating acute appendicitis At the operation, a 1 datively 
normal appendix was removed The symptoms continued and subsequent studies seemed 
to indicate that thev were of rheumatic origin She was transferred to the medical 
seivice and during the couise of her treatment it was thought advisable to remove sev- 
eral bad teeth, two 111 the left upper jaw weie lemoved without incident and five dajs 
later three in the left lower jaw were extracted 

Next day the jaw pained severely and swelling appeared in the cheek and neck 
The temperatuie rose on the second day to ioi°F and the white blood count to 14,500, 
with 87 per cent of polymoi phonuclears The swelling spread over to the right side of the 
neck and into the floor of the mouth very rapidly during the next 24 hours, and difficulty 
in swallowing and bieathing began to be experienced Under cliloroform anesthesia. Dr 
Rudolph Schulhnger made a curved incision over the submental and submaxillary tri- 
angles The submaxillary sahvaiy glands were lemoved and the tissues beneath the floor 
of the mouth were exposed, from which pus and seropurulent fluid without much odor 
drained Dakin’s fluid was instilled through drainage tubes for two days with some 
improvement, but then the exudate took on the tvpical foul odor of anaerobic infections 
On the fifth day zinc peroxide applications were started The foul odor promptly 
disappeared and the wound showed marked improvement Thereafter healing progressed 
rapidly and the patient left the hospital on the eighteenth day 

No dark field examination was made of the pus obtained at the time of the opera- 
tion, nor in fact until the day after the zinc peroxide treatment was begun Then fusi- 
form bacilli were found 111 the pus but they did not grow out m the anaerobic culture 
which yielded hemolytic streptococci, green streptococci and Staphylococcus albus Five 
days later only the green stieptococci lemaiiied, and two days later the cultures yielded 
no growth 

Case 2 — No 509567 R S , female, age 20, had had the left lower third molar 
removed without incident three weeks previous to admission Two days before, the 
right lower third molar had been removed It had an overhanging gum Next day the 
submaxillary and sublingual tissues began to swell On the day of admission she began 
to have difficulty in swallowing Her temperature rose to I02°F , W B C to 25,700, 
and her pulse was 92 The tissues under the mandible weie hard and tender Cold 
applications were made foi 24 hours, but her temperature remained above 103° F all 
dai^ and 111 the evening rose to 104° F , W B C to 33,000, and pulse to 89 

35 



FRANK L MELENEY 


Annals of Surccry 
Janunrj 1038 


Opeiahon — The submental triangle was opened by the oral surgeon The tissues 
over the right submaxillary gland uere cut Necrotic foul smelling material was found in 
the submental region, and the wound was dressed with Dakin’s solution The tempera- 
ture fell to 101° F after operation but mounted again to 103° F next da\, later falling to 
101° F There was slight general improaemcnt but the swelling under the tongue in- 
creased, swallow’ing became more difficult, and the foul odor of the discharge was most 
distressing It W'as obvious that a deeper and wider incision would be ncccssare, and 
she W'as referred to me for operation which was done, under chloroform anesthesia The 
submaxillar^ triangles were opened and foul pus eeacuated Part of the right subniaxillarj 
gland and the necrotic submental nodes were reino\ed, the wound was flushed with 
zinc peroxide suspension and then packed with gauze soaked in the same material, two 
rubber tubes being placed in each submaxillare triangle Thereafter the temperature 
steadily fell, the edema subsided, the foul odor disappeared, the necrotic tissue separated 
and the sw’allowing rapidly improeed Ele\cn dajs after the last operation the granula- 
tions were active and the wound w'as healing rapidh 

A dark field examination of the pus reaealed spirochaetac, fusiform bacilli, vibrios and 
COCCI The cultures jielded anaerobic hcinohtic streptococci, fusiform bacilli and green 
streptococci 

On the sixth daj onlj a few anaeiobic streptococci and fusiform bacilli were found 
on the right side and none on the left On the eleventh daj the smears and cultures were 
negativ'e for these organisms 

REFERENCES 

^ Plant, H C Lc bacille fusiforme et le spirillum sputiginimi dans Ics angines ulcercuses 
Compt rend Soc de Biol , 58, 805, 1905 

“ Vincent, H Rccherches bacteriologiciues sin I’angme a b icilles fusiformes Ann de 
rinstit Pasteur , 13, 609, 1899 

“ Ludwig, W F Ueber enie ncue Art von Halsentzundungen Wurtt Korrespondenzbl , 
6, No 4, 1837 

‘Smith, D T Oral Spiiochetcs and Related Organisms in Fuso-spirochefal Disease 
Baltimore, 1932, Williams &. Wilkins Co 

“ Meleney, F L Zinc peroxide 111 the treatment of Micro-aerophilic and anaerobic infec- 
tions with special reference to a group of chronic ulcerative burrowing non-gangrenous 
lesions of the abdominal wall Annals 01 Starruv, lor, 997, 1935 
" Melcney, F L Zinc peroxide in sutgical infections S Clin North America, 16, 691, 
1936 

^Melenej, F L, and Johnson, B A The pi oplij lactic and activ’c treatment of surgical 
infections with zme peroxide Surg , Gjnee &, Obst , 64, 387, 1937 
®Melenej, F L, and Johnson, B A Further laboratorj and clinical experiences m the 
treatment of chronic, undermining, bui rowing ulcers with zinc peroxide Surgerj, 
I, 169, 1937 

"Meleney, F L Use of zinc peroxide in oral surgen International Jour Ortho &. Oral 
Surg, 23, 932, 1937 

Discussion — Dr I S Ravdin (Philadelphia) expiessed his appieciation 
of the oppoi tunity to say a few words 111 regard to the use of zinc peroxide in 
the control of infections due to anaerobic and micro-aeiophilic oiganisms His 
experience with the use of this substance began shortly after Doctoi Meleney 
obtained his first potent prepaiation The results in the early cases weie 
variable, and all must be deeply in Doctoi Meleney’s debt not only foi demon- 
strating the efficacy of this method of theiapy, but also for seeing to it that 
the manufacturers finally piovided a uniformly potent mateiial 

The mvasiveness of these organisms once they have gained a foothold is 
well known to all who have had the oppoi tunity of obseivmg their activity 

36 



Volume 107 
Number 1 


ZINC PEROXIDE IN INFECTIONS 


In the region described by Doctor Meleney, they may not only involve the 
orbit and pencianial tissues but they may also cause extensive necrosis of 
the facial bones and the calvaiium 

It has been Doctor Ravdin’s impiession that the micio-aeiophihc strepto- 
cocci are frequently not piimaiy mvadeis of an intact mucous membiane but 
that they invade the submucous tissues once tbe pi unary defense of an intact 
mucosa bas been destroyed Doctoi Meleney has pointed out ceitam of the 
impoitant characteristics in the difteiential diagnosis of the hemolytic strep- 
tococcus infections of the mouth and neck and those due to the anaeiobic and 
micro-aerophilic streptococci This was piobably not meant to imply that 
the two types of oigamsms aie not at times found simultaneously m infections 
of the flooi of the mouth In such instances there is lapid invasion with con- 
sideiable edema and neciosis The systemic eftect is often piofound and the 
tiue natuie of the combined infection is often not appieciated until the moie 
lapidly invading hemolytic sti eptococcus is brought undei contiol and theie 
remains the moie slowly progiessmg, neciotizmg lesion which results fiom 
the micio-aeiophilic oigamsms 

Doctoi Meleney very rightly pointed out that zinc pei oxide is not m itself 
a panacea It does not take the place of sound surgery when an extensive 
infection exists in the hyomaiidibular and cervical tissues The advantages 
of zinc peroxide ovei other substances which liberate oxygen he in seveial 
diiections First, the oxygen is libeiated moie slowly, and second, the salt 
which IS foimed as the oxygen is liberated is not in itself mjunous to the 
tissues One does not observe, theiefore, the tissue injury which may result 
fiom the use of pei borate or potassium chlorate solutions 

It IS only fail to state that the excellent lesults which have been obtained 
by many, which amply verify Doctor Meleney’s obseivations, could not have 
been achieved had zinc peroxide not been used with the same caie with which 
Doctoi Meleney uses it The ti eatment demands the utmost care — moi e than 
IS usually given by a junioi house officer 

Dr Henry S Dunning (New York) called attention to the fact that a 
gieat many postexti action infections are seen at the Columbia Dental School, 
and are piobably increasing They aie veiy severe and an effoit has been 
made for a long time to impiess on the dental piofession the necessity of 
lemoving infected teeth with the least possible amount of tiaumatism and 
without in any way, if possible, damaging the membrane aiound an apical 
abscess It is lealized that these are full of dynamite, as also aie infections 
around third molars If the thud molai stays m the gum a long time, a flap 
of gum foims ovei it, undei that an ulcer forms, and in this a mixed infection 
may develop, as a lule with Vincent’s spiiilla pi edominatmg Until recentl) 
ti eatment of these has been with Dakin’s solution and perborate of soda for 
some time before the extraction period Sometimes these flaps aie so large 
that they are traumatized by biting against them It is very serious to operate 
upon a case and take out these submeiged third molars before the condition 
subsides and the gum is less swollen However, the patient is suffeimg a 
great deal of the time Almost immediately after the tooth is removed, the 
flap of gum diops in the wound and that is the end of it — unless infection 
develops 

In one of the patients described this evening, which Doctoi Dunning tieated 
with Doctor Meleney, a true Ludwig’s angina developed very rapidly Doctor 
Dunning had another case that in four days resisted the most radical surgeiy 
that could be instituted and ended fatally 

The postopeiative treatment of the wounds in postextraction cases is of 

37 



FRANK L MELENEY 


Annals of Surgery 
Jnnuar\ 1938 


vital impoitance Some of the cases encountered m the Oral Singeiy Clime 
have been opeiatecl upon caiefully and followed up a feu days, hut others 
have gone untreated, some have been packed, and some cuietted Doctor 
Dunning said he could not speak sti ongly enough against packing or anything 
that will pi event drainage or a blood clot foimmg in the alveolus of the bone 
He had been advocating leaving them wide open, putting in nothing at all 
except, pel haps, a sponge between the teeth m cases of hemorrhage, and 
having the patient bite on it, then uashing the wounds until they absolutely 
heal up A ceitam numbei of these w'ounds w'lll go on to infection whether 
they have had good treatment or not If they do go on to a Ludwag’s angina 
01 to a laige sulipei losteal abscess, then incision and drainage should be insti- 
tuted at once m a hospital as soon as the case is seen These mouth infections 
have been treated wnth pei maiiganate, pcrboiate of soda Dakin’s solution, 
zinc peroxide, and other agents, and in the cases Doctor Dunning has seen, 
zinc peroxide has given the licst results It has been much moie efficient in 
cleaning up these foul smelling w'otinds than anything else he had ever seen 
In infected jaws wuth osteomyelitis it has done more than anything eyer 
know'll, and paiticulaily m the type of case shown at this time has it been 
very, veiy successful in helping to clcai up the infection Doctor Meleney 
should receive united thanks foi all the w'oik he has done m bringing the 
use of zinc peroxide to the attention of the profession 


38 



GLOSSITIS RHOMBICA MEDIANA 

Hayes E Martin, M D and M Elizabeth Howe, M D 

New York, N Y 

FROM Till, HEVD VND NECK SERMCE MEMOHI IE HOSPITAL NEW lORK 

Glossitis ihombica mediana is a benign disease of tbe tongue cbaiactenzed 
by tbe piesence of a mass oi plaque, ovoid oi rhomboid m shape, situated m tbe 
midlme of the dorsum of the tongue, just anterior to the V formed b}'^ the vallate 
papillae Theie are usually no subjective symptoms, and the condition is com- 
monly discovei ed by the physician or dentist, oi even b}'- the patient himself, m 
the couise of an incidental examination of the oial cavity 

The piocess appears to be incidental and of little or no clinical significance, 
except that the diagnosis may be confused with that of cancer of the tongue Of 
the II cases presented m this repoit, ten weie refeired to the Memoiial Hosjiital 
with the tentative diagnosis of cancel of the tongue Oui puipose is to desciibe 
the chai actei istic featui es of glossitis i hombica mediana, and to point out that it 
may be readily differentiated clinically fiom cancer 

The condition was fiist desciibed, in 1914, by Brocq and Pautriei,^ who 
leported 17 cases undei the title “glossite losangique mediane de la face dorsale 
de la langue ” Subsequently spoi adic case 1 epoi ts ajipear in the htei atm e, until 
1922, when Arndt" lecoided one case and mentioned that 40 otheis of similar 
natuie had been obseived m an 18 months’ peiiod at the Skin Clinic of the 
Univeisity of Beihn In 1923, Fordyce and Cannon® described two cases of a 
lesion of the dorsum of the tongue, previously unknown to them, which clin- 
ically and histologically seems typical of the condition now undei discussion In 
1924, Lane‘s reported one case, and by modifying and shortening the oiiginal 
title given to it by Biocq and Pautiier, gave to the disease the still lather cum- 
bersome name “glossitis rhombica mediana,” b}'’ which it is now commonly 
known in the Ameiican literature Zimmerman® reviewed the subject, m 1929, 
on the basis of 29 cases collected fiom the literature Since 1929, Abshiei® and 
Loos and HoibsP have each lecorded one case In 1934, Gougeiot and 
Dechaume® reported a senes of lingual plaques which they considered typical 
of the doisal glossitis of Biocq and Pautriei, of which some weie not rhomboid 
and others were not located in the midlme They concluded that these 
“placques depapillees” weie atypical 01 attenuated foims of glossitis ihombica 
mediana In the piesent leport, we have excluded all such atypical foims as 
being confusing and 11 relevant 

It appeals piobable that Spencer and Cade® have not recognized clinically 
the lesion which is now generally designated as “glossitis rhombica mediana ” 
They use the lattei term to desciibe a condition m which the rhomboid area on 
the doisum of the tongue becomes coated with a “heavy fur” because “this por- 

39 



RIARTIN AND HOWE 


Annals Of SurKer> 
January 103S 


tion of the tongue is least pressed against tlie palate oi scrubbed against the 
teeth ” Obviously, the phenomenon which they describe is a natural and com- 
mon consequence of limitation m the normal i ange of tongue movement follow- 
ing any painful foim of glossitis (cancer, sepsis, ladiation leaction, etc ) The 
piesence of a heavy fin in the ihomboid area is the exact oj^posite of the non- 
papillated, lelatively smooth and pink appeal ance generally consideied as being 
characteiistic of glossitis ihombica mediana Neither Butlm^*’ nor Blair^^ 
makes any mention of a tongue lesion m Inch m any way i esembles the condi- 
tion now under discussion 

Incidence — The condition is comparatnely lare, or at least seldom recog- 
nized Including our senes of li, there aic lepoited m the literature a total of 
42 cases In 0111 clinic, the incidence is less than i per cent of all patients 
lefeired for diagnosis and treatment of suspected cancel of the tongue 


TAncE I 

AGE IXCIDENCE AND SEX DISTRIBUTION OE UL Rri’OKTI D C ISES 01 
GLOSSITIS RIIOMBICA MEDIANA 


Age 

Sex 

15- 

M 

'20 

F 

21 - 

-30 

F 

31 

M 

-40 

F 

41- 

M 

50 

F 

51- 

M 

60 

F 

M 

—Total — 

F Both 

Zimmerman 

0 

3 

3 

0 

8 

4 

5 

0 

6 

0 

22 

7 

29 

(Collected senes) 













Abshier 









I 


I 


I 

Loos and Horbst 







I 




I 

I 

Martin and Howe 




4 


4 

2 

I 


9 

2 

1 1 

All cases 

0 

3 

3 

0 

12 

4 

9 

3 

8 

0 

32 

10 

42 


Age and Sex — Glossitis rhombica mediana appears to be a disease mainl} 
affecting middle aged males In our sei les, thei e v ci e nine males (S2 per cent) 
and two females (18 per cent) In Zimmei man’s collected senes of 29 cases, 
there were seven (24 per cent) females Loos and Hoibsts single case oc- 
curred in a female The average age in oin sei les was 43 — the } oungest patient 
being 35 and the oldest 57, with ten of the 1 1 cases between the ages of 35 and 
50 In Zimmerman’s collected senes, thei e w'ci e three females below the age of 
20 and three males below the age of 30 

Etiology — Pi edisposing Causes — In oui opinion, theie is little 01 no evi- 
dence that this disease develops as the lesult of any of the common forms of 
chronic irritation In all of our patients, theie w'as a notew^oithy absence of 
the usual sequelae of chionic nritation m the foim of leukoplakia or diffuse 
glossitis The incidence and degree of dental sepsis and the “coating” of the 
tongue m our senes w^ei e about the same as those of the coi responding age and 
social group The Wassermann reaction was found to be negative in all of 
our patients This is contraiy to the findings of Brocq and Pautrier, 
Dubreuilh,^^ May,^® and Fordyce and Cannon, but in all of these repoi ts, it is 
significant that the process remained indifferent to vigoious and piolonged 
antiluetic therapy All of oui male patients had used tobacco and a similar 

40 





Volume 107 
Isumber 1 


GLOSSITIS RHOMBICA MEDIANA 


history is noted in the repoi ts of others, but we feel that the absence of leuko- 
plakia in all of our cases probably eliminates this souice of chronic irntation as 
an etiologic factor Since, in our opinion, theie is so little evidence in support 
of an inflammatory or iiritative oiigin foi glossitis ihombica mediana, we have 
sought for an embiyologic explanation, and have felt that it might possibly 
represent a persistence of the tubeiculum impai 

Embiyologic Development — The tongue, embiyologically, is a phaiyngea! 
derivative — a “mucous membiane sac which becomes stufifed with skeletal 




Fiq 1 

DERIVATIONS OF THE PARTS 
OF THE TONGUE 

s From 1st branchial arch 
Tuberculum impar 
o Foramen cecum 
HxFrom Ilnd branchial arch 
jKFromJIIrd branchial arch 

Figs I, 2 and 3 — Dnwings showing the embryologic development of the tongue (after Arej) 


The developinq tonque The adult tonque 


muscle ” The mucosa of the body or apical half aiises fiom thiee piimordia 
the paired lateial swielhngs of the fiist oi mandibulai aiches, and from the 
median somewhat triangular tulieiculum impai wflnch foims the pharyngeal 
floor between the first pair of bi anchial pouches The mucosa of the i oot arises 
from a median ventral sw^elling, the copula, foimed by the union m the midline 
of the second branchial aiches It receives some tissue fiom the third and 
fouith arches as well (Fig i) The mucosa of the apical half is papillae bear- 
ing, that of the root becomes infiltrated b}'- lymphoid tissue The body and 
loot are demarcated from each other by the sulcus teiminahs 

The tuberculum impar, m embryo, foims the posteiior medial portion of the 
apical half and is m contact and contmuit)’’ with the copula Betw^een these twm 
is the point of origin of the thyroid diveiticulum wdiich, wuth fetal growdh, 
becomes depressed into a pit and foims the foiamen cecum (Fig 2 ) As devel- 
opment pioceeds, the paired lateial sivellings of the first arches increase in size, 
at first fuse with the tubeiculum impar, then grow moie rapidly and outstrip it 
Simultaneously, there is a “slipping foiwaid” of the entire mucosa of the 
tongue During this time, the tuberculum impai is fixed at the foramen cecum 
(and perhaps drawm caudad by the caudad proceeding thyroid) w'hile it is tend- 

41 




MARTIN AND HOWE 


Annals Of Surf?crj 
Jnniiarj 19oS 


mg to be overgiown aiiteuoily and lateially and overlapi^ed posteriorly Be- 
cause of the eventual V shape of the sulcus teiminalis, theie seems to have been 
fixation of the cential poition of the loot as well (Fig 3) 

Consequentl)^ the tubeiculum impar does not normally appear 111 the human 
adult tongue, hut if any of the factois tending to cause its disappearance were 
deficient or if it were 1 eactivated by some metabolic or nutritional stimulus, a 
peisistent tubeiculum impar could result It miglit peisist m its most peifect 
form — a ihomboid aiea m the midline of the postcrioi dorsum of the tongue — 
but it could he anteriorl}’’ or lateiall)' displaced, and of any shape It could he 
split (Fig 2) and appeal m eithei two 01 three segments It could appeal m 
some foim anywheie m the tongue except postoioi to the joianicii cecum and 
the sulcus tenninahs This peisistence might he fiank and on the surface 01 
veiled liy a supei ficial covering of the usual lingual mucosa 

Loos and Hoihst have come to the same conclusion as to the origin of the 
process, hut classify it as belonging m the group ot the \ascular nevi, a classifica- 
tion w'hich. III our opinion, is not w'ell suppoitcd h) histologic findings It 
w'ould seem to us that the tubeiculum impai, wdiencvei it has made an appear- 
ance, has simpl}' demonstrated its kinship with the unpapillated, lymphocyte 
mfiltiated base of the tongue lathei than w'lth the papillae hearing apex Undei 
these conditions, glossitis ihomhica mediana is moie logically classified as an 
anomaly lathei than as a disease 

Symptoms and Clinical Findings — In general, the piocess is of long 
duration and is usually attended by no subjectne synqitoms Ten of 0111 cases 
w'eie referred to us wnth lesions discoveied accidentally and only one com- 
plained of vague discomfoit Of Brocq and Pautiier’s 17 cases, one complained 
of slight pain on mastication, and one of a localized burning sensation In 
May’s case, theie w'as slight mteiference wnlh the movements of the tongue 
The duration in most of our patients w'as short (three weeks to ten months), 
but w^e believe that if it w'eie not for modem dental caie and clinic facilities, 
many of these cases w'ould have gone foi yeais without remaik Biocq and 
Pautiiei reported a case of seven )"eais’ duiation, and Loos and Hoihst one of 
about 30 yeai s’ duration 

The typical lesion, as wt have observed it, is a nonulceiated rhomboid or 
ovoid mass or plaque situated m the midline of the dorsum of the tongue just 
anteiior to the apex of the V formed by the ciicumvallate papillae (Figs 4 
and 5) The mass or plaque usually extends forw'aid foi a distance of 2 to 
3 cm , but IS always sharply limited posteriorly by the sulcus tei mmahs The 
surface of the lesion may be onl}'^ slightly laised wnth holders wdiich merge 
giadually into the normal level of the surrounding mucosa In othei instances, 
the lesion may be raised as much as 4 to 5 Mm , wnth its edges aiising rathei 
abiuptly from the tongue suiface In most instances, the involved aiea pie- 
sents a definite difiference m color and an absence of the noimal papillaiy, 
furred chaiacter of the mucosa of this poition of the tongue The change m 
the color and surface textuie of the mucosa is usually lather abrupt and may 

42 



Volume 107 
'\umUer 1 


GLOSSITIS RHOMBICA MEDIANA 


extend seveial millimeteis beyond the laised poitions of the lesion The sin- 
f ace may be smooth and glistening oi occasionally slightly fissm ed and mam- 
millated Theie is no sin face ulceiation, but moie oi less induiation is aluays 
piesent Pam and tenderness aie chaiacteiistically absent Tbe size and ex- 
tent of the lesion, even though untieated and of long standing, is self limited 
to about 1^x3 cm 

Diagnosis — Unless one is familiar with both diseases, glossitis ihombica 
mediana is quite apt to be confused with cancel of the tongue Such chaiac- 
teristics as chromcity, absence of subjective symptoms, induiation and appai- 
ent mfiltiation of the suiface are common to both diseases In our opinion, 
a clinical diagnosis of glossitis rhombica mediana should be made fiom the 



Fig 4 — Photograph of Case 2 showing the 
tjpical midline situation of the growth in instances 
of glossitis rhombica mediana 


Fig s — Drawing of the lesion in Case 1 1 
showing more in detail the position and general 
gross characteristics of the growth 


unique position of the lesion — duectly vi the midlme of the tongue ]ust 
anteiioi to the V line of the cii cumvallate papillae This aiea of the tongue is 
singulaily free from punmy cancer, although it may of course be invaded by 
extension from adjacent aieas 

So far as we know, there is no instance of a malignant giowth arising 
piimarily in this aiea in about 2,000 cases of tongue cancer in the lecords of 
the Memoiial Hospital Cancel of the tongue characteristically aiises m the 
lateral bordeis, the tip and at the base, posterior to the sulcus teiminalis 
Occasionally, giowths arise on the dorsum of the anteiior half, but never in 
the rhomboid aiea, to oui knowledge The same legional incidence also may 
be used to dififeientiate two othei faiily common chronic lesions of the tongue 
namely, gumma and tuberculous ulcers, which m oui expeiience, are not found 
to aiise m the ihomboid aiea In our opinion, the diagnosis of glossitis rhom- 

43 



MARTIN AND HOWE 


AnnaUof Surj^cry 
jQnuar5 I'isy 


bica mediana may be made safely on the clinical features alone without biopsy 
The unique position of this lesion m the midline of the rhomboid aiea of the 
tongue IS its most significant diagnostic feature Biopsy does no paiticular 
harm, but m oui opinion, is unneccssaiy except for pui poses of lecord 
jMorbid Anatomy and Histologic Findings — The lesion is quite sharply 
delimited m its holders and tends to involve only the mucous and submucous 
tissues whose thickness is inci eased to a vaiiable degice Theie is little or 
no tendency towaid deep infiltration oi invasion of the muscular body of 
the tongue, fiom which the mass is quite leadily separated b}' surgical excision 



Fig 6 — Cnse s Pliotomiciognph show 
ing (A) H>pertroph> hornification md 
desquamation of epithelium (B) Nodiilai 
mass of bmphocjtes in\ading epithehuni 
(C) Subepithelial fibrosis and numerous 
plasma cells (high power) 



Fig 7 — Photomicrogiaph showing (A) 
Epithelial h>pertiophj and downgrowth (B) 
Ljmphocjtic infiltration of subepithelial and 
epithelial tissues (C) Subepithelial fibrosis 
and edema (D) \trophj and degeneration 
of muscle fibers (low power) 


The histologic findings aie not uniform Theie is usually a vaiiable de- 
gree of hyperti ophy of the epithelium with a tendency toward plexiform down- 
giowth of well differentiated cells, and occasionally, oideily pearl foimation 
The surface layers are hormfied and desquamating, and while well developed 
fissuring IS common, theie may be only slight indenting of the suiface cells 
A common finding is a diffuse lymphocytic infiltiation of the subepithelial 

44 



A'’olume 107 
Number 1 


GLOSSITIS RHOMBICA MEDIANA 


tissues Plasma cells may also appeal and occasionally aie a conspicuous 
feature (Case 5) Nodular masses of lymphocytes aie commonly found just 
below the tips of the down-gi owing 


epithelial pegs, and in a few instances, 
such nodulai masses have disiupted the 
basal layei of the epithelium and he half 
in the subepithehal tissue and half in the 
epithelial tissue Raiely, nodulai masses 
appeal entiiely within the epithelial layer 
(Fig 6) 

There is almost always a consideiable 
degiee of fibiosis m the subepithehal tis- 
sues which may extend down to, and 
occasionally into, the muscle layei When 
the lattei condition occuis, the adjacent 
muscle fibeis aie ati opined 01 show 
marked hyaline degeneiation and edema 
The blood capillaries and the lymphatics 
aie dilated and new capillaiies may he 
seen m the piocess of foimatiou Occa- 
sional thrombi apjieai in the most supei- 
ficial capillaiies (Figs 7 and 8) 

We have found no evidence of malig- 
nant degeneiation in any of the speci- 
mens examined in oui laboiatoiy The 
epithelial giowth is quite exubeiant, but 
not disoideily, and the cells themselves 
are normal The moiphology and histol- 
ogy, as desciibed in pievious leports, are 
about the same as ours 



Fig 8 — Cise s Pliotomiciognpli slioi\ 
ing a higher poi\ei detail of Fig 7, particii 
Hilj the diffuse Ijmphocjtic infiltration -of 
subepithehal tissue There is a tendciica 
toa\aid grouping of l>niphoc>tes at the tips 
of the epithelial pegs and inaasion of the epi 
thelium by Ijmphocvtes at these points 


CASE REPORTS 

Case I — F T, white, male, age 37, was admitted m June, 1932 Two months pie- 
viously, he had noted on his tongue a small, painless “ulcer,” which had gradually m- 
ci eased in size He was a “heavy smoker ” 

Examination revealed m the midline of the dorsum of the tongue, anterior to the 
circumvallate papillae, a deep red area measuring ijdxi cm In the center of this area 
was a nonulcerated, raised nodule less than i cm m diameter The lesion was slightly 
indurated The remaindei of the tongue was “coated” There was moderate dental 
sepsis, but no leukoplakia The blood Wasseimann reaction was negative 

Tieatmcnt and Clinical Com sc — The lesion pio\ed unresponsive to heavy doses ot 
potassium iodide, and was excised by the endotherm knife in October, 1932 The wound 
healed by secondary intention The patient was last seen m February, 1936, at which 
time there was no evidence of recurrence 

Case 2 — W M , white, male, age 39, was admitted m January, 1933 Two and 
one-half yeais previously, he had been informed bj his dentist of the presence of a lesion 

45 



MARTIN AND HOWE 


Annals of Surpco 
Januarj llHS 


on his tongue It was s\mptoinless and had not increased in size He was a moderate 
pipe smoker 

Examuiaiwn revealed in the midline of the dorsum of the tongue, just anterior to the 
circumvallate papillae, a laised, irregulai, nonulcerated lesion measuring cm m 
Its longest diameter (Fig 4) There was moderate associated glossitis, but no leuko- 
plakia The blood Wassermann reaction was negitne 

Ticatmcnt and Cluneal Com sc — The lesion was remo\ed bj surgical excision in 
Febiuary, 1933, healing bj' primarj union The patient was last seen in August, 1936, 
at which time there was no recurrence 

Case 3 — V S , white, male, age 35, w'as first seen in December, 1934 Fue months 
pi e\ loiisl}’’, during a tonsillectomy, a “tumor” was removed from the dorsum of the tongue 
He was referred to the Memorial Hospital wath a diagnosis of “epithelioma ” The 
patient smoked about 20 cigarettes dailj 

Examuiatwn repealed m the midline of the dorsum of the tongue, posteriorly, a ridge 
like, pinkish, nonulcerated lesion 3 cm in its longest diameter To the left of this was a 
small, superficial, whitisli slightlj' indurated area with the appearance of a superficnl 
abscess The mucosa of the entire tongue was hj pcrti opined There was moderate 
dental sepsis, but no leukoplakia The blood Wassermann and Kahn tests were negatne 
Ticatmcnt and Clinical Comsc — No actne treatment was gnen in our clinic, and 
lie was last seen in May, 1935, at which time there was no apparent change in the lesion 
He has failed his subsequent appointments 

Case 4 — O kl , w’hite, male, age 57, was first seen in Ma\, 1935 Two months pre- 
vious! v, a small circular plaque appeared on the dorsum of the tongue It caused no dis- 
comfort and had not increased m size He stated that he had smoked about 30 cigarettes 
daily for some jears 

Lxanitnatwn reiealed, in the midline of the dorsum of the tongue, just anterior to the 
eallate papillae, a raised, pinkish, slightlj induiated, rectangular patch The surround- 
ing mucosa presented a furred eellowish appearance There was moderate dental sepsis, 
but no leukoplakia The blood Wassermann and Kahn tests were negatne 

Ticatmcnt and Cluneal Comsc — He was followed at inter\als until August, 1935, 
without any apparent change in the lesion, but has failed his subsequent appointments 
Case 5 — J R, w'hite, male, age 42, was first seen in Sejitember, 1935 Fne months 
previouslj, he had noted a reddish spot m the center of his tongue It was symptomless, 
but during the preceding month had slowlj increased in size He admitted being a 
model ate smoker 

Examination revealed, in the midline of the posterior third of the dorsum of the 
tongue, a slightlj raised, pinkish area, measuring 2 cm in its longest diameter Fs 
borders were ill defined and irregular The surrounding mucosa w'as pale ^ellow' Intra- 
oral hjgiene was fair, and there was no leukoplakia The Kahn test was negatne 

Ticatmcnt and Clinical Comsc —In September, 1935 a total of eight milhcuries m 
four gold filteied ladon seeds were implanted in the lesion Regression was incomplete, 
and, in November, 1935, the lesion was surgically excised He was last seen in Septem- 
ber, 1936, at which time there was no evidence of the original disease 

Case 6 — I S, white, male, age 49, was admitted in October, 1935 Three weeks 
preiiously, he had noticed a pinkish area on the dorsum of his tongue There w'ere no 
subjective sjmptoms He had smoked about 40 cigarettes daily for seieral years 

Examination revealed, m the midline of the dorsum of the tongue, just anterior to 
the circumvallate papillae, an ovoid, pinkish, smooth area with slight thickening ol 
the mucosa at the center The surioundmg mucosa was tliicklj coated Tlie Wasser- 
niann reaction w'as negative 

Ticatmcnt and Clincial Comsc — He was advised to stop smoking and as to the proper 
proceduies to improve oral hygiene He was last seen in August, 1936, when there was 
some improvement in the general 01 al hygiene, but there still remained one small area 
of residual glossitis 


46 



Volume 107 
NumOer 1 


GLOSSITIS RHOMBICA MEDIANA 


Case 7 B K, white, male, age 43, was first seen in December, 1935 Two months 
previoush^ because of an “uncomfortable” feeling in his tongue, he consulted his own 
physician who leferred him to Memorial Hospital for diagnosis and treatment At no 
time had then been actual pain in the tongue He smoked about 15 cigarettes dad) 

Examination levealed, m the midhne of the doisum of the posterior thud of the 
tongue, a leddened aiea, measuring 2x1 cm, over which the epithelium was smooth and 
glistening There was slight resistance at the center of this area, but tiue induration 
was not present The blood Wasseimann reaction was negative 

Ticatmcnt and Clinical Com sc — He was not seen again until March, 1936, at which 
time marked regression was noted No treatment of any kind had been given In April, 
1936, the tongue was fairly noimal in appearance He was last seen in October, 1936, 
with no recurrence 

Case 8 — C L , white, female, age 46, was first seen in June, 1936 Ten months 
previously, she had noted a “spot” m the center of hei tongue which looked like a collec- 
tion of “white pimples” A little later she noted a buinmg sensation m this region and 
the area became red and roughened Three months previousl) a biopsy had been made 
and reported as “squamous carcinoma” Some radium treatment had been given Ihere 
was no history of smoking 

Examination revealed, in the midhne of the doisum of the tongue just anteiior to the 
cncumvallate papillae, an oval, smooth, deep led, moderately indurated area 2Yz\.z cm 
in extent and slightly raised above the surface of the tongue Over the surface of the 
lesion, the papillae were ati opined and theie was an absence of the furring present over 
the remaining surface of the tongue There was no marked dental sepsis The histologic 
slides were obtained and reviewed and no evidence of cancer was found The patient 
was referred back to lier private physician witliout treatment 

Case 9 — h S , white, male, age 40, was referred to Memorial Hospital in Septem- 
ber, 1932, because of hoarseness He was not aware of any abnormality of the tongue 
He had smoked 15 to 20 cigaiettes a day for many years After examination of the lar)nx, 
a diagnosis of pachydermia of the vocal cords was made, and he was obseived at intervals 
of about three months until September, 1936, when during the examination of his larynx, 
the examining physician noted an ovoid, sharply demarcated, pinkish area 111 the midhne 
of the dorsum of the tongue just anterior to the circumvallate papillae Its size was 
about 1^x3 cm The lesion was slightly raised and slightly indurated, and m its anterioi 
aspects there were a few shallow transverse fissures There was complete edentation and 
no glossitis 

Tieatment and Clinical Cow sc — No treatment was given The patient returned again 
m March, 1937, for examination of his larynx, at which time no change was noted m 
the appearance of the tongue lesion, and although the patient was aware of it, he stated 
that it produced no symptoms 

Case 10 — G H , white, male, age 50, was seen in consultation m March, 1937 
About ten months previously, he had first noted an area on the midhne of the dorsum 
of the tongue which appeared to be of a different color from the rest of the tongue sur- 
face He was a moderate smoker There were no subjective symptoms The patient 
stated that it was not raised above the surface at the beginning, but that later a slight 
elevation occurred About nine months aftei the first appearance of the above men- 
tioned lesion, he consulted a physician for an unrelated complaint and spoke to him 
about the tongue This physician leferred him to a surgeon who took a biopsy and 
treated him by the insertion of radon seeds An acute localized radiation reaction occurred 
which regressed without causing any appreciable change m the appearance or character 
of the lesion 

Examination revealed, m the midhne of the dorsum of the tongue in the rhomboid 
aiea, a pinkish red area, ovoid in shape, which lacked the furred appearance of the re- 
mainder of the tongue The lesion was slightly raised and nodular and presented one 

47 



MARTIN AND PIOWE 


Annalsof SlirRcrj 
Tantiar> 


tiansveise fissuie, but no ulceration The histologic slide was obtained for review and 
the findings were tjpical of those observed in glossitis rhombica mediaiia 

Ticatmoit and Cltntcal Cotiise — He was referred back to his physician without 
treatment 

Case II — L S, white, female, age 44, was fust seen in Februarv, 1937 Three 
and one-half months previously, a “pimple” the size of a pea had appeared on the dorsum 
of the tongue and had grown slowly At first she had es.perienced a sense of irritation 
111 this legion, but latei all abnormal sensations had disappeared 

Eraminatton revealed, 111 the midline of the dorsum of the tongue, just anterior to 
the line of the circumvallate papillae, a pale, pinkish, raised, lobulated, nonulcerated, 
slightly indurated lesion measuring cm and elevated about 4 Mm above the sur- 

rounding mucosa (Fig s) The anterior third of the lesion was covered by normal 
mucosa, but in the posterior portion, the mucosa was smooth and glistening The 
mucosa of the remainder of the tongue was normal m appearance There was moderate 
dental sepsis The blood Wassermaun and Kahn tests wcie negative No treatment was 
given and she was directed to return foi interval observation 

Treatment — No tieatment is indicated except in patients with maiKed 
cancel phobia wheic mental relief is to be obtained only with disappearance 
of the tuinoi In such instances suigical excision is the method of choice 
The lesion may be removed under local anesthesia by an elliptical incision 
just wide enough to completely include the inaigms and taincd down to the 
musculature of the tongue The necessary depth of excision can be accurately 
gauged by the palpable induiation The incision is closed by inteirupted 
sutuies to be lemoved on the fifth or sixth postoperative day In our ex- 
peiience, and as one might expect fiom the histologic findings, the lesions 
have exhibited about the same response to radiation as the adjacent normal 
tissues Three of oui piesent senes and several eailier cases (not included 
in this senes because of insufficient clinical data) were iriadiated wnthout 
benefit Electrodesiccation or the endotheim knife has been lecommended 
by some authois, but these methods piolong convalescence unnecessarily, since 
they leave an open wound to heal Suigical excision with immediate suture 
was used m a few of oui cases to lelievc maiked cancel phobia and to obtain 
histologic matenal 


SUMMARY AND CONCLUSIONS 

Glossitis rhombica mediana is not a malignant piocess It may be dif- 
ferentiated fiom cancer of the tongue by its typical shape and location, and 
biopsy should not be necessaiy foi diagnosis The lesion is piobably not of 
mflammatoiy or iiiitativ'^e oiigin We believe that it may be of embiyonal 
origin and that it may lepiesent a belated appeal ance of that portion of the 
tongue derived fiom the tubeiculum imjjai No tieatment is indicated, but, 
if because of cancerphobia the individual patient demands lemoval of the 
lesion, surgical excision is the method of choice 

REFERENCES 

‘Brocq, L, and Pautrier, L M Glossite losangique mcdiane de la face dorsale de la 
langue Ann de dermat et syph , S, i, 1914 

48 



Volume 107 
Number 1 


GLOSSITIS RHOMBICA MEDIANA 


“Arndt (Case report) Zentralbl f H?ut u Geschlechtskr, 3, 341, 1922 

“Fordyce, J H, and Cannon, ABA Hitheito Undcsenbed Condition of the Tongue 
Arch de dermat et syph, 8, 749, 1923 

* Lane, J E Glossitis Rhombica Mediana Arch de dermat et syph , g, 547, 1924 

® Zimmerman, L Etiologj and Diagnosis of Brocq’s Glossitis Rhombica Mediana 
Dermat Ztschr , 54, 168, 1929 

®Abshier, A B Glossitis Rhombica Mediana, Report of Case with Results of Treat- 
ment Arch Dermat and S>ph, 30, 409, 1934 

' Loos, H O , and Horbst, L Nature of Glossitis Rhombica Mediana Arch f Ohren-, 
Nasen-, und Kehlkopfh , 138, 122, 1934 

® Gougerot, H , and Dechaume, M Critical Study of Smooth Syphilitic Plaques , Dif- 
ferentiation of Smooth Non-syphilitic Plaques , Atypical Forms of Lozenge-hke 
Median Glossitis Ann d mal ven , 28, 801, 1934 

^ Spencer, W G , and Cade, S Diseases of the Tongue 3rd ed Philadelphia, Blakiston’s 
Son and Co , 1931 

Buthn, H T Diseases of the Tongue 2nd ed London, Cassell and Co , 1900 
Blair, V P Surgery and Diseases of the Mouth and Jaws 2nd ed St Louis, C V 
Mosby Co , 1916 

’“Dubreuilh, W Glossite mediane de la face dorsale de la langue Ann de dermat et 
syph, 5, 615, 1914-191S 

“May, J Glossite losangica mediana An facultad de med (Montevideo), 7, 219, 
1922 

” Arey, L B Developmental Anatomy 3rd ed Philadelphia, Saunders &. Co , 1934 


49 



PLASTIC RECONSTRUCTION OF THE ESOPHAGUS' 

Carl Egghrs, M D 

Xi w \onK, X "i 

This oiieiation has to be considered chiefl) in patients with an impermeable 
stiictuie m wliom the piospect of a permanent gastrostomy fuinislies sufficient 
indication to wairant such a seiious and difficult piocedure It may also he 
considei ed in cases of resection of the esophagus foi any reason At the pres- 
ent time such an indication is laicly pi evented, hut when resection of the 
esophagus foi carcinoma becomes a moie common proeeduie, a \\ider field ^\lll 
be opened up 

The fiist attempts at reconstiuction seem to have been made b}' E Bircher, 
in 1S94 He constiucted a skin tube of the thoracic wall and united it with 
the esophagus stump abo\ e and the gasli ostomy opening below Both his cases 
died The method w as also used by Pa)'r, Lever, Kuttner and Frangenheim, 
all of wdiom found diffieult)' lesultmg fiom the deeelopment of fistulae These 
occuiied at the junction of the skin tube and the gastrostoni) and weie due to 
ulcer formation caused by digestion of the skin tube bv gastric juice Wullstein 
pioposed a plastic piocedure which utih/ed a loop of jejunum below, w’lth a 
skin tube connecting with the esophagus above 

One of the best knowm methods is that oiigmally pioposed by Roux, who 
completely mobih/ed a long looj) of jejunum, and after 1 eestabhshing continuity 
of the gut, implanted the low'ei end into the anterior wall of the stomach, wdiile 
Its upper end was drawn thiough a subeutancous channel on the anteiioi chest 
w'all and united with the esophagus stump Numerous authois used this pio- 
cedure, but most of the cases resulted in failure 

Lexer combined the tw'o methods by using a much shoi ter loop of jejunum 
for the low'er esophagus, and foiming the upper portion from a skin tube as 
suggested by Bucher This method has found many supporters and a considei - 
able series of successful cases has been leported One such case w'as opeiated 
upon by Fiangenheim in 1921, and is leported bj Habeiland, foimcity an 
assistant of Fiangenheim, in the 1936 Aichiv fur Klmische Chiruigie, wdiich 
cites the piesent condition of a patient 15 )'eais after the esophagojilast}" He 
has grow’ii to be a healthy young man, able to eat and sw'allow^ everything 
There are included in the article numeious jihotogi ajihs and roentgenograms 
of the patient illustrating the peiistaltic action of the new esojihagus An- 
other similar case w^as repoited by Alton Ochsner and Neal Owens before 
the American Suigical Association, m 1934 (ref Annals or Surgery, ioo, 

ioS 5 > 1934) 

Besides skin of the chest w'all and small intestine, the tiansverse colon has 

* Read before the New York Surgical Society, February 10, 1937 Submitted for 
publication April 16, 1937 


50 



% olumc 107 
>(umber 1 


RECONSTRUCTION OF ESOPHAGUS 


also been used for plastic reconsti uction of the esophagus Similai methods of 
procedure were proposed independently by Kelhng and Vulhet Successful 
lesults were lepoited by V Hackei and Schlagenhaufei A veiy interesting 
method is the construction of an esophagus tube from the wall of the stomach 
It was oiigmally proposed by M Hirsch, and the names of Jianu and Halpein 
aie connected with the further development of this pioceduie Finally there is 
the total tiansplantation of the stomach under the skm of the anterior chest wall 
with inseition of the esophagus stump into the fundus of the stomach, as pio- 
posed by Kiischner All these different methods aie ingenious, and lequiie a 
gieat deal of patience and peiseveiance on the pait of the patient as well as the 
suigeon 

Case Report — A McK , male, 
age 50, had a resection of the thoracic 
portion accomplished three years ago 
for stenosis of the esophagus A gas- 
trostomy had been performed previ- 
ously The clinical diagnosis was 
carcinoma, but the biopsj'^ was nega- 
tive The procedure employed was 
that described by Doctor Toiek The 
patient made a good recoveiy, and was 
able to manage quite well with the aid 
of a rubber esophagus which connected 
his esophagus stump with the gas- 
trostomy (Fig i) 

He was presented in that condi- 
tion before the New York Surgical So- 
ciety May 9, 1934, and the case report 
was in the Annals of Surgerv, ioi, 

940, March, 193S He was also cited 
in a discussion of Doctor Ochsner’s 
case of esophagoplasty before the 
American Surgical Association (ref 
Annals of Surgeri, ioo, 1055, 1934) 

The patient became anxious to dis- 
card the tube in order to be able to 
woik and to eat in restaurants The 
various plastic procedures ivere there- 
fore reviewed and it W'as decided to 
construct an esophagus from the skin 
of the chest wall This method seemed 
to offer the simplest solution, especially 
if one consideied that any mtra-abdom- 
mal operation might be difficult on ac- 
count of adhesions resulting from a 
previous perforation of a duodenal ulcer and the presence of a gastrostomj The procedure 
was to be dnided into stages as follows (i) Construction of a skm tube (2) Closure 
of the upper end by joining the esophagus stump wnth the skm tube (3) Closure of the 
lower end by joining the skm tube wnth the gastrostomj 

The fiist stage was carried out May 16, 1935 Two pei pendicular incisions w'crc 
made over the left anterior part of the chest, outlining a three-inch strip of skin extend- 
ing from the esophageal opening to the gastrostomj The skm edges were now^ carc- 

51 


I 



Fig 1 — Photogriph illustrating the ruhher csoph 1 
gus connecting the upper esophagus stump uitli the 
gastrostomi The interposed rubber bulb is used to 
f-icilitate the passage of food downward 



CARI EGGERS 


Annals of Surgery 
January 


fully undermined and by rolling them toward the midline they could be approximated 
with interrupted plain catgut sutures to establish a complete, skin lined tube ten inches 
long The superficial fascia of the flap was now likewise appioximated with interrupted 
plain catgut to reinforce the skin suture line All sutures approximating the skin edges 
weie so placed that thej emerged at the skin margin without penetrating the skin itself 
Above, construction of the skin tube was carried bejond the esophageal opening in 
order to have a funnel which would catch all sain a coming out of the opening, and 


OL 



Tig 2- — Dnwing illustrating the formation of i ten inch subcutaneous 
skin tube to ser\e as a neu esophagus (a) Esophagus stump (b) Upper end 
of new esophagus (r) Suture of superficial fascia of skin tulic (d) Com 
pleted esophagus from skin of chest wall (r) lower end of new esophagus 
(/) Gastrostomy opening 

to carry it dowmward Below, how'ever, the tube was constructed only to just above 
the gastrostomj in order to permit free access to it (Fig 2) 

The lateral skin margins were now undermined and thoroughly mobilized as fai 
as the axilla on both sides This permitted approximation over the newly formed skin 
tube in the upper two-thirds without undue tension Below', however, it was necessar\ 
to make counter incisions to relax the tension The releasing incisions were not covered 
with grafts, but allowed to granulate They were used temporarily for drainage, m order 
to prevent stagnation of secretion under the large mobilized skin flaps Other drams were 

52 



Volume 10? 
Number 1 


RECONSTRUCTION OF ESOPHAGUS 


placed at points ot vantage and a large dry diessing applied The patient withstood 
the operation well, and primary union, without any disturbance of healing, resulted in the 
entire ten inch tube as well as in its covering 

A month later, June 17, 1935, the uppei end of the anstomosis was completed The 
deep closure was quite simple, but there was so much tension on the edges of the under- 
mined skin which was used to cover it, that subsequent separation was feared How- 
ever, only partial separation resulted, and the defect was later closed with a small peduncu- 
lated flap obtained from the adjacent skin 





Fig 3 — Roentgenogiam demonstrating the function of new "skin tube’ 
esophagus Food passes down a err npidK b\ gra\itj plus muscular contraction 
of pharjnv and esophagus stump 


There remains, then, the third step in the complete operation namely, the anastomosis 
between the low'er end of the skin tube and the gastrostoma No doubt it could be car- 
ried out by the same procedure used at the upper end However, the patient is reluctant 
to have this done, and after studaing all the facts in the case, as well as the aaailable 
literature, I agree with him Ochsner states that of 32 patients avho were operated upon 
by this method, 21 recovered, but that m 18 instances there was fistula formation at the 

53 



CARL EGGERS 

lowei end These fistiilae, due to ulcei foiniitioii and digestion of the skin tube by 
regurgitated gastric juice, ln\e been a source of gie.it annojance to ncarlj all patients 
In spite of the fact that our patient has a Janewae gastrostonij , ■which insures against free 
leakage, he has had regurgitation with irritation and painful superficial ulceration It is 
for this icason he piefers to lea\e conditions as thc\ arc 

The patient has constructed for himself a 
small tube, bent like a knee, one end of whicb 
fits snuglj into the lower end of the skin tube, 
the other into the gastrostomj There is no 
leakage at all He is able to eat c\crj thing, and 
docs not require an unusual quantity of fluid to 
wash down solid foods He is able to cat in 
restaurants At nigbt he remo\es the tube, and 
then swallows water in order to wash out the 
esophagus to prc\cnt fermentation There has 
at no time been am iriitation 

A recent roentgenologic studj has show n ex- 
cellent function (Fig 3) It lias not been deter- 
mined to what degree graMtv plajs a role in the 
propulsion of food 1 he impression one gets is 
that the contraction of the pbanngeal muscles 
alone is sufiicientlj powerful to squirt food 
through the skin lined tube ten inches in length 
As a matter of fact, food passes dowai so rapidlj 
tint It was not possible for Doctor Stewart to 
take a mo\ing picture of the process 

The patient is well (Fig 4) He has gained 
50 pounds since the tune of his esophageal ob- 
struction Anj further operatne intenention 
IS hardh justified, but should one consider it, 
the transplantation of a short loop of jejunum 
reaching from the stomach to the lower end of the skin tube w'ould be the method of 
choice 

Discussion — Dr John B Flick (Philadelphia) called attention to the 
fact that in most clinics caicinoma of the esophagus tends to resist treatment by 
vaiious means despite the development of exact methods of diagnosis and the 
lefinement of surgical technic Theoreticall)', however, malignant lesions of the 
esophagus can be diagnosed early and should be cm able by surgical removal of 
the lesion m selected cases No othei method of tieatment at piesent offers any 
prospect of cure One leason foi the infiequent cure of cancer of the esophagus 
Ijy the sui geon is the neglect of the patient, and also of the practitionei , to inves- 
tigate eaily, A^ague symptoms of distuibance m SAAalloAvmg Foi a long time 
cancer of the esophagus is a puiely local piocess 

Dr Franz Torek (New Yoik) expiessed his pleasuie m the fact that the 
demonstiation of Doctoi Eggers’ lesults brought out the fact that there must be 
thorough exposure, an undei lying piinciple Avithout Avhich success cannot be 
obtained Carcinoma can be tieated successfully only by radical removal If 
radium Avere capable of ti eating the carcinoma without doing other damage, it 
might be a veiy good form of theiapy It is not sufficient, 111 suigeiy, to remoA^e 
the caicinoma alone, a ceitam amount of supposedly healthy tissue must also 
be removed 



Eig 4 — Photognpli sliowing the fiml 
lesiilt Complete reconstruction of the esoph 
ngus except it its lower end wliere the 
skin tube connects with the gastrostomj 


54 



INFLAMMATORY TUMORS OF THE GASTRO-INTESTINAL 

TRACT^ 

Guilford S Dudley, M D , and Laurence AIiscall, AI D 

New Yoriv, N Y 

The not uncommon confusion of the so-called mflammatoiy tumois 
of the gastro-mtestmal tiact with malignant and other diseases and the pool 
results which may follow failure to make this difteiential diagnosis wan ants 
a leview of the subject 

The terms, mflammatoiy tumor, infective gianuloma,^^ non-specific 
granuloma, chronic cicatiizmg enteiitis,^® legional ileitis, and otheis, aie 
all synonymous They infer a type of chionic pioductive mflammator)'- le- 
action to infection with a tendency to the foimation of a tumor or mass 
Thus, they should be sharply diffeientiated from the specific gianulomata 
of tuberculosis, lues, actinomycosis, etc 

A fairly thorough leview of the hteiatuie yields a vast amount of varied 
mfoimation both factual and conjectuial in charactei Since lecognition 
of the more widely accepted facts will piobably lead to bettei diagnosis and 
treatment, it seems pieferable to outline them lathei than discuss many of 
the points still remaining controvei sial 

Ninety yeais ago Virchow,^ discussing chionic peiitonitis, desciibed the 
foimation of flat or villous-hke thickenings on the peiitoneum eithei single 
or multiple He had observed their occuirence in the region of the ap- 
pendix, hepatic, splenic, and sigmoid flexui es of the colon In some instances 
paitial nai rowing of the lumen with constiiction was piesent It was his 
impiession that this peritonitis resulted fiom any inflammation of the 
intestinal wall by diiect continuation oi from other abdominal organs 

The problem lay practically doimant m the literature until IMoynihan," 
in 1906, lead a papei entitled, “The Mimici}’^ of Malignant Disease in the 
Large Intestine,” in which, he lepoited six cases with a mistaken preopeia- 
tive diagnosis of malignant disease Four of these weie diagnosed as con- 
sisting of chronic inflammatory tissue from vaiious causes He stated that 
“The mflammatoiy tumors of the large intestine, excluding the tuberculous 
conditions, aie, it would appeal, fai moie fiequent than we haAe supposed 
The exact natuie of the conditions piesent aie not always the same The 
inflammation may begin m and penetiate the mucosa, a false dnerticulum 
may foim and may peifoiate, extensive undermining ulceiation may be 
combined with a form of polypoid growth or, finally, the inflammatory de- 
posit may affect the peiitoneal coat, chiefly 01 solely, leaving the mucosa 

* Read before the New York Surgical Society, No\ ember 25, 1936 Submitted for 
publication March 4, 1937 


55 



DUDLEY AND MISCALL 


Annal«!of SurRen 
January 1938 


supple and intact ” While oftering no etiologic classification, he emphasized 
the mimicry of malignant disease 

In 1908, A W Mayo-Robson'* detailed the lecord of ii abdominal cases 
m which he had failed to diffeientiate inflammatory from malignant disease 
His eiiois had occiiried, once in the esophagus, foui times m the stomach, 
once each in the small intestine, cccum, ascending colon, transverse colon 
and splenic flexure, and twice in the rectum He related the satisfactory 
and fiequently suipiismg results which he had obtained with short circuiting 
opeiations m some of these cases which had been diagnosed hopelessly in- 
cuiable cancel In view of this experience, he lecommended exploration 
of all doubtful cases Although he could offei no definite etiologj’^, he 
clearly separated this gioup from the specific granulomata 

In 1909, Heinrich Biaun’ reviewed the literature and, adding tw'O cases, 
w'as the fiist to desciibe in detail the gioss and microscopic pathologic pic- 
tures He defimtel}' set this apart from the specific granulomata In 1911, 
Gififin'* lepoited an mflammator} mass aiouiid a duerticulum of the rectum 
and observed the possibility of fistula formation Betw'een 1907 and 1917, 
Proust and Lejais,® Hamann," and Lee® each added case reports Lee’s 
case illustiated the possibiht} of abscess foimation in this disease In 1912, 
McGrath,® having found chionic extranuicosal inflammation with mass 
formation m 27 cases of symptomatic diverticula of the large bowel, quoted 
Telling “Of all the secondary lesults this piohferative inflammation is 
the most impoitant, the most fiequent and probably the most o\erlooked” 
He cautioned against the hasty labeling of colonic masses as malignant dis- 
ease He attributed the lack of luminal intestinal symptoms (bloody and 
purulent stools, etc ) to the relative ficedom of the mucosa fiom involvement 
and stated that caieful handling of such inflammatory masses may avert 
adhesions, fistulae, abscesses, peiitonitis and death 

Thus, to this time, attention had been diiected to the presence of these 
tumois frequently closely lesembhng malignant disease, both clinically and 
pathologically, to then inflammatory nature as distinct from tuberculosis, 
lues and actinomycosis, to the dangei of intrapei itoneal infection and to the 
production of stiictures 01 fistulae in the conise of the disease The lesions 
had occuiied in both the large and small intestines, stomach and esophagus, 
wnth the only ascribable causes mentioned being foieign bodies, ulcers and 
diverticula 

It w^as not until Moschowntz and Wilensky,^^ m 1923, repoited four 
cases under the caption of “Non-specific Granulomata of the Intestines” 
that the suigical profession in this countiy showed real interest 111 the sub- 
ject Although lecognizing the etiologic importance of foreign bodies and 
diverticula, they believed that the cause W'as usually unknowm and felt that 
the erroneous diagnosis of hypei plastic tubeiculosis concealed many instances 
of this disease They noted that after sidetracking opeiations, the tumors 
frequently tended to disappear Without doubt, then papei is lesponsible 
for the present increase in the recognition of the disease 

56 



Volume 107 
liumtjcr 1 


INFLAMMATORY TUMORS OF INTESTINE 


In 1928, Barron/^ studying the occurrence of simple, nonspecific ulcers 
fiom esophagus to anus (ulcers other than those due to tuberculosis, lues, 
dysentery, typhoid fever, parasites and malignant disease) mentions them 
as anothei possible and difficultly recognized cause of this type of inflamma- 
tion, especially in the colon In 1931, Mock^® ventured the opinion that de- 
creased blood supply and trauma maj' be etiologic factois 111 some cases His 
advice to remove a section foi biopsy in all appaiently inoperable intestinal 
tumors should be accepted guardedly, since such proceduie ma} excite serious 
sequelae In 1932, Wilensky^^ summarized his attitude towaid the pioblem 
by stating “Non-specific gianuloma of the intestinal tiact ofleis no chai- 
actenstic clinical concept because the etiology, symptoms and signs are 
protean and indefinable ” In 1932, Raiford^'" classified the nonspecific 
granulomata of the gasti o-intestinal tract as one of the lymphoblastomata, and 
emphasized the occasional difficulty of accuiate pathologic diagnosis In 
1933, Erdmann and Burt^® suggested that the process may originate m 
an injury to the mucosa with subsequent ingiess of infection of a low-grade 
type In 1932, Crohn, Ginzburg and Oppenheimer^'^ intioduced the term, 
“regional ileitis ” They believed that the terminal ileum is involved selec- 
tively enough to constitute a new clinical entity Their observation of 
the growth of a gianuloma at the site of previous strangulation of intestine 
suppoits Mock’s contention that the process may be initiated by an impaired 
blood supply In 1933, Hams, Bell and Biunn^® suggested the name, 
“chronic cicatrizing enteritis,” based upon then belief that the piocess oc- 
curs throughout the small intestinal tract This review indicates the lather 
wide acceptance of many facts 

Pathologically, the inflammatoiy tumoi may be desciibed as a chronic, 
pioductive, inflammatory leaction to vaiious etiologic factois and may often 
involve all the coats of the gut Eaily, it lesembles chronically infected 
granulation tissue with many new blood vessels infiltrated by lymphoid and 
polymorphonucleai cells Giant cells of the foreign body type are not in- 
frequently found Fibroblastic elements soon appear in the reaction \\hich 
may now pi ogress in several ways It may persist as a pioductive inflam- 
mation and, with progi essively diminishing blood supply, may eventuate in 
adhesive peritonitis or fistula foimation, or by suppuiation m abscess forma- 
tion or peiitonitis Fibroblastic predominance may lesult in a dense stenosing 
cicatiix The small intestine, paiticulaily the ileum, shows mucosal ulcera- 
tion and cicatnzation somewhat more often than the lest of the gasti 0- 
mtestmal tiact It should be emphasized that any part of the gastro-intestinal 
tract may be afifected even though in the 51 cases leviewed, 26, or 51 per 
cent, occur! ed m the ileocecal region mth six in the cecum, 13 m the cecum 
and ileum togethei and seven in the ileum alone Excepting the younger 
age incidence m the ileum most cases have been leported in the cancer age 
group (40 to 60) 

Giossly, the lesion is most often confused with malignant disease in 

57 



DUDLEY AND MISCALL 


\nnalsof Surjrcrv 
Januarj 1038 


the laige bowel and stomach, and with either malignant disease or tuberculosis 
m the small bowel and cecum 

The known causes may be grouped as either mtra- or e\tra-mtestinal 
From within the gastro-intestinal tract diverticula, foreign bodies, non- 
specific ulcers, colitis and polypi represent the major causes From without 
the gastro-mtestinal tiact foreign bodies, progiession from other foci, and 
embariassed blood supply are the important known factors However, in 
addition, a large number of cases remain without any indication of the actual 
origin The impoitance of these factors varies vith the portion of the tract 
affected In most of the cases involving the stomach, an ulcei has accounted 
for the reaction Cases involving eithei oi both the ileum and cecum have 
usualty shown no more definite cause than the occasional presence of a 
foreign body or embarrassed blood supply Especially m the ileum does the 
question of etiology remain unceitam Howeier, it maj be suggested that 
the marked amount of Ij'inphoid tissue in this area may be contributory to 
ulceration, thus possibly initiating the disease here The large intestine ex- 
hibits diverticula and foreign bodies as piimaiy factors 

The multiplicity and diversity of symptoms and signs preclude any great 
degree of accuracy m preoperative diagnosis Some points, howeier, de- 
seive emphasis as possilile aids Long standing indefinite symptoms such 
as a low grade of fevei, anoiexia, nausea and abdominal pain may suggest 
subacute or chronic disease of the gastio-mtestinal tract 

The pathologic stage of the disease gives use to wide vaiiation m the 
clinical picture The stage of infection may be ushered m as an enteritis 
or a colitis, adhesive peritonitis, diveiticuhtis, mtra-abdominal abscess, visceial 
perforation or peiitonitis Suffice it to state that usually the piocess remains 
of indolent nature and only larely, as in sigmoid diverticulitis, progresses to 
an acute fulminating peritonitis The stage of intestinal obstruction is 
usually incomplete and may occui either befoie or after fibiotic stenosis of 
the bowel 

Enumeration of the symptoms and signs of the above wmuld entail a 
description of almost all mti a-abdommal diagnoses Local tendeiness, 
leukocytosis and a palpable mass may be present Furthei considerations 
m diagnosis must take into account the location of the disease The high 
percentage of eiror in preoperatu^e diagnosis makes it essential to appiaise, 
at the same time, the possibility of diagnosis at operation 

The complaints of a young individual may have suggested duodenal ulcei 
wdiich roentgenologic evidence of pyloric defect or obstiuction may have 
corroborated Anemia may be present but the tiue cachexia of cancer is 
usually absent Palpation of a mass in the upper abdomen may readily tin ow^ 
the weight of evidence to malignant disease Inflammatory tumor must 
be thought of if the mass is larger, more tender and less hard than to be 
expected m the lattei If at opeiation a laige tuinoi of the stomach and 
duodenum wuth many inflammatory adhesions and without metastases in the 
liver be encountered, the diagnosis may be reasonably suspected Competent 

58 



A olume 107 
Jsiimbei 1 


INFLAMMATORY TUAIORS OF INTESTINE 


obseiveis haA'e repoited the presence of inflammatory tnmois m the stomach 
and duodenum tieated surgically as inopeiable caicmoma Subsequent dis- 
appeaiance of these tumois has attested to then mflammatoiy natuie 

The occuiience of indefinite symptoms m the light lowei quadrant may 
easily lead to erroi It is here that the mflammatoiy tumoi is most common 
Theie may be a histoiy of one or fiequent attacks of ententis, peihaps ulceia- 
tive in type with abdominal ciamps, nausea and vomiting, slight fevei and 
anemia At this stage the diagnosis is usually not made The mimicry of 
acute appendicitis is usually misleading but long duiation of symptoms and 
anemia may arouse suspicion Many cases opeiated upon and dismissed 
as clnomc appendicitis leveal the correct diagnosis with the subsequent de- 
velopment of a mass oi intractable fistulae Diiect tiauina oi sti angulation 
of intestine in a henna may antedate the onset of symptoms and the de- 
velopment of a mass A mass palpated before or at opeiation calls for 
diffeientiation from ileocecal tuberculosis, lymphosaicoma, carcinoma and 
benign tumors 

The inflammatoi )'■ tumoi is usually not shaiply limited in extent, may 
involve the ileum, cecum oi both and is usually firm, Avith many adhesions 
The presence of fistulae, either visceiovisceial or external, either initial or 
postoperative, almost labels the disease Pen-intestmal abscesses aie not 
uncommon Dense fibrosis of the ileum may exist The lesion may be mul- 
tiple The absence of active, pulmonaiy tuberculosis almost rules out ileocecal 
tubeiculosis Lymphosaicoma does not spiead as Avidely, noi does it have 
the excess of inflammatory adhesions Carcinoma may be partially luled 
out by the smaller aiea involved, the veiy hard consistency of the tumor, 
the piesence of metastases and the lack of eaily adhesions Benign tumors 
should be recognized easily 

It may be suggested that the use of roentgenologic studies with barium, 
in the presence of small intestinal obstruction, submits the patient to the 
possible piecipitation of acute intestinal obstruction and should be used 
only with the greatest caution The factors mentioned above hold good 
for the entire small intestinal tract 

If the symptoms are of colonic nature one must look for presumptive 
aids in the histoiy such as colitis, nonspecific ulceis, foieign bodies and 
especially diveiticula The inflammatory tumor does not develop the bloody 
stools, anemia and cachexia of right-sided colonic caicmoma noi the acute 
obstruction of left-sided colonic caicmoma A tender mass may be palpable 
and associated with leukocytosis, indicating infection Proctoscopy Avith 
biopsy and i oentgenologic studies are useful At operation the inflammatory 
tumoi IS laiger, more widespiead, less hard and lacks the metastases of 
malignant disease Many mflammatoiy adhesions and small abscesses may 
be found 

Surgical recommendations should be governed by several factors First, 
conservative suigeiy may, and frequently does, result m cure Avitbout the 
added risk of radical interA^ention Second, the ever present chance for 

59 



DUDLEY AND MISCALL 


Annals of Suaen 
January 1038 


error should allow for the occasional necessity of fiiithei surgery Third, 
any surgical procedure meeting these standaids and offering the oppoitunity 
of accurate diagnosis certaml}’- has meiit m itself 

We believe that these criteiia definitely favor the side-tracking opeiations 
as the best solution of the problem, at least, until moie is known of the 
etiology and diagnosis of the disease The application m any part of the 
gasti o-intestinal tiact of this treatment seems to show sound basic advantages 
ovei the moie ladical piocedures 

If all findings do not label a gastric mass as malignant, a gastro-enterostomy 
and biopsy of the regional nodes should be performed This procedure 
ma)'- cure an inflammatory tumoi and, if the biopsy is reported malignant, 
secondary lesection may be completed Avith little loss to the patient Further- 
more, lesection for an inflammatoiy mass cariies not only the higher risk 
inherent m the operation itself but also the added danger of severe infection 
and fatal peritonitis 

In the ileocecal legion conseivative suigeiy offers a definite advantage 
A simple side-tiacking operation, with biopsy of legional lymph nodes, pei- 
mits of more accurate diagnosis and probably will cure the inflammatory 
tumoi It will reduce the incidence of complications often following radical 
procedures Lymphosarcoma, notoriously, is not amenable to surgical cuie 
Radiation therapy may be of some benefit Hypei plastic tubeiculosis may 
be resected after the diagnosis has been pi oven Adenocaicinoma of the 
ileum may be secondarily lesected even though these tumoi s metastasize 
and recur early 

Surgeiy of the laige bowel cariies the risk of severe and fatal peritonitis 
calling for care and judgment in selection of the operative pioceduie Such 
procedure should be at least consistent with possible lecoveiy Any abscess 
should be incised and diained only, even though it is known that fistulae 
may persist Simple removal of a foreign body may effect a cure Biopsy 
m this region, except for lemoving a regional lymph node, is inadvisable 
If the diagnosis of inflammatoiy tumoi can be reasonably suspected, shoit 
circuiting types of operations ceitamly aie desiiable If piacticable, colo- 
colostomy or enterocolostomy may be pei formed , if not, simple colostomy 
If the tumor is readily delivered outside the abdominal caMty a Mikulicz 
type of proceduie may be carried out In the event of dlsco^ely that the 
process is of malignant natuie, secondaiy opeiation may then be pei formed 
A total of 43 cases taken fiom the literatuie may be divided into three 
gioups seven of these involved the ileum alone Thirteen involved the 
ileum and cecum and m some of these 13 there w^as additional involvement 
of other portions of the large or small bowel Tw^enty-three involved only 
the large intestine exclusive of the cecum 

In the ileum alone, the seven case reports show seven resections wuth 
one death and two recurrences requiring secondary opeiation The 13 
case reports with ileum and cecum involved show^ed the following results 
With nine resections, five cures occurred The other four cases had two 

60 



Volume 107 
dumber 1 


INFLAMMATORY TUMORS OF INTESTINE 


Table I 


ANALYSIS or CASES REVIEWED IN THE LITER \TURE 


Pai t Involved 

Age and Se\ 

Treatment 

Result 

Comment 

Reported By 

Esophagus 



Gastrostomy 

Cure 


Robson lOOS 

Pylorus 

31 

M 

Gastro enterostomy 

Cure 

Ulcer? 

Robson lOoS 

Pjlorus 

47 

M 

Gastro enterostomy 

Cure 

Ulcer’ 

Robson ipoS 

Pylorus 

48 

M 

Gastro enterostomy 

Cure 

Ulcer? 

Robson 1908 

Pj lorus 

50 

M 

Diet and rest 

Cure 

Ulcer? 

Robson 1908 

Stomach 

56 

r 

Resection 

Cure 

Ulcer? 

Mod 1931 

Stomach 

52 

F 

Resection 

Cure 

Ulcer? 

Mock 1931 

Stomach duodenum 






and pancreas 

38 

M 

Resection 

Death 

Ulcer? 

Mock 1931 

Stomach 

54 

M 

Resection 

Death 

Ulcer? 

Kolodny 1935 

Stomach 

43 

M 

Resection 

Cure 

Ulcer? 

Kolodny T 93 S 


Ileum 

20 

M 

Resection 

Two lecuirences 

Coffin 19-5 

Ileum 

25 

M 

Resection 

Death 

(strang hernia) 

Torn meso 

Mod 1931 

Small intestine 

31 

M 

Resection 

Cure 

Pneu death (i 
mo ) 

Case 1931 

Ileum 

52 

M 

Resection 

Cure 

Ulceration 

Andrews I 93 - 

Ileum 

30 

r 

Resection 

Cure 


Ilanford 1933 

Ileum 

42 

r 

Resection 

Cure 


Lrdmann and Burt 

1933 

Ileum 

24 

M 

Resection 

Death 


Harriss Bell and 
Brunn 1933 

Ileum 

28 

r 

(a) Short-ciicuit 
( 5 ) Resection 

Curt 

1 no opoi itions 

Bockus and Lee 

1935 

Cecum and ileum 

23 

M 

Resection 

Cure 


Jones and Eiscnberg 
191S 

Cecum and ileum 

23 

M 

Resection 

Fistula ab 

scess 

and rcsec 

Moschowitz and Wi- 
lensky 1923 

Cecum and ileum 

22 

r 

Resection 

Cure 

I men sutme 

Mod 1931 

Cecum and ileum 

18 

M 

Resection 

Cure 


Erdmann and Burt 
1933 

Cecum and ileum 

Cecum ileum and 

39 

r 

Resection 

Cure 


Erdmann and Burt 

1933 

colon 

60 

F 

Resection 

Death 

2nd rescc (fis- 
tula) 

Erdmann and Burt 
1933 

Cecum and ileum 

37 

r 

I and D abscess 

r istula 

2nd resec 

Erdmann and Burt 

1933 

Cecum and ileum 

30 

F 

Resection 

Cure 


Molesworth, 1933 

Cecum and ileum 

49 

F 

Resection 

Abscess 

2nd I and D 

Gordon 1933 

Cecum and ileum 

21 

r 

Appcndicectomy 

Fistula 


Janssen 1933 

Cecum and ileum 

64 

M 

Short circuit and 
Roentgen ray 

Cure 

and ex oper 

Eggers 1933 

Cecum and ileum 

18 

r 

Resection 

Death 


Harass Bell and 
Brunn 1933 

Cecum and ileum 

19 

r 

I and D abscess 
appcndicectomy 

Cure fis- 
tula 

2nd resec 

Harass Bell and 
Brunn 1933 


Cecum 

SO 

M 

Resection 

Cure 

Robson 1908 

Cecum 


F 

E\p celiotomv 

Cure 

Jones and Eisenbesg 
1918 

Cecum 

Cecum and ascending 

41 

M 

Resection 

Cure 

Golob 1932 

colon 

Cecum and ascending 

33 

M 

Resection 

Cure 

Moschowitz and Wi- 
lensky 1923 

colon 

1 1 

r 

Resection 

Cure 

Moschov itz and M 1 

.ensky 1923 


61 



DUDLEY AND MISCALL 


Annals of Surccrj 
January 1938 


Tadlf I {Conlmued) 


Part Involved Age and Sex Treatment 
Cecum and ascending 


colon 

57 M 

Short circuit and 
Roentgen ray 

Ascending colon 

70 

Short circuit 


Trans colon 

50 

M 

Short circuit 

Trans colon 

so 

F 

Resection 

Trans colon 

32 

r 

Resection 

Trans and splenic 
colon 

62 

r 

Short circuit 

Splenic flexure small 
intestine 

50 

r 

Double short circuit 

Splenic flexure 

44 

M 

Resection 

Splenic flexure 

20 

M 

Exteriorized cxcisioi 


Sigmoid 

58 

r 

I and D abscess 

Sigmoid 

52 

M 

Colectomy 

Sigmoid 

Sigmoid (tubes and 

7 

F 

Exp oper 

o\ aries) 

49 

F 

Exp oper 

Colon and ileum 


M 

Resection 


Rectum 

28 

F 

Colostomy — Ab 
pern sec 

Rectum 

SO 

M 

Colostomy 

Rectum 

so 

M 

Colostomy 

Rectum 

S6 

r 

Resection 


Result 

Comment 

Reported By 

Cure 


Eggers, 1933 

Cure 


Robson 1908 

Cure 

Cure? 

2nd abscess 

I and D cure 

Robson 1908 
Moynihan 1908 

Lee 1917 

Cure 


Moynihan 1908 

Cure 

Fistula 

Cure 

2nd oper 

Robson 1908 
Moschonitz and Wi- 
lensky 1923 

Mock I93t 

Cure 

Cure 

Cure 

Dncrticulitis 

Di\ erticulitis 

Moynihan 1908 
Moynihan 1908 
Ashurst 1908 

Cure 

Recurrence 

Tno — 2nd opers 

Mock 1931 

Coffin 192s 

Cure 


Moynihan 1908 

Cure 

Cure 

Cure 

Closure 

Closure 

Diverticulitis 

Robson 1908 

Robson 1908 

Giffin 1911 


deaths with three secondaiy fistulae and t^\o secondaiy abscesses requiring 
foul additional operations One death followed a primary opeiation and 
one a secondaiy lesection foi fistula One fistula persisted The two cases 
with secondaiy abscesses, both of which weie incised and drained, ended 
with two fistulae which weie both reoperated upon a third time Four 
consen'ative opeiations weie performed in this group One short circuit 
followed by radiotherapy yielded a cine as did one appendicectomy In- 
cision and drainage of two pi unary abscesses resulted in two fistulae, which 
also were subsequently resected 

It IS to be noted that three deaths, two recurrences, two secondary ab- 
scesses and three secondaiy fistulae lequirmg eight additional operative 
procedures do not incline one to consider that this type of surgery is all that 
is to be desired It is certainly worthy of consideration, from a diagnostic 
standpoint, that all four cases having abscesses that vere incised and diained, 
subsequently developed fistulae of an ileal type which tended to persist for 
a long time 

The 23 cases involving the laige bowel showed these results With ii 
resections eight cures resulted, with two lecurrences, two fistulae, and one 
abscess In 12 cases conservative surgery yielded 12 cures Seven of these 
12 had a short circuiting pioceduie performed, and all recovered without 
any complications 


62 



Volume 107 
Isiimber 1 


INFLAMMATORY TUMORS OF INTESTINE 


If the latter two gioups of cases, totaling 36, aie consideied togelhei 
these lesults may be obseived Twenty lesections yielded 13 cuies, \Mth t\\o 
deaths fiom piimaiy opeiation, two lecunences requiiing two secondaiy 
opeiations, resulting in one death, five peisistent fistulae and thiee secondaiy 
abscesses all lequinng leoperation In 16 of these cases, conseivative sur- 
geiy of one type 01 anothei yielded 13 cuies Short circuiting peifoiined 
eight times showed eight cuies, exploiatoij'- celiotomy in foui cases, three 
cures, exterioiization m one case, one cuie, incision and drainage m thiee 
cases, one cuie with two peisistent fistulae Omitting those cases that had 
only incision and drainage of an abscess fiom this gioup of 16, conseivative 
surgeiy showed only one case without a favoiable lesiilt This may be con- 
trasted, veiy definitely, with the frequent complications resulting from radical 
surgery 

The appended case repoits aie from the Second Suigical Division of Belle- 
vue Hospital, New York 


CASE REPORTS 

Case I — S T , female, age 47, white, was admitted to the hospital April 17, 1926, ivith 
a seven weeks’ history of irregularly, recurrent pain m the left lower quadrant with some 
nausea but no vomiting Previously she had been quite constipated There had been no 
weight loss 

She was subacutely ill without abnormal physical findings other than those localized 
to the abdomen In the left lower quadrant there was a firm, round, orange-sized mass 
slightly tendei and fairly mobile Rectal and vaginal examinations were normal 

The temperature varied between normal and 101° F , white blood cells, 17,200, poh- 
morphonuclears, 85 per cent, red blood cells, 4,500,000, hemoglobin, 95 per cent, stools 
negative for blood, Wassermaiin negative, blood chemistry normal, cystoscopy normal, 
proctoscopy shoived no visible pathology Roentgenologic examination revealed incomplete 
obstruction of the inidsigmoid 

She was operated upon 12 days after admission and a large, mobile mass w^as found in 
the left lower quadrant This was composed of inflamed, thickened and adherent omentum 
and sigmoid colon Several small abscesses were encountered during tbe exploration A 
small splinter of wood about 2 cm long was found 111 this mass when the omentum was 
separated from the sigmoid However, no perforation of the sigmoid was seen The 
splinter was removed and the abdomen closed with drainage 

The patient made an excellent convalescence, having been discharged on her twenty- 
fourth postoperative day, with the wound completely healed For three years she has had 
no recurrence of symptoms and the mass has disappeared 

Case 2 — G M, male, age 42, wdiite, was admitted September 18, 1934, vith a two 
day history of abdominal pain most marked 111 the left lower quadrant He had had con- 
siderable vomiting and some dvsuria His past history elicited no prominent sjmptoms 
He was acutely ill, dehydrated and had a distended and tender abdomen Rectal examina- 
tion sho\ved marked tenderness on the left side No mass was palpated Temperature, 
loi 4° F , urine, negative , white blood cells, 12,600 , polymorphonuclears, 82 per cent 

He w'as operated upon shortlj’^ after admission and a diffuse peritonitis was found In 
addition, the sigmoid w'as grossly inflamed and thickened and had many inflammatorj ad- 
hesions about it The abdomen w as closed with drainage 

He had a stormy com alesceiice and was discharged on his thirtieth postoperatnc daj 
The w'ound healed completeli’- without the formation of a fistula Subsequent studies hae e 

63 



DUDLEY AND MISCALL 


Annnisof Surteo 
January I'HS 


proven the presence of multiple diverticula of the sigmoid The inflammation of one of 
these doubtless accounted for his illness 

Case 3 — AI R, female, age 37, was admitted August i, 1933, with a thiee months’ 
historj of cramping, epigastric pain after meals Alkalies cased the pain iiiegularly but 
vomiting ga\e constant and immediate relief She remembered having Ind tarrj stools 
several times Slie had lost about 40 pounds in three to foui months Episodes of epigastric 
pain with vomiting had recurred for nine years and during this period lepeatcd observation 
in various hospitals had resulted in no definite diagnosis Three jears before her admis- 
sion, hematemesis and melena had been noted for the first time, and during the last three 
yeai s both of these have recurred on sev eral occasions 

She was a markedlj emaciated joung female, appearing chionicalh ill and complaining 
of fairlj severe epigastric pain Her head, neck, lungs, heart and cvticmitics revealed no 
positive findings The abdomen was soft, nontendcr, not distended and no masses were 
palpable Rectal and vaginal examinations were negative 

Tempeiature rose to a maximum of loi” F on several dajs Pulse and respirations 
normal Blood pressure, 98/72, urine, negative, white blood cells, 8,400, poljmorpho- 
nuclears, 74 per cent, red blood cells, 4,500,000, hemoglobin, 80 per cent Wassermann, 
negativ'e , blood chemistry, normal Repeated G I series show cd onlj a v ei j lai gc atonic 
stomach and dilated duodenum 

After having left the hospital against advacc on three occasions she finallv consented to 
an exploratory celiotomy because of almost constant vomiting She was operated upon 
August 15, 1933, with a preoperativc diagnosis of high obstruction 

The operative findings consisted of a markcdl) dilated stomach and duodenum , a 
lemon sized mass m the jejunum, six inches below the angle of Treitz, causing almost com- 
plete obstruction , many soft small lymph nodes were found in the mesentery at this point 
The mass was resected and a side-to-side anastomosis done and the abdomen closed with- 
out drainage 

Postopcratively a wound infection cleared fairlv rapidlj She progressed well for about 
tw 0 weeks when the vomiting recurred Conservativ e measures were of no av ail Roent- 
genologic studies again showed marked dilatation of the stomach and duodenum It was 
felt that she might have been obstructed at the jejunojejunostomj stoma and she was 
reoperated upon September 27, 1933, six weeks after her first operation 

The abdomen contained a mass of adhesions between both the parietal and visceial 
peritoneum The anastomosis appeared patent The first portion of the jejunum was 
slightly hypertrophied and had a granular appearance An anterior gastio-enterostomj 
was performed with an entero-anastomosis 20 inches below the angle of Treitz The 
wound healed by primary union and she made good progress for another two weeks At 
this time recurrence of vomiting seemed to indicate another obstiuction from adhesions and 
she was reoperated upon November 4, 1933, six weeks after the second operation 

At operation the gastro-entcrostomj and both entero-anastomoses were apparentlj 
functioning The peritoneal cavity contained a mass of adhesions The stomach was not 
dilated The exploratorj celiotomy, with lysis of the adhesions, was comjileted Post- 
operatively she made some progress for about two W'eeks but died suddenly on the six- 
teenth postopei ative day, approximately 30 hours after a recurience of the vomiting 

Pathologic examination of the tissue removed from the jejunum at the fiist operation 
showed a stenosmg lemon-sized tumor of the jejunum It was interpreted as a chronic, pro- 
ductive inflammatory tissue The mucosa was slightly ulcerated and the tumor showed a 
marked amount of fibrosis with infiltration by many lymphoid cells Some giant cells were 
also present 

Autopsy revealed the presence of two other similar tumors, one in the duodenum and 
one low down in the jejunum The origin of these tumors is unknown 

Case 4 — M M , female, age 46, white, was admitted in December, 1934, with a one 
week’s history of generalized abdominal cramps, with considerable nausea and vomiting and 
slight diarrhea She believed this to be due to some type of food poisoning With the 

64 



A oliimc 107 
Iv umber 1 


INFLAMMATORY TUMORS OF INTESTINE 


onset of fever and some abdominal distention accompanied bv constipation, she came to the 
hospital She admitted having had some irregular lower abdominal pain with constipation 
for a few months before the present illness 

She was well developed and well nourished but chromcallj' ill Examination show’cd 
only abdominal distention and tenderness in both lower quadrants A slight cystocele and 
rectocele were present, and the culdesac w'as slightly boggy but not tender 

Temperature on admission 103° F , pulse and respirations, normal, urine, negatue, 
blood pressure, 105/70, white blood cells, 12,000, polymorphonuclears, 78 per cent, Wasser- 
mann, negative, Widal, negative, red blood cells, 4,000,000, hemoglobin, 70 per cent The 
stool was negative foi blood Culture and direct examination of the stool show'ed no ab- 
normal findings Proctoscopy negative A barium enema, which was repeated, showed 
finger printing in the sigmoid and was interpreted as an infiltrative lesion A diagnosis of 
possible foreign body perforation of the sigmoid with abscess formation w’as made, and 
operation carried out January 9, 1935 

OpemUon — ^The pelvis and lower abdomen were a mass of adhesions in which w-re 
embedded the tubes and ovaries and the small and large intestines This mass w’as the 
seat of an inflammatory reaction, the tissue being of porky consistency The sigmoid W'as 
incorporated in this mass and its wall was tremendously thickened The tubes w'ere also 
markedly enlarged There was a small amount of odorless pus, enclosed 111 the meshes of 
these adhesions 

Both tubes were removed by sharp dissection and an appendicectomy with simple 
ligation of the stump effected The abdomen was closed with drainage 

She died on the eighteenth postoperative day from an acute nephritis and sepsis A 
postmortem examination revealed a small amount of purulent exudate in the lower abdomen, 
which showed a hemolytic streptococcus in pure culture as did the pus from the orig- 
inal abscess 

Friable adhesions were piesent throughout the abdomen, particularly low down The 
wall of the large intestine at the rectosigmoid junction was thickened, firm and indurated 
without ulceration of the mucosa The ileum and small intestine were intimately adherent 
to this mass Microscopic examination of this tumor of the rectosigmoid region showed a 
chronic productive inflammatory reaction with an increase m the connective tissue, infiltra- 
tion by lymphoid cells and some edema The surgical specimen w'as reported as showing 
a chionic productive salpingitis 

Although the origin of this tumor of the 1 ectosigmoid junction is not 
definitely established it seems probable that it may be due to piogression 
from the pathologic piocess in the tubes 

Case s — T G , female, age 61, white, was admitted June 10, 1935, with a four months’ 
history of cramplike abdominal pain with nausea and irregular vomiting She had noted 
intermittent constipation with distention She had had no melena or hematemesis She 
had gradually become weaker during the past two months, with a weight loss of approxi- 
mately 30 pounds She stated that on several occasions she had had some ferer 

The patient was subacutely ill Examination showed fairly marked tenderness over 
the lower abdomen, particularly on the left side An irregular suprapubic mass ^\as 
palpable but could not be definitely outlined On bimanual examination the tumor seemed 
to be intimately connected with the posterior vaginal wall 

Her temperature ran irregularly between normal and 102° F , red blood cells, 
4,000,000, hemoglobin, 80 pei cent, white blood cells, 11,000, polymorphonuclears, 85 per 
cent, urine, negative, blood pressure, 140/90, proctoscopic examination, negative, stools 
negative for blood 

At operation, June 14, 1935, an orange-sized mass was found in the sigmoid adherent 
to the ileum, which caused subacute obstruction of both the ileum and the large bowel 
The adhesions encapsulated 50 cc of thick, greenish pus 

65 



DUDLEY AND MISCALL 


Annals of Surgery 
January 1'J38 


In separating the adhesions the abscess was opened, and in attempting to free the 
sigmoid from the ileum, a small opening was accidentally made into the large bowel 
This was closed after a small piece of tissue had been removed for biopsy The wound 
was closed with drainage 

Postoperatnely, she dei eloped a fecal fistula which drained for a considerable length 
of time 'Ihc patient refused furthci surgerj of aii> tjpe and left the hospital, returning, 
howeier, to the O P D for subsequent diessings flic fistula persisted for appro\imatel> 
one year when it finally closed spontaneousl> It is now a jear and one-half since opera- 
tion and the patient is in excellent health 

The specimen removed from the tumor in the rectosigmoid region showed a dense 
granulation tissue in which there were numerous vessels Considerable fibrous tissue of a 
dense character, with numerous fibroblasts, was present and was infiltrated bj many 
round cells 

Case 6 — C L, male, age 40, white, was admitted Maj 15, 1934, complaining of 
epigastric pain of ten j ears’ duration This occurred about an hour after each meal and 
was relieved by alkalies and emesis There was no historj of hematemcsis or melena 
During the past month he had had almost constant vomiting, having been able to retain onlj 
fluids He had been operated upon previousl} for hemorrhoids and for a perforated 
appendix, both in 1932 

The patient was emaciated No abdominal tenderness was present No mass was 
palpated Temperature, pulse and respirations normal Urine, negative, white blood cells, 
15,000, polymorphonuclears, 70 per cent, red blood cells, 5,000,000, hemoglobin, 100 per 
cent, gastro-intestinal roentgenograms showed complete retention of the gastric meal at 
24 hours 

At operation. May lO, 1934, an orange-sized mass was found in the first portion of the 
duodenum and extended slightly over onto the gastric side There were man> adhesions to 
the surrounding structures No metastases wcie felt 

A posterior gastro-enterostomy was performed, although it was felt that the tumor 
might be a carcinoma A lymph node was taken for biopsj 

The patient made an uneventful postoperative rccoverj and left the hospital on the 
eighteenth postoperative dav, against advice Since that tune he has gamed 35 pounds in 
weight Gastro-intestinal roentgenologic studies show good function of the gastro- 
enterostomj stoma, with a slight area of narrowing of the proximal jejunum about one-half 
inch distal to the site of anastomosis The lymph node was reported to show subacute 
and chronic inflammatorj changes without evidences of malignant disease It is two and 
one-half years since operation and the patient is now enjojing excellent health 

Case 7 — F A, male, age 54, white, was admitted Februarv i, 1932, with a 15 vear 
history of epigastric pain with irregular vomiting The pain had recurred frequentlj 
during this time He had lost considerable weight He was emaciated The abdomen 
was soft and nontender No mass was palpated Rectal examination was negative 

Temperature, pulse and respiiations normal Urine, normal , red blood cells, 4,000,000, 
hemoglobin, 80 per cent , white blood cells, 9,500 , polj morphonuclears, 70 per cent , stools 
negative for blood, gastric analjsis showed both free and combined acid, gastro-intestinal 
roentgenologic examination demonstrated an ulcer of the first portion of the duodenum with 
considerable residue at 24 hours 

At operation a lemon sized tumor was found in the first portion of the duodenum 
mainlj on the anterior and inferior duodenal wall A crater was palpated in the center of 
the tumor No metastases were present in the liver although there were many fairlj large 
regional nodes A posterior gastro-enterostomy was performed with biopsy of a regional 
node The patient made an uneventful recovery except for a slight wound infection and 
was discharged from the hospital on the twentj -sev’cnth postoperative day 

The biopsy of the regional node was reported to show chronic inflammation without 
evidence of malignant disease 

The patient has been followed for nearly five years and has had two herniae repaired 

66 



A olume 107 
Number 1 


INFLAMMATORY TUMORS OF INTESTINE 


during that time He has gained approximately 40 pounds in weight and has absolutelj no 
gastric symptoms 

These lattei two cases may be called duodenal ulcers t\ith chronic pio- 
ductive inflammation around them causing tumoi formation 

Case 8 — J K , male, age 60, white, was admitted m May, 1921, with a 48 hour history 
of lower abdominal pain and vomiting Examination showed an acutely ill patient with a 
temperature of 101° F, and leukocytosis of 23,000 No palpable abdominal mass Pre- 
operative diagnosis yvas acute diffuse peritonitis 

Operation revealed a mass within the pelvis imolvmg the lower segment of the 
sigmoid and upper rectum The mass did not have the consistency suggestne of carcinoma 
A peach pit yvhich had ulcerated through the inflamed colon was found and removed No 
other pathologic specimen A diffuse lower abdominal peritonitis was present A sigmoid 
colostomy was performed and the peritoneal cavity yvas drained Death on the ninth post- 
operative day' No autopsy 

This case was an inflammatory tumor lesultmg fiom a foreign bod) 

Case 9 — G F, male, age 55, yvhite, yvas admitted m October, 1935, yyith a four 
months’ history of frequent and painful defecation There yvas no history of blood in stools 
Positive physical findings yvere confined to rectal examinations Digital examinations 
shoyved hard, tender mass on the anterior rectal yvall at tip of finger Proctoscopic exam- 
ination shoyved no ulceration , no bleeding A biopsy specimen yvas reported as chronic 
inflammatory process Roentgenologic examination of lungs, lumbar spine and pehis 
shoyved no metastases Temperature 996° F , erythrocyte count, 4,400,000, hemoglobin, 
86 per cent, leukocyte count, 11,700, polymorphonuclears, 85 per cent Stool negative for 
blood by chemical examination Preoperative diagnosis Carcinoma of rectum 

Operation shoyved hard, fixed mass the size of an orange at rectosigmoid junction 
Adjacent loops of small intestine yvere adheient to the mass No fiee fluid, no palpable 
metastasis in liver Condition considered inoperable carcinoma Node remoycd from 
pelvis adjacent to mass Sigmoid colostomy performed 

Pathologic lepoit of this node, chronic lymphadenitis 

Readmitted in March, 1936, for proctoscopic examination Tyventy-six pound yy eight 
gam Spinal anesthesia Tyvo proctoscopes inserted, one through anus and one through 
colostomy Impossible to make the tyvo proctoscopes meet No erosion no bleeding On 
left side of rectum a hard mass, outside the gut, could be felt No biopsy 

This case y^ery suggestiv^e of inflammatory tumor of rectosigmoid yyith 
cicatricial stenosis 

Case 10 — G N , male, age 14, yvhite, yvas admitted February' 5, 1920, complaining of 
generalized abdominal cramps yvith vomiting For the past four months he had had recur- 
rent attacks similar to the present one He yyas emaciated and someyvhat anemic The 
abdomen yvas symmetrical yvith some tenderness m the right loyyer quadrant yyhere there 
yvas a mass Temperature rose to 100° F on seyeral occasions Pulse and respirations 
normal Urine, negative, yyhite blood cells, 14,000, polj morphonuclears, 65 per cent, red 
blood cells, 3,500,000, hemoglobin, 70 per cent 

At operation, February 12, 1920, a tumor niyolving the terminal portion of the ileum, 
cecum and appendix yvas found The ileum and right half of the colon yvere resected, and 
an end-to-side anastomosis performed 

The patient developed a fecal fistula yyliich persisted for nine months, and on tyyo 
occasions he dey'eloped secondary abscesses around this fistula yyhich required incision and 
drainage The fistula finally closed and the patient yvas folloyyed for fiye years His onh 
complaints during this time yvere irregular recurrence of pain m the right loyyer quadrant 
yvith opening of the fistula on tyvo occasions 

67 



DUDLEY AND MISCALL 


Annals Of Surcco 
January 1038 


The cecum, ileum and appendix were the seat of a chronic productive inflammatory 
reaction which was definitdj not tuberculous The cecal mucosa was ulcerated There 
W'as a fistula between the terminal portion of the ileum and the cecum which was embedded 
in a mass of adhesions 

The origin of the inflammatoiy reaction in this case was unknowm and 
it lepiesents a case similar to tliosc dcsciibed under the heading of regional 
ileitis 

Case II — P F, male, age 37, while, was admitted Alav 4, 1922, complaining of 
increasing constipation for five months He has also had, during the last fi\e weeks, 
irregular cramping pain particularlj m the lower abdomen He had lost approximatelj 40 
pounds in tw'o and one-half months He was markedh emaciated and chromcallj ill In 
the left upper quadrant theie was an orange-si/td mass which w is fairh tender Rectal 
examination, negative Temperature, pulse and respirations, normal Urine, negative, 
wdiite blood cells, 9,000, polj morphoiniclears, 82 per cent, red blood cells, 3,600,000, 
hemoglobin, 70 per cent Stool negatne for blood Barium enema showed defcctne filling 
at the splenic flexure 

At operation, Mai 12, 1922, a large mass was found iinohing the splenic flexure of 
the colon This was resected and a side-to-side anastomosis performed The abdomen 
W'as closed with drainage The patient died on the fourth postoperatiie dai, haiing de\ el- 
oped a seiere pulmonarj infection 

The wall of the large intestine was markedh thickened and firm, forming a tumor 
about five inches long and four inches m diameter The mucosa was ulcerated There 
W'as marked fibroblastic proliferation in the wall of the gut with infiltration with manj 
plasma cells 

This W'as inteipretecl as a cliionic piocluctivc inflaininatory icaction prob- 
ably on the basis of a colitis 

CONCLUSIONS 

It should be emphasi/ed that these tumors occui thioiighout the gastio- 
intestinal tiact and that, w'hile the etiology vanes, the pathology' is es- 
sentially the same in all legions It is oui belief that incision and drainage 
alone is indicated m the piesence of abscess, even though fistulae ma} pei- 
sist In the piesence of intestinal obstuiction nothing but conservative 
surgeiy should be earned out In the absence of abscess, side-ti acking and 
legional node biops)' caiiies a low'ei mortality and a low'ei incidence of com- 
plications than resection The observation of kloschow'itz and Wilenslc}', 
that the disease is often cuied by this ty^ie of pioceduie, still holds good In 
addition, conseivatism piovides the oppoitunit)' foi subsequent opeiation 
w'hen lequiied b)' a confirmed diagnosis of malignant disease 

It IS to be noted that the pioblem lies moie in avoiding radical surgei}' 
with its high mortalit)' in a condition not demanding it than in assuiing 
radical surgery to those individuals who ma}' not be benefited by it 

The authors w'lsh to express tlieir appreciation for the generous aid of Dr Rudolf M 
Paltauf, in the translation of foreign literature 

REFERENCES 

^Virchow Virchow's Archiv , 5, 335 ff , 1853 

“Mojnihan, B G A Mimicry of Malignant Disease in the Large Intestine Edinburgh 
Med Jour, 21, 228, 1907 

“Robson, A W M An Address on Some Abdominal Tumors Simulating Malignant 
Disease and Their Treatment British Med Join , i, 425, 1908 

6S 



\ olume 107 
Isumber 1 


INFLAMMATORY TUMORS OF INTESTINE 


Ih%d The Hunterian Lecture, Duodenal Ulcer and Its Treatment British Med Jour, 
February 2, 248, igoy 

* Braun, H Deutsch Ztschr f Chir , i, 12, 100, 1909 

“Giffin, H Z Annals or Surgery, 53, 533, 1911 

“ Proust and Lejars Quoted by Coffen, T H J A M A , 85, 1303, 1925 

’Hamann, C A Annals or Surger-v, 51, 782, 1910 

®Lee, B J Annals or Surgery, 65, 265, 1917 

“McGrath, B F Intestinal Diveiticulae Their Etiology and Pathogenesis Surg , 
Gynec, and Obst , 15, 429, 1912 
Telling Lancet, March 21, 1908, 28 Quoted bj' McGrath 
“ Moschowitz, E, and Wilensk}^ A O Non-specific Granulomata of the Intestines 
Am Jour Med Sci , 166, 48, 1923 

Barron, M E Simple Non-specific Ulcei of the Colon Arch Surg , 17, 35s, 1928, and 
Surg , Gynec , and Obst , 870, May, 1930 
’“Mock, H E Infective Granuloma Suig, Gynec, and Obst, 52, 672, 1931 
“Wilensky, A O Non-specific Granuloma of the Intestine Med Joui and Rec , 135, 
445, 1932 

’“Raiford, T S Arch Surg , 25, 148, July and August, 1932 

’“Erdmann, J F, and Burt, C V Non-specific Granuloma of the Gastro-Intestinal Tract 
Surg , Gynec , and Obst , 57, 71, 1933 

Crohn, B B , Ginzburg, L , and Oppenheimer, G D Non-specific Granulomata of the 
Intestines Annals of Surgery, 98, 1046, December, 1933 
Harris, Bell, & Brunn Chronic Cicatrizing Enteritis Surg , Gynec , and Obst , 57, 

637, 1933 

’“Jones, N M , and Eisenberg, A A Inflammatory Neoplasm of the Intestines Simulating 
Malignancy Surg , Gynec , and Obst , 27, 420, 1918 
“ Bull, W T Accidents Which May Follow Removal of Portions of the Omentum m 
Operations for Hernia Annals of Surgery, 17, 269, 1893 
’Pack and Davis Caicinoid Tumors of the Small Intestines Am Jour Surg, 9, 472, 
1930 

"Weinstein, M L Lympho-sarcoma of the Jejunum Am Jour Surg , 17, 355, 1932 
“Mayo, C H Quoted by Jones and Eisenberg 
Kauffman Lehrbuch der Spez Path , i, Walter de Gruyter, Berlin, 1931 
“Hairis and Rosenblum Primary Carcinoma of Jejunum Arch Surg, 23, 805, 1931 
’“King, E L Benign Tumois of the Intestines with Special Reference to Fibroma 
Suig, Gynec, and Obst, 25, 54, 1917 

Liu, J H Tumors of the Small Intestine with Special Reference to the Lymphoid Cell 
Tumors Arch Surg, ii, 602, 1925 

“Fiedler, F W Benign Tumors of the Small Intestines Memphis kled Jour, 9, 185, 
October, 1932 

“ Davies, J H T Proc Royal Soc Med , 26, 128, 1932 

““ Gregory, H H C Two Case Reports of Melena Caused by Innocent Growths of the 
Small Intestine Brit Jour Child Dis , 29, 197, 1932 
Golob, M Infectious Granuloma of the Intestines with Special Reference to tlie Dif- 
ficulty of Pre-operative Differential Diagnosis kled Jour and Rec, 135, 390, 1932 
“ Coffen, T H Non-specific Granuloma of the Intestine Causing Intestinal Obstruction 

J A M A , 8s, 1303, 1925 

“ Ewing, J Neoplastic Disease W B Saunders, page 42, Philadelphia, 1928 
Molesworth, H W L Granuloma of the Intestine Brit Jour Surg , 34, 21-370, 

1933-1934 

“ Goidon, D Annais or Surgerv, 97, 130, 1933 

“"Hanford, Jannssen, and Eggers Discussion of Gordon’s Paper Annals of Surgerv, 
97, 130, 1933 


69 



DUDLEY AND MISCALL 


Annals Of Surgery 
January 1938 


“ Monsarrat Bntisli Med Jour , 2, 65, 1907 

“Rankin, F W, and Major, S G Tumors of the Mcscnttr\ Surg , Gmilc, and Obst , 
54, 809, 1932 

“Rankin, F W, and Newell C E Benign Tumors of tlie Simll Intestine Surg, 
Gynec , and Obst , 57, 501, October, 1933 

'“Rankin, F W , and Ma^o, C, 2nd Carcinonn of the Sm ill Bowel Surg, G>nec, 
and Obst , 50, 939, I930 

“Cave, H W Tumors of the Small Intestine Annais or SLUiim, 96, 269, 1932 
‘ Ulman, A, and Abesliouse, B S A^^Als 01 Slrchi^, 95, 875 1932 
“Jennings, J E Annais 01 Soiirhin, 93, 828, 1931 
“Hartwell and Cecil Am Jour Med Set, 140, 174, August, 1910 
■‘“Clifton, H C, and Landry, B B Boston Med and Surg Jour, 8, 197, Julj 7, 1927 
Barker, L F internat Clin , September, 1931 
“Andrews, C Obstruction of the Small Intestine Due to Benign Granuloma Isebr 
State Med Jour, 17, 106, 1932 

“Kolodin, A Infective Granuloma of the Stomach An\ais 01 SeiiorRv, 102 30, 
Julj, 1935 

“ Ashurst Awals or Slrguiv, 47, 300, 1908 

“ Bockus, Heiirv L, and Lee, Walter Estell Regional (Terminal) Ileitis Annais of 
Surgery, 102, 412-421, September 1935 

Discussion — Dr Carl Egc.i rs (New York) said tliat it would be 
helpful if a common termmolog) could be found foi tbese conditions The 
name proposed by Doctoi Dudle}, namel), “nonspecific granuloma” or 
“inflammatory tumors of the gastio-mtcstinal tiact” may serve very well 
It seems better than to have a specific name for inflammatoiy tumois in 
each section of the gastro-mtcstinal tract Somehow he had never had 
under his care a patient with an inflammatory tumor of the lower ileum 
other than tubeiculous Howcvei, he had come in contact with inflamma- 
tory tumors of the pyloric icgion, so-called hypcrtiO])hic tumors or hyper- 
trophic ulcers, as well as with mflammatorv' tumors of the cecum and 
especially the sigmoid 

The first pyloric case encountered was in a man who, foui years pre- 
viously, had had a diagnosis made of inopeiable carcinoma of the stomach 
and a gastro-enterostomy with a iMuiphy button bad been performed He 
came in now with lecuirence of his symptoms It was learned that the 
button had appaiently not passed Roentgenologic examination showed a 
foreign body m his stomach He was operated upon and the two c}lmdrical 
portions of the button, the so-called male and female part, were lecovered 
from his stomach , the remainder seemed to have been digested There w as 
no sign of a tumor The gastio-enterostomv was intact The man died of 
postoperativ^e pneumonia At autopsy the steel spring of the button w^as 
found to be stuck m the pylorus, it had not shown m the roentgenogram 
Since then he had seen a number of laige tumois in this region They bring 
out a point stressed by Doctor Dudley, namely, that a side tracking operation 
IS safe and is an ideal procedure in these cases Most cases are cured b}^ a 
gastro-enterostomy, but one has to be suie not to overlook a caicmoma 

Two cases with large palpable tumois of the cecum were of interest 
The first case of this type was seen many years ago He had intestinal 
symptoms and a palpable mass Various diagnoses were suggested, ranging 
from tumor of the colon to tumoi of the kidney The roentgenologic ex- 
amination was not conclusive At operation there was found a laige tumor 
occupying the cecum and ascending colon extending into the mesentery, 
and evidently inoperable An ileocolostomy was pei foi med, after which 
he w^as given some roentgenotheiapy more as a palliative measure than 

70 



Volume 107 
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INFLAMMATORY TUMORS OF INTESTINE 


with the intention of curing the lesion, and he did veiy \\ell The mass 
disappeared completely and he has had no symptoms since 

Foui years ago a second case came under observation which presented 
a large palpable tumor of the cecum, Avith obstructive symptoms He was 
an old caidiac case An ileocolostoni}'’ was performed as a preliminarv 
piocedure, with the intention of removing the tumor at a second stage A 
few weeks latei when his heait condition had impioved, reopeiation to 
remove the tumoi was undertaken and it was found that the mass had dis- 
appeared It has not lecurred 

Both of these cases illustrate the value of a side tracking opeiation m 
the presence of these inflammatoiy tumors Unfortunately we do not 
know the pathology of these cases, since no pathologic examination ^\as pos- 
sible They weie evidently large gianulomata 

Inflammatory tumoi s of the sigmoid seem to he the most common, and 
one can distinguish two gioups of cases In some patients one has diveiticula 
and diverticulitis , in othei s, there ai e large palpable tumors of the sigmoid 
m whom one does not see any diverticula in the roentgenogiams or at 
operation This constitutes a lathei mteiesting group Di Eggers has 
collected 51 personally observed cases of inflammatory conditions of the 
sigmoid giving symptoms sufficiently severe to lequire surgical consulta- 
tion or opeiation In most instances, consultation onl}’^ Sometimes these 
tumors weie veiy large In a few instances a diagnosis of ovarian cyst 01 
ovarian tumor was made m the beginning Some have had very high fe\ei, 
usually with a high leukocyte count Another surpiising feature has been 
the speed with which they may disappeai after rest in bed, emptying of 
the bowel, and other measures In a numbei of instances we operated and 
found a laige tumor, which looked inflammatory, red, partly covered with 
fibi 111 and unlike carcinoma If one has seen a number, one may differentiate 
with leasonable ceitamty After making the diagnosis, the tumoi, in some 
instances has not been lesected, but has been replaced and the patients 
have recoveied The moitahty connected with resection is known and if 
one can lecognize the tumor as inflammatoiy m chaiacter, one may be 
conservative 

He lecalled an interesting case, seen m 1930, with a tumoi which 
reached to the umbilicus She had been in bed with fe\ei for a fe^\ weeks 
It had been diagnosed as a tubo-ovaiian condition but on questioning, 
symptoms of an intestinal disoider ^^ere elicited At opeiation a laige 
tumoi in the pelvis adheient to the bladdei, anterioi and latei al abdominal 
wall and adnexa was found She had a very high leukocytosis — up to 
50,000 The mass was apparently an inflammatory one Resection \\as 
not performed, but the mass was hbeiated and placed m a more favoiable 
position highei m the abdomen vheie it would not be so likely to reform 
adhesions The lymph nodes of the mesenteiy which drained the tumor 
were cultuied but no giowth obtained Aftei a prolonged conv'-alescence 
the patient lecoveied and she has had no lecurrence of symptoms since 
During hei convalescence she ivas given roentgenotheiap} , w'hich m some 
of these inflammatoiy conditions appeals to be of ^alue 

Doctor Eggeis then piesented a series of lantern slides m order to il- 
lustrate certain points connected wuth the diagnosis of sigmoiditis and divertic- 
ulitis, as well as its possible undeiFnng pathology The first was that 
of a patient who had been admitted on two different occasions, with several 
3^ears’ mteival Each time she piesented a large palpable tumor which 
subsided m five or six davs with rest m bed application of an icebag and 
attention to the bowUs No diverticula w'ere ever demonstiated 

71 



DUDLEY AND MISCALL 


Annals of Siirccn 
January 1938 


The next showed a middle-aged female, who presented a tumor m the 
left lower abdomen with S3'mptoms suggestive of a sigmoid lesion lather 
than a pelvic mass The roentgenologic examination was reported negatne 
A year later she was seen again, and hearing in mind the previous negative 
roentgenologic finding, a diagnosis of pelvic disease was made At operation 
a lathei haid inflammatory tumor of the sigmoid was found It was re- 
placed and the abdomen closed without diainage Subsequent roentgenologic 
examinations, expecially aftei defecation, showed what ^\as considered to 
represent a typical sigmoiditis Foui years have passed, and though the 
patient has had occasional intestinal symptoms, she has remained well The 
modem technic of visualising sigmoid lesions, particularly after defecation, 
is most iinpoitant 

Another mteiesting case was one in whom a diagnosis of sigmoiditis 
had been made on the basis of intestinal symptoms and a palpable mass 
It had been verified roentgenologically His diet ivas regulated and mineral 
oil administered A yeai latei he was taken acutelv ill, with what was 
thought to be acute appendicitis Knowung that he had dnerticula of the 
sigmoid, peiforation of this segment of the gut was consideied There w'eie 
signs of peritonitis ovei the entiie low'cr abdomen At operation fluid was 
evacuated, and the appendix removed It did not explain the symptoms 
The sigmoid w'as inspected It w'as red, hard, and covered w'lth fibrin No 
gioss peifoiation w'as seen, it w'as evidently closed off by fibrin The tumor 
mass W'as leplaced and the abdomen drained He made a good recovery 
Cultuie of fluid show'ed colon bacilli and stieptococci Intestinal symptoms 
consisting of pain and Aomiting, and suggesting obstruction continued A 
resection w'as perfoimed about six months latei with a good lesiilt 

A fourth case w'as that of an elderly male, m wdiom a diagnosis of carcinoma 
of the sigmoid had been made He had pain, tenderness and a palpable mass 
Roentgenologic examination demonstrated a small dnerticulum next to the 
mass Diagnosis of sigmoiditis w’as made and as tbe patient w'as not a 
good surgical risk, loentgenotheiapv and observation were adwsed He 
continues to leniain well, six yeais later 

A fifth case illustrated the value of taking roentgenograms before and 
after defecation as the lesion may show after defecation, wdien it does not 
do so befoie This patient had a palpable tumoi appaiently with a perfoia- 
tion of the lumen of the gut into the mass It was lesected and found to be 
inflammatory Caieful micioscopic studies bad been made, and it bad been 
detei mined that the lesion w'as the lesult of perforation of a diverticulum 
into the w'all of the gut 

Di Eggers thought that in a case, such as that just cited, one may ob- 
tain a clue to the etiology of some of these inflammator}' tumors of the 
gastro-mtestinal tract A foreign body may be consideied to be tbe cause 
in some cases A few of the cases, cited herewuth may have had a mucosal 
ulcer as the port of entry In tw’o instances it w'as appaiently a perforation 
of a diverticulum into the w'all of the gut The mucosa was normal, but 
there was an infected diverticulum in the w'all It w'as the speaker’s feeling 
that infected diverticula w'eie piobably frequently the cause of inflammatory 
intestinal tumors One may visualize the process as follow's We usually 
picture a diverticulum as projecting beyond the serosa of the gut W'all 
Perforation of such a diverticulum may form a local abscess or peritonitis 
How'ever, a diverticulum has a beginning, and befoie it projects beyond the 
serosa, it must w'ork its w'ay betw'een the fibers of the gut w'all At any 
time dm mg this process, stagnation and infection may occur As the re- 
sult of the increased tension it may peifoiate m different diiections The 

72 



Volume 107 
Numl)cr 1 


INFLAMMATORY TUMORS OF INTESTINE 


leason many of these inflammatory tumors subside is because they peifoiate 
into the lumen and diain that way Others peiforate into the \\all, spiead 
along between the layers and foim the laige hard tumois ne sometimes see 
Still otheis perforate externally and form a local abscess or peiitonitis 

Dr Percy Klingenstein (New Yoik) thought that Doctor Dudlcj 
had brought out veiy iinpoitant considerations in connection with the cases 
cited 111 the futuie, now that attention has been diawn so actively to this 
condition, with lefinements m i oentgenology, so that the small intestine 
will become less a silent field in i oentgenologic study of the abdomen, moie 
accuiate preopeiative diagnosis will be made The lesions, as Doctoi 
Eggers stated, do tend to localize on the left side, yet in Doctor Khngenstein’s 
experience there have been a numbei localized on the light side The 
factoi accounting for this is not known A moie exact classification could 
be made if the etiology weie more definitely undei stood 

Dr Seward Erdman (New Yoik) asked Doctoi Dudley whethei, in 
looking up the hteiatuie, he had noted that the majoiity belonged in the 
cancel age group If so, this would be in contiast to the many patients 
shown during the meeting who weie young, in a number of instances 
Doctoi Erdman was also surprised to observe that so many of the cases 
were on the right side 

Dr Guileord S Dudley (closing) answeied that his impiession 
legal ding age has been that those inflammatoiy lesions involving the small 
intestine and particulaily the ileum, or ileum and cecum, tend to be m a 
youngei age group, wheieas those involving only the large intestine tend 
to occur in oldei patients, that is, m the cancer age gioup Common tei- 
mmology was the thought uppeimost in mind in captioning the papei 
piesented “Inflammatory Tumois of the Gasti o-intestinal Tiact” being 
chosen m piefeience to one that would have been confined to any paiticulai 
poition of the tiact 

Dr Laurence Miscall (closing) pointed out that m the literatuie the 
occuiience of inflammatoiy tumors thioughout the gastro-intestinal tiact 
IS geneially recognized Many authois have noted minoi variations m the 
pathologic pictuie and an abundance of etiologic factoi s m the dififerent 
paits affected The common occuirence of fistulae and abscesses complicat- 
ing ladical opeiative piocedures on inflammator} tumois of tlie gastro- 
intestinal tiact is impiessive These complications have often lequired scc- 
ondaiy oi teitiaiy reopeiation The conseivative procedines seem indicated 
Fust, they may cure the patient Second, they may i educe the incidence of 
complications Third, if leoperation becomes necessary it may be earned 
out when the acute infectious stage may have subsided and been leplaced 
by fibiosis 


73 



NONSPECIFIC GRANULOMATA OF THE INTESTINE* 

Ralph Colp, M D 
New York, N Y 

rnOM Tllb SURGICAL SFIIMCF OF THE MOOST SINAI HOSPITAL NF« TOIIK, N 1 

The appended case reports are presented as instances of nonspecific granu- 
lomata of the intestines The first five aie examples of legional ileitis, a 
pathologic and clinical entity desciibcd b}' Ciohn, Ginzburg and Oppenheimer,^ 
in 1933 While the various clinical couises of this condition may be divided 
arbitrarily into gioups, according to their symptomatolog)', the disease is so 
protean m its clinical manifestations that it is rarely diagnosed preoperatively 
The diagnosis m Case i was made by the roentgenologist, and m Cases 2, 3, 
and 4, only at the time of opeiation The surgical treatment is far from 
standardized and the efficacy of the vaiious piocedures employed will be deter- 
mined, and conectly evaluated, only after careful follow-up examinations have 
been made over long periods of time 

The type of opeiation for regional ileitis should be largely determined by 
the extent of the pathology of the diseased ileum Undoubtedly some of the 
proven milder cases lesult m spontaneous lecovery, but it would seem better 
judgment in the early ones to divide the ileum through healthy bowel and side- 
track the fecal current A secondary resection may be performed later should 
the disease progress If, how ever, the ileitis has advanced to marked stricture 
and internal fistula foimation, as was present in Cases 3 and 4, resection of the 
involved bow^el in one stage is piobably the safest proceduie Radical resection, 
however, apparently does not guaiantee against recuirence of this condition 
because cases of this nature have ahead) been reported Case 5 is one of this 
type In 1931, an ileocecal lesection for nonspecific terminal ileitis W'as per- 
formed, removing about 40 cm of the ileum, the cecum, and portion of the 
ascending colon Roentgenologic examination, in 1933, show'ed some irregu- 
larity of the anastomosed teiminal ileum, but it w'as not until 1936 that the 
patient began to complain of inci easing abdominal pain At this time the roent- 
genologic examination revealed maiked changes m the teimmally anastomosed 
ileum, which operation verified The ileum w^as divided again through healthy 
bowel, and an ileosigmoidostomy w^as peifoimed The prognosis m these par- 
ticular cases must be guarded 

Case 6 is presented as another type of nonspecific granuloma of the intes- 
tines, classified by Ginzbuig and Oppenheimei as belonging to the gioup of 
localized hypei trophic colitis Similar to the majority of these cases, this pa- 
tient gave a history of a mild colitis accompanied by temperature Physical 
examination disclosed a palpable mass m the light lower quadrant Roent- 

* Read before the New York Surgical Society, November 25, 1936 Submitted 
for publication March 4, 1937 


74 



A'oliime 107 
IS umber 1 


NONSPECIFIC GRANULOMATA OF INTESTINE 


genologic examination revealed a constiicting lesion confined to the right half 
of the bowel Because of the patient’s poor general condition, it u as decided to 
perfoim a two stage proceduie for lesection of the light half of the colon Fol- 
lowing division of the teiniina! ileum and peifoimance of an ileosigmoidostoni) 
the patient improved so maikedly that the second stage was deemed unneces- 
sary An ileosigmoidostomy w'as elected m pieference to an ileoti ansversc 
colostomy because it was felt that the light half of the colon w'ould be put at 
almost complete rest by this proceduie Subsequent loentgenologic examina- 
tions by means of a baiium enema appaieiitly suppoited this contention 

CASE REPORTS 

Case I — No 391710 M K, female, age 43, was admitted to the surgical sen tee 
of the Mount Sinai Hospital April 4, 1936 One yeai before admission, the patient es.- 
penenced several attacks of abdominal pam associated with nausea and diarrhea, each 
of which lasted two w'eeks During the past six months she had seieral episodes of 
abdominal pain associated with nausea, vomiting and diarrhea, usually following the 
ingestion of spicy foods Coincidently, she noticed pain and discomfort about the anus, 
and small amounts of blood in tlie bowel movement 

Physical Examination — Negative except for the presence of hemorrhoids Sig- 
moidoscopy w'as negative A baiium enema w’as given and although the roentgenogram 
of the colon was negative, the ileum showed definite pathology The gastro-intcstinal 
senes, with special reference to the ileum, show'cd the presence of an ulcerative lesion 
involving more than two feet of the ileum, not involving the cecum 

Opciatwn — May 15, 1936 Under spinal anesthesia, exploration retealed the tipical 
findings of a regional nonspecific ileitis involving about 18 mciics of the terminal ilcum 
This was evidenced by a marked leatherj contraction of the bowel with inters als of scs- 
eral strictures and intervening dilatation of the diseased bowel The mesentcr} was 
edematous, thickened and shortened, and there W'as marked enlargement of the mesenteric 
nodes A typical side-to-side isoperistaltic ilcosigmoidostomj was performed after dnision 
of the ileum proximal to the lesion The postoperatne course w’as uiiesentful, and the 
patient was discharged April 26, 1936 

The patient w'as last seen March 4, 1937 She had gained about ten pounds in weight 
and felt absolutely well Her bow’els moved three times a das and the stools ssere 
normal in consistency She had had no recurrence of the cramps Roentgenologic ex- 
amination, follosving a barium meal, disclosed no abnormalitj, other than the defect 
occasioned by the ileosigmoidostomj 

Case 2 — No 377721 M C , male, age 30, svas admitted to the Mount Sinai Hospital 
April 3, 1935 He had been a patient one ss'eek prior to tlie present admission At this 
time he had suffered an attack of upper abdominal pain ssith associated digestise dis- 
tuibances He had nevei been franklv jaundiced altliough the icteric index ssas 16 
The van den Bergh direct was delaj'cd positisc, and blood bilirubin 07 mg The gall- 
bladder roentgenograms svere negatise The diagnosis upon discharge ssas cholelithiasis, 
chronic cholecj stitis and possiblj a common duct calculus ssith cholangeitis Six dajs 
after discharge from the hospital, he suddenlj experienced another sesere attack of 
sharp epigastric pain ssuth nausea and s'omiting During the attack, sshich lasted one 
day, he felt feserish but had no chills Upon his second admission, he ssas acutelj iH 
and smmited bile stained material frequently The temperature ssas 100 2°F, pulse 96 
The hemoglobin ssas 85 per cent The ss'hite blood count and differential ssere normal 
The urine contained a trace of bile The blood Wassermann ssas negatise, and the 
blood chemistry normal There ssere distention and diffuse tenderness oser the entire 
abdomen ssith the maximum tenderness localized in the right upper quadrant 

The clinical impression ss'as that the patient ssas suffering from either a penetrating 

75 



RALPH COLP 


Annals of Surgcrj 
Jnnuar\ 10^8 


peptic ulcer, or an acute cholecystitis B> inidniglit, on the tlaj of admission, the 
abdominal pain had become excruciating, and temperature had risen to :o3°F The 
entire abdomen was rigid Repeated abdominal punctuies were negative, and roentgeno- 
logic examination failed to disclose the presence of air under the diaphragm, but showed 
some dilatation of the small bowel The patient’s general condition graduallj improved, 
the temperature subsided, and the abdomen became soft, although at times there weie 
episodes of abdominal pain Stools were guaiac positue on one occasion At this time, 
the patient was noted to have a leucopenia The white count was about 4,000, 40 to 50 
per cent Ijmiphocjtes The red blood cells appeared normal The fragility test was 
found to be increased above normal Tlic blood am\lase was 35, the icteric index, ii, 
van den Bergh direct was negatue, and blood bilirubin 02 mg Duodenal drainage was 
peifoimed and bile obtained, microscopic examination of which failed to rc\eal pus cells, 
bacteria or cholesterol cr^staIs A gastro-intestinal senes failed to show anj e\idence 
of abnormality Because of the persistence of the abdominal pain, and the inabihtj to 
make a definite diagnosis, it was felt that surgical mteryciition was justified 

Opeialion — May i, 1935 Under spinal anesthesia, an upper right rectus muscle split- 
ting incision was made The gallbladder was found to be markedlj distended, and con- 
tained about 60 cc of dark green bile There were no stones It was adlierent to the 
transverse colon and duodenum bj innumerable adliesions The common duct appeared 
normal, as did the pancreas There were numerous lecent adliesions in the lower abdomen 
suggestive of a peritonitis, and tliere was a chronically inflamed appendix About eight 
inches from the cecum, there w'as found a firm edematous, irregular mass in the ileum 
almost occluding the lumen at this point Proximal to this, for about 12 inches, the ileum 
w'as dilated and its walls markedly hypertrophied The mesenterj of the diseased 
boyy'el yvas edematous, thickened and shortened The mesenteric nodes y\ere enlarged 
and acutelj inflamed The lesion yyas apparently that of teimmal ilcitis 

A cholecystostomy was performed and the ileum yyas dnidcd through an apparentlj 
normal boyvel proximal to the lesion A side-to-side isoperistaltic ileotransyerse colostomy 
yvas performed The postoperative course y\as complicated bj a mild, nonsuppuratiye, 
left-sided parotitis, and a slight yyound infection He yyas discharged Maj 17, 1935 

The patient yvas last seen Noy ember 25, 193G He had gamed 12 pounds m yveight 
and had no complaints Roentgenologic examination October 23, 1935, bj means of a 
barium meal, shoyved noflimg unusual 

Case 3 — No 372484 S K, male, age 27, was admitted to the surgical seryice of 
the Mount Sinai Hospital October 22, 1934 For the past fiye jears he had been suffer- 
ing from vague abdominal pains About one and one-half jears ago these pains seemed 
to localize m the right loyver quadrant , he yvas told he had a chronic appendicitis In 
April, 1924, the pain became more seyere and cohekj, and roentgenologic examination 
shoyved a lesion yvhich yvas interpreted as a chronic ileal intussusception Since then he 
has had severe attacks of acute pain during yvhich his abdomen became distended, and 
yvhen seen in one of these episodes, peristalsis yvas visible 

Physical Eiainitiation on Octobei 2, 1934, rey'ealed an emaciated young man yvho 
appeared chronically ill Examination of the abdomen rey’ealed marked distention and 
visible peristalsis The hemoglobin yvas 90 per cent, red blood count 5,200,000, yvhite 
blood count 29,000, polymorphonuclears 90 per cent The urine yvas negative 

Opciatwn — October 25, 1934 Under spinal anesthesia, through a lowei right rectus 
splitting incision, a hard fifarotic mass occupying the ileum and coyered by omentum 
yvas found about seven feet from the ileocecal junction Proximal to this there yvas a 
huge dilatation of the intestine yvith marked hypertrophy of its yvall, the diameter of the 
ileum at this point measuring about five inches This fusiform dilatation extended orally 
for about 12 inches and its termination yvas marked by another fibrotic contraction 
The mesentery of the involved boyvel yvas thickened and edematous yvith marked enlarge- 
ment of the mesenteric nodes Beyond this segment the intestine appeared normal, al- 

76 



A olumc 107 
^ limber 1 


NONSPECIFIC GRANULOMATA OF INTESTINE 


though the musculature appeared hjpertrophic An examination of the remainder of the 
intestine revealed no further patholog} 

An intestinal resection of about two feet of diseased bowel was performed with a side- 
to-side ileo-ileal anastomosis The wound w-as closed in laiers and without drainage 
The postoperative course was smooth The pathologic report was “regional ileitis of 
the ulcero-granulamatous tape, with foreign bodj reaction and earh fistula formation" 
The w'ound healed ba primary union and the patient was dischaiged No\ ember S, 1934 
The patient w'as last seen April 27, 1937 He had gained ten pounds in weight and 
had no complaints His bow'els moaed once a da\ and w'ere normal m consistencj 

Case 4 — No 399413 S D, male, age 29, w’as admitted to the Surgical ScrMCC of 
the Mount Sinai Hospital October 7, 1936 During the past two months, he had become 
markedly constipated, and during this period there had been a loss of 35 pounds in 
weight, increasing weakness, anorexia, and occasional abdominal cramps, which began 
in the umbilical region and radiated to both lower quadrants A week before admission, 
he had a mild attack of dianhea, but at no time were his stools bloodj' or tarr\ 

Physical Etaiiiinatioii disclosed a lather anemic, chronicallj' ill male The general 
examination w'as negative, except that m the midhne aboie the pubis there was an irreg- 
ular, rather fixed mass the size of a lemon On rectal exaniination, there was felt a 
hard, irregular mass adherent to the anterior rectal wall which ga\e the mipressioii of i 
malignancy of the rectosigmoid Proctoscopic examinations on seieral occasions, how'- 
ever, failed to reieal an\ pathologi The patient left the hospital against ad\ice, and 
was readmitted November 4, 1936, having spent sc\eral weeks in rest and forced feed- 
ing and had gamed ii pounds 111 weight He de\ eloped no new' symptoms other than the 
occurrence of a slight disuiia and dribbling at the end of inmation Roentgenologic 
examination showed no abnormahtj either in stomach, duodenum, small intestine or in 
the colon 

Opoation — November 4, 1936 Under spinal anesthesia, the abdomen was opened 
through a left para-umbilical muscle splitting incision The entire pehis w'as found 
occupied by a large mass of matted small intestine adherent to the peritoneum o\er the 
sacrum, the base of the bladder, and to the sigmoid b\ firm, dense adhesions Upon 
liberating these, the matted mass of intestines was found to extend from the ileocecal 
junction proximallv for two feet, the appeal ance w'as tipical of regional ileitis The 
cecum appeared normal A tipical ileocecal resection was performed, dniding the 
ileum through normal bow'd and lesectmg about one-half of the ascending colon A side- 
to-side isoperistaltic ileosigmoidostoniy was performed and the wound closed without 
drainage The pathologic leport was chronic and acute ulcerative ileitis W'lth conspicuous 
fibrosis and stenosis, ileo-ileal fistula, and chronic peritonitis with foreign bod} reaction 
The postoperative course was normal, except foi a slight superficial wound infection, 
and he was discharged on the sixteenth da} 

The patient was seen April 15, 1937, at winch time the wounds A\ere healed The 
bow'cls w'ere regular, moi mg three times a da\ 

Case 5 — No 400559 H C, male, age 37, iias admitted to the Surgical Senice of 
the klount Sinai Hospital No\ember 5, 1936 Eight }ears before, Januar\ 18, 1928, 
he had been operated upon at the hospital follow'uig a three weeks’ histori of abdominal 
pain, w'hich, during the latter part of the illness, localized to the right lower quadrant 
At operation, a large mass, the size of a grapefruit, was found which consisted of cecum, 
appendix, terminal ilcuin, and an adherent loop of sigmoid The appendix which was 
acuteh inflamed was found hing m the mesentery of the terminal ileum, which was almost 
two inches thick The appendix was remoied and drainage instituted 

Eight months after discharge, the abdominal wound, which had closed coniplctel}, 
again began to dram graMsh fluid and continued to do so for a period of two months, 
when it healed spontaneoush Two }ears later, ifaA 5, 1931, he entered the hospital for 
an abdominal wall abscess in the region of the scar This was incised and a fistulous tract 
found, which, after hpiodol injection, was seen to lead down to the region of the cecum, 



RALPH COLP 


Annals of Surgery 
Tnnuarj 1038 


the lipiodol entering the cecum and the ascending colon The fecal drainage ceased and 
patient was discharged, onl> to return five months later with a fecal fistula Because 
of the induration and inflammatorv reaction about the sinus, he was ad\ised to return 
after this had subsided for operatue inter\eiition 

Opciatwn — October 30, 1931 There were extensive adhesions binding the small 
intestine and cecum to each other and to the anterior abdominal wall The fistulous tract 
was found leading down, not to the cecum but to the terminal ileum, about tw'o inches 
from the ileocecal junction A mass was felt in the ileocecal region which was found 
to be for the most part thickened, indurated, edematous and hjperplastic ileum, extending 
about 30 cm from the ileocecal junction The cecum md ascending colon appeared 
grossly free, except just at the region of the ileocecal ^alve About 40 cm of ileum, 
cecum and 10 cm of ascending colon were resected, and 1 side-to-side ileotransverse 
colostomy performed Drains were placed in lumbar gutter The pathologic report 
w'as “hyperplastic granuloma of the terminal ileum with fistula ” 

The postoperative course was quite uneventful He was discharged on the eighteenth 
postoperative day, November 22, 1931, with the wound healed Since his discharge from 
the hospital five jears ago, he has been observed everv six months in the Surgical 
Follow-Up Clinic He has felt perfectlj well with the exception of occasional pain in 
the abdomen The bowel movements have been waterv, but contained neither blood 
nor pus and were never more than three a d ij His appetite is good and there has been 
no W'eight loss On his last visit to the Follow -Up Clinic three months ago, he com- 
plained of increasing pain in the abdomen, and a gastro-intestinal series showed a nar- 
rowing of the lumen at the part of the bowel in the region of the anastomosis, t>pical of 
terminal ileitis He was advised to enlti hospital for operation 

Opciatwn — November 7, 1936 Under spinal anesthesia, the abdomen was opened 
through a left para-umbilical rectus muscle splitting incision The previous ileocolostom> 
stoma was found without difficultv The colonic portion of stoma was soft and appeared 
normal Eighteen inches of the previouslj anastomosed terminal ileum showed the char- 
acteristic lesions of so called regional ileitis The intestine was enlarged and indurated, 
the surface was dull, and had a Icatherv feel There was no evidence of cither stricture 
or fistula formation The mesentcrj was markedh thickened, shortened, and edematous 
The Ijmph nodes showed definite hvpeitrophv Bevond this 18 inches of terminal 
ileum, the bowel appeared normal The normal ileum was divided two feet from the 
ileotransverse colostomj together with Us mesenterj, and the proximal portion of the 
ileum, after both ileal ends had been closed, was anastomosed to the sigmoid bv a side-to- 
side isoperistaltic ileosigmoidostoiu) The wound was closed m lajers without drainage 
Following operation, patient made an uneventful lecoverj and was allowed up on the 
tenth postoperative da} At present, he has two bowel movements a daj, which are 
slightly watery in consistencj 

The patient was again seen Januarj 21, 1937, at which time he had gamed seven 
pounds in weight He was having three bowel mov ements a daj , the consistencj of which 
was gradually becoming thicker 

Case 6 — No 378320 C W, male, age 16, was admitted to the Surgical Servace of 
the Mount Sinai Hospital April i, 1935 He had been in this hospital a jear previously 
with lobar pneumonia He had been perfectlj well until three months before admis- 
sion, when he began to experience diarrhea and tenesmus For three months, he had had 
transient pam in the right lower quadrant, usuallj unrelated to meals or bowel move- 
ments He had been treated in the Out-Patient Department where the diarrhea had been 
moderatelv controlled He had lost 15 pounds in weight m three months 

Physical Examination — He appeared asthenic and somewhat emaciated There was 
moderate tenderness and slight rebound tenderness in the right lower quadrant and no 
palpable masses Rectal examination levealed slight tenderness on the right Hemo- 
globin 72 per cent, white blood count 19,600, polymorphonuclears 72 per cent Tem- 
perature 101° F The stool was guaiac-positive and showed many red blood cells and 

78 



Volume 107 
Isiimher 1 


NONSPECIFIC GRANULOMATA OF INTESTINE 


white blood cells on micioscopic examination The blood Wasscrnnnn ^\as ncRatuc 
The blood agglutinations for dysentery were negative, stool culture jielded only B coh 
and enterococcus Sigmoidoscopy revealed a very finely granular mucosa in a few spots, 
but for the most part the only abnormality noted was a moderate congestion It was 
considered that these represented only minimal lesions of a possible mild ulceiatne 
colitis Barium enema revealed an irregular constneting lesion of both the ascendnii; 
colon and hepatic flexure, markedly obstructing the passage of barium Because of 
obstruction, it was not possible to fill the cecum completely, but the impression was 
gained that there w^as also a narrowing of the cecum and spasm and perhaps some narrow - 
mg of the terminal ileum A few diverticula of the descending colon w'crc noted 

The patient ran a persistently low grade febrile course In the right lower quadrant, 
a small tender sausage-hke mass gradually' became more noticeable Because of non- 
bloody diarrhea, palpable mass, and right lower quadrant pain and tenderness, it W’as 
felt that there was probably present a localized granuloma rather than an ulcerative 
colitis The von Pirquet test was negative, but, nevertheless, the possibility of a hyper- 
trophic tuberculosis of the large intestine could not be excluded Examination of con- 
centrated stool w'as negative for tubercle bacilli 

Opel ation — April 20, 1935 Under spinal anesthesia. Dr Leon Ginzburg performed 
a celiotomy through a four inch left rectus incision The teimmal ileum appeared normal, 
but the cecum and ascending colon w'cre the seat of extensive inflammatory disease and 
were covered over by omental adhesions No formal exposure of these areas was 
attempted The ileum was divided about six inches from the ileocecal junction, and 
a side-to-side ileosigmoidostomy was performed Follow'ing operation, patient ran an 
uneventful course and was discharged 

Since discharge, the patient’s improvement has been amazing When last seen, 
November 23, 1936, he had gamed 30 pounds m weight, and the mass palpable m the 
abdomen before operation could hardly be felt He was symptom free Bow'cls aic 
regular, once a day, and normal m appearance Roentgenologic examination show'ed 
evidence of the ileotransverse colostomy The proximal half of the colon filled fairly 
well The barium, as it filled the colon, proceeded so rapidly that it w’as impossible to 
see the stoma clearly After evacuation the cecum and the ascending colon were seen 
and appeared somewhat narrow'ed, but theie w'as no evidence of a mass m the lumen 
of the cecum The part of the ileum visualized showed no definite abnormality 

REFERENCE 

^ Crohn, B B , Ginzburg, L , and Oppenheimer, G D Nonspecific Granulomata of the 
Intestines Annals or Surgery, 98, 1046, December, 1933 

Discussion — Dr Henry W Cave (New' York) cited what he believed to 
be a lather unusual case of terminal ileitis opeiated upon by him some yeais 
ago He presented it for the reason that the specimen show's rather discrete 
granulomatous areas appealing almost like ulcerations m the terminal ileum 
w'lth one laige encircling, consti icting, granulomatous involvement The patient 
was a man, age 31, w'ho came to the hospital complaining of symptoms of acute 
intestinal obstruction, and a very lapid loss of w'eight For the past three and 
one-half months he had passed considerable amounts of blood and mucus by 
rectum At opei ation a thickened terminal ileum w'lth granulomatous ulcera- 
tions was found Doctoi McCallum, w'ho at that time w'as pathologist of the 
College of Physicians and Surgeons, w'as interested in this specimen He made 
cultures and sections and finally came to a diagnosis of w hat he called a chronic 
ulcerative infectious gianuloma of the teiminal ileum 

Dr Ralph Colp (New York) closing said In regard to Doctor Cave’s 
mention of the fact that the divided sigmoid is lather difficult to close, espe- 

79 





■\ ohime 107 
> limber 1 


NONSPECIFIC GRANULOMATA OF INTESTINE 


cially m cases of ulceiative colitis in A\hicli the lectiun is not paiticulaily in- 
volved, von Beck,’^ in 1913, lepoited an opeiation in cases of ulceratne colitis 
in which he divided the ileum neai the ileocecal junction, and the colon at the 
sigmoid The terminal ileum was closed and the proximal loop of colon was 
brought out as a colostomy, thus isolating the colon He then recommended 
the anastomosis of the pioximal ileum to the distal segment of the sigmoid by 
end-to-end suture (Fig i) Doctoi Colp said the teaching in the past had 
been that intrapeiitoneal anastomoses are lathei dangerous and should be 
avoided Mdienevei possible In a lecent case, however, he had employed a pio- 
cedure similai to the von Beck operation, but with modifications The ileum 
was divided and the pioximal colon was bi ought out as a colostomy, thus isolat- 
ing the colon Then he brought the pioximal ileum out, through a left lectus 
incision, as an ileostomy, and the distal poition of the sigmoid out as a sig- 
moidostomy, approximating the mtiapeiitoneal poition of both loops by intei- 
rupted seiosal sutuies (Fig 2) The sigmoid and rectum aie put at rest for 
any desiied peiiod, and, if multiple polypi aie piesent, a sigomidoscope may be 
intioduced thiough the rectum and through the sigmoidostomy, and any polypi 
which may be piesent may be fulgurated At some futuie time, provided the 
general condition of the patient is satisfactory, the spui between the ileum and 
sigmoid may be crushed, and an extrapei itoneal closure perfoimed In that 
way the danger of intrapeiitoneal leakage is avoided The isolated colon may 
then be removed, if necessary 

REFERENCE 

^ Beck, Berhard von Beitrage zur Khnische Chirurgie, 84 , 339-343> 1913 


81 



THE SO-C‘VLLED HEPATO-RENAL SYNDROME 

John H Gvhlock, MD, vnd S\MUi:r> II Kllin, MD 

Ni w \oitK, N \ 

IHOM THf SUnOlCM Of TIIF MT StN \1 JIOSPITM NF^V lOIlK 

SiNcn 1924, when He}cl“^ called attention to tlic unusual postoperatue 
couise puisued by some patients aftei gallbladder surgen, there have appeared 
many articles on this subject, a careful analysis of w Inch indicates that a few' 
important points have been presented by three 01 foui contributors and that 
most of the remaining articles contain confirmator}' experiences by tbeir 
autboi s 

It w’lll be lemembcicd that Ileyd in bis original and subsequent 
papers”'* described a series of postoperatne complications otbei than those 
w'hicb may leasonably be expected, as, for instance, bemoribage, shock, gastric 
dilatation and embolism 111 the first 24 boms and infection resulting m peri- 
tonitis or abscess formation in the succeeding 48 to 72 boms He dnided 
these unusual cases into tbi ee clinical groups 

Group I — After a simple cbolecj stectonn m a patient in good geneial 
condition and wdiose preoperative studies ba\e indicated competent renal, 
cardiac and respnatory function, recovery from the anesthetic is unduly 
delayed The patient lemains semicomatose for four to six hours, develops 
a talking debiium, subsultus tendinum, lapidly passes into coma with high 
tempei ature and dies 

Group II — In this group, the patients ba^e bad a latber se\ere form of 
biliaiy infection wntb a bistoiy of jaundice and possibh a previous gall- 
bladdei opeiation Follow’ing a cboledocbotoni} with common duct drainage, 
the postoperative piogiess seems satisfactoiy for 36 to 48 hours The patient 
then becomes nntable and nervous and passes into a pionounced vasomotor 
collapse wntb cold clammy extiemitics, and death finally supeivenes This 
clinical couise was noted by Heyd in spite of a definitely diminishing jaundice 
and ample renal function He consideied these cases to be due to the libera- 
tion of some pancreatic toxins with inadequate Inei piotection These 
patients did not exhibit alkalosis as did some m Giouji I 

Group III — In a senes of patients admitted with a clinical pictuie of 
calculus cholangeitis, panel eatitis 01, laieljq caicmoma of the bead of the pan- 
creas, operation w^as undertaken for the lelief of these conditions and included, 
often, the institution of biliary diamage, eitbei externally, or internally by 
cholecystogasti ostomy The immediate postoperative course seemed satisfac- 
tory Icterus diminished appreciablj^ and deb3xbation w'as oveicome If 
external biliary diamage ivas utilized, tbe patient w'as lefed bis owm bile 
After five or six days, m the presence of a constantly diminishing jaundice. 

Submitted for publication March 23, 1937 

82 




A olum^ 107 
dumber I 


THE HEPAIO-RENAL SYNDROME 


these patients became somnolent, and soon passed into a state of coma ^\hlch 
ended m death 

Heyd excluded infection as the cause of the syndiome presented in Group 
III, although his articles contain little mention of autopsy findings He pre- 
sented the theoiy that an increased burden was tin own on an aheady com- 
promised liver of detoxifying a fuither inciement of poisonous products and 
that the liver was unable to perfoim this function, resulting in a progiessne 
exhaustion of livei capacit)' In suppoit of this view, he quoted Grahams’"’ 
woik which stiessed the frequent association of disease of the gallliladdei and 
definite evidence of hepatitis May w'e, at this time, call attention to the paper 
of Colp, Doubilet and Geiber^” whose findings are at some variance with those 
of Graham They peifoimed liver biopsies m 49 cases of acute and chionic 
cholecystitis with and without jaundice Studies with finei histologic technic 
levealed no changes m the hvei cells in biliaiy tiact disease without jaundice 
Focal hvei cell degeneration seen m cases wnth jaundice repiesented, m their 
opinion, a reaction to bile stasis and w'as in no w'ay 1 elated to the primary dis- 
ease of the gallbladclei The}' believe that the penjiortal infiltiations obseived 
m biliaiy tract disease aie not specific of the disease but lepiesent a leaction 
of the liver to extiahejiatic infection They conclude that hepatitis is not an 
accompaniment of cholecystitis as evidenced by the absence of inflammatoiy 
and parenchymal changes m the hvei 

Heyd’s obseivations aioused considerable discussion and theie soon ap- 
peared a senes of communications wdnch moie 01 less corioboiated his clinical 
findings Boyce and McFetiiclge^ feel that the so-called “liver deaths’ 
aftei biliaiy suigeiy fall into tw’o distinct groups 

Gioup I — Death occuis shoitly aflei opeiation w'lth hyperpyiexia as the 
outstanding symptom and degenerative changes in the liver the only positive 
finding at autopsy 

Gioup II — Death is defeired foi 10 to 14 days when uiemic symptoms 
predominate and postmortem examination leveals the degenerative Inei 
damage j)lus similai degenerative changes in the convoluted tubules of the 
kidneys 

They attempted to lepioduce these clinical syndromes experimentally, Init 
w'ere successful wnth Group II only Using dogs, they ligated the common 
duct and maintained the obstiuction foi 18 dajs Following lelease of the 
obstruction, the clinical picture piesented by the cases in Gioup II was repro- 
duced Uianalysis and blood chemisti}' revealed the changes chaiactenstic of 
an acute lenal insufficiency All the animals died in uremic coma and autopsy 
levealed the degeneratne changes in the hvei and kidne}s seen in humans 

These authois contend that the release of the biliary obstruction lathei 
than the obstruction itself is responsible foi the fatal outcome in some (.ascs 
of biliaiy suigeiy The hepatic changes piesent in bihar} disease aie aggra- 
vated m some cases by the surgery instituted to iehe\c it, which imposes upon 
an aheady damaged livei an intolerable burden This includes anesthesia, 
suigical tiauma, a diop in inti a-abdominal tempeiature and changes in intra- 

83 



GARLOCK AND KLEIN 


\nrtalsor Surcery 
January 1038 


hepatic and biliaiy picssuie Ihey state that, as a lesult of the degenerative 
hepatic changes, seen also in cases of livei injury, liypeithyroidism, intestinal 
obstruction and bums, theie is released into the circulation a toxic substance 
which IS presumed to be a watei -soluble foieign protein When, after liver 
function fails, the kidneys take up the function of detoxification, there is 
resulting damage to their convoluted tubules, through which foreign proteins 
are excreted These authois conclude that the hepato-renal syndrome is a 
single pathologic piocess of which the kidney disturbance repiesents the second 
stage In view of the fact that most of these cases must, by inference, have a 
considerable degiee of im]iaiiment of hepatic function these authors suggest 
preoperative lenal function tests as an indication of luei function with the 
hope that these tests may actuallj reflect the efficicnex of the Incr The same 
suggestion was made bv Wilcnsk} and Colp,” in 1927 

On the other hand, the ohscivalions of Ilelwig and Sehut/’'' aie worthy of 
note In those cases coming to aiitojis} thej' w'cre stiiiek with the fact that 
most of the definite pathologic findings weie confined to the liver and kidneys 
The liver usually appeared enlarged, piesented fattv degeneiation, cloud) swell- 
ing and polymoiphonucleai leukocytic infiltrations with focal hemorrhages 
and parenchymatous cell neciosis The kidne)s wcie iisuall) enlarged His- 
tologically, theie w'as evident neciosis of the tubular e|Mthehum On the basis 
of the clinical course of a patient who icceived a laceration of the hvci in an 
automobile accident and wdio de\ eloped svmptoms identical with those undei 
discussion and, also, because of the rcpoit of a similar instance of Iner trauma 
by Furtw'aengler, Hehvig and Schiit/ conducted a senes of expeiimcnts on 
dogs which consisted essentiall) of pulpification of most of the luei Those 
animals that died wnthin 12 houis fioni hemonhage and shock were found to 
have albumin, casts and led blood cells in the mine Those that survived the 
opeiation show^ed a use in blood nitiogen, albumin, casts and lecl blood cells 
in the urine and piogressive ohguiia In the fiist gioup, aiitops) disclosed 
degeneiation of the kidney epithelium and hemoiihagic necrosis of the livei 
111 another senes of expenments, the same lesults weie obtained by ligation of 
the hepatic aiteiy wduch caused pnmarily a In'er neciosis 

The clinical behavioi 111 these tiaumatic cases and then siinilanty both 
clinically and at neciopsy, to those desenbed b) Heyd and otheis haxe led 
these authois to assume that hvei damage, wdiethei tiaumatic 01 infectious 111 
ongin, pioduces a selectn^e toxin wdiich may severel) damage the kidneys In 
view of the fact that this syndiome has always follow^ed damage to the Inei 
and has occuned in individuals wnth pieviously noimal kidne}s (detei mined 
by kidney function tests), they believe that the pathologic changes in the 
kidney aie secondaiy to the In^ei changes and aie dependent upon a specific 
toxin elaboiated in the course of liver cell destiuction 

Oui interest in this mysteiious syndiome w'as lecently intensified by the 
clinical course and subsequent pathologic studies of a patient wdio w'as opeiated 
upon foi calculus gallbladdei and bile duct disease We believe that this case 
IS of considerable importance Fust, because of the caieful studies conducted 

84 



Volume 107 
^ umber 1 


THE HEPATO-RENAL SYNDROME 


both befoie and aftei opeiation, and second, liecaiise the autops} findings aic 
at such vaiiance with those lepoited in the liteiatuie on the subject 

Case Report — Hosp No 375648 R B , white, female, niarncd, age 54, ^\ is icl- 
iiiitted to the Mt Smai Hospital Tamiar\ 14, 1935 Her personal, faniih, and past 
histones were irrelevant Her present illness began two a ears bcfoie admission, with 
pain in the right uppei quadrant wdiich radiated around to the hack The pain was 
always related to the ingestion of fatt\ foods These s\mptoms occurred onh rarch 
aftei a self-imposed fat restricted diet During the period of her present illness she had 
lost 30 pounds m w'eight She also suffered from gencrahred pruntis and was told she 
w'as a diabetic During the vear prior to admission, and especialh m the latter half, 
she experienced frequent attacks of abdominal pain associated with jaundice, fe\cr, and 
occasional chills The last episode of jaundice occurred one week before admission to 
the hospital At no time was the jaundice pronounced With the subsidence of the pain 
the jaundice lapidly disappeared 

Physical Examination disclosed a model ately obese w'oman whose skin presented a 
yellow'ish color The conjunctivae and sclerae, how'e\ei, w'cre not icteric There was 
a heipes simplex on the uppei hp Her heart and lungs were negatnc The abdomen 
W'as soft not distended There w’as tenderness in the right upper quadrant and epigastrium, 
and a mass w'hich was thought to be gallbladder was palpable as fat as the umbilical 
line There w'as no evidence of ascites Oral cholecvstograpln failed to \isualiEc the 
gallbladder No evidences of gallstones were seen The clinical diagnosis on admission 
W'as chronic cholecystitis and cholelithiasis W'lth hvdrops of the gallbladder 

Lahoiaioiy Data Hemoglobin 90 per cent, w'hite blood cells 9,000, of which 6S 
pel cent w'ere poly moi phonuclear iieutrophiles, 26 per cent lymphocNtes, 4 per cent 
monocytes, and 2 pei cent eosuiophiles The blood smear appeared normal The stools 
W’ere colored and contained bile and urobilin Guaiac test for occult blood w'as faintly 
positive The urine was ahvays negative for sugar, acetone, and diacctic acid The 
specific gravity varied from 1016 to 1020 albumin negative Microscopic examination 
negative On three occasions before operation, bile in the urine w'as reported 1 plus 
Urobilin on four occasions w'as present i 20 The Janney test for glucose tolerance 
evoked a normal response The blood Wasserinann was negative Blood chemistry 
studies revealed the following 

Urea nitrogen 9 mg per 100 cc 

Sugar 1 10 rag per 100 cc 

Cholesterol 275 rag per 100 cc 

Cholesterol ester 145 rag per 100 cc 

Icteric index 15 

van den Bergh direct — faint delay’ed positive, indirect — i 250,000, Mg o 4 

The electrocai diograra show'ed no definite abnormaht\ Blood pressure 100/64 

Opciatwn January 22, 1935, eight davs after admission (T H G) Spinal 
anesthesia was employed, using 120 mg of neocame An upper right rectus incision 
was made Some difficulty was encounteicd in entering the peritoneal canty because of 
lather extensne adhesions The great omentum w’as adherent to the parietal peritoneum 
The liver edge was obliterated by adhesions which anchored it to the costal margin 
After combined blunt and sharp dissection, the stomach, duodenum, and colon were 
finally separated from the under surface of the Iner The latter structure was freed from 
the costal margin The Iner w’as slightly enlarged, normal in appearance, with a shghth 
rounded anterior edge The gallbladder was small and shrunken and contained a few 
stones Further exploration show'ed an unusual condition of the common and hepatic 
ducts The duct system, which was easily brought to mcw' through its entire extent, 
W'as found to be enormoush dilated The common duct was fulh two inches in diameter 
Each hepatic duct measured about one inch in diameter The entire common duct down 
to the ampulla of Vater and both hepatic ducts as far as their tertiary dnisions were 

85 



CARLO CK AND KLEIN 


\nnalsof *'urceo 
January lO^S 


filled with biliary calculi A vertical incision was made in the common duct about two 
inches above the duodenum and through which 48 calculi of various sizes and shapes 
were removed The duct sjstcm was irrigated A free flow' of vcllow bile followed the 
rcmo\al of the calculi A subserous choices stcctonn was performed The h\er bed 
was stwii over A No ” French citlukr was pined in the coniinon duct and the re- 
mainder of the incision in the duet sutured snugly around the tube Iwo cigarette drams 
w'ere placed dow’n to Morrison’s pouch and the wound closed 111 lasers Time of opera- 
tion One hour and fis'e minutes 

Postopc) alive Com sc There ssas no sanation m the blood pressure postoperatisels 



Tig I — RoentgenoRnm (lateral aicw) made after the injection 
of lipiodol through the choledochostonij •ihowing the enorinous dila 
tation of the bile ducts 


Fust Poslopci alive Day Hemoglobin, 93 per cent Temperature, 1012° F Patient 
comfortable No distention Profuse drainage of bile through common duct tube 

Second Posfofici alive Day Urine iicgatisc for bile and urobilin Icteric index, 20 
van den Bergh direct — prompt positis’c Indirect — i 100,000 Mg i 0 

Thud Poslopci alive Day Urine iicgatis'c for bile Urobilin i 10 Roentgenologic 
examination svas made after injection of lipiodol into the common duct drainage tube 
This shosved the biliary radicals to be irregularlj outlined There svas marked dilatation 
of the hepatic and common ducts (Fig i) No esidence of obstruction and nothing to 
suggest the presence of stones Temperature loj 8° F Wound clean No cough or 
chest pain Abdomen soft Condition excellent 

Fomth Poslopci alive Day Roentgenologic examination 24 hours aftei the lipiodol 
injection shosved a small amount of opaque material still present m the biliarj system 
The common duct svas completely emptj 


86 



■\ olume 107 
Number 1 


THE HEPATO-RENAL SYNDROME 


Fifth Posfopciattve Day It was noted that the patient presented marked asthenia 
Had drained about 15 ounces of bile daity since operation The asthenia was thought 
to be due to long standing chronic prancreatic and intermittent biliary obstruction plus 
the recent loss of bile and pancreatic ferments through the common duct tube For this 
reason the refeeding of the drained bile was instituted This was continued until two days 
before death The w^ound appeared clean Blood count white blood cells, 14,650, 
polymorphonuclear leukocytes, 72 per cent, lymphocytes, 10 per cent, monocytes, 16 
per cent , eosinophiles, i per cent , basophiles, i per cent 

Snfh Postopciativc Day Temperature, 1004° F Wound edges reddened and puffed 
The skin sutures were removed and about one ounce of thick sanguinopurulent material 
w^as evacuated from the upper and low'er angles A smear of this material showed a 
moderate amount of pus cells and debris, but no organisms The culture, however, re- 
vealed B colt, enterococcus and Staphylococcus albus The chest was clear , the abdomen 
was soft and not distended Marked asthenia persisted Bile was being refed b> mouth 
Hemoglobin, 75 per cent , blood pressure, 100/72 Patient was given a transfusion of 
500 cc by the citrate method 

Seventh Postopeiativc Day Hemoglobin, 90 per cent, white blood cells, 15,900, 90 
per cent polymorphonuclear leukocytes, lymphocytes, 4 per cent, monocytes, 6 per cent 
Urine, bile negative , urobilin i 5 

Eighth Postopeiativc Day Patient appeared profoundly asthenic Eyes sunken, 
conjunctivae injected, voice subdued and monotonous, and reaction to stimuli sluggish, 
beginning to ooze blood from the w'ound There was no icterus The clinical condition 
was ascribed to either hepatic or pancreatic insufficiency However, because of apparent 
tenderness on pressure over the right lower chest near the axillary region, the possibility 
of a subphrenic infection or an abscess of the Iner was considered Consequently, aspira- 
tion was performed Liver blood w'as obtained, which was negative upon culture Be- 
cause of the oozing of blood from the wound, the packing was removed to facilitate 
investigation The wound surfaces were found separated down to the peritoneum with 
hemorrhage coming from several small vessels and oozing from the entire wound surface 
The vessels were ligated and the wound was packed Urine was negative for sugar, acetone 
and bile Blood calcium 9 7 mg per 100 cc Hemoglobin 72 per cent Patient given 500 
cc of blood by the citrate method Blood urea nitrogen 69 mg per 100 cc 

Ninth Postopeiativc Day Blood urea nitrogen rose to 105 mg per too cc Urine, 
cloudy, acid, sp gr , 1018, albumin 2 plus, sugar and bile negative, urobilin present in i 5 
dilution Hemoglobin 88 per cent, white blood cells 28,000 , 88 per cent polymorphonuclear 
neutrophiles, and 8 per cent lymphocytes General condition seemed slightly improved 

Tenth Postopeiativc Day Urine, cloudy, acid, sp gr , 1010, albumin i plus Micro- 
scopic examination showed a few white blood cells, very few red blood cells, and epithelial 
cells Culture of urine revealed B coli and the enterococcus The biliary drainage which 
was still profuse, was slightly positive for diastase and trypsin Blood chemistry deter- 
minations were as follows 


Cholesterol 

200 mg per 100 cc 

Cholesterol ester 

105 mg per 100 cc 

Total protein 

64% 

Albumin 

3 9 % 

Globulin 

25% 

Carbon dioxide 

44 volumes per ce 

Urea nitrogen 

76 mg per 100 cc 

Sugar 

195 per 100 cc 

Chlorides 

535 mg per 100 cc 

Uric acid 

4 0 mg per 100 cc 

Creatinine 

3 5 mg per 100 cc 

Icteric index 

17 


87 



GARLOCK AND KLEIN 


Annals Of Surpcn 
January 1038 


Eleventh Postopeiative Day Patient’s condition became grave Seemed stuporous 
and could be aroused only with great difficulty Pulse weak and rapid Blood pressure 
90/60 The course was progressuely down lull Several foci of local infection were 
now’ present (i) The wound, (2) a gangrenous patch on the anterior wall of the vagina, 
(3) a right parotitis Blood culture, ncgatBc Hemoglobin, 88 per cent, red blood cells, 
4810,000, platelets 240,000, white blood cells, 38,700, polj morphonuclear neutrophiles, 85 
per cent, of w’hich there w'ere 15 per cent w’lth segmented nuclei and 70 per cent non- 
segmented , Ijmphocvtes, 6 per cent, monoc\tes, 9 per cent, reticuloc\tes, os per cent 
Blood volume studies 


Rel itive cell volume 38% 
Serum volume 3,500 cc 

Cell volume 2,14000 

Total blood volume 5,640 cc 

Blood volume per kilo 85 cc 


She had been recening luer extiact intramuscularh , two cubic centimeters twice 

dailj 

Tiuelfth Postopeiative Da\ Urine, sp gr , 1012, albumin 2 plus, bile negatiae, 
urobilin i 20, occasional er^tbroc^tcs and clumps of Icukocjtcs seen microscopicalh 
Blood urea 90 mg per 100 cc , cholesterol 180 mg, serum calcium 96 mg, chlorides 510 
mg Stool examination, tan color, urobilin present Guaiac test positwe for occult blood 
Icteric index 30 A note b\ the medical consultant read “From the histor\ and the 
operatne findings, there is c\er\ reason to behc\e that this patient had a \erj badlj 
damaged luer parenclunn before operation I behe\e that the postoperatue asthenia is 
probably due largelj to luer insufficiencj, perhaps combined with pancrcitic insufficicncj , 
and that the nitrogen retention is the result of the prolonged low blood pressure The 
blood piessure at the time of examination was 74/46, just baieh sufficient to maintain a 
minimal amount of kidiiej function ’’ 


riiiiteenth Postopeiative Da^ Blood chemistr\ 


Urea nitrogen 
Creatinine 
Cholesterol 
Calcium 
Phosphorus 
Chlorides 
Carbon dioxide 
Total protein 
Albumin 
Globulin 
Icteric index 
van den Bergh 


114 mg per 100 cc 
3 mg per 100 cc 
160 mg per 100 cc 
8 7 mg per 100 cc 
3 g mg per 100 cc 
575 mg per 100 cc 
34 5 volumes per cent 

56% 

3 4 % 

2 2% 

30 

direct — Prompt positu e, indirect — i 60,000, mg 15 


Oozing from the wound continued from the eighth iiostoper itu c dai Tonight patient had 
a profuse epistaxis Pulse gradualh became wcikei and the p.itient died with a terminal 
temperature of 1074° F (Table I ) 

Postmoi teiii Exaiiiiiiatioii The body was that of a pale, wcll-de\ eloped, well-noiiiished 
female of 54 The skin was light yellow’, but the sclcrae weic not icteric An incision 
into the subcutaneous tissues 111 the left upper margin of the wound disclosed white turbid 
fluid exuding from the fat The peritoneum w’as cierjw’here smooth and glistening 
There was no free fluid m the abdominal cacitj Several small areas of bronchopneumonia 
were present in the left lower lobe There was a small blackish-red ulcer on the anterior 
vaginal wall just inside the labia minora The stomach was dilated and filled with a large 
amount of bloody fluid The gastric mucosa was pink and congested On the anterior 

SS 



Volume 107 
Number 1 


THE HEPATO-RENAL SYNDROME 


Table I 

SUMMARY or THE POSTOPERA.TIVE TEMPERATURE, PULSE, BILIARY DRAINAGE, FLUID INTAKE 

AND URINARY OUTPUT 


Date 

Pulse 

Tempera- 

ture 

Unnary 

Output 

Biliary 

Drainage 

Fluid Intake 

Bv Mouth Intravenous 

Jan 22 
(oper ) 

88 

100° F 


12 ounces 

54 ounces 

Jan 23 
(ist p 0 day) 

100 

102° F 

33 ounces 

10 ” 

65 " 

Jan 24 

no 

101° F 

57 ” 

10 ” 

72 ” 

Jan 25 

100 

loi 6° F 

65 ” 

10 ” 

58 ” 

Jan 26 

100 

101° F 

38 ” 

7 ” 

80 ” 

Jan 27 

100 

100 8° F 

48 ” 

10 ” 

74 ” 

Jan 28 

112 

100 4° F 

30 ’ 

5 ” 

42 ” 

Jan 29 

104 

100 2° F 

22 ” 

4 ” 

40 ” 

Jan 30 

122 

102 8° F 

Inconti- 

3 ” 

Nothing 10 ounces 

Jan 31 

130 

Chill 

nent 

ii 

10 ounces 

po 

38 ” 25 

Feb I 

126 

106 8° F 
101 2° to 

)) 

Profuse 

40 ” 96 ” 

Feb 2 

120 

104 2° F 
104° F 

14 ounces 

? 

4 ” 71 5 ” 

Feb 3 

120 

104° F 

18 ” 

? 

583 ” 

Feb 4 

120-160 

Died 


? 



107 4° F 


wall near the lesser curvature was a small superficial erosion o 5 cm long There were 
also many tiny homogeneous red areas The duodenum, small intestine, colon and rectum 
were congested and filled with bloody contents The pancreas was moderately fatty 
The pancreatic duct was slightly dilated and opened into the common duct i Mm above 
the papilla of Vater 

The liver weighed 2,165 Gui The anterior and superioi surfaces were adherent to 
the diaphragm The capsule was covered by fibrous adhesions The organ was firm and 
Its inferior edge was sharp On section, the surface was pale and grayish-green The 
lobular structure could be identified The bile ducts m the larger portal fields were 
thickened and contained turbid yellow-brown bile On the anteiior surface of the liver 
in the region of the gallbladder fossa there was a white cylindrical prominence, which, on 
section, was found to be a thick-walled channel filled with turbid milky fluid This channel 
was found to communicate with the bile ducts The gallbladder fossa was clean In the 
floor of the walled-off drainage tract a longitudinal opening into the common duct was 
present The common bile duct was distended to 2 cm in diameter and contained a small 
amount of bloody mucus The mucosa was thickened and red The duct opened into the 
duodenum by a patent orifice The common bile duct, traced upwaid, was distended 
throughout and became continuous with the two distended, thickened, congested hepatic 
ducts The intrahepatic bile ducts rvere dilated throughout There were no stones in any 
of the biliary ducts 

The kidneys weighed 360 Gm together They were of equal size and flabby The 
capsules stripped with ease, leaving a smooth grayish-ydiow surface The cut surface 
presented a somewhat widened cortex which was jaundiced The markings within it were 
fairly well delineated The corticomedullary demarcation was sharp The pelves were 
congested The ureters were narrow and pale The renal arteries and veins were smooth 
and clear 

Mtaoscopic Examuiation — Kidneys The capsule was thin The general architecture 
of the kidney appeal ed unchanged The convoluted tubules of the cortex were, in general, 

89 



GARLOCK AND KLEIN 


\nnalsof SurBcry 
Taniiarj 10 y 


of normal size and width In some areas, they were closelj approximated, in other places, 
however, thej appeared separated b> a widening of the mtertubular stroma which was 
spongj and frequently infiltrated with Ijmphocytes, occasional pol> morphonuclear leuko- 
cytes and rare plasma cells The mtertubular capillaries, for the most part, contained few’ 
red blood cells, in places, howeter, they w'crc congested The W'alls of the interlobular 
arteries were normal The afferent arterioles occasionally show'ed slight hjalmization 
The lumen of the coinoluted tubules frequently contained granuhr masses, occasionallj 
desquamated epithelial cells The epithelial lining of the con\oluted tubules did not show 
striking changes However, on close examination, one quite frequentb found the epithelial 
cells vacuolated, with occasional loss of nuclei Some of them contained jellowish-brown 
material, which was apparenth bile pigment Some of the tubules presented a flattened 
epithelium, and such tubules contained a few polymorphonuclear leukoevtes Onlj rarely 
were tubules found where the epithelium showed more severe degenerative changes, such 
as hyaline droplet degeneration 

The majoritv of the glomeruli were well preserved, onl> a verv few were fibrotic 



Fig 2 — Photomteroenph of ’Section from the kulne\ The glo 
meruhis cnhrqcd aiKl the intcrcnpilhr} stroma is prominent nnd 
spong> as if distended \\ith fluid 


In the vicinity of such fibrotic glomeruli the tubules were atrophic, the stroma increased 
and infiltrated with Ijmphocvtes Most of the glomeruli were strikmglj large Their 
capsules were not thickened, the parietal epithelial cells were flattened, m general. Bow- 
man’s space was empty In spite of the striking size of the malpighian corpuscles, there 
was no increase m their cellularity The covering epithelial cells of the tufts were not 
enlarged, neither were the endothelial cells unduly prominent The capillaries contained 
a normal amount of red blood cells and onl> occasional leukocj tes The mtercapillarv’ 
connective tissue framework (Zimmermann*') was prominent and it appeared spongv , as if 
distended by fluid (Fig 2) 

The medulla of the kidney showed frequent nests of Ijmphocvtes, plasma cells and 
infrequent polymorphonuclear leukocytes within the stroma The Henle’s loops contained 
inspissated homogeneous material and occasional leukocytes Bile stained casts were seen 
and occasional granular and hyaline cjlmders Very infrequentl>, round calcified masses 
were noted enclosed within the lumen In one area where the medulla bordered on the 
penpelvic connective tissue and fat tissue there was a hemorrhage, and some of the 
adjacent tubules contained blood One section showed a large hemorrhage beneath the 
pelvic epithelium extending into the penpelvic fat tissue Around this hemorrhage there 
was considerable infiltration with polymorphonuclear leukocytes 

Live) The capsule was thin The lobular structure was distinct and intact The 

90 



■\ olunie 107 
Is^umber 1 


THE HEPATO-RENAL SYNDROME 


periportal connective tissue seemed markedly increased The central veins contained but 
little blood The liver cells about the central veins appeared somewhat shrunken and 
contained some yellowish-brown granular pigment The sinus walls and Kupffer cells were 
separated from the liver cords, forming appreciable Disse spaces Ihe latter contained 
much granular debus, rarely a red blood cell In places, large amounts of bile pigment 
were contained within cacuolated, swollen, or shrunken hvei cells, surrounded oi com- 
pressed by fibrous tissue from the portal fields The latter were much enlarged by fibrous 
tissue and infiltration with inflammatory cells consisting mainly of lymphocytes, some 
plasma cells and polj morphonuclear leukocj'tes (Fig 3) The bile ducts within the portal 
fields were increased in numbei In some of the bile ducts there were poh morphonuclear 
leukocytes between the epithelial cells The portal veins and hepatic artery presented no 
changes A section of a large bile duct slightly removed from the region of the hilus 
showed an edematous wall and infiltration by numerous polymorphonuclear leukoevtes, 
eosinophiles, active phagocytes, and fibroblasts There was hemorrhage into some of the 



riG 3 — Photomicrograph of section from the liver showing acute and 
chronic cholangeitis 


liver cords abutting upon this duct and some hemorrhage into the wall of the duct There 
was much bile pigment in the cells about the portal fields Throughout the sections, there 
was no evidence of liver cell necrosis 

Summary The liver show^ed the pathologic picture of an acute and 
chionic cholangeitis and cholangeiohtis with icteius Theie was no evidence 
of severe i:)arenchyinal damage 

The kidneys showed focal inteistitial inflammation and edema There 
was, however, no evidence of seveie degenerative change in the tubular 
epithelium, but theie was a staking glomeiulai lesion 

Anatomic Diagnosis Acute and chionic cholangeitis Acute intercapil- 
lary glomerulonephritis (MacCallum^-) Jaundice (slight) Gastiic ero- 
sions Vaginal ulcei Bronchopneumonia, left lower lobe Pulmonary edema 
and congestion Mild pai enchymatous degeneration of the liver, heart and 
kidneys Acute congestion of the spleen Fibrous pleural adhesions 

Discussion Conceining the cases in Group I of Heyd’s classification, 
namely, those chai actei ized by hyperpyrexia and death within 48 hours of 
operation, considerable disagreement and controversy already exist Thus, 

91 



GARLOCK AND KLEIN 


\nmlsof Mircon 
Jnniiarj 10 S 


Touioft,'*® in a lecent communication, is iiglitfully cautious against entei- 
tammg a diagnosis of “livei sliock,” unless theic has been a coi i oborative 
complete postmoitem examination He leviewed a sciies of cases from the 
Mt Smai Hospital that were subjected to simple cholecystectomy ^\ltb drain- 
age The patients weie neithei jaundiced noi acutely ill at the time of the 
opeiation and bad not been subjected to any pievious opeiative piocedure on 
the biliaiy tract Without appaient cause, they dec eloped the classic picture 
of rapidly rising tempeiature, shock and early death In a number of in- 
stances, the clinical diagnosis of “Inei shock” cias entci tamed, yet careful 
postmoitem examination levealed a pie\iously uniecogni^ed mtra-abdominal 
01 pulmonaiy infection to explain the whole picture 

On the other hand, the e\])eriences of the senioi author (J H G ) 12 or 
13 years ago at the old New Yoik Hospital came to mind and those records 
were recentl)’’ leviewed m oidei to corroboiatc the imjiiession gained at that 
time On the Second Suigical Division, in those dajs, man)' cases of acute 
cholecystitis weie tieated as emcigencies, as is being advocated b) a number 
of surgeons at the piesent time A gioup of the jiatients so treated de- 
veloped the typical picture undei discussion and died within 48 hours with 
hypeipyiexia as the outstanding symptom Yet, careful jjostmoitem exam- 
ination, in two instances, failed to lev'cal the cause of death Theie was not 
the slightest evidence of infection and the hv'ei sections showed onlv occa- 
sional peiiportal accumulations of pol)inoii)honuclcai leukocytes These cases 
were disconcertingly puzzling at the time and the thought was entertained 
that a profound physiologic 01 chemical change had taken place w Inch could 
not be detei mined by any known clinical or laboratoiy methods Since then, 
as far as w'e know, nothing of any impoitance has developed to throw light 
on this obscuie picture 

The various clinical and pathologic aspects of the so-called “hepato-renal” 
syndrome, as reported m the hteiature, deseive careful consideration, m the 
light of the case repoi ted herewith klany of the 1 epoi ted instances of "hepato- 
renal” syndrome aie based on clinical grounds only and lack coi roborative 
autops}' findings Those reports that include postmortem examinations pre- 
sent a curious lack of uniformity of the pathologic picture Ceitainly, the 
degree and extent of the degenei ativ'e changes encounteied m the liver and 
kidneys vaiy considerably Why should one patient present minimal post- 
mortem findings while another, with the identical clinical pictuie, exhibits ex- 
tensiv'e degenei ative changes^ This consideiable v'aiiation m the degiee and 
extent of the pathologic findings suggests to us a possible explanation It 
seems possible that many of these patients have some degiee of kidney damage 
before the suigical attack on the biliaiy system and that their inaigm of safety 
from the standpoint of kidney leserve is indeed small This impairment may 
not be appaient before operation 01 may not be demonstrable by any known 
laboratory methods Following the proceduie on the diseased biliary tract, 
with its associated surgical tiauina and the greatly alteied physiology that must 
necessarily follow, the already impaired kidneys aie unable to cope with the 

92 



A ohimc 107 
Isumbcr 1 


THE HEPATO-RENAL SYNDROME 


additional load thiown upon them and soon break down completely Cei- 
tamly, the clinical pictuie with the lelatively fiee interval of five to ten days 
aftei opeiation is suggestive confiimation of this thought It must not be 
f 01 gotten, too, that the same syndiome has been known to follow opeiations 
upon the gasti o-intestmal tiact and also, aftei extensive cutaneous bums, 
conditions knoun to be closely linked with distuibances of protein metabolism 
Theie is anothei gioup of patients who develop the typical so-called 
“hepato-ienal” syndrome and, yet, the findings at autopsy aie minimal and 
offei no anatomic explanation of the cause of death Doctor Klempeiei, 
pathologist at Mt Smai Hospital, has given the case herewith repoited con- 
siderable study and thought, and he feels vei y definitely that the slight paren- 
ch3anatous degeneiation of the liver and kidneys found at necropsy is in- 
sufficient to explain the (.ause of death Ceitainly, the livei sections aside 
from the cholangeitis show nothing of gieat moment, and the reason for the 
hemorrhages fiom the mucous membiane surfaces cannot be demonstrated 
In reviewing the sections of the kidneys, however, one is impressed by the 
peculiar appeal ance of the glomeruli Most of them aie strikingly laige with- 
out any cellulai mciease The intei capillai y connective tissue fiamework 
(Zimmeimann) is piominent and appears spongy, as if distended by fluid 
(Fig 2) The teim “serous glomeiulitis” is suggested to describe this fea 
ture A similai finding has been described by W G MacCallum In re- 
viewing the kidney sections of hundieds of cases showing glomeiular changes 
111 a series of about 5,000 autopsies, he noted a peculiai exudation into the 
glomeruli of patients dying of an acute illness, which lesulted in toxic injuiy 
to the kidneys The most sti iking featuie was the distension of the lobules of 
the glomeruli into a club shape by an exudate which separated the capillai les 
fiom one anothei and fiom the ovei lying basement membrane The latter 
structuie was sti etched and smooth and widely sepal ated from the under- 
lying capillaries His illustiation of this condition stiongly resembles that 
piesented by the kidneys in our case In othei cases, wheie the illness was 
of longei duration, the lobules weie adheient and covered ovei by a smooth 
basement membiane, while the capillai les weie sepaiated by definitely stain- 
able connective tissue He concluded that the first picture might veiy well 
be interpreted as the initial stage of glomeiular injury which goes on, with 
continuation of the disease piocess, to the chionic form known to clinicians 
as gloinei ulonephi itis 

Aftei a critical leview of the liteiatuie and a careful study of the case 
leported heiewith, we have formed the opinion that no logical 01 satisfactory 
explanation of the syndromes oiiginally described by Heyd has as yet been 
offered Although thought by many authois to follow surgeiy of the biliary 
tiact only, these clinical pictuies have appealed also in cases of intestinal ob- 
struction, cutaneous bums, etc The lack of uniformity of anatomic changes 
to explain the cause of death is notewoithy, as is also the variation in the 
extent of the degeneiative changes We believe that the syndiomes under 
discussion are dependent upon piofound chemical changes which we are 

93 



GARLOCK AND KLEIN 


Annals Of Surffery 
January 1938 


unable to definitely determine b}’’ the clinical and laboiatory methods avail- 
able at the persent time 


REFERENCES 

^Bartlett, W, Jr Renal Complications of Biliary Tract Infections Surg, Gjncc, and 
Obstet , 56, 1080, i()33 

"Behrend, M Surgical Diseases of the Gall Bladder, Liver, Pancreas, and Their Treat- 
ment Phila , r A Davis Co , 213, 1927 

“Bojcc, F F An Experimental Studj of the So-called Li\cr Death Sjndrome in Biharj 
Surgery Proc Soc Exper Biol and Med , 32, 479, December, 1934 
‘Boyce, F F, and McFetndge, E M So called “Lner Death’ — A Clinical and Experi- 
mental Study Arch Surg, 31, 103, Julj, 1935 
'^Bojee, F F, and McFetndge, E M “Lner Deaths” in Surgcr\ New Orleans Med 
and Surg Jour , 88, 563, March, 1936 

"Boyce, F F, and McFetndge, E M The So-called ‘Lner Death” Arch Surg, 32, 
1080, June, 1936 

"Boyce, F F, Veal, J R, and McFetndge, E M An Anahsis of the Mortalit} of 
Gall Bladder Surgerj Surg, G\nec and Obstet, 63, 43, luh, 1936 
"Cave, Henr^ W Dangers Incident to Cholec3 stcctoinj Axxals 01 Slrgirv, 84, 
371, September, 1926 

" Cole, W H The Role of Hepatic Insufficience in Surgical Problems Jour Missouri 
State Med Assn, 30, 331, September, 1933 

Colp, R, Doubilct H, and Gerber, I E The Relation of Cholecestitis to Pathologic 
Changes in the Lner Axxais or Si,rglr\, 102, 202, 1933 
“Connell, F G Rapid-High Temperature Deaths Following Bilnr\ Tract Surgtrj 
A^^ALS or SURGIR3, 94, 363, September, 1931 
Counell, F G Lner Deaths (So called) — Rapid High Temperature Deaths Axxals 
or SuRGun, 100, 319, 1934 

’"Eiss, S Conservation of Hepatic Function m Gall Bladder Operations Annals of 
Surgery, 98, 348, 1933 

“Fitz-Hugh, T, Jr Hepato-Urologic Sindromes Med Clinics N Ainer , 12, noi, 
Januarv, 1929 

’"Graham, E A Hepatitis A Constant Accompaniment of Cholecistitis Surg,G\nec, 
and Obstet , 26, 321, 1918 

’“Helwig, F C, and Orr, T G Traumatic Necrosis of the Lner with Extensne Reten- 
tion of Creatinine and High Grade Nephiosis Arch Surg, 24, 136, 1932 
’"Hehvig, F C, and Schutz, C B A Lner Kidnej Sindrome — Clinical, Pathological, 
and Experimental Studies Surg, Ginec, and Obstet, 55, 370, 1932 
’"Helwig, F C A Review' of the Recent Adiances in the Knowledge of the Pathologi of 
the Liver Am Jour Surg , 19, 462, 1933 

’" Helwig, F C , and Schutz, C B A Further Contribution to the Ln cr Kidnes Ss n- 
drome Jour Lab and Clin Med, 21, 264, 1933-1936 
’”Heuer, G J The Factors Leading to Death in Operations upon the Gall Bladder and 
Bile Ducts Annals of Surgfrv, 99, 881, June, 1934 
-■•Hewitt, H W Liver Deaths Following Surgerv of the Gall Bladder Jour Mich 
Mea Soc , 34, 421, Julv, 1935 

" Heyd, C G Hepatitis Associated with or Sequential to Inflammatorv Diseases of the 
Abdomen L I Med Jour, 17, 17, 1923 

"'■ Heyd, C G , MacNeal, W J , and Killian, J A Hepatitis 111 Its Relation to Iiiflani- 
matorv Disease of the Abdomen A Clinical and Laboratory Studj Trans Am 
Assn of Obstet, Gynec, Abd Surgeons, 36, 231, 1923 
‘ Heyd, C G The Liver and Its Relation to Chronic Abdominal Infection Annals of 
Surgery, 79, 33, 1924 


94 



■\ olume 10" 
>nmber 1 


THE HEPATO-RENAL SYNDROME 


Heyd, C G , MpcNeal, W J , and Killian, J A Hepatitis and Its Relation to Inflam- 
matory Disease of the Abdomen A Clinical and Laboratory Stud} Am Jour 
Obstet and Gynec, 7, 413, 1924 

“ Heyd, C G “Liver Deaths” in Surgery of the Gall Bladder Tr Sect of Surg , Gen 
and Abd , of the A M A , p 144, 1931 

Hevd, C G “Liver Deaths” in Surger> of the Gall Bladder JAMA, 97, 1847, 
December, 1931 

“ Heyd, C G Liver Function and “Liver Deaths ” Surg , Gynec , and Obstet , 57, 407, 

1933 

^Heyd, C G Significance of Livei Function from the Surgeon’s Standpoint N Y 
State Jour Med, 33, 1317, Novembei 15, 1933 
™Judd, E S, Nickel, A C, and Wellbrock, W L A The Association of the Liver m 
Disease of the Bihar} Tract Surg , Gynec , and Obstet , 54, 13, 1932 
“’■Lieber, kl M, and Stewart, H L Renal Changes Following Biliary Obstruction, 
Decompression and Operation on the Biliary Tract Arch Path , 19, 636, 1935 
^"MacCallum, W G Glomerular Changes in Nephritis Bull Johns Hopkins Hosp , 55, 
416, 1934 

'“Riley, J \V Post-opeiative Complications of Biliary Tract Surgerv Their Preven- 
tion and Treatment Jour Oklahoma State Med Assn, 24, 190, 1931 

Schutz, C B , Helwig, F C , and Kuhn, H P A Contribution to the Study of So-called 
Liver Death JAMA, 99, 633, August 20, 1932 
'“Sharpies, C W Liver Deaths Following Operation of Biliary Tract West Jour 
Surg , Obstet , and Gynec , 42, 337, 1934 

Stanton, E MacD Immediate Causes of Death Following Operations on Gall Bladder 
and Ducts Am Jour Surg, 8, 1026, May, 1930 

Sutton, J E,Jr High Temperature Liver Death Syndiome Proc Soc Exper Biol 
and Med , 32, 712, February, 1935 

Touroff, A S W Unrecognized Post-operative Infection A Cause of the Syndrome 
of So-called “Liver Shock” Surg, Gynec, and Obstet, 62, 941, June, 1936 
^Walters, W, and Parham, D Renal and Hepatic Insufficiency 111 Obstructive Jaundice 
Surg , Gynec , and Obstet , 35, 605, 1922 

Weiss, S Liver Deaths and Their Prevention Am Joui Surg, New Series, 23, 96, 

1934 

“Wilensky, A O, and Colp, R Retention of Nitrogen Bodies of the Blood to Surgical 
Problems in Liver and in Biliary Tract Disease Arch Path , 15, 635, 1927 

Zimmermann, K W Uber den Bau des Glomerulus der menschhchen Niere Z 
mikrosk-anat Forschg , 18, 520, 1929 


95 



TUMORS VENTRAL TO THE SACRUiM 
Lorin D Wiiittakkr, M D 

lELLOW IN SUnOERl TIIF MA^O FOUNDATION 

A\D 

John drJ Prmberton, M D 

nmsioN OF suncERr, the ma^o ciimc 
RocnFSTLn, IMisv 

The legion veiitial to the sacium and sacrococcygeal joint is the site of 
many complex fetal changes While tumors arising m this region aie rare — 
accoidmg to Ewing'' occuiiing onl}' once m 34,582 tumors of the newhorn, 
and according to statistics at Ihe Maj'o Chine, foi the period 1922-1936, 
occurring in only one out of approximately eveiy 40000 registiations — then 
incidence is such as to piompt consideration of then pathogenesis, diagnosis 
and treatment 

This study is based on a set les of 22 cases of tuinoi ventral to the sacrum 
seen at The Mayo Clinic from 1922 to 1936, inclusive, m w Inch the diagnosis 
was confiimed at opeiation liundling^ has pieviously leporled 19 such cases 
which were encountered at the clinic prior to 1922, and Fletcher, Woltman 
and Adson" have pieviously reported m detail the five cases of chordoma 
which are included in this repoi t 

Located embryonically in the vential sacrococcvgeal legion are the spinal 
cord, neive tissue, postanal portion of the hindgut, neurenteiic canal, caudal 
end of the notochord and the bony veitebral canal Tlie embr}onic develop- 
ment- and subsequent disappeaiance of the structures in this region aid m 
explaining the origin of these tumors The primitive streak lies posterior 
to the neural groove and arises, as does the neural groove, from the embryonic 
area The notochoid is formed by the piohferation of cells from the anterior 
end of the primitive streak It is epithelial m origin Early in its develop- 
ment the notochord is surrounded by secondaiy mesoderm This, then, be- 
comes the primitive veitebial column As the vertebral bodies are foimed, 
after the fourth week, the continuity of the notochoid is broken The noto- 
chord disappears in the region of the veitebral bodies, but peisists m the 
region of the intervertebral fibrocai tilages After the fouith month the 
notochord has disappeared as a separate stiucture, but lemnants are believed 
to persist as the nucleus pulposus of the intervertebral fibrocartilages Linck 
and Warstat® were of the opinion that rests of chordal cells exist outside 
the axial skeleton anlage, and these can be recognized m the sacrococcygeal 
region in the adult These rests may he either m the body of the sacral 
veitebrae or on their anterior or posterioi aspects 

As the notochord is forming, the primitive gioove appeals on the surface 
of the primitive streak The anterioi end of the groove, which is embraced 
by the posterior portion of the neural fold, deepens and forms a canal between 
the neural groove and the ventral-lying entodermal vesicle, which is the primi- 

* Now residing in Peoria, Illinois Submitted for publication May 14, 1937 

96 



Volume 107 
Number 1 


TUMORS VENTRAL TO THE SACRUM 


tive intestinal canal This is called the “neui enteric canal” (Fig i), and it 
gradually moves to a position caudal to the proctodeum The neui enteric 
canal is but a tiansitory passage and disappears in man before the neural 
groove closes to form the neural tube 

The postanal gut is formed by the union of the proctodeum and that poition 
of the hindgut proximal to the neurentenc canal The pioctodeum is a sur- 
face depression limited at its depth by the pioctodeal membrane The dis- 
appearance of this membiane completes the foimation of the lectuin and anus 
The union of pioctodeum and hindgut, howevei, does not take place at the 
distal end of the hindgut”’ That poition of the hindgut distal to the union 
with the proctodeum is known as the “postanal gut,” and it lies on the ventral 



Fig I — Dorsal viei\ of a human erabrjo i 54 Mm long (modified 
after Graf Spee) Longitudinal (sagittal) section through an advanced 
embryo of Bombinator (modified after Goetta in Herturg Oscar, and 
Mark E L Textbook of the Embryology of Man and Mammals Lon 
don, Swan, Sonnenschun and Co , 1892, p 120, fig 80) 

surface of the coccyx (Fig 2) This stiuctuie ati opines early It is ap- 
parent, therefoie, how these primitive stiuctures, as they atrophy, may leave 
a nidus for furthei giowth, with the foimation of a tumoi 

Tumors ventral to the sacrum have at times been popularly known as 
“Middeldoi pf ” tuniois, but this term should be limited to those teratomatous 
tumors that aiise from the postanal gut, as first clearly described by Middel- 
dorpf Tumoi s ventral to the sacium may vary fioni those the size of an 
egg to laige growths which fill the tiue pelvis and push the anus and genitalia 
forward They may be rather superficial or be quite deeply placed within the 
hollow of the sacrum The tumoi s are usually encapsulated and rarely invade 
the rectum but, as will be shown later, they may invade the bony sacrum or 
encroach on the intervertebral foramina and compress the nerve trunks 

97 


WHITTAKER AND PEMBERTON 


Annals of SurRorj 
January lOSS 


The geneial symptoms piocluced vaiy greatly AMtli the associated path- 
ologic changes In some cases there ma}-^ be no symptoms , or an indefinite 
dull ache oi pain in the lowei part of the back oi pelvis, which may occa- 
sionally be associated wnth constipation, ma} be the onl}" complaint In othei 
cases serious neive encioachment ma)’’ pioduce weakness in the legs, sciatic 
pain, rectal oi uiinary incontinence, and aical numbness In some cases drain- 
ing peiiiectal sinuses fiom incised dermoids are seen Consequently, digital 
examination of the lectum is the most A'alued single proceduie m the diagnosis 
of tumors vcntial to the sacium, and this alone almost ahvajs will gne the 
clue to the diagnosis It is impoitant, however, to examine thoroughly the 
hollow of the sacium If this is done, the true diagnosis is established and 


Hindgcit 



Tig 2 — Reconstruction of the Iiindgut of an cmbr^o 6$ long 

(modified after Kcibcl) 


the patient may be saved needless hemonhoidectoin}’’, piostatic massage, 
arthritic treatment, or even laminectomy, foi lelief of his symptoms 

Conditions to be consideied in the difleiential diagnosis, suggested by this 
series of cases, include Cord tumoi, tumoi of the cauda equina, anterior 
spina bifida wnth meningocele, primaiy sarcoma of the sacrum, pelvic tumors 
such as ovarian C3'^sts, fibi om3'^oinata or adenoin3'omata, masses of metastatic 
lymph nodes, rectal fistulae and peiirectal abscesses 

The treatment of choice is surgical removal, utilizing the posterior ap- 
proach through a modified Kiaske incision Radium and roentgen therap3'^ 
are advised when removal is incomplete, since prolongation of life and relief 
of symptoms can fiequently be obtained b3’^ these measures (Table I) 

Chordomata — The term "chordoma” was fiist used b3" Ribbert, in 1894, 
and the first saci ococcygeal choidoma w^as described by Feldmann,'* in 1910 
The term is now used to describe tumoi s whose cellulai stiucture has the 
characteristic appeal ance microscopically of the notochord There are ap- 
proximately 125 cases of chordoma on record 


98 



Yolumc 107 
umber 1 


TUMORS VENTRAL TO THE SACRUM 


Table I 

TUMORS VENTRAL TO SACRUM 



No 

of 

Cases 

Sex 

Age 

Range 

Predominant 

Symptoms 

No of 

Cases 

Reveal- 
ing Mass Prognosis 
Rectally 

Diagnosis 

M 

P 

Chordoma 

8 

5 

3 

Kto65 

Pain in lower part of 
spine, nerve in- 
volvement,* con- 
stipation 

8 

Poor 

Dermoid cyst 

9 


9 

H to 48 

Dull pelvic pain, 
draining sinus, 
mass at birth 

7 t 

Good 

Teratoma 

I 


I 

7 

Perineal mass at 
birth 

t 

Good 

Fibrosarcoma 

I 

1 


51 

Pain in rectum , nerve 
involvement 

I 

Poor 

Chondromyx- 

osarcoma 

I 

I 


73 

Mass, loss of weight, 
constipation 

I 

Poor 

Squamous cell 
epithelioma 

I 

I 


53 

Sciatic pain 

I 

Poor 

Fibroma 

Total 

I 

22 

8 

I 

14 

29 

3 mos to 
73 yrs 

Sacral pain 

I 

19 

Good 


* Sensory disturbance noted m three cases 
Numbness, rectal or unnary incontinence 
t No record of rectal examination m the cases of two infants 
t No record of rectal examination 

Chordomata arising' fiom the remnant of the notochord may, as stated 
previously, have as then oiigm the nucleus pulposus or the lests of chordal 
cells outside the axial skeleton However, since chordomata occui with about 
equal frequency m the sacrococcygeal and doisum sellae legions, and since 
one has not been reported in the thoracic region, it seems more plausible to 
many that then oiigin is in the choidal cell lests outside the axial skeleton 
anlage Anatomically the tumors seem to arise m i elation to the vertebial 
body rather than the nucleus pulposus 

Sacrococcygeal choidomata may arise within the veitebral body and pioject 
eithei ventrally oi doi sally, or both, oi they may aiise ventral oi doisal to 
the sacrum It is only in those aiismg or piojectmg ventrally, hoiiever, that 
we are interested These tumors may grow to a large size, are usually en- 
capsulated, may invade intei vei tebi al foramina and cause pressure on nerve 
structures, and may cause maiked bony destruction, they rarely if evei, how- 
ever, involve the rectum Metastasis is laiely seen, although the incidence 
of recurrence is quite high, being given by Stewart^- as 86 5 per cent Re- 
current lesions aie local and recuiience is usually due to incomplete removal 
of the original growth Grossty these tumors are gelatinous, lobulated and 
usually quite friable, microscopically, ceitam catena have been established 

99 




WHITTAKER AND PEMBERTON j^Suary “ w"! 

on which to base the diagnosis Fletcher, Woltinan, and Adson,'’ for example, 
have based the diagnosis on ‘'(^) The formation of intracellular and extra- 
cellulai mucus, (b) the presence of physaliphoious or vacuolated mucus 
containing cells, (c) the lobulated ariangement of the tumor cells, Avhich 
usually glow in coids, (d) the occasional occuiience of vacuolation of the 
nuclei, and (e) the close resemblance to notochoidal tissue as seen in the 
nuclei pulposi of the intei vertebral disks” 

The last five cases m this group of cases of chordoma have been previ- 
ously repoited in detail by Fletcher, Woltman and Adson Tliey vill be 
reviewed briefly here only to complete the sei les 

Case I — A girl, age fi\e jeirs, was brought to the clinic August 6, 1930 She had 
had increasing constipation for two and onc-half jears, and obstipation had been present for 
ten dajs Rectal examination re\ealed a mass posterior to the rectum, pushing it anteriorh 
against the pubis This mass measured 8x6x4 cm and nearlj filled the pcKis Roentgeno- 
grams of the pehis were negatne Ihe mass was remo\cd, as completelj as possible, 
August 15, 1930 It extended from the \entral sacrum back around the cocc\x and out 
into the right buttock Radium was applied following operation Fi\e months later the 
bow'els were regular and the patient was doing niceh The microscopic report was 
chordoma 

Case 2 — A girl, age three months, w’as brought to the clinic March 11, 1935 In 
the previous three weeks her right hip had appeared laiger Constipation had also been 
present for three weeks Examination rc\ealtd a firm mass m the right buttock RectalK 
the mass was felt on the right, 6 cm m diameter, pushing the rectum to the left Roent- 
genograms of the pthis were negatne I he mass was incompleteh removed March 13, 
193s It was verj friable, vascular, and was invading the right gluteal muscles The 
patient returned home and later died Ihc microscopic icport was chordoma 

Case 3 — A man, age 39, registered at the clinic June 25, 1936 He had had pain 
111 the lower part of his back and at the end of his spine foi the previous five months 
This pain was worse at night During the same period an increasing constipation was 
noted Rectal examination revealed a firm, smooth rounded mass, 7x5 cm, posterior 
to the rectum and attached to the sacruni It was not tender The lumen of the rectum 
was partiallj obstructed Roentgenograms levcalcd destruction of the lower half of the 
sacrum The tumor was removed as complctclv as possible Julv 7, 1936 It was en- 
capsulated Roentgen thcrapj was instituted following operation On discharge the 
patient was free of svniptoins and only some loughncss of the sacrococcj goal area per- 
sisted The microscopic repoit was chordoma (Fig 3) 

Case 4 — A woman, age 65, legistered at the clinic September 4, 1923 She had had 
a severe, sharp pain at the end of her spine for five vears Hcmorrhoidectomj and 
injection of the pen-anal nerves with alcohol, in 1920, had given no relief There was 
sciatic projection of this pain, and rectal incontinence and some loss of vesical control 
was also noted Rectal examination revealed a relaxed anal sphincter and a mass ventral 
to the sacrum Sensorj impairment of the fourth and fifth sacral nerves was found 
Roentgenograms revealed destiuction of the upper portion of the sacrum On October 
6, 1923, the tumor, which had inv’aded the sacrum, was mcompletelj removed and radium 
was applied The patient died two years later The microscopic report was chordoma 
Case 5 — A man, age 58, registered at the clinic Janiiarj 26, 1925 He had had pro- 
gressive tenderness and pain at the end of his spine for three months Rectal examination 
revealed a hard round mass, 4 cm in diameter, posterior to the rectum It was not 
tender Roentgenograms levealed necrosis of bone m the sacium The tumor was re- 
moved as thoroughly as possible January 30 Radiotherapy was then instituted Nine 
years later the patient felt well The microscopic report was chordoma 

Case 6 — ^A man, age 47, registered at the clinic for the second time April 6, 1925, 
with-the complaint of pain and numbness in the legion of his rectum and coccyx of 18 

100 



Volume 107 
Number 1 


TUMORS VENTRAL TO THE SACRUM 


months’ duiation He had also had progressive trouble with his bladder for one month 
Rectal examination revealed a relaxed anal sphincter associated with anesthesia A 
firm, smooth, fixed mass, 7 cm m diameter, was palpated ventral to the sacrum, and 
1 oentgenograms revealed destruction of the lower two-thirds of the sacrum On May 9, 
1925, incomplete lemoval of the mass was accomplished It was friable and resembled 
a colloid tumor Roentgen therapy was administered In 1929 a recurrent growth was 
partially removed The patient died fi%e years after the onset of his symptoms The 
microscopic report was chordoma 

Case 7 — A man, age 61, registered at the clinic December 9, 1927 He had had 
progressive pain in his right hip associated with sensory disturbance for eight months 
Urinaiy incontinence had been present for three weeks Rectal examination revealed 
a relaxed sphincter and a firm mass filling the pelvis, apparently arising from the 
ventral aspect of the sacrum Roentgenograms revealed some destruction of the sacrum 



Tig 1 — (Cise 3 ) Photomicrograph of chordoim 


Biopsy only was attempted and ladiothcrapy was advised Ihe microscopic report wis 
chordoma 

Case 8 — A man, age 26, first registered at the clinic August 19, 1930 He had had 
pain at the end of his spine, which was projected to the genitalia and inner thigh, and 
increasing constipation for one year Rectal examination revealed a fixed tumor, 7 5 
cm in diameter, ventral to the sacrum He was operated upon, elsewhere, and was 
given radium treatment He returned to the clinic January 7, 1932, complaining ot 
severe pain Examination at this time revealed urinary and rectal incontinence and a 
mass ventral to the sacrum Roentgenograms revealed cystic degeneration of the right 
half of the sacrum The mass was removed as completely as possible January 14, 1932 
On discharge the patient was free of pain and the function of his bladder had improved 
The microscopic report was chordoma 

Five of these eight patients weie males and three females In only two 
cases was theie any suggestive history of previous trauma The ages ranged 
throughout the life span, two of the patients being childien Sacrococc3'’geal 
chordomata ai e quite rare m children 

Pam was the initial symptom in the case of each adult patient This pam 
was usually localized in the back at the lower end of the spine Sciatic 
projection was frequent Later, sensory disturbances frequently appeared, 

101 



Wlin TAKER AND PEMBERTON ^aT.IVrf'ms 

as did uiinaiy and lectal incontinence In\olveinent of nerves depended on 
enci oachment of the tumoi on the sacral neive iilexus and trunks Consti- 
pation was fieqiiently noted Roentgenograms revealed some bony destruc- 
tion of the sacium in five of the cases The duration of symptoms varied 
fiom three weeks to five years, the aveiage liemg 17 months Rectal exam- 
ination levealed a mass m each case, and A\as the most valuable single finding 
in the examination The mass ^\ as fii m, usuallv smooth, fixed to the saci um, 
and was not tendei 

The diagnosis can he made positively only aftei micioscopic examination 
Howevei, tlie piesence of a film, smooth, fixed and nontendei mass ventral 
to the sacrum, associated ^\lth pain in the sacial region, latei \\ilh sensory 
distui bailees and usually with lectal and uiniaiy incontinence, is quite sug- 
gestive of saci ococcygeal chordoma The conditions which most frequently 
have to be consideied m the dififeiential diagnosis of saci ococcygeal chordoma 
aie Tumor of the cauda equina, meningocele and saicoma or enchondroma 
of the sacrum 

Surgical leinoval of the tumoi as completely as possible oflfeis the best 
chance foi cine The Kiaske type of incision postciior to the lectuin, with 
removal of the cocejx, piobably gives the most satisfactoiv approach to these 
tumoi s, however, the doisal appioach, unioofing the tumoi and removing it 
intrasacially, may be a better approach when maiked iinohement of the 
sacium IS piesent Because of its ramifications, complete lemoval of the 
tumor IS sometimes veiy difficult 

The piognosis in this group of cases is quite pool and the percentage of local 
lecuirence is extremely high Howevei, surgical icmoval followed by exten- 
sive iriadiation does piolong life, relieve pain and often gives a long period of 
freedom from symptoms Chesky’^ repoited the a^elage length of life after 
operation to be six and one-half }cais 

Dermoid Cysts — Dermoid cysts aie ectodcimal in oiigin and are lined 
wuth epithelium wdiich is constantly secreting and desquamating Such C3'sts 
are filled wuth sebaceous material and may contain ectodermal deiivatives 
These cysts occui wdiere ectodermal structure is not found undei noi inal condi- 
tions It IS generally agieed that such cj^sts oiiginate by inclusion of a poition 
of ectoderm dining faulty coalescence of cutaneous surfaces m embiyomc life 
They occui along the course of ectodermal invaginations Those presenting as 
tumoi s ventral to the sacium may arise fiom the proctodeal membiane 01 from 
coccygeal vestiges Galletly® w’^as of the opinion that they may also arise from 
the neuienteiic canal, which is an ectodeimal invagination 

Dermoid cysts may be located close to the saci ococcygeal region or be quite 
deeply situated 111 the hollow’^ of the sacrum If large, they may bulge into the 
perineum and push the genitalia foiwaid or they may encioach on the lectal 
lumen These cysts are encapsulated, have little 01 no blood supply of conse- 
quence, never invade the rectum, but if laige may infiequently cause eiosion of 
the sacrum and injuiy to neive ti links Thej'^ aie not fixed primarilj'- 

102 



Yolumo 107 
Number 1 


TUMORS VENTRAL TO THE SACRUM 


ABBREVIATED REPORT OF NINE CASES OF DERMOID CYSTS 

Case I — A woman, age 30, legistered at the clinic November 15, 1922 She had 
undergone an operation for a perirectal “abscess” elsewhere, and a draining perirectal 
sinus had persisted She had also been subjected to three operations for fistula-in-ano 
Rectal examination at the clinic levealed a definite thickemng on the posterior rectal 
wall 7 5 cm above the anal margin On August 31, 1923, the sinus tract was dissected 
out, and it was found to lead to a small cyst anterior to the sacrococcygeal joint The 
pathologic diagnosis was dermoid cyst containing hair 

Case 2 — A woman, age 23, registered at the clinic June 2, 1925 She had had 
urinary difficulty for six months and partial rectal incontinence for five months Rectal 
examination revealed a firm mass ventral to the sacrum which pushed the rectum to the 
right and displaced the pelvic organs upward Roentgenograms of the pelvis were 
negative On June 8, 1925, a large mass, 10 cm m diameter, which was buried m the 
hollow of the sacrum, was completely removed Complete relief of symptoms follow^ed 
The pathologic diagnosis was dermoid cyst containing onl> fat 

Case 3 — A girl, age four months, was brought to the clinic August 9, 1926 A 
tumor over her right buttock had been noticed at birth It had recently become moie 
prominent Examination revealed a soft tumor with firm nodules extending up to the 
sacrum, and roentgenograms revealed a soft tissue shadow below the pelvis on the right 
On August 14, 1926, a mass 10 cm in diameter, arising ventral to the sacrum and extend- 
ing dowm to the right buttock, was completely removed Complete relief of symptoms 
followed The pathologic diagnosis was polcystic dermoid containing fat and hair 

Case 4 — A girl, age seven months, was brought to the clinic June 23, 1928 Since 
birth she had had a large mass in the sacrococcygeal region posteriorly Roentgenograms 
revealed lower lumbar and sacral spina bifida On June 28, 1928, the mass, which measured 
25x15x10 cm , was removed from the sacrococcygeal region A second mass, about 7x5 
cm , and ventral to the sacrum, was later found and this also was removed Recovery 
was complete The pathologic diagnosis was dermoid cyst 

Case s — A woman, age 48, registered at the clinic September 23, 1929 She com- 
plained of distress in the low'er part of her pelvis and rectum of six months’ duration 
Rectal examination revealed a fluctuating mass ventral to the sacrum, 2 cm above the 
anal margin Roentgenograms of the sacrum were negative On September 27 the 
fluctuating mass was incised and about 100 cc of thick pus escaped The thick-walled 
sac was removed and recovery was complete The pathologic diagnosis was dermoid cyst 
Case 6 — A woman, age 40, registered at the clinic December 5, 1932 She had had 
a dull pain in the lower part of her abdomen and sacral part of her back for 15 years 
A perirectal draining sinus had been present since incision of an abscess years before 
Rectal examination revealed a hard, irregularly lobulated mass arising from the left 
lateral wall of the sacrum On December 8, 1932, the mass was incised and 120 cc of 
putty-like matter escaped Marked inflammation was present The mass was excised as 
completely as possible Slight drainage persisted intermittently for some time The 
pathologic diagnosis was dermoid cyst 

Case 7 — A woman, age 44, registered at the clinic August 9, 1934 For three months 
she had noticed some discomfort in the rectum after a bowel movement She had 
accidentally discovered a “tumor” in her rectum three months prior to registration while 
giving herself an enema Rectal examination revealed a smooth soft mass ventral to 
the sacrum, and roentgenograms revealed spina bifida of the fifth lumbar and first sacral 
vertebrae On August 21, 1934, a mass measuring about 7x5 cm was enucleated from 
the ventral portion of the sacrum Recovery was complete The pathologic diagnosis 
was dermoid cyst 

Case 8 — A girl, age two and one-half years, registered at the clinic June 24, 1935 
She had had a gradually enlarging tumor over the lower end of the sacrum since birth 
Rectal examination revealed a mass measuring 4x8 cm , ventral to the sacrum and 
palpable just within the rectal sphincter Roentgenograms revealed an anomaly of the 
last sacral vertebra On June 28, 1935, a cystic mass filled with thick creamy material 

103 



WHITTAKER AND PEMBERTON Annai.ofsurKc^ 

January 1D3S 

was found extending from the coccjx to the ventral surface of the sacrum, it was com- 
pletely removed It measured 5x4x3 cm Drainage persisted for some time The 
pathologic diagnosis was dermoid cyst 

Case 9 — A woman, age 33, registered at the clinic July 6, 1936 She had had a dull 
constant ache m the low’er part of her back for more than 15 jears Rectal examina- 
tion re\ealed a mass 10x6x4 cm, Ijing ventral to the sacrum and to the left of mid- 
hne It w'as fixed and w'as not tender Roentgenograms revealed 1 soft tissue shadow 
in the lower part of the pelvis On Juh 10, 1936, the mass, which was found to be well 
encapsulated, was removed in its entiretv Recovery was complete The pathologic 
diagnosis was dermoid cjst 

It IS inteiesting that each of these nine patients was a female Tiiree of 
them were infants, and the av'crage age of the other six was 36 The infants 
presented sacrococcygeal tumors at birth, two patients had had symptoms for 15 
or more years, and four patients had had symptoms for from three to seven 
months In two cases incision of an “abscess” had been perfoimed, this was 
followed by a persistent discharge until the time of excision of the dermoid cyst 
Roentgenograms weie made in seven cases and in two cases associated lumbar 
and sacral spina bifida was noted In one case theie w'as an anomalous last 
sacral vertebi a 

The symptoms are not pointedlj suggestive Four patients complained of 
dull aching distress 111 the lower part of the back or abdomen, or in the rectum 
One patient complained of a pciirectal draining sinus, and one complained of 
partial urinaiy and lectal incontinence 'i he thiee infants presented definite 
evidence of a tumor Rectal examination levealed the mass ventral to the 
sacrum in seven cases, rectal examination was not made in the cases of two 
infants In those cases uncomplicated bv a draining sinus or a pievious opera- 
tive attempt at drainage or removal rectal examination revealed smooth fluc- 
tuant masses which were movable 01 only paitially fixed and were not tender on 
pressuie In cases complicated by pievious opcidtion to institute drainage, 
marked inflammatory leaction may occui about the tumor and it mav' then 
become fixed and tender 

The posterior suigical a]3]5ioach is the one of choice Complete remov'al of 
the lining of the dermoid cyst is essential and usually, complete enucleation can 
be earned out without difficulty If this is done the wound heals rapidly and 
complete relief of symptoms will follow 

Teratomata — Teiatomata are tumors in which tissue itpresenting all 
three embryonal layers are arranged in disoi derly fashion Their origin is not 
well defined, various theories hav'ing been presented which are based on eithei 
their bigerminal 01 monogerminal origin The bigeiminal theoiy explains the 
origin of such tumors as an independent development of a blastomeie during 
segmentation, a rudimentaiy duplication, or the so called parasitic twin The 
monogerminal theory explains their origin as disordeily giovvths of remnants 
of fetal structures 

In the ventral sacrococcygeal region there are possibl)' sufficient fetal rem- 
nants to explain the vaiious types of teratomata without resorting to the bi- 
germinal theoiy of rudimentary twin Middeldorpf was the first to attribute 
teratoma ventral to the sacrum to the peisistence of a fetal structure He pre- 

104 



Volume 107 
Number 1 


TUMORS VENTRAL TO THE SACRUM 


sented the case of a girl, one year old, who had had a tumoi m the region of the 
anus since birth It opened to the outside and occasionally discharged a dark 
brown mucoid fluid There was no connection with the rectum This tumoi 
was composed of fatty tissue containing a structure resembling a small loop of 
intestine He believed that the tumor was derived fiom the postanal gut 
Hansmann’’^ was of the opinion that when the neurentenc canal remnant was the 
source of a tumoi, there was frequently an associated anteiioi sacral defect 

Teratomata are most frequently found m the newborn and in infants The 
attachment to the rectum is not intimate, but it may be to the sacrum or coccyx , 
they may be attached to the sacrum by a pedicle or may be enveloped in a 
capsule 

Case I — A girl, age seven, was brought to the clinic June 20, 1929 A large mass 
protruding from the perineal region had been noted since birth Rectal evamination was 
not made Roentgenograms revealed a large soft tissue mass in the pelvis containing 
fragments of bone The sacral curve was absent At operation, June 25, 1929, the 
mass was found to be attached to the ventral median raphe of the sacrum and coccyx, 
displacing the genitalia downward and anteiior This mass was completely remo\ed 
It weighed 550 Gm The perineal portion measured 10x7 cm and the portion ventral 
to the sacrum was 9 cm in diameter Recovery was complete The pathologic diagnosis 
was teratoma 

Miscellaneous Tumors — This group of tumoi s vential to the sacitim 
consisted of three malignant tumors (a fibiosarcoma, chondromyosarcoma, and 
a squamous cell epithelioma, possibly vesical m type) and one benign tumoi 
(fibioma) There was no evidence of malignancy elsewhere m any of the cases 
of malignant tumor Two of these patients with malignant lesions had symp- 
toms of nerve root pressure, the thud complained only of pain and constipa- 
tion In the case of the fibi oma there was marked inflammatory fixation, which 
peimitted only partial removal 

Case I — A man, age 51, registered at the clinic July 9, 1928 He had had a dull 
aching pam in the rectum, bearing down in type, of increasing severity for one j'ear 
Weakness in his legs had been piesent for six months, sciatica for two months, and urinary 
difficulty for two months Rectal examination revealed a lelaxed sphincter and an 
irregular, nontender mass ventral to the sacrum Roentgenograms of the pelvis were 
negative On July 18, 1928, a large tumor, 10x15x5 cm , was found eroding the ventral 
surface of the sacrum The mass was removed almost m its entirety , it weighed 122 
Gm The patient died one year later The pathologic diagnosis was fibrosarcoma 

Case 2 — A man, age 73, registered at the clinic November 29, 1934 He had had 
a mass m the coccygeal region with pain on sitting for eight months Constipation had 
been present for six months He had lost 35 pounds (15 9 Kg ) in the two years prior 
to his registration Rectal examination revealed a firm mass ventral to the sacrococcygeal 
area, and roentgenograms revealed destruction of the lower part of the sacrum and coccyx 
A soft tissue shadow was present On December 12, 1934, the tumor, which had en- 
croached on the rectum, was incompletely removed It weighed 350 Gm Again on 
January 14, 1936, a recurrent tumor about 6x4 cm was removed Radium treatment 
was instituted and there was some improvement The pathologic diagnosis was 
chondromyxosarcoma 

Case 3 — A man, age 53, registered at the clinic December 26, 1931 He had had 
severe sciatic like pain, shooting in character, for four months Some numbness and 
tingling of the left leg had also been present for four months Rectal examination 
revealed a hard, fixed mass behind the rectum ventral to the sacrum It w'as not tender 
Roentgenograms of the pelvis were negative At operation January 5, 1932, the mass, 

105 



WHITTAKER AND PEMBERTON 


Amiftla Of Surgery 
Junuarj 103S 


which W’as found to be Iiigh iii the hollow of the sacrum, was incompletely removed 
Extensive radlotherap^ followed The patient died six months later At the time of 
his examination and at operation no other e\idence of mahgnancj was found The patho- 
logic diagnosis was squamous cell epithelioma, possibly aesical in type 

Case 4 — A woman, age 29, registered at the clinic Eebruary 15, 1929 She had had 
a dull aching pain, without projection, 111 the sacral region for six months Rectal ex- 
amination reaealed a mass posterior to the rectum The mass aaas rounded, smooth, 
not tender, and extended almost to the proniontorv of the sacrum At operation, March 
1, 1929, the mass aaas found to be quite fixed and edematous It aaas incompletely re- 
moa'ed The pathologic diagnosis aaas fibroma 

SUMM \RY 

Tumors aiising vcntial to the sactum probalyly aiise ftom lemnants of fetal 
structuies The most important fetal changes m this region include the devel- 
opment and suhsequent disappearance of the notochord, neui enteric canal, proc- 
todeum and hindgut 

The subjective sym]ytoms of tumor ventral to the sacium aie not definitely 
suggestive but include pain m the sacial region, constipation, and vesical and 
icctal incontinence Rectal examination revealed the mass in each case m 
which it was made It is the most impoit.nnt single diagnostic piocedure 

1 he most satisfactory tieatment of such tumois is surgical excision through 
a modified Kraske type of posteiior intision In the case of malignant tumors 
complete lemoval is often difficult and ladiotheiapy may help to relieve pain 
and to piolong life 

The incidence of recurience is high, and lecurience is usually local The 
piognosis vanes with the tjpe of tumoi, being pool in instances of malignancy 

REFERENCES 

'CheskN, V E Sncrococcy geil Cliordonn Arch Surg , 24, 1061-1067, June, 1932 
■ Cuniiinglnm, D J Textbook of Aintomy Ed 5 New York, William Wood and 
Company, 27-55, 1923 

“Ewing, James Neoplastic Diseases A Treatise on Tumors Ed 3 Philadelphia, 
W B Saunders Compaiw, 1035, 1928 

‘Fcldmann, I Chordoma Ossis Sacn Beitr 7 path Anat n z allg Path, 48, 

630-634- 1910 

“ Fletcher, Eleanor M , Woltman, H W , and Adson, A W Sacrococcy goal Chordomas 
a Clinical and Pathologic Stud\ Arch Neurol and Ps\chiat , 33, 283-299, Februar\, 

^ 1935 

/^Galletly Quoted by Ruen, R W Sacro-cocc\ geal Ctsts and Tumors Brit Jour 
Surg, 23, 337-361, October, 1935 

■Hansmann, G H A Congenital Cystic Tumor of the Neui enteric Canal with 
Special Reference to Its Histolog\ and Pathological Significance Surg, Gynec 
S. Obstet , 42, 124-127, January, 1926 

,^^Hundhng, H W Ventral Tumors of the Sacrum Sing, Gynec & Obstet, 38, 
518-533, April, 1924 

'’Liiick, A , and Warstat Quoted by Kwartin, Boris, and Stewart, J D Sacrococcygeal 
Chordoma Axnals or Surger\, 86, 771-775, November, 1927 
Middeldorpf, K Zur Kenntniss dci angebornen Sacralgcschwulste Virchow-’s Arch 
f path Anat u Physiol, loi, 37-44, July, 1885 
“Ribbeit Tiber die Ecchondrosis Physalifora Sphenooccipitahs Centralbl f allg 
Path u path Anat , 5, 457-468, 1894 

Stewart Quoted by Harmos, Oscar, and Palmer, L A Chordoniata and Report of 
Case Virginia Med Month, 62, 638-648, Febiuary, 1936 

106 



INTRAMEDULLARY DERMOID CYST 

F Keith Bradfokd, MD 
Chicago, III 

Dermoid and epideimoid tumois within the spinal canal aie of infre- 
quent occuiience About one-thud of those lepoited are intiamedullary 
tumois But of the mtiamedullaiy gioup, epidermoid tumois aie much moie 
common than tiue deimoid cysts 

Gross^ collected fiom the liteiatuie 19 deimoid and epideimoid tumors 
within the spinal canal to which he added one In oidei to bung the liteia- 
ture up to date the following additional cases of dermoid and epideimoid 
tumors have been collected and classified as carefully as the original papeis 
peiinit 

Shallow’s^^ patient was a man, age 30, who had had pain in the luinhai 
region, uiinary letention, and hypeiesthesia of the sacial dermatomes foi 
thiee 3^ears At opeiation an exti amedullary tumoi filling the spinal canal 
at the level of the fouith lumbar vertebia and compressing the cauda equina 
was lemoved with subsequent impiovement The cyst was lined by corni- 
fied, stiatified squamous epithelium and contained many sebaceous glands 
and a few ban follicles Through the comtesy of Di B L Ci an fold of 
the Jefleison Hospital in Philadelphia I was able to examine sections of this 
tumoi It is classified as an extiameduUaiy deimoid cyst 

Dehez'^ reported the case of a female, age 5, who for foui months 
had had unnaiy and fecal letention, a paiaplegia, and anesthesia of the sacial 
deimatomes At opeiation an extiaduial tumoi involving the cauda equina 
extended fiom the thud lumbai to the fiist sacial vertebia The tumor which 
contained grayish-yellow' cheesy material w'as lemoved wuth resulting im- 
provement One yeai later the patient died of a metastasizing abdominal 
tumoi which the author considered a sarcoma of the kidney No necropsy 
was performed No desciiption of the micioscopic appearance of the sur- 
gical specimen is given The pathologist’s diagnosis of deimoid cyst must, 
theiefoie, be accepted provisionally 

The case reported by Craig and MitchelP was that of a boy, age 8, who 
gave a history of pam m his back, tired feeling m the low'er extremities, and 
occasional enuresis for three years The only neurologic findings were 
absent knee jeiks and hyperesthesia of both groins The tumor disclosed 
at operation was extramedullary, 3 6 cm in length, compressing the conus 
medullaris and cauda equina at the level of the last thoracic and first lumbar 
vertebrae The patient w'^as relieved of all symptoms The tumor contained 
the typical crumbly, peaily contents of an epideimoid growth Microscopic 
examination revealed a lamellated appearance, but no nuclei The tumor is 
classified as an extramedullary epideimoid of cholesteatomatous t}pe 

Submitted for publication April 24, 1937 

107 



F KEITH BRADFORD \nnaIsofSurEcrj 

January 1^)3S 

Schioeder’s^ patient was a woman, age 35, who had liad a paraplegia and 
hypesthesia below the second lumbar dermatome for iS months At opera- 
tion an extramedullaiy tumor 2 5 cm long was lemoved at the level of the 
last two thoiacic veitebiae wheie it compressed the conus medullaiis The 
patient lecovered The tumor was cystic, filled \Mth yello\\ish ■white mate- 
iial Micioscopically the cyst ■was lined with coinified, stratified squamous 
epithelium The tumor is an extramedullaiy epidermoid 

Bouchut, Dcchaume, and Michailidis^ have lepoited the case of a man, 
age 71, who had had pain in his lowei extiemities of 15 years’ duration w’hich 
lessened as motoi difficulty inci eased Urinary letention had been present 
foi ten years Examination show'cd a paiaplegia and hypesthesia of the last 
lumbat and all the sacral dei matomes At necropsy an intramedullar}^ tumor 
of the conus medullaiis was found to have enlarged the coid so that it filled 
the canal at the level of the twelfth thoiacic ceitebia On section the cyst 
w'hich filled the cord was seen to contain an 01'}, jiearly lamellatcd substance 
which was assumed to be sloughed la}eis of epidermis In addition, theie was 
a dysembryoplasia of the adjacent poitions of the sjunal cord wuth muscle, 
glial tissue, and syimgomyelic cavities lined 1)} epithelium with the appearance 
of ependyma This is concluded to be a case of intramedullaiy epidennoid 
of cholesteatomatous Upe associated with a malfoimation of the spinal cord 
Ottonello’s’- patient was a woman, age 20, who had had pam in the 
scapular legion one }eai befoie w'lth the giadual appearance subsequently 
of paiesis and sensoiy loss 111 hei lowei extiemities Physical examination 
levealed a dimple at the level of the thud thoiacic vertebra through iihicli a 
sinus emptied At operation an extramedullaiy tumor 65 cm long and 
2 cm w'lde, wdiich had compressed the coid at the second, thud, and fourth 
thoracic vertebrae, w'as lemoved and along with it a sinus wdiich connected 
the tumoi to the dimple just mentioned The c}st contained sebaceous mate- 
iial and many hairs The lining of the cyst w'as a poorly developed stratified 
squamous eqithehum Although it w'as obstructed m places, the sinus com- 
municated wuth the cyst More supeificially the sinus contained m its w'all 
abundant hair follicles and sebaceous and sudorifeious glands But these 
gradually diminished in number m the deeper poitions and had disappeared 
entiiely wdiere the sinus communicated through the dm a mater wnth the 
cyst This case is classified as an extrameduhaiy dermoid cyst and con- 
genital dermal sinus 

Hipsley® leported, as a deimoid cyst within the spinal canal, a case which 
appears to be one of congenital dermal sinus A female, age 3, had at the 
level of the fiist thoracic spine a sinus wdiich had been draining Foi foui 
w'eeks there had been difficulty m w'alking and seveie pain m the left chest 
Examination levea’ed a red aiea 25 cm m diameter aiound the sinus open- 
ing fiom which a few hairs could be seen protiudmg A probe passed easily 
into the sinus to a depth of 2 5 cm Attempts to flex the thoiacic spine w'ere 
lesisted At operation the spine of the second thoiacic vertebra was found 
to be bifid and through a perfoiation m its base, sebaceous material escaped 

108 



Volume 107 
Number 1 


INTRAMEDULLARY DERMOID CYST 


An exti amedullar)'' mass, i 8 cm long and i 2 cm wide, was firmly adherent 
to the dura matei It was removed with subsequent improvement of the 
patient The meager desciiption given states “The contents and lining of 
the cyst resembled the contents and lining membiane of a sebaceous cyst 
of the skin ” It seems piobable that this is simply a case of congenital dermal 
sinus, chronically infected, symptoms occuning when diamage ceased from 
obstruction of the sinus The haus protiuding fiom the ostium rule out 
any other kind of sinus It would, however, be possible that the cystic mass 
removed at opeiation was a deimoid cyst combined with a congenital deimal 
sinus as m the case leported by Ottonello 

Of the four cases lecently leported by Naffzigei and Jones^^ the third 
case IS omitted heie because it is veiy doubtful that it comes within the 
group described m this paper The fii st and fourth cases were dei mold cysts , 
the second, an epidei moid The first case was subai achnoid , the second and 
fourth, subpial Roentgenologic changes, consisting of eiosion of the pedi- 
cles and bodies of the vertebiae, occuiied only m the fiist two cases Theie 
was m addition a sacial spina bifida in the first case of the senes 

The fiist case occuned in a woman, age 62, who had complained of pam 
111 hei back foi 42 3'eais and a paiaplegia foi one yeai A tumoi 152 cm 
long and 38 cm wide involving the cauda equina fiom the twelfth thoracic 
to the second sacial veitebrae i\as paitiahy removed with almost complete 
lecoveiy subsequently Most of the mass lemoved was a ciumbly, fatty 
mateiial containing many haiis, but theie was also a poition of capsule 
which levealed, upon micioscoiiic examination, a thinned-oiit layer of strati- 
fied squamous epithelium 

The second case was in a woman, age 27. who developed incontinence 
of mine and feces follownng pam in hei back for tw'o yeais A cystic 
tumor weighing 9 Gm involving the conus medullaiis from the last thoiacic 
to the second lumbai veitebiae w^as lemoved wnth good impiovement The 
cyst was lined with a stiatified squamous epithelium 

The fourth case occuiied in a man, age 45, who had stiff eied wntli uri- 
naiy symptoms foi 16 yeais During the last twm yeais pain in the sacial 
dermatomes and a paiapaiesis had developed At operation a subpial tumor 
55 cm long w^as found extending fiom the eleventh thoiacic to the third 
lumbai veitebrae Below% it compressed the cauda equina and it w'as pos- 
sible to sepal ate the capsule, but above, the capsule meiged wnth the conus 
medullaris fiom wdiich it had to be seveied Microscopically there was found 
to be a hypeikeiatotic, stiatified squamous epithelium beneath wdiich w^ere 
scatteied hair folhcles, sebaceous and sw'eat glands, and fat cells 

Puech, Plichet, Visalh, and Brun^^ have leported the case of a man, age 
37, wdio had had pai esthesias, paiaparesis, and urinaiy distuibance for one 
yeai At opeiation an intiamedullaiy tumoi w^eighmg 4 Gm w'as removed 
piecemeal at the level of the sixth and seventh thoiacic vertebiae ivith sub- 
sequent recovery Micioscopic examination levealed only a rather struc- 

109 



F KEITH BRADFORD 


\nnalsof Surgery 
7 a nil a rj 1D38 


tureless, lamellated mass without cells This tunioi can be classified as an 
intramedullary epidermoid of cholesteatomatous type 

A case pathologically very similar to the one here piesented has been 
reported by Love and Kernohan ® A man, age 40, had complained of a 
piogiessive paiaparesis and incontinence Following the demonstiation with 
lipiodol of a subaiachnoid block opposite the second lumbar ^ertebrae, a 
laminectomy was peifoimed which levcaled a cystic mass w'lthm the conus 
medullaris On incision of this, giumous mateiial, hair and material resem- 
bling pus escaped The wound healed without infection, but the patient’s 
neuiologic condition w-as little altered Diagnosis Intramedullar}’^ deimoid 
cyst 

SYNOPSIS OF CASE REPORT 

The patient, a male, age 3, de\ eloped normallj until one jear before admission when 
pain occurred at irregular intervals in both lower extremities, two months prior to 
admission pains became more severe, and were accompanied bv fecal and urinary in- 
continence and mabihtj to walk Examination showed a rather flaccid paraparesis, 
pen-anal analgesia, and a palpable defect 111 the sacral laminae Roentgenologic ex- 
amination revealed marked dilatation of the lumbar canal Operation was performed con- 
sisting of incision and evacuation of an intramcdullarv dermoid evst and excision of a 
mural nodule Subsequent improvement occurred 

Case Report — No 157304 D W, male, age 3, was first seen bv the Pediatric 
Service of the Univcrsitj of Chicago Clinics August 7, 1936 Chief complaint “Pam 
111 lower extremities and mabihtj to walk for six weeks” 

The patient was the oiilj child of a mother, age 20 The birth weight was six 
pounds, SIX ounces The pregnancy and dehverj were normal Both parents were in 
good health and there was no liistorj of familial disease The child sat up at six months, 
talked at 12 months, and walked it 13 months Dentition was normal, and the patient 
had been continuouslj well except for his present illness 

In August, 1935 (age two), the patient first complained of pains m both lower 
extremities These were described as being intermittent and worse first m one place 
then in another These pains progressed for almost a v'ear before other svmptoms de- 
V eloped 

In June, 1936 (age three), the pain was so severe that the patient asked to be 
earned when going somewhere instead of walking as fornierlv It was soon evident that 
the lower extremities vveie too weak for the patient to walk although he could be held 
in a standing position and take a few steps The patient also became incontinent of 
feces and urine although he had previously had perfect control Since June, 1936, 
the patient had been extremely irritable and uncomfortable, frequentlj refused to eat, 
and had lost seven pounds m weight 

Examwatwn August 7, 1936, revealed a well developed, thin, blond male, appre- 
hensive and irritable Temperature normal, complete blood count and uranaljsis were 
negative, weight 26 pounds The patient lay supine with his legs modcratclj flexed and 
objected to other positions He was quite intelligent and bright as was evident when 
his apprehension was overcome The chest and abdomen were negative The left 
testis was undescended, but the genitalia were otherwise normal The teeth were in 
good condition and the nose and throat normal 

Ncuiologic Exaimnatwn revealed a normal head, but the neck was slightly stiff 
and the patient complained when it was flexed The cranial nerves were normal 
throughout Motor function, sensation, and reflexes were normal m the upper extreme- 
ties and trunk The abdominal reflexes were aetive and equal Motor function was 
very difficult to determine in the lower extremities The patient complained when his 

110 



Tolumc 107 
Jvumber 1 


INTRAMEDULLARY DERMOID CYST 


legs were manipulated in any manner, especially upon the Kernig test All movements 
seemed possible, but the patient was reluctant to use his extremities because of pain 
Atrophy was present in the left buttock, but to no great extent elsewhere The limbs 
were flaccid although not extremely so Sensation to pm prick, judged by the patient’s 
responses, was normal except in the pen-anal region where little response to painful 
stimuli was obtained The plantar reflexes were normal The tendon reflexes t\ere 
variable and hypo-active although both knee jerks and both ankle jerks were obtainable 
When supported, the patient could stand, keeping his knees and hips flexed A few 
faltering steps were possible when the patient was w^ell supported, but it w'as impossible 



Tig I — On tlie left is a reproduction of the roentgenogr-im of 
the lumbosacral spine of the patient with an intramedullar} dermoid 
c>st On the right a roentgenogram of a normal lumbosacral 
spine in a child of the same age has been reproduced for com 
panson The dilatation of the spinal canal without an> appreciable 
thinning or deformity of the pedicles is clearly shown 


for him to stand or walk alone Ot'er the lumbosacral joint was a tuft of blond hair 
several centimeters long, and at the tip of the coccyx a dimple was present, but the 
skin was intact and not inflamed nor did any sinus lead from it Palpation oier the 
sacrum revealed an absence of the sacral laminae 

Roentgenologic Examination August 7, 1936, repealed a remarkable dilatation of the 
spinal canal m the region of the fourth and fifth lumbar and the first sacral \ertebrae 
(Fig i) There w'as a failure of fusion of the laminae of the fourth lumbar \ertebra 
and for this age, normal lack of fusion of the lumbar and the sacral vertebrae 

A preoperative diagnosis of spina bifida occulta wuth intraspinal tumor or mjelo- 
dysplasia was made 


111 



F KEITH BRADFORD 


Annalsof Surccry 
January 1033 


Opctatwn August ii, 1936 Dr Paul C Bucy performed a laminectomy of the 
last four lumbar and the first sacral vertebrae The spines and laminae were normal 
except that the fourth lumbar vertebra contained a small defect in the laminae besides 
an incompletely developed spinous process The fifth lumbar contained a somewhat 
larger defect, and the first sacral vertebra had the developing bone of the spinous process 
and laminae still separate from the remainder of the vertebra At the level of the fourth 
and fifth lumbar vertebrae the canal was grossly enlarged and the dura mater was 
quite tense Upon incising the dura mater it was apparent that a tremendously dilated 
spinal cord entirelj filled the caudal end of the dural sac The greatest dilatation of 
the spinal cord was at the level of the fourth and fifth lumbar vertebrae where it was 



I IG 2 — The drawing at the left represents the appeannee at 
operation The cord has been incised between the posterior col 
umns exposing a large cjstic caMt> A\Inch extends both above 
and below the incision A nodule is seen on the right its inner 
surface covered with caseous debris and hair Tlierc are numerous 
small blood vessels over the surface of the thinned portion of spinal 
cord to which the nodule is attached At the right is a diagram 
malic cross section through the conus mcdullans at the level of 
the nodule 

increased to four 01 five times the normal size Above this level, extending to the 
third lumbar vertebra, the dilatation was to about twice the normal size At the top 
of the exposure the dura mater pulsated normally On the right side at the fourth lumbar 
vertebra there was on the surface of the dura mater a tangle of arteries and veins 
considerably more extensive than elsewhere With the dura mater open it could be seen 
that five or six of these vessels passed to the spinal cord with a corresponding increase 
in vascularity at this point Ihe posterior roots taking their origin in the tensely 
dilated spinal cord could be seen coursing caudally and laterally ov^er it Because of its 
cystic appearance the spinal cord was aspirated and 12 cc of whitish yellow, opaque fluid 
were obtained On microscopic examination this showed many epithelial cells The 
cord was then incised longitudinally between the posterior columns exposing a cyst lined 
by a translucent membrane (Fig 2) More fluid was obtained and several masses of 
caseous material in which were mingled many fine blond hairs With the collapse of 
the spinal cord it was evident that the vessels entering its right side at the level of the 

112 



■V 7/)7 

Aiiniber i ' 

lumbar V 

'"'^acuated ^or exan^"'”^ ''°«f'-o!/ed ? 

at tbe ,un„/’^ ^«cis,o„ „j ’"^t'on ^ ^ at a considerabj of c,?^ 

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a'^c/ej ,,,„ ^a^W’edral cp//c /• ^ajeai of fi anb/e c on 

“r" a, „ 

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ilS ’ and sebaceous L ^^out 

^'ands fp-jg. 



F KEITH BRADFORD 


Annals Of Surcerj 
Tanuarj 103S 


3) Marked gliosis was present in the contiguous portion of the spinal cord The 
portion of c\st wall rcnio\cd at some distance from the nodule showed an tincormficd, 
stratified sciuamous epithehum and onh a thin lajcr of conncctne tissue beneath separating 
It from the sclerotic spinal cord No dermal structures were present in this portion 

There can be htt’e doubt that these findings repiesent a developmental 
defect m the cleavage of the surface and nctnal ectoderm similar in many 
lespects to the developmental anomaly icsponsible for the de\elopment of 
extramedullai)' deimoid and epideimoid tumois elsewhere in the central 
nervous system and to the congenital dermal sinuses leported by Wa’ker and 
Bucy In this paiticular instance the bit of surface ectoderm lesponsible 
for the tuinoi has lemamed fiiml} attached to the neiiial giooac and become 
enfolded witlnn that structure upon its closuie to form the neural tube and 
eventually the spinal coid It seems likely that the nodu’e composed of 
dermal and epidermal structures lepicsents the original implant and that the 
cystic cavity and its lining of stiatified squamous epithelium ha\e resulted 
fiom secretion fiom the dermoid nodule and the piogrcssne enlargement 
and lining of this cavity from the “mother” epithelium piesent on the nodule 
It is to be hoped that removal of the dermoid nodule will tciminate this 
progressne process since extirpation of the epithelial lining of this large cy'st 
w'as not feasible 

Dtscussiou — In the 20 cases included by Gloss'"’ in his report, fi\e were 
intiamedullary (Chiaii,- BanofT" Maimcsco and Diaganesco'’ Melnikoff- 
RaswedenkofF,^” and Gross"’) Only that of BanofF was a dermoid cyst 
It occuiied in an anencephahe monstei, extending throughout the spinal eoid 
and bulb It is haidly comparable to the case herein desciibed where there 
w'ere no apparent congenital defects except the tiimoi m the caudal end of 
the spinal coi d and minoi changes in the caudal poi tion of the spine Tw elve 
additional cases have been found in the hteratuie to which the one here re- 
poited IS added The cases of Bouchut and of Puech bung the total num- 
ber of intiamedullary epidermoid tumors to six Only the case of laanoff, 
that of Love and Keinohan, and the one presented heie weie intiamedullary 
dermoid cysts Ten of the 13 cases invohed the region of the conus medul- 
laiis and cauda equina Of the ihiee cases m the upper thoracic legioii two 
W’ere accompanied by spina bifida and congenital dcimal sinuses 

The similaiity’ m structure and development of deimoid tumois and con- 
genital deimal sinuses should be nientioned Both aie due to inipioper 
Separation of the neurectoderm fiom the suiface ectodeini A congenital 
dermal sinus, a deimoid tunioi, 01 a combination of both may’ develop, de- 
pending upon w'hether 01 not the portion of surface ectodeini piesent in the 
legion of the iieuial tube, as an inclusion, retains an epitbehal connection 
with the sui face 

Summary — A case of mtiamedullaiy dermoid evst in a male child tliiee 
years old is leported and the hteiatuie leview’ed Epidermoid and dermoid 
tumois w’lthin the spinal canal aie dysraphisins of the same geneial nature 
as congenital dermal sinuses 


114 



Volume 107 
Number 1 


INTRAMEDULLARY DERMOID CYST 
REFERENCES 


^ Bouchut, Dechaume, J , and Michaihdis Kyste cholesteatoinateux intramedullaire par 
dysembryoplasie nerveuse Lyon med 150, 694-697, December 18, 1932 

“ Chian Centrales Choleastom des Dorsalmarkes Prager med Wchnschr , 39, 378- 
380, 1883 

“ Craig, J , and Mitchell, A Spinal Tumors in Childhood Arch Dis Childhood, 
6 , n-i6, 1931 

* Delrez, L Kyste Dermoide Rachidien et Sarcome du Rem Chez le meme Enfant 
Liege med , 22, 1667-1675, December 15, 1929 

' Gross, Sidney W Concerning Intraspinal Dermoids and Epidermoids, with Report of 
a Case Jour Nerv and Ment Dis , 80, 274-284, September, 1934 

“ Hipsley, P L Dermoid Cyst of Spinal Canal Australian and New Zealand Jour 
Surg , 2, 421, April, 1933 

’’ Ivanoff, N S A Case of Cholesteatoma of the Spinal Cord J Neuropat 1 psikiat , 
Korsakova, Mosk , pp 80-81, 1903 

® Love, J G , and Kernohan, J W Dermoid and Epidermoid Tumors of Central 
Nervous System Reprinted with additions fiom JAMA, 107, 1876-1882, De- 
cember 5, 1936 

” Marmesco et Draganesco Kyste Epidermoide Cholesteatomateuv de la Moelle Epimere, 
Rev Neurol , 40, 338-355, 1924 

Alelnikoff-Raswedenkoff, N Ubei epidermoide und dermoide Cholesteatome des 
Grosshirns und Ruckenmarks Deutsch Ztschr f Nervenh , 127, 123-130, 1932 

^Naffziger, H C, and Jones, 0 W Dermoid Tumors of the Spinal Cord Arch 
Neurol and Psychiat , 33, 941-958, May, 1935 

“Ottonello, Paolo Dermoide spinale associate a rachischisi Riv di pat Nerv, 41, 512- 
531, May-June, 1933 

Puech, P , Plichet, A , Visalli, F , and Brun, N Cholesteatome intramedullaire Re^ 
Neurol , 66, 56-62, July, 1936 

Schroeder, A H Cholesteatoma modular An Frac de med Montevideo, 17, 59i- 
616, August, 1932 

Shallow, Thomas A Dermoid Cyst of the Cauda Equina Surg Chn N Amer , 8, 
885-889, August, 1928 

’“Walker, A E, and Bucy, P C Congenital Dermal Sinuses Brain, 57, 401-421, 
December, 1934 


115 



TEARS OF THE SUPRASPINATUS TENDON 

ULSUiMl. or Twni-.\I^ oplrvtld casks 
Tom a Outland, M D , axd Walpcr F Siikpiikrd, ]\I D 

Sviiti , l*\ 

It would seem almost imneccssarj, m view of the complete and painstak- 
ing monograph of Codman, to attempt to pi esent additional material on lesions 
of the supraspmatus tendon, but because of the scarcit} of medical literature 
dealing with this subject and the fact that we believe that the diagnosis of 
such injuries more often than not goes unrecognized, mc arc presenting a 
brief and admittedl} incomplete lestime of the salient points in the condition 
of supraspinatus tendon tear in conjunction with a repoit of a group of cases 
operated upon b} the senior author 

Betw'een 192S and 1934, we diagnosed this condition three times, since 
1934 we ha\e seen and diagnosed 14 cases m this clinic, of which 12 have 
come to operation, at which time the lesion was demonstrated and a repair 
of the tendon effected It would appeal fiom what we ha\e learned in these 
lecent cases, that we ha\c preMousl} seen other instances, many of them 
less w'ell defined s\ mptomatically, without lecogm/mg the real condition, and 
for this leason we wish to emphasi/e the neeessit) for careful study of all 
obscuie cases of shouldei dysfunction 

Anatomy — Ihc tendinous mscilion of the supiasiimaliis, together with 
the infraspinatus, teies major and tcies minor (foimmg the musculotendinous 
cuff) IS closelv attached to the capsule of the shoulder joint reinforcing the 
lattei in its iippei half bile standaid anatomic text-hooks state that the 
supraspinatus is inseited into the uppei facet of the gi eater tubeiosity, it is 
so intimately blended with the contiguous infiaspmatus as to be indistin- 
guishable from it 

Its function is to pull the gieatci tubeiosity under the aciomion, fix the 
humeial head m the glenoid, and abduct the shoulder thiough the first few 
degiees, at wdiich point the deltoid assumes the bin den and continues the 
motion thioughout the aic of scapulohumei al motion 

Etiology — Ruptuie of the supraspinatus, though ceitain factois may 
predispose to it, is tiaumatic m origin The injuiv apparently may occur 
in one of tw^o w'ays — eithei m falling the patient abducted his arm in an 
attempt to bieak the fall, the rupture occuiiing dining the movement befoie 
the shouldei stiuck the giound, or a direct blow (or fall) w^as leceived on 
the back of the shoulder wuth pioduction of a fonvard displacement of the 
humeral head w'lth consequent luptuie of the tendon Dislocation of the 
shoulder may occur 01 the displacement may be only momentaiy, follow'ed 

by spontaneous replacement 

Submitted for publication March 4, 1937 

116 


Volume 107 
Number 1 


TEARS OF THE SUPRASPINATUS TENDON 


Accoiding to Codman and Akerson^ the tendon may have been pre\jousl) 
weakened as the lesult of (i) Defects left as a lesult of so called calcified 
deposits, (2) necrosis of the tendon oi othei diffuse pathologic process oi of 
the same phenomena which are known as aithiitis m othei joints, (3) at- 
tution Finally, age may be consideied as a piedisposing factoi since the 
condition is commonly seen in patients aiound or beyond the fifth decade 

Pathology — The site of rupture of the supraspmatus is commonly at, 
or very close to, the gi eater tubeiosity The pioximal fiagment then letiacts, 
enlaigmg the gap and frequently teaiing the flooi of the buisa, thus creating 
an opening through which theie is a dnect communication between the bursa 
and shoulder joint 

Diagnosis — The fact that in no instance when a diagnosis of supraspina- 
tus teal was made have we been unable to demonstrate the lesion is good 
evidence that the symptomatologj'^ is cleai cut Codman has outlined iS 
conditions, symptoms, and signs which indicate complete lupture of the 
supraspmatus Of these, we have found the following objectives signs of 
gieatest importance 

(1) Diminution 01 loss of the powei to abduct This vanes with the 
size of the tear and also with the neivous make-up and fortitude of the patient 

(2) Tenderness ovei the gi eater tuberosity Dawbarn’s sign has not been 
of especial help, since theie may be hyperesthesia in the distribution of the 
ciicumflex nerve 

(3) Undue prominence of the gieatei tuberosity due to the fact that its 
tendinous coveiing is absent 

(4) Ciepitus of a fine nature, palpable over the tubeiosity as it moves 
under the acromion on passive motion of the arm 

(5) A negatn^e loentgenogiam 

Desaiphon oj a Typical Lesion — In Wilson’s^ cases all the tears were 
of the complete type, the largest rent measuring two and one-half inches and 
involving the subscapularis and infiaspinatus tendons as well The common- 
est tear measui es about one and one-half inches, is roughly triangular in shape 
with the base toward the gieatei tubeiosity and the apex of the tear ma} 
extend up under the aciomion, especially in old cases The underlying joint 
capsule is neaily always torn thiough exposing the inside of the joint The 
edges of the tendon aie ragged and thinned, and calcification may be piesent 
in the cases of long standing As a rule, veiy little tissue remains attached 
to the greater tuberosity The head of the humerus is unaffected m the early 
case In the aveiage case the nisei tions of the other short muscles aie un- 
affected If dislocation occurs, however, lupture 111 varying degree may be 
piesent m the adjacent structures 

Tieatment — The treatment, unless the tear be veiy small, is operation 
and sutuie of the tendon There is reason to believe that incomplete tears 
may be successfully tieated by rest m abduction 

We have undei tieatment at the piesent a patient Yith classical symptoms 

117 



OUTLAND AND SHDPIIERD Aminisofs„aer> 

Janunrj 10^5 

of a tcai, but in view of the fact that considerable power in abduction was 
retained, tieatnient on an abduction splint was advised Rest in abduction 
w'as earned out until the crepitus disappeared (four weeks), wdien active 
motion was staited Piogiess has been slow' and, wdiile the outcome is ap- 
parently going to be satisfactorj , we feel that operative repair w'ould have 
shoilcned the convalescence 

For the complete ttai w’lth wide separation, opeiatne repair is the 
only logical treatment Usuallj it is possible to attach the retracted tendon 
to the tubeiosity b} one of scvcial methods Anatomic approximation of 
the letracted ends and sutuie with two oi three bca\y silk mattress sutures 
is probably the best method and is generally possible in early cases In 
the older case where the edges of the tear are ringed with scar tissue, the 
lattei ma) he excised hack to noimal tendon, oi the sutuies may he placed 
well back in healthy tendon tissue so that the necessary tension can he ap- 
plied when approximating the fragments We haAc picferred this to the 
former ptocedure If theie is insufficient tendon attaehed to the tuberosity 
to peiinit simple sutuie, a groo\e ma> he cut m the tuhcrosit\ and the prox- 
imal portion of the tendon diawn close to the gioo\e and anchored by 
mattiess sutures passed tliiough drill holes made through the tuherosit} 
into the groo\e In the older case with such wide reti action that suture 
IS not possible, the reinn.ints of the att.ichmcnt can he reinoAed and the 
enlaiged and iiregulai tuhciosit} may he remoeed to ])rc\cnt impingement 
of the tuhciosity on the acromion during abduction This was done m one 
case with good icsults so far as relief of pain was concerned, hut with, of 
cotiise, no impro\eincnt in strength 

Following operation the arm is iinmohili/ed h\ the use of an axillai} pad, 
sling and bandage As soon as the wound is dr\, sinusoidal current and 
“bending” exeicises are begun 'Ihc latlci consists of allowing the aims 
to hang loosely at the side and then bending foiwaid In this manner a 
position of abduction is obtained without muscular eflort At the end 
of tlnee w'eeks, supported actne motion and actne exercises on the finger 
laddei and the use of a weight and pulley are started ImproAement gener- 
ally extends OAei a peiiod of fioin tlnee to six months 

The folloAving lesuine of 12 opeiatcd cases is piesented The lesults 
have been classified as excellent, good, fair and poor This classification 
is, of course, aihitraiy, hut in general the desciiptive terms mean as fol- 
loAvs Excellent — complete relief of pain and fioin 75 to 100 per cent le- 
tuin of poAvei of abduction, good — pain relieved, active abduction present 
but considerably Aveaker than normal, fan — lelief of pain, abduction vei}' 
Aveak, pool — little 01 no lelief from pain or inciease in poAvei of abduction 

CASE REPORTS 

Case I — S O , female, age 46, Avhile lifting a heavy object from a shelf felt some- 
thing snap in her shoulder, Avliich became Aerj weak and painful Chiropractic treat- 
ments did not afford relief Operation Avas performed 14 months later Operatne 

118 



Volume 107 
Is umber 1 


TEARS OF THE SUPRASPINATUS TENDON 


Findings Complete tear of supraspinatus tendon, flooi of bursa, and capsule Approxi- 
mation of the tendons was possible Repair with mattress sutures Result Good 

Case 2 — L , male, age 59 No definite injur}' Does heavj labor Pam began 
one week ago Was unable to abduct arm No tieatment Kahn test four plus Opera- 
tive Findings Floor of bursa thick and red but not torn, complete tear of supraspinatus 
tendon and long head of biceps Both repaired Result Good 

Case 3 — C K , male, age 69 Fell from roof 18 hours previous! j , striking on shoul- 
der Typical findings of complete tear, floor of bursa torn, bursa filled with sjnoMal 
fluid, complete tear of supraspinatus tendon Result Four months after operation, 
good and still improving — probably the eventual result will be excellent 

Case 4 — F W, male, age 59 Fell three days previously while getting on passenger 
coach and attempted to break his fall by grasping hand rail No treatment Patient 
known diabetic Operative Findings T3'pical complete tear one and one-half inches long 
involving both supraspinatus and infraspinatus tendons equallv, floor of bursa not ruptured 
Result Good 

Case 5 — M S , male, age 32 Dislocated shouldei (caught under coal slide Decem- 
ber 17, 1934) Shoulder quite weak and stiff Twice manipulated under anesthesia for 
peri-arthritis Passive motion increased but no active abduction and much pain Opera- 
tion August 29, 1935 Opeiative Findings Bursa not torn, section of bursa discolored and 
appeared cystic on palpation , floor incised and triangular tear seen, part of superficial 
fibers intact but thin, deep fibers ruptured Result Fair 

Case 6 — N D S , female, age 60 Both shoulders dislocated and reduced by 
manipulation Right shoulder remained weak in abduction but not painful Treated by 
massage Operated upon 14 months later Operative Findings Bursa open, small 
tear near insertion easily repaired, but about one inch proximally was a large tear in- 
volving the supraspinatus and infraspinatus tendon with edges widely retracted Result 
Fair (seen only for six weeks postoperatively) 

Case 7 — L L , male, age 52 Struck by falling barn door one week before examina- 
tion Pam not prominent, such pain as was present referred to deltoid insertion Unable 
to abduct arm and tender over tuberosity (latter very prominent) No treatment 
Operative Findings Bursal floor torn, complete tear of supraspinatus and infraspinatus 
tendons, insertion much frayed, biceps not ruptured Result Excellent 

Case 8 — J K M , male, age 54 Fell from derrick Severe pain and inability 
to abduct Treated with physiotherapj Operation performed seven weeks later Opera- 
tive Findings Floor of bursa thick and rough but intact, complete tear with wide re- 
traction, very few shreds at insertion Impossible to approximate tendon and tuberositj 
removed Result Fair, pain relieved, no power m abduction 

Case 9 — T H , male, age 57 Fell from box car two days before operation 
Pam referred to insertion of deltoid, weakness in abduction Operative Findings Floor 
of bursa intact, tuberosity very prominent, area of jellowish discoloration about this, 
when floor of bursa was incised, a triangular tear three-quarters of an inch wide was 
seen, yellowish discoloration due to degeneration of tendon about the margins of the 
tear, yellowish material not amoiphous but fibers of tendon apparent in it Result 
Excellent after five months 

Case 10 — D A , male, age 56 Auto accident 24 hours previously Fracture dis- 
location of shoulder Open reduction effected Operative Findings Complete rupture 
of supiaspmatus and subscapularis , long head of biceps intact Result Excellent 

Case II — B C, male, age 42 Knocked down by horse eight days previousl} 
Dislocated shoulder Shoulder reduced No return abductitin, tender over tuberosity 
Operative Findings Small triangular tear 111 supraspinatus tendon, bursa not open 
Good approximation secured Result Good 

Case 12 — J K , male, 42 Thrown from auto Dislocation shoulder and fracture 
greater tuberosity Tieated bv reduction of dislocation and phj siotherapj to the shoulder 

119 



OUTLAND AND SHEPHERD 


\nnnJsof MirgeD 
January 


Loss of abduction, not nnicli pain, no crepitus in passiNc abduction Operation sc\en 
weeks later Operatne Findings Bursa scarred and adherent to tendons, old triangular 
tear (small), either incomplete or, more likch, filled in with scar Result Poor 

CoittjrnNT — Wliile we ate inclined to be cautious in attempting to draw 
definite conclusions fiom this small senes of eases, the following points 
seem avorthy of emphasis 

(1) Complete teai of the supiaspinalus tendon is apparently possible 
without pioducmg a rent in the flooi of the buisa Case 4 illustrates this 
w'ell The teai was one and one-half inches long and situated about three- 
quarters of an inch fioin the tuberosity and mvohcd the supraspinatus 
and infiaspinatus tendons to an equal dcgiee While the edges of the 
tear wcie not widely separated with the patient relaxed under anesthesia, 
the tear w-as complete and nnohed the capsule as well Yet the o\erlymg 
buisa was intact, although the floor was quite hcmoiihagic In view of 
the foregoing, it appeals that an exploration is not complete unless the 
floor of the bursa is incised and the tendon Msuah/cd 

(2) Fne of oui operated eases wcie the result of shoulder dislocation 
It ma}' be concluded that the belief expiesstd in certain text-books that 
the subscapulans is occasionally torn but that other tendons arc rarely 
ruptuied, is open to question Certainl} the piactice of testing all patients 
w’lth dislocated shoulders for the ability to aclnelv abduct immcdiatel} after 
1 eduction is effected is desirable 

(3) The piesencc of constitutional disease (lues or diabetes) in two of 
OUI cases is inteicstmg and suggests that systemic disease maj be a pre- 
disposing factoi 111 suiiraspinatus tendon tears 

(4) The piescnct of the degtncratnc changes in the toin tendon noted 
in Case 9 ma\ bcai out Codman’s belief that the calcification found m so 
called subacromial buisitis w’lth calcified dej^osits in the tendon represents 
slight supraspinatus tendon tears which nature attempts to lepair The 
alternative conclusion is that the deposit picceded and predisposed to the 
teal Against this latter is the fact that the patient ]>rcMouslv had had no 
complaint icfeiable to the shouldci Furtheimoic the yellowish material 
w'as not the usual cheesy or (m older cases) taitai-hke substance ordmarih 
found 111 instances of bursitis, since tendinous fibers could still be identified 
111 the substance 

(5) While the aveiage age of oui patients w'as 50 years, Case 5 was 
a lobust niiiiei of 32 Thus, the diagnosis cannot be absolutely ruled out 
on the basis of youth 

SUMJIARY 

(1) Ruptuie of the supiaspinatus tendon is a coninion lesion 

(2) It occurs most frequently m laboiing men ovei 40 

(3) The lesion piesents a charactei istic liistoiy wntli w^ell defined 
physical findings 


120 



Volume 107 
Number 1 


TEARS OF THE SUPRASPINATUS TENDON 


(4) Continued shoulder disability following any trauma should be con- 
sidered a general indication of ruptuie 

(5) Complete sepaiation of the tendon demands surgical repaii 

REFERENCES 

^ Codman, E A The Shoulder Boston, Mass , Thomas Todd Company, 1934 
“ Keyes, E L Observations on Rupture of the Supraspmatus Tendon Annals of 
S uRGERV, 97, 849, June, 1933 

® Wilson, P D Complete Rupture of the Supraspmatus Tendon JAMA, 433, Febru- 
ary 7, 1931 

* Codman, E A , and Akerson, I B The Pathology Associated with Rupture of the 
Supraspmatus Tendon Annals of Surgery, 93, 348, January, 1931 


121 



DUPUYTREN S CONTRACTURE * 

A Bnucn Gill, AI D 

PiiiLMin pim, I’a 

Although the literature is voluminous, oui Knowledge of the etiology 
and the cure of Dupuytren’s contiacture has not been paiticulaily advanced 
during the past 20 years Eighteen 3 ears ago the author^ read a paper on 
this subject before the Philadelphia Acadeiu) ol Surgery To this paper 
but little can be added today 

Etiology — The etiolog}"^ may be considered with refeience to exogenous 
factors, or trauma, and endogenous factois, or the \er3" numerous condi- 
tions or agents w’hich produce biochemic.il changes in the palmer fascia, 
or to a combination of these two gioups of factors 

It cannot be denied that in a small group of cases tiieie is a hereditarj' 
tendency to Dupuytren’s contiacture Man\’^ authors have spoken of it, 
one cites an instance of 17 cases in 53 members of one family during a 
period of thiee geneiations The author has a patient with bilateral Dupuy- 
tien’s contracture wdiosc tw’o brotheis, and a grandmotber, two aunts and 
one cousin on his father’s side have the same condition These facts, of 
course, do not explain the etiology The} sim])!} point to some unknown 
hereditary, constitutional factor as the cause and demonstrate the irrelevance 
of trauma as the chief factor 

Trauma, acute or chionic, cannot be considered as a piimc factor but 
onl}’’ as a possible contributing or exciting cause of fibrositis of the palmar 
fascia One authoi found this condition in only four of 21,800 manual 
laboiers, another in onl}'' five of 2,000 industiial workers Me}erding, of 
the Alayo Clinic, m reporting Dupu}'tren s contiacture in 273 patients found 
45 pel cent occuried in farmeis and laborers, and 55 per cent m mental 
workeis These figures would have a definite meaning onl}" if we knew 
the relative number of manual and mental workeis tieated at the Mayo 
Clinic as a w'hole In his cases the contiacture w"as bilateral m 64 per cent 
Of tbe unilateral cases 70 per cent occuried 111 the light hand The average 
age of his patients w"as 54, the youngest 17 and the oldest So 

We may conclude in part w'lth Dacis and Fincsilvei that tiauma is not 
a piime factoi because 

(1) The onset is usually after middle life, even m individuals wdio have 
been doing haid manual laboi from then youth up 

(2) It is by no means confined to manual laborers and is comparatively 
uncommon in them 

(3) It is more often bilateral than unilateial In the use of tools and 

*Read before the Phihdelphia Academj of Surgerj, February 15, 1937 Submitted 
for publication April 19, 1937 


122 



volume 107 
Number 1 


DUPUYTREN'S CONTRACTURE 


implements theie is usually more pi assure and strain placed on the palm 
of one hand than upon the other 

(4) The ulnai poition of the palmai fascia is most commonly aflfected, 
while It IS at least doubtful if this poition of the palm is more subjected to 
injuiy than the remaining portion 

(5) Tiauma to the hand, both acute and chronic, is common, while 
Diipuytren’s contiactuie is raie 

Yet It must be borne in mind that trauma may be an inciting or con- 
tributing factor m Dupuytren’s contiactuie in ceitam cases, as it undoubtedly 
IS in some cases of acute and chronic aithritis, myositis and fibrositis in 
othei parts of the body 

We aie reduced to the conclusion that Dupuytren’s contractuie is es- 
sentially of endogenous origin Some change occurs in the metabolic or 
biochemical processes taking place w the palmar fascia ivhich pioduces an 
mflammatoiy leaction with the consequent pioduction of scar tissue This 
reaction may be acute and manifested by fanly lapid swelling, ledness, 
tenderness and pain on function The author has observed this m his 
own left hand and has seen it m other persons Usually, however, the 
inflammation is chionic and insidious, although there aie often alternating 
peiiods of exacerbation and remission 

There aie many etiologic factors in the production of chionic inflamma- 
tions m various paits of the body They are often more active with the 
degenerative processes that accompany advancing age Dupuytren’s con- 
tractuie bears an interesting resemblance to chionic arthritis although it 
has no direct i elation to diseases of joints One obseiver found arthritis 
present in only lo per cent of 40 cases of Dupuytren’s contracture The 
factors which cause the arthntides are numeious and they cannot always 
be determined in every case But we have come more and more to the 
realization that manj'^ conditions which produce a distuibance of the normal 
metabolism of the body may cause aithritis Of these conditions, focal 
infections occupy a prominent but not an exclusive place The author has 
seen cases of Dupuytren’s contracture which appeared to be diiectly con- 
nected in their oiigin and their clinical course with focal infections One 
patient had a chronic suppurating osteomyelitis of the jan During this 
period he developed an acute arthiitis of one ankle and about the same 
time a beginning Dupuytren’s contracture of the light hand In two pa- 
tients with subacute palmar fibrositis the condition impioved maikedly after 
the extraction of dead teeth which had apical abscesses m whom no exacerba- 
tion or extension of the disease occurred subsequently Meyerding reports 
the presence of focal infections in 141 of his 273 cases One author found 
Dupuytien’s contractuie occuired more frequently in diabetes than in any 
other constitutional disease Pemberton, as is well known, has found dis- 
oiders of sugar metabolism in many cases of aithritis 

Dupuytren’s contractuie has been noted frequently in cases of syringomyelia 
and has been ascribed to a trophoneurotic lesion One author believes that 

123 



A BRUCE GILL 


Annals Of Surcerj 
January 1038 


Dupuytien’s conliactuie is the result of a funicuhtis or a neurodocitis of 
the extrameningeal tract of the sympathetic nerve between the ganglion and 
the plexus The cause of this condition is a ceivical arthiitis He believes 
that it is a tiophoneuiotic lesion, but not necessaiily of rheumatic origin 
It is kno\\n that m arthritis there is maiked distuibance of the circulation 
about the joint which may be a piimai}’^ vasomotor disturbance and not 
merely a condition secondary to the arthritis 

Hale Powers, a neuiologist, has icpoited 29 cases which he discoveied 
with few exceptions in making neuiopsychiatnc examinations foi the U S 
Veteians’ Admmistiation Many of these were cases of neurosis Many 
had been gassed A numbei of them had pulmonary tubeiculosis He came 
to the conclusion that Dupuytren’s contractuie is due to an overexcitation 
or hyperactivity of the sympathetic ganglia This lesults m atrophic dis- 
tui bailees at the peiiphery Some of the cases of Dupuytien’s contracture 
were associated Mitli hypertiophic osteo-arthi opathy of the fingeis, scleroderma 
and multiple chondiomata He ascribes all of these peripheral manifesta- 
tions to the one cause and believes that in his cases the sympathetic hyper- 
activity could be ascribed to upper pulmonaiy disease He agrees with 
Janssen that Dupuytien’s contiacture is not inflammatoiy in its patholog)’- 
but IS a hyperplasia of the connective tissue of the palmar fascia This view 
of the pathology is contraiy to the usually accepted opinion of its being a 
chronic inflammatory process I ha^e seen cases vhich presented the ordi- 
nary signs of inflammation such as a faiily acute onset, swelling, tenderness 
and ledness of the ovei lying skin Put thei more, hyperplastic normal fascia 
should show no tendency to contraction such as is found m Dupuytien’s 
contracture 

We may possibly giant the opinion that visceral disease is an etiologic 
factor m a certain group of cases such as those obseived by Powers, but 
certainly w^e see many cases of Dupuytren’s contractuie m which there is 
no evidence of such visceral disease 

Fibrositis IS one of the elements in the pathology of chionic arthritis 
Arthiitis and Dupuytren’s contracture aie not infiequently found together 
111 the same individual, and it is possible that the coincidence w'ould be 
higher m the statistics had all patients wuth Dupuytren’s contracture been 
examined caiefully foi arthiitis, how^ever incipient and mild Does it not 
seem possible that the same causes wdiich cause fibiositis about a joint or in 
fascia of the back 01 m bursae may cause a fibiositis of the palmar fascia 
which IS a veiy active structure of the hand and is subject to the w^ear and 
tear of almost constant use and wdiich is subject to the degeneiative piocesses 
of old age? 

How the various etiologic factors produce the pathologic changes wdiich 
occui m chronic arthiitis w^e are not certain Theie is some reason to be- 
lieve that the changes occui in the structuies in and about the joint because 
of primary disturbance of the blood supply It may be possible that this 
pi unary disturbance occurs thiough the vasomotor system 

124 



A oliime 107 
Climber 1 


DUPUYTREN’S CONTRACTURE 


It IS interesting to quote fioiii my foimei papei on this subject an opinion 
of Kenneth Black^ that lie beheves that “It, Dupuytren’s contracture, will 
eventually be recognized to be due to a ceitam internal condition (possibly 
akin to gout oi iheumatism) among persons of advancing yeais ” 

The many obseivations made by various wiiteis on the etiology of 
Dupuytren’s contiacture during lecent yeais, only a few of which I ha\e 
touched upon, should lead us to take a broad point of view as to the origin 
of this condition It is piobably not an entity in itself It is moie probably 
due to one oi moie of many constitutional conditions Local traumatism, 
if It has any influence, plajj-s but a secondary pait as an inciting oi inducing 
factor 

Ti eafmenf — ^Excision of the palmai fascia offers the only means of com- 
plete cuie, but a numbei of consideiations should deteimine our judgment 
as to the necessity oi the time foi opeiation The author very decidedly 
disagrees with Meyei ding’s dictum that all cases should be operated upon 
and the eaihei the bettei The method of opeiation which offeis the best 
chance for a successful lesult must also be determined 

Dupuytien’s contiacture passes thiough a senes ot stages duimg its 
course of development The ulnar ponton of the fascia is fiist affected, most 
commonly that portion which extends to the fourth digit It may begin 
acutely as mentioned in the first pait of this paper, or may develop veiy 
slowly and escape paiticulai attention for a long period Theie is no con- 
tracture of the fingers and not the slightest inteifeience with the function 
of the hand duung this stage Some cases never progress beyond this 
point The patient should be tieated by eradication of focal infections and 
the correction of any constitutional disoidei which might have any possible 
bearing on the metabolic piocesses of the body In a general way he should 
be treated m much the same waj'’ as you would treat a case of incipient 
arthiitis by searching for the possible etiologic factors and by removung them 
Operation is contraindicated foi the following reasons (i) The function 
of the hand has not been impaiied (2) The contracture may never pro- 
gress It may even regress if you can remove the constitutional causes 
(3) If the case is a piogiessive one, the fibiosis may extend after operation 
to othei parts of the fascia unless you excise the entn e palmar fascia, includ- 
ing its extensions as far as the second phalanges of all the fingers Indeed, 
the pi ogress of the case may be accelerated by the tiaumatism of the opera- 
tion The authoi opeiated upon a case, in 1923, by excising the entne 
fascia from the little fingei over to and including the index finger To his 
dismay the patient lapidly developed a fibiosis of the entire hand with a 
resulting permanent partial ankylosis of all the joints of the fingers and 
thumb and of the wrist, and was accompanied by a maiked thickening of 
the palmans longus tendon abov'^e the wiist He had failed to mvestigate 
etiologic factors before operating The patient had had an abscessed tooth 
extracted several weeks befoie opeiation A later examination of the tonsils 

126 



A BRUCE GILL 


Annals of Surgery 
January 1038 


revealed that both of them retained in their crypts a veij' large quantity of 
cheesy, piiiulent secietion 

During the second stage of tins disease the fibrosis extends toward the 
radial side of the hand and toward the fingers There may be a beginning 
contracture of the fourth finger, then of the fifth, and even of the third 
Here also the condition may become stationaiy and may not impair the 
function of the hand Within the past year a dentist came to me from 
another city, having made all piepaiations to remain for operation He had 
a Dupuytren’s contiacture of six )'ears’ duration It involved the fascia 
of the fourth and fifth fingers but without contiacture of the fingers His 
tonsils and one devitalized tooth had been removed a year ago He had 
observed no progress of the condition for the past year It did not m the 
slightest degree mteifeic vith his work as a dentist I told him I should 
not operate upon him A look of amazement and of pleasure spread over 

his face He said, "I am going over to New York and have a good time 

I haven’t had a vacation in 20 years ” I ad\ ised him as to a careful search 
for focal infections, told him to return if the condition should progress and 
become annoying, and sent him on his way rejoicing 

In the third stage there is maikcd contractuie of one or more fingers 

and the function of the hand is seiiously impaired Opeiation should be 
recommended, but, again, only aflei careful search for the etiologic factors 
and after their removal if possible 

The author employs the operation he recommended 18 years ago, a com- 
plete excision of the fascia through an incision in the distal palmar crease 
and through the creases at the base of the fingei and at the proximal intei- 
phalangeal joint if it is necessaiy to excise the digital extensions of the 
palmar fascia At that time he emplojed and advised the tiansplantation 
of a small piece of fat, from the abdomen or thigh, beneath the skin of the 
palm In his operations during recent yeais he has omitted from the piocedure 
the transplantation of fat and is at present undecided as to its value But 
the use of an incision along the line of a natuial crease rather than counter 
to It requires no argument Various surgeons vho have leported cases 
operated upon by flap incision or by veitical, elliptical, oval or semioval in- 
cisions have had some cases of sloughing of skin -which required skin graft- 
ing later The author has never had this accident occur following the 
ti ansverse incisions along the creases of the hand and the fingers Dissection 
of the skin fiom the underlying fascia without making button holes is prob- 
ably moie difficult than through othei incisions, but it can ahvays be ac- 
complished by exeicismg due care and patience It is never necessarj’-, e\en 
in the severe cases, to excise a portion of the skin of the palm and replace 
it with a graft 

The operation is perfoimed most easily by using a tourniquet about the 
arm and undei geneial anesthesia The incisions aie closed with interrupted 
silk sutuies The hand, with the fingers extended, is diesscd on a well 
padded palmar splint until the wounds are healed Baking and massage 

126 



Volume 107 
J^umber 1 


DUPUYTREN’S CONTRACTURE 


of the hand and fingeis aie begun after two weeks if theie is aii}- indication 
for their use 


REFERENCES 

^ Gill, A Bruce Dupuytren’s Contracture, with a Description of a Method of Operation 

Annals of Surgery, 70, 221, August, 1919 
"Black, Kenneth Brit Med Jour, 50, 326, 1915 

Discussion — Dr John Homans (Boston) noticed that Doctoi Gill 
had said nothing about this disease occurring in women However, they 
are subject to it, though in very much smaller numbers than men, just as 
they do not suftei as much as men fiom ciiculatory diseases in the ex- 
tiemities As to the treatment of this condition, Doctor Gill had not con- 
sidered roentgen therap}'’ He knew of one patient who has an incipient 
disease of this soit, who finds that if he has a moderate exposme the condi- 
tion improves He was especially interested m the effect of early opeiation 
and thought Doctor Gill’s aigument verj' stiong In the face of a disease 
wdiose etiology is so poorly understood his theory was certainly very sound 
He had had an adventure with one case — it may or may not have been 
Dupuytien’s contracture — but the patient had a contracture of the palmar 
fascia leading to the little finger He did not recall that it showed any in- 
flammation The fascia was dissected out without any particular difficulty 
and the only thing noticed was that it w'as unusually adherent to the under- 
lying tissues After the operation the hand was placed m a splint, the 
finger at first remained straight, but as soon as the splint was removed 
it turned right up The newly formed scar tissue seemed actually thicker 
than the original and he felt that the operation had done more harm than 
good The patient sued him At the time, however, thinking that he had 
done the i ight thing, he defended himself very vigorously 

As to the use of fat He used a couple of fat transplants and found it 
difficult to secure healing without more induiation and thickening and felt 
It to be undesirable The cases weie no worse off but they w^ere ceitamly 
no better 

Dr a Bruce Gill in closing stated that he had not discussed any methods 
of treatment except excision of the palmai fascia Multiple incision of the 
fascia (fasciotomy) with subsequent splinting of the hand as devised by 
Adams and employed generally for years w'as ineffective in securing a com- 
plete or a permanent cure and fiequently lesulted in marked fibrous anky- 
losis of numerous joints of the hand and fingers Doubtless many of these 
patients had a chionic arthritis of these joints Roentgen therapy, injections 
of fibrolysin and othei conservative methods of tieatment likewise cannot 
be relied upon to improve or remove the defoimity Excision of the palmar 
fascia w^as the only method of cuie 


127 



GLOMUS TUMOR 

GLOMANGIOM V 

Anatolg Kolodni, MD, PhD 

Niw Youk, N \ 

During the past decade theie have appeared in the liteiature case re- 
ports of patients wlio liad snfteied for yeais from a painful nodule some- 
where about the body, most fiecpiently about the uppei cxtremit}', who had 
been cined by its lemoval Ihe histogenesis of these tumors was easily 
established and, because its oiigm was traced to the subcutaneous glomus, it 
was named glomus tumoi , oi better, glomangioma, as suggested by Bailey ^ 

While the histologic structure of this giowth is now well known, its 
clinical behavioi and course ai e not fully established A characteristic clinical 
picture and the typical pathologic findings observed lecently m a case of 
glomangioma of a fingei justif)’’ its report heic Sweating of the finger 
appearing upon irritation of the nodule adds to oui know ledge of the physiolog} 
of sweating 

Case Report — A female, white, age 22, commenced feeling a pain o\er the palmar 
aspect of the distal phalativ of the right middle finger At first the pain was mild and 
she felt It onl} on hitting the piano ke\ while plajing Later on the pain became much 
more se\crc and appeared on the slightest provocation Merc touch of the finger tip 
pressure on the nail of the finger, or a sudden change of the temperature ushered in an 
episode of pain These seizures consisted of three phases a prehminarv slight pain fol- 
lowed at once by the appearance of beads of perspiration over the palmar aspect of the 
terminal phalanx of the finger, followed by a sharp, burning, stabbing pain referred to 
the finger tip, which radiated rapidly through the ulnar half of the hand, forearm and 
arm to the precordium This produced a sensation of “pulling” in the finger that was 
followed by a tired feeling in the right hand The pain would then suddenlv disappear 
and after a few seconds be succeeded bj a new attack, of much lesser mtensitv Thus, the 
episodes would gradually wear avva> Icavang the patient exhausted If the provoking 
stimulus was very severe the attacks that followed were correspondmglv more seveie, 
greater 111 number and more rapid in sequence The terminal phalanx of the middle 
finger remained normal 111 all respects with the exception of having a much softer skin, 
as a result of habitual guarding of the finger against contact with atij object The 
patient’s condition was not recognized for vears and she was frequently considered a 
psj choneurotic 

Exaiitmatwii — First examined b\ the author ten jears after the onset of the pain 
On inspection, there was nothing abnormal about the right hand However slight pies- 
sure with the tip of a lead pencil over one point on the palmar side of the finger tip 
provoked an attack, followed by the many subsequent subjectiv^e sensations as previously 
outlined Objectivelj one saw the appearance of fine beads of perspiration over the 
palmar aspect of the terminal phalanx These appeared five to six seconds after the 
pressure of the pencil This pressure point was about i cm from the finger end and o 25 
cm laterally from the midline of the palmar side , pressure on points even only 0 25 cm 
away provoked no attack 

Opoation — Under block anesthesia with novocain, a flap of the palmar skin and 

Submitted for publication April 21, 1937 

128 



■\ olume 107 
Jsumljcr 1 


GLOMUS TUMOR 


subcutaneous tissue of the terminal phalanx of the finger was turned up A dark bluish, 
spongy nodule was discovered at the pressure point described above This nodule meas- 
ured 02x03 cm but rapidly increased to twice this sire when it was touched with a 
forceps Two thin thread-like blood vessels were attached to the nodule, one at each 
end of it The grow'th was just beneath the subcutaneous tissue, between it and the 
underlying bone It was there unattached to the neighboring structuies and it shelled out 
easily from its niche-hke resting place The skin flap w'as sutured back m place The 
w'ound healed readily and theie was no disturbance of sensation or disfigurement of tlie 
finger tip One month after the operation the patient was able to play the piano freel> 
for the first time m years 

Pathologic Exaiiniiatioii — The nodule presented a ball of contorted blood vessels, re- 
sembling m their structure the vessels of the cutaneous glomus (Fig i) Some vessels 
were surrounded by a layer 01 tw'o of smooth muscle fibeis, wuth a fine collagenous 
membrane intervening between them and the endothelial lining of the \essels (Fig 2) 
Hugging the muscle fibers w'ere groups of large cells with a scant! cjtoplasm and 
densely staining nuclei About them w'ere seen abundant endothelial cells w'lth pale 
large vesicular nuclei and deeply staining nucleoli These polygonal cells are the char- 
acteristic glomus cells Other vessels lack the smooth muscle fibers but aie densely 
surrounded by glomus cells (Fig 3) The glomus cells are m intimate contact w’lth 
numerous nonmyelinated nerve fibiils which are easilj traced to the larger peiiglomic 
fibers The entire mass of contorted vessels is enveloped by dense collagen fibeis, wdnch, 
broadly taken, might be considered a capsule of the nodule 

One of the two blood vessels attached to the poles of the nodule presented a normal 
histologic structuie of an artery, while the other appeared as a vein Thus, the nodule 
strikingly resembled the anastomotic unit of a peripheral aiteriovenous anastomosis We 
have here the afferent artery, the contorted Sucquet-Hoyer canal, with the neuroreticular 
and vascular structures about it, and the collecting vein 

Comment — While this condition has been known foi centuries, the le- 
sion has attracted a great deal of attention only of late Because of its larity, 
most recent repoits in the hteiature ate based upon groups of cases assembled 
fiom clinical recoids that weie piepaied long befoie the true nature of the 
lesion was known Thus, while the excellent histologic reports aie based 
upon recent studies of the available tissue material, the quoted old clinical 
reports aie not complete and aie at times maccuiate and misleading 

A generally accepted eiror is the desciiption of the lesion as a “purplish- 
blue discoloiation of the skin, mounted on top of a small cutaneous eleva- 
tion “ The fact that the condition fi equently remains unrecognized for 
yeais proves the fallacy of this desciiption In the present case there was 
neithei a discoloiation of the skin nor any palpable or visible elevation or 
dimpling of it This erior is based upon a faulty j^resumption that the 
nodule is always situated “subepidei mally,” as stated by Stout ^ Originating 
fiom the subcutaneous glomus, situated in the leticular aiea of the skin, 
this oveigiowth may expand toward the epideimis, and become visible by its 
discoloiation of the ovei lying skin, or it may extend beneath the subcutaneous 
tissue, as m the present case, without any discoloration of the skin 

The present knowledge of the nature of the lesion suggests the proper 
suigical appioach to it, especially when it is situated about the finger tip — 
its most frequent site The approach must be one that will expose the 
nodule and at the same time will not disfigure the finger or interfere with 

129 



ANATOLE KOLODNY 




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130 



Volume 107 
"Number 1 


GLOMUS TUMOR 


its sensation Such an approach is the one used in this case It ob\iatcs 
failure to locate the lesion and the necessity of repeated operations, as ob- 
served in Cases i and 4 of the gioup leported by Lewis and Geschicktei 
Since a glomangioma is merely an 01 ganoid oveigiowth of the noiinal 
cutaneous glomus, retaining its physiologic functions, the appeal ance of 
beads of sweat on the terminal phalanx of the finger during a paioxysm of 
pain IS of physiologic impoitance Our present conception of the plnsiology 
of sweating is crowded with numerous hypotheses Dieden"’ and otheis 
believe m a central nervous system contiol of sweating, with special stimu- 
lating and inhibitory nerve fibers supplying the sweat glands In suppoit 
of this view the observation of Rowntree and Adson is quoted that aftei 
sympathectomy and ganglionectomy, sweating is abolished Adamkewich® 
goes even further In addition to a spinal cord sweat center he accepts a 
reflex path by way of the spinal cord to the brain Thus he explains the 
known obseivation of bilateial sweating of the hands following unilateial 
iriitation of the skin In geneial, it is considered that sweating cannot occui 
without the necessaiy neive stimulus, and that the sweat glands are not 
subject to diiect stimulation 

One could with difficulty account foi the sweating in the piesent case 
as a lesult of a sensory leflex (pain — spinal coid — sweat glands), since 
sweating was limited to the teiminal phalanx, while the provoked pain ex- 
tended all along the extiemity The maiked dilatation of the component 
blood vessels of the glomangioma upon nutation, as obseived duiing the 
operation, led to a pathologic exaggeration of the physiologic function of 
the cutaneous glomus This function is the 1 egulation of the general tempera- 
tuie of the body, when fully opened the cutaneous glomus aids the dispersal 
of heat by allowing an inci eased flow' of blood to pass thiough it But m a 
local pathologic exaggeiation of this function, as in a glomangioma, this 
dilatation induces local sweating as an additional means to achle^ e a dispersal 
of heat It seems, therefoie, that the general tendenc)' to place the sneat 
glands undei the sole contiol of the cential neivous system is too narrow, 
and some autonomy must be gi anted the sw'eat glands in their function 

REFERENCES 

^Bailey, O T Cutaneous Glomus and Its Tumors Am J Path, 11, 915, November, 
1935 

"Jirka, E J , and Scuderi, C S Glomus Tumor JAMA, 107, 201, July 18, 1936 
■'Stout, A P Tumors of the Neuromj'o-Artenal Glomus Am J Cancer, 24, 255, 
June, 1935 

‘ Lewis, Dean, and Geschickter, C F Glomus Tumor JAMA, 105, 775, September 5, 

1935 

“Dieden Klmische und experimentelle Studien ubcr die Inner\ation dcr Schweissdruscn 
Deutsch Arch klin Med, 117, 180, 1915 
°Adamke\\ich Die Sekrction des Schweisses Berlin, Hirschwald, 1878 


131 



INTERNAL FIXATION FOR RECENT FRACTURES OF THE 
NECK OF THE FEIMUR ^ 


jMi.lvik S IIlxdi.rsox, jM D 

]lo(iiF STJ It, Minn 

arcTios ON onmoii me stnomr, tiij sr\ro cnsic 

A TRACTUun of the hip is often the death blow of the elderly patient 
Fractures nnohing the tiochanter unite rcadil}, although deformity and 
shortening arc common, ^\hcrcas fiacturcs of the femoral neck arc notorious 
for then failuie to unite It is the latter group that I shall discuss m this 
paper 

Ihe aveiage moitalit\ rate among patients admitted to hospitals for 
treatment of fiactures of the neck ot the temiii is about 15 per cent The 
rate urns higher 111 some of the hospitals where the derelicts of the laige 
cities aic cared for, and most probahh in the sparseh settled sections of 
oui country w'heie hospital facilities aie not aeailahlc 

If patients who ha\c fiactuies of the neck of the femur can be assured 
of a hcttei chance of a good result h) operatnc tieatmcnt, with no greater 
mortaht) iisk the} should he operated upon In our e\peiicnce at The 
Mayo Clinic the operatnc tieatmcnt carries no higher mortaht} rate than 
treatment by nonopeiativc, tonsenatnt measures proMded the opeiation 
IS performed ten days 01 moie aftci the injur} Most of the deaths incident 
to fiacture of the neck of the femiii occur in the fiist week or ten days 
If the patient suivncs that dangerous period, the tieatmcnt, either con- 
servative 01 opeiatnc, can he undertaken with comparatnc safet} Imme- 
diately follow'ing the accident a 1 homas extension splint 01 simple Buck’s 
extension traction may he used to steady the leg and case the pain Some 
patients, manifestly, can stand no ical tieatmcnt and the life of the weak, 
debilitated, elderly individual simply ebbs aw ay 

There is no need foi haste in 1 educing the fiactuie for one can safely 
observe the patient foi from ten days to tlnce weeks before reduction of 
the fiactuie is undertaken, proMded ti action is maintained, w'lth no ap- 
preciable disadvantage acciuing Pam can be conti oiled by the traction 
and by administration of opiates If the Whitman method of tieatmcnt 
IS used, the patient faces tlnce months of fixation 111 a plaster spica cast 
Operative treatment, wuth internal fixation by metal, has the A'cry decided ad- 
vantage that the plaster spica eithei can be dispensed wuth entiiely or Avoin 
for only a few weeks and then movement instituted 

In The Mayo Clinic Ave haA^e obtained m the past, by the Whitman method, 
approximately 6 ^ pei cent bony unions in those cases in Avhich patients Avere 

* Read before the meeting of the Louisiana State Medical Society, Monroe, Louisiana, 
Apiil 26-29, 1937 Submitted for publication June 2, 1937 

132 



A olume 107 
Is umber 1 


FRACTURE OF NECK OF FEMUR 


less than 6o yeais of age and about 54 pei cent bon}'^ unions in those cases 
in which patients iveie more than 60 yeais of age Thiee months 01 moie 
of confinement in a plastei spica, and the sequelae of stiff knees and hips, is 
a haidship and 01 deal for patients and all otheis concerned The method 
of fixation by use of a nail, lepoited by Smith-Petersen'' m 1931, not only 
gnes a higher percentage of bony unions but convalescence is easici and 
shoitei Since 1933, we have used eithei the Smith-Petersen nail 01 the 
lag-screw in the tieatment of all patients ivith fiesh fiactuie of the neck 
of the femui whom we consideied presented leasonably good suigical iisks 

Operative tieatment of fiacture of the neck of the femur is not new 
It has been uiged by vaiious suigeons m the past but Smith-Petei sen was 
the fiist caiefully to lepoit cases He advocated use of a triple flanged nail 
and theie weie included in his lepoit enough recoids of cases, follow'ed 
thiough to completion, to give his lepoit leal w'oith Followung this, va- 
rious devices for fixation have been advocated, such as cannulated Smith- 
Peteisen nails, wne, pins, screw^s, sciew'-bolts, lag-screw's and so on IMoorc 
has lecently repoited a numbei of cases in which he successfully ajiphed 
his method of placing three stiff wuies at diffeient angles in such a inannei 
that the head was held fiiinly to the neck of the bone His method has 
the advantage that theie is veiy little exposure of tissue and local anesthesia 
IS used 

Intel nal fixation is not a simple proceduie, although it would seem that 
it should be, after one has accuiately 1 educed a fiacture of the neck of 
the femui, to fix it with a nail, pm 01 sciew Certain anatomic peciiliai ities 
of the neck of the femur explain why this is not easy The i^eck of the 
femur is not moie than one inch (2 5 cm ) in diametei , it is placed at an 
angle with the shaft of appi oximately 130° and m addition it has an ante- 
torsion angle of about 15° These facts, along wuth a situation wdieiein the 
fiactuie IS deeply covered wnth fat and muscle, and the proximal fiagment 
cannot be grasped, rendeis the task of nailing a fiactuie of the neck of the 
femur anything but simple 

Methods Employed — It goes without saying that the fiist essential of 
any pioceduie is propei reduction of the fiactuie (Fig lA) To be cer- 
tain that this IS accomplished, anteropostei lor roentgenogi aphic views (Fig 
iB) aie not sufficient, but lateral roentgenogi ams must be made also Lateral 
views (Figs 2a and b) are not ahvays easily obtained but the operation 
should not be attempted unless the suigeon has this mfoimation at his 
command Taking roentgenogi ams of fractured hips is not a daily routine 
in the aveiage hospital, theiefoie, technicians should practice on normal 
individuals and peifect themselves in the technic of taking lateral views, so 
that, when the surgeon is depending so absolutely on the roentgenograms 
for the success of his opeiation, they wull not be found inexperiencc^l and 
unprepared 

One method may be called the “open method,” in which the fracture 
is reduced after the hip joint has been laid wide-open Reduction is ac- 

133 



MHI.VIN S Iiniv.’DERSON 


\nnal’iof Surpoo 
Januarj in'*s 


complishecl under msu.i1 contiol, and the nail, or whalevei fixation is used, 
may also be placed more oi less under visual contiol Even so, the accuracy 
of the reduction and the placing of the nail, pins, oi sciew always should be 



I ic I — (A) Antcroposltnor \ic\\ litforc reduction (11) Antcropnacrior \icw ifter rciUiclion Note 
fivonblt Ml^oid po'-ition of lie id on neck 


\erified by roentgenograpluc examination bcfoic the patient leaves the operat- 
ing table Such an operation is a major procedure, entailing a laige incision 
and considerable dissection, with the attendant iisk of shock and infection 



Fig 2 — (n) Latcrnl mcw bcfoie reduction (b) Lntcrnl mcu nfter reduction 


Howevei, this method has been piactically abandoned and has been le- 
placed by the second method, often enoneously called the “blind” method 
of insertion of a nail oi sciew With propei care as to details such as roent- 

134 


Volume 107 
^ umber 1 


FRACTURE OF NECK OF FEiMUR 


genograms at the opeiatmg table, calculations as to the angle and depth of in- 
sertion of the nail oi pins or screw, it is anything but blind in the sense of 
being uncontrolled 

Guidmg IVue foi Cannulate Nail oi Lag-sciczv — Many instruments 
have been devised to aid m ascertaining the proper angle for inseition of 
the nail oi sciew I have used a ntimbei of these instiumcnts hut none is 
sufficiently satisfactory that I am willing to drive the nail m oi mseit the 
screw without additional contiol It is extiemely important tliat mseition 
of the nail or sciew be accuiate toi if it has to be withdrawn and inserted 
again, much damage may be done to the neck and head of the femui , as 
has been mentioned, the neck is leally quite nanow The placing of a 
guiding wiie undei fluoioscopic control oi by means of a senes of loentgeno- 
grams, to insuie accuiacy, solves the problem 

The idea of a cannulated nail, to be mseited ovei a thin guidmg wiie 
was developed independently in three places of which I know Johansson,"* 
of Gothenbuig, Sweden, was the fiist to use such a nail King,"’ of Mel- 
bourne, Australia, did the same thing as did T at The Mayo Clinic and it 
has doubtless been done elsewhere also Definite information as to the 
position of the guiding wiie enables the surgeon to be certain that the line 
and angle at which he mseits the cannulated nail oi screw is accuiate, for 
neithei can go wrong on the guiding wiie The length of nail to be used, 
and how fai it is to be inseited, can be detei mined by measuring the portion 
of wiie that pi oti tides from the tiochanter and subti acting this from the 
known total length of the wire 

Selection oj Cases — It must be emphasued that if immediate opeiation 
for fractuie of the hip is perfoimed loutinely on a fiacture service, an un- 
necessarily high mortality will result A number of these patients aie definitely 
senile, have advanced ai tei losclerosis and, theiefoie, piesent pool surgical 
1 isks On admittance of patients to the hospital a thoi ough medical examina- 
tion should be insisted upon They should be made as comfoi table as 
possible, to this end, as has been stated, extension is used eithei vith or 
without a Thomas splint If, aftei ten days, the patients aie in good condi- 
tion, the relatives may be assuied that treatment to secuie bony union 
probably will not entail a moitality iisk of moie than 3 oi 4 pei cent, 
whereas, if such treatment is loutinely instituted in cases of fiactuie of the 
hip almost as soon as the diagnosis is made, the moitality iisk vill be 
nearer 20 per cent This delay in staiting treatment is not necessary if 
patients aie young and lobust It may be that time and expeiience vill 
piove that immediate mteinal fixation, accomplished skillfully and quickly, 
undei spinal 01 local anesthesia even if the patient is an elderh , weak in- 
dividual, will save some of them , thus fai , howevei , there is no e\ idence to 
that effect On the contiary, in seveial localities, wheie e\ery patient \\as 
operated upon at once, regardless of age and condition, the mortalit} uas 
truly appalling and many deaths that would have occuired anjwa) ^\ere 
accoidingly charged to suigical opeiation, much to its discredit The dela\ 

135 



MELVIN S HENDERSON 


Annals of Surgery 
January 10*^8 


makes no difference in the end-result insofar as obtaining union is concerned , 
therefoie, tlierc is no need for huiry 

The t3'pe of fi actui e has a definite heai ing on wliat type of internal 
fixation should he used Geneiall}' speaking, trochanteric fractures and 
many of the basilar neck fiactures ait not suited to the use of either the 
Smith-Peteisen nail oi the lag-sciew The amount of bone left in the 
distal fragment is too small to gne adequate fixation to that portion of the 
nail which lies within it If the de\iccs just icfcired to aie used under 
such conditions, full abduction must he maintained In in} expeiicnce, the 
technic of Moore, in Avhich three oi four small wiics are used, is preferable in 
these types of cases Quite often, also, tiochantciic fractures aie com- 
minuted 

Reduction 0/ the P> actui e — The fiaetuic should he accurately i educed 



Tig 3 — (A) Locitingr uirc uith guiding wire inserted Anteroposterior mcw (D) Locitmg wire 
with guiding wire inserted ndNnntigcoush into middle of held 


Sometimes this is accomplished mcicly by ti action during the peiiod of 
waiting If so, manipulation need not be earned out and some surgeons 
insert the device for internal fixation with the patient m bed, most suigeons, 
how^ever, prefei the safety of the opciatmg loom If the fi actui e is not 
1 educed under ti action, manipulative i eduction, such as has been described 
by Leadbettei,® should be cairied out and the i eduction pioved by anteio- 
posterior and lateial i oentgenograms 

Technic of Opeiotion — A convenient cutaneous incision is a diagonal one, 
1 tinning fiom the vicinity of, and slightly posteiior to, the anterioi siipenoi 
iliac spine, dowmw'aid and backward, just below the trochantei This 
makes possible satisfactory exposuie of the trochanter and of a poition 
of the shaft just below it Aftei caieftil calculation, based on study of antero- 
posteiior and lateial i oentgenograms, a stiff pointed wore is inseitcd undei 
hand control and lateral and anteropostei lor i oentgenograms are taken 

136 


Volume 107 
NumOcr 1 


FRACTURE OF NECK OF FEMUR 


Then, if direction and position are correct, the guiding wire is directed 
through the lower portion of the trochanter into the neck, into the head, 
and inserted to a depth of appi oximately lo cm Roentgenogi ams are taken 
again, in antei oposterior (Fig 3A) and lateial diiections (Fig 3B), to 
determine whether the wire is deep enough m the head and near enough 
to the middle of the neck and head to warrant inserting tlie nail 01 sciew 
If conditions are satisfactory it is an advantage, after the length of nail that 
IS necessary has been calculated in the mannei described, to nisei t the 
wire a shoit distance into the acetabulum, thus helping to steady the head 
as the nail or screw is inserted Then the cannulated Smith-Peteisen nail 
or cannulated lag-screw is threaded over the wire and inseited to the proper 
depth It is well to veiify this final step by another anteropostei 101 roentgeno- 
gram (Fig 4) The original Smith- __ 





^ ■ - is 





Petersen nail has thi ee nai row flanges 
that are sharp and can be diiveu in 
fairly easily When the nail is made 
cannulate, the centei, wheie the 
flanges meet and through which the 
guiding wire glides, is somewhat 
thicker than when this nail is not can- 
nulate This means that moie bone 
must be displaced and pushed aside 
as the nail is diiven in, lequirmg moie 
force in the hammeiing By slipping 
a small cannulated leamei ovei the 
wire a small channel can be prepared 
in the bone and inseition of the nail 01 
screw can be rendered easiei 

A point in technic which must be 
emphasized is the necessity of having 
the nail deep enough in the proximal fiagment (head) so that it gets a good 
hold, and valgus position of this fragment should be obtained if possible 
If the lag-sciew is used, caie must be taken to see that all of the large 
threads on the end of the lag-screw aie well in the head If one thiead 
IS left in the neck and two thieads m the head manifestly one of the chief 
advantages of a lag-sciew will be lost namely, its ability to appioximate the 
head and neck 

After the foregoing pioceduies have been completed, the wound is 
closed and a single plastei spica applied This spica is worn for about two 
weeks 

Lag-scieiu — A lag-sciew is similar to the screws -bolt described by Henry 
and has long been used by mechanics to appioximate surfaces wheie it is 
impossible to use a bolt 

The lag-screwq"’ modeled to oui requirements b} iMr George Little, 

137 


Tic 4 — ^Lag screw of duralumin inserted on 
guide vire bj aid of locking bar and placing 
sleeve 


MELVIN S HENDERSON 


Annnlsof Siirtrcry 
Jnnuarj 1038 


chief of the instrument shop at the Chine, can best lie described by referring 
to the di awing which shows the assemblage m cross-section and end view 
(Fig 5) All parts of the assemblage are cannulated by a No 47 drill 
The lag-sciew has three laige threads, notched to pi event turning of the 
sciew when the placing sleeve is unsciewed A Kirschner wire is inserted 
as a guide (Fig 6a) Previous to mseition of the lag-screw a cannulated 
learner is lun down over the nire so that the screw w’lll not have too much 
bone through wdneh to cut (Fig 6b) The lag-sciew is inserted over the 
guiding wme by aid of the placing sleeve locked into position by means 
of a locking bar (Fig 6c) All the large tin cads must be in the head of 
the femur and roentgenogiams aie taken to be certain that the lag-screw' is 
placed at sufficient depth Next, the locking bar is loosened, removed and 



Tig s — L ag screw assemblage witli nicasurcniciils The ^sashcr to be used beneath the 
sleeve nut should be of the same material as the lag screw (a and a ) Lag screw (b) Tele 
scoping sleeve nut (c) Round washer (d) Larger washer that can be molded 


the placing sleeve is unscrew^ed and withdrawn This leaves the lag-sciew' 
entirely buiied (Fig 6d) but the guiding wne permits slipping the tele- 
scoping sleeve nut (Fig 6d), on which is a w'ashei, clowm to the distal end 
of the lag-screw which is threaded to leceive it The sleeve nut is tightened 
by aid of a socket wrench until the washei impinges on the tiochanter and 
IS molded aiound it and the sleeve nut furthei tightened This draw's the 
fragments together tightly (Fig 6e) The guiding wme is then lemoved, 
the wound closed, and a plastei spica applied 

Monel metal is thought to be a satisfactory mateiial fiom which to con- 
struct the lag-sciew', telescoping sleeve nut and w'ashei, but the last wmrd 
has not been said on this question All must be made of the same metal or 
an electrolytic, initative reaction will be set up and Cause a collection of 

138 


A olunie 107 
Isiimber 1 


FRACTURE OF NECK OF FEMUR 


fluid that on culture is found to be stenle Theie may be no evidence of 
fluid until SIX 01 even ten weeks aftei insertion of the metal Once pres- 
ent, It peisists until the metal is lemoved If the effusion is excessive, 
lepeated aspiiations may be necessary I do not know whethei the slight 
movement that occuis between the female poition, that is, the telescoping 
sleeve nut, and the male poition, that is, the distal, thieaded end of the lag- 
screw, IS sufficient to pioduce the electiolytic reaction Dentists have long 
been bothered bj- electiolytic reactions aftei the filling and capping of teeth 
In those cases in our sei les in which this sterile fluid did collect, no untowai d 
effect was noted insofar as the end-iesult was conceined Lag-sciews made 
of duialumin have caused the least leaction and we intend to use them in 
the futuie They should not be left in place (Fig 7) longei than six 
months Those removed (Fig 7) have shown distinct evidence of erosion 
due to tissue leaction and it is conceivable that this may easily become so ex- 
tensive that the lag-sciew would be weakened, the threads destioyed and 
removal made difficult 

We have not enough cases in which the lag-sciew has been used to 
justify our offering any comparison as to the lelative merits of it and of 



Tio 6 — (a) Kiischner guide wire in situ (b) Reamer introduced over the wire to 
make a channel and prevent binding of the screw on insertion (c) Lag screw being 
inserted by aid of placing sleeve and locking bar (d) Lag screw in position, channel m 
trochanter enlarged to facilitate insertion ot sleeve nut (e) Sleeve nut tightened The 
large threads are in the head of the femur onl> The Kirschner guide uire has been 
remoi ed 


the Smith-Peteisen nail They are both foims of metal, internal fixation 
The lag-screw has the advantage of appioximatmg the femoial head and 
neck and can easily be made to fit the individual patient by meiely screwing 
down the telescoping sleeve nut Its use entails a more complicated pi ocedui e 
than use of the nail and time alone will show whether its apparent and 
theoretic advantages aie borne out in actual piactice 

Postopei ahve Caie — Motion of the hip and knee may be started safely 
after 14 days This is best done by aid of a system ot overhead suspension, 
with sling, ropes and pulleys The patient, by pulling on the rope, flexes the 
knee, and so the hip, hut he must not be permitted to ovei-do Flexion 
of the hip by this passive method to an angle of 45° to 60° is ample It must 
be remembered that there is nothing in the internal fixation that uill cause 
bony union to develop more rapidly It is estimated that even under the best of 
conditions bony union never occurs m less than 90 days (Fig 8A) There- 
fore, weight-bearing m less than that period should not be permitted and a 

139 



MELVIN S HENDERSON 


\nnalsof ‘'urccry 
Jnnuar> 1038 


safe uile is to insist that full weight-beaiing be dela}ed until six months 
have elapsed (Fig 8A) It was at first hoped that the si/e and strength 
of the Smith-Petcrsen nail would icndei possible much earlier ^\ eight-bear- 
ing but Smith-Peteisen himself now warns against this Internal fixation 
of these fractures entircl}’’ changes the pictuic of convalescence Patients 
are out of bed and soon aie getting about on crutches and then uholc view 
of life IS much moie cheeiful than otheiwise 



DiscttsKiott of Case; in U' Inch Opcialwn Ha'; Been Pei fanned — This re- 
poit IS based on 14 cases, in ir of wdiich the jiaticnts were women and 
111 thiee, men In all, more than one ycai has elajised since the operation 
and the condition of the patient is known The ages of the patients were 
as follow s One w'as betw'een 20 and 30 years of age , one, betw een 40 and 

50 tw'o, between 50 and 60, fi\e, be- 
tween 60 and 70, foui, between 70 
and 80, and one, moie than 80 

Five patients were opeiated upon 
more than thice yeais ago, thiee, 
moie than two jears ago, three, more 
than 18 months ago and thiee more 
than one ^ear ago Thcie were no 
deaths attributable to the operation al- 
though tw’o jiaticnts ha\e died since 
coinalescencc One of these w'as a 
woman, more than 80 jeais of age, 
who Ined for 18 months aftei inser- 
tion of a Smith-Petcrscn nail and 
walked comfoi table although feebly, 
she died of the changes of senility 

Tic 7— Ligscrc« issembhge ten \^ceks nficr The liail W aS IlOt reillOC ecl The Otliei 
insertion - , . 

ot these tw'o patients w'as 70 years of 
age and died of a heart attack 16 months aftci opeiation She hkewnse had 
solid bony union and the nail w'as neeei lemoved Both of the two patients 
wdio died w^ere of the group of five w’ho w'ere opeiated upon more than three 
yeais ago The other three patients in this group obtained bony union but 
one, now age 70, has definite aithiitis, wnth some shrinking and 11 1 egularit}'^ 
in the size and shape of the femoial head The remaining two, both now' over 
70 yeais of age, have 1101 mal function 

Of the three patients wdio were opeiated upon more than tw'o years 
ago, all have excellent results, with noimal function One was a w^oman, 
age 20, mjuied while horseback iiding, one w'as age 56 and the othei, age 72 
Of the three cases in which moie than 18 months have elapsed since 
the operation, one has not done well She was 70 yeais old when she was 
operated upon, and 15 years before she had undergone resection of the 

140 



Volume lOT 
IvumUer 1 


FRACTURE OF NECK OF FEMUR 


stomach foi caicinoma We suspected that the fractiue of the hip might 
be attiibiitable to metastasis but it did not appear to be so on careful study, 
therefoie, a Smith-Peteisen nail was inserted A late, slightly purulent 
diainage of low giade followed, the nail was lemoved thiee months aftei 
inseition The diainage has ceased and now, 21 months aftei waid, I feel 
ceitam that the fiactuie is united There is poor function, howevei , the 
patient is old, frail and weak, and I fear hidden, late metastases, although 
this cannot be proved Of these thiee patients, the othei two, one 61 and 
the other 67 years of age, have, to all intents and purposes, noimal function 
and both have boii)'^ union 

Of the three patients wdio weie opeiated upon moie than one year ago. 
one, a w'oman, age 76, was tieated by means of a cannulate, large-thi eaded, 



Tig 8 — (A) Lag screw remo\ed Anteroposterior view shows bony union eight months after operation 
(B) Same patient as is represented in Fig 7 Lateral view eight months after operation 


wood screw It did not hold properly, seious diainage of low grade de- 
veloped six weeks aftei operation and the screw was lemoved after six 
months I would put hei case down as a failure although I believe that bony 
union IS present In the two olhei cases the patients w^eie age 77 and 54, 
1 espectively , both have solid bony union with excellent function 

Summary — Of 14 patients subjected to operation inoie than one year 
ago, 12, 01 86 pel cent, obtained really excellent results, that is, they have 
bony union with excellent function One has union in malposition and she 
IS m poor health, so the result cannot be called good No serious infection 
occurred, drainage followed late in twm cases There weie no deaths from 
the operation and in all cases convalescence was much moie satisfactory than 
has been our experience in treating fiactures of the neck of the femur by 
the conservative method 


141 


MELVIN S HENDERSON 


\nnal<;of Surcery 
January 1038 


CONCLUSIONS 

Internal fixation is a definite step forward in the handling of fractures 
of the neck of the femin foi it latses appreciably the percentage of unions 
The next step is to estcdjhsh its value in the early lestoration of function 
and whether atiophy of the head follows in its wake more often than occurs 
following conseivative tieatinent 

REEERENCES 

'Henderson, M S Fractures of the Neck of the Femur, Recent and Old, a Report of 
631 Cases South Med Jour, 27, 1032-1039, December, 1934 
° Henderson, M S Discussion Proc Staff Meet M'i\o Clinic, ii, 615-618, September 

23, 1936 

“Henrj, M O Intrncapsular Fractures of Hip, New Deuce for Lateral Osteo-SMithcsis 
Jour Bone and Joint Surg , 16, 168-172, Jnninr\, 1934 
‘Johansson, Saen On the Operatne Treatment of Medial Fractures of the Neck of the 
Femur Acta Orthopaed Scandiii , 3, 362-392, 1932 
“King, Thomas Recent Intracapsular Fractures of the Neck of the Femur a Critical 
Consideration of Then Treatment and a Description of a New Teclinique Med 
Jour Australia, i, 5-15, Januarj 6, 1934 

“ Leadbetter, G W A Treatment for Fracture of the Neck of the Femur Jour Bone 
and Joint Surg, 31, 931-940, October, 1933 

"Macej, H B Report of the Fracture Seraicc for 1935 Proc Staff Meet Maao Clinic, 
II, 613-614, September 23 1936 

“Moore, A T Fracture of the Hip Joint Treatment In E\tra-articular Fixation with 
Adjustable Nails Surg, G\ncc & Obstet , 64, 420-436, Fcbriiars 13, 1937 
“ Smith-Petersen, M N, Ca\e, E F, and Vangorder, G W Intracapsular Fractures of 
the Neck of the Femur, Tieatment bj Internal Fixation Arch Surg, 23, 713-759 
November, 1931 


142 



BRIEF COMMUNICATIONS 
AND CASE REPORTS 

A METHOD OF EEDDCING LARGE DIAPHRAGMATIC HERNIA 

FROM ABOVE 

Harry G Slow, MD 
Cle\el\nd, Ohio 

There has been diveigence of opinion over the best surgical appioach 
for the repan of chaphi agmatic hernia Some advocate an abdominal incision 
Otheis open both the chest and abdomen In the combined appioach reduc- 
tion IS made easiei by traction fiom below on the hei mated visceia 

We agree that pai asternal heiniae aie best approached through the ab- 
domen This type ma}'^ invade eithei pletiial cavity or both at the same 
time If the hernia invades both pleuial cavities (a difficult pieoperative 
diagnosis) then theie is less chance of causing a bilateial pneumathorax in 
using the abdominal approach, and both sides may be repaired at the same 
sitting We aie suggesting a method by which the i eduction of all othei 
herniae can be readily acconiplished thiough the chest wall Any adherence 
of the herniated viscera to the stiuctuies of the thoiax can be dealt with 
under direct vision If the hei mated viscus is held too snugly by a tight iing, 
then the rent in the diaphragm can be enlarged at one end Phrenic neive 
damage is to be avoided In case one finds an obstiucted gangienous intestine 
in the chest cavity, it will then be necessary to open the abdomen so as to 
bring the clamped-off bowel out thiough the abdominal wound Anastomosis 
IS not piactical It is wise to bear m mind the possibility of an acutely ob- 
structed diaphi agmatic hernia when the cause of an intestinal obstiuction is 
unexplained Its detection will save opening the abdomen when the bettei 
appioach may be by way of the chest The histoiy of a severe antecedent 
tiauma to the toiso ma} arouse the suspicion of the correct diagnosis in 
the examiner’s mind Unequal movement of the costal margins on respiia- 
tion, a displaced cardiac dulness oi abnoimal auscultatory findings in the 
thorax will be an indication for taking a scout film of the chest, which will 
confirm the diagnosis The use of contrast media to accentuate the roent- 
genologic findings IS, at such a time, haidly feasible 

Case Report — A male, age 46, was seen in consultation with Dr E R Brooks, 
April I, 1936 The patient had been in an automobile wreck six months before, but did 
not know what struck him, probably it was the steering wheel, as he was driving He 
was unconscious for several minutes following the accident The right side of his chest 
and abdomen were lame for the next three weeks Two months ago he started to have 
abdominal cramps and an increasingly more marked gurgling in his upper abdomen and 

Submitted for publication May 15, 1937 

143 



Fig 


HARRY G SLOAN 


\nnalsor Surccry 
a nil ary 1933 



144 


\ olume 107 
Isumljet 1 


REDUCTION OF DIAPHRAGMATIC HERNIAE 


right chest Examination of his chest showed no cardiac displacement but the unequal 
flare of his costal margins on deep breathing plus the gurgling heard over his right chest 
on auscultation On' roentgenologic examination, Dr Eugene Freedman made the fluoro- 
scopic diagnosis of an anterior right-sided diaphragmatic hernia (Figs i, 2 and 3) 

Opciafioti — The stomach was washed out, m order to eliminate regurgitation during 
the maniplations Anesthesia — Avertin (60 mg per kilo) plus nitrous oxide, without 
intratracheal catheter The head of the table was raised 20 degrees and the patient placed 
on his left side, his bod3' rotated 111 the long axis 30 degrees, so that his right chest was 
uppermost The right arm was raised above his head Block of the seventh, eighth and 
ninth intercostal spaces, posteriorly, with 10 cc of i per cent novocain solution in each 



interspace Incision 30 cm long m the eighth interspace from the posterior axillary 
line to the midline in front Intercostal muscles divided and the chest opened wndely with 
a nb spreader Due to the presence in the chest of the abdominal viscera, there was 
little change in respiration with the jchest open One saw the retracted lung lying in 
the upper medial area of the chest 

In the lower chest we found small intestine, colon, stomach and most of the right 
lobe of the liver The liver had been rotated on its transverse axis and, as one looked 
into the chest from the front, the lower liver surface presented, with the fundus of the 
gallbladder pointing up tow'ard the right shoulder The liver had been drawn into the 
chest, from the notch, to the area on its lateral margin which corresponded to the posterior 
axillary line on the chest wall 

We were able by the sense of touch to hook an index finger beneath the medial edge 
of the rent m the diaphragm and then catch this edge in front and behind with tw'O Lower 
angled, bladder hooks In the intervals of relaxation of the diaphragm that followed each 
respiratory movement, we reduced the hollow viscera into the abdominal cavity This 
gave enough space in the chest so that we could catch the lateral edge of the rent in the 
diaphragm with two more bladder hooks The liver was then easily reduced Upward 

145 



HARRY G SLOAN 


Annalsof Surccry 
January 


traction on the bladder hooks helped greatly in the reduction One reduces intestines 
during a celiotomy in the same manner b\ acrtical traction on the \sound edges 

Dr W E Lower had adapted these hooks from the ordinarj smgle-toothed cer\ical 
\olsellum They are made in pairs — right and left angled — the blades of the forceps are 
bent 30 degrees latcrallj, just distal to the lock (Fig 4) llieir use permits upward trac- 
tion of the wound edges of the diaphragm without baling the handles of the instruments 
get m the operator’s waj 1 heir use materi ilh helps in the reduction of the hernial con- 
tents 111 the chest appioaeh lhc\ also are helpful in holding the edges of the rent 
together while the sutiiies are being laid for the repair 



Fig 3 — Appennnee of ^\ol1ml ten dn>s nftcr opcntion 


There w'as no tendenc) after 1 eduction for the abdominal contents to reenter the 
chest as the In cr acted as a stopper to hold them in their normal position 

The tear m the diaphragm was clean cut, 15 cm m length and laj in the axis of 
seven o’clock — looking from abo\e dowai Its origin was at the nipiile line, starting 2 cm 
from the attachment of the diaphiagm to the chest wall, and extended mcdialh and 
posteriorly into the cential tendon It was closed with silk sutures placed at 5 kim 
intervals There w'as no tension on the suture line Closure of the chest wall with three 
silver w’lie sutures which encircled the eighth and ninth ribs Closure of the intercostal 
muscles with interiupted silk Befoie pulling tight the last muscle suture we asked the 
anesthetist to expand the lung by increasing the gas pressure and then aspirated the 
remaining air left m the pleural ca\itj b\ catheter suction Fine silk in the subcutaneous 
fat, clips in the skin 

During the operation the blood pressure remained around 120/90, pulse 76 to 80 In 

146 



Vol^ime 107 
Number 1 


JEJUNITIS WITH INTESTINAL OBSTRUCTION 


order to reduce postopei ative retching, we gave nothing by mouth for two days following 
operation Continuous intravenous drip was supplied by a cannula in the internal saphe- 
nous vein at the ankle for 48 hours Convalescence w^as uneventful (Fig 5) Discharge 
April 15, 1936 

Fluoroscopic examination and roentgenograms of the stomach and colon, April 14, 
1936, showed all the visceia to be back in their normal positions Both diaphragms 
moved normally under the fluoroscope 

Follow-up — September 14, 1936 He had gained ten pounds in weight, and was 
eating everything without complaint Both diaphragms move normally 


ACUTE INFLAMMATORY JEJUNITIS WITH INTESTINAL 

OBSTRUCTION ^ 

Percy Klingenstein, M D 
New York, N Y 

Case Report — The patient, a male, age 21, presented himself for admission to the 
Mount Sinai Hospital, w'lth a history of acute abdominal pain and vomiting, which had 
begun seven hours previously For a period of two months preceding admission the 
patient had had pen-umbihcal discomfort He appeared acutely ill, and piesented re- 
sistance, tenderness, and rebound^tendeiness in the right lower quadrant of the abdomen 
A leukocytosis was present, and a diagnosis of an acute appendicitis was made He was 
operated upon (Garlock) through a McBurney incision The appendix was found to be 
bound dowm by a few edematous adhesions It, however, aside from slight injection, did 
not show gross evidences of an acute process Search for a Meckel’s diverticulum or 
terminal ileitis was negative The abdomen was closed m layers, and an uneventful 
convalescence ensued 

About a month later the patient was readmitted because of persistent pain and diar- 
rhea, the stools numbeiing from two to five a day and in some, dark blood w'as noted 
There was no pus or mucus The pain w'as quite seveie and was frequently accompanied 
by a desire to defecate The physical examination, including sigmoidoscopy, was essen- 
tially negative Barium enema w^as negative In view of the negative findings it was 
felt that the patient was suffering from a functional mucous colitis and was discharged 
to receive country convalescent care and then be admitted to the Mental Health Clinic 
About a month later he was again readmitted with a history of recurring generalized 
abdominal pains which seemed to be more marked after taking food, although they bore 
no definite relationship to meals They seemed to be most marked in the left lower 
quadrant of the abdomen Bowel movements averaged two a day 

Physical Examinahon revealed a thin, asthenic, chronically ill j’^oung man with gen- 
eral, moderate abdominal distention There was slight tenderness throughout the abdo- 
men, most marked m the left lowei quadrant No masses could be palpated During a 
48 hour period of observation the patient continued to have increasingly severe cramps 
and at this time visible peristalsis was noted m the left lower quadrant He vomited once 
A tender mass could be palpated per rectum 

Opeiatwn — Through a four inch left lower rectus incision the peritoneum and 
omentum were found to be deeply injected Loops of presenting small intestine were 
markedly dilated Palpation revealed a sausage shaped mass occupying an area in the 
small intestine about one foot in length, located in the distal jejunum Its proximal end 
was hard and infiltrated , the distal end was edematous and covered by a shaggj' peritoneal 
exudate The proximal intestine was hugely dilated, the distal collapsed A lateral 

* Presented before the New York Surgical Society, November 25, 1936 Submitted 
for publication March 5, 1937 


147 



PERCY KLINGENSTEIN 


Annals Of Surcery 
January 1033 


anastomosis was made between the afferent and efferent loops The anastomosis was 
made sufficiently distant from the tumor mass to permit of suhseciuent resection without 
disturbing the anastomosis, if this should be found to be nccessarj The wound was 
closed in lasers without drainage, and an tines entful postoperatise consalescence ensued 
Subsequent Couist — The patient has been seen on numerous occasions, and until 
recentls has appeared to he in the best of health Tor the past four or fise months, hoss- 
cs'er, there has been some abdominal discomfort, although he his maintained his ss eight 
and his boss els base been mosing norm ills Recent roentgenologic c\ammation of the 
gastio-intestmal tract res cals scseral areas of stenosis in the small boss el producing dilata- 
tion proMinal to them Some of these loops arc markcdls dilated and arc situated in 
both the jejunum and ileum 


COLECTOiMY FOR CIIROXIC ILEOCOLITIS 

rObTOI’Kll VTIVI. IXjnSTINSIi OnSlRUCTIOV 1>I U1 oil STIOV or ILHUM R\ 
UNTUiosTOMi 11)111. sunrimi Mc sns(i:‘ss iii cos liiy 

Case Report — The patient, a male, age i8 ssas first admitted to the Mount 
Sinai Hospital in August, 1935, coinplaiiiing of abdomiinl cramps sshich had been 
present for si\ ssccKs, accompanied bs some tcmi>criture and profuse ssscats There 
had occurred a similar episode three months before .idmission He had had three to 
four loose brossn stools dailj during the period of his iircsent complaint Ro blood, 
mucus or pus had been noticed in the esacuations Ihcre ssas an appreciable loss m 
ss eight The abdominal pain was for the most part confined to the right lower quadrant 
Ph\<:ical L\annualwu rescaled a thin undernouirished ehronicalls ill joung man 
Except for the abdomen, sshcrc moderate tenderness m the right lower quadrant could 
be elicited and a thickened area of intestine could be palpated, the jihjsical examination 
ssas ncgatise The stools consistcntl) shossed a foui plus guaiac Sigmoidoscops re- 
vealed no abnormahts Gastro-intcstinal roentgenologic studs shossed an irregular 
stenosis of the terminal ileum ssith dilatation proximalls In addition, the colon from 
the cecum to the region of the splenic flexure shossed loss of haustrations and marked 
disturbance 111 the mucosal pattern, indicatise of an ulcerating lesion Barium enema 
revealed an irregular stenosing lesion of the entire proxim.il half of the large boss el 
Opel at wn — Under general anesthesia, the abdomen ssas opened through a left, 
midrectus incision The terminal ileum, cecum and ascending colon ssere found thick- 
ened and edematous The sigmoid appeared normal The terminal ileum ssas disided 
one foot proximal to the ileocecal angle and a side-to-side ilcosigmoidostomj ssas 
performed A ss'ound infection developed, but otherssise the consalescence svas unesent- 
ful 

The patient svas readmitted one and onc-h.alf months later for colectoms During 
this time he had gained some ss'cight, but his stools still contained blood and he still 
continued to base abdominal cramps, although on the sshole his condition had improsed 
considerablj 

Opeiation — Under general anesthesia, the scar resulting from the presious operation 
svas excised, adhesions divided and separated, and the presaouslj effected ileosig- 
moidostomj identified The terminal ileum, ascending, transs’erse and splenic flexures 
svere resected after separating the omentum The resection extended into the upper- 
most portion of the descending colon ss'here the boss el appeared healths Retroperitoneal 
spaces svere peritoneahzed The ss'ound ss'as closed m layers svithout drainage except for 
rubber tissue drains placed superficially at cither angle 

Pathologic Examination — Gioss — The specimen (Fig i) consisted of the terminal 
18 cm of ileum, appendix, and 45 cm of ascending, transserse, and splenic flexures of the 

148 



A olume lOT 
Number 1 


COLECTOMY FOR ILEOCOLITIS 


colon The mucosa of the proximal portion of the resected ileum was soft, succulent 
and presented innumerable pinhead-size, delicate pink excrescences The more distal 
5 cm of the resected ileum was smooth, its mucosal folds completely obscured, the 
mucosa thickened, and there \\ere many shallow, punched out mucosal defects varying 
m size from a pinhead to cm m diameter The bases of the ulcerations were finely 
irregular, hemorrhagically discolored The mucosa about these ulcerated areas was pearl 
gray with here and there a hemorrhagic, punctate zone The wall of the ascending 
colon was slightly thickened, firmer than is usual, the mucosa irregularly mottled, dark 
red, pink and gray The basic architecture of the colonic mucosa was completely 
obliterated There were noted in the proximal portion of the ascending colon, and 



Fig 1 — Gross specimen of resected terminal ileum, ascending, transverse and splenic 
flexures of colon for ileocolitis 

more particularly m the cecal area, several shallow, punched out ulcers with hemorrhagic 
bases There were many slightly pouting, longitudinal folds, soft in consistencj, 
varying in breadth from to ij4 cm, doughy in consistency and separated, one from 
the other, by hemorrhagically discolored, craggy, slightly depressed, linear zones To- 
ward the terminal portion of the specimen it was noted that the pouting linear strands 
described before represented portions of the normal colonic mucosa which was present 
at the terminal portion of the resected specimen 

The appendix measured s cm in length and had been previously opened, its 
mucosa was slightly thickened, succulent, and in its basal portion presented two pinhead- 
sized punched out, superficially ulcerated areas, the bases of which were pearl gray 
The serosal aspect of the specimen presented dull gray, exceedingly fine mammillations 
There were numerous pencoloiiic lymph nodes, oval m shape, varying from to 
2 cm in length and to i cm in breadth They were rather soft in consistency, 
their sectioned surfaces moist, their peripheral portion pearl gray, while the central 
zone was light red 

Microscopic Diagnosis — Chronic ulcerative colitis involving the terminal ileum 

149 



PERCY KLINGENSTEIN 


Viinnl'Jof burcen 
January 193S 


Poslopciativc Coinsc—Tht patient appeared to be doing ver\ well following this 
procedure until four daj s after operation, when he presented classical signs of an intestinal 
obstruction, t\hich was confirmed bj a scout roentgenogram of the abdomen which 
shoi\ed distended small bowel with fluid lei els Celiotom} was performed fiie dajs 
after the colectomi through a right midrectus incision Numerous distended coils of 
tlie small intestine were encountered bound down b} recent adliesions There was a 
large quantity of free fluid in the abdomen The intestines were traced down to the 
region of the ileosigmoidostonii and it seemed that some loops ran under the mesentery 
of the ileum used in making this anastomosis It was deemed inadiisable to disturb 
this mesentery for fear of compromising the blood suppl} An enterostony, using a 
No 26 French catheter, according to the method of Witzel, was effected in the most 
distal, distended loop The tube was brought out through the low'er angle of the in- 
cision Following this procedure the patient did well, the enterostomj functioned e\- 
cellentli, and the patient appeared to be well on the road to recoieri, with normal 
temperatuie and pulse fi^e da^s after the second operation On the sixth day there 
was a repetition of the entire clinical picture but this time w’lth a rise in temperature, 
cramps and abdominal tenderness The enterostomj stopped draining and was irrigated 
a number of times without success, fluid being readily introduced but with no return 
The patient now appeared extremelj ill Roentgenologic examination again supported 
the diagnosis of an intestiinl obstruction, and one w'eek after the preiious operation, 
an incision W'as made betw'eeii the tw'o existing scars The abdominal exploration re- 
vealed a diffusing fibrino purulent peritonitis with pus and fibrin binding down loops 
of gut e\er^w'here, particularh m the upper quadrants In separating the loops of 
intestine, a laige abscess ca\it\ W'as encountered 111 which the proximal tw'o inches of 
the enterostomj tube w'ere seen emerging through a free perforation in the ileum The 
tube W'as w'lthdrawii and the perforation repaired The abdomen w'as closed without 
drainage Culture of the pus rejealed B colt, enterococci and Staphylococci ainciis 
Follow'ing this operation patient was criticallj' ill for a long w'hile, and required a 
number of transfusions The wound became seterelj infected and had to be wideh 
opened A large quantitj of pus was discharged through the upper angle of the in- 
cision It seemed to come from an intra-abdomiml collection and w'as traced to the 
subphrenic region, being Msualized b\ an injection of hpiodol A counter incision, 
for more dependent drainage, w'as deemed adMsable, w’hich was accomplished by ex- 
cising the tenth rib, in the postaxillarj line, and suturing the pleura to the diaphragm 
A small rent in the pleura resulted 111 a pneuniathorax Subsequenth, with a probe 
111 the abdominal sinus, the subphrenic abscess was incised Following this the pa- 
tient made a gradual but prolonged com alescence, being discharged well, approximately 
three months after the colectoim 

Discussion — Dr Henri W Caje (A^ew York) discussed the question 
of colectomy 111 lefeience to chronic ileocolitis In the last eight months he 
had pel formed three colectomies for chionic ulceiative colitis, and emphasized 
w'hat he consideied teij' impoitant points 

(1) The importance of three preopeiative pi eparations of these patients 
(a) Lojv lesidue diet (b) Intraj'enous fluids (c) Fluid diet, 24 to 48 
hours preceding the opeiation, and also pills containing lead and opium for 
72 houis piior to the operation, as \vas suggested by Mont Reid in patients 
suffering wnth tumors of the laige bowel 

(2) Careful selection of cases wheie colectomy is indicated Recently 
he had seen a patient who had chionic ulcerative colitis, and upon w'hom he 
expected to effect a terminal ileostoni}’- and possible colectomy, until it was 
discovered the patient w'as alleigic to poik and milk He was taken off 
these two foods for four months, and has showm a remarkable recovery since 

150 



Volume 107 
Number 1 


INFLAMMATORY TUMOR OF MESENTERY 


(3) A more thoiou^h side-tiack of the fecal current can be accomplished 
by perfoimmg an end-to-side ilecolostomy The Rankin clamp and the 
Fill ness clamp are excellent in accomplishing an end-to-side anastomosis 
In the great majority of cases of the chronic ulcerative type, such as Doctor 
Klingenstem cited, it is prefeiable to effect a permanent terminal ileostomy, 
and then, if the colectomy is necessaiy, he has used a long, left paiamedian 
incision, through which it is easier to sevei the splenocohc ligament Trans- 
fusion is advocated at the time of the fiist stage, as well as immediately 
following the second or thud stage pioceduies In patients wheie the ulcera- 
tion involves the lectum, rubber-guai ded clamps aie preferable to ciushing 
clamps of any kind, because with an unguarded clamp theie is gieat danger 
of cutting into the thin friable wall of the bowel with resultant soiling 

Dr Ralph Colp (New^ York) recalled, relative to Doctor Cave’s mention 
of the fact that the divided sigmoid is lathei difficult to close, especially m 
cases of ulcerative colitis in wdnch the rectum is not paiticularly involved, 
that, m 1913, von Beck reported an operation foi ulceratne colitis, in wdnch 
he divided the ileum neai the ileocecal junction, and the colon at the sigmoid 
The terminal ileum was closed and the proximal loop of colon was brought 
out as a colostomy, thus isolating the colon He then recommended the 
anastomosis of the proximal ileum to the distal segment of the sigmoid by 
end-to-end suture Doctor Colp said the teaching in the past had been that 
intraperitoneal anastomoses are rather dangerous and should be avoided 
whenever possible In a recent case, howevei, he undertook a procedure 
similar to the von Beck operation, but wnth modifications He divided the 
ileum and brought out the pioximal colon as a colostomy, thus isolating 
the colon He then hi ought the proximal ileum out through a left rectus 
incision as an ileostomy, and the distal portion of the sigmoid out as a sig- 
nioidostomy, approximating the intraperitoneal poition of both loops by in- 
terrupted serosal sutures The sigmoid and rectum are put at rest for a 
desired period, and, if multiple polypi ate piesent, a sigmoidoscope may lie 
introduced through the rectum oi thiough the sigmoidostoray, and any polypi 
which may be present may be fulgurated At some future time, provided 
the general condition of the patient is satisfactory, the spur betw^een the 
ileum and sigmoid may be crushed, and an extrapentoneal closure effected 
In that way the danger of inti apei itoneal leakage is aroided The isolated 
colon may then be removed, if necessarjL 


CHRONIC INFLAMMATORY TUMOR OF THE iMESENTERY 

Case Report — The patient, a male, age 50, was first seen by Dr Maurice Rash- 
baum, who identified a large, lobulated, movable abdominal mass during the course of a 
routine physical examination The patient at that time was ignorant of its existence 
and it had given rise to no abdominal symptoms He ivas referred to the Diagnostic 
Clinic of the Mount Sinai Hospital where complete roentgenologic studies of the gastro- 
intestinal tract were made, but no definite diagnosis w'as arrived at There had been 
some recent weight loss There w'as no diarrhea, cramps or constipation 

Physical Examination except for the abdomen was entirely negative In the right 
lower quadrant of the abdomen there w'as a hard nodular mass, nontender and freelv 
movable In spite of the negative roentgenologic examination, on account of the firm- 
ness and nodularity of the mass, a preoperative diagnosis of carcinoma, possiblr in a 
mobile cecum or m a loop of small intestine, was made 

151 



PERCY KLINGENSTEIN AnnalsofSurgety 

January 1038 

Opeiation through a five inch, right, midrectus, muscle-splitting incision disclosed 
the mass previously noted occupying the root of the mesentery of the terminal ileum 
It was the size of a small orange, hard, nodular, with local lymph node involvement 
The intestines were agglutinated to it and in one area were compressed In view of 
the fact that the nature of the lesion could not be decided upon and that it was com- 
pressing the lumen of the bowel, a resection was performed This necessitated a wide 
removal of the terminal ileum The resection reached the most distal portion of the 
ileum so that an end-to-end anastomosis was impractical A side-to-side ileotransverse 
colostomy was, therefore, accomplished, and an ileostomy of the Witzel type was added 
m the ileum proximal to the anastomosis The tube was brought out through the 
lower angle of the incision The wound was closed in layers 



Fig I — Gross specimen of resected ileum %Mth Hrge infl'immatory tumor of 

the mesenterj 

Pathologic Examination — Gioss — The specimen (Fig i) consisted of 46 niches of 
intestine with its mesentery A large mass occupied the root of the mesentery The 
mass measured about 8 cm in diameter and was globular It was firm, well defined, 
and on section revealed normal fat tissue traversed by numerous interlacing dense 
white strands of fibrous tissue, and was hemorrhagic in places Normal vessels, with 
unconstncted lumina, were seen coursing through the mass In its periphery a few 
small fleshy nodes of lymphoid tissue were noted The mesenterj to the right and 
left of this mass was markedly shortened by adhesions , this folded, thickened mesentery 
was firmly adherent to one face of the mass The mesentery of the central portion of 
resected bowel approximated the normal length and presented large hemorrhagic areas 
This fore-shortened mesentery at each end of the resected ileum converted the entire 
length of bowel into a large horseshoe shaped loop, the bowel itself, as it surrounded 
the tumor, was thrown into numerous coils The seiosal surface of the ileum was 

162 



Volume 107 
Number 1 


INTESTINAL OBSTRUCTION 


hemorrhagic The opened ileum revealed a perfectly intact mucosa No fistulous 
tracts were demonstrable 

Mta oscoptc Diagnosis — Fibromatous, chronic inflammatory mesenteric tumor 
Postopeiative Couise — The ileostomy tube drained well almost immediately after 
operation It was clamped off after a period of ten days, following which patient’s 
bowels functioned normally The wound healed by primary union except for a small 
amount of suppuration at the upper angle where a dam had been inserted at the time 
of operation Patient was discharged well, 24 days after operation 


OBSTRUCTION DUE TO APPENDICES EPIPLOICAE 

Carl Baumeister, M D , 

Council Bluffs, Iowa 

C W Hargens, MD and C F Morsman, MD 
Hot Springs, S Dak 

Reported cases of obstiuction of the intestine by means of constiiction 
by two appendices epiploicae becoming adherent across its antemesentei ic sur- 
face are lare In 1924, Klingenstem^ leviewed all of the known cases There 
had been but thiee instances of this complication recoided In 1933, Pat- 
terson^ repotted that theie had been but two othei cases occuiimg in the 
intervening years In 1933, Mclvei® mentioned that the appendices epiploicae 
may also act as an obstructive band by becoming attached thiough inflam- 
matory processes He added an additional case There are, therefore, only 
five reported cases of intestinal obstiuction due to adheient appendices 
epiploicae To this list we wish to add a sixth instance 

Case Report — J K, a very obese male, age 62, enteied the Sisters Hospital at 
Hot Springs, South Dakota, March 13, 1937, complaining that he had had no bowel 
movement since March 9 Four days before he came under our care, his abdomen 
had begun to become distended, which was accompanied by generalized abdominal pains, 
and he had vomited twice on the day of onset, since which time he had only been 
able to pass a small amount of flatus and a little stool which had the appearance 
of soap water The abdomen had become swollen to tremendous proportions He had 
been becoming increasingly constipated during the preceding four months, and had had, 
occasionally, bright red blood in his stool during that time He had lost eight pounds, 
in weight in the past few months He had never had a hernia, but had had an ap- 
pendicectomy ii years ago His appetite had always been inordinate 

Examination — Showed four plus distension of the abdomen, and the right rectus 
appendicectomy scar The bowel sounds were not distinct, and there could be heard an 
occasional tinkling Rectal examination did not reveal any masses but showed some 
large internal hemorrhoids Examination was otherwise negative except for the presence 
of marked obesity Diagnosis Acute mechanical obstruction of the large bowel, 
probably due to carcinoma of large bowel with probably secondary paralytic ileus 
(early) (One of us mentioned the possibility of the blood per rectum being due to 
hemorrhoids and the obstruction to adhesive bands ) 

Opel ation — A tremendously distended large and small bowel was disclosed A 
cecostomy was performed The source of obstruction was not ascertained The patient 
was only slightly relieved by the operation He developed a complete secondary paralvtic 
ileus, and bubbling rales m his chest There ensued a peripheral vascular failure 


Submitted for publication April 22, 1937 

153 



BAUMEISTER, HARGENS AND MORSMAN 


Annals Of Surpcry 
January 1933 


With rapid pulse, the heart finally becoming markedly irregular, with a rapid fall in 
blood pressure before his exitus, March i8 

Final Diagnosis — Pnmarj cause of death Acute colonic obstruction with secondary 
paralytic ileus Seeondary or immediate cause of death Acute cardiac failure following a 
peripheral vascular failure (etiologic factor of this bronchopneumonia and paralytic ileus) 
Contributory cause Extreme obesity 

Autopsy — (Three hours after death) Penioncal Cavity There was no free fluid 
present The peritoneum, except in the right lower quadrant, was smooth and shiny, 
there being no engorgement of blood vessels or exudate visible Entering the cecum 
was a rubber drainage tube Around the cecum was an abscess cavity with walls about 
I cm thick The external surface of the abscess cavity had moist, yellowish, moderately 
easily separable adhesions between it and the omentum On breaking into the abscess 
cavity, about i6o cc of greenish yellow, moderately thick, very foul B colt pus were 
found The adhesions surrounding the cavity weie principally lateral and inferior 
The general peritoneal cavity did not appear to be contaminated The liver border 
was 2 2 cm below the ensiform cartilage and 4 5 cm below the costal margin 

Laige Intestine — As the large intestine ascended from its junction with the recto- 
sigmoid there were a number of constrictions across its anterior surface These were 
caused bj' adhesions between appendices epiploicae which were located on opposite sides 
of the gut They were not diverticula The first one of the constrictions between 
adherent appendices epiploicae was at a point 173 cm above the rectosigmoid junction 
The bowel below this point was not distended Above this point the gut was distended 
for 18 cm , but was of fairly good color This was followed by another adhesion between 
two appendices epiploicae Then came a portion of gut 177 cm in length which was 
not distended, at the proximal end of which there was another adhesion between two 
appendices epiploicae Proximal to this last adhesion between the appendices epiploicae 
there was distention of the entire gut including the duodenum and stomach This col- 
lapsed loop of large gut between the two constrictions was an interesting example of 
a blind collapsed loop with obstruction at either end 

Small Intestine — This was uniformly greatly distended Portions of the lower ileum 
and the beginning of the jejunum had a mottled, purplish color There was no distinctly 
gangrenous gut There were no perforations apparent 

Discussion — This case presented an interesting problem in differential 
diagnosis It was another example of the fact that two pathologic entities, t e , 
hemorrhoids and adhesive bands, can cause bleeding per lectum and intestinal 
obstruction, as do the much more commonly occuiring neoplasms of the 
rectosigmoid 


REFERENCES 

^ Khngenstein, Perej Some Phases of the Pathology of Appendices Epiploicae with 
Report of Four Cases and Review of the Literature Surg , Gynec & Obstet , 38, 

376, 1924 

° Hunt, V C Torsion of Appendices Epiploicae Annals or Surgery, 69, 31-46, IQIQ 
® Riedel Ueber die Drehung der Appendices Epiploicae und ihre Folgen (Unpora Aliens 
und Stramge im Bauche) Munchen Med Wchnschr , 52, 2308-2311, 1905 
* Patterson, Daniel C Appendices Epiploicae and Their Surgical Significance, with 
Report of Three Cases New Eng Jour Med, 209, No 25, 1255-1259, December 21, 

1933 

® Hamilton, Thos Two Cases of Torsion of an Appendix Epiploicae Med Jour 
Australia, i, No 22, 773, Maj 28, 1932 

“IklcHer, M A Acute Intestinal Obstruction Amer Jour Surg, 19, 163-206, Jan- 
uarj, 1933 


154 



^ olume 107 
Number 1 


GUNSHOT WOUND OF ILIAC BONE 


GUNSHOT WOUND OF RIGHT ILIAC BONE ^ 

COMPLICATED BY UNCONTROLLABLE SINUSES OP RIGHT GLUTEAL REGION 

Sigmund Mage, MD 
New York, N Y 

Case Report — An Italian, age 41, received on January 29, 1916, a gunshot 
wound of the lower abdomen , the bullet traversed the right iliac fossa and pierced 
the right iliac bone An immediate abdominal exploration was performed at the 
Volunteer Hospital, New York City, the findings of which we have nevei been 
able to ascertain 

Two days later the bullet was lemoved from the subcutaneous tissues of the 
right gluteal legion, through an incision which remained the site of a persistent 
draining sinus He apparently was free of any discomfort until December, 1926, when 
he was admitted to the Beekman Street Hospital for the incision and drainage of a 
large right gluteal abscess, which seemed to originate in the region of a defect in 
the iliac bone created by the bullet (Fig 1) Ever since then he has been under 
more or less continuous observation for recurrent abscesses and an increasing num- 
ber of draining sinuses His hospital admissions were December, 1926, July, 1929, 
March, 1931, September, 1932, January, 1933, and finally April, 1935 

All efforts to control the spread of the infection or to discover its cause have been 
unsuccessful On two occasions the defect in the ilium was fully exposed and found 
to be a clean cut, rigid walled opening, without evidence of acute infection in the 
surrounding bone — curettmgs from which merely revealed a very low grade osteitis 
No foreign body was discovered Repeated cultures of the discharge from sinus tracts 
usually returned a gram-negative bacillus of the B colt group Anaerobic cultures 
were negative There was never any clinical or roentgenologic finding of a gastro- 
intestinal origin Tuberculosis and mycotic infections were suspected and sought 
without result 

Although the patient’s general condition did not suffer materially, he was eco- 
nomically incapacitated because of the local condition On his last admission in April, 
1935, there were at least 70 sinuses distributed over the right gluteal area, extending 
posteriorly to the left lumbar region and anteriorly to the right iliac fossa (Fig 3A 
and B) It was then felt that two possible factors for the persistence of the infection 
had to be eliminated (i) A foreign body on the inner aspect of the iliac bone (2) 
The defect m the iliac bone, inasmuch as the recurrent abscesses and sinuses seemed 
to originate m or about its site It was decided that removal of a segment of ilium, 
which included the defect, might accomplish both these objectives 

Opeiatwn — April 27, 1935 An incision was made along the crest of the right 
ilium, extending from the anteiior superior to the posterior superior iliac spine, mo- 
bilizing the gluteal muscles A triangular segment of bone, 10 cm at its base, 2^2 cm 
at its apex and 7l4 cm on its side, was excised (Fig 2) Grossly, it showed nothing 
remarkable, and microscopic examination revealed only a verj low grade osteitis 
with more of a tendency to a reparative reaction than an inflammatory one The 
underlying psoas-ihacus muscles showed considerable fibrotic changes, but no sinus 
tracts were noted extending inwardly and no foreign body was found The exposed 
area was packed and allowed to granulate 

The many sinus tracts, which literally honej'-combed the gluteal muscles and 
which in themselves were possible factors for the persistence of the infection, were 
destroyed by a number of subsequent procedures, in which all detectable tracts were 
fully exposed, cauterized and then allowed to granulate from below up The patient 

* Presented before the New York Surgical Society, February 24, 1937 Sub- 
mitted for publication May 22, 1937 


155 




SIGMUND MAGE 


Annals of Surgery 
January 1938 


1 



Fig I — Roentgenogram showing 
the defect in the right iliac bone 
created by the bullet 




Fig 2 — Postoperatu e roentgeno 
gram drawing the extent of the 
wedge shaped resection of the right 
iliac bone 



Fig 


3 — (A) Photograph, prior to resection of the right ihac bone, showing the posterior appearance of 
the multiple draining sinuses (B) Lateral view 


156 


Volume 107 
iMirober 1 


GUNSHOT WOUND OF ILIAC BONE 

was discharged to the OPD Septembei 14, 1935, after a hospitalization of 142 dais, 
with extensive granulating wounds which were finally healed by July, 1936 (Fig 4 A 
and B) We had thought we had effected a temporary arrest of the infection because, 
for the first time in 21 years, the patient had gone for a period of over six months with 
all the sinuses completely healed Examination, February 24, I937, however, revealed 
a recurrence of activity and we are presenting the case for interpretation of the pathology 
and for advice as to future therapy 



Fig 4 — (A) Photograph, subsequent to resection of the right iliac bone, shoving the lateral appear 
ance of the right hip after the sinus had healed (B) Posterior Mew 

While the clinical behavior of this case may be characteristically that of 
an osteomyelitis of the iliac bone, its mode of onset, gross, micioscopic and 
roentgenologic findings have not been so The mici oscopic sections have shown 
a very low grade of osteitis, chaiacteuzed by occasional collections of mononu- 
clear cells and a distinct tendency towaid lepair rather than activity The 
evidence of a bone infection has been most meager and certainly not in 
proportion to the clinical manifestations On the theory that the defect 
caused by the bullet might have mechanically been responsible foi keeping 
up a low giade infection, we attempted a ladical extiipation of the bone 
about that area A complete iliectomy may be necessary, on the basis of 
the available evidence, but it is difficult to see any particular reason for a 
more hopeful outcome resulting from that piocedure Despite most careful 
and thorough search, it is conceivable that this condition may still be de- 
pendent upon an undetected foreign body However, ive do not feel justi- 
fied in fuither extensive investigation unless that possibility becomes more 
tangible 


157 



SIGMUND MAGE 


Annals <5f Suruen 
Tanuary 1938 


Discussion — Dr Robert H Kennedy (New York) stressed the im- 
portance of Doctor Mage’s case of chronic osteomyelitis of the ilium from 
the economic point of view The patient has been nuclei hospital treatment 
for 21 years At first, when he piesented himself at Beekman Stieet Hos- 
pital II yeais ago, it seemed simple to make a diagnosis Osteomyelitis from 
an old gunshot wound Howevei , this was not vei ified by the roentgenologic 
findings It was thought that a foieign body might be present and this pos- 
sibility was investigated No foreign body was found A vain search was 
made for actinomycosis, tubei culosis, and even for a foreign body m the 
abdomen The patient developed one sinus after another Then Doctor 
Mage decided that infection was being kept up because there was a rigid 
cavity He tried to take away some of the rigidity by resecting bones The 
pathologist could report onl}^ osteitis Doctor Kennedy was not quite con- 
vinced that theie was sufficient evidence to justify removing the rest of the 
flare of the ilium which was done lathei recently, but whether this be so or 
not, one point was brought out When there is an osteomyelitis, it is im- 
portant in the early stages to perfoim just as radical a procedure as may seem 
necessary, m the hope of earlier cuie 


158 



MEMOIR 

FRANCIS ALEXANDER CARRON SCRIMGER 

1880-1937 


The American Surgical Association desires to give expiession to its deep 
sense of loss in the death of Dr Fiancis Alexandei Cairon Sciiingei, V C, 



Francis Alexander Carron Scrimger, MD 

159 



MEMOIR 


Anmls of SiiiRcn 
lanuary 1938 


of Monti eal, who died suddenly on Febiuaiy 13, 1937, in his fifty-seventh 
year, of coronary thrombosis He had been a member of this Association 
since 1930 

Educated at McGill Univeisity, where he received his B A degree in 1901, 
and his medical degiee m 1905, Doctoi Sci linger started his postgiaduate 
training in the Royal Victoria Hospital, where he was for three yeais an 
intein m the Departments of Medicine and Suigei)^ and then studied in 
Euiope for a yeai, piincipally in Diesden and Beilin Uidoii his return 
to Monti eal he was appointed to the suigical staff of the Royal Victoiia 
Hospital, wheie he soon gave evidence of his excellent clinical knowledge 
and of the investigative spirit which always chaiacterized his suigical caieei 
When wai broke out he was appointed Medical Officer to the 14th Bat- 
talion, and left with the fiist contingent fiom Canada While in chaige of a 
field dressing station at the second battle of Ypies he was awaided the Vic- 
toiia Cl OSS for distinguished biaveiy Latei he seived at the base with the 
Canadian Geneial Plospital No i, at Etaples, then with the Granville PIos- 
pital, in England, and again m charge of the McGill Unit, No 3 Canadian 
General Hospital, at Boulogne, with the lank of Lieutenant-Colonel His 
war seivice lasted neaily five years Upon demobilization he letuined to 
Canada and lejomed the staff of the Royal Victoria Hospital His caieei 
fiom that time on was one of steady, quiet advance along clinical lines, and 
lesulted m seveial impoitant achievements in research In 1936, he was 
appointed Chief Suigeon to the Hospital, and Associate Piofessor of Sur- 
geiy at McGill University 

'Doctor Sci linger possessed a gieat capacity foi friendship and had a wide 
cncle of close fi lends He was particularly valued as a consultant by his 
medical confieres because of his wide knowledge, his diagnostic ability, his 
geneial soundness and cleainess of view, and his unusual skill as an opeiator 
On this continent and in the Old Country he had many friends and was 
known as one of Canada’s outstanding surgeons This leputation was lecog- 
nized by his election to membership in the most important suigical societies of 
this continent, among them the Ameiican College of Surgeons, the Ameri- 
can Association for Thoiacic Suigery, the International Society of Surgery, 
the Intel ui ban and the Halsted Societies 

We, his confieies in the American Suigical Association, Avish to record 
oui veiy leal sorrow at his death Edward W Archibald 

EDITORIAL ADDRESS 

Original typed manuscripts and illustrations submitted to this Journal 
should be forwarded prepaid at the author’s risk, to the Chairman of the 
Editorial Board of the ANNALS OF SURGERY 

Walter Estell Lee, M D 
1833 Fine Street, Philadelphia, Pa 

Contributions m a foreign language when accepted will be translated 
and published in English 

Exchanges and Books for Review should be sent to James T Pilcher, 

M D , Managing Editor, 121 Gates Avenue, Brooklyn, N Y 

Subscriptions, advertising and all business communications should be 
addressed 

ANNALS OF SURGERY 
227 South Sixth Street, Philadelphia, Pa 

160 



Anmls or SurKcrv 
Januarj , 1938 



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Annals of Surgerj 
January 1938 


STANDARD BOOKS FOR SURGEONS 


NEW WORK 


THE OCULAR FUNDUS 
IN DIAGNOSIS AND TREATMENT 


JUST READY 


By DONALD T ATKINSON, M D , F A C S 

Consulting Ophthalmologist to the Santa Rosa Infirmar> and the Ni'c Hospital San Antonio, Texas, 

Fellow of the American Academj of Ophthalmologj and Oto-Larj ngology 

Imperial octavo, 259 pages, illustrated tvith 106 engravings including 58 colored 'plates 

Cloth, $10 00, net 

This work clearly outlines the general characteriEtics of the ocular fundus in health and disease It is 
invaluable to everyone tv ho uses the ophthalmoscope in diagnosis — to neurologists, obstetricians and surgeons 
as well as to ophthalmologists Its outstanding feature is the inclusion of 58 colored plates prepared by the 
author, who is himself an artist and produces exactly what he interprets from the fundus and hence pre 
sents a more accurate picture than could a professional artist working from descriptions Each plate is accom 
panied by descriptive matter, necessarily bnef, but showing the clinical findings and laboratory reports that 
have a direct bearing upon the conditions illustrated In addition to these colored plates there are 48 draw 
mgs in black and ■white also prepared by the author This comprehensive, well organized material will be a 
distinct aid in the diagnosis of conditions revealed by the ophthalmoscope 


ENDOCRINOLOGY 

Clinical Application and Treatment 
By AUGUST A WERNER, M D , F A C P 

Assistant Professor of Internal Medicine St Louis Umversitj School of Medicine Associate Physician, St Mary’s 
Group of Hospitals, Physician, Endocrine Clinic St Louis City Hospital Staff Member, 

St Louis City Hospital Sanitarium and Infirmary , etc 

Octavo, 672 pages, illustrated with 265 engravings Cloth, $8 50, net 
The purpose of this work is to make clinical endocrinology more understandable to the physician, to 
point the way to correct diagnosis and to offer help in the relief of these ailments The author presents a 
review of the anatomical structure and arrangement of the autonomic nervous system and the functions of 
the endocrine glands Metabolism and the influence of the glands are then discussed, the functions of the 
endocrines are considered and known or postulated hormones are identified In the treatment of endocrine con 
ditions the author advocates only those preparations and methods which have proven their efficiency This 
book summarizes what is actually known in endocrinology, systematizes our present knowledge of the normal 
and abnormal physiology of the ductless glands and applies this information to the recognition of the endocrine 
syndromes The work is a safe and conservative guide to both diagnosis and treatment 


SURGICAL DISEASES OF THE CHEST 

By EVARTS A GRAHAM, A B , M D , F A C S JACOB J SINGER, M D., F A C P 

Professor of Surgery, ■Washington Umversitv School of Associate Professor of Clinical Medicine AVashington Uni- 
Medicine Surgeon-in-Chief, Barnes Hospital, versity School of Medicine Assistant Physician, 

St Louis, Missouri Barnes Hospital, St Louis, Missouri 

HARRY C BALLON, MD, CM, FACS 

Formerly Assistant Professor of Surgery, AVashington University School of Medicine St Louis, 

Formerly Assistant Surgeon, Barnes Hospital St Louis Missouri 

Imperial octavo, 1070 pages, illustrated with 637 engravings Cloth, $15 00, net 
The field of thoracic surgery is one that is expanding so rapidly that a continued revision of the manu 
script has been necessary to keep it fully abreast of the new knowledge In its present form it reflects every 
advance to the date of publication Its authors are recognized authorities and their book summarizes their 
unusual experience in the field of thoracic surgery While less emphasis is placed on the surgical technique 
and on the actual features of the operation, than in most books designed exclusively for surgeons, the essen 
tial aspects of the operative surgical procedures have not been neglected and many of the operations have been 
described and illustrated in detail 


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Annols of Surgert' X 
Januarj 


i . I 

Lowsley & Kirwin— UROLOGY FOR NURSES 

This new book adequately answeis the urgent demand foi a te\t m Urology 
which not only covers the basic science but also stresses the netver refine- 
ments of practice as well as presenting the Nursing factors in pioper detail 
The methods are based on moie than fifteen years of expeiience in a laige, 
modern urological clinic through which thousands of patients pass annu- 
ally Every instrument and method here described has been put to the 
severest test of actual usage The mateiial is readily accessible to the teach- 
ing nuise, student and busy graduate It has a chapter on special instru- 
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the operation itself The nurse’s woik in the operating and cystoscopic room 
in the preparation, assistance and care of the instruments after use is 
described in detail It has a chapter on diet and glossary 

Octavo pages loi illushations Cloth, ^5 00 

By OSWALD SWINNEY LOWSLEY, M D , Director, Department of Urology 
(James Buchanan Brady Foundation), New York Hospital, and THOMAS 
JOSEPH KIRWIN, M D, Attending Surgeon, Department of Urology (James 
Buchanan Brady Foundation), New York Hospital 

J. B. LIPPINCOTT COMPANY 

Dept AS Washington Square Philadelphia 


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19 




Annals of Surcery 
January 1938 


The Journal of 
Bone and Joint Surgery 

The Official Publication of the 
American Orthopaedic Association 
British Orthopaedic Association 
American Academy of Orthopaedic Surgeons 
Owned and published by the American Orthopaedic Association 

Published Quarterly: 

January, April, July, and October 


The only publication in English dealing exclusively with 
bone and joint conditions 

Thiough the cooperation of its Foreign Editors, its pages 
include contnbutions from recognized leaders in this spe- 
cialty from foreign countries as well as from the United 
States and Canada 

In the choice of papers for publication emphasis is laid on 
the practical and clinical subjects 

A journal of value to general surgeons as well as to those 
dealing with the problems of orthopaedic and traumatic 
surgery 


Editor, E. G. BRACKETT, M.D. 

8 THE FENWAY, BOSTON, MASSACHUSETTS, U. S. A. 


ORDER BLANK 

The Journal of Bone and Joint Surgery 

8 The Tenway, Boston, Massachusetts 

Please enter my subscnption to The Journal of Bone and Joint Surgery for one year 
beginning with the issue for 

□ Enclosed find $ in payment Will remit on receipt of bill 

Name Street 

City State 

Subscription Price— Payable m Advance— $5 oo m the United States, $5 25 in Canada, $5 75 in Foreign 

Countries 


20 


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Annals of Surgery 
January, 1988 


^‘REQUIRED 

READING'’ 


Your Personal Guide 
to a More 
Successful Practice 

■p^r George D Wolf is a highly success- 
ful physician who decided it was high 
time that someone put out a book that 
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of the most important books any doctor can 
have — a book that answers and clarifies hun- 
dreds of questions and problems regarding 
business ethics and economics constantly 
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The volume should be carefully read by 
the physician s secretary or office nurse as 
well, as much of the information and sug 
gestions tendered in it can be applied and 
put into service without any instruction from 
the doctor whatsoever There is also a par- 
ticularly useful section devoted to mate 
rial teaching nurses how to give instruc 
tions to patients for home self-treatment 
Nothing has been 


omitted It IS all 
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from How to 
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THE 

PHYSICIAN'S 

BUSINESS 

by 

GEORGE D. WOLF, M.D. 

Attending Otolaryngologist, Sydenham Hospital, 
Hen York City Attending Laryngologist, River 
side Hospital, iVen York City, Fellow, New York 
Academy of Mcdtcmc, FcUon, American Medical 
Association, etc 


Ready Soon! 

^^There is no finer 
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the subject^^ 

TAr Bacons new book is comprehen- 
sive, practical and authoritative It 
offers an unbiased, informative descrip 
tion of the diversified conditions included 
in proctologic practice, and covers every 
phase of the subject It emphasizes the 
application of the procedure to the pa 
tient — not the patient to the procedure 
487 illustrations (mostly originals) 
crisply picture the author’’ s wtde cltntcal 
and sttrgtcal experience 

Dr Bacon s text stresses the underly- 
ing pathology of the Anus, Rectum and 
Sigmoid Colon as basic to treatment He 
describes the various methods of exami 
nations Diseases are detailed, giving 
Definition, Etiology, Symptoms, Diagno 
SIS, Medical and/or Surgical Treatment 
Particular attention is given to Hemor- 
rhoids and to Tumors, including infec- 
tious, benign and malignant tumors of 
the sigmoid and rectum A comprehen- 
sive, selected bibliography completes each 
chapter 600 pages 487 illustrations 

ANUS, RECTUM 

AND 

SIGMOID COLON 

Diagnosis 

and 

'Treatment 


HARRY E. BACON, M.D. 

FACS, FAPS, Assistant Professor of 
Proctology, Temple University School of 
Medicine, Associate in Proctology, Graduate 
School of Medicine, Unncrsity of Penn 
sylrania 


Foreword by 


J P LOCKHART-MUMMERY, M A ,MB , 
D Ch (Cantab ), F R C S (Eng ), Fmcritus 
Surgeon, St Mark*s Hospital, London, 
England 


Published by 

J. B. LIPPINCOTT 
COMPANY 

Washington Square Philadelphia 


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Januarj 103S 



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Januarj 1938 




NEW BINOC FEVER THERMOMETER 

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VOL 107 


FEBRUARY, 1938 


NO 2 


ANNALS of 
SURGERY 

A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 

Aho the Official Publication of the Ameucan Stngical Association, 
the Southern Smgical Association, Philadelphia Academy of 
Siugery, and New York Surgical Society 



EDITORIAL BOARD 

WALTER E LEE, MD ROY D McCLURE, MD 
Chau man, Philadelphia Deti oit, Mich 

BARNEY BROOKS, M D GEORGE P MULLER, M D 
Nashville, Tenn Philadelphia 

E D CHURCHILL, M D H C NAFFZIGER, M D 
Boston, Mass San Fiancisco, Cal 

EVARTS A GRAHAM, M D D B PHEMISTER, M D 
St Louis, M 0 Chicago, III 

ROSCOE R GRAHAM, M D W F RIENHOFF, JR , M D 
To; onto, Canada Baltimoi e, Md 

SAMUEL C HARVEY, MD A 0 WHIPPLE, M D 
New Haven, Conn New Yoi k 

JAMES TAFT PILCHER, M D , Managing Editor 

J B LIPPINCOTT COMPANY, Pubhshers 

PHrLADELPUIA MONTREAL LONDON NEW \ORK 



Entered at the Post Office at Philadelphia and admitted for transmission through the mails at second class rales | 

Pnce$iooo a jear Cop> right 1038, by J E Lippincott Company, 227-231 South Sixth Street Printed in U S A j 




Vol. 107 


CONTENTS 

FEBRUARY, 1938 


No 2 


ACUTE INTESTINAL OBSTRUCTION John Scudder, M D 

Raymund L Zwemer, M D 
Allen O Whipple, M D 

New York N Y 161 

SHORT-INTERVAL STAGE OPERATIONS FOR SE- 
VERE HYPERTHYROIDISM Arthur B McGraw, M D 

Detroit Mich 198 

FACTORS INFLUENCING PROGNOSIS IN CARCI- 
NOMA OF THE BREAST Herbert H Davis, M D 

Omaha Nebr 207 

INTRATRACHEAL SUCTION IN THE MANAGE- 
MENT OF POSTOPERATIVE PULMONARY COM- 
PLICATIONS Cameron Haight, M D 

Ann Arbor Mich 218 

SPONTANEOUS CHOLEDOCHOGASTROSTOMY AND 

CHOLECYSTOGASTROSTOMY Marshall Davison, M D 

Leon J Aries, M S , M D 

Chicago III 229 

STONES IN THE COMMON BILE DUCT Frank C Beall, M D 

Port Worth Texas 238 

APPENDICITIS IN ARMY SERVICE Raymond W Bliss, M D 

Leonard D Heaton, M D 

El Paso, Texas 242 

VOLVULUS OF THE CECUM AND ASCENDING 

COLON Mandel Wemstem, M D 

Long Island City N Y 248 

ARGENTAFFINE TUMORS OF THE GASTRO-INTES- 

TINAL TRACT Thomas E Wyatt, M D 

Nashville Tenn 260 


THE MECHANISM OF SPASTIC VASCULAR DIS- 
EASE AND ITS TREATMENT Peter Hembecker, M D 

George H Bishop, Ph D 

St Louis Mo 270 


NEOPLASMS OF THE ABDOMINAL WALL Joseph A Lazarus, M D 

New York N Y 278 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS J C White, M D 

G P Whitelaw, M D 
W H Sweet, M D 
E S Hurwitt, M D. 


2 


{Contents continued on page 4) 


Boston Mass 287 





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No dextrose solutions 
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production of products for safe intravenous 
injection, these unlicensed solutions rccei\ e 
the same exacting care in production and 
testing as biologicals 

Like biologicals, dextrose solutions in 
Saftiflasks are produced w'lth scientific skill 
and knowledge They are tested and re 
tested chemically, bactenologically, phjs 
lologically by technicians of the calibre 
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from the manufacture of the products tested 
Specify dextrose solutions SafliflisJts 

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Berkeley, California Ml No Canal Street, Chicago 
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Annals of Surcerv 
February, 1938 


CONTENTS— Conhnued 

GIANT CELL TUMOR OF THE CERVICAL SPINE DeForest P Willard, M D 

Jesse Thompson Nicholson, M D 


Philadelphia Pa 298 


RATIONALE OF BONE DRILLING IN DELAYED 
AND UNUNITED FRACTURES 


Proviso V Prewitt, M D 
E R Easton, M D 


New York N Y 303 


BRIEF COMMUNICATIONS AND CASE REPORTS 

STAB WOUND OF THE HEART TWENTY -ONE TEARS AFTER 


SUTURE 

John F X Jones, M D 



Philadelphia Pa 

311 

AN AMBULATORY TREATMENT OF FRACTURE OF THE PATELLA 

Eugene St Jacques, M D 



Montreal Canada 

311 

MEMOIR 

INGERSOLL OLMSTED 

Donald C Balfour, M D 

314 

BOOK REVIEWS 

POSTGRADUATE SURGERY 

Charles Gordon Heyd, M D 

316 

THE MANAGEMENT OE FRACTURES, DISLOCATIONS AND SPRAINS 

Robert L Preston, M D 

319 

BOOKS RECEIVED 


320 


DOUBLE LUMEN TUBES FOR 
SMALL INTESTINAL INTUBATION 

T Greer Miller M B , F A C P 
and 

W Ofller Abbott M B , Philadelphia 



This double channel tube principle is used for three special purposes First for treating- and diagnosing 
obstructive lesions of small intestines second for controlling patient with intestinal obstruction by enabling 
him to feed yet to draw off residue above point of blockage third for use after gastro enterostomy 

As shown in the illustration one lumen of the tube is used to inflate the balloon the other entirely inde- 
pendent for feeding or aspiration and inflation of the balloon stimulates peristalsis to propel the apparatus 
through the whole small intestine in from three to four hours 

The terminal balloon may be distended to cause active peristalsis capable of carrying the tip of the tube to 
the cecum in four hours in a normal individual or at a slower rate in a case of intestinal obstruction 
By attaching the lumen leading to the balloon to a recording instrument a tracing of intestinal activity 
that may be of diagnostic signiflcance can be obtained 

Suction applied to the larger lumen will empty the intestine in a normal case or in a case of intestinal 
obstruction 

The lumen used for suction may also be used for the injection of barium sulphate suspension in making 
roentgenological studies of small intestinal lesions 

P9140 Abbott double lumen tube (No 11) with balloon proximal to perforated metal end see illustration 
P91i2 Abbott tube similar to above (No 3) -with the balloon distal to the perforated metal end 
P9144 Abbott tube for use after gastro enterostomy (No 12) double lumen with perforated metal and piece 
but \Mthout balloon 

(See Journal of American Medical Association January 4 1936) 

GEORGE P Dll I Ikll^&SONCO 
ARCH & 23rd T I U U I IN PHILADELPHIA 


4 


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MfcCct'Htffo^y/ Fo/PoWiiqtmse Phin - endb^cope 

This appropriately named cystoscope possesses such broad uiilily < 
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Sectional view of 
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for examining the 
verumontanum 
and ejaculatory 
duct orifices which 
are splendidly vis- 
ualized, being 
seen in their 
natural relation- 
ship to the sur- 
rounding topo- 
graphy As further 
evidence of the 
wide utility en- 
enjoyed by this 
instrument, precise 
bladder mspec- 
tion as well as 
examination of the 
urethra are pos- 
sible 








4 



i 




A A i 


I 


• 1 


* 1 ^ 


i 


:»• • 


I 


‘ « 


• i> 

III 

:»■ 



f 




iCTlAi 



Annil'i of SurKcry 
February 1038 



AVERTIN 

with 

AMYLENE HYDRATE 

S INCE the introduction of Avertin 
with Amylene Hydrate for basal 
anesthesia, approximately 400 reports on its use in general surgery, 
gynecology, obstetrics and other specialties have been published in 
North American journals In many of our largest hospitals this method 
of basal anesthesia is now employed daily 

Avertin with Amylene Hydrate appeals so favorably to patients, anes- 
thetists and surgeons because they appreciate that this method provides 
satisfactory basal anesthesia Write for booklet "Avertin with Amylene 
Hydrate” (recently revised), giving detailed information regarding dos- 
age and manner of use, signs and symptoms of basal anesthesia and 
the postoperative stage, the use of supplemental anesthesia in reduced 
dosage, as well as indications and contraindications 

Avertin with Amylene Hydrate is supplied in bottles ot 
25 cc and 100 cc (each 1 cc containing 1 Gm of Avertin) 

The painphlet on Avertm vitth Amylene Hydrate 
IS sent free to physicians on request 

WiNTHROP CHEMICAL 

pharmaceuticals of merit for the physician 

NEW YORK N Y WINDSOR, ONT 

Factories Rensselaer, N Y — Windsor, Ont 

AVERTIN, Reg US Pat Off S. Can idcntifsmg Winthrop brand of TRIBROMETHANOL. 

557 AM 





Please mention Avnals or Suegerv when irnting advertisers 


7 




Annals of Surgerv 
February 1938 


FOR Varicose Veins 

Hemorrhoids, Varicocele, Hydrocele, etc 



Formula No. 61 

riie action of Formula No 61 is to reinforce the 
vein wall where necessary so that normal size and 
function may be regained and retained 
Formula No 61 may be injected either intravcn 
ously or extravenously, consequently is indicated 
in the treatment of “sunburst” types 
Write for literature on simplified technic 

FARNSWORTH LABS, CHICAGO 


Cook County 

Graduate School of Medicine 

(IN AFFILIATION WITH COOK COUNTV HOSPITAL) 
Incorporated not for profit 

ANNOUNCES CONTINUOUS COURSES 

MEDICINE — Informal Course, Intensive Per- 
sona] Courses, Special Courses 
SURGERY — General Courses One Two, Three, 
and Six Months Two Weeks’ Intensive 
Course m Surgical Technique with practice 
upon living tissue. Clinical Course, Special 
Courses 

GYNECOLOGY & OBSTETRICS— Diagnostic 
Courses Clinical Courses, Special Courses 
FRACTURES & TRAUMATIC SURGERY— In- 
formal Practical Course Ten-Day Intensive 
Course starting February H 1938 
OTOLARYNGOLOGY— Two Weeks Intensive 
Course starting April 4 1938 
OPHTHALMOLOGY— Two Weeks Intensive 
Course starting April 18, 1938, Personal 

Course in Refraction Methods 
UROLOGY — General Course Two Months Inten- 
sive Course Two Weeks Special Courses 
CYSTOSCOPY — Ten Day Practical Course 
GENERAL INTENSIVE AND SPECIAL 
COURSES IN ALL BRANCHES OF MEDI- 
CINE AND SURGERY 

TEACHING FACULTY 

Attending Staff of Cook County Hospital 

Address Registrar 427 South Honore Street 
Chicago, Illinois 


INDEX TO ADVERTISERS 


SURGICAL SUPPLIES 

American Cystoscope Makers, Inc 
Kny-Scheerer Corporation 
George P Filling & Son Co 
Taylor Instrument Companies 

LIGATURES 

Davis & Geek, Inc 
Davis & Geek, Inc 
Johnson & Johnson 
C De Witt Lukens 


General Electric X-Ray Corp 


X-RAY PLATES 


PHARMACEUTICAL SUPPLIES 

Alba Pharmaceutical Company 
Anglo-French Drug Co , Inc 
Ciba Pharmaceutical Products Inc 
Cutter Laboratories 
Farnsworth Laboratory 
E Fougera Jk Co , Inc 
HolImann-LaRoche, Inc 
Ell Lilly & Company 
Loeser Laboratory 
Parke, Davis & Company 
Petrolagar Laboratories, Inc 
Purdue Frederick Company 
Schering & Glatz, Inc 
E R Squibb & Sons 
William R Warner & Co Inc 
Winthrop Chemical Co , Inc 
Zonite Products Corp 

HOTELS 

Benjamin Franklin 
Chalfonte-Haddon Hall 

PUBLISHERS 

Journal of Bone and Joint Surgery 
Lea & Febiger 
J B Lippincott Company 

SCHOOLS 

Cook County Graduate School of Medicine 
Chicago Post-Graduate School of Surgery 


Page 

5 

Inside Back Cover 
4 
25 


Id 

Insert 8-9 
15, 28 
16 


21 


Inside Front Cover 
Back Cover 
3 
S 
19 
12 

13 

Back Cover 
9 
11 

Inside Back Cover 
27 

14 
23 

7 

17 


22 

22 


24 

20 

10, 18, 26 


8 

10 


8 


Please mention Anvals or Surgfri when writing advertisers 






fyinp- fr, ., '«on of 3 , 

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fAen a ^ Aacjt of 

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WITH SWAGED-ON ATRAUMATIC NEEDLES 


T his group of products comprises over a hundred suture and needle 
combinations specially designed for specific procedures, particularly 
those in which minimi/>ed suture trauma and the convenience of needles 
which cannot possibly become unthreaded, are desirable A few products 
from this group are shown on these pages Full information on others 
may be obtained from your dealer or by mail from us, upon request 


Intestinal Sutures 

K ALMERID plain or chromic catgut, 
celluloid-lmen or silk with Atraumatic 
needles m the several types indicated inte- 
grally affixed Suture lengths 36 inches for 
products 1342., 1352, 1372 and 1542, all 
others 28 inches 

IHERMO-FLEX (non-bo liable ) 


Plain Catgut 


^o 

1 501 

Straight Needle 

NBCDLC 

A-I 

DOZEN 

S3 60 

1503 

%- Circle Needle 

A -3 

4 

20 

1504 

Small 1/2- Circle Needle 

A -4 

4 

20 

1505 

’/2- Circle Needle 

A -5 

4 

20 

10-Day Chromic Catgut 




1541 

Straight Needle 

A-I 

$3 60 

1542 

Two Straight Needles 

A-I 

4 

20 

1543 

%- Circle Needle 

A -3 

4 

20 

>544 

Small V2- Circle Needle 

A -4 

4 

20 

>545 

'/2- Circle Needle 

A -5 

4 

20 


CLAUSTRO-THERMAL 

(hoi table) 



Plain Catgut 




1301 

Straight Needle 

A-I 

S 3 

60 

1303 

%- Circle Needle 

A -3 

4 

20 

>304 

Small '/2- Circle Needle 

A -4 

4 

20 

>305 

'A -Circle Needle 

A -5 

4 

20 

10 -Day Chromic Catgut 




>341 

Straight Needle 

A-I 

S 3 

60 

1342 

Two Straight N eedles 

A -1 

4 

20 

>343 

%- Circle Needle 

A -3 

4 

20 

>344 

Small ’A- Circle Needle 

A -4 

4 

20 

>345 

>A -Circle Needle 

A -5 

4 

20 


Intestinal Sutures (cont’d) 


Celluloid- Linen 


NO 

1351 

NEEDLE 

Straight Needle* a-i 

DOZEN 

S3 60 

1352 

Two Straight Needles* a-i 

4 20 

1354 

Small ’A-Circle Needle* A-4 

4 20 

Black Silk 


1371 

Straight Needle* a-i 

S3 60 

1372 

Two Straight Needles* a-i 

4 20 

>374 

Small 'A-Circle Needle* A-4 

4 20 

Sizes 

00 0 I, except *00 

0 only 


In packages of 12 tubes of a kind and size 



A I 


DIWI^rFRS 022 TO 026 



Eye Sutures 

F ine sizes of plain, lo-day chromic cat- 
gut, and black silk with small Atrau- 
matic needles Suture length 1 8 inches ex- 
cept as noted Boilable 

B-I B-4 



NO 

1 661 

MATERIAL 

Black Silk 

son 

6-0 

NERWIP 

n -3 

1663 

Plain Catgut 

4-0 

B-5 

1665 

Black Silk 

6-0 

B-I 

1665 

BhckSilk 

4-0 

B-I 

1 667 

Plain Catgut 

1-0 

B-4 

1 669 

I o-Day Catgut 

4-0 

B-5 

1669 

I o-Day Catgut 

3-0 

B-5 

1669D 

10-Day Catgut t 

4-0 

B-5 

1 669D 

I o-Day Catgut t 

3-0 

B-5 


DOUBLE 

ARMED 


1 66z 

Black Silk * 

6-0 

B -3 

1 664 

Black Silk ' 

6-0 

B-1 

1 664 

Black Silk * 

4-0 

B-I 

1666 

Plain Catgut * 

3-0 

B-4 

1668 

lo-Diy Catgut* 

4-0 

B-5 

1 668 

1 o-Day Catgut * 

3-0 

B-5 

i668d 

10-Day Catgut t 

4-0 

B-5 

I 668d 

1 o-Day Catgut t 

3-0 

B-5 


* 1 2 inches 

f 9 inches 



Package of 12 tubes of a kind $4 20 

Cleft Palate and Harelip Sutures 


r I r-2 ( ^ 

ct rriNo 1 1 ri iN< m i Tist 



^0 MATJ RIAL «>I7r NFKDLK 

1751 Kal-dcrmic 00 c-i 

1752 Aluniiniim-Bron7eWire 00 c-i 

1753 Black Braided Silk 000 c-2 

1754 Alunuiium-BronzeWirt 00 c-4 

1755 Kal-dermic 00 c-3 

1758 Aluminum-Bronze Wire 00 c-3 

Suture length i S inches 

Package of 12 tubes of a kind $4 20 


Thyroid Sutures 

T hermo-flex (,w,i-htir,Ue)or Claustro- 

Thermal {bailable) catgut, and black 
braided silk with half-circle, taper point 
Atraumatic needles Suture length28 inches 


NO MNTFRIAI. SI7r M 1 r 

1635 Non-Boihble Plain Catgut o i-i 

1625 Boihble Plain Catgut o t-i 

1624 Black Braided Silk 000 i-z 

Package of I 2 tubes of a kind $4 20 

Plastic Sutures 

F ine sizes of Kal-dermic, silk and silk- 
worm gut with small, cutting point 
Atraumatic needles Suture length 1 8 
inches. Boilable 



NO 

1651 

MAIPRIAL 

Kal-dermic 

si?r 

8-0 

r n i>i r 

B-I 

1651 

Kal-dermie 

6-0 

n-1 

1652 

Kal-dcrmic 

8 0 

It- 5 

1652 

Kil-dermic 

6-0 

B-5 

1652 

Kal-dermic 

4-0 

B-5 

>653 

Black Silkworm 

4-0 

B-1 

1655 

Kal-dermic 

4-0 

B-Z 

1658 

Black Silk 

4-0 

B-Z 

Package of I2 tubes of a 

kind 

S4 20 


Other D & G Sutures 

S pecial needled sutures are also pre- 
pared for dental, tonsil, circumcision, 
obstetrical, ureteral, renal, nerve, arter) , 
and emergency work These are in addition 
to our complete line of unneedled sutures 
embracing catgut, ribbon gut, kangaroo 
tendons, and a variety of other non-absorb- 
able materials 




DISCOUNTS ON QUANTITIES 


DAVIS & GECK, INC , 217 DUFFIELD STREET, BROOKLYN, NEW YORK 

Cop} ngiit Z 9 J 8 Z>at 2 $ i GeeJe, Inc Pnoted in U S A 



s u 


s 


R G 



J OHN HUNTER (1728-1 793) obt lin- 
ed imich of the expeiience on which 
his “A Treitise on Blood Infl inim ition 
ind Gunshot Wounds ’ was bised vshile 
sciving IS stiff nacal siugeon during the 
w ir with Fiance In 1776 he w is ap- 
pointed Surgeon Extraordinary to the 
King md in 1 785 performed his first 
lig-ition of the femorxl iitery in Hunter s 
C in il for popliteil 'ineurisin The old 
operation h id pro\ ed tins itisf ictory and 
this impiovement of Hunter s was a 
signihc int contribution to surgery 


D&G Sutures 

‘^IHhY ARh HhAl i>ll<RILIZhD 


DAVIS & GECK INC 




Annals of SurKen 
February 1938 


1 / ^ 



25 Patients ca^ 


Of one hundred cases developing type I ific it»tp!nHTTTWf5?Sfl 
pneumonia, seventy will recover and five In a senes of 160 type 
will die regardless of treatment The re- 
maining twenty-five will die without treat- which specific uim? 
ment, but can be saved by prompt adminis- twenty-four hours of >■ 
tration of Antipneumococcic Serum, Felton reduced to onc-third <1 

Reports in recent medical literature serum-treated cases, and 
have shown that the very early use of spec- average rate m cases ' i 


Antipneumococcic Serum (Felton) l^pe I, Hefined and Concentrated, is ^ 
available m syrmge packages contaimng 10,000 and 30,000 units, Antipneu 
mococcic Serum (Felton) Types I and n. Refined and Concentrated, in syiinpe 
packages contammg, respectively, 10,000 and 80,000 units of each type 


PARKE, DAVIS & COMPANY • Detroit, 

THE WORLD'S LARGEST MAKERS OF PHARMACEUTICAL AKD RWLOGICAL ^ 


Plense mention Annals or Slrcerv when writing -id\erti'crs 



Annals of Surirery 
February 1938 


Actual Practice in Surgical Technique 






i Wx/'v ' 'V ^ Vv 
I Cy \ 

= j * « ' 


--sr,'V^ \ 


^ -/ 

IMetliod of Holding Connel Stitch IT'rom 
Principles of Operative Surgery, 
by A V Portipilo, M D 

Special Courses — 

Urology Cystoscopy Orthopedic Surgery 
Thoracic Surgery Surgical Pathology Labora 
tory Diagnosis and Technique Bronchoscopy 
Eye, Ear, Nose, and Throat Goiter Surgery 
Gynecology Surgical Anatomy Proctology 
Visitors always welcome 


CHICAGO POST-GRADUATE 
SCHOOL OF SURGERY 

(Formerly — Laboratory of Surgical Technique) 
(Incorporated not for profit) 

Near Cook County Hospital 

1 Two Weeks Surgical Technique Course 
rotary course continued throughout the year 
Combines Clinical Teaching and ACTUAL 
PRACTICE BY THE STUDENTS under 
competent supervision A review of the neces 
sary Surgical Anatomy is embraced in the 
work 

2 General Surgery One to Three Months 
Course designed for students who wish to 
review more thoroughly Anatomy, Surgical 
PathoIog>, Surgical Technique, and Clinical 
Surgery 

3 Special instruction and practice in the tech 
nique of one or more operations is available 
to surgeons who wish to review the Anatomy 
and Technique of certain operations 

Personal Instruction Actual Practice Op 
crating Rooms, Equipment and Method 
of Teaching Ideal and Unsurpassed For 
information as to Courses, Fees, Regis 
tration Requirements, Etc , address 


A V PARTIPILO, MDjFACS, Director, 1950 S Ogden Ave , Chicago, 111 , Phono Hayinnrket 7044 


Lowsley & Kirwin— UROLOGY FOR NURSES 

This new book adequately answers the urgent demand for a text in Urology 
which not only coveis the basic science but also stresses the newer refine- 
ments of practice as well as presenting the Nuising factors in pioper detail 
The methods are based on moie than fifteen years of experience in a large, 
modem uiological clinic thiough which thousands of patients pass annu- 
ally Every instiument and method here described has been put to the 
severest test of actual usage The mateiial is readily accessible to the teach- 
ing nurse, student and busy giaduate It has a chapter on special instru- 
ments and equipment, instructions regarding their care Special emphasis 
IS placed upon the part of the nuise in pre-operative and post-operative 
caie, which, in such procedures as prostatectomy, is often as important as 
the opeiation itself The nuise’s work in the operating and cystoscopic room 
in the prepaiation, assistance and care of the instruments after use is 
described in detail It has a chapter on diet and glossary 

Octavo 49^ pages loi illusti ations Cloth, $3 00 

By OSWALD SWINNEY LOWSLEY, M D , Director, Department of Urology 
(James Buchanan Brady Foundation), New York Hospital, and THOMAS 
JOSEPH KIRWIN, M D, Attending Surgeon, Department of Urology (James 
Buchanan Brady Foundation), New York Hospital 


J . 


B. LIPPINCOTT 

Dept AS Washington Square 


COMPANY 


Philadelphia 


10 


Please mention AbNALS of Suegeev when writing advertisers 


Annals of Surgery 
February, 1938 



Discipline is the development of the fac- 
ulties by instruction and exercise " When 
functions such as habit time of bowel 
movement are neglected through lack of 
discipline or intelligence, they require care- 
ful training to restore them to a normal state 
Petrolagar has proved to be an agree- 
able and effective means of assisting in the 


establishment of bowel discipline Because 
Petrolagar mixes intimately with the bov/el 
contents, it increases the bulk in the stool 
to a soft mass which is easily passed 
Petrolagar is prepared in five types — 
providing the doctor with a variation of 
treatment to suit the individual patient 
Petrolagar Laboratories, Inc , Chicago, 111 


Petrolagar is a mechanical emulsion of pure liquid petrolatum (65% by volume) and agar agar Accepted by 
the Council on Pharmacy and Chemistry of the AmericanMedical Association for the treatment of constipation 


Petrolagar 


Please mention Vnnu-S of Surgeri -tthen untinp adicrticers 



Annal ofSiircor 
February 1938 




SYNTROPAN ^ROCHE^ 

A new non narcotic synthetic substance which has a 
definite antispasmodic action on spastic smooth milscle 
Try Syntropan, in place of atropine or belladonna, 

TO CONTROL MUSCULAR SPASM 

PACKAGES and DOSE For oral administration tablet, 

50 mg , Elled in tubes of 20 One tablet (50 mg ) 3 or 4 times 
a day or as required For parenteral administration (sub 
rutaneous qr intramuscular injection) ampuls 1 cc each 
containing 10 mg One ampul 3 tames a day or as required 

*Thc phoephate salt of 3 dtctby! BmiRO-2 
2 dimethyl propanol cater of tropic acid. 

HOFFMANN-LA ROCHE INC NUTLET N J 


ac]™K]g 



CaQBBBC] 


Mt*-- 










Please mention Annals or Surgery when writing advertisers 





Annals of SurRorv 
Fcbruarj 1038 


B ^^ pROGRESS m the therapeutic field is the aim of 
the Lilly Research Laboratories Research acconi- 
phshes this progress Confidence on the part of 
the medical profession should be reserved for medicinal 
products which are supported by adequate laboratory 
and clinical research i Look for the Lilly trade-mark 





FOR SPINAL ANESTHESIA 
Ampoules 'Metycame' (Gamma-[2-methyl-piper- 
idmo]-propyl Benzoate Hydrochloride, Lilly) 10 
percent, 2 cc , give prompt, sustained anesthesia 

FOR REGIONAL NERVE BLOCK 

Ampoules 'Metycaine' 20 percent, 5 cc , are sup- 
plied (To be diluted before using ) 

Literalure will be supplied to physicians 
upon recfnest 

Eli Lilly and Company 

INDIANAPOLIS, INDIANA, U S A 


Please mention Annai-s or Sotgery ■when writing advertisers 



Annals of Surcen 
February 1938 


/y 


CHARACTERIZED BY THE 

^ PWRITY 


Control of the production of Squibb Cyclo- 
propane begins with the selection and testing of 
the raw materials used, to make certain that 
they measure up to Squibb standards 

Elaborate purification methods are used in 
the process of manufaaure to render the gas 
free from deleterious substances A careful 
chemical analysis is made before the gas is 
released for sale 

This extreme care in produaion results in an 
exceptionally pure gas Squibb Cyclopropane has been generally accepted 
by anesthetists throughout the country as a dependable anesthetic agent 
Squibb Cyclopropane is supplied in 30-, 75-, and 200-gallon cylinders 
and in 2-, 6-, and 25-gallon Amplons The 30-gallon cylinders and the 
2- and 6-gallon Amplons are especially suitable for portable machines 
Note Because of the great potency of Cyclopropane in low concen- 
trations It IS important that the anesthetist be thoroughly familiar with 
the technique of administration 



*Amplon IS a trade mark of E R Squibb &. Sons 


Voi tnjoimatton and booklet on Cyclop) opane address 
Anesthetic Division, 743 Fifth Ave , Neiv Yoik, N. Y, 


. E R!Sqxjibb SlSons.New'York 

MANUFACTURING CHEMISTS TO THE 
MEDICAL PROFESSION SINCE 1858 


Please mention A^^ALS OF Surgery when writing advertisers 




Annals ol Surgery 
February, 19^8 


OPERATIVE PROCEDURE 

PLATE NO 78 


Operations for Harelip— Single Cleft 



Absolute sterilization by heat, without impairment of tensile strength, is the daily 
production standard of Ethicon Sutures As taken from the sterile tubes, they 
possess more tensile strength than is required to ligate the largest human blood 
vessel or to suture the densest human tissue Ethicon Sutures are produced by 
exclusive procedures, from the raw material to the final stage of packaging and 
inspection in our laboratories They are supple, smooth and uniform 

ETHlCON“r“SUIiES 



JOHNSON & JOHNSON, NEW BRUNSWICK, N J , CHICAGO, ILL. 

MANUFACTURERS OF SURGICAL SUTURES SINCE 1887 


Please mention Annai-s op Surgery when writing advertisers 


15 




Annals of Surgery 
February 1938 


Lmulzerxs 

Sterile Catgut 


(Bartlett Process) 






ANNALS OF SURGERY 

VOL 107 FEBRUARY. 1938 No 2 


ACUTE INTESTINAL OBSTRUCTION 

EVAIiTJATION OF RESULTS IN TWENTY-ONE HUNDRED FIFTY CASES, WITH 
DETAILED STUDIES OF TWENTY-FIVE SHOWING POTASSIUM AS A TOXIC I \CTOR 

John Scudder, M D , Raymund L Zwemer, Ph D , 

AND Allen 0 Whipple, M D 
New York, N Y 

FROM THE DEPARTMENT OF BURGERF SCtJDDER MEMORIAL HOSPITAL RANIPET, INDIA, AND THE DEPARTMENTS OF 
SUnOERT, SURGICAL PATHOLOGY AND ANATOMY OP COLUMBIA DNI\ERSITY COLLEGE OF PHYSICIANS AND SURGEONS, 
AND OF THF PRESBYTERIAN HOSPITAL NEW YORK, N Y 

In the Orient, the problem of the neglected case of acute intestinal ob- 
struction IS difficult and the mortality high Even in the United States, despite 
advances m surgery and a cleai er knowledge of many of the altered biochemical 
reactions, the death rate during the last 15 yeais has varied little (loi to ii i 
per 100,000), but the total number is constantly increasing®^” 

Mortality rates from as high as 61 per cent®^ to as low as 19 per cent®- 
indicate what little umfoimity exists regaiding treatment and operative pro- 
cedure In comparing the results obtained for similar lesions at different hos- 
pitals, this disparity becomes especially apparent For these reasons, Lincoln 
Davis®® objected to the evaluation of statistics from various institutions unless 
they could be compared case by case 

Since the obseivations of Leichtenstern®^ and Nothnagel,®® the pulse rate 
has been used as a criterion in prognosis In Miller’s®'^ series, 71 per cent of 
the fatal cases exhibited either a subnormal temperature, or one above 100° F 
A rapid, shallow lespiiation was stressed by Braun and Boruttau® as an 
ominous sign in obstruction 

In the neglected case, the quick pulse, the rapid respiration and the elevated 
or subnormal temperature contrast strongly with the normal values found m 
the early one In ordei to test whether a combination of these three variables 
would give a truer picture of the patient’s condition, and thus afford a measure 
whereby the relative toxic state of each might be gauged, an index combining 
them was derived and applied in 570 cases of acute intestinal obstruction 

Determinahon of the Index — The index is the product of the three vari- 
ables Temperature, pulse, and respiration The noi mals taken are Tempera- 
ture, 986° F , pulse, 72, respiration, 16 To each, an arbitrary value of one 
IS given 

Temperature Factor For each rise or fall of one degree Fahrenheit, one is 

added to the normal of one 

Pulse Factor For every rise of ten in the pulse rate, one is added 

to the normal of one 
161 




SCtJDDER, ZWEMER AND WHIPPLE 


Annals of Surgerj 
February 1938 


Respiiatory Factor For each rise of five m the lespiratory late, one is 

added to the normal of one 

Example A strangulated heinia of three days’ dmation was admitted with 
Temperatme, 996° F , pulse, 112, respiration, 26 Index in this 
case 2 X 5 X 3 = 30 as compared with Noimal Index i x i x i = i 



Ch\rt I — Ordinates Temperature, pulse rate and respiration, indeK Abscissas Percentage 

of recoverj 


Table I 


DETERMINATION OE FACTORS 


98 6° 
97 6 ° 

99 6° 
96 6° 

100 6° 
95 6°1 

101 6° 

102 6 ° 

103 6° 


; Factor 

Pulse Factor 

Respiration Factor 

= I 

72 = I 

16 = I 

= 2 

82 = 2 

21 = 2 

= 3 

92 = 3 

26 = 3 

= 4 

102 = 4 

31 = 4 

= 5 

112 = 5 

36 = 5 

= 6 

122 = 6 

41 = 6 


The indices of 1,150 cases of acute mechanical obstruction (Group I*) were 
detennmed and charted, with the lecovery rate plotted against the index The 
declivity of the line shows that survival stands m inverse propoition, and mor- 
tality in direct proportion to the magnitude of the index 

162 




, X\cr;, 

Y. i! j i'-^n^J y> : 

' -^/i '©<53 rW, '*> 

"^v? M ’ O V- 
- ' v r }^ ^ 





Volums 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 



This same cm relation is seen in i,ooo cases of strangulated external hernia 
(Group (Chart 3) 

Amlysts of the Results of Opeiative Piocedmes — ^\Vith the objective value 
of the index revealed in 2,150 casesf the types of surgical piocedures were 
gauged in respect to the patient’s condition 

The reduction of a strangulated hernia with viable intestine gave the 
optimum piognosis in all cases The addition of an entei ostomy raised the 
mortality In the gangrenous hernia, a lesection with primary anastomosis 
augured better than did the principle of mai supialization (Chait 4) 

In analyzing the 925 opeiations with viable intestine, the relief of obstruc- 
tion, whether effected by division of the adhesions, detorsion of a volvulus, or 
reduction of an intussusception, offeied the patient the best chance as judged 
by 76 per cent recovery m 520 cases, and a highei survival at each index up to 
60 (Chart 5) 

A primary entei ostomy with the relief of obstiuction raised the mortality 
rate in 149 cases Giouped as to indices, the lecovery rate was lower m those 

Cases of obstruction are grouped according to the Massachusetts General Hospital 
plan Group I Acute mechanical obstruction, except those due to neoplasms Group II 
Obstruction due to neoplasms Group III Obstruction due to strangulated external 
hernia This paper does not include Group II, nor children under 12 years of age 

tThe statistical data were reviewed by Dr E B Wilson of the School of Public 
Health, Boston The scatter diagrams were made at Ins suggestion 

163 


SCUDDER, ZWEMER AND WHIPPLE ^eTuan^s 



Chart 3 — Ordiintes Toxicity index Abscissas Percentage of recovery Scatter diagram 
showing percentage of reco\erj for each index Brackets indicate the number of cases and the 
range of indices taken for each point on the chart 


enterostomy cases below 6o, and about the same for both the enterostomy 
and nonenterostomy groups above this index (22 and 19 per cent respectively) 
Enterostomy or cecostomy tvttJwnt the removal of the lesion gave a 70 
per cent mortality, a figure woise than that lepoited by Tieves,^-- in 1884 
A short-circuiting operation around the lesion failed to achieve the same suc- 
cess as did its removal 


Table II 

PERCENTAGE OF RECOVERY IN 2,150 CASES OF ACUTE INTESTINAL OBSTRUCTION, 
GROUPED ACCORDING TO ETIOLOGY (CHILDREN UNDER 12 EXCLUDED) 


Group I (Massachusetts General Hospital Classification) 


Recovery 

Lesion 

Lived 

Died 

Total 

Per Cent 

Bands and adhesions 

360 

213 

573 

63 

Volvulus of small intestine 

90 

66 

156 

58 

Volvulus of large intestine 

70 

57 

127 

55 

Intussusception 

38 

31 

69 

55 

Miscellaneous 

18 

18 

36 

50 

Gallstones and foreign bodies 

8 

9 

17 

47 

Meckel’s diverticulum 

6 

9 

15 

40 

Internal strangulated hernia 

14 

22 

36 

39 

Cause not ascertained 

24 

62 

86 

28 

Mesenteric thrombosis 

4 

31 

35 

II 

Totals 632 

Group II 

Obstruction due to tumors not included 

518 

1,150 

55 

Group III 

Strangulated external hernia 

765 

235 

1,000 

76 5 

Total of Senes 

1,397 

164 

753 

2,150 

65 



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Toxjcity 

Indtced 


Chart 4 — Ordinates TovicitA index Abscissas Percentage of recovery Surgical 
procedures in i 000 cases of strangulated hernia Brackets indicate the number of cases and 
the range of indices for each point on the chart 


SUHOICAL PROCEOURC^ JN 925 CA:>Z:> Or ACUTE INTESTINAL 
0B5TRUCTI0N 50WEL CON:>IDEREO VIABLE 

Ttecovery 


Type of operation Ca6e^ 

Rehef of obstruction only - 520 

Lateral Aotemooio about leoion --*—•* 45 

Relief of obotruetfon end Enterostomy 119 
Kchcfof obstruction end Entcrotomy — — 63 
Enterootomy or Cecootomy — — 110 


Torcentaqe 

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ToAlctty Indices 

Chart s — Ordinates Toxicitj index Abscissas Percentage of recoverj Contrast of the 
recovery rate for different surgical procedures in 925 cases of obstruction The figures represent 
the number of cases For example there were 362 cases, whose indices ranged from one 
to 20, in which the obstruction was relieved The percentage of recovery for this group was 82 s 
The next figure, 105, indicates that number of cases whose obstruction was relieved The 
indices for this group fell between 21 and 40 The percentage of recovery was 67 5 In the 
same range of indices there were 30 cases which had the obstruction relieved and a primary 
enterostomy, their percentage of recoverj was 10 per cent less than the los cases who did not 
have a primarj enterosfomj with the relief of obstruction 


SCUDDER, ZWEMER AND WHIPPLE f 


Annals of Surgerj 
February 1938 


111 analyzing the 178 cases with gangrene of the intestine, a resection with 
a piimary anastomosis in the mildly toxic case was preferable, whereas, in the 
seveiely ill patient, resection with delayed anastomosis gave bettei results 
Again, the exteiiorization of the gangienous bowel earned the greatest number 
of failures 




60 


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OPERATIVE PROCEDURES IN 176 CASES OP ACUTE INTESTINAL 
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Type of operotion Ce,e6 p"°ent7ge 

fiescction vfith Primary Anastomosis 67 41^ 

f?e&«ction and Enterootomy 49 50^ 

Marduptal{3atton Exteriorl3atten 42 17/ 



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Chart 6 — Ordinates Toxicity index Abscissas Percentage of recovery Contrast of 
recover} rate for three diffeient surgical procedures used in dealing with gangrenous intestine 
JIarsupialization of the loop was not as successful as resection and enterostomy or resection 
with primary anastomosis 


After summaiizing these cases, we are forced to again raise the following 
questions'^ What is the toxic depressoi substance in acute intestinal obstruc- 
tion^ Why IS strangulation oi gangrene moie lapidly fatal? In what manner 
does an entei ostomy increase the moi tality ? Why is gastric lavage beneficial ? 
Why IS the slow pulse so often misleading? Finally, how does salt solution 
mitigate the toxemia of obstruction ? 

Our attention was diiected to the adrenal glands by Wohl, Burns and 
Claik,^^° who reported cortical cell depletion m experimental obstruction un- 


Legend for Plate II — Normal human adrenal cortex Segment of a median section Note large 
clear cells ^^hlch contained lipoid (Xioo) Nos 2 and 3 — Adrenal cortex sections (full uidth) from two 
patients djing of intestinal obstruction Note disorganized cell arringement and presence of connectue 
tissue between cell columns It resembles Type 7 or 8 of Z\%emer*s''“ classification Postmortem cell 
changes and shrinkage due perhaps to technic should be discounted (Xioo) No 4 — Same adrenal as 
No 1 at a lower magnification, to show cell tjpes from capsule to medulla (X60) No 5 — Normal cat 
adrenal cortex The relative thickness of rounded adrenals is greater than that of the folded primate type 
(X60) No 6 — ^Adrenal cortex from Cat No 3636 showing absence of lipoid loaded “spongiocytes ’* 
This animal died three and one half days after esophageal obstruction (X60) 

* A more complete discussion and bibliography is given by Cooper, H S F Cause 
of Death in High Obstruction Arch Surg, 17, 918-967, 1928, and by Mclver, M A 
Acute Intestinal Obstruction New York, Paul B Hoeber, Inc , 1934 

166 



Plate II 

Photomickographs Illustrating Various Phases of Adrenal Histopatholog\ 









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See opposite page for legend 

167 



SCUDDER. ZWEMER AND WHIPPLE 


Annals of Surgery 
February 1938 


treated by saline solutions Examination of sections secured from autopsy 
cases at the Peter Bent Brigham Hospital revealed various stages of cortico- 
adrenal depletion according to the classification of Zwemer 

Acute intestinal obstruction and adrenal insufficiency have many features 
in common With the latter a definite disturbance in potassium metabolism 
has been shown to exist In experimental obstruction in cats, 

we have reported a rise in blood potassium to lethal levels The potassium 
values for the contents of obstructed loops, peritoneal fluid and vomitus were 
many times that of blood In experimental intestinal obstruction in dogs. 
Cutler and Pijoan^® confirmed the occurrence of a hyperpotassemia 

Coincident with the experimental work, studies were begun on patients 
We report here 25 cases, in 20, potassium determinations were made on 
blood secured at the time of admission , in tv o, the blood was taken after the 
administration of therapy, and in three, after operation 

Methods — Unless otherwise stated, fasting blood was collected in the morn- 
ing by the same person The sample Avas drawn with a sterile dry syringe from 
the antecubital vein without a tourniquet and placed into a Sanford-Magath 
hematocrit tube containing heparin After centrifuging at 3,000 r p m for 
one hour, the cell volume was read, and plasma separated immediately from 
the cells Samples showing any hemolysis were discarded The potassium 
content of o i Ml of whole blood and o 4 Ml of plasma was determined by 
the method of Truszkowski and Zwemer The values given represent 

the average of two determinations, differing by not more than 2 per cent 
from the mean 

The specific gravity of whole blood and plasma was measured by the falling 
drop* method of Barbour and Hamilton ® Plasma protein was calculated 
by the formula of Weech, Reeves and Goettsch 

The following figures are given as normal for potassium in the blood of 
humans Whole blood, 164 to 200 mg per cent, serum potassium, 18 to 21 mg 
per cent, cells, 350 to 465 mg per cent, aA'erage, 418 mg per cent Because 
of the wide normal range, emphasis should be placed on the change in potassium 
level rather than in absolute values 

Summary or the Potassium Content Data — Plasma Potassium In 
the 20 untreated patients, Avhose blood was taken on admission, the plasma 
potassium was raised m seven (Cases i, 2, 3, 4, 9, 19, 20) and low in five 
(Cases 5, 8, 14, 16, 18), the highest value being 33 4 mg per cent (Case 9) 
and the lowest 13 4 mg per cent (Case 5) In Case 23, a plasma potassium 
value of 28 2 mg per cent was found after 300 cc of 5 per cent salt solution 
Plasma K decreased m 12 following administration of saline and other treat- 
ment In two (Cases 14 and 22), despite saline, there was an increase 
m the plasma A'alue Both cases showed extention of the gangrenous process 
at autopsy 

Case Report — Case 20 Bronchopneumonia complicated by a strangulated femoral 
hernia “ Plasma potassium was high, rising to 30 i mg per cent following operation , 

* Pipettes may be obtained from Eimer & Amend, New York 

168 



Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


decreasing after the administration of eschatinf and salt solution but again climbing 
to 323 mg per cent in spite of further therapy Elimination by kidne\s poor as indi- 
cated by oliguria and a rise m the N P N The K m the urine, however, was 450 mg 
per cent Profuse sweating and muscular twitchings were prominent features’"’ 

Cell Potassium — In 20 untieated cases the aveiage cell potassium was 359 
with a range of 302 to 438 mg pei cent In 14 of these, cell K was distinctly 
low Tieated by injections of salt solutions, cell potassium rose m 12 (Cases 
3-9, II, 13, 14, 15, 18) , and fluctuated in Cases 10, 13, 16, 19 and 20 In 
other conditions the importance of cell K changes has been stressed 

Whole Blood Potassium on admission was above normal m five (Cases 5, 
6, 7, 12, 13), and low in Case 20 

Pentoneal Fluid Potassium varied from 132 to 286 mg per cent in ii 
cases 

Spinal Fluid Potassium was lower than the plasma potassium when they 
were taken simultaneously in Cases ii and 12 

Potassium Content of Gang) enons Loop Fluid — The values ranged from 
109 to 637 mg per cent in four cases (Cases 5, 14, 20, and 22) Death oc- 
curred in all 

Potassium Content of Entei ostomy Fluid — Analysis of potassium in both 
plasma and entei ostomy fluid m Case 9 showed the results to be identical 
In Case 25, the intestinal fluid K was twice that of plasma 

Potassium Content of Gastiic Fluid — In eight cases (Cases 14, 16, 18, 
19, 20, 22, 24 and 25) deteiminations of potassium in both plasma and 
gastric contents showed a range in the latter from 185 to 65 8 mg per cent , 
the average concentration of the gastric juice potassium being 2 5 times that 
of blood taken simultaneously 

Plasma Specific Gravity — The average in 18 cases was i 0297 with a range 
from I 0264 to I 0379 This contrasts with the average normal plasma density 
of I 0260 to I 0270 

Hematocrit — This showed 48 2 pei cent cells in the 20 untreated cases 
with a lange from 33 to 59 per cent This average of 48 2 per cent contrasts 
with the normal figure of 45 per cent 

Plasma Piotein — In the untieated cases the average plasma protein was 
7 8 Gm per cent with a range from 6 6 to 10 6 Gm per cent This is higher 
than the average normal of 7 o Gm per cent 

Discussion — Certain phenomena associated with acute intestinal obstruc- 
tion may be partly explained by consideiing potassium in their interpretation 

Simple Obstiuction — In the progressive dehydration accompanying this 
lesion, a lethal rise in blood potassium has been demonstrated experimentally, 
the rapidity depending upon the site of obstruction 

Intestinal Sh angulation and Gang} ene — Interference with the vasculai sup- 
ply of the intestines is always associated with a higher mortality In our 
experimental work, we attribute the earlier development of toxemia to a more 
lapid and sustained rise in blood potassium, occasioned by a loss of fluids, 

t Eschatin has been furnished by the kindness of Parke, Davis &. Company 

169 




SCUDDER. ZWEMER AND WHIPPLE 


Annals of Surger\ 
February 1938 


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170 



Volume 107 
Isumber 2 


ACUTE INTESTINAL OBSTRUCTION 


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z/3/37 178 318 18 4 so % I 0275 7 % Location of lesion Transi. crse colon Cured 

7 30 A M 2/6/ 37 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surgery 
February 1938 


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Volume 107 
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ACUTE INTESTINAL OBSTRUCTION 


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SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surgerj 
Tebruary 1938 


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Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


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SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surgerj 
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SCUDDER, ZWEMER AND WHIPPLE 


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178 



4PM 114 321 17 S 30 % I 0258 6 4% S minutes after transfusion of 600 cc of 

whole blood 


Tolumo 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


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4/14/37 222 482 IS r 43 % I 0229 S 4% riuid intahe since admission 26 400 cc 

8 30 A M Bilateral pittinp edema of legs 

Blood urea N 13 mg % Parenteral fluids 
stopped 

{Continued on next page) 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surgerv 
February 1938 


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180 


Location of lesion Twist at upper and Cured 
lower ileum 9/1/37 



\ olumc 107 
Vuiaher 2 


ACUTE INTESTINAL OBSTRUCTION 


obstruction, hemorrhage into the loop, and tissue necrosis togethei with inade- 
quate excretion Analysis of gangienous loop fluid in foui (Cases 5, 14, 
20, and 22) revealed potassium content many tunes that of plasma, wheieas, 
noimally, the potassium content of succus entencus is the same as that of the 
plasma 



Chart 7 — Ordinates Dajs Abscissas Plasma and cell potassium plasma 
protein and hematocrit readings At bottom of chart the amount of fluid ad 
ministered parentally is indicated Solid black represents intrarenous Ringer’s 
solution, slanting lines Ringer’s solution by cljsis See Cases 3 and 4 for 
details Note the fall in plasma potassium and the rise in cell potassium after 
the administration of saline solution Blood dilution is indicated b\ the fall 
in the hematocrit readings and plasma protein Recovery in both cases 



lOOOcc 


200 ce 


DEC JS 

Chart 8 — Case s Ordinates Days Abscissas Plasma potas 
Slum and plasma protein In spite of the administration of saline solu 
tion the plasma potassium continued to rise Autopsy showed exten 
sion of the gangrenous process 


A resection of the gangienous loop with a primary anastomosis gave the 
best lesults in the model ately toxic patient®® (Chart 6), probably for the 
following reasons (i) The exclusion of the danger of perforation, (2) the 
elimination of infection, (3) the removal of the neciotic portion of the intes- 
tine with Its abnormally high potassium content , (4) the maintenance of the 


181 



continuity 

function 

Enteros 

obstruction 


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Chart io — Case 20 Ordinates Time in hours Abscissas Plasma and 
cell potassium plasma protein and hematocrit readings At bottom of chart 
the types and amounts of fluids administered are detailed In estimation 
of the fluid loss, 1,500 cc were allotted to insensible perspiration See case 
report for details 

merits have been controversial Haden and Orr,^^ Drag- 

stedt,^® and Morton and Pearse®® have shown that animals with intestinal 
fistulae died with the same manifestations of toxemia, and as soon as animals 
with obstruction at the same level We have investigated the effect of com- 
plete intestinal fistulae upon both hemoconcentration and blood potassium and 


Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


find the lesultant hyperpotassemia similar to that occurring m acute intestinal 
obstruction, experimental adrenal insufficiency, and experimental 
potassium poisoning 

The 70 per cent mortality following enterostomy ivithout the removal of the 
lesion (Chart 5) may thus be explained by two factors (i) In failing to re- 
move the obstruction, absorption of fluids and intestinal secretions is prevented , 
(2) the external loss of fluids and electrolytes through a fistula placed above 
the obstruction accentuates the dehydration with consequent earlier and gieatei 
rise m blood potassium 

Enteiotomy—Thxs was performed in 63 cases with a gross moitaiity of 
57 per cent Comparing this group with the lehef of obstruction and entei- 
ostomy, the mortality m the latter is 9 pei cent higher and the recovery late 
IS less at each index (Chart 5) This contrasts with Holden’s®^ success, ob- 


PH # 35 < 12<?0 


■.'"III 


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n 



Chart i i — Case 22 Ordinates Days Abscissas Plasma and cel! 
potassium, plasma protein and hematocrit readings Daily fluid balance is 
indicated at top of chart T indicates transfusion Note the fall in cell 
potassium following each transfusion, also the increase in plasma proteins 

tamed by relieving the obstruction, removing the intestinal content by stripping 
through an enterotomy, and the giving of hypei tonic salt solution subcuta- 
neously His procedure eliminates the toxic intestinal fluid (rich m potas- 
sium) , preserves the continuity of the gastro-mtestmal tract and combats a 
potential h)^perpotassemia by the adeqiite advnmsbahon of salts and fintds 
In our senes, the gut was stripped m only two cases More chemical studies 
on both the blood and intestinal contents are needed m this controversy of 
enterotomy vetsixs enterostomy ss. 87 . so ns Continued gastric suction has 
reduced the need for either 


Gastric Lavage — Introduced by KussmauP® m the treatment of intestinal 
obstruction, gastiic lavage is a recognized procedure The advent of continued 
gastric suction has carried the value of decompression one step farther Carl- 
son^® suggested some noxious element was washed out by vomiting In our 
experimental work, the abnormally high potassium content of the vomitus 
indicates that secretion of this base into the gastiic lumen, followed by vomit- 

183 





Chart 13 — Electrocnrdiograplnc Report Leads i 2 and 3 Taken September 
8 1036 Control Sinus rh>thm Ventricular rate 80 P-R = o 17 to o 19 Left pre 
ponderance P3 inverted Ti, Ta T3 npnght Well marked left preponderance is the 
chief finding 


184 


Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


mg, may be regarded as pait of an auxiliary or emeigency mechanism for 
lowering blood potassium The values are repoited in eight cases 

Pulse m Obshuction — The slow pulse is often deceptive Eisberg-^ 
counsels against delaying operation until disturbances m the pulse become 
manifest 

The action of potassium on the heart both m vwo and m viUo has been 
amply demonstiated “• ^7. ss 73, 79 Gautielet®^ introduced into fiogs’ circul- 



Chart 14 — Electrocardiographic Report Senes of lead 2 after taking potassium 
See I — sinus rhythm, \entricular rate 80 P-R = 019 

See 2 — sinus rhythm, rentricular rate 78 P-R =2 o 17 

Sec 3 — sinus rhjthm, Aentricular rate 76 P-R r= o 15 

Sec 4 — sinus rhythm ventricular rate 80 P-R = 018 

Section I IS essentially identical with the control There is not howerer the \aria 
tion in the P-R as noted in the control The form of the complexes is similar 

Section 2 The \oltage throughout is distinctlj lower and the conduction time is less 
than before, being o 17 throughout 

Section 3 The low voltage persists the P waves now being of exceedinglj low 
amplitude and the conduction time is further reduced to 0 15 

Section 4 This resembles very closely the first section in that the voltage is higher 
thm m the second and third sections The conduction time is greater 

lation potassium ions obtained by electiolytic dissociation, and found that like 
potassium salts, they pioduce a decrease m the number of conti actions, a 
gradual diminution in the amplitude of the beat, and finally cessation of the 
heart action, electrocardiograms taken resembled those of muscular fatigue 

185 


SCUDDER, ZWEMER AND WHIPPLE 


Annalsof Surgery 
February 1938 


A relationship of hyperpotassemia to some of the peculiarities of heart 
action IS suggested by two sets of expei imental data and two human cases As 
part of a study of human potassium toleiance^^® one of us (J S ) took 20 mg 
of potassium per pound of body weight Electi ocardiograms taken at intervals 
revealed that with an increase of 50 per cent m the capillary plasma potassium, 
there occurred a slowing of the late, a decrease in the p r interval and a de- 
crease in the amplitude of the complexes , all of which disappeared within two 
hours, at which time the plasma potassium had returned to normal 

A cat with a complete intestinal fistula showed, in addition to the above 
changes, T wave changes m leads two and three Cats dying of potassium 
poisoning gave the following electrocai diographic changes Flattening and in- 
version of T waves m leads two and three, and mtiaventricular block and 
ventricular fibrillation 

Case Report — Case 2 A male, age 60, was admitted September 24, 1936, with the 
complaint of severe epigastric pain of eight hours’ duration The past history was im- 
portant as he had had a partial thyroidectomy for cardiac insufficiency due to hyper- 
thyroidism in May, 1935 The patient was referred to the Aledical Service with a tenta- 
tive diagnosis of coronary thrombosis because his electrocardiogram was suggestive of 
severe heart muscle damage The exacerbations of the patient’s pain, blood pressure, 
which remained constant, and good heart sounds were not consistent with coronary oc- 
clusion Difference of opinion delajed operation for two days An obstruction due to 
a band was found The electrocardiograms showed improvement after treatment The 
plasma potassium was 29 mg per cent before, and 17 mg per cent after operation and 
therapy 

Dr Levy recalled another patient whose unusual history, absence of typical 
physical findings and electrocardiograms suggestive of severe heart muscle 
damage was watched for six days Necropsy revealed several feet of gangre- 
nous intestine, but no heart disease 

The Action of Salt — In four conditions associated with dehydiation, salt 
solutions have proved beneficial i e , Asiatic cholera, fistulae of the gastro- 
intestinal tract, adrenal insufficiency and acute intestinal obstruction 

(1) Choleia — Although intravenous saline was first used by Latta,®° 
during the 1831-1832 Edinburgh epidemic,®^ the mortality for this disease was 
not appreciably decreased until Rogers®® ^®® intioduced his treatment The 
rediscovery of a low plasma bicarbonate by Sellai ds^®® led to sodium bicar- 
bonate therapy, which lesulted in fewer cases of terminal uremia 

(2) Salt Treatment tn Intestinal Fistulae — Pawlow,®® prolonged the lives 
of dogs with pancreatic fistulae by feeding sodium bicarbonate The admin- 
istration of sodium chloride and sodium bicarbonate has yielded similar results 
in other types of fistulae of the gastro-mtestinal tract ®®’ 

(3) Salt Tieatment in Adienal Insufficiency — Soddu’s^^® observation, in 
1898, that adrenalectomized animals given salt lived longer, was neglected until 
1 ecent confirmation 1 s is 43 70 102 113 134 Lowered alkaline reserve and the 
benefits of sodium bicarbonate and other sodium salts have been emphasized 
in this condition In the adrenalectomized animals, the giving of sodium 
bicarbonate in amounts proportional to the lowered CO2 was suggested by 
Zwemer 


186 



Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


Diagram of corpuscles and 

SERUM OF NORMAL AND CHOLERA BLOODS 

Lost 
FLUID 


Serum 


CoRPUtCLCS 

Corpuscles Corpuscles Composition 

Normal Cholera of Cholera 

Blood. Blood. Blood. 



Fig I — Hematociit readings (cell volume) of normal and abnormal 
blood (Rogers^'’®) 



Table III 





MORTALITY IN CHOLERA 



Mortality 

Date 

Type of Saline 

Cases Deaths 

Per Cent 

1831 (Latta and 

Saline intravenous 

166 


84 

Mackintosh®') 





1893 (Wall®') 

Hypotonic subcutaneously 

193 


70 


Calcutta Medical College Hospital Series 



1895-1905 

Rectal and subcutaneous hypotonic 





saline 

1.243 

783 

59 

1906 

Normal saline intravenous 

112 

57 

51 

1907 

Rectal and subcutaneous saline 

158 

94 

59 5 

1908-1909 

Roger's hypertonic saline intravenous 

294 

96 

32 6 

1910-1914 

Roger’s hypertonic saline intravenous 





and permanganate per os 

858 

222 

26 

1915-1919 

Roger’s hypertonic and Roger’s alka- 





line saline intravenous and perman- 
ganate per os 

1,429 

298 

20 8 

Formula for Roger’s saline solution 





Sodium chloride Gr 120 ( 

8 0 Gm ) 




Potassium chloride Gr 6 ( 

0 4 Gm ) 




Calcium chlonde Gr 4 ( 

0 25 Gm ) 




Distilled water one pint (568 cc ) 

This prescription, therefore, contains 15 2 Gm per 




hter, constituting a i 52 per cent solution 




187 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surcery 
Tebruarj 1938 


(4) Salt Treatment m Intestinal Obstuiction — Hartwell and Hoguet^® 
showed the survival period in the obstructed dog was doubled by subcutaneous 
salt solution injections Similar to Rogers’®®- ^®° treatment of cholera, Haden 
and Orr"*® have advocated hypertonic saline in bowel occlusion In the ex- 
tremely toxic patient, Orr has urged a 2 per cent salt solution by hypo- 
dermoclysis, and a 3 to 5 per cent solution intravenously, the initial dose 
being I Gm of NaCl per Kg of body weight, in order to restore the blood 
chlorides 


Vdsculdr 


Tnttrsiitial IniM Cellular 



Tig 2 — Acid base composition of body fluids 
rills diagram is constructed from average values for 
individual factors expressed in terms of acid base 
equivalence » e , as cubic centimeters of tenth normal 
solutions per lOO cc of fluid Base factors are super 
imposed in left hand and acid factors in right hand of 
each column They represent, as is actually the case 
a structure composed not of salt but of individually 
sustained concentrations of ions Exact acid base 
equivalence indicated by equal height of two parts of 
each column is obtained bj adjustabilit> of bicarbonate 
ion concentration (HCO3) to any change elsewhere in 
structure (From Mclver, M A Acute Intestinal 
Obstruction, New York, Paul B Hoeber Inc , 1934 ) 


Hypertonic salt solutions shorten the survival m experimental adrenal 
insufficiency '’'® It appears from our experience that these strong solutions 
should not be used alone m seveie dehydi atwn because the resultant blood 
dilution IS accomplished by ingress of cell water 

The similarity of the blood changes in the above four conditions is striking, 
and the values reported in the literature foi three of them are given In each, 
the beneficial action of sodium solutions has been attributed to correction of 
the altered biochemical changes of the blood, maintenance of blood volume, 
or the washing out of a hypothetical toxin ^®® 

Since an increased blood potassium is found in certain phases of Asiatic 
cholera,® adrenal insufficiency, intestinal fistulae, and acute intestinal ob- 
struction, the success of saline therapy® ®® ^®® might be attributed in part 
to Its effect on potassium metabolism 

188 





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189 


'‘i^av7ijns 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surgery 
February 1938 


SUMMARY 

( 1 ) Two thousand, one hundred fifty cases of acute intestinal obstruction, 
objectively analyzed, are reported with an evaluation of various surgical pro- 
cedures used in relation to the patient’s condition 

(2) Twenty-five additional cases are given in detail with determinations 
of plasma and blood density, hematocrit, plasma proteins, plasma, whole 
blood and cell potassium together with other constituents of the blood before 
and after therapy 

(3) The potassium contents of gangrenous loops, enterostomy drainage, 
gastiic secretion, peiitoneal and spinal fluids aie given of several 

(4) Disturbances in blood potassium resulting from derangements m body 
fluids explain some of the symptoms found and the procedures used in acute 
intestinal obstruction 

(5) Hyperpotassemia is not peculiar to intestinal obstruction, but may 
be expected in all conditions associated with rapid, or excessive, entry of potas- 
sium into the blood stream together with dysfunction of the numerous regu- 
latory mechanisms 

We wish to express appreciation to the following hospitals and person- 
nel for the use of their records 

India American Presbyterian Hospital, Miraj , the late Dr C E Vail who in- 
spired this study Bowring Hospital, Bangalore Kohlapur Mission Hospital, Dr N 
Dunning London Mission Hospital, Neyyoor, Dr I Orr and Dr T H Somervell 
Madras General Hospital, Madras, Sir Frank Connor, Surgeon General with the Gov- 
ernment of Madras Mission Hospital, Ongole, Dr A G Boggs Missionary Medical 
College for Women, Vellore, Dr I S Scudder Mysore State Hospital, Mysore, Dr 
F Robinson Nagpur Mission Hospital, Nagpur, Dr Augustine Royapuram Hospital, 
Madras, Sir Frank Connor St Luke’s Hospital, Vengurla, Dr R H H Goheen 
Scudder Memorial Hospital, Ranipet, Dr G Scudder 

Ceylon Colombo General Hospital, Dr Briercliffe, Director of Medical Services 
in Ceylon 

China Chinese Red Cross Hospital, Shanghai, Dr Yen Peking Union Medical 
College, Peking, Dr H H Loucks St Luke’s Hospital, Shanghai, Dr A W Tucker 
and Dr J C McCracken 

Hawaii Queens Hospital, Honolulu , Dr N P Larsen 

Japan St Luke’s Hospital, Tokj^o, Dr Bowles 

United States Billings Memorial Hospital and the University of Chicago Clinics, 
Chicago, Dr L G Dragstedt and Dr D Phemister Cook County Hospital, Chicago, 
Dr K Meyer Massachusetts General Hospital, Boston, Dr A W Allen and Dr E 
D Churchill Passavant Hospital, Chicago, Dr J Wolfer Peter Bent Brigham Hos- 
pital, Boston, Dr E Cutler Presbyterian Hospital, New York, Dr A O Whipple 
San Francisco Hospital, Dr L Eloesser and Dr H Brunn Stanford Hospital, San 
Francisco, Dr E Holman 

Dr S B Wolbach, Harvard Medical School, for autopsy sections on the adrenals 

Dr Louis Bauman for the blood chemical analyses (Chlorides, NPN, Blood 
Urea, CO=) 

Prof R L Levy and Dr H G Bruenn for the electrocardiograms 

190 



Volume lOT 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


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192 



■Volume 107 
Number 2 


ACUTE INTESTINAL OBSTRUCTION 


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421, 1932 


193 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Surcerj 
February 1938 


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194 



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Number 2 


ACUTE INTESTINAL OBSTRUCTION 


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1934 

““ Scudder, J A Yardstick of Acute Intestinal Obstruction , a Preliminary Report Based 
on 570 Cases Jour Christian Med Assn India, 10, 287-290, 1935 
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“ Stewart, H A On Certain Relations Between Lipoid Substances and the Adrenals 

195 



SCUDDER, ZWEMER AND WHIPPLE 


Annals of Suri:erv 
February lO'ig 


Tr Internat Cong Med, 1913 London, 1914 sect 111 Gen Path and Path Anat, 
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“■^Swingle, W W Studies on Functional Significance of Suprarenal Cortex, Blood 
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666-678, 1927 

Swingle, W W , and Eisenman, A J Studies on Functional Significance of Su- 
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“"Tileston, W, and Comfort, C W, Jr The Total Nonprotein Nitrogen and the Urea 
of the Blood in Health and in Disease, as Estimated by Fohn’s Methods Arch 
Int Med, 14, 620-649, 1914 

Thaler, J I Evidence of Permeability of Tissue Cells to Potassium Proc Soc 
Exper Biol and Med , 33, 368-371, 1935 

“^Toennis, W, and Brusis, A Veraenderungen des morphologischen Blutbildes bei 
akuter und chronischcr Darminhaltsstauung (Em Beitrag zur intestinalen Autoin- 
toxikation) Deutsche Ztschr f Chir, 233, 133-146, 1931 
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and Treatment Philadelphia, Henry C Lea & Co , 1884 
““ Truszkowski, R , and Zwemer, R L Cortico-Adrenal Insufficiency and Potassium 
Metabolism Biochem Jour 30, 1345-1353, 1936 
“““ Truszkowski, R , and Zwemer, R L Determination of Blood Potassium Biochem 
Jour, 31, 229-233, 1937 

“‘Van Beuren, F T, Jr, and Smith, B C Status of Enterostomy in Treatment of 
Acute Ileus, Statistical Inquiry Arch Surg, 15, 288-297, IP27 
““Walters, W, and Bollman, J L Toxemia of Duodenal Fistula, Physiologic Changes 
Concerned in Production of Its Characteristic Chemical Reactions of Blood JAMA, 
89, 1847-1853, 1927 

““ Wangensteen, O H , and Paine, J R Treatment of Acute Intestinal Obstruction 
by Suction with the Duodenal Tube JAMA, loi, 1532-1539, 1933 

Weech, A A , Reeves, F B , and Goettsch, E The Relationship Between Specific 
Gravity and Protein Content in Plasma, Serum, and Transudate from Dogs Jour 
Biol Chem, 113, 167-174, 1936 

Welch, C S , Masson, J C , and Wakefield, E G Qinical and Laboratory Findings 
After Excessive Loss of Intestinal Fluid from the Ileum Surg, Gynec, and Obst, 
64, 617-621, 1937 

““Wittstock, C Chemical Researches Into the Nature of Cholera Lancet, i, 169-171, 
1833-1834 

““Wohl, M G, Burns, J C, and Clark, J H Adrenal Glands in Dogs With High In- 
testinal Obstruction Proc Soc Exper Biol and ^fed , 33, 543-546, 1936 
“‘Wyman, L C, and Walker, B S Studies on Suprarenal Insufficiency IV The 
Blood Sugar in Suprarenalectomized Rats Am Jour Phjsiol, 89, 215-222, 1929 
‘“Yonkman, F F Acid Intoxication of Adrenal Insufficiency in Dogs Am Jour 
Physiol , 86, 471-482, 1928 

‘“Zwemer, R L A Study of Adrenal Cortex Morpholog> Am Jour Path, 12, 
107-I14, 1936 


196 



Volume 107 
Ivumbor 2 


ACUTE INTESTINAL OBSTRUCTION 


’“‘Zwemer, R L An Experimental Study of the Adrenal Cortex II Prolongation 
of Life After Complete Epinephrectomy Am Jour Physiol , 79, 658-665, 1927 
’“Zwemer, R L, and Ljons, C Leucocyte Changes After Adrenal Remoial Am 
Jour Physiol, 86, 545-SSi, 1928 

Zwemer, R L , Smith, J M , and Shirley, M The Adrenal Cortex and Blood Sugar 
Anat Rec , 45, 250, 1930 

Zwemer, R L, and Sullivan, R C Blood Chemistry of Adrenal Insufficiencj in 
Cats Endocrinology, 18, 97-106, 1934 

’“Zwemer, R L, and Truszkowski, R Factors Affecting Human Potassium Tolerance 
Proc Soc Exper Biol and Med , 35, 424-426, 1936 
’“Zwemer, R L, and Truszkowski, R The Importance of Cortico- Adrenal Regulation 
of Potassium Metabolism Endocrinology, 21, 40-49, 1937 
’’“Zwemer, R L The Adrenal Cortex and Electrolyte Metabolism Endocrinology, 
18, 161-169, 1934 


197 



SHORT-INTERVAL STAGE OPERATIONS FOR 
SEVERE HYPERTHYROIDISM 

Aethuk B McGkaw, MD 
Detboit, Mich 

FROM THE DEPARTMENT OF SURGERY OF TUE HENRI FORD IIOSPITAD, DETROIT, MICH 

Notwithstanding the continued improvements that from time to time 
have been devised m pre- and postoperative care, multiple stage operations 
still offer the best solution for the conduct of safe, yet adequate, surgical relief 
of the extremely toxic goitei patient Their value has been repeatedly cited 
and amply demonstrated by vaiious authois, but the intrinsic problems and 
alternatives of the operative procedures themselves have not always received 
proportionate attention It is with some of these latter problems that this 
report is concerned 

Stage operations for hyperthyroidism, if one may judge from articles on 
the subject in periodicals and in text-books, are nearly always performed by 
one of two classical methods The first method^ 2 3 4, 7, 14, it consists of the 
exposure of the superior thyroid poles through separate, short incisions, permit- 
ting ligation of the polar aiteiies or, at least, their main branches These polar 
ligations can be effected rapidly, almost bloodlessly, and if necessary without 
bringing the patient to the operating room A subsequent subtotal thyroidec- 
tomy can then be performed after whatever interval the patient’s improvement 
permits In the days before our present knowledge of the efficacy of iodine 
as a preoperative measure,^- such preliminary polar ligations were the only 
safe way to deal surgically with an extremely toxic goiter In the light of 
present knowledge about preoperative treatment, more than ligations can 
often be accomplished safely at the first stage Furthermore, there is the un- 
sightliness of the additional two small scars to consider The other classical 
method® is that of perfoiming a subtotal hemithyroidec- 

tomy as a first stage, discharging the patient on a strict convalescent regimen 
for a period of usually not less than six weeks, then rehospitahzation for prepa- 
ration and subtotal removal of the other thyroid lobe In the case of some 
very sick patients a series of operations may be necessary, commencing with 
ligations and followed by lobectomies Under ideal conditions, and with pa- 
tients who both can and will cooperate during the interval between operations, 
this second type of delayed operation is probably the method of choice, being 
safe in both stages, free from the risk of infection attending the early reopening 
of a wound, and on completion productive of as satisfactory an ultimate result 
as a single stage operation on a less toxic patient Certain local factors, how- 
ever, led us to seek, long ago, an alternate way of handling those goiter patients 
in whom some type of stage operation was obviously the only safe procedure 
Such a method, its development, and its results in our hands, in 161 consecu- 
tive cases over a period of the past 13 years, are herewith described 

198 



Volume 107 
dumber 2 


HYPERTHYROIDISM 


The factors refeired to above which complicated our delayed stage opeia- 
tioiis weie laigely social and economic The gieat majoiity of oiu patients, 
goiter or otherwise, were in the self-supporting, but low wage eainmg, stratum 
of factoiy woikeis and then wives, many of them had had only an elemental y 
education, and many were of alien birth, unable or impel fectly able to speak 
and understand English The number of women in this gioup was just double 
that of the men, a prepondeiance much less than that leported by various 
authors Some of these patients thought they were so much improved by a 
single lobectomy that they would not retui n foi the second opei ation Others 
waited long beyond the requested inteival and retui ned for the second opera- 
tion with their original degree of hyperthyi oidism fully recurient Otheis 
found the economic strain made invalidism oi even strict rest bet^^een opeia- 
tions difficult or impossible, with the lesult that their condition before the 
second operation was sometimes moie precaiious than it had been preiious 
to the first These factois combined to make delayed stage operations an 
unsatisfactory procedure m our hands 

Forced to make some compromise, and wishing if possible to use only a 
single peiiod of hospitalization by shoitening the interval between stage thy- 
loidectomies, we first tiied to consider the theoietic possibilities and then 
put them to clinical test ^^^e knew that with the use of fine silk suture mate- 
rial, stiictest asepsis, and gentle technic, wounds, even those of operations on 
the cential neivous system, could be leopened without ensuing infection, aftei 
the lapse of but a few days’ tune® furtherinoie seemed prob- 

able that the optimum time foi leopening a clean wound would he m the 
period after the edema and othei reactions to operative trauma had laigely 
subsided and befoie vasculaiization and cicatrization had proceeded to a point 
wheie they would complicate a second opei ation — le, somewhere between 
the fifth and twelfth postoperative days The crux of our problems was 
whether or not sufficient clinical iinpiovement foi a safe reoperation would 
dependably occur within the above mentioned interval, when eaily leopenmg 
of a thyroid wound would least likely lesult m infection oi poor healing 
After trial and observation of time intervals vaiying from one day to two 
weeks, we became convinced that the optimum period for “short-interval” 
stage thyroidectomies is from seven to ten days between operations After 
bilateral ligation of the supenoi polai arteiies, and more stiikingly after 
subtotal hemithyroidectomy, it is surprising how lapidly clinical improvement 
occurs after the first critical 36 to 48 hours have passed 

Table I shows ceitain facts about 189 consecutive stage thyroidectomies 
pel formed dining the yeais 1924 tlnough 1936 These lepresent 12 per cent 
of the 1435 thyi oidectomies performed dining the same period Before 1928, 
when the relative incidence of goiter patients began to deciease.-® 19 per cent 
of our thyroidectomies were pei formed in stages, but since 1928 only 8 per cent 
Section (A) indicates our expeiience iMth dela}ed hvo-stage operations 

199 



ARTHUR B McGRAW 


Annals of Surgery 
February 1938 


Table I 

TYPES OF TWO STAGE THYROIDECTOMIES 
(iSp Consecuhve Cases, ip24-ipj6) 



Total 

Operative 

Wound 


Cases 

Mortality 

Infection 

(A) Delayed (4-6 wk interval) 

(B) Reoperation within 48 hrs 

14 

21% 

7 0% 

i — Wound closed after 24-36 hrs 

13 

0% 

7 5% 

2 — Double lobectomy 48 hrs after ligation 
(C) Reoperation after 6-12 days 

1 — Double lobectomy completed after bilateral liga- 

I 

100% 

0 % 

tion 

94 

0% 

23 0% 

2 — Separate lobectomies completed 

48 

0% 

10 5% 

3 — Other combinations of procedure 

19 

49% * 

15 0% 

* This mortality figure is accounted for by the fact that Group 3 includes all 

patients who 


survived operations of more than tivo stages, also all patients who failed to survive the 
operations planned for them 

The high mortality (21 per cent) in oui small series of 14 operations 
of this type was partly responsible for our efforts to shorten the in- 
terval, even though we did not feel that the mortality was due to any fault 
in the underlying principles of delayed stages themselves We laid it rather 
to our inability to get the patients to cooperate m applying the principles cor- 
rectly Sections (B) and (C) deal with the patients upon whom operation 
was not delayed beyond 12 days In 13 toxic patients upon whom the com- 
plete operation was performed, the wound was packed open as a time saving 
safety measure, and sutured on the first 01 second subsequent day No infec- 
tion occurred after these opeiations We rejected this type of stage opera- 
tion, however, because we did not think it advisable to employ it on exti emely 
toxic patients, and felt that a reduction of the amount of surgery on the gland 
itself was a more important safety factor than a meie reduction of the time 
of operation by the few minutes involved in wound closure Of the 161 “short- 
interval” stage operations, 94, or 58 per cent, first had a bilateral superior 
polar ligation through a collar incision After an interval varying from six to 
12 days, the original wound was reopened and a subtotal bilateral excision 
was performed as the second and final stage Forty-eight patients, or 30 per 
cent, had first one lobe and later the other lobe subtotally resected after a 
similar interval and likewise through the same collar incision Among the 
20 remaining cases various combinations were tried, usually three stage opera- 
tions beginning with a bilateral ligation, followed by one and later a second 
subtotal lobectomy, all performed through the same collar incision The 
basic technic of all operations in this senes was that originally developed by 
Kocher in Switzerland and Halsted in this country and described by the 
latter in his “Operative Story of Goiter In various details, suggestions in 
a more recent illustrated descriptive article by Halsted’s pupils, Reid and 

200 



^ oUime 107 
ly umber 2 


HYPERTHYROIDISM 


Andrus, were followed Silk was used in every case After making the 
usual collar incision and freeing the sternohyoid and sternothyioid muscles 
of one side along their mesial borders, the upper pole was first carefully freed 
from Its blood supply and mobilized, thus aiding a safe yet thoiough exposure 
of the middle portion and lower pole This done, excision of the entiie uppei 
pole and all but a small posterolateral slice of the remainder of the lobe w as 
proceeded with, woiking from the peripheiy towaid the trachea and isthmus 
Where two separate lobectomies weie performed, sufficient exposuie was 
usually obtained at the second operation by reti acting the sternohyoid and 
sternothyioid muscles laterally Where preliminary ligations weie effected, 
the resulting edema and induration of these ribbon muscles at the second 
operation hindered exposui e and often necessitated transverse division between 
clamps 


Table II 

DURATION OF HOSPITALIZATION 

Average number of days m hospital before operation I2 9 

Average number of days in hospital between stages 8 8 

Average number of days in hospital after second stage 105 

Average total days in hospital 32 2 


Table II deals with the period of hospitalization of these “short-interval” 
cases At the present time, and for some years past, the usual hospital stay 
of a moderately toxic goitei patient is seven days before operation and eight 
to ten days after operation The table shows the average number of days 
elapsing before the first stage, between stages, and after the second stage The 
extra number of days before the first operation is reasonably accounted for 
by the severe degree of toxicity of these cases The number of days after the 
final operation, however, is only at the upper limit of what we usually find 
adequate for less toxic patients with complete operations The total numbei 
of days m the hospital averaged 32 2 This suggests that a “short-intei val” 
procedure for stage thyroidectomies will save a patient on an average a week’s 
hospital stay m addition to the four weeks of invalidism and economic depend- 
ence necessary between discharge after the first of two delayed-stage opera- 
tions and reentry to prepare for the second operation It furthermore elimi- 
nates poor cooperation on the patient’s part and any tendency not to return 
for the second operation Our care of patients between stages has con- 
sisted simply in replacing them on their original pi eoperative regimen of rest, 
high fluid and carboh)ffirate intake, Lugol’s solution, and mild sedation as soon 
as their immediate reaction to the first operation permits This is usually 
possible by the third day In selecting the day for the second operation we 
have been guided mainly by the patient’s tempeiature, pulse, condition of 
wound, clinical appearance and subjective symptoms of improvement A sig- 
nificant drop in the metabolic rate early after the first operation has occurred 
so seldom that had we depended on this sign alone v e v ould not have operated 
a second time within so short a period A few patients have been told m 

201 



ARTHUR B McGRAW 


Annals of Surgery 
rebruary 1038 


advance that stage operations were to be performed, but most of them have 
not been told until the morning of the second operation 

Table III 

EVIDENCE or SEVERE HYPERTHYROIDISM 

Initial preop B M R +70% or higher 
Initial preop B M R +50% or higher 

Initial B M R below +50% but with associated toxic myocarditis 
Highest postop rectal temp above 103“ P 
Highest postop rectal temp above 102“ P 
Average preop pulse pressure 


29% of senes 
74% of senes 
45% of series 
40% of senes 
74% of senes 
70 Mm Hg 


Table III summarizes some clinical obseivations, and is piesented as show- 
ing the severe toxicity or otheiwise complicated natuie of the series of cases 
under consideiation 


Table IV 

OPERATIVE MORTALITY AMONG l6l "SHORT-INTERVAL” OPERATIONS 


(A) Gross mortality 


12 deaths 

7 5% of group 

(B) After 9 j. operations planned for initial ligations 

II deaths 

1 1 5% of subgroup 

(a) After ligation only 


in 7 instances 


(b) After ligation -f single lobectomy 


in I instance 


(c) After ligation + bilateral lobectomy 

in 2 instances 


(d) After ligation and 2 separate lobectomies 

in I instance 


(C) After 48 operations planned as 2 separate lobectomies 

I death 

2 0% of subgroup 

(This death occurred after the first lobectomy) 



(D) Assigned causes of death — whole group 



(a) Mvocardial failure 


10 instances 


(b) Acute hyperthyroidism 


9 instances 


(c) Pneumonia 


2 instances 


(E) Deaths by age decades — whole group 




10-19 yrs group 

5 patients 

0 deaths 

0 0% of group 

20-29 yrs group 

24 patients 

0 deaths 

0 0% of group 

30-39 yrs group 

51 patients 

2 deaths 

3 9% of group 

40-49 yrs group 

35 patients 

0 deaths 

0 0% of group 

50-59 yrs group 

32 patients 

5 deaths 

15 5% of group 

60-69 yrs group 

14 patients 

5 deaths 

36 0% of group 

Total 

i6r patients 

12 deaths 

7 5% of group 


Table IV deals with the operative mortality of this series In the “short- 
interval” group of operations 12 patients should be considered operative deaths 
These deaths are analyzed in Table IV Not only were all of these patients 
severely toxic, but nine of the 12 were advanced thyrocardiacs, and two sub- 
ject, in addition, to attacks of angina pectoris For eight months of the cur- 
rent year (1937) we have had at our disposal a newly developed type of oxygen 
tent for immediate postoperative use^® The tent is operated by the gradual 
vaporization of liquid oxygen Its use has given such satisfactory aid in re- 
ducing or abolishing the severe reaction of toxic patients to operation that we 
ha\e hopes of lowering the moitality rate in our future stage operations on 
patients who are very poor risks 


202 



Volume 107 
Number 2 


HYPERTHYROIDISM 


Table V 

POSTOPERATIVE COMPLICATIONS OTHER THAN V OUND INFECTION 
{Eithre Senes of i8g Stage Operations) 


Hypothyroidism 

24 — 

12 5% 

Shock 

2 — 11% 

Recurrence 

22 — 

II 5% 

Pneumonia 

2 — 11% 

Vocal cord paresis 

18 — 

9 5% 

Hematoma 

2 — I I % 

Death 

15 — 

8 0% 

Acute hemorrhage 

I — 0 55% 

Acute hyperthyroidism 
Myocardial failure 

14 — 

13 — 

7 5% 

7 0% 

Tetany 

I — 0 55% 


Table V shows the postoperative complications other than infection en- 
countered in this seues in the descending older of then frequency The vocal 
cold weakness or paialyses weie all unilateial They occuiied in I2 5 pei cent 
of the separate lobectomies and in ro 5 per cent of the stage opeiations wheie 
only ligations weie performed first In the matter of recun ent or peisistent 
hypei thyi oidism, however, the diffeience in lesults between the two t}pes of 
short-interval operation is moie significant Eighteen of the 21 reciiirences 
weie 111 opeiations othei than two sepaiate lobectomies, the peicentages being 
17 and 6 lespectively Some degiee of hypothyi oidism occuired postopeia- 
tively in 24 patients These patients lepiesent 13 5 per cent of the entiie 
series Subtracting the recun ent and hypothyi oid patients leaves 745 per 
cent with an entuely satisfactory ultimate lesult 

Table VI 

WOUND INFECTION 

{Entire Senes of i8g Stage Operations) 


Total 

32 - 

- 17 

0% 

Bnef 

23 - 

- 12 

8% 

Protracted 

5 - 

- 2 

6% 

Severe 

3 - 

- I 

6% 

Contributory to death 

0 - 

- 0 

% 

Permanently disfigunng 

0 - 

- 0 

% 

In prelim ligation operations 

22 - 

- 23 

0% 

In 2 lobectomy operations 

5 - 

- 10 

5% 


Of all complications, however, wound infection has been the most fiequent 
and given us the most serious concern We believe, though, that we have 
learned some points about its control Were it not for the facts shown in 
Table VI, which lists every wound in which theie was the slightest deviation 
fiom clean healing, and were it not for our belief that every infection can be 
laid to some obsei ved or undetected flaw in technic, we would long ago have 
abandoned ti ying to shorten the interval between stages As 82 5 per cent 
of wounds healed per pi imam, as tin ee-quarters of the infections were of a 
transient and trivial natuie, and as no wound infections contributed to opera- 
tive mortality 01 caused permanent disfigurement, we feel this disagreeable 
complication is one that can be progiessively reduced by ever increasing care 
in technic Infection occuri ed only half as frequently in separate single lobec- 
tomies as m all other types of operation, 105 per cent as against 215 per cent 

203 



ARTHUR B McGRAW 


Annals of Surgery 
Februarj 1938 


DISCUSSION 

In addition to the use of fine silk and careful hemostasis thi oughout both op- 
erations, It IS of great importance and help to avoid bleeding wherever pos- 
sible, especially during dissection of the skin flaps by caie m keeping m the 
proper tissue planes and by avoiding all unnecessary tearing or section oi 
vessels The quantity of ligature material left in the subcutaneous tissues is 
thus materially lessened If the patient’s condition permits, unilateral lobec- 
tomy IS the first stage operation of choice It gives proportionately more symp- 
tomatic relief and improvement within the subsequent interval of seven to ten 
days and permits one to leave the remaining lobe with its fascial and muscular 
coverings unmolested until the second stage is undei taken We consider this 
noninterference with the unoperated lobe very impoitant At the fiist stage, 
furthermore, the entire isthmus and pyramidal lobe, if present, should also be 
thoroughly removed — even at the expense of dealing first with the smaller of 
two diffusely hyperplastic lobes At the second operation the region of the 
previously operated thyroid fossa should be left strictly untouched, sponged, 
or explored At the conclusion of the first stage it is preferable to omit sub- 
cutaneous suture of the skm flaps, to use skin clips for the skin edges rather 
than through-and-through sutures, and to avoid draining the wound Before 
proceeding with the second operation, the slightest imperfection m wound 
healing should be allowed to clear up completely The incision line and neck 
should receive very thorough but gentle preoperative cleansing The wound 
should be reopened gently and slowly, to cause as little subcutaneous bleeding 
as possible, and to allow any area in the wound suspicious of infection to be 
detected before the wound is widely opened and the temptation not to post- 
pone the operation great Duiing the second operation the already operated 
side should be left as stiictly untouched as was the other lobe at the first opera- 
tion At the end of the second operation the wound should again be reclosed 
without subcutaneous skm sutures and again prefeiably with skm clips 
Contrary to our original fears the final scars of these two stage operations have 
surprised us with their excellence The matter of drainage after the second 
operation must be left to the operator’s judgment in the individual case No 
drams should be left m situ more than 24 hours With the above mentioned 
precautions m technic, a short-interval two stage thyroidectomy is submitted 
as an operation that can safely and satisfactorily be employed as an alternative 
to delayed stage operations for patients with severely toxic goiter 

SUMMARY 

( 1 ) Certain goiter patients for reasons usually involving their financial or 
educational status do not cooperate satisfactorily m the conduct of two stage 
thyroidectomies where the operations are spaced four to six weeks apart 

(2) The feasibility is discussed of conducting the entire surgical treatment 
of such goiter patients within a single period of hospitalization of a month or 
less through shortening the interval between operations to a week or ten days 

204 



Volume 107 
Kumber 2 


HYPERTHYROIDISM 


(3) A consecutive senes of i6i such "shoi t-intei val” two stage thyioidec- 
tomies IS presented, the lesults analyzed by tables and discussed 

(4) Technical points of two stage opeiations aie descnbed, chiefly those 
tending to minimize the risk of wound infection These include the use of 
silk, gieat care to avoid mcuiimg unnecessaiy bleeding as well as meticulous 
hemostasis , avoidance of subcutaneous sutui es in closui e of the wound 

The author wishes to express his indebtedness to Dr Roy D McClure, Surgeon-in- 
Chief, Henry Ford Hospital, Detroit, Mich , for the privilege of collaborating in the 
study and surgical procedures of this series of patients and for permission to reiiew the 
cases considered herein for the purposes of this report Appreciation is also made to Dr 
Edward Canipelli for his help m the preparation of the tables 

REFERENCES 

^Crile, G W Graves’ Disease A New Principle of Operating Based on a Study of 
352 Operations JAMA, 56, 637-641, 1911 
“Crile, G W Surgical Treatment of Exophthalmic Goiter Surg , Gjnec L Obstet , 
30, 27, January, 1920 

® Crile, G W Protection of the Patient in Surgery of the Thj roid Surg , Gynec &. 
Obstet , 32, 213, March, 1921 

*Judd, E S Results in the Treatment of Exophthalmic Goiter N Y State Med Jour, 
20, 287, September, 1920 

®Halsted, W S The Treatment of Wounds, etc , Surgical Papers of W S Halsted, 
I, 105-106, Baltimore, Johns Hopkins Univ Press, 1924 
® Halsted, W S The Employment of Fine Silk in Preference to Catgut, etc JAMA, 
60, 1119-1126, 1913, also Surgical Papers of W S Halsted, i, 29-37, Baltimore, 
Johns Hopkins Univ Press, 1924 

■^Halsted, W S The Preliminary Ligation of the Thyroid Arteries, etc Annals of 
Surgery, s 8. 178-182, 1913, Pt II, Tr Am Surg Assn, 31, 319-321, 1913, also 
Surgical Papers of W S Halsted, 2, 220, Baltimore, Johns Hopkins Univ Pi css, 
1924 

® Halsted, W S The Excision of Both Lobes of the Thyroid Gland for Gra\es’ Disease 
Annals of Surger\, 58, 178-182, 1913, Pt I, Tr Am Surg, Assn, 31, 312-318, 
1913, also Surgical Papers of W S Halsted, 2, 222, Baltimore, Johns Hopkins 
Univ Press, 1924 

® Halsted, W S The Operative Story of Goiter — The Author’s Operation Johns 
Hopkins Hospital Reports, Baltimore, 19, 17-257, 1920, also Surgical Papers of 
W S Halsted, 2, 366, Baltimore, Johns Hopkins Univ Press, 1924 
"Hartman, F W A New Type of Oxygen Tent — Shown at the Scientific Exhibit of 
the 1937 Annual Meeting of the American Medical Association Details not j et pub- 
lished 

Heidenhain, L Ersetzung des Katgut durch Seide — Replacement of Catgut by Silk 
Centralbl f Chir , 26, 225-230, 1899 

"Kocher, Th Eine einfache Methode zur Erzielung Sicherer Asepsis — A Simple Method 
of Achieving Safer Asepsis Corr B1 f Schw'ciz Aerzte, 18, 3-20, 1888 
"Lahey, F H Multiple Stage Measures m Surger}' of Severe H> perthj roidism 
JAMA, 78, :862 -i 865, June, 1922 

“Lahey, F H Preliminary Ligations in Thjroidism Surg Clin North America, 4, 
1373-1377, December, 1924 

"Lahey, F H Reduction of Mortality in Hj perthj roidism New' England Jour Med, 
213, 475-479, September, 1935 

“Lahey, F H Stage Operations in Hyperthj roidism Surg Chn Nortli America, 15, 
1611-1624, December, 1935 


205 



ARTHUR B McGRAW 


Annals of Surpen 
Februorj 1038 


^'Lahey, F H, and Schwalm, L J Pole Ligation in Treatment of Hyperthyroidism 
Surg , Gynec & Obstet , 63, 69-76, Julj’-, 1936 

“Lahey, F H Stage Operations in Severe Hyperthjroidism Annals or Surgery, 
104, 961-970, December, 1936 

“ Lahey, F H The Management of Severe Hyperthyroidism Surg , Gynec & Obstet , 
64, 304-312, February (No 2 A), 1937 

"AtcClure, R D The Incidence of Operations for Goiter in Southern Michigan — Effect 
of Iodized Salt After Twelve Years’ General Use JAMA, 109, 782-785, Sep- 
tember, 1937 

^Marshall, S F, and West, T H Stage Operations in Severe Hyperthyroidism Surg 
Clin North America, 16, 1567-1581, December, 1936 

“Plummer, H S Results of Administering lodin to Patients Having Exophthalmic 
Goiter JAMA, 80, 1955, 1923 

"“Reid, M R, and Andrus, W DeW The Surgical Treatment of Goiter With Special 
Reference to Operative Technic Arch Surg, 24, 531-549, April, 1932 
Rolleston, H D The Endocrine Organs in Health and Disease, Oxford University 
Press, 219, 1936 


206 



FACTORS INFLUENCING PROGNOSIS IN CARCINOMA OF THE 

BREAST •' 

Herbert H Davis, MD 
Oauha, Nebr 

rnoil TUE DEr\nTMBNT OF SCnOBRI, BSHERSITr OF NEBRASKA COLLEGE OP MEDICINE, OMAHA, NEBB 

There aie many excellent ai tides m the literature concerning the prog- 
nosis of caicinonm of the bieast Man}'- surgeons have studied this fiom the 
clinical viewpoint and many pathologists have attempted to estimate the piog- 
nosis upon an histologic study of the tumor There have been veiy few 
lepoits con elating clinical and pathologic study 

A clinical classification is piesented The histologic classification of 
Haagensen is used It is hoped that these classifications may be used m future 
studies at laiger hospitals and clinics In this way we may leain the prognosis 
of cases of cei tain extent and microscopic type Thus we may determine, foi 
example, that a carcinoma of the breast wuth only pectoral gland metastasis 
of a comedo cai cmoma type results in a certain percentage of cm es This is 
much moie satisfactory than stating that one suigeon cures 35 pei cent of his 
cases wdule anothei cuies only 25 per cent The former surgeon probably 
sees earlier stages of the disease due to caring for a moie intelligent class of 
people 

A standard method of study of these cases, giving both clinical and micro- 
scopic types and stages of the disease, should have approximately the same 
results if treated similarly After finding these lesults, the value of various 
forms of treatment can be better determined 

This study is based upon a caieful review of 60 cases of carcinoma of the 
bieast caied foi in private practice at Immanuel Hospital by my father, B B 
Davis, and myself, also upon 23 cases at the Umveisity of Nebraska Hospital 
treated by vaiious surgeons In both groups the study begins at the earliest 
date that microscopic sections of the tumors were kept for lecoid This began 
at Immanuel Hospital in 1922, and at the Umveisity of Nebraska Hospital 
in 1927 No cases are included that were admitted for treatment later than 
1932, so that there aie at least foui j'-ears intei veiling since they were fiist 
seen I have peisonally leviewed the histones, studied the microscopic sec- 
tions and obtained reports of then piesent condition No effort is being made 
to pi ove any cei tain fact but the study is made merely to see what the results 
have been It is realized that this senes of cases is far too small to justify 
one in drawing very definite conclusions from them 

In the operable cases the treatment was radical mastectomy by one of the 
standard methods, removing the breast and dissecting out the axilla, with re- 

*Read before the Western Surgical Association, Kansas City, Mo, December 12, 
1936 Submitted for publication April 12, 1937 

207 



HERBERT H DAVIS 


Annals of Surgerv 
February 1938 


moval of the lymph nodes there Exception was made m only three cases 
In these a simple mastectomy without axillary dissection was performed In 
addition to radical mastectomy, postoperative roentgen-therapy was carried out 
in ten cases and pieoperative radiation in three In recent years I have used 
preoperative radiation much more frequently Recurrence has usually been 
treated by irradiation and occasionally by local excision 


Table I 

BREAST CASES 







Carcinoma 



Hospital 

Cases 

Studied Micro- 

scopically 


Pnmary 

Operable 

Recurrent 




Total 

No 

Per Cent 

No 

Per Cent 

Immanuel 1922-1932 
(private cases) 
University 1927- 


60 6 

51 

51 

94 

3 

6 

1932 


23 2 

19 

15 

71 

2 

9 

Totals 


83 8 

70 

66 

88 

5 

7 



Table II 







PRIMARY BREAST 

CARCINOMA 






OPERABLE 

CASES 







Results — November, igsd 






Well 



Dead 






Carcinoma Operative Other 

Total 

Hospital Total Operated 

Known Per 

Deaths Deaths Causes 



Cent 

Per 

No ^ ^ No 
Cent 

Per 

Cent 

Per 

No „ . 

Cent 




Cent 

Immanuel 51 

51 

41 12 29 

25 

6x 2 

5 2 

5 

29 70 

University 15 

14 

13 4 31 

8 

61 I 

7 0 

0 

9 69 

Total 66 

65 

54 16 30 

33 

6x 3 

6 2 

3 

38 70 


In the early years of the study, six cases m the Immanuel Hospital series 
were diagnosed on their records as carcinoma which, on study of the sections, 
I believe were benign Four of these I know to be well but have not been 
able to follow-up the other two The diagnosis in 54 cases was carcinoma, 
checked either by microscopic section or by death from metastases Fifty-one 
of these cases were operated upon I know the results m 41, 12 of which are 
well now, which is a period of four to 14 years after operation This is 29 

208 






Volume 107 
I\umbor 2 


PROGNOSIS IN CANCER OF BREAST 


per cent of the traced cases The percentage of five-year so-called cures is 
actually higher as several of the cases reported as dead were well for longer 
than five years Besides this, two cases had opeiative deaths and two died 
of causes unrelated to the carcinoma 

Of 13 traced Univeisity Hospital cases, four, or 31 per cent, are now well 
In the combined series I laiow the lesults in 54 out of 65 operated cases Of 
the 54, 16 cases, 01 31 per cent, are well while 33 cases, or 61 per cent, are 
dead as a direct lesult of the caicmoma The other eight deaths were not due 
to carcinoma itself 

The average age of the patients upon admission was 53^4, years The 
youngest pioved case was 28 Most of the cases pieviously diagnosed car- 
cinoma, but which I consider benign, were of the younger age groups The 
oldest case was 80 


Table III 

AGE INCIDENCE 




Immanuel 



University 



Total 


Age 

No 

Unknown 

Result 

No 

Unknown 

Result 

No 

Unknown 

Result 


Well Dead 

Well Dead 

Well Dead 

20-29 

0 

0 

0 

0 

I 

0 

0 

I 

I 

0 

0 

I 

30-39 

5 

0 

I 

4 

I 

0 

0 

I 

6 

0 

I 

5 

40-49 

12 

4 

5 

3 

9 

2 

I 

6 

21 

6 

6 

9 

50-59 

23 

2 

5 

16 

5 

0 

I 

4 

28 

2 

6 

20 

60-69 

9 

3 

I 

5 

3 

0 

I 

2 

12 

3 

2 

7 

70-79 

3 

I 

0 

2 

2 

0 

I 

I 

5 

I 

I 

3 

80 

I 

0 

0 

I 

0 

0 

0 

0 

I 

0 

0 

I 

Age not 
stated 

I 

I 

0 

0 

0 

0 

0 

0 

I 

I 

0 

0 


— 

— 

— 

— 

— 

— 

— 

— 

— 

— 

— 



Totals 

54 

II 

12 

31 

21 

2 

4 

15 

75 

13 

16 

46 


It IS seen that 61 cases, 01 81 per cent, were between the ages of 40 and 
69 The series is inconclusive in proving any age group more malignant than 
the others A much larger series of cases is needed 

Chart I indicates that the private cases came for treatment somewhat 
earlier than the University Hospital cases In the former, 16 were operated 
upon within a month of the time of the first symptom In the University Hos- 
pital series only two presented themselves that early and one of those was 
admitted for trouble other than the carcinoma of the breast, which was dis- 
covered in the course of the routine physical examination Thirty-six, or 67 
per cent, of the private cases were seen within two months of the onset Dur- 
ing the same length of time only five, or 24 pei cent, of the University Hos- 
pital cases were admitted In another series of 60 cases at the University 

209 






HERBERT H DAVIS 


Annals of Surgerj 
February 1938 


Hospital which was leviewed two years ago it was found that 50 per cent had 
had symptoms foi over one year before admission 



UNDER 12 2 4 4 6 6 8 8 10 10 12 12 18 18 24 24 36 36 48 

I O IMMANUEL 

MONTH X UNIVERSITY MONTHS 


Chart i — Show ing duration of tumor pret lous to admission 


Chart 2 shows that 75 per cent of the cases still well were operated upon 
within SIX months of the onset and 25 pei cent between six and 12 months 
Theie was not a single cure in cases of one yeai or ovei This proves very 



1ST 6MO 2ND 6M0 3RD 6MO 4TH 6M0 5TH 6M0 6TH 6M0 

Chart 2 — Shows the precipitant decrease of fa\orable prognoses 
predicated upon the duration of the disease previous to admission 


conclusively that early diagnosis and treatment are very essential in the cure 
of carcinoma of the breast The question of the advisability of surgery for 
cases of long duration is raised 

Aside from the duration of disease, a knowledge of the extent of it is im- 

210 



Volume 107 
Number - 


PROGNOSIS IN CANCER OF BREAST 


portant in determining piognosis Foi this purpose the following clinical 
classification is presented 

P*l — Early, nonadherent tumor without metastasis 
P 2 — Tumor adherent to skin or fascia without metastasis 
P 3 — Tumor with only pectoral node metastasis 
P 4 — Tumor with general axillary node metastasis 
P 5 — Tumor involving pectoral fascia with axillary node 
metastasis 

P 6 — Large bulky tumor 

(a) Without axillary node metastasis 

(b) With axillary node metastasis 
P 7 — Tumor with skin metastasis 

P 8 — Tumor with bone metastasis 

P 9 — Tumor with intrathoracic metastasis 

Pio — Tumor with several types of distant metastases 

Pi I — Bilateral breast tumor 

Pi 2 — Carcinoma during pregnancy or lactation 

R I — Local recurrence m scar 

R 2 — Metastasis to skin 

R 3 — Axillary involvement 

R 4 — Distant recurrence 

(a) Bony 

(b) Intrathoracic 

(c) Cerebral 

(d) Abdominal 

*P = Primary R = Recurrent 

Of the piimary classes, the fiist six, and possibly the last two, may be opeia- 
ble Class y may possibly be made operable by pieoperative ii radiation Classes 
8 to 10 inclusive are distinctly inoperable and palliation only can be considered 

Table IV 

CLINICAL CLASSiriCATION OF BREAST CARCINOMA 


Immanuel University Total 


P*I 

24 

I 

24 

P 2 

I 

5 

6 

P 3 

9 

2 

II 

P 4 

10 

4 

14 

P 5 

0 

0 

0 

P 6a 

0 

0 

0 

P 6b 

5 

2 

7 

P 7 

0 

I 

I 

P 8 

0 

I 

I 

P 9 

0 

0 

0 

Pio 

I 

2 

3 

Pii 

0 

0 

0 

Pl2 

I 

0 

I 

Not stated 

0 

I 

I 

Totals 

51 

19 

70 


* P = Primary 

211 



HERBERT H DAVIS 


Annals of Sureery 
February 1DS8 


Most of the recurrent cases are inoperable, with the possible exception of 
those occurring in Class i, i e , local recurrence With adequate radical mas- 
tectomy this IS rare 

As the private cases were seen soonei after the onset, the clinical class in 
general is lower than m the University Hospital cases Forty-four cases, or 
86 per cent, of the Immanuel Hospital cases were of one of the first four clini- 
cal classes, while only 12 cases, or 63 per cent, of the University Hospital cases 
were m these classes 


Table V 

PERCENTAGE OF CURES DEPENDING UPON CLINICAL EXTENT 

Well Dead Uiiknowii 



Total 

No 

Per Cent 

No 

Per Cent 

No 

Per Cent 

p I 

25 

10 

40 

10 

40 

5 

20 

P 2 

6 

3 

50 

3 

50 

0 

0 

P 3 

II 

2 

18 

6 

55 

3 

27 

P 4 

14 

0 

0 

13 

93 

I 

7 

P 5 

0 

0 

0 

0 

0 

0 

0 

P 6a 

0 

0 

0 

0 

0 

0 

0 

P 6b 

7 

I 

14 

4 

57 

2 

29 

P 7 

I 

0 

0 

I 

100 

0 

0 

P 8 

I 

0 

0 

I 

100 

0 

0 

P 9 

0 

0 

0 

0 

0 

0 

0 

Pio 

3 

0 

0 

3 

100 

0 

0 

Pii 

I 

0 

0 

I 

100 

0 

0 

P12 

0 

0 

0 

0 

0 

0 

0 

? 

I 

0 

0 

0 

0 

I 

100 

Totals 

70 

16 

23 

42 

60 

12 

17 


Table V shows that the cures decrease rapidly when gross metastases are 
found in the axilla 

While Types Pi and P2, which are the cases with no demonstrable axillary 
metastases, give at least 40 to 50 per cent of cures, even low axillary metastases 
result m only 18 per cent now reported as well There is only one case now 
well in which the cancer had spread to the other cixillary nodes This raises 
the question of the advisability of very thorough dissection of the central and 
mfraclavicular groups of axillary nodes lying along the course of the axillary 
vein If the results are so poor, may it not be better to leave these high 
axillary nodes and so decrease the number of cases of postoperative swelling 
of the arm^ A larger series of cases would be necessary to decide this 
question 

Histologically I am using the classification of Haagensen It considers 
(l) The manner of growth of cells, (2) cell morphology, and, (3) the reac- 
tion of the stroma In detail it is as follows 

212 



Volume 107 
Number 2 


PROGNOSIS IN CANCER OF BREAST 


Table VI 

HAAGENSEN’s histologic CLASSiriCATION 
Manner of Growth of Cells 

(1) Papillary Origin in a cyst formed in a duct 

(2) Comedo Growth mainly within ducts 

(3) Plexiform Growth in plexiform strands 

(4) Adenoid arrangement of cells 
Cell Morphology 

(5) Size of cells 

(6) Size of nuclei 

(7) Variation in size and shape of nuclei 

(8) Hyperchromatism of nuclei 

(9) Number of mitoses 

(10) Secretory activity of cells 

(11) Clearness of cytoplasm 
Reaction of Stroma 

(12) Fibrosis 

(13) Hyaline degeneration 

(14) Lymphocytic infiltration 

(15) Gelatinous degeneration 

(16) Invasion of lymphatics 

Let US now consider the manner of growth of cells The results in the 
cases undei consideration are as follows 

Well Dead Unknown 



Total 

No 

% 

No 

% 

No 

% 

(i) Papillary 

2 

0 

0 

2 

100 

0 

0 

(2) Comedo 

15 

5 

33 

7 

47 

3 

20 

(3) Plexiform 

37 

9 

24 

22 

60 

6 

16 

(4) Adenoid 

8 

3 

38 

4 

50 

I 

12 

Totals 

62 

17 

27 

35 

57 

10 

16 


Two died of shock of operation Two died of other disease 

Different parts of the same tumor may be of quite different histologic 
types Even in a single microscopic section there may be several types very 
distinctly repiesented In following Haagensen’s classification with four 
types, depending upon manner of growth of cells, we found two distinct types 
in nine cases, three types in three, and all four types in one case We classified 
these cases in the prevailing type from the sections studied Therefore, his- 
tologic grading is definitely subject to error 

How does the growth of cells histologically affect each of these classes ^ 


CLASS PI — EARLY NONADHERENT TUMOR WITHOUT METASTASES 



Total 

Well 

Dead 

Unknown 

Papillary 

0 

0 

0 

0 

Comedo 

10 

4 

3 

3 

Plexiform 

9 

3 

5 

I 

Adenoid 

3 

2 

0 

I 

Not stated 

3 

I 

2 

0 

Totals 

25 

10 

10 

5 

Per cent 


40% 

40% 

20% 


213 



HERBERT H DAVIS 


Annals of Surgcrv 
February 1938 


CLASS P2 — TUMOR ADHERENT TO SKIN WITHOUT METASTASES 



Total 

Well 

Dead 

Unknown 

Papillary 

0 

0 

0 

0 

Comedo 

I 

I 

0 

0 

Plexiform 

5 

2 

3* 

0 

Adenoid 

0 

0 

0 

0 


— 

— 

— 

— 

Totals 

6 

3 

3 

0 

Per cent 

* One was an operative death 

CLASS P3 — TUMOR WITH ONLY 

50% 

PECTORAL 

50% 

NODE METASTASES 


Total 

Well 

Dead 

Unknown 

Papillary 

I 

0 

I* 

0 

Comedo 

I 

0 

I 

0 

Plexiform 

5 

2 

I 

2 

Adenoid 

3 

0 

2t 

I 

Not stated 

I 

0 

I 

0 


— 

— 

— 

— 

Totals 

II 

2 

6 

3 

Per cent 


18% 

55% 

27% 


* Had local excision, i yr , 9 mos later, radical mastectomy Died 


12 yrs after first operation 

t One died of cerebral hemorrhage suddenly several years after 
operation 


CLASS P4 — TUMOR 

WITH GENERAL 

AXILLARY 

NODE 

METASTASES 


Total 

Well 

Dead 

Unknown 

Papillary 

0 

0 

0 

0 

Comedo 

2 

0 

2 

0 

Plexiform 

10 

0 

9* 

I 

Adenoid 

2 

0 

2 

0 

Totals 

14 

0 

13 

I 


Per cent 93% 7% 

*(i) One died of shock four days after operation (2) One died of 
apoplexy i yr after operation (3) Had tumor for 2 yrs before opera- 
tion and died 5}^ yrs after onset 

In Classes 5 and 6a there were no cases 

CLASS p6b — LARGE BUI K\ TUMOR WITH AXILLARY NODE METASTASES 



Total 

Well 

Dead 

Unknown 

Papillary 

0 

0 

0 

0 

Comedo 

0 

0 

0 

0 

Plexiform 

6 

I* 

3 

2 

Adenoid 

I 

0 

If 

0 

Totals 

7 

I 

4 

2 

Per cent 


14% 

57% 

29% 

* Age 51, tumor i yr 

Veri’- large ulcerating mass with bulky axil- 

lary metastases Had 

considerable adenoid type also 

Performed 


Simple mastectomy only, postoperative roentgenotherapy Still well 
12 yrs after onset 

f Died four days postoperative of shock 

214 



Volume 107 
Number 2 


PROGNOSIS IN CANCER OF BREAST 


CLASS P7 — TUMOR WITH SKIN METASTASES 

One case, 6 mos duration, roentgenotherapy only Died 9 mos 
from onset No microscopic section 

CLASS p8 — TUMOR WITH BONE METASTASES 

One case, 2 mos duration, roentgenotherapy to spine Died 4 mos 
after onset No microscopic section 


CLASS PIO — TUMOR WITH SEVERAL TAPES OF DISTANT METASTASES 


Papillary 
Comedo 
Plexiform 
Adenoid 
No section 


Total 

o 

0 

1 

o 

2 


Well 

o 

o 

o 

o 

o 


Dead 

o 

0 

1 

o 

2 


Totals 
Per cent 


303 

100% 


CLASS PI I — BILATERAL BREAST TUMOR 

Case, age 42 Second breast operation — radical mastectomy Five 
years before had first radical mastectomy of other breast Died 7 yrs 
after onset 


An inteiestmg fact in the above study is that, while both cases of a papil- 
lar}^ carcinoma, which is usually considered not highly malignant, died, they 
each lived a consideiable time The case m piivate piactice, age 50, had a 
tumor for two years befoie treatment, and it had invaded the pectoral lymph 
nodes This case lived 12 yeais The case at the University Hospital, age 
55, also had a tumor for two years befoie treatment with invasion of all the 
axillary nodes She was given preopeiative roentgenotherapy followed by a 
radical mastectomy She lived 51/3 yeais from the date of onset In both 
of these cases the ultimate death may be attributed to the delay m institution 
of treatment This senes of cases, again, is too small from which to draw 
definite conclusions 

Using the above classification, Haagensen divided the cases histologically 
into three grades 

(I) When papillaiy or comedo, when adenoid aiiangement of cells was 
marked, when gelatinous degeneration Avas piesent, or if lacking any of these 
preceding characteristics, when A’^ariation in the size and shape of the nuclei 
was slight and there were but few mitoses 

(II) All others 

(III) Highly malignant tumois Absence of adenoid aiiangement, maiked 
variation in the size and shape of nuclei, and numerous mitotic figures If 
any two of these three piesent — Grade 3 

What are the results in the various grades in each clinical class consideied 
separately ^ 


215 



HERBERT H DAVIS 


Annals of Surgery 
February 1938 


CLASS PI — EARLY NONADHERENT TUMOR WITHOUT METASTASES 



Total 

Well 

Dead 

Unknown 

Grade i 

II 

7 

I 

3 

Grade 2 

6 

I 

3 

2 

Grade 3 

5 

I 

4 

0 

Unknown 

3 

I 

2 

0 

Totals 

25 

10 

10 

5 

Per cent 


40% 

40% 

20% 

CLASS P2— 

-TUMOR ADHERENT TO SKIN WITHOUT METASTASES 


Total 

Well 

Dead 

Unknown 

Grade i 

I 

I 

0 

0 

Grade 2 

3 

0 

3 * 

0 

Grade 3 

2 

2 

0 

0 


— 

— 

— 

— 

Totals 6 

Per cent 

* One was an operative death 

3 

50% 

3 

50% 

0 

CLASS P3— 

-TUMOR WITH ONLY PECTORAL NODE METASTASES 


Total 

Well 

Dead 

Unknown 

Grade i 

5 

I 

3 * t 

I 

Grade 2 

4 

I 

I 

2 

Grade 3 

I 

0 

I 

0 

Not stated 

I 

0 

I 

0 


— 

— 

— 

— 

Totals 

II 

2 

6 

3 

Per cent 


18% 

55 % 

27% 

* Had local excision, i yr , 9 
Died 12 yrs after first operation 

mos later, 

radical 

mastectomy 


t One died of cerebral hemorrhage, suddenly, several years after 
operation 


CLASS F4 — TUMOR WITH GENERAL AXILLARY NODE METASTASES 



Total 

Well 

Dead 

Unknown 

Grade i 

5 

0 

5 * 

0 

Grade 2 

3 

0 

3 

0 

Grade 3 

6 

0 

5 

I 

Totals 

14 

0 

13 

I 

Per cent 


0% 

93 % 

7% 

* Tumor for 2 

yrs before operation, died 5}/^ yrs 

after onset 

One died of apoplexy i yr after operation 

One died of 

shock 4 days 

after operation 





CLASS P6b — ^LARGE BULKY TUMOR WITH AXILLARY NODE METASTASES 


Total 

Well 

Dead 

Unknown 

Grade i 

I 

0 

I* 

0 

Grade 2 

I 

0 

I 

0 

Grade 3 

5 

I 

2 

2 

Totals 

7 

I 

4 

2 

Per cent 


14% 

57 % 

29% 

* Died of shock 4 days postoperative 





216 





A olHme 107 
umber 2 


PROGNOSIS IN CANCER OF BREAST 


The result of summarizing the statistics noted in the preceding tabula- 
tions, relative to the question of giadmg, is appended 




Total 


Well 


Dead 


Unknown 



Per 


Per 


Per 


Per 


No 

Cent 

No 

Cent 

No 

Cent 

No 

Cent 

Grade r 

23 

roo 

9 

39 

10 

44 

4 

17 

Grade 2 

17 

100 

2 

12 

II 

65 

4 

23 

Grade 3 

19 

100 

4 

21 

12 

63 

3 

16 

Unknown 

4 

100 

1 

25 

3 

75 

0 

0 


It IS to be noted that we obtain distinctly bettei results in Grade i than 
in Glades 2 and 3 Unexpectedly, the lesults aie a little better in Grade 3 
than m Grade 2 This would piobabl}'' not be tiue for a laige senes 

SUMMARY 

(1) A method of study is piesented to deteimme the prognosis m car- 
cinoma of the breast Tins consideis both the clinical extent of the caicmoma 
and the histologic stud} 

(2) A new clinical classification depending upon the extent of the growth 
IS discussed 

(3) The histologic classification of Haagensen is used 

(4) This study is based on 75 cases of proved caicmoma of the bieast 

(5) The most impoitant factors in deteimming prognosis aie delay in 
institution of treatment and the extent of the disease 

(6) The histologic classification seems to be of less impoitance than the 
clinical study, but has a definite value 

(7) No attempt has been made to deteimme the value of various forms of 
treatment 

(8) It IS realized that this senes of cases is quite small It is hoped that 
this method of study may be adopted at largei clinics so that a gi eater number 
of cases may be folloived 


217 



INTRATKACHEAL SUCTION IN THE MANAGEMENT OF 
POSTOPERATIVE PULMONARA" COMPLICATIONS 

Cameron Haight, M D 

An-j, Arbor, Mich 

rnOM THE DEPARTMENT OF SURaERl, tlMA ERSITl OF MICHIGAN ANN ARBOR MICII 

Stasis of secretions within the ti acheobronchial tiee is an important cause 
of postopeiative pulmonaiy complications, notably atelectasis, aspiration 
“pneumonia,” suppurative pneumonitis and pulmonary abscess The constant 
maintenance of adequate inti abronchial diamage is essential m the prevention 
and treatment of such complications The various measures, such as carbon 
dioxide inhalations, posture and bronchoscopy, which have previously been 
advocated as piophylaxis in this regaid will be briefly mentioned, because 
these measures aie of importance and also because a combination of several 
or all of the theiapeutic measures is frequently necessary Attention will be 
particulaily called to intiatracheal suction by means of a cathetei introduced 
thiough the nares Its purpose is the same as bi onchoscopic aspiration, and 
it may be used either in pieference to bi onchoscop}', to supplement bioncho- 
scop}’’ when repeated aspiiations aie necessaiy, oi as an altei native to broncho- 
scopy when the latter is not available The term “intrati acheal suction” will 
be used in this article to mean the application of actual suction for the removal 
of intratracheal or inti abronchial secretions, whether by bronchoscopy or by 
an intiatracheal catheter 

The writer’s interest in this subject was aroused by the constant necessity 
of pi eventing the retention of bionchial secretions in postopeiative cases of 
pulmonary suppuration If adequate diamage of these secretions is not pro- 
vided, the patient is pi one to develop eithei an extension of the disease or an 
aspiration pneumonia in pieviously unaffected poitions of either lung To 
prevent the development of such complications, it is necessary that diamage 
of the bionchial tree be free at all times When patients aie willing to co- 
operate, and when thej^ are not so ill that they are unable to cooperate, fiee 
drainage can be maintained by postural methods, such as the Trendelenburg 
position, as advocated by Gray,® by rolling the patient from side to side as 
advocated by Sante,^® by hyperventilation with 15 per cent carbon dioxide 
inhalations, by sufficient naicotics to control pain and promote effective cough- 
ing, and lastly by ivell directed musing care, so that patients will be assisted 
to cough and expectoiate freely wdien necessary In other instances intra- 
tracheal suction, either by bronchoscopic aspiration or by an intiatracheal 
catheter, must be employed, occasionally as an emergency measure when pa- 
tients are literally drowming in their own secretions The results of mtra- 
ti acheal suction have, at times, been dramatic m their suddenness Thus, 
Submitted for publication June 24, 1937 

218 



■\ olume 107 
Number 2 


INTRATRACHEAL SUCTION 


patients with tracheal lales piioi to the pioceduie may have been dyspneic 
and cyanotic and at times unconscious because of anoxemia, m spite of an 
optimum ox3fgen supply by intianasal cathetei oi an oxygen tent Such pa- 
tients, if a too extensive pneumonic involvement has not aheady occuiied, 
can be rapidl}'’ lestoied to consciousness, quiet bieathmg and a noimal coloi, 
meiely by the leinoval of the obstiuctmg secietions so that a noimal an way 
IS piovided The methods which have been successfully applied m the post- 
opeiative management of thoiacic suigei}^ patients have been found to be of 
equal advantage m the tieatment of bionchial stasis occuiimg m geneial sui- 
gery patients This aiticle is piesented piimanly because of the wide applica- 
tion of these measuies m geneial suigical cases The treatment of post- 
opeiative complications arising fiom septic and aseptic pulmonaiy emboli will 
not be consideied, inasmuch as the etiologic factoi is quite distinct fiom the 
complications winch aie directly the lesult of letamed bionchial secietions 
Howevei, when bionchial secietions aiise as a lesult of emboli, then manage- 
ment IS the same as when the secietions aie due to other causes 

Causes of Retained Tiaclieohi oncJual Secietions — Troublesome secietions 
within the tiacheobionchial tiee aftei opeiation may be due to aspiiation of 
oral and pharyngeal secietions, either duimg or immediately following the 
opeiation Moie often they aie actual secietions which have noimally formed 
within the tiacheobionchial tiee oi which have lesulted fiom predisposing 
causes such as the nutating effect of the anesthetic agent, chionic bionchitis, 
mild bionchiectasis oi othei pulmonaiy oi bionchial conditions pioductive of 
secretions The stasis of noimal secietions is in itself sufficient to produce an 
inflammatoiy leaction which lesults in a bionchial exudate 

The letention of secretions may be due to seveial causes, among them 
being (i) The inability oi unwillingness of the patient to cough and ex- 
pectoiate effectively, (2) the lack of application of helpful measuies for aid- 
ing cough and expectoi ation , and (3) iinpioper instruction of the patient 
legardmg the necessity of effective cough and expectoration 

The most impoitant causes of the patient’s inability to cough effectively 
aie (i) Unconsciousness because of anesthetic agents, such as ethei, avertin, 
sodium ainytal and too heavy pieopeiative and postopeiative naicotic doses, 
(2) unconsciousness because of comatose 01 semicomatose conditions at- 
tiibutable to the patient’s age 01 geneial condition, (3) insufficient stiength 
because of the lecentness 01 severity of the opeiation, (4) ineffectual cough 
due to pain m the opeiative wound 01 lesulting fiom uppei abdominal binders 
which may have been applied too tightly so that effective inspiration is pre- 
vented , (5) secietions which aie too tenacious to be expelled by an othei wise 
effective cough, and (6) thoracic opeiations which have pioduced excessive 
flaccidity of the thoracic wall 

The postopeiative position of the patient befoie he has legained conscious- 
ness fiom anesthesia is of impoitance in favoiing 01 pi eventing the develop- 
ment of postoperative pulmonaiy complications As the semi-Fowlei position 
favois the giavitation of 01 al and pharyngeal secietions into the tracheo 

219 



CAMERON HAIGHT 


Annals of Surgciv 
1 ebruory 1038 


bionchial tree and the bases of the lungs, and as it favois stasis of bronchial 
secretions unless the patient is able to cough effectively, the Trendelenburg 
position IS prefeiable, unless it is contraindicated because of actual or potential 
infection within the peritoneal cavity 

The constant occurrence of viscid bronchial secretions in cases of atelec- 
tasis has been stressed by Lee, Tuckei and Clerf^^ in one of the first publica- 
tions on pulmonary atelectasis Because of the thick, mucoid, tenacious 
character of this bronchial secretion and the inability or disinclination of the 
patient to clear this secretion fiom the bronchi, it accumulates in the deeper 
portions of the bronchial tree until at some point oi points this stream of 
mucus completely occludes the lumen If this occlusion takes place in small 
bronchioles, a lobular atelectasis occurs, if in a bronchus leading to one lobe, 
a lobar atelectasis, and if in a mam bronchus of either lung, a massive 
atelectasis Coryllos"* believes that great viscosity of the bronchial secretion, 
so characteristic of bronchial stasis, results from the rapid growth of pneu- 
mococci which gives to the bronchial exudate a degree of viscosity sufficient 
to produce obstruction of small or even larger sized bronchi 

The urgent indications for application of measures to clear the tracheo- 
bronchial tree are several These indications may consist of a wet but un- 
productive or incompletely productive cough, tracheal or bronchial rales, 
rhonchi or wheezes heard with or without the stethoscope, or signs of atelec- 
tasis or pneumonia as detected either by physical or roentgenologic examina- 
tions With regard to roentgenologic examinations, it is frequently difficult, 
with a portable roentgenologic unit, to differentiate between a postoperative 
bronchopneumonia and a lobular atelectasis, due to retained secretions or a 
mucous plug The clinical picture may aid in the differentiation and, in occa- 
sional doubtful cases, it is usually advisable to bronchoscope the patient to 
be certain that a condition which can be relieved by bronchoscopy is not 
being ovei looked 

Prevention of Retained Secietions — Several of the methods of preven- 
tion of postopei ative pulmonary complications have been briefly mentioned 
These will be more fully discussed and additional measures will be mentioned 
Preoperatively, it is obviously advisable that a dental prophylaxis be given 
when indicated and when the operation is not one of emergency Should the 
patient have a small amount of sputum, he should be encouraged to clear the 
tracheobronchial tiee thoroughly befoie operation In many cases of pul- 
monary diseases, it is necessary to employ a postiiial drainage for this purpose 

When anesthesia is complicated by excessive pharyngeal secretions, it is 
preferable that the opeiation be carried out with the patient in the Trendelen- 
burg position when possible Should it be known that numerous secretions 
are being aspiiated into the trachea during operation, it may be advisable for 
the anesthetist to inseit a large intratracheal catheter and to administer the 
anesthetic agent through this catheter Periodic aspirations by the insertion 
of a smaller catheter through the larger one can then be carried out during 
the course of the operation In other instances of aspirated secretions m 

220 



Volume 107 
Is umber 2 


INTRATRACHEAL SUCTION 


which It IS not necessaiy to lesoit to the intratracheal method of administra- 
tion of anesthesia, it may be advisable to bionchoscope the patient immediately 
after opeiation, should an avertm or ether anesthesia pi event him from 
awakening immediately on completion of the opeiation As anesthetic agents 
which produce a long peiiod of unconsciousness after operation are highly 
conducive to the development of postopeiative complications, it is prefeiable 
that other agents, vhich allow the patient to awaken piomptly after opera- 
tion, should be employed if they provide an equally satisfactoiy anesthesia 
When the patient awakens immediately after the opeiation, the anesthetist 
should, habitually, instiuct the patient to cough and clear the tracheobronchial 
tree as thoioughly as possible 

Postoperatively, the use of the Tiendelenburg position^ is of importance 
This position should be maintained until the patient legains consciousness 
and it IS prefeiable to maintain it for at least 24 hours, as suggested by Gray 
Should a patient raise considerable sputum after opeiation, it may be advisa- 
ble for this position to be continued foi an even longei period Many pa- 
tients, however, are able to cough moi e effectively when they are in the semi- 
Fowler position than when they aie in the Trendelenburg position Therefore, 
if the patient is conscious, the particulai position which is best suited to the 
individual patient should be employed 

Coughing and expectoration can be aided when the patient is in the Tren- 
delenbuig position by having him he on one side for fifteen or more minutes 
and then on the other side in order to allow alteinate clearing of the upper- 
most lung The lateral position also favois the ciliary drainage of secretions 
from the uppermost lung If one lung is known to be, or to have been, the 
site of an atelectasis, suppuiative pneumonitis, bronchiectasis or broncho- 
pneumonia, this lung IS kept uppeimost for approximately twice as long as 
the contralateral lung When the patient is conscious and has no bronchial 
secretions, it is peimissible to allow him to assume the dorsal recumbent 
position, but even under these circumstances, it is advisable to change to the 
lateral position from time to time to pi event hypoventilation of the bases of 
the lungs 

The routine use of 15 pei cent caibon dioxide and 85 per cent oxygen 
inhalations every two, three or four hours, followed after each inhalation by 
voluntary assisted cough, is advocated as a prophylactic measure even when 
secretions are not present When secietions are piesent, drainage is facili- 
tated by the administiation of carbon dioxide immediately after changing the 
patient to the lateral position The carbon dioxide should be so administered 
that it will cause hyperventilation, and again the patient should be encouraged 
to cough and expectorate after each administiation Not only does the hyper- 
ventilation tend to clear the tiacheobronchial tree by means of the increased 
inflow and outflow of air, but the carbon dioxide specifically produces relaxa- 
tion of the bronchial musculatuie^ and consequent enlargement of the lumen 
of the bronchi which facilitate the dislodgment of obstructing secretions 
Coiyllos^ IS of the opinion that, under the influence of carbon dioxide, the 

221 



CAMERON HAIGHT 


Annals of SurRcrv 
Febniorj 1938 


bronchial exudate tends to lose its viscosity and to become transformed into 
a thin frothy secietion A woid of caution might be mentioned regarding 
the use of carbon dioxide inhalations, if they are given when the patient is 
in an improper position and are not followed by voluntaiy cough For in- 
stance, as Lubin^^ has stated, when patients with a lower lobe atelectasis are 
given carbon dioxide inhalations in the upiight position without subsequent 
appropiiate postuial changes, the secretions aheady piesent m the lower 
bronchial stems will gravitate moie deeply into the lower lobes This is 
particulaily true when the secietions are thin 

When the patient is mstiucted to cough, it is frequently advisable for 
the muse to assist m the procedure by suppoiting painful wounds, such as an 
uppei abdominal incision, by means of gentle piessure with a hand on each 
side of the abdomen so that less tension is placed upon the incision during 
the cough If the necessity of effective coughing is explained to the patient, 
he vill usually coopeiate more fully than otherwise, even when coughing is 
accompanied by consideiable pain 

The judicious use of narcotics to pi event excessive pain dining coughing 
IS of importance, and the patient should be especially encouiaged to cough as 
soon as each individual dose of the narcotic has produced its maximum effect 
Caie should be taken that the amount of the naicotic should not be sufficient 
to abolish the cough leflex oi to cause piolonged peiiods of sleep or drowsi- 
ness when secretions aie piesent Steam inhalations with the addition of 
menthol, and one of the many expectorants may be advantageously employed 
when the secietions aie excessively tenacious Ati opine should not be used 
to “dr)’- up” the secretions, as it will only cause bionchial secretions to become 
thicker than otherwise and diainage will be less efficient 

It may be imagined, fiom the stress that has been placed upon the neces- 
sity for adequate cough and expectoiation, that patients are considerably 
exhausted by the piocedure Such is not the case, and it should be realized 
that a few timely and effective coughs at periodic intervals are much less 
tiring than the more or less constant, irritative and ineffective type of cough 
which occurs when tracheobi onchial secretions aie being retained The in- 
effective t3’pe of cough IS paiticulaily wearing on a patient and it is also 
objectionable because it tends to force the secretions farther out into the 
bronchial tree and parenchyma 

Indtcatwns foi Ivti ah ached Siichoii — As caieful attention in carrying 
out the details of the above mentioned measures usually suffices to provide 
adequate diainage of the bronchial tree, intratracheal suction is usually un- 
necessaiy Intratracheal suction is indicated, however, when the cough re- 
mains u et and unproductive, either because the patient is unable to cooperate, 
due to insufficient strength or unconsciousness, or rarely because of unwill- 
ingness to cooperate Tbe significance of a wet unpioductive cough should 
not be underestimated, in that it is a most impoi tant sign which indicates that 
secietions are still piesent and are not being effectively expectorated When 
the patient is unconscious, one cannot always rely on this sign, as coughing 

222 



■\ olumo 10" 
I«uinber J 


INTRATRACHEAL SUCTION 


may be absent unless the cough leflex is pi evoked, as by aspiiation of the 
phaiynx In the unconscious patient, theiefoie, the diagnosis of letained 
seci etions can at tunes be made only by auscultation of the chest, in oi dei to 
deteimine if ihonchi, wheezes or a wet t 3 ^pe of bieathmg is piesent, or by 
listening foi these signs with the stethoscope placed in fiont of the patient’s 
mouth Moie often, when letamed seci etions aie piesent in an unconscious 
patient, tiacheal lales and noisy lespiiations aie audible when the hstenei 
stands a considerable distance from the patient’s bed The diagnosis of re- 
tained seci etions is then obvious The piesence of cyanosis in a conscious oi 
unconscious patient is suggestive of an impaired respiiatoiy pathway when 
the cj^anosis cannot be explained by othei causes 

It is impossible to be dogmatic about the lelative indications for bioncho- 
scopic aspiiation oi aspiration with an inti atracheal catheter Both methods 
ha^e a place Fiequently the}^ can be used intei changeably and it is often a 
matter of election as to which should be used The wiitei uses both methods 
and has no stioiig piefeieiice for eithei one When a single aspiiation will 
probably be sufficient, bronchoscop}'^ may be piefened, m that it is the moie 
ceitain of the two methods as it piovides actual inspection of the mterioi of 
the tiacheobionchial tiee Bionchoscopy thereby enables the suigeon to be 
certain that complete evacuation of seci etions has been obtained and that a 
mucous plug has not been ovei looked Foi the same reason, bionchoscopy is 
probably prefeiable when a definite atelectasis is piesent Bionchoscopy also 
allows the swollen inflamed mucosa to be shumken with applications of a 
solution of equal parts of i-iooo adrenalin and lo per cent cocaine FIow- 
ever, bronchoscopy may possibly cause a gieatei degiee of trauma to the 
tracheal and bronchial mucosa and theieb}^ cause the fuither foimation of 
secretions This is undoubtedly of importance in some unconscious patients 
for whom it is necessary to resoit to intratracheal suction eveiy four oi six 
hours in order to maintain adequate drainage In such cases, the intiatiacheal 
catheter is the preferable method, although it may be advisable to cany out 
a bronchoscopic aspiration as the initial proceduie In most cases in which 
intratracheal suction is necessar}'-, a single aspiration or several aspirations 
with the intratracheal catheter will suffice, and it is then unnecessary to resort 
to bronchoscopy As bronchoscopy is more strenuous for a critically ill pa- 
tient, intratracheal catheter suction is the piefeiable procedure in such in- 
stances The deciding criterion may be the method which is the moie quickly 
available It is not unusual that an aspirating machine is alieady at hand to 
allow the nurse to remove pharyngeal secretions, and as a sterile No i6 
French soft rubber urethral catheter is usually present on the catheteiization 
tray, the catheter method of suction can be employed without delay This 
method is especially advantageous at night, when a delay in assembling the 
bronchoscopic equipment may be unavoidable, and also m instances m which 
a bronchoscopist is not available 

Method foi Use of the Inti atracheal Cathetei — An oidinaiy No l6 
French soft rubber urethral catheter, or preferably a Robinson urethial 

223 



CAMERON HAIGHT 


Annals of Surgery 
rebruary 1938 


catheter of similiar size which differs m that it has a double instead of a 
single opening, is connected to the suction machine with a glass connecting 
tube and a fairly stiff long rubber connecting tube The catheter should be 
relatively new so that it will not have become unduly softened by lepeated 
sterilizations It is mtioduced into the nares and is diiected posteriorly until 
it can be felt to touch the arytenoids The presence of the catheter at this 
level usually stimulates the cough reflex The cathetei is then withdrawn 
slightly and is next quickly advanced into the trachea simultaneous with the 
expiratory phase of the cough or during the deep inspiration which follows it 
If the patient tends to swallow the catheter due to an inactive cough reflex, 
this can be prevented by slightly withdrawing and advancing the catheter 
several times m quick succession, in order to stimulate the cough reflex 
Should the cough reflex still be absent, as occasionally occurs m deeply un- 
conscious patients, it can as a rule be stimulated by carrying out the above 
maneuver with the suction turned on The introduction of the catheter into 
the esophagus can usually be avoided if the surgeon remembers to advance the 
catheter during the expiratoiy phase of the cough, for the obvious reason that 
a person cannot swallow and cough at the same time 

When the diagnosis of retained secretions has been accurately made, a 
considerable amount of thick, tenacious purulent secretion will usually be 
obtained as soon as the catheter enters the trachea The amount of secretion 
obtained is frequently surprisingly laige Furthermore, the presence of the 
catheter m the trachea incites further coughing which m turn dislodges 
bronchial secretions into the trachea where they can be removed by suction 
The procedure so far is carried out Avith the patient m the recumbent posi- 
tion and with the foot of the bed elevated Aftei the trachea has been cleared, 
the catheter is introduced faither so that it enters the primary bronchi When 
the patient is recumbent the catheter usually enters the right stem bronchus , 
it IS usually advisable to turn the patient on the left side in order to introduce 
the cathether into the left stem bronchus The smaller bronchi are not 
aspirated, but the forceful coughing which accompanies the procedure tends 
to expel their secretions into the mam bronchi or trachea where they can be 
aspirated The lemoval of secretions from the smaller bronchi can be aided 
by turning the patient from side to side, once oi twice during aspiration of 
the stem bronchi, so that postuie will aid the cough in dislodging the secre- 
tions from the smaller bronchi The foot of the bed, meanwhile, is kept 
elevated When the cathetei has been advanced well into the stem bronchus, 
the outer end of the catheter will be found to be within three or four inches 
of the nose The aspiration is continued usually for one or two minutes, 
depending on the amount of secietions present, and until no further purulent 
material is seen coming through the glass connecting tube 

The secretions obtained by intratracheal suction are quite thick and tend 
to plug the catheter and rubber connecting tube In spite of this, it is 
usually possible to keep the aspirating S3^stem clear by rapidly pinching and 

224 



^ olume 107 
Number 2 


INTRATRACHEAL SUCTION 


releasing eithei the connecting tube oi the catheter in oi der to cause a sudden 
stoppage and leapphcation of the suction If the system becomes plugged 
and the above maneuver does not suffice, the glass connecting tube is dis- 
connected from the cathetei, so that steiile water can be sucked thiough the 
glass and rubber connecting tubes to reestablish their patency If, after re- 
connecting the system, the catheter itself is found to be plugged, it is neces- 
sary to remove it temporarily so that it likewise can be cleared As the suc- 
tion tends to provoke excessive coughing and slight cyanosis, it is usually 
necessary to apply suction intermittently by repeatedly pinching the catheter 
for a period of several respiratory phases from time to time, so that the 
patient will not be too much upset by the procedure 

A reaccumulation oi reformation of secretions is to be expected, even 
though the bionchial tree has been completely cleared of secretions at the 
first aspiration The patient’s condition will frequently have improved suf- 
ficiently following one or two aspiiations so that pulmonary aeration, volun- 
tary cough and expectoration will subsequently be sufficient to keep the 
tracheobronchial tree clear In occasional instances it may be necessary to 
repeat the aspirations at intervals of four, five or six hours over a period of 
one or more days until the patient is able voluntarily to cough and expectorate 
effectively The insertion of the catheter causes a mild degiee of trauma to 
the lowei pharynx, larynx and tracheobronchial tree and therefore it is unwise 
to employ the procedure more often than is actually necessaiy Furthermore, 
the insertion of the catheter has the theoretical objection of contaminating 
the bronchial tree with pharyngeal organisms Clinically we have seen no ill 
effects fioni this 

The number of cases in which intratracheal suction has had to be employed 
at the University of Michigan Hospital has been relatively few, but the 
various types of cases in which it has been used have been diversified These 
postoperative conditions have included partial gastrectomy, cholecystectomy, 
thyi oidectomy, prostatectomy, splanchnicectomy and osteoplastic bone flaps as 
well as postoperative pulmonary cases The thoracic and postoperative ab- 
dominal conditions, especially those with an upper abdominal incision, are 
prone to develop retained secretions because of pain on coughing The tem- 
porary unconscious states that may result fiom intracranial operations and 
operations on the urinary tract in the presence of uremia, have also been 
found to favor the retention of secretions 

ILLUSTRATIVE CASE REPORT 

Case Report — A male, age 58, had had a slight chronic cough which was productive 
of a small amount of greenish and occasionally foul sputum On admission the amount of 
sputum varied between 3 and 34 Gm daily Occasional rales were noted at the base of 
the left lung and over the right middle lobe A roentgenogram (Fig lA) showed pul- 
monary emphysema and increased bronchovascular markings at both bases, more so on 
the left side 

Operation — October 22, 1936 Under nitrous oxide and oxygen anesthesia, a large 
carcinoma involving the pylorus and lower portion of the stomach was found A resec- 

225 



CAMERON HAIGHT 


Annals of Surger\ 
February 1938 


tion of the lower two-thirds of the stomach and a Polya type of gastro-enterostomy were 
performed The patient’s convalescence was satisfactory until the evening of the tenth 
postoperative day when a disruption of the wound occurred A secondary closure of the 
^vound was promptly effected under light nitrous oxygen anesthesia The duration of the 
anesthesia was 20 minutes and the patient reacted promptly He was inadvisedly placed 



Fig I — (A) Preoperatue roentgenogram October lo 1936, showing bilateral pulmonary em 
phjsema The increased broncho\ascular markings in both bases especially the left suggest a chronic 
basilar pneumonitis ^\lth probable slight bronchiectasis 

(B) Portable roentgenogram November 2 1936 three and one half hours after the development of 
coma and one and one half hours after intratracheal suction was instituted Consciousness had returned 
at the time this roentgenogram was made An extensive pneumonic involvement has occurred through 
out the right lung and in scattered areas in the left lung 

(C) Roentgenogram November g 1936 showing that a marked clearing of the pneumonitis in the 
right lung has occurred but much residual parenchymal infiltration remains in both upper pulmonary 
fields cspeciallj the right The left costophrcnic picuntis is evident 

(D) Roentgenogram March 3 1937 showing a further improvement of the pneumonitis There 

IS a p^ench>mal scarring on the left and a slight diffuse interstitial pneumonitis in the right upper 
lobe The left costophrcnic pleuntis is essentially unchanged 

226 



Volume lO: 
Number 2 


INTRATRACHEAL SUCTION 


in the senii-Fowler position, and carbon dioxide inhalations and assisted cough and ex- 
pectoration were unintentionally omitted His condition was apparently satisfactory until 
early the following morning The nurse’s note states that at 6 a M a “large amount of 
mucus was present in the throat ’’ About 7 a m the patient became suddenly dyspneic 
and comatose, the pulse was rapid and thready, the blood pressure dropped to 60/40, and 
the skin was cold Intravenous fluids (gum acacia, and 5 per cent glucose) and ephednne 
were immediately given to combat shock, and the patient was placed in an oxygen tent 
The flow of oxygen into the tent was at the rate of eight liters per minute 

When he was seen by the writer in consultation shortly afterwards, the patient was 
still unconscious Tracheal rales were audible at a considerable distance, numerous 
rhonchi could be heard in both lungs and the patient was deeplj cyanotic in spite of the 
oxygen It was obvious that he was drowning in his bronchial secretions An intra- 
tracheal catheter was quickly introduced according to the technic described above and a 
tremenduous amount of thick, purulent secretion was removed The aspiration was 
carried out with the patient in the Trendelenburg position, and he was turned first on 
one side and then on the other to allow the removal of secretions from both bronchial 
trees Consciousness returned about 15 minutes later, and, shortly theieafter, a roent- 
genogram was taken with a portable unit (Fig iB) The patient’s condition improved 
rapidly, being aided by a blood transfusion However, he did not regain sufficient strength 
to cough effectively and a “wet cough’’ pei sisted It was, therefore, necessary to continue 
intratracheal suction every two hours for the following 24 hours and every four hours 
for the next two da>s At each aspiration 10 to 30 cc of purulent material w'as removed 
The catheter was introduced with the patient in the recumbent position and he was rolled 
from one side to the other during each aspiration Between aspirations he was changed 
from one lateral position to the other Because of the greater pneumonic in\olvement of 
the right lung, this side was kept uppermost for approximately twice as long (one hour) 
as the contralateral side (one-half hour) so that drainage from the right lung would be 
facilitated The foot of the bed was elevated for the first 24 hours and the oxygen tent 
was kept in place for 48 hours Voluntap cough became progressively more productive, 
beginning on the afternoon of the first postoperative day, but as the patient’s strength had 
been so exhausted by the second operation, and by the critical complication which followed 
It, the cough effort did not become completely effective until the third postoperative day 
when intratracheal suction was discontinued A roentgenogram (Fig iC) on the eighth 
postoperative day showed marked clearing of the pneumonitis in the right lung and a 
small left pleural effusion The patient was discharged from the hospital 26 days after 
the secondary closure of the wound 

He returned for examination two and one-half months later, at which time further 
improvement of the pneumonitis was evident (Fig iD) The minimal left pleural effu- 
sion had remained sterile and relatively unchanged in amount during the interval 

This case is presented to illustrate the relief of an apparently hopeless com- 
plication by the use of intratracheal suction 

SUMMARY AND CONCLUSIONS 

The constant maintenance of adequate diamage of the tiacheobronchial 
tiee IS essential in the prevention and effective treatment of postoperative 
pulmonary complications Many of the so-called postopeiative pneumonias 
are due to the aspiration of pharyngeal secretions or to the retention of 
tracheal oi bronchial secretions Postoperative complications in such in- 
stances can usually be avoided by keeping the tracheobronchial tiee constantly 

227 



CAMERON HAIGHT 


Annals of Surpen 
rebruarj 193 S 


free of secretions Such measuies as posture, caibon dioxide inhalations, 
assisted cough and expectoi ation and the use of naicotics, inhalations and 
expectorants have been discussed The indications for inti atracheal suction, 
vhich IS employed by means of bronchoscopy oi by an intratiacheal catheter 
mtioduced through the nares, have been described Particulai attention has 
been called to the advantages and the method of use of the intratracheal 
catheter Although it is not always possible to prevent the development of post- 
opeiative pulmonary complications, it is believed that the incidence and the 
severity of such complications can be greatly minimized by following out the 
preventive and theiapeutic measures desciibed 

REFERENCES 

^ Boulant and Cheret Cited bv Corvllos ■* 

° Brown, A L Bronchoscopic Observations in Postoperative Atelectasis Action of 
Carbon Dioxide JAMA, 95, 100, Juh 12, 1930 
^ Brunn, H , and Brill, S Observations on Postoperative Pulmonary Atelectasis Con- 
sideration of Some Factors in Its Etiologj, Prevention and Treatment Annals of 
Surgery, 92, 801, November, 1930 

‘Corillos, P N Postoperatne Pulmonary Complications and Bronchial Obstruction 
Surg, Gjnec, and Obstet , 50, 795, 1930 

Corvllos, P N , and Birnbaum, G L Syndrome of Pneumococcic Bronchial Obstruc- 
tion Experimental Production of Atelectasis or Lobar Pneumonia with Human 
Pneumonic Sputum, Suggestions for Prevention and Therapeutic Treatment Arch 
Int Med , 51, 290, 1933 

“Faulkner, W B , Jr Internal Drainage, Its Application m Pulmonary Suppuration 
JAMA, 95, 132s, November i, 1930 

"Faulkner, W B, Jr, and Faulkner, E C Internal Drainage A Causative Factor in 
the Production of Postoperative Massive Collapse of the Lung (Pulmonary Atelec- 
tasis) Suggestions as to Prevention and Treatment Act Chir Scandinav, 69, 
105, 1932 

“ Gray, H K Postoperative Pulmonary Complications and Postoperative Use of the 
Trendelenburg Position Minn Med, 18, 273, May, 1935 
“ Harrington, S W Relief of Postoperative Massive Collapse of the Lung by Broncho- 
scopj Annals of Surgeev, 85, 152, 1927 

“Jackson, C, and Lee, W E Acute Massive Collapse of the Lungs Annals of Sur- 
gery, 82, 364, September, 1925 

Lee, W E , Tucker, G , and Clerf, L Postoperative Pulmonary Atelectasis Annals 
OF Surgerv, 88, 6, Juh, 1928 

“Lubin, M L Internal Drainage Its Significance in the Prevention and Treatment of 
Postoperative Pulmonarv Atelectasis Am Jour Surg , ig, 80, January, 1933 
“ Sante, L Massive Atelectasis of the Lung Annals of Surgfry, 85, 608, 1927, 
J A M A , 88, 1539, 1927 

’‘Thompson, S A Bronchial Catheterization Am Jour Surg, 31, 260, February, 1936 
“Tucker, G Bronchoscopic Observations on Obstructive Atelectasis Arch Otolaryngol, 
I 3 > 31S- 1931 

“ Van Allen, C kl , and Lindskog, G E Obstructn^e Pulmonarv Atelectasis Arch 
Surg, 21, Part II, 1195-1213, December, 1930 


228 



SPONTANEOUS CHOLEDOCHOGASTROSTOMY AND 
CHOLECYSTOGASTROSTOMY 

Marshall Davison, B S , M D , and Leon J Aries, M S , M D 

Chicago, III 

FROM THE DEPARTMENT OF SURGERY, NORTIIM ESTFRN DNI\ ERSITi MFDtCAL SCHOOL AND THE SURGICAL SERVICE 
OF SIVRSIIALL DAMSON, COOK COUNTi HOSPITAL, CHICAGO ILL 

The obseivation of an instance of spontaneous anastomosis between the 
shoi t pi oximal end of a ti aumatically severed stnctured common bile duct and 
the p5dorus of the stomach, and two cases of spontaneous cholecystogas- 
trostomy, is unusual 

Benign stiictuies of the bile ducts may result fiom inflammatory processes 
and occasional^ fiom the passage of gallstones, but injuiy to the common duct 
fiom operative tiauma is the more common etiology Previous to 1914, be- 
nign stiictures of the common duct were infrequent and weie recorded indi- 
vidually This was probably due to the fact that cholecystostomy was the 
operation of choice lathei than cholecystectomy or common duct drainage 
Since that time a tremendous literatuie has developed on the reconstructive 
suigery of the extrahepatic bile ducts This is not only the result of forward 
steps in leparative suigeiy, hut is also due to advances m the technic of 
operating upon malignant lesions 

The fiist cholecysto-enterostomy was leported, in 1882, by Winiwarter 
In 1892, Doyen perfoimed an end-to-end anastomosis of the common duct 
Muiphy,'^ in 1892, peifoimed a cholecystoduodenostomy employing the Mur- 
phy button, with an excellent result Jenckle repoited a case m which he 
perfoimed a hepaticocholangiogastrostomy, but the lesult was not recorded 
Vaiious types of anastomoses between the common duct and the stomach, 
duodenum, small bowel, or colon have been advanced Howevei, we have 
been able to collect only seven cases of spontaneous internal biliary fistula in 
6,000 autopsies at the Cook County Hospital One was due to peiforation of 
a carcinoma, and one to pei foi ation of an ulcei of the stomach The remaining 
five were the result of peiforation of stones into the duodenum In none of 
the cases was the condition diagnosed during life, but was recorded incidentally 
at autopsy, with the exception that gallbladder histoi les were obtained in three 
cases, and stones weie demonstrated clinically m two 

Judd and Burden^ have reported 153 cases of spontaneous internal biliary 
fistulae which required opei ative 1 ehef , but were able to diagnose the condition 
preoperatively m only two instances They believe that the presence of a 
fistula IS a complication lather than a cure of the preexistent pathology The 
presence of a fistula with adequate drainage becomes complicated only as time 
passes, when the tract becomes progressively shrunken in caliber due to the 

Submitted for publication December 4, 1936 

229 



DAVISON AND ARIES 


Annals of Surgen 
Februory 1938 


piesence of active infection or to latent cicatrization Pohlandt® demonstrated 
such a spontaneous cholecystogastrostomy by using a thin mixture of barium 
orally, followed by the injection of air into the stomach He states that in 
such cases the bile passages are occasionally outlined by taking a flat roent- 
genogram of the abdomen, and that air can be demonstrated m the gallbladder 
and ducts if a fistula exists This procedure was tried in our case without 
success, probably because the fistulous opening was too small 

Forty-four cases of internal biliary fistula have been diagnosed preopera- 
tively, according to Candel and Wolfson, who demonstrated a cholecysto- 
colostomy by the presence of air in the bile passages It is difficult to demon- 
strate choledochogastnc fistulae by such an opaque medium as hpiodol, since 
the stomach cannot be filled under pressure We have used 7 per cent sodium 
bi omide solution as a contrast medium, from which there was no ill effect 
Methods of Collective Anastomosis In instances in which the diagnosis 
of a choledochogastnc or intestinal fistula has been made preoperatively, or 
111 which the condition is found unexpectedly at operation, certain prosthetic 
measures may occasionally be employed 

When insufficient or no common duct lemains, one of several procedures 
may be possible The rubber tube is employed most widely^ , one end may 
be placed in the duct and the other into the stomach or duodenum,^ eventually 
passing spontaneously into the bowel A modification of this method has been 
suggested by Hoche,® in which the tube, placed into the duodenum, has several 
openings in its wall, allowing bile to escape into the duodenum , the distal end 
of the tube is brought out through the abdominal wall from a point lower 
in the duodenum, so that the tube may be withdrawn externally after several 
weeks, and the residual duodenal fistula allowed to close This method, 
however, occasionally results in a persistent duodenal fistula The tube must 
have a large lumen to prevent the precipitation of bile salts and pigments and 
thus block the biliary tree Tubes may pass into the bowel before the duct 
heals and thus predispose to stricture formation Absorbable tubes of gelatin, 
and more recently absorbable tubes of magnesium,® have served as prostheses 
Williams, in 1914, used the fistulous tract, formed by the drainage of the 
common duct to the anterior abdominal wall, for transplantation into the 
duodenum Lahey,® Lihenthal,® and Walters^^ have used these external 
fistulous tracts in cases where there was little or no common duct present 
This method does not give uniformly satisfactory results 

Experimentally, m dogs, plastic tubular flaps have been taken from the 
mucosa of the stomach and anastomosed with the gallbladder In reviewing 
the literature, we find that Stubenrauch,^^ in 1906, used a full-thickness tubular 
flap of the pylorus of the stomach and anastomosed this to the gallbladder suc- 
cessfully To our knowledge, there have been no other reports of this 
procedure Gohrbandt- has anastomosed the mtrahepatic bile duct to the 
stomach by dilating the duct and using a rubber tube as an intermediary He 
has also punctured the liver with a trochar, and into this opening has inserted 
a rubber tube, followed by anastomosis of the liver to the stomach over the tube 

230 



A olumo 107 
Number 2 


CHOLEDOCHO- AND CHOLECYSTOGASTROSTOMY 

Case Reports 

Case I —A white female, age 38, presented herself in March, 1928, ivith the 
liistory of having suffered intermittent pain m the right upper quadrant for three days, 
which had become progressively worse It radiated to the back and right scapular 
region, and was followed by nausea, repeated vomiting and jaundice The past his- 
tory was that of the occurrence of a similar pain in the right upper quadrant of the 
abdomen every two or three months for the previous year Bed rest and occasional 
opiates were necessary for relief Selective dyspepsia for fats and fresh fruit was 
present The patient had had typhoid fever 21 years previously 

Physical Evamination revealed a fairly well developed white woman who was 
mildly jaundiced The liver edge was palpable two fingers below the costal margin 
The gallbladder region was exquisitely tender Gallbladder visualization revealed five 
opacities present below the transverse process of the second lumbar vertebra, which were 
interpreted as stones The icteric index was 15 per 100 cc of blood serum and the 
urine showed bile All other laboratory findings were negative 

Operation — April 24, 1928 A transverse subcostal incision was made and a chole- 
CAStectomy performed The gallbladder contained 25 stones and Avas 3 Mm thick Tavo 
gauze drains Avere inserted After the drains Avere removed, the Avound failed to 
close and continued to drain bile for six Aveeks Cessation of the drainage Avas im- 
mediately folIoAved by a chill, fever, and progressive jaundice A diagnosis of common 
duct stone Avith obstruction and ascending cholangeitis Avas made 

Second Opetatwn — June 28, 1928 An incision Avas made through the existing trans- 
verse subcostal scar The common duct Avas explored, a stone removed, and a T tube 
inserted into the duct Drainage was alloAved to continue for six weeks 

The patient Avas well for one year, Avhen she returned Avith symptoms of pain and 
mild jaundice Avhich Avere treated conservatiA^ely Avith calomel and magnesium sulfate 
The attacks Avere mild in nature but Avould recur every three or four months in spite 
of dietary regimen BetAveen these episodes the patient felt comfortable She pre- 
sented herself to the Gynecologic Department in 1933, at Avhich time a hysterectomy Avas 
performed In December, 1934, the patient developed a progressive jaundice associated 
Avith severe pruritus 

Third Operation — ^January ir, 1935 After proper preoperative preparation Avith 
blood transfusions, glucose, and calcium, a third transcostal incision Avas made The 
common duct Avas dissected out of a mass of adhesions and a benign stricture of it Avas 
found, the tAvo-thirds of the duct distal to the stricture Avas completely obliterated by 
cicatrization The liver Avas sAvollen, a mottled, broAvnish-green in color, AVith a rounded 
edge Since insufficient common duct remained proximal to the stricture into Avhich a 
T tube could be placed, it was thought best to attempt the formation of an external 
biliary fistula Avhose external orifice could later be transplanted into the stomach or 
duodenum With this in view, a catheter Avas inserted into the proximal end of the 
common duct and external drainage A\'as instituted HoAvever, notwithstanding the fact 
that all persons had been instructed as to the dangers of removing the tube, on the 
sixth postoperative day, an attendant accidentally pulled the catheter out Avhile arrang- 
ing the bed clothing Since jaundice Avas expected to return, the patient Avas kept in 
the hospital for two months, but although the wound closed Avithin tAvo Aveeks there 
Avas no occurrence of either jaundice or pain The stools Avere dark greenish-broAvn m 
color 

The patient left the hospital March 17, 1935, and remained perfectly Avell for three 
months, at which time the previous symptoms returned These began as an ache in the 
right upper quadrant, Avhich radiated to the shoulder and was accompanied by nausea, 
jaundice, and an unbearable pruritus 

Fourth Operation — ^July 31, 1935 A transverse subcostal incision was made, for 
the fourth time, through the old scar, and after much difficulty the common duct A\as 

231 



DAVISON AND ARIES 


Annals of Surgerv 
Februnry 19C8 


isolated and explored Parenthetically, it is interesting to note that up to this time 
no herniation had resulted following the repeated use of the transverse subcostal in- 
cision The fascial layers were all fused, and the parietal peritoneum was adherent to 
the anterior surface of the stomach and transverse colon After freeing the adhesions 
and dissecting down to the region of the common duct, it was only possible to identify 
the duct by needle aspiration The stomach was separated with difficulty from the 
region of the duct, and a fistulous tract was identified extending between the lateral 
aspect of the proximal end of the common duct and the lesser curvature of the stomach 
at the pyloric junction (Fig i) 


^.Hepatic ducl^ 

dilated 



Gall bladi 


[der remov( 


at previous operatic 


^ A \ -'-^tract ^ 

i j 

Point of 

, previous 

ex.p1 oration of 
/ common duct' 

® ^ Common duct: 

> °W}Terated 

' 1 ! 
- I 

y \ ' 






Tig I — (Case i) Spontaneous choledochogastrostomy Illustrating the fistulous 
communication beUveen the proximal common duct and the stomach The dotted lines 
indicate the previous position of the gallbladder and common bile duct uhose distal 
portion preaiously had become obliterated following common duct drainage 


It would seem that the lumen of the fistula had originally been sufficiently large 
to carry the bile into the stomach, but after four months the lumen had become so 
small that jaundice supervened It is difficult to explain the mechanism of this 
fistulous tract, which formed without any underlying prosthesis or the ulceration of a 
stone, and within a very short period of time The gastric fistula was closed by im- 
brication, and a Y tube was placed into the right and left hejiatic ducts with the hope 
of forming an external fistulous tract that could subsequently be implanted into the 
duodenum The patient had an uneventful postoperative course The jaundice dis- 
appeared rapidly, but the icteric index remained elevated for six weeks 

Subsequent infrequent obstructions of the drainage tube would cause back pain 
that would radiate to the shoulder This we ascribed to increase of the intrahepatic 
pressure following the period of inadequate drainage Radiopaque material injected into 
the biliarj’- tree revealed the Y tube to be in place However, in November, 1935, 
the tube became obstructed, and was spontaneously extruded from the fistulous tract , 
drainage rapidly ceased and jaundice developed During the following month the jaun- 

232 



Volume 107 
Number 2 


CHOLEDOCHO- AND CHOLECYSTOGASTROSTOMY 


dice, however, gradually disappeared, and it was inferred that another anastomosis had 
formed spontaneously between the common duct and the stomach 

The patient again presented herself m February, 1936, complaining of abdominal 
pain, intermittent jaundice, clay-colored stools, and pruritus She continued to lose 
weight and strength, so that some type of reconstructive anastomosis between the re- 
mainder of the common duct and the gastro-intestinal tract appeared to be imperative 
Previously, we had outlined a plan of forming a tubular flap from the stomach to 
anastomose with the proximal common duct as described by Stubenrauch 

Fifth Opuatton — February 10, 1936 For the fifth time, a transverse subcostal in- 
cision was made through the old scar, through which, however, at this time a small 
hernia had developed The stomach was found intimately adherent to the undersurface 
of the liver , by sharp dissection a fistulous communication was exposed between the 
stomach and the common hepatic duct at its point of emergence from the body of 



the liver Since there was no extrahepatic portion of the common duct remaining, 
It was technically impossible to perform an anastomosis between it and the stom- 
ach As a procedure of necessity, one arm of a T tube was inserted into the 
mtrahepatic portion of the hepatic duct and the other arm introduced into the stom- 
ach The long end of the tube was brought out of the lateral margin of the 
abdominal wound The wall of the stomach was inverted around the intragastric por- 
tion of the tube, and the opposed surface sutured to the liver capsule at the T junc- 
tion of the tube to prevent leakage and to reduce the possibility of later scar contraction 
diminishing the patency of the fistula Bile began to drain through the long arm of the 
T tube, and the stools became greenish in color The collected bile was dark, viscid, 
and cloudy, and for this reason it was not reinjected After eating, the patient com- 
plained of pain m the right upper quadrant, however, by allowing the long arm of 

233 



DAVISON AND ARIES 


Annals of Surtren 
Februnpy irS8 


the T tube to remain open for two hotiis after meals, stomach contents regurgitating 
into the T tube did not obstruct the biharj drainage and the symptoms were relieved 
The patient is well and gaming weight at the present time, eight months following the 
last operation, and eight years after her initial complication 

Case 2 — S G The historj obtained through an interpreter was that of pain in 
the right upper quadrant of the abdomen of two w-eeks’ duration, radiating to the right 
shoulder, accompanied by %omiting The past history was negative except for an 
occasional chill follow’ed by fever during the past tw'o jears, which the patient attributed 
to colds She had had five children 

Physical Examination revealed a thin female with abdominal tenderness localized 
to the right upper quadrant of the abdomen The gallbladder could not be visualized 
on two occasions A flat roentgenogram of the abdomen revealed no shadow's sugges- 
tive of stones The urine contained a trace of albumin Cjstoscopj and pvelography 
revealed no lesion of the urinary tract White blood count, 7,300, Wassermann reac- 
tion, negative 

Opoatwu — September ii, 1935 A tiansverse subcostal incision was made, and a 
chronic phlegmonous cholecystitis with secondary cicatrization and shrinkage of the 
gallbladder w-as found There w’cie old, dense adhesions between the gallbladder and 
the stomach Dissection at the point of apposition between the pylorus and the mid- 
portion of the gallbladder demonstrated a spontaneous fistula to exist between these 
tw'o structures (Fig 2) There w'as no evidence of ulcer in the stomach The proximal 
common bile duct w'as dilated, the liver enlarged and discolored, its edge was rounded, 
and extended three fingers breadth below- the costal margin There were no stones in 
either the common duct or gallbladder After liberating the fistula and imbricating the 
opening into the stomach, a cholecj stectomy w-as performed 

Postopciativc Coiitsc — An une\entful comalesccnce ensued At a subsequent exam- 
ination, three months later, she did not complain of anj symptoms 

This patient probably bad passed stones into the stomach thiough the 
spontaneous cholccystogastrostomy , the dilatation of the common duct was no 
doubt due to the small caliber of the fistulous opening 

Benign biliaiy fistula into the gastro-intestinal tract may exist unrecognized, 
and w'lthout symptoms, until the fistulous tract becomes narrow-ed by cicatri- 
zation or inflammator}' change to an extent sufficient to produce obstructive 
jaundice If sufficient infection is present in the letained bile, liver abscesses 
■with a septic syndiome may develop 

Case 3 — For nine years the patient, a white female, age 46, had suffered from 
intermittent attacks of pain in the right upper quadrant of the abdomen These pains 
were sharp, radiated to the right shoulder and around the right costal margin to the 
back, but w-ere never associated w’lth %omiting, jaundice, or clay-colored stools About 
one w-eek before admission to the hospital she suddenly experienced a chill follow-ed bj 
pain in the right upper quadrant of the abdomen This pain was sharp, burning in 
character, and radiated to the right shoulder and to the back During the preceding 
w-eek she had vomited one or tw'O times each day On the second day of the attack 
she had noticed an increasing jaundice w'lth lighter stools and a dark green urine On 
entrance into the hospital, she appeared acutely ill, slightly irrational, severely jaundiced, 
and markedlj delndrated The liver edge was palpable, and there was tenderness in 
the gallbladder region The icteric index w'as 180, the urine contained considerable 
bile , the urea nitrogen in the blood w-as 105 per 100 cc , creatinin, i 5 mg Her tem- 
perature reached 104° F In view- of the long hlstor^ of intermittent attacks of pain 
in the right upper quadrant, the present attack w-as interpreted as being due to a stone 
in the common duct w'lth resultant obstructive jaundice and septic cholangeitis In 

234 



Numte 2^ CHOLEDOCHO- AND CHOLECYSTOGASTROSTOMY 

spite of active, conservative treatment, the patient apparently developed cholemia and 
died after five days, ii days after the onset of the acute attack 

Autopsy — Dr Richard H Jaffe The patient was an obese white woman whose 
skin had a deep yellow coloi and whose abdomen was slightly distended The liver 
was markedly swollen and extended for 4 cm below the costal margin, was soft in 
consistency, and a deep olive-green in color The intrahepatic bile ducts were much 
dilated and were filled with a thin, dirty-green bile In the right lobe soft confluent 
bright yellow areas up to 5 Mm m diameter were found The gallbladder was shrunken 
to about the size of a cherry, and was firml3' adherent to the lesser curvature of the 
stomach At this region the mucosa of the stomach showed a pmhead-sized opening 
with everted edges, from which a narrow fistulous tract extended into the lumen of the 
gallbladder The gallbladder contained a small amount of mucopurulent material The 
hepatic ducts and the common duct were markedly dilated The common duct meas- 



fistulus tract s. 

betojeen pylorus 
and ga.II bladder 

Fig 3 — (Case 3 ) Photograph of the gross specimen of liver stomach, and duo 
denum showing a facetted stone in the ampulla of Vater with obstruction and marked 
dilatation of tne common bile duct and a spontaneous fistula between the gallbladdei 
and pylorus The gallbladder is shrunken (outlined bj white marker) and contains a 
probe lying m the fistulous tract between the pylorus of the stomach and the gallbladder, 
probably at the site of passage of a previously existent stone 

ured 25 Mm in diameter and within the lumen of the duct, above the opening of the 
pancreatic duct, a facetted light-brown stone measuring 13 Mm m diameter was 
present (Fig 3) The cystic duct was tortuous and moderately dilated The pan- 
creatic duct was of normal caliber The pancreas revealed several pmhead-sized opaque, 
light-yellow areas The other autopsy findings were those usually found in death 
from septicemia 

Anatonuc Diagnosis — Obstruction of the common duct by a stone, with marked 
dilatation of the extra- and intrahepatic bile ducts and ascending cholangeitis , multiple 
abscesses in the right lobe of the liver, and in both kidneys Chronic cholecystitis with 
marked shrinkage of the gallbladder Spontaneous cholecystogastrostomy 

This case represents one of benign obstruction of the common duct caused 
by a stone proximal to the ampulla of Vater The stone has caused stagnation 

235 



DAVISON AND ARIES 


Annals of Surgen 
February, 1938 


of the biliary flow with subsequent dilatation of the extra- and intrahepatic 
bile ducts There was only this single stone in the common duct, but since it 
was facetted, other stones must have been previously present which had left 
the gallbladder either through the common duct, or through the fistulous tract 
which connected the gallbladder with the stomach Because of the extreme 
shrinkage of the gallbladder, this fistulous tract undoubtedly had decreased 
m size The stasis of bile in the common duct led to an ascending biliary 
tract infection, and from this infection multiple abscesses developed in the liver, 
and later, by way of the blood stream, m the kidneys 

Two factors are lesponsible for the patient’s death Namely, the severe 
damage to the liver parenchyma by the long-standing stagnation of the bile 
flow, and septicemia from the ascending infection of the biliary system As is 
usual in cases of benign obstruction of the biliary passages, the gallbladder 
was small and shrunken Since the stone was located proximal to the 
opening of the pancieatic duct, the panel eas was not affected by the occlusion 
of the common duct Subterminally a small amount of infected bile had en- 
tered the pancreatic duct and had caused multiple foci of fat necrosis 

CONCLUSIONS 

(1) Benign biliary fistulae into the gastro-intestmal tract may exist unrec- 
ognized and without symptoms other than chionic gallbladder disease until 
the fistulous tract becomes narrowed either by cicatrization oi inflammatory 
change to an extent sufficient to produce obstiuctive jaundice If sufficient 
infection is present in the retained bile, ascending bihaiy tract infection may 
then occur 

(2) There is nothing in the symptomatology m these cases, in which there 
IS an obstructive jaundice clinically, to lead one to suspect the existence of such 
a fistula 

(3) Diagnosis of the condition is theoretically possible, befoie obstruction 
occurs, by the roentgenologic finding of injected opaque material or air from 
the stomach oi duodenum in the biliaiy passages This would no longer be 
a possible finding after the fistula had become obstiucted 

(4) Inadequate biliaiy drainage through a fistulous communication be- 
tween the common duct and the stomach or duodenum must be recognized 
as a cause of obstiuctive jaundice 

(5) Since the condition is obviously infrequent, its presence must be taken 
as a clinical rarity rathei than a frequent cause of obstructive jaundice 

(6) These cases aie mechanically amenable to treatment, but, as is true 
m all cases of obstructive jaundice, the ultimate prognosis is dependent upon 
the duration and completeness of the obstruction, and the consequent damage 
to the liver bj'^ back pi essure or infection 

REFERENCES 

^ Desplas, B Etude anatomique des resultats d’une prosthese par sonde perdue entre 

le canal hepatique et I’estomac sans suture directe Bull et mem Soc de nat de 

chir, 57 , 770-774, May 30, 1931 


236 



NSers"' CHOLEDOCHO- AND CHOLECYSTOGASTROSTOMY 

"Gohrbandt, Erwin Anastomosen intrahepatischer Gallengange mit dem Magen und 
Darmkanal (unter Benutzung von Gummiprosthesen) Arch f klin Chir, 179, 

665-671, 1934 

Hoche, Otto Ueber Umgehungs- und plastische Operationen im Bereich der Gallen- 
wege Arch f khn Chir, 176, 622-627, 1933 

*Judd, E S, and Burden, V G Internal Biliary Fistula Annals of Surgeri, 81, 
305-312 1925 

'^Lahej, F H Transplantation of Common Duct Fistula into Duodenum, 2 cases Tr 
New York Surg Soc , Annals or Surgery, 67, 765-767, 1923 

” Lilienthal, Howard Transplantation of Common Duct Fistula into Stomach Annals 
OF Surger\, 67, 765-767, 1923 

'Murphy, J B Cholecysto-intestinal, Gastio-intestinal, Entero-mtestinal Anastomosis 
and Approvimation without Sutures Med Rec , 42, 665-676, 1892 

® Pannella, P Cholecystoduodenal Anastomoses with Tubes of Reabsorbable Metal 
(Magnesium) in Drainage of Bile Ducts Arch et atli d’ soc ital de chir, 38, 
809-812, 1932 

* Pohlandt, Klaus Gallenblasen-Magenfistcl nach Steindurchbruch Beitr z khn Chir , 

159 . 138-147, 1934 

Schrager, V L , Ivy, A C , and Morgan, J E A Method for the Plastic Recon- 
struction of the Common Bile Duct Surg , Gynec , and Obstet , 54, 613-619, 1932 

Stubenrauch Ueber plastische Anastomosen zwischen Gallenwegen und Magendarm- 
canal zur Heilung der completen ausseren Gallenfistel Arch f khn Chir , 79, 
1015-1030, 1906 

“Walters, Waltman Strictures of the Common and Hepatic Bile Ducts Surg, Gynec, 
and Obstet , 48, 305, 1929 

“Walters, W, Parker, R L, and Nj'gaaid, K K Strictures of the Common Bile 
Duct Proc Staff Meet , Mai 0 Clin , 10, 817-820, December 26, 1935 


237 



STONES IN THE COMMON BILE DUCT* 

Frank C Beall, MD 

Fort Worth, Texas 

Those of us who were doing surgery 20 years ago can recall the spirited 
debates which took place between the proponents of cholecystostomy and 
cholecystectomy in the tieatment of diseases of the gallbladder As I began 
to replace the routine cholecystostomy with cholecystectomy, I was immedi- 
ately impressed (and I presume others must have been) with the fact that 
convalescence after cholecystectomy was usually much smoother and more 
rapid than after cholecystostomy It might be reasoned that the cause of 
this is that, with cholecystectomy, the body is relieved at once of a source 
of toxemia However, I do not believe this is the only reason, nor, indeed, 
the chief reason I believe it is the effect of the loss of bile from the body 
that delays the convalescence m many cases of cholecystostomy 

That excessive loss of bile from the body is deleterious cannot be denied 
Hooper and Whipple (quoted by HowelB) state that In the dog, complete 
diversion of the bile to the surface is followed by the death of the animal m 
less than a month Man seems to be moie adaptable Judd^ has reported 
two cases of biliary fistula m association with complete stricture of the com- 
mon bile duct of 12 and 21 months’ duration He did not remark on the 
condition of the patients In his discussion, however, he said "As an 
adjuvant in cases of clnonic biliary fistula, Gerster and Nissen advocated 
feeding bile collected from the fistula It is well tolerated and the general 
improvement, when debility and asthenia become marked, is striking ” I, 
myself, have repeatedly seen cases of biliary fistula develop distressing symp- 
toms, usually loss of weight, great weakness, anoiexia, nausea, diarrhea, and 
a weak, rapid pulse, and have seen these symptoms promptly ameliorated by 
the administration of bile or the bile salts At the present time it is my 
piactice to administer bile salts in all cases where there is any considerable 
bile drainage 

We know that the presence of the bile salts in the intestinal tract is essen- 
tial for the digestion of fats and believe the bile has other important functions 
Walters^ has published the results of some interesting experiments upon the 
effects of calcium on the coagulability of the blood in the presence of jaundice 
He found that it took approximately twice as much calcium, given intra- 
venously, to laise the blood calcium in dogs who were jaundiced from liga- 
tion of the common duct to the same level as it did in normal dogs, and 
also that about 50 per cent more calcium was required to kill such a jaundiced 
dog than was required to kill a normal dog This is evidence that there is a 
marked deficiency m the body calcium in the presence of obstructive jaundice 

* Read before the Texas Surgical Society at San Antonio, Texas, October 10, 1935 
Submitted for publication May 8, 1937 


238 



\ olumo 107 
dumber 2 


COMMON DUCT STONES 


Rudolph and Cole (quoted by Walters^) claim that the oral administiation 
of calcium has no effect on the coagulability of the blood m jaundiced pa- 
tients while othei obseivers have lepoited maiked calcium effects in othei 
conditions (pleural effusions, edema, etc ) fiom its administration by mouth 
This would indicate that, in jaundiced patients, the process of calcium absoip- 
tion IS disturbed Cushny (quoted by Walteis^) says that calcium salts aie 
absorbed with gieat difficulty fiom the stomach and intestines and that then 
absorption is facilitated by the fatty acids, with which they combine to foim 
a soap of calcium, which is more readily taken up by the suiface epithelium 
Herein may he the explanation of the calcium deficiency which occurs m ob- 
structive jaundice If the bile salts aie absent from the intestinal tract theie 
can be no digestion of fats and so no fatty acids, which Cushny seems to 
think IS essential for calcium absoiption This would suggest that the ad- 
ministration of bile salts might be helpful m jaundiced patients and that the 
administration of bile salts and fats might be helpful m any form of oral cal- 
cium therapy 

The tendency to diarrhea, often of a putrid character, both in cases of 
obstructive jaundice and m cases of biliaiy fistula, is well known Howelk 
attempts to explain this diarrhea as being due to an excessive bacterial de- 
composition of the nitrogenous constituents of the food which become coated 
by the undigested fats when the bile salts are lacking, and so are insulated 
from the digestive action of the pancreatic trypsin 

Obstruction of the common bile duct, due to the back piessure of the 
confined bile, causes a dilatation of the biliary tiee and an impaiiment of 
function or, if the obstiuction is of a marked degiee, atrophy of the paren- 
chymal cells of the liver In the cases of obstruction fiom stones there is 
the added factor of infection Due to the degree and duration of the ob- 
struction and to the severity of the infection, we have all giades of hvei 
damage, from those which are hardly recognizable to the most marked degrees 
of biliary cirrhosis, the so-called “livers of surgical delay ” 

In no field of surgery, perhaps, unless it be that which is conceined with 
the relief of prostatic hypertrophy, is careful preoperative prepaiation and 
equally careful postoperative treatment so essential for success as that of the 
surgery of the bile ducts As I have said, the cases of stone in the common 
duct may come to us handicapped by any degiee of hepatic dysfunction, and 
many of them also have other serious secondary complications, chiefly pan- 
creatitis and renal insufficiency Many of them pi esent themselves in an acute 
phase with a highly active cholangeitis' or cholecystitis Fortunately, the 
acute septic conditions which accompany stones m the common duct are prone 
to be remittent, and so we can usually tide these acute cases over and operate 
upon them at a more favorable time Rarely an emergency operation, usually 
drainage of the gallbladder must be performed 

The great majority of cases of stone in the common duct aie not m need 
of emergency surgery They need surgery, but they need carefully planned 
surgery, undei taken at the right time The great value of fluids, sugars, 

239 



FRANK C BEALL 


Annals of Surgery 
j ebruary 1938 


intravenous calcium and tiansfusions, both as preoperative and postoperative 
measures, is too well known to need comment Everything which can be 
done to build up and conseive the patient’s strength should be done There is 
just one point at which I seem to diverge from generally accepted principles, 
and that is in regaid to drainage of the common duct aftei the removal 
of stones | | 

Why diain the common duct^ In the great majority of cases I think it is 
entirely unnecessaiy I can urge against it, my belief that an excessive loss 
of bile fiom the body may have deleterious effects and, in a seriously sick 
patient, may tuin the tide between success and failure In 20 years I have 
sewed a tube into the common bile duct just twice — both within the last year 
The fiist was in a woman who had been jaundiced and who had had some 
pain foi two years The jaundice and pam had begun shortly after a 
cholecystectomy At opeiation I found a chalky mass filling the common 
and hepatic ducts, just like a stag-hoin stone of the kidney, and m front of 
it, down near the papilla of Vatei, a definitely faceted stone, evidently one 
which had been foinied 111 the gallbladder The chalky mass in the bile 
ducts was, of necessity, bioken up and lemoved piecemeal, and I sewed a 
tube into the common duct, thinking it might provide a means of egress for 
any pai tides of the stone that might have been left behind The second case 
was 111 a man who had been having gallstone colics foi about three months 
and who had been jaundiced for about six weeks The man was much debili- 
tated and had lost considerable weight At opeiation I found a small, con- 
tracted, thick walled, edematous gallbladder which contained several faceted 
stones No stones weie found 111 the common duct The head of the pancreas 
was large and hard It was because of this evident pancreatitis, and the fact 
that the man had chionic jaundice, that induced me to put a tube into the 
common duct through the stump of cystic duct, after cholecystectomy Both 
of these patients recovei ed very well, but I am not sure but that their recovery 
would have been hastened had I omitted the common duct drainage 

A casual survey of the literature has revealed but one article which advo- 
cates the closuie of the common duct after the removal of stones Richter 
and Buchbmder^ advised the closuie of the incision in the common duct and 
the closure of the abdominal wound without drainage m order to avoid adhe- 
sions Two weeks after the appeal ance of this aiticle there was a letter of 
comment from the late Di Wm S Halsted,'’ from which I quote 

“I have welcomed the communication of Doctors Richter and Buchbmder 
upon this impoitant subject (Omission of Diainage m Common Duct Sur- 
gery) Although undoubtedly not giving the last word, the authors seive 
the purpose of stimulating controveisy on the vital subject of drainage of 
the common duct — a subject 1^hlch suigeons in greater pait the world over 
seem to regard as settled 

“The authors emphasize the desii ability of closing the abdominal wound 
without drainage m order to avoid adhesions, taking it for granted, I presume, 
that It would be supeifluous to call attention to the much more serious and 

240 



Volume 107 
Number 2 


COMMON DUCT STONES 


occasionally disastrous lesults which follow the piolonged loss of bile by way 
of the incision in the common duct ” 

Doctor Halsted then went on to explain his method of diainmg the com- 
mon duct by a catheter introduced thiough the cystic duct and finished the 
letter as follows 

“All we gam, as a rule, by diamage of the common duct is relief of ten- 
sion This relief is secured by drainage by way of the cystic duct and tends 
to secure prompt healing in the line of sutuie of the common duct Aside 
from the deplorable condition of the patient brought about by the gieat loss 
of bile, It seems irrational to me to place a diain m the infected common duct 
through the line of incision into it, with the expectation that piimary healing 
of the wound will take place Unquestionably, the entire line of sutuie, con- 
taminated inside and out with pus-producing organisms and fuither imperiled 
by the pressure of the tube, has m many instances broken down ” 

The strange thing to me is that this article by Richter and Buchbinder, 
and the comment on it by such a master surgeon as was Halsted, should have 
apparently been passed unnoticed by the surgeons of this country for moie than 
25 years My own practice for 20 yeais has been, except in very few instances, 
to close the incision m the common duct after the removal of stones This I 
effect with the finest of catgut and then place a soft lubbei dram close to the 
line of incision m the duct I have had no cause to regi et this pi ocedure In a 
few instances there has been a slight amount of bile leakage, but I have had 
no mortality I believe that, if the common duct is closed aftei the removal 
of stones, the patients will, m most cases, have an easier, quicker, happier, 
and safer convalescence 


REFERENCES 

^ Howell, W H Text-Book of Physiology Philadelphia, W B Saunders Co , 1933 
“Judd, E Starr Lewis Surgery, 2, 1955 Hagerstown, Md , W B Pryor Co, 1929 
“Walters, Waltman Obstructive Jaundice Physiologic and Surgical Aspects (Pam- 
phlet) Journal-Chronicle, Owatonna, Minn, 1934 
* Richter, H M , and Buchbinder, J R The Omission of Drainage in Common Duct 
Surgery JAMA, 73, 1750-1751, December 6, 1919 
“ Halsted, W S The Omission of Drainage m Common Duct Surgery JAMA, 73, 
1896-1897, December 20, 1919 


241 



APPENDICITIS IN ARMY SERVICE 

A REPORT OP TAVENTY-ONE HUNDRED CASES 

Raymond W Bliss, M D 

LIECT COL , MEDICAL CORPS U S ARMY 

Fl Paso, Texas 

AND 

Leonard D Heaton, M D 

CAPTAIN MEDICAL CORPS U S ARMY 

Ft Warren, Wyoming 

FROM THE SURQrCAL SBRMCE STATION HOSPITAL FORT SAM IIOOSTOV TEXAS 

From January, 1931, to October, 1936, 2,100 operations for appendicitis 
were performed at the Station Hospital, Fort Sam Houston, Texas, with 10 
deaths, a mortality of o 47 per cent Appendicectomies incidental to other 
operations are not included This series is presented as being fairly typical 
of appendicitis and its operative results as obtained in Army hospitals 

It is generally agreed that early operation will result in a low mortality 
rate Our patients are usually admitted early in their illness We receive 
them from the Army personnel, officers and enlisted men , their families , 
from the CCC camp enrollees, and, occasionally, fiom the Veterans’ Ad- 
ministration In the first two years covered by this report a good many were 
admitted by the Veterans’ Administration Since then this class of patients 
has been cared for in Veterans’ hospitals All of this personnel receives its 
medical care from the Army Medical Department In most cases they report 
any illness eaily, they are entitled to admission to this hospital, and, in gen- 
eral, they entei the hospital without question when advised to do so by 
medical officers 

Table I shows the age grouping Our youngest patient was an infant, 
age two months, with an acute suppurative appendix and our oldest a retired 
soldier, age 71, with an appendiceal abscess Both recovered 

Table I 
AGE GROUPING 


Age 

Number 

Per Cent 

0- 5 

2 

0 09 

5-10 

34 

I 6 

10-15 

50 

2 4 

15-20 

168 

7 9 

20-30 

1356 

64 7 

30-40 

367 

17 5 

40-50 

100 

4 7 

50-60 

20 

0 95 

60+ 

3 

0 16 


Submitted for publication January 14, 1937 

242 



Volume 107 
Number 2 


APPENDICITIS IN ARMY SERVICE 


Table II shows the patients’ status Of the 437 dependents, 271 were 
women and 166 children 


Table II 


STATUS or PATIENTS 


Enlisted men 

1,085 

c c c 

349 

Veterans’ Bureau 

149 

Officers 

80 

Dependents of enlisted men 

295 

Dependents of officers 

142 

Total 

2,100 


Tables III and IV give our classification of the types encountered and 
the number of each type We realize that this classification is open to argu- 
ment For example The acute catarrhal type, the so-called acute inflammatory 
type IS so classed by the operator, the pathologist may call it suppurative 
With us the acute catarrhal type represents the simplest type of acute appen- 
dicitis without obvious signs of associated peritonitis We believe that pa- 
tients with this form of the disease would, in the mam, recover from that 
particular attack without operation We further believe that this form of 
the disease cannot be diagnosed without operation 

Table III 

DEFINITIONS OF PATHOLOGIC CLASSIFICATIONS 

(1) Acute catarrhal — Acute inflammatory process limited to the appendix 

(2) Acute suppurative — Acute inflammatory process not limited to the appendix Gan- 

grenous type included Local peritonitis in varying degrees present Plastic lymph 
present Free fluid has seropurulent appearance Not ruptured 

(3) Ruptured with peritonitis — ^Varying degrees of pentonitis No abscess formation 

(4) Ruptured with abscess formation 

(5) Chronic or interval — Evidence of previous attacks — old adhesions present No acute 

inflammation 


Table IV 


PATHOLOGIC CLASSIFICATION 


(i) Acute catarrhal 

Number in This Senes 
Cases Per Cent 

I. 157 55 24 

(2) Acute suppurative 

567 

26 84 

(3) Ruptured with pentonitis 

54 

2 58 

(4) Ruptured with abscess 

36 

I 72 

(5) Chronic or interval 

286 

13 62 

Total 

2,100 



The acute suppurative and gangrenous types are giouped under the one 
heading of acute suppurative — the severe fulminating type of the disease 
This type probably has some mechanical or obstructive element connected 

243 



BLISS AND HEATON 


Annals of Sureen 
February 1938 


with the pathology phis the infection These appendices will quickly rupture 
without operation and especially repiesent the type m which early operation 
will keep mortality statistics low In the third class no attempt has been made 
to classify the degiee of peritonitis present as localized or spreading 

We think that the chronic or interval cases represent, in the mam, pa- 
tients who have had pi evious attacks of the acute catarrhal type with resultant 


pericecal and peri-appendiceal adhesions 

Table V 

TYPE or INCISION 

Type 

Cases 

Per Cent 

Transverse 


1,129 

53 6 

McBumey 


397 

18 9 

Right rectus 


464 

22 14 

Midline 


no 

5 36 

Total 

2,100 

Table VI 

ANESTHESIA 

No of Operations 

Per Cent 

Spinal 


1,930 

91 8 

Gas-oxygen-ether 


170 

8 2 

Total 

Total patients 

2,100 

Table VII 

MORTALITY STATISTICS 

2, 

100 

Total deaths 

Mortality per cent 


10 

0 47 

Classification 

Operations 

Per Cent 
Operations 

Mortality 
Deaths Percentage 

Acute catarrhal 

r.i 57 

55 0 

0 0 

Acute suppurative 

567 

27 0 

2 0 35 

Ruptured with pentonitis 

54 

2 5 

7 12 9 

Ruptured with abscess 

36 

I 7 

0 0 

Chronic or interval 

286 

13 6 

I 0 34 


Table V shows the type of incision used In women, the midline or right 
rectus incision is used so that the pelvic organs may be more easily explored 
In men and children, in whom the diagnosis seems to be uncomplicated 
appendicitis, we very generally use a transverse incision, placed at about the 
level of the anterior superior spine, which divides the external oblique fascia, 
the internal oblique muscle, and the peritoneum transversely This incision 
IS easily enlarged if desirable by cutting the rectus sheath and retracting the 
rectus muscle toward the midline It avoids the nerves, gives an excellent 

244 



Volume 107 
dumber 2 


APPENDICITIS IN ARMY SERVICE 


and adequate exposure for the purpose intended, is ideal if drainage is 
requii ed , and in our experience is not followed by muscular weakness or 
hei nia 


Table VIII 


MORTALITY STATISTICS 


Age 

Number in Senes 

Number of Deaths 

20-30 

1.356 

6 

30-40 

367 

2 

50-60 

20 

2 

Incisions 

McBumey 

397 

4 

Transverse 

1,129 

3 

Right rectus 

464 

3 

Status 

Enlisted men 

1,085 

6 

c c c 

349 

1 

V B 

149 

3 

Anesthesia 

Spinal 

1.930 

9 

Gas-oxygen-ether 

170 

Table IX 

I 


MORTALITY RATES IN SERIES OF CASES OF ACUTE APPENDICITIS WITH LOCAL PERITONITIS 
REPORTED IN LITERATURE (SCHULLINGER^) 


Year of 
Publication 

Author 

Place 

Number 
of Cases 

Period 

Studied 

Mortality 

Percentage 

1925 

Adams 

London Hospital 

467 

1919-1923 

6 2 

1925 

Love 

St Thomas’ Hosp 

271 

1919-1923 

5 2 

1927 

Colp 

Mt Sinai Hosp , N Y 

975 

1916-1926 

3 1 

1933 

Walker 

Boston City Hospital 

265 

1927-1930 

1 5 

J 933 

Seelye 

Memorial Hospital, 

287 

1929-1932 

1 4 



Worcester, Mass 




1934 

Bower 

Philadelphia Hospitals 

3.317 

1928-1932 

2 50 

1934 

Garlock 

New York Hospital 

350 

X928-July 

0 57 



II Division 


1932 


1936 

Schullinger 

Presb3d;enan Hospital 

630 

1916-1933 

1 9 



New York 






Total cases 

6,562 

Average mor- 






tality rate 

2 8 

Cases covered by this report at Station Hospital, Ft 




Sam Houston, Texas 


567 

1931-1936 

35 


Table VI shows that we very generally use spinal anesthesia This seems 
to us to be decidedly the anesthetic of choice and we believe has a decided 

245 






BLISS AND HEATON 


Annals of Surgery 
I ebruary 1938 


influence on our mortality rates With this anesthetic, liandling of the in- 
testines, packs, and retraction are reduced to the minimum We liave had no 
ill effects following its use in this senes 

Table X 


TOTAL MORTALITY RATES IN SERIES OF CASES OF ACUTE APPENDICITIS AND ASSOCIATED 
LESIONS REPORTED IN THE LITERATURE (SCHULLINGER* AND MCKENNA^') 


Year of 



Number 

Period 

Mortality 

Publication 

Author 

Place 

of Cases 

Studied 

Percentage 

1923 

Lower and 

Cleveland 

2,067 

Not stated 

3 I 


Jones 





1924 

Deaver and 

Lankenau Hosp , Phila- 





Magoun 

delphia 

5.488 

1900-1920 

5 0 

1925 

Adams 

London Hosp 

1,677 

1919-1923 

5 8 

1925 

Love 

St Thomas’ Hosp 

goi 

1919-1923 

8 4 

1927 

Colp 

Mt Sinai Hosp , New 






York 

2,841 

1916-1926 

5 2 

1928 

Weeden 

New York Hosp 

1,588 

1914-1927 

4 9 

1931 

Miller 

Touro Infirmary and 






Chanty Hosp , New 






Orleans 

2,415 

1924-1929 

9 9 

1931 

McDonald 

St Mary’s and St Luke’s 






Hospitals, Duluth, 






Minn 

1,574 

1925-1930 

4 5 

1932 

Boland 

Atlanta hospitals 

4,270 

1927-1932 

4 4 

1932 

Raynor 

Manchester Royal In- 






firmary 

1,877 

1928-1931 

5 0 

1932 

Colt and 

Aberdeen Royal Infirm- 





Momson 

ary 

1,349 

1911-1930 

5 5 

1933 

Bauer 

General Hosp , Malmo, 






Sweden 

5,208 

1903-1930 

3 3 

1933 

Walker 

Boston City Hosp 

2,106 

1927-1930 

5 8 

1934 

Bower 

Philadelphia hospitals 

14,904 

1928-1932 

4 79 

1934 

Nuttall 

Liverpool Royal Infirm- 






ary 

551 

Not stated 

2 5 

1934 

Garlock 

New York Hosp , II Di- 






Vision 

r,i88 

r92i-July 

4 7 





1932 


1934 

Keyes 

Barnes and St Louis 






Children’s hospitals 

1,099 

1915-1932 

5 0 

1934 

Quain 

Bismarck, N D 

1,000 

Sept 1927 

3 8 





to Oct 1932 


1936 

SchulhngeH 

Presbytenan Hosp , New 






York 

2.653 

1916-1933 

5 08 

1936 

McKenna^ 

St Joseph’s Hosp , Chi- 






cago 

3,187 

1922-1935 

2 48 



Total cases 

57,943 

Average mor- 






tality rate 

5 0 

Cases covered by this report at Station Hosp , Ft Sam 




Houston, Texas 


2,100 

1931-1936 

0 47 


246 



Volume 107 
Number 2 


APPENDICITIS IN ARMY SERVICE 


Table VII is a tabulation of our mortality statistics Autopsies uere 
performed upon the ten patients who died Death in one patient, aftei an 
interval appendicectomy, occuiied on the fifth postoperatne day and came 
without warning while the patient was leading Autopsy showed a pul 
monary embolus The abdomen was clean In the other nine patients death 
resulted fiom a spreading peiitonitis, two showing a Streptococcic infection 
of all serous cavities Table VIII is a further analysis of oui mortality sta- 
tistics In Tables IX and X comparative mortality statistics aie noted Table 
IX, acute appendicitis with local peiitonitis, coi responds with our acute sup- 
purative classification These figures are taken mainly from SchulhngeA 
and McKenna ^ 

In acute appendicitis, we believe in operating when we make a diagnosis 
of appendicitis Our belief m this covers late as well as early cases To- 
gethei with all surgeons we have opeiated upon many patients with the ful- 
minating type of the disease and removed gangrenous appendices, almost 
ready to rupture, a few houis after the onset of symptoms Frequently, the 
symptoms and physical signs in these patients have been mild and might 
easily lead the patient and suigeon to procrastinate We cannot determine 
the type of appendiceal involvement by the symptoms and physical signs 
and we believe, therefore, that many lives may be saved by operating at the 
eaihest possible moment aftei the diagnosis of appendicitis is made 

In oui practice we bury the stump after carbolization or cauterization We 
employ drainage only in cases of ruptured appendix with abscess foimation 
or with peritonitis Small, soft cigarette oi folded rubber tissue drains aie 
used In the cases without abscess formation we believe diainage, m most 
instances, to be of doubtful value We have not used serum therapy in this 
series Postoperatively, we avoid dehydration by hypodermoclysis or intia- 
venous injection of salt solution We use the Bartlett tube, oi some modi- 
fication of it, when indicated and believe it to be a life saving measure 

Summary — (i) An analysis is presented of 2,100 operations for appen- 
dicitis, performed between January, 1931, and October, 1936, with ten deaths, 
a mortality of 0 47 per cent 

(2) The average mortality foi 58,000 cases in civil hospitals has been 
5 pel cent 


CONCLUSIONS 

In our opinion, the lower rate in this senes is due to early admission to 
the hospital, with prompt operation 

We believe that spinal anesthesia contiibutes to a lowei mortality rate 

REFERENCES 

^ Schullmger, Rudolph N Arch Surg , 32, 65, Januarj , 1936 
“ McKenna, Hugh Annals of Surger\, 104, 617, October, 1936 


247 



VOLVULUS OF THE CECUM AND ASCENDING COLON 

Mandel. WEnsrsTEEsr, MD 
Long Island Cm, N Y 

Torsion or volvulus of the cecum and ascending colon is an infrequent and 
rare cause of intestinal obstruction In 1841 Rokitansky^^ made the first 
report of a case of this type The earliest, thorough consideration of this 
condition was published by Von Zoege Manteuffel,-'^ in 1898 That this con- 
dition IS raie may be ascertained from the report of Sweet^^ who reviewed 
the cases of intestinal obstruction admitted to the Massachusetts General Hos- 
pital from the period of 1873-1930, not including those due to strangulated 
external herniae Of the 520 cases thus studied, only six, or i 5 per cent, 
were due to volvulus of the cecocolon To these the author adds anothei case, 
making the incidence seven during a period of 57 years However, foreign 
authors, as Gatelher, Moutiei and Porcher,® and DuRoux,® state that the 
condition is moie fiequent where people subsist on coarse vegetable diets, as 
m Russia, Finland, Poland, and Scandinavia Moreau^® claimed that volvulus 
occuried moie frequently among Nordic people 

The disease is most common in the thud and fourth decades of life, and the 
sex ratio is approximately three males to one female Volvulus of the ceco- 
colon occuis only in the presence of a defect in development, namely, a con- 
genitally long mesentery of the cecum, produced by an abnormal rotation of 
the cecum from left to right ® In addition to an abnormally long mesentery, 
the production of volvulus requires a fixed point about which the intestine 
can rotate This point may be the mesentery of the small intestine, or a con- 
genital or inflammatory band resulting from a previous opeiation The first 
case heiewith reported had a chionic adhesive appendicitis with its tip fixed 
to the posterior parietes by many firm adhesions As a fixed point, this was 
the contributing cause of the obstruction 

Obviously, the occurrence of volvulus m a “cecum mobile” is dependent 
upon the length of mesenteiy upon which the cecum hangs In fact, Chalfant® 
estimated that there is marked mobility of the right colon in about 20 per cent 
of persons of all ages The greater relative frequency of volvulus m males 
may be due to the fact that males are more exposed to violent muscular effort 
Howevei, some cases cannot be explained on such a basis, since they occui 
during sleep Overeating and dietary indiscretion, especially when followed 
by exercise, also piedispose to an attack of volvulus Sudden movements as 
running, jumping, and lifting a heavy weight may piecipitate an attack Ha- 
bitual constipation, which tends to produce enteroptosis, may be associated 
with a congenitally enlaiged colon, unrelieved even by operation The second 
case reported m this paper clearly demonstrates this concomitant megacolon 

Submitted for publication June 19, 1937 

248 



Volum# 107 
>iumUcr i. 


VOLVULUS OF THE CECOCOLON 


This patient fiequently noted “something move a gieat deal” m his abdomen, 
especially when he jumped fiom a shoit height m the course of his woik 
Diastic purgation may cause an attack of volvulus as pointed out by Coinei 
and Sargent In the eai ly months of pregnancy, when the enlarging uterus 
pushes a mobile cecum upwaid, a paitial twist may be produced In addi- 
tion, the \omitmg associated with the piegnant state may be the precipitating 
factoi A^olvulus of the cecum complicating labor has been reported by 
Basden ^ Schiodei and Brettschneidei-'* studied the literature and collected 
ten cases of volvulus of the light half of the colon complicating piegnancy A 
case of postoperative volvulus of the cecum was reported by Nelson 

\"olvulus of the cecum has been known to be of three types,® namely 
(i) Cecal bascule, m uhich the posteiioi surface of the cecum looks forward 
and the axis of lotation is tiansverse, (2) lotation in an oblique axis, m which 
the cecum may occupy the umbilical 01 even the left hypochondi lac region, 
and (3) lotation of the cecum about its long axis 

Embiyology — The piimitive alimentaiy canal appears at the end of the 
fifth week in the foim of a tube, and is subdivided into three paits The fore- 
gut, the midgut, and the hmdgut The blood supply detei mines these di- 
visions, the foregut being supplied by the celiac axis, the midgut by the su- 
perior mesenteiic aiteiy, and the hmdgut by the inferior mesenteric artery 
Physiologically, the same subdivisions pievail The foregut is digestive in 
function, the midgut absoiptive, and the hmdgut excietory Fiom the foregut, 
the stomach and duodenum aiise dowm to the bile papilla The midgut gives 
origin to the remainder of the small intestine, cecum, ascending colon, and the 
light half of the transverse colon The hmdgut foims the balance of the colon 
and lectum 

Among the anomalies of the alimentai y ti act, there ai e those due to varia- 
tions in lotation, descent, and fixation of the intestine® In the embryo of 
from five to five and one-half wrecks, the intestine projects forward into the 
umbilical coid in the form of a wide V-shaped loop supported by a common 
dorsal mesenteiy At the apex of the loop is the vitelline duct The limb 
pioximal to it IS continuous wnth the duodenal end of the foregut and that 
distal wnth the hmdgut At about the sixth w^eek a bud-hke enlargement ap- 
peals in the limb of the loop distal 01 caudal to the opening of the vitelline 
duct, wdnch indicates the futui e position of the cecum and its appendix When 
the embiyo has reached a length of about 40 Mm (tenth week) the coils of 
intestine lather suddenly leturn to the abdominal cavity, throwing the cecum 
over to the light side of the abdominal cavity This position it letains until 
about the fourth month after bn th As the large intestine increases in length, 
the cecum and appendix move fai thei to the right, still undei the liver, and at 
about the sixth month descend to then normal position m the right iliac fossa 
During the process of rotation and descent, the peritoneal surface of the meso- 
colon, wheie it comes into contact with the posterioi abdominal wall, is nor- 
mally lost, so that fusion occui s, wnth fixation of the ascending and descending 
colon 


249 



MANDEL WEINSTEIN 


Annals of Surgerv 
February 1938 


Developmental anomalies particularly affect the right half of the colon and 
small intestine Rotation may be incomplete, the cecum and ascending colon 
remaining to the left, while the transverse colon maintains the normal position 
Anomalies of rotation are usually coexistent with deficiencies in fixation so 
that volvulus may result Likewise, lack of peritoneal fusion may be frequent, 
resulting m abnormal mobility of the ascending colon This mobility may be 
partial or complete If complete, the whole ascending colon retains its mesen- 
tery, and a definite hepatic flexure may be absent Torsion of the cecum and 
lower ascending colon may result if in partial fixation the cecum itself remains 
free Thus, one can readily understand how an abnormally long mesentery, a 
mobile cecum, and a precipitating factor such as muscular effort, may lead to 
torsion of the cecocolon 

Pathology — The torsion usually occurs in a clockwise manner^® 29 gj-- 
planation by Von Zoege Manteuffel-^ being the peculiar mesenteric attach- 
ment of the ileum Philopwicz^® found volvulus to occur counter-clockwise 
in only two out of 24 cases, whereas Weible-® reported it clockwise in 30 out 
of 37 cases Von Zoege Manteuffel’s conclusions were based upon 20 col- 
lected cases and four of his own He observed that torsion up to 180° may 
occur in the axis of the bowel without interfering with its blood supply, but 
if the twist goes beyond this point, the mesentery which is necessarily present 
becomes strangulated Rankin states that a twist of more than one and one- 
half turns results in strangulation due to occlusion of the vascular elements, 
gangiene, and occasionally perfoiation Observations in the two cases re- 
ported in this study do not confirm the above findings Both cases presented 
more than two complete turns, and serious occlusive vascular phenomena failed 
to result One may conclude that the thoroughness and tightness at the con- 
stricting site are deciding factors, rather than the number of turns about a 
fixed point Unless permanent fixation bands are present to completely oc- 
clude the intestine, frequent detorsion may occur due to the great mobility of 
the cecum 

Homan^° mentions the rapid gas formation in the involved portion of 
intestine, which does not develop elsewhere to the same degree This observa- 
tion was made in both my cases, and the enormously distended cecum was 
out of all proportion to the almost collapsed state of the small intestine proxi- 
mal to the obstruction In the usual case of intestinal obstruction, even an ob- 
structive lesion low-down causes a marked dilatation of the proximal gut, 
demonstrating the fact that mechanisms other than those peculiar to intestinal 
obstruction are involved here In volvulus, the loop is well isolated^ by the 
twisted ileum and ileocecal valve proximally, and the transition point of cecum 
into ascending colon distally In addition, a large amount of fluid intestinal 
content appears to be absent, another differentiating characteristic from the 
usual type of intestinal obstruction In other words, this segment is “closed” as 
far as the intestinal lumen is concerned, but not with respect to the vascular 
supply Cannon” and Keith^® demonstrated in the cat that the receptively re- 
laxed cecum and ascending colon, upon receiving the liquid contents of the 

250 



Volume 10" 
Number 2 


VOLVULUS OF THE CECOCOLON 


small intestine, undergo activity in the form of an antiperistalsis which retards 
and churns tlieir contents for a considerable period This delay favors equally 
fermentation and the absorption of fluid 

However, other causes foi the lapid gaseous distention of the involved 
loop will be presented and desciibed The origin of these intestinal gases is 
by diffusion from the blood stieam into the lumen, the decomposition of in- 
testinal contents, and the passage of atmospheric air from the stomach into 
the small intestine and colon First, one must consider the mechanism of the 
diffusion of blood gases to and fiom the intestinal lumen^'’ through the 
mucosa Absoiption into the blood stream is an important method of elimi- 
nating intestinal gases The i ate of absoi ption vanes with the different gases 
in the intestine These are Carbon dioxide, hydiogen sulphide, oxygen, hy- 
diogen, methane, and nitrogen The rate of diffusion of carbon dioxide is 
^ ery rapid as compared to the other gases, and there is always an attempt at 
equilibrium between the gases in the lumen and those in the blood circulating 
111 the intestinal wall Expeiiments have been performed ligating the veins 
of any empty intestinal loop There results a distention of the intestine by a 
bloody fluid exudate within a few hours, owing to an increase m capillary 
piessure and damage caused by a pool supply of oxygen If the intestinal 
loop is distended with air before the veins aie obstructed, the volume of gas 
will increase oi\ing to a diffusion into the lumen of carbon dioxide from the 
blood 

One may, theiefore, conclude that m cecocolon volvulus, the constricting 
mechanism causes a deficient arterial oxygen supply to the involved viscus, 
together with an accumulation of carbon dioxide m the lumen due to the 
venous stasis m the intestinal wall The oxygen will be absorbed and re- 
placed by carbon dioxide and other gases, making an ideal culture medium 
for the anaerobic organisms that normally are found in the colon Anaerobic 
infections very frequently complicate surgery of the colon, and present one 
of the most virulent types of infection Ruptured diverticulitis of the sig- 
moid presents a high mortality because of such contamination In studying 
the intestinal flora in health and disease, KahiA^ noticed that uniformly a 
majority of the control cases exhibited a nonproteolytic anaerobic spore-bear- 
ing group of organisms The Clostudmm welclm was the most frequently 
encountered species m the stools of normal individuals, although usually m 
smaller numbers than in some of the pathologic series So virulent are these 
colonic anaerobes that Weinberg,®® of the Pasteur Institute, produced two 
types of serum with anaerobic organisms This serum is being widely used 
at the present time m the treatment of peiitonitis 

Patients may give a history of abortive attacks of volvulus, prior to ad- 
mission for operation Following relief of pain, they evacuate copious, very 
foul smelling stools This would confiim the fact that the anaerobic con- 
tent of the involved closed loop may be the cause of the greatly distended 
cecum 

Symptoms and Diagnosis — ^Volvulus of the cecum presents the clinical 

251 



MANDEL WEINSTEIN 


Annals of Surcerv 
February 1938 


picture of intestinal obstruction, and because of its larity, is seldom diagnosed 
except at operation or at autopsy Pain initiates an acute attack, and, be- 
cause of the severity, is unlike any abdominal pain previously experienced by 
the patient In both of the cases herewith leported, constipation of two or 
three days’ duration preceded this onset One of the patients had mild at- 
tacks for a period of 17 years, while the othei was free from such disturb- 
ances Evidently, where theie is megacolon and great mobility of the ceco- 
colon, the patient experiences so-called chronic attacks The pain of volvulus 
IS intermittent and cramp-like in character, caused by the peristaltic and 
distending phenomena of hollow viscera, as in any other type of acute 
intestinal obstruction Like most acute abdominal conditions, a patient’s 
symptoms may be vague and indefinite, simulating the more frequently ob- 
served visceral inflammations such as gallbladdei disease, as reported by 
Sarles Great abdominal distention accompanies the attack, and promptly 
disappears if the obstruction should be relieved spontaneously This is fol- 
lowed by the evacuation of a copious foul stool and gas A large tympanitic 
mass may be observed in some cases, but the location varies with the amount 
of mobility of the cecum, as well as its location Vomiting, of course, is a 
usual accompaniment, and, inasmuch as the obstruction is at a low point in 
the intestinal tract, signs of toxemia are delayed The elevation of blood 
urea, decrease in plasma chlorides, and increased combining power of the blood 
for carbon dioxide obtain with regulaiity only in high intestinal obstructions 
Viable bowel has little absorptive power of toxins Enemata and cathartics 
are of no avail during an attack The patient’s only relief is obtained by 
operation, with mechanical detorsion of the volvulus 

Like all congenital abnormalities, volvulus of the cecum may be accom- 
panied by other defects Case 2 also presented an elevation of the light 
diaphragm If more extensive studies and observations were possible, fur- 
ther abnormalities would probably be discovered Chalfant’s^ case demon- 
strated a mammalian bicornate uterus in addition to the cecal anomaly 

Treatment — For those patients who come to operation, one of three pro- 
cedures should be considered 

( 1 ) Untwisting of the volvulus with the separation of adhesive bands that 
may be present 

(2) A plastic operation to avoid recuirence 

(3) Resection of the involved colon 

(l) The simplest method, of course, is untwisting the obstiucted loop 
This method may not be applicable in patients with extreme distention of 
the colon, because slight trauma may rupture and tear the already thinned- 
out cecal wall One may find omental or inflammatoiy bands completing the 
obstruction and these should be severed If, as in Case 2, an adherent ap- 
pendix helps to precipitate the obstruction, then this must be released and 
removed As unsatisfactory as simple mechanical untwisting may seem to 

252 



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iHUmbcr 2 


VOLVULUS OF THE CECOCOLON 


the surgeon foi peimanent lelief, yet if the condition of the patient does not 
warrant further surgery, one must be content with this procedure 

(2) Cecostomy and sutuie of the untwisted cecum to the abdominal 
wall constitutes the operation of choice The replacement of the greatly dis- 
tended cecal segment may be facilitated by a radical reduction m its size, fol- 
low mg wdiich, fixation bands to the posterior abdominal wall may be more 
easily visualized, and the exact status of the vasculai disturbance ascertained 
Since the enormous distention may be caused by anaerobic gas formation, as 
previously mentioned, and not by fluid content m the lumen, perforation by 
trocar and cannula is a i datively safe procedure Thiough this opening into 
the collapsed cecum, a Pezzer cathetei No 30 01 32 is inserted, fixed to the 
margin by catgut, and inverted by a purse-stnng suture In closing the ab- 
dominal wound, several interrupted sutures include the cecal wall above and 
below' the cecostomy opening, thus fixing the cecum to the abdominal wall 
m the corrected position After the resumption of 1101 mal bowel evacuations, 
the cecostomy gradually ceases to function and the Pezzer catheter may be 
removed The opening eventually closes wnthout any further surgical pro- 
cedure 

(3) Resection of the cecum with adjacent involved viscera is reserved only 
for far advanced cases Accompanying this late stage volvulus, one usually 
finds gangrenous areas of the intestinal wall with neciosis The bowel is so 
devitalized that contamination of the adjacent peritoneal surfaces is usually 
present Even slight handling and manipulation may be disastrous The 
only recourse is rapid resection of the gangrenous portion, delivery of the 
two open loops of gut outside the abdomen with or without tubes Later, if 
the patient survives, an attempt may be made to effect continuity and peri- 
toneahzation How’ever, this ladical piocedure lesults in a mortality of 50 
per cent, according to Jacobsen 

Case I — No 17254 H J , male, age 62, white, steam engineer, was admitted to 
the Boulevard Hospital July 23, 1935, at 9 pm, with the chief complaint of pain in 
the abdomen 

History — The patient had never suffered from a serious ailment, even in childhood 
Never operated upon Cardiorespiratory and urologic systems were essentially negative 
For many years, there had been present reducible, bilateral inguinal herniae However, 
for 30 years he had been troubled with symptoms of "stomach ulcer,” characterized 
by the classic picture of hunger-pain, black, tarry stools Roentgenograms, taken several 
years ago, confirmed the diagnosis of ulcer Loss of 30 pounds in weight during the 
past year, accompanied by moderate fatigue upon exertion 

The pain which caused him to come to the hospital was different from anything 
previously experienced, and had occurred without any warning signs or symptoms 
Early on the morning of admission, the patient had suffered pain m the umbilical region, 
which had gradually increased in severity No flatus had been passed since the onset, 
and an enema upon admission yielded practically nothing Before entrance, the patient 
had felt nauseated but did not vomit Soon after being placed in bed, however, he 
vomited brownish-green material on two occasions 

Examination — Reveals an elderly man who appears acutely ill The abdomen pre- 
sented a large mass to the right of the umbilicus, the size of a grapefruit, tympanitic to 

253 



MANDEL WEINSTEIN 


Annals ofSursery 
February 1938 


percussion, and somewhat mobile Borborygmus was present No visible peristalsis 
noted, some tenderness to palpation. Examination of inguinal regions demonstrated 
complete bilateral inguinal herniae, of large size, which were easily reducible Blood 
pressure 170/70 Temperature, 1004° F, pulse, 84, respirations, 22 Uranalysis, es- 
sentially negative Leukocytes, 9,400, polymorphonuclears, 72 per cent, lymphocytes, 
28 per cent 

Operation — Anesthesia gas-oxygen-ether The peritoneal cavity was opened through 
a right rectus incision over the mass at the level of the umbilicus A loop of greatly 
dilated intestines with thmned-out wall presented itself, which was identified as a mobile 
cecum in the upper abdomen It was found to be twisted upon itself several turns because 
of an abnormally long mesentery The ascending colon was located in the right side 
of the abdomen, but there seemed to be no point of fixation of the cecum in the right 
iliac fossa After untwisting the cecum, the small intestine was seen to enter it in the 



Fit* I — Case i Drawing representing the findings at operation A distended 
mobile cecum was rotated around two fixed points, one being the appendix bound 
down at its tip by numerous adhesions and the other the ascending colon Note the 
obstruction of the small intestine by the cord like appendix 


usual manner The normal intestinal color immediately returned The appendix, how- 
ever, was fibrous, tense, cord-like, and fixed to the posterior parietes by broad bands 
of adhesions which also contributed to the picture of intestinal obstruction by obstructing 
the ileum (Fig i) The patient’s condition did not warrant prolonged surgery The 
appendix was removed m the usual manner, after untwisting the volvulus Since the 
periappendiceal adhesions were factors in the causation of obstruction, we assumed that 
opportunity for recurrence would be lessened once the adhesions were removed The 
abdominal incision was sutured in layers 

Postoperative Course — A relatively smooth convalescence ensued, aided by intra- 
venous S per cent glucose and saline, together with the Wangensteen suction syphonage 
apparatus However, after the sutures were removed on the ninth postoperative day, 
patient coughed severely, and produced an evisceration through the wound Secondary 
suture was immediately undertaken, with through-and-through, interrupted, heavy black 

254 




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VOLVULUS OF THE CECOCOLON 


silk, embracing all layeis of the abdominal wall He was discharged from the hospital 
two w'ceks later in good condition, with a well healed abdominal wound 

On September 17, 1935, appro\imately tw’o months subsequent to discharge from 
the hospital, he was icadmitted for abdominal pain, constipation, vomiting, and abdominal 
distention The same tympanitic abdominal tumor was present For about two days 
prior to this recurrent attack of pain, the patient had been constipated, but the present 
sMiiptoms began only the night before admission Suction syphonage drainage with 
the Lejine tube, and intravenous glucose and saline were instituted All his symptoms 
disappeared after several copious bowel evacuations had been effected, and he left the 
hospital at the end of four daj s 



Tig 2 — Case i A postoperatn e barium en Fig 3 — Case i Roentgenogram showing a 

eiin stud) showing the cecum still located in the raising of the right leaf of the diaphragm, with 
upper abdomen CecopeM had not been performed cods of intestine between it and the liver 

There was no megacolon present 

Follow-Up — Sfvteen months later the patient seemed well, and stated that he had 
no pain However, he had been troubled with gas, and aften expelled huge quantities 
subsequent to a stool evacuation Constipation still troubled him His wound was well 
healed, and the abdomen not distended Roentgenologic studies reveal no great colonic 
distention The cecum is moderately dilated and still occupies a position m the upper 
abdomen, in the median line or to the left (Fig 2) Megacolon is not present In 
addition, his roentgenograms show an elevation of the right diaphragm, and the presence 
of coils of intestine between it and the right lobe of the liver (Fig 3) 

Comment — ^This case demonstrates another factor m the production of 
cecocolon volvulus m addition to an abnormally long mesentery, namely, in- 
flammatory fixation bands around which the cecum may rotate and obstruct 
the intestinal lumen In Chalfant’s patient an omental band sui rounded the 
intestine at the point of stiicture Freeing of a firm adhesion band in Mc- 
Gowan and Dixon's case^^ appai ently cured the patient The elevation of the 
right leaf of the diaphragm was discovered incident to a routine roentgenologic 
study to determine related anomalies 


256 


MANDEL WEINSTEIN 


Annals of Surgery 
Tebruary 1938 


The occurience of volvulus was not related to the chronic ulcer illness and 
happened suddenly, without warning, except for a two to three day interval 
of constipation If, at the time of operation, circumstances permitted, this 
patient would be more secui e from future attacks if his cecum were sutured to 
the abdominal wall 


Case 2 — No 19817 E H , white, age 40, laborer, was admitted to the Boulevard 
Hospital June 16, 1936, with the diagnosis of intestinal obstruction Temperature, 992° F, 
pulse 80, respirations 20 

Htstoty — During his childhood, patient had measles, scarlet fever, and frequent 
attacks of tonsillitis Had never had any symptoms referable to his cardiorespiratory 
system, except frequent “colds ’’ For the past 17 years, has suffered attacks of abdom- 



Fig 4 — Case 2 Drawing representing the findings at operation An enormously 
distended cecum, the result of ^ oh ulus of the cecocolon, occupied a large part of the 
abdominal cavity 

inal pain, occurring approximately every six months These would last from a few 
hours to as long as one day, coming on at two hour intervals in the beginning, and 
then increasing in frequency However, for the past few years, these attacks have 
returned practically every month and would cause discomfort for as long as a whole 
week No nausea or vomiting ever accompanied these episodes, and he always managed 
to carry on his usual work He noticed that for two or three dajs prior to the attacks, 
he was constipated, and m the interim his stools were dry, hard, and contained mucus 
with occasional streaks of blood Relief of pain was obtained by doubling up, crossing 
his knees, and making very firm pressure on his abdomen Cathartics and enemata 
never gave relief After an attack, he noticed his stools were frothy, contained mucus, 
were copious in amount, and very foul smelling 

Even though he was termed a laborer, he did no heavy work If he were to jump 
a few feet or bend over suddenly, he would feel something move in his abdomen, 
whereupon he experienced “sour stomach and belching” These incidents were of 

256 



Volume 107 
>.umber 2 


VOLVULUS OF THE CECOCOLON 


momentary duration He always believed that “his intestines were loose inside of 
linn ” Flatus was always evacuated with difficulty, and seemed small m amount 

Present attack began one and one-half weeks before admission with spasms of 
pain, more frequent than ever before The pain was of such severity that, for the 
first time, the patient had cold sweats For 24 hours prior to operation, his attacks 
of pain at times recurred every two to four minutes For three days he was completely 
constipated, not even passing flatus On the day pieceding admission to the hospital 
he had taken castor oil, but with no relief 

Physical Examination — Revealed a middle aged male, not in shock Blood pres- 
sure 150/go Head, neck, cardiovascular, and respiratory systems essentially negative 
Abdomen markedly distended, tympanitic throughout, no masses felt Uranalysis 
negative. Blood count, 12,000 leukocytes, 62 per cent neutrophils, 2 per cent eosinophils. 



Tig s — Case 2 Postoperative roentgenogram Pig 6 — Case 2 Lateral roentgenogram show 

Barium enema study indicating a large redundant ing cecum fixed to the abdominal wall following 
colon, e\ idently congenital cecopexy Still greatly extended 

36 per cent lymphocytes For about ten hours, the patient’s intestinal tract was decom- 
pressed by Wangensteen’s method of suction syphonage with a Levine tube, with only 
slight relief from pain, and no diminution of the abdominal distention 

Opci atioii — Under subdural block, using 120 milligrams of neocaine, the peritoneal 
cavity was entered through a right rectus incision A small amount of tan colored 
fluid was encountered The cecum and part of the ascending colon were enlarged, 
distended, and thinned-out, to an unbelievably large size (Fig 4) The obstructive 
mechanism was a torsion of more than one complete turn produced by a very mobile 
cecum suspended fiom the posterior parietes by a long anomalous mesentery The 
intestinal wall of the involved loop showed no discoloration, or any signs of permanent 
vascular impairment The colon distal to the affected area was somewhat enlarged and 
distended, while the small intestine itself was almost collapsed 

The involved intestine was untwisted, and a trocar and cannula were introduced, 
which effected the evacuation of a large quantity of gas, without any accompanying in- 
testinal fluid content Through this small opening a Pezzer catheter No 30 was 
inserted, and fixed to the edges of the opening into the intestine The cecum itself 
was fixed to the peritoneal opening by several sutures, and the abdominal wound closed 
in layers 


257 


MANDEL WEINSTEIN 


Annal? of Surccrv 
February 1938 


Postoperative Couise — The patient was returned to bed in good condition, and 
the Wangensteen suction syphonage was immediately reapplied, and two and three 
thousand cubic centimeters of 5 per cent glucose and saline were administered intra- 
venously during each 24 hours Relief from pain was immediate, and the patient 
made an uneventful recovery Before discharge from the hospital, on the thirteenth 
day postoperative, the Pezzer catheter was removed, as the bowels were functioning 
normally The cecal opening closed completely several weeks later 

Follow-Up — Eight months after discharge from the hospital, the patient stated 
he has enjoyed excellent health, and for the first time as far back as he could recall, 
he has had one or two daily bowel movements without cathartics His wound was 
closed and well healed and presented no herniation A moderate amount of distention 
was still present This was evidently due to the fact that he has a congenitally en- 
larged and ptosed colon (Figs 5 and 6) 

Comment — This case illustrates the rapid and extensive gas formation in 
the closed loop, and the collapsed state of the small intestine The latter was 
evidently helped by the Wangensteen decompression, but the pathology m the 
proximal loops did not resemble that occurring in the usual type of intestinal 
obstruction, with the accompanying infectious inflammatory process of the 
visceial wall involving the intestine for a great distance proximal to the point 
of obstruction The lack of complete vascular, occlusive phenomena may be 
accounted for by the fact that the great mobility of the cecocolon, in spite of 
the torsion, permitted sufficient blood to pass the point of sti angulation The 
operative procedure of cecopexy and cecostomy selected for this patient is 
the method of choice The congenital enlargement and mobility of the re- 
maining colon IS well illustrated m the roentgenograms, as well as the fixation 
of the cecum, still distended, to the anterior abdominal wall 

CONCLUSIONS 

(1) Cecocolon volvulus is a form of intestinal obstruction of infrequent 
occurrence, depending foi its mechanism upon a mobile cecum with an ab- 
normally long mesentery 

(2) Abortive attacks of torsion may precede a severe acute attack, and are 
usually subsequent to periods of constipation 

(3) Rapid and extensive gas formation in the involved loop is probably 
caused by the action of colonic anaerobes growing in an oxygen deficient 
region 

(4) Other congenital anomalies frequently accompany this condition, and 
should be searched for An elevation of the right diaphragm was discovered 
in one of the cases herewith reported 

(5) The procedure of choice, if operated upon soon enough, is detorsion, 
cecostomy, and cecopexy 

(6) Two cases with cecocolon volvulus are herewith reported, whose 
course and findings closely resemble those previously recorded in the literature 

Note — The author wishes to take this opportunity to express his thanks and apprecia- 
tion to Dr Pol N Coryllos for the many helpful suggestions offered 

258 



Volume lOT 
NumboT 2 


VOLVULUS OF THE CECOCOLON 


REFERENCES 

’•Basden, M M Volvulus of Cecum Complicating Labor Brit Med Jour, i, 1119, 

1934 

" Cannon, W B Functions of the Large Intestine JAMA, 59, i, July 6, 1912 
® Chalfant, S S Torsion of the Cecum with Review of the Literature and Report of 
a Case Am Jour Obst and Gynec, 2, 6, December, 1921 
* Corner, E M , and Sargent, WPG Volvulus of the Cecum with an Account of 
Rare and Possibly Common Cases Annals of Surgery, 41, 63, 1905 
Counsellor, V S Discussion of Pratt and Fallis’ Article in J A M A at Rochester, 
Minn JAMA, 89, 1225, 1927 

° DuRoux, P Torsion du gros Intestine Revue Gyn , 19, 325, 1912 
" Elliott, R R , and Barclay- Smith, E Antiperistalsis and Other Muscular Activities 
of the Colon Jour Physiol , 31, 272, 1904 
® Gatelher, J , Moutier, F , and Porcher, P Les volvulus due caecum Arch d mal de 
I’app digestif , 21, 20, January, 1931 
® Graham, E A Surgical Diagnosis W B Saunders Co , 2, 629, 1930 

“ Homan, J Torsion of the Cecum and Ascending Colon Arch Surg , 3, 395, 1921 

Jacobsen, H Volvulus due caecum Acta chir Scandiav , 56, 181, 1923 
“ Kahn, M C Anaerobic Spore-bearing Bacteria of the Human Intestine in Health 
and m Certain Diseases Jour Infect Dis, 35, 423, November, 1924 
’’Keith, A A New Theory of the Causation of Enterostasis Lancet, 2, 371, 1915 
’* McGowan, J M , and Dixon, C F Volvulus of the Cecum Report of a Case Proc 
Staff Meet Mayo Clinic, ii, 337, 1936 

” Mclver, M A , Benedict, E B , and Clive, M W , Jr Postoperative Gaseous Dis- 
tention of the Intestine Arch Surg , 13, 588, October, 1926 

“ Moreau, C Un cas d’occlusion intestinale par torsion due caecum et de Tongine due 
colon ascendant Bull et mem Soc de chir de Pans, 22, 583, 1930 
’"Nelson, J M Postoperative Volvulus of Cecum Am Jour Surg, s, 398, 1928 
Ohman, E Volvulus of Cecum Finska Lak-Sallsk Handl , 66, 597, July, 1924 
’® Pratt, J P , and Falhs, L S Volvulus of Cecum and Ascending Colon JAMA, 
89, 1225, 1927 

“ Philopwicz, W Weitere Beitrage zur Casuistick und Aetiologie des Dumdarm-Vol- 
vulus Arch f klin Chir , 97, 844, April, 1912 
’’Rokitansky, C Intestinal Strangulation Arch Gen Med, 14, 202, 1837 
” Rankin, F W Surgery of the Colon D Appleton & Co , N Y , i, 80, 1926 
” Sarles, M Volvulus due caecum a symptomatologie pseudo-vesiculare avec diarrhee 
Arch de mal I’app digestif , 19, 731, 1929 
’* Schroder and Brettschneider Quoted by Ohman 

^ Sweet, R H Volvulus of Cecum Acute and Chronic with Report of 8 Cases New 
Eng Jour Med, 213, 287, 1935 

’’Treves, F Lectures on Anatomy of the Intestinal Canal and Peritoneum in Man 
Brit Med Jour , i, 1888 

” Von Zoege Manteuffel Die Achsenderhungen Des Caecum Verhandl d deutsch 
Gesellsch f Chir , 27, 526, 1930 

’’Wangensteen, O H Therapeutic Consideration in the Management of Acute Intes- 
tinal Obstruction Arch Surg, 26, 933, 1933 
’’Weible, R E Volvulus Torsion of the Whole Mesentery Surg, Gynec, and 
Obstet, 19, 644, November, 1914 

“Weinberg Quoted by Dixon, D F, and Bargen, J A -Vaccination Preceding Colonic 
Operations as Protection against Peritonitis NYS Med Jour, 35, 10, May 
IS, 1935 


259 



ARGENTAFFINE TUMORS OF THE GASTRO-INTESTINAL TRACT 

REPOET OF THREE CASES ONE AVITH DISTANT METASTASES 

Thomas E Wyatt, MD 
Nashville, Tenn 

FROM THE DEPARTMENT OF SDROEIIT, \ANDERBILT UNIVERSITi NASHVILLE, TENN 

There have been numerous reports of “carcinoids” oi argentaffine tumois 
of the gastro-mtestinal tract Excellent summaries of this hteratuie have 
been made by Foibus,^” Cooke^ and Raiford By elaborating on the work of 
Masson,”® Lubarsch”^ and Obeindorfei”® they have definitely classified this 
neoplasm 

Although it was recognized that this tumor produced distant metastases, 
as was reported, in 1890, by Ransom,^'^ it was still consideied benign by some 
authors, as late as 1934 It is still questioned whether 01 not the tumor is 
of epithelial origin and consequently properly classified as a caicinoma 
Thus they present a definite clinical problem although the peculiaiities of 
the tumors may have excited an interest which is beyond their significance 
No doubt this tumor has escaped recognition on numerous occasions when 
appendicectomy has been performed In relatively few instances is it recog- 
nized grossly and the diagnosis is made only after histologic examination 
In the small intestine, it has been encountered most frequently at operation 
and in the large bowel at autopsy It has manifested itself clinically by caus- 
ing intestinal obstruction and intussusception Occasionally it has made it- 
self known by its metastases, and on several occasions has been discovei ed in 
a Meckel’s diverticulum In the appendix it is usually encounteied 111 asso- 
ciation with acute or chronic appendicitis In no case, m the literature, has 
it been diagnosed preoperatively in any part of the gasti o-mtestinal tract 
The histone aspects of the argentaffine tumors have been so ivell piesented 
by Forbus, in 1925, that only a brief resume is necessaiy Lubarsch, in 1888, 
leported two cases of multiple growths in the ileum and designated them as 
primary carcinoma although they appeared somewhat atypical Ransom 
then, in 1890, described a tumor resembling that of Lubarsch except that al- 
though the primary site was m the ileum, it extended through the wall of the 
intestine and a short distance into the mesentery There were also nodules 
111 the liver identical m cellular appearance to those m the ileum 

In quick succession there followed several reports of this type of tumor 
m which there were metastases to regional lymph nodes and to the liver 
Several other cases of primary tumor were reported and many of these were 
spoken of as “endothelial sarcoma ” Lubarsch by the use of a silver impi eg- 
nation method of staining was able to show a definite relationship between the 
cell nests of the tumor and the crypts of Leiberkuhn, which suggested an epi- 
Submitted for publication August 16, 1937 

260 




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ARGENTAFFINE TUMORS OF THE INTESTINE 


thelial origin To Lubarsch goes the credit of definitely distinguishing this 
tumor from the cylindrical cell adenocarcinoma occurring in the gastro-intes- 
tmal tract 

Because of certain morphologic resemblances Bunting considered these 
tumors analogous to the basal cell caicmomata of the skin, which had been 
described by Krompecher Oberndorfer, in 1907, first termed these tumois 
“carcinoid ” His observations were made on six cases of multiple tumors 
of the small intestine, and he differentiated them fiom caicmoma on the 
basis that they weie generally multiple, that they had no tendency to infiltrate 
surrounding tissue, that the cells were found m undifferentiated masses, that 
growth was slow and that they did not metastasize He then held that they 
were embryonal malformations 

Huebschniann^® first made the suggestion, in 1910, that these tumors might 
possibly arise from chromaffine cells Oberndorfer then found that then cells 
stained with chromium salts Cosset and Masson,^® in 1914, by studies of the 
chromaffine cells of the gastro-intestinal tract, discovered the cytoplasmic gran- 
ules which reduce an ammoniacal solution of silver 

McGlannon and McCleary,-- Dukes and Lockhart-Mummery® had previ- 
ously found that carcinoid tumors were rich m cells with cytoplasmic granules 
which gave the characteristic argentaffine reaction Foibus, Hasegawa^^ and 
Danisch® substantiated the finding of silver reducing cytoplasmic gianules in 
cells m the crypts of Lieberkuhn Forbus by this method of staining was able 
to point out a third type of tumor which morphologically lesembled the car- 
cinoid tumor but followed the clinical course of cylindrical cell adenocarci- 
noma The cells of this tumor did not contain granules which 1 educed silver 

Previously Trappe'*'* had stated that carcinoid tumors arose from pancreatic 
rests m the intestinal tract and Saltykow,®® m 1912, agreed with Toenniessen 
that the carcinoids were derived from rests composed entirely of cells like 
those of the islets of Langerhans 

At the present time it is generally conceded that “carcinoid” or “argen- 
taffine” tumors arise from the Kultschitsky cells found in the base of the ciypts 
of Leiberkuhn This theory is adhered to by many later authors, among them 
Gaspar,^^ who showed excellent evidence by means of serial sections that this 
tumor arises from the cells m the crypts of Leiberkuhn and that the cells of 
both the primary tumor and its metastases contain silvei reducing granules 
in their basal portions as do the Kultschitsky cells of the intestinal epithelium 
On this basis he concluded that this tumor should be classified as carcinoma 
Cooke, Raiford and Humphreys^’’ also used these histologic methods and weie 
able to demonstrate silver reducing granules m cells of both the pi unary tumor 
and its metastases 


CASE REPORTS 

Case I — A female, age 18, white, was admitted to the Surgical Service of the 
Vanderbilt University Hospital complaining of pain and tenderness in the right lower 
quadrant of the abdomen of 20 hours’ duration, nausea and vomiting appeared after 

261 



THOMAS E WYATT 


Annals of Surgery 
February 1938 


the onset of pain She had had no previous similar illness There were no genito- 
urinary symptoms and no diarrhea 

Physical Exaimiiaiion — The patient was a pale, rather poorly nourished girl who 
appeared to be very ill Temperature, 1002° F , white blood cells, 9,300 Uranalysis 
was negative The salient physical findings were confined to the abdomen On pal- 
pation there was tenderness over the entire right side, more marked in the right lower 
quadrant There was mild muscular rigidity over the area of tenderness 

A diagnosis of acute appendicitis was made and the appendix was removed through 
a right rectus incision The mesenteric lymph nodes were not remarkable at time of 
operation 

Pathologic Eiaimmtwn — Gioss The appendix was 7 cm in length The proximal 
two-thirds were rather pale but the tip was bulbous and red, the blood vessels were 
engorged On opening the appendix the lumen was found to be patent and filled with 
mucopurulent mateiial The mucosa was somewhat hemorrhagic There was no evidence 
of perforation 



Fig I — Case i Photomicrograph of 
a tumor cell nest showing the silver reduc 
ing granules of the tumor cells (oil im 
mersion) 



Fig 2 — Case 2 Photomicrograph show 
mg typical arrangement of cell groups with 
invasion of the musculature (high power) 


Microscopic — The tip of the appendix showed the normal architecture to have 
been obliterated by cell nests and strands, the picture being typical of the argentaffine 
tumor In addition the walls of the organ were infiltrated with polymorphonuclear 
leukocytes Sections through the proximal two-thirds showed it to be essentially 
normal The tumor cells were found to reduce silver (Fig i) 

Follow-Up — The patient reported herself well nine years after operation 
Case 2 — A female, age i8, white, was seen 21 hours after onset of generalized 
abdominal pain The pain became localized m the right lower quadrant ten hours after 
onset At this time she became nauseated and vomited several times There were no 
urinary symptoms, no diarrhea or djsmenorrhea One jear previously she had a similar 
attack which lasted for two days and which was not so severe The remainder of 
the past history was not remarkable 

Physical Evamination — The patient was a well developed and well nourished young 
white girl who appeared to be quite ill and in much pain Temperature, 1008° F , 
white blood cells, 32,000 Uranalysis was negative The only physical findings of im- 
portance were confined to the abdomen, which was noted to move very poorly on respira- 
tion There was almost board-hke rigidity of the abdominal muscles and marked 
tenderness over the entire right lower quadrant 

262 



Volume 107 
Number 2 


ARGENTAFFINE TUMORS OF THE INTESTINE 


The diagnosis of acute appendicitis was made and the appendix was removed 
through a right rectus incision The mesenteric lymph nodes were palpable but were 
very small and soft 

Pathologic Examination — Gioss The appendix was 5 5 cm in length It was 
markedly swollen, reddened and covered with a shaggy fibrinous exudate The lumen, 
although patent, was filled with purulent material The walls were much thicker 
than normal, particularly in the distal third, and on section they gave a “gristly” feel 
as the knife passed through them 

Mici oscopic — Sections through the distal third showed the typical appearance of 
the argentaffine (Fig 2) tumor, while sections through the proximal two-thirds showed 
no evidence of the tumor In addition, the walls were densely infiltrated with poly- 
morphonuclear leukocytes The tumor cells reduced silver 

Follozv-Up — On two occasions this patient has returned to the hospital with 
symptoms of partial intestinal obstruction which disappeared with conservative treat- 
ment She was well five months after operation 



Fig 3 — Case 3 Photomicrograph of subset Fig 4 — Case 2 Photomicrograph of a metastasis 
ous tumor of the cecum, showing invasion of to the liver (high power) 

the musculature (high power) 


Case 3 — K male, age 55, colored, had had numerous admissions to the hospital 
He had been found to have syphilitic aortitis with aneurysm of the aortic arch, tabes 
dorsalis and perforating ulcers of the feet Death was presumably due to syphilis There 
was no history referable to the gastro-intestmal tract which would lead one to suspect 
the presence of a tumor of the cecum At autopsy m addition to the aortitis and pul- 
monarj congestion there were two tumois found in the cecum One was an ulcerated 
firm polypoid mass measuring 5 6x6 cm The second was a movable subserous mass 
approximately the same size as the first tumor (Fig 3) On section they were both 
yellowish-white in color There were several small shrunken areas noted in the liver 
which had the same yellowish-white color as the tumors of the cecum 

Mici oscopic — Both tumors were found to be identical in structure, and were 
typical of the argentaffine tumor Sections of the metastases in the liver showed the 
same type of tumor as was found in the cecum (Fig 4) Cells of both tumors of the 
cecum were found to reduce an ammoniacal solution of silver as did the cells of the 
metastases in the liver 


263 



THOMAS E WYATT 


Annals of Surgery 
February 1938 


Pathology — Humphreys found, fioni a study of the hteratuie, of all re- 
ported cases of aigentaffine tumois of the gastro-mtestinal tract, with excep- 
tion of the appendix, that 30 per cent were multiple as opposed to the usual 
single cylindrical cell carcinoma Discovery of one of these tumors at oper- 
ation should lead to a seaich for others 

They are most likely to occur as nodules in the submucosa and if pedun- 
culated, ulceration may be present They are usually small in size but may 
attain the size of any other malignant neoplasm of the bowel They have 
on occasion been mistaken for ordmar}'^ adenocarcinoma since there is so 
little difference in gross appearance They have occasionally been encoun- 
tered as “napkin-nng” tumors constricting the lumen of the intestine In con- 
sistency, they aie usually rubbery rather than being hard The color on cut 
section IS usually a yellowish-white but some have been described as white 
or gray 

Microscopically these tumois are composed of lound or polygonal cells 
The nuclei are vesiculai and contain a large amount of chromatin The cyto- 
plasm IS pale and its outline is indefinite 

The cells are usually clumped in nests or strands with an outer 11m of 
cells whose nuclei are peculiarly hyperchromatic and, seen in section, they 
are drawn away from the dense stroma They may form in groups about 
what appears to be a lumen Some of the cell stiands extend into the muscle 
layers 

The stroma of the argentaffine tumor is usually very dense and places the 
cell groups in “splendid isolation ” Mitotic figures are scarce 

Arising supposedly as it does from the Kultschitsky cell of the intestinal 
epithelium, most of the cells contain granules which reduce silver Not all 
the cells contain granules, and these are termed “indifferent ” Sections of 
a normal appendix and cylindrical cell adenocai cinoma will, if stained with 
silver, usually show an occasional cell containing granules Sections of pri- 
mary argentaffine tumors and their metastases, stained with silver, contain 
large numbers of cells with the characteristic granules 

These tumors in the appendix aie usually located at the tip, sometimes 
forming a bulb-hke mass They rarely extend beyond the proximal two- 
thirds of the organ The histologic picture in the appendix is exactly as m 
other parts of the intestine except that m most cases thei e is an inflammatory 
process present 

In the appendix the tumor is not always appaient on gross examination 
and the diagnosis is often made only after study of several sections Nor- 
ment^® states that, in his series, only 34 per cent of the appendices containing 
the tumors were enlarged at the site of the neoplasm However, cases have 
been reported in which the bulbous tip of the organ has become so large that 
It could be palpated through the abdominal wall 

Comment — Incidejice and Malignancy The hteratuie contains a large 
number of reports of isolated cases of carcinoid of the appendix and an 
occasional report of a series of cases Many authors fail to make any dis- 

264 



Volume 107 
Number 2 


ARGENTAFFINE TUMORS OF THE INTESTINE 


tinction between cylindncal cell adenocaicmoma and the spheroidal cell ar- 
gentaffinoma Otheis make caieful distinction but do not considei the silvei- 
redncing tumor malignant 

The largest senes lepoited is by Noiment, who found 67 carcinomata in 
45,000 appendices lemoved at opeiation Two of these he designates as the 
columnai cell type and the lemammg 65 as the spheioidal cell aigentaffinoma 

Smith,®'’ in his senes, found 21 carcinoids 111 7,865 appendices lemoved at 
Opel ation 

Accoiding to St George, ^heie was no case of caicmoid encounteied in 
Bellevue Hospital prioi to 1916, and since that time carcinoids of the appendix 
weie found only twnce m 18,700 autopsies Also at Bellevue Hospital in a 
senes of 9,108 appendicectomies the tumoi ivas found only seven times 

In tlie Vanderbilt University Hospital, tlie twm cases cited herewith weie 
the only aigentaffine tumors found in 2,179 appendicectomies The single case 
of multiple tumoi s of the large bowel is the only case m 1,744 autopsies 

These tumors aie repoited to arise from all parts of the gastro-mtestinal 
tract except the esophagus, duodenum, and lectum They are of couise en- 
countered more fiequentl}’^ m the appendix than elsewdiere Of all the cai- 
cmoids of the appendix wdiich have been lepoited, only five have extended 
beyond the oigan itself The extent of metastases vaned from extension to 
the mesentery only, to wndespi ead metastases in the mesentery, omentum, and 
m one case m the pleura 

Humphre3^s, m 1933, bi ought the total numbei of aigentaifine tumors of 
the small intestine to 152 Since that time there have been seven moie 
repoited One each bj^ Christophei' and Jones, both of which were located 
in the ileum and had not metastasized One by Price®® Avas found m a 
Meckel’s diverticulum and had not metastasized Twm by Lee and Taylor,®'’ 
both of W'hich w^ere in the ileum and both of wdnch had metastasized to the 
regional lymph nodes One by Wanen and Gates^'’ and one by Wood^®, 
both of these tumors were encountered m the ileum and had metastasized to 
the regional nodes 

With these seven additional cases the total now lepoited is 159 and of this 
number 36 have metastasized (Table I), lepresentmg 225 per cent of the 
series of tumors of the small intestine This figuie may be compaied with 
that obtained by Craig® who studied a series of adenocai cinomata of the small 
intestine and found that 36 per cent had metastasized at time of operation 

With the present case there are now nine leported tumoi s of the large 
bowel, three of w^hich had metastasized In the instances leported by Raiford, 
one had metastasized to the regional nodes and the other to regional nodes, 
liver and lungs Although the senes is small, it is of inteiest to compare it 
with the figures of Hayes,’® who found in a study of a large senes of adeno- 
caremomata of the laige bowel that 37 per cent had metastasized at time of 
operation 

Prognosis and Tieatment — Fiom the foregoing statistics it is evident that 
carcinoid or aigentaffine tumoi is not a harmless lesion It is tiue that many 

265 



THOMAS E WYATT 


Annals of Sureery 
February 1938 


Table I 

SYNOPSIS OF MALIGNANT CARCINOIDS COLLECTED FROM THE LITERATURE 


Author 

Year 

Primary Site of 
Tumor 

Site of Metastases 

Age 

Race 

Sex 

Ransom 

1890 

Small bowel 

Liver 




Vers^ 

1908 

Small bowel 

Regional lymph nodes 




Enstratoff 

1911 

Small bowel 

Liver 




Saltykow 

1912 

Small bowel 

Regional lymph nodes 




Dietrich 

1913 

Ileum 

Liver 

62 

W 

F 

Schopper 

1913 

Ileum 

Liver and regional nodes 

54 

W 

M 

Engel 

1920 

Small bowel 

Regional lymph nodes 




Bakke 

1921 

Small bowel 

Regional lymph nodes 




Schnebel 

1923 

Ileum 

Liver 

50 

W 

M 

Dukes and Lockhart- 







Mummery 

1926 

Ileum 

Peritoneum, liver, re- 

76 

W 

F 




gional nodes 




Stewart and Taylor 

1926 

Appendix 

Pelvis 

31 

W 

F 

Decker 

1928 

Small bowel 

Regional lymph nodes 




Brocher 

1928 

Small bowel 

Liver 

28 

W 

F 

Obemdorfer 

1929 

Appendix 

Regional lymph nodes 

28 

W 

F 

Oberndorfer 

1929 

Ileum 

Regional lymph nodes 

52 

W 

F 

Obemdorfer 

1929 

Ileum 

Regional lymph nodes 

81 

W 

F 




Mesentery 




Oberndorfer 

1929 

Ileum 

Regional lymph nodes 

41 

W 

F 




Mesentery 




Obemdorfer 

1929 

Ileum 

Regional lymph nodes 

48 

W 

F 

Pack and Davis 

1930 

Ileum 

Regional lymph nodes 

73 

W 

M 

GdspAr 

1930 

Jejunum 

Regional nodes and liver 

74 

W 

F 

Philips and Isaac 

1930 

Appendix 

Ext to omentum 




Khoflach 

1930 

Appendix 

Ext to mesentery 

64 

W 

M 

Ritchie 

1930 

Ileum 

Mesentery and liver 




Marangos 

1931 

Ileum 

Regional nodes and liver 

68 

W 

F 

Cooke 

1931 

Ileum 

Regional lymph nodes 

67 

W 

M 




and liver 




Cooke 

1931 

Ileum 

Regional lymph nodes 

65 

W 

F 




and liver 




Cooke 

1931 

Ileum and 

Regional lymph nodes 

60 

W 

M 



jejunum 

and liver 




Scholte 

1932 

Ileum 

Mesentery and regional 

40 

W 

M 




lymph nodes 




Mori 

1932 

Appendix 

Mesentery, pleura. 

49 

W 

M 




omentum 




Mori 

1932 

Ileum 

Regional lymph nodes 

26 

W 

M 

Mori 

1932 

Ileum 

Regional lymph nodes 

59 

W 

M 

Meeker 

1932 

Small intestine 

Regional lymph nodes 

61 



Raiford 

1933 

Stomach 

Regional lymph nodes 

55 

W 

M 




and liver 




Raiford 

1933 

Ileum 

Regional lymph nodes 

45 

w 

F 




and peritoneum 




Raiford 

1933 

Ileum 

Regional lymph nodes 

57 

w 

M 




and liver 




Raiford 

1933 

Appendix 

Ext to cecum and ileum 

16 

w 

F 


266 




^ olume 107 
Isumber » 


ARGENTAFFINE TUMORS OF THE INTESTINE 


Author 

Year 

Primary Site of 
Tumor 

Site of Metastases 

Age 

Race 

Sex 

Raiford 

1933 

Sigmoid 

Regional lymph nodes, 
liver, lungs 

53 

C 

M 

Raiford 

1933 

Cecum 

Regional lymph nodes 

46 

W 

F 

Humphreys 

1934 

Ileum 

Regional lymph nodes 

60 

W 

M 

Humphreys 

1934 

Ileum 

Regional lymph nodes 

60 

w 

M 

Humphre3^s 

1934 

Ileum 

Regional lymph nodes 

47 

c 

M 

Lee and Taylor 

1934 

Ileum 

Regional lymph nodes 

Sr 

w 

F 

Lee and Tajdor 

1934 

Ileum 

Regional lymph nodes 

53 

w 

F 

Warren and Gates 

1934 

Ileum 

Regional lymph nodes 

53 

w 

F 

Ward 

1936 

Ileum 

Regional lymph nodes 

62 

w 

F 


of the tumors weie unsuspected and were found at autopsy yet many caused 
definite symptoms It is a fact that none of these tumors have been diag- 
nosed preoperatively, but it is of extreme importance that they be recognized 
when once encountered as they offer a much better prognosis than does adeno- 
carcinoma The tumor appears to grow slowly and to metastasize late If 
metastases aie not present at time of operation prognosis is good, and favor- 
able results have been obtained with removal of the tumoi and the regional 
nodes containing metastases Few tumors of the appendix have metastasized 
in spite of their frequency It is possible, howevei , that the presence of these 
tumors in the appendix leads to an inflammatory process which brings about 
their earlier recognition 

All “carcinoids” must be considered slow growing malignant tumors 

As in other malignancies of the gastro-intestinal tract, surgical intervention 
is the only means of treatment The effect of i oentgenotherapy on the growth 
of these tumors has not yet been determined 

SUMMARY 

( 1 ) A brief resume of the theories concerning the argentaffine tumors has 
been presented 

(2) Two cases of argentaffine tumor of the appendix have been presented, 
as well as one case of a multicentric argentaffine tumor of the cecum with 
metastases to the liver 

(3) This tumor is a carcinoma arising from the Kultschitsky cell of the 
intestinal epithelium 

(4) The pathology of these tumors has been briefly reviewed 

(5) The reported cases in the literature have been collected, and 22 5 per 
cent of tumors of the small intestine were found to have metastasized Of the 
nine cases of the large bowel, three had metastasized 

(6) All “carcinoids” are slow growing but malignant tumors A good 
prognosis is presented after surgical intervention, even when metastases to 
the regional nodes have occurred 

I wish to thank Dr Ernest W Goodpasture for his assistance and the use of 
the records of the Department of Pathology 

267 





THOMAS E WYATT 


Annals of SurEer\ 
Februarj 1938 


REFERENCES 

^ Carr, J T Argentaffine Tumors of the Small Bowel with Report of Two Which 
Caused Intestinal Obstruction Am Jour Surg , 13, 56, 1931 
° Christopher, Frederick Iliac Carcinoid Surg , Gynec , and Obstet , 58, 903-905, 1934 
“Cooke, H H Carcinoid Tumors of the Small Intestine Arch Surg, 22, 568, 1931 
‘ Cowdry, E V Special Cytology, vol I New York, N Y , Paul B Hoeber 
“ Craig, W McK Lymph Glands in Carcinoma of the Small Intestine Surg , Gynec , 
and Obstet, 38, 479, 1924 

“ Danisch, F Zur Histogenese der Sogenonnten Appendix karzinoide Beitr z Path 
Anat u z allg Path , 72, 687, 1924 

Darnall, W E, and Kilduff, R A Carcinoma of the Appendix Am Jour Surg, 
17, 32, 1932 

“Dukes and Lockhart-Mummery Carcinoid Tumor of the Ilium with Metastases 
Journal Path and Bact , 29, 398, 1926 

“ Ewing, James Neoplastic Diseases Third Edition, W^ B Saunders Co , Phila 
Forbus, W D Argentaffine Tumors of the Appendix and Small Intestine Bull 
Johns Hopkins Hosp , 37, 130, 1925 

Goevaerts, J Les Tumeurs Carcmoides de I’lntestme grele Scalpel, 85, 949-960, 
1932, (Abs Am Jour Cancer) 19, 178, 1933 
’“Caspar, Istvan Metastasizing “Carcinoid” Tumor of Jejunum Am Jour Path, 6, 

51S. 1930 

’“Cosset, A, and Masson, P Tumeurs endocnnes de I’appendice Presse Med Par, 
22, 237, 1914 

’‘ Hasegawa, T Tiber die Carcmoide der Wurmfontsatzes und des Dunndarmes Vir- 
chows Arch f path Anat , 244, 8, 1923 

“Hayes, J M Involvement of the Lymph Glands m Carcinoma of the Large Intestine 
Minnesota Med , 4, 653-663, 1921 

“ Huebschmann, P Sur le carcinome primitif de I’appendice vermiculaire Rev Med 
de la Suisse Rom Geneve, 30, 317, 1910 
“ Humphreys, E M Carcinoid Tumors of the Small Intestine Report of Three Cases 
with Metastases Am Jour Cancer, 22, 765, 1934 
’“Jones, C B Argentaffine Cell Tumors “Carcinoids” of Small Intestine and Appendix 
Am Jour Surg , 34, 294, 1936 

’“ Krompecher, G Tiber die Basalzellentumoren der Zjlinderepithelscheimhaute mit be- 
sonder Berucksichtigung der “Karzinoide” des Danns Beitr z path Anat u z 

allg Path, 65, 79, 1919 

“Lee, W, and Taylor, J S Argentaffine Tumors of the Terminal Ileum Surg Gynec, 
and Obstet , 59, 469, 1934 

^ Lubarsch, O Ueber den primaren Krebs des Leum nebst Bemerkungen uber das gleich- 
zeitige Varkommen von Krebs und Tuberculose Virchows Arch f path Anat,iii, 
280-317, 1888 

“ McGlannon, A , and McCleary, S Carcinoid Tumors of the Small Intestine 
JAMA, 89, 850, 1927 

“ Marangos, G N Zur Kenntnisder Dunndarmcarcinoide Beitr z Path Anat u z 
allg Path, 86, 48, 193 1 , (Abs Am Jour Cancer), 15, 1762, 1931 
Masson, P Carcinoids (Argentoffine-cell Tumors) and Nerve Hyperplasia of the Ap- 
pendicular Mucosa Am Jour Path , 4, 181, 1928 
"■’Masson, P The Significance of the Muscular “Stroma” of Argentaffin Tumors (Car- 
cinoids) Am Jour Path , 6, 499, 1930 

“ Meeker, L H A Case of Malignant Carcinoid of the Ileum Arch Path , 14, 264, 
1932 

“■ Mori, F Uber die Karzinoide des Wunnfortsatzes und des Dunndarmes Beitr z klin 
chir, 153, 71, 1931, (Abs Am Jour Cancer), 16, 389, 1931 

268 



Mrs" ARGENTAFFINE TUMORS OF THE INTESTINE 

=’Norment, William Tumors of the Appendix Surg , Gynec , and Obstet , 55, 590, 1932 
^ Oberndorfer, S Karzmoide Tumoren des Dunndarmes Frankfurt Ztschr f Path , i, 
426-432, 1907 

Pack, G T , and Davis, A H Carcinoid Tumors of the Small Intestines Am Jour 
Surg , 9, 472, 1930 

'"■Phillips, E W M , and Isaac, D H Piiniaiy Carcinoma of the Appendix Brit Med 
Jour, 1, 1127, 1930 

"'■’Price, I Carcinoid Tumour of a Meckel’s Diverticulum Report of a Case Bnt Jour 
Surg, 23, 30, 1935-1936 

Raiford, T S Carcinoid Tumors of the Gastro-intestinal Tract (So-called Argen- 
taffine Tumors) Amer Jour Cancer, 18, 803, 1933 
”* Ransom, W B Primary Carcinoma of the Ilium Lancet, 2, 1020, 1890 
'“Ritchie, G Argentaffine Tumors of the Small Intestine Arch Path, 10, 853, 1930 
Saltykow, S Ubcr die Genese der Karzmoiden Tumoren, sowie der Adenomyome des 
Darmes Beitr z path Anat u z allg Path , 54, 559, 1912 
Scholte, A J Em Fall von Angioma Telangiectaticum cutis mit chromischec Endo- 
carditis und Mahgnen Dunndarmcarcmoid Beitr z path Anat u z Allg Path , 
86, 440, 1931, (Abs Am Jour Cancer), 16, 132, 1931 
Semsroth, K The Histiogenetic Interpretation of Certain Carcinoids of the Small In- 
testines Arch Path , 6, 575-584, 1928 

Smith, G Primary Epithelial Tumors of the Vermiform Appendix Arch Path, 15, 

78, 1933 

‘“Stewart, M J, and Taylor, A L Carcinoid Tumor of Appendix with Large Pehic 
Deposits Jour Path and Bact , 29, 136, 1926 
‘^Stewart, M J and Tajlor, A L Carcinoid Tumor of Meckel’s Diverticulum Jour 
Path and Bact, 29, 135, 1926 

“St George, A V Carcinoids of the Appendix Am Jour Clin Path, 4, 297, 1934 
“ Toenniessen, E Untersuchungen Uber die in der submukose des Dunndarmes vorkom- 
menden epithelen Tumoren Ztschr f Krebsforfch Beal, 8, 355, 1910 
“Trappe, M Ueber geschevulstortige Fehlbildungen von Niere, Milz haut und Darn 
Frankfurt Ztschr f path, i, 109, 1907 

“Vance, C A Primar> Carcinoma of the Vermiform Appendix Am Jour Surg, 24, 

854, 1934 

“Warren, Shields and Gates, Olive Multiple Malignancy with Metastasizing Carcinoid 
of Ileum and Miliary Tuberculosis Arch Path, 18, 524, 1934 
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“ Wood, W G A Carcinoid Tumour of Lower Ileum Bnt Jour Surg , 23, 764, 
1935-1936 


269 



THE MECHANISM OF SPASTIC VASCULAR DISEASE AND ITS 

TREATMENT * 

Peter Heinbecker, M D , and George H Bishop, Ph D 

St Louis, Mo 

FROM TUB DEPARTMENT OF SURGERY AND THE LABORATORY OF NEDROPHYStOLOGY OSCAR JOHNSON INSTITUTE 
MASHINGTON UNI^ ERSITY SCHOOL OP MEDICINE ST LOUIS MO 

By spastic vascular disease is meant the pathologic state of blood vessels 
whereby they undergo abnormal contraction on exposure to cold or on 
emotional excitement In mild cases there is no pathology demonstrable his- 
tologically in the vessels or tissues In the more severe cases, presumably 
as a result of the disease process or of associated metabolic disturbances, there 
occurs swelling of the intima m small aiteries and arterioles which may progress 
to actual occlusion (Fig i) Tiophic disturbances in the tissues other than 
the blood vessels then result These consist of atrophy of the skin and sub- 



PiG I — (A) Photomicrograph of a blood \essel in the skin obtained by biopsy from a patient 
exhibiting Raynaud’s sjndrome Note the swelling of the cells of the intima (X6oo) (B) Photo 
micrograph of a blood vessel in the tissue from a finger amputated because of gangrene The patient 
had advanced Raynaud’s disease Note the thickening and disorganization of the intima, and the 
thickening of the media There is marked narrowing of the lumen (X300) 

cutaneous tissues, and occasionally of the deeper tissues, including even the 
bones Scaly necrosis occunmg at the tips of the fingers and toes is a typical 
lesion, and actual gangrene of the superficial layers, skin and subcutaneous 
tissue may develop 

The spastic attacks are of variable severity In some patients there is a 
bluing of the fingers or toes on exposure to cold with some feeling of numbness 
On warming, the involved areas become reddened and remain so for a some- 
what longer period than the normal This reddening is most marked m 
persons exhibiting some degree of redness of the skin in the normal state In 
this group the attacks do not lead to trophic changes even in the vessels them- 

* Aided by grants from the Committee on Scientific Research of the American 
Medical Association, the National Research Council, Division of Medical Sciences, and 
the Rockefeller Foundation 

Submitted for publication June 8, 1937 

270 



Volume 107 
Number 2 


SPASTIC VASCULAR DISEASE 


selves In the more severe cases the spasm is both moi e pronounced and more 
prolonged There is maiked cyanosis and pallor dining an attack The 
degree of cold lequired to piecipitate an attack is less than in the mild cases 
Trophic changes, especially neciosis at the tips of the extremities, are fre- 
quent 111 the most severe cases lelease fiom spasm may be incomplete for 
days Attacks may occui at ordinal y room temperatui es, 70° F 01 higher 
IMaiked trophic changes are almost mvaiiably piesent 

The course of the disease is variable It may lemam mild throughout 
life or it may be piesent foi several years and then disappear entirely The 
onset of the disease occurs geneially in early life at the time of, or shortly 
after, pubeit) Manifest evidence of the disease may, however, present itself 
later, at the time of a pregnancy 01 during a period m which the individual 
gives evidence of dysfunction of the leproductive system 

Two opposing theories have been presented to explain the mechanism of 
the spasm of blood vessels The fiist of these regards it as an expression 
of hyperfunction of the centers of the sympathetic nervous system Chief 
support foi this theoi)'’ rests m the symmetrical or bilateral nature of the 
lesions, the paroxysmal character of the attacks and the knowledge that blood 
vessels have a vasoconsti ictor innervation The second theory regards the 
etiologic factor as inherent in the walls of the vessels themselves, and not 
primaiily the result of any dysfunction of their innervation 

Hyperfunction of any part of the central nervous system, always difficult 
to establish or disprove, is often found to be an expression of the elimination 
of an inhibitory mechanism This is exemplified, foi instance, m spastic 
disease of somatic musculatui e On the basis of experimental evidence, secured 
from a study made on labbits, the release from the dorsal root nonmyelinated 
vasodilators would not be expected to increase appreciably the contraction 
of the blood vessels, for it has been shown by Bishop, Hembecker and O’Leary^ 
that in these animals reflexly initiated vasodilation over the dorsal roots is not 
of great magnitude Continued experience with patients exhibiting the Ray- 
naud phenomena has not yielded any consistent evidence of a generalized 
hyperfunction of the sympathetic nervous system which if present could reason- 
ably be expected to express itself m hyperactivity of sweat glands or pilomotoi 
muscles Hyperfunction of the central nervous system doubtlessly accom- 
panies a generalized inciease in metabolism in hyperthyroidism Such an 
increase is not associated with any tendency to pathologic spasm of peripheral 
blood vessels Hyperfunction of the nervous system is present in the early 
stages of certain virus infections but it does not result in spasm of peripheral 
blood vessels comparable to that seen in spastic vascular states 

The fact that the lesions are symmetrical is without conclusive significance 
as to their origin Indeed, the nervous control of peripheral structures in- 
nervated by the autonomic system is primarily unilateral, as it is in the somatic 
system The disease process involving it might, therefore, be expected to be 
frequently primarily unilateral The impression that the attacks are ex- 
pressions of spasmodic activity of the central division of the sympathetic 

271 



HEINBECKER AND BISHOP 


Annals of Surgery 
February 1938 


nervous system was gamed by observers who failed to recognize the import 
of the conditions under which the attacks are initiated, i e , on exposure to 
cold or on emotional excitement Under both ciicumstances the mechanism 
whereby constriction is produced is a combined reflex and humeral one 
Cold produces a leflex excitation of vasoconstrictor impulses to blood vessels 
and it reflexly produces an inci eased secietion of epinephrine Emotional 
activity expresses itself through motor impulses over the sympathetic nervous 
system which affect blood vessels, sweat glands and pilomotor musculature 
as well as causing an inci eased secietion of epinephiine The above reactions 
were not well understood until lecently It sbould be boine m mind that m a 
spastic attack these influences will be present, whatevei the pathologic 
condition of the constrictor mechanism 

The above analysis is consideied to mitigate against the validity of the 
conception that hyperfunction of the autonomic nervous system is the piimary 
underlying mechanism It cannot be said to disprove it Indeed, reflex 
activity of the autonomic nervous system is believed by us to be a definite fac- 
toi m the development of an attack Noimally, on exposuie to cold, there 
IS a leflex constriction of blood vessels While this may be primal ily local 
as IS any somatic leflex, there is usually a geneialized response moie charac- 
teristic of autonomic reflexes in general None of our experimental findings 
have indicated that the response in persons with spastic vascular disease 
shows any qualitative difference fiom the normal There does appear to be 
a definite quantitative increase in effect This is exemplified through study of 
the effect of changing environmental temperature on the skin temperature 
in a normal person and in a pei son afflicted with Raynaud’s disease It is found 
that the extremities of such persons appioach the environmental temperature 
moie than do those of normal persons Deneivated blood vessels show a 
lessened response to temperature stimuli as compared to innervated ones 
Other evidences of leflex influences m spastic vascular disease have been 
obtained For instance, in a patient with Raynaud’s disease pain developed 
in all fingers of one hand in the plethysmograph when the air was 21° C, 
although a thermometei between two fingers, gangrenous at their tips, read 
34° C This occuiied within five minutes after cooling started, the air 111 the 
room being originally at 32° C , and the initial temperature between the fingeis 
33 5° C Reflex constrictions resulting in pain, therefoie, occurred before 
significant cooling Dipping the elbow of either arm in water at 6° C re- 
sulted in homolateral pain in the fingers within two minutes, but not contra- 
laterally (local reflexes), with no measurable change in temperature of the 
palm or fingers This pain peisisted for ten minutes, accompanied by cyanosis, 
with the arm m the air, at 32° C The patient was put 111 a cold room at 6° C 
with both arms wiapped to the shoulder in three inches of cotton batting 
Pains occurred while the tempeiatuie between the fingers was still rising 
(initial temperature 33 5° C, pain occurred at 34° C, and intense pain at 
33 8° C ), On coming out of the cold room the pain stopped after four 
minutes with no detectable change of temperature in the fingers of the 

272 



Tolumo 107 
dumber 2 


SPASTIC VASCULAR DISEASE 


wrapped hand (338° C) The pain was obviously due to leflex spastic 
constriction and not to changes in temperature of the fingeis 

The evidence indicating that there is an etiologic factoi inherent in the 
blood vessel walls, not piimaiily dependent upon dysfunction of then nerve 
supply, is twofold First, is the demonstiation that local anesthetization of the 
neive supply to a digit during an attack does not lelieve the spasm completely, 
as It should if hyperfunction of the neives were solely lesponsible Partial 
lelief would occur fiom inteiiuption of the normal impulses responsible for 
vasomotor tone Second, is the knowledge that surgical removal of the nerve 
supply of the limbs which exhibit the Raynaud’s syndrome does not prevent 
the development of attacks in well advanced cases on exposure to cold or 
during an emotional episode The explanation offeied is that the attacks 
are now initiated by the action of epinephrine on sensitized blood vessels 


Table I 

EFFECT or EXOGENOUS EPINEPHRINE AND INTRAVENOUS GLUCOSE UPON 
BLOOD VESSELS EXHIBITING THE RAYNAUD SYNDROME 


Time 

Pulse 

Blood Pressure 

Condition of Fingers 

8 20 

100 

118/78 

No attack 

8 21 

I cc epinephnne subcutaneously 

8 30 

106 

134/84 

Burning of fingers of both hands 

8 35 

118 

138/86 

Bluish discoloration, hands feel cold 

8 40 

113 

144/84 

Burning pam 

8 42 

50 cc 

50% glucose intravenously 

8 45 

115 

148/85 

Burning pain 

9 00 

98 

148/78 

Less pam — fingers feel warmer 

9 05 

98 

135/72 

Hands almost as at start 

9 15 

96 

120/68 

Hands feel as at start 


Table II 

EFFECT OF INSULIN ADMINISTRATION UPON BLOOD VESSELS EXHIBITING 
THE RAYNAUD SYNDROME 

Time Blood Sugar Condition of Fingers 

1 1 00 54 mg % Fingers free of spasm 

1105 15 units insulin subcutaneously 

1 1 45 46 mg % No change in fingers 

1215 Severe pain in all fingers — fingers cold and cya- 

notic — no sweating 

12 30 26 mg % Fingers very cyanotic — some cyanosis of whole 

arms 

1 00 No change 

2 00 27 mg % Fingers still cyanotic and painful 

2 30 Meal of eggs, bread, sweetened lemonade 

2 40 Pam disappearing 

Cyanosis not so marked 
2 50 Fingers free of spasm 

That such sensitivity to circulating epinephrine exists, in well established 
cases of Raynaud’s disease exhibiting intact innervation, has been shown by 

273 



HEINBECKER AND BISHOP 


Annals of Surfcen 
February 1038 


us m studies on six clinical cases (Table I) With doses of epinephrine rang- 
ing from 0 2 to I o cc (i i,ooo Parke-Davis), average o 5 cc it is possible 
to initiate an attack in such diseased extremities The spasm frequently 
involves the part of the extremity quite central to the region showing obvious 
involvement during an attack initiated by cold The unaffected extremities 
under such circumstances showed no unusual changes indicating a definitely 
increased sensitivity of the involved areas In well established cases the at- 
tacks could be induced in a warm room by giving lO to 15 units of insulin 
subcutaneously (Table II) It was possible to relieve an attack with dramatic 
suddenness by the intravenous administration of 20 per cent glucose The 
lattei fact, again, definitely suggests that there is no alteration in nervous tone 
to account for an attack, because the injection of 20 per cent glucose has not 
been demonstrated to effect vasomotor activity The amount of fluid injected 
IS not sufficient to explain the opening up of constricted vessels on the basis 
of increased amount of circulating fluids It is only possible to explain the 
effect as a consequence of circulating epinephrine After denervation of the 
pupil in cats, sensitivity to epinephrine is increased 20 to 40 fold (Heinbecker^) 
Grant,® Hampel,^ and otheis, have shown that denervated blood vessels show 
a definite increased response to exogenous epinephrine 

Nature of the Local, Inherent EHologtc Factor — The demonstration that 
vessels subject to abnormal spasm on exposure to cold are sensitized to 
epinephrine suggests that the local, inherent etiologic factor is similar to 
that developed m denervated vessels That it is not due to denervation fol- 
lows from the fact that cases may recover entirely Investigations, reported by 
Heinbecker,® have shown that this is to be regarded as a trophic or metabolic 
change, mild degrees of which may be produced in smooth musculature, gen- 
erally by thyroid feedings and by hypophysectomy It is diminished by thyroid- 
ectomy, gonadectomy and adrenalectomy Hyper- or hypodynamic response 
of such hormonal imbalance is more readily demonstrated m tissue already sen- 
sitized by denervation than in normal tissue Examination of such tissues by 
routine cytologic methods fails to reveal any definite structural change There 
IS no alteration m salt content or arrangement as revealed by spectrographic 
or micro-incineration methods The fat content likewise is apparently un- 
altered The fact that there is no demonstrable cytologic change in the dis- 
eased blood vessel is not without parallel when we consider allergic states 
where violent reactions in smooth musculature occur without any demon- 
strable pathologic change Heinbecker has presented evidence, not incon- 
sistent with the interpretation, that in sensitized tissues there is an accumulation 
of epinephrine or of a substance upon which it acts 

The demonstration that change in smooth musculature, similar to that 
induced by denervation, may follow from hormonal imbalances, invites the 
suggestion that this may be the mechanism responsible for initiating a local, 
inherent etiologic factor in persons exhibiting the Raynaud syndrome Such 
an imbalance does not in itself produce Raynaud’s disease in animals One 
is forced, therefore, to infer a fundamental constitutional or metabolic dis- 

274 



VoUime lOT 
Number 2 


SPASTIC VASCULAR DISEASE 


order, or tendency to such a disorder, m the blood vessels of certain persons 
This, m itself, may lead to spastic disease but it is frequently made manifest 
only through hormonal imbalances such as occur at the time of puberty, preg- 
nancy, etc Manifestation of the local etiologic factor is usually in the extremity 
where circumstances of circulation and innervation are most favorable for 
evidence of impairment 

Disettsston — Spastic vascular disease may be regarded as a constitutional 
or trophic change in the walls of blood vessels, which makes them respond more 
than normally to reflexly initiated vasoconstrictor impulses and to circulating 
epinephrine The reflexes and the epinephrine secretion being stimulated by 
exposure to cold or by emotional excitement Cold itself plays a minor role, 
if any, as a d'lrect constrictor agent in the typical spasm 

Treatment of spastic vascular disease should, ideally, be directed toward 
the prevention or elimination of the local etiologic factor This, in the present 
state of our knowledge being an impossibility, treatment must concern itself, 
primarily, with an elimination of the exciting factors When such meas- 
ures are ineffectual, then means of preventing the attack by modification of the 
innervation and tone of the involved blood vessels are warranted in addition 

Elimination of the exciting factor, cold, can be accomplished by the wearing 
of proper protection for the hands and feet This will suffice in the mild 
cases If It is possible for the individual to live in a warm climate he may 
under such circumstances remain free from attacks Attacks in the emo- 
tionally unstable may be lessened by the institution of a proper psycho- 
therapeutic regimen 

When attacks develop on exposure to a temperature of 70° F , surgical 
measures designed to dimmish the tone of the involved vessels and to eliminate 
them from the influence of constrictor nerve impulses are warranted Such 
effects may be accomplished by sympathetic denervation of the involved ex- 
tremities Two courses are open One the institution of preganglionic and 
the other of postganglionic denervation Postganglionic denervation is perma- 
nent There can be no question of regeneration, and it will eliminate all 
possible reflexes by constrictor impulses, but it leads to a sensitization to 
epinephrine This, m itself, may result m a constriction of the blood vessels 
on exposure to cold or on emotional excitement, because under such circum- 
stances epinephrine is secreted In about one-half the clinical cases operated 
upon temporary relief only is accomplished and m many instances attacks still 
occur The diminution in some cases, brought about by denervation, is only 
temporary Experimental investigation of the duration of decreased tone 
after postganglionic denervation has yielded results which show that such 
altered tone does not last for more than 10 to 12 months and may be of 
much shorter duration (Heinbecker) After this time the only benefit to be 
derived from denervation is the elimination of reflexly instituted constrictor 
impulses Preganglionic denervation of the cat’s ins sensitizes it to only 
about 10 to 20 per cent of the degree of sensitization produced by postganglionic 
denervation (Heinbecker) The duration of the decrease in tone in de- 

275 



HEINBECKER AND BISHOP 


Anna1‘; of Surgery 
Fcbruarj 1038 


nervated cat’s ins is about one-half that resulting after postganglionic de- 
nervation (Heinbecker) If regeneration be pi evented by proper technic the 
reflexly exerted constrictor impulses will be eliminated permanently It is felt 
that because of the lessened sensitization to epinephrine resulting fiom 
preganglionic denervation it is the procedure of choice This idea is supported 
by the fact that clinical results reported aftei surgical inteiference in cases 
in which the lower extremity was affected weie moie satisfactoiy than in 
those involving the upper extremity The bettei results m the lower extremity 
cases are attributed to the fact that the operative proceduie geneially employed 
is one in which the preganglionic fibers foi the most part are intenupted 
(White^) 

The surgical procedure recommended in instances wheie the upper extiem- 
ity IS involved would be one which would denervate the pieganglionic fibers 
coming from the first, second and third thoracic nerves An operative pro- 
cedure recently described by Telford,® and by Smithwick,’^ in which they 
advise the resection of a portion of the second and thud thoiacic neives from 
the spinal ganglion outward foi one and one-half inches, and a section of the 
sympathetic trunk below the third ganglion, may have the disadvantage of in- 
completeness By this proceduie the preganglionic fibeis from the second and 
third thoracic level, and fiom levels below this, are eliminated Preganglionic 
neurons from the first thoracic level, and above, are not eliminated The 
number of fibers derived from these souices in the cat are considerable 
(Kuntz, Alexander and Furcolo®) If it w'ere possible to eliminate the first 
thoracic nerve the procedure would doubtless be more efficient, but this is not 
possible because the first thoracic nerve is an important motor nerve to the 
upper extremity Under the circumstances it seems advisable to advocate the 
cutting of the rami commumcantes from the first thoracic nerve also This, 
of course, adds the complications associated with Hoinei’s syndrome Opeia- 
tion upon the lower extremity consists in lemoval of the second and third and 
sometimes the fourth lumbar ganglia By this proceduie pieganglionic fibeis 
to tbe lower extremity aie interrupted Postganglionic neurons for the lower 
extiemity he, for the most part, in the fifth lumbai, and fiist and second 
sacral ganglia In this procedure the degree of semtization is minimized 
The end-1 esults repoited by all operators aie quite satisfactory 

CONCLUSIONS 

Inasmuch as spastic vascular disease is not pnmaiily dependent upon the 
dysfunction of innervation but to a local, inherent, trophic etiologic factor, 
there will always be cases m which the disease piocess will progress to a 
point where sensitization to epinephrine, in itself, will be enough to bring about 
an attack whenever an unusual amount is secreted despite the elimination of 
othei influences Then too, when the disease is progressive, changes leading 
to occlusion of vessels always develop Surgical procedures cannot be ex- 
pected to greatly improve those cases in which occlusive disease is already 
present to a marked degree at the time of operation Future efforts should 

276 



Volume 107 
Number 2 


SPASTIC VASCULAR DISEASE 


be dnected to seaich foi the cause of the constitutional deiangement ap- 
parently piesent in these cases 


REFERENCES 

^Bishop, G H, Hembecker, P, and O’Leary, J L Am Jour Physiol, io6, 647, 1933 
■ Hembecker, P Am Jour Physiol , 120, 401, 1937 
® Grant, R T Clin Sci , 2, i, 1935 
* Hampel, C W Am Jour Phvsiol , 3, 3, 1935 

“White, J C The Autonomic Nervous System New York, Macmillan Company, 
1935 

" Telford, E D Bnt Jour Surg , 23, 448, 1935 
"Smithwick, R H Annals of Surgerv, 104, 339, 1936 

®Kuntz, A, Alexandei, W F, and Furcolo, C L Complete Sympathetic Denervation 
of the Upper Extremities Annals or Surgery, 107, 25-31, January, 1938 


277 



NEOPLASMS OF THE ABDOMINAL WALL 

WITH SPECIAL REFERENCE TO MALIGNANT “IMPLANTATION” TUMORS 

Joseph A Lazarus, MD 
New Yobk, N Y 

Klot/ in 1921, collected 408 cases of tumors involving the abdominal 
wall, of which 248 were fibromata, 67 fibrosarcomata, 17 fibromyxomata, 60 
sarcomata, one endothelioma, one angioma and one angiosarcoma Since 
then an occasional case report has found its way into the literature from time 
to time A survey of the Index Medicus shows but few instances of adeno- 
carcinoma present in the abdominal wall unassociated with some type of 
fistulous communication with, or direct extension from, an abdominal organ 
harboring carcinoma 

To indicate the relative rarity of malignant tumors of the abdominal wall, 
Gurlts,® out of a total of 16,637 cases of malignant tumors, found only 27 ma- 
lignant tumors of the abdominal wall, of which there were 13 carcinoma^^a and 
14 sarcomata Dvorak,^ reviewing the records of 28,013 admissions at the 
University Hospital of the University of Minnesota, between 1910 and 1923, 
found only nine cases of abdominal wall tumors, of which number there were 
only two carcinomata and one sarcoma arising by direct extension 

Vosburgh^'^ classifies abdominal tumors as 

(1) Superficial (sebaceous cysts, papillomata and cutaneous moles and 
lipomata) 

(2) Fibromata (hard and soft), the harder arising from the aponeu- 
roses and tendinous insertions, while the softer ones take origin in the sub- 
cutaneous tissues and in the fibrous sheaths of vessels and nerves 

(3) Desmoids are fibromata in which the constituent elements have a 
special arrangement and arise usually m the anterior or lateral abdominal 
wall, and in about one-half of the cases are associated with the rectus muscle 
or Its sheaths, usually the posterior Desmoids are seven times more fre- 
quently encountered m women than in men These tumors are usually small 
although they may grow to large size, are smooth and ovoid, with their long 
axes parallel to the long axis of the rectus muscle On section the cut sur- 
face IS of a glistening white color with fibers interwoven Microscopically 
the tumors may be poor or very rich m cellular elements, and are poor in 
blood supply, which makes them liable to early necrosis 

(4) Carcinoma — Carcinomata of the abdominal wall fall into two groups, 
namely (a) Those involving the abdominal wall proper, and (b) those aris- 
ing from the umbilicus Primary carcinoma of the abdominal wall proper, 
while possible, must be extremely rare, since, with the exception of those 
cases already discussed, no such case has been found by the writer in a re- 
submitted for publication June 28, 1937 

278 



Volume 107 
Number 2 


NEOPLASMS OF ABDOMINAL WALL 


view of the literature Secondary carcinomata in the abdominal wall occur 
(a) By direct extension from an adjacent intra-abdominal organ, (b) through 
a fistulous communication with a hollow abdominal organ harboring a carci- 
noma, and (c) by true metastasis from a distant organ or by direct implanta- 
tion at the time of a previous operation 

Carcinoma of the umbilicus is not a rare phenomenon and may occur either 
as a primary or as a secondary growth Squamous carcinoma is the most 
frequent primary carcinoma of the umbilicus and usually arises from epithelial 
remnants of the urachus or omphalomesenteric duct Columnar cell carci- 
noma of the umbilicus usually indicates a secondary growth from an intra- 
abdominal organ 

(5) Sarcomata m the majority of cases represent a malignant transfor- 
mation of preexisting benign tumors, such as a nevus or a fibroma There are 
some tumors which start as sarcomata 

(6) Melanosarcoma which is generally a part of a general sarcomatosis , 
and finally 

(7) Endometrioma (not mentioned by Vosburgh^'^), or a transplant to the 
uterine mucosa during the period of menstruation found m the abdominal wall 
particularly after operations on the uterus, especially caesarean section 

Since the case herein cited is that of an adenocarcinoma of the abdominal 
wall occurring 13 years after the removal of an apparently benign ovarian 
cyst, It might be well to note that as far as the writer was able to ascertain, 
there are only 14 references in the literature (six collected by Dvorak^ and 
eight by Polano^^) in which the presence of a carcinoma of the abdominal 
wall, following the removal of a supposedly benign ovarian cyst, did not arise 
by direct extension from an abdominal oigan harboring carcinoma which 
was adjacent to that portion of the abdominal wall, or in the case of a hollow 
viscus affected with carcinoma, with some type of fistulous communication 

An unusual case reported by Dvorak, and simulating the one about to be 
described, was that of a woman, age 69, who 15 years previously had had 
the uterus, left ovary and tube together with a cyst and two tumors of the 
uterus removed Following the operation the abdominal wound became in- 
fected so that healing was delayed The pathologic report of the specimen 
was unfortunately not stated For 13 years the patient was apparently well, 
she then noted a lump in the left lower abdominal quadrant, which, during 
the next two years, grew to the size of a football, and was accompanied by 
sharp shooting pains The tumor extended from a point 5 cm below and 
9 cm to the left of the umbilicus to a point on the pubic crest 3 cm to the 
right of the midline, was slightly tender to palpation and appeared to be 
imbedded m the musculature of the abdominal wall The skin was not ad- 
herent to the mass A diagnosis of desmoid of the rectus sheath was made 
and removal advised Adenopathy was absent 

The tumor, including a large part of the left rectus muscle and its an- 
terior sheath, was removed The pathologic report was adenocarcinoma, 
made up of alveolar glands lined by columnar epithelial cells Three courses 

279 



JOSEPH A LAZARUS 


Annals of Surgery 
Februarj 1938 


of deep 1 oentgenotherapy weie given, followed later by implantations of ra- 
dium to a local recurrence The patient developed a laige incisional hernia 
She lived about five )^ears after operation, succumbing finally to local and 
distant metastases to the vertebrae Postmortem examination levealed two 
fistulous communications, one with the ileum and the othei with the trans- 
verse colon There were no metastases in the peritoneum, noi in the pleural 
and pericardial cavities The lymph nodes were also fiee, but metastases were 
found m the fouith and fifth lumhai vertebrae The local recurrence con- 
sisted of a mass 5x2 cm , consisting of many atypical and poorly formed al- 
veolai structures lined by tall columnar cells The findings suggested a pa- 
pillary cystadenocarcmoma of ovarian oiigin 

Although there was no pi oof to substantiate it, the origin of this tumor 
was believed to be an implantation of a portion of the apparently benign ovar- 
ian cyst into the abdominal wall incision at the time of the opeiation per- 
formed 20 years previously 

In 1864, Wagnei described a case of a patient who developed three sub- 
cutaneous cystic tumors, one below the left breast, one in the right axilla and 
one in the left flank following frequent tapping of the abdomen for ascites 
resulting fiom a laige inti a-abdominal, benign, papillary, serous cyst of the 
left ovary At autopsy the subcutaneous cysts were of identical histologic 
structure to that found in the affected ovary 

Jaquet® (quoted by Dvoiak) reported a case of a dermoid of the ovar}- 
removed 111 1S74, and 17 3'^eais later the patient developed a malignant tumor, 
measuring 15 cm in diametei, in the abdominal wall 

Olshausen^- leported a case of a patient, 46 yeais of age, who 21 yeais 
pieviously had a left oophorectomy performed Seventeen years later he re- 
moved a tumor fiom the right side of the abdominal wall above the umbilicus 
Histologically the charactei of the tumoi was that of a benign papillary cyst- 
adenoma of the ovaiy Olshausen was of the opinion that this tumor le- 
sulted from an implantation in the abdominal wall during tbe course of the 
oophorectomy performed 17 years previously 

This same author also leported a case of a woman, who at the age of 
29 had a bilateral oophorectomy performed for papillaiy cysts About 20 
years later she noticed a mass in the right side of the abdomen which had 
progressively inci eased in size The tumor was found situated in the abdomi- 
nal wall and when lemoved was diagnosed, from its gioss appeal ance, as un- 
doubtedly carcinoma No histologic leport appears in the piotocol Just as 
in the previous case, Olshausen believed this tumoi to have occurred as a re- 
sult of implantation at the time of the oophorectomy, since the tumor was 
present in the scar of the pi evious operation 

Tauber^® reports that Schneutgen,^^ up to 1918, was able to collect only 
eight cases from the liteiature of benign ovarian tumor implantations in the 
abdominal wall, and added one case of his own 

Bland-Suttoiff performed a hysteiectomy and bilateral oophorectomy for 
what appeared to be benign papillaiy ovarian cysts Six years later the patient 

280 



■\ olumo 107 
Isumbcr 2 


NEOPLASMS OF ABDOMINAL WALL 


noticed a lapidly glowing tumoi in the light side of the steinum in the second 
intei costal space, which piomptly lecuiied after lemoval and eioded the en- 
tiie inanubiium Histologically this tumoi was identical with the piimaiy 
tiiinois of the ovaiies At autopsy theie was no lecuirence in the abdomen 
An interesting case is lepoited b}'^ Taubei of a woman who, in 1919, was 
exploied for ascites, but appaiently no tumoi found Two years later with 
lecuiience of ascites, celiotomy levealed bilateial papillaiy ovarian cysts, 
with thiee small cysts on the anterioi paiietal peiitoneum below the umbilicus 
These weie lemoved along with both ovaiies Histologically theie was no 
eridence of malignancy Five yeais later she letuined with a cystic tumoi in 
the anteiioi abdominal wall aiound the umbilicus, which pioved to be a ma- 
hgnant ovaiian cyst Tauber also lepoits that Lang® lemoved a pseudomu- 
cinous cyst fiom the left ovaiy of a patient, age 30, and aftei two months 
an adenocai cmoma developed in the scar of the pievious celiotomy 

Taking the ten cases collected by Dvorak, including the one he leported, 
along rMth the case heiewith desciibed, bungs the total of cases, m which 
appaiently benign ovaiian cysts weie followed at vaiymg inteivals by benign 
or malignant tumoi s of ovaiian oiigin in the abdominal wall, to ii cases 
Of these ii cases, the abdominal wall tumoi was found malignant in seven, 
and benign in foui The longest inteival between the lemoval of the original 
tumoi and the discoveiy of the abdominal wall tumoi was 21 yeais, while 
the shoitest inteival was two months In six of the ii cases, howevei, the 
interval was over ten yeais While in all of these ii cases the piimary tumor 
of the ovaiy was appaiently benign, Cullen® collected nine cases of malignant 
abdominal wall tumors following extiipation of malignant ovarian tumoi s 
In addition to the ten cases discussed by Dvoiak, Polano collected seven 
cases, and added one of his own, of malignant abdominal wall tumors oc- 
curiing in the scais of previous celiotomies foi the lemoval of appaiently 
benign ovaiian cysts At autopsy, his own case was found to have a caici- 
noma of the stomach, and Polano believed that this was the primary giowth 
Unfortunately out of the seven case leports which he collected from the htei- 
ature, necropsy was obtained in only one (PfannenstieP®), and in this case 
the autopsy failed to disclose any intia-abdominal evidence of malignancy 
The absence of concrete evidence of the existence of an mtra-abdominal ma- 
lignant focus in SIX out of eight cases led Polano to the conclusion that in 
spite of the fact that oophoi ectomies foi appaiently benign ovarian cysts ante- 
dated the finding of malignant tumoi s in the abdominal wall, these tumors 
might have had nothing at all to do with the original ovarian cysts, but 
might be metastatic tumoi s developing from some preexisting malignant tu- 
mors of othei abdominal oigans present but overlooked at the time of the 
original operation, or having developed subsequent to the oophorectomy 
In order to understand the mysterious cn cumstances of malignant ab- 
dominal tumors following the lemoval of apparently benign primary ovarian 
tumors, it might be well to lefer to the excellent paper of Mayfield^^ in 1927 
From an analysis of 100 cases, Mayfield comes to the conclusion that the 

281 



JOSEPH A LAZARUS 


Annals of Surcerv 
February 10S8 


size of the cysts is no indication as to the character of their pathology and that 
often both benign and malignant features were found present in the same 
specimen This same author noted various degrees of malignancy in the 
same type of tumors, which might explain the variations in the time interval 
between the removal of the original cyst and the appearance of the abdominal 
wall tumor He also looks upon bilateral, papillary ovarian cysts as always 
suspiciously malignant, even though the microscopic findings may not con- 
firm the suspicion, since it is so easy to overlook a small area of malignancy 
unless complete serial sections are made and examined of the removed speci- 
men So that the removal of a cystic tumor of the ovary which to all in- 
tents and purposes has been judged benign from microscopic and gross exami- 
nations may still have been malignant , and the long interval existing between 
the removal of the original ovarian tumor and the finding of the malignant 
abdominal wall neoplasm may be explained on the ground that the grade of 
malignancy of the original tumor was extremely low 

Instances of abdominal wall implants of other types of benign tumors 
following some type of operation upon the female generative organs such as 
fibromyomata and adenomyomata, also designated endometriomata, have been 
frequently described in the literature (Brewer^, Cullen^, Mahle and Mac- 
Carty^®, Lochrane®, and others) 

Diagnosis — To determine whether a tumor is situated in the abdominal 
wall or beneath it, the patient, lying on her back, is instructed to sit up un- 
aided In so doing, the abdominal muscles are contracted and should the 
tumor become invisible and nonpalpable, it is certain that it is not situated 
in the abdominal wall Should the tumor, however, still remain palpable 
and immovable, even though it can no longer be seen, with the patient’s 
muscles contracted, it can be stated that it is situated in the abdominal wall 
An intra- or subcutaneous tumor does not change at all during the maneuver 
The exact nature of the abdominal wall tumor can only be determined by 
biopsy 

Treatment — Benign tumors are treated by extirpation In dealing with 
a definitely malignant tumor of this type, treatment becomes a definite sur- 
gical problem Since one can only be reasonably certain of whether a malig- 
nant tumor of the abdominal wall is primary or secondary to some intra-ab- 
dominal organ, exploratory celiotomy is indicated in all cases to establish the 
presence or absence of a malignant mtra-abdominal tumor, and even then one 
cannot always with absolute certainty rule out the presence of such a growth 
A negative exploration then leaves the operator with the problem of what to 
do with the abdominal wall tumor In the event the tumor is a small one, ex- 
tirpation should be effected and the defect in the abdominal wall repaired 
wherever possible With tumors involving a large portion of the abdominal 
wall, one should proceed cautiously before deciding upon extirpation One 
must reason in such cases that a tumor which has grown large enough to in- 
volve a large portion of the abdominal wall must already have given rise to 
metastases Extirpation then would result in a large incisional hernia with- 

282 



Volume 107 
Number 2 


NEOPLASMS OF ABDOMINAL WALL 


out any further compensating’ advantages over the employment of irradiation 
It IS the writer’s opinion that malignant tumors invading large segments of 
abdominal wall had best be considered beyond the scope of radical removal, 
and treated with deep i oentgenotherapy or radium 

Case Report — S Z , female, age 42, single, presented herself November 28, 1936, 
complaining of menorrhagia, pain in the pelvis and a burning sensation in the lower ab- 
domen of three months’ duration Her mother had died of cancer, but she did not know 
the organ involved 

Her menstrual history was entirely normal Menstruation commenced at the age 
of 13, was regular every 28 days, lasted three to four days, and was unassociated with any 
pain Thirteen years previously she was operated upon for a “cyst of the left ovary’’ 
which was considered benign Unfortunately, no record could be found of the histologic 
findings of the specimen removed Since the removal of the ovary she noted a slightly 
increased growth of hair on the face, a deepening of the voice and diminished libido 
Otherwise she felt perfectly well 

Three months previously she noted an increase in the menstrual flow There was no 
metrorrhagia, but she complained of a dull, intermittent aching pain deep in the pelvis 
and a burning sensation in the lower abdomen There was no loss of weight, no anorexia 
or symptoms referable to the gasto-intestinal tract The rest of the history was entirely 
irrelevant 

Physical Examination revealed a well developed, robust patient Blood pressure 
118/90 Situated in the lower abdomen to the right of the midlme, and extending from 
the symphysis pubis to the level of the umbilicus, there was a firm, hard, irregular mass, 
neither tender nor movable The mass could be felt when the patient was asked to sit up 
from a recumbent position Directly over it was a long right lower rectus scar of the 
previous operation Vaginally one could not make out any relationship between the mass 
and the uterus which felt perfectly normal 

A scout roentgenogram of the pelvis revealed an indefinite small shadow situated 
over the sacrum which was thought to be a calcified lymph node Roentgenologic exam- 
ination of the genito-unnary tract was negative A barium enema likewise showed no 
abnormalities Uranalysis was negative Blood count Hemoglobin, 88 percent, red 
blood corpuscles, 4,320,000, white blood corpuscles, 5, 200, morphonuclears, 55 per cent, 
lymphocytes, 34 per cent, rods, 7 per cent, monocytes, 4 per cent 

A tentative diagnosis of abdominal tumor not associated with the uterus was made, 
and exploratory operation advised 

Operation — December 3, 1936 Under spinal anethesia, a three and one-half inch 
midsuprapubic incision was made Upon extending the incision through the subcutaneous 
fat, it was immediately noted that the tumor involved the abdominal wall and extended 
from the symphysis pubis up to the level of the umbilicus, involving both sheaths and body 
of the right rectus muscle The peritoneum was opened by retracting the tissues to the 
left and incising through the left rectus muscle and peritoneum Exploration failed to 
reveal any involvement of the pelvic or abdominal viscera With the hand in the peri- 
toneal cavity, the affected portion of the abdominal wall was exposed and found to simu- 
late an extensive, convex, pancake-hke tumor of cartilaginous-hard consistency, extending 
from the symphysis pubis to the umbilicus, and from the linea alba laterally to a line 
drawn from the crest of the ilium to the midportion of the twelfth rib It was of a yel- 
lowish-white color and the most central part of the growth was of a softer consistency 
than the peripheral portions A portion of the tumor was removed for biopsy 

Pathologic Examination — (Dr A A Eisenberg, Sydenham Hospital) The speci- 
men measured 3x1 5 cm The external surface was of a grayish-white color and the 
consistency of the tissue was firm On section the tissue was uniformly white 

283 



JOSEPH A LAZARUS 


Annals of Surgerj 
Februarj 1938 


Sections show numerous carcinomatous areas scattered throughout the entire sec- 
tions, with many of them arranged in the form of small acini The cells show numerous 
mitotic figures and anaplastic changes Occasionally one sees a group of small acini 
presenting as adenomata Between the acini there is a moderate lymphocytic infiltra- 
tion and a few hemorrhagic areas (Figs i and 2) 

Diagnosis — Adenocarcinoma Dr Francis Carter Wood who examined the slide be- 
lieved that the specimen could very well represent ovarian tissue and noted a group of 
large cells extremely suggestive of arrhenoblastoma 

Postopeiaiive Couise — Following her discharge from the hospital the patient was 
placed upon intensive deep roentgenotherapy resulting in considerable shrinkage of the 



Tic I — Photomicrograph show ing the nrrange Fig 2 — Photomicrograph indicating the char 

ment of cells particular^ indicating groups of acter of the cells slightly siiggestue of cells seen 
cells suggesting arrangement seen in arrhenoblas m arrhenoblastoma (X 725 ) 
toma of the ovary (Xias) 

tumor Yet, m spite of the reduction in size of the original growth, she developed a large 
hard node in the left groin which is responding to irradiation Her general condition 
to date IS good 


SUMMARY AND CONCLUSION 

Carcinomatous tumors of the abdominal wall unassociated with fistulous 
communications with, 01 direct extension from, an abdominal organ harbor- 
ing carcinoma are extremely rare A careful review of the literature reveals 
seven cases including the author’s case in which, following the removal of an 
apparently benign cyst of the ovary, after an interval ranging from two 
months to 21 years, a carcinomatous tumor occurred in the abdominal wall 
either m the scar of the original operation or close to it, apparently without 
any other mtra-abdommal involvement (Dvorak, 6 , Lazarus, i) Polano col- 
lected seven cases of malignant abdominal wall tumors occurring m the scars 
of previous celiotomies for the removal of apparently benign ovarian cysts 
and added one of his own At postmortem, however, his own case was found 
to have a carcinoma of the stomach, which the writer believed w^as the growth 
responsible for the abdominal w^all tumor Of the seven cases wdiich he col- 

284 



A oUime 107 
Number 2 


NEOPLASMS OF ABDOMINAL WALL 


lected fiom the hteiatuie, autopsy was peifoimed in only one and this one 
failed to leveal any evidence of inti a-abdominal malignancy The lemaimng 
SIX cases without postmoitem evidence led Polano to the conclusion that 
one cannot with ceitainty state that a given mtia-abdominal carcinoma, even 
though histologically lesemblmg the aichitectme of an ovaiian cyst that had 
pieviously been lemoved fiom the same patient, was secondary to such a 
cyst, since one might have ovei looked a malignant growth in another mtra- 
abdommal viscus which had been present at the tune of original operation oi 
had developed subsequent to the oophorectomy In view of the fact that, 
of the ten cases leported by Dvoiak and also the one repoited by the 
wiitei, autopsies ueie obtained in only thiee, and in none of these was 
theie found any mti a-abdommal pathology other than that occurring in the 
ovaiy, it might be justly aigued, with Polano, that the failure to confirm by 
complete autopsy the pi esence oi absence of a malignant growth elsewhere m 
the body invalidates, to a ceitam degiee, the conclusion that a malignant tumor 
of a supposedly benign ovaiian cyst is the lesult of an implantation taking 
place at the time of the oiigmal opeiation That such a phenomenon is pos- 
sible, howevei, has been definitely established by the few autopsies that have 
been obtained and repoited Furtbermoie, it is difficult to understand the 
undei lying reason of a malignant abdominal wall tumoi occurring after the 
lemoval of a benign cystic tumoi of the ovaiy unless we assume the possibil- 
ity of such a tumoi possessing low giade malignant possibilities at the time 
of the oiiginal opeiation 

Biopsy IS the only leliable means of determining the natuie of a tumor of 
the abdominal wall The piognosis is always bad Treatment of small tumors 
consists of thorough abdominal exploration followed by extiipation of the 
growth and deep loentgenotheiapy In the large tumoi s extirpation is not 
advised since lemoval of large sections of abdominal wail always leads to seri- 
ous postoperative herniation, without in any way adding to the life expectancy 
of the patient, which is not ofteied by the less mutilating use of irradiation 
therapy 

A case is herewith piesented of an extensive adenocaicinoma of the ab- 
dominal wall, in the region of the scar of the previous opeiation, in a young 
woman who, 13 years previously, had had an oophorectomy performed for 
a supposedly benign ovarian cyst Exploiatoiy celiotomy failed to reveal the 
pi esence of any intia-abdominal pathology The tieatment administered m 
this case was deep loentgenotheiapy 

REFERENCES 

^ Bland-Sutton, Sir John Tumoi s. Benign and Malignant, pp 622-626, 1922 
"Brewer, G E Typical Fibromyoma of Abdominal Wall Following Hysterectomy 

Annals or Surgery, 74, 1921 

® Cullen, T S The Umbilicus and Its Diseases Philadelphia, W B Saunders Com- 
pany, 1916 

^Dvorak, H Implantation Malignancy of the Abdominal Wall Surg, Gynec, and 

Obstet, 50, 907-913, 1930 


285 



JOSEPH A LAZARUS 


Annals of Surgerv 
February 2038 


® Gurlts Quoted by Zweifel and Payr Die Klinik der Boesartigen Geschwuelste Leip 
zig S Hirzel, 3, 1924 
"Jaquet Quoted by Dvorak 

'^Klot, B von Ueber bindegewebige Bauchdecken-tumoren und ihre klinische Bedeutung 
in Anschluss an einen Fall von Fibrom in einer Appendektomienarbe Beitr z klin 
Chir, 123, 28, 1921 
® Lang Quoted by Tauber 

®Lochrane, C D Endometrial Adenoma of Abdominal Wall Following Ventrosuspen- 
sion of Uterus Jour Obstet and Gynec, Brit Emp, 3, 213, 1923 
Mahle and MacCarty Ectopic Adenomyoma of Uterine Type Jour Lab and Clin 
Med , 5, 221, 1920 

“ Mayfield, A L Papillary Cystadenoma of the Ovary , Clinical and Pathologic Analysis 
of 100 Cases Northwest Med, May, 1927 

“ Olshausen, R Impfmetastasen der Carcinome Deutsche med Wchnschr , p 750, 1902 
Idem Ueber Bauchwandtumeren especiell ueber Desmoide Ztschr f Geburtsh u 
Gynaek, 41, 271, 1899 

Pfannenstiel Ueber Karzinombildung nach Ovariotomien Ztschr f Geburtsh , 28, 349 
“ Polano, Oscar Zur Entstehung maligner Bauchdecken-tumoren nach Entfurnung gu- 
tartiger Eierstocksgeschwuelste, p 416 Ztschr f Geburtsh u Gynaek, p 56, 1905 
“ Schneutgen Quoted by Tauber 

“ Tauber, R Maligne Degeneration von Implantationen in den Bauchdecken nach Exstir- 
pation Papillarer Ovanaltumoren Zentralbl f Gjnaek, 51, 1505, 1927 
"Vosburgh, A S Johnson’s Operative Therapeutics, 3, 764-765 
“Wagner, E Fall von mehrfachen Cysten des Ovanums, Peritonaeums und des Sub- 
cutanen Bmdergewebes Arch f Heilk, s, 92, 1864 


286 



BLOOD LOSS IN NEUROSURGICAL OPERATIONS 

J C White, M D , G P Whitelaw, M D , W H Sweet, M D , 

AND E S Huewitt, MD 
Boston, Mass 

rnO\I TUB BOBaiC^L services of toe M^SStCHnSETTS OBVERVE HOSPITAL AKD THE 80 R 0 ICAL LABOIUTORIES OF 
THE HARVARD MEDICAL SCHOOL AT THE M ASSACHCBETTS QEKEBAL HOSPITAL, BOSTON, MASS 

The purpose of this paper is to call attention to the large volume of 
blood lost in major neurosurgical operations in contrast to the comparatively 
moderate amounts lost during operations on the abdominal viscera, the thorax, 
and the extremities In another aiticle^ water balance in neurosurgical 
patients has been consideied Both communications point out certain as- 
pects of blood loss and water balance in brain operations which must be 
understood and skillfully handled m order to avoid serious disturbances 
m the blood and tissue fluids 

Gatch and Little,^ and also Coller and Haddock,® have shown that 
in the average celiotomy it is unusual for hemorrhage to exceed 200 cc 
In their determinations they record no statistics on neurosurgical operations, 
and m a search through the literature we have been unable to find any 
such data It is, therefore, of interest to point out that in extensive cranioto- 
mies a blood loss of from 500 to 1,200 cc is quite usual, while in unusually 
vascular tumors hemorrhage in excess of one and one-half liters may occur 
Many neurosuigeons, fully conscious of the importance of hemostasis, are un- 
aware of the amount of blood which is removed, so unostentatiously, by the 
suction apparatus and which is absorbed by the multitude of small pledgets 
This was brought out in our early measurements when the surgeon’s rough 
estimate of the amount of blood lost was compared with the figures obtained 
from the hemoglobin content of the drapes, pledgets, and contents of the 
suction bottle 

In addition to this excessive loss of blood, we have shown^ that a patient 
undergoing an operation for an intracranial tumor may lose up to 1,000 cc 
of fluid from his skin and lungs This also is, at times, in excess of the 
loss of water vapor which takes place m other surgical operations In 
the latter, careful hemostasis is essential to prevent postoperative hema- 
tomata and poor wound healing But in many intracranial and m certain 
spinal cord operations bleeding is so profuse that the surgeon must use 
every resource at his command to keep it within a safe limit 

ObsetvaHons — The determination of blood loss during operation was 
made by the method of Gatch and Little^ The hemoglobin, which is ex- 
tracted from the drapes and cotton pledgets by rinsing them thoroughly 

* With the single exception of a laminectomy m a case of fracture of the spine with 
a blood loss of 672 cc (Gatch and Little*) 

Submitted for publication August 16, 1937 

287 



WHITE, WHITELAW, SWEET AND HURWITT tX'ufrf ms 

m a known amount of water is con\erted to acid hematin by the addition 
of hydrochloric acid The color intensity of the unknown sample is then 
measured against a standard containing i cc of the patient’s blood obtained 
preoperatively, diluted to loo cc , and acidified The calculated volume 
of blood lost IS probably from 5 to 10 per cent less than the actual amount 
because of the difficulty of recovering all the hemoglobin from the dry 
goods, instruments, and the floor of the operating 100m Since this work 
has been completed, Pilcher and Sheard^ have described a more sensitne 
method of quantitatively estimating blood loss in which the hemoglobin 
content is measured by a spectrophotometric and photelometnc method, 
but for the purposes of this investigation the method of Gatch and Little 
should be sufficiently exact 

Table I shows the amount of blood lost in a series of 37 standard 
neurosurgical operations This should be compared with the data m Table 
II obtained by Gatch and Little- and by Coller and Maddock^ in a series 
of general surgical operations The greatest loss of blood recorded m Table 
II, 1,272 cc , occurred in a radical resection for carcinoma of the breast 
Our maximal blood loss, 2,150 cc , took place during the removal of a 
large frontoparietal meningioma (Patient 5) The patient was given Lvo 
tiansfusions, and made an uneventful recovery The other two patients 
(Nos 2 and 29) who lost over two liters of blood did not survive In 
Patient 2, a meningioma of the cribriform plate, death appeared to be re- 
lated to the hemorihage and shock In Patient 29, howe\er, the hemoirhage 
was well compensated’’' and shock did not develop Death in this case 
was presumably due to cerebral injury with consequent hyperthermia, but 
no autopsy was permitted In spite of the fact that 15 of these patients 
lost over a liter of blood, only two developed severe postoperative shock, 
and only one death was attiibutable to a reduced blood volume The reason 
a greater loss of blood can be tolerated in intracranial than m intia-abdominal 
operations will be considered later in the discussion In no instance where 
an extensive craniotomy was performed was the loss of blood less than 487 
cc Where no resection of biain tissue was carried out, the hemorrhage 
occurred mainly during the closure of the scalp When the skull is not ex- 
cessively vascular, careful hemostasis can reduce the amount of bleeding 
during the incision of the scalp and turning down the bone flap to an amount 
not in excess of 100 cc , but bleeding when the hemostats are removed and 
the stitches are placed m the galea is more difficult to control 

To summaiize the volumes of blood lost during operation by three 
different surgeons, it was found that in simple craniotomies, where nothing 
more than an exploration and cerebral biopsy was carried out, the average 
loss amounted to between 500 and 900 cc (Table I ) In patients with 

*The term "compensation,” as applied m this article to the reaction of the body to 
hemorrhage, does not imply restoration of the red blood corpuscles or plasma volume 
It simply means the maintenance of a relativeb adequate supph of blood to the heart and 
vital organs through the hemostatic activity of the sj mpatho-adrenal mechanism 

288 



Voliimo 107 
iNumbei 2 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS 


Table I 

BLOOD LOSS AND EARLY POSTOPERATIVE REACTIONS IN A SERIES OF 37 NEUROSURGICAL 

OPERATIONS 

Transfusions averaged 500 cc of citrated blood 


Pl- 

tient 

Age 

Operation 

Anesthetic 

Time — 
Hours 

Blood 

Loss 

Ce 

Shock 

Trans- 

fusion 

Postoperative Course 

I 

47 

Partial removal of left 
frontoparietal glio- 
blastoma miiltiforme 

Local 

2M 

1.449 

0 

0 

Died m 17 hours Au' 
topsy showed herniation 
of cerebellum into fora- 
men magnum 

2 

S6 

E\ploration and de- 
compression of menin- 
gioma of cribriform 
plate 

Local 

3K 

2,023 

4 - 

2 

Died in 40 hours prob- 
ably from intracranial 
hemorrhage No autopsy 

3 

14 

Exploration for epi- 
lepsy 

Avertin and 
local 

2M 

964 

0 

0 

Uneventful 

4 

24 

Excision of cerebral 
cicatrix for epilepsy 

Local and 
evipal 

3 

i, 4 S 6 

0 

I 

Uneventful 

5 

26 

Removal of large 
frontoparietal menin- 
gioma 

Local 

2 

2, ISO 

++ 

2 

Uneventful 

6 

25 

Negatne cerebral ex- 
ploration 

Local 


S42 

0 

0 

Uneventful 

7 

20 

Bone flap to evacuate 
subdural hematoma 

Local and 
ether 

2 H 

S99 

0 

0 

Uneventful 

8 

37 

Resection of menin- 
gioma of tuberculum 
sellae 

Local 

2K 

574 

0 

0 

Patient did well at first 
but then slipped into 
coma and died on the 
ninth day 

9 

IS 

Laminectomy for ex- 
treme scoliosis with 
cord compression 

Avertin and 
ether 

IH 

334 

0 

0 

Uneventful 

10 

SI 

Partial removal of 
acoustic neuroma 

Local 


638 

0 

0 

Died on second day 
Cause of death was not 
explained by postmortem 

II 

44 

Laminectomy for 
arachnoiditis 

Avertin lo- 
cal and ether 


I. 264 

+ 

0 

Uneventful 

12 

16 

Cervicothoracic gan- 
glionectoniy 

Avertin and 
local 

I 

107 

0 

0 

Uneventful 

13 

S3 

Section of fifth cranial 
nerve root for trigemi- 
nal neuralgia 

Local and 
evipal 

I 

86 

0 

0 

Uneventful 

14 

22 

Partial removal of 
glioblastoma multi- 
forme 

Local 

2M 

1,333 

+ 

I 

Good convalescence for 6 
days Died on ninth day 
of epidural hematoma 

IS 

42 

Negative cerebral ex- 
ploration 

Local 

2 l: 

I, 100 

0 

0 

Fair convalescence Sub 
sequently reexplored ab- 
scess drained patient died 

16 

SI 

Evacuation of cerebel- 
lar cyst 

Local 

2M 

1, 176 

4 * 

I 

Died on eighth day Au- 
topsy did not reveal cause 
of death 

17 

14 

Partial resection of 
ependymoma of third 
ventricle 

Avertin and 
local 

3K 

620 

0 

0 

Uneventful 

18 

31 

Excision of cerebral 
cicatiix for epilepsy 

Local and 
evipal 

3 H 

1,300 

0 

I 

Uneventful 

19 

46 

Partial excision of 
temporal lobe glioma 

Avertin and 
local 

aU 

900 

0 

I 

Slow recovery with her- 
niation of brain and 
clouded mentality 

20 

41 

Exploration of third 
ventricle 

Avertin and 
local 

A 

700 

0 

0 

Uneventful 

21 

27 

Excision of cerebral 
cicatrix for epilepsy 

Local 

3 H 

1,330 

0 

I 

Died in 40 hours prob- 
ably acute perforation of 
esophagus or stomach 
No autopsy 


289 



WHITE, WHITELAW, SWEET AND HURWITT ^”bru»rv“7938 


Table I (Conlmued) 


Pa- 

tient 

Age 

Operation 

Anesthetic 

Time — 
Hours 

Blood 

Loss 

Cc 

Shock 

Trans- 

fusion 

Postoperative Course 

22 

46 

Cervical cordotomy 
and posterior root sec- 
tion 

Gas oxygen 
and local 

2}^ 

If 034 

+ 

I 

Uneventful 

23 

7 

Cranioplasty for pre- 
mature closure of su- 
tures 

Avertm and 
local 


630 

0 

0 

Uneventful 

24 

28 

Suboccipital decom- 
pression for arachnoi- 
ditis 

Avertm and 
local 

3 

I, 010 

0 

I 

Uneventful 

2 S 

45 

Removal of large men- 
ingioma of sphenoid 
ridge 

Local and 
evipal 

4 H 

I,S 70 

+ 

I 

Spinal fluid leak and 
meningitis Died m 3 
weeks 

26 

39 

Removal of neurofi- 
broma of lumbar cord 

Avertm and 
local 

2 

860 

0 

0 

Uneventful 

27 

S 3 

Cervical cordotomy 

Local and 
gas-oxygen 


sso 

+ 

0 

Uneventful 

28 

46 

Partial removal of pi- 
tmtary adenoma 

Avertm lo 
cal and ether 

2'A 

1,200 

0 

0 

Died in 8 hours 

29 

54 

Subtotal resection of 
meningioma of sphe- 
noid wing 

Avertm and 
local 

2M 

2,050 

0 

r 

Died on fourth day 

30 

S 3 

Partial removal of glio- 
blastoma multiforme 

Local and 
ether 

3 

7 S 3 

0 

I 

Period of coma due to 
cerebral edema followed 
by recovery 

31 

IS 

Negative cerebellar 
exploration 

Local 


927 

0 

I 

Uneventful 

32 

16 

Myoplastic craniot- 
omy for oxycephaly 

Avertin- 
ether and 
novocain 

iM 

487 

0 

0 

Uneventful 

33 

ai 

Parietal bone flap and 
evacuation of subdu- 
ral hematoma 

Avertin- 
ether and 

novocain 

2 

918 

0 

0 

Uneventful 

34 

47 

Negative cerebellar 
exploration 

Local 


708 

0 

I 

Uneventful 

3 S 

S 7 

Total resection of men- 
ingioma of frontal lobe 

Local 

iH 

If 187 

0 

I 

Uneventful 

36 

38 

Frontoparietal explo- 
ration and biopsy 

Local and 
ether 


ifOSO 

0 

I 

Transitory hemiparesis 

37 

S 3 

Subtotal resection of 
frontoparietal astro- 
cytoma 

Local 

2M 

If 289 

0 

0 

Transitory hemiparesis 
with complete recovery 


relatively avascular tumors, the loss of blood rose to between 600 and 1,200 
cc In three patients with large meningiomata, the hemorrhage exceeded 
2,000 cc * In five laminectomies the loss of blood varied from 334 to 1,263 cc 
A hemorrhage of over a liter in the course of an opeiation on the spinal 
cord may seem excessive, but with an epidural abscess 01 a vascular tumor, 
or in a hypertensive patient, both the muscles and the bony lamina may 
bleed profusely Indeed, in a patient with a hemangioma and compression 
of the spinal cord, the attempt to expose the tumor had to be given up 
after two trials on account of seveie hemorrhage On the other hand, in 
two patients where cervicothoracic ganghonectomy and section of the fifth 

* Since this article was submitted for publication one of us, W H S , has carried out 
additional determinations of blood loss in Dr P Bailey’s clinic at the University of 
Chicago The results there were similar to those reported above, with a maximum of 
1900 cc during the removal of a meningioma 

290 






Volume 107 
Number 2 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS 


cianial nerve root were earned out, bleeding amounted to only 107 and 86 cc , 
a volume comparable to that which has been reported m routine appendicecto- 
mies and heinior rapines (Table II) 


Table II 

BLOOD LOSS DURING ORDINARY SURGICAL OPERATIONS 
From StahsHcs by Gatch and Little and Caller and Haddock^ 




Gatch and Little 



Coller and Maddock 




Amount 



Weight 




of 



of 



Operation 

Blood 


Operation 

Blood 




Lost 



Lost 




Cc 



Gm 

I Abdominal Incisions 


I 

Partial gastric resection 

III 

A 

Midline or right rectus 


2 

Exc thyroglossal cyst 

174 


1 

Suspension of uterus, ap- 


3 

Exploratory, kidney 

208 



pendicectomy 

22 

4 

Repair inguinal hernia, appen- 



2 

Hysterectomy, appendi- 



dicectomy 

54 



cectomy 

209 

5 

Repair ventral hernia 

92 


3 

Suspension of uterus 


6 

Exc sarcoma thigh 

161 



(Baldy-Webster) 

28 

7 

Exc teratoid tumor abdomen 

546 


4 

Panhysterectomy 

310 

8 

Radical mastectomy 

1,272 


5 

Appendicectomy 

17 

9 

Partial gastric resection 

274 


6 

Panhysterectomy for 


10 

Colostomy 

13 



large fibroids 

304 

II 

Repair inguinal hernia 

13 


7 

Hysterectomy, appendi- 


12 

Repair ventral hernia 

147 



cectomy 

206 

13 

Hemorrhoidectomy 

8 


8 

Gastrectomy, Polya 


14 

Repair inguinal hernia 

51 



method, carcinoma 

232 

15 

Appendicectomy 

14 


9 

Cholecystectomy 

51 

16 

Cholecystectomy 

55 


10 

Cholec> stectomy 

66 

17 

Appendicectomy 

13 


II 

Cholecystectomy 

145 

t8 

Repair ventral hernia 

306 


12 

Exploratory celiotomy, 







appendicectomy, plas- 
tic operations on both 







ovaries 

120 





13 

Exploratory celiotomy 

14 





14 

Appendicectomy, repair 







of abdominal wound 
and separation of ad- 
hesions 

62 




B 

Hernia 






15 

Left inguinal 

11 





16 

Left inguinal 

32 




C 

McBurney 






17 

Appendicectomy 

4 





18 

Appendicectomy 

7 





19 

Appendicectomy 

6 





20 

Appendicectomy 

8 





21 

Appendicectomy 

7 





22 

Appendicectomy 

6 





291 



WHITE, WHITELAW. SWEET AND HUE WITT 

’ X corUtir} xuoo 

Table II {Conltnued) 



Amount 


Operation 

of 

Blood 

Other Operations 

Lost 

Cc 

23 

Thyroidectomy 

504 

24 

Thyroidectomy, ade- 



nomata, local 

16 

25 

Thyroidectomy, ade- 



nomata 

61 

26 

Thyroidectomy 

252 

27 

Radical breast amputa- 



tion for cancer removal 
of pectoral muscles and 
axillary 6videment 

710 

28 

Double simple breast am- 



putation for nonmalig- 
nant disease 

400 

29 

Double simple breast am- 



putation for nonmahg- 
nant disease 

420 

30 

Drainage, acute osteo- 



myelitis of humerus 

176 

31 

Sequestrectomy, tibia 

59 

32 

Sequestrectomy, tibia 

40 

33 

Laminectomy, fracture of 



spine 

672 

34 

Amputation of middle 



finger, metacarpopha- 
langeal joint 

44 

35 

Nephrectomy, left lumbar 

816 


It IS obvious that the excessive bleeding which occuis in the usual 
iieurosuigical operation is due to certain legional conditions which are not 
encounteied in the ordinal y pioceduies within the abdominal or thoracic 
cavities, or in the extremities In operations on the brain and spinal cord, 
hemostasis is rendered difficult because of tbe extreme vasculaiity of the 
scalp and the muscles of the back, and owing to the pioblem piesented b) the 
control of bleeding in the course of the elevation and closure of the bone 
flap or duiing the resection of the spinal laminae In the lemoval of vascular 
menmgiomata, and other brain tumors, the problem is further complicated 
by the difficulty of rapidly locating and controlling the vessels in the depths 
of the wound In operations on the sympathetic sti uctures and the peripheral 
nerves, these conditions aie not encounteied and the loss of blood is no 
greater than m other surgical procedures 

Another matter of interest is the protracted reduction of the concentra- 
tion of red blood corpuscles, hemoglobin, and hematocrit readings which 
continue progressively for from four to six days after operation These 

292 



Volume 10 ' 
dumber 2 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS 

Table III 

HEMOCONCENTRATIONS AETCR NEUROSURGICAL OPERATIONS 



PVTILNT 6 

Patient 

7 

Patient 8 

Patient 

13 

Patient is 

Patient 

2 Q 

Patient 30 

Blood Loss 















Cc 


S42 



399 



S74 



86 


1100 


2050 


753 























U 

u 



u 



U 



U 






c 


U 


r* 

0 


r* 

U 


0 

r* 

u 


0 

c 3 

u 

0 

rt 

0 


0 

0 

u P 


CQ 

Xi 

E 

0 

CQ 

X 

E 

u 



E 

a> 

pq 

X 3 

E 

U 

P3 

E 

fa 

Xi 

E 

“ ^ i 




a 

« 

a 

a 

ft! 

a 

a 


a 

a 

Pi 

a a 

a 

a 

a 

a a a 

Prtop 

4 54 

79 

42 

3 IS 

9S 

42 

395 

84 

42 

4 7S 

79 

43 

4 62 

SS 32 

6 2 

03 

45 

442 87 44 
















Transfusion 

Transfusion 

Postop 

1 33 

St 

39 

4 39 

81 

37 

430 

87 

44 

4 71 

82 

41 

4 57 

62 31 

S3 

84 

41 


ist dty 

tot 

76 


3 61 

72 


3 64 

77 


464 

73 


4 II 

S8 

5 I 

82 

43 

3 96 75 36 

end d ij 

4 02 

6S 

33 

3 26 

70 


381 

67 

33 

403 

79 

40 

3 39 

48 

50 

81 

44 


3rd da> 

407 

72 


0 39 

70 

34 

3 32 

68 


4 28 

76 


3 59 

47 

54 

8S 

40 


4th dnj 

3 67 

63 

34 

3 12 

74 


2 99 

57 

29 




3 19 

46 

Diel 


3 49 70 37 



















Transfusion* 

5th daj 

403 

7r 



69 





0 99 

81 


3 43 

50 22 





6tli day 

3 63 

69 


336 

72 

30 

294 

66 





3 62 

52 





7lh daj 

3 6s 

70 

34 s 

4 13 

71 


3 42 

84 

34 




3 79 

48 




2nd Operation 
Transfusion* 

8tli daj 

3 67 

71 












49 




3 74 83 38 

gth daj 

3 29 

67 


4 04 

So 

32 







3 71 

54 





loth daj 

3 89 

72 

36 

388 

8S 








3 59 

47 




4 33 loi 45 
Transfusion* 

12th daj 




4 13 

87 

34 







3 77 

SO 





* Transfusions for low serum protein 



Patient 

31 

P jtient 

32 

Patient 

33 

P WENT 

34 

Patient 

35 

Patient 36 

Patient 

37 

Blood Loss 




















Cc 


927 



487 



918 


708 


1187 


1030 


1289 





La 

u 



c 

u 



U 



1 


5 


u 



1 


u 


"rt 

u 


rt 

u 


fS 

0 


f3 

u 

rt 

u 

rt 

u 




ca 

x: 

£ 

pa 

-0 

E 

<u 

pa 

JO 

B 

CQ 

.0 

E 

07 


S 

OJ 


E 

0 

ca 

ja 

9 


Pi 

a 

a 

Pi 

a 

a 

Pi 

a 

a 

Pi 

a 

a 

a a 

a 

a a 

a 

Pi 

a 

a 

Preop 

4 18 

78 

38 

5 03 

75 

34 

464 

10s 

45 

565 

85 

SI 

4 56 86 

40 

446 94 

41 

5 36 

87 

45 


Transfusion 







Transfusion 

Transfusion 

Transfusion 




Postop 




















ist daj 

3 SI 

60 

39 

5 or 

60 

33 

4 17 

7S 

33 

S 24 

80 

44 

338 63 

31 

3 82 77 

37 

4 59 

84 

42 

2nd daj 




















3rd day 

3 97 

65 

32 

486 

S8 

31 




5 13 


43 

3 85 66 

26 

3 77 63 

34 

486 

84 

30 

4th daj 







3 36 

60 

33 











Sth daj 




S 57 

66 

33 














6th day 















3 13 63 

32 

4 S8 

75 

28 

7th day 

CO 

60 

26 




3 12 

38 

23 

s 56 

80 

42 

3 72 68 

32 






Sth day 







Transfusion t 











pth day 

Transfusionf 

















loth day 







3 St 

67 












12th day 

4 79 

80 



















t Transfusions for anemn 

Transfusions contained approximateiy 500 cc of cifrated blood 
Hemoglobin measured bj Sahli method 


293 





WHITE, WHITELAW, SWEET AND HURWITT ^■"."bruarribTs 

data aie piesented in Table III In patients whose blood changes were 
followed for two weeks, the ei3Throcyte count, hemoglobin, and hematocrit 
reached a minimum between the fourth and sixth days after opeiation 
These concentrations then giadually inci eased, letuimng appi oximately half- 
way back to then preopeiative levels within a ten-day period Theoretically, 
one might expect the maximum i eduction of erythrocytes, hemoglobin, and 
hematocrit to take place within I2 hours aftei opeiation, as the i educed 
number of red blood cells aie diluted by tissue fluid enteiing the blood 
vessels Independent obseivations made by Di John Talbott’’ at this hospital 
confiim our obseivations He mteiprets the continued reduction in the 
concentiation of red corpuscles as a depicssion of the blood-foiming elements 
111 the body 

Methods of Reducing Hemoiihage at Opeiation — A valuable means of 
conti oiling bleeding duiing cianiotomies is the anesthetic A wide infiltra- 
tion of the scalp with a l pei cent iiovocain-epinephiine'’ solution diminishes 
bleeding Our prefeience is to supplement tins with basal avertin, as this 
drug pioduces a model ate fall in blood piessuie and thereby diminishes 
hemoirhage from the ceiebial vessels In addition to this, basal naicosis 
conti ibutes to the comfort of the patient and i educes nervousness and rest- 
lessness In patients wdio cannot toleiate aveitin because of hypertension 
or poorly functioning kidneys, w^e have employed piehmmary phenobarbital, 
nembutal, or pai aldehyde narcosis in conjunction w'lth a thoiough regional 
infiltration Occasionally this must be supplemented wnth a veiy light ether 
anesthesia when the patient is extiemely nervous oi uncoopeiative Moiphine, 
as IS generally known, cannot be used wnth safety in individuals wnth in- 
creased intiacianial piessuie, because of its depiessing effect on the respira- 
tory center 

Administration of the general anesthetics ether and nitrous oxide should 
be avoided whenever possible because they increase bleeding In the case 
of ethei, the woik of Finesinger and Cobb*"’ has demonstrated that this drug, 
like alcohol, acts as a vasodilator on the cerebral vessels As a lesult, sat- 
isfactory hemostasis is not only moie difficult to achieve, but the vascular 
iietwoik 111 the biam is engorged and the w'Oikmg space wnthm the cianial 
cavity conespondingly i educed Nitrous oxide-oxygen anesthesia also pro- 
duces increased bleeding because it so frequently causes partial asphyxia, 
and IS worse than ether on account of the secondary elevation in blood 
pressure wdiich goes with it When a geneial anesthetic must be used, a 
preliminary infiltration of the scalp w ith o 5 pei cent novocain-epinephrme 
solution IS of value not only as a hemostatic agent, but also because a lightei 
level of anesthesia can be employed 

While details concerning the surgical technic of hemostasis aie outside 
the scope of this papei, it is nevertheless impoitaiit to point out that the 
surgeon can always afford sufficient time to caiiy this out wath the most 

* For the purpose of local vasoconstriction, o 2 cc of a i 1,000 solution of epinephrine 
should be added to each 100 cc of novocain 

294 



Volume 107 
Number 2 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS 


meticulous care It should be emphasized that neurosurgical patients tolerate 
piolonged opeiations well and that m our opinion postoperative shock de- 
pends on tiauma to the biam and the amount of blood shed rathei than on 
the duiation of the operation A brisk hemorrhage coming late in the re- 
section of a brain tumor, when the vascular system has reached its limit 
of compensation, is seiious Such a complication can never be foreseen, 
but much can be done to foiestall its depleting effects by constant attention 
to hemostasis and the maintenance of a maximum reserve of blood within the 
vascular bed Tune taken to control bleeding is never wasted 

One further point concerning hemorrhage at operation should be men- 
tioned If the neurosurgeon will measure the volume of blood lost during 
a series of operations, he may develop the ability to make a fairly accurate 
estimation by inspection of the drapes, the bucket which contains discarded 
gauze and cotton pledgets, and the contents of the suction bottle Assuming 
a hemorrhage of 1,200 to 1,500 cc as the upper limit of the average patient’s 
ability to compensate for reduced blood volume,'^ it is better either to give 
an immediate transfusion 01 to postpone the total extirpation of a tumor to 
a second session when this point is reached 

It will be seen on examining the statistics on blood loss given in Table I 
that these actual measurements have served to make the members of oui 
neurosurgical operating team “hemorrhage conscious” During the three 
year period of this investigation every effort has been made to promote 
more effective hemostasis, and the improvement m the latter third of the 
series has been distinctly encouraging 

Replacement of Blood Lost dm mg Opei atwn — The customary procedure 
on the Neurosurgical Service has been to start an intravenous infusion of 
5 per cent glucose 111 normal saline at the beginning of every extensive 
operation and to permit 500 to 1,500 cc to run in slowly during the opera- 
tion Citrated blood may then be substituted for the saline solution when- 
ever there is an alarming fall m blood pressure When it is estimated that 
a hemorrhage of a liter 01 more has occurred, a transfusion is given before the 
patient is sent to the ward After hemorrhages exceeding 1,200 to 1,500 cc , 
or whenever the hlood pressure remains at a critically low level, multiple 
transfusions are given This can be earned out on the ward if the intra- 
venous infusion has been kept running The total fluid intake on the day 
of operation should rarely exceed 2,000 cc and should be given slowly 
over a period of five to eight hours 

Discussion — From the data we have presented on blood loss during 
operations on the central nervous system, emphasis must be laid on certain 
fundamentals which differentiate this special field of surgery The out- 
standing feature is the increased volume of hemorrhage, which is from two 
to five times greater than m routine celiotomies Again, although a liter 
of blood IS lost during the aveiage operation for brain tumor, these patients 

* Such an extensive hemorrhage can be tolerated only if it takes place gradually 
during a three or four hour operation 


295 



WHITE, WHITELAW, SWEET AND HURWITT 

rarely go into surgical shock, unless the hemorrhage is rapid or exceeds 
1,200 cc Experience with transfusion donors has taught that a healthy 
individual can withstand a sudden bleeding up to 500 01 600 cc While 
rapid hemorrhage above this amount will cause characteristic symptoms, 
a slow loss of twice this volume over a period of three to four hours 
can usually be tolerated This situation is quite different from that which 
IS encountered m operations on the abdominal viscera Here no such ex- 
tensive bleeding can be withstood because it takes place in a much shortei 
space of time In addition, water is lost by vaporization from the skin and 
lungs at a more rapid rate ^ These and other, as yet poorly understood, 
factors tend to produce surgical shock to a greater degree than duimg intra- 
cranial procedures of apparently gi eater severity and duration 

Because sudden brisk hemorrhage may occui at any time during brain 
tumor resections and throw the patient into a state of uncompensated blood 
loss, it IS of extreme importance to preserve every possible drop of blood 
and to be able to replace any excessive reduction in blood volume without 
delay The latter is accomplished by the constant intravenous administration 
of a 5 per cent solution of glucose m normal saline duimg operation, with 
a compatible donor waiting in an adjacent room In sudden uncompensated 
hemorihage the suigeon is thereby prepared foi the tiansfusion of citrated 
blood and the deficit can be restored with the minimum loss of time 

SUMMARY 

(1) Hemorrhage in the couise of extensive intracranial operations 
averages fiom 500 to 1,500 cc This is fiom two to five times gi eater than 
the usual volume lost m other tj^pes of operations 

(2) In spite of excessive bleeding, neurosurgical patients raiely go into 
shock if less than 1,200 cc of blood is lost, unless the hemorrhage is rapid, 
or damage is done to the centers which control cii dilation and respiration 

(3) Hemorrhage during operation can be 1 educed by 

(a) Meticulous hemostasis As neurosurgical patients withstand a pro- 
tracted operation well, time consumed in cutting down the loss of blood is 
never misspent 

(b) Choice of the anesthetic Ether anesthesia causes excessive bleeding 
secondary to dilation of the cerebral blood vessels Similarly, the administra- 
tion of nitrous oxide commonly results in a rise of blood piessure and an 
increase in bleeding The most effective means to 1 educe hemorrhage is the 
infiltration of novocam-epinephrme solution in the scalp This may be sup- 
plemented by avertm or by one of the barbituric acid derivatives if a basal 
narcosis is desired 

(4) Replacement of blood lost during any extensive craniotomy is best 
carried out by a constant intravenous infusion of 5 per cent glucose in 
normal saline One thousand to 1,500 cc administered in this way will 
take care of a giadual loss of a liter of blood Aftei a sudden brisk 
hemorrhage, 01 failure of the organism to compensate for an excessive loss 

296 



Volumo 107 
Number 2 


BLOOD LOSS IN NEUROSURGICAL OPERATIONS 


of blood, the infusion appaiatus is available for the transfusion of citrated 
blood 

(5) Our determinations have shown that ordinarily a single transfusion 
of 500 cc IS sufficient after a hemorrhage of from 1,200 to 1,500 cc When 
over this amount has been lost, or the blood pressure has failed to respond 
to the fiist transfusion in the operating room, the intravenous drip ap- 
paratus serves foi a subsequent transfus’on of blood on the ward 

(6) The neurosurgeon should be able to make a leasonably accurate 
estimate of the volume of blood lost m the course of an operation Recog- 
nizing a hemorrhage of 1,500 cc as the maximum amount that can be 
tolerated by an aveiage patient, it is advisable to transfuse 01 to postpone 
the total extiipation of a tumor to a second stage when this limit is ap- 
proached 


REFERENCES 

‘White, J C, Sweet, W H, and Hurwitt, E S Water Balance in Neurosurgical 
Operations Annais of Surgery, 107, March, 1938 
“ Gatch, W D , and Little, W D Amount of Blood Lost during Some of the More 
Common Operations JAMA, 83, 2, 1075, October 4, 1924 
® Coller, F A , and Maddock, W G Dehydration Attendant on Surgical Operations 
J A M A , 99, 87s, September 10, 1932 

‘ Pilcher, F , Jr , and Sheard, C Measurements on the Loss of Blood during Transurethral 
Prostatic Resection and Other Surgical Procedures, Determined by Spectrophoto- 
metnc and Photelometnc Methods Proc Staff Meet Mayo Clinic, 12, 209, April 7, 

1937 

“Talbott, J H Personal communication 

“ Finesinger, J E , and Cobb, S The Cerebral Circulation The Action of Narcotic 
Drugs on the Pial Vessels J Pharm & Exper Therap , 53, i, January, 1935 


297 



GIANT CELL TUMOR OF THE CERVICAL SPINE 
Deforest P Willard, M D , and Jesse Thompson Nicholson, M D 

PHiL\Dri,pniA, Pa 

Giant cell tumor of the ceivical spine is a comparatively rare lesion The 
common sites for this type of tumor, in order of frequency, are the lower end 
of the femur, the upper end of the tibia, the lower end of the radius and the 
upper end of the humerus Some difficulty is encountered m estimating its 
frequency of occuirence in the vertebrae because of the repetition of cases re- 
ported m the literature If this source of error can be disregarded, giant cell 
tumor IS found m the vertebrae in 8 per cent of the cases The cervical ver- 
tebrae are reported involved in seven instances If statistics can be relied upon 
this represents i pei cent of the total number of cases of giant cell tumor oc- 
curring in the vertebiae, and 15 per cent of the veitebral lesions (Table I) 

Table I 

FREQUENCY OF CERVICAL INVOLVEMENT AMONG THE REPORTED GIANT 
CELL TUMORS OE THE VERTEBRAE 

Involvement 


Reporter 

Year 

No 

of Cervical Vertebrae 

Dean Lewis' 

1924 

17 

I 

Kolodny- 

1928 

8 

? 

Simmons^ 

1931 

4 

I 

Geschickter & Copeland' 

1935 

8 

0 

Meyerdmg® 

1936 

4 

I 

Peirce & Lampe® 

1936 

5 

0 

Simmons^ 

1936 

3 

3 

Bosworth® 

1936 

I 

I 

Buzby® 

1936 

I 

0 

Harbin'” 

1937 

3 

0 

Osgood" 

1937 

I 

I 

Compere'" 

1937 

I 

0 


56 8 

The age of the individual is, in a decided majoiity of all giant cell tumors, 
above 20, the oldest being 68 and the youngest four and one-half years In 
the vertebral lesions the majority are under the age of 20 The sexes are 
about equally represented 

Giant cell tumoi is classified as nonmahgnant Coley, however, in report- 
ing 50 cases, states that ten died of metastases Meyerdmg® reports but one 
death from metastases in 61 cases Both Simmons,^ and Kolodny” deny the 
possibility of metastasis unless the tumor changes its chaiacteristics Ge- 
schickter and Copeland^ recognize a “malignant variant, which is usually the 
result and not the cause of recurrence ’’ This would indicate that inadequate 

Submitted for publication May 26, 1937 

298 



olume 107 
Isiimber 2 


GIANT CELL TUMOR OF SPINE 


lemoval oi tieatment is responsible for this secondaiy change They also 
claim if this “malignant vaiiant” structuie is piimaiy, and lecuiience lesults, 
metastasis is apt to follow • 

Geschicktei and Copeland claim that the giant cell tiimoi occiii ring in the 
small bones (iibs, metacai pals, metatarsals, laminae of spine, etc ) aie spindle 
cell valiants (Giant cell tumors have a stroma of lound cells with few spindle 
cells In the “vaiiant” the numbei of spindle cells is inci eased ) In 3/ of 
these cases theie weie no lecuirences except an mopeiable one of the sacium, 
m which a laminectomy was attempted In Dean Lewis’^ series of 17 vertebial 
tumors, 13 healed aftei partial lemoval He emphasized this significant le- 
sponse, since ossification of the site of giant cell tumois of the long bones is 
extremely laie unless the tumoi is completely removed 01 destroyed 

The tieatment of giant cell tumois, in geneial, cannot be pro\en by statis- 
tics Many have been subjected to comlimations of radiation, curettage, cau- 
teiization, Colejds toxins, lesection and amputation Simmons, Meyerding, 
and GeschicKter and Copeland all agiee that theie were no deaths 01 lecui- 
1 dices following eithei amputation 01 lesection 

Following cuiettage alone, Simmons lepoits 19 cases with one death fiom 
hemorrhage and one recuiience Geschicktei and Copeland, m 105 cases, find 
one death and 31 lecunences Of the lecmiences, 16 weie cuied after a sec- 
ond or thud cuiettement, seven had secondary infection wath three amputa- 
tions Bloodgood states that 80 pei cent are cuied by curettement He rec- 
ommends caiiteiization of the base wuth puie phenol, then 95 pei cent alcohol 
and finally zinc chloiide Meyerding leviews ten in which he paitially filled 
the cavity with a bone giaft following the cuiettage None of these cases had 
1 ecurrences 

Radiation is usually combined with other methods of tieatment Theie 
aie, howfever, a few^ cases lepoited in which radiation alone was used Sim- 
mons states m eight cases theie were six cuies, one death, one amputation 
Geschickter and Copeland in ten cases find that five came to subsequent 
suigeiy 

Fiom these leports, if it is not too piesumptuous to conclude, the treatment 
of choice would be cui ettement This failing, resection or amputation must be 
performed 

Case Report — A white female, age 9, was brought to the Children’s Hospital 
clinic in May, 1936, because her head tilted to one side This had been noticed six 
months previously No pertinent history, other than a tonsillectomy ten months before, 
could be obtained 

Physical Examination showed the head tilted to the right 30° and rotated to the 
left 20° There was slight limitation of rotation to the right and lateral flexion to the 
left Reflexes and sensation were normal, but there was some atrophv of right arm 
and evidence of muscle weakness, especially loss of power in grip of right hand Upon 
questioning, the child admitted a sensation of “numbness of the fingers ” 

A roentgenogram at this time was interpreted as showing a forward dislocation 
of the right inferior facet of the third cervical vertebra Hyperextension failing to 
reduce this lesion after two weeks, a Walton manipulation was made and a plaster 
bandage applied to head and torso 


299 



WILLARD AND NICHOLSON 


Annals of Surfccn 
Febr\icry 1938 


The patient returned in July for a change of the plaster encasement Examination 
failed to elicit any sensory or motor disturbances There was at this time a fulness of 
the neck on the right side of the spinous process of the fourth cervical vertebra Roent- 



Fig 2 — Photomicrograph showing t>pical giant cells in a stroma of round cells containing many 

spindle cells 

genologic examination showed a rounded cystic tumor projecting posteriorly from the 
fourth cervical vertebra (Fig i, A and B) Comparison with previous roentgenograms 
proved it to have been present previously as a faint irregular shadow of only one-half 

300 






Volume 107 
Number 2 


GIANT CELL TUMOR OF SPINE 


the diameter of the present mass Roentgenologic examination of the other bones and 
lungs proved negative The blood calcium and phosphorus were normal 

A biopsy was performed August 14, 1936 The mass appeared well defined and 
localized to the fourth right cervical lamina The spinous processes and laminae on the 
right side of the third, fourth and fifth cervical vertebrae were removed Convalescence 
in a bivalved plaster encasement was uneventful 

Pathologic Examination — Dr A D Waltz “Grossly the specimen consists of 
several pieces of bony material, the largest about i cm across The narrow innei 
portion IS deep red in color, soft and friable, breaking away easilj The next and 
widest portion is also deep red but contains some bony material The outer portion 
is grayish-wdnte and hard Microscopically the inner friable portion is made up of 
spindle, oval or rounded cells, profusely studded with large giant cells showing many 
central nuclei The W'ldest portion shows a netw'ork of bony trabeculae surrounding 



j-jG 3 — (A) Ruentgenogr-vms (hteral view) one year postoperative showing increase in bone 
density at site of laminectomy, indicating bon> ankjlosis but no evidence of recurrence of tumor 
growth (B) Anteroposterior view 


larger or smaller spaces, which contain the same type of tumor and giant cell as de- 
scribed above External to this is osteoid tissue, which is covered by a thin shell of 
hard bone Giant cell tumor originating in the marrow cavity” (Fig 2) 

One course of roentgenotherapy was instituted by Dr Ralph Bromer two weeks 
after operation This was not repeated for fear of disturbance to the thyroid and para- 
thyroid glands 

Roentgenologic examination, in April, 1937, showed ossification but no increased 
size m the suspicious involvement of the right pedicle and transverse process of the 
fourth cervical vertebra, which had not been removed at operation 

September 13, 1937, the patient was symptom free Examination revealed the 
head tilted slightly to the left and the chin to the right of the midline Neck motion 
Extension, 30° , flexion, 45° , flexion to right, 25° , flexion to left, 25° , rotation to right, 
35° , and rotation to left, 45° One-eighth inch atrophy of upper and lower arm No 
disturbance of reflexes or sensation Roentgenologic examination at this time showed 
no recurrence of the tumor growth but solid bony fusion bridging the site of the 
laminectomy (Fig 3, A and B) 


SUMMARY 


A case is lepoited of a female, age 9, who had a giant cell tumor of the 
lamina of the fourth ceivical -veitebra The tumoi was almost completely re- 

301 



WILLARD AND NICHOLSON 


Annals of Surgerj 
Februnn 1938 


moved by performing a laminectomy Pathologically it resembled the spindle 
cell variant of giant cell tumor recognized by Geschickter and Copeland One 
year after operation the patient is symptom free and roentgenologic examina- 
tion does not show any recurrence 

BIBLIOGRAPHY 
^ Lewis, Dean JAMA, 83, 1224, October 18, 1924 

“ Kolodny, Anatole Bone Sarcoma, Chicago, 1927 Surgical Publishing Co 
° Simmons, Channmg C Malignant Changes Occurring in Benign Giant Cell Tumors 
of Bone Surg , Gynec , and Ostet , 53, 469, October, 1931 
‘Geschickter, Charles F, and Copeland, Murray M Tumors of Bone Amer Jour 
Cancer, New York, 1936 

®Meyerding, H W Roentgen-ray Therapy of Bone Tumors Jour Bone and Joint 
Surg, 18, 617, July, 1936 

” Peirce, C B , and Lampe, Isadore Giant Cell Bone Tumors JAMA, 107, 1867, 
December 5, 1936 

Simmons, Channmg C Personal communication 
® Bosworth, David W Personal communication 
“ Buzby, B Franklin Personal communication 

“ Harbin, Maxwell Report at American Academy of Orthopaedic Surgery, Cleveland, 

1937 

“ Osgood, Robert B Discussion of above 

“ Compere, Edward L Operative Treatment of Low Back Lesions American Academy 
of Orthopaedic Surgery, Cleveland, 1937 


302 



RATIONALE OF BONE DRILLING IN DELAYED AND UNUNITED 

FRACTURES 

Proviso V Prewitt, MD and E R Easton, MD 

New Yohk, N Y 

In elucidating as comprehensive a subject as osteogenesis in fracture 
lepaii, following the dulling opeiation, the following aspects must be 
evaluated (i) Skeletal maturity (2) Effect of local environmental bio- 
physical states upon bone pioduction (3) Noimal bone a balanced physio- 
logic mechanism (4) Possible physiologic effects lesulting from the drill- 
ing operation 

Skeletal Matin ity — In the phenomenon of skeletal matuiity is compie- 
hended not only the matuiation of the component bones of the skeleton, but 
in addition, a mechanism which contiols and coordinates the linear and 
volumetric relations of these components one to the othei — acceleratoiy and 
inhibitory influences 

For the growth of a bone its resident center of ossification is most essential 
Quite as necessary, however, foi properly cooidinated giowth and solidity, 
aie the pituitaiy and parathyioid secretions The factor of adequate local 
cii dilation IS assumed m either developing bone or m the process of its repair 

This mechanism presents quite a striking similaiity to the heart with its 
associated vagosympathetic influence The heart muscle, while automatic, 
is at all times subject to the tonic activity of the craniobulbar outflow of nervous 
impulses on the one hand, and the sympathetic autonomic impulses on the 
other, the resultant caichac 1 espouse being the algebraic sum of the two op- 
posing influences 

In the case of a bone, its growth is intimately dependent upon its ossi- 
fication centei The activity of this center and the consequent development of 
the bone are determined by the pituitary (in close association with the cranio- 
bulbar outflow) and the parathyioid secretions (in close association with the 
sympathetic autonomic outflow) The ascendancy of pituitary function may 
result in aciomegaly 01 gigantism, while preponderance of the parathyroid 
secietion may result in destruction of bone or Recklinghausen’s disease 

Effect oj Local Envn onmental Biophysical States upon Bone Pi oduction — 
Following a previous statement that the ossification centei s determine the 
limits of the mass of a bone subject to the secondary influences of hormones 
elaborated by the pituitary, parathyroid and peihaps other glands, the actual 
deposition of bone is a synthetic leaction occuning immediately at the site 
of bone production The differential impoi tance of the various components of 
the bone in the process of new bone formation has been conclusively demon- 
strated 

Conclusions from the clinical application of bone grafts are, however, open 

Submitted for publication March 10, 1937 

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Annals of Surgcn 
rebriiary 1938 


to question m the light of present facts The work of Ollier/ McWilliams/ 
Phemister, et al , confirmed the findings of Duhamel, m the mid-eighteenth 
century, concerning the prime importance of the periosteum in osteogenesis 
Based upon similar corroboration. Mock,® Delangeniere,^ Albee,® and Haas® 
insist upon bone grafts containing periosteum 

The m vitro studies of Dobrowolskaja’^ revealed slight bone growth from 
periosteum alone, steady bone growth from pieces of cortical bone alone, 
and luxuriant growth from spongy bone containing marrow Ollier,^ Barth,® 
Axhausen,® Macewen,^® and Groves^^ have demonstrated that a tube inserted 
into the medullary canal soon became filled with bone Johnson^® showed that 
when the nutrient arterial supply to the bone marrow and inner one-half of the 
cortex IS intact, it is productive of a much more rapid bone repair than is 
the case with the blood supply to the periosteum and outer one-half of the 
cortex Berg and Thalhimer^® felt they obtained even greater growth from 
those tiansplants containing endosteum than from those including periosteum 
Therefore, in the clinical application of bone grafts there is insufficient 
control of the components of the grafts or its recipient to permit of trust- 
worthy conclusions The weight of evidence, however, definitely favors 
endosteum over periosteum as a source of osteogenesis 

In a series of very well controlled experiments, McGaw and Harbin^^ 
attempted to determine the use of bone marrow and endosteum as a free graft 
to stimulate or hasten osteogenesis A small mass of marrow and endosteum 
removed from the tibia m dogs was substituted for a thiee-eighths inch re- 
sected segment of fibula in the same subject The opposite fibula was similarly 
resected for control They concluded that “Bone mariow and endosteum 
play a very active role in the formation of callus and new bone in dogs ” 
There are now well controlled series of human experiments which confirm 
this 

The experimental studies upon hyperparathyroidism show conclusively 
that the halisteresis, or solution of mineral salts, is a local reaction at the inter- 
phase between tissue fluids and the bone The secondary effects of narrow 
zones of decalcification of trabeculae, haversian canal, subperiosteal and 
endosteal surfaces result only from the foregoing phenomenon Conversely 
there is incontrovertible evidence that bone synthesis or pioduction is a 
similai local suiface process 

The local question arises What are the causative biophysical processes 
underlying this mechanism of bone production^ It is not sufficient to state 
that certain important bone constituents and adequate circulation are impera- 
tive At present all of the chemical and physical requirements are not known 
Rosahn^® recently reported the serum phosphatase content of a group of 
normal rabbits varying in age from 15 to 71 days He found the phosphatase 
values in this group to describe a signiflcant linear decrease with increasing age 
and weight Such findings might logically be anticipated since all bones of 
the body are growing, the sum total of the local reactions being equivalent 

304 



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OSTEOGENESIS IN FRACTURES 


to a general reaction, thereby increasing this enzyme in the general cir- 
culation 

That bone repair is a local phenomenon has been conclusively demonstrated 
by Willems and Regan^® In an adequately large series of perfectly controlled 
experiments upon rabbits, phosphatase determinations were made of the 
fracture foci at increasing intervals following the experimental production of 
comminuted fractures of both ulnae They conclude that "Following frac- 
ture of adult rabbit bone there is a rapid rise in the phosphatase activity at 
the site of bone injury which reaches a peak at some time near the twenty- 
second day and drops gradually as repair progresses ” They also state that 
Some of the rabbits showed a slight elevation of plasma phosphatase at the 
time when the phosphatase activity at the site of fracture was maximum This 
elevation was so slight that its significance is questionable 

Phosphatase determinations on the foreleg bones after removal of the 
fractured segment in the two 56 day animals gave figures within the normal 
range of the unfractured whole foreleg bones While the number of experi- 
ments is too small to permit of indisputable conclusions, it is more than sug- 
gestive that enzymic activity associated with bone repair is limited to the site 
of the bone injury 

Since the above experimental evidence demonstrates the unquestionable 
piesence of local phosphorus anabolism m fracture repair, it might logically 
by hypothecated that at least two other phenomena occur simultaneously Cal- 
cium IS deposited during this process Its deposition may result from enzymic 
synthesis or electrolytic concentration at certain cellular or membrane inter- 
phases As yet there is no evidence to support either hypothesis 

The laying down of fibroblasts and endothelial tissue for sustentacular and 
circulatory functions, respectively, in soft tissue, does not result in mineral 
deposition as m the case of osteogenesis The presence of these tissues, how- 
ever, IS universal in successful bone repair Wherein then does bone repair 
differ from ordinary soft tissue repair^ As shown above, the cells of bone 
marrow and endosteum play a very active role m new bone formation It 
seems logical, therefore, to suppose that locally a system of fibroblasts is 
formed in the meshes of which the periosteal, endosteal and marrow cells are 
supported The rapidly growing endothelial cells develop into a sustaining 
circulatory network which permits of the elaboration of such enzymes by the 
bone cells as are necessary for the production of new bone 

Normal Bone a Balanced Physiologic Mechanism — Before attempting to 
discuss this subject, a comparison of certain generalized destructive bone dis- 
eases such as Recklinghausen’s disease, osteomalacia, Paget’s disease and semle 
atrophy may be informative 

A well advanced case of Recklinghausen’s disease is characterized by 
Thinned cortex, porosity, bone cysts, osteoclasts with their Howship’s lacunae 
and marrow fibiosis, grossly and microscopically Biologically there is a de- 
crease in serum phosphorus and an increase in both the serum calcium and 

305 



PREWITT AND EASTON 


Annals of Surgery 
Tebruary 1938 


phosphatase There is an associated increase in urinary excretion of cal- 
cium 

Regardless of any concept of a hormonal effect by the paiathyroids m the 
etiology of this disease, there is not only definite evidence of complete lack of 
osteogenetic activity by periosteum, endosteum, cortex and medullary sub- 
stance, but a positive swing m the dii ection of osteoclasis In osteomalacia the 
bones show wide osteoid margins, very little marrow scarring and relatively 
few osteoclasts Chemically a marked reduction m serum calcium is shown, 
the greater portion being excreted through the bowel From these facts one 
might hypothecate an attempt at osteogenesis, particularly by the periosteum 
with a concomitant failure of mineial anabolism 

Lamellation and thickening of the coitex of long tubular bones without 
giant cell tumors and cysts, as in Recklinghausen’s disease, characterize Paget’s 
disease The blood reveals a very high phosphatase content There is no 
mineral imbalance Herein is demonstrated a hyperosteogenetic function by 
the peiiosteum with commensuiate mineral deposition and a concomitant in- 
crease m phosphorus enzyme 

Senile osteoporosis is a process of chionic atrophy of bone In a very 
advanced case may be seen oily cysts due to liquefaction of marrow fat, m 
some of the long bones This disease lepresents a failuie of histogenesis on 
the part of the bone components and an inability to retain the minerals 
previously present 

Considering the bone locally, eliminating any attempt at conjecture or 
hypothesis concerning the pi unary etiology of the above pathologic states, a 
dissociation between cellular activity and mineral metabolism is immediately 
obvious For example Conti asting Recklinghausen’s disease with Paget’s 
disease, there is not only a negative reaction by the cellular structure but 
active destruction There is also loss of mineral substance from the bone 
In Paget’s disease on the other hand, there are cellular production and addition 
of minerals Theie is positive cellular reaction with loss of minerals in 
osteomalacia, and finally in senile osteoporosis there is little or no cellular 
change but marked loss of minerals 

After correlating all of the above facts and hypotheses, it would seem 
that in growing bone the processes of cellular proliferation and mineral deposi- 
tion are simultaneous, the balance being in tbe positive phase In certain 
destructive diseases of bone, as Recklinghausen’s disease, there is a negative 
balance, while m normal bone the piocesses of osteogenesis and osteoclasis 
are in balance That the mineral salts are actively held, and not meiely pas- 
sively present, is evidenced by their disappearance from the head of the femur 
after fracture in certain cases and in senile osteoporosis This phenomenon, 
together with that of callus production without calcification, shows bone 
formation to consist of two processes, namely Cellular proliferation and 
mineral deposition, and, further, that since cellular proliferation always pre- 
cedes calcification, the latter process is dependent upon, and results from, the 
former 


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Volume 107 
Number 2 


OSTEOGENESIS IN FRACTURES 


Physiologic Effects Resulting jiom the Dulling Opeiatwn — Notwith- 
standing the fact that Beck’^’^ is given piioiity in the dulling of malunited 
fractures by Cartel, et al this credit is justly due to an Ameiican surgeon 
Daniel Brainard^® was awaided fiist prize by the American Medical Asso- 
ciation, in 1854, for his essay on a “New Method of Ti eating Ununited Fiac- 
tures ” In this essay aie detailed repoits of successfully peiforated cases of 
ununited fractures of radius, ulna, tibia, fibula and mandible The method 
consisted m passing a spear shaped drill, called a “peifoiator,’’ varying from 
two millimeters to more than one-eighth of an inch in diametei , subcutaneously 
through the healthy bone m each fragment, traversing the line of fiactuie 
This pioceduie of making multiple drill holes was repeated at mteivals of 
from five to ten days Again, in 1858, Bramard“° repoited 13 cases of un- 
united fractures ti eated by subcutaneous perf 01 ation of the bone The technic 
as desciibed by Beck,’^’^ Carter,^® Bolder,-^ Bozsan^“ and others, while varying 
slightly in type of mstiuments, site of application, etc , lemains identical in 
principle with the method oiiginally introduced by Brainard, in 1854, in this 
country In the cases herewith piesented the method was highly successful in 
the pioduction or stimulation of osteogenesis 

ILLUSTRATIVE CASE REPORTS 

Case I — A J , male, age 20, sustained a compound fracture of the middle third of 
the left tibia and a double fracture of the left fibula, resulting from a fall down an 
elevator shaft, in 1930 Slide graft effected in 1931 Graft absorbed In 1932, the 
tibia was pierced ten or 12 times with bone drill Bony union solid after three months 
Case 2 — A U , female, age 61, slipped on an orange peel, fracturing the neck of 
the left femur After reduction and the application of a plaster spica for eight weeks, 
no union resulted and there was a distinct slipping of the fragments Four days after 
reduction and retention with a Jones traction splint, the hip was drilled according to 
the technic of Bozsan Splint left in place for 16 weeks, then walking calipers Roent- 
genologic examination one year after operation showed firm bony union with some 
absorption of neck 

Case 3 — E L , female, age 54, fell in December, 1934, fracturing the surgical 
neck of the left humeius At an open reduction operation, February 26, 1935, the 
coracobrachialis and short head of the biceps were found to be interposed between the 
fragments The fracture was pierced eight to ten times with a drill and fixed with 
two Easton nails, which were removed after two months April 10, 1935, roentgenologic 
examination demonstrated solid bony union 

Case 4 — V P , female, sustained a compound fracture of the left tibia and fibula 
at the junction of the upper and middle thirds Union was delayed The fracture was 
drilled (Dr J V Bohrer) Solid bony union was present after six weeks 

Case 5 — F C , female, age 55, fell September 21, 1935, fracturing the right tibia 
and fibula at the junction of the middle and lower thirds Treated by a plaster encase- 
ment elsewhere The encasement was removed after five weeks and the patient allowed 
to walk Nonunion resulted Wassermann three plus The fracture was drilled De- 
cember 3, 1935, and the plaster encasement was applied for six weeks, during the last 
three of which the patient was allowed to walk with leg still m the plaster bandage 
At end of six weeks solid bony union was present 

Case 6 — J M , male, age 17, was thrown from a motorcycle February 7, 1934, re- 
ceiving compound comminuted fractures of the right tibia and fibula at junction of 
middle and lower thirds Nine months later, October 14, 1934, upon discharge from 

307 



PREWITT AND EASTON 


Annals of Surgery 
February 1938 


hospital, there was a posterior bowing, false point of motion, exuberant callus, and no 
calcification was demonstrable by the roentgenograms The fracture was drilled March 
2, 1935 Roentgenologic examination showed increasing bony union although a false 
point of motion was still present On July i6, 1935, union was firm, there was no 
false point of motion, and calcification was apparently present 

Case 7 — N C , female, age 59, fell November 7, 1935, fracturing the neck of 
the femur at its midportion Eleven days after reduction by the Ledbetter method 
and application of plaster spica, the fracture was drilled and fixed with Easton nails, 
because of anticipated delajed or nonunion The nails were removed 72 days later 
The plaster encasement was removed one month after removal of the nails, at which 
time there was roentgenologic evidence of early union On June 15, the patient walked 
without support Roentgenologic examination showed firm union at the site of fracture 
Case 8 — G W, male, age 54, fell down a flight of stairs fracturing both the 
tibia and fibula in their distal thirds The injury to soft parts was considerable Trac- 
tion was maintained for one month by a Steinman pin, followed by immobilization in a 
plaster encasement There was no evidence of union after three months Three weeks 
after drilling and immobilization m a plaster bandage, union was firm 

Case 9 — B W , female, fell January 28, 1936, sustaining a subcapital fracture 
of the neck of the femur Wassermann three plus Reduction was effected by a com- 
bination of the Murray and Ledbetter methods, and a plaster spica applied The frac- 
ture was drilled and two Easton fixation nails inserted through a window in the plaster 
encasement two weeks after the reduction because of anticipated delajed or nonunion 
On June 30, the patient walked without support, and roentgenologic examination showed 
firm union at fracture site 

Case 10 — W O’S, male, age 45, was struck by a car, December 5, 1936, sustaining 
a complete oblique fracture of midportion of the shaft of left tibia and fibula Reduction and 
application of plaster incasement under general anesthesia December 21, 1936, fragments 
were overriding and there was no union Multiple drilling and fixation of fragments with 
Easton nails was effected at open reduction January 28, 1937, nails were removed, solid 
bony union was evident clinically and m roentgenograms December 13, 1937, result was 
excellent, no defective gait 

Case II — C K, female, age 78, fell on the sidewalk December 28, 1936, sustaining 
a subcapital fracture of neck of femur Immediate reduction by Leadbetter method and 
plaster spica No union resulted February 18, 1937, open reduction, multiple drilling 
and fixation of fragments with Westcott nail April 10, 1937, roentgenogram showed bony 
callus December 10, 1937, bony union solid Walks without support, gait normal 

Case 12 — S H , female, age 51, fell down stairs, Februarj’- 9, 1937, fracturing neck 
of femur Reduced by Leadbetter method and applied Whitman plaster spica same dav 
April 3, 1937, roentgenogram showed slipping of fragments Open reduction, multiple 
drilling and fixation of fragments with Westcott nail April 27, 1937. roentgenogram 
showed callus formation December 13, 1937, solid bony union Function normal 

Case 13 — A R , male, age 23, struck by a car December 12, 1936, sustaining com- 
pound comminuted fracture of middle third of right tibia and fibula and simple com- 
minuted fracture of middle third of left tibia May 12, 1937, false motion very definite 
in left tibia Fragments multiple drilled and plaster encasement applied Three weeks 
later union was firm clinically December 21, 1937, solid bony union with very satisfactory 
functional results 

Case 14 — N C, female, age 22, on September 28, 1936, m auto accident, sustained 
a compound fracture right radius and ulna, two inches above wrist joint and complete 
transection of ulnar nerve and artery Immediate debridement, open reduction, ligation of 
artery and repair of nerve were effected and plaster encasement applied February 12, 1937, 
no union Same date multiple drilling of radial fragments March 17, 1937, multiple drilling 
of ulnar fragments and fixation with No 28 stainless steel wire Arm immobilized m 
a plaster encasement Four months later solid bony union m both bones December 20, 

308 



Volume lOT 
Number 2 


OSTEOGENESIS IN FRACTURES 


1937, bony union solid, circulation normal, function of ulnar nerve nearly normal 
Patient recently played 25 games of tennis without discomfort 

Delay and nonunion of fractures occur with greater frequency in certain 
localities than in others , for example The neck of the femur, lower third of 
the leg, certain carpal bones, etc , because of the relative paucity of blood 
supply The circulation to these areas is supplied by one relatively small 
artery with few or no anastomotic branches In other localities, malunion 
may result from the interposition of massive impenetrable hematomata 
There is evidence that the molecular dissociation of such clots inhibits the 
enzymic and proliferative processes so essential to new bone formation 

The drilling operation is indicated where (a) One of the opposing frag- 
ments is viable (b) There is a potentially adequate arterial blood supply 
m one of the fragments (c) The distance between the fragments is not too 
great to be spanned by a reasonable amount of new bone 

The passing of a proper drill through the normal bone of both fragments 
traversing the fracture area (a) Injures all coats of the arteries and veins, 
particularly the endothelial linings, (b) injures normal periosteum, bone cor- 
tex, endosteum and marrow , (c) leaves conduits which contain a soft pulpy 
mixture of the foregoing elements Normal adult tissue of this type, when 
injured, resumes its embryonic capacity to reproduce itself 

Based upon all of the foregoing facts and hypotheses the production of 
new bone probably occurs as follows The fibroblasts ramify throughout the 
multiple drill holes forming a sort of arbor Perhaps the first element to 
permeate the connective tissue stroma, and aid in its completion, is the 
capillaries resulting from reproduction by the injured endothelial cells 

The last and slowest growing types of cells to invade those legenerating 
areas are those derived from the medulla and cortex of the normal bone As 
the bone cells revert to the embryonal types, with capacity to reproduce, they 
also acquire a glandular function, in that they elaborate an enzyme or enzymes 
through the action by which calcium and phosphorus are taken from the blood 
stream and tissue fluids to be deposited within the interstices of this newly 
formed mass of cells 

Osteogenesis and osteoclasis are the opposite extremes of a highly com- 
plex reversible biophysical reaction When the circulation is inadequate as in 
some cases of fractured head of the femur, the "N” point is necrosis and 
absorption of the proximal fragment — osteoclasis 

If all constituents in this highly complex reversible osteogenetic reaction 
are coordinated, the “N” point is represented by normal adult calcified bone 

CONCLUSIONS 

The bone regeneration following the drilling operation for delayed or 
unumted fractures results from (i) Injury to the fracture area with the 
consequent enrichment of local circulation, the so-called “freshening up” 
process (2) Grinding and depositing within the drill canals the various bone 
cells, stimulating them to renewed embryonal activity to grow and reproduce 

309 



PREWITT AND EASTON 


Annals of Surgen 
tebruarj 1938 


(3) Causing ceitain of the bone cells to elaboiate calcium and phosphorus 
conjugating enzymes so necessary for the deposition of calcium phosphate 
within the mass of callus, the so-called “bony callus ’’ 

REFERENCES 

^ Ollier, L Traite Experimental et Clinique de la Regeneration des os et de la Produc- 
tion Artificielle du Tissu Osseux Pans, Victor Masson et Fils, 1867 
" McWilliams, C A The Function of the Periosteum in Bone Transplantation Based 
on Four Human Transplantations without Periosteum, and Some Animal Experi- 
ments Surg, Gynec , and Obstet , 18, 159, 1914 
® Mock, H E Periosteal Transplants in the Repair of Delayed Union, Ununited Frac- 
tures and Loss of Bone Substance Surg, Gynec, and Obstet, 46, 641, 1928 
* Delangeniere, H Greffes Osteo-Periostiques Technique et Applications J de Chir , 
17, 30s, 1921 

“Albee, F H The Inlay Bone Graft as a Treatment of Ununited Fractures A Re- 
port of Fifteen Successful Cases Amer Jour Surg , 28, 21, 1914 
“Haas, S L Regeneration of Bone from Periosteum Surg, Gynec, and Obstet, 17, 
164, 1913 

’ Dobrowolskaja, N A On the Regeneration of Bone in Its Relation to the Cultiva- 
tion of Bone Tissue Brit Jour Surg, 4, 332, 1916 
® Barth, Arthur Uber Histologische Befunde Nach Knochemmplantationen Arch f 
kill! Chir , 46, 409, 1893 

“Axhausen, George Die Jistologischen und Khnichen Gesetze der Freien Osteoplastic 
auf Grund von Thiewersuchen Arch f klin Chir , 88, 23, 1909 
” Macewen, Sir William The Growth of Bone, Observations on Osteogenesis An Ex- 
perimental Inquiry into the Development and Reproduction of Diaphysical Bone 
Glascow, James Maclehose & Sons, 1912 

Groves, E W Hey On Modern Methods of Treating Fractures 2nd Ed, William 
Wood Co , N Y , 1922 

“Johnson, R W, Jr A Physiological Study of the Blood Supply of the Diaphysis 
Jour Bone and Joint Surg , g, 153, 1927 

“Berg, A A, and Thalhimer, William Regeneration of Bone Am Surg, 67, 331, 1918 
331, 1918 

“ McGaw, W H , and Harbin, M The Role of Bone Marrow and Endosteum m 
Bone Regeneration Jour Bone and Joint Surg, 32, 816, 1934 
“Rosahn, Paul D Serum Phosphatase in Normal Young Rabbits Proc Exper Biol 
and Med , 32, 1601, 1935 

“ Wilkins, Walter E , and Regan, Eugene M Course of Phosphatase Activity in Heal- 
ing Fractured Bone Proc Exper Biol and Med , 32, 1373, 1935 
“ Beck, A Zur Bekandlung der Verzogerten Konsohdation bei Unterschenkelbruchen 
Zentralbl f Chir , 56, 2690, 1929 

“ Carter, Ralph M A New Treatment for Delayed Union or Non-Union in Fractures 
Jour Bone and Joint Surg, 16, 925, 1934 

“ Brainard, Daniel Prize Essay (American Medical Association) on a New Method of 
Treating Ununited Fractures and Certain Deformities of the Osseous System 
Baker, Goodwin and Co , New York, 1854 

“ Brainard, Daniel Report of Thirteen Cases of Ununited Fractures Treated by Sub- 
cutaneous Perforation of the Bone Chicago Med Jour, 50, 421, 1858 
Bohler, Lorenz Pseudoarthrosenbekandlung mit der Beck’schen Bohrung Zentralbl 
f Chir, 57, 1654, 1930 

“ Bozsan, E J A New Treatment of Intracapsular Fractures of the Neck of the Femur 
and Legg-Calve-Perthes Disease Technique Jour Bone and Joint Surg, 16, 75, 

1934 


310 



BRIEF COMMUNICATIONS 
AND CASE REPORTS 


STAB WOUND OF THE HEART TWENTY-ONE YEARS AFTER 

SUTURE 

John F X Jones, M D 

Philadelphia, Pa 

Case Report — G L P , Negro, male, age i8 at the time of operation, 21 years ago, 
when a stab wound in the left ventricle was sutured by the author, at St Joseph’s Hos- 
pital, April 18, 1916 The patient was presented before the Philadelphia Academy of 
Surgery, and reported in the Annals of Surgery, 65, 120, January, 1917 

The patient was discharged from St Joseph’s Hospital early in June, 1916, and was 
not seen again until May 5, 1937, when he appeared as a very muscular individual, weigh- 
ing 160 pounds Height five feet, ten inches 

He IS now 39 years of age He has married, and is the father of six children During 
the intervening 21 years he has worked at hard manual labor, frequently as a long- 
shoreman At present he has a four plus Wassermann and a four plus Kahn reaction 
It IS not known how long these have existed 

Physical Examination — May S, 1937 Along the left side of the thorax there is an 
area of softening of bone and of cartilage, extending downward along the left sternal 
margin from the second to the fifth rib, measuring 7 i by 3 cm This region of diminished 
resistance protrudes when the patient coughs Treatment of his neglected lues may im- 
prove this condition A protective corset over this weakened area seems indicated 

An electrocardiogram, May 10, 1937, by Dr R V Patterson, showed “The rate 
is 80 per minute, the rhythm is regular, the conduction function is normal, left ventricular 
hypertrophy and myocardial degeneration are definitely indicated” 

Orthodiagraphic studies made by Dr John T Farrell, Jr, May ii, I937 j showed 
little, if any, enlargement of the heart He states “The third and fourth ribs on the left 
side are deformed anteriorly and there is an adhesion deforming the left half of the 
diaphragm Outside of these variations the intrathoracic structures are essentially normal 
Looking at the film, the heart appears to be a little larger than the average but with 
the measurements of the orthodiagram it is well within normal limits ” 


AN AMBULATORY TREATMENT OF FRACTURE OF THE 

PATELLA 


Eugene St Jacques, MD 
Montreal, Canada 

In the Annals of Surgery, ioi, 1082-1090, April, 1935, there appeared 
an article on “An Ambulatory Method of Treating- Fractures of the Patella,” 
by Roger Anderson of Seattle His method requires “Reduction by the ap- 
plication of skeletal traction to the upper patellai fragment, and immobilization 
through the agency of a plaster case in which are incorporated both this supe- 
rior transfixion and a distal anchoring pm passed through the upper end of the 

Submitted for publication November 18, 1936 

311 



EUGENE ST JACQUES 


Annals of Surgery 
February, 1038 



312 



Tolume 107 
Number 2 


TREATMENT OF FRACTURE OF PATELLA 


tibia ” This technic, together with the rather cumbersome apparatus required 
to maintain reduction, seems unnecessaiily complicated when compared with 
a simpler and equally efficient method m use in our clinic The latter pro- 
cedure IS a modification of the operation employed by Professor Delbet of 
Pans 

A horseshoe-shaped incision is made over the patella, and the knee joint is 
exposed sufficiently to allow the removal of blood clots The aponeurosis of 
the quadriceps muscle is elevated fiom the anterior surface of the patella 
m order to expose the line of fracture adequately By means of a sharply 
pointed awl, veitical peiforations aie made through the central portions of 
both fragments A double stiand of silkworm gut is threaded through the 
eye of the awl to serve as a tractor for the "metallic silk" used for fixation of 
the fragments This metallic suture consists of a finely twisted bronze- 
aluminum wire manufactured by Shearer of Bern Its caliber is about one 
millimeter, which is too gieat to allow threading it through the eye of the 
perforating instrument, hence the use of the silkworm-gut ti actor In some 
cases the procedure is facilitated by perfoiatmg and drawing the suture through 
each fragment separately A strand of wire 45 to 50 cm m length will 
usually be adequate After di awing the doubled strand thiough the two 
fragments from below upwards, so that equal lengths project from each 
orifice, the loop formed at the upper end is cut Then, again using the 
silkworm-gut threaded on a heavy needle as a tractor, each of the four 
lengths of “metallic silk” is woven through the tendon expansion close to the 
lateral margins of the patellar fragments towards the line of fracture 

At this point the joint is filled with Calot’s fluid,* an antiseptic olive oil 
compound, in order to prevent the formation of adhesions and to facilitate 
early mobilization With the aid of a Farabeuf clamp, or other heavy clamp, 
an assistant then brings the fragments into anatomic alignment, while the 
operator draws tightly and knots the adjacent ends of wire on the medial and 
lateral aspects of the patella The margins of the reflected quadriceps aponeu- 
rosis are approximated with No 2 chromic catgut and the skin is closed 
with an mtradermic suture of silkwoim-gut 

Immediately postoperatively, a simple wooden splint is applied posteriorly 
for immobilization This is worn until the fifth day when it is removed and 
active motion of the knee encouraged On the tenth day the patient is allowed 
out of bed with the splint reapplied to afford confidence On the twelfth day 
the splint IS discarded and walking is allowed without restraining apparatus 

We have employed this method with consistently excellent results for more 
than 20 years The rigid fixation of the fracture allows early resumption of 
knee motion, which m turn prevents intra-articular adhesions and the extensive 
atrophy which commonly follows prolonged immobilization of the knee In 
addition the duration of hospitalization and the duration of disability are 
considerably shortened 

* Calot’s fluid Creosote, 3 grams , iodoform, 7 grams , ether, 25 cc , olive oil 
(sterilized) 50 cc 


313 



MEMOIR 

INGERSOLL OLMSTED 
1864-1936 


Dr Ingersoll Olmsted, of Hamilton, Ontario, whose death occurred in 
his seventy-third year, on November 12, 1936, was one of Canada’s most dis- 
tinguished and respected surgeons He was born in Ancaster, and his early 
education was at the Collegiate Institute of Hamilton He received his M B 



Incersoli. Olmsted M D 

degree from the Univeisity of Toronto, in 1887, and following that went to 
Philadelphia to be an intern in the Germantown Hospital He returned to 
Hamilton in 1888, became resident physician m the Hamilton City Hospital 
and while theie founded a training school for nuises Doctor Olmsted main- 
tained such interest and activity in the fundamental fields, particularly bac- 

314 



Volume 107 
Number 2 


INGERSOLL OLMSTED 


tenology, that he was otfeied an assistant prof essoi ship m that field at the 
Univeisity of Pennsylvania in 1893 Soon aftei he accepted tins position 
he used himself as the subject of an expeiiment, an infection developed and 
It was necessaiy to amputate his light leg below the knee On recoveiing 
fiom this, he lesigned his position and went abroad wheie he studied in the 
clinics of Gieat Britain and continental Euiope When he leturned to Amei- 
ica, he continued his studies at Johns Hopkins Univeisity, and again letuincd 
to Hamilton wdieie he set up in piwate piactice, confining his woik almost 
entirely to geneial surgeiy Doctoi Olmsted was a Fellow of the Royal Col- 
lege of Suigeons of Canada and of the Ameiican College of Suigeons, and 
he was honored m 1934 by the Hamilton Academy ot Medicine with a life 
membeiship m recognition of his conti ibutions to medical science Suiviving 
besides his wife, Edith Olmsted, aie two sons, Aichie and Di Alexandei I 
Olmsted, both of Hamilton, and a daughtei, Mis Geoige Hendrie 

The suigical caieei of Doctoi Olmsted, extending as it did ovei a peiiod 
of almost 50 yeais, exemplifies the changing status of the geneial singeon, 
foi It is not now possible that a geneial suigeon can encompass with the same 
degiee of pioficiency as many fields as Doctor Olmsted, with his inquisitive 
mind, could mastei Suigeons of his day weie confionted wnth the necessity 
of acquiiing experience m many of the technical diagnostic fields, and since 
many of these weie m then early stages ot development, it was possible for 
such an eneigetic, studious and seiious-minded woikei as Doc^-oi Olmsted, 
who had already had a sound tiaining in the fundamental sciences, to leain 
what was knocvn at that time 111 such fields Foi example, he was a competent 
roentgenologist, did his cystoscopic examinations, was one of the the eailiest 
to use the bionchoscope, earned on his routine clinical laboiatoiy wmik, and 
made his pathologic examinations, and on this wide knowledge of diagnostic 
procedures built his suigical piactice It might be expected, theiefore, that a 
surgeon with such a background would be an astute diagnostician of keen 
surgical judgment, and not only w^as this tiue of Doctoi Olmsted, but he w^as 
also a master technician and alwaji^s the tiue physician in the caie of his patients 
In his every activity, whethei m the practice of his profession or in his 
enjoyment of the out-of-doois, paiticulaily m golf, hunting and fishing, his 
inspii mg enthusiasm and zealous study made him always a stimulating teachei , 
companion and colleague The influence of such a man and his wmrk in a 
community detached from any teaching center of medicine cannot be over- 
estimated, and he was the acknowdedged leadei of his profession in his part 
of Canada His death is a loss to the medical piofession, not only of Canada 
but also to those who came under his tutelage, wherever they have gone 

Donald C Balfour 


315 



BOOK REVIEWS 


Postgraduate Surgery By Rodney Maingot, F R C S (Eng ), Senior 
Surgeon to the Royal Waterloo Hospital and to the Southbend General Hos- 
pital , later Chief Assistant to a Surgical Unit, St Bartholomew’s Hospital 
Three volumes, 5,584 pages New York D Appleton-Century Company, 
Inc , 1936 

“Postgraduate Surgery,” edited by Rodney Maingot, attempts to cover m 
a practical manner the whole field of surgery In this creditable work the 
American reader is made acquainted with the leading surgical teachers of 
Great Britain, particularly of London The references are few and, as a rule, 
are unfamiliar to the American student Many of the technical details of 
operative surgery described herein are somewhat different from American 
surgical practice and are valuable as offering a ready means for comparison 
and evaluation One’s enthusiasm for the work under discussion will depend 
largely upon what we mean by “postgraduate surgery ” The editor in his 
preface states that “the work has been written specially for postgraduates 
engaged m the practice of surgery , for senior resident officers , for fellowship 
candidates and for medical officers of the fighting services as well as for the 
busy general practitioners who may be called upon to undertake urgent surgi- 
cal measures and who are desirous of keeping abreast with all the modern de- 
velopments m surgery ” The reviewei is willing to subscribe to the first four 
categories, but is emphatic m his belief that this is not a work for the busy 
general practitioner who may be called upon to undertake urgent surgical 
measures 

“Postgraduate Surgery” is presented in three volumes, containing 5,584 
pages, and a thousand illustrations, each volume having an extensive index 
The material m Volume I is presented in five parts (i) Anesthesia, (2) ab- 
domen, (3) rectum and anus , (4) roentgen ray diagnosis , (5) radium therapy 
Volume 1 1 is in ii parts devoted to the head, spinal column and salivary 
glands , neck , bi east , thorax , female genital organs , urinary system and male 
genital organs, sympathetic nervous system, adrenal gland, injection therapy, 
infections of the hand, and a section on orthopedics Volume III is a miscellane- 
ous ariangement of 24 parts devoted to a conjurie of surgical topics, including 
a second section on orthopedics , cardiovascular system , plastic surgery , ob- 
stetric surgery, lymphatic system Following thereafter are hernia, deep 
roentgen ray therapy, venereal disease, eye, ear, nose, pharynx and throat, 
with a part devoted to tonsils and adenoids , tongue , esophagus , jaws , teeth, 
etc , and concluding with the thymus gland It is apparent that in a considera- 
tion of modern surgery no one mind can hope to grasp even the fundamentals 
of such a wide and diverse giouping of surgical topics and probably the ar- 
rangement of these parts came as the result of the extension of the editor’s 
thought for completeness The range of material is encyclopedic and has 

316 



Volume 107 
Number 2 


BOOK REVIEWS 


stimulated the revieiver to read sections wholly outside the beaten track of the 
restricted specialties of this country This work is m fact a senes of mono- 
graphs and as such presents an uneven texture of presentation Some of the 
contributions are outstanding and invaluable — abdomen, rectum and anus, 
roentgen ray diagnosis, urinary system and male genital organs, and lymphatic 
system With few exceptions there is an undue prolixity and too much space is 
consumed in mere tabulation and disjointed paragraphs which render the 
reading difficult to follow One senses the mam impress of continental writers 
on English surgical thought as opposed to the contributions of American au- 
thors It comes somewhat as a shock to see the words “vomits” and “feeds,” 
etc , used as substantives, together with the recommendation of remedies that 
are distinctly proprietary and apparently have not been passed upon by any 
group for new and nonofficial remedies Many "drugs” that are m daily use 
in Great Britain are totally unknown m the United States 

The Amencan opinion in regard to peptic ulcer is distinctly at variance 
with the presentation in Volume I, Chapter VI — “the treatment of chronic 
peptic ulcer is primarily and essentially medical ” This statement without 
proper qualification is overly dogmatic and is not in consonance with American 
experience Apparently, the various contributors have had considerable diffi- 
culty in limiting the scope of their presentation Some have a minimum of 
description for the clinical phases of the condition under discussion but are 
most extensive in technical details of operative procedures Others pass over 
the technical part and devote most of their space to descriptive surgery One 
reads with considerable doubt “after the Polya types of operation, obstruction 
is very rare ” Section 4, Chapter I “the medical treatment of gastric, duo- 
denal and anastomotic ulcer” consists of four and one-half pages and contains 
some rather startling statements “If suitable treatment is given for a suffi- 
cient period, nearly every gastric ulcer eventually heals, as well as about 75 
per cent of duodenal ulcers, and 50 per cent of the much more intractable 
anastomotic ulcers which follow gastric operations”, “When the ulcer is 
healed the patient should begin the post-ulcer regimen which he should 
keep up for the rest of his life” , “The suitable diet should not form clots in the 
stomach,” yet in the next paragraph prepared chalk is given as “it has the 
advantage of being insoluble ” 

Hepatic failure is discussed under the general term “cholemia” and while 
“liver deaths” are mentioned, the author did not have a very clear under- 
standing of just what IS meant by this serious type of complication Section 8, 
on the pancreas, consists of exactly five pages with nine illustrations , eight of 
them being devoted to methods by which pancreatitis may be produced at 
operation 

The reviewer searched in vain for the name of John B Murphy either in 
the indices or in the text on peritonitis This was particularly surprising be- 
cause the modern conception of peritonitis has been developed in the last 
35 years According to Sampson Handley the names of Lawson Tait, 
Malcolm, Treves readily come to mind and the pathologic interpretation of 

317 



BOOK REVIEWS 


Annals of Surgen 
Februarj 1938 


peritonitis by Dudgeon and Sargent is associated with the name of John B 
Murphy, on the operative and therapeutic side 

Orthopedics is considered in Part XVI of Volume II and continued in 
Part XVII of Volume III, both sections under the same authorship In 
Volume II, page 1,905, diverticula of the esophagus draw nine lines of de- 
scription and the author provides a single illustration which shows that the 
“sac has been displaced and stitched in upright position ” Additional infor- 
mation on esophageal diverticula is given in Volume III, pages 4,824 and 5,054 
In spite of this the subject is very inadequately covered Disease of the thy- 
roid gland receives but two-thirds of a page of description and the section on 
radical operation on the breast is very brief and without any illustrations 
The hormonal or endocrine treatment of chronic cystic mastitis is not men- 
tioned In Part IX, the section on the thorax is divided into two sections, 
section I dealing with medical conditions and section 2, surgery of the thorax 

Many of the operations illustrated in the section on gynecology are im- 
plemented by instruments unknown to American students One’s risibilities 
are touched on reading on page 2,586 on “Sterility in Women” “Being Ameri- 
can she was thoroughly up-to-date and had a ‘gold’ button introduced into 
the cervix immediately before marriage ” In consonance with present day 
teaching the endocrine backgi ound of the menstrual cycle should merit a fuller 
discussion 

The Injection Treatment of Hernia (Volume II, Part XIV, section i), is in 
the nature of a special pleading The author’s advocacy is not confirmed by 
the American experience in the treatment of hernia by injection Figure 1,839, 
page 3,254, depicting the technic of an injection into the left inguinal canal, has 
no place in any surgical textbook The surgeon ( ^) in street clothes with the 
ubiquitous wrist watch on his left arm, is making an injection into the left 
inguinal region of an undraped patient There is no visible evidence of ade- 
quate preparation of the patient or of the operator foi a surgical procedure 
under aseptic conditions Irrespective of the merits of the injection treatment 
of hernia the technical procedure should be surrounded always with the same 
safeguards as accompany other surgical procedures 

Many of the monographs m this system are excellent In fact, most of 
them are first class piesentations of the subject For the students the work is 
primarily designed to serve it is to be recommended For the American sur- 
geon of experience and competency it is valuable A knowledge of English 
and continental surgical thinking should prove useful m rounding out our own 
surgical knowledge 

The publisher has produced three very ornamental volumes But, what a 
load to handle ' Volume I weighs eight pounds. Volume II eight and one- 
half pounds, and Volume III nine pounds, and each one is handled with the 
greatest difficulty with or without the aid of a bookrest It seems a pity that 
each volume was not subdivided, lighter paper employed and smaller compass 
given to mam subdivisions m order that the books could be handled easily and 
without fatigue In comparison with previous surgical publications from 

318 



Volume 107 
Number 2 


BOOK REVIEWS 


British authors these three volumes are following the best tradition of English 
surgery Lucidity of expression, conservatism and a background of good 
surgical judgment are in keeping with the best of surgical thought The work 
is recommended to surgical interns, residents, and to the rising generation of 
surgeons There is also an additional appeal to those already m the ranks of 
surgery to see in its entirety a splendid pageant of modern surgery 

Charles Gordon Heyd 


The Management or Fractures, Dislocations, and Sprains By 
John Albert Key, B S , M D , and H Earle Conwell, M D , F A C S Second 
Edit Cloth Pp 1,246 with 1,222 illusti ations St Louis, C V Mosby 
Company, 1937 

The authois have written an excellent book on the tieatment of acute 
injuries of the bones and joints They have covered the acute phase of the 
subject completely and have given in detail the technic, indications, counter- 
indications, and dangers of the various methods of treatment 

Veiy little space has been allotted to the chionic phase of bone and joint 
injuries , malunion and nonunion, the treatment of which constitutes a large 
part of the practice of orthopedic surgeons Although it would have been 
desiiable to make the book complete by adequately covering this phase of the 
subject, the authors have admirably fulfilled their purpose, as stated in the 
preface, of writing a book foi the student, the general practitioner, and the 
surgeon 

Robert L Preston 


319 



BOOKS RECEIVED 


The receipt of books for review is hereby acknowledged This statement shall be 
regarded as sufficient acknowledgment of the courtesy of the publishers Selections will 
be made for review predicated upon the interests of the readers of the Annals of Sur- 
gery and as space permits 

The 1936 Year Books of General Surgery, Edited by Evarts A Graham, M D , 
Urology, Edited by John H Cunningham, M D , Pediattucs, Edited by Isaac A and 
Arthur F Abt, M D , General Medicine, Edited by Doctors Dick, Brown, Minot, Castle, 
Stroud and Eusterman, Obstetrics and Gynecology, Edited by Joseph B DeLee, M D , 
and J P Greenhill, M D , General Therapeutics, Edited by Bernard Fautus, M D , 
and Samuel J Nichamin, M D , Eye, Ear, Nose and Throat, Edited by E V L 
Brown, Louis Bothman, George E Shambaugh, Elmer W Hagens and George E 
Shambaugh, Jr, MD, Neurology, Psychiatry and Endocrinology, Edited by Hans 
H Reese, M D , Harry A Paskind, M D , Ph D , and Elmer L Sevnnghaus, M D , 
Dermatology and Syphilology, Edited by Fred Wise, M D , and Marion B Sulz- 
berger, M D , Radiology, Edited by Charles A Waters, M D , Whitmer B Firor, M D , 
and Ira S Kaplan, B Sc , M D , Chicago The Year Book Publishers, Inc , 1936 

Synopsis of Gynecology By H S , and R J Crossen, M D and ed St Louis 
C V Mosby Co , 1937 

Synopsis of Digestive Diseases By John J Kantor, Ph D , M D St Louis 
C V Mosby Co , 1937 

Synopsis of Genito-Urinary Diseases By Austin I Dodson, M D and ed 
St Louis C V Mosby Co , 1937 

Textbook of Surgical Nursing By Henry S Brookes, Jr, MD St Louis 
C V Mosby Co , 1937 

Textbook of General Surgery By Warren H Cole, M D , and Robert Elman, 
M D New York and London D Appleton-Century Co , Inc , 1936 

Proctology By Frank C Yeomans, M D New York and London D Appleton- 
Century Co , 1936 

Urology By Edward L Keyes, PhD, FRCS (Hon London), and Russell S 
Ferguson, M D 6th ed New York and London D Appleton-Century Co , 1936 

Surgical Pathology of the Diseases of the Neck By Arthur E Hertzler, M D 
Philadelphia J B Lippincott Co , 1937 

The 1937 Year Book of the Eye, Ear, Nose and Throat Edited by E V L 
Brown, M D , Louis Bothman, M D , George E Shambaugh, M D , Elmer W Hagens, 
M D , and George E Shambaugh, Jr , M D Chicago The Year Book Publishers, 1937 

The 1937 Year Book of Urology Edited by John H Cunningham, M D Chicago 
The Year Book Publishers, 1937 


EDITORIAL ADDRESS 

Oncinal typed manuacripte and illustrationi lubmittsd to this Journal 
should be forwarded prepaid, at the author’s risk, to the Chairman of the 
Editorial Board of the ANNALS OF SURGERY 

Walter Eatell Lee, M D 
1833 Pine Street, Philadelphia, Pa 

Contributions in a foreign lanyuaKO when accepted will be translated 
smd published in English 

Exchantes smd Books for Renew should bo sent to James T Pilcher 
M D , Manaemc Editor, 121 Gates Arenue, Brooklyn, N Y 

Subscriptions, advertisme and all business communications should be 
addressed 

ANNALS OF SURGERY 
227 South Sixth Street, Philadelphia, Pa 

320 



Annals of SurRon 
February 19SS 



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ZONITE, even when highly diluted, is a powerful germicide and 
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ZONITE IS a powerful deodorant It is non-toxic and may be used 
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Please mention Annals of Surgery when Avnting advertisers 


17 




Annals of Surcery 
February 1938 


This book discusses 

i what NOT to do! 

rr^HIS book discusses how to avoid complications and technical 
X errors, and how to act when face to face with some of the 
abnormal circumstances which constantly present themselves dur- 
ing the course of a surgical operation It is a new and different 
type of surgery, conceived and projected from the vast experiences 
of the author and his associates It is well constructed, easily 
readable, rich m illustrations and case histones 

This work shows not only errors and safeguards in connection 
with surgical operations in general, and pre- and postoperative 
care of the patient, but covers failures in surgery, the ' bad risk 
patient and the errors and safeguards in blood transfusions , oper- 
ations on the head, neck, thorax, abdomen, in genera, stomach, 
intestinal operations, liver, biliary system, pancreas and spleen, 
hernia , urinary tract , male genitalia , gynecologic operations , ex- 
tremities, spinal cord, and failures due to defective instruments 
and foreign bodies left within the body No suigeott can afford to 
be without a copy 696 pages 668 illustrations Price $10 00 
(Slightly higher in Canada ) 

ARTHUR DEAN BEVAN, M.D. says 
in his Foreword: 

"This splendid work of Dr Thorek on 'Surgical Errors and 
Safeguards’ should be a welcome addition to the library 
of every progressive surgeon and advanced medical student ’’ 

SURGICAL ERRORS 
AND SAFEGUARDS 

BY MAX THOREK, M.D. 

Professor Clinical Surgery, Cook County Graduate School of Medicine 
Foteword by Arthur Dean Sevan, MD, Professor and Head of the 
Depaitment of Surgery, Rush Medical College of the University of Chicago 

J. B. LIPPINCOTT COMPANY 

East Washington Square Confederation Building 

Philadelphia Montreal, Canada 


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Annals of Surgerv 
February, 1938 


CONTRAST MEDIA VARY 
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7 Facilitates diagnosis of many obscure conditions 

8 Reveals pathologic conditions which ordinary 
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AnntlBofSurierr 
Februitr, 1S3S 


Important Recent Publications 


MODERN UROLOGY 

Edited by HUGH CABOT, MD,LLD,CMG,FACS 

Professor of Surgery, The Mayo Foundation, Graduate School of the University of Minnesota, and Consulting 

Surgeon to the Mayo Clinic, Rochester, Minnesota 

Third edition Two octavo volumes totaling 1813 pages, illustrated with 920 engravings and 

21 plates Cloth, $20 00, net 

Since the last edition of this encyclopedic work appeared there have been great advances in technique 
and radical changes in conception The revision of the text has been correspondingly radical So 
extensively has it been rewritten that it is practically a new work The contributors present the 
widest possible representation of urologic opinion m America They include the leading diagnosticians, 
therapeutists, surgeons and pathologists in this field — men whose reputations are based on their ac- 
complishments and whose opinions and conclusions may be accepted without question The illustrations 
are profuse and, for the most part original and portray the various operative steps In its present 
form this text is a comprehensive, scholarly and authoritative study It is thoroughly modern in its 
spirit and material but soundly conservative in its principles and practice 


THE NORMAL ENCEPHALOGRAM 

By LEO M DAVIDOFF, M D and CORNELIUS G DYKE, M D 

Assistant Professor of Neurology in the College of Physicians Assistant Professor of Radiology in the College of Physicians 
and Surgeons Columbia University, Attending Neu and Surgeons, Columbia University, Assistant Director 

rological Surgeon to the Neurological Institute of of the Department of Radiology of the Neurological 

New York, New York City Institute of New York, New York City 

Octavo, 224 pages, illustrated with 149 engravings Cloth, $5 50, net 
This book has been written to meet the needs of general practitioners and specialists Neurological sur- 
geons, neurologists, roentgenologists, pediatricians and internists as well as general practitioners are all 
called upon to diagnose these conditions and must be familiar with the normal encephalogram in order to 
make correct interpretations of the roentgenograms This book supplies such knowledge It offers a 
description of the technique, the indications and contra-indications for the performance of the test and 
the reactions of the patient during and after the procedure The book consMuies an encephalographtc 
anatomy It provides an important fundamental aid to diagnosis and details the factors on which the 
correct interpretation of the encephalogram depends 


NEUROLOGICAL SURGERY 

By LOYAL DAVIS, MS., M D , FACS, Ph D , D Sc (Hon ) 

Professor of Surgery and Chairman of the Division of Surgery, Northwestern University Medical School, 

Chicago, Illinois 

Octavo, 429 pages, illustrated with 172 engravings and z plates Cloth, $6 00, net 
This important new publication has been written for the general practitioner even more than for the 
neurological surgeon Its primary purpose is to give in clear and precise language, the facts that will 
add to the knowledge of the possibilities of surgical treatment in neurological disease The recent 
advances in this field have been so rapid that not every physician is familiar with what can be accom- 
plished and many accept the attitude that such diseases cannot be successfully treated This work demon- 
strates the effectiveness of neurosurgery in the light of recent knowledge It covers injuries, tumors 
and abscesses of the cranio-cerebral and intracranial regions and the spinal cord, injuries of the periph- 
eral nerves, surgical lesions of the cranial nerves, osteomyelitis, cysts, primary and metastatic tumors 
of the skull, the surgery of the autonomic nervous system and surgical treatment of epileptiform seizures 
It IS an authoritative source of information that will be as welcome as it is needed 


LEA 85 FEBIGER 

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□ Cabot’s Modern Urology (2 Vols ) $20 00 

□ Davidoff & Dyke’s The Normal Encephalogram s 50 


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Name Address 

(A of S 3 38) 

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Annals of Surgerv 
February 19 3S 


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Annals of Surgery 
February 1938 



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Annals of SufRon 
February 1938 



Blind Man’s Buff Is No Fun in Medicin 



AGAROL IS available in 6, 10 
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Annals of Surgery 
February 1938 


The Journal of 
Bone and Joint Surgery 

The Official Publication of the 
American Orthopaedic Association 
British Orthopaedic Association 
American Academy of Orthopaedic Surgeons 
Owned and published by the American Orthopaedic Association 

Published Quarterly: 

January, April, July, and October 


The only publication in English dealing exclusively with 
bone and joint conditions 

Thiough the cooperation of its Foreign Editors, its pages 
include contributions from recognized leaders in this spe- 
cialty from foreign countries as well as from the United 
States and Canada 

In the choice of papeis for publication emphasis is laid on 
the practical and clinical subjects 

A journal of value to general surgeons as well as to those 
dealing with the problems of orthopaedic and traumatic 
surgery 


Editor, E. G. BRACKETT, M.D. 

8 THE FENWAY, BOSTON, MASSACHUSETTS, U. S. A. 


ORDER BLANK 

The Journal of Bone and Joint Surgery 
8 The Fenway, Boston, Massachusetts 

Please enter my subscription to The Journal of Bone and Joint Surgery foi one year 
beginning with the issue for 

□ Enclosed find $ in payment □ Will remit on receipt of bill 

Name Street 

City State 

Subscription P; /ce— Payable in Advance-5500 in the United States, 5525 in Canada $575 in Foreign 

Countries 


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Annuls of Surgery 
February 1938 


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Annals cf Surgery 
February, 1938 


^^REQUIRED 

READING” 


Your Personal Guide 
to a More 
Successful Practice 

r\r George D Wolf is a highly success 
ful physician who decided it was high 
time that someone put out a book that 
showed the doctor how to put his profession 
on a more profitable basis The result is one 
of the most important books any doctor can 
have — a book that answers and clarifies hun 
dreds of questions and problems regarding 
business ethics and economics constantly 
confronting the busy doctor 

The volume should be carefully read by 
the physician s secretary or office nurse as 
well, as much of the information and sug 
gestions tendered in it can be applied and 
put into service without any instruction from 
the doctor whatsoever There is also a par- 
ticularly useful section devoted to mate 
rial teaching nurses how to give instruc 
tions to patients for home self treatment 
Nothing has been 


omitted It IS all 
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from How to 
make a Radio 
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Give Expert Court 
Testimony Every 
doctor will find a 
single reading 
worth many times 
the book s cost to 
him Price only 
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DO YOU KNOW • 

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ing money from pa 
tients who fail to pay? 

How to make your office 
secretary or nurse do 
many of the things you 
now must do yourself? 

How to equip and plan 
your office to make It 
most efficient? 

How to pick a profitable 
location and lay out 
your office? 

How to avoid lawsuits? 

How to keep records for 
your income tax? 


THE 

PHYSICIAN'S 

BUSINESS 

by 

GEORGE D. WOLF, M.D. 

Attending Otolaryngologist, Sydenham Hospital, 
New York City, Attending Laryngologist, River 
side Hospital, New York City, Fellow, New York 
Academy of Medicine, Fellow, American Medical 
Association, etc 


Ready Soon! 

^^There is no finer 
book on 
the suhjecP^ 

■pvr Bacon s new book is comprehen 
sive, practical and authoritative It 
offers an unbiased, informative descrip 
tion of the diversified conditions included 
in proctologic practice, and covers every 
phase of the subject It emphasizes the 
application of the procedure to the pa 
tient — not the patient to the procedure 
487 dlustrations (mostly originals) 
atsply pictuie the author’s wide clinical 
and singical experience 

Dr Bacon s text stresses the underly- 
ing pathology of the Anus, Rectum and 
Sigmoid Colon as basic to treatment He 
describes the various methods of exami 
nations Diseases are detailed, giving 
Definition, Etiology, Symptoms, Diagno 
SIS, Medical and/or Surgical Treatment 
Particular attention is given to Hemor- 
rhoids and to Tumors, including infec 
tious, benign and malignant tumors of 
the sigmoid and rectum A comprehen 
sive, selected bibliography completes each 
chapter 600 pages 487 illustrations 

ANUS, RECTUM 

AND 

SIGMOID COLON 

Diagnosis 

and 

T'reatment 

by 

HARRY E. BACON, M.D. 

F A C S f f A P S , Assistant Processor of 
Proctology, Temple University School of 
Medicine, Associate in Proctology, Graduate 
School of Medicine, University of Penn 
sylvanta 

Foreword by 

J P LOCKHART-MVMMERY, M A ,MB , 

B Ch (Cantab ), FRCS (Eng), Emeritus 
Surgeon, St Mark*s Hospital, London, 
England 


Published by 

B. LIPPINCOTT 
COMPANY 


Washington Square 


Philadelphia 


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Annals or Su*t rv 
February 1<)38 



The insomniac will nod with ready assent to the philosophy of Voltaire 
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elements contribute to a happy well-balanced life 

To those who are denied the benefits of restful sleep, medinal (soluble 
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Medinal tablets are supplied in boxes of 12, and in bottles of 50, too 
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A PRODUCT or JOHNSON & JOHNSON 

@1936 JOHNSON & JOHNSON 




VOL 107 


MARCH, 1938 


NO 3 


ANNALS of 
SURGERY 

A MONTHLY REVIEW OF SURGICAL SCIENCE AND PRACTICE 

Also the Official Publication oj the Amencan Suigical Association, 
the Southern Suigical Association, Philadelphia Academy of 
Sufgeiy, and New York Suigical Society 



EDITORIAL BOARD 


WALTER E LEE, MD 
Chairman, Philadelphia 

BARNEY BROOKS, MD 

Nashville, Tenn 

E D CHURCHILL, M D 

Boston, Mass 

EVARTSA GRAHAM, MD 

St Louis, Mo 

ROSCOER GRAHAM, MD 

T 01 onto, Canada 

SAMUEL C HARVEY, M D 

New Haven, Conn 


ROY D McCLURE, MD 

Deti oit, Mich 

GEORGE P MULLER, M D 

Philadelphia 

H C NAFFZIGER, MD 

San Fi ancisco. Cal 

D B PHEMISTER, MD 

Chicago, III 

W F RIENHOFF, JR , M D 

Baltunoi e, Md 

A O WHIPPLE, M D 

New Yoik 


JAMES TAFT PILCHER, M D , Managing Editor 

J B LIPPINCOTT COMPANY, Publishers 

PHILADELPHIA MONTREAL LONDON NEW TORK 


Entered at the Post Office at Philadelphia and admitted for transmission through the mails at second class fates 
Price §10 oo a year Copjnght 193S, by J B Lipp ncott Companj, 727 - 2^1 South Sisth Street Printed in U S A 




Vol 107 


CONTENTS 

MARCH, 1938 


No 3 


ACUTE ILEUS 


Frederick T vanBeuren, Jr , M D 
Beverly C Smith, M D 

New York NY 321 


ACUTE INTESTINAL OBSTRUCTION 


T Todyo, M D 


Kogoshima Japan 340 


PERFORATED GASTRIC AND DUODENAL ULCER John A McCreery, M D. 

New York, N Y 350 


MESENTERIC LYMPHADENITIS AND THE ACUTE 

ABDOMEN William E Adams, M