TUMOR OF THE HARD PALATE; ACUTE
APPENDICITIS; PERINEPHRITIC ABSCESS.
CLINICAL
LECTURE DELIVERED AT THE JEFFERSON MEDICAL COLLEGE
HOSPITAL.BY W. W. KEEN, M.D.,
LL.D.,Professorof the Principles ofSurgeryinJefferson MedicalCollege, Philadelphia.
[Reprinted
from
International Clinics, Vol. IV.,Second
Series.]TUMOR OF THE HARD PALATE; ACUTE APPEN-
DICITIS; PERINEPHRITIC ABSCESS.
CLINICAL LECTURE DELIVERED AT THEJEFFERSOX MEDICAL COLLEGE HOSPITAL,
/
BY W. W. KEEN,
M.D., LL.D.,Professor of the Principlesof SurgeryinJeffersonMedical College, Philadelpliitu
Gentlemen, —Ihave
three cases to bringbefore you
to-day, one
of appendicitis, another aperinephritic abscess,
and
the third atumor which
arisesfrom
the hard palate. I shall operateon
themouth
casefirst, sinceit is never wise to operate
on
infectious casesand
after-wards on
thosewhich
are not, lest the lateronesbecome
infectedand
suppurate.TUMOR OF THE HARD PALATE; REMOVAL; RECOVERY.
Case
I.— This man is twenty-sixyearsof age; hisfatherdied of
phthisis;his mother
is healthy,and
he himself has always been healthy
until tenyears ago, when
he noticed a small tumor on
the back
part
of the roof of his mouth. This
has gradually increased since, and now
he has difficulty in swallowingand
talking. When
I examine
the mouth
I find that thereisatumor
attached totheroofofthemouth
atthe junction of the hard
and
soft palates. It isnot connected with the base of the skull, as Ihave
determinedby
the fingerand
the laryngoscopicmirror. It is about the sizeofan
egg.There
issome
bleedingand some
discharge.The
trouble in these casesis chieflythe hemorrhage.What
Ipro- pose todo
here will be, first, to split the cheekbackward and
slightlydownward
so as not to injure Steno's duct, and, as faras possible, to avoid thebranches of theseventh nerve.Then
I canlay hisheadon
one sidewith a pillowunder
his shoulder,and
the blood can escape sidewaysand
tracheotomywill not benecessary. I will thenseverthe attachments tothe soft palateon
each sideand
below, next chisel it loosefrom
the hard palate, seizethemass
with a pair of forcepsand
quicklywrench
itloose. Iwillperformthe operation asquicklyaspos-196 INTERXATIOXAI.
CLINICS.sible,
on
account of hemorrhage. Speed but not haste will bemy
object.
Two
or threesponges pressed firmlyupon
the bleeding surface will arrestmost
of the hemorrhage,and
if pressuredoes not stop the bleeding I will tieany
large vessel, or, if necessary, use the Paquelin cautery.In some
of thesecases it isdifficult to get agood
light,and
I propose tohave
a mirror with a small electric light attached tomy
forehead, so that I can
throw
the light in the back of his throat, if necessary.In
these casesyou must
always operate as quickly as possible, not wasting time over each bleedingvessel (except thosein the cheek incision), until thetumor
is removed.You must
operate quickly, too, for another reason,—
namely, thatyou
cannot give ether while operating,and you wish
to avoid painby
the speedy termination of the operation.I
have now
split thecheekand
controlled the hemorrhage.Next
Igethim
well etherized again,and now you
see thetumor. It is, as I said,about as large asan
egg. I think it isasarcoma
ofthe spindle- cell variety, but it is rather hard,and may
be a fibroma,which
willhave
to be determinedby an
examination with the microscope.The tumor having
been quicklyremoved
as above described, I find thehard
palate has been leftintactexceptatone smallpoint,and
that only the anterior layerof the soft palate has been removed.The
bleedingis not very serious. Pressure has stopped
most
ofit veryreadily,and
the Paquelin cautery does the rest.The wound
in the cheek is then suturedand
dressed.[The
microscopicexaminationshowed
thetumor
to bea smallspindle-celledsarcoma.
The
patienteasilyrecovered,and went home
in ten days, with a healing ulcerin the roof ofthe mouth.]APPENDICITIS;
OPEPvA.TION;EECOVEEY.
Case
II.—
This caseis an admirable lessonupon
the need ofoper- ation in appendicitis in spite of seeming but delusive betterment. I wishyou
to understand it thoroughly, asyou
will oftenhave
to deal with itslike,and
the treatment of late years hasimproved
amazingly,owing
chiefly to the labors ofAmerican
surgeons. Several seriesof post-mortem examinationshave shown
us that about one-thirdof all .adults, takenindiscriminately, at
some
time or other during their lives liave sufferedfrom
attacksofappendicitisfrom
whicli theyhave
recov- ered. It is, therefore, a verycommon
disorder,though
it isby no
means
always recognized, for the attacks, unless severe, are often be- lieved to be simply colic or othermere
intestinaldisorder.Willard
Parker,who,
in 1867,was
the firstto impressupon
the profession theACUTE
APPENDICITIS.197
need for operation, called it, in the vocabulary of his time, "peri- typhlitis,"
under
tlie impression that the troublebegan
in thehead of the colon ; butwe now know, from more
accurate observation, that in ninety-nine cases out of onehundred
the disorder begins in the ap- pendix; notfrom
thehistoricalgra})e-seedor the hypothetical apple-pip, butfrom
aconcretionoffaecal matter,from
ulceration beginningin themucous membrane
following occlusiou of the calibre of theappendix
with retentionof itssecretion, orfrom
gangrene.Speaking
clinically ratherthan pathologically, thesecasesmay
be divided into five classes.First, those with slight but well-recognized
symptoms, which
after reaching a certain point pass on to resolution. This is probably the course of the large majority of cases,and
especially ofthe unrecog- nized ones. Secondly, those inwhich
rupture of tlieappendix
takes placewithout previousagglutinationoftheintestines.The
contentsof theappendix
escaping into the peritoneal cavity will produce a wide- spreadand
often fulminating peritonitis, so thatyour
patientmay
dieeven
within twelvehours.In
the first classno
operation is necessary;
inthe second class
no
recoveryis possible without the speediestopera- tion that can be done.The
thirdclass lies between these two,and
of this class our present case is an admirable instance.Thispatient,a
man
offorty-five years,began
tobe ill onFebruary
3,eightdaysago,with pain all overthe
abdomen
; butby
the thirdday
the painhad
graduallybecome
focussed inthe right iliac fossaand was
quite severe.
He
entered the hospitalnightbeforelast,and when
Isaw him
Icame
readytodo an
operationifnecessary.He had
hadconsider- ablefever, but ithad
abated so thatwhen
heentered the liospital his temperaturewas
only 100°.He was
not sufferingmuch
pain,and
was, in fact,what might
be called almost comfortable, although sick.In
the right iliacfossa I found distinct tumefactionand
resistance tothe touch overan
areaabouttwo
inches in breadth, parallelwith Poupart's ligament.The
right legwas
flexed at the hip, as thiswas
themost
comfortable posture.There was no
oedema, norwas
the tenderness verygreat,northe pain severe.The most
tender pointwas two
inchesfrom
the anterior superior spineon a linedrawn
tothe umbilicus.To
find this point of greatest tenderness (which
Stimson
has proposed to call "McBurney's
point," asMcBurney
w^as the firstdistinctly to for- mulate itsexistenceand
to point out themanner
offindingit),examine
with the tipof one finger,and
notwiththewhole hand
; or,betterstill,
ask the patientto indicatewith one finger the point ofgreatesttender- ness.
The
point corresponds about with the attachment of the appen- dixto thecolon ;and
ifyou
findtendernesshere withthe other rational198 INTERNATIONAL
CLINICS.signs of appendicitis,
you may
bealmost sure that thatis the disorderyou have
todeal with.But
this so-calledMcBurney's
pointmay
be delusive.The
point ofgreatesttenderness is really the pointofgreat- est inflammation. Ihave
seen itjust underthe liverwhen
an abscesswas
causedby gangrene
ofthe tipof anappendix
ascending behindthe colon, oratthebrim
ofthe pelviswhen
theappendix
lay transversely.As
the casewas
not urgent, the time evening,and
the light neces- sarily insufficient, I decided towatch
the case for twenty-four hours or more. Yesterdaymorning
his temperaturewas
only 99°,and
I thought it barely possible that hemight
escape withoutan
operation.But
thismorning
I found that his temperaturehad gone up
to 101.2°last night,
and
I decided instantly to operate,and
shalldo
so before you.This
is the eighthday
of his disorder. WillardParker
laiddown
the rule thatan operationought
to bedone
between the eighthand
twelfth days, but, as the statistics of Dr. Fitzhave
shown, sixty- eight per cent, of our patientswould
dieby
that time,and
so, insteadof
waiting tillthe eighth or twelfth day, surgeons graduallylearned to operatemore
promptly, imtil Fitz, in a discussion last year before the Association ofAmerican
Physicians, declared that the second or thirdday was
not tooearly,and
inmy
opinion he isquite right.All thistime
you
will notice that I have been illustrating the third clinical class, inwhich
a localized abscess forms,by
the case in hand.You must remember
thatthis thirdclass issuddenlytransferredsome-
times into the second classby
the rupture of the abscessand
thecon- sequentlightingup
of general peritonitis.Hence when you
operate in such a case as the present, withundoubtedly
a local circumscribed abscess,you must
be extremelycare- ful to use the greatest gentlenessafteryou have
opened it, lestyou
should rupturethe sacand pour
out its contents into the peritoneal cavity. Ihave known
arough
assistant to rupture such a sac during the operation,undoubtedly producingthe death ofthe patient;and
not rarely itwill rupturespontaneously, iftheoperation is delayed,with a similar fatal result.Hence
the great danger of delayed operations.The
fourthclass ofcasesare thosewhich
run a long chronic course formonths
ora year, butthese are very rare.The
fifthand
lastclass arethose ofrecurrent appendicitis, inwhich
theremay
be even adozen attacks, as in Bernardy's case, in this city, in which twelve attacks occurred within eleven months.For
a very excellent discussion of thewhole
question ofappendicitis in its various bearings I begto referyou
to the Transactions of theNew York
State Medical Society for 1891.ACUTE
APPENDICITIS.199
To
return to our case.Having now
looked over its varioussymptoms, jon
will see that theman
does notseem
seriously sick,and
that his temperature is not high,and
yet, as I think I shall convince you, hemust
absolutely be operated on, for he undoubt- edly hasan
abscess which, if not evacuated, places his life in the greatest peril.Remember
especially that,when
two, three, or four dayshave
passedand
no betterment occursand
the localand
physical signsremain
the same, with slighttumefaction, tenderness,and moder-
atefever,your duty
isto operate. If, as in the vastmajorityofcases,you
find pus,you
will almost certainlyhave
saved life. Ifyou
find none,you
will probably find theappendix
diseased;and
ifyou
find nothing wrong,— which will not be more
than once in a hundred
times,
—
the operation will scarcelyhave added
anything to the riskof the patient. If the
appendix
be found distended, inflamed, or otherwise diseased, tie it asclose to the csecumas possibleand
cut off the diseased end,and
thenyou may
either invaginate thestump and
cover itby
afew
stitches through the outer coats of the colon, or simply disinfect itand
let italone, asyou
prefer.I
now make
an incision parallel with Poupart's ligamentand two
finger-breadths
above
it, over thesite of the tumefaction. Aftercut- ting a little distance into theabdominal
wall I notice that the tissues are mattedtogether,which
clearly indicatestome
that there is inflam-matory
troubleand
probably pus underneatli,and
in amoment you
observe thepus
escaping.The amount
is nearly half a pint, as far asI can judge.What now
shall Ido
as to theappendix?
I shall search for itwith great care. Insertingmy
finger, I feel a round, finger-like body, but considerably thicker than the finger, adherent towhat
I believeto be the head of the colon. It isbound
tothe colonby
recentlymph, and
it is separated with asmuch
ease as thetwo
lay- ers ofthe pleurain a recent pleurisy. I find this to bethe appendix,though
itis so surroundedby
thickened tissueand new
formation thatit is almost impossible to assert this positively until I
have removed
the mass.Having
looseneditdown
tothebase, Ithrow
a silkligaturearound
itand
cut itoff.You
will notice that the portionremoved
isalmostall inflammatorytissue surrounding the undistended tube ofthe appendix.
The
free end oftheappendix
is gangrenous,and
hascom-
pletely sloughed away, thus opening the calibre of theappendix and
permitting the escape of the contents.The
abscesswhich we have opened
isintraperitoneal,and
yet shut offfrom
the generalperitoneumby
the agglutinated neighboring intestines,Ishall
wash
thisout with hot water, insert a drainage-tube,and
200 INTERNATIONAL
CLINICS.partly close the opening.
We
shallhave
necessarily considerable sup- puration forsome
days to come, with gradual shrinking of the cavityand
itsfinal obliteration. Iwas
not careful,you
notice, to disinfect the cutend
of the appendix, for the simple reason that the Avhole abscess is alreadyinfected,and
itwould
be needless troubleand
waste of time todo
so.One
other point in reference to such a case. It emphasizes the need forthe physician tocall the surgeon in consultation atthe very outset of the case, not necessarily forhis knife, but for his best judg- ment.The
physician shouldhave
the benefit of the surgeon's ex- periencefrom
the very beginning,and
the surgeon shouldknow
the case
"at
first hand," instead of through the statements of the physicianwhen
he iscalled atalater period.The
surgeon should be familiar with the case, with aview
to early and, if need be, instant interference.The
longer the delay before the surgeon is called the greaterthe probability of dangerto the patient.[In five
weeks
the patientwent home
well, after a jjrolonged but uncomplicated convalescence,]PEEINEPHRITIC ABSCESS; OPERATION; PvECOVERY.
Case
III.—
This third case is anexample
of a comparatively rareform
of abscess,and
yet, curiously enough, about three years ago Iwent
straightfrom
one house to anotherand
operatedon two
such abscesses, both patients, Iam
glad to say, recovering without a drawback.The
case is oneofperinepliritic abscess in a Russian,aged
thirty-three.
He comes
of a tubercular family on his mother'sside, butthis is the only taintwe
can discover.He was
never sick uutil the 1stofJanuary
of this year,when
hewas
suddenly attacked with greatpain in the rightlumbar
region without apparent cause. Tiiiswas
attended at firstwithsome
jaundice,and
his temperaturewas
very high.He had
all the ordinaryphenomena
of high fever, butno
especial
symptom was
noted.He was
admitted to the hospitalon
the 7th of February, sulfering with great pain in the right loin,marked
tenderness, slight fulness,and
rather extensive dulness, farmore
so thanwould accompany
a normal kidney.There was
no solidtumor;
palpationby bimanual
examination simplygave
a sense of increased resistance withoutfluctuation.The
skinwas
not discolored.He was
notable to lieon
the right side.His morning
temperaturewas
102.3°, but ranup
at night to 105°. Physical examination of the viscera, both of the chestand
of theabdomen, showed
nothing abnormal.The
specific gravity of the urinewas 1022
; no sugar,no
PERINEPHEITIC
ABSCESS. 201albumin^
no
pus,no
peptones.The
diagnosis,yon
see, isonemade by
exclusion.There
isan
acute inflammatory process, asshown by
the swelling, pain, tenderness,and
induration.There
is probably accu- mulation of fluid, asshown by
the dulnessand
the absence of a solid tumor,and by
the increased resistance. Itiscertainlynotpyelitis norany
otheraffection insidethe kidney,for theurine is normal,and
there isno
increased frequency of urination.His
high temperatureshows
the septic character of the process. I propose, therefore, to dissectdown
tothe abscess, evacuate, scrape, flush,and
drain.The
incision Imake
isan
oblique one in the loin, precisely such asyou have
seenme make
to reach a floatingkidney.When
Ireach themuscular
wall I find considerable matted tissue,—
another evi-dence, just as in the last case, of the inflammatory process going
on
at a deeper level.
There
isno oedema on
the surface, but it does not surpriseme
to finda deeperoedema
in the layers of connective tissuebetween
the muscles of the belly-wall. Ihave now
reached,you
observe, thelumbar
fascia,which
looks yellowish, is elastic,and
evidently tense;and on my making
a slight cutin ityou
see the pus welling out in large quantities. Aftermaking an
opening thewhole
length ofmy
incision, I passmy
fingers into the cavity,and
Ican passdown
behind the kidney, in front of the muscles of theabdominal
wall, well into the right iliac fossa,and
againfarup
towardstheliver.The
cavity has heldundoubtedly from
one totwo
pints of pus, and, asyou
can easilyunderstand, for such a cavity tocontractand
heal will take considerable time.With
a sharp spoon I scrapeaway
the flaky,granulartissuewhich
lines thecavity.