DOUBLE CARCINOMA OF THE COLON *

THE third and last specimen is from a man between forty and fifty who had suffered terribly from difficult passages from the bowels for a number of months. Finally a small, almost immovable tumor, appeared to the right of the umbilicus, and later on distention of the small intestines, with pain and vomiting. Every half-hour or hour there would be a paroxysm of peristaltic contractions with excruciating pain. He finally asked to be relieved at any risk. On account of his extreme emaciation and weakened condition I thought it out of the question to attempt extirpation, and resolved to try to relieve him by means of anastomoses between the intestine above and below the stricture. Laparotomy revealed the tumor to be a carcinoma of the ascending colon; consequently I united the lower part of the distended ileum with the empty transverse colon 5 to 6 inches away from the tumor. The patient did not get much relief, and died ten days after the operation, growing gradually weaker, as in the other case. The autopsy showed no peritonitis, the omental flap was partially adherent to the intestine, the peritoneum between the plates united, but at the distal end of the plate, in the colon, an island of necrosis of the intestinal wall from pressure atrophy caused by the plate. Thus in this case perforation of the intestine was only a question of a short time. The carcinoma of the ascending colon, as the specimen shows, is 3 inches long and has caused almost complete occlusion of the bowel. The reason why no relief followed the operation was found below the anastomosis in the splenic flexure of the colon, where a second carcinoma had developed, causing, as you see, almost complete obstruction of the colon. This second carcinoma was not discovered during the operation, as it was hidden high up under the spleen. The emptiness of the transverse colon, together with the rarity of a second carcinoma, was the cause of my not suspecting its presence. If it had been discovered, the anastomosis would have been made between the ileum and the sigmoid flexure, of course. The mortality from even palliative operations upon the intestines is large, because, as a rule, the patients do not come to us for operation until they are exhausted by serious intestinal disturbances, usually of long continuance. This is so generally the case that collapse, even after a short operation, is of frequent occurrence.

Senn's operation of intestinal anastomosis with the plates does not take any more time than the abdominal operation for artificial anus. The last operation here mentioned was of thirty-eight minutes' duration from the time of the incision in the abdomen to the dressing of the abdominal wound.

*Jour. Amer. Med. Assoc., 1888, vol. xi, p. 606. Chic. Gynecol. Soc., June 29, 1888.

A CASE OF TRAUMATIC CYST OF THE

PANCREAS*

CHESTER A. King, aged eight, was admitted to Emergency Hospital October 6, 1887, with the following history: He had enjoyed good health up to recent illness. Eleven weeks ago he fell from a horse and sustained injury to his abdomen, showing a red spot over the umbilicus, and a similar spot over the processus spinosus of the third lumbar vertebra. He complained, during first eight weeks, of intermittent attacks of pain, located in the region about umbilicus. About three weeks after injury a swelling appeared in the epigastrium and has been increasing steadily since. After injury the patient lost appetite; his bowels were loose, irregular, and the feces of a whitish, curdled appearance, according to his mother's statement. Vomiting had been a prominent symptom during the period from the time of injury until his admission into the hospital. He had been treated for typhomalarial fever.

Status Præsens.-Patient is of normal size for his age, but thin and emaciated. Examination shows lungs and heart normal. In the epigastrium and upper half of mesogastrium is a round prominence caused by a tumor 7 inches in transverse diameter, 8 inches in longitudinal diameter. Percussion over the tumor is dull on the right side, continuous with the liver dulness, on the left side reaching over the border of the ribs. Between the seat of dulness of the tumor and heart-dulness there is a tympanitic area from the ventricle. The circumference of abdomen at the end of the xiphoid process, 24 inches; midway between this and the umbilicus, over the most prominent part of the tumor, 25 inches; at the umbilicus, 231⁄2 inches. After inflation of the bowel with Richardson's syringe the transverse colon is seen passing along and over the lower border of the tumor. The tumor moves with the respiration. There is transmitted pulsation from the aorta, but no expansion or bruit. Over the surface of the tumor is a feeling of fluctuation. The tumor is slightly movable from side to side.

Exploratory puncture brings out a syringeful of deep straw-colored, not perfectly clear, fluid of alkaline reaction, which contains a small number of red blood-corpuscles, but no other formed elements. The location of the tumor is in the median line behind the stomach, above the transverse colon—that is, in the region of the pancreas. Taken together with the microscopic character of its fluid contents, containing no other formed elements than a few blood-corpuscles, and finally its relation to a distinct trauma, made the diagnosis of a pancreatic cyst rather plausible. It was resolved to operate by laparotomy in two tempos, if the thickness of the cyst-wall would permit of such procedure. October 9, 1887, after the usual preparations for laparotomy, a longitudinal incision was made in the linea alba, about 3 inches long, midway between the umbilicus and the xiphoid process. After opening the peritoneal cavity the parietal peritoneum was stitched to the skin and the mesocolon was divided longitudinally and a few small vessels ligated. Beneath this was the glistening white smooth surface of the cyst-wall. This was united by a circular row of fine silk sutures, including a space about 2 inches long and 1 inch broad, to the abdominal wound. No cyst-fluid escaped along any of the sutures, and consequently the original plan of operating in two tempos was carried out. The wound cavity was packed

* Reported with statistics by A. Holmboe, M.D., Chicago Med. Jour. and Examiner, 1888, vol. Ivi, p. 74.

with iodoform gauze; an antiseptic dressing was applied, held in position by an elastic bandage. The following day the temperature rose to 101.5° F., but came down to normal the evening of the same day and remained so. No other untoward symptoms followed this operation.

On October 16th, a week after the laparotomy, the patient was again anesthetized, and the cyst opened by Paquelin's cautery. The cyst-wall was of considerable thickness -about 1/4 inch. About 40 ounces of thin, yellowish, semitransparent fluid escaped. A large drainage-tube, over 1⁄2 inch in diameter and 9 inches long, was introduced to the bottom of the cyst, passing upward and backward toward the left side of the vertebral column, behind the stomach. No irrigation was used at the time of the operation, but a heavy antiseptic dressing and an elastic bandage were applied.

The following day the temperature rose to 101° F., but became normal the next day and remained so. His bowels were regular before the second operation. After this, however, they did not move for five days, when an enema was given. Later on the bowels again became regular. There was profuse discharge the first four to five days after the operation, after which time the discharge rapidly decreased in quantity. When leaving the hospital, November 9th, the dressing which had been applied four days before was perfectly dry. At no time during the after-treatment was there any erosion or maceration of the skin surrounding the wound, although it was constantly in contact with the secretion from the cyst-wall.

The depth of the fistula at the time of leaving the hospital was 3 inches. The general condition of the patient was greatly improved.

In an article on "Complicated Diseases of the Pancreas and their Surgical Treatment" Karl Hagenbach, in Basel, has collected reports of 15 cases of true cysts of the pancreas.* Adding to these 15 cases the reports of 3 cases operated upon in this country during the latter part of 1887 (Bull, Fenger, Steele), we find, altogether, the following 18 cases of cysts of the pancreas so far reported in literature:

From the tabulated cases on p. 508 the following résumé may be drawn:†

There were 11 males and 7 females.

Age from 8 years (Fenger) to 46 years (Küster).

Trauma was given as the cause in 3 cases (Kulenkampff, Senn, Fenger).

Duration from five weeks (Senn) to 13 years (Gross). In Kramer's case the time has been indefinitely given as "some weeks."

Place of development is not stated in 5 cases; in 2 cases the head is given as the seat of origin; in 11 cases, the tail.

As to symptoms, a certain suddenness of onset is noticeable in a number of the cases; otherwise, common gastric and intestinal disturbances seem to be most prominent. Location, relations, etc., of tumor have only in a limited number of cases been sufficiently characteristic to warrant a diagnosis of pancreatic cyst (Senn, Küster, Subotik, Gussenbauer, Bull, Fenger, Steele).

Icterus is mentioned as a complication in 4 cases.

Diabetes in 1 case (Bull).

Sixteen cases were operated, of which 10 recovered and 5 died.

* Deutsche Zeitschrift für Chirurgie, 1887, vol. xxxiii.

For further details, see original reports.

Methods of operating* are distributed with the respective results as follows:

Extirpation of the whole cyst: 3 cases with 2 deaths and 1 recovery. Partial excision of cyst-wall, uniting the remainder with the abdominal wound: 2 cases with 2 deaths.

Puncture and aspiration: 1 case with 1 death.

Incision and drainage in one tempo: 4 cases with 4 recoveries. Incision and drainage in two tempos: 5 cases with 5 recoveries.† From the above figures it seems reasonable to conclude, as Senn stated in his monograph of 1885, that the operation to be recommended for cysts of the pancreas should be incision and drainage, and it seems to be a matter of little or no importance whether this operation is performed in one or two tempos.

Careful chemical analysis of the cyst-content has been made in several cases, showing the presence of tyrosin, leucin, mucin, serum-albumin, sodium and potassium salts, etc. The cyst-fluid has also proved itself able to digest starch, emulsify fat, etc., and thereby established its pancreatic origin. In Gussenbauer's and Senn's cases a digestion eczema was noticed around the abdominal wound. The quantity of the cystfluid varies from a pint up to several quarts. Blood in varying quantity is frequently found in these cysts. Küster considers the presence of blood characteristic, even for pancreatic cysts, when found in a cyst of the upper abdominal region (Hagenbach). In Thiersch's and Gussenbauer's cases blood was prevalent to such an extent that Hagenbach considers it doubtful whether these two cases can, properly, be classed under retention cysts, believing it possibly more correct to place them among hematomas. Senn, however, thinks it safe to classify them as hemorrhagic retention cysts.

* Method of operating employed in Dr. Steele's case was incision and drainage; but if in one or two steps, I do not know. Recovery.

† Bull's case was operated on July 19th, discharged cured November 19th, but died two weeks later from diabetes.