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., 
Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. 
[Reprinted from International Clinics, Vol. IV., Second Series.] TUMOR OF THE HARD PALATE; ACUTE APPEN- 
DICITIS; PERI NEPHRITIC ABSCESS. 
CLINICAL LECTURE DELIVERED AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL. 
( 
Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. 
W. W. KEEN, M.D., LL.D., 
Gentlemen,—I have three cases to bring before you to-day, one 
of appendicitis, another a perinephritic abscess, and the third a tumor 
which arises from the hard palate. I shall operate on the mouth 
case first, since it is never wise to operate on infectious cases and after- 
wards on those which are not, lest the later ones become infected and 
suppurate. 
TUMOR OF THE HARD PALATE; REMOVAL; RECOVERY. 
Case I.—This man is twenty-six years of age; his father died of 
phthisis; his mother is healthy, and he himself has always been healthy 
until ten years 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 swallowing and talking. When I examine 
the mouth I find that there is a tumor attached to the roof of the mouth 
at the junction of the hard and soft palates. It is not connected with 
the base of the skull, as I have determined by the finger and the 
laryngoscopic mirror. It is about the size of an egg. There is some 
bleeding and some discharge. 
The trouble in these cases is chiefly the hemorrhage. What I pro- 
pose to do here will be, first, to split the cheek backward and slightly 
downward so as not to injure Steno’s duct, and, as far as possible, to 
avoid the branches of the seventh nerve. Then I can lay his head on 
one side with a pillow under his shoulder, and the blood can escape 
sideways and tracheotomy will not be necessary. I will then sever the 
attachments to the soft palate on each side and below, next chisel it 
loose from the hard palate, seize the mass with a pair of forceps and 
quickly wrench it loose. I will perform the operation as quickly as pos- 196 
INTERNATIONAL CLINICS. 
sible, on account of hemorrhage. Speed but not haste will be my 
object. Two or three sponges pressed firmly upon the bleeding surface 
will arrest most of the hemorrhage, and if pressure does not stop the 
bleeding I will tie any large vessel, or, if necessary, use the Paquelin 
cautery. In some of these cases it is difficult to get a good light, and 
I propose to have a mirror with a small electric light attached to my 
forehead, so that I can throw the light in the back of his throat, if 
necessary. 
In these cases you must always operate as quickly as possible, 
not wasting time over each bleeding vessel (except those in the cheek 
incision), until the tumor is removed. You must operate quickly, 
too, for another reason,—namely, that you cannot give ether while 
operating, and you wish to avoid pain by the speedy termination of 
the operation. 
I have now split the cheek and controlled the hemorrhage. Next 
I get him well etherized again, and now you see the tumor. It is, as 
I said, about as large as an egg. I think it is a sarcoma of the spindle- 
cell variety, but it is rather hard, and may be a fibroma, which will 
have to be determined by an examination with the microscope. The 
tumor having been quickly removed as above described, I find the 
hard palate has been left intact except at one small point, and that only 
the anterior layer of the soft palate has been removed. The bleeding 
is not very serious. Pressure has stopped most of it very readily, and 
the Paquelin cautery does the rest. The wound in the cheek is then 
sutured and dressed. [The microscopic examination showed the tumor 
to be a small spindle-celled sarcoma. The patient easily recovered, and 
went home in ten days, with a healing ulcer in the roof of the mouth.] 
APPENDICITIS; OPERATION; RECOVERY. 
Case ll.—This case is an admirable lesson upon the need of oper- 
ation in appendicitis in spite of seeming but delusive betterment. I 
wish you to understand it thoroughly, as you will often have to deal 
with its like, and the treatment of late years has improved amazingly, 
owing chiefly to the labors of American surgeons. Several series of 
post-mortem examinations have shown us that about one-third of all 
adults, taken indiscriminately, at some time or other during their lives 
have suffered from attacks of appendicitis from which they have recov- 
ered, It is, therefore, a very common disorder, though it is by no 
means always recognized, for the attacks, unless severe, are often be- 
lieved to be simply colic or other mere intestinal disorder. Willard 
Parker, who, in 1867, was the first to impress upon the profession the ACUTE APPENDICITIS. 
197 
need for operation, called it, in the vocabulary of his time, “peri- 
typhlitis,” under the impression that the trouble began in the head of 
the colon ; but we now know, from more accurate observation, that in 
ninety-nine cases out of one hundred the disorder begins in the ap- 
pendix ; not from the historical grape-seed or the hypothetical apple-pip, 
but from a concretion of faecal matter, from ulceration beginning in the 
raucous membrane following occlusion of the calibre of the appendix 
with retention of its secretion, or from gangrene. Speaking clinically 
rather than pathologically, these cases may 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 of the unrecog- 
nized ones. Secoudly, those in which rupture of the appendix takes 
place without previous agglutination of the intestines. The contents of 
the appendix escaping into the peritoneal cavity will produce a wide- 
spread and often fulminating peritonitis, so that your patient may die 
even within twelve hours. In the first class no operation is necessary ; 
in the second class no recovery is possible without the speediest opera- 
tion that can be done. The third class lies between these two, and of 
this class our present case is an admirable instance. 
This patient, a man of forty-five years, began to be ill on February 
3, eight days ago, with pain all over the abdomen ; but by the third day 
the pain had gradually become focussed in the right iliac fossa and was 
quite severe. He entered the hospital night before last, and when I saw 
him I came ready to do an operation if necessary. He had had consider- 
able fever, but it had abated so that when he entered the hospital his 
temperature was ouly 100°. He was not suffering much pain, and was, 
in fact, what might be called almost comfortable, although sick. In 
the right iliac fossa I found distinct tumefaction and resistance to the 
touch over an area about two inches in breadth, parallel with Poupart’s 
ligament. The right leg was flexed at the hip, as this Avas the most 
comfortable posture. There was no oedema, nor was the tenderness 
very great, nor the pain severe. The most tender point was two inches 
from the anterior superior spine on a line drawn to the umbilicus. To 
find this point of greatest tenderness (which Stimson has proposed to 
call “ Mcßurney’s point,” as Mcßurney was the first distinctly to for- 
mulate its existence and to point out the manner of finding it), examine 
with the tip of one finger, and not with the whole hand ; or, better still, 
ask the patient to indicate with one finger the point of greatest tender- 
ness. The point corresponds about with the attachment of the appen- 
dix to the colon ; and if you find tenderness here with the other rational 198 
INTERNATIONAL CLINICS. 
signs of appendicitis, you may be almost sure that that is the disorder 
you have to deal with. But this so-called Mcßurney’s point may be 
delusive. The point of greatest tenderness is really the point of great- 
est inflammation. I have seen it just under the liver when an abscess 
was caused by gangrene of the tip of an appendix ascending behind the 
colon, or at the brim of the pelvis when the appendix lay transversely. 
As the case was not urgent, the time evening, and the light neces- 
sarily insufficient, I decided to watch the case for twenty-four hours 
or more. Yesterday morning his temperature was only 99°, and I 
thought it barely possible that he might escape without an operation. 
But this morning I found that his temperature had gone up to 101.2° 
last night, and I decided instantly to operate, and shall do so before 
you. This is the eighth day of his disorder. Willard Parker laid 
down the rule that an operation ought to be done between the eighth 
and twelfth days, but, as the statistics of Dr. Fitz have shown, sixty- 
eight per cent, of our patients would die by that time, and so, instead 
of waiting till the eighth or twelfth day, surgeons gradually learned to 
operate more promptly, until Fitz, in a discussion last year before the 
Association of American Physicians, declared that the second or third 
day was not too early, and in my opinion lie is quite right. 
All this time you will notice that I have been illustrating the third 
clinical class, in which a localized abscess forms, by the case in hand. 
You must remember that this third class is suddenly transferred some- 
times into the second class by the rupture of the abscess and the con- 
sequent lighting up of general peritonitis. 
Hence when you operate in such a case as the present, with 
undoubtedly a local circumscribed abscess, you must be extremely care- 
ful to use the greatest gentleness after you have opened it, lest you 
should rupture the sac and pour out its contents into the peritoneal 
cavity. I have known a rough assistant to rupture such a sac during 
the operation, undoubtedly producing the death of the patient; and not 
rarely it will rupture spontaneously, if the operation is delayed, with a 
similar fatal result. Hence the great danger of delayed operations. 
The fourth class of cases are those which run a long chronic course 
for months or a year, but these are very rare. The fifth and last class 
are those of recurrent appendicitis, in which there may be even a dozen 
attacks, as in Bernardy’s case, in this city, in which twelve attacks 
occurred within eleven months. For a very excellent discussion of 
the whole question of appendicitis in its various bearings I beg to refer 
you to the Transactions of the New York State Medical Society for 
1891. ACUTE APPENDICITIS. 
199 
To return to our case. Having now looked over its various 
symptoms, you will see that the man does not seem seriously sick, 
and that his temperature is not high, and yet, as I think I shall 
convince you, he must absolutely be operated on, for he undoubt- 
edly has an abscess which, if not evacuated, places his life in the 
greatest peril. Remember especially that, when two, three, or four 
days have passed and no betterment occurs and the local and physical 
signs remain the same, with slight tumefaction, tenderness, and moder- 
ate fever, your duty is to operate. If, as in the vast majority of cases, 
you find pus, you will almost certainly have saved life. If you find 
none, you will probably find the appendix diseased; and if you find 
nothing wrong,—which will not be more than once in a hundred 
times,—the operation will scarcely have added anything to the risk 
of the patient. If the appendix be found distended, inflamed, or 
otherwise diseased, tie it as close to the caecum as possible and cut off 
the diseased end, and then you may either invagiuate the stump and 
cover it by a few stitches through the outer coats of the colon, or 
simply disinfect it and let it alone, as you prefer. 
I now make an incision parallel with Poupart’s ligament and two 
finger-breadths above it, over the site of the tumefaction. After cut- 
ting a little distance into the abdominal wall I notice that the tissues 
are matted together, which clearly indicates to me that there is inflam- 
matory trouble and probably pus underneath, and in a moment you 
observe the pus escaping. The amount is nearly half a pint, as far 
as I can judge. What now shall Ido as to the appendix? I shall 
search for it with great care. Inserting my finger, I feel a round, 
finger-like body, but considerably thicker than the finger, adherent to 
what I believe to be the head of the colon. It is bound to the colon 
by recent lymph, and it is separated with as much ease as the two lay- 
ers of the pleura in a receut pleurisy. I find this to be the appendix, 
though it is so surrounded by thickened tissue and new formation that 
it is almost impossible to assert this positively until I have removed 
the mass. Having loosened it down to the base, I throw a silk ligature 
around it and cut it off. You will notice that the portion removed is 
almost all inflammatory tissue surrounding: the undistended tube of the 
*■' o 
appendix. The free end of the appendix is gangrenous, and has com- 
pletely sloughed away, thus opening the calibre of the appendix and 
permitting the escape of the contents. The abscess which we have 
opened is intraperitoueal, and yet shut off from the general peritoneum 
by the agglutinated neighboring intestines. 
I shall wash this out with hot water, insert a drainage-tube, and 200 
INTERNATIONAL CLINICS. 
partly close the opening. We shall have necessarily considerable sup- 
puration for some days to come, with gradual shrinking of the cavity 
and its final obliteration. I was not careful, you notice, to disinfect 
the cut end of the appendix, for the simple reason that the whole 
abscess is already infected, and it would be needless trouble and waste 
of time to do so. 
One other point in reference to such a case. It emphasizes the 
need for the physician to call the surgeon in consultation at the very 
outset of the case, not necessarily for his knife, but for his best judg- 
ment. The physician should have the benefit of the surgeon’s ex- 
perience from the very beginning, and the surgeon should know 
the case “at first hand,” instead of through the statements of the 
physician when he is called at a later period. The surgeon should be 
familiar with the case, with a view to early and, if need be, instant 
interference. The longer the delay before the surgeon is called the 
greater the probability of danger to the patient. 
[ln five weeks the patient went home well, after a prolonged but 
uncomplicated convalescence.] 
PERINEPHRITIC ABSCESS; OPERATION; RECOVERY. 
Case lll.—This third case is an example of a comparatively rare 
form of abscess, and yet, curiously enough, about three years ago I 
went straight from one house to another and operated on two such 
abscesses, both patients, I am glad to say, recovering without a 
drawback. The case is one of perinephritic abscess in a Russian, aged 
thirty-three. He comes of a tubercular family on his mother’s side, 
but this is the only taint we can discover. He was never sick until 
the Ist of January of this year, when he was suddenly attacked with 
great pain in the right lumbar region without apparent cause. This 
was attended at first with some jaundice, and his temperature wTas very 
high. He had all the ordinary phenomena of high fever, but no 
especial symptom was noted. He was admitted to the hospital on 
the 7th of February, suffering with great pain in the right loin, 
marked tenderness, slight fulness, and rather extensive dulness, far 
more so than would accompany a normal kidney. There was no solid 
tumor; palpation by bimanual examination simply gave a sense of 
increased resistance without fluctuation. The skin was not discolored. 
He was not able to lie on the right side. His morning temperature 
was 102.3°, but ran up at night to 105°. Physical examination of 
the viscera, both of the chest and of the abdomen, showed nothing 
abnormal. The specific gravity of the urine was 1022 ; no sugar, no PERINEPHEITIC ABSCESS. 
albumin, no pus, no peptones. The diagnosis, you see, is one made by 
exclusion. There is an acute inflammatory process, as shown by the 
swelling, pain, tenderness, and induration. There is probably accu- 
mulation of fluid, as shown by the dulness and the absence of a solid 
tumor, and by the increased resistance. It is certainly not pyelitis nor 
any other affection inside the kidney, for the urine is normal, and there 
is no increased frequency of urination. His high temperature shows 
the septic character of the process. I propose, therefore, to dissect 
down to the abscess, evacuate, scrape, flush, and drain. 
The incision I make is an oblique one in the loin, precisely such 
as you have seen me make to reach a floating kidney. When I reach 
the muscular 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 is no oedema on the surface, but it does not 
surprise me to find a deeper oedema in the layers of connective tissue 
between the muscles of the belly-wall, I have now reached, you 
observe, the lumbar fascia, which looks yellowish, is elastic, and 
evidently tense; and on my making a slight cut in it you see the pus 
welling out in large quantities. After making an opening the whole 
length of ray incision, I pass my fingers into the cavity, and I can pass 
down behind the kidney, in front of the muscles of the abdominal 
wall, well into the right iliac fossa, and again far up towards the liver. 
The cavity has held undoubtedly from one to two pints of pus, and, 
as you can easily understand, for such a cavity to contract and heal 
will take considerable time. 
With a sharp spoon I scrape away the flaky, granular tissue which 
lines the cavity. There is not much bleeding, and not a vessel has 
required a ligature. The slight oozing is quickly checked by thorough 
flushing with hot water, which answers a double purpose as a hserao- 
static and a cleansing agent. I then insert two large rubber drainage- 
tubes, one passing up and the other down, at the ends of the incision, 
and hold them in place by stitches through the skin. A large sub- 
limate dressing completes the case. 
[At the end of a week the patient’s temperature, which had been 
kept up by the septic process, suddenly dropped to 96°, without ap- 
parent cause and without apparent ill effect, but after two days it rose 
to normal and fluctuated a little above it for some time afterwards. 
In three weeks he went home, with a simple linear wound, not quite 
healed, but with the cavity entirely obliterated.]