INTERESTING CASES OCCURRING IN 
THE SURGICAL CLINIC OF 
PROFESSOR W. W. KEEN, M.D., LL.D., 
In the Jefferson Medical College Hospital, Philadelphia. 
REPORTED BY A. G. ELLIS, 
Medical Student. 
[Reprinted from International Clinics, Vol. IL, Ninth Series.] INTERESTING CASES OCCURRING IN THE 
SURGICAL CLINIC OF 
PROFESSOR W. W. KEEN, M.D., LL.D., 
In the Jefferson Medical College Hospital, Philadelphia. 
REPORTED BY A. G. ELLIS, 
Medical Student. 
SUBDURAL DRAINAGE OF THE LEFT VENTRICLE FOR HYDRO- 
CEPHALUS. 
Gentlemen,-We have here a child, four months of age, suffer- 
ing from acute hydrocephalus. The case was kindly referred to me 
by Professor E. E. Graham, and is of unusual interest, and an 
unusual operation will be done in an attempt to save its life. The 
child's head has enlarged very rapidly, the circumference increasing 
an inch in one week. Lumbar puncture w'as done, but without suc- 
cess. In a case of internal hydrocephalus such as this is, the fluid 
can sometimes be drawn from the ventricles into the spinal canal 
through the foramen of Magendie and evacuated by lumbar punc- 
ture. In the present case only two cubic centimetres could be ob- 
tained in this way, with the advantage of showing, however, that the 
fluid was sterile. 
The operation to be done is the ingenious one suggested by 
Cheyne, of London,-i.e., subdural drainage of the lateral ventricle. 
The ventricle is punctured, three or four strands of catgut are 
slipped in, and then, instead of bringing the ends out through the 
bone and scalp, they are simply pushed under the dura. By this 
means the fluid, it is hoped, will be drained into the subdural lymph- 
space and absorbed. The great advantage of this lies in the fact that 
there is no external wound to dress day after day, and therefore no 
danger of infection. I care not who the surgeon is or what his 
technique may be, if he dresses a wound in which drainage makes 
this necessary day after day, and it may be two or three times a day, 
it is only a question of time when infection will follow. By Cheyne's 
method the skull is shut up, and the wound in the brain must be 
aseptic. 2 
A METHOD OF DRAINAGE AFTER SCHEDE'S OPERATION. 
After reflecting a flap of scalp, I make a small trephine opening 
a half-inch in diameter, and then I make a small opening in the 
dura. By using rather stiff catgut just taken out of alcohol, I can 
push the catgut through the thin cortex into the ventricle as soon as 
I have made the opening. A very little fluid flows out, nor do I 
wish a free escape at the time. If much fluid is taken out at once, 
convulsions follow, and death ensues on the spot or in a day or two. 
It is a question if this is not best in many such cases of unfortunates. 
The other ends of the catgut are now slipped under the dura and 
the wound is closed. The stitches in the scalp are put in very close, 
to prevent leakage, as it is desirable to have the wound close up as 
soon as possible. 
[Considerable leakage occurred during the first twenty-four 
hours. This was arrested by iodoform collodion. The child re- 
covered from the operation, though the temperature immediately 
afterwards and for fourteen days rose as high as 105° and 106° F. 
No assignable cause for this could be discovered. The fever then 
ceased, but the child was not improved by the operation. The head, 
which in the month preceding the operation had increased one and 
one-eighth inches in circumference, at first shrunk, then again en- 
larged even beyond its former size. The child was still living several 
weeks after operation, but without any improvement.] 
A METHOD OF DRAINAGE AFTER SCHEDE'S OPERATION. 
The next case to which I wish to call your attention is that of a 
man who was operated on last week. 1 bring him before you 
especially to show the method of drainage used since the operation. 
This man had an old empyema, with a fistulous opening, which 
had existed for two years and a half. The opening was just below 
the second rib, higher up than I have ever seen before. The direc- 
tion of the sinus and extent of the cavity could not be well de- 
termined by the probe. A T-shaped incision was made, the three 
flaps were drawn back, the opening into the thorax was found, and 
with bone-nippers I made an opening large enough to permit me 
to look in. Schede's operation as modified by myself was determined 
upon, and the second, third, and fourth ribs were removed, thus 
taking the whole chest wall, excepting the soft parts external to the 
ribs, but including the thickened plura, from the lower border of the 
first rib. The cavity was packed with iodoform gauze for three days. A METHOD OF DRAINAGE AFTER SCHEDE's OPERATION. 
3 
Of course it was already an infected wound, and, not wanting the pus 
to collect or remain in the cavity, I used the plan of drainage intro- 
duced by Cathcart, of Edinburgh, and slightly modified by myself. 
A large jar of water is placed on a stand by the bedside. Leading 
from it is a rubber tube on which is placed a clip. This clip is not 
allowed to shut off the water entirely, but is held open with a small 
bit of tubing or other object so as to permit the water to run very 
slowly. This tube terminates in a "Y." This "Y" need not be of 
Fig. 1. 
Keen's improved method of drainage by siphonage. 
glass: a good enough one can be made of tin, or even of two pieces 
of tubing united by end-to-side anastomosis. One of the upper tubes 
leading from the " Y" goes into the man's chest and is held in place 
by plaster, the other upper tube is connected with the bottle of water. 
The third or lower tube from the " Y" is fastened to the side of the 
bed in a loop so as to form a siphon. This, of course, must be lower 
than the one leading from the wound. There is also a piece of glass 
tubing inserted in the tube from the wound, so that the action of the 
apparatus can be observed. The tube forming the loop fills slowly 4 
FOCAL EPILEPSY, WITH THREE FRACTURES OF THE SKULL. 
and then siphons over, thus making marked suction each time it 
empties. Only a slow trickle comes from the jar, so the suction is ex- 
pended on the fluid in the cavity, which is thus drained out every 
few minutes. 
[This man was desperately ill after the operation, but was 
rescued by hypodermocylsis. Unfortunately, this caused two sloughs 
as large as the hand on each thigh, but they finally healed. His 
highest temperature was 101.6° F. He is sitting up in bed occa- 
sionally now, in order to avoid bed-sores. In a day or two the stitches 
will be cut, to let the chest wall fall in. 
An immense cavity was left by the operation, as the flap of soft 
tissues over the chest was far too small to cover its sides and floor. 
It is slowly filling up by granulation. Meantime the patient's 
general condition is excellent, and he is up and about. The micro- 
scopical examination by Professor Coplin suggests probably a pleural 
endothelioma as the origin of the empyema.] 
A CASE OF FOCAL EPILEPSY, WITH THREE FRACTURES OF 
THE SKULL, ONE OF THE BASE AND TWO OF THE VAULT. 
This patient is a railroad brakeman from Florida, whose head 
was caught between a car and a piece of timber. He comes to us 
with three distinct lesions: First, there is a marked depressed frac- 
ture of the skull over the left temple, where an angular ridge is 
distinctly felt. Second, there is a small depression in the vault of 
the cranium over the right parietal bone, which was presumably a 
fracture. Third, at the time of the accident he had bleeding from 
the nose and also vomited blood, but had no bleeding from the ears. 
This would indicate a fracture of the base of the skull in the anterior 
fossa, and he has another lesion which confirms this diagnosis. The 
right optic nerve is atrophied and this eye is practically blind. This 
shows a lesion at the base of the brain in front of the optic chiasm. 
This is an irreparable loss for which nothing can be done. The 
fracture on the left temple is giving no trouble. But on Kovember 
1 the man had an attack of epilepsy, and four or five days after that 
he had a second attack. These started in the left foot, which began 
to shake before the attack came on. It is rather surprising that the 
arm is not affected also, but the leg centre seems to be the only one 
injured. Here is a case in which the knowledge of the localization 
of function assists the surgeon most markedly. Twenty years ago I 
should probably have trephined at the fracture on the left temple, TREATMENT OF EXSTROPHY OF THE BLADDER. 
5 
as that is so much more depressed and seems to have been so much 
more severe. But the history of his attacks clearly point to the much 
less marked depression on the right side, which is over the lower 
border of the centre for the left leg. The patient's epilepsy may be 
caused by laceration of the brain without fracture, or by a depressed 
fracture or by a fracture of the inner table only. On account of 
this uncertainty, the operation will be largely exploratory, but when 
the skull is opened whatever is necessary will be done. 
I open the skull with a large gouge and hammer, as I shall not 
replace the bone and this is a quicker method than trephining. The 
dura is normal and the bone seems not to have been fractured, in 
spite of the depression. I will now apply a faradic current by a 
double electrode before opening the dura. I test the strength of the 
current first, and make it just strong enough to flex my index finger. 
Moving it over the centres of motion, we see the fingers of the left 
hand flexed and movement in the calf of the leg. There is no soft- 
ness of the dura and no reasonable probability of a cyst or clot 
being present. But I will make a small opening in the dura, in 
order to be able to look in and see if the brain is normal. I shall 
make an opening small enough to be closed with one stitch. The 
advantage of such a small opening is that we are able to see if a 
larger one ought to be made, without making a large circular inci- 
sion with perhaps no reason for it. I see that the brain looks per- 
fectly normal, so the wound will be closed. 
Hereafter the wound can be reopened and pieces of bone put in 
to fill the gap. You may wonder why nothing was done to the brain. 
It seems to me there could be no good in any operation on it. There 
is nothing to encourage interference with it. Even if an existing 
scar were cut out, the resulting one would probably be as bad, and 
in fact no scar is visible. 
[Nine days after the operation he left the hospital, entirely well 
from the operation. His subsequent history is unknown.] 
TREATMENT OF EXSTROPHY OF THE BLADDER; THE RECTUM 
A SUCCESSFUL RECEPTACLE FOR URINE AND THE MEN- 
STRUAL DISCHARGE FOR TWENTY-TWO YEARS AND SEVEN 
YEARS RESPECTIVELY IN TWO CASES. 
This little baby has the rather unusual condition of exstrophy 
of the bladder, a malformation caused by failure of development in 
the anterior wall of the bladder and abdomen. The urine constantly 6 
TREATMENT OF EXSTROPHY OF THE BLADDER. 
exudes and excoriates the skin, making a very deplorable state of 
affairs. Treatment, as a rule, is unsatisfactory. Various forms of 
flap operations have been devised, the best probably being the one 
in which a piece from above is turned down with the skin side 
towards the bladder and then a flap from each side is placed over this 
by sliding it sidewise. But this makes no urethra, and there is no 
possibility of making one. In these cases it is necessary for the 
patient constantly to wear a urinal. This, of course, is excessively 
difficult to keep clean and sweet. I have found that the best means 
of keeping such a urinal free from smell is to put a teaspoonful of 
chloral into it every time it is emptied. This answers the purpose 
well enough to make it a point worth knowing. 
Recently another method of treating these cases has been devised 
by Fowler, and it is the method above all others in my estimation, 
though by no means free from danger. The operation consists first 
in opening the belly and finding the ureters. Then the rectum 
is opened and the ureters are implanted in its sides. This does ad- 
mirably, and the patient is kept thoroughly dry except for the 
mucus secreted by the mucous membrane of the posterior wall of 
the bladder. But this is only slight in amount and can easily be 
attended to. I have recommended this operation in the present case 
when the child is old enough, and have advised the parents to wait 
some time. The child is so small now that the operation would be 
very difficult. When it is ten or twelve years old, or even before 
if it grows fast, the operation can be done. 
The question naturally arises whether the urine will irritate the 
rectum, and if it will be retained under such circumstances. The 
rectum seems to answer such purpose very well. In confirmation of 
this, only last week I saw a patient with a most interesting history. 
She is a woman who during an attack of typhoid fever noticed that 
urine was escaping from the vagina. Soon after faeces also made 
their exit by this passage, the infection of the fever having caused 
gangrenous sloughs from both the recto-vaginal and vesico-vaginal 
septa. One of my colleagues and I did a number of operations to 
relieve this unfortunate woman, she being a social pariah on account 
of her condition. In all she had thirteen operations done. She was 
nearing the climacteric and was a widow. After the operation had 
been explained to her, she readily consented to have the vagina 
entirely closed. To obtain this result, at the last operation I excised FRACTURE OF NOSE. 
7 
the remnant of the urethra left and totally closed the vagina. That 
was in 1876, and she has been well and dry and clean ever since and 
able to work as a nurse. Both urine and fseces now pass through the 
rectum, and while she menstruated that discharge also took the 
same course. The urine has never irritated the rectum, and she has 
done well ever since the operation, with the exception of one occa- 
sion, when a small calculus formed in the vagina and acted as a ball 
valve. It was readily crushed through the anus and the recto-vaginal 
fistula by a simple curved pair of haemostatic forceps. She generally 
voids urine two or three times during the night. 
I have recently had another case in which for an incurable vesico- 
vaginal fistula Professor Parvin seven years ago totally closed the 
vagina after making a recto-vaginal fistula. No trouble has been 
experienced from the urine and menstrual discharge in the rectum, 
but there has been such contraction of the recto-vaginal fistula as to 
give her great annoyance. Dilatation has relieved her entirely. 
A NOSE DEFORMED BY FRACTURE GREATLY IMPROVED. 
Our next operative case is one in which an attempt will be made 
to restore the shape of a nose which has been deformed by a com- 
pound fracture. The patient is a girl who some time ago fell and 
sustained a compound fracture which has left a saddle-shaped nose. 
I have had a dentist make a cast of this nose, and then from that 
a model by which he made a plate to be inserted. The plate is a 
double one, with an air space between in order to make it light. The 
plate is made of silver and then gilded. Along the margins is a 
row of holes, which have been left with the hope that granulation 
tissue will grow up through these and, becoming fibrous, will hold 
the plate firmly in place. The first operation of this kind by myself 
was done four years ago, and the gold piece is yet in place and has 
given no trouble. A similar case in Australia, done some years be- 
fore my own, was doing perfectly well seven years after operation. 
Other supports have been used, such as celluloid, which does very 
well. Aluminum is too easily destroyed by the fluids of the tissues. 
If there was no scar a small opening at the side would be made 
and the plate slipped in, but as there is a scar here, an incision in it 
will make it no worse. An incision is made, and the tissues are 
loosened from the bone and cartilage with a dissector, being very 
careful to avoid infection by not invading the cavity of the nose. A 8 
SARCOMA OF AN ECTOPIC TESTICLE. 
few cases have given trouble by irritation, but this has not occurred 
in the two cases mentioned. The external wound will be sewed with 
a fine needle and the finest silkworm gut. The stitches will be re- 
moved as soon as possible. In order to guard against the possible 
collecting of blood under the plate, I shall put in a double strand of 
silkw'orm gut for drainage, which will be removed to-morrow. A 
dressing covering both eyes as well as the wound will be applied, 
great care being taken not to use too much pressure, as a slough 
might easily form over the plate. 
[The patient made an excellent recovery by first intention. 
Some months later one corner of the plate, which was not pushed 
far enough from the wound, protruded and the plate was removed. 
A second attempt to insert the plate will be made in the autumn.] 
We owe this case to the courtesy of Professor Hearn. The 
patient is thirty years of age, was married five years ago, but has no 
children. Six years ago the left testicle descended into the inguinal 
canal. Soon after the right came down the same distance. In this 
position they are subject to pressure and violence and are apt to 
undergo sarcomatous degeneration. At the present time there is a 
hard mass in the right inguinal region where the right testicle lodged. 
It is ten centimetres long and half as wide. The skin over it is 
freely movable, but the tumor is tightly adherent to the pelvic brim. 
There is another tumor, at least twenty centimetres in length and six 
in width, extending from the left of the umbilicus, under the liver 
and colon, towards the right side and the xiphoid. It is dense and 
also fixed. We have, therefore, (1) a partially descended testicle in 
the left inguinal canal, (2) a sarcoma of the right partially descended 
testicle, and (3) a large sarcoma in the retro-peritoneal tissue of the 
abdomen, in all probability secondary to the one in the groin. Oper- 
ation is out of the question here. The man has come too late. An 
ectopic testicle should be placed in the scrotum by operation or, fail- 
ing in this, be removed. It is generally of no value sexually, and 
this man would seem to belong to this class. I have seen one man 
who had both testicles in the scrotum, normally developed genitals, 
and normal sexual desire and its normal gratification, and yet who 
had not a single spermatozoon in the spermatic fluid. 
In the last few years many operations for transposing an ectopic 
SARCOMA OF AN ECTOPIC TESTICLE. MYXO-SARCOMA OF THE TONSIL. 
9 
testicle into the scrotum have been done, especially in France. 
Some years ago I assisted Professor J. Chalmers Da Costa in operat- 
ing on such a case. He found that he could not bring the testicle 
down far enough, and therefore he dissected the cord loose from the 
posterior aspect of the testicle and simply turned the latter down into 
the scrotum, with an excellent result. 
MYXO-SARCOMA OF THE TONSIL. 
This case has been an interesting one and has presented several 
serious phases. The patient is a girl eighteen years of age, sent to us 
by Dr. J. D. McLean. She presented herself several months ago 
with a growth in the right tonsil. An operation was urged at that 
time, but this was declined by her parents. The tumor had increased 
in size until it nearly filled the entire oro-pharynx and very seriously 
interfered with her breathing when she returned early in October. 
The glands of the neck were involved and they were first removed. 
My intention was to extirpate both carotids, as suggested by Dawbarn, 
to prevent recurrence, if possible, by starving the growth. By at- 
tacking the glands first and laying bare the vessels, I should have 
instant control of them in case of serious haemorrhage when removing 
the tumor. While removing them dyspnoea became most alarming, 
and tracheotomy seemed imminent. To avoid this, if possible, about 
one-third of the tumor was cut off with a pair of scissors. One of the 
first steps in the operation on the neck had been to throw a loose 
ligature around the cartotid, so as to enable me instantly to control 
haemorrhage should it be alarming. This was not required, as the 
bleeding was moderate. The relief was immediate, and the haemor- 
rhage was easily controlled by iodoform gauze. The Trendelenburg 
posture was of the greatest assistance. In fact, without it operation 
on the immense growth would have been almost impossible. After 
removing the glands in the neck, the external carotid artery was 
dissected out, its branches were ligated, and about four and a half 
centimetres of the artery excised. The remainder of the tumor was 
then removed through the mouth, without splitting the cheek. 
When the patient had recovered, which she did nicely, Professor 
J. Chalmers Da Costa operated upon the glands and dissected out the 
external carotid artery on the opposite side. This operation proved a 
serious one. The glands were involved more than was suspected and 
were very adherent. So strong was the adherence that the jugular 10 
LEONTIASIS OSSIUM. 
vein was torn in removing them, but was secured by double ligatures. 
Then the external carotid was looked for, but could not be found. 
A dissection was made far up the neck without result, and then the 
carotid artery was followed down as far as possible, when it was 
found that there was no division on that side and consequently no 
external carotid to excise. This is a rare condition and made the 
operation a puzzling one. 
[The patient recovered from the second operation. Unfor- 
tunately, two months after the operations there was a slight recur- 
rence on the postero-lateral wall of the right pharynx, for which 
another operation will soon be done.] 
RECURRENT CARCINOMA 
This woman had her breast removed by anothei surgeon a year 
or two ago, and now presents the following condition. The right 
arm is oedematous to such a degree that it is at least twice as large as 
the left. The glands above the clavicle are involved and can be easily 
felt. No enlarged glands are to be detected in the axilla, but there 
must be involvement of those near the vein, as is shown by the 
oedema of the arm. The sternum is tender to the touch. 
In the way of local treatment nothing can be done in this case. 
Only one operation is possible, and that is not very promising,-the 
removal of both ovaries. This treatment is in the experimental stage 
at present. Just what connection there is between these organs and 
the growth or hinderance of cancer is not known: whatever is said 
about it is only theory. It is thought that there is probably an 
ovarian secretion, which when poured into the system is favorable 
to the growth of cancer. The operation has been done several times. 
A very few of the patients have improved, but the majority go on 
to death. However, considering the comparative safety of abdominal 
operations, in a woman to whom the ovaries are no longer of func- 
tional value the procedure is worth trying. It is the only hope, and 
I shall suggest to this woman such an operation at an early date. 
[The operation was declined.] 
LEONTIASIS OSSIUM. 
The last case is that of a girl ten years of age. Six years ago the 
left eye became inflamed and gave considerable trouble. Shortly 
afterwards a swelling was noticed in the frontal region above that 
eye. This enlarged, the eyeball being pushed downward, and optic Fig. 2.-The ease of leontiasis ossium after the second operation. LEONTI ASIS OSSIUM. 
11 
neuritis was present. A tumor of the frontal lobe was thought pos- 
sible, although the absence of cerebral symptoms gave rise to un- 
certainty. There had been no mental symptoms, as is generally the 
case in frontal tumors. The child remained as bright as any one 
of her age would be. There was no epilepsy nor headache. 
A large flap of skin was turned up, but on trephining the skull 
was found to be enormously thickened. The bone was so soft that 
it was easily gnawed away with the bone-forceps, and could even be 
shaved off with a scalpel. The dura was exposed over a large area. 
An examination of the orbit showed no necessity for interfering with 
its roof, as was feared. The bone was at least three centimetres 
thick. The fragments being diseased, it was not desirable to replace 
them. 
[The child made an excellent recovery, and two months later a 
piece of celluloid was inserted to protect the brain. This operation 
also was followed by primary union.] INTERNATIONAL CLINICS. 
Ninth Series. A Quarterly of Clinical Lectures on Medicine, Neurology, 
Surgery, Gynaecology, Obstetrics, Ophthalmology,: Laryngology, 
Pharyngology, Rhinology, Otology, and Dermatology, and 
SPECIALLY PREPARED ARTICLES ON 
TREATMENT AND DRUGS. 5* 
By Professors and Lecturers in the Leading Medical Colleges of the 
United States, Germany, Austria, France, Great Britain, and Canada. 
EDITED BY 
JUDSON DALAND, M D., 
Philadelphia, Pa. 
Illustrated. Price per annum : Cloth, per set, $8.00; Half Leather, per set, $g.00. Each 
volume contains about 300 pages, octavo, is printed from large, clear type on 
good paper, and is neatly bound in Cloth and Half Leather. A copious 
index is contained in each volume ; and Volume IV. of each series 
contains in addition a general index of the four volumes for 
the year. Ninth Series commences April, 1899. 
BY SUBSCRIPTION ONLY. 
" This work, as the title sets forth, is a collection of the best and most prac- 
tical clinical lectures delivered in the leading medical colleges of the United 
States, Great Britain, and Canada. These lectures, after having been reported by 
competent medical stenographers, are arranged by the editors in a form best suited 
for the purposes of this work, and afterwards they are returned to the professors 
and lecturers for their personal revision. The reader is thus given the final 
thoughts and most advanced practical ideas of our ablest professional teachers. 
These handsome and well-printed volumes, which are issued with great 
regularity every quarter, contain a vast amount of instructive and readable 
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fail to exercise a marked influence on thought and practice, whilst the fact that 
a venture of this magnitude should have attained its seventh year of existence 
demonstrates that its volumes have obtained a recognized and sure place in 
periodical medical literature. Each volume contains some fifty or sixty lectures 
and commentaries upon cases of disease; a certain number of the forms are 
elaborated into general disquisitions, but the majority are purely clinical-that 
is, they are based upon cases under observation at the time of the delivery of the 
lecture. In our opinion, this is the only right form into which a clinical lecture 
should be cast. It does not and ought not to aim at being an exhaustive survey 
of the topic with which it deals, such a review should be reserved for the mono 
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to the patient and deduct therefrom the lessons they convey. " -London Lancet.