The Later History of Four Sur- gical Cases 1. My First Case of Brain Tumor (1887) 2. Two Patients with Rectal Cancer Surviving Many Years; Describing also a Simple and Successful Method of Dressing an Inguinal Anus. 3. Traumatic Rupture of Middle Meningeal Artery without Skull Fracture (1902) Reprinted from The Journal of the American Medical Association May 10, 1913, Vol. LX, pp. lll18-lll20 Copyright, 1913 American Medical Association Five Hundred and Thirty-Five Dearborn Avenue CHICAGO THE ' LATER HISTORIES OF FOUR SUR- GICAL CASES 1. MY FIRST CASE OF BRAIN TUMOR (1887). 2. TWO PATIENTS WITH RECTAL CANCER SURVIVING MANY YEARS; DESCRIBING ALSO A SIMPLE AND SUCCESSFUL METHOD OF DRESSING AN INGUINAL ANUS. 3. TRAUMATIC RUPTURE OF MIDDLE MENINGEAL ARTERY WITHOUT SKULL FRACTURE (1902). W. W. KEEN, M.D. PHILADELPHIA BRAIN TUMOR Case 1.-In December, 1887, I removed a large tumor from the brain.1 It was my first case of modern cerebral surgery. The weight of the tumor was 3 ounces and 49 grains, and its size 2% by 2 Vi by 1% inches, its circumference being 7% by 6 inches. The tumor was a fibroma arising from the dura. Dr. W. .1. Taylor has stated2 that the patient "lived for nearly twenty years" after the operation. This is an unintentional error, for it was 25 years last December since the operation, and the patient was still alive a few months ago. His sight is poor, but is sufficient to enable him to find his way about, though not to enable him to read. He has once in a year or so an epileptic attack in spite of his use of bromids. He is now 50 years old and bids fair to live for some years. CANCER OF THE RECTUM Case 2. I made an inguinal artificial anus (Maydl), Nov. 5, 1892, and eleven days later- resected G inches of the rectum, leaving both the inguinal and the perineal openings patent. The cancerous nature of the growth was established by micro- scopic as well as clear clinical evidence. The patient, Air. B. (Case 2 of my original paper3), was 32 years old at the date of the operation. He lived until 19QG, a period of fourteen years, and then died without local recur- rence. It is possible that his death was caused by internal 1. Keen, W. W. : Am. .Tour. Med. Sc., October, 1888, p. 329. 2. Taylor, W. J. : Tr. Am. Surg. Assn., 1912, p. 361. 2 malignant disease, but this was not determined. I never attended him after the operation, though 1 often saw him socially. Meantime he had been able to enter into all ordinary busi- ness and social life, to travel to Egypt and elsewhere, and to ride a horse and a bicycle. When later I proposed to close the perineal opening where the bowel pTotruded moderately he declined, for the reason that he was comfortable and had satis- factory control of the contents of the bowel. Case 3.-I operated on the patient, Mr. F. (Case 3 of my original paper3). Dee. 14, 1892. He was then 46 years of age. As in the prior case. 1 made an inguinal anus (Maydl) and twelve days later resected inches of the rectum. Micro- scopic examination confirmed the clinical diagnosis. The lower (perineal) end of the bowel was left open as well as the inguinal anus. After a time he was so much annoyed by the prolapse of the bowel that he willingly acquiesced in my sug- gestion to have the perineal opening closed. Operation and liesuits.-Feb. 16, 1900: Placing the patient on his right side, I carried an incision through the skin about one-third inch away from the perineal opening of the bowel. 1 then dissected down to the muscular coat of the bowel imme- diately at the level of the perineum. By the finger and by blunt dissection and scissors, I was able to detach the com- plete layer of mucous membrane from the bowel so that it hung down like a cuff. This was then cut off at a level with the muscular coat, and the margins of the mucous cuff were united by a through-and-through catgut suture. This stump was next invaginated, and two rows of Lembert sutures were applied through the muscular coat. I was surprised on releas- ing my control of the closed end of the rectum to see the enor- mous cavity into which it retreated. 1 could easily introduce my entire fist to a distance even beyond my wrist, and yet at no place had the peritoneal cavity been invaded. When the patient was resting quietly this retraction to the bottom of the cavity took place, but the moment that he attempted to vomit, cough or struggle, the stump of the bowel would be pushed down to the level of the perineum or even beyond it. The stump of the bowel was now brought down to within an inch of the surface of the perineum, and the perineal wound was closed with interrupted silkworm-gut sutures, four of which secured the rectal stump in position. If this had not been done, there would have been an immense dead space in which bloody serum would have accumulated and might easily have led to an infection. When the bowel was pulled down, the lax tissues about it filled up practically this whole cavity. 3. This was originally reported in the Therapeutic Gazette for April and May, 1897. 3 A rubber drainage-tube was introduced both anteriorly and posteriorly to avoid this danger of infection. The operation lasted an hour and three quarters, and was tedious rather than difficult. The mechanical result was most satisfactory to me. The patient's temperature showed no appreciable fall after the operation. The wound healed by first intention except at two points, one exactly corresponding to the middle of the closed stump of the bowel, the other close by. A very slight discharge of mucus occurred at these points. To avoid danger from down- ward pressure I kept him in bed till the wound was securely healed. He went home in four weeks. I have seen and heard from him from time to time. The last occasion was Jan. 14, 1913, a little over twenty years after the primary operation. He is now 66 years old, is perfectly well, and weighs rather more than ever before. His business and social life are normal, except when his bowels are loose. The discharge even then rarely escapes beyond the dressing and soils his underclothing. The result of the operation to occlude the perineal anus is very gratifying. He says of this that "there is nothing to show. It is simply a 'closed incident.'" METHOD OF DRESSING INGUINAL ANUS As lie lias had so long and so successful an experience in dressing the inguinal anus and in observing the con- dition of the culdesac from the open inguinal anus to the closed perineal anus, I quote in detail his method of dressing the inguinal anus. This is always a problem of serious import to the patient. Many devices, often cumbrous and costly have been used. Mr. F.'s method is so simple and so effective that I believe a detailed description - for even the little details are important - will be welcomed both by the surgeon and his patient. The accompanying illustrations well illustrate his present condition. His suggestion of a "dummy" truss lias been of great value to other patients after a similar operation. The truss as he says is the "key to the situation." Mr. F. writes: The bowel ends protrude, normally, about half an inch outside the wall of the abdomen (Fig. 1.) The end of the unused bowel does not vary in size; it is inert. The end of the active bowel is like it when conditions are normal. . . . I have fairly regular movements every morning, depending, of course, somewhat on regular habits of eating and drinking, which also affect the character of the discharges as to their being formed or semi-liquid. . . . My motions are never under control as with a normal sphincter. At the same time they give me fair warning. If formed they do not hurry 4 me and in cases of necessity, as when traveling, I can carry a movement for hours. But if semiliquid or worse they must be cared for promptly. . . Now, as to protection -(Figs. 2 and 3.) You are right in wanting this in detail, for it is that which must take the place of control, and it is the key to the situation. I am sending you under separate cover a T-baudage and pads of absorbent cot- ton which have served me so well all these years. I have seen expensive surgical appliances of silver cup, rubber tube and reservoir which were of no use at all. Lying on my back with the bandage spread out under me, I first wrap a string of absorbent cotton around the bowel ends. Then I place over the abdomen a layer of cotton about 8 by 11 inches, reinforcing it at the bottom with another strip 3 inches wide to make double Fig. 1.-The two ends of the divided bowel at the inguinal anas twenty years after operation (Case 3). thickness. This is better to support the flange at the truss and to increase absorption. Over this pad I lay a smaller piece of cotton or linen cloth-any clean old rags will do-then another sheet of cotton, split thin, then another cotton rag and on this a square about 5 by 6 inches of rubber cloth. These cotton pads extend one-third of their length over the bowel ends to the right and two-thirds to the left and down the side, as it is in the latter direction that the movements spread most. Then I bring the bandage over from the right side, lap ::t with the end from the left side and fasten with five safety- pins 1% inches long, beginning at the bottom and drawing fairly tight. I then bring up the split ends of the T and fasten each end to the lower edge at the encircling bandage. The bandage should not cover the lower edge of the pads by half an 5 inch. This is a good deal of detail, but it is all-important. The cloth square between the pads catches the moisture which goes through the cotton, and the one under the rubber will be wet while the cotton under it is dry. The rubber protects the bandage when the discharge is profuse. In dressing a move- ment, I simply fold back the cotton not soiled and gather off the feces with a square of soft paper, cleanse with part of the cotton pad and redress with new as may be necessary. Next, standing, I adjust my truss; and let me say here that a truss is an absolute necessity. It is the only insurance against disastrous leakage down into the clothing of liquid Fig. 2.--Front view showing truss and drossing (Case 3). feces. It constricts the lower edge of the bandage, holding it tight to the groin and making the bandage and pads a safe reservoir even with liquid discharges, if they are not too pro- fuse. Of course if they are profuse all pads will be saturated, and sometimes there will be leakage. But it must be a bad dis- charge that gets so far. You will find a slit in the middle of the wide bandage. This is to catch the edge of the back flanges of the truss and prevent the truss from slipping down-another important detail. The bandage I send you is made up as I use it. Open it carefully. The patient must keep a few on 6 hand. It is made of 40-inch brown muslin. The strip half as wide as the bandage makes two T's. The culdesac, which you perhaps considered an experiment, has served its purpose in preventing prolapse of the bowel, leakage of mucus and pain in the surrounding muscular tissue. The discharge from it at the open end is negligible. Once in a great while I find a thimbleful of gray matter, soft and odor- less, on the pad. Once 1 thought there must be some accumula- tion of it and I tried to void it by hanging down, head to the floor from the foot-rail of my bed and manipulating the pos- terior end with my hands, hut with no result; so I ceased to Fig. 3.-Rack vi.'-w showing truss and dressing (Case 3). bother about it. Tt gives me no pain except sometimes it swells whim 1 strain my abdominal muscles to effect a move- ment. HEMORRHAGE FROM THE MIDDLE MENINGEAL ARTERY Case 4.-A young midshipman at Annapolis was injured in a football scrimmage. I first saw him three days after the occurrence of the accident.4 His mental condition at that time was very dull, bis headache was severe and he had had convul- sions, chiefly in the right arm, though the right leg and entire side had been involved to some extent. Disregarding a bruise, the only physical evidence of injury, I opened his head, Nov. 7 19, 1902. about 3 inches away from the bruise, and removed nine tablespoonfuls of blood. He made an excellent recovery and, in spite of my injunction to drop back one year in the Academy, he studied extra hard, made up all his lost time, graduated with his class and entered on his career as an officer in the Navy. Jan. 10, 1909. over six years after the accident, he was examined for life-insurance by Dr. Julius F. Lynch of Norfolk, Va. Dr. Lynch writes me, "I recommended him as a first-class risk and the policy was issued promptly." A little over a month after the policy was issued he was killed by an explosion in a coal-bunker on the man-of-war then lying in the harbor of Naples. He knew the danger he ran in entering the bunker where there was believed to be a fire, but gallantly faced it, forbidding the men to enter until he him- self had explored it. The surgical interest of the case lies chiefly in the excellent physical condition found after so long a period subsequent to such a severe cerebral injury. 1729 Chestnut Street: