CLINICAL REPORT 
OF 
SIX SURGICAL CASES 
BY 
DR. G. W. CALE. CLINICAL REPORT 
OF 
Six Surgical Cases. 
BY 
GEORGE W. CALE, M. D.. 
PROFESSOR OF ANATOMY AND CLINICAL SURGERY ST. LOUIS COLLEGE OF PHYSICIANS 
AND SURGEONS, ST. LOUIS, MO. Case I. — Traumatic Insanity. 
» 
“ II. — Traumatic Epilepsy. 
“ III. — Recurrent Appendicitis. 
“ IV. — Ovariotomy. 
“ V. — Oophorectomy (Second Operation). 
“ VI. — Adenoma of Parotid Gland (Illustrated). (Reprint from St. Louis Clinique for February 189-2). 
Clinical Report of Six Surgical Cases. 
Traumatic Insanity. 
Case I. O. C., male, aet. 24, bridge 
•carpenter; case of Dr. Hall, of Eldora- 
do, 111. Family history good. The pa- 
tient enjoyed good health until about 
seven years ago, when he was struck on 
the head with an unturned wagon spoke. 
The wound was situated over the supe- 
rior longitudinal sinus, about midway 
between the fissure of Rolando and the 
■external occipital protuberance. The 
wound, which was thought by the attend- 
ing physician only to affect the scalp, 
suppurated for three months. 
Three years ago the patient began to 
complain of severe pain in the occipital 
and parietal regions of the head; he 
became very imaginative, and as he ex- 
pressed it, “ Everything went wrong.” 
He thought his family and friends were 
plotting against him. About this time 
he began to have attacks of petit mat. 
His manner and disposition became 
greatly changed; he was morose, un- 
grateful, peevish, and appeared to be 
unconcerned about anything and everjr- 
thing which should have interested him ; 
he would lie when it was to his advant- 
age to be truthful; he also developed 
a mania for stealing. 
On October 17th, 1888, he was sent 
to the insane asylum at Anna, Illinois, 
where he remained sixteen months. At 
the end of this time he was somewhat 
improved in health, and accordingly 
discharged. When he returned to his 
old home he soon appeared in his old 
role, and being adjudged insane by the 
family was returned to the asylum in 
ten months, and there remained five 
months. At the expiration of this time 
he was discharged on trial and remained 
out but one month. After remaining 
in the asylum for four months he 
was brought to St. Louis, on an order 
of the Court, for treatment. 
Being in the category of nervous dis- 
eases, Dr. Keating Bauduy was first 
consulted; he examined the case thor- 
oughly, pronounced it of traumatic ori- 
gin, and referred the case to me for 
operation. The day before the opera- 
tion the scalp was shaven. The day of 
the operation the scalp w'as first 
scrubbed with soap and water, and then 
with a 1-2000 solution of the bi-chloride 
of mercury. The upper portion of the 
scalp was then constricted by tying a 
piece of rubber tubing around the head 
above the eyes and ears, and below the 
external occipital protuberance. A pear- 
shaped flap was made, over the site of 
the scar, with the pedicle toward the 
left ear ; this was elevated with the peri- 
osteum attached, and a depression 
found in the bone which corresponded 
with the scar in the scalp. 
The periosteum was adherent to the 
depressed bone. This piece of bone 
which was about the size of a ten cent 
piece was then removed with a chisel 4 
GEORGE W. CALE. 
and mallet; a corresponding portion of 
the inner table was found to be pressing 
on the brain just to the left of the supe- 
rior longitudinal sinus, and removed 
with the aid of a sharp bone curette. The 
dura mater appeared normal. Four 
strands of catgut were laid in the 
wound, the outer ends protruding at 
the most dependent angle in order to 
insure efficient drainage. The flap was 
then stitched in position, the entire op- 
eration having been performed under a 
constant stream of a 1-3000 sublimate 
solution. Collodion was painted over 
the line of incision, and a dressing of 
sublimate gauze, cotton and rubber, 
held in place by a crinoline bandage. 
On the second day a small quantity of 
blood and serum was pressed from the 
wound; on the third day the catgut 
drain was removed, and two days later 
the sutures, the wound having healed 
by first intention. 
Since the operation, which was per- 
formed Oct 30th, the patient has never 
had a pain of any description in his 
head. His disposition became very 
cheerful, and his manner was entirely 
changed. He was discharged well on 
the 12th day and returned to his home. 
Since that time we have had a number of 
letters from his family, who state that 
he is perfectly sane and appears and acts 
a-s he did before the reception of the 
injury seven years ago. 
This case will be detailed more fully 
at some future time by Dr. Bauduy and 
myself. 
Traumatic Epilepsy. 
Case II. A. O. H. ; male, «et. 26 ; 
farmer; case of Dr. E. Magoon, of 
Clarence, Mo. Family history good. 
When about six years old the patient 
was struck on the top of the head with 
a grubbing hoe, the point of injury be- 
ing over the paracentral lobule of the- 
left side. The scar was transverse in 
direction, about one inch in length, the 
inner end corresponding with the edge 
of the superior longitudinal sinus. The 
wound healed by granulation. The 
patient had good health until he reached 
the age of 21 years, when without any 
premonitory sj'mptoms or warning of 
any kind, he had a severe epileptic con- 
vulsion ; no vomiting. In twelve 
months he had a second attack, two 
years and a half later he had a third 
attack. The attacks then came month- 
ly, semi-monthly and weekly. 
About the first of July, 1891, he con- 
sulted Dr. Magoon, who prescribed the 
bromides and checked the attacks until 
the middle of the following October, 
when he liad three convulsions in one 
night. He was brought to me the latter 
part of October by Dr. Magoon, and I 
asked Dr. Bauduy to see him with me. 
Pressure on the scar caused pain and 
slight dilatation of the pupils. We con- 
cluded the case one of traumatic origin, 
and decided to operate. 
The patient was prepared exactly as 
Case 1, and a pear-shaped flap elevated. 
A piece about the size of a five cent 
piece, corresponding in position with 
the scar in the scalp, was removed with 
a chisel and mallet; both tables of the 
skull were thickened, but there was no 
appreciable compression. The dura 
mater was normal in appearance. 
Catgut strands were used for drain- 
age, and the wound treated as Case 1. 
The patient progressed nicely until the 
tenth day, when he had a slight attack 
of vertigo ; he also had a similar attack 
on the eleventh day and was discharged 
on the twelfth day. His general health 
was improved, his eyes clear, and his 
appetite good. Since his return home 
he has increased in weight forty pounds* 
but has had several severe seizures. REPORT OF SIX SURGICAL CASES. 
5 
Recurrent Appendicitis. 
opening and drawn through the poste- 
rior opening by means of a pair of haem- 
ostatic forceps. The anterior incision 
was closed with silk sutures, and ap- 
plications of towels wrung out of hot 
carbolic acid solutions made over both 
openings. 
The following day the temperature 
dropped to 99 and the pulse to 72, and 
in a few days became normal. The 
discharge gradually became less and at 
the end of three weeks the drainage 
tube was removed. Patient was dis- 
charged well in five weeks. 
Ovariotomy. 
Case IV. S. E. B. ; female ; set. 18 ; 
sent by Dr. Brown, of Edina, Mo. The 
patient first menstruated at the age of 
eleven years, the menses appearing ev- 
ery three weeks. Three years ago she 
noticed a swelling in the region of the 
right ovary, which grew rapidly, being 
accompanied by pain. In March, 1891, 
Dr. Brown diagnosticated ovarian tu- 
mor and punctured it with a trocar, re- 
moving about one gallon of a very 
gelatinous, yellow substance. 
The sac refilled rapidly and she was 
sent to me for operation. On examina- 
tion the abdomen was found enormous- 
ly distended, dull on percussion, except 
in the lateral lumbar regions, and some- 
what painful on manipulation. Two 
inches above the umbilicus was a deep 
transverse furrow running across the 
abdomen, which appeared to have been 
caused by the tight bands of the pa- 
tient’s clothes. 
The urine contained a large number 
of epithelial cells from the bladder; 
otherwise normal. 
The abdomen and pubes were shaven, 
scrubbed with soap and water, and 
then with sublimate solution. 
A median incision was made below 
Case III. H. Q. ; col’d; male, set. 
41; laborer. Case of Dr. Jennings, in 
May, 1889, the patient noticed a swell- 
ing in the right iliac region which was 
accompanied by pain and fever; this 
developed into an abscess. After exist- 
ing for a month it was opened over the 
middle of the crest of the ilium ; this 
suppurated for about one month, when 
the wound closed. In two months the 
abscess reformed and was again opened, 
but closed in a short time. 
The patient had continued pain in the 
right iliac region until November 2nd, 
when the pains were very severe and 
paroxysmal, and radiated over the ab- 
domen. On examination we found a 
firm tumor in the right iliac fossa, about 
the size of a large orange, which was 
very painful on pressure. The patient 
kept his thighs Hexed on his abdomen. 
His temperature was 103 and pulse 95. 
The abdomen was shaven, scrubbed with 
soap and water, and then with sublimate 
solution. An incision six inches in length 
was made in the semi-lunar line, and 
the head of the coecum presented in the 
wound, being adherent to the parietal 
peritoneum. I separated the adhesions 
posteriorly with my fingers and came 
upon a large abscess filled with a very 
offensive greenish yellow pus, the 
amount discharged being about one pint. 
This abscess cavity was irrigated with 
water which had been boiled and cooled. 
I then passed the index finger of my 
right hand down to the lower and back 
part of the cavity and was able to feel it 
through the muscles of the back with my 
left hand ; in this I took a sharp pointed 
knife and cut down, using the point of 
my right index finger as a guide, and 
opened the abscess cavity at its most 
dependent portion posteriorly. A large 
fenestrated rubber drainage tube was 
passed downward from the anterior 6 
GEORGE W. CADE. 
the umbilicus about three inches in 
length and a large cyst was drained 
through a trocar of large calibre: the 
fluid was so thick that this part of the 
operation required nearly twenty min- 
utes. The abdominal incision was then 
enlarged upward a distance of four 
sutures on the fifth day. The patient 
did well except for the annoyance 
caused by an attack of bronchitis which 
was very much augmented by the anaes- 
thetic. She was discharged well and 
returned to her home exactly three 
wTeeks from the day of operation. 
inches and a second large cyst, which 
accounted for the furrow in the abdomi- 
nal wall, was pulled down, incised, 
drained and removed, the pedicle hav- 
ing been transfixed with an aneurism 
needle armed with strong, cable twist 
silk first tied in two halves and then 
en masse. 
Some of the contents of the cyst 
which was a yellowish brown gelatinous 
substance escaped into the abdominal 
cavity: this was removed with moist 
sterilized gauze. 
A rubber drainage tube was inserted, 
the lower end reaching to the space of 
Douglas and the abdominal wound 
closed with silk sutures. The tube was 
removed the following day and the 
The weight of the tumor and contents 
was about 40 pounds. 
Oophorectomy. 
Case V. A. R., female, ret. 38, mar- 
ried, mother of two children, both liv- 
ing, younger 8 years old. Case of Dr. 
Barnes. Patient menstruated regularly 
and without pain until three years ago. 
She then complained of constant pain 
in the region of both ovaries and across 
lower half of the abdomen ; also pain 
extending from the upper lumbar re- 
gions downward and forward across the 
abdomen. These were more severe at 
her menstrual periods and she was REPORT OF SIX SURGICAL CASES 
7 
compelled to remain in her bed a great 
portion of the time. One year ago the 
pain became so severe that an operation 
was decided on and the right ovary was 
removed by Dr. Bernays, the left at the 
time of operation being perfectly normal 
in appearance. 
She left the hospital in about one 
month and has since complained of 
abdominal weakness which I think is 
more imaginative than real, as I could 
find no possible cause for it. The first 
corresponding in position to the incision 
of the first operation ; this was separa- 
ted on the right side and two fingers, 
the first and second, of the left hand 
introduced into the abdominal cavity. 
The left ovary was found behind and to 
the right of the uterus; this was raised 
in the abdominal incision and the broad 
ligament and tube which were unusually 
long and lax were tied in two parts and 
then en masse after transfixion as in 
case IV. 
of last November the patient was stand- 
ing on a chair, in order to reach some- 
thing which had been placed on a high 
shelf, when she lost her balance and fell 
over the back of- the chair, striking her 
abdomen below the umbilicus, thus 
sustaining quite a severe blow. Since 
that time she has suffered great pain 
again near the region of the right ovary. 
A second operation was determined on 
and after the abdomen had been pre- 
pared in the usual manner the incision, 
a median one, was made in the scar of 
the first operation. The omentum was 
found adherent to the abdominal wall 
Fig. 2. 
The pedicle was dropped back into 
the cavity, the omentum pulled down 
and placed beneath the abdominal in- 
cision and the wound closed with five 
deep and two superficial silk sutures. 
Collodion was painted over the incision, 
gauze and cotton applied and held in 
place by a flannel bandage. 
The patient did not vomit; pulse 
never rose above 88 nor temperature 
above 99.5. She made a rapid recovery. 
The ovary contained several small clear 
cysts on the surface, and at each end 
a haematoma about the size of a hazel 
nut. 8 
GEORGE W. CALE. 
Adenoma of Parotid Gland. 
Case VI. I. L., female, ®t. 41. Case 
of Dr. Youngs of Rich Hill, Mo. 
The tumor started three and one half 
years ago in a small nodule under the 
lobe of left ear: continued to grow 
until it had attained the size of a large 
orange. It extended from near the 
external angular process of the frontal 
bone to an inch and a half behind the 
mastoid process of the temporal bone 
and as far down as an inch and a half 
below the angle of the jaw: the lobe of 
the ear was elevated from the side of 
the face. 
The upper and pos- 
terior part of the tumor 
was nodulated and cov- 
ered by tight skin of a 
bluish red color. The 
tumor was of firm con- 
sistence and contained 
several soft spots about 
the size of a pigeon’s 
egg which felt as if 
filled with jelly. None 
of the submaxillary or 
cervical glands were 
enlarged. 
The operation was 
performed with the as- 
sistance of Dr. Jen- 
nings, and Dr. Black, 
late U. S. A. An incision was made 
along the posterior border of the 
tumor, in the direction of the sterno- 
mastoid muscle, extending from its up- 
per margin to within a short distance of 
the clavicle; a second incision was 
made beginning near the zygoma, pass- 
ing downward about three-eighths of an 
inch anterior to the ear, to the first in- 
cision ; these two were connected by a 
V-shaped incision beneath the lobe 
of the ear. The glandular mass was 
then carefully dissected out; it wras 
attached to all contiguous structures, 
including the masseter and sterno-mas- 
toid muscles, and extended far beneath 
the angle of the jaw. The haemor- 
rhage amounted to nothing, only five 
small vessels requiring ligatures (silk). 
The facial nerve had to be sacrificed 
as it was impossible to dissect it from 
the tumor mass. The wound was irri- 
gated with a 1-2500 sublimate solution, a 
rubber drainage tube 
inserted, extending 
from the angle beneath 
the ear to lower angle, 
and closed with 25 silk 
sutures. The dressing 
consisted of iodoform 
collodion and a com- 
press of sublimate 
gauze and cotton. 
Vomiting caused some 
slight secondary hem- 
orrhage, which escaped 
from the wound 
through the drainage 
tube, and stopped in 
a very short time with- 
out any interference. 
The dressings were 
changed the following day on account 
of the hemorrhage, and subsequently 
every second day. The drainage tube 
and the sutures were removed on the 
fourth day, and the patient returned 
home on the ninth day, the wound hav- 
ing healed by first intention. ( See 
figs. 1, 2 and 3 ) Chloroform was the 
anaesthetic used in all of the cases. 
Fig 3. 
78 Vandeventer Place.