Clinical lecture on an obscure tumor of the abdomen, amputation of the breast for Paget's disease followed by cancer, tuberculosis of the tonsil and soft palate, by a method which avoided splitting of the cheek or dividing the jaw : delivered at the Jefferson Medical College Hospital / by W.W. Keen.

  • Keen, William W. (William Williams), 1837-1932.
Date:
1897
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Licence: Public Domain Mark

Credit: Clinical lecture on an obscure tumor of the abdomen, amputation of the breast for Paget's disease followed by cancer, tuberculosis of the tonsil and soft palate, by a method which avoided splitting of the cheek or dividing the jaw : delivered at the Jefferson Medical College Hospital / by W.W. Keen. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    ,§urt)ial (fflinif. OBSCURE TUMOR OF ABDOMEN- AMPUTATION OF BREAST FOR PAGET'S DISEASE FOLLOWED BY CANCER —TUBERCULOSIS OF TONSIL AND SOFT PALATE; OPERATION BY A METHOD WHICH AVOIDED SPLITTING OF THE CHEEK OR DIVIDING THE JAW. Delivered at the Jefferson Medical College Hospital, November 25, 1896, BY PROF. W. W. KEEN, M. D. The first case I shall show you is a man with an Obscure Tumor in the Epigastrium, who has been examined at my request by my colleague, Prof. James C. Wilson, from the medical standpoint as well as by myself from the surgical. Please remember, gentlemen, no matter how much knowledge you have you will not uncommonly run across obscure cases. Never hesitate for a moment to say they are obscure, and to ask for a consultation with one in whose judgment and acute clinical powers you have confidence, as I have in those of Prof. Wilson. You will remember that this man w’as be- fore you three weeks ago. I show him now in order that you may observe the effect of treatment, and to show you that the tenta- tive diagnosis we then made is, without much doubt, correct. His history, you may re- member, was as follows : O. D., age thirty-seven, was admitted to the Jefferson Hospital Nov. 2, 1896. His family and personal history have been very good, with the exception of the fact that he has had 4 attacks of gonorrhoea and 5 chancroids with suppurating buboes in each groin about five years ago. He denies any primary syph- ilitic attack or secondary symptoms. His present trouble began about one year ago with pain in the epigastric region, which also was felt, but to a less extent, in both hypo- chondriac regions. The attacks , have been irregular, the intervals being from one day to about two weeks. Occasionally during the last summer he had attacks of vomiting on rising, the fluid ejected being practically clear. He has never vomited blood nor has he ever passed blood in his stools. His weight is practically the same as it has been for a num- ber of years. His appetite is good ; bowel movements regular. His food has never lain any length of time in his stomach. On examination, a hard, nodular tumor, apparently about i by inches, is felt in the epigastrium just beneath the abdominal wall, or possibly even in it. It is slightly tender, and dull on percussion. The dulness is continuous with that of the liver, which extends about 2 inches below the border of the ribs. He has never had jaundice. On November 4th the stomach was emptied, a test meal given him, and free hydrochloric acid found. The urine is clear amber, acid, sp.gr. 1.027, neither albumin, sugar, nor bile pigment is found. Microscopically, also, nothing is found except normal constituents of the urine. His temperature is normal. The diagnosis here lay, first, between a tumor of the liver; second, of the pylorus; third, possibly of the omentum ; and, fourth, on account of its apparently superficial position, that it might possibly be a tumor of the abdominal wall. Careful examina- tion showed that it was movable in relation to the abdominal wall, and, therefore, was certainly not connected with it. The absence of all gastric symptoms, vomiting, dyspepsia, retained food, dilatation of the stomach, etc., militated, in the opinion of Prof. Wilson and myself, against its being pyloric, or, in fact, any form of gastric tumor. Omental tumors are not, as you know, very common. Hepatic tumors are much more common. The presumption, therefore, simply on the doctrine of chances, was rather in favor of its being hepatic. The man’s admission of the very frequent possibility of syphilitic infection should weigh very seriously with us, although he denies, at least, any knowledge of such an infection. The absence of marked hepatic disturbance itself would look toward a syphi-