SUPERNUMERARY AXILLARY MAMMARY GLANDS
Journal of the American Medical Association
were irregular and of firm consistence. All masses were slightly movable, and palpation did not cause pain. The upper growth did not involve the inferior maxilla. The lowest palpable growth was just above the sternoelavicular articulation. The skill was freely movable over the growths and was of mu nial color. Pupils were equal and reacted normally. Examination of larynx showed involvement of right recurrent laryngeal. A specimen xvas removed by Dr. Kinsella and the pathologic department
... c department reported the growth to be an endothelioina. Removal xvas advised. Operation.-Under ether anesthesia preceded by morphin and ntropin, the vessels xverc exposed just above the sternoelavicular juncture; a Crile clamp xvas placed on both artery anil vein. The usual Z incision xvas made, the flaps wore dissected up and the growths including the sternoniastoid muscle, Ihe internal jugular vein and the subinaxillary gland were removed en bloc. The carotid artery and pnoumogustrir nerve xvere more or less adherent to the mass and infiltrated, but owing to the palhologist's report that the growth was not malignant and in consideration of the patient's age, it xvas deemed advisable not to excise these structures. A small rubber tissue drain was placed in a stab-wound at the lower part of the opérai ¡ve held. The Haps were approximated with catgut. Postoperative History.-Patient was placed ill a sitting posture. On the fourth day be was up and about the Ward. The wound had practically healed within a Week and the patient was feeling line, although the hoarseness had not disappeared. NOTE.-While correcting the proof sheet, I learned that the patient had txvo lymph-nodes removed from the left side of neck shortly alter the lirst, operation, and had developed erysipelas, from which he recovered. 482(1 Del mar Avenue. Patient.\p=m-\Mrs.S. B., aged 56, was admitted to the Medi co\x=req-\ Chirurgical Hospital on Jan. 5, 1912, complaining of pain in the right hypochondrium and vomiting. Her family history was negative, excepting death of father from rheumatism. The patient had been in good health prior to four years ago, but since then had had several attacks of illness, which were diagnosticated acute gastritis. Her habits were good, although she had used tea freely. Dec. 21, 1911, following a severe headache and a feeling of weakness, the patient was seized with severe pain in the right hypochondrium, which lasted about three minutes. This pain was not referred, but recurred three or four times daily, apparently without relation to the time of the ingestion of food, until date of admission to the hospital, and was somewhat relieved by vomiting. Following the first attack of pain, jaundice was noticed. After coming to the hospital, her condition showed marked improvement for a time, the attacks of pain and vomiting ceased, and the jaundice diminished considerably. Examination.-There xvas some tenderness in the right hypochonili'iiiiu and a small mass was palpable, xvhich did not move with respiration. An ¡r-ray examination did not reveal gallstones, but showed the pylorus to be in relation with the gallbladder legion, suggesting adhesions. Au examination of the urine revealed a I race of albumin, a small amount of bile, a trace of indican and a few narrow-hyaline casts. Caminiilge reaction xvas negative. A blood-count .Ian. (i, 1012, showed erythiocyles. 8,860,000; hemoglobin, HO per cent., and leukocytes, 11,000. Repeated examinations of the fecas gave negative results. Jan. 17, 1012, an examination of the gastric contents extracted one hour after a test-breakfast, gave the following result: Reaction, acid; total acidify, 00; free hydrochloric acid, 0.1 per cent.; lactic acid, negative; pepsin, presen!.; starch digestion, stage of cryllirodextrin; occult blood, negative; bile, negative; mucus, a small amount. Up lo this time, the patient's condition hud been improving, but now vomiting recurred. There was no recurrence of the pain over the gall-bladder region, but the patient vomited frequently large quantities of bile-stained fluid. January 23, there occurred a severe chill, and the pulse became more rapid and feeble. The temperature pursued a very irregular course, varying from a subnormal level to 101.0 F. An examination of the blood at this time showed a leukoeytosis of 215,201) ; the differential leukocyte count resulted as folloxvs: Folymorphonuclear cells, 81 per cent.; small lymphocytes, 7 per cent.; large lymphocytes, 11 per cent., and eosinophils, 1 per cent. Operation.-January 20, Dr. Ernest Laplace operated and found the duodenum markedly adherent to the under surface of the liver, and kinked nt the site of adhesions. Situated betxx-een the duodenum and the liver xx-as the much-shriveled gall-bladder. It xx-as necessary to tear away the liver tissue in breaking up the adhesions, leaving nn excavation in the liver, considerable hemorrhage resulting. The gall-bladder could not be liberated from the duodenum, and Owing to the patient's Weakened condition, it xvas deemed advisable to desist before the operation was completed. The patient, died three days later, and necropsy was refused. The stenosis of the duodenum in this ease was due partly to the constricting cieatrix of an old ulcer and partly to the kinking occasioned by the adhesions. Among other points of interest presented by this ease are compression of the gallbladder and common duct, apparently due to the adhesions either old or recent, accompanied by jaundice, and indications of a secondary acute inflammatory process obviously occasioned by. perforation of the duodenum at the site of an old ulcer.