A Stenosing Carcinoma of the 
Transverse Colon. . 
Excision. Murphy-Button Anastomosis 
(End to End). 
BT 
MORRIS MANGES, M. D., 
Assistant Visiting Physician to Mount Sinai Hospital, 
AND 
HOWARD LILIENTHAL, M. D., 
Assistant Visiting Surgeon to Mount Sinai Hospital. 
HKPR1NTBI) PROM THU 
Nrui Ycrfc JMc&fral Journal 
for September 1, 1894- Reprinted from the New York Medical Journal 
for September 1, 
A STENOSING CARCINOMA OF THE 
TRANSVERSE COLON. 
EXCISION. MURPHY-BUTTON ANASTOMOSIS (END TO END). 
By MORRIS MANGES, M. I)., 
ASSISTANT VISITING PHYSICIAN TO MOUNT SINAI HOSPITAL, 
ANI> HOWARD LILIENTHAL, M. I)., 
ASSISTANT VISITINO 8UKOEON TO MOUNT SINAI HOSPITAL. 
Julius 0., fifty-one years old, salesman, came under my care 
on May 2f», 189T. His family history was negative. For ten 
years ho has had more or less discomfort from his stomach. 
Two years ago he had a slight left hemiplegia. 
His present trouble began fourteen months ago, when he 
was sick for four months with what was called typhoid fever. 
After that he was treated for a year for intestinal indigestion. 
In spite of all treatment and diets, the pains from which he suf- 
fered were not relieved, so that for the past five months he has 
ha<l hypodermic injections of morphine twice daily. 
The pains were very variable; they often came on after a good 
night’s rest, even while in bed; sometimes any slight exertion 
would bring them on. Most frequently they appeared after 
meals (usually several hours) and preceding or following stools. 
The pains wero colicky in character, and usually began some- 
what to the left of the umbilicus, and radiated upward and to 
tho right; when standing, they shot backward. They were 
always accompanied by a good deal of rumbling in the bowels 
and the passage of very offensive flatus. 
Copyright 1SU4, by D. Appleton and Company 2 
CARCINOMA OF THE COLON. 
The stools were always constipated, so that he had to resort 
to cascara and enemata. Formerly they were “crumb-like,” 
but never scybalous or flattened. The evacuations themselves 
were not painful, except when there was occasionally some rec- 
tal irritation from small external haemorrhoids. There was never 
any haemorrhage from the bowels. 
In July, 1893, there was continuous vomiting for two weeks. 
Since then it would occur on very slight provocation, but dur- 
ing the past two weeks this feature has been less marked. No 
haematemesis. 
Ilis diet had been restricted, yet he asserts that he could 
digest his food fairly well, and that what he ate had no effect 
upon the pains. In fact, ho had been kept upon a milk and 
then on a fish diet for two months, without obtaining any relief 
from the pains. 
Ilis treatment before I saw him consisted of pancrobilin, 
pancreatin, and all the various ferments, intestinal irrigation, etc. 
Examination, May 26, 1891^.— The patient is somewhat 
emaciated, walks bent forward and uses a cane. Heart and 
lungs negative. The rigidity of the abdominal walls renders 
examination difficult. Liver and spleen normal. The lower 
border of the stomach does not reach umbilicus; no succussion. 
Tenderness, especially to the left of the umbilicus. No glandu- 
lar enlargements. Spine is not tender; pupils normal in size 
and reaction ; patellar reflexes lessened. Temperature normal. 
Urine, specific gravity, UOIO; faint trace of albumin ; no casts. 
29th.—Comes into office with attack. The pain is more 
stationary to-day and is restricted to the left side of abdomen, 
and is especially along the colon at the level of the umbilicus. 
Had retained oil enema all night, but it came away without any 
stool. Visible intestinal peristalsis and many borborygmi. 
June 1st.—For the first time abdomen is soft enough to per- 
mit thorough palpation. A distinct hard tumor, about the size 
of a hen’s egg, can be felt in the left umbilical region ; it is 
quite painful and is transversely situated at the level of the um- 
bilicus and about two inches to the left of it. It is freely mov- 
able laterally. Marked intestinal peristalsis. 
7th.—Inflation of the rectum and colon negative, as the in- CARCINOMA OF THE COLON. 
3 
joctod air caused so much pain that it could not he retained. 
The above-described mass can he distinctly felt, and can even 
he moved to the right of the umbilicus. 
10th.—Admitted to my service at the Mount Sinai Hospital. 
Ewald tost breakfast expressed after an hour; 40 c. c. ob- 
tained; contains no free hydrochloric acid; faint trace of lactic 
acid; total acidity, 0-10 per cent. HOI; no starch or dextrin 
reaction ; trace of peptone. Inflation of stomach does not show 
any marked dilatation. 
15th.—Transferred to Dr. Lilienthal’s service for operation. 
In determining the nature of the tumor several factors 
would indicate malignancy—viz., the age of the patient, 
his somewhat cachectic appearance, and the hardness of 
the mass. On the other hand, the slow growth and the 
absence of enlarged glands were against this assumption; 
yet in abdominal carcinomata this is of less significance 
than it would be elsewhere, for enlarged mesenteric glands 
are usually beyond the reach of the palpating fingers. 
As to its site, the entire clinical picture is that of a 
stenosis at some point in the intestinal tract, as shown by 
the colicky pain, the increased peristalsis, borborygmi and 
constipation. Is the stenosis due to a lesion in the wall of 
the gut or to the pressure and adherence of some omental 
growth ? The superficiality of the tumor might indicate 
the latter; but this was evidently not the case here, for 
there was only a single nodule and ascites was absent. The 
lateral mobility, also, spoke against the omental location. 
It was this latter feature, together with the transversely 
elongated shape, its situation, and the close relation of the 
colics to the movements of the bowels which led me to as- 
sume that the stenosing carcinoma involved the transverse 
colon. A cicatricial stenosis was excluded by the history 
and clinical signs. 
The results of the analysis of the stomach contents sug- 
gested the possibility of the gastric location of the tu- 4 
CARCINONA OF THE COLON. 
mor ; yet a more careful consideration of all tlie factors ren- 
dered this improbable. Judging from the shape of the 
mass, the pylorus would be the part involved, for the 
greater curvature is always infiltrated diffusely and not 
as was the case here. And if it were indeed the pylorus 
—the possibility of the pylorus occupying the left umbili- 
cal region has been shown by Osier in his recent lectures 
on abdominal tumors—then a marked gastrectasis with its 
characteristic symptoms must have been present. 
Subghoal IIistoby of the Case, by Db. Lilienthal.— 
On June 11th I saw the patient with Dr. Manges. There was 
a certain spareness, not amounting to emaciation, and it would 
have been easy to palpate the abdomen were it not for the sen- 
sitiveness and nervousness of the man. Still, a mass as big as 
an egg could be made out at about the level of the navel. Its 
long axis was transverse as to patient’s body and it could be 
moved to the right or to the left of the umbilicus for about two 
inches. It felt hard and was not tender, but after a moment’s 
manipulation there was an intensely painful peristaltic move- 
ment with a gurgling as if gas had passed through a very nar- 
row place in the bowel. The patient said that this phenomenon 
was of constant occurrence on handling the tumor. I agreed 
with Dr. Manges in his diagnosis and decided to perform ab- 
dominal section. 
June 18th.—0. was chloroformed and a median cut was 
made, entering the abdomen from two inches above to about 
two inches below the navel. The tumor, which just before the 
operation had been to the left of the median line, could not now 
be felt, but was soon found well to the right, and on being 
brought into view proved to be a hard, cicatricial-looking mass 
in the transverse colon. The omentum, which hung very low, 
was firmly adherent to the mass. It was at once decided to 
remove the growth by resecting the diseased gut and its adher- 
ent omentum. The mesocolon contained numerous very small 
nodules, probably secondary to the tumor. The resection was 
accomplished without difficulty, but the intestinal clamps were 
not perfectly secure; consequently some fiecal matter escaped CARCINOMA OF THE COLON. 
5 
and hud to bo very carefully wiped away and the surrounding 
intestines protected with iodoformized gauze. I desire here to 
acknowledge my indebtedness to the house surgeon, Dr. M. \V. 
Ware, whose care and skill at this stiigo of the operation were 
of great value. A large wedge of mesocolon, and that part of 
the omentum which adhered to the now growth, was also re- 
moved, and with it, of course, the entire distal omentum; in 
all, the greater part of the great omentum. The tumor with 
four inches of colon was removed, the lines of excision being 
well in healthy tissue. A large Murphy button an inch and 
three quarters in diameter was used to approximate the ends 
of the gut and, as each half of the button took up about an 
inch more of gut, six inches in all were removed. The button 
was a very “ tight fit” in the colon. The two halves were 
pressed home as firmly as I could push them, but the mesocolic 
side formed so thick a mass that the halves of the button were 
here about one third of an inch apart with the mesocolon and 
gut tightly wredged between them. On the side of the gut 
opposite the mesocolon this defect was made up by the spring 
cup of the Murphy button. This spring gave me some concern, 
for I feared it might not be strong enough to hold the ends of 
the intestine well in apposition. At one spot opposite the 
mesocolon I had not cut the free ends of the gut quite close 
enough, and, fearing the interposition of a bit of mucous mem- 
brane, I broke Dr. Murphy's rule and re-enforced with three 
Lembert sutures. The excision and approximation of the gut 
took not longer than six or seven minutes. The abdomen was 
now completely closed and the patient left the table in fair 
condition. 
On the next day the temperature rose to 102° F., then to 
103° + , hut there was no vomiting or other evil symptom. The 
subsequent progress of the case was uneventful. The patient 
was kept well narcotized until the sixth day, when his bowels 
were moved by high enema. There was tenderness in the re- 
gion of the button, which, by the way, could be easily felt 
through the belly wall as a laterally movable body. After the 
tenth day full diet was permitted. The pain which was com- 
plained of before operation had entirely disappeared. 6 
CARCINOMA OF TIIE COLON. 
On the eighteenth day following operation, T)r. T. I). Tuttle, 
the house surgeon, at my direction performed massage from right 
to left over the colon. About two hours later an enema was 
followed hy a stool containing the button, which, in spite of its 
great size, was passed without pain. • The following day Mr. 0. 
was discharged from my service recovered. 
On August 16th the patient reported himself as much im- 
proved in general health. lie had gained five or six pounds 
and looked well. He was still slightly constipated, but his 
bowels were easily regulated by cascara. There had been abso- 
lute freedom from pain. 
Examination of the specimen by Dr. F. S. Mandelbaum, as- 
sistant pathologist to the hospital, revealed the structure of 
cylindrical-celled adeno-carcinoma—apparently a degenerated 
adenoma. It was hard and cicatricial in character and had 
closed the gut so that its lumen was only large enough to admit 
a lead pencil. 
I can not close this report without adding my testimony 
to the mass already extant in appreciation of Dr. Murphy’s 
beautiful instrument. The drainage holes and the spring 
cup guarding against all accident not the result of care- 
lessness make success in enterorrhaphy almost certain. The New York Medical Journal. 
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