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Public Relations Collection
Don W. Stacks and Donald K. Wright, Editors

The Public
Relations
Firm

Bob “Pritch” Pritchard

Stacey Smith
The Public Relations Firm
The Public Relations Firm

Bob “Pritch” Pritchard, APR, Fellow PRSA,

Captain, U.S. Navy (Ret.)
Stacey Smith, APR, Fellow PRSA
The Public Relations Firm
Copyright © Business Expert Press, LLC, 2015.

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.

First published in 2015 by

Business Expert Press, LLC
222 East 46th Street, New York, NY 10017
www.businessexpertpress.com

ISBN-13: 978-1-60649-664-0 (paperback)

ISBN-13: 978-1-60649-665-7 (e-book)

Business Expert Press Public Relations Collection

Collection ISSN: 2157-345X (print)

Collection ISSN: 2157-3476 (electronic)

Cover and interior design by S4Carlisle Publishing Services Private Ltd.,

Chennai, India

First edition: 2015

10 9 8 7 6 5 4 3 2 1

Printed in the United States of America

 Dedication
This book is dedicated to my mom, Shirley Smith, who taught me that if
you really love what you do then a job isn’t work at all, and to my JJ&W
colleagues who made all these years so much fun!

Stacey Smith, APR, Fellow PRSA

Senior Counsel & Partner
Jackson Jackson & Wagner

I dedicate this book to my father, who passed before he could see the final
result. He was a great man and one of my greatest supporters and advisers.
I hope I made you proud, dad! I also want to thank my wife of 20 years,
Brenda Gayle, for her support and encouragement.

Bob “Pritch” Pritchard, APR, Fellow PRSA

Captain, U.S. Navy (Ret.)
Instructor & Faculty Adviser, Lindsey + Asp
 Abstract
This book takes an in-depth look at the client/agency relationship by dis-
cussing what business leaders should expect of their public relations firms.
It discusses how and why they should pick an agency along with the types
of firms at their disposal. The business of public relations is covered in
the first section of the book. The second section provides detail on the
relationship between firm and client and focuses on what firms must do
to satisfy client expectations of their work. The third and final section
outlines how firms establish success or failure. Expert advice is provided
on everything from hiring a firm to defining output and outcome expec-
tations and everything in between.

Keywords
PR firms; PR agencies; Hiring a PR firm (agency); How to Hire a Public
Relations (pr) firm (agency); Hiring a pr (public relations) firm (agency)
(company) (person); How PR firm’s bill; Evaluating a pr firm (agency)
(plan) (campaign); PR firm billing rates; pr firm (agency) contracts ; pr
practitioner roles, Responsibilities; Public relations evaluation; Client-
Firm relationship; Public relations research; Public relations execution
 Table of Contents

Preface...................................................................................................xi
Introduction ..........................................................................................1
Part I The Business.................................................................... 3
Chapter 1 Why Hire a Public Relations Firm?....................................5
Chapter 2 Types of Firms..................................................................17
Chapter 3 Hiring a Firm...................................................................27
Chapter 4 Defining the Work...........................................................35
Chapter 5 How Firms Bill................................................................45
Part II The Working Relationship between
Client and Firm............................................................. 57
Chapter 6 The Client–Firm Relationship..........................................59
Chapter 7 Progress Reports...............................................................69
Chapter 8 Research and Execution...................................................77
Chapter 9 Evaluation........................................................................87
Part III Meeting Expectations: Measurement
and Evaluation.............................................................. 93
Chapter 10 Meeting Client Expectations............................................95
Chapter 11 Wrapping Up.................................................................103
References............................................................................................107
Index..................................................................................................109
 Preface
My coauthor and I were asked to collaborate on this book by our editor,
Don Stacks. Don is one of the top researchers in public relations, espe-
cially in measurement and evaluation. He’s also been my mentor since I
first entered academe in the fall of 2001, so it was a tremendous honor to
be asked by him to write a book.
This is my first book, though I had contributed several chapters to
other texts. Stacey Smith, my coauthor, had the edge on me as she’s coau-
thored one of the top case study textbooks and edited and wrote for the
well-thought-of industry publication pr reporter for more than 20 years.
Still, the challenge was a little daunting for us both.
When Stacey and I first sat down to organize this book, we had in
mind practicing business executives. It has always been our hope that this
book will help inform management practice and help current and future
business leaders identify and better utilize public relations firms and in-
dependent professionals.
But, we also knew the audience was broader than that. We hope
this volume is helpful to students and faculty in any number of pub-
lic relations classes, including Introduction to Public Relations. And
while a niche market, we hope our book will be especially helpful to
students and faculty starting or growing a student-run public rela-
tions firm. As these experiential learning laboratories have become
more popular, the need for information on the business side of agency
operations is more in evidence than ever.
We start our book with an in-depth look at the client/agency rela-
tionship, discussing what business leaders should expect of their public
relations firms. We discuss how and why they should pick an agency along
with the types of firms at their disposal. The business of public relations
is covered in the first section of the book. The second section provides
detail on the relationship between firm and client and focuses on what
firms must do to satisfy client expectations of their work. The third and
final section outlines how firms establish success or failure.
xii PREFACE

While we met and overcame significant challenges during spring

2014, the process of writing this book has been a real pleasure and learn-
ing experience for Stacey and me. As you will read in our bios, I’m deeply
involved with student-run public relations firms and Stacey is Senior
Counsel and Partner at one of the top behavioral public relations and
management consulting firms in the country. Even with that experience
we are better professionals for this journey, giving us a more global and
well-rounded knowledge of firm operations.
We would be remiss if we failed to acknowledge the help and sup-
port of our editor, our families, and our colleagues in writing this book.
A special “Thank you” goes out to Peter Debreceny and Ron Culp, who
reviewed our second round edits and provided exceptionally insightful
comments. And, of course, we want to give a special acknowledgment to
our editor, Don Stacks. Without his expert guidance and patience this
book might well have ended up on Jimmy Fallon’s “Do not read” list.
 Introduction

Why do organizations decide to hire outside public relations counsel?

What drives them to this decision and how, with so many competitors
vying for their attention and their business, do they find the right match
in terms of skills, people power, budget, and work style? How will they
measure the success of the relationship?
Public relations agencies/firms are ubiquitous in many ways, mean-
ing there are a lot of choices to be considered from a friend or a family
member who “does PR” to small firms, large agencies, and independent
practitioners. Typically, the organization seeking counsel makes a deter-
mination based on their own perception of need for various skills, depth
of experience, extra hands, or industry understanding.
The organization issue that needs addressing might be in the arena of
public policy; therefore, an agency with lobbying and political experience
is needed. Or it might be in the arena of sales support; thus the need is
for skills in marketing and sales promotion and publicity. Or needs may
require organizational development skills, which would call for an agency
that understands internal communication, facilitation, and organization
development. However, the tasks the organization thinks they want to
address may be only symptoms of a different, more complex issue needing
an entirely different approach or set of skills.
Where should an organization start? What are the questions they
should ask? What are some realistic expectations? These are the under­
lying issues this book seeks to address. If an organization is considering
hiring an agency/firm to assist, starting with this book will make that
relationship and its outcomes all the more successful.

Stacey Smith
Rye, NH
Robert “Pritch” Pritchard
Norman, OK
2 INTRODUCTION

Note: It is the preference of these authors to refer to “agencies” as “firms”

in general and in this book. Some say the term “agency” suggests that
counsel is in a vendor relationship, offering a product that is interchange-
able with others offering the same product. Others say the term implies
the firm is acting as an agent of the client, which captures a singular task
such as speaking to the media on the client’s behalf, for example.
Public Relations has been referred to over the past several decades as
both a science and an art (www.instituteforpr.org). Like an organization’s
relationship with its attorneys, the professional services we offer clients
are not a “product,” but counsel. And today, public relations encompasses
much more than just media relations. Therefore the authors prefer (and
will use herein) the term “firm” in place of “agency.” We urge you to con-
sider this semantics nuance when you seek your next relationship with
a public relations firm. We also prefer to use the term “public relations”
rather than its sometimes pejorative abbreviation “PR.” An entity that
approaches your organization and its issues like a vendor will provide a
very different and a much shallower and less effective manner from a firm.
 PART I

The Business

Many consider public relations a part of the promotional trinity: Ad-

vertising, Marketing, and Public Relations, sometimes called the “3 Ps”:
Publicity, Product, Promotion. In actuality, all three have something in
common, but also have a great many differences. To begin with, public
relations deals with two-way symmetrical communication (Grunig and
Hunt 1984)—where messages are communicated with the purpose of
achieving a dialogue between an organization, brand, issue, and specified
target audiences or public. Although often put at the end of the promo-
tional process, public relations is vital when trying to influence people to
do or purchase something. Today, this is even more important as we find
more and more promotional messages being transmitted through social
media, a media that encourages two-way symmetrical communication.
Second, while public relations continues to have its “artsy” side—that
is the creation of well-written and graphically designed communication
materials—it is also heavily influenced by the social sciences and even the
natural sciences. This is especially true when the objective of the public
relations campaign or program is to influence an audience. The under-
lying strategy (theory) in many cases is attitude change that results in
some behavior change (Bowen et al. 2010; Michaelson and Stacks 2014).
Indeed, Michaelson and Stacks (2014, p. 25) propose a model of public
relations in the following graphic, where the message is first evaluated
and then moved from objective to objective, depending on the stage of
the BASIC life cycle.
4 THE PUBLIC RELATIONS FIRM

Figure I.1 The communication life cycle

This model requires that research be conducted on the problem at

hand before a strategy or campaign can be conducted and it relies heavily
on social scientific research on the influence process. It is an example of
what the Institute for Public Relations (www.instituteforpr.org) calls the
“science beneath the art.”
But the most important aspect of the difference between public
relations and advertising or marketing is that public relations is the
business of change, reinforcing current beliefs, or inducing resistance
to change, and its outcomes can be measured in terms of how re-
turns on expectations (ROE) influence returns on investment (ROI)
(Stacks 2011). The public relations effort has to begin with an estab-
lished baseline, with set objectives that mirror the client’s goals, and
then demonstrate effectiveness by correlating success to other business
functions (e.g., marketing, human resources, and finance) in driving
toward meeting the business’ goal. This book explores how that is
done by outside consultants (“counsels”) who are hired by the client
to influence the behaviors of targeted audiences. Part I sets the basics.
 CHAPTER 1

Why Hire a Public

Relations Firm?

“The media and our opponents were bearing down through the news
media and our leadership team kept fanning the flames, with no clue
how to back off and resolve the issues. I had done all I could—they
needed to hear from a different voice”
—Director of Communications, Government Entity

“We needed to have some concrete, objective data on what employees

were thinking and needing in terms of communication systems”
—Director of Communications, Major Airline

“I had just taken over as head of the organization—I needed a candid

assessment of the organization’s relationships”
—Superintendent, Public/Private School

“We were having trouble reaching customers with our messaging.

Either we were using the wrong channels or the wrong messages!”
—Executive Director, Non-Profit Organization

“My department was lean—too lean and we needed some extra hands
that I couldn’t afford to hire full time—to get the launch done”
—Director of Public Relations at a large
manufacturing company
6 THE PUBLIC RELATIONS FIRM

As we noted in the Introduction, there are a myriad of reasons organiza-

tions hire outside public relations firms. Tactical reasons can include:

• Needing skill sets that are not currently resident in the

department
• Needing extra hands to handle a project, temporary or
otherwise
• Seeking a wider range of creative thinking
• Making use of a firm’s relationships/contacts with traditional
and social media

Strategic reasons are broader and higher level. They can include:

• Experience with significant problems or opportunities that

the organization may be facing including strategic planning,
crises, reputational issues
• Building credibility for role and function of public relations
with senior management or Board of organization
• Evaluation of staff, organizational structure, department
structure, and effectiveness
• Research expertise with stakeholder groups to identify
perceptions, attitudes, and behaviors along with effective
methods of communication

So the question one must ask is what actual needs does the organization
have and what type of public relations firm is best to help fill those needs?

Evaluating Your Needs

This is a bit like deciding you have a hip problem and going to an ortho-
pedist for help. What if the problem is not the hip? What if it is muscular
or a bad mattress? Will the orthopedist see only skeletal solutions? Did
you need the expert first or the generalist to help you evaluate what is
necessary?
Hiring the right public relations firm means diagnosing the right prob-
lem. Now a crisis where “60 Minutes” is knocking at your door or the
 Why Hire a Public Relations Firm? 7

entirety of local media is camped in your parking lot is pretty indicative

that you need some help. Even a shortage of staffing is pretty self-evident.
There is work to be done and not enough people to do it—so hiring
“extra hands” is obvious. But is it? Have you identified the core problem,
or just a symptom of a bigger problem that should be addressed? If cus-
tomer satisfaction levels are down it could be that systems are not working
well, but what if staff morale is down as well and causing a domino effect?
Or, perhaps your communication staff is spending their time on activi-
ties that are more “make-work” than advancing the relationships that the
organization actually needs. Much like zero-based budgeting, every pub-
lic relations function should have a Strategic Plan that addresses all critical
audiences.
Unless it is a crisis of major proportions, the best place to initially
determine the type of firm you may need is the corporate communica-
tions department’s Strategic Plan.1 Make sure to have clear goals, objec-
tives, and strategies based on the goals and objectives for the organization
as whole for all priority audiences.2 And if not, then this may be your first
skill set to consider when hiring a public relations firm.

Key Elements to Look For in a Strategic Plan

There is a great difference between a general plan and one that is strate-
gic. A strategic plan first and foremost has public relations goals that are
directly related to the business goals and objectives of the organization
as a whole. They should seek to further the ability of the organization to
succeed by targeting priority audiences (customer, clients, employees, com-
munity, shareholder, and so forth) critical to making organizational goals
achievable. Each of these priority audiences should have targeted, measure-
able goals for the time period of the plan. There should be a strategy on
how to achieve the goals taking into account the possible barriers—both
structural and psychological—to reaching those goals. Then the tactics

1
For a more on the importance and role of the organization’s communication strategy
see Bowen, Rawlins, and Martin (2010), p. 26.
2
For a more on understanding and measuring public relations outcomes see Michaelson
and Stacks (2014), pp. 35–47.
8 THE PUBLIC RELATIONS FIRM

should include one-way, two-way and interpersonal communication tactics

because research has proven that behavior is motivated by not just by
information but relationships (Deci and Ryan, 2000, p. 71). Finally, there
should be some type of measurement in the plan that can give leadership
a sense of whether the strategy, tactics and expenditures are making a
difference.3

Three Arenas of Public Relations Practice

There are three broad arenas of public relations practice in which the pub-
lic relations firm operates. These are sales support, public policy, and orga-
nizational effectiveness. Each of these arenas have specific functions (also
known as functional areas), goals, clients, and collaborators that must be
examined and taken into account when making a decision about the type
of public relations that firm should be engaged (see Table 1.1).
Sales Support is the most traditional role of public relations. This is the
area where public relations builds and maintains awareness for an organi-
zation’s products or services while assisting marketing and sales in moving
potential customers toward action. It also works with customer service
and satisfaction issues. Many of the traditional media outreach activities
of the field are part of sales support. Organizations often hire public rela-
tions firms for their media contacts, skill, and experience with events and
awareness opportunities.
Public Policy is an arena of public relations that sometimes overlaps
with public affairs, legal, or lobbying functions. The need in this area is
ensuring that the Federal, State, and local rules and laws in place to do
not hamper the ability of an organization to operate effectively and effi-
ciently in the marketplace. Sometimes this means local zoning ordinances
might be a problem, or State and Federal laws might get in the way. Taxes
alone (those you have to pay as well as those that you may not want to
pay) keep some public relations/public affairs functions very busy. Often
corporate communication departments do not have the expertise or the
connections to stay on top of potential issues or defeat or pass legislation
that may arise or be needed. Demonstrating the organization is a positive

3
See Bowen, Rawlins, and Martin (2010), pp. 24–35.
 Why Hire a Public Relations Firm? 9

Table 1.14 Three arenas of practice: How public relations serves &
adds value
Organizational
Sales Support Public Policy Effectiveness
Functions: Functions: Functions:
Consumer relations Constituency relations Employee & retiree
Sell products & services Issues anticipation & relations
Publicity & promotion tracking Recruitment & retention
Other marketing support Crisis management Employee engagement
Fundraising Damage control Shareholder relations
Enrollment, attendance at Lobbying/government Financial relations
events relations Supplier relations
Awareness Community relations Industry relations
Customer delight & Social responsibility Alumni or member
Loyalty Contributions, focused relations
philanthropy Change management
Volunteer programs
Goals: Goals: Goals:
sales & profits, brand maintain a hospitable teamwork, one clear voice,
preference, market share, environment & a cadre of motivation, productivity,
relationship marketing active supporters loyalty, morale,
understanding, cost-
effectiveness, support
Clients: Clients: Clients:
sales & marketing CEO, Board, unit CEO, CFO, COO, unit
departments managers, senior managers managers
Collaborators: Collaborators: Collaborators:
same as clients law, strategic planning, risk human resources
management departments department, corporate
secretary, quality or
re-engineering teams,
training units

and contributing member of the community is another part of this arena.

Public relations firms can assist with all these areas.
Finally, Organization Effectiveness is the third area where public relations
can make a difference—and a large one at that. Many of the issues that orga-
nizations have to deal with externally stem from internal communication
problems. Top down communications outlining what senior management
needs from employees and is trying to achieve is often not received, unheard,

4
Patrick Jackson (1989, February 13). pr reporter.
10 THE PUBLIC RELATIONS FIRM

or even acted upon. Bottlenecks can occur at all levels of the organization
making communication difficult. Bottom up communication is also often
blocked either because middle management does not want it going to the
top, employees feel it will not matter if they do communicate upward, or
senior managers do not or cannot hear what is being said as constructive.
Finally, and often most difficult, is lateral communications—overcoming
the “silo” mentality and departments that work at cross purposes, rather than
as a team trying to achieve the same goals.
All of these are areas where organizations can suffer and public rela-
tions skills and techniques can help greatly. Before we move to describing
how firms differ from each other, three points need to be emphasized:

1. Public relations is a staff, not a line function. Therefore, it is a con-

sulting & service position which is always responsible to its client.
Confusion arises when public relations tasks become a “product”
(e.g., a magazine in a membership organization or a user group to
unite customers).
2. Excellent public relations is about outcomes. Any of the ­techniques
or processes of public relations can be used in each of the arenas (e.g.,
publications, events, publicity, speeches, one-on-one, symbolic com-
munications), but the focus remains on what has been achieved on
behalf of the organization’s business goals (see Chapter 10 for a more
complete discussion on outcomes).
3. By nature public relations is non-linear, a seamless web. ­Anything
done in one arena affects the other arenas. Over-promising in sales
support may bring a public policy response; lack of organizational
effectiveness will affect sales, and so forth.

Sizes of Firms/Agencies

Having a handle on what types of work is needed when hiring a public

relations firm can definitely help in narrowing the choices. There are pub-
lic relations firms that are considered “large” in that they have multiple
offices in many different cities and countries, each with a sizable staff of
senior practitioners and junior associates. There also are mid-sized and
small public relations firms.
 Why Hire a Public Relations Firm? 11

Large Firms

One of the major benefits of large firms is their reach, both geographic
and in terms of media and customer markets. Their breadth offers them
the ability to have specialties in all areas of public relations (sales sup-
port, public policy, and organization effectiveness) and to work seam-
lessly across offices. Typically they have a research function that is skilled
and integrated into support services for all their activities on the client’s
behalf. And they will most likely have had experience in your particu-
lar industry or situation regardless of what it is. Firms like this include
Edelman (the largest in 2014), Weber Shandwick, Fleishman-Hillard ,
MSL Group, Burson-Marsteller, Hill & Knowlton, and Ketchum. Many
of these firms have long and illustrious histories.
A drawback typically found with large firms or agencies is that the
attention of senior managers is often focused on developing new business
rather than servicing the client’s account. So after the “sale” of getting
their business, clients might see more junior account executives rather
than the head honchos you met at the beginning. This can be an issue
in other firms of all sizes, but large firms seem to be more prone to this
shortcoming. Large firms are generally aware of this reputation and are
sure to be careful to provide the appropriate top-level attention to the
project. However, most likely there will be bigger clients with larger bud-
gets on the docket who definitely have the potential to consume the firm’s
energy and time. Also, large firms are generally more expensive and the
rates that are charged for more junior practitioners may be more than
they are worth—skill wise. Patchy skills across offices is another draw-
back. But, depending on needs, a large firm with connections and reach
may be just what a client wants.

Medium and Small Firms

Medium and small firms can offer a greater degree of attention from their
senior members. Typically they have similar connections with the media
in their catchment area (a geographical boundary that includes all readers
of local/regional newspapers and viewers of broadcast/cable television)
and, if they have specialties, they can have connections there as well.
Some will have a wide range of expertise but it is usually more limited
12 THE PUBLIC RELATIONS FIRM

than the large firms. So, they may be highly skilled at sales support or
public policy, but not organization effectiveness issues. Small firms are
sometimes called “boutique” agencies or firms.
The medium to small firms have the flexibility to address a client’s
needs by often connecting with other small firms or independent profes-
sionals (see below) who can fill gaps in their capabilities. The benefit of
this model is that you do not pay for what you do not need. There is no
overhead cost to those functions that the client is not using. And the skills
of the small firm professional can be wide and deep for they have had to
do lots of different tasks and handled many different client types given
their size. There is little ability to silo in a small firm. And, with a small
firm clients may be the “large fish” and get the attention their business
needs and deserves.
However, medium and small firms do not have the national or global
reach that a large firm will have (although some are part of networks that
can make those national & global connections such as GlobalCom, PRN,
Global Network, and so forth.). And, if a lot of attention and work is
needed, they may not have the depth of staff to cover your needs.

Independent professionals

Finally, there are independent professionals. These are professionals who

often set themselves up as “So-and-So and Associates” to give the ap-
pearance of employing more than just one or two people. But these can
also, depending on your needs, be your best bet. They can focus strictly
on your needs and situation. They can function as an employee without
the overhead and long-term costs of a full-time employee. They can give
your public relations department flexibility and additional skills, creativ-
ity, fresh thinking and an extra pair of hands at a reasonable cost. Much
like the smaller firms, the independent professional also offers boutique
services, often in specialized areas that fit in with the area in which they
practice.
Regardless of which direction a client might choose, it is important
to first evaluate your needs. Firms of all sizes can offer senior managers a
fresh perspective on the public relations function, what it can and should
achieve, and the tools and tactics to get there. Evaluating your needs first
 Why Hire a Public Relations Firm? 13

will help make the search go much easier and you are more likely to find
the right fit with less effort.
Each year a variety of publications that report on the profession pub-
lish a ranking of the top firms by a variety of indices including revenues
and staff size. Many of these figures are self-reporting by the firms. Some
publications do more detailed checking of the facts and figures submit-
ted. These lists are by no means exhaustive and only include those firms
that chose to participate or are legally allowed to reveal their numbers
(for instance, those that are part of a larger holding company.) Figure 1.1
presents such a listing.

Public Relations/Advertising/Marketing

The next issue to address is the focus of the firm. For that reason, it is im-
portant to be aware of the difference between marketers, advertisers, and
public relations firms.
In the field of communication, there are marketing professionals/
agencies whose job it is to research and understand the motivations and
behaviors of customers and potential customers so that they can craft prod-
ucts and services to meet their need (or create a need amongst them in
order to sell a product or service). Marketers do not typically concern
themselves with audiences other than customers or relationships beyond
the sale.
Advertising professionals/agencies are typically paired with market-
ers because they too are typically focused on producing ads for products
and services that the marketers have identified and researched. However,
advertising agencies can also do advertising on reputational issues such
as branding, social responsibility, community service, and shareholder/
donor investment. That said, their work is primarily about creating
awareness through one-way communication that is paid for by the client.
And similar to marketing, advertising focuses on customers and relation-
ships built around sales.
Public relations is responsible for all relationships with all publics and
audiences an organization has—not just one segment. Any one of these
publics can cause havoc for the organization so relationships need to be
built and maintained constantly.
 14

Revenue
Rank 2013 US 2012 US Change Rank Staff Staff Change ($) per US
2014 Agency Name Revenue ($) Revenue ($) % 2013 2013 2012 % employee Location
1 Edelman 450,349,686 406,253,336 11% 1 2443 2249 9% 184,343 Chicago
2 Waggener Edstrom 98,270,000 101,352,000 23% 2 567 682 217% 173,316 Bellevue, WA
Communications
3 APCO Worldwide 76,614,800 75,255,177 2% 3 295 288 2% 259,711 Washington, DC
THE PUBLIC RELATIONS FIRM

4 W2O Group 69,680,000 56,097,000 24% 5 366 283 29% 190,383 San Francisco
5 FTI Consulting (1) 64,000,000 61,000,000 5% 4 205 220 27% 312,195 New York
6 ICF SCM 48,135,325 42,826,374 12% 7 280 260 8% 171,912 Fairfax, VA
7 MWW 46,629,000 42,875,000 9% 6 210 207 1% 222,043 New York
8 ICR 43,322,436 37,339,790 16% 8 104 91 14% 416,562 Norwalk, CT
9 Finn Partners (2) 43,026,957 26,546,000 62% 11 287 205 40% 149,920 New York
10 Ruder Finn 37,444,000 33,704,000 11% 9 202 193 5% 185,366 New York

Figure 1.1 US Agency Rankings 2014 PR Week

Courtesy of PR Week (http://www.prweek.com/us/abr2014rankings)
 Why Hire a Public Relations Firm? 15

There is a long-standing debate over what to call public relations.

In the 1980s it went through the “Integrated Marketing Communica-
tions” phase. Prior to that professionals jumped from “Public Affairs”
to “Public Information” to “Marketing Communications” and so on.
Currently, “Strategic Communications” is a popular term for many. At
the heart of the work done under all of these monikers is building and
maintaining mutually beneficial relationships. That said, public relations
is still a likely term you will find in a firm’s name, even with all the nega-
tive connotations it carries (for instance, its [incorrect] association with
“spin”). Therefore, when shopping for a firm, remember that you may
encounter a variety of different titles which may or may not include the
term “public relations.”

Summary
To find the best “fit” when hiring a public relations firm, it is critical to
understand the problems or opportunities your organization is facing and
the type of expertise is necessary for solving those problems. The general-
ist firm can help identify issues by researching the situation and bringing
past experience to the table. Likely, your issues will be related to one or
more of the areas of “sales support,” “public policy,” or “organization ef-
fectiveness.” Therefore, the firm you seek should have skills that align in
one or more of these areas. Firms come in all sizes: large, medium, small
(boutique), and independent professionals. Your situation analysis and
scope of work will help the right size firm to interview. Understanding
that public relations work is non-linear and outcomes focused will assist
you in finding counsel who can guide you and your organization in build-
ing (or re-building) mutually supportive relationships with your audi-
ences. Chapter 2 will further explore types of firms and their specialties.
Another random document with
no related content on Scribd:
 The nature of the bacterial invasion is of more interest to the
pathologist than to the surgeon as such. In general, however, it may
be said that, in addition to the ordinary pyogenic organisms, the
colon bacilli are perhaps the most frequently to blame, while the
more putrid types are the result of actual escape of bacteria from the
intestine, as through a perforated appendix, and the addition of a
mixed type to one which began perhaps as a simple one. Thus in the
so-called putrid forms multiple bacterial contamination is usually
discovered upon making cultures. The pneumococcus, the capsule
bacillus, and the gonococcus are also not infrequently found, in
cases of peritonitis whose nature and origin will be suggested by the
discovery of the particular germ involved in each case.
Symptoms.—While varying much in time and intensity, and even
completely changing their type during the successive
stages of the disease, there are, nevertheless, certain cardinal
symptoms which are universally recognized in cases of surgical
peritonitis. These include vomiting, pain, tenderness, with more or
less shock, followed sooner or later by abdominal spasm and
distention, while to these symptoms there is sure to be added bowel
obstruction of some type which becomes, toward the end, perhaps
the most profound feature, and which may even mask the
significance of other symptoms. According as the lesion is localized
or generalized pain may be referred to a particular area or may be
general and intense. Local pain, with tenderness, usually implies, at
least at first, a localized lesion, and is not so likely to be
accompanied by vomiting as the more diffuse form. Depression is
found to correspond largely to the type and degree of sepsis, while
collapse is a prominent feature in the more severe cases. The pain,
which is sometimes intense, subsides, and it should be emphasized
that a speedy subsidence is not necessarily a favorable symptom. It
too often marks the transition of an ordinarily acute case into one of
intensely septic or even putrid type. Tenderness may be acute and
localized, or diffuse and only evoked on deep pressure. One of the
most significant symptoms is abdominal rigidity, which persists
throughout the active state of the disease, and which, when followed
or accompanied by meteorism, may to some extent mask and
obscure all conditions within. If the patient be not seen until this
stage is reached diagnosis can be made only by history and
conjecture, for it is almost impossible to determine anything by
palpation.
Temperature is an uncertain factor. It sometimes rises high at first,
and then falls, while if it fall too low the prognosis is serious. The
pulse also shows very irregular variations, usually rising, however, as
the disease becomes more severe, and being often almost
uncountable at the end. A combination of rising pulse and falling
temperature is of serious import.
In addition to the vomiting, which is a pronounced early feature of
the disease, we have, as bowel obstruction comes on, an added
fecal character to the vomitus, which sometimes is most
characteristic of complete obstruction. This obstruction is due in part
to toxic paralysis of the muscular coat of the bowels, and in part to
the result of adhesions or fixations by which bowel motility is
completely prevented. Thus in many instances of peritonitis following
acute appendicitis there are loops of intestine glued together by
exudate in such a way as to practically occlude or disable them.
The depression, shock, and final collapse of the disease are
characteristic, as is also the facial appearance, the cheeks becoming
discolored and the orbits hollowed out, so that the eyes early sink
back. Other expressions of diminished blood pressure are not
lacking—coldness of the extremities; cold, clammy perspiration;
lividity of the skin, and the like.
While this is a picture of the most common expressions of acute
septic or surgical peritonitis, it is occasionally found that conditions
equally serious arise without such marked symptoms, and that the
patients become rapidly worse, finally dying, who neither vomit
continuously nor show extreme meteorism nor abdominal rigidity.
Such cases are thereby stamped as those of more extreme toxicity,
where systemic reaction is paralyzed almost from the outset, and are
accordingly the more hopeless on that account.
Ordinarily it is not difficult to recognize the onset and the course of
peritonitis in surgical cases. The condition may be confounded with
one of septic intoxication from some focus which has not involved
the peritoneum; otherwise differentiation is rarely difficult. The
occurrence of such a condition does not necessarily indicate faulty
technique on the part of an operator, as the condition is too often
present when the surgeon begins his work. On the other hand, it too
often follows faulty technique and constitutes the strongest argument
for vigilance both in preparation, performance, and after-treatment.
Treatment.—But little will be said here about non-operative
treatment, although first it should be emphasized that
treatment in the past was too often of the non-operative type. Many
cases of peritonitis could be saved by operation were it performed
while the infection is still localized, but this is at a period when they
too rarely reach the surgeon’s hands, he being called in as such
when the inefficacy of drug treatment has been already
demonstrated. Without denying that the surgeon is not blameless in
all these respects, blame should, nevertheless, be placed where it
properly belongs, at the door of the man who fails to recognize and
carry out plain surgical principles.
The opium treatment for peritonitis, with which the name of Clark
will always be associated, was introduced at a time when many
things were considered as peritonitis which were not necessarily
such. It was furthermore an advance on previous methods and gave
better results. That, however, is no excuse for adhering to it when
better means are at hand. On the other hand it must not be denied
that much can be done medicinally to give comfort and meet certain
indications. In spite of the many disadvantages attaching to the use
of opiates it seems unnatural to let patients suffer as they would
without them. It is justifiable, then, to use them in cases which are
hopeless, or in those which refuse operation; but given
indiscriminately and early they often mask symptoms which, if
properly appreciated, would lead to early diagnosis, and, it is to be
hoped, early operative relief. Views also differ regarding catharsis. It
is a great disadvantage to permit the intestines to retain fecal matter
for days and add a consequent copremia to the other features of the
disease. On the other hand, intestinal activity tends to disseminate
infection, and is, consequently, most undesirable. If at the outset the
intestinal canal could be emptied and then left at rest it would best
meet the somewhat contrary indications.
Ordinarily, however, it is of small advantage to keep bombarding
the stomach with repeated doses of laxatives which are more often
rejected than retained, and which have little effect.
One of the most distressing features is vomiting, and here it is well
to follow Berg’s suggestion and test the vomitus with litmus paper. If
it be found alkaline small doses of morphine should be given, each
with a drop or two of aromatic sulphuric acid, in a little chopped ice. If
it be found acid small doses of milk of magnesia are advised or
some such preparation, with minute doses of morphine, frequently
repeated. The greatest relief in these cases, where the upper bowel
is emptying itself into the stomach, will be obtained from lavage. In
the same way tympanites and meteorism are best treated by passing
a rectal tube high, leaving it in place, and utilizing it for lavage of the
bowel, using warm water with a little sodium salicylate. Not the least
distressing feature of such a case is the reflex hiccough which is
produced by diaphragmatic spasm, since the phrenic nerve
distributes sensitive fibers as well to the peritoneum. For this there is
no really effective remedy. Small doses of Siberian musk, with or
without morphine, beneath the skin will sometimes quickly relieve it.
Depression and lowered blood pressure are best treated by
adrenalin and digitalis, rather than by strychnine, which stimulates
peristalsis. Fever, when high, should be treated by cold sponging
rather than by antipyretics. The kidneys should be kept active, if
necessary by hypodermoclysis, and the skin equally so by hot-air
baths, as through both of these emunctories much elimination may
be effected. The question of catharsis comes up again in considering
what can be done to improve elimination of ptomains by watery
stools, but these are hard to secure; it is, after all, questionable
whether their effectiveness in this regard has not been greatly over-
rated. Richardson, for instance, is inclined to believe that cases
reported as cured by free catharsis would, in all probability, have
recovered without it, it being doubtful whether the really infectious
element be present.
Surgical treatment of peritonitis includes a recognition of the
cause, and, if possible, its removal. Richardson has grouped in the
following suggestive manner the indications for operative
intervention in the early stages, when cases are not without hope:
General pain, becoming local; or local, becoming general,
according to cause;
 Tenderness, showing the same indications;
Abdominal rigidity;
Green vomitus;
Rising pulse and temperature;
Diminished peristalsis without too much shock.
On the other hand, in cases of fully developed peritonitis, where
the surgeon may still consider the possibility of intervention, but
where prognosis is far less favorable, the conditions include:
Lessening or vanishing pain;
More general tenderness;
Great distention, replacing rigidity;
Excessive dark or fecal vomitus;
Obstipation;
Rapid and feeble pulse;
Pain extremely severe;
Low temperature and the ordinary evidences of reduced blood
pressure.
In such cases the decision rests largely upon the degree of
collapse. To operate upon a moribund patient is hopeless and brings
discredit upon surgery. Before operating upon any serious case of
this kind the circumstances should be fully explained to those
concerned, and they should be impressed with the fact that should
the patient die he dies not in consequence of the operation but in
spite of it.
The operation itself will in a large measure depend upon what can
be learned of the etiology of the disease and the diffuseness of the
resulting infection. To reach a localized focus the incision may be
made at any point which will best afford access; but in dealing with a
generalized process the middle line, and an extensive incision, will
ordinarily afford the best opportunity for doing whatever is necessary.
The preliminary incision may be made short, as for exploratory
purposes. Unless a loop of distended bowel be at once blown into
the opening there will be prompt escape of fluid, whose character will
reveal much of what has gone wrong within. If reasonably clear the
operator is fortunate. If it be purulent he has to combat a most
serious condition; if it be offensive, it is probably due to
contamination from a septic abscess or from intestinal gases, while if
the fluid be nondescript and contain floating particles of fecal matter
there is an intestinal or gastric perforation. So soon as one comes
upon fixation or adhesion of viscera he will find lymph, in condition of
greater or less organization. Inside the masses thus bound together
he will probably find the greatest centre of pernicious activity.
The more one sees of these intra-abdominal conditions the more
respect he, as a surgeon, feels for the omentum. Only recently have
surgeons learned to appreciate the kindly activities of this duplicature
of the peritoneum, with its slight or heavy load of contained fat. It
manifests a tendency which may be almost regarded as a sagacity
or instinct for shifting itself toward a local focus of infection, and there
throwing out lymph by which it becomes attached and helps to form
a protective barrier that often is most effective. Were it not for this
tendency many cases of acute appendicitis, for instance, which now
recover would be lost during the early days of the attack, in
consequence of a quickly disseminated infection. Thus a
gangrenous appendix, or hernia, or gall-bladder, is frequently so
wrapped up in a protective layer of omentum that the operator has
first to detach this, or go through it, before he comes upon the actual
site of the trouble. Some such disposition of the omentum, then, may
be easily discovered during the earliest moments of his exploration,
and if later he conclude to remove a portion of it, because of actual
or impending gangrene, he nevertheless sacrifices it with a feeling of
regret because of the good it has already done.
The further treatment of these cases is essentially a matter of what
can be done to remove the exciting cause. Questions of gravest
import, and often difficult of immediate decision, will present in nearly
every case; as, for instance, whether to resect a portion of intestine,
to remove a gall-bladder, to hunt for an appendix when embarrassed
with the difficulty of the effort and necessity for widely separating
intestinal coils, or of the treatment of distended bowel, which it may
perhaps be impossible to restore to place, of extensive and complete
flushing of the abdominal cavity, or of mere local cleanliness. And
after these questions have been decided, and action taken, there
comes still the question of drainage, with the wisdom of or necessity
for counteropening, as in the loin or in the cul-de-sac, and the
character of drain to be used. As to what should be attempted in
general there will rarely be much room for doubt. As to how best to
accomplish it should be decided according to the training, the
experience, and the opportunities of the operator, and the nature of
the environment. When the entire peritoneal cavity is invaded, and
flooded with more or less infectious material the more thoroughly it
can be washed out the better. At the same time to do this with any
degree of even apparent thoroughness requires practical
evisceration of the patient, and an amount of time spent and shock
produced by handling the viscera, which are exceedingly depressing
and may of themselves be more than can be borne. The meteorism,
which is so conspicuous a feature of most of these cases, means the
distention of the bowel to such a degree that when once the
intestines lie upon the surface of the body they can usually be
restored with the greatest difficulty; and this would raise the question
of the desirability of either one or more punctures, through which gas
should be allowed to escape, or a sufficiently wide opening, with the
introduction of a Monk tube, and the complete emptying both of gas
and putrefying fecal matter. The latter is certainly in theory the much
more desirable measure, if the patient’s condition will only justify it.
Probably after pelvic drainage the Fowler semi-sitting posture in bed
would be desirable, while after high drainage the Trendelenburg
position, with the pelvis higher than the thorax, would be preferable.
If free abdominal irrigation is to be practised a large quantity of
warm sterile saline solution should be used, to which may be added
perhaps a small proportion of acetozone or of mercury bichloride.
The silver salts also make equally effective and less irritating fluid,
the nitrate being used in the proportion of 1 to 10,000, or the citrate
or lactate in proportion of 1 to 500 or 1 to 1000. These metallic salts
will coagulate the albuminoid fluids and give to the peritoneum an
opaque appearance, which, however, need cause no alarm.
Another question of importance is that of enterostomy. In some of
these cases the acute bowel obstruction is the most predominating
and distressing late feature, and an enterostomy may be attempted,
even though it be known it will serve but a temporary purpose, in
order to relieve distress. There never can be more than sentimental
objection to it, in such cases, with the possibility of something more
than mere temporary relief. It can be effected under local cocaine
anesthesia, by attaching to the parietal peritoneum the first loop of
distended small intestine that presents, and, after firmly fixing it in
place, making a small opening, and then preferably inserting a glass
or other tube for better drainage purposes.
These constitute the precautions to be followed and the advice to
be given in cases of septic or surgical peritonitis. How successful
they may be, or how satisfactory the termination of the case, cannot
be foretold by statistics nor by reports of cases in the hands of
others. Success will depend in large measure upon the early or late
period at which the case is thus treated, and upon the general
surgical discretion and experience of the operator. It is probable that
disappointment will result more often than success. Nevertheless
every life thus saved is one snatched from a certainly fatal
termination without it, and if successful but once in ten times one life
has thereby been saved that may be worth saving, without saving
the other nine. While I would advise to make the attempt in any case
which offers a reasonable prospect of success, caution should be
used against doing it without a full understanding with those
concerned that it is an effort in the right direction, concerning which
no promise can be made; death results not from the operation so
much as in spite of it.
Summarizing, briefly, the best methods of treating a diffuse septic
peritonitis we may agree with Le Conte,[53] that they consist of the
following measures: The least possible handling of peritoneal
contents, the elimination of time-consuming procedures, most
perfect drainage of the pelvis by a special suprapubic opening, as
well as free drainage through the operative incision, the semi-sitting
posture of the patient after its conclusion, the prevention of peristaltic
movements by withholding all fluids by the mouth, and perhaps by
small amounts of opium, and the absorption of large quantities of
water through the rectum, by which there may be produced a
reversal of the current in the lymphatics of the peritoneum, making it
a secreting rather than an absorbing surface and increasing urinary
secretion. It is inexpedient to waste time sponging peritoneal
surfaces or wiping away lymph, for danger of septic absorption is
increased rather than diminished. Patients with diffuse septic
peritonitis bear brief operations fairly well, but prolonged ones badly;
therefore a minimum amount of work should be done.
[53] Annals of Surgery, February, 1906.

One of the most valuable procedures in carrying out the above

advice is Murphy’s method of slowly introducing large quantities of
water into the rectum. The rectal tube used for the purpose ends with
a sort of nozzle containing three or four openings, and the reservoir
containing the solution is elevated but a few inches above the level
of the bed, the intent being that it shall simply trickle into the bowel
no faster than absorption can occur. In this way from a pint to a quart
may be absorbed each hour, the pressure being continuous, and the
flow so regulated that no accumulation of fluid takes place in the
bowel. Murphy claims that by this method the lymph current in the
peritoneal lymphatics is so reversed that the peritoneum is bathed
with free discharge and that this should be afforded escape by
suitable drainage methods, coupled with Fowler’s (the sitting)
posture.

TUBERCULOUS PERITONITIS.
Acute or chronic tuberculosis of the peritoneum assumes usually,
first, the miliary form, after which, in the slow cases, infiltration and
great thickening occur to such an extent as to alter the appearance,
texture, and behavior of the peritoneum itself. It is rarely a primary
condition, but is usually secondary to some other tuberculous focus,
which may be one or more of the mesenteric nodes, these being
involved in consequence of infection from the alimentary canal; or
the peritoneum may be easily infected either from the genito-urinary
tract or directly from the intestine. In children, the most common path
of infection is through the mesenteric nodes; in females, through the
Fallopian tubes, and in males, either through the intestine or the
kidneys or ureters. The peritoneum, under these circumstances,
behaves very much as does the pleura, in the presence of acute or
chronic tuberculous lesions which extend to and involve it. Thus it
may become so thickened, and even “leathery,” as to have lost all its
original characteristics, and to appear more like a dense, firm
membrane than in its original semblance.
Peritoneal tuberculosis appears in three different types: A
fibrinoplastic type, characterized especially by adhesions; an
ulcerative and sometimes absolutely suppurative form, marked
always by the presence of pus and pyoid; and an ascitic type,
characterized by leakage of increasing amounts of serum and the
development of well-marked ascites.
The first, or fibrinoplastic, is a localized lesion, and leads to the
formation of dense adhesions, as, for instance, between a Fallopian
tube and the pelvic walls or the other viscera. As the disease
spreads all the tissues become matted together in a mass which
renders them almost indistinguishable, frequently much resembling
malignant disease. In some instances it may be possible to remove
the entire affected area. At other times it is best to let it alone.
The ulcerative form is characterized by more general symptoms of
conspicuous febrile type. It produces rapid loss of strength and
weight, frequently attended with evidences of intestinal ulceration
and with abdominal tenderness and pain. A certain proportion of
these cases justify exploration, though but few of them will be found
favorably disposed for radical surgical measures.
The ascitic type is characterized by rapid accumulation of fluid,
with accompanying malaise and debility. As the abdomen distends
and the diaphragm is pushed upward respiration becomes more
difficult and rapid. A certain protrusion of the umbilicus also
characterizes many of these cases. Their course is not so febrile, but
it may be possible, especially in the early stages, to make out some
enlargement of mesenteric nodes, or involvement of the viscera,
which will aid in diagnosis. It is most common in children, but it may
be met with at any age. In general such a collection of fluid, which
cannot be accounted for by recognizable disease of the heart, liver,
or kidneys may be suspected to be tuberculous.
Treatment.—Treatment of tuberculous peritonitis should be
surgical when possible. This statement is based partly
upon the fact that it is so commonly a secondary condition. Such
treatment will depend, in large measure, upon the extent to which it
may be possible to remove any exciting foci of the disease; but
experience shows that even this is not always necessary to bring
about a cure, as in those cases of the ascitic type where it is
desirable only to wash out the abdominal cavity and close it again,
this simple procedure seeming to suffice.
It is the cases of the ascitic type which seem most benefited by
incision and irrigation, usually without drainage, and it is these which
are perhaps as hopeless as any under non-operative treatment. It
was Van de Warker, of Syracuse, who, in 1883, first recognized the
value of simple irrigation in these cases, and while at present we find
it impossible to explain the benefit which so often and so rapidly
accrues, the measure is universally recognized as that offering the
most hope. This, like every other surgical procedure, should be
practised early rather than late, preferably so soon as diagnosis is
made, or, when this is difficult, it should be made a part of an
exploratory operation intended partly for diagnostic purposes. The
measure itself is simple. A small opening in the middle line, between
the pubis and the umbilicus, permits free escape of all contained
fluid, which should be facilitated by changing the position of the
patient, thus preventing plugging of the opening by presenting bowel.
Every drop which can escape having been removed, the abdomen is
then flushed repeatedly with either warm saline solution or a plain
watery solution of acetozone, 1 to 1000, or silver lactate or citrate, in
the same proportion or a little stronger. My own preference has
always been for the latter, and with a silver solution I have obtained a
large degree of success. There is no objection to leaving a small
amount of either of these fluids in the abdominal cavity—i. e., no
more than an ordinary effort to empty it before closing the wound. An
incision one inch long, made for this purpose, will serve nearly every
indication. Through it the parietal peritoneum, as well as that
covering numerous loops of intestine, can be inspected, and through
it also a finger may be inserted for exploratory purposes, for the
detection of mesenteric nodular disease or of any other focus.
Should any serious local condition be revealed which might be
benefited by radical measures, this would be the time to practise
them.
Before closing the wound margins it would be well to thoroughly
disinfect them, for over them has flowed infected fluid, and we
sometimes see tuberculous foci develop at this point. This fact
explains also the disadvantage obtaining in these cases of making
drainage openings. They serve their purpose admirably for a short
time, but, becoming thus infected, lead to the establishment of
tuberculous fistulas and sinuses, which may call for subsequent
operation. Fecal fistula may even be a more remote consequence.
As the peritoneum is approached it will be found more or less
altered, and there may even be observed bowel or omentum
adherent behind it; therefore caution must be observed.
A final caution should also be given in order that we may avoid
mistaking that form of ascites which is frequently seen in connection
with cancer of the abdominal viscera extended to the peritoneum,
and particularly that form spoken of as miliary carcinosis or miliary
sarcomatosis, for a tuberculous collection. While surgeons are
occasionally deceived, one will usually find much in the history of the
case, and in the results of local examination, which may save
making this error, if it be so regarded; but, in effect, the opening and
the evacuation will give relief, even though this character of the
disease makes it less amenable to help from any such source.
 C H A P T E R X LV I I .
INJURIES AND SURGICAL DISEASES OF THE
STOMACH.

CONGENITAL MALFORMATIONS OF THE STOMACH.

These malformations are quite rare, at least those raising the
question of possible surgical remedy. Transposition does not require
relief, nor does a stomach abnormally small allow it. More or less
stenosis of the pylorus as a congenital defect has been observed,
but it is extremely rare. Along with it is often associated a certain
hypertrophy of the stomach muscle. Hour-glass deformity may be of
congenital or acquired origin. The latter two conditions permit of easy
surgical remedy. Pyloric stenosis may be atoned for by gastro-
enterostomy or treated directly by a plastic operation, while the hour-
glass stomach permits of an anastomotic rearrangement, either of its
dilated portions with each other or with the bowel below.
The acquired malformations are connected with the consequences
of ulceration and stricture. They include more or less complete
stenosis, either cicatricial or malignant, various forms and types of
gastroptosis and gastric dilatation, in which sometimes enormous
degrees of distention are produced, with disturbed or practically
destroyed stomach digestion. These cases will be considered by
themselves a little later, along with their surgical relief.
The anatomical relations of the nerves supplying the stomach are
worthy of the surgeon’s especial consideration. Its sympathetic nerve
supply is in particular and intimate relation with the seventh, eighth,
and ninth spinal roots, by which we account for the tenderness of the
overlying surface in ulcer of the stomach, and the pain which is often
referred to the region of the left shoulder-blade. When the stomach is
adherent to the gall-bladder, in cases of biliary calculi, the pain is
often referred to the right shoulder, but so soon as the pylorus
becomes entangled and bound down pain is referred also to the left
side as well.
 HOUR-GLASS STOMACH.
Hour-glass stomach is now more common, and is to be attributed
more to results of pathological conditions than to any congenital
anomaly, it being now well established that it is usually the result of
perigastric adhesions of chronic ulceration, with cicatricial
constriction, as well perhaps of subsequent malignant implantation.
Cancerous infiltration may produce the so-called “leather-bottle”
stomach. Moynihan suggests, among other methods of diagnosis,
the passage of a stomach tube and lavage with a quantity of fluid. If
there be loss of a certain amount of this, when it is returned, it will
indicate that a portion has escaped into the distal sac of the
stomach. Again if the stomach be washed until the fluid returns clear,
and then if there suddenly comes an amount of offensive fluid, or if
the stomach be washed clean, the tube withdrawn and passed again
a few moments later, and if then offensive fluid escape, the facts can
be best explained on the hypothesis of an hour-glass constriction.
“Paradoxical dilatation” may also be noted, i. e., the fact that
palpation will still elicit a splashing sound after a stomach tube has
been passed and while the organ is apparently empty.
Moynihan has suggested still another method of recognition. The
area of stomach resonance being outlined, a Seidlitz powder in two
halves is then administered. After about twenty or thirty seconds
great increase in resonance of the upper part of the stomach will be
found, while the lower part remains unaltered. If now a bulky pouch
can be felt or outlined the diagnosis is determined, as the increase in
resonance occurs in the distended cardiac segment.
The method of treating an hour-glass stomach will consist either,
in selected cases, of a plastic operation by which an incision made in
one direction is closed in the opposite, i. e., a measure like that
practised at the pylorus for benign stricture, or else the separate
sacs of the stomach must be united by an anastomotic opening and
a gastrogastrostomy thus performed.

FOREIGN BODIES IN THE STOMACH.

 These are most commonly those which have been swallowed,
either by design or through inadvertence, and may consist of almost
all imaginable substances. In those animals that have the constant
habit of licking their own fur or that of others, and thus scraping off a
quantity of hair, hair-balls in the stomach are frequently formed, and,
as may be seen in museums, these sometimes obtain relatively
enormous size—a foot or more in diameter. Hair-balls in the human
being are of rare occurrence, and are the result of the habit of
chewing the hair, observed in some hysterical or insane patients.
There are several instances now on record of successful removal of
such hair-balls from human stomachs. Artificial dentures, partial or
complete, are not infrequently passed into the stomach, sometimes
during sleep. In dealing with a case of this character extreme caution
should be exercised, because many individuals have deceived
themselves, or have been deceived, and the missing teeth supposed
to have been swallowed have been found in some place where they
have been mislaid and forgotten. Children have a habit of swallowing
almost anything left loose in the mouth, and all sorts of toys and
small playthings have disappeared into their stomachs, sometimes
causing death, and occasionally passing through the alimentary
canal. The insane sometimes show a maniacal tendency to swallow
foreign bodies, such as nails or anything else which they can get into
the mouth. Hysterical patients and museum freaks evince the same
habit, and it is wonderful how tolerant the stomach becomes in some
of these individuals, and what objects seem to pass the pylorus and
escape externally without doing serious harm. Still, sooner or later
nearly every one of these individuals comes to grief. Thus from one
patient at the Erie County Hospital, in Buffalo, Gaylord removed an
astonishing amount of junk, including nails, screws, pieces of glass,
knife-blades, and the like. As a general rule, any reasonably smooth
object which can pass through the esophagus may also pass
through the pylorus.
Symptoms.—The symptoms produced by these foreign bodies
will vary according to their size, number, and
character. A hair-ball may lie for a long time within the stomach,
producing few symptoms, and none by which it may be recognized.
So long as no perforation of the entire thickness of the stomach walls
occur, nor any infection which may produce a local peritonitis, the
disturbances they set up may be limited to those included under the
name “dyspepsia.” So soon, however, as pain, tenderness, or septic
indications, or those of local peritonitis supervene, the abdomen
should be promptly opened. Today we have the cathode rays as an
aid in diagnosis, which will clear up doubt in most instances, and
afford a definite indication for operation. Nevertheless a negative
result does not necessarily imply that no foreign body is present.
Treatment.—The operation indicated is gastrotomy, i. e., opening
of the stomach at a suitable or convenient point,
removal of the foreign body or bodies, and the complete closure of
the wound as well as of the abdominal incision, without drainage. If
due care be maintained throughout, and the element of previous
infection be excluded, prognosis is good. When perforation with local
peritonitis, and perhaps abscess, has already occurred, there is a
local indication as to exactly where to open; one should then
complete the operation with the establishment of suitable drainage.

WOUNDS OF THE STOMACH, INCLUDING RUPTURE.

As already indicated, the stomach maybe ruptured, especially if
weakened by previous disease, by severe abdominal contusion. It is
subject to all possible wounds by perforation, either gunshot or by
puncture. As it is more protected than the bowel below it is less liable
to perforating injuries. Much will depend upon the nature and the
extent of the injury. A small perforation may be protected by prolapse
of the mucosa in such a way that little escape of contents takes
place. On the other hand it may be extensive, and nearly the entire
gastric contents may be poured out into the upper abdomen. The
location of the stomach lesion by no means necessarily corresponds
to that of the abdominal wall, this being particularly true in gunshot
cases. Extravasation depends in amount and rapidity upon the
stomach contents and their fluidity. If the posterior wall alone be
injured it will empty rather into the cavity of the lesser omentum.
Stomach injury may always be diagnosticated if, after abdominal
injury, the vomited matter contains blood. The pain is usually severe
and involves generally the entire upper abdomen. In proportion as
the lesion lies near the diaphragm the breathing may be affected.
Collapse is usually prompt and may be due to hemorrhage from a
vessel of considerable size. Pain, collapse, and hematemesis
constitute indications for the promptest possible opening of the
abdomen and investigation, with suitable suture of the stomach
wound, toilet of the peritoneal cavity, and drainage, which should be
posterior as well as anterior. Every ragged or compromised margin
of a stomach wound, especially gunshot, should be neatly excised,
and sutures applied in such a way as to only bring clean and fresh
surfaces together. An external opening of sufficient length should be
made to permit easy and complete withdrawal of the entire stomach,
and a complete search over both its surfaces in order that no lesion
may escape detection. If the opening made into the stomach be
sufficiently large to permit, it would be best to thoroughly empty its
contents and gently wipe it out, in order that it may be left not only
empty but clean. Should the puncture be very small it would be well
to pass a stomach tube from above and wash out the stomach,
protecting the opening by pads and pressure, and thus preventing
contamination of the peritoneum.
While apparently spontaneous rupture, i. e., without previous ulcer
or disease, is most rare, there are a few cases on record where
patients have been seized with intense paroxysmal pain and have
died more or less quickly, and where the condition has been found
with little or nothing to explain it. Immediate operation might possibly
have saved some of these had the possibility of its occurrence been
recognized. Perforation from within may also occur, as it is known to
have happened in the cases of sword or knife swallowers.
Suture of the stomach is practised in exactly the same way in
these cases as for other purposes and the method will be described
later, along with the other operations upon this viscus.

TUBERCULOSIS AND SYPHILIS OF THE STOMACH.

The gastric mucosa presents a remarkable contrast to that of the
intestinal tract, the latter being exceedingly likely to succumb to
tuberculous infection, which is exceedingly rare in the former.
Primary tuberculous ulceration of the stomach, then, is most
unusual. When tuberculous ulcers are found there they are usually
the result of a secondary or perforating process. Such ulcers may
attain great size, as in one case reported by Simmonds where the
ulcerated area measured four by eight inches, yet produced no
symptoms during life. This would correspond almost to a lupus of the
gastric mucosa. Tuberculous gummas are even more rare, and,
occurring in the stomach, are pathological curiosities rather than
surgical possibilities.
Syphilis of the stomach is met with either as gumma or ulcer, the
latter leading almost inevitably to more or less stricture as recovery
follows suitable treatment. Although it is claimed that 10 per cent. of
cases of chronic ulcer of the stomach have suffered from syphilis at
some time, it by no means follows that such ulcers are to be
considered as of genuinely syphilitic origin, as a syphilitic patient is
not exempt from other stomach conditions. However, symptoms of
gastric ulcer, associated with actual manifestations of syphilis, might
well indicate associated syphilitic lesions and would probably yield,
with the others, to suitable treatment.
Lesions of either character, which do not subside under proper
medical treatment, and which require a surgical operation, would be
equally benefited by it whether of one of these types or of the other.

DILATATION OF THE STOMACH.

The acute form of gastric dilatation was described by Fagge in
1872, the chief symptoms being excessive vomiting and anuria, and
the disease proving fatal within three days, the dilatation being
enormous. For a condition occurring as rapidly and progressively as
this does there is as yet no satisfactory explanation, careful autopsy
failing to disclose a sufficient reason. It has been known in at least
twelve instances to follow surgical operation, four only of which were
upon the abdomen, and none of them upon the stomach proper, in
all instances the patients apparently progressing favorably. The
stomach becomes rapidly and enormously distended, and bent upon
itself with a sharp kink in the lesser curvature. Thus it seems to
occupy the entire upper abdomen. Two factors at least seem to
assist in the condition: A paresis of the gastric musculature, and the
fact that as it becomes distended it itself produces obstruction of the
duodenum, and thus aggravates the primary condition.
It has been suggested that these acute cases of postoperative
dilatation are closely connected with certain cases of ileus and
obstruction after abdominal operations, the dilatation once initiated
tending to more and more obstruct the duodenum, as well as cause
upward pressure on the diaphragm and embarrassment of the
heart’s action. Hence the value of the stomach tube in treatment of
such conditions.
Symptoms.—The symptoms are usually sudden and fulminating,
beginning with intense pain, which finally involves the
entire abdomen. Vomiting comes early and persists, the vomited fluid
being greenish in color and large in amount, changing later to a
brownish color and having an offensive odor. The act of vomiting is
passive rather than active or violent. In spite of it the stomach never
seems to empty itself. The outline of the dilated stomach may be
seen through the abdominal wall, bulging being often extreme. With
the passage of the stomach tube there may be escape of a large
amount of gas as well as of fluid. Thirst is intolerable and never
satisfied. The amount of urine is almost always reduced and
sometimes anuria is practically complete.
Treatment.—The treatment is too often ineffectual, since the
condition itself is lethal almost from the beginning.
Early and frequent lavage, or perhaps leaving the stomach tube in
place, would be indicated. It might be practicable to pass a small
tube through the nostril and leave it, as is done with the insane.
Gastrostomy would be theoretically indicated, could it be done
sufficiently early. The same is perhaps true of gastro-enterostomy,
although it has never had a fair trial, these cases coming to the
surgeon too late to permit of much help.
Chronic Dilatation of the Stomach.—Chronic dilatation of the
stomach, often spoken of as
gastrectasis, is a frequent complication of various other conditions,
being essentially a consequence rather than a primary condition. It
may be due to:
1. Pyloric stenosis or its equivalent in the first part of the
duodenum:
 (a) From cicatricial processes following ulcers of the pyloric
region;
(b) From perigastritis with cancer of the stomach;
(c) From pylorospasm and hypertrophy continuing after
recovery from ulcer, and including more or less thickening
of the biliary region;
(d) From neoplasms outside the pylorus proper;
(e) From cancer of the pyloric end of the stomach;
(f) From pressure upon the duodenum by pancreatic lesions;
(g) From the results of gallstones ulcerating and causing great
local disturbances;
(h) From displacement of the pylorus, due either to falling of
the stomach or dragging of an attached but movable right
kidney.
2. A dilatation due to old lesions which have subsided, the atonic
stretching not having been repaired.
It will be seen, then, that the condition may be met as a sequel to
many different pathological processes. As such, therefore, it has no
constant etiology nor necessarily distinctive features. In general it is
recognized by tardiness in escape of gastric contents, associated
with vomiting, the vomitus being distinctive, consisting often of old
and undigested food, or perhaps of food which has rested in the
stomach until putrefaction has occurred. The vomitus also contains
evidences of fermentation, with sarcinæ and yeast cells and much
mucus. In cases of ulcer it is usually very sour, owing to excess of
free hydrochloric acid. When due to cancer the acid is usually due to
excess of lactic acid, while hydrochloric acid may be nearly or totally
absent. Even if vomiting does not occur after ingestion of food,
heaviness and discomfort, with much eructation of gas, are
produced. Constipation and diminished urine secretion are almost
invariable accompaniments. When the obstruction is of the
mechanical type a visible peristaltic wave can often be seen and felt,
and this is a sign which should be regarded as always indicating
operation.
Patients gradually lose flesh and become anemic and run down,
suffering from what has been often vaguely called indigestion, their
lives sometimes being terminated by starvation, occasionally by