![]() CATEGORIES: BiologyChemistryConstructionCultureEcologyEconomyElectronicsFinanceGeographyHistoryInformaticsLawMathematicsMechanicsMedicineOtherPedagogyPhilosophyPhysicsPolicyPsychologySociologySportTourism |
SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 3 pagecontained a bone shaped like the Arab T.
Among the older writers we frequently read of hairs, worms, and snakes being found in the cavities of the heart. The Ephemerides, Zacutus Lusitanus, Pare, Swinger, Riverius, and Senac are among the authorities who mention this circumstance. The deception was possibly due to the presence of loose and shaggy membrane attached to the endocardial lining of the heart, or in some cases to echinococci or trichine. A strange case of foreign body in the heart was reported some time since in England. The patient had swallowed a thorn of the Prunus spinosa (Linn.), which had penetrated the esophagus and the pericardium and entered the heart. A postmortem examination one year afterward confirmed this, as a contracted cicatrix was plainly visible on the posterior surface of the heart about an inch above the apex, through which the thorn had penetrated the right ventricle and lodged in the tricuspid valve. The supposition was that the thorn had been swallowed while eating radishes. Buck mentions a case of hydatid cysts in the wall of the left ventricle, with rupture of the cysts and sudden death.
It is surprising the extent of injury to the pericardium Nature will tolerate. In his "Comment on the Aphorisms of Hippocrates," Cardanus says that he witnessed the excision of a portion of the pericardium with the subsequent cure of the patient. According to Galen, Marulus, the son of Mimographus, recovered after a similar operation. Galen also adds, that upon one occasion he removed a portion of carious sternum and found the pericardium in a putrid state, leaving a portion of the heart naked. It is said that in the presence of Leucatel and several theologians, Francois Botta opened the body of a man who died after an extended illness and found the pericardium putrefied and a great portion of the heart destroyed, but the remaining portion still slightly palpitating. In this connection Young mentions a patient of sixty-five who in January, 1860, injured his right thumb and lost the last joint by swelling and necrosis. Chloroform was administered to excise a portion of the necrosed bone and death ensued. Postmortem examination revealed gangrene of the heart and a remarkable tendency to gangrene elsewhere (omentum, small intestines, skin, etc.). Recently, Dalton records a remarkable case of stab-wound of the pericardium with division of the intercostal artery, upon which he operated. An incision eight inches long was made over the 4th rib, six inches of the rib were resected, the bleeding intercostal artery was ligated, the blood was turned out of the pericardial cavity, this cavity being irrigated with hot water. The wound in the pericardium, which was two inches long, was sutured and the external wound was closed. Recovery followed. Harris gives an instance of a man who was injured by a bar of iron falling on his shoulder, producing a compound fracture of the ribs as low as the 7th, and laying the heart and lungs bare without seriously injuring the pericardium.
Rupture of the heart from contusion of the chest is not always instantly fatal. According to Ashhurst, Gamgee has collected 28 cases of rupture of this viscus, including one observed by himself. In nine of these cases there was no fracture, and either no bruise of the parietes or a very slight one. The pericardium was intact in at least half of the cases, and in 22 in which the precise seat of lesion was noticed the right ventricle was ruptured in eight, the left in three, the left auricle in seven, the right in four. The longest period during which any patient survived the injury was fourteen hours.
Among the older writers who note this traumatic injury are Fine, who mentions concussion rupturing the right ventricle, and Ludwig, who reports a similar accident. Johnson mentions rupture of the left ventricle in a paroxysm of epilepsy. There is another species of rupture of the heart which is not traumatic, in which the rupture occurs spontaneously, the predisposing cause being fatty degeneration, dilatation, or some other pathologic process in the cardiac substance. It is quite possible that the older instances of what was known as "broken-heart," which is still a by-word, were really cases in which violent emotion had produced rupture of a degenerated cardiac wall. Wright gives a case of spontaneous rupture of the heart in which death did not occur for forty-eight hours. Barth has collected 24 cases of spontaneous rupture of the heart, and in every instance the seat of lesion was in the left ventricle. It was noticed that in some of these cases the rupture did not take place all at once, but by repeated minor lacerations, death not ensuing in some instances for from two to eleven days after the first manifestation of serious symptoms. A more recent analysis is given by Meyer of cases reported since 1870: Meyer collects 25 cases of rupture of the left ventricle seven of the right ventricle, and four of the right auricle. Within the last year Collings has reported a case of idiopathic rupture of the heart in a man of fifty-three, who had always lived a temperate life, and whose only trouble had been dyspepsia and a weak heart. There was no history of rheumatism or rheumatic fever. The man's father had died suddenly of heart disease. After feeling out of sorts for a time, the man experienced severe pain in the precordium and felt too ill to leave his bed. He gradually became worse and sick after taking food. Speech became thick, the mouth was drawn to the right, and the right eye was partially closed. The left arm became paralyzed, then the right leg. The tongue deviated to the right on protrusion. The sphincters were unaffected. The heart sounds were faint and without added sounds. The man was moved to a water-bed, his body and head being kept horizontal, and great care being taken to avoid sudden movement. Later, when his pelvis was raised to allow the introduction of a bed-pan, almost instantaneous death ensued. Upon postmortem examination prolonged and careful search failed to reveal any microscopic change in the brain, its vessels, or the meninges. On opening the pericardium it was found to be filled with blood-clot, and on washing this away a laceration about 1 1/2 inches in length was found in the left ventricle; the aperture was closed by a recent clot. The cavities of the heart were dilated, the walls thin and in advanced stage of fatty degeneration. There was no valvular disease. The aorta and its main branches were atheromatous. Both lungs contained calcifying tubercle; the abdomen was loaded with fat; the spleen was soft; the kidneys were engorged, but otherwise healthy.
Stokes gives the case of a man who was severely crushed between the arms of a water-wheel of great size and the embankment on which the axle of the wheel was supported; a peculiar factor of the injury being that his heart was displaced from left to right. At the time of report, after recovery from the injury, the patient exhibited remarkable tolerance of great doses of digitalis. When not taking digitalis, his pulse was 100 to 120, regular, and never intermittent.
Hypertrophy of the Heart.--The heart of a man of ordinary size weighs nine ounces, and that of a woman eight; in cases of hypertrophy, these weights may be doubled, although weights above 25 ounces are rare. According to Osler, Beverly Robinson describes a heart weighing 53 ounces, and Dulles has reported one weighing 48 ounces. Among other modern records are the following: Fifty and one-half ounces, 57 ounces, and one weighing four pounds and six ounces. The Ephemerides contains an incredible account of a heart that weighed 14 pounds. Favell describes a heart that only weighed 3 1/2 ounces.
Wounds of the aorta are almost invariably fatal, although cases are recorded by Pelletan, Heil, Legouest, and others, in which patients survived such wounds for from two months to several years. Green mentions a case of stab-wound in the suprasternal fossa. The patient died one month after of another cause, and at the postmortem examination the aorta was shown to have been opened; the wound in its walls was covered with a spheric, indurated coagulum. No attempt at union had been made.
Zillner observed a penetrating wound of the aorta after which the patient lived sixteen days, finally dying of pericarditis. Zillner attributed this circumstance to the small size of the wound, atheroma and degeneration of the aorta and slight retraction of the inner coat, together with a possible plugging of the pericardial opening. In 1880 Chiari said that while dissecting the body of a man who died of phthisis, he found a false aneurysm of the ascending aorta with a transverse rupture of the vessel by the side of it, which had completely cicatrized. Hill reports the case of a soldier who was stabbed with a bowie-knife nine inches long and three inches wide. The blade passed through the diaphragm, cut off a portion of the liver, and severed the descending aorta at a point about the 7th dorsal vertebra; the soldier lived over three hours after complete division of this important vessel. Heil reports the case of a man of thirty-two, a soldier in the Bavarian army, who, in a quarrel in 1812, received a stab in the right side. The instrument used was a common table-knife, which was passed between the 5th and 6th ribs, entering the left lung, and causing copious hemorrhage. The patient recovered in four months, but suffered from amaurosis which had commenced at the time of the stab. Some months afterward he contracted pneumonia and was readmitted to the hospital, dying in 1813. At the postmortem the cicatrix in the chest was plainly visible, and in the ascending aorta there was seen a wound, directly in the track of the knife, which was of irregular border and was occupied by a firm coagulum of blood. The vessel had been completely penetrated, as, by laying it open, an internal cicatrix was found corresponding to the other. Fatal hemorrhage had been avoided in this case by the formation of coagulum in the wound during the syncope immediately following the stab, possibly aided by extended exposure to cold.
Sundry Cases.--Sandifort mentions a curious case of coalescence of the esophagus and aorta, with ulceration and consequent rupture of the aorta, the hemorrhage proceeding from the stomach at the moment of rupture.
Heath had a case of injury to the external iliac artery from external violence, with subsequent obliteration of the vessel. When the patient was discharged no pulse could be found in the leg.
Dismukes reports a case in which the patient had received 13 wounds, completely severing the subclavian artery, and, without any medical or surgical aid, survived the injury two hours.
Illustrative of the degree of hemorrhage which may follow an injury so slight as that of falling on a needle we cite an instance, reported by a French authority, of a child who picked up a needle, and, while running with it to its mother, stumbled and fell, the needle penetrating the 4th intercostal space, the broadened end of it remaining outside of the wound. The mother seized the needle between her teeth and withdrew it, but the child died, before medical aid could be summoned, from internal hemorrhage, causing pulmonary pressure and dyspnea.
Rupture of the esophagus is attributable to many causes. Dryden mentions vomiting as a cause, and Guersant reports the case of a little girl of seven, who, during an attack of fever, ruptured her esophagus by vomiting. In 1837 Heyfelder reported the case of a drunkard, who, in a convulsion, ruptured his esophagus and died. Williams mentions a case in which not only the gullet, but also the diaphragm, was ruptured in vomiting. In this country, Bailey and Fitz have recorded cases of rupture of the esophagus. Brewer relates a parallel instance of rupture from vomiting. All the foregoing cases were linear ruptures, but there is a unique case given by Boerhaave in 1724, in which the rent was transverse. Ziemssen and Mackenzie have both translated from the Latin the report of this case which is briefly as follows: The patient, Baron de Wassenaer, was fifty years of age, and, with the exception that he had a sense of fulness after taking moderate meals, he was in perfect health. To relieve this disagreeable feeling he was in the habit of taking a copious draught of an infusion of "blessed thistle" and ipecacuanha. One day, about 10.30 in the evening, when he had taken no supper, but had eaten a rather hearty dinner, he was bothered by a peculiar sensation in his stomach, and to relieve this he swallowed about three tumbler-fuls of his usual infusion, but to no avail. He then tried to excite vomiting by tickling the fauces, when, in retching, he suddenly felt a violent pain; he diagnosed his own case by saying that it was "the bursting of something near the pit of the stomach." He became prostrated and died in eighteen and one-half hours; at the necropsy it was seen that without any previously existing signs of disease the esophagus had been completely rent across in a transverse direction.
Schmidtmuller mentions separation of the esophagus from the stomach; and Flint reports the history of a boy of seven who died after being treated for worms and cerebral symptoms. After death the contents of the stomach were found in the abdominal cavity, and the esophagus was completely separated from the stomach. Flint believed the separation was postmortem, and was possibly due to the softening of the stomach by the action of the gastric acids. In this connection may be mentioned the case reported by Hanford of a man of twenty-three who had an attack of hematemesis and melanema two years before death. A postmortem was made five hours after death, and there was so much destruction of the stomach by a process resembling digestion that only the pyloric and cardiac orifices were visible. Hanford suggests that this was an instance of antemortem digestion of the stomach which physiologists claim is impossible.
Nearly all cases of rupture of the stomach are due to carcinoma, ulcer, or some similar condition, although there have been instances of rupture from pressure and distention. Wunschheim reports the case of a man of fifty-two who for six months presented symptoms of gastric derangement, and who finally sustained spontaneous rupture of the posterior border of the stomach due to overdistention. There was a tear two inches long, beginning near the cardiac end and running parallel to the lesser curvature. The margin of the tear showed no evidence of digestion. There were obstructing esophageal neoplasms about 10 1/3 inches from the teeth, which prevented vomiting. In reviewing the literature Wunschheim found only six cases of spontaneous rupture of the stomach. Arton reports the case of a negro of fifty who suffered from tympanites. He was a hard drinker and had been aspirated several times, gas heavily laden with odors of the milk of asafetida being discharged with a violent rush. The man finally died of his malady, and at postmortem it was found that his stomach had burst, showing a slit four inches long. The gall bladder contained two quarts of inspissated bile. Fulton mentions a case of rupture of the esophageal end of a stomach in a child. The colon was enormously distended and the walls thickened. When three months old it was necessary to puncture the bowel for distention. Collins describes spontaneous rupture of the stomach in a woman of seventy-four, the subject of lateral curvature of the spine, who had frequent attacks of indigestion and tympanites. On the day of death there was considerable distention, and a gentle purgative and antispasmodic were given. Just before death a sudden explosive sound was heard, followed by collapse. A necropsy showed a rupture two inches long and two inches from the pyloric end. Lallemand mentions an instance of the rupture of the coats of the stomach by the act of vomiting. The patient was a woman who had suffered with indigestion five or six months, but had been relieved by strict regimen. After indulging her appetite to a greater extent than usual, she experienced nausea, and made violent and ineffectual efforts to discharge the contents of the stomach. While suffering great agony she experienced a sensation as if something was tearing in the lower part of her belly. The woman uttered several screams, fell unconscious, and died that night. Postmortem examination showed that the anterior and middle part of the stomach were torn obliquely to the extent of five inches. The tear extended from the smaller toward the greater curvature. The edges were thin and irregular and presented no marks of disease. The cavity of the peritoneum was full of half-digested food. The records of St. Bartholomew's Hospital, London, contain the account of a man of thirty-four who for two years had been the subject of paroxysmal pain in the stomach. The pains usually continued for several hours and subsided with vomiting. At St. Bartholomew's he had an attack of vomiting after a debauch. On the following day he was seized with vomiting accompanied by nausea and flatus, and after a sudden attack of pain at the pit of the stomach which continued for two hours, he died. A ragged opening at the esophageal orifice, on the anterior surface of the stomach was found. This tear extended from below the lesser curvature to its extremity, and was four inches long. There were no signs of gastric carcinoma or ulcer.
Clarke reports the case of a Hindoo of twenty-two, under treatment for ague, who, without pain or vomiting, suddenly fell into collapse and died twenty-three hours later. He also mentions a case of rupture of the stomach of a woman of uncertain history, who was supposed to have died of cholera. The examination of the bodies of both cases showed true rupture of the stomach and not mere perforation. In both cases, at the time of rupture, the stomach was empty, and the gastric juice had digested off the capsules of the spleens, thus allowing the escape of blood into the abdominal cavities. The seats of rupture were on the anterior walls. In the first case the coats of the stomach were atrophied and thin. In the second the coats were healthy and not even softened. There was absence of softening, erosion, or rupture on the posterior walls.
As illustrative of the amount of paralytic distention that is possible, Bamberger mentions a case in which 70 pounds of fluid filled the stomach.
Voluntary Vomiting.--It is an interesting fact that some persons exhibit the power of contracting the stomach at will and expelling its contents without nausea. Montegre mentions a distinguished member of the Faculty of Paris, who, by his own volition and without nausea or any violent efforts, could vomit the contents of his stomach. In his translation of "Spallanzani's Experiments on Digestion" Sennebier reports a similar instance in Geneva, in which the vomiting was brought about by swallowing air.
In discussing wounds and other injuries of the stomach no chapter would be complete without a description of the celebrated case of Alexis St. Martin, whose accident has been the means of contributing so much to the knowledge of the physiology of digestion. This man was a French Canadian of good constitution, robust and healthy, and was employed as a voyageur by the American Fur Company. On June 16, 1822, when about eighteen years of age, he was accidentally wounded by a discharge from a musket. The contents of the weapon, consisting of powder and duck-shot, entered his left side from a distance of not more than a yard off. The charge was directed obliquely forward and inward, literally blowing off the integument and muscles for a space about the size of a man's hand, carrying away the anterior half of the 6th rib, fracturing the 5th rib, lacerating the lower portion of the lowest lobe of the left lung, and perforating the diaphragm and the stomach. The whole mass of the discharge together with fragments of clothing were driven into the muscles and cavity of the chest. When first seen by Dr. Beaumont about a half hour after the accident, a portion of the lung, as large as a turkey's egg was found protruding through the external wound. The protruding lung was lacerated and burnt. Immediately below this was another protrusion, which proved to be a portion of the stomach, lacerated through all its coats. Through an orifice, large enough to admit a fore-finger, oozed the remnants of the food he had taken for breakfast. His injuries were dressed; extensive sloughing commenced, and the wound became considerably enlarged. Portions of the lung, cartilages, ribs, and of the ensiform process of the sternum came away. In a year from the time of the accident, the wound, with the exception of a fistulous aperture of the stomach and side, had completely cicatrized. This aperture was about 2 1/2 inches in circumference, and through it food and drink constantly extruded unless prevented by a tent-compress and bandage. The man had so far recovered as to be able to walk and do light work, his digestion and appetite being normal. Some months later a small fold or doubling of the stomachal coats slightly protruded until the whole aperture was filled, so as to supersede the necessity of a compress, the protruding coats acting as a valve when the stomach was filled. This valvular protrusion was easily depressed by the finger. St. Martin suffered little pain except from the depression of the skin. He took his food and drink like any healthy person, and for eleven years remained under Dr. Beaumont's own care in the Doctor's house as a servant. During this time were performed the experiments on digestion which are so well known. St. Martin was at all times willing to lend himself in the interest of physiologic science. In August, 1879, The Detroit Lancet contains advices that St. Martin was living at that time at St. Thomas, Joliette County, Province of Quebec, Canada. At the age of seventy-nine he was comparatively strong and well, and had always been a hard worker. At this time the opening in the stomach was nearly an inch in diameter, and in spite of its persistence his digestion had never failed him.
Spizharny relates a remarkable case of gastric fistula in the loin, and collects 61 cases of gastric fistula, none of which opened in the loin. The patient was a girl of eighteen, who had previously had perityphlitis, followed by abscesses about the navel and lumbar region. Two fistulae were found in the right loin, and were laid open into one canal, which, after partial resection of the 12th rib, was dilated and traced inward and upward, and found to be in connection with the stomach. Food was frequently found on the dressings, but with the careful use of tampons a cure was effected.
In the olden times wounds of the stomach were not always fatal. The celebrated anatomist, Fallopius, successfully treated two cases in which the stomach was penetrated so that food passed through the wound. Jacobus Orthaeus tells us that in the city of Fuldana there was a soldier who received a wound of the stomach, through which food passed immediately after being swallowed; he adds that two judicious surgeons stitched the edges of the wound to the integuments, thereby effecting a cure. There is another old record of a gastric fistula through which some aliment passed during the period of eleven years.
Archer tells of a man who was stabbed by a negro, the knife entering the cartilages of the 4th rib on the right side, and penetrating the stomach to the extent of two inches at a point about two inches below the xiphoid cartilage. The stomachal contents, consisting of bacon, cabbage, and cider, were evacuated. Shortly after the reception of the injury, an old soldier sewed up the wound with an awl, needle, and wax-thread; Archer did not see the patient until forty-eight hours afterward, at which time he cleansed and dressed the wound. After a somewhat protracted illness the patient recovered, notwithstanding the extent of injury and the primitive mode of treatment.
Travers mentions the case of a woman of fifty-three who, with suicidal intent, divided her abdominal parietes below the navel with a razor, wounding the stomach in two places. Through the wound protruded the greater part of the larger curvature of the stomach; the arch of the colon and the entire greater omentum were both strangulated. A small portion of the coats of the stomach, including the wound, was nipped up, a silk ligature tied about it, and the entrails replaced. Two months afterward the patient had quite recovered, though the ligature of the stomach had not been seen in the stool. Clements mentions a robust German of twenty-two who was stabbed in the abdomen with a dirk, producing an incised wound of the stomach. The patient recovered and was returned to duty the following month.
There are many cases on record in which injury of the stomach has been due to some mistake or accident in the juggling process of knife-swallowing or sword-swallowing. The records of injuries of this nature extend back many hundred years, and even in the earlier days the delicate operation of gastrotomy, sometimes with a successful issue, was performed upon persons who had swallowed knives. Gross mentions that in 1502 Florian Mathias of Bradenberg removed a knife nine inches long from the stomach of a man of thirty-six, followed by a successful recovery. Glandorp, from whom, possibly, Gross derived his information, relates this memorable case as being under the direction of Florianus Matthaesius of Bradenburg. The patient, a native of Prague, had swallowed a knife eight or nine inches long, which lay pointing at the superior portion of the stomach. After it had been lodged in this position for seven weeks and two days gastrotomy was performed, and the knife extracted; the patient recovered. In 1613 Crollius reports the case of a Bohemian peasant who had concealed a knife in his mouth, thinking no one would suspect he possessed the weapon; while he was excited it slipped into the stomach, from whence it subsequently penetrated through to the skin; the man recovered. There is another old case of a man at Prague who swallowed a knife which some few weeks afterward made its exit from an abdominal abscess. Gooch quotes the case of a man, belonging to the Court of Paris, who, nine months after Date: 2014-12-29; view: 617
|