SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 3 page

contained 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: 565