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: 552
|