SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 6 page

the intestines, and recovery. Shah mentions an abdominal wound with

protrusion of three feet of small intestine. By treatment with ice,

phenol, and opium, recovery was effected without peritonitis.

Among nonfatal perforating gunshot wounds of the abdomen, Loring:

reports the case of a private in the First Artillery who recovered

after a double gunshot perforation of the abdomen. One of the balls

entered 5 1/2 inches to the left of the umbilicus, and two inches above

the crest of the ilium, making its exit two inches above the crest of

the ilium, on a line with and two inches from the 4th lumbar vertebra.

The other ball entered four inches below and to the rear of the left

nipple, making its exit four inches directly below the point of

entrance. In their passages these balls did not wound any of the

viscera, and with the exception of traumatic fever there was no

disturbance of the health of the patient. Schell records the case of a

soldier who was wounded July 3, 1867, by a conoid ball from a Remington

revolver of the Army pattern. The ball entered on the left side of the

abdomen, its lower edge grazing the center of Poupart's ligament, and

passing backward, inward, and slightly upward, emerged one inch to the

left of the spinous process of the sacrum. On July 6th all the symptoms

of peritonitis made their appearance. On July 11th there was free

discharge of fecal matter from both anterior and posterior wounds. This

discharge continued for three days and then ceased. By August 12th both

wounds were entirely healed. Mineer reports a case of a wound from a

revolver-ball entering the abdomen, passing through the colon, and

extracted just above the right ilium. Under simple treatment the

patient recovered and was returned to duty about ten weeks afterward.

There are a number of cases on record in which a bullet entering the

abdominal cavity is subsequently voided either by the bladder or by the

bowel. Ducachet mentions two cases at the Georgetown Seminary Hospital

during the late war in which Minie balls entering the abdominal wall

were voided by the anus in a much battered condition. Bartlett reports

the case of a young man who was accidentally shot in the abdomen with a

Colt's revolver. Immediately after the accident he complained of

constant and pressing desire to void his urine. While urinating on the

evening of the third day, the ball escaped from the urethra and fell

with a click into the chamber. After the discharge of the ball the

intolerable symptoms improved, and in two or three weeks there was

complete recovery. Hoag mentions a man who was wounded by a round

musket-ball weighing 400 grains. It had evidently passed through the

lung and diaphragm and entered the alimentary canal; it was voided by

the rectum five days after the injury. Lenox mentions the fact of a

bullet entering the abdominal wall and subsequently being passed from

the rectum. Day and Judkins report similar cases. Rundle speaks of the

lodgment of a bullet, and its escape, after a period of seven and

one-half years, into the alimentary canal, causing internal

strangulation and death.

Wounds of the liver often end very happily, and there are many cases on

record in which such injuries have been followed by recovery, even when

associated with considerable loss of liver-substance. In the older

records, Glandorp and Scultetus mention cures after large wounds of the

liver. Fabricius Hildanus reports a case that ended happily, in which a

piece of liver was found in the wound, having been separated by a

sword-thrust. There is a remarkable example of recovery after multiple

visceral wounds, self-inflicted by a lunatic. This man had 18 wounds,

14 having penetrated the abdomen, the liver, colon, and the jejunum

being injured; by frequent bleeding, strict regimen, dressing, etc., he

recovered his health and senses, but relapsing a year and a half later,

he again attempted suicide, which gave the opportunity for a postmortem

to learn the extent of the original injuries. Plater, Schenck,

Cabrolius, the Ephemerides, and Nolleson mention recovery after wounds

of the liver. Salmuth and the Ephemerides report questionable instances

in which portions of the liver were ejected in violent vomiting.

Macpherson describes a wound of the liver occurring in a Hindoo of

sixty who had been struck by a spear. A portion of the liver was

protruding, and a piece weighing 1 1/4 ounces was removed, complete

recovery following.

Postempski mentions a case of suture of the liver after a stab-wound.

Six sutures of chromicized cat-gut were carefully tightened and

fastened with a single loop. The patient left his bed on the sixth day

and completely recovered. Gann reports a case of harpoon-wound of the

liver. While in a dory spearing fish in the Rio Nuevo, after a sudden

lurch of the boat, a young man of twenty-eight fell on the sharp point

of a harpoon, which penetrated his abdomen. About one inch of the

harpoon was seen protruding from below the tip of the ensiform

cartilage; the harpoon was seven inches long. It was found that the

instrument had penetrated the right lobe of the liver; on passing the

hand backward along the inferior surface of the liver, the point could

be felt projecting through its posterior border. On account of two

sharp barbs on the spear-point, it was necessary to push the harpoon

further in to disengage the barbs, after which it was easily removed.

Recovery followed, and the patient was discharged in twenty-one days.

Romme discusses the subject of punctured wounds of the liver, as a

special text using the case of the late President Carnot. He says that

in 543 cases of traumatism of the liver collected by Elder, 65 were

caused by cutting or sharp-pointed instruments. Of this group, 23

recovered and 42 died. The chief causes of death were hemorrhage and

peritonitis. The principal symptoms of wounds of the liver, such as

traumatic shock, collapse, local and radiating pains, nausea, vomiting,

and respiratory disturbances were all present in the case of President

Carnot. From an experience gained in the case of the President, Romme

strongly recommends exploratory celiotomy in all penetrating wounds of

the liver. Zeidler reports three cases of wound of the liver in which

recovery ensued. The hemorrhage in one case was arrested by the tampon,

and in the other by the Pacquelin cautery.

McMillan describes a man of twenty who was kicked by a horse over the

liver and rupturing that organ. A large quantity of offensive fluid was

drawn off from the liver, and the man recovered. Frazer reports a case

of rupture of liver and kidney in a boy of thirteen who was squeezed

between the tire and driving chain of a mill, but who recovered despite

his serious symptoms. Allen mentions recovery after an extensive

incised wound of the abdomen, liver, and lung. Massie cites an instance

of gunshot wound of the right hypochondrium, with penetration and

protrusion of the liver. The patient, a boy of seven, recovered after

excision of a small part of the protruding liver. Lawson Tait has

incised the liver to the extent of three inches, evacuated two gallons

of hydatids, and obtained successful recovery in ten weeks.

There are several cases of wound of the liver followed by recovery

reported by surgeons of the United States Army. Whitehead mentions a

man of twenty-two who on June 3, 1867, was shot in the liver by a slug

from a pistol. At the time of the injury he bled freely from the wound

of entrance continuing to lose blood and bile until daylight the next

morning, when the hemorrhage ceased, but the flow of bile kept on. By

June 10th there was considerable improvement, but the wound discharged

blood-clots, bile, and serum. When the patient left the hospital on

July 15th the wound was healthy, discharging less than 1 1/2 ounces

during the twenty-four hours, of a mixture of free bile, and bile mixed

with thick material. When last heard from--July 27, 1867--the patient

was improving finely in flesh and strength. McKee mentions a

commissary-sergeant stationed at Santa Fe, New Mexico, who recovered

after a gunshot wound of the liver. Hassig reports the case of a

private of twenty-six who was wounded in a fray near Paducah, Kentucky,

by a conoid ball, which passed through the liver. The ball was cut out

the same day. The patient recovered and was returned to duty in May,

1868. Patzki mentioned a private in the Sixth Cavalry, aged

twenty-five, who recovered from a gunshot wound of the abdomen,

penetrating the right lobe of the liver and the gall-bladder.

Resection of the Liver.--It is remarkable to what extent portions of

the liver may be resected by the knife, cautery, or ligature, and the

patient recover. Langenbuch records a case in which he successfully

removed the greater portion of the left lobe of a woman of thirty. The

lobe had been extensively deformed by tight lacing, and caused serious

inconvenience. There was considerable hemorrhage, but the vessels were

secured, and the woman made a good recovery. McWhinnie, in The Lancet,

records a case of dislodgment of an enlarged liver from tight lacing.

Terrilon mentions an instance in which a portion of the liver was

removed by ligature after celiotomy. The ligature was removed in seven

days, and the sphacelated portion of the liver came off with it. A

cicatrix was completed at the end of six weeks, and the patient, a

woman of fifty-three, made an excellent recovery. Bastianelli

discusses those cases in which portions of the liver, having been

constricted from the general body of the organ and remaining attached

by a pedicle, give rise to movable tumors of the abdomen. He records

such a case in a woman of thirty-seven who had five children. A piece

of liver weighing 500 grams was removed, and with it the gall-bladder,

and the patient made an uninterrupted recovery. Tricomi reports a case

in which it was found necessary to remove the left lobe of the liver.

An attempt had been made to remove a liver-tumor the size of a fist by

constricting the base with an elastic ligature. This attempt was a

failure, and cure was also unsuccessfully attempted by wire ligature

and the thermocautery. The growth was cut away, bleeding was arrested

by the thermocautery and by iron-solution, the wound entirely healed,

and the patient recovered. Valerian von Meister has proved that the

liver has marvelous powers of regeneration, and that in rabbits, cats,

and dogs, even three-fourths of the organ may be reproduced in from

forty-five to sixty-five days. This regeneration is brought about

chiefly by hypertrophy of the lobules.

Floating liver is a rare malady in which the liver forms an abdominal

prominence that may be moved about, and which changes its situation as

the patient shifts the attitude. The condition usually arises from a

lax abdominal wall following repeated pregnancies. The accompanying

illustration exhibits a typical case verified by postmortem examination.

Hypertrophy of the Liver.--The average weight of the normal liver is

from 50 to 55 ounces, but as noted by Powell, it may become so

hypertrophic as to weigh as much as 40 pounds. Bonet describes a liver

weighing 18 pounds; and in his "Medical and Surgical Observations,"

Gooch speaks of a liver weighing 28 pounds. Vieussens, the celebrated

anatomist, reports an instance in which the liver weighed 20 pounds,

and in his "Aphorisms," Vetter cites a similar instance. In 1811 Kraus

of Germany describes a liver weighing 25 pounds; modern instances of

enlarged liver are too numerous to be quoted here.

Rupture of the gall-bladder, although generally followed by death, is

not always fatal. In such cases bile is usually found in the abdominal

cavity. Fergus mentions a case in which, after this accident, the

patient was considered convalescent and was walking about, when, on the

seventh day, peritonitis suddenly developed and proved fatal in two

days. Several cases of this accident have been reported as treated

successfully by incision and drainage (Lane) or by inspiration (Bell).

In these cases large quantities of bile escaped into the abdominal

cavity. Peritonitis does not necessarily follow. Cholecystotomy for

the relief of the distention of the gall-bladder from obstruction of

the common or cystic duct and for the removal of gall-stones was first

performed in 1867 by Bobbs of Indianapolis, but it is to Marion Sims,

in 1878, that perfection of the operation is due. It has been gradually

improved and developed, until today it is a most successful operation.

Tait reports 54 cases with 52 perfect recoveries. Cholyecystectomy, or

excision of the gall-bladder, was first practiced in 1880 by Langenbuch

of Berlin, and is used in cases in which gall-stones are repeatedly

forming. Ashhurst's statistics show only four deaths in 28 cases.

At St. Bartholomew's Hospital, in London, is a preserved specimen of a

gall-bladder which had formed the contents of a hernial sac, and which,

near the fundus, shows a constriction caused by the femoral ring. It

was taken from a woman of forty-five who was admitted into the hospital

with a strangulated femoral hernia. The sac was opened and its

contents were returned. The woman died in a few days from peritonitis.

The gall-bladder was found close to the femoral ring, and showed a

marked constriction. The liver was misshapen from tight lacing,

elongated and drawn downward toward the ring. There was no evidence

that any portion of intestine or other structure besides the

gall-bladder had passed through the ring.

The fatality of rupture of the spleen is quite high. Out of 83 cases of

injury to this organ collected by Elder, and quoted by MacCormac, only

11 recovered; but the mortality is less in punctured or incised wounds

of this organ, the same authorities mentioning 29 recoveries out of 35

cases. In his "Surgery" Gooch says that at the battle of Dettingen one

of Sir Robert Rich's Dragoons was left all night on the field,

weltering in his blood, his spleen hanging out of his body in a

gangrenous state. The next morning he was carried to the surgeons who

ligated the large vessels, and extirpated the spleen; the man recovered

and was soon able to do duty. In the Philosophical Transactions there

is a report of a man who was wounded in the spleen by a large

hunting-knife. Fergusson found the spleen hanging from the wound and

ligated it. It separated in ten days and the patient recovered.

Williams reports a stab-wound of the spleen in a negro of twenty-one.

The spleen protruded, and the protruding part was ligated by a silver

wire, one-half of the organ sloughing off; the patient recovered. Sir

Astley Cooper mentions a curious case, in which, after vomiting, during

which the spleen was torn from its attachments, this organ produced a

swelling in the groin which was supposed to be a hernia. The vomiting

continued, and at the end of a week the woman died; it was then found

that the spleen had been turned half round on its axis, and detached

from the diaphragm; it had become enlarged; the twist interrupted the

return of the blood. Portal speaks of a rupture of the spleen simply

from engorgement. There was no history of a fall, contusion, or other

injury. Tait describes a case of rupture of the spleen in a woman who,

in attempting to avoid her husband's kick, fell on the edge of the

table. There were no signs of external violence, but she died the third

day afterward. The abdomen was found full of blood, and the spleen and

peritoneal covering was ruptured for three inches.

Splenectomy, excision of the spleen, has been performed a number of

times, with varying results, but is more successful when performed for

injury than when for disease. Ashhurst has tabulated a total of 109

operations, 27 having been for traumatic causes, and all but five

having terminated successfully; of 82 operations for disease, only 32

recovered. Vulpius has collected 117 cases of splenectomy, with a

death-rate of 50 per cent. If, however, from these cases we deduct

those suffering with leukocythemia and lardaceous spleen, in which the

operation should not be performed, the mortality in the remaining 85

cases is reduced to 33 per cent. Terrier speaks of splenectomy for

torsion or twisting of the pedicle, and such is mentioned by Sir Astley

Cooper, who has found records of only four such cases. Conklin reports

a successful case of splenectomy for malarial spleen, and in reviewing

the subject he says that the records of the past decade in operations

for simple hypertrophy, including malaria, show 20 recoveries and eight

deaths. He also adds that extirpation in cases of floating or displaced

spleen was attended with brilliant results. Zuccarelli is accredited

with reporting two cases of splenectomy for malarial spleen, both of

which recovered early. He gives a table of splenectomies performed in

Italy, in which there were nine cases of movable spleen, with two

deaths; eight cases of simple hypertrophy, with three deaths; 12 cases

of malarial spleen, with three deaths; four cases of leukemia and

pseudoleukemia, with two deaths. In his experiments on rabbits it was

proved by Tizzoni, and in his experiments on dogs, by Crede, that an

individual could live without a spleen; but these observations were

only confirmatory of what had long been known, for, in 1867, Pean

successfully removed a spleen from a woman of twenty. Tricomi reports

eight cases in which he had extirpated the spleen for various morbid

conditions, with a fortunate issue in all but one. In one case he

ligated the splenic artery. In The Lancet there is an account of three

recent excisions of the spleen for injury at St. Thomas Hospital in

London, and it is added that they are among the first of this kind in

Great Britain.

Abnormalities of Size of the Spleen.--The spleen may be extremely

small. Storck mentions a spleen that barely weighed an ounce; Schenck

speaks of one in the last century that weighed as much as 20 pounds.

Frank describes a spleen that weighed 16 pounds; there is another

record of one weighing 15 pounds. Elliot mentions a spleen weighing 11

pounds; Burrows one, 11 pounds; Blasius, four pounds; Osiander, nine

pounds; Blanchard, 31 pounds; Richardson, 3 1/2 pounds; and Hare, 93

ounces.

The thoracic duct, although so much protected by its anatomical

position, under exceptional circumstances has been ruptured or wounded.

Kirchner has collected 17 cases of this nature, two of which were due

to contusions of the chest, one each to a puncture, a cut, and a

shot-wound, and three to erosion from suppuration. In the remaining

cases the account fails to assign a definite cause. Chylothorax, or

chylous ascites, is generally a result of this injury. Krabbel mentions

a patient who was run over by an empty coal car, and who died on the

fifth day from suffocation due to an effusion into the right pleural

cavity. On postmortem examination it was found that the effusion was

chyle, the thoracic duct being torn just opposite the 9th dorsal

vertebra, which had been transversely fractured. In one of Kirchner's

cases a girl of nine had been violently pushed against a window-sill,

striking the front of her chest in front of the 3d rib. She suffered

from pleural effusion, which, on aspiration, proved to be chyle. She

ultimately recovered her health. In 1891 Eyer reported a case of

rupture of the thoracic duct, causing death on the thirty-eighth day.

The young man had been caught between a railroad car and an engine, and

no bones were broken.

Manley reports a case of rupture of the thoracic duct in a man of

thirty-five, who was struck by the pole of a brewery wagon; he was

knocked down on his back, the wheel passing squarely over his abdomen.

There was subsequent bulging low down in the right iliac fossa, caused

by the presence of a fluid, which chemic and microscopic examination

proved was chyle. From five to eight ounces a day of this fluid were

discharged, until the tenth day, when the bulging was opened and

drained. On the fifteenth day the wound was healed and the man left the

hospital quite restored to health.

Keen has reported four instances of accidental injury to the thoracic

duct, near its termination at the base of the left side of the neck;

the wounding was in the course of removals for deep-seated growths in

this region. Three of the cases recovered, having sustained no

detriment from the injury to the thoracic duct. One died; but the fatal

influence was not specially connected with the wound of the duct.

Possibly the boldest operation in the history of surgery is that for

ligation of the abdominal aorta for inguinal aneurysm. It was first

practiced by Sir Astley Cooper in 1817, and has since been performed

several times with a uniformly fatal result, although Monteiro's

patient survived until the tenth day, and there is a record in which

ligature of the abdominal aorta did not cause death until the eleventh

day. Loreta of Bologna is accredited with operating on December 18,

1885, for the relief of a sailor who was suffering from an abdominal

aneurysm caused by a blow. An incision was made from the ensiform

cartilage to the umbilicus, the aneurysm exposed, and its cavity filled

up with two meters of silver-plated wire. Twenty days after no evidence

of pulsation remained in the sac, and three months later the sailor was

well and able to resume his duties.

Ligation of the common iliac artery, which, in a case of gunshot

injury, was first practiced by Gibson of Philadelphia in 1812, is,

happily, not always fatal. Of 82 cases collected by Ashhurst, 23

terminated successfully.

Foreign bodies loose in the abdominal cavity are sometimes voided at

stool, or may suppurate externally. Fabricius Hildanus gives us a

history of a person wounded with a sword-thrust into the abdomen, the

point breaking off. The sword remained one year in the belly and was

voided at stool. Erichsen mentions an instance in which a cedar

lead-pencil stayed for eight months in the abdominal cavity. Desgranges

gives a case of a fish-spine in the abdominal cavity, and ten years

afterward it ulcerated through an abscess in the abdominal wall.

Keetley speaks of a man who was shot when a boy; at the time of the

accident the boy had a small spelling-book in his pocket. It was not

until adult life that from an abscess of the groin was expelled what

remained of the spelling-book that had been driven into the abdomen

during boyhood. Kyle speaks of the removal of a corn-straw 33 inches in

length by an incision ten inches long, at a point about equidistant

from the umbilicus to the anterior spinous process of the right ilium.

There are several instances on record of tolerance of foreign bodies in

the skin and muscles of the back for an extended period. Gay speaks of

a curious case in which the point of a sheath-knife remained in the

back of an individual for nine years. Bush reported to Sir Astley

Cooper the history of a man who, as he supposed, received a wound in

the back by canister shot while serving on a Tartar privateer in 1779.

There was no ship-surgeon on board, and in about a month the wound

healed without surgical assistance. The man suffered little

inconvenience and performed his duties as a seaman, and was impressed

into the Royal Navy. In August, 1810, he complained of pain in the

lumbar region. He was submitted to an examination, and a cicatrix of

this region was noticed, and an extraneous body about 1/2 inch under

the integument was felt. An incision was made down it, and a rusty

blade of a seaman's clasp-knife extracted from near the 3d lumbar

vertebra. The man had carried this knife for thirty years. The wound

healed in a few days and there was no more inconvenience.

Fracture of the lower part of the spine is not always fatal, and

notwithstanding the lay-idea that a broken back means certain death,

patients with well-authenticated cases of vertebral fracture have

recovered. Warren records the case of a woman of sixty who, while

carrying a clothes-basket, made a misstep and fell 14 feet, the basket

of wet clothes striking the right shoulder, chest, and neck. There was

fracture of the 4th dorsal vertebra at the transverse processes. By

seizing the spinous process it could be bent backward and forward, with

the peculiar crepitus of fractured bone. The clavicle was fractured two

inches from the acromial end, and the sternal end was driven high up

into the muscles of the neck. The arm and hand were paralyzed, and the

woman suffered great dyspnea. There was at first a grave emphysematous

condition due to the laceration of several broken ribs. There was also

suffusion and ecchymosis about the neck and shoulder. Although

complicated with tertiary syphilis, the woman made a fair recovery, and

eight weeks later she walked into a doctor's office. Many similar and

equally wonderful injuries to the spine are on record.

The results sometimes following the operation of laminectomy for

fracture of the vertebrae are often marvelous. One of the most

successful on record is that reported by Dundore. The patient was a

single man who lived in Mahanoy, Pa., and was admitted to the State

Hospital for Injured Persons, Ashland, Pa., June 17, 1889, suffering

from a partial dislocation of the 9th dorsal vertebra. The report is

as follows--"He had been a laborer in the mines, and while working was

injured March 18, 1889, by a fall of top rock, and from this date to

that of his admission had been under the care of a local physician

without any sign of improvement. At the time of his admission he

weighed but 98 pounds, his weight previous to the injury being 145. He

exhibited entire loss of motion in the lower extremities, with the

exception of very slight movement in the toes of the left foot;

sensation was almost nil up to the hips, above which it was normal; he

had complete retention of urine, with a severe cystitis. His tongue was

heavily coated, the bowels constipated, and there was marked anorexia,

with considerable anemia. His temperature varied from 99 degrees to 100

degrees in the morning, and from 101 degrees to 103 degrees in the

evening. The time which had elapsed since the accident precluded any

attempt at reduction, and his anemic condition would not warrant a more

radical method.

"He was put on light, nourishing diet, iron and strychnin were given

internally, and electricity was applied to the lower extremities every

other day; the cystitis was treated by irrigating the bladder each day

with Thiersch's solution. By August his appetite and general condition

Date: 2014-12-29; view: 653