SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 7 page

were much improved, and his weight had increased to 125 pounds, his

temperature being 99 degrees or less each morning, and seldom as high

as 100 degrees at night. The cystitis had entirely disappeared, and he

was able, with some effort, to pass his urine without the aid of a

catheter. Sensation in both extremities had slightly improved, and he

was able to slightly move the toes of the right foot. This being his

condition, an operation was proposed as the only means of further and

permanent improvement, and to this he eagerly consented, and,

accordingly, on the 25th of August, the 9th dorsal vertebra was

trephined.

"The cord was found to be compressed and greatly congested, but there

was no evidence of laceration. The laminae and spinous processes of the

8th and 9th dorsal vertebrae were cut away, thus relieving all pressure

on the cord; the wound was drained and sutured, and a plaster-of-Paris

jacket applied, a hole being cut out over the wound for the purpose of

changing the dressing when necessary. By September 1st union was

perfect, and for the next month the patient remained in excellent

condition, but without any sign of improvement as to sensation and

motion. Early in October he was able to slightly move both legs, and

had full control of urination; from this time on his paralysis rapidly

improved; the battery was applied daily, with massage morning and

evening; and in November the plaster-of-Paris jacket was removed, and

he propelled himself about the ward in a rolling chair, and shortly

after was able to get about slowly on crutches. He was discharged

December 23d, and when I saw him six months later he walked very well

and without effort; he carried a cane, but this seemed more from habit

than from necessity. At present date he weighs 150 pounds, and drives a

huckster wagon for a living, showing very little loss of motion in his

lower extremities."

Although few cases show such wonderful improvement as this one,

statistics prove that the results of this operation are sometimes most

advantageous. Thorburn collects statistics of 50 operations from 1814

to 1885, undertaken for relief of injuries of the spinal cord. Lloyd

has compiled what is possibly the most extensive collection of cases of

spinal surgery, his cases including operations for both disease and

injury. White has collected 37 cases of recent date; and Chipault

reports two cases, and collected 33 cases. Quite a tribute to the

modern treatment by antisepsis is shown in the results of laminectomy.

Of his non-antiseptic cases Lloyd reports a mortality of 65 per cent;

those surviving the operation are distributed as follows: Cured, one;

partially cured, seven; unknown, two; no improvement, five. Of those

cases operated upon under modern antiseptic principles, the mortality

was 50 per cent; those surviving were distributed as follows: Cured,

four; partially cured, 15; no improvement, 11. The mortality in White's

cases, which were all done under antiseptic precautions, was 38 per

cent. Of those surviving, there were six complete recoveries, six with

benefit, and 11 without marked benefit. Pyle collects 52 cases of

spinal disease and injury, in which laminectomy was performed. All the

cases were operated upon since 1890. Of the 52 cases there were 15

deaths (a mortality of 29.4 per cent), 26 recoveries with benefit, and

five recoveries in which the ultimate result has not been observed. It

must be mentioned that several of the fatal cases reported were those

of cervical fracture, which is by far the most fatal variety.

Injury to the spinal cord does not necessarily cause immediate death.

Mills and O'Hara, both of Philadelphia, have recorded instances of

recovery after penetrating wound of the spinal marrow. Eve reports

three cases of gunshot wound in which the balls lodged in the vertebral

canal, two of the patients recovering. He adds some remarks on the

division of the spinal cord without immediate death.

Ford mentions a gunshot wound of the spinal cord, the patient living

ten days; after death the ball was found in the ascending aorta. Henley

speaks of a mulatto of twenty-four who was stabbed in the back with a

knife. The blade entered the body of the 6th dorsal vertebra, and was

so firmly embedded that the patient could be raised entirely clear of

the bed by the knife alone. An ultimate recovery ensued.

Although the word hernia can be construed to mean the protrusion of any

viscus from its natural cavity through normal or artificial openings in

the surrounding structures, the usual meaning of the word is protrusion

of the abdominal contents through the parietes--what is commonly spoken

of as rupture. Hernia may be congenital or acquired, or may be single

or multiple--as many as five having been seen in one individual. More

than two-thirds of cases of rupture suffer from inguinal hernia In the

oblique form of inguinal hernia the abdominal contents descend along

the inguinal canal to the outer side of the epigastric artery, and

enter the scrotum in the male, and the labium majus in the female. In

this form of hernia the size of the sac is sometimes enormous, the

accompanying illustration showing extreme cases of both scrotal and

labial hernia. Umbilical hernia may be classed under three heads:

congenital, infantile, and adult. Congenital umbilical hernia occurs

most frequently in children, and is brought about by the failure of the

abdominal walls to close. When of large size it may contain not only

the intestines, but various other organs, such as the spleen, liver,

etc. In some monsters all the abdominal contents are contained in the

hernia. Infantile umbilical hernia is common, and appears after the

separation of the umbilical cord; it is caused by the yielding of the

cicatrix in this situation. It never reaches a large size, and shows a

tendency to spontaneous cure. Adult umbilical hernia rarely commences

in infancy. It is most commonly seen in persons with pendulous bellies,

and is sometimes of enormous size, in addition to the ordinary

abdominal contents, containing even the stomach and uterus. A few years

since there was a man in Philadelphia past middle age, the victim of

adult umbilical hernia so pendulous that while walking he had to

support it with his arms and hands. It was said that this hernia did

not enlarge until after his service as a soldier in the late war.

Abbott recites the case of an Irish woman of thirty-five who applied to

know if she was pregnant. No history of a hernia could be elicited. No

pregnancy existed, but there was found a ventral hernia of the

abdominal viscera through an opening which extended the entire length

of the linea alba, and which was four inches wide in the middle of the

abdomen.

Pim saw a colored woman of twenty-four who, on December 29, 1858, was

delivered normally of her first child, and who died in bed at 3 A.M. on

February 12, 1859. The postmortem showed a tumor from the ensiform

cartilage to the symphysis pubis, which contained the omentum, liver

(left lobe), small intestines, and colon. It rested upon the abdominal

muscles of the right side. The pelvic viscera were normally placed and

there was no inguinal nor femoral hernia.

Hulke reports a case remarkable for the immense size of the rupture

which protruded from a spot weakened by a former abscess. There was a

partial absence of the peritoneal sac, and the obstruction readily

yielded to a clyster and laxative. The rupture had a transverse

diameter of 14 1/2 inches, with a vertical diameter of 11 1/2 inches.

The opening was in the abdominal walls outside of the internal inguinal

ring. The writhings of the intestines were very conspicuous through the

walls of the pouch.

Dade reports a case of prodigious umbilical hernia. The patient was a

widow of fifty-eight, a native of Ireland. Her family history was good,

and she had never borne any children. The present dimensions of the

tumor, which for fifteen years had been accompanied with pain, and had

progressively increased in size, are as follows: Circumference at the

base, 19 1/2 inches; circumference at the extremity, 11 1/4 inches;

distance of extremity from abdominal wall, 12 3/4 inches. Inspection

showed a large lobulated tumor protruding from the abdominal wall at

the umbilicus. The veins covering it were prominent and distended. The

circulation of the skin was defective, giving it a blue appearance.

Vermicular contractions of the small intestines could be seen at the

distance of ten feet. The tumor was soft and velvety to the touch, and

could only partially be reduced. Borborygmus could be easily heard. On

percussion the note over the bulk was tympanitic, and dull at the base.

The distal extremity contained a portion of the small intestine instead

of the colon, which Wood considered the most frequent occupant. The

umbilicus was completely obliterated. Dade believed that this hernia

was caused by the weakening of the abdominal walls from a blow, and

considered that the protrusion came from an aperture near the umbilicus

and not through it, in this manner differing from congenital umbilical

hernia.

A peculiar form of hernia is spontaneous rupture of the abdominal

walls, which, however, is very rare. There is an account of such a case

in a woman of seventy-two living in Pittsburg, who, after a spasmodic

cough, had a spontaneous rupture of the parietes. The rent was four

inches in length and extended along the linea alba, and through it

protruded a mass of omentum about the size of a child's head. It was

successfully treated and the woman recovered. Wallace reports a case of

spontaneous rupture of the abdominal wall, following a fit of coughing.

The skin was torn and a large coil of ileum protruded, uncovered by

peritoneum. After protracted exposure of the bowel it was replaced,

the rent was closed, and the patient recovered.

CHAPTER XIII.

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