Gastrectomy or extirpation of the stomach is considered by most surgeons entirely unjustifiable, as there is seldom hope of cure or prospect of amelioration. La Tribune Medicale for January 16, 1895, gives an abstract of Langenbuch's contribution upon total extirpation of the stomach. Three patients were treated, of whom two died. In the first case, on opening the abdominal cavity the stomach was found very much contracted, presenting extensive carcinomatous infiltration on its posterior surface. After division of the epiploon section was made at the pylorus and at the cardiac extremities; the portions removed represented seven-eighths of the stomach. The pylorus was st.i.tched to the remains of the cardiac orifice, making a cavity about the size of a hen's egg. In this case a cure was accomplished in three weeks. The second case was that of a man in whom almost the entire stomach was removed, and the pyloric and cardiac ends were st.i.tched together in the wound of the parietes. The third case was that of a man of sixty-two with carcinoma of the pylorus. After pylorectomy, the line of suture was confined with iodoform-gauze packing. Unfortunately the patient suffered with bronchitis, and coughing caused the sutures to give way; the patient died of inanition on the twenty-third day.

Enterostomy, or the formation of a fecal fistula above the ileocecal valve, was performed for the first time by Nelaton in 1840, but the mortality since 1840 has been so great that in most cases it is deemed inadmissible.

Colostomy, an operation designed to make a fistulous opening in any portion of the r.e.c.t.u.m, was first practiced by Littre. In early times the mortality of inguinal colostomy was about five per cent, but has been gradually reduced until Konig reports 20 cases with only one death from peritonitis, and Cripps 26 cases with only one death. This will always retain its place in operative surgery as a palliative and life-saving operation for carcinomatous stenosis of the lower part of the colon, and in cases of carcinoma of the r.e.c.t.u.m in which operation is not feasible.

Intestinal anastomosis, whereby two portions of a severed or resected bowel can be intimately joined, excluding from fecal circulation the portion of bowel which has become obstructed, was originally suggested by Maisonneuve, and was studied experimentally by von Hacken. Billroth resorted to it, and Senn modified it by subst.i.tuting decalcified bone-plates for sutures. Since that time, Abbe, Matas, Davis, Brokaw, Robinson, Stamm, Baracz, and Dawburn, have modified the material of the plates used, subst.i.tuting catgut rings, untanned leather, cartilage, raw turnips, potatoes, etc. Recently Murphy of Chicago has invented a b.u.t.ton, which has been extensively used all over the world, in place of sutures and rings, as a means of anastomosis. Hardly any subject has had more discussion in recent literature than the merits of this ingenious contrivance.

Foreign Bodies in the r.e.c.t.u.m.--Probably the most celebrated case of foreign body introduced into the r.e.c.t.u.m is the cla.s.sic one mentioned by Hevin. Some students introduced the frozen tail of a pig in the a.n.u.s of a French prost.i.tute. The bristles were cut short, and having prepared the pa.s.sage with oil, they introduced the tail with great force into the r.e.c.t.u.m, allowing a portion to protrude. Great pain and violent symptoms followed; there was distressing vomiting, obstinate constipation, and fever. Despite the efforts to withdraw the tail, the arrangement of the bristles which allowed entrance, prevented removal.

On the sixth day, in great agony, the woman applied to Marchettis, who ingeniously adopted the simple procedure of taking a long hollow reed, and preparing one of its extremities so that it could be introduced into the r.e.c.t.u.m, he was enabled to pa.s.s the reed entirely around the tail and to withdraw both. Relief was prompt, and the removal of the foreign body was followed by the issue of stercoraceous matter which had acc.u.mulated the six days it had remained in situ.

Tuffet is quoted as mentioning a farmer of forty-six who, in masturbation, introduced a barley-head into his urethra. It was found necessary to cut the foreign body out of the side of the glans. A year later he put in his a.n.u.s a cylindric snuff-box of large size, and this had to be removed by surgical methods. Finally, a drinking goblet was used, but this resulted in death, after much suffering and lay treatment. In his memoirs of the old Academy of Surgery in Paris, Morand speaks of a monk who, to cure a violent colic, introduced into his fundament a bottle of l'eau de la reine de Hongrie, with a small opening in its mouth, by which the contents, drop by drop, could enter the intestine. He found he could not remove the bottle, and violent inflammation ensued. It was at last necessary to secure a boy with a small hand to extract the bottle. There is a record of a case in which a tin cup or tumbler was pushed up the r.e.c.t.u.m and then pa.s.sed into the colon where it caused gangrene and death. It was found to measure 3 1/2 by 3 1/2 by two inches. There is a French case in which a preserve-pot three inches in diameter was introduced into the r.e.c.t.u.m, and had to be broken and extracted piece by piece.

Cloquet had a patient who put into his r.e.c.t.u.m a beer gla.s.s and a preserving pot. Montanari removed from the r.e.c.t.u.m of a man a mortar pestle 30 cm. long, and Poulet mentions a pederast who accidentally killed himself by introducing a similar instrument, 55 cm. long, which perforated his intestine. Studsgaard mentions that in the pathologic collection at Copenhagen there is a long, smooth stone, 17 cm. long, weighing 900 gm., which a peasant had introduced into his r.e.c.t.u.m to relieve prolapsus. The stone was extracted in 1756 by a surgeon named Frantz Dyhr. Jeffreys speaks of a person who, to stop diarrhea, introduced into his r.e.c.t.u.m a piece of wood measuring seven inches.

There is a remarkable case recorded of a stick in the a.n.u.s of a man of sixty, the superior extremity in the right hypochondrium, the inferior in the concavity of the sacrum. The stick measured 32 cm. in length; the man recovered. It is impossible to comprehend this extent of straightening of the intestine without great twisting of the mesocolon.

Tompsett mentions that he was called to see a workman of sixty-five, suffering from extreme rectal hemorrhage. He found the man very feeble, without pulse, pale, and livid. By digital examination he found a hard body in the r.e.c.t.u.m, which he was sure was not feces. This body he removed with a polyp-forceps, and found it to be a cylindric candle-box, which measured six inches in circ.u.mference, 2 1/2 in length, and 1 1/2 in diameter. The removal was followed by a veritable flood of fecal material, and the man recovered. Lane reports perforation of the r.e.c.t.u.m by the introduction of two large pieces of soap; there was coincident strangulated hernia.

Hunter mentions a native Indian, a resident of Coorla, who had introduced a bullock's horn high up into his abdomen, which neither he nor his friends could extract. He was chloroformed and placed in the lithotomy position, his b.u.t.tocks brought to the edge of the bed, and after dilatation of the sphincter, by traction with the fingers and tooth-forceps, the horn was extracted. It measured 11 inches long. The young imbecile had picked it up on the road, where it had been rendered extremely rough by exposure, and this caused the difficulty in extraction.

In Nelson's Northern Lancet, 1852, there is the record of a case of a man at stool, who slipped on a cow's horn, which entered the r.e.c.t.u.m and lodged beyond the sphincter. It was only removed with great difficulty.

A convict at Brest put up his r.e.c.t.u.m a box of tools. Symptoms of vomiting, meteorism, etc., began, and became more violent until the seventh day, when he died. After death, there was found in the transverse colon, a cylindric or conic box, made of sheet iron, covered with skin to protect the r.e.c.t.u.m and, doubtless, to aid expulsion. It was six inches long and five inches broad and weighed 22 ounces. It contained a piece of gunbarrel four inches long, a mother-screw steel, a screw-driver, a saw of steel for cutting wood four inches long, another saw for cutting metal, a boring syringe, a prismatic file, a half-franc piece and four one-franc pieces tied together with thread, a piece of thread, and a piece of tallow, the latter presumably for greasing the instruments. On investigation it was found that these conic cases were of common use, and were always thrust up the r.e.c.t.u.m base first. In excitement this prisoner had pushed the conic end up first, thus rendering expulsion almost impossible. Ogle gives an interesting case of foreign body in the r.e.c.t.u.m of a boy of seventeen.

The boy was supposed to be suffering with an abdominal tumor about the size of a pigeon's egg under the right cartilages; it had been noticed four months before. On admission to the hospital the lad was suffering with pain and jaundice; sixteen days later he pa.s.sed a stick ten inches long, which he reluctantly confessed that he had introduced into the a.n.u.s. During all his treatment he was conscious of the nature of his trouble, but he suffered rather than confess. Studsgaard mentions a man of thirty-five who, for the purpose of stopping diarrhea, introduced into his r.e.c.t.u.m a preserve-bottle nearly seven inches long with the open end uppermost. The next morning he had violent pain in the abdomen, and the bottle could be felt through the abdominal wall. It was necessary to perform abdominal section through the linea alba, divide the sigmoid flexure, and thus remove the bottle. The intestine was sutured and the patient recovered. The bottle measured 17 cm. long, five cm. in diameter at its lower end, and three cm. at its upper end.

Briggs reports a case in which a wine gla.s.s was introduced into the r.e.c.t.u.m, and although removed twenty-four hours afterward, death ensued.

Hockenhull extracted 402 stones from the r.e.c.t.u.m of a boy of seven.

Landerer speaks of a curious case in which the absorptive power of the r.e.c.t.u.m was utilized in the murder of a boy of fifteen. In order to come into the possession of a large inheritance the murderess poisoned the boy by introducing the ends of some phosphorous matches into his r.e.c.t.u.m, causing death that night; there was intense inflammation of the r.e.c.t.u.m. The woman was speedily apprehended, and committed suicide when her crime was known.

Complete transfixion of the abdomen does not always have a fatal issue.

In fact, two older writers, Wisemann and Muys, testify that it is quite possible for a person to be transfixed without having any portion of the intestines or viscera wounded. In some nations in olden times, the extremest degree of punishment was transfixion by a stake. In his voyages and travels, in describing the death of the King of Demaa at the hands of his page, Mendez Pinto says that instead of being reserved for torture, as were his successors Ravaillac, and Gerard, the slayer of William the Silent, the a.s.sa.s.sin was impaled alive with a long stake which was thrust in at his fundament and came out at the nape of his neck. There is a record of a man of twenty-five, a soldier in the Chinese war of 1860, who, in falling from his horse, was accidentally transfixed by a bayonet. The steel entered his back two inches to the left of the last dorsal vertebra, and reappeared two inches to the left and below the umbilicus; as there was no symptom of visceral wound there were apparently no injuries except perforation of the parietes and the peritoneum. The man recovered promptly.

Ross reports a case of transfixion in a young male aborigine, a native of New South Wales, who had received a spear-wound in the epigastrium during a quarrel; extraction was impossible because of the sharp-pointed barbs; the spear was, therefore, sawed off, and was removed posteriorly by means of a small incision. The edges of the wound were cleansed, st.i.tched, and a compress and bandage applied.

During the night the patient escaped and joined his comrades in the camp, and on the second day was suffering with radiating pains and distention. The following day it was found that the st.i.tches and plaster had been removed, and the anterior wound was gaping and contained an ichorous discharge. The patient was bathing the wound with a decoction of the leaves of the red-gum tree. Notwithstanding that the spear measured seven inches, and the interference of treatment, the abdominal wound closed on the sixth day, and recovery was uninterrupted. Gilkrist mentions an instance in which a ramrod was fired into a soldier's abdomen, its extremity lodging in the spinal column, without causing the slightest evidence of wounds of the intestines or viscera. A minute postmortem examination was held some time afterward, the soldier having died by drowning, but the results were absolutely negative as regards any injury done by the pa.s.sage of the ramrod.

Humphreys says that a boy of eleven, while "playing soldier" with another boy, accidentally fell on a rick-stake. The stake was slightly curved at its upper part, being 43 inches long and three inches in circ.u.mference, and sharp-pointed at its extremity. As much as 17 1/2 inches entered the body of the lad. The stake entered just in front of the right spermatic cord, pa.s.sed beneath Poupart's ligament into the cavity of the abdomen, traversed the whole cavity across to the left side; it then entered the thorax by perforating the diaphragm, displaced the heart by pushing it to the right of the sternum, and pierced the left lung. It then pa.s.sed anteriorly under the muscles and integument in the axillary s.p.a.ce, along the upper third of the humerus, which was extended beyond the head, the external skin not being ruptured. The stick remained in situ for four hours before attempts at extraction were made. On account of the displacement of the heart it was decided not to give chloroform. The boy was held down by four men, and Humphreys and his a.s.sistant made all the traction in their power.

After removal not more than a teaspoonful of blood followed. The heart still remained displaced, and a lump of intestine about the size of an orange protruded from the wound and was replaced. The boy made a slow and uninterrupted recovery, and in six weeks was able to sit up. The t.e.s.t.i.c.l.e sloughed, but five months later, when the boy was examined, he was free from pain and able to walk. There was a slight enlargement of the abdomen and a cicatrix of the wound in the right groin. The right t.e.s.t.i.c.l.e was absent, and the apex of the heart was displaced about an inch.

Woodbury reports the case of a girl of fourteen, who fell seven or eight feet directly upon an erect stake in a cart; the tuberosity was first struck, and then the stake pa.s.sed into the a.n.u.s, up the r.e.c.t.u.m for two inches, thence through the rectal wall, and through the body in an obliquely upward direction. Striking the ribs near the left nipple it fractured three, and made its exit. The stake was three inches in circ.u.mference, and 27 inches of its length pa.s.sed into the body, six or seven inches emerging from the chest. This girl recovered so rapidly that she was able to attend school six weeks afterward. In a case reported by Bailey a middle-aged woman, while sliding down a hay-stack, struck directly upon a pitchfork handle which entered the v.a.g.i.n.a; the whole weight of the woman was successfully maintained by the cellular tissue of the uterov.a.g.i.n.al culdesac.

Minot speaks of the pa.s.sage of one p.r.o.ng of a pitchfork through the body of a man of twenty-one, from the perineum to the umbilicus; the man recovered.

Hamilton reports a case of laceration of the perineum with penetration of the pelvic cavity to the depth of ten inches by a stick 3/4 inch thick. Prowse mentions the history of a case of impalement in a man of thirty-four, who, coming down a hay-stack, alighted on the handle of a pitchfork which struck him in the middle of the s.c.r.o.t.u.m, and pa.s.sed up between the skin and fascia to the 10th rib. Recovery was prompt.

There are several cases on record in which extensive wounds of the abdominal parietes with protrusion and injury to the intestine have not been followed by death. Injuries to the intestines themselves have already been spoken of, but there are several cases of evisceration worthy of record.

Doughty says that at midnight on June 7, 1868, he was called to see a man who had been stabbed in a street altercation with a negro. When first seen in the street, the patient was lying on his back with his abdomen exposed, from which protruded an enormous ma.s.s of intestines, which were covered with sand and grit; the small intestine (ileum) was incised at one point and scratched at another by the pa.s.sing knife. The incision, about an inch in length, was closed with a single st.i.tch of silk thread, and after thorough cleansing the whole ma.s.s was returned to the abdominal cavity. In this hernial protrusion were recognized four or five feet of the ileum, the cec.u.m with its appendix, part of the ascending colon with corresponding portions of the mesentery; the distribution of the superior mesentery, made more apparent by its living pulsation, was more beautifully displayed in its succession of arches than in any dissection that Doughty had ever witnessed.

Notwithstanding the extent of his injuries the patient recovered, and at last reports was doing finely.

Barnes reports the history of a negro of twenty-five who was admitted to the Freedmen's Hospital, New Orleans, May 15, 1867, suffering from an incised wound of the abdomen, from which protruded eight inches of colon, all of the stomach, and nearly the whole of the small intestines. About 2 1/2 feet of the small intestine, having a whitish color, appeared to be filled with food and had much of the characteristic feeling of a sausage. The rest of the small intestine had a dark-brown color, and the stomach and colon, distended with gas, were leaden-colored. The viscera had been exposed to the atmosphere for over an hour. Having nothing but cold Mississippi water to wash them with, Barnes preferred returning the intestines without any attempt at removing blood and dirt further than wiping with a cambric handkerchief and the stripping they would naturally be subjected to in being returned through the opening. In ten minutes they were returned; they were carefully examined inch by inch for any wound, but none was found.

Three silver sutures were pa.s.sed through the skin, and a firm compress applied. The patient went to sleep shortly after his wound was dressed, and never had a single subsequent bad symptom; he was discharged on May 24th, the wound being entirely healed, with the exception of a cartilage of a rib which had not reunited.

Rogers mentions the case of a carpenter of thirty-six who was struck by a missile thrown by a circular saw, making a wound two inches above the umbilicus and to the left. Through the opening a ma.s.s of intestines and a portion of the liver, attached by a pedicle, protruded. A portion of the liver was detached, and the liver, as well as the intestines, were replaced, and the man recovered.

Baillie, Bhadoory, Barker, Edmundson, Johnson, and others, record instances of abdominal wounds accompanied by extensive protrusion of 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 b.a.l.l.s 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 pa.s.sages these b.a.l.l.s did not wound any of the viscera, and with the exception of traumatic fever there was no disturbance of the health of the patient. Sch.e.l.l 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 pa.s.sing 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, pa.s.sing 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 b.a.l.l.s entering the abdominal wall were voided by the a.n.u.s 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 pa.s.sed through the lung and diaphragm and entered the alimentary ca.n.a.l; it was voided by the r.e.c.t.u.m five days after the injury. Lenox mentions the fact of a bullet entering the abdominal wall and subsequently being pa.s.sed from the r.e.c.t.u.m. 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 ca.n.a.l, 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 a.s.sociated with considerable loss of liver-substance. In the older records, Glandorp and Scultetus mention cures after large wounds of the liver. Fabricius Hilda.n.u.s 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 pa.s.sing 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 princ.i.p.al 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 quant.i.ty 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. Ma.s.sie 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. Ha.s.sig reports the case of a private of twenty-six who was wounded in a fray near Paducah, Kentucky, by a conoid ball, which pa.s.sed 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 att.i.tude. The condition usually arises from a lax abdominal wall following repeated pregnancies. The accompanying ill.u.s.tration 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 quant.i.ties 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 pa.s.sed 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.