above. Elsewhere, the percussion note was normal. Pressure
over the splenic area elicited marked tenderness.
There was also a fracture of the left femur and an extensive
scalp wound. Pulse slightly over 100, and of increasing frequency.
Temperature, 101°.
Splenectomy five hours after the accident.
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ELIOT: RUPTURE OF THE SPLEEN 349
Gas and Ether. A vertical incision along the upper outer border
of the left rectus, above the level of the umbilicus, extending from
its outer extremity downward and outward along and parallel to the
costal margin, a distance of four inches. A considerable amount
of semiclotted blood was found in the peritoneal cavity and
rapidly wiped away, disclosing the spleen with a deep rupture
two and a half inches long in its phrenic surface. The spleen was
double its normal size, and at its pedicle was closely adherent to
the fundus of the stomach. It was also moderately adherent to
the diaphragm. The rent was still bleeding freely, but imme-
diately ceased when the pedicle was compressed. After tempo-
rary control of the bleeding, the spleen was separated from the
diaphragm above and from the fundus of the stomach below, and
its pedicle clamped with two large strong forceps. The remain-
ing clotted blood was then removed with saline irrigation and the
woimd closed, leaving an aperture at its lower extremity for the
handles of the clamps. The operation required fifteen minutes,
and toward the latter end the patient's pulse became feeble and
rapid, responding, however, to an infusion of looo c.c. of saline
solution.
During the first twenty-four hours there was considerable dis-
charge from the woimd, and the patient's general condition was
such as to require a moderate amount of stimulation. The pulse,
never higher than 140, decreased to 88 on the third day. The
clamps were removed without pain on the second and third days,
respectively, and without any sign of a renewal of the hemorrhage.
Three weeks after there was a rise of temperature to 103®, and
30 ounces of clear fluid was withdrawn from the left chest. There-
after the convalescence was uninterrupted and complete. At no
time was there any indication of enlarged glands or of an enlarged
thjToid, or any pain along the shafts of the long bones. The frac-
ture of the femur united slowly, but satisfactorily, and the patient
today is attending regularly to his work as a guard on the elevated
raikoad.
Laboratory Reports. The spleen was normal outside of the rup-
ture, which penetrated into the hilus.
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350 ELIOT: RUPTURE OF THE SPLEEN
For a few days after the operation the urine showed a faint trace
of albumin and casts.
The fluid from the chest was alkaline, of a specific gravity of
1015, and contained a large amount of albumin. It contained
no growth of any kind.
The following blood counts were made: Number coimted in
each 300:
June
On admission. 1. 4. 6. 8.
Polymorphonuclear 92.5 M.O 76.0 .. 88.0
Transitional 2.5 2.6 5.5 5.0
Large mononuclear , . . 4.0 3.0
Lymphocytes 4.0 13.0 12.5 .. 4.0
Basophiles
Eosinophiles 1.0 2.0
Blood plates Inc. . . Inc. . . Inc.
Leukocytes 54,000 24,000 28,100 .. 80,000
June
Tl Is! 15. 20. 80.
Polymorphonuclear 64.5 66.0 75.0 56.0 69.0
Transitional : . . 7.0 12.0 7.5 15.0 5.5
Lar^ mononuclear 0.5 1.5 .. 4.5 1.0
Lymphocytes 26.5 16.5 16.6 20.0 24.0
Basophiles 0.6 0.6
Eosinophiles 1.0 1.5 5.5
Blood plates (Much Great \ _ jnc, inc.
( Inc. Inc. j
Leukocytes 20.000 17,000 .. 13,800
One year afterward: White blood cells, 17,000; red cells,
5,800,000; polymorphonuclear, 52.5; transitional, 4.5; large mono-
nuclear, 13.5; lymphocytes, 28.5; basophiles, 0.5; eosinophiles,
0.5.
There was considerable pallor of the red cell with moderate
polychrom. There was 95 per cent, hemoglobin.
Case II. — L. S., female, aged thirty-four years (May 14, 1906).
Eight years ago patient was curetted for retained secundines.
Four years ago she was operated on for ruptured ectopic gestation,
in a condition of almost complete exsanguination. Since then she
has been in excellent health.
This morning, at 10 o'clock, patient fell a distance of nine feet,
striking the region of the lower ribs against the edge of an ash-can.
She was unable to rise and there was severe pain in the left side,
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ELIOT: RUPTURE OF THE SPLEEN 351
intensified by movement and by deep respiration. To lie on her
left side was impossible, and lying on her back was also painful.
There has been no vomiting. The pain seemed to diminish for
a time and then returned with increasing severity, and the patient
began to feel weak and thirsty. Brought to the hospital in an
ambulance.
Five hours after the accident the pulse was regular, 132, and
of low tension. The respiration was shallow and increased in
frequency. There was a fracture of the eighth and ninth ribs
near the axillary line.
Examination of the abdomen showed a diminished respiratory
movement on the left side. Rigidity present throughout the entire
left side was most marked in the ileocostal space and over the left
lower costal arch. Moderate pressure over the splenic area was
very painful. In the left flank there was a dulness, merging with
the area of normal splenic dulness above. Elsewhere the percus-
sion note was unchanged.
The patient was acutely anemic and presented the usual appear-
ance of a patient suffering from internal hemorrhage.
Splenectomy six hours after the accident.
Gas and Ether. A vertical incision was made along the upper
outer border of the left rectus, above the level of the umbilicus,
extending from its upper extremity downward and outward along
the costal margin a distance of four inches. A considerable
amoimt of clotted and fluid blood was found in the peritoneal
cavity and rapidly evacuated, disclosing the spleen with a deep
rupture two and one-quarter inches long on its internal surface, in
front of the hilus, and on its outer surface, denuded of its peritoneal
coat, an irregularly circular orifice three-quarters of an inch in
diameter, communicating with the larger rent internally. The
spleen was double the normal size and was still bleeding. The
pedicle was clamped with two strong forceps and the spleen re-
moved. The remaining clotted blood was then quickly washed
away with saline irrigation, and, after the insertion of a cigarette
drain to the pedicle, the wound was closed, lea\ing an aperture at
its lower extremity for the handles of the clamps. The duration
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352 ELIOT : RUPTURE OF THE SPLEEN
of the operation was twenty-one minutes, and at its end, the pulse
being 140 and weak, an infusion of 1200 c.c. of saline solution
was given.
During the following night the pulse was at times almost imper-
ceptible, and there were several attacks of vomiting, but the
patient responded well to stimulation, and at the end of twenty-four
hours was in a very satisfactory condition. The clamps were re-
moved at the end of forty-eight and seventy-two hours, respec-
tively. The healing of the wound was satisfactory, although
there was a gradual rise of temperature to 103° on the fourth day
and a continuation of a temperature averaging 102® imtil the
fourteenth day, when it fell to normal. On the nineteenth day
there was a sudden rise of temperature to 103°, with the physical
signs of fluid in the left chest. At the end of ten days the tempera-
ture was again normal and the signs of fluid had entirely disap-
peared. The patient was discharged in excellent condition at the
end of the forty-fifth day.
The following abstracts of successive blood counts are added:
Days.
On ad- , • »
miflsion. 2d. 4th. 6th. 8th. 10th.
Polymorphonuclear . . . 94.5% 80% 77% .. 75% 80%
Leukocytes ...... 296,000 68,000 28,000 86,900 89,400 82,900
Lymphocytes 5% 5% 8% 14% . « 17.6%
Days.
12th. I4th. 16th. 18th. 20th. 28d.
Polymorphonuclear 67% 67% 66% 64%
Leukocytes 22,6C0 17,700 28,900 14.800 13.700 10,000
Lymphocytes . . 24% 25% 19%
Days.
'24th. 26th. 29th. 85th! 88th. 41st.
Polymorphonuclear . . . 52% 53% 44% 61% .. 42%
Leukocytes 15,000 18,000 10,000 12,000 14,400 18.800
Lymphocytes 22% 26% 40% 18% .. 40%
Hemoglobin, 80%.
Red cells, 3,260,000.
Since her discharge from the hospital the patient has had sev-
eral attacks of "indigestion," with pain of moderate or sUght
severity in the gall-bladder region. About forty-eight hours
before admission, and ten and a half months after splenectomy,
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ELIOT: RUPTURE OF THE SPLEEN 353
she was seized with sharp, severe pain in the same region, which
radiated to the back, aUhough not to the shoulder, and was intensi-
fied by movement from one side to the other in bed and by respira-
tion. There was constant nausea, but only one attack of vomiting
on the afternoon of the day of admission, the vomiting consisting
of the gastric contents. The bowels had moved each day. The
prostration was marked, and, at the time of admission, the pulse
was no, the temperature 102°, and respiration 44. The patient
looked acutely sick, and the pain, which had continued from the
onset, was then very intense and prohibitive of any movement in
bed.
On examination, the patient was in the dorsal position with the
thighs flexed on the abdomen. The right side of the abdomen was
held rigid and motionless and was exquisitely painful to the touch.
There was intense rigidity of the upper part of the right rectus,
and, to a lesser extent, of its lower portion as well. There was
well-marked resistance of the upper part of the right costal arch,
and pressure over the arch above the situation of the gall-bladder
caused pain. The extreme tenderness prevented satisfactory
percussion. Under a general anesthetic, fhe gall-bladder could be
distinctly felt projecting below the border of the liver to a point
opposite the level of the umbilicus, and forming an oval, smooth,
and deeply elastic tumor.
Gas and Ether. Through a vertical incision parallel to the upper
outer border of the right rectus muscle the peritoneal cavity was
opened and the gall-bladder exposed, with the transverse colon
and omentum moderately adherent. There was a small amount of
clear serous fluid in the peritoneal cavity. The gall-bladder was
double the normal size and its wall stretched and elastic. It was
rapidly and easily separated from the liver above, and, after liga-
tion of the edge of the gastrohepatic omentum and cystic duct
with chromic gut, was cut away without its cavity being opened.
The wound was closed in layers with chromic gut, a cigarette drain
being inserted to the stump of the ligated duct. The patient was
on the table less than forty-five minutes.
Am Surg 23
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354 ELIOT: RUPTURE OF THE SPLEEN
On opening the gall-bladder its cavity contained a considerable
amount of turbid serous fluid; its walls were found to be thickened,
and near the orifice leading into the cystic duct were two large
calculi.
Postoperative Course. First day after operation, recovery
from the anesthetic took place without event. There was no
nausea or vomiting and very little restlessness. During the day
the patient was quiet, complaining at times of pain in the wound
from which there was no biliary discharge. The quantity of urine
passed was 24 ounces. There was a trace of albumin, but no casts.
Second Day. Patient's condition was satisfactory throughout
the day. She vomited once 6 ounces of greenish fluid and was at
times restless and complained of pain. The wound was dressed
and the drain loosened a trifle. Toward evening she appeared
drowsy and the pulse was a little more rapid. The total amount
of urine passed was 39 ounces.
Third Day, The drowsy condition increased, deepened rap-
idly into coma, from which she could not be aroused. The patient
lay flat on her face, unconscious, and did not even groan. The
eyelids were closed. The pupils, equal, markedly dilated, reacted
to light. Respirations were labored and rapid, and had both an
inspiratory and respiratory effort. The prostration increased and
seemed very marked. The temperature rose steadily throughout
the day, and by evening had reached 103°. The pulse was also
very rapid, varjing between 130 and 148, but was of fair quality
and of moderate excursion. The general leukocytosis was 55,000,
with a polymorphonuclear of 90 per cent. Examination of the
lungs showed a number of rales over the left base and a good many
over the right base, but without noticeable change in the respira-
tor)^ murmur. Abdominal distention gradually appeared, and
during the day a profuse biliary fistula, discharging a large amount
of yellow-brown material, was formed. There was no rigidity of
the abdominal muscles or any sign of fluid in the peritoneal ca\it}*.
The urine was 1027; acid; good trace of albumin; no sugar.
Microscopically, there were urates and many hyaline casts. Urea
amounted to 3.3 per cent. There was no diacetic acid. There
was a very faint reaction for acetone.
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ELIOT: RUPTURE OF THE SPLEEN 355
Throughout the day the patient received active stimulation of
strychnine, digitalis, and whisky in clyses and saline enemata.
For the distention, stupes and hypodermics of physostigmine sali-
cylate were employed. At noon, hypodermic injections of adren-
alin and thyroid extract were begun, the adrenalin in doses of
2-minim doses every hour for four hours, and afterward included
in a clysis containing 3 drams of whisky and 1000 c.c. of saline
solution with 15 minims of adrenalin once in four hours. Early in
the afternoon feeding by spleen tissue was also begun in the form
of 5-grain suppositories every six hours, and of enemata of spleen
broth containing 5 oimces, twice a day.
Fourth Day. The condition of the patient grew steadily worse,
and toward midnight was most alarming. At that time the pulse
could scarcely be felt, and was counted at 150. Respiration was
36, and shallow. The temperature was 104°. The patient's con-
dition seemed most extreme and she appeared moribund. In an
effort to check what appeared to be a form of toxin absorption,
lavage was given, followed by a cathartic with colon irrigation.
At half-past two in the morning the patient appeared for the first
time to be holding her own, and soon after began to show a con-
tinued but manifest improvement, in that the pulse became slower
and stronger and the saline enemata brought away each time
quantities of foul fecal material, with a considerable amoimt of
flatus. The temperature also gradually fell to 102°. The coma
continued without change and the pupils were still dilated. The
condition of the abdomen showed no sign of peritonitis.
Fifth Day. Toward noon today the coma decreased and the
patient seemed to be slightly conscious of her environment. Fol-
lowing a clysis, the patient had a chill with a rise of temperature
to 105°, but by night the temperature had again fallen to 103°.
Late in the afternoon the patient began to moan and could be
aroused by effort. Although always in a very stupid condition,
yet on several occasions she asked for water. Her entire condi-
tion showed great improvement, and during the day she was given
48 ounces of fluid nourishment. During the morning the right
pupil was slightly larger than the left, but later on both were
equal and contracted. This afternoon the pulse was as low as 90.
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3S6 ELIOT: RUPTURE OF THE SPLEEN
Sixth Day. Patient talked at intervals during the day, and said
that she remembered nothing of what had transpired since the
operation. Her mind was quite clear, and she took increasing
quantities of fluid nourishment. Patient looked much stronger,
the temperature was as low as ioo°, and the pulse in the 8o's. The
abdominal condition was unchanged. There are still many crep-
itant rales over the left base as well as over the right base, although
less abundant. On this day, although the biliary fistula was dis-
charging freely, the conjimctivae and skin became slightly icteric
and the urine showed the presence of bile. Several cultures of the
blood failed to disclose any organism.
Subsequent Course. The patient continued to steadily gain
ground. The jaundice, at first somewhat deepened, had by the
end of a week entirely disappeared. The temperature remained,
however, irregularly and persistently high, varying between 99° in
the morning and 103° at night. During this time the pulse varied
between 94 and 115, being usually slightly over 100. On the
twenty-sixth day signs of a small amount of fluid were detected by
Dr. James over the right base and about i dram of slightly puru-
lent fluid was withdrawn by the needle. On the following day
the temperature rose to 103° and the pulse to 140, and immediate
thoracotomy was performed under cocaine, evacuating a very
small amount of pus. After the operation the patient was rest-
less and somewhat neurasthenic, but never at any time showed
any distinct manifestation of hysteria. The discharge from the
opened pleural cavity was always small, and, after the removal of
the tube, rapidly healed to a small sinus with excellent expansion
of the lung. For more than two weeks the patient ran an irregu-
larly high temperature, but since that time the temperature gradu-
ally fell to normal, where it has remained for more than a week.
The patient is now up and dressed, feeling strong, and gaming
steadily in weight. She is still taking spleen broth, and three
suppositories are taken daily.
Laboratory Notes, i. The culture taken from the fluid in the
abdominal ca\ity at the time of the first operation showed no
culture.
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ELIOT: RUPTURE OF THE SPLEEN
357
2. The gall-bladder presented somewhat thickened walls and
had a deeply congested mucous membrane. The mucosa was
somewhat eroded, and on microscopic examination showed chronic
suppurative inflammation.
3. The blood culture and the culture from the gall-bladder were
negative.
4. The culture from the fluid in the right chest showed rather
thick bacilli; which gave all the reactions of the Bacillus coU com-
munis.
The following differential counts were made on admission, 350
cells being taken in the first four, and 200 cells in the later counts:
Days.
coma 1st.
coma 2d.
coma 3d.
4th.
5th.
6th.
Leukocytes ....
86,200
35.000
19,800
19,800
81,000
36,000
perct.
perct
per ct.
per ct.
per ct.
perct.
Polymorphonuclear
004
89.6
, ,
78.8
73.0
70.0
Transitional . . .
6.8
6.4
. ,
6.0
6.5
7.5
Large mononuclear
2.4
2.8
, ,
4.4
10.0
•2,6
Lymphocytes . . .
0.4
1.2
, ,
8.8
8.6
9.5
Basophiles ....
. ,
, ,
, .
, ,
Bosmophiles . . .
. .
, ,
2.0
3.0
Blood plates ...
Inc.
Inc.
Inc.
Inc.
Inc.
Pallor
Consid.
Consid.
Consid.
Inc.
Inc.
Polychromatophilic
Mod.
Mod.
, .
Mod.
Mod.
Mod.
Poikilocytes . . .
Mod.
Mod.
Mod.
Mod.
Mod.
Basophiles, granular
. ,
, ,
, ,
Normoblasts . . .
. ,
1.0
Megaloblasts . . .
. .
Stimulating forms .
, ,
8.0
Myelocytes ....
1.0
1.0
••
5.0
3.0
Days.
7lh.
8th.
9lh.
10th.
13th.
16th.
Leukocytes. . . .
37,000
27,400
84,000
28,800
80,000
29,600
perct.
perct.
perct.
perct.
perct.
perct.
Polymorphonuclear
72.5
72.6
2.5
73.0
76.5
78.0
Transitional . . .
7.0
6.0
9.0
8.5
6.5
6.0
Large mononuclear
10.0
12.5
1.0
12.5
8.5
18.0
Lymphocytes . . .
9.0
11.0
7.0
6.5
9.0
8.5
Basophiles ....
. ,
Eosinophiles . . .
1.0
0.5
0.5
0.5
0.5
Blood plates . . .
Inc.
Inc.
Inc.
Inc.
Inc.
Inc.
Pallor
Inc.
Inc.
Consid.
Inc.
Inc.
Inc.
Polychromatophilic
Mod.
Mod.
Mod.
Mod.
Mod.
Mod.
Poikilocytes . . . .
Mod.
Mod.
Mod.
Mod.
Mod.
Mod.
Basophiles, granular .
Mod.
Normoblasts . . . .
1.0
. ,
, .
Megaloblasts . . . .
, .
Stimulating forms .
2.0
Myelocytes
1.0
1.0
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358
ELIOT : RUPTURE OF THE SPLEEN
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Date.
S>* ! ' I ' I â–
S^ [Reac-, «-,__ Tur- .Predpl-' Albu-
$g ,tlon. ; ^*°'- bidliy. tauT mln.
Microscopic exam-
ination.
March 6(A.O./ 1082 I Acid.; Amber. I Clear. I Flocc. '
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March 9(Calh.)
1027
Acid.
Reddish.
Flocc.
Weaker
' trace.
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|T«ce. 1
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Acid.
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Gran.
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Trace.
March 16 ... .
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March 19 ... .
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April 4
..
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I cles and epithelium
present in good
number.
I Crates, many hyaline
castit; urea 8.2%, no
' diacetic, acetone.
Urates, few hyaline
casts and white
blood corpuscles; no
diaoetlc; no acetone.
Little pus. Bile pres-
ent.
No pus. Bile present.
Bile present.
Bile present.
No bile.
No bile.
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