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364
ELIOT: RUPTURE OF THE SPLEEN
Days.
18th.
20th.
22d.
24th.
26th.
29th.
Leukocytes. . . .
24,200
16.800
16.800
17.000
24.000
25.800
perct.
perct.
perct.
perct.
perct.
perqt-
Polymorphonuclear
67.5
65.0
61.0
60.0
55.0
77.5
Transitioiial . . . .
7.0
6.0
5.0
6.5
4.0
9.5
Larfi:e mononuclear
16.0
15.5
12.5
14.0
14.5
2.5
Lymphocytes . . .
9.0
11.0
19.0
19.0
4.0
10.0
Basophiles
0.5
0.6
, ,
, .
, ,
0.5
Eofilnophlles . . .
2.0
1.8
0.5
2.5
, ,
Blood plates . . .
Inc.
Inc.
Inc.
Inc.
Inc.
Inc.
Pallor
Inc.
Inc.
Inc.
Inc.
Inc.
Inc.
Polychromatophilic
Mod.
Mod.
Consid.
Inc.
Inc.
Inc.
Polkilocytes . . .
Mod.
Mod.
Consid.
Inc.
Inc.
Inc.
Basophiles, granular
. Consid.
Mod.
Mod.
Mod.
Mod.
Mod.
Normoblasts . . .
1.0
, ,
. .
, ,
, ,
, .
Megaloblasts . . .
.,
. . •
Stimulating forms .
.
, .
, ,
, ,
, .
Myelocytes ....
PATHOLOGICAL REPORTS.
March 7. Culture from abdominal cavity. No growth. (March 2.) Thachcr.
March 7. " Gall-bladder." Somewhat thickened fibrous walls, deeply con-
gested interior surface, split open; would contain about one and
one-half ounces of fluid. One stone, faceted on two surfaces,
about size of pigeon's egg; stone is dark brown externally, and
somewhat lighter within.
Microscopic examination. Chronic suppurative inflammation of
gall-bladder. Wall thickened; mucosa partly eroded.
March 13. Blood culture. No growth (March 16). Thacher.
March 7. Culture from gall-bladder. Contaminated. Thacher.
April 2. Culture fluid from right chest.
Microscopic examination. Rather thick bacilli which give all the
reactions of Bacillus coli communis. Tuttle.
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ELIOT: RUPTURE OF THE SPLEEN 365
BlBL]CX3RAPHY.
Lamarchia. Cent. f. Chir., 1899, p. 43.
Pauchet. Bull, et m^m. de la Soc. de chir., 1902, No. 41.
Auvray. Ibid., 1904, No. 33.
Roeser. Beit. f. Chir., Bnins, 1902, vol. xxxvi, p. 228.
Fontoynont. Bull, et m^m. de la Soc. de chir., tome xxxi, p. 36.
Bardenheuer and Boger. Cent. f. Chir., 1905, p. 78.
Morison. Lancet, January 7 and 14, 1899.
Ballance. Trans. Clin. Soc., 1896, vol. xxix, p. 77.
Hdrz. Beit. f. Chir., Bruns, vol. 1, p. 188.
Hammer. Ibid., p. 684.
Berger. Archiv f. klin. Chir., 1902, Band Ixviii.
Bessel-Hagen. Ibid., 1900, Band bdi.
Noltzel. Beit. f. Chit., vol. xlviii, p. 309.
Carstens. New York and Philadelphia Med. Jour., 1905.
Von Beck. Miinch. med. Woch., 1897, p. 1319.
Heaton. Brit. Med, Jour., 1899, vol.ii, 476.
Lewerenz. Cent. f. Chir., 1899, vol. xxvii, p. 654.
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REPORT OF A CASE OF NON-PARASITIC CYST OF
THE SPLEEN.
By THOMAS W. HUNTINGTON, M.D.,
SAN FRANCISCO.
Because of its rarity, an unusual interest attaches to the fol-
lowing case. In a paper read before this Association in 1905 by
Powers, of Denver, 32 cases of non-parasitic cysts of the spleen
were tabulated. While these probably do not represent all re-
ported cases up to that time, it is nevertheless a fact that non-
parasitic cysts of the spleen have been encountered by the surgeon
infrequently, and, more rarely, has a definite diagnosis been made
prior to exploratory incision.
On January 12 of the present year I was consulted by a woman,
aged twenty- three years, and obtained the following history:
Family History. Parents both living, and well. Otherwise,
family and personal history negative.
Past History. She was well up to the age of twenty-one years,
and led an active life. Aside from slight digestive disturbances,
has never consulted a physician until recently. Menstrual func-
tion normal. Was married fifteen months pre\dously, and has
never been pregnant. For a little less than one year previous to
above date she had lived in Manila, where she enjoyed usual
health, escaping all diseases of a tropical character. Has never
had typhoid fever. Two years ago she noticed a slight enlarge-
ment in the left upper abdominal quadrant. As it occasioned no
pain or discomfort she attached no special significance to it.
Did not mention it to her relatives, and it was not until after
her marriage that special attention was attracted to it. In its
early history it seemed to be a rounded, smooth, rather resistant
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HUNTINGTON: NON-PARASITIC CYST OF THE SPLEEN 367
mass about the size of a large orange. Careful inquiry failed to
elicit any history of a traumatism.
Present Condition. The patient is a slightly built, rather deli-
cate-looking person; features somewhat drawn, suggesting the
later stages of pregnancy. Present weight, io6 pounds, which
is for her the maximum. The skin rather tawny and apparently
pigmented over irregular areas. On the whole, she seems fairly
well nourished.
Physical Examination. Three weeks prior to operation. On in-
spection the abdomen below the navel line appears normal, present-
ing no abnormal or unusual features. Between the costal car-
tilage and above the navel the abdominal wall is forced markedly
forward, as if by a spherical mass, which lies a little to the left of
the median line. Percussion note over this area is absolutely flat.
Dulness begins about two inches below the left nipple and extends
to navel. Fluctuation was clearly manifest over the entire area.
On manipulation the tumor seems slightly movable, but maintains
its position fairly well, as above outlined. Over the convexity of
the tumor, mobility is more apparent than in its upper portion,
suggesting anchorage of its superior surface. Transverse colon
was made out with tolerable accuracy at the transverse navel line.
Gastric resonance not identified. At no stage of the examination
and manipulation was pain or tenderness elicited. Circulatory
apparatus normal. Urine normal. Hemoglobin, 85 per cent.
Leukocytes normal. Red blood cells, 4,300,000.
Through force of circumstances it seemed necessary to defer an
operative undertaking for about four weeks. Accordingly, final
judgment as to the nature of the tumor was deferred, and the
patient instructed to report at the end of two weeks.
Fourteen days later, on January 26, 1907, the following record
was made: The tumor mass previously described has increased
perceptibly in size during the past two weeks. The increased
size is manifest in more marked elevation of the anterior abdominal
wall, as well as in increased area of dulness. The tumor could
easily be made out below the navel and entirely filled the space
between the navel and the costal margins. The central point is
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370 HUNTINGTON: NON-PARASITIC CYST OF THE SPLEEN
mobility of the spleen would have given additional facility to such
an undertaking. But, despite the fact that Powers has collated a
scries of lo cases treated by splenectomy without a fatality, I choose
marsupialization because of the promise of a more satisfacton*
result.
There can be no question that an organ of so great functional
importance as the spleen should be guarded jealously, and removed
only when its retention becomes a positive menace, or its integrity-
destroyed. This position is emphasized by the following well-
recognized facts, to which attention is called by Moynihan: "Both
experimentally and clinically it has been determined that, follow-
ing splenectomy, there is a diminution in the amount of hemo-
globin; a reduction in the number of red corpuscles; an increase
in the total number of white corpuscles." These changes attain
their maximum in about a fortnight, and there is then a gradual
return to the normal, which is reached in about four months.
Mental disturbance is occasionally noted and frequently there is
a general enlargement of lymphatic glands. In animals, absence
of the spleen has been followed by marked changes in the bone-
marrow, loss of weight, weakness, thirst, polyuria, rapidity of puke,
and enlargement of the th}Toid. Furthermore, experimental work
l)oints strongly to the probability that absence of the spleen renders
the subject more liable to septic infection.
In dealing with a spleen which has been disorganized and non-
functionating for a protracted period prior to operation, immediate
after-effects of splenectomy are less noticeable, owing to the fact
that compensation has in a measure taken place during the pre-
ceding weeks, months, or years.
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FOUR CASES OF RUPTURE OF THE KIDNEY, WITH
REMARKS UPON CONSERVATIVE OPER-
ATIVE TREATMENT.
By THOMAS R. NEILSON, M.D.,
PHILADELPHIA.
The object of this contribution is to place upon record 4 cases of
subparietal injury of the kidney which have been met with in the
experience of the writer in his service at the Episcopal Hospital,
Philadelphia, and which were treated surgically by conservative
measures, and to consider the question of the employment of such
means, rather than the radical one of nephrectomy, when possible,
in the treatment of this class of injuries.
Case I. — Rupture of left kidney, with laceration of peritoneum
and severe hemorrhage into abdominal cavity; fracture of tenth rib;
laparotomy and lumbar incision; gauze packing; recovery.
Jacob B., aged twenty-five years, a farm-hand, was admitted to
hospital at 3.30 a.m. on April 14, 1901. Late in the afternoon of
the preceding day he fell from and was run over by a heavy farm
wagon which he was driving.
On admission, the patient complained chiefly of pain in the left
chest, and stated that he had passed bloody urine. The abdomen
was markedly distended and muscles rigid, especially in the lower
part. Examination further disclosed a fracture of the tenth left rib
near its angle. The only visible marks indicating that the man had
been run over were a contusion in the left axilla and an abrasion of
the left arm. The temperature was 99°, pulse 80, and respiration,
40. Later in the morning some fourteen ounces of bloody urine
were obtained by catheter. It was found that the patient had a
stricture of the urethra, the result of traumatism some years pre-
viously, and for several days after admission, until dilatation
had partly relieved the condition, the catheter had to be relied
upon entirely.
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372 neilson: ruptube of the kidney
I first saw the man toward evening on the 14th, about twent}'-
four hours after the injury. The pulse had then become more
frequent, the countenance pinched and anxious; there was abdom-
inal pain and the distention had increased, and hematuria con-
tinued. I decided upon immediate operation.
Opening the abdomen by an incision through the outer border
of the left rectus muscle, I found a great quantity of blood and dots
in the peritoneal cavity, and on searching for its source quickly
discovered a tear in the peritoneum over the left kidney, which was
ruptured and bleeding. Placing a pad of gauze firmly over the
kidney to temporarily control the hemorrhage, and finding no
intra-abdominal organ injured, the abdominal incision was closed,
after mopping out the blood and clots and inserting a glass drain-
age tube in the pelvis. The patient was then turned on his right
side, and the left kidney exposed by an oblique lumbar indsion.
A large amount of blood and clots distended in the region about the
kidney, and were removed, and the kidney was found to have
been lacerated in several places, mostly in its lower half. Strips
of iodoform gauze w6re firmly packed about it, controlling the
hemorrhage, and the angles of the wound sutured.
While on the operating table the patient's condition became so
bad that, in addition to free hypodermic stimulation, normal saline
solution was given, both by intravenous transfusion and by hypo-
dermoclysis.
After operation the pulse was 124 and the temperature 99.4°.
During the night his condition twice became alarming from
symptoms indicating edema of the lungs.
During the next two days the pulse varied from 130 to 144, and
the temperature rose once to 101.6°. Thereafter both gradually
fell, the chart showing nothing of special interest.
The urine, the day following operation, contained a large amount
of flocculent sediment of the color of iron rust; there was a moder-
ate trace of albumin, a considerable number of red corpuscles, and
a few granular casts. On the 19th it was noted that it was slightly |
acid, contained a faint trace of albumin, a few clumps of pus cells, |
and numerous bacilli. On the 2 2d it was alkaline, contained i
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neilson: rupture of the kidney 373
more pus cells, and very numerous bacilli. On the 23d a culture
from the urine (still drawn by the catheter) was made, and the
organisms were found to be streptococci and the Bacillus aerogenes.
Shortly thereafter the number of bacteria became greatly reduced,
salol having been given for a number of days. The urinary
infection was more than likely produced by the catheter.
The general condition improved steadily from the third or
fourth day, by which time abdominal distention had disappeared.
The abdominal drainage tube was then removed, the incision healing
without incident. From the lumbar incision there was rather pro-
fuse colorless discharge (urine) by the fifth day, which continued
in quantity for several days. The gauze packing was entirely re-
moved by the tenth day, and a wick of gauze was inserted to main-
tain drainage. The fistulous tract closed quite slowly, but finally
healed soundly, the patient being discharged from the hospital on
July 17.
Case II. — Rupture of right kidney, with laceration 0} peritoneum
and hemorrhage into peritoneal cavity; laparotomy and lumbar
incision; gauze packing; death from secondary hemorrhage.
Paul F., aged sixteen years, was admitted to hospital in the
evening of June 4, 1904. While playing ball in the street he ran
in front of a trolley car, the fender of which struck him in the
right hypochondriac region and on the head.
On admission there was found an ecchymosis of the upper
right side of the abdomen and a contusion of the right side of the
head and face. The boy was pale, his pupils dilated, but re-
sponding to light. The pulse was 100 and the temperature
100.4°. There was some abdominal pain and distention, but no
muscular rigidity. Bloody urine was voided. Vomiting occurred
during the night. Under stimulating treatment the condition
improved.
By the next day the general condition was much improved, and
the boy sujffered less pain.
On June 9 the patient complained of great abdominal pain, and
tenderness in the lumbar region had increased. In view of these,
I operated, choosing the abdominal route. .
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374 neilson: rupture of the kidney
The abdomen was opened through the right rectus muscle.
No visceral injury was found, but there was a small quantity of
blood in the peritoneal cavity, which had gained entrance from a
tear of the peritoneum overlying the right kidney, the region about
which was distended by a large hematoma. Closing the abdom-
inal wound, I exposed the kidney by an oblique lumbar wound.
The removal of blood and clots was followed by a great rush of
blood, which was controlled by the introduction of iodoform
gauze packs about the kidney. The organ had been nearly
bisected by a transverse tear somewhat above its middle.
After operation the patient's condition was very bad, the pulse
being i6o. Reaction, however, took place, although slowly, and in
forty-eight hours his condition was decidedly improved. Some
bloody oozing into the dressings occurred. The temperature
rose on the second day to 103°, but shordy afterward a gradual
fall took place, the pulse also coming down at the same time.
The patient did very well, although some urine escaped from the
wound, until June 22.
On that day, in the forenoon, the balance of the gauze packs
was entirely removed by the resident. At 12.30 p.m., on visiting
the ward, I was struck by the pallor and restlessness of the boy,
and going to the bedside and lifting the sheet, I found that he was
bleeding badly from the wound, the dressing being saturated and
a quantity of blood in the bed. The wound was quickly and
firmly packed with gauze, controlling the hemorrhage; intra-
venous transfusion of normal saline solution was given, and free
hypodermic stimulation employed. The patient's condition
forbade any attempt at immediate operation, but I hoped that
reaction might occur sufficiently to permit nephrectomy to be
done. No improvement took place, however, and the boy died at
8.30 P.M.
Case III. — Rupture of the right kidney; fracture of tenth and
eleventh ribs and of transverse processes of first and second lumbar
vertebrce; lumbar incision; gauze packing; recovery.
Barney McG., aged fifty years, a laborer, while at work at a coal
wharf, was struck in the back by a heavy iron bucket. He was
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nehson: rupture of the kidney 375
brought immediately to hospital, where he was admitted in the
afternoon of December 17, 1904.
Examination disclosed a large hematoma in the right lumbar
region, which was exceedingly tender. The patient voided urine
containing a large amount of blood. A diagnosis of ruptured
kidney was made, and I operated immediately.
Making an oblique lumbar incision, the kidney was exposed and
delivered. There were a number of lacerations of the convex
border and of both the anterior and posterior surfaces as well as sev-
eral contusions. The transverse processes of the first and second
lumbar vertebrae and the last two ribs were fractured, and the
hematoma was found to extend between the muscle planes of the
loin.
While the pedicle of the kidney was firmly held, preventing
hemorrhage, loose fragments of bone were removed, and the sharp
bases of the fractured transverse processes of the lumbar vertebrae
were cut off with bone forceps.
Iodoform gauze packs were then placed carefully about the kid-
ney, which was returned, and the wound sutured in part. After
operation the bladder was washed out, and there is no note of any
recurrence of hematuria.
The highest temperature recorded after operation was 101°, on
the second day, and the pulse rose no higher than 118, the first
observation after operation. During the first seven days the
smallest amount of urine voided was twenty-six ounces, on the
third day, the largest, fifty-six ounces, on the seventh.
During the first forty-eight hours there was some bloody oozing
into the dressing.
The progress of the case was satisfactory throughout, and the
patient was discharged on February 11, 1905, with a small sinus
remaining, but no urine escaped from it.
Case IV. — Rupture of left kidney; lumbar incision; gauze pack-
ing; recovery,
James A., six years old, was admitted to hospital on May 4,
1905, having fallen from a pile of limiber upon which he was play-
ing. He was brought at once by his mother to the dispensary of
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376 neilson: rupture of the kidney
the hospital, where his condition was found to be such that he was
sent to the receiving ward.
On admission, his appearance indicated shock. His lips were
pale, but the pulse was, however, only 96, and the temperature
normal. There was no mark of injury to be seen, but the child
complained of pain, and was tender to pressure in the left lumbar
region. Bloody urine was obtained by catheter.
When I saw the boy, not long after his admission, I determined
that his condition was due to hemorrhage from a ruptiffe of the
kidney, and operation was promptly done.
Opening the loin by an oblique lumbar incision, the kidney was
exposed and delivered, and a quantity of blood and clots removed
from the surrounding tissues. There were a nimiber of small
tears of the convexity and anterior surface of the organ, but it was
most severely injured at its lower pole, from which quite a large
piece was entirely detached. This was removed. Iodoform
gauze packs were placed over the lacerations, the kidney replaced
and held firmly by hammock strips of gauze at its poles. The
wound was partly closed by silkworm-gut sutures.
The next day the patient's temperature rose to 101.8° and the
pulse was 148. Bloody oozing saturated the dressings, and the
child had two severe concisions, the nature of which was not noted.
Thereafter he did very well, both temperature and pulse gradually
becoming normal.
The daily amount of urine voided during the first week varied
from fifteen to twenty ounces.
On the ninth day the packing was removed from about the
kidney, no bleeding occurring, and a small gauze drain was inserted.
Several days later it was noted that there was a slight discharge
of urine from the wound, but this lasted only for a few days.
On June 24 the boy was discharged, the wound being com-
pletely healed.
f In connection with these cases mention may be made of an in-
stance in which a severe rupture of the liver was associated with
rupture of the right kidney, hemorrhage from both organs being
controlled by gauze tampons. This case occurred also in the
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nehson: rupture of the kidney 377
service of the writer at the Epi^opal Hospital, and was reported to
the Philadelphia Academy of Surgery in April, 1903.
The patient was a man, aged twenty-six years, who, while en-
gaged in decorating a church, fell from a step-ladder a distance
of ten feet, striking his right side upon the end of a pew. With
assistance, he was able to walk home, where he remained until the
morning of the third day after his injury, when he was admitted to
the hospital. During the sixty hours preceding admission there had
been pain over the lower right ribs, distress from accumulation of
gas in the stomach, some general abdominal distention, hematuria,
and twice hematemesis.
At the hospital the man's condition was found to be clearly
indicative of hemorrhage, pallor of lips and conjunctiva?, pulse
120 and scarcely perceptible, temperature 97.5°. There was ten-
derness in the right upper quadrant of the abdomen, with rigidity
of the rectus muscle; the liver dulness extended two and one-quarter
inches below the costal margin; the patient once vomited a small
quantity of blood and voided bloody urine. The leukocyte count
was i2,ocx).
Stimulation by tincture of digitalis and strychnine was given
hypodermically, and normal saline solution by hypodermoclysis
before operation, which was done a few hours after admission.
While the hematuria pointed to renal lesion, the localized abdom-
inal tenderness, with rigidity of the upper part of the right rectus
muscle and the increase in the liver dulness indicated injury of
the liver; and, accordingly, the abdomen was opened through the
right rectus muscle.
A large amount of blood and clots were found in the abdominal
cavity, the hemorrhage having occurred from a number of lacera-
tions on the upper and lower surfaces and the posterior border of
the Uver, as well as from the upper pole of the right kidney, which
was also ruptured and bleeding into the abdomen through a rent in
the peritoneum overlying it. Hemorrhage from both organs was
effectually controlled by iodoform gauze tampons, placed firmly
against the lacerations. To afford thorough drainage, a second
wound was made posteriorly between the eleventh and twelfth ribs,
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378 neilson: rupture of the kidney
and one end of each gauze pack was carried through it. Re-
covery without incident occurred, the patient being discharged from
the hospital fifty-one days after operation.
The literature of the subject of renal injuries, since the publi-
cation, in 1878, by Maas,^ of Freiburg, of a study of 71 collected
cases, has grown, through the contributions of many writers, until
it may be considered, in view of the infrequency of such cases in
individual experience, to have reached fairly abundant proportions.