Abnormalities of Size of the Spleen

Anomalies and Curiosities of Medicine
by George M. Gould, M.D., Walter L. Pyle, M.D.

(Page 34 of 42)

The spleen may be extremely small. Storck mentions a spleen that barely weighed an ounce; Schenck speaks of one in the last century that weighed as much as 20 pounds. Frank describes a spleen that weighed 16 pounds; there is another record of one weighing 15 pounds. Elliot mentions a spleen weighing 11 pounds; Burrows one, 11 pounds; Blasius, four pounds; Osiander, nine pounds; Blanchard, 31 pounds; Richardson, 3 1/2 pounds; and Hare, 93 ounces.

The thoracic duct, although so much protected by its anatomical position, under exceptional circumstances has been ruptured or wounded. Kirchner has collected 17 cases of this nature, two of which were due to contusions of the chest, one each to a puncture, a cut, and a shot-wound, and three to erosion from suppuration. In the remaining cases the account fails to assign a definite cause. Chylothorax, or chylous ascites, is generally a result of this injury. Krabbel mentions a patient who was run over by an empty coal car, and who died on the fifth day from suffocation due to an effusion into the right pleural cavity.

On postmortem examination it was found that the effusion was chyle, the thoracic duct being torn just opposite the 9th dorsal vertebra, which had been transversely fractured. In one of Kirchner's cases a girl of nine had been violently pushed against a window-sill, striking the front of her chest in front of the 3d rib. She suffered from pleural effusion, which, on aspiration, proved to be chyle. She ultimately recovered her health. In 1891 Eyer reported a case of rupture of the thoracic duct, causing death on the thirty-eighth day. The young man had been caught between a railroad car and an engine, and no bones were broken.

Manley reports a case of rupture of the thoracic duct in a man of thirty-five, who was struck by the pole of a brewery wagon; he was knocked down on his back, the wheel passing squarely over his abdomen. There was subsequent bulging low down in the right iliac fossa, caused by the presence of a fluid, which chemic and microscopic examination proved was chyle. From five to eight ounces a day of this fluid were discharged, until the tenth day, when the bulging was opened and drained. On the fifteenth day the wound was healed and the man left the hospital quite restored to health.

Keen has reported four instances of accidental injury to the thoracic duct, near its termination at the base of the left side of the neck; the wounding was in the course of removals for deep-seated growths in this region. Three of the cases recovered, having sustained no detriment from the injury to the thoracic duct. One died; but the fatal influence was not specially connected with the wound of the duct.

Possibly the boldest operation in the history of surgery is that for ligation of the abdominal aorta for inguinal aneurysm. It was first practiced by Sir Astley Cooper in 1817, and has since been performed several times with a uniformly fatal result, although Monteiro's patient survived until the tenth day, and there is a record in which ligature of the abdominal aorta did not cause death until the eleventh day. Loreta of Bologna is accredited with operating on December 18, 1885, for the relief of a sailor who was suffering from an abdominal aneurysm caused by a blow. An incision was made from the ensiform cartilage to the umbilicus, the aneurysm exposed, and its cavity filled up with two meters of silver-plated wire. Twenty days after no evidence of pulsation remained in the sac, and three months later the sailor was well and able to resume his duties.

Ligation of the common iliac artery, which, in a case of gunshot injury, was first practiced by Gibson of Philadelphia in 1812, is, happily, not always fatal. Of 82 cases collected by Ashhurst, 23 terminated successfully.

Foreign bodies loose in the abdominal cavity are sometimes voided at stool, or may suppurate externally. Fabricius Hildanus gives us a history of a person wounded with a sword-thrust into the abdomen, the point breaking off. The sword remained one year in the belly and was voided at stool. Erichsen mentions an instance in which a cedar lead-pencil stayed for eight months in the abdominal cavity. Desgranges gives a case of a fish-spine in the abdominal cavity, and ten years afterward it ulcerated through an abscess in the abdominal wall. Keetley speaks of a man who was shot when a boy; at the time of the accident the boy had a small spelling-book in his pocket. It was not until adult life that from an abscess of the groin was expelled what remained of the spelling-book that had been driven into the abdomen during boyhood. Kyle speaks of the removal of a corn-straw 33 inches in length by an incision ten inches long, at a point about equidistant from the umbilicus to the anterior spinous process of the right ilium.

There are several instances on record of tolerance of foreign bodies in the skin and muscles of the back for an extended period. Gay speaks of a curious case in which the point of a sheath-knife remained in the back of an individual for nine years. Bush reported to Sir Astley Cooper the history of a man who, as he supposed, received a wound in the back by canister shot while serving on a Tartar privateer in 1779. There was no ship-surgeon on board, and in about a month the wound healed without surgical assistance. The man suffered little inconvenience and performed his duties as a seaman, and was impressed into the Royal Navy. In August, 1810, he complained of pain in the lumbar region. He was submitted to an examination, and a cicatrix of this region was noticed, and an extraneous body about 1/2 inch under the integument was felt. An incision was made down it, and a rusty blade of a seaman's clasp-knife extracted from near the 3d lumbar vertebra. The man had carried this knife for thirty years. The wound healed in a few days and there was no more inconvenience.

Fracture of the lower part of the spine is not always fatal, and notwithstanding the lay-idea that a broken back means certain death, patients with well-authenticated cases of vertebral fracture have recovered. Warren records the case of a woman of sixty who, while carrying a clothes-basket, made a misstep and fell 14 feet, the basket of wet clothes striking the right shoulder, chest, and neck. There was fracture of the 4th dorsal vertebra at the transverse processes.