A CASE OF RUPTURE OF THE LIVER SUCCESSFULLY TREATED BY ABDOMINAL SECTION

Christopher Martin
1897 The Lancet  
operation I commenced Faradaisation, continuing it on alternate days, in addition to the free movements; the aim was to develop the remains of the injured external rotators with other muscles which might be compensatory and to improve innervation. I picked out the deltoid in particular, the trapezius, rhomboids, &c., also the triceps; and to counteract the constant tendency of the forearm to pronation I tried to increase the development of the supinators longus and brevis, and by inducing
more » ... d by inducing strong contractions of the biceps with the forearm flexed to improve its action as a supinator ; the radial extensors of the carpus, longior and brevior, were also treated. Rapid increase in the size of all these muscles, with quickened response to stimulus, gave encouragement, and very soon operations were extended with the small button electrode to the small muscles of the undersized thumb, index, and middle fingers, and to the palmar surface of their tips to improve tactile sensibility, with palpable benefit. Sometimes one pole was placed over a muscle and the other over the brachial plexus in the posterior triangle or over the individual nerve supply, and sometimes both poles were placed over either end of one of the longer arm muscles. Frequent intermissions were given to avoid overtiring a muscle. After a month other factors equally as effectual and important helped in the improvement. Nearly all day now the child had his good arm enveloped by a towel tied round his body; he also had a thick stall on the little and ring fingers of the other hand to prevent his customary exclusive use of them. His mother's devotion to a set purpose and her intelligent supervision were now invaluable ; she daily gave all her spare time to the various amusements and devices we designed to teach the child external rotation, abduction, supination, and the use of his unaccustomed fingers ; it became quite a matter of habit with all the family to discourage the tendency of the limb to internal rotation and pronation ; the happy disposition of the child helped us greatly. At the end of two months there was such evident improvement in every way that our task daily grew in interest and lost all tediousness ; we began to cultivate the deficient finer movements and sense of touch in the underdeveloped left thumb, index, and middle fingers ; with the finger-stall over the other two he was attracted to hold and pick up things. At first he was so awkward and feeble that it was a most difficult matter to get him to take up large lumps of sugar and drop them into a basin, but before many weeks he could confidently pick up such difficult things as pills, small buttons, and safety-pins, coins, &3.. with fore. finger and thumb opposed in a strong and natural grasp. With his sound arm tied up he now played for hours daily with a variety of articles and with vastly improved method ; he was also regularly enticed to reach out after things put round him in different positions, to lift up and take things down from places above him. At the end of four months the regular Faradaisation and free movements-which were now quite painless and easy-with the persistent education of the limb, had effected improvement beyond our hopes The humerus was very slightly shorter on the one side, but comparison revealed no differences in the muscles now. Force of habit and larger development of the internal rotators always had a tendency to reassert themselves, but the child was now rapidly learning to counteract them by the better use of his improved external rotatory mechanism, which would, however, probably be always weak. At the end of five months we thought our results interesting enough for Mr. Pearce Gould to see, and by his desire the child, now thirteen months old, was taken up to the Middlesex Hospital and shown to his class. It was an interesting case for his hearers, and gave him an object lesson to impress on them that the Schultze method of artificial respiration requires I all possible gentleness. Subsequently the little patient went to Germany for a few months. Faradaisation was now almost superfluous, but a battery was taken for occasional use, which the parents could competently manage themselves. The child was taken recently to see the famous German surgeon, Professor Kraske of Freiburg. I gave him a brief history from the commencement and a statement of the treatment; he has sent me a letter written by a colleague at his request from which the following is an extract, 16Besides symptoms pointing to what we call 'Erb's paralysis' -lesion of the fifth and sixth cervical roots above the clavicle-Professor Kraske found the growth of the left humerus impaired, which he was inclined to attribute to traumatic lesion of the upper epiphysis. As to the ultimate result of treatment, Professor I Kraske did not feel entitled to express any definite opinion. Since the nervous disturbance had gradually been giving way he considered further improvement very probable." Professor Kraske also says he advised the application of a bandage, which will, while it is worn, fix the humerus in a normal position and prevent its inward rotation. Seven months of treatment had so altered the condition of affairs when Professor Kraske saw the child that it was very difficult for him to realise fully the nature of the primary lesion and the true characters of the resulting deformity. Interesting as his views were, his prognosis was of far more practical importance, and was fully justified, for I now hear that since the intermittent use of Professor Kraske's bandage improvement has been even more rapid than before. Although I anticipate ultimate success in extent greatly beyond what has been attained, I think the treatment has gjne far enough and been successful enough to make the case instructive and to point the moral that in cases of this nature one need not despair of improvement ; in fact, in an apparently hopeless instance the commencement of treatment may justify a prognosis which amply repays us for the experiment and encourages us to persevere. Brighton. SURGEON TO THE BIRMINGHAM AND MIDLAMD HOSPITAL FOR WOMEN. IN the early part of the afternoon of May 4th, 1896, a strong, healthy young coal miner, aged nineteen years, was caught, whilst down in the pit, between two sets of trucks and received a severe " rolling crush." He was carried to the surface and sent home in a cart, and Mr. J. M. McCarthy, of St. George's, Salop, was sent for. When he saw him, about 4 P.M., the patient had recovered from the first shock. He complained of great pain in the right side of the chest. There were signs of bruising both on the front and back of the chest, especially on the right side. His pulse was 76, his temperature 98° F., and there was nothing then in his general condition to point to any grave internal injury. In the evening he seemed to be better, and he slept during the night till 5 A.M. Next morning (the 5th) he was, however, decidedly worse, and as the day wore on well-marked symptoms of grave abdominal mischief supervened. The pulse became more and more rapid, the temperature steadily went up, the abdomen became distended, the face pinched, and the respiration sighing. Mr. McCarthy wired for me to go over at once prepared to operate. In his telegram he said : 11 case of traumatic peritonitis ; probably ruptured viscus." When I saw the patient, about 9 P.M., his temperature was 103°, his pulse 130, his breathing short and distressed, his face pinched, and the abdomen was hard, tense, and distended-tympanitic in front, dull at the flanks, and evidently containing much free fluid. There were, however, no signs of free gas in the peritoneal cavity-no obliteration of the liver dulness-showing that the stomach and intestine had probably escaped. There was no vomiting either of blood or bile, no hemoptysis, and no bsematuria. He had passed flatus and the urine was clear. The symptoms were those of progressive intra-peritoneal haemorrhage and advancing peritonitis. These symptoms, the absence of signs of injury to the lungs, stomach, intestines, kidney, and bladder, and a consideration of the mechanism of the crush, led us to diagnose a rupture of the liver. Mr. McCarthy agreed with me that the patient's only chance lay in immediate abdominal section. To this the patient readily consented; but his parents gave way most reluctantly. The operation was done under difficulties, by the uncertain light of a paraffin lamp, in a miner's cottage, in a pit village on a Shropshire bill-side. About 9.30 P.M. Mr. H. H. Rubra put the patient under chloroform, and, with Mr. McCarthy's able assistance, I opened the abdomen in the middle line by an incision reaching from the ensiform cartilage to the umbilicus. As soon as the peritoneum was opened an immense quantity of black blood-fluid and clotted-escaped, and on. examination, the liver was found to be ruptured. A rent, from one to two inches deep, ran from before
doi:10.1016/s0140-6736(01)96017-9 fatcat:33737dzxrzgtnl2zacd6qqkcra