SOME RECENT SURGICAL CASES* 
By H. C. DALTON,' M.D., 
Superintendent City Hospital, St. Louis, Mo. 
Case I.—Stab Wound of Liver—Laparotomy—Recovery. 
William D., set. 22, moulder, admitted April 24, 1890. He 
stated that an hour before admission he was stabbed in the 
abdomen with a long, narrow-bladed knife. Pulse was 92, 
respiration 26, temperature 99 ; no pain. 
A small wound was noticed in the median line, an inch below 
the ensiform cartilage. The probe failed to show penetration. 
This, together with the general good condition of the patient, 
led us to believe that the abdomen had not been penetrated. 
The wound was dressed antiseptically, and patient put to bed. 
A short while thereafter pain developed, and the temperature 
rose to 102.4 ; pulse 102. An incision was made from the 
ensiform cartilage to the umbilicus. When the cavity was 
opened a small wound, half an inch in length, was noticed on the 
upper surface of the left lobe of the liver. The finger passed 
underneath the liver discovered a large lacerated wound of the 
organ near the diaphragm, from which was coming an alarming 
hemorrhage. I endeavored to reach this point in order to suture 
the wound ; but in attempting this by elevating the liver and 
depressing the stomach, such fearful hemorrhage supervened as 
to render the procedure impossible. The hemorrhage was 
indeed so great that we all thought the patient would die upon 
the table. To tampon the region around the wound in the liver,, 
in order to produce sufficient compression to stop the hem- 
orrhage, was now all that was left us. This I did by stuffing in 
as much iodoform gauze as I could possibly get into this space. 
* Reprint from The St. Louis Courier of Medicine, August, 1890. 2 
I presume as much as a hatful of gauze was used. The end of 
each strip was left protruding from the wound. This procedure 
stopped the hemorrhage ; but a considerable amount of blood 
was left in the peritoneal cavity. I deemed it wiser to allow it 
to remain rather than risk an attempt at its removal. The case 
was too urgent to admit of a periteneal toilet. The upper third 
of the wound was left open, the lower two-thirds closed by bow- 
knot silk sutures. 
In a few hours the pulse and temperature fell almost to nor- 
mal, and we flattered ourselves that the outlook was favorable ; 
but in twenty-four hours * the temperature rose to 103.6, the 
pulse to 120, and the respiration to 40. The patient was restless 
and in considerable pain. 
He was etherized, wound opened and the dressing removed. 
I attempted to remove it layer by layer, in order to repack at 
once should the hemorrhage return. This I was unable to do on 
account of the matting together of the gauze, and the adhesion 
between it anti the surrounding parts. A large amount of 
coagulated blood was removed from the cavity, particularly 
from the dorsal gutters. As soon as the gauze was removed, the 
hemorrhage became as great as, if not greater than, at the first 
dressing. The gauze was packed in as vigorously as in the first 
instance. 
Patient did badly for some hours, was very restless, com- 
plained of great pain, and vomited quite often. His pulse was 
rapid and weak, but his temperature was not much elevated ; 
about 101. At midnight, eight hours after the operation, his 
pulse was almost imperceptible. His cries for water were 
piteous. Believing that he would die in a few hours, I directed 
the nurse to give him all the water he wanted: this I had not 
done previously, because everything he had swallowed was 
ejected, also because the stomach was greatly compressed by the 
gauze ; hence it was necessary to keep it as quiet as possible. 
I was very much astonished, eight hours later, by finding the 
patient very much better. There was no pain, and the nausea 
and vomiting had almost ceased ; temperature was 100.2 ; pulse 
92 ; respiration 26. The gauze was removed forty-eight hours 
after the second packing. Its removal was not accompanied by 3 
hemorrhage ; a good many blood clots were removed ; the peri- 
toneal cavity thoroughly cleaned and closed. 
The wound healed by granulation. He was discharged well, 
May 27, 1890, and is before you for examination. 
Case II.—Abscess of Liver Following Dysentery.—Early 
Operation. —Recovery. 
G. A. L., set. 38, laborer, admitted March 19, 1890. About 
live weeks before admission he had quotidian intermittent fever. 
Prior to that time his health had been good. Five days before 
coming to the hospital acute diarrhoea developed, followed in a 
day or two by a severe case of dysentery, which was relieved 
after three or four days treatment. 
On the 29th inst., (ten days after admission) I noticed that, 
although the dysentery had disappeared several days before, 
there was still fever ; temperature ranging from 102 to 103. 
Percussion gave hepatic dullness inferiorly as low as an inch below 
the costal border, extending superiorly almost to the nipple. Deep 
pressure in the intercostal spaces, from the seventh to the ninth 
rib in the axillary line, gave slight tenderness. There were 
neither chilly sensations, nor sweating ; in fact, nothing pointing 
to hepatic abscess, i. e., if we leave out of view a slight tender- 
ness on deep pressure, and the general enlargement of the organ. 
Suspecting, however, that we had to deal with an hepatic 
abscess in an early stage, I thought aspiration in order. The 
needle was passed between the eighth and ninth ribs in the axil- 
lary line, and pus was found about two inches and a half from 
the surface. The next day I resected two inches of the ninth 
rib, and after exposing the liver, stuffed enough gauze into the 
wound to keep it open well down to the liver ; applied an anti- 
septic dressing and a firm bandage. 
In forty-eight hours the dressing was removed and the liver 
found strongly adherent to the wound. The needle of the aspira- 
tor was passed, the abscess located, and an incision made by the 
side of the needle, evacuating about an ounce and a half of pus. 
The abscess was thoroughly irrigated with Thiersch solution. 
Patient made a rapid recovery and is now well and is present this 
evening. The primary operation was done in order to shut off the 
pleural and peritoneal cavities so that no pus should pass into 
them at the time of the incision of the liver. Primary operation 
should always be done in early operations for hepatic abscess ; 
for we may be sure inflammatory adhesion between the liver and 
thoracic wall, or the abdominal wall, has not had time to form. 
Per contra when we are certain adhesion has taken place—the 
operation may be completed at once. In fact, it then amounts 
to but little more than opening an ordinary abscess. 
The lesson we learn from this case is the necessity of carefulK 
watching the liver in all cases of dysentery and diarrhoea, boldly 
using the aspirating needle in case we are in doubt—giving the 
patient the benefit of the doubt. We may do this the more readily 
because we know how very.rarely ill consequences follow aspira- 
tion of the liver, when we perform the operation strictly antisep- 
tically. In order to make “assurance doubly sure” in this 
regard, we need but to thoroughly clean the needle, and then 
boil it for half an hour in a solution of two and a half per cent, 
carbolic acid. 
Case III.—Gunshot Wound oe Kidney, Livek and Lung— 
Non-Interference—Recovery. 
W. S., colored, set. 25, laborer, admitted October 8, 189tfr 
An hour before admission he received a gunshot wound of back, 
his assailant being twenty yards away. He was suffering intense- 
ly from shock and pain ; pulse 135 and weak ; temperature sub- 
normal ; respiration 30 ; extremities cold. 
The bullet entered an inch to the right of the last dorsal ver- 
tebra, ranged upward and lodged under the skin on a level with, 
and an inch external to the right nipple. The urine was drawn 
and found quite bloody. The course of the bullet showed unmis- 
takably that it had passed through the kidney, liver, and right 
lung. This was confirmed later by the development of jaundice 
and pneumonia ; the latter developing on the second day. By 
the third day the entire lung was' solidified ; in addition to this 
there was absence of vocal fremitus over the lower portion of the 
lung, indicating extravasation of blood into the pleural cavity. 
The urine became clear on the third day. For five days the 5 
patient suffered intensely and looked as if he would die in a few 
hours. His pulse remained at about 140 ; respiration 50 ; tem- 
perature 103. After this he steadily improved and was dis- 
charged well, November 22, 1889. 
I did not deem an operation advisable in this case. From the 
course of the bullet and the absence of liver resonance, I exclud- 
ed injury of the intestine. Even had I found unmistakable evi- 
dence of intestinal perforation, I should not have operated at the 
time of his admission to the hospital, as 1 believe he would have 
died upon the table. 
I watched the case closely, and stood ready to operate 
should occasion arise, i. e., should symptoms of septicaemia 
develop. I did not regard a temperature of 103 as at all ex- 
cessive following an injury to so many important organs ; and, 
as the temperature did not go higher, I excluded sepsis—and 
hence never saw the time when I thought an operation indicated. 
Case IV.—Gunshot Wound of Liver and Kidney— 
Non-Interference—Recovery. 
W. B., colored, aet. 24, laborer, admitted April 26, 1890. An 
hour before admission patient was shot by a 32-calibre revolver 
at a distance of four feet. He fell to the floor, and in a few min- 
utes vomited, the ejecta being free from blood. His pulse was 
100, and steady ; respiration 23, temperature (rectal) 100, urine 
bloody. 
The wound of entrance was on a level with, and two inches to 
the right of the ensiform cartilage. It was not probed. The 
bullet was found underneath the skin, two inches to the right of 
the eleventh dorsal vertebra. It was not disturbed. In its 
course it had penetrated the liver and right kidney. 
The next morning the temperature was 102, respiration 18, 
• pulse 78. From this time the patient recovered rapidly, and 
was discharged well. May 14, 1890. 
Some of the gentlemen who saw the case with, me thought an 
operation advisable ; but I failed to see the necessity for it. 
There was resonance on percussion in the dorsal region, showing 
absence of hemorrhage from the injured organs. The liver dull- 
ness was normal (no increased resonance), indicating that the 6 
intestines were uninjured, This condition led me to adopt the 
waiting course, ready to operate should occasion arise demand- 
ing it. 
About two years ago I reported a case of shot wound of the 
liver in which the patient recovered without an operation. The 
bullet passed through the liver, through the diaphragm, into the 
pleural cavity and back again into the peritoneal cavity, lodging 
in the post-peritoneal space in the right lumbar region. An 
abscess formed at this side which was incised in a few days. 
Faeces passed out of the wound, showing that the gut had been 
cut by the bullet. 
These cases teach us that, as a general thing, shot wounds of the 
liver and kidney are best let alone, unless grave symptoms be 
present indicating hemorrhage and rapidly developing peritonitis. 
Should such urgent symptoms be present, no one would question 
the advisability of an operation.