Hulke reports a case remarkable for the immense size of the rupture which protruded from a spot weakened by a former abscess. There was a partial absence of the peritoneal sac, and the obstruction readily yielded to a clyster and laxative. The rupture had a transverse diameter of 14 1/2 inches, with a vertical diameter of 11 1/2 inches. The opening was in the abdominal walls outside of the internal inguinal ring. The writhings of the intestines were very conspicuous through the walls of the pouch.
Dade reports a case of prodigious umbilical hernia. The patient was a widow of fifty-eight, a native of Ireland. Her family history was good, and she had never borne any children. The present dimensions of the tumor, which for fifteen years had been accompanied with pain, and had progressively increased in size, are as follows: Circumference at the base, 19 1/2 inches; circumference at the extremity, 11 1/4 inches; distance of extremity from abdominal wall, 12 3/4 inches. Inspection showed a large lobulated tumor protruding from the abdominal wall at the umbilicus. The veins covering it were prominent and distended. The circulation of the skin was defective, giving it a blue appearance. Vermicular contractions of the small intestines could be seen at the distance of ten feet. The tumor was soft and velvety to the touch, and could only partially be reduced. Borborygmus could be easily heard. On percussion the note over the bulk was tympanitic, and dull at the base. The distal extremity contained a portion of the small intestine instead of the colon, which Wood considered the most frequent occupant. The umbilicus was completely obliterated. Dade believed that this hernia was caused by the weakening of the abdominal walls from a blow, and considered that the protrusion came from an aperture near the umbilicus and not through it, in this manner differing from congenital umbilical hernia.
A peculiar form of hernia is spontaneous rupture of the abdominal walls, which, however, is very rare. There is an account of such a case in a woman of seventy-two living in Pittsburg, who, after a spasmodic cough, had a spontaneous rupture of the parietes. The rent was four inches in length and extended along the linea alba, and through it protruded a mass of omentum about the size of a child's head. It was successfully treated and the woman recovered. Wallace reports a case of spontaneous rupture of the abdominal wall, following a fit of coughing. The skin was torn and a large coil of ileum protruded, uncovered by peritoneum. After protracted exposure of the bowel it was replaced, the rent was closed, and the patient recovered.
CHAPTER XIII.
SURGICAL ANOMALIES OF THE GENITO-URINARY SYSTEM.
Wounds of the kidney may be very severe without causing death, and even one entire kidney may be lost without interfering with the functions of life. Marvand, the Surgeon-Major of an Algerian regiment, reports the case of a young Arab woman who had been severely injured in the right lumbar region by a weapon called a "yataghan," an instrument which has only one cutting edge. On withdrawing this instrument the right kidney was extruded, became strangulated between the lips of the wound, and caused considerable hemorrhage. A ligature was put around the base of the organ, and after some weeks the mass separated. The patient continued in good health the whole time, and her urinary secretion was normal. She was discharged in two months completely recovered. Price mentions the case of a groom who was kicked over the kidney by a horse, and eighteen months later died of dropsy. Postmortem examination showed traces of a line of rupture through the substance of the gland; the preparation was deposited in St. George's Hospital Museum in London. The case is singular in that this man, with granular degeneration of the kidney, recovered from so extensive a lesion, and, moreover, that he remained in perfect health for over a year with his kidney in a state of destructive disease. Borthwick mentions a dragoon of thirty who was stabbed by a sword-thrust on the left side under the short rib, the sword penetrating the pelvis and wounding the kidney. There was no hemorrhage from the external wound, nor pain in the spermatic cord or testicle. Under expectant treatment the man recovered. Castellanos mentions a case of recovery from punctured wound of the kidney by a knife that penetrated the tubular and cortical substance, and entered the pelvis of the organ. The case was peculiar in the absence of two symptoms, viz., the escape of urine from the wound, and retraction of the corresponding testicle. Dusenbury reports the case of a corporal in the army who was wounded on April 6, 1865, the bullet entering both the liver and kidney. Though there was injury to both these important organs, there was no impairment of the patient's health, and he recovered.
Bryant reports four cases of wound of the kidney, with recovery. All of these cases were probably extraperitoneal lacerations or ruptures. Cock found a curious anomaly in a necropsy on the body of a boy of eighteen, who had died after a fall from some height. There was a compound, transverse rupture of the left kidney, which was twice as large as usual, the ureter also being of abnormal size. Further search showed that the right kidney was rudimentary, and had no vein or artery.
Ward mentions a case of ruptured kidney, caused by a fall of seven feet, the man recovering after appropriate treatment. Vernon reports a case of serious injury to the kidney, resulting in recovery in nine weeks. The patient fell 40 feet, landing on some rubbish and old iron, and received a wound measuring six inches over the right iliac crest, through which the lower end of the right kidney protruded; a piece of the kidney was lost. The case was remarkable because of the slight amount of hemorrhage.
Nephrorrhaphy is an operation in which a movable or floating kidney is fixed by suture through its capsule, including a portion of kidney-substance, and then through the adjacent lumbar fascia and muscles. The ultimate results of this operation have been most successful.