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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 24-February-2012, Vol 125 No 1350

A case of rupture of the liver
By Ivan Wilson, M.D., M.R.C.S., Eng. Read before the Hawke's Bay Division.
Published in NZMJ 1911 May;10(38):8–9.
On November 5th last at 5.30 p.m., a man aged 35 years was admitted into the Napier Hospital suffering from a kick on the abdomen from a horse. On admission he was in a state of collapse, showing signs of severe shock and haemorrhage. His skin was blanched and cold, his pulse imperceptible, and his respirations rapid and shallow. He was very restless and complained of great pain in the right side of the chest on inspiration. On examining the abdomen, I found two red marks, one in the epigastrium and the other in the right hypochondrium just above the costal margin, corresponding to the kicks from the two hind hoofs. The abdomen was fixed on respiration, somewhat distended, and soon showed signs of fluid in both flanks.
On passing a catheter, I obtained several ounces of pure blood, and on passing a measured amount of saline into the bladder and receiving most of it back I concluded that the bladder wall was intact, and that the haemorrhage was renal. He was then given two pints of saline slowly per rectum, and the pulse steadily improved. About 8 p.m. his bowels acted twice, and each time he had a large amount of melaena, the stools being dark and tarry. About this time he also coughed up some bright red blood. No fracture of the ribs could be discovered. After consultation with the staff, I decided to perform laparotomy, as although the intra-peritoneal haemorrhage had apparently ceased as indicated by the improving pulse, the melaena pointed to a probable injury to the bowel.
Dr. Henley assisted at the operation. Open ether was administered, and the patient stood the operation well except at one stage, when the pulse became very feeble but quickly responded to saline intravenously with Pituitary Extract minims XX. On opening the abdomen I found the peritoneal cavity full of blood and blood clot, and on passing my hand round the liver found a huge laceration towards the posterior part of the right lateral surface. It was large enough to admit the whole hand. The right kidney did not feel damaged, although it must have had some injury from the blow to cause the rather sharp haematuria which occurred. The blood was turned out from the peritoneal pouches, and the whole abdomen then flushed out clean with normal saline. A rapid examination of the intestines revealed no injury. As the tear in the liver was too far back and too lacerated to suture, I packed it with plain sterilized gauze, the latter acting as a drain through the incision in the right rectus muscle.
After History.—The patient had slight melaena, blood in the urine and rusty-coloured sputum for a few days after the operation, but these all cleared up. Later he had a thin layer of fluid over the base of the right lung, but this absorbed in about a week. The packing I removed for the first time four days after the operation. The sinus rapidly filled in, and the wound was completely healed and the patient up and convalescent four weeks after the operation.
Apart from the severe injuries this patient sustained, and the bad prognosis one could not help giving on his admission, I think the interesting point about the case is the melaena. No injury to the, intestine could be found at the operation, nor did the subsequent history of the case point to any involvement of the bowel, and yet at the time one felt that it was a symptom of bad omen. I think the explanation for the melaena lies in the severe injury to the liver, that organ probably being infiltrated with blood which passed along the bile capillaries to the hepatic ducts, and thus to the intestine.
     
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