SOME CASES OF DISPLACEMENT OF ABDOMINAL VISCERA.
Theodore Fisher, M.D., M.R.C.P., Physician
to
Out-patients Pathologist
Read before the Bristol
to Bristol Royal to the Bristol
Hospital for Sick Children; Royal Infirmary.
Medico-Chirurgical Society,
March
13th,
1901.
accompanying illustrations, with one exception, are reproductions of rough sketches jotted down as memoranda of displacements of abdominal organs seen in the post-mortem room. Although the conditions represented may not, in the majority of instances, be of great practical importance, some The
at least possess a
certain
measure
of interest.
Figure I. represents a diaphragmatic hernia in a female infant, aged six months, which was admitted into the Bristol Royal Infirmary in 1898, under the care of Dr. Waldo, for The child was very the of emaciated, autopsy, only eight weighed, pounds. The whole of the left side of the chest was filled with marasmus, and died and
soon
after admission.
at the time
intestines, which had found their way into the thorax
by
a
218
DR.
deficiency
in the
THEODORE
posterior
attachment of the
aperture which admitted two should
have
joined
the
FISHER
diaphragm. An diaphragm All ligament.
existed where the
fingers
external
arched
the intestines, except the duodenum and the lower half of the colon and rectum, had passed into the chest. The left
lung
was
completely collapsed, was displaced to
and the heart
the
of the
right
intestine
sternum.
remaining
The
in the abdo-
stretched from the aperture in the diaphragm to the anus men
in almost stomach
a
was
straight line. The greatly dilated and
reached to the
pubes.1
Diaphragmatic herniae are most commonly congenital; and although the deficiency which allows the escape of the stomach intestines from the abdominal
or
cavity varies in size, it is most commonly small and situated the all the Hernia. Nearly Nearly all Diaphragmatic Diaphragmatic Hernia. posteriorly?as in the above case intestines in intestines in the the left cavity. leftpleural pleuralcavity. ?at the position of the attachment of the diaphragm to the external arched ligament. When talking to Prof. Fawcett about the position of this deficiency, he mentioned to me that during the developof the diaphragm an aperture becomes formed at ment that point which is comparatively late in closing, and in some of the lower vertebrates, such as the reptilia and amphibia, it persists. Although, no doubt, the existence of this aperture in the human subject is as common on the right are are
the left side, herniae are much more common on the left owing to the fact that hollow viscera are in contact with the left
as
on
half oi the
diaphragm.
When
necessarily follow, however, 1
that
aperture is present it does a
hernia will
occur.
At
not
least,
regretted that the above diagram was not from a sketch, and possibly does not accurately represent the position of the stomach.
It is to be
therefore
an
ON
CASES
DISPLACEMENT OF ABDOMINAL VISCERA.
OF
2ig
patients may live until past middle-life before the prolapse occurs would lead one to think so.1 Generally the most prominent symptoms are those of intestinal obstruction ; but occasionally collapse associated with dyspnoea, and the discovery of a tympanitic note on the left side of the chest, More than once may lead to the diagnosis of pneumothorax. ?the stomach has been aspirated through the chest-wall.2 Figure II. also represents a congenital condition. The caecum was attached to the lumbar vertebrae immediately below the duodenum. Posteriorly, the caecum was devoid of periThe vermiform appendix, directed upwards and to toneum. the right, reached the margin
the fact that
of the ribs.
The condition
was
and
not obviously congenital adhesions of an produced by abnormally movable caecum,
but how the occupy
a
caecum
the lum-
is
obvious.
bar vertebrae
not
During development caecum
the
to
to
came
position over
the
the left
from
moves
right hypochondrium,
and from there down
to
the
may become arrested in almost any part of
It
iliac fossa.
its course, but not
this
the
explain
outside what normal
we
caecum
lay
may call its
The
path.
interest of the
in
position
The
case.
arrest will
mere
practical
38 years, the knee. 1
that
Vide case in 2
situation
The
who
a
died
man
The ccecum ccBcurn is attached in front of oj the lumbar vertebra, and the vermiform the to right appendix is directed upwards to costal margin.
lies in the
case
situation of the vermiform
appendix in of diagnosis.
FIG. II. II.
appendix. would
lead
Inflammation ot to
displacement occurred in a of septicaemia following
aged
49, recorded
Vide case recorded
an
difficulty man, aged
some
cellulitis
by Goodhart, Lancet, 1893,
by Hollis, Lancet, 1895, i. 1095.
i. 362.
of
220
DR.
THEODORE
FISHER
displacement of the of different character, dependent upon the persistence of a foetal condition. The csecum was displaced upwards, and lay partly on the anterior surface of a slightly enlarged liver. It was, however, not fixed in that position. The caecum and ascending colon possessed a mesentery of sufficient length to allow the caecum to be easily placed in Figure
III. is
a
diagram illustrating
the left iliac fossa. was
a
also
but
csecum
At the time of the
autopsy
the
caecum
diagram?in the right hypooften occupied other positions. The probably long meso-caecum present in this case is a persistent fcetal condition. During a great part of fcetal life the large intestine a possesses long mesentery.
situated?as shown in the
chondrium,
but
When
the
colon
is
it
position
occupy the
assumes
the
to
permanently mesentery becomes
shortened, and commonly disappears from the
and
occurred
in
32 years, disease.
who died of cardiac
Figure right half movable cacurn, immeccecum, lying Freely movable Freely lying immethe right beloiv the costal margin. right costal diately beloiv diately margin.
ascending colon displacement woman, aged
The
caecum.
a
IV. of
represents the
the
transverse
colon and part of the stomach turned upwards, so as to overlie the anterior surface of the liver.
The transverse meso-colon has been clearness.
The
cause
transverse
colon
and
intestine
following
of
this
stomach
omitted for the sake of
upward displacement was
carcinoma of the
of the
distension of the small
Deep depressions overlying colon and stomach, a fact that seemed to indicate that they had been for some little time in this abnormal position. I only remember having noticed a well-marked displacement of similar character on one other occasion; but possibly, if looked for, caecum.
in the liver substance marked the situations of the
ON
CASES
the condition
OF
DISPLACEMENT
might
be
with
met
ABDOMINAL
not
few weeks before the
VISCERA.
infrequently
The other instance occurred in the
degree. a
OF
post-mortem
221
in minor room
only
case
from which the above sketch There the trans-
made.
was
colon
verse
lay
falciform the
left
ligament right?that is half
colon
of the
interest,
as
say, the
transverse
of
a
was
case.
illustrates
V.
Figure condition
a
no
very great and it will be referred The
only briefly.
verse
to
of the stomach
in the above
to
well
as
situated where
was
portion
the
on
side of the
the left
on
turned
was
it
but
upwards, liver
only
colon
was
trans-
FIG.
adherent to
A portion the stomach the liver.
the back of the uterus, and
lay
IV.
of the transverse colon and of lying on the tipper upper surface of
behind the small intes-
tines.
The
transverse
colon
probably abnormally long, in pelvic inflammation, had contracted meso-
was
and the great omentum, involved
until the transverse colon contact
came
into
with the uterus.
The condition
represented in Figure entirely different character. sketch roughly illustrates the posi-
is of
VI.
The
tion of in
adherent to to Transverse colon adherent the back and lying uterus and back of the the uterus behind intestine. behind the small intestine. the small
an
some
infant,
of the abdominal organs aged 14 months, which
died of tetany. Abnormal distension been great, and had of the abdomen had lasted for several weeks. The liver was so
displaced backwards and posterior surfaces The right kidney bad been right iliac fossa. The cause
much
downwards that the rested
on
the
right
iliac
crest.
pushed before the liver into the
DR.
222
THEODORE
FISHER
of this
displacement was great distension of the stomach and
intestines. This distension is, unfortunately, not shown in the
diagram.
The close
con-
nection of the liver with the
right kidney no doubt plays an important part in the causation of movable kidney. Pressure exerted from outside
the abdomen may apparently displace the liver directly
downwards,
and the
kidney
be
carried downwards with it, or ?as in this case?the liver Liver
displaced backwards, pushing right kidney into the right iliac fossa.
may
the
be rotated
and downwards
brought within the abdomen. to the
kidney
backwards
by
pressure
to bear upon it from
Examination of the relation of the liver
would lead
one
to
think that pressure from below upon the anterior half of the liver,
producing rotation, would be much likely to displace the kidney
more
than external pressure. common
The
most
effect of external pressure
is to compress the liver at
a
level
below the line of its contact with the
kidney. External pressure must tend in many instances to
tighten the grasp of the liver upon the kidney, rather than displace it. Possibly repeated flatulent distension of the abdomen may, when occurring in early life, be sufficient to
loosen the normal attachments FIG.
of the
right kidney. Figure VII. is an example
of
Acute dilatation
VII.
of
the stomach.
ON
CASES
OF
DISPLACEMENT
OF
the stomach reached the left iliac
the
VISCERA.
As shown in the
dilatation of the stomach.
acute
ABDOMINAL
fossa,
223
diagram,
and extended also to
of the middle line,
overlapping and hiding from view exception of the ascending colon. There was no obstruction of the pylorus, and the duodenum shared to some extent in the dilatation. The clinical history right
all the intestines with the
gave
indication of the time of onset of the dilatation.
no
It
aged 36, admitted, under the care of Mr. Munro Smith, in 1898, with swelling of the left eyelid. Cerebral symptoms set in, and the patient died. A suppurating thrombus was found in the left cavernous sinus, for which no
occurred in
cause
a
woman,
could be found.
Figure VIII. represents an
extreme
degree of a not
uncommon
condition. Thetransversecolon is
distended
greatly
as
a
con-
sequence of
of the
malignant growth sigmoid flexure. Part of
the distended
colon, most of the
stomach, and a small portion of the liver were the only viscera seen on
the anterior aspect of
the abdomen..
which
stomach,
The
adherent
was
to
the
colon, had been drawn downwards, and its low-
transverse
est
point
was
situated
slightly
below and to the right of the umbilicus. The condition occurred in
a woman
aged
39 years.
Figure IX. is not a diagram of a displaced organ, but is reproduced here because it represents
a
condition which
FIG.
VIII.
transverse colon in in Greatly dilated transverse case of stricture of the sigmoid flexure.
a a
appears to be frequently mistaken for a displaced kidney. It is the so-called Riedel's lobe of the liver, an appendage situated generally just outside it. The lobe is said to
or
gallstones,
and to be
produced by
over
the gall-bladder
be associated with
concomitant dilatation of the
CASES
224
OF
DISPLACEMENT
The
gall-bladder.
gall-bladder
OF
as
ABDOMINAL
it dilates is
VISCERA.
thought
to
drag
a
tongue of liver substance downwards and forwards with it. Six years ago two examples of the lobe occurred in the post-mortem room
of the Bristol
another,
Royal Infirmary
but I did not make
a
within
represents what
was
man, aged 44, who General Hospital in of Dr. Harrison. to
few weeks of
a
chronic
felt was
during
life in
a
in the Bristol
1894, under the care Ascites, due probably
peritonitis,
The abdomen
one
The illustration
sketch of either.
was
an
had been present. easy
one
to
pal-
the limits of the tumour
pate, allowing and its connection with the liver could be
clearly defined. It was looked upon as a congenital abnormality, and when the two other examples were met with in the IX. post-mortem room, not being aware at the Riedel's lobe of the liver. time of Riedel's description of this lobe, or of his explanation of its causation, I probably somewhat hastily concluded that they also were congenital. The presence or absence of gallstones is unfortunately not recorded. While, has of which been noticed the association however, gallstones with Riedel's lobe is interesting, and seems to be a reasonable explanation of the existence of the lobe, it is well to bear the fact FIG.
in mind that the anterior border of the liver presents considerable variability in outline. For example, the degree to which the left lobe is cut off from the
right, and its downward projection into the considerably in different cases. This variaepigastrium, of bility in the shape the liver suggests that a downward projection in the position of Riedel's lobe may be congenital, and the association noticed with gallstones merely a coincidence.1 differs
1 Note.?Since writing the above I have read an article by Glenard,2 in which the causation of Riedel's lobe of the liver is briefly discussed. Glenard considers that a floating lobe is generally associated with (non-cirrhotic), enlargement of the liver and that it is produced by the pressure of the costal margin upon the upper surface of the liver, in cases where there has been tight-lacing of a corset or the pressure of a belt. The frequency with which pressure of this character produces a line of atrophy upon the upper surface of the liver is well known, and when the anterior margin of the liver happens to be abnormally curved, it is possible that pressure may partially detach a portion and produce a floating lobe. 2
Revue des maladies de la
nutrition, November, 1898.
Theodore Fisher, M.D., M.R.C.P., Physician
to
Out-patients Pathologist
Read before the Bristol
to Bristol Royal to the Bristol
Hospital for Sick Children; Royal Infirmary.
Medico-Chirurgical Society,
March
13th,
1901.
accompanying illustrations, with one exception, are reproductions of rough sketches jotted down as memoranda of displacements of abdominal organs seen in the post-mortem room. Although the conditions represented may not, in the majority of instances, be of great practical importance, some The
at least possess a
certain
measure
of interest.
Figure I. represents a diaphragmatic hernia in a female infant, aged six months, which was admitted into the Bristol Royal Infirmary in 1898, under the care of Dr. Waldo, for The child was very the of emaciated, autopsy, only eight weighed, pounds. The whole of the left side of the chest was filled with marasmus, and died and
soon
after admission.
at the time
intestines, which had found their way into the thorax
by
a
218
DR.
deficiency
in the
THEODORE
posterior
attachment of the
aperture which admitted two should
have
joined
the
FISHER
diaphragm. An diaphragm All ligament.
existed where the
fingers
external
arched
the intestines, except the duodenum and the lower half of the colon and rectum, had passed into the chest. The left
lung
was
completely collapsed, was displaced to
and the heart
the
of the
right
intestine
sternum.
remaining
The
in the abdo-
stretched from the aperture in the diaphragm to the anus men
in almost stomach
a
was
straight line. The greatly dilated and
reached to the
pubes.1
Diaphragmatic herniae are most commonly congenital; and although the deficiency which allows the escape of the stomach intestines from the abdominal
or
cavity varies in size, it is most commonly small and situated the all the Hernia. Nearly Nearly all Diaphragmatic Diaphragmatic Hernia. posteriorly?as in the above case intestines in intestines in the the left cavity. leftpleural pleuralcavity. ?at the position of the attachment of the diaphragm to the external arched ligament. When talking to Prof. Fawcett about the position of this deficiency, he mentioned to me that during the developof the diaphragm an aperture becomes formed at ment that point which is comparatively late in closing, and in some of the lower vertebrates, such as the reptilia and amphibia, it persists. Although, no doubt, the existence of this aperture in the human subject is as common on the right are are
the left side, herniae are much more common on the left owing to the fact that hollow viscera are in contact with the left
as
on
half oi the
diaphragm.
When
necessarily follow, however, 1
that
aperture is present it does a
hernia will
occur.
At
not
least,
regretted that the above diagram was not from a sketch, and possibly does not accurately represent the position of the stomach.
It is to be
therefore
an
ON
CASES
DISPLACEMENT OF ABDOMINAL VISCERA.
OF
2ig
patients may live until past middle-life before the prolapse occurs would lead one to think so.1 Generally the most prominent symptoms are those of intestinal obstruction ; but occasionally collapse associated with dyspnoea, and the discovery of a tympanitic note on the left side of the chest, More than once may lead to the diagnosis of pneumothorax. ?the stomach has been aspirated through the chest-wall.2 Figure II. also represents a congenital condition. The caecum was attached to the lumbar vertebrae immediately below the duodenum. Posteriorly, the caecum was devoid of periThe vermiform appendix, directed upwards and to toneum. the right, reached the margin
the fact that
of the ribs.
The condition
was
and
not obviously congenital adhesions of an produced by abnormally movable caecum,
but how the occupy
a
caecum
the lum-
is
obvious.
bar vertebrae
not
During development caecum
the
to
to
came
position over
the
the left
from
moves
right hypochondrium,
and from there down
to
the
may become arrested in almost any part of
It
iliac fossa.
its course, but not
this
the
explain
outside what normal
we
caecum
lay
may call its
The
path.
interest of the
in
position
The
case.
arrest will
mere
practical
38 years, the knee. 1
that
Vide case in 2
situation
The
who
a
died
man
The ccecum ccBcurn is attached in front of oj the lumbar vertebra, and the vermiform the to right appendix is directed upwards to costal margin.
lies in the
case
situation of the vermiform
appendix in of diagnosis.
FIG. II. II.
appendix. would
lead
Inflammation ot to
displacement occurred in a of septicaemia following
aged
49, recorded
Vide case recorded
an
difficulty man, aged
some
cellulitis
by Goodhart, Lancet, 1893,
by Hollis, Lancet, 1895, i. 1095.
i. 362.
of
220
DR.
THEODORE
FISHER
displacement of the of different character, dependent upon the persistence of a foetal condition. The csecum was displaced upwards, and lay partly on the anterior surface of a slightly enlarged liver. It was, however, not fixed in that position. The caecum and ascending colon possessed a mesentery of sufficient length to allow the caecum to be easily placed in Figure
III. is
a
diagram illustrating
the left iliac fossa. was
a
also
but
csecum
At the time of the
autopsy
the
caecum
diagram?in the right hypooften occupied other positions. The probably long meso-caecum present in this case is a persistent fcetal condition. During a great part of fcetal life the large intestine a possesses long mesentery.
situated?as shown in the
chondrium,
but
When
the
colon
is
it
position
occupy the
assumes
the
to
permanently mesentery becomes
shortened, and commonly disappears from the
and
occurred
in
32 years, disease.
who died of cardiac
Figure right half movable cacurn, immeccecum, lying Freely movable Freely lying immethe right beloiv the costal margin. right costal diately beloiv diately margin.
ascending colon displacement woman, aged
The
caecum.
a
IV. of
represents the
the
transverse
colon and part of the stomach turned upwards, so as to overlie the anterior surface of the liver.
The transverse meso-colon has been clearness.
The
cause
transverse
colon
and
intestine
following
of
this
stomach
omitted for the sake of
upward displacement was
carcinoma of the
of the
distension of the small
Deep depressions overlying colon and stomach, a fact that seemed to indicate that they had been for some little time in this abnormal position. I only remember having noticed a well-marked displacement of similar character on one other occasion; but possibly, if looked for, caecum.
in the liver substance marked the situations of the
ON
CASES
the condition
OF
DISPLACEMENT
might
be
with
met
ABDOMINAL
not
few weeks before the
VISCERA.
infrequently
The other instance occurred in the
degree. a
OF
post-mortem
221
in minor room
only
case
from which the above sketch There the trans-
made.
was
colon
verse
lay
falciform the
left
ligament right?that is half
colon
of the
interest,
as
say, the
transverse
of
a
was
case.
illustrates
V.
Figure condition
a
no
very great and it will be referred The
only briefly.
verse
to
of the stomach
in the above
to
well
as
situated where
was
portion
the
on
side of the
the left
on
turned
was
it
but
upwards, liver
only
colon
was
trans-
FIG.
adherent to
A portion the stomach the liver.
the back of the uterus, and
lay
IV.
of the transverse colon and of lying on the tipper upper surface of
behind the small intes-
tines.
The
transverse
colon
probably abnormally long, in pelvic inflammation, had contracted meso-
was
and the great omentum, involved
until the transverse colon contact
came
into
with the uterus.
The condition
represented in Figure entirely different character. sketch roughly illustrates the posi-
is of
VI.
The
tion of in
adherent to to Transverse colon adherent the back and lying uterus and back of the the uterus behind intestine. behind the small intestine. the small
an
some
infant,
of the abdominal organs aged 14 months, which
died of tetany. Abnormal distension been great, and had of the abdomen had lasted for several weeks. The liver was so
displaced backwards and posterior surfaces The right kidney bad been right iliac fossa. The cause
much
downwards that the rested
on
the
right
iliac
crest.
pushed before the liver into the
DR.
222
THEODORE
FISHER
of this
displacement was great distension of the stomach and
intestines. This distension is, unfortunately, not shown in the
diagram.
The close
con-
nection of the liver with the
right kidney no doubt plays an important part in the causation of movable kidney. Pressure exerted from outside
the abdomen may apparently displace the liver directly
downwards,
and the
kidney
be
carried downwards with it, or ?as in this case?the liver Liver
displaced backwards, pushing right kidney into the right iliac fossa.
may
the
be rotated
and downwards
brought within the abdomen. to the
kidney
backwards
by
pressure
to bear upon it from
Examination of the relation of the liver
would lead
one
to
think that pressure from below upon the anterior half of the liver,
producing rotation, would be much likely to displace the kidney
more
than external pressure. common
The
most
effect of external pressure
is to compress the liver at
a
level
below the line of its contact with the
kidney. External pressure must tend in many instances to
tighten the grasp of the liver upon the kidney, rather than displace it. Possibly repeated flatulent distension of the abdomen may, when occurring in early life, be sufficient to
loosen the normal attachments FIG.
of the
right kidney. Figure VII. is an example
of
Acute dilatation
VII.
of
the stomach.
ON
CASES
OF
DISPLACEMENT
OF
the stomach reached the left iliac
the
VISCERA.
As shown in the
dilatation of the stomach.
acute
ABDOMINAL
fossa,
223
diagram,
and extended also to
of the middle line,
overlapping and hiding from view exception of the ascending colon. There was no obstruction of the pylorus, and the duodenum shared to some extent in the dilatation. The clinical history right
all the intestines with the
gave
indication of the time of onset of the dilatation.
no
It
aged 36, admitted, under the care of Mr. Munro Smith, in 1898, with swelling of the left eyelid. Cerebral symptoms set in, and the patient died. A suppurating thrombus was found in the left cavernous sinus, for which no
occurred in
cause
a
woman,
could be found.
Figure VIII. represents an
extreme
degree of a not
uncommon
condition. Thetransversecolon is
distended
greatly
as
a
con-
sequence of
of the
malignant growth sigmoid flexure. Part of
the distended
colon, most of the
stomach, and a small portion of the liver were the only viscera seen on
the anterior aspect of
the abdomen..
which
stomach,
The
adherent
was
to
the
colon, had been drawn downwards, and its low-
transverse
est
point
was
situated
slightly
below and to the right of the umbilicus. The condition occurred in
a woman
aged
39 years.
Figure IX. is not a diagram of a displaced organ, but is reproduced here because it represents
a
condition which
FIG.
VIII.
transverse colon in in Greatly dilated transverse case of stricture of the sigmoid flexure.
a a
appears to be frequently mistaken for a displaced kidney. It is the so-called Riedel's lobe of the liver, an appendage situated generally just outside it. The lobe is said to
or
gallstones,
and to be
produced by
over
the gall-bladder
be associated with
concomitant dilatation of the
CASES
224
OF
DISPLACEMENT
The
gall-bladder.
gall-bladder
OF
as
ABDOMINAL
it dilates is
VISCERA.
thought
to
drag
a
tongue of liver substance downwards and forwards with it. Six years ago two examples of the lobe occurred in the post-mortem room
of the Bristol
another,
Royal Infirmary
but I did not make
a
within
represents what
was
man, aged 44, who General Hospital in of Dr. Harrison. to
few weeks of
a
chronic
felt was
during
life in
a
in the Bristol
1894, under the care Ascites, due probably
peritonitis,
The abdomen
one
The illustration
sketch of either.
was
an
had been present. easy
one
to
pal-
the limits of the tumour
pate, allowing and its connection with the liver could be
clearly defined. It was looked upon as a congenital abnormality, and when the two other examples were met with in the IX. post-mortem room, not being aware at the Riedel's lobe of the liver. time of Riedel's description of this lobe, or of his explanation of its causation, I probably somewhat hastily concluded that they also were congenital. The presence or absence of gallstones is unfortunately not recorded. While, has of which been noticed the association however, gallstones with Riedel's lobe is interesting, and seems to be a reasonable explanation of the existence of the lobe, it is well to bear the fact FIG.
in mind that the anterior border of the liver presents considerable variability in outline. For example, the degree to which the left lobe is cut off from the
right, and its downward projection into the considerably in different cases. This variaepigastrium, of bility in the shape the liver suggests that a downward projection in the position of Riedel's lobe may be congenital, and the association noticed with gallstones merely a coincidence.1 differs
1 Note.?Since writing the above I have read an article by Glenard,2 in which the causation of Riedel's lobe of the liver is briefly discussed. Glenard considers that a floating lobe is generally associated with (non-cirrhotic), enlargement of the liver and that it is produced by the pressure of the costal margin upon the upper surface of the liver, in cases where there has been tight-lacing of a corset or the pressure of a belt. The frequency with which pressure of this character produces a line of atrophy upon the upper surface of the liver is well known, and when the anterior margin of the liver happens to be abnormally curved, it is possible that pressure may partially detach a portion and produce a floating lobe. 2
Revue des maladies de la
nutrition, November, 1898.
