SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN. 5 page

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In the New England Medical Journal, 1843, is an account of a vermiform

appendix which was taken from the body of a man of eighty-eight who had

died of pneumothorax. During life there were no symptoms of disease of

the appendix, and after death no adhesions were found, but this organ

was remarkably long, and in it were found 122 robin-shot. The old

gentleman had been excessively fond of birds all his life, and was

accustomed to bolt the meat of small birds without properly chewing it;

to this fact was attributed the presence of these shot in the appendix.

A somewhat similar case was that of a man who died in the Hotel-Dieu in

1833. The ileum of this man contained 92 shot and 120 plum stones.

Buckler reports a case of appendicitis in a child of twelve, in which a

common-sized bird-shot was found in the appendix. Packard presented a

case of appendicitis in which two pieces of rusty and crooked wire, one

2 1/2 and the other 1 1/2 inches long, were found in the omentum,

having escaped from the appendix. Howe describes a case in which a

double oat, with a hard envelope, was found in the vermiform appendix

of a boy of four years and one month of age. Prescott reports a case of

what he calls fatal colic from the lodgment of a chocolate-nut in the

appendix; and Noyes relates an instance of death in a man of thirty-one

attributed to the presence of a raisin-seed in the vermiform appendix.

Needles, pins, peanuts, fruit-stones, peas, grape-seeds, and many

similar objects have been found in both normal and suppurative

vermiform appendices.

Intestinal Injuries.--The degree of injury that the intestinal tract

may sustain, and after recovery perform its functions as usual, is most

extraordinary; and even when the injury is of such an extent as to be

mortal, the persistence of life is remarkable. It is a well known fact

that in bull-fights, after mortal injuries of the abdomen and bowels,

horses are seen to struggle on almost until the sport is finished.

Fontaine reports a case of a Welsh quarryman who was run over by a

heavy four-horse vehicle. The stump of a glass bottle was crushed into

the intestinal cavity, and the bowels protruded and were bruised by the

wheels of the wagon. The grit was so firmly ground into the bowel that

it was impossible to remove it; yet the man made a complete recovery.

Nicolls has the case of a man of sixty-nine, a workhouse maniac, who on

August 20th attempted suicide by running a red-hot poker into his

abdomen. His wound was dressed and he was recovering, but on September

11th he tore the cast off his abdomen, and pulled out of the wound the

omentum and 32 inches of colon, which he tore off and threw between his

pallet and the wall. Strange to say he did not die until eight days

after this horrible injury.

Tardieu relates the case of a chemist who removed a large part of the

mesentery with a knife, and yet recovered. Delmas of Montpellier

reports the history of a wagoner with complete rupture of the

intestines and rupture of the diaphragm, and who yet finished his

journey, not dying until eighteen hours after.

Successful Intestinal Resection.--In 1755 Nedham of Norfolk reported

the case of a boy of thirteen who was run over and eviscerated. It was

found necessary to remove 57 inches of the protruding bowel, but the

boy made a subsequent recovery. Koebererle of Strasburg performed an

operation on a woman of twenty-two for the relief of intestinal

obstruction. On account of numerous strictures it was found necessary

to remove over two yards of the small intestine; the patient recovered

without pain or trouble of any kind. In his dissertation on "Ruptures"

Arnaud remarks that he cut away more than seven feet of gangrenous

bowel, his patient surviving. Beehe reports recovery after the removal

of 48 inches of intestine. The case was one of strangulation of an

umbilical hernia.

Sloughing of the Intestine Following Intussusception.--Lobstein

mentions a peasant woman of about thirty who was suddenly seized with

an attack of intussusception of the bowel, and was apparently in a

moribund condition when she had a copious stool, in which she evacuated

three feet of bowel with the mesentery attached. The woman recovered,

but died five months later from a second attack of intussusception, the

ileum rupturing and peritonitis ensuing. There is a record in this

country of a woman of forty-five who discharged 44 inches of intestine,

and who survived for forty-two days. The autopsy showed the sigmoid

flexure gone, and from the caput ceci to the termination the colon only

measured 14 inches. Vater gives a history of a penetrating abdominal

wound in which a portion of the colon hung from the wound during

fourteen years, forming an artificial anus.

Among others mentioning considerable sloughing of intestine following

intussusception, and usually with complete subsequent recovery, are

Bare, 13 inches of the ileum; Blackton, nine inches; Bower, 14 inches;

Dawson, 29 inches; Sheldon, 4 1/2 feet; Stanley, three feet; Tremaine,

17 inches; and Grossoli, 40 cm.

Rupture of the Intestines.--It is quite possible for the intestine to

be ruptured by external violence, and cases of rupture of all parts of

the bowel have been recorded. Titorier gives the history of a case in

which the colon was completely separated from the rectum by external

violence. Hinder reports the rupture of the duodenum by a violent kick.

Eccles, Ely, and Pollock also mention cases of rupture of the duodenum.

Zimmerman, Atwell, and Allan report cases of rupture of the colon.

Operations upon the gastrointestinal tract have been so improved in the

modern era of antisepsis that at the present day they are quite common.

There are so many successful cases on record that the whole subject

deserves mention here.

Gastrostomy is an operation for establishing a fistulous opening in the

stomach through the anterior wall. Many operations have been devised,

but the results of this maneuver in malignant disease have not thus far

been very satisfactory. It is quite possible that, being an operation

of a serious nature, it is never performed early enough, the patient

being fatally weakened by inanition. Gross and Zesas have collected,

respectively, 207 and 162 cases with surprisingly different rates of

mortality: that of Gross being only 29.47 per cent, while that of Zesas

was for cicatricial stenoses 60 per cent, and for malignant cases 84

per cent. It is possible that in Zesas's statistics the subjects were

so far advanced that death would have resulted in a short time without

operation. Gastrotomy we have already spoken of.

Pyloroplasty is an operation devised by Heineke and Mikulicz, and is

designed to remove the mechanic obstruction in cicatricial stenoses of

the pylorus, at the same time creating a new pylorus.

Gastroenterostomy and pylorectomy are operations devised for the relief

of malignant disease of the pylorus, the diseased portions being

removed and the parts resected.

Gastrectomy or extirpation of the stomach is considered by most

surgeons entirely unjustifiable, as there is seldom hope of cure or

prospect of amelioration. La Tribune Medicale for January 16, 1895,

gives an abstract of Langenbuch's contribution upon total extirpation

of the stomach. Three patients were treated, of whom two died. In the

first case, on opening the abdominal cavity the stomach was found very

much contracted, presenting extensive carcinomatous infiltration on its

posterior surface. After division of the epiploon section was made at

the pylorus and at the cardiac extremities; the portions removed

represented seven-eighths of the stomach. The pylorus was stitched to

the remains of the cardiac orifice, making a cavity about the size of a

hen's egg. In this case a cure was accomplished in three weeks. The

second case was that of a man in whom almost the entire stomach was

removed, and the pyloric and cardiac ends were stitched together in the

wound of the parietes. The third case was that of a man of sixty-two

with carcinoma of the pylorus. After pylorectomy, the line of suture

was confined with iodoform-gauze packing. Unfortunately the patient

suffered with bronchitis, and coughing caused the sutures to give way;

the patient died of inanition on the twenty-third day.

Enterostomy, or the formation of a fecal fistula above the ileocecal

valve, was performed for the first time by Nelaton in 1840, but the

mortality since 1840 has been so great that in most cases it is deemed

inadmissible.

Colostomy, an operation designed to make a fistulous opening in any

portion of the rectum, was first practiced by Littre. In early times

the mortality of inguinal colostomy was about five per cent, but has

been gradually reduced until Konig reports 20 cases with only one death

from peritonitis, and Cripps 26 cases with only one death. This will

always retain its place in operative surgery as a palliative and

life-saving operation for carcinomatous stenosis of the lower part of

the colon, and in cases of carcinoma of the rectum in which operation

is not feasible.

Intestinal anastomosis, whereby two portions of a severed or resected

bowel can be intimately joined, excluding from fecal circulation the

portion of bowel which has become obstructed, was originally suggested

by Maisonneuve, and was studied experimentally by von Hacken. Billroth

resorted to it, and Senn modified it by substituting decalcified

bone-plates for sutures. Since that time, Abbe, Matas, Davis, Brokaw,

Robinson, Stamm, Baracz, and Dawburn, have modified the material of the

plates used, substituting catgut rings, untanned leather, cartilage,

raw turnips, potatoes, etc. Recently Murphy of Chicago has invented a

button, which has been extensively used all over the world, in place of

sutures and rings, as a means of anastomosis. Hardly any subject has

had more discussion in recent literature than the merits of this

ingenious contrivance.

Foreign Bodies in the Rectum.--Probably the most celebrated case of

foreign body introduced into the rectum is the classic one mentioned by

Hevin. Some students introduced the frozen tail of a pig in the anus of

a French prostitute. The bristles were cut short, and having prepared

the passage with oil, they introduced the tail with great force into

the rectum, allowing a portion to protrude. Great pain and violent

symptoms followed; there was distressing vomiting, obstinate

constipation, and fever. Despite the efforts to withdraw the tail, the

arrangement of the bristles which allowed entrance, prevented removal.

On the sixth day, in great agony, the woman applied to Marchettis, who

ingeniously adopted the simple procedure of taking a long hollow reed,

and preparing one of its extremities so that it could be introduced

into the rectum, he was enabled to pass the reed entirely around the

tail and to withdraw both. Relief was prompt, and the removal of the

foreign body was followed by the issue of stercoraceous matter which

had accumulated the six days it had remained in situ.

Tuffet is quoted as mentioning a farmer of forty-six who, in

masturbation, introduced a barley-head into his urethra. It was found

necessary to cut the foreign body out of the side of the glans. A year

later he put in his anus a cylindric snuff-box of large size, and this

had to be removed by surgical methods. Finally, a drinking goblet was

used, but this resulted in death, after much suffering and lay

treatment. In his memoirs of the old Academy of Surgery in Paris,

Morand speaks of a monk who, to cure a violent colic, introduced into

his fundament a bottle of l'eau de la reine de Hongrie, with a small

opening in its mouth, by which the contents, drop by drop, could enter

the intestine. He found he could not remove the bottle, and violent

inflammation ensued. It was at last necessary to secure a boy with a

small hand to extract the bottle. There is a record of a case in which

a tin cup or tumbler was pushed up the rectum and then passed into the

colon where it caused gangrene and death. It was found to measure 3 1/2

by 3 1/2 by two inches. There is a French case in which a preserve-pot

three inches in diameter was introduced into the rectum, and had to be

broken and extracted piece by piece.

Cloquet had a patient who put into his rectum a beer glass and a

preserving pot. Montanari removed from the rectum of a man a mortar

pestle 30 cm. long, and Poulet mentions a pederast who accidentally

killed himself by introducing a similar instrument, 55 cm. long, which

perforated his intestine. Studsgaard mentions that in the pathologic

collection at Copenhagen there is a long, smooth stone, 17 cm. long,

weighing 900 gm., which a peasant had introduced into his rectum to

relieve prolapsus. The stone was extracted in 1756 by a surgeon named

Frantz Dyhr. Jeffreys speaks of a person who, to stop diarrhea,

introduced into his rectum a piece of wood measuring seven inches.

There is a remarkable case recorded of a stick in the anus of a man of

sixty, the superior extremity in the right hypochondrium, the inferior

in the concavity of the sacrum. The stick measured 32 cm. in length;

the man recovered. It is impossible to comprehend this extent of

straightening of the intestine without great twisting of the mesocolon.

Tompsett mentions that he was called to see a workman of sixty-five,

suffering from extreme rectal hemorrhage. He found the man very feeble,

without pulse, pale, and livid. By digital examination he found a hard

body in the rectum, which he was sure was not feces. This body he

removed with a polyp-forceps, and found it to be a cylindric

candle-box, which measured six inches in circumference, 2 1/2 in

length, and 1 1/2 in diameter. The removal was followed by a veritable

flood of fecal material, and the man recovered. Lane reports

perforation of the rectum by the introduction of two large pieces of

soap; there was coincident strangulated hernia.

Hunter mentions a native Indian, a resident of Coorla, who had

introduced a bullock's horn high up into his abdomen, which neither he

nor his friends could extract. He was chloroformed and placed in the

lithotomy position, his buttocks brought to the edge of the bed, and

after dilatation of the sphincter, by traction with the fingers and

tooth-forceps, the horn was extracted. It measured 11 inches long. The

young imbecile had picked it up on the road, where it had been rendered

extremely rough by exposure, and this caused the difficulty in

extraction.

In Nelson's Northern Lancet, 1852, there is the record of a case of a

man at stool, who slipped on a cow's horn, which entered the rectum and

lodged beyond the sphincter. It was only removed with great difficulty.

A convict at Brest put up his rectum a box of tools. Symptoms of

vomiting, meteorism, etc., began, and became more violent until the

seventh day, when he died. After death, there was found in the

transverse colon, a cylindric or conic box, made of sheet iron, covered

with skin to protect the rectum and, doubtless, to aid expulsion. It

was six inches long and five inches broad and weighed 22 ounces. It

contained a piece of gunbarrel four inches long, a mother-screw steel,

a screw-driver, a saw of steel for cutting wood four inches long,

another saw for cutting metal, a boring syringe, a prismatic file, a

half-franc piece and four one-franc pieces tied together with thread, a

piece of thread, and a piece of tallow, the latter presumably for

greasing the instruments. On investigation it was found that these

conic cases were of common use, and were always thrust up the rectum

base first. In excitement this prisoner had pushed the conic end up

first, thus rendering expulsion almost impossible. Ogle gives an

interesting case of foreign body in the rectum of a boy of seventeen.

The boy was supposed to be suffering with an abdominal tumor about the

size of a pigeon's egg under the right cartilages; it had been noticed

four months before. On admission to the hospital the lad was suffering

with pain and jaundice; sixteen days later he passed a stick ten inches

long, which he reluctantly confessed that he had introduced into the

anus. During all his treatment he was conscious of the nature of his

trouble, but he suffered rather than confess. Studsgaard mentions a man

of thirty-five who, for the purpose of stopping diarrhea, introduced

into his rectum a preserve-bottle nearly seven inches long with the

open end uppermost. The next morning he had violent pain in the

abdomen, and the bottle could be felt through the abdominal wall. It

was necessary to perform abdominal section through the linea alba,

divide the sigmoid flexure, and thus remove the bottle. The intestine

was sutured and the patient recovered. The bottle measured 17 cm. long,

five cm. in diameter at its lower end, and three cm. at its upper end.

Briggs reports a case in which a wine glass was introduced into the

rectum, and although removed twenty-four hours afterward, death ensued.

Hockenhull extracted 402 stones from the rectum of a boy of seven.

Landerer speaks of a curious case in which the absorptive power of the

rectum was utilized in the murder of a boy of fifteen. In order to come

into the possession of a large inheritance the murderess poisoned the

boy by introducing the ends of some phosphorous matches into his

rectum, causing death that night; there was intense inflammation of the

rectum. The woman was speedily apprehended, and committed suicide when

her crime was known.

Complete transfixion of the abdomen does not always have a fatal issue.

In fact, two older writers, Wisemann and Muys, testify that it is quite

possible for a person to be transfixed without having any portion of

the intestines or viscera wounded. In some nations in olden times, the

extremest degree of punishment was transfixion by a stake. In his

voyages and travels, in describing the death of the King of Demaa at

the hands of his page, Mendez Pinto says that instead of being reserved

for torture, as were his successors Ravaillac, and Gerard, the slayer

of William the Silent, the assassin was impaled alive with a long stake

which was thrust in at his fundament and came out at the nape of his

neck. There is a record of a man of twenty-five, a soldier in the

Chinese war of 1860, who, in falling from his horse, was accidentally

transfixed by a bayonet. The steel entered his back two inches to the

left of the last dorsal vertebra, and reappeared two inches to the left

and below the umbilicus; as there was no symptom of visceral wound

there were apparently no injuries except perforation of the parietes

and the peritoneum. The man recovered promptly.

Ross reports a case of transfixion in a young male aborigine, a native

of New South Wales, who had received a spear-wound in the epigastrium

during a quarrel; extraction was impossible because of the

sharp-pointed barbs; the spear was, therefore, sawed off, and was

removed posteriorly by means of a small incision. The edges of the

wound were cleansed, stitched, and a compress and bandage applied.

During the night the patient escaped and joined his comrades in the

camp, and on the second day was suffering with radiating pains and

distention. The following day it was found that the stitches and

plaster had been removed, and the anterior wound was gaping and

contained an ichorous discharge. The patient was bathing the wound

with a decoction of the leaves of the red-gum tree. Notwithstanding

that the spear measured seven inches, and the interference of

treatment, the abdominal wound closed on the sixth day, and recovery

was uninterrupted. Gilkrist mentions an instance in which a ramrod was

fired into a soldier's abdomen, its extremity lodging in the spinal

column, without causing the slightest evidence of wounds of the

intestines or viscera. A minute postmortem examination was held some

time afterward, the soldier having died by drowning, but the results

were absolutely negative as regards any injury done by the passage of

the ramrod.

Humphreys says that a boy of eleven, while "playing soldier" with

another boy, accidentally fell on a rick-stake. The stake was slightly

curved at its upper part, being 43 inches long and three inches in

circumference, and sharp-pointed at its extremity. As much as 17 1/2

inches entered the body of the lad. The stake entered just in front of

the right spermatic cord, passed beneath Poupart's ligament into the

cavity of the abdomen, traversed the whole cavity across to the left

side; it then entered the thorax by perforating the diaphragm,

displaced the heart by pushing it to the right of the sternum, and

pierced the left lung. It then passed anteriorly under the muscles and

integument in the axillary space, along the upper third of the humerus,

which was extended beyond the head, the external skin not being

ruptured. The stick remained in situ for four hours before attempts at

extraction were made. On account of the displacement of the heart it

was decided not to give chloroform. The boy was held down by four men,

and Humphreys and his assistant made all the traction in their power.

After removal not more than a teaspoonful of blood followed. The heart

still remained displaced, and a lump of intestine about the size of an

orange protruded from the wound and was replaced. The boy made a slow

and uninterrupted recovery, and in six weeks was able to sit up. The

testicle sloughed, but five months later, when the boy was examined, he

was free from pain and able to walk. There was a slight enlargement of

the abdomen and a cicatrix of the wound in the right groin. The right

testicle was absent, and the apex of the heart was displaced about an

inch.

Woodbury reports the case of a girl of fourteen, who fell seven or

eight feet directly upon an erect stake in a cart; the tuberosity was

first struck, and then the stake passed into the anus, up the rectum

for two inches, thence through the rectal wall, and through the body in

an obliquely upward direction. Striking the ribs near the left nipple

it fractured three, and made its exit. The stake was three inches in

circumference, and 27 inches of its length passed into the body, six or

seven inches emerging from the chest. This girl recovered so rapidly

that she was able to attend school six weeks afterward. In a case

reported by Bailey a middle-aged woman, while sliding down a hay-stack,

struck directly upon a pitchfork handle which entered the vagina; the

whole weight of the woman was successfully maintained by the cellular

tissue of the uterovaginal culdesac.

Minot speaks of the passage of one prong of a pitchfork through the

body of a man of twenty-one, from the perineum to the umbilicus; the

man recovered.

Hamilton reports a case of laceration of the perineum with penetration

of the pelvic cavity to the depth of ten inches by a stick 3/4 inch

thick. Prowse mentions the history of a case of impalement in a man of

thirty-four, who, coming down a hay-stack, alighted on the handle of a

pitchfork which struck him in the middle of the scrotum, and passed up

between the skin and fascia to the 10th rib. Recovery was prompt.

There are several cases on record in which extensive wounds of the

abdominal parietes with protrusion and injury to the intestine have not

been followed by death. Injuries to the intestines themselves have

already been spoken of, but there are several cases of evisceration

worthy of record.

Doughty says that at midnight on June 7, 1868, he was called to see a

man who had been stabbed in a street altercation with a negro. When

first seen in the street, the patient was lying on his back with his

abdomen exposed, from which protruded an enormous mass of intestines,

which were covered with sand and grit; the small intestine (ileum) was

incised at one point and scratched at another by the passing knife. The

incision, about an inch in length, was closed with a single stitch of

silk thread, and after thorough cleansing the whole mass was returned

to the abdominal cavity. In this hernial protrusion were recognized

four or five feet of the ileum, the cecum with its appendix, part of

the ascending colon with corresponding portions of the mesentery; the

distribution of the superior mesentery, made more apparent by its

living pulsation, was more beautifully displayed in its succession of

arches than in any dissection that Doughty had ever witnessed.

Notwithstanding the extent of his injuries the patient recovered, and

at last reports was doing finely.

Barnes reports the history of a negro of twenty-five who was admitted

to the Freedmen's Hospital, New Orleans, May 15, 1867, suffering from

an incised wound of the abdomen, from which protruded eight inches of

colon, all of the stomach, and nearly the whole of the small

intestines. About 2 1/2 feet of the small intestine, having a whitish

color, appeared to be filled with food and had much of the

characteristic feeling of a sausage. The rest of the small intestine

had a dark-brown color, and the stomach and colon, distended with gas,

were leaden-colored. The viscera had been exposed to the atmosphere for

over an hour. Having nothing but cold Mississippi water to wash them

with, Barnes preferred returning the intestines without any attempt at

removing blood and dirt further than wiping with a cambric handkerchief

and the stripping they would naturally be subjected to in being

returned through the opening. In ten minutes they were returned; they

were carefully examined inch by inch for any wound, but none was found.

Three silver sutures were passed through the skin, and a firm compress

applied. The patient went to sleep shortly after his wound was dressed,

and never had a single subsequent bad symptom; he was discharged on May

24th, the wound being entirely healed, with the exception of a

cartilage of a rib which had not reunited.

Rogers mentions the case of a carpenter of thirty-six who was struck by

a missile thrown by a circular saw, making a wound two inches above the

umbilicus and to the left. Through the opening a mass of intestines and

a portion of the liver, attached by a pedicle, protruded. A portion of

the liver was detached, and the liver, as well as the intestines, were

replaced, and the man recovered.

Baillie, Bhadoory, Barker, Edmundson, Johnson, and others, record

instances of abdominal wounds accompanied by extensive protrusion of

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