MISCELLANEOUS SURGICAL ANOMALIES. 2 page

Mullings divorce-case, recorded in The Lancet. It appeared that Mrs.

Mullings, a few hours after her confinement at Torquay, packed her

newly-born infant boy in a portmanteau, and started for London. She had

telegraphed Dr. J. S. Tulloch to meet her at Paddington, where he found

his patient apparently in good condition, and not weak, as he expected

in a woman shortly to be confined. On the way to her apartments, which

had been provided by Dr. Tulloch, Mrs. Mullings remarked to the Doctor

that she had already borne her child. Dr. Tulloch was greatly

surprised, and immediately inquired what she had done with the baby.

She replied that it was in a box on top of the cab. When the box was

opened the child was found alive. The Lancet comments on the remarkable

fact that, shortly after confinement, a woman can travel six or seven

hours in a railroad train, and her newly-born babe conveyed the same

distance in a portmanteau, without apparent injury, and without

attracting attention.

Booth reports a remarkable case of vitality of a newly-born child which

came under his observation in October, 1894. An illegitimate child,

abandoned by its mother, was left at the bottom of a cesspool vault;

she claimed that ten hours before Booth's visit it had been

accidentally dropped during an attempt to micturate. The infant lived

despite the following facts: Its delivery from an ignorant,

inexperienced, unattended negress; its cord not tied; its fall of 12

feet down the pit; its ten hours' exposure in the cesspool; its

smothering by foul air, also by a heavy covering of rags, paper, and

straw; its pounding by three bricks which fell in directly from eight

feet above (some loose bricks were accidentally dislodged from the

sides of the vault, in the maneuvers to extricate the infant); its

lowered temperature previous to the application of hot bottles,

blankets, and the administration of cardiac stimulants. Booth adds that

the morning after its discovery the child appeared perfectly well, and

some two months afterward was brought into court as evidence in the

case. A remarkable case of infant vitality is given on page 117.

Operations in the Young and Old.--It might be of interest to mention

that such a major operation as ovariotomy has been successfully

performed in an infant. In a paper on infant ovariotomy, several

instances of this nature are mentioned. Roemer successfully performed

ovariotomy on a child one year and eight months old; Swartz, on a child

of four; Barker, on a child of four; Knowsley Thornton, on a child of

seven, and Spencer Wells Cupples, and Chenoweth, on children of eight.

Rein performed ovariotomy on a girl of six, suffering from a

multilocular cyst of the left ovary. He expresses his belief that

childhood and infancy are favorable to laparotomy.

Kidd removed a dermoid from a child of two years and eleven months;

Hooks performed the same operation on a child of thirty months. Chiene

extirpated an ovary from a child of three; Neville duplicated this

operation in a child one month younger; and Alcock performed ovariotomy

on a child of three.

Successful ovariotomies are infrequent in the extremely aged. Bennett

mentions an instance in a woman of seventy-five, and Davies records a

similar instance. Borsini and Terrier cite instances of successful

ovariotomy in patients of seventy-seven. Carmichael performed the

operation at seventy-four. Owens mentions it at eighty; and Homans at

eighty-two years and four months. Dewees records a successful case of

ovariotomy in a woman over sixty-seven; McNutt reports a successful

instance in a patient of sixty-seven years and six months; the tumor

weighed 60 pounds, and there were extensive adhesions. Maury removed a

monocystic ovarian tumor from a woman of seventy-four, his patient

recovering. Pippingskold mentions an ovariotomy at eighty. Terrier

describes double ovariotomy for fibromata in a woman of seventy-seven.

Aron speaks of an operation for pilous dermoid of the ovary in a woman

of seventy-five. Shepherd reports a case of recurrent proliferous cyst

in a woman of sixty-three, on whom successful ovariotomy was performed

twice within nine months. Wells mentions an ovarian cyst in a woman of

sixty-five, from which 72 pints of fluid were removed.

Hawkins describes the case of a musician, M. Rochard, who at the age of

one hundred and seven was successfully operated on for strangulated

hernia of upward of thirty hours' duration. The wound healed by first

intention, and the man was well in two weeks. Fowler operated

successfully for strangulated umbilical hernia on a patient of

sixty-eight.

Repeated Operations.--Franzolini speaks of a woman of fifty on whom he

performed six celiotomies between June, 1879, and April, 1887. The

first operation was for fibrocystic disease of the uterus. Since the

last operation the woman had had remarkably good health, and there was

every indication that well-merited recovery had been effected. The

Ephemerides contains an account of a case in which cystotomy was

repeated four times, and there is another record of this operation

having been done five times on a man. Instances of repeated Cesarean

section are mentioned on page 130.

Before leaving this subject, we mention a marvelous operation performed

by Billroth on a married woman of twenty-nine, after her sixth

pregnancy. This noted operator performed, synchronously, double

ovariotomy and resections of portions of the bladder and ileum, for a

large medullary carcinomatous growth of the ovary, with surrounding

involvement. Menstruation returned three months after the operation,

and in fifteen months the patient was in good health in every way, with

no apparent danger of recurrence of the disease.

Self-performed Surgical Operations.--There have been instances in which

surgeons and even laymen have performed considerable operations upon

themselves. On the battlefield men have amputated one of their own

limbs that had been shattered. In such cases there would be little

pain, and premeditation would not be brought into play in the same

degree as in the case of M. Clever de Maldigny, a surgeon in the Royal

Guards of France, who successfully performed a lithotomy on himself

before a mirror. He says that after the operation was completed the

urine flowed in abundance; he dressed the wound with lint dipped in an

emollient solution, and, being perfectly relieved from pain, fell into

a sound sleep. On the following day, M. Maldigny says, he was as

tranquil and cheerful as if he had never been a sufferer. A Dutch

blacksmith and a German cooper each performed lithotomy on themselves

for the intense pain caused by a stone in the bladder. Tulpius,

Walther, and the Ephemerides each report an instance of self-performed

cystotomy.

The following case is probably the only instance in which the patient,

suffering from vesical calculus, tried to crush and break the stone

himself. J. B., a retired draper, born in 1828, while a youth of

seventeen, sustained a fracture of the leg, rupture of the urethra, and

laceration of the perineum, by a fall down a well, landing astride an

iron bar. A permanent perineal fistula was established, but the patient

was averse to any operative remedial measure. In the year 1852 he

became aware of the presence of a calculus, but not until 1872 did he

ask for medical assistance. He explained that he had introduced a

chisel through his perineal fistula to the stone, and attempted to

comminute it himself and thus remove it, and by so doing had removed

about an ounce of the calculus. The physician started home for his

forceps, but during the interval, while walking about in great pain,

the man was relieved by the stone bursting through the perineum,

falling to the floor, and breaking in two. Including the ounce already

chiselled off, the stone weighed 14 1/2 ounces, and was 10 5/8 inches

in its long circumference. B. recovered and lived to December, 1883,

still believing that he had another piece of stone in his bladder.

In Holden's "Landmarks" we are told that the operation of dividing the

Achilles tendon was first performed by an unfortunate upon himself, by

means of a razor. According to Patterson, the late Mr. Symes told of a

patient in North Scotland who, for incipient hip-disease, had the

cautery applied at the Edinburgh Infirmary with resultant great relief.

After returning home to the country he experienced considerable pain,

and despite his vigorous efforts he was unable to induce any of the men

to use the cautery upon him; they termed it "barbarous treatment." In

desperation and fully believing in the efficacy of this treatment as

the best means of permanently alleviating his pain, the crippled

Scotchman heated a poker and applied the cautery himself.

We have already mentioned the marvelous instances of Cesarean sections

self-performed, and in the literature of obstetric operations many of

the minor type have been done by the patient herself. In the foregoing

cases it is to be understood that the operations have been performed

solely from the inability to secure surgical assistance or from the

incapacity to endure the pain any longer. These operations were not the

self-mutilations of maniacs, but were performed by rational persons,

driven to desperation by pain.

Possibly the most remarkable instances of extensive loss of blood, with

recoveries, are to be found in the older records of venesection. The

chronicles of excessive bleeding in the olden days are well known to

everybody. Perhaps no similar practice was so universally indulged in.

Both in sickness and in health, depletion was indicated, and it is no

exaggeration to say that about the hospital rooms at times the floors

were covered with blood. The reckless way in which venesection was

resorted to, led to its disuse, until to-day it has so vanished from

medical practice that even its benefits are overlooked, and depletion

is brought about in some other manner. Turning to the older writers, we

find Burton describing a patient from whom he took 122 ounces of blood

in four days. Dover speaks of the removal of 111 and 190 ounces; Galen,

of six pounds; and Haen, of 114 ounces. Taylor relates the history of a

case of asphyxia in which he produced a successful issue by extracting

one gallon of blood from his patient during twelve hours. Lucas speaks

of 50 venesections being practiced during one pregnancy. Van der Wiel

performed venesection 49 times during a single pregnancy. Balmes

mentions a case in which 500 venesections were performed in twenty-five

years. Laugier mentions 300 venesections in twenty-six months.

Osiander speaks of 8000 ounces of blood being taken away in thirty-five

years. Pechlin reports 155 venesections in one person in sixteen years,

and there is a record of 1020 repeated venesections.

The loss of blood through spontaneous hemorrhage is sometimes

remarkable. Fabricius Hildanus reports the loss of 27 pounds of blood

in a few days; and there is an older record of 40 pounds being lost in

four days. Horstius, Fabricius Hildanus, and Schenck, all record

instances of death from hemorrhage of the gums. Tulpius speaks of

hemoptysis lasting chronically for thirty years, and there is a similar

record of forty years' duration in the Ephemerides. Chapman gives

several instances of extreme hemorrhage from epistaxis. He remarks that

Bartholinus has recorded the loss of 48 pounds of blood from the nose;

and Rhodius, 18 pounds in thirty-six hours. The Ephemerides contains an

account of epistaxis without cessation for six weeks. Another writer in

an old journal speaks of 75 pounds of blood from epistaxis in ten days.

Chapman also mentions a case in which, by intestinal hemorrhage, eight

gallons of blood were lost in a fortnight, the patient recovering. In

another case a pint of blood was lost daily for fourteen days, with

recovery. The loss of eight quarts in three days caused death in

another case; and Chapman, again, refers to the loss of three gallons

of blood from the bowel in twenty-four hours. In the case of

Michelotti, recorded in the Transactions of the Royal Society, a young

man suffering from enlargement of the spleen vomited 12 pounds of blood

in two hours, and recovered.

In hemorrhoidal hemorrhages, Lieutaud speaks of six quarts being lost

in two days; Hoffman, of 20 pounds in less than twenty-four hours, and

Panaroli, of the loss of one pint daily for two years.

Arrow-Wounds.--According to Otis the illustrious Baron Percy was wont

to declare that military surgery had its origin in the treatment of

wounds inflicted by darts and arrows; he used to quote Book XI of the

Iliad in behalf of his belief, and to cite the cases of the patients of

Chiron and Machaon, Menelaus and Philoctetes, and Eurypiles, treated by

Patroclus; he was even tempted to believe with Sextus that the name

iatros, medicus, was derived from ios, which in the older times

signified "sagitta," and that the earliest function of our professional

ancestors was the extraction of arrows and darts. An instrument called

beluleum was invented during the long Peloponnesian War, over four

hundred years before the Christian era. It was a rude

extracting-forceps, and was used by Hippocrates in the many campaigns

in which he served. His immediate successor, Diocles, invented a

complicated instrument for extracting foreign bodies, called

graphiscos, which consisted of a canula with hooks. Otis states that it

was not until the wars of Augustus that Heras of Cappadocia designed

the famous duck-bill forceps which, with every conceivable

modification, has continued in use until our time. Celsus instructs

that in extracting arrow-heads the entrance-wound should be dilated,

the barb of the arrow-head crushed by strong pliers, or protected

between the edges of a split reed, and thus withdrawn without

laceration of the soft parts. According to the same authority, Paulus

Aegineta also treated fully of wounds by arrow-heads, and described a

method used in his time to remove firmly-impacted arrows. Albucasius

and others of the Arabian school did little or nothing toward aiding

our knowledge of the means of extracting foreign bodies. After the

fourteenth century the attention of surgeons was directed to wounds

from projectiles impelled by gunpowder. In the sixteenth century arrows

were still considerably used in warfare, and we find Pare a delineating

the treatment of this class of injuries with the sovereign good sense

that characterized his writings. As the use of firearms became

prevalent the literature of wounds from arrows became meager, and the

report of an instance in the present day is very rare.

Bill has collected statistics and thoroughly discussed this subject,

remarking upon the rapidity with which American Indians discharge their

arrows, and states that it is exceptional to meet with only a single

wound. It is commonly believed that the Indian tribes make use of

poisoned arrows, but from the reports of Bill and others, this must be

a very rare custom. Ashhurst states that he was informed by Dr. Schell,

who was stationed for some time at Fort Laramie, that it is the

universal custom to dip the arrows in blood, which is allowed to dry on

them; it is not, therefore, improbable that septic material may thus be

inoculated through a wound.

Many savage tribes still make use of the poisonous arrow. The Dyak uses

a sumpitan, or blow-tube, which is about seven feet long, and having a

bore of about half an inch. Through this he blows his long, thin dart,

anointed on the head with some vegetable poison. Braidwood speaks of

the physiologic action of Dajaksch, an arrow-poison used in Borneo.

Arnott has made observations relative to a substance produced near

Aden, which is said to be used by the Somalies to poison their arrows.

Messer of the British Navy has made inquiries into the reputed

poisonous nature of the arrows of the South Sea Islanders.

Otis has collected reports of arrow-wounds from surgical cases

occurring in the U. S. Army. Of the multiple arrow-wounds, six out of

the seven cases were fatal. In five in which the cranial cavity was

wounded, four patients perished. There were two remarkable instances of

recovery after penetration of the pleural cavity by arrows. The great

fatality of arrow-wounds of the abdomen is well known, and, according

to Bill, the Indians always aim at the umbilicus; when fighting

Indians, the Mexicans are accustomed to envelop the abdomen, as the

most vulnerable part, in many folds of a blanket.

Of the arrow-wounds reported, nine were fatal, with one exception, in

which the lesion implicated the soft parts only. The regions injured

were the scalp, face, and neck, in three instances; the parietes of the

chest in six; the long muscles of the back in two; the abdominal

muscles in two; the hip or buttocks in three; the testis in one; the

shoulder or arm in 13; forearm or hand in six; the thigh or leg in

seven.

The force with which arrows are projected by Indians is so great that

it has been estimated that the initial velocity nearly equals that of a

musket-ball. At a short distance an arrow will perforate the larger

bones without comminuting them, causing a slight fissure only, and

resembling the effect of a pistol-ball fired through a window-glass a

few yards off.

Among extraordinary cases of recovery from arrow-wounds, several of the

most striking will be recorded. Tremaine mentions a sergeant of

thirty-four who, in a fray with some hostile Indians, received seven

arrow-wounds: two on the anterior surface of the right arm; one in the

right axilla; one on the right side of the chest near the axillary

border; two on the posterior surface of the left arm near the

elbow-joint, and one on the left temple. On June 1st he was admitted to

the Post Hospital at Fort Dodge, Kan. The wound on the right arm near

the deltoid discharged, and there was slight exfoliation of the

humerus. The patient was treated with simple dressings, and was

returned to duty in July, 1870.

Goddard mentions an arrow-wound by which the body was transfixed. The

patient was a cutler's helper at Fort Rice, Dakota Territory. He was

accidentally wounded in February, 1868, by an arrow which entered the

back three inches to the right of the 5th lumbar vertebra, and emerged

about two inches to the right of the ensiform cartilage. During the

following evening the patient lost about eight ounces of blood

externally, with a small amount internally. He was confined to his bed

some two weeks, suffering from circumscribed peritonitis with

irritative fever. In four weeks he was walking about, and by July 1st

was actively employed. The arrow was deposited in the Army Medical

Museum.

Muller gives a report of an arrow-wound of the lung which was

productive of pleurisy but which was followed by recovery. Kugler

recites the description of the case of an arrow-wound of the thorax,

complicated by frightful dyspnea and blood in the pleural cavity and in

the bronchi, with recovery.

Smart extracted a hoop-iron arrow-head, 1 3/4 inches long and 1/2 inch

in breadth, from the brain of a private, about a month after its

entrance. About a dram of pus followed the exit of the arrow-head.

After the operation the right side was observed to be paralyzed, and

the man could not remember his name. He continued in a varying

condition for a month, but died on May 13, 1866, fifty-two days after

the injury. At the postmortem it was found that the brain-tissue, to

the extent of 3/4 inch around the track of the arrow as a center, was

softened and disorganized. The track itself was filled with thick pus

which extended into the ventricles.

Peabody reports a most remarkable case of recovery from multiple

arrow-wounds. In a skirmish with some Indians on June 3, 1863, the

patient had been wounded by eight distinct arrows which entered

different parts of the body. They were all extracted with the exception

of one, which had entered at the outer and lower margin of the right

scapula, and had passed inward and upward through the upper lobe of the

right lung or trachea. The hemorrhage at this time was so great that

all hope was abandoned. The patient, however, rallied, but continued

to experience great pain on swallowing, and occasionally spat blood. In

July, 1866, more than three years after the injury, he called on Dr.

Peabody to undergo an examination with a view of applying for a

pension, stating that his health was affected from the presence of an

arrow-head. He was much emaciated, and expressed himself as tired of

life. Upon probing through a small fistulous opening just above the

superior end of the sternum, the point of the arrow was found resting

against the bone, about 1 1/2 inches below, the head lying against the

trachea and esophagus, with the carotid artery, jugular vein, and

nerves overlying. After some little difficulty the point of the arrow

was raised above the sternum, and it was extracted without the loss of

an ounce of blood. The edge grazed against the sheath of the innominate

artery during the operation. The missile measured an inch at the base,

and was four inches long. The health of the patient underwent

remarkable improvement immediately after the operation.

Serious Insect-stings.--Although in this country the stings of insects

are seldom productive of serious consequences, in the tropic climates

death not unfrequently results from them. Wounds inflicted by large

spiders, centipedes, tarantulae, and scorpions have proved fatal. Even

in our country deaths, preceded by gangrene, have sometimes followed

the bite of a mosquito or a bee, the location of the bite and the

idiosyncrasy of the individual probably influencing the fatal issue. In

some cases, possibly, some vegetable poison is introduced with the

sting. Hulse, U.S.N., reports the case of a man who was bitten on the

penis by a spider, and who subsequently exhibited violent symptoms

simulating spinal meningitis, but ultimately recovered. Kunst mentions

a man of thirty-six who received several bee-stings while taking some

honey from a tree, fell from the tree unconscious, and for some time

afterward exhibited signs of cerebral congestion. Chaumeton mentions a

young man who did not perceive a wasp in a glass of sweet wine, and

swallowed the insect. He was stung in the throat, followed by such

intense inflammation that the man died asphyxiated in the presence of

his friends, who could do nothing to relieve him. In connection with

this case there is mentioned an English agriculturist who saved the

life of one of his friends who had inadvertently swallowed a wasp with

a glass of beer. Alarming symptoms manifested themselves at the moment

of the sting. The farmer made a kind of paste from a solution of common

salt in as little water as possible, which he gave to the young man,

and, after several swallows of the potion, the symptoms disappeared as

if by enchantment. There is a recent account from Bridgeport, Conn., of

a woman who, while eating a pear, swallowed a hornet that had alighted

on the fruit. In going down the throat the insect stung her on the

tonsil. Great pain and inflammation followed, and in a short time there

was complete deprivation of the power of speech.

Mease relates the case of a corpulent farmer who, in July, 1835, was

stung upon the temple by a common bee. He walked to a fence a short

distance away, thence to his house, 20 yards distant, lay down, and

expired in ten minutes. A second case, which occurred in June, 1811, is

also mentioned by Mease. A vigorous man was stung in the septum of the

nose by a bee. Supported by a friend he walked to his house, a few

steps distant, and lay down. He rose immediately to go to the well,

stepped a few paces, fell, and expired. It was thirty minutes from the

time of the accident to the man's death. A third case is reported by

the same author from Kentucky. A man of thirty-five was stung on the

right superior palpebrum, and died in twenty minutes. Mease reports a

fourth ease from Connecticut, in which a man of twenty-six was stung by

a bee on the tip of the nose. He recovered after treatment with

ten-grain doses of Dover's Powder, and persistent application of

plantain leaves. A fifth case was that of a farmer in Pennsylvania who

was stung in the left side of the throat by a wasp which he had

swallowed in drinking cider. Notwithstanding medical treatment, death

ensued twenty-seven hours afterward. A sixth case, which occurred in

October, 1834, is given by the same author. A middle-aged man was stung

by a yellow wasp on the middle finger of the right hand, and died in

less than twenty minutes after having received his wound. A seventh

case was that of a New York farmer who, while hoeing, was bitten on the

foot by a spider. Notwithstanding medical treatment, principally

bleeding, the man soon expired.

Desbrest mentions the sting of a bee above the eyebrow followed by

death. Zacutus saw a bee-sting which was followed by gangrene.

Delaistre mentions death from a hornet-sting in the palate. Nivison

relates the case of a farmer of fifty who was stung in the neck by a

bee. The usual swelling and discoloration did not follow, but

notwithstanding vigorous medical treatment the man died in six days.

Thompson relates three cases of bee-sting, in all of which death

supervened within fifteen minutes,--one in a farmer of fifty-eight who

was stung in the neck below the right ear; a second in an inn-keeper of

fifty who was stung in the neck, and a third of a woman of sixty-four

who was stung on the left brow. "Chirurgus" recalls the details of a

case of a wasp-sting in the middle finger of the right hand of a man of

forty, depriving him of all sense and of muscular power. Ten minutes

after receiving it he was unconscious, his heart-beats were feeble, and

his pulse only perceptible.

Syphilis from a Flea-bite.--Jonathan Hutchinson, in the October, 1895,

number of his unique and valuable Archives of Surgery, reports a

primary lesion of most unusual origin. An elderly member of the

profession presented himself entirely covered with an evident

syphilitic eruption, which rapidly disappeared under the use of

mercury. The only interest about the case was the question as to how

the disease had been acquired. The doctor was evidently anxious to give

all the information in his power, but was positive that he had never

been exposed to any sexual risk, and as he had retired from practice,

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