MISCELLANEOUS SURGICAL ANOMALIES. 3 page

no possibility of infection in that manner existed. He willingly

stripped, and a careful examination of his entire body surface revealed

no trace of lesion whatever on the genitals, or at any point, except a

dusky spot on one leg, which looked like the remains of a boil. This,

the doctor stated, had been due to a small sore, the dates of the

appearance and duration of which were found to fit exactly with those

of a primary lesion. There had also been some enlargement of the

femoral glands. He had never thought of the sore in this connection,

but remembered most distinctly that it followed a flea-bite in an

omnibus, and had been caused, as he supposed, by his scratching the

place, though he could not understand why it lasted so long. Mr.

Hutchinson concludes that all the evidence tends to show that the

disease had probably been communicated from the blood of an infected

person through the bite of the insect. It thus appears that even the

proverbially trivial fleabite may at times prove a serious injury.

Snake-bites.--A writer in an Indian paper asserts that the traditional

immunity of Indian snake-charmers is due to the fact that having been

accidentally bitten by poisonous serpents or insects more than once,

and having survived the first attack, they are subsequently immune. His

assertion is based on personal acquaintance with Madari Yogis and

Fakirs, and an actual experiment made with a Mohammedan Fakir who was

immune to the bites of scorpions provided by the writer. The animals

were from five to seven inches long and had lobster-like claws. Each

bite drew blood, but the Fakir was none the worse.

The venom of poisonous snakes may be considered the most typical of

animal poisons, being unrivaled in the fatality and rapidity of its

action. Fortunately in our country there are few snake-bites, but in

the tropic countries, particularly India, the mortality from this cause

is frightful. Not only are there numerous serpents in that country, but

the natives are lightly dressed and unshod, thus being exposed to the

bites of the reptiles. It is estimated by capable authorities that the

deaths in India each year from snake-bites exceed 20,000. It is stated

that there were 2893 human beings killed by tigers, leopards, hyenas,

and panthers in India during the year 1894, and in the same year the

same species of beasts, aided by snakes, killed 97,371 head of cattle.

The number of human lives destroyed by snakes in India in 1894 was

21,538. The number of wild beasts killed in the same year was 13,447,

and the number of snakes killed was 102,210.

Yarrow of Washington, who has been a close student of this subject, has

found in this country no less than 27 species of poisonous snakes,

belonging to four genera. The first genus is the Crotalus, or

rattlesnake proper; the second is the Caudisona, or ground-rattlesnake;

the third is the Ancistrodon, or moccasin, one of the species of which

is a water-snake; and the fourth is the Elaps, or harlequin snake.

There is some dispute over the exact degree of the toxic qualities of

the venom of the Heloderma suspectum, or Gila monster. In India the

cobra is the most deadly snake. It grows to the length of 5 1/2 feet,

and is most active at night. The Ophiophagus, or hooded cobra, is one

of the largest of venomous snakes, sometimes attaining a length of 15

feet; it is both powerful, active, and aggressive. The common snakes of

the deadly variety in the United States are the rattlesnake, the

"copperhead," and the moccasin; and it is from the bites of one of

these varieties that the great majority of reported deaths are caused.

But in looking over medical literature one is struck with the scarcity

of reports of fatal snake-bites. This is most likely attributable to

the fact that, except a few army-surgeons, physicians rarely see the

cases. The natural abode of the serpents is in the wild and uninhabited

regions.

The venom is delivered to the victim through the medium of a long fang

which is connected with a gland in which the poison is stored. The

supply may be readily exhausted; for a time the bite would then be

harmless. Contrary to the general impression, snake-venom when

swallowed is a deadly poison, as proved by the experiments of Fayrer,

Mitchell, and Reichert. Death is most likely caused by paralysis of the

vital centers through the circulation. In this country the wounds

invariably are on the extremities, while in India the cobra sometimes

strikes on the shoulder or neck.

If called on to describe accurately the symptoms of snake-venom

poisoning, few medical men could respond correctly. In most cases the

wound is painful, sometimes exaggerated by the mental condition, which

is wrought up to a pitch rarely seen in other equally fatal injuries.

It is often difficult to discern the exact point of puncture, so minute

is it. There is swelling due to effusion of blood, active inflammation,

and increasing pain. If the poison has gained full entrance into the

system, in a short time the swelling extends, vesicles soon form, and

the disorganization of the tissues is so rapid that gangrene is liable

to intervene before the fatal issue. The patient becomes prostrated

immediately after the infliction of the wound, and his condition

strongly indicates the use of stimulants, even if the medical attendant

were unfamiliar with the history of the snake-bite. There may be a

slight delirium; the expression becomes anxious, the pulse rapid and

feeble, the respiration labored, and the patient complains of a sense

of suffocation. Coma follows, and the respirations become slower and

slower until death results. If the patient lives long enough, the

discoloration of the extremity and the swelling may spread to the neck,

chest and back. Loss of speech after snake-bite is discussed in Chapter

XVII, under the head of Aphasia.

A peculiar complication is a distressing inflammation of the mouth of

individuals that have sucked the wounds containing venom. This custom

is still quite common, and is preferred by the laity to the surer and

much wiser method of immediate cauterization by fire. There is a

curious case reported of a young man who was bitten on the ankle by a

viper; he had not sucked the wound, but he presented such an enormous

swelling of the tongue as to be almost provocative of a fatal issue. In

this case the lingual swelling was a local effect of the general

constitutional disturbance.

Cases of Snake-bite.--The following case illustrative of the tenacity

of virulence of snake-venom was reported by Mr. Temple, Chief Justice

of Honduras, and quoted by a London authority. While working at some

wood-cutting a man was struck on a heavy boot by a snake, which he

killed with an axe. He imagined that he had been efficiently protected

by the boot, and he thought little of the incident. Shortly afterward

he began to feel ill, sank into a stupor, and succumbed. His boots were

sold after his death, as they were quite well made and a luxury in that

country. In a few hours the purchaser of the boots was a corpse, and

every one attributed his death to apoplexy or some similar cause. The

boots were again sold, and the next unfortunate owner died in an

equally short time. It was then thought wise to examine the boots, and

in one of them was found, firmly embedded, the fang of the serpent. It

was supposed that in pulling on the boots each of the subsequent owners

had scratched himself and became fatally inoculated with the venom,

which was unsuspected and not combated. The case is so strange as to

appear hypothetic, but the authority seems reliable.

The following are three cases of snake-bite reported by surgeons of the

United States Army, two followed by recovery, and the other by death:

Middleton mentions a private in the Fourth Cavalry, aged twenty-nine,

who was bitten by a rattlesnake at Fort Concho, Texas, June 27, 1866.

The bite opened the phalangeal joint of the left thumb, causing violent

inflammation, and resulted in the destruction of the joint. Three years

afterward the joint swelled and became extremely painful, and it was

necessary to amputate the thumb. Campbell reports the case of a private

of the Thirteenth Infantry who was bitten in the throat by a large

rattlesnake. The wound was immediately sucked by a comrade, and the man

reported at the Post Hospital, at Camp Cooke, Montana, three hours

after the accident. The only noticeable appearance was a slightly wild

look about the eyes, although the man did not seem to be the least

alarmed. The region of the wound was hard and somewhat painful,

probably from having been bruised by the teeth of the man who sucked

the wound; it remained so for about three hours. The throat was bound

up in rancid olive oil (the only kind at hand) and no internal remedy

was administered. There were no other bad consequences, and the patient

soon returned to duty.

Le Carpentier sends the report of a fatal case of rattlesnake-bite: A

private, aged thirty-seven, remarkable for the singularity of his

conduct, was known in his Company as a snake-charmer, as he had many

times, without injury, handled poisonous snakes. On the morning of July

13, 1869, he was detailed as guard with the herd at Fort Cummings, New

Mexico, when, in the presence of the herders, he succeeded in catching

a rattlesnake and proving his power as a sorcerer. The performance

being over and the snake killed, he caught sight of another of the same

class, and tried to duplicate his previous feat; but his dexterity

failed, and he was bitten in the middle finger of the right hand. He

was immediately admitted to the Post Hospital, complaining only of a

little pain, such as might follow the sting of a bee or wasp. A

ligature was applied above the wound; the two injuries made by the

fangs were enlarged by a bistoury; ammonia and the actual cautery were

applied; large doses of whiskey were repeated frequently, the

constitution of the patient being broken and poor. Vomiting soon came

on but was stopped without trouble, and there were doubts from the

beginning as to his recovery. The swelling of the hand and arm

gradually increased, showing the particular livid and yellowish tint

following the bites of poisonous snakes. A blister was applied to the

bitten finger, tincture of iodin used, and two ounces of whiskey given

every two hours until inebriety was induced. The pulse, which was very

much reduced at first, gained gradually under the influence of

stimulants; two grains of opium were given at night, the patient slept

well, and on the next day complained only of numbness in the arm. The

swelling had extended as far as the shoulder-joint, and the blood,

which was very fluid, was incessantly running from the wound. Carbolic

acid and cerate were applied to the arm, with stimulants internally. On

the 15th his condition was good, the swelling had somewhat augmented,

there was not so much lividity, but the yellowish hue had increased. On

the 16th the man complained of pain in the neck, on the side of the

affected limb, but his general condition was good. Examining his

genitals, an iron ring 3/4 inch in diameter was discovered, imbedded in

the soft tissues of the penis, constricting it to such a degree as to

have produced enormous enlargement of the parts. Upon inquiry it seemed

that the ring had been kept on the parts very long, as a means of

preservation of chastity; but under the influence of the snake's venom

the swelling had increased, and the patient having much trouble in

passing water was obliged to complain. The ring was filed off with some

difficulty. Gangrene destroyed the extremity of the bitten finger. From

this date until the 30th the man's condition improved somewhat. The

progress of the gangrene was stopped, and the injured finger was

disarticulated at the metacarpal articulation. Anesthesia was readily

obtained, but the appearance of the second stage was hardly

perceptible. Le Carpentier was called early on the next morning, the

patient having been observed to be sinking; there was stertorous

respiration, the pulse was weak and slow, and the man was only partly

conscious. Electricity was applied to the spine, and brandy and

potassium bromid were given, but death occurred about noon. A necropsy

was made one hour after death. There was general softening of the

tissues, particularly on the affected side. The blood was black and

very fluid,--not coagulable. The ventricles of the brain were filled

with a large amount of serum; the brain was somewhat congested. The

lungs were healthy, with the exception of a few crude tubercles of

recent formation on the left side. The right ventricle of the heart was

empty, and the left filled with dark blood, which had coagulated. The

liver and kidneys were healthy, and the gall-bladder very much

distended with bile. The intestines presented a few livid patches on

the outside.

Hydrophobia.--The bite of an enraged animal is always of great danger

to man, and death has followed a wound inflicted by domestic animals or

even fowls; a human bite has also caused a fatal issue. Rabies is

frequently observed in herbivorous animals, such as the ox, cow, or

sheep, but is most commonly found in the carnivore, such as the dog,

wolf, fox, jackal, hyena, and cat and other members of the feline

tribe. Fox reports several cases of death from symptoms resembling

those of hydrophobia in persons who were bitten by skunks. Swine,

birds, and even domestic poultry have caused hydrophobia by their

bites. Le Cat speaks of the bite of an enraged duck causing death, and

Thiermeyer mentions death shortly following the bite of a goose, as

well as death in three days from a chicken-bite. Camerarius describes a

case of epilepsy which he attributed to a horse-bite. Among the older

writers speaking of death following the bite of an enraged man, are van

Meek'ren, Wolff, Zacutus Lusitanus, and Glandorp. The Ephemerides

contains an account of hydrophobia caused by a human bite. Jones

reports a case of syphilitic inoculation from a human bite on the hand.

Hydrophobia may not necessarily be from a bite; a previously-existing

wound may be inoculated by the saliva alone, conveyed by licking.

Pliny, and some subsequent writers, attributed rabies to a worm under

the animal's tongue which they called "lytta." There is said to be a

superstition in India that, shortly after being bitten by a mad dog,

the victim conceives pups in his belly; at about three months these

move rapidly up and down the patient's intestines, and being mad like

their progenitor, they bite and bark incessantly, until they finally

kill the unfortunate victim. The natives of Nepaul firmly believe this

theory. All sorts of curious remedies have been suggested for the cure

of hydrophobia. Crabs-claws, Spanish fly, and dragon roots, given three

mornings before the new or full moon, was suggested as a specific by

Sir Robert Gordon. Theodore De Vaux remarks that the person bitten

should immediately pluck the feathers from the breech of an old cock

and apply them bare to the bites. If the dog was mad the cock was

supposed to swell and die. If the dog was not mad the cock would not

swell; in either case the person so treated was immune. Mad-stones, as

well as snake-stones, are believed in by some persons at the present

day. According to Curran, at one time in Ireland the fear of

hydrophobia was so great that any person supposed to be suffering from

it could be legally smothered.

According to French statistics, hydrophobia is an extremely fatal

disease, although the proportion of people bitten and escaping without

infection is overwhelmingly greater than those who acquire the disease.

The mortality of genuine hydrophobia is from 30 to 80 per cent,

influenced by efficient and early cauterization and scientific

treatment. There is little doubt that many of the cases reported as

hydrophobia are merely examples of general systemic infection from a

local focus of sepsis, made possible by some primitive and uncleanly

treatment of the original wound. There is much superstition relative to

hydrophobia; the majority of wounds seen are filled with the hair of

the dog, soot, ham-fat, and also with particles of decayed food and

saliva from the mouth of some person who has practiced sucking the

wound.

Ordinarily, the period of incubation of hydrophobia in man is before

the end of the second month, although rarely cases are seen as many as

six months from the reception of the bite. The first symptoms of the

disease are melancholia, insomnia, loss of appetite, and occasionally

shooting pains, radiating from the wound. There may be severe pain at

the back of the head and in the neck. Difficulty in swallowing soon

becomes a marked symptom. The speech assumes a sobbing tone, and

occasionally the expression of the face is wild and haggard. As regards

the crucial diagnostic test of a glass of water, the following account

of a patient's attempt to drink is given by Curtis and quoted by

Warren: "A glass of water was offered the patient, which he refused to

take, saying that he could not stand so much as that, but would take it

from a teaspoon. On taking the water from the spoon he evinced some

discomfort and agitation, but continued to raise the spoon. As it came

within a foot of his lips, he gagged and began to gasp violently, his

features worked, and his head shook. He finally almost tossed the water

into his mouth, losing the greater part of it, and staggered about the

room gasping and groaning. At this moment the respirations seemed

wholly costal, and were performed with great effort, the elbows being

jerked upward with every inspiration. The paroxysm lasted about half a

minute. The act of swallowing did not appear to cause distress, for he

could go through the motions of deglutition without any trouble. The

approach of liquid toward the mouth would, however, cause distress." It

is to be remarked that the spasm affects the mechanism of the

respiratory apparatus, the muscles of mastication and deglutition being

only secondarily contracted.

Pasteur discovered that the virulence of the virus of rabies could be

attenuated in passing it through different species of animals, and also

that inoculation of this attenuated virus had a decided prophylactic

effect on the disease; hence, by cutting the spinal cord of inoculated

animals into fragments a few centimeters long, and drying them, an

emulsion could be made containing the virus. The patients are first

inoculated with a cord fourteen days old, and the inoculation is

repeated for nine days, each time with a cord one day fresher. The

intensive method consists in omitting the weakest cords and giving the

inoculations at shorter intervals. As a curious coincidence, Pliny and

Pasteur, the ancient and modern, both discuss the particular virulence

of saliva during fasting.

There is much discussion over the extent of injury a shark-bite can

produce. In fact some persons deny the reliability of any of the

so-called cases of shark-bites. Ensor reports an interesting case

occurring at Port Elizabeth, South Africa. While bathing, an expert

swimmer felt a sharp pain in the thigh, and before he could cry out,

felt a horrid crunch and was dragged below the surface of the water. He

struggled for a minute, was twisted about, shaken, and then set free,

and by a supreme effort, reached the landing stairs of the jetty,

where, to his surprise, he found that a monstrous shark had bitten his

leg off. The leg had been seized obliquely, and the teeth had gone

across the joints, wounding the condyles of the femur. There were three

marks on the left side showing where the fish had first caught him. The

amputation was completed at once, and the man recovered. Macgrigor

reports the case of a man at a fishery, near Manaar, who was bitten by

a shark. The upper jaw of the animal was fixed in the left side of the

belly, forming a semicircular wound of which a point one inch to the

left of the umbilicus was the upper boundary, and the lower part of the

upper third of the thigh, the lower boundary. The abdominal and lumbar

muscles were divided and turned up, exposing the colon in its passage

across the belly. Several convolutions of the small intestines were

also laid bare, as were also the three lowest ribs. The gluteal muscles

were lacerated and torn, the tendons about the trochanter divided,

laying the bone bare, and the vastus externus and part of the rectus of

the thigh were cut across. The wound was 19 inches in length and four

or five inches in breadth. When Dr. Kennedy first saw the patient he

had been carried in a boat and then in a palanquin for over five miles,

and at this time, three hours after the reception of the wound, Kennedy

freed the abdominal cavity of salt water and blood, thoroughly cleansed

the wound of the hair and the clots, and closed it with adhesive

strips. By the sixteenth day the abdominal wound had perfectly closed,

the lacerations granulated healthily, and the man did well. Boyle

reports recovery from extensive lacerated wounds from the bite of a

shark. Both arms were amputated as a consequence of the injuries.

Fayrer mentions shark-bites in the Hooghley.

Leprosy from a Fish-bite.--Ashmead records the curious case of a man

that had lived many years in a leprous country, and while dressing a

fish had received a wound of the thumb from the fin of the fish.

Swelling of the arm followed, and soon after bullae upon the chest,

head, and face. In a few months the blotches left from this eruption

became leprous tubercles, and other well-marked signs of the malady

followed. The author asked if in this case we have to do with a latent

leprosy which was evoked by the wound, or if it were a case of

inoculation from the fish?

Cutliffe records recovery after amputation at the elbow-joint, as a

consequence of an alligator-bite nine days before admission to the

hospital. The patient exhibited a compound comminuted fracture of the

right radius and ulna in their lower thirds, compound comminuted

fractures of the bones of the carpus and metacarpus, with great

laceration of the soft parts, laying bare the wrist-joint, besides

several penetrating wounds of the arm and fore-arm. Mourray gives some

notes on a case of crocodile-bite with removal of a large portion of

omentum. Sircar speaks of recovery from a crocodile-bite. Dudgeon

reports two cases of animal-bites, both fatal, one by a bear, and the

other by a camel. There is mention of a compound dislocation of the

wrist-joint from a horse-bite. Fayrer speaks of a wolf-bite of the

forearm, followed by necrosis and hemorrhage, necessitating ligature of

the brachial artery and subsequent excision of the elbow-joint.

Injuries from Lightning.--The subject of lightning-stroke, with its

diverse range of injuries, is of considerable interest, and, though not

uncommon, the matter is surrounded by a veil of superstition and

mystery. It is well known that instantaneous or temporary

unconsciousness may result from lightning-stroke. Sometimes

superficial or deep burns may be the sole result, and again paralysis

of the general nerves, such as those of sensation and motion, may be

occasioned. For many years the therapeutic effect of a lightning-stroke

has been believed to be a possibility, and numerous instances are on

record. The object of this article will be to record a sufficient

number of cases of lightning-stroke to enable the reader to judge of

its various effects, and form his own opinion of the good or evil of

the injury. It must be mentioned here that half a century ago Le Conte

wrote a most extensive article on this subject, which, to the present

time, has hardly been improved upon.

The first cases to be recorded are those in which there has been

complete and rapid recovery from lightning-stroke. Crawford mentions a

woman who, while sitting in front of her fireplace on the first floor

of a two-story frame building, heard a crash about her, and realized

that the house had been struck by lightning. The lightning had torn all

the weather-boarding off the house, and had also followed a spouting

which terminated in a wooden trough in a pig-sty, ten feet back of the

house, and killed a pig. Another branch of the fluid passed through the

inside of the building and, running along the upper floor to directly

over where Mrs. F. was sitting, passed through the floor and descended

upon the top of her left shoulder. Her left arm was lying across her

abdomen at the time, the points of the fingers resting on the crests of

the ilium. There was a rent in the dress at the top of the shoulder,

and a red line half an inch wide running from thence along the inside

of the arm and fore-arm. In some places there was complete vesication,

and on its palmer surface the hand lying on the abdomen was completely

denuded. The abdomen, for a space of four inches in length and eight

inches in breadth, was also blistered. The fluid then passed from the

fingers to the crest of the ilium, and down the outside of the leg,

bursting open the shoes, and passing then through the floor. Again a

red line half an inch wide could be traced from the ilium to the toes.

The clothing was not scorched, but only slightly rent at the point of

the shoulder and where the fingers rested. This woman was neither

knocked off her chair nor stunned, and she felt no shock at the time.

After ordinary treatment for her burns she made rapid and complete

recovery.

Halton reports the history of a case of a woman of sixty-five who,

about thirty-five minutes before he saw her, had been struck by

lightning. While she was sitting in an outbuilding a stroke of

lightning struck and shattered a tree about a foot distant. Then,

leaving the tree about seven feet from the ground, it penetrated the

wall of the building, which was of unplastered frame, and struck Mrs.

P. on the back of the head, at a point where her hair was done up in a

knot and fastened by two ordinary hair-pins. The hair was much

scorched, and under the knot the skin of the scalp was severely burned.

The fluid crossed, burning her right ear, in which was a gold ear-ring,

and then passed over her throat and down the left sternum, leaving a

burn three inches wide, covered by a blister. There was another burn,

12 inches long and three inches wide, passing from just above the crest

of the ilium forward and downward to the symphysis pubis. The next burn

began at the patella of the right knee, extending to the bottom of the

heel, upon reaching which it wound around the inner side of the leg.

About four inches below the knee a sound strip of cuticle, about 1 1/2

Date: 2014-12-29; view: 1029