MISCELLANEOUS SURGICAL ANOMALIES. 4 page inches, was left intact. The lightning passed off the heel of the foot,
bursting open the heel of a strongly sewed gaiter-boot. The woman was
rendered unconscious but subsequently recovered.
A remarkable feature of a lightning-stroke is the fact that it very
often strips the affected part of its raiment, as in the previous case
in which the shoe was burst open. In a discussion before the Clinical
Society of London, October 24 1879, there were several instances
mentioned in which clothes had been stripped off by lightning. In one
case mentioned by Sir James Paget, the clothes were wet and the man's
skin was reeking with perspiration. In its course the lightning
traveled down the clothes, tearing them posteriorly, and completely
stripping the patient. The boots were split up behind and the laces
torn out. This patient, however, made a good recovery. Beatson
mentions an instance in which an explosion of a shell completely tore
off the left leg of a sergeant instructor, midway between the knee and
ankle. It was found that the foot and lower third of the leg had been
completely denuded of a boot and woolen stocking, without any apparent
abrasion or injury to the skin. The stocking was found in the battery
and the boot struck a person some distance off. The stocking was much
torn, and the boot had the heel missing, and in one part the sole was
separated from the upper. The laces in the upper holes were broken but
were still present in the lower holes. The explanation offered in this
case is similar to that in analogous cases of lightning-stroke, that
is, that the gas generated by the explosion found its way between the
limb and the stocking and boot and stripped them off.
There is a curious collection of relics, consisting of the clothes of a
man struck by lightning, artistically hung in a glass case in the
Museum of the Royal College of Surgeons, London, and the history of the
injury, of which these remnants are the result, is given by Professor
Stewart, the curator, as follows: At half past four on June 8, 1878,
James Orman and others were at work near Snave, in Romney Marsh, about
eight miles from Ashford. The men were engaged in lopping willows, when
the violence of the rain compelled them to take refuge under a hedge.
Three of the men entered a shed near by, but Orman remained by the
willow, close to the window of the shed. Scarcely were the three inside
when a lightning-stroke entered the door, crossed the shed, and passed
out the window, which it blew before it into the field. The men noticed
that the tree under which Orman stood was stripped of its bark. Their
companion's boots stood close to the foot of the tree, while the man
himself lay almost perfectly naked a few yards further on, calling for
help. When they left him a few moments previously, he was completely
clad in a cotton shirt, cotton jacket, flannel vest, and cotton
trousers, secured at the waist with leather straps and buckles. Orman
also wore a pair of stout hobnail boots, and had a watch and chain.
After the lightning-stroke, however, all he had on him was the left arm
of his flannel vest. The field was strewn for some distance with
fragments of the unfortunate man's clothing. Orman was thrown down,
his eyebrows burned off, and his whiskers and beard much scorched. His
chest was covered with superficial burns, and he had sustained a
fracture of the leg. His strong boots were torn from his feet, and his
watch had a hole burned right through it, as if a soldering iron had
been used. The watch-chain was almost completely destroyed, only a few
links remaining. Together with some fused coins, these were found close
by, and are deposited in a closed box in the Museum. According to
Orman's account of the affair, he first felt a violent blow on the
chest and shoulders, and then he was involved in a blinding light and
hurled into the air. He said he never lost consciousness; but when at
the hospital he seemed very deaf and stupid. He was discharged
perfectly cured twenty weeks after the occurrence. The scientific
explanation of this amazing escape from this most eccentric vagary of
the electric fluid is given,--the fact that the wet condition of the
man's clothing increased its power of conduction, and in this way saved
his life. It is said that the electric current passed down the side of
Orman's body, causing everywhere a sudden production of steam, which by
its expansion tore the clothing off and hurled it away. It is a
curious fact that where the flannel covered the man's skin the burns
were merely superficial, whereas in those parts touched by the cotton
trousers they were very much deeper. This case is also quoted and
described by Dr. Wilks.
There was a curious case of lightning-stroke reported at Cole Harbor,
Halifax. A diver, while at work far under the surface of the water, was
seriously injured by the transmission of a lightning-stroke, which
first struck the communicating air pump to which the diver was
attached. The man was brought to the surface insensible, but he
afterward recovered.
Permanent Effect of Lightning on the Nervous System.--MacDonald
mentions a woman of seventy-eight who, some forty-two years previous,
while ironing a cap with an Italian iron, was stunned by an extremely
vivid flash of lightning and fell back unconscious into a chair. On
regaining consciousness she found that the cap which she had left on
the table, remote from the iron, was reduced to cinders. Her clothes
were not burned nor were there any marks on the skin. After the stroke
she felt a creeping sensation and numbness, particularly in the arm
which was next to the table. She stated positively that in consequence
of this feeling she could predict with the greatest certainty when the
atmosphere was highly charged with electricity, as the numbness
increased on these occasions. The woman averred that shortly before or
during a thunder storm she always became nauseated. MacDonald offers as
a physiologic explanation of this case that probably the impression
produced forty-two years before implicated the right brachial plexus
and the afferent branches of the pneumogastric, and to some degree the
vomiting center in the medulla; hence, when the atmosphere was highly
charged with electricity the structures affected became more readily
impressed. Camby relates the case of a neuropathic woman of
thirty-eight, two of whose children were killed by lightning in her
presence. She herself was unconscious for four days, and when she
recovered consciousness, she was found to be hemiplegic and
hemianesthetic on the left side. She fully recovered in three weeks.
Two years later, during a thunder storm, when there was no evidence of
a lightning-stroke, she had a second attack, and three years later a
third attack under similar circumstances.
There are some ocular injuries from lightning on record. In these cases
the lesions have consisted of detachment of the retina, optic atrophy,
cataract, hemorrhages into the retina, and rupture of the choroid,
paralysis of the oculomotor muscles, and paralysis of the optic nerve.
According to Buller of Montreal, such injuries may arise from the
mechanic violence sustained by the patient rather than by the thermal
or chemic action of the current. Buller describes a case of
lightning-stroke in which the external ocular muscles, the crystalline
lens, and the optic nerve were involved. Godfrey reports the case of
Daniel Brown, a seaman on H.M.S. Cambrian. While at sea on February 21,
1799, he was struck both dumb and blind by a lightning-stroke. There
was evidently paralysis of the optic nerve and of the oculomotor
muscles; and the muscles of the glottis were also in some manner
deprived of motion.
That an amputation can be perfectly performed by a lightning-stroke is
exemplified in the case of Sycyanko of Cracow, Poland. The patient was
a boy of twelve, whose right knee was ankylosed. While riding in a
field in a violent storm, a loud peal of thunder caused the horse to
run away, and the child fell stunned to the ground. On coming to his
senses the boy found that his right leg was missing, the parts having
been divided at the upper end of the tibia. The wound was perfectly
round and the patella and femur were intact. There were other signs of
burns about the body, but the boy recovered. Some days after the injury
the missing leg was found near the place where he was first thrown from
the horse.
The therapeutic effect of lightning-stroke is verified by a number of
cases, a few of which will be given. Tilesius mentions a peculiar case
which was extensively quoted in London. Two brothers, one of whom was
deaf, were struck by lightning. It was found that the inner part of the
right ear near the tragus and anti-helix of one of the individuals was
scratched, and on the following day his hearing returned. Olmstead
quotes the history of a man in Carteret County, N.C., who was seized
with a paralytic affection of the face and eyes, and was quite unable
to close his lids. While in his bedroom, he was struck senseless by
lightning, and did not recover until the next day, when it was found
that the paralysis had disappeared, and during the fourteen years which
he afterward lived his affection never returned. There is a record of
a young collier in the north of England who lost his sight by an
explosion of gunpowder, utterly destroying the right eye and fracturing
the frontal bone. The vision of the left eye was lost without any
serious damage to the organ, and this was attributed to shock. On
returning from Ettingshall in a severe thunder storm, he remarked to
his brother that he had seen light through his spectacles, and had
immediately afterward experienced a piercing sensation which had passed
through the eye to the back of the head. The pain was brief, and he was
then able to see objects distinctly. From this occasion he steadily
improved until he was able to walk about without a guide.
Le Conte mentions the case of a negress who was struck by lightning
August 19, 1842, on a plantation in Georgia. For years before the
reception of the shock her health had been very bad, and she seemed to
be suffering from a progressive emaciation and feebleness akin to
chlorosis. The difficulty had probably followed a protracted
amenorrhea, subsequent to labor and a retained placenta In the course
of a week she had recovered from the effects of lightning and soon
experienced complete restoration to health; and for two years had been
a remarkably healthy and vigorous laborer. Le Conte quotes five similar
cases, and mentions one in which a lightning-shock to a woman of
twenty-nine produced amenorrhea, whereas she had previously suffered
from profuse menstruation, and also mentions another case of a woman of
seventy who was struck unconscious; the catamenial discharge which had
ceased twenty years before, was now permanently reestablished, and the
shrunken mammae again resumed their full contour.
A peculiar feature or superstition as to lightning-stroke is its
photographic properties. In this connection Stricker of Frankfort
quotes the case of Raspail of a man of twenty-two who, while climbing a
tree to a bird's nest, was struck by lightning, and afterward showed
upon his breast a picture of the tree, with the nest upon one of its
branches. Although in the majority of cases the photographs resembled
trees, there was one case in which it resembled a horse-shoe; another,
a cow; a third, a piece of furniture; a fourth, the whole surrounding
landscape. This theory of lightning-photographs of neighboring objects
on the skin has probably arisen from the resemblance of the burns due
to the ramifications of the blood-vessels as conductors, or to peculiar
electric movements which can be demonstrated by positive charges on
lycopodium powder.
A lightning-stroke does not exhaust its force on a few individuals or
objects, but sometimes produces serious manifestations over a large
area, or on a great number of people. It is said that a church in the
village of Chateauneuf, in the Department of the Lower Alps, in France,
was struck by three successive lightning strokes on July 11, 1819,
during the installation of a new pastor. The company were all thrown
down, nine were killed and 82 wounded. The priest, who was celebrating
mass, was not affected, it is believed, on account of his silken robe
acting as an insulator. Bryant of Charlestown, Mass., has communicated
the particulars of a stroke of lightning on June 20, 1829, which
shocked several hundred persons. The effect of this discharge was felt
over an area of 172,500 square feet with nearly the same degree of
intensity. Happily, there was no permanent injury recorded. Le Conte
reports that a person may be killed when some distance--even as far as
20 miles away from the storm--by what Lord Mahon calls the "returning
stroke."
Skin-grafting is a subject which has long been more or less familiar to
medical men, but which has only recently been developed to a
practically successful operation. The older surgeons knew that it was
possible to reunite a resected nose or an amputated finger, and in
Hunter's time tooth-replantation was quite well known. Smellie has
recorded an instance in which, after avulsion of a nipple in suckling,
restitution was effected. It is not alone to the skin that grafting is
applicable; it is used in the cornea, nerves, muscles, bones, tendons,
and teeth. Wolfer has been successful in transplanting the mucous
membranes of frogs, rabbits, and pigeons to a portion of mucous
membrane previously occupied by cicatricial tissue, and was the first
to show that on mucous surfaces, mucous membrane remains mucous
membrane, but when transplanted to skin, it becomes skin. Attempts
have been made to transplant a button of clear cornea of a dog, rabbit,
or cat to the cornea of a human being, opaque as the result of
ophthalmia, and von Hippel has devised a special method of doing this.
Recently Fuchs has reported his experience in cornea-grafting in
sections, as a substitute for von Hippel's method, in parenchymatous
keratitis and corneal staphyloma, and though not eminently successful
himself, he considers the operation worthy of trial in cases that are
without help, and doomed to blindness.
John Hunter was the first to perform the implantation of teeth; and
Younger the first to transplant the teeth of man in the jaws of man;
the initial operation should be called replantation, as it was merely
the replacement of a tooth in a socket from which it had accidentally
or intentionally been removed. Hunter drilled a hole in a cock's comb
and inserted a tooth, and held it by a ligature. Younger drilled a hole
in a man's jaw and implanted a tooth, and proved that it was not
necessary to use a fresh tooth. Ottolengni mentions the case of a man
who was struck by a ruffian and had his two central incisors knocked
out. He searched for them, washed them in warm water, carefully washed
the teeth-sockets, and gently placed the teeth back in their position,
where they remained firmly attached. At the time of report, six years
after the accident, they were still firmly in position. Pettyjohn
reports a successful case of tooth-replantation in his young daughter
of two, who fell on the cellar stairs, completely excising the central
incisors. The alveolar process of the right jaw was fractured, and the
gum lacerated to the entire length of the root. The teeth were placed
in a tepid normal saline solution, and the child chloroformed, narcosis
being induced in sleep; the gums were cleaned antiseptically, and 3 1/2
hours afterward the child had the teeth firmly in place. They had been
out of the mouth fully an hour. Four weeks afterward they were as firm
as ever. By their experiments Gluck and Magnus prove that there is a
return of activity after transplantation of muscle. After excision of
malignant tumors of muscles, Helferich of Munich, and Lange of New
York, have filled the gap left by the excision of the muscle affected
by the tumor with transplanted muscles from dogs. Gluck has induced
reproduction of lost tendons by grafting them with cat-gut, and
according to Ashhurst, Peyrot has filled the gaps in retracted tendons
by transplanting tendons, taken in one case from a dog, and in another
from a cat.
Nerve-grafting, as a supplementary operation to neurectomy, has been
practiced, and Gersung has transplanted the nerves of lower animals to
the nerve stumps of man.
Bone-grafting is quite frequently practiced, portions from a recently
amputated limb, or portions removed from living animals, or bone-chips,
may be used. Senn proposed decalcified bone-plates to be used to fill
in the gaps. Shifting of the bone has been done, e.g., by dividing a
strip of the hard palate covered with its soft parts, parallel to the
fissure in cleft palate, but leaving unsevered the bony attachments in
front, and partially fracturing the pedicle, drawing the bony flaps
together with sutures; or, when forming a new nose, by turning down
with the skin and periosteum the outer table of the frontal bone, split
off with a chisel, after cutting around the part to be removed.
Trueheart reports a case of partial excision of the clavicle,
successfully followed by the grafting of periosteal and osseous
material taken from a dog. Robson and Hayes of Rochester, N.Y., have
successfully supplemented excision of spina bifida by the
transplantation of a strip of periosteum from a rabbit. Poncet hastened
a cure in a case of necrosis with partial destruction of the periosteum
by inserting grafts taken from the bones of a dead infant and from a
kid. Ricketts speaks of bone-grafting and the use of ivory, and remarks
that Poncet of Lyons restored a tibia in nine months by grafting to the
superior articular surface. Recently amalgam fillings have been used
in bone-cavities to supplant grafting.
In destructive injuries of the skin, various materials were formerly
used in grafting, none of which, however, have produced the same good
effect as the use of skin by the Thiersch Method, which will be
described later.
Rodgers, U.S.N., reports the case of a white man of thirty-eight who
suffered from gangrene of the skin of the buttocks caused by sitting in
a pan of caustic potash. When seen the man was intoxicated, and there
was a gangrenous patch four by six inches on his buttocks. Rodgers used
grafts from the under wing of a young fowl, as suggested by Redard,
with good result. Vanmeter of Colorado describes a boy of fourteen with
a severe extensive burn; a portion beneath the chin and lower jaw, and
the right arm from the elbow to the fingers, formed a granulating
surface which would not heal, and grafting was resorted to. The
neck-grafts were supplied by the skin of the father and brother, but
the arm-grafts were taken from two young puppies of the Mexican
hairless breed, whose soft, white, hairless skin seemed to offer itself
for the purpose with good prospect of a successful result. The outcome
was all that could be desired. The puppy-grafts took faster and proved
themselves to be superior to the skin-grafts. There is a case reported
in which the skin of a greyhound seven days old, taken from the
abdominal wall and even from the tail, was used with most satisfactory
results in grafting an extensive ulcer following a burn on the left leg
of a boy of ten. Masterman has grafted with the inner membrane of a
hen's egg, and a Mexican surgeon, Altramirano, used the gills of a cock.
Fowler of Brooklyn has grafted with the skin from the back and abdomen
of a large frog. The patient was a colored boy of sixteen, who was
extensively burned by a kerosene lamp. The burns were on the legs,
thighs, buttocks, and right ankle, and the estimated area of burnt
surface was 247.95 square inches. The frog skin was transferred to the
left buttocks, and on the right buttocks eight long strips of white
skin were transferred after the manner of Thiersch. A strip of human
skin was placed in one section over the frog skin, but became necrotic
in four days, not being attached to the granulating surface. The man
was discharged cured in six months. The frog skin was soft, pliable,
and of a reddish hue, while the human white skin was firm and rapidly
becoming pigmented. Leale cites the successful use of common warts in a
case of grafting on a man of twenty who was burned on the foot by a
stream of molten metal. Leale remarks that as common warts of the skin
are collections of vascular papillae, admitting of separation without
injury to their exceptionally thick layer of epidermis, they are
probably better for the purposes of skin-grafting than ordinary skin of
less vitality or vascularity. Ricketts has succeeded in grafting the
skin of a frog to that of a tortoise, and also grafting frog skin to
human skin. Ricketts remarks that the prepuce of a boy is remarkably
good material for grafting. Sponge-grafts are often used to hasten
cicatrization of integumental wounds. There is recorded an instance in
which the breast of a crow and the back of a rat were grafted together
and grew fast. The crow dragged the rat along, and the two did not seem
to care to part company.
Relative to skin-grafting proper, Bartens succeeded in grafting the
skin of a dead man of seventy on a boy of fourteen. Symonds reports
cases of skin-grafting of large flaps from amputated limbs, and says
this method is particularly available in large hospitals where they
have amputations and grafts on the same day. Martin has shown that,
after many hours of exposure in the open air at a temperature of nearly
32 degrees F., grafts could be successfully applied, but in such
temperatures as 82 degrees F., exposure of from six to seven hours
destroyed their vitality, so that if kept cool, the limb of a healthy
individual amputated for some accident, may be utilized for grafting
purposes.
Reverdin originated the procedure of epidermic grafting. Small grafts
the size of a pin-head doing quite as well as large ones.
Unfortunately but little diminution of the cicatricial contraction is
effected by Reverdin's method. Thiersch contends that healing of a
granulated surface results first from a conversion of the soft,
vascular granulation-papillae, by contraction of some of their elements
into young connective-tissue cells, into "dry, cicatricial papillae,"
actually approximating the surrounding tissues, thus diminishing the
area to be covered by epidermis; and, secondly, by the covering of
these papillae by epidermic cells. Thiersch therefore recommends that
for the prevention of cicatricial contraction, the grafting be
performed with large strips of skin.
Harte gives illustrations of a case of extensive skin-grafting on the
thigh from six inches above the great trochanter well over the median
line anteriorly and over the buttock. This extent is shown in Figure
228, taken five months after the accident, when the granulations had
grown over the edge about an inch. Figure 229 shows the surface of the
wound, six and one-half months after the accident and three months
after the applications of numerous skin-grafts.
Cases of self-mutilation may be divided into three classes:--those in
which the injuries are inflicted in a moment of temporary insanity from
hallucinations or melancholia; with suicidal intent; and in religious
frenzy or emotion. Self-mutilation is seen in the lower animals, and
Kennedy, in mentioning the case of a hydrocephalic child who ate off
its entire under lip, speaks also of a dog, of cats, and of a lioness
who ate off their tails. Kennedy mentions the habit in young children
of biting the finger-nails as an evidence of infantile trend toward
self-mutilation. In the same discussion Collins states that he knew of
an instance in India in which a horse lay down, deliberately exposing
his anus, and allowing the crows to pick and eat his whole rectum. In
temporary insanity, in fury, or in grief, the lower animals have been
noticed by naturalists to mutilate themselves.
Self-mutilation in man is almost invariably the result of meditation
over the generative function, and the great majority of cases of this
nature are avulsions or amputations of some parts of the genitalia. The
older records are full of such instances. Benivenius, Blanchard,
Knackstedt, and Schenck cite cases. Smetius mentions castration which
was effected by using the finger-nails, and there is an old record in
which a man avulsed his own genitals. Scott mentions an instance in
which a man amputated his genitals and recovered without subsequent
symptoms. Gockelius speaks of self-castration in a ruptured man, and
Golding, Guyon, Louis, Laugier, the Ephemerides, Alix, Marstral, and
others, record instances of self-castration. In his Essays Montaigne
mentions an instance of complete castration performed by the individual
himself.
Thiersch mentions a case of a man who circumcised himself when
eighteen. He married in 1870, and upon being told that he was a father
he slit up the hypogastrium from the symphysis pubis to the umbilicus,
so that the omentum protruded; he said his object was to obtain a view
of the interior. Although the knife was dirty and blunt, the wound
healed after the removal of the extruding omentum. A year later he laid
open one side of the scrotum. The prolapsed testicle was replaced, and
the wound healed without serious effect. He again laid open his abdomen
in 1880, the wound again healing notwithstanding the prolapse of the
omentum. In May of the same year he removed the right testicle, and
sewed the wound up himself. Four days later the left was treated the
same way. The spermatic cord however escaped, and a hematoma, the size
of a child's head, formed on account of which he had to go to the
hospital. This man acted under an uncontrollable impulse to mutilate
himself, and claimed that until he castrated himself he had no peace of
mind.
There is a similar report in an Italian journal which was quoted in
London. It described a student at law, of delicate complexion, who at
the age of fourteen gave himself up to masturbation. He continually
studied until the age of nineteen, when he fell into a state of
dulness, and complained that his head felt as if compressed by a circle
of fire. He said that a voice kept muttering to him that his generative
organs were abnormally deformed or the seat of disease. After that, he
imagined that he heard a cry of "amputation! amputation!" Driven by
this hallucination, he made his first attempt at self-mutilation ten
Date: 2014-12-29; view: 731
|