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

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