These acrobats with the sword have rendered important service to

medicine. It was through the good offices of a sword-swallower that the

Scotch physician, Stevens, was enabled to make his experiments on

digestion. He caused this assistant to swallow small metallic tubes

pierced with holes. They were filled, according to Reaumur's method,

with pieces of meat. After a certain length of time he would have the

acrobat disgorge the tubes, and in this way he observed to what degree

the process of digestion had taken place. It was also probably the

sword-swallower who showed the physicians to what extent the pharynx

could be habituated to contact, and from this resulted the invention of

the tube of Faucher, the esophageal sound, ravage of the stomach, and

illumination of this organ by electric light. Some of these individuals

also have the faculty of swallowing several pebbles, as large even as

hen's eggs, and of disgorging them one by one by simple contractions of

the stomach. From time to time individuals are seen who possess the

power of swallowing pebbles, knives, bits of broken glass, etc., and,

in fact, there have been recent tricky exhibitionists who claimed to be

able to swallow poisons, in large quantities, with impunity. Henrion,

called "Casaandra," a celebrated example of this class, was born at

Metz in 1761. Early in life he taught himself to swallow pebbles,

sometimes whole and sometimes after breaking them with his teeth. He

passed himself off as an American savage; he swallowed as many as 30 or

40 large pebbles a day, demonstrating the fact by percussion on the

epigastric region. With the aid of salts he would pass the pebbles and

make them do duty the next day. He would also swallow live mice and

crabs with their claws cut. It was said that when the mice were

introduced into his mouth, they threw themselves into the pharynx where

they were immediately suffocated and then swallowed. The next morning

they would be passed by the rectum flayed and covered with a mucous

substance. Henrion continued his calling until 1820, when, for a

moderate sum, he was induced to swallow some nails and a plated iron

spoon 5 1/2 inches long and one inch in breadth. He died seven days

later.

According to Bonet, there was a man by the name of Pichard who

swallowed a razor and two knives in the presence of King Charles II of

England, the King himself placing the articles into the man's mouth. In

1810 Babbington and Curry are accredited with citing the history of an

American sailor in Guy's Hospital, London, who frequently swallowed

penknives for the amusement of his audiences. At first he swallowed

four, and three days later passed them by the anus; on another occasion

he swallowed 14 of different sizes with the same result. Finally he

attempted to gorge himself with 17 penknives, but this performance was

followed by horrible pains and alarming abdominal symptoms. His

excrement was black from iron. After death the cadaver was opened and

14 corroded knives were found in the stomach, some of the handles being

partly digested; two were found in the pelvis and one in the abdominal

cavity. Pare recalls the instance of a shepherd who suffered

distressing symptoms after gulping a knife six inches long. Afterward

the knife was abstracted from his groin. Fabricius Hildanus cites a

somewhat similar case.

Early in the century there was a man known as the "Yankee

knife-swallower," whose name was John Cummings, an American sailor, who

had performed his feats in nearly all the ports of the world. One of

his chief performances was swallowing a billiard ball. Poland mentions

a man (possibly Cummings) who, in 1807, was admitted to Guy's Hospital

with dyspeptic symptoms which he attributed to knife-swallowing. His

story was discredited at first; but after his death, in March, 1809,

there were 30 or 40 fragments of knives found in his stomach. One of

the back-springs on a knife had transfixed the colon and rectum. In

the Edinburgh Philosophical Journal for 1825 there is an account of a

juggler who swallowed a knife which remained in his stomach and caused

such intense symptoms that gastrotomy was advised; the patient,

however, refused operation.

Drake reports a curious instance of polyphagia. The person described

was a man of twenty-seven who pursued the vocation of a

"sword-swallower." He had swallowed a gold watch and chain with a seal

and key attached; at another time he swallowed 34 bullets and voided

them by the anus. At Poughkeepsie, N.Y., in August, 1819, in one day

and night he swallowed 19 pocket-knives and 41 copper cents. This man

had commenced when a lad of fifteen by swallowing marbles, and soon

afterward a small penknife. After his death his esophagus was found

normal, but his stomach was so distended as to reach almost to the

spine of the ilium, and knives were found in the stomach weighing one

pound or more. In his exhibitions he allowed his spectators to hear the

click of the knives and feel them as low down as the anterior superior

spine of the ilium.

The present chief of the dangerous "profession" of sword-swallowing is

Chevalier Cliquot, a French Canadian by birth, whose major trick is to

swallow a real bayonet sword, weighted with a cross-bar and two

18-pound dumbbells. He can swallow without difficulty a 22-inch cavalry

sword; formerly, in New York, he gave exhibitions of swallowing

fourteen 19-inch bayonet swords at once. A negro, by the name of Jones,

exhibiting not long since in Philadelphia, gave hourly exhibitions of

his ability to swallow with impunity pieces of broken glass and china.

Foreign Bodies in the Alimentary Canal.--In the discussion of the

foreign bodies that have been taken into the stomach and intestinal

tract possibly the most interesting cases, although the least

authentic, are those relating to living animals, such as fish, insects,

or reptiles. It is particularly among the older writers that we find

accounts of this nature. In the Ephemerides we read of a man who

vomited a serpent that had crept into his mouth, and of another person

who ejected a beetle that had gained entrance in a similar manner. From

the same authority we find instances of the vomiting of live fish,

mice, toads, and also of the passage by the anus of live snails and

snakes. Frogs vomited are mentioned by Bartholinus, Dolaeus,

Hellwigius, Lentilus, Salmuth, and others. Vege mentions a man who

swallowed a young chicken whole. Paullini speaks of a person who, after

great pain, vomited a mouse which he had swallowed. Borellus,

Bartholinus, Thoner, and Viridet, are among the older authorities

mentioning persons who swallowed toads. Hippocrates speaks of asphyxia

from a serpent which had crawled into the mouth.

Borellus states that he knew a case of a person who vomited a

salamander. Plater reports the swallowing of eels and snails. Rhodius

mentions persons who have eaten scorpions and spiders with impunity.

Planchon writes of an instance in which a live spider was ejected from

the bowel; and Colini reports the passage of a live lizard which had

been swallowed two days before, and there is another similar case on

record. Marcellus Donatus records an instance in which a viper, which

had previously crawled into the mouth, had been passed by the anus.

There are also recorded instances in French literature in which persons

affected with pediculosis, have, during sleep, unconsciously swallowed

lice which were afterward found in the stools.

There is an abundance of cases in which leeches have been accidentally

swallowed. Pliny, Aetius, Dioscorides, Scribonius-Largus, Celsus,

Oribasius, Paulus Aegineta, and others, describe such cases.

Bartholinus speaks of a Neapolitan prince who, while hunting, quenched

his thirst in a brook, putting his mouth in the running water. In this

way he swallowed a leech, which subsequently caused annoying hemorrhage

from the mouth. Timaeus mentions a child of five who swallowed several

leeches, and who died of abdominal pains, hemorrhage, and convulsions.

Rhodius, Riverius, and Zwinger make similar observations. According to

Baron Larrey the French soldiers in Napoleon's Egyptian campaign

occasionally swallowed leeches. Grandchamp and Duval have commented on

curious observations of leeches in the digestive tract. Dumas and

Marques also speak of the swallowing of leeches. Colter reports a case

in which beetles were vomited. Wright remarks on Banon's case of

fresh-water shrimps passed from the human intestine. Dalton, Dickman,

and others, have discussed the possibility of a slug living in the

stomach of man. Pichells speaks of a case in which beetles were

expelled from the stomach; and Pigault gives an account of a living

lizard expelled by vomiting. Fontaine, Gaspard, Vetillart, Ribert,

MacAlister, and Waters record cases in which living caterpillars have

been swallowed.

Sundry Cases.--The variety of foreign bodies that have been swallowed

either accidentally or for exhibitional or suicidal purposes is

enormous. Nearly every imaginable article from the minutest to the most

incredible size has been reported. To begin to epitomize the literature

on this subject would in itself consume a volume, and only a few

instances can be given here, chosen in such a way as to show the

variety, the effects, and the possibilities of their passage through

the intestinal canal.

Chopart says that in 1774 the belly of a ravenous galley-slave was

opened, and in the stomach were found 52 foreign bodies, including a

barrel-hoop 19 inches long, nails, pieces of pipe, spoons, buckles,

seeds, glass, and a knife. In the intestines of a person Agnew found a

pair of suspenders, a mass of straw, and three roller-bandages, an inch

in width and diameter. Velpeau mentions a fork which was passed from

the anus twenty months after it was swallowed. Wilson mentions an

instance of gastrotomy which was performed for the extraction of a fork

swallowed sixteen years before. There is an interesting case in which,

in a delirium of typhoid fever, a girl of twenty-two swallowed two iron

forks, which were subsequently expelled through an abdominal abscess. A

French woman of thirty-five, with suicidal intent, swallowed a

four-pronged fork, which was removed four years afterward from the

thigh. For two years she had suffered intense pain in both thighs. In

the Royal College of Surgeons in London there is a steel button-hook 3

1/2 inches in length which was accidentally swallowed, and was passed

three weeks later by the anus, without having given rise to any symptom.

Among the insane a favorite trait seems to be swallowing nails. In the

Philosophical Transactions is an account of the contents of the stomach

of an idiot who died at thirty-three. In this organ were found nine

cart-wheel nails, six screws, two pairs of compasses, a key, an iron

pin, a ring, a brass pommel weighing nine ounces, and many other

articles. The celebrated Dr. Lettsom, in 1802, spoke of an idiot who

swallowed four pounds of old nails and a pair of compasses. A lunatic

in England e swallowed ten ounces of screws and bits of crockery, all

of which were passed by the anus. Boardman gives an account of a child

affected with hernia who swallowed a nail 2 1/2 inches long. In a few

days the nail was felt in the hernia, but in due time it was passed by

the rectum. Blower reports an account of a nail passing safely through

the alimentary canal of a baby. Armstrong mentions an insane

hair-dresser of twenty-three, in whose stomach after death were found

30 or more spoon handles, 30 nails, and other minor articles.

Closmadenc reported a remarkable case which was extensively quoted. The

patient was an hysteric young girl, an inmate of a convent, to whom he

was called to relieve a supposed fit of epilepsy. He found her

half-asphyxiated, and believed that she had swallowed a foreign body.

He was told that under the influence of exaggerated religious scruples

this girl inflicted penance upon herself by swallowing earth and holy

medals. At the first dose of the emetic, the patient made a strong

effort to vomit, whereupon a cross seven cm. long appeared between her

teeth. This was taken out of her mouth, and with it an enormous rosary

220 cm. long, and having seven medals attached to it. Hunt recites a

case occurring in a pointer dog, which swallowed its collar and chain,

only imperfectly masticating the collar. The chain and collar were

immediately missed and search made for them. For several days the dog

was ill and refused food. Finally the gamekeeper saw the end of the

chain hanging from the dog's anus, and taking hold of it, he drew out a

yard of chain with links one inch long, with a cross bar at the end two

inches in length; the dog soon recovered. The collar was never found,

and had apparently been digested or previously passed.

Fear of robbery has often led to the swallowing of money or jewelry.

Vaillant, the celebrated doctor and antiquarian, after a captivity of

four months in Algiers, was pursued by Tunis pirates, and swallowed 15

medals of gold; shortly after arriving at Lyons he passed them all at

stool. Fournier and Duret published the history of a galley slave at

Brest in whose stomach were found 52 pieces of money, their combined

weight being one pound, 10 1/4 ounces. On receiving a sentence of three

years' imprisonment, an Englishman, to prevent them being taken from

him, swallowed seven half-crowns. He suffered no bad effects, and the

coins not appearing the affair was forgotten. While at stool some

twenty months afterward, having taken a purgative for intense abdominal

pain, the seven coins fell clattering into the chamber. Hevin mentions

the case of a man who, on being captured by Barbary pirates, swallowed

all the money he had on his person. It is said that a certain Italian

swallowed 100 louis d'ors at a time.

It occasionally happens that false teeth are accidentally swallowed,

and even passed through the intestinal tract. Easton mentions a young

man who accidentally swallowed some artificial teeth the previous

night, and, to further their passage through the bowel, he took a dose

of castor oil. When seen he was suffering with pain in the stomach, and

was advised to eat much heavy food and avoid aperients. The following

day after several free movements he felt a sharp pain in the lower part

of his back. A large enema was given and the teeth and plate came away.

The teeth were cleansed and put back in his mouth, and the patient

walked out. Nine years later the same accident again happened to the

man but in spite of treatment nothing was seen of the teeth for a month

afterward, when a body appeared in the rectum which proved to be a gold

plate with the teeth in it. In The Lancet of December 10, 1881, there

is an account of a vulcanite tooth-plate which was swallowed and passed

forty-two hours later. Billroth mentions an instance of gastrotomy for

the removal of swallowed artificial teeth, with recovery; and another

case in which a successful esophagotomy was performed. Gardiner

mentions a woman of thirty-three who swallowed two false teeth while

supping soup. A sharp angle of the broken plate had caught in a fold of

the cardiac end of the stomach and had caused violent hematemesis.

Death occurred seventeen hours after the first urgent symptoms.

In the Museum of the Royal College of Surgeons in London there is an

intestinal concretion weighing 470 grains, which was passed by a woman

of seventy who had suffered from constipation for many years. Sixteen

years before the concretion was passed she was known to have swallowed

a tooth. At one side of the concretion a piece had been broken off

exposing an incisor tooth which represented the nucleus of the

formation. Manasse recently reported the case of a man of forty-four

whose stomach contained a stone weighing 75 grams. He was a joiner and,

it was supposed, habitually drank some alcoholic solution of shellac

used in his trade. Quite likely the shellac had been precipitated in

the stomach and gave rise to the calculus.

Berwick mentions a child of eight months who was playing with a

detached organ-handle, and put it in its mouth. Seeing this the mother

attempted to secure the handle, but it was pushed into the esophagus. A

physician was called, but nothing was done, and the patient seemed to

suffer little inconvenience. Three days later the handle was expelled

from the anus. Teakle reports the successful passage through the

alimentary canal of the handle of a music-box. Hashimoto,

Surgeon-General of the Imperial Japanese Army, tells of a woman of

forty-nine who was in the habit of inducing vomiting by irritating her

fauces and pharynx with a Japanese toothbrush--a wooden instrument six

or seven inches long with bristles at one end. In May, 1872, she

accidentally swallowed this brush. Many minor symptoms developed, and

in eleven months there appeared in the epigastric region a fluctuating

swelling, which finally burst, and from it extended the end of the

brush. After vainly attempting to extract the brush the attending

physician contented himself with cutting off the projecting portion.

The opening subsequently healed; and not until thirteen years later did

the pain and swelling return. On admission to the hospital in October,

1888, two fistulous openings were seen in the epigastric region, and

the foreign body was located by probing. Finally, on November 19, 1888,

the patient was anesthetized, one of the openings enlarged, and the

brush extracted. Five weeks later the openings had all healed and the

patient was restored to health.

Garcia reports an interesting instance of foreign body in a man between

forty-five and fifty. This man was afflicted with a syphilitic

affection of the mouth, and he constructed a swab ten inches long with

which to cleanse his fauces. While making the application alone one

day, a spasmodic movement caused him to relinquish his grasp on the

handle, and the swab disappeared. He was almost suffocated, and a

physician was summoned; but before his arrival the swab had descended

into the esophagus. Two weeks later, gastro-peritoneal symptoms

presented, and as the stick was located, gastrotomy was proposed; the

patient, however, would not consent to an operation. On the

twenty-sixth day an abscess formed on the left side below the nipple,

and from it was discharged a large quantity of pus and blood. Four days

after this, believing himself to be better, the man began to redress

the wound, and from it he saw the end of a stick protruding. A

physician was called, and by traction the stick was withdrawn from

between the 3d and 4th ribs; forty-nine days after the accident the

wound had healed completely. Two years afterward the patient had an

attack of cholera, but in the fifteen subsequent years he lived an

active life of labor.

Occasionally an enormous mass of hair has been removed from the

stomach. A girl of twenty a with a large abdominal swelling was

admitted to a hospital. Her illness began five years previously, with

frequent attacks of vomiting, and on three occasions it was noticed

that she became quite bald. Abdominal section was performed, the

stomach opened, and from it was removed a mass of hair which weighed

five pounds and three ounces. A good recovery ensued. In the Museum of

St. George's Hospital, London, are masses of hair and string taken from

the stomach and duodenum of a girl of ten. It is said that from the age

of three the patient had been in the habit of eating these articles.

There is a record in the last century of a boy of sixteen who ate all

the hair he could find; after death his stomach and intestines were

almost completely lined with hairy masses. In the Journal of the

American Medical Association, March 1, 1896, there is a report of a

case of hair-swallowing.

Foreign Bodies in the Intestines.--White relates the history of a case

in which a silver spoon was swallowed and successfully excised from the

intestinal canal. Houston mentions a maniac who swallowed a rusty iron

spoon 11 inches long. Fatal peritonitis ensued and the spoon was found

impacted in the last acute turn of the duodenum. In 1895, in London,

there was exhibited a specimen, including the end of the ileum with the

adjacent end of the colon, showing a dessert spoon which was impacted

in the latter. The spoon was seven inches long, and its bowl measured

1 1/2 inches across. There was much ulceration of the mucous membrane.

This spoon had been swallowed by a lunatic of twenty-two, who had made

two previous ineffectual attempts at suicide. Mason describes the case

of a man of sixty-five who, after death by strangulated hernia, was

opened, and two inches from the ileocecal valve was found an earthen

egg-cup which he had swallowed. Mason also relates the instance of a

man who swallowed metal balls 2 1/2 inches in diameter; and the case of

a Frenchman who, to prevent the enemy from finding them, swallowed a

box containing despatches from Napoleon. He was kept prisoner until the

despatches were passed from his bowels. Denby discovered a large

egg-cup in the ileum of a man. Fillion mentions an instance of recovery

following the perforation of the jejunum by a piece of horn which had

been swallowed. Madden tells of a person, dying of intestinal

obstruction, in whose intestines were found several ounces of crude

mercury and a plum-stone. The mercury had evidently been taken for

purgative effect. Rodenbaugh mentions a most interesting case of beans

sprouting while in the bowel. Harrison relates a curious case in which

the swallowed lower epiphysis of the femur of a rabbit made its way

from the bowel to the bladder, and was discharged thence by the urethra.

In cases of appendicitis foreign bodies have been found lodged in or

about the vermiform appendix so often that it is quite a common lay

idea that appendicitis is invariably the result of the lodgment of some

foreign body accidentally swallowed. In recent years the literature of

this subject proves that a great variety of foreign bodies may be

present. A few of the interesting cases will be cited in the following

lines:--

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

similar objects have been found in both normal and suppurative

vermiform appendices.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

after this horrible injury.

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

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

reports the history of a wagoner with complete rupture of the

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

journey, not dying until eighteen hours after.

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

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

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

boy made a subsequent recovery. Koebererle of Strasburg performed an

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

obstruction. On account of numerous strictures it was found necessary

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

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

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

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

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

umbilical hernia.

Sloughing of the Intestine Following Intussusception.--Lobstein

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

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

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

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

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

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

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

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

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

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

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

fourteen years, forming an artificial anus.

Among others mentioning considerable sloughing of intestine following

intussusception, and usually with complete subsequent recovery, are

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

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

17 inches; and Grossoli, 40 cm.

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

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

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

which the colon was completely separated from the rectum by external

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

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

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

Operations upon the gastrointestinal tract have been so improved in the

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

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

deserves mention here.

Gastrostomy is an operation for establishing a fistulous opening in the

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

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

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

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

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

respectively, 207 and 162 cases with surprisingly different rates of

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

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

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

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

operation. Gastrotomy we have already spoken of.

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

designed to remove the mechanic obstruction in cicatricial stenoses of

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

Gastroenterostomy and pylorectomy are operations devised for the relief

of malignant disease of the pylorus, the diseased portions being

removed and the parts resected.

Gastrectomy or extirpation of the stomach is considered by most

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

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

gives an abstract of Langenbuch's contribution upon total extirpation

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

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

much contracted, presenting extensive carcinomatous infiltration on its

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

the pylorus and at the cardiac extremities; the portions removed

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

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

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

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

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

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

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

was confined with iodoform-gauze packing. Unfortunately the patient

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

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

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

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

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

inadmissible.

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

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

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

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

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

always retain its place in operative surgery as a palliative and

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

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

is not feasible.

Intestinal anastomosis, whereby two portions of a severed or resected

bowel can be intimately joined, excluding from fecal circulation the

portion of bowel which has become obstructed, was originally suggested

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

resorted to it, and Senn modified it by substituting decalcified

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

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

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

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

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

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

had more discussion in recent literature than the merits of this

ingenious contrivance.

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

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

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

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

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

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

symptoms followed; there was distressing vomiting, obstinate

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

arrangement of the bristles which allowed entrance, prevented removal.

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

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

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

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

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

foreign body was followed by the issue of stercoraceous matter which

had accumulated the six days it had remained in situ.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

broken and extracted piece by piece.

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

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

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

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

perforated his intestine. Studsgaard mentions that in the pathologic

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

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

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

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

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

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

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

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

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

straightening of the intestine without great twisting of the mesocolon.

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

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

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

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

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

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

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

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

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

soap; there was coincident strangulated hernia.

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

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

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

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

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

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

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

extremely rough by exposure, and this caused the difficulty in

extraction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

greasing the instruments. On investigation it was found that these

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

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

first, thus rendering expulsion almost impossible. Ogle gives an

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

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

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

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

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

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

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

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

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

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

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

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

was necessary to perform abdominal section through the linea alba,

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

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

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

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

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

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

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

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

into the possession of a large inheritance the murderess poisoned the

boy by introducing the ends of some phosphorous matches into his

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

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

her crime was known.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

there were apparently no injuries except perforation of the parietes

and the peritoneum. The man recovered promptly.

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

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

during a quarrel; extraction was impossible because of the

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

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

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

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

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

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

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

contained an ichorous discharge. The patient was bathing the wound

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

that the spear measured seven inches, and the interference of

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

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

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

column, without causing the slightest evidence of wounds of the

intestines or viscera. A minute postmortem examination was held some

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

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

the ramrod.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

inch.

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

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

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

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

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

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

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

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

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

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

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

whole weight of the woman was successfully maintained by the cellular

tissue of the uterovaginal culdesac.

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

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

man recovered.

Hamilton reports a case of laceration of the perineum with penetration

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

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

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

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

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

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

abdominal parietes with protrusion and injury to the intestine have not

been followed by death. Injuries to the intestines themselves have

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

worthy of record.

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

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

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

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

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

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

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

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

to the abdominal cavity. In this hernial protrusion were recognized

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

the ascending colon with corresponding portions of the mesentery; the

distribution of the superior mesentery, made more apparent by its

living pulsation, was more beautifully displayed in its succession of

arches than in any dissection that Doughty had ever witnessed.

Notwithstanding the extent of his injuries the patient recovered, and

at last reports was doing finely.

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

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

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

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

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

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

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

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

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

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

with, Barnes preferred returning the intestines without any attempt at

removing blood and dirt further than wiping with a cambric handkerchief

and the stripping they would naturally be subjected to in being

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

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

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

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

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

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

cartilage of a rib which had not reunited.

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

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

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

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

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

replaced, and the man recovered.

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

instances of abdominal wounds accompanied by extensive protrusion of

the intestines, and recovery. Shah mentions an abdominal wound with

protrusion of three feet of small intestine. By treatment with ice,

phenol, and opium, recovery was effected without peritonitis.

Among nonfatal perforating gunshot wounds of the abdomen, Loring:

reports the case of a private in the First Artillery who recovered

after a double gunshot perforation of the abdomen. One of the balls

entered 5 1/2 inches to the left of the umbilicus, and two inches above

the crest of the ilium, making its exit two inches above the crest of

the ilium, on a line with and two inches from the 4th lumbar vertebra.

The other ball entered four inches below and to the rear of the left

nipple, making its exit four inches directly below the point of

entrance. In their passages these balls did not wound any of the

viscera, and with the exception of traumatic fever there was no

disturbance of the health of the patient. Schell records the case of a

soldier who was wounded July 3, 1867, by a conoid ball from a Remington

revolver of the Army pattern. The ball entered on the left side of the

abdomen, its lower edge grazing the center of Poupart's ligament, and

passing backward, inward, and slightly upward, emerged one inch to the

left of the spinous process of the sacrum. On July 6th all the symptoms

of peritonitis made their appearance. On July 11th there was free

discharge of fecal matter from both anterior and posterior wounds. This

discharge continued for three days and then ceased. By August 12th both

wounds were entirely healed. Mineer reports a case of a wound from a

revolver-ball entering the abdomen, passing through the colon, and

extracted just above the right ilium. Under simple treatment the

patient recovered and was returned to duty about ten weeks afterward.

There are a number of cases on record in which a bullet entering the

abdominal cavity is subsequently voided either by the bladder or by the

bowel. Ducachet mentions two cases at the Georgetown Seminary Hospital

during the late war in which Minie balls entering the abdominal wall

were voided by the anus in a much battered condition. Bartlett reports

the case of a young man who was accidentally shot in the abdomen with a

Colt's revolver. Immediately after the accident he complained of

constant and pressing desire to void his urine. While urinating on the

evening of the third day, the ball escaped from the urethra and fell

with a click into the chamber. After the discharge of the ball the

intolerable symptoms improved, and in two or three weeks there was

complete recovery. Hoag mentions a man who was wounded by a round

musket-ball weighing 400 grains. It had evidently passed through the

lung and diaphragm and entered the alimentary canal; it was voided by

the rectum five days after the injury. Lenox mentions the fact of a

bullet entering the abdominal wall and subsequently being passed from

the rectum. Day and Judkins report similar cases. Rundle speaks of the

lodgment of a bullet, and its escape, after a period of seven and

one-half years, into the alimentary canal, causing internal

strangulation and death.

Wounds of the liver often end very happily, and there are many cases on

record in which such injuries have been followed by recovery, even when

associated with considerable loss of liver-substance. In the older

records, Glandorp and Scultetus mention cures after large wounds of the

liver. Fabricius Hildanus reports a case that ended happily, in which a

piece of liver was found in the wound, having been separated by a

sword-thrust. There is a remarkable example of recovery after multiple

visceral wounds, self-inflicted by a lunatic. This man had 18 wounds,

14 having penetrated the abdomen, the liver, colon, and the jejunum

being injured; by frequent bleeding, strict regimen, dressing, etc., he

recovered his health and senses, but relapsing a year and a half later,

he again attempted suicide, which gave the opportunity for a postmortem

to learn the extent of the original injuries. Plater, Schenck,

Cabrolius, the Ephemerides, and Nolleson mention recovery after wounds

of the liver. Salmuth and the Ephemerides report questionable instances

in which portions of the liver were ejected in violent vomiting.

Macpherson describes a wound of the liver occurring in a Hindoo of

sixty who had been struck by a spear. A portion of the liver was

protruding, and a piece weighing 1 1/4 ounces was removed, complete

recovery following.

Postempski mentions a case of suture of the liver after a stab-wound.

Six sutures of chromicized cat-gut were carefully tightened and

fastened with a single loop. The patient left his bed on the sixth day

and completely recovered. Gann reports a case of harpoon-wound of the

liver. While in a dory spearing fish in the Rio Nuevo, after a sudden

lurch of the boat, a young man of twenty-eight fell on the sharp point

of a harpoon, which penetrated his abdomen. About one inch of the

harpoon was seen protruding from below the tip of the ensiform

cartilage; the harpoon was seven inches long. It was found that the

instrument had penetrated the right lobe of the liver; on passing the

hand backward along the inferior surface of the liver, the point could

be felt projecting through its posterior border. On account of two

sharp barbs on the spear-point, it was necessary to push the harpoon

further in to disengage the barbs, after which it was easily removed.

Recovery followed, and the patient was discharged in twenty-one days.

Romme discusses the subject of punctured wounds of the liver, as a

special text using the case of the late President Carnot. He says that

in 543 cases of traumatism of the liver collected by Elder, 65 were

caused by cutting or sharp-pointed instruments. Of this group, 23

recovered and 42 died. The chief causes of death were hemorrhage and

peritonitis. The principal symptoms of wounds of the liver, such as

traumatic shock, collapse, local and radiating pains, nausea, vomiting,

and respiratory disturbances were all present in the case of President

Carnot. From an experience gained in the case of the President, Romme

strongly recommends exploratory celiotomy in all penetrating wounds of

the liver. Zeidler reports three cases of wound of the liver in which

recovery ensued. The hemorrhage in one case was arrested by the tampon,

and in the other by the Pacquelin cautery.

McMillan describes a man of twenty who was kicked by a horse over the

liver and rupturing that organ. A large quantity of offensive fluid was

drawn off from the liver, and the man recovered. Frazer reports a case

of rupture of liver and kidney in a boy of thirteen who was squeezed

between the tire and driving chain of a mill, but who recovered despite

his serious symptoms. Allen mentions recovery after an extensive

incised wound of the abdomen, liver, and lung. Massie cites an instance

of gunshot wound of the right hypochondrium, with penetration and

protrusion of the liver. The patient, a boy of seven, recovered after

excision of a small part of the protruding liver. Lawson Tait has

incised the liver to the extent of three inches, evacuated two gallons

of hydatids, and obtained successful recovery in ten weeks.

There are several cases of wound of the liver followed by recovery

reported by surgeons of the United States Army. Whitehead mentions a

man of twenty-two who on June 3, 1867, was shot in the liver by a slug

from a pistol. At the time of the injury he bled freely from the wound

of entrance continuing to lose blood and bile until daylight the next

morning, when the hemorrhage ceased, but the flow of bile kept on. By

June 10th there was considerable improvement, but the wound discharged

blood-clots, bile, and serum. When the patient left the hospital on

July 15th the wound was healthy, discharging less than 1 1/2 ounces

during the twenty-four hours, of a mixture of free bile, and bile mixed

with thick material. When last heard from--July 27, 1867--the patient

was improving finely in flesh and strength. McKee mentions a

commissary-sergeant stationed at Santa Fe, New Mexico, who recovered

after a gunshot wound of the liver. Hassig reports the case of a

private of twenty-six who was wounded in a fray near Paducah, Kentucky,

by a conoid ball, which passed through the liver. The ball was cut out

the same day. The patient recovered and was returned to duty in May,

1868. Patzki mentioned a private in the Sixth Cavalry, aged

twenty-five, who recovered from a gunshot wound of the abdomen,

penetrating the right lobe of the liver and the gall-bladder.

Resection of the Liver.--It is remarkable to what extent portions of

the liver may be resected by the knife, cautery, or ligature, and the

patient recover. Langenbuch records a case in which he successfully

removed the greater portion of the left lobe of a woman of thirty. The

lobe had been extensively deformed by tight lacing, and caused serious

inconvenience. There was considerable hemorrhage, but the vessels were

secured, and the woman made a good recovery. McWhinnie, in The Lancet,

records a case of dislodgment of an enlarged liver from tight lacing.

Terrilon mentions an instance in which a portion of the liver was

removed by ligature after celiotomy. The ligature was removed in seven

days, and the sphacelated portion of the liver came off with it. A

cicatrix was completed at the end of six weeks, and the patient, a

woman of fifty-three, made an excellent recovery. Bastianelli

discusses those cases in which portions of the liver, having been

constricted from the general body of the organ and remaining attached

by a pedicle, give rise to movable tumors of the abdomen. He records

such a case in a woman of thirty-seven who had five children. A piece

of liver weighing 500 grams was removed, and with it the gall-bladder,

and the patient made an uninterrupted recovery. Tricomi reports a case

in which it was found necessary to remove the left lobe of the liver.

An attempt had been made to remove a liver-tumor the size of a fist by

constricting the base with an elastic ligature. This attempt was a

failure, and cure was also unsuccessfully attempted by wire ligature

and the thermocautery. The growth was cut away, bleeding was arrested

by the thermocautery and by iron-solution, the wound entirely healed,

and the patient recovered. Valerian von Meister has proved that the

liver has marvelous powers of regeneration, and that in rabbits, cats,

and dogs, even three-fourths of the organ may be reproduced in from

forty-five to sixty-five days. This regeneration is brought about

chiefly by hypertrophy of the lobules.

Floating liver is a rare malady in which the liver forms an abdominal

prominence that may be moved about, and which changes its situation as

the patient shifts the attitude. The condition usually arises from a

lax abdominal wall following repeated pregnancies. The accompanying

illustration exhibits a typical case verified by postmortem examination.

Hypertrophy of the Liver.--The average weight of the normal liver is

from 50 to 55 ounces, but as noted by Powell, it may become so

hypertrophic as to weigh as much as 40 pounds. Bonet describes a liver

weighing 18 pounds; and in his "Medical and Surgical Observations,"

Gooch speaks of a liver weighing 28 pounds. Vieussens, the celebrated

anatomist, reports an instance in which the liver weighed 20 pounds,

and in his "Aphorisms," Vetter cites a similar instance. In 1811 Kraus

of Germany describes a liver weighing 25 pounds; modern instances of

enlarged liver are too numerous to be quoted here.

Rupture of the gall-bladder, although generally followed by death, is

not always fatal. In such cases bile is usually found in the abdominal

cavity. Fergus mentions a case in which, after this accident, the

patient was considered convalescent and was walking about, when, on the

seventh day, peritonitis suddenly developed and proved fatal in two

days. Several cases of this accident have been reported as treated

successfully by incision and drainage (Lane) or by inspiration (Bell).

In these cases large quantities of bile escaped into the abdominal

cavity. Peritonitis does not necessarily follow. Cholecystotomy for

the relief of the distention of the gall-bladder from obstruction of

the common or cystic duct and for the removal of gall-stones was first

performed in 1867 by Bobbs of Indianapolis, but it is to Marion Sims,

in 1878, that perfection of the operation is due. It has been gradually

improved and developed, until today it is a most successful operation.

Tait reports 54 cases with 52 perfect recoveries. Cholyecystectomy, or

excision of the gall-bladder, was first practiced in 1880 by Langenbuch

of Berlin, and is used in cases in which gall-stones are repeatedly

forming. Ashhurst's statistics show only four deaths in 28 cases.

At St. Bartholomew's Hospital, in London, is a preserved specimen of a

gall-bladder which had formed the contents of a hernial sac, and which,

near the fundus, shows a constriction caused by the femoral ring. It

was taken from a woman of forty-five who was admitted into the hospital

with a strangulated femoral hernia. The sac was opened and its

contents were returned. The woman died in a few days from peritonitis.

The gall-bladder was found close to the femoral ring, and showed a

marked constriction. The liver was misshapen from tight lacing,

elongated and drawn downward toward the ring. There was no evidence

that any portion of intestine or other structure besides the

gall-bladder had passed through the ring.

The fatality of rupture of the spleen is quite high. Out of 83 cases of

injury to this organ collected by Elder, and quoted by MacCormac, only

11 recovered; but the mortality is less in punctured or incised wounds

of this organ, the same authorities mentioning 29 recoveries out of 35

cases. In his "Surgery" Gooch says that at the battle of Dettingen one

of Sir Robert Rich's Dragoons was left all night on the field,

weltering in his blood, his spleen hanging out of his body in a

gangrenous state. The next morning he was carried to the surgeons who

ligated the large vessels, and extirpated the spleen; the man recovered

and was soon able to do duty. In the Philosophical Transactions there

is a report of a man who was wounded in the spleen by a large

hunting-knife. Fergusson found the spleen hanging from the wound and

ligated it. It separated in ten days and the patient recovered.

Williams reports a stab-wound of the spleen in a negro of twenty-one.

The spleen protruded, and the protruding part was ligated by a silver

wire, one-half of the organ sloughing off; the patient recovered. Sir

Astley Cooper mentions a curious case, in which, after vomiting, during

which the spleen was torn from its attachments, this organ produced a

swelling in the groin which was supposed to be a hernia. The vomiting

continued, and at the end of a week the woman died; it was then found

that the spleen had been turned half round on its axis, and detached

from the diaphragm; it had become enlarged; the twist interrupted the

return of the blood. Portal speaks of a rupture of the spleen simply

from engorgement. There was no history of a fall, contusion, or other

injury. Tait describes a case of rupture of the spleen in a woman who,

in attempting to avoid her husband's kick, fell on the edge of the

table. There were no signs of external violence, but she died the third

day afterward. The abdomen was found full of blood, and the spleen and

peritoneal covering was ruptured for three inches.

Splenectomy, excision of the spleen, has been performed a number of

times, with varying results, but is more successful when performed for

injury than when for disease. Ashhurst has tabulated a total of 109

operations, 27 having been for traumatic causes, and all but five

having terminated successfully; of 82 operations for disease, only 32

recovered. Vulpius has collected 117 cases of splenectomy, with a

death-rate of 50 per cent. If, however, from these cases we deduct

those suffering with leukocythemia and lardaceous spleen, in which the

operation should not be performed, the mortality in the remaining 85

cases is reduced to 33 per cent. Terrier speaks of splenectomy for

torsion or twisting of the pedicle, and such is mentioned by Sir Astley

Cooper, who has found records of only four such cases. Conklin reports

a successful case of splenectomy for malarial spleen, and in reviewing

the subject he says that the records of the past decade in operations

for simple hypertrophy, including malaria, show 20 recoveries and eight

deaths. He also adds that extirpation in cases of floating or displaced

spleen was attended with brilliant results. Zuccarelli is accredited

with reporting two cases of splenectomy for malarial spleen, both of

which recovered early. He gives a table of splenectomies performed in

Italy, in which there were nine cases of movable spleen, with two

deaths; eight cases of simple hypertrophy, with three deaths; 12 cases

of malarial spleen, with three deaths; four cases of leukemia and

pseudoleukemia, with two deaths. In his experiments on rabbits it was

proved by Tizzoni, and in his experiments on dogs, by Crede, that an

individual could live without a spleen; but these observations were

only confirmatory of what had long been known, for, in 1867, Pean

successfully removed a spleen from a woman of twenty. Tricomi reports

eight cases in which he had extirpated the spleen for various morbid

conditions, with a fortunate issue in all but one. In one case he

ligated the splenic artery. In The Lancet there is an account of three

recent excisions of the spleen for injury at St. Thomas Hospital in

London, and it is added that they are among the first of this kind in

Great Britain.

Abnormalities of Size of the Spleen.--The spleen may be extremely

small. Storck mentions a spleen that barely weighed an ounce; Schenck

speaks of one in the last century that weighed as much as 20 pounds.

Frank describes a spleen that weighed 16 pounds; there is another

record of one weighing 15 pounds. Elliot mentions a spleen weighing 11

pounds; Burrows one, 11 pounds; Blasius, four pounds; Osiander, nine

pounds; Blanchard, 31 pounds; Richardson, 3 1/2 pounds; and Hare, 93

ounces.

The thoracic duct, although so much protected by its anatomical

position, under exceptional circumstances has been ruptured or wounded.

Kirchner has collected 17 cases of this nature, two of which were due

to contusions of the chest, one each to a puncture, a cut, and a

shot-wound, and three to erosion from suppuration. In the remaining

cases the account fails to assign a definite cause. Chylothorax, or

chylous ascites, is generally a result of this injury. Krabbel mentions

a patient who was run over by an empty coal car, and who died on the

fifth day from suffocation due to an effusion into the right pleural

cavity. On postmortem examination it was found that the effusion was

chyle, the thoracic duct being torn just opposite the 9th dorsal

vertebra, which had been transversely fractured. In one of Kirchner's

cases a girl of nine had been violently pushed against a window-sill,

striking the front of her chest in front of the 3d rib. She suffered

from pleural effusion, which, on aspiration, proved to be chyle. She

ultimately recovered her health. In 1891 Eyer reported a case of

rupture of the thoracic duct, causing death on the thirty-eighth day.

The young man had been caught between a railroad car and an engine, and

no bones were broken.

Manley reports a case of rupture of the thoracic duct in a man of

thirty-five, who was struck by the pole of a brewery wagon; he was

knocked down on his back, the wheel passing squarely over his abdomen.

There was subsequent bulging low down in the right iliac fossa, caused

by the presence of a fluid, which chemic and microscopic examination

proved was chyle. From five to eight ounces a day of this fluid were

discharged, until the tenth day, when the bulging was opened and

drained. On the fifteenth day the wound was healed and the man left the

hospital quite restored to health.

Keen has reported four instances of accidental injury to the thoracic

duct, near its termination at the base of the left side of the neck;

the wounding was in the course of removals for deep-seated growths in

this region. Three of the cases recovered, having sustained no

detriment from the injury to the thoracic duct. One died; but the fatal

influence was not specially connected with the wound of the duct.

Possibly the boldest operation in the history of surgery is that for

ligation of the abdominal aorta for inguinal aneurysm. It was first

practiced by Sir Astley Cooper in 1817, and has since been performed

several times with a uniformly fatal result, although Monteiro's

patient survived until the tenth day, and there is a record in which

ligature of the abdominal aorta did not cause death until the eleventh

day. Loreta of Bologna is accredited with operating on December 18,

1885, for the relief of a sailor who was suffering from an abdominal

aneurysm caused by a blow. An incision was made from the ensiform

cartilage to the umbilicus, the aneurysm exposed, and its cavity filled

up with two meters of silver-plated wire. Twenty days after no evidence

of pulsation remained in the sac, and three months later the sailor was

well and able to resume his duties.

Ligation of the common iliac artery, which, in a case of gunshot

injury, was first practiced by Gibson of Philadelphia in 1812, is,

happily, not always fatal. Of 82 cases collected by Ashhurst, 23

terminated successfully.

Foreign bodies loose in the abdominal cavity are sometimes voided at

stool, or may suppurate externally. Fabricius Hildanus gives us a

history of a person wounded with a sword-thrust into the abdomen, the

point breaking off. The sword remained one year in the belly and was

voided at stool. Erichsen mentions an instance in which a cedar

lead-pencil stayed for eight months in the abdominal cavity. Desgranges

gives a case of a fish-spine in the abdominal cavity, and ten years

afterward it ulcerated through an abscess in the abdominal wall.

Keetley speaks of a man who was shot when a boy; at the time of the

accident the boy had a small spelling-book in his pocket. It was not

until adult life that from an abscess of the groin was expelled what

remained of the spelling-book that had been driven into the abdomen

during boyhood. Kyle speaks of the removal of a corn-straw 33 inches in

length by an incision ten inches long, at a point about equidistant

from the umbilicus to the anterior spinous process of the right ilium.

There are several instances on record of tolerance of foreign bodies in

the skin and muscles of the back for an extended period. Gay speaks of

a curious case in which the point of a sheath-knife remained in the

back of an individual for nine years. Bush reported to Sir Astley

Cooper the history of a man who, as he supposed, received a wound in

the back by canister shot while serving on a Tartar privateer in 1779.

There was no ship-surgeon on board, and in about a month the wound

healed without surgical assistance. The man suffered little

inconvenience and performed his duties as a seaman, and was impressed

into the Royal Navy. In August, 1810, he complained of pain in the

lumbar region. He was submitted to an examination, and a cicatrix of

this region was noticed, and an extraneous body about 1/2 inch under

the integument was felt. An incision was made down it, and a rusty

blade of a seaman's clasp-knife extracted from near the 3d lumbar

vertebra. The man had carried this knife for thirty years. The wound

healed in a few days and there was no more inconvenience.

Fracture of the lower part of the spine is not always fatal, and

notwithstanding the lay-idea that a broken back means certain death,

patients with well-authenticated cases of vertebral fracture have

recovered. Warren records the case of a woman of sixty who, while

carrying a clothes-basket, made a misstep and fell 14 feet, the basket

of wet clothes striking the right shoulder, chest, and neck. There was

fracture of the 4th dorsal vertebra at the transverse processes. By

seizing the spinous process it could be bent backward and forward, with

the peculiar crepitus of fractured bone. The clavicle was fractured two

inches from the acromial end, and the sternal end was driven high up

into the muscles of the neck. The arm and hand were paralyzed, and the

woman suffered great dyspnea. There was at first a grave emphysematous

condition due to the laceration of several broken ribs. There was also

suffusion and ecchymosis about the neck and shoulder. Although

complicated with tertiary syphilis, the woman made a fair recovery, and

eight weeks later she walked into a doctor's office. Many similar and

equally wonderful injuries to the spine are on record.

The results sometimes following the operation of laminectomy for

fracture of the vertebrae are often marvelous. One of the most

successful on record is that reported by Dundore. The patient was a

single man who lived in Mahanoy, Pa., and was admitted to the State

Hospital for Injured Persons, Ashland, Pa., June 17, 1889, suffering

from a partial dislocation of the 9th dorsal vertebra. The report is

as follows--"He had been a laborer in the mines, and while working was

injured March 18, 1889, by a fall of top rock, and from this date to

that of his admission had been under the care of a local physician

without any sign of improvement. At the time of his admission he

weighed but 98 pounds, his weight previous to the injury being 145. He

exhibited entire loss of motion in the lower extremities, with the

exception of very slight movement in the toes of the left foot;

sensation was almost nil up to the hips, above which it was normal; he

had complete retention of urine, with a severe cystitis. His tongue was

heavily coated, the bowels constipated, and there was marked anorexia,

with considerable anemia. His temperature varied from 99 degrees to 100

degrees in the morning, and from 101 degrees to 103 degrees in the

evening. The time which had elapsed since the accident precluded any

attempt at reduction, and his anemic condition would not warrant a more

radical method.

"He was put on light, nourishing diet, iron and strychnin were given

internally, and electricity was applied to the lower extremities every

other day; the cystitis was treated by irrigating the bladder each day

with Thiersch's solution. By August his appetite and general condition

were much improved, and his weight had increased to 125 pounds, his

temperature being 99 degrees or less each morning, and seldom as high

as 100 degrees at night. The cystitis had entirely disappeared, and he

was able, with some effort, to pass his urine without the aid of a

catheter. Sensation in both extremities had slightly improved, and he

was able to slightly move the toes of the right foot. This being his

condition, an operation was proposed as the only means of further and

permanent improvement, and to this he eagerly consented, and,

accordingly, on the 25th of August, the 9th dorsal vertebra was

trephined.

"The cord was found to be compressed and greatly congested, but there

was no evidence of laceration. The laminae and spinous processes of the

8th and 9th dorsal vertebrae were cut away, thus relieving all pressure

on the cord; the wound was drained and sutured, and a plaster-of-Paris

jacket applied, a hole being cut out over the wound for the purpose of

changing the dressing when necessary. By September 1st union was

perfect, and for the next month the patient remained in excellent

condition, but without any sign of improvement as to sensation and

motion. Early in October he was able to slightly move both legs, and

had full control of urination; from this time on his paralysis rapidly

improved; the battery was applied daily, with massage morning and

evening; and in November the plaster-of-Paris jacket was removed, and

he propelled himself about the ward in a rolling chair, and shortly

after was able to get about slowly on crutches. He was discharged

December 23d, and when I saw him six months later he walked very well

and without effort; he carried a cane, but this seemed more from habit

than from necessity. At present date he weighs 150 pounds, and drives a

huckster wagon for a living, showing very little loss of motion in his

lower extremities."

Although few cases show such wonderful improvement as this one,

statistics prove that the results of this operation are sometimes most

advantageous. Thorburn collects statistics of 50 operations from 1814

to 1885, undertaken for relief of injuries of the spinal cord. Lloyd

has compiled what is possibly the most extensive collection of cases of

spinal surgery, his cases including operations for both disease and

injury. White has collected 37 cases of recent date; and Chipault

reports two cases, and collected 33 cases. Quite a tribute to the

modern treatment by antisepsis is shown in the results of laminectomy.

Of his non-antiseptic cases Lloyd reports a mortality of 65 per cent;

those surviving the operation are distributed as follows: Cured, one;

partially cured, seven; unknown, two; no improvement, five. Of those

cases operated upon under modern antiseptic principles, the mortality

was 50 per cent; those surviving were distributed as follows: Cured,

four; partially cured, 15; no improvement, 11. The mortality in White's

cases, which were all done under antiseptic precautions, was 38 per

cent. Of those surviving, there were six complete recoveries, six with

benefit, and 11 without marked benefit. Pyle collects 52 cases of

spinal disease and injury, in which laminectomy was performed. All the

cases were operated upon since 1890. Of the 52 cases there were 15

deaths (a mortality of 29.4 per cent), 26 recoveries with benefit, and

five recoveries in which the ultimate result has not been observed. It

must be mentioned that several of the fatal cases reported were those

of cervical fracture, which is by far the most fatal variety.

Injury to the spinal cord does not necessarily cause immediate death.

Mills and O'Hara, both of Philadelphia, have recorded instances of

recovery after penetrating wound of the spinal marrow. Eve reports

three cases of gunshot wound in which the balls lodged in the vertebral

canal, two of the patients recovering. He adds some remarks on the

division of the spinal cord without immediate death.

Ford mentions a gunshot wound of the spinal cord, the patient living

ten days; after death the ball was found in the ascending aorta. Henley

speaks of a mulatto of twenty-four who was stabbed in the back with a

knife. The blade entered the body of the 6th dorsal vertebra, and was

so firmly embedded that the patient could be raised entirely clear of

the bed by the knife alone. An ultimate recovery ensued.

Although the word hernia can be construed to mean the protrusion of any

viscus from its natural cavity through normal or artificial openings in

the surrounding structures, the usual meaning of the word is protrusion

of the abdominal contents through the parietes--what is commonly spoken

of as rupture. Hernia may be congenital or acquired, or may be single

or multiple--as many as five having been seen in one individual. More

than two-thirds of cases of rupture suffer from inguinal hernia In the

oblique form of inguinal hernia the abdominal contents descend along

the inguinal canal to the outer side of the epigastric artery, and

enter the scrotum in the male, and the labium majus in the female. In

this form of hernia the size of the sac is sometimes enormous, the

accompanying illustration showing extreme cases of both scrotal and

labial hernia. Umbilical hernia may be classed under three heads:

congenital, infantile, and adult. Congenital umbilical hernia occurs

most frequently in children, and is brought about by the failure of the

abdominal walls to close. When of large size it may contain not only

the intestines, but various other organs, such as the spleen, liver,

etc. In some monsters all the abdominal contents are contained in the

hernia. Infantile umbilical hernia is common, and appears after the

separation of the umbilical cord; it is caused by the yielding of the

cicatrix in this situation. It never reaches a large size, and shows a

tendency to spontaneous cure. Adult umbilical hernia rarely commences

in infancy. It is most commonly seen in persons with pendulous bellies,

and is sometimes of enormous size, in addition to the ordinary

abdominal contents, containing even the stomach and uterus. A few years

since there was a man in Philadelphia past middle age, the victim of

adult umbilical hernia so pendulous that while walking he had to

support it with his arms and hands. It was said that this hernia did

not enlarge until after his service as a soldier in the late war.

Abbott recites the case of an Irish woman of thirty-five who applied to

know if she was pregnant. No history of a hernia could be elicited. No

pregnancy existed, but there was found a ventral hernia of the

abdominal viscera through an opening which extended the entire length

of the linea alba, and which was four inches wide in the middle of the

abdomen.

Pim saw a colored woman of twenty-four who, on December 29, 1858, was

delivered normally of her first child, and who died in bed at 3 A.M. on

February 12, 1859. The postmortem showed a tumor from the ensiform

cartilage to the symphysis pubis, which contained the omentum, liver

(left lobe), small intestines, and colon. It rested upon the abdominal

muscles of the right side. The pelvic viscera were normally placed and

there was no inguinal nor femoral hernia.

Hulke reports a case remarkable for the immense size of the rupture

which protruded from a spot weakened by a former abscess. There was a

partial absence of the peritoneal sac, and the obstruction readily

yielded to a clyster and laxative. The rupture had a transverse

diameter of 14 1/2 inches, with a vertical diameter of 11 1/2 inches.

The opening was in the abdominal walls outside of the internal inguinal

ring. The writhings of the intestines were very conspicuous through the

walls of the pouch.

Dade reports a case of prodigious umbilical hernia. The patient was a

widow of fifty-eight, a native of Ireland. Her family history was good,

and she had never borne any children. The present dimensions of the

tumor, which for fifteen years had been accompanied with pain, and had

progressively increased in size, are as follows: Circumference at the

base, 19 1/2 inches; circumference at the extremity, 11 1/4 inches;

distance of extremity from abdominal wall, 12 3/4 inches. Inspection

showed a large lobulated tumor protruding from the abdominal wall at

the umbilicus. The veins covering it were prominent and distended. The

circulation of the skin was defective, giving it a blue appearance.

Vermicular contractions of the small intestines could be seen at the

distance of ten feet. The tumor was soft and velvety to the touch, and

could only partially be reduced. Borborygmus could be easily heard. On

percussion the note over the bulk was tympanitic, and dull at the base.

The distal extremity contained a portion of the small intestine instead

of the colon, which Wood considered the most frequent occupant. The

umbilicus was completely obliterated. Dade believed that this hernia

was caused by the weakening of the abdominal walls from a blow, and

considered that the protrusion came from an aperture near the umbilicus

and not through it, in this manner differing from congenital umbilical

hernia.

A peculiar form of hernia is spontaneous rupture of the abdominal

walls, which, however, is very rare. There is an account of such a case

in a woman of seventy-two living in Pittsburg, who, after a spasmodic

cough, had a spontaneous rupture of the parietes. The rent was four

inches in length and extended along the linea alba, and through it

protruded a mass of omentum about the size of a child's head. It was

successfully treated and the woman recovered. Wallace reports a case of

spontaneous rupture of the abdominal wall, following a fit of coughing.

The skin was torn and a large coil of ileum protruded, uncovered by

peritoneum. After protracted exposure of the bowel it was replaced,

the rent was closed, and the patient recovered.