Reprinted from the Medical Bbiep, Jan., 2887. .A. CASE OIF1 GASTROTOMY FOR THE Removal of a Swallowed Knife, Recovery of the Patient, BY X3H. -A.. C. BEBHAYS, OF ST. LOUIS, MO. Smith & Owens Printing Co., 318 N. Third Street, St. Louis, Mo. CHIP No. XII. Reprinted from the MEDICAL Brief, Jan., 1887 A Contribution to the Surgery of the Stomach. Gastrotomy for the Removal of a Swallowed Knife. Recovery of the Patient. With Illustrations. to make the knife disappear in his throat and then pull it out with his fingers, after the spectators had suffi- ciently admired his skill and daring. The first act of this programme suc- ceeded admirably, the artist pushed the knife down into his oesophagus, handle foremost, his chin being raised and head thrown back, so that the canal into which the knife was pushed formed a straight line. Suddenly, while in this position, the knife es- caped the control of the performer. Amid the agonizing screams of the family and of the victim, the knife was carried down into the stomach by the contractions of the pharyngeal and oesophageal muscles. It was swallowed exactly in the same way as any other substance which is intro- duced into the fauces. The screams in Hoffmann’s dwelling attracted the neighbors and the policeman on the beat. The latter telegraphed for an ambulance intending to remove Hoff- mann to the City Hospital, whilst others summoned medical aid. The first medical man to arrive was the family physician, Dr. Hugo Kinner, BY AUGUSTUS C. BERNAYS, A. M., M. H. Heidelberg; M. R. C. S., England; F. R. M. S., London; Member German Society Sur- geons of Berlin; Prof, of Anatomy St. Louis College Physicians and Surgeons; Con- sulting Surgeon St. Louis City Hos- pital and Female Hospital. In compliance with your request I submit the following report of a most remarkable case for the benefit of your many thousands of subscribers. Joseph Hoffmann, a German tailor, aged thirty-eight, was amusing his wife and children with various tricks and funny performances, at his home No. 1207 S. Broadway, on the even- ing of November 17th, 1886. They were sitting around a table and, being somewhat exhilarated, Hoffmann in- tended to close his entertainment by his chef d’oeuvre, of sword swallow- ing, in which performance he is an expert. He had frequently pushed pokers, canes and handles of ladles down his gullet before, but on this evening he chose an ordinary case- knife (see Fig. 2, which is a fac- simile of the one used). He intended 4 A CONTRIBUTION TO THE SURGERY OF THE STOMACH. don’t make me suffer unnecessary pain, you can’t help me anyhow.” At that moment he had another severe spell of vomiting, but the spasms did not relieve his stomach of any of its contents, and it seemed to me that he suffered great pain. A change seemed to have come over his thoughts and with an expression of hope on his countenance, he mounted an impro- vised operating table. Dr. Barck administered chloroform and a hypo- dermic injection of morphia was made. While the patient was being narcotized, Drs. Kinner, Hauck and I quickly prepared the necessary instru- ments, sponges, etc. The patient passed into a remarkably quiet anaes- thesia, which was not interrupted by a single spell of vomiting during the entire operation. I began the first incision about an inch below the ensiform process and cut straight down on the linea alba to within about an inch from the umbili- cus. This cut was about five inches in length and was quickly carried through into the abdomen. The sec- ond step of the operation consisted in pulling the stomach out of the abdominal incision. The stomach contained some beer and the rem- nants of a light supper, besides the knife. I introduced my whole left hand into the abdomen and soon suc- ceeded in pulling out the pyloric end of the stomach which contained the handle of the knife. The dotted line shows the position of the knife. The end of the blade was located in the fundus of the stomach, near the angle of the ninth rib, a lit- tle to the left of the vertebral column. one of the busiest practitioners of the south side. After he had assured himself of the condition of his patient he quieted him and stepping to the nearest telephone sent for me. Dr. Kinner and I were soon in earnest consultation by means of the electric current, and it was settled that I should drive down to Hoffmann’s residence, see him at once and come prepared to operate. The well known oculist, Dr. Chas. Barck and Dr. Eugene Hauck accompanied me to the scene of the accident. When we arrived at the house, Hoffmann was having a violent spell of vomiting, and presented the ap- pearance of a person frightened al- most out of his wits. The patient had evidently made up his mind that he must die and he did not grasp the probability of being saved by an operation as readily as I expected. He refused, saying: “ Oh, let me die ! The third step of the operation consisted in opening the stomach and extracting the knife. I had Dr. Kin- ner and Dr. Hauck to grasp the ante- rior wall of the stomach with two “army ” bullet forceps, about an inch A contribution to the surgery of the stomach. 5 ends were also cut off close. It will be seen that the sutures which were employed by me are very similar to the ones used by Billroth, of Vienna, in his operations on the stomach, I now replaced the stomach in the abdomen. There was little or no bleeding, and the toilet of the abdominal cav- ity was very simple. The operation was finished by sewing up the external wound in the usual way. I ap- plied about eighteen silk sutures and dressed the wound in the same manner that I am accustomed to, after ovariotomy. The dressings were held in place by an elastic web bandage. The patient was carried to his bed. He rallied quickly after having been under the influence of chloroform about an hour. The knife had been in his stomach less than an hour, before the oper- ation. The after-treatment was conducted by Dr. Kinner in a most judicious but strict manner, and was followed by a most brilliant result. The patient never vomited at all after the op- eration ; his temperature reached 100° F. only on one occasion, for a short time, and his pulse never exceeded 86. He was given a spoonful of water about every two or three hours during the first four days, but large nutrient enemata of peptonized milk, beef tea, etc. were given threetimes a day. The en- tire wound healed by first inten- tion. I remov- ed the apart on eith- er side of the handle of the table knife,and pull up the stomach so that none of the contents could escape after I had opened it. I then cut through the walls of the stomach upon the handle of the knife within, making a straight cut be- tween the two forceps not exceeding five-eighths of an inchin length. I then pushed the stomach back over the knife handle about half an inch, and, grasping it with my fingers, easily extracted it without a drop of the gastric contents escaping. Thus far the operation had consumed scarcely five min- utes. The most difficult and tedious part of the op- eration was the suture of the small cut in the stomach. The success of the operation, my pa- tient’s life, depended upon this procedure, and I performed it with the utmost care after the following method: I first united the edges of the cut by five interrupted sutures ; four of these sutures embraced the peritoneal and muscular layer, fallowed only the middle one to pass through the mucous membrane of the stomach. They were less than one-eighth of an'inch apart, and were made with the finest kind of cat-gut. The ends of the sutures were cut close. I next introduced eight ordinary Lembert su- tures over and between the five first sutures. These, when tied, completely buried out of sight the direct sutures. These latter were made with the thinnest kind of twisted Chinese silk, and their A CONTRIBUTION TO THE SURGERY OF THE STOMACH. Case No. Name of Op- erator. Literature .and Bibliography. Patient- Age and Station. Nature of the Foreign Body. Length of tin® the object was retained in the Stomach. Physical Condi- tion of Patient before the Op- eration. THE OPERATION. AFTER-TREATMENT AND REMARKS. FINAL RESULTS. 1 Daniel Schwabe, in Kcenigs- berg, Prussia, 1635. Baldinger’s New Magazine for Physicians, Vol. XIII, 1791, Page 567 Berlin Clinical Weekly, No. 7, 1883. Hart Enochs Old and New Prus- sia, 1684. A. Gruen- heyde, far- mer, 22 yrs of age. Table knife, 18 etm. long, 15 ctm. broad in. in length). 41 days. No serious in- convenience. Incision one and a half inches be- low and parallel to the ribs on the left side. Stomach pulled up by means of a curved needle. Stomach cut through on the point of the swal- lowed knife. The incision “snapped shut” after the knife had been ex- tracted . Abdominal incision closed by five sutures. Operation without anaesthetics Removed external sutures on second and third day. Bloody urine, and stools dur- ing first days. Wound washed with wine— strict diet during two weeks. Wound en- tirely healed during this time. The patient lived many years, enjoying perfect health. 2 Tilanus, of Leyden, 1848. Ort, Diss. con- tin. casum gas- trotomiae c e t. Lugduni, Batav- or, 1853 Adelmann, Prague Quarterly Review of Practical Med- icine, Vol. 131, 1876, page 80. Insane girl in the town of Zuepthen, 32 yrs old. Silver fork, 21 ctm. long, and some pieces of crockery of tri- angular shape 2 ctm. in their greatest diam- eter. 3 days. Very weak pa- tient. Great diffi- culty of swallow- ing. Diagnosis is proven by sounds and by examina- tion of region of the stomach. Patient is anaesthetized with ether. Incision only about 3 inches in length in linea alba. Stomach is drawn forth with two forceps, an opening, one inch in length into the anterior wall of the stomach, causing considera- ble hemorrhage. Finding of the fork and crockery consumes time and is found very troublesome. The stomach is closed by 5 stitches, the ends of which were conducted and allowed to hang out of the lower angle of the abdominal incision. The latter was closed by a simple suture. Vomiting of green- ish fluid, pain and tympanites during first and second days. Feeble and high pulse on the second day, death on the third. Post-Mortem shows plas- tic material which has caused a conglomeration and adhesion between the stomach, liver and abdom- inal parietes. The in- cision in the stomach en- tirely closed. The stom- ach much distended. The upper third of the oeso- phagus is much lacerated and perforated opposite the larynx. A pus-sinus extends along the lobe of the thyroid body. 3 Bell, of W apello. iowa, 1855. The American Journal of the Medical Sciences, 1855, July No., p, 272 Male, aged 27. A bar of lead 9 inches long, 1-5 inch in di- ameter. 9 days. No serious in- convenience a t first. Vomiting on the eighth day and great prostration. The foreign body can not be detected with certainty. An incision beginning near the um- bilicus extends directly outward to- wards the point of the second false rib, about four inches long. The bar is extracted with a forceps through an incision which is made upon the foreign body. The contraction of the stomach suffices to close the open- ing. Prolapse of some intestines during the operation. Abdomen closed by the interrupted suture. Some symptoms of gastritis. The after treatment consisted of morphine injec- tions, two venesec- tions andenemata.Ex- ternal wound healed in5 days. Patient en- tirely recovered in 2 weeks. Complete recovery. 1 Leon Labbe, in Paris, 1876. Gazette Heb - dom. Second Se- ries. XIII(XXIII) 18, 1876, p. 273. Lausseur, male clerk, aged 18. Fork, five- pronged; Ger- man silver. 2 years and 10 days. No serious in- convenience for 6 months. Later on had attacks of syn- cope and severe symptoms of gas- tralgia. Futile attempts were made by ex- ternal applications to cause adhe- sions between stomach and abdomi- nal parietes. Laparotomy parallel to the ribs less than two inches in length. Stomach pulled out by means of forceps. Attached to the abdominal incision by sutures be- fore opening it. The fork was then extracted with a polypus forceps. A strong collodium cuirass was applied over the abdomen. Allowed solid food af- ter fifth day. Wound healed nicely, except- ing over the gastric fistula. Patient dismissed on the 15th day, but a small fistula leading into the stomach was still open. Table of Gastrotomies for tlio Removal off Foreign Bodies. A CONTRIBUTION TO THE SURGERY OF THE STOMACH. 5 Kochee, in Bern, 1883. Correspondenz- blatt fur Schwei- zer Mrzte, 1883. Nos. 23 and 24. Male, 37 years old. Piece of a broken instru- ment called coin catcher. 1 day. No serious incon- venience. Oblique incision 2 ctm. from edge of ribs. Stomach secured by two loops of thread. Incision into stom- ach over an inch long. Coin ex- tractor easily removed; incision closed by 10 Lembert sutures. Careful diet, no fe- ver, wound heals kindly. Complete recovery. 6 Gussenbauer of Prague, 1883. Vienna Medical Weekly, 1883, No. 51 and' 52. Profe s s- ional sword swallower, 19 yrs old. Broken sword blade 10% in. in length. Bro- ken end sharp. 2 days. Great pain,emet- tics, and hanging by the feet are tried. Fever, vom- iting, singultus. Operation is very difficult; the sword blade is extracted with great difficulty after the stomach was opened, Death in two days, of septic peritonitis. Autopsy revealed the fact that the point of the sword had perforated the stomach, and the broken end had perforated the oesophagus. 7 SCHOENBOEN, In Koenigsberg 1883. V. Langenbeck’s 'Archiv. of Surg- ery, Vol. 29, page 609. Girl, 15 years old. Hair tumor, kidney-shaped and hard. About 4 years. Vomiting, a free- ly movable tumor in the left hypo- chondriac region. Laparotomy in the linea alba. Tu- mor found loose in the stomach. The incision into the stomach was made parallel to the major curvature. Six- ty-five Madelung’s intestinal sutures were employed to close the stomach. First intention of all sutures. Dismissed from hospital after 3 weeks. Complete recovery. 8 Thoenton, London, 1884. Lancet, 1884, No. 3. Girl, 17 yrs of age. Hair tumor, weight 2% lbs. Several years. Diagnosis: Ab- dominal tumor. Great prostration. Incision into the stomach was closed by several rows of sutures The tumor filled up the entire cavity of the stomach. A sponge was left in the abdomen, but re- moved on the second day. Patient had par- otitis of both glands. Final complete recov- ery. 9 Billroth, Vienna, 1885. 7. Hacker, Oper- ations on the stomach in Prof Billroth’s Clinic, from 1880 to 1885. Vienna: Pub- lished by Teplitz & Deutsche. Girl, 19 yrs of age. Artificial den- ture, 6 teeth. 2 days. But little incon- venience. Incision along the ribs 4% inches in length, beginning near ensiform process. The foreign body is very difficult to find, but is finally ex- tracted through a small opening, the stomach being held by two loops of thread. Some ordinary interrupted sutures and a few Lembert sutures in three rows. The healing process goes on without any feverish reaction. Pa- tient leaves the hos- pital after five weeks. Complete recovery. 10 Cbede, Staff Surgeon in Dresden, 1885. V. Langenbeck’s Archiv. of Surg- ery, Vol. 33, page 574, 1886. F. Mticke, a barber, 24 yrs of age. Hard rubber denture, eight teeth & clamps 15 days. Vomiting, in- somnia, great nervousness. Oblique incision 5 inches long par- allel to the ribs, beginning near the ensiform process. Stomach was drawn out. Foreign body was found near the pylorus, Incision into stom- ach 2 inches long. Three tiers of sutures were used to close the stom- ach. No vomiting, no fe- verish reaction, pa- tient dismissed on the 21st day. Complete recovery. 11 A.C.Bernays, St. Louis, Mo., 1886. Medical Brief, St. Louis, Mo., Jan. 1887. Jos. Hoff- mann, tail- or, aged 38. Silver-plated table knife, 9% inches long, (24% ctms.) 1 hour. Frequent pain- ful contractions of stomach, but no vomiting. Incision in linea alba 5 inches long between umbilicus and ensiform pro- cess. Stomach drawn out and held by 2 Hegar’s kugelzangen. Incision on knife handle about % inch in length; 5 direct interrupted sutures, buried by a row of eight Lembert su- tures. Stomach replaced. Abdom- inal incision closed by 18 sutures. No vomiting, no fever. First intention; patient left his bed ten days after opera- tion. Complete recovery. 8 A CONTRIBUTION TO THE SURGERY OE THE STOMACH. stitches on the fifth day. The patient got up on the tenth day and was dis- charged from medical attendance on the fourteenth day. The photograph, from which fig. 1 is copied, was taken on December 6th, nineteen days after the operation. The patient is as well in every respect as he was previous to the accident. The distinguishing feature of my own case is; Firstly, the prompt manner in which the operation was performed, the knife having remained in the stomach only about one hour. Secondly, the knife which I removed seems to have been the longest ob- ject, which has been successfully removed from the stomach by gastrot- omy. Thirdly, there are some minor peculiarities in regard to the method of suture and the employment of anti- septics, which differ from former cases. The table which precedes shows that only ten cases of gastrotomy are recorded in the history of surgery, which can be compared to the one just described. We must exclude, from comparison with our own, all cases where adhe- sions had been formed between the stomach and the abdominal walls. In the latter cases, the operation of gas- trotomy loses its dangerous features and becomes an operation of little more importance than the opening of an abscess. Including these latter cases, there are twenty-six cases of gastrotomy on record with four deaths. Seven of these, however, are so im- perfectly described by the authors that they must be discarded from all tables which lay claim to our conside- ration, for scientific purposes. Since the publication of the above article two new cases of gastrotomy have appeared in contemporaneous journals. Dr. Polaillon, of Paris, reported a case of gastrotomy for the removal of a fork, to the Paris Academy of Med- icine on August 24th, 1886. Particu- lars are unknown, excepting that the patient recovered. Dr. M. H. Richardson, of Boston, reports a case of gastrotomy, in the Boston Medical and Surgical Journal, December 16th, 1886, which ended in recovery. The patient swallowed and retained a set of false teeth in the lower part of his oesophagus for nearly a year. Gastrotomy was per- formed and after the whole hand was introduced into the stomach, the for- eign body was drawn into the stom- ach by the fingers which reached through the cardia into the oesopha- gus. The stomach was sutured and returned to the abdomen. The above table requires but little explanation. The facts speak for themselves. The operation shows a surprisingly small number of deaths, the mortality being only eighteen per cent. All the case have peculiarities, only two are nearly alike, they are the cases of Billroth and Cr6de. In both of these a set of false teeth was swallowed by the patients while asleep. The lives of both patients were saved by the operation of gastrot- omy. This should be a warning for all those who wear artificial dentures, to remove them before retiring. These two cases should be added to the table. The percentage of mor- tality will then be reduced from 18 to 15 per cent. 903 Olive St., St. Louis, Mo.’ Dr. A. F. Bock, Dr. Maurice Andre, Dr. W. F. Kier, and a number of other colleagues saw my patient during his illness, by my invitation, and assisted me by their experience in regard to some details of the diet and regime. I desire to express my thanks to these gentlemen. Messrs. Sennewald & Addington and Roepke, who are among our prominent druggists, gratuitously and liberally furnished medicines, antiseptics, wines, etc., which were used during the period of re-convalescence. DR. A. E. FOOTE MINERALS and BOOKS MEDICAL, AGRICULTURAL, HORTICULTURAL, EDUCATIONAL, ETC. 1317 ARCH STREET PHILADELPHIA, PENNA., U. S. A. PLEASE RETURN THIS SUP, WHETHER THE ARTICLE IS WANTED OR NOT, AND SAVE US TROUBLE AND EXPENSE The Relations of the Surgeon to the General Practitioner and the Public. “ A MODERN INSTANCE.” Citizen .-—Dear Doctor, I wish you would call at my house this morning and see my daughter; she has fever and a sore throat. Surgeon:—l can not go; your family physician will attend to the case much better than I could. Citizen :—The operation you performed on me was so successful that I have the greatest confidence in you, and I want you. Our family physi- cian is not aware that daughter is sick; please come. Citizen:—l suppose some foolish code, you doctors have, is at the bot- tom of this. I want you to go and see my daughter, and I will pay your price. Surgeon:—l will not go. Send for your family doctor. Surgeon :—I am sorry sir ; I will not go, and for your information let me tell you that the Code is not in my way at all. Under its ruling I could go at once. The Code was written forty years ago, when but little was understood of the dangers of the poisoning of wounds by subtile germs such as are probably the cause of your daughter’s illness. The modern surgeon must stand on a higher ethical level than that of any code, not only because of the reason I gave you, but also because he depends, for a large proportion of his practice on the good will of the general practi- tioner, whom I consider to be the most useful member of our social organization, and I will always be found protecting his interests. Good morning sir, take my advice: Call in your family doctor.® * The above conversation took place in Dr. Bernays’ office, while the writer was waiting. G. F. L.