INTESTINAL WORMS AS A COMPLICATION IN ABDOMINAL SURGERY. By ALBERT L. STAVELY, M. D. From the Johns Hopkins Hospital Reports, Vol. Ill, Nos. 7, 8, 9, Baltimore, Md. INTESTINAL WORMS AS A COMPLICATION IN ABDOMINAL SURGERY. By ALBERT L. STAVELY, M. D. Several remarkable instances of complications occurring in abdom- inal surgery through the presence of ascarides lumbricoides have been observed in the Gynecological Department. A lumbricoid worm has thus been found provocative of such alarming symptoms following cceliotomy as to raise a question as to the existence of peritonitis or ileus. Cases. From August to November, 1891, a period of four months, six cases were complicated in this way. In five the parasite was ascaris lumbricoides, and in one taenia mediocanellata. First Case.-Emily O., set. 29, single, neurotic; was admitted for the removal of a small cystoma of left ovary. In addition to her local troubles, she complained of attacks of hoarseness and dyspnoea, during which she became cyanosed and frequently vomited. An uncomplicated cystectomy was performed by Dr. Kelly. The operation was followed by severe nausea and vomiting lasting three days, with slight nausea continuing until the ninth day. During this time she was nervous, restless and irritable, slightly tympanitic, and distressed by flatulence, and her sleep was much disturbed by dreams. The bowels were moved as usual by the third day. On the afternoon of the ninth day, after eating a light meal, she com- plained of feeling faint and swooned away; her pulse became rapid, irregular and almost imperceptible, and her body was drenched with sweat, the skin mottled, and the extremities cold; the eyes occasion- ally opening and dosing spasmodically. After an hour she vomited freely, ejecting a large lumbricoid worm, followed by immediate cessation of all distressing symptoms. After this she made a rapid and complete recovery. 372 Albert L. Stavely. [72 Second Case.-Nora D., n egress, set. 31, entered the hospital, November 4, 1891, suffering from severe headache and backache, excessive weakness and profuse leucorrhoea. On November 11th, 1891, Dr. Robb operated, removing a pyosal- pinx of the left tube and an acutely inflamed right tube. There was also general pelvic peritonitis and adhesions. A long, thickened vermiform appendix, much inflamed at its extremity, was firmly adherent to the right ovary. During enucleation the pus sac rup- tured and pus escaped into the pelvis. About two inches of the vermiform appendix were amputated and the proximal extremity cauterized. Cultures from the pyosalpinx proved to be sterile; those from the appendix developed streptococci. On examining the ampu- tated end of the appendix a large segment of a tapeworm was found. After the operation she had nausea for three days. On the third day she had great dyspnoea and suddenly became pulseless. After passing a large amount of flatus she improved somewhat, but was still restless and gasped for breath at intervals. On the fifth day she vomited a quantity of dark-colored blood and passed blood from the rectum, again becoming pulseless, and in a few hours died. At the autopsy a round ulcer was found in the duodenum, the peri- toneal cavity was full of blood, and extending almost the whole length of the small intestines a tsenia mediocanellata was found. There was a wide-spread infection of the peritoneum, originating in the vermiform appendix. Third Case.-Louisa B., set. 23, married, was admitted, Octo- ber 6, 1891, for general pelvic peritonitis and for the removal of densely adherent tubes and ovaries. Coeliotomy by Dr. Kelly. The principal symptoms were constipa- tion, bearing-down pain during defecation, loss of flesh and appetite, sharp pains in the lower part of the abdomen, nervousness and weakness. While manipulating the small intestines during the operation a large lumbricoid worm was distinctly felt through the wall and was squeezed between the thumb and finger with the object of killing it. After the operation she had hiccough for a half-hour, and nausea with vomiting for three days, and slight abdominal pain. On the second day she screamed almost constantly for eight hours. Following this there were no untoward symptoms. The worm was never observed in the stools. 73] Intestinal Worms as a Complication in Abdominal Surgery. 373 Fourth Case.-Maggie Q., set. 23, married, admitted October 28, 1891. Coeliotomy by Dr. Kelly for intestinal adhesions, following a double salpingo-oophorectomy performed in another clinic for the relief of " ovarian pains." Preceding the final operation the most prominent symptoms were constant pain in the hepatic and gastric regions, increased on exertion, eructations, diarrhoea, palpitation of the heart, hot flushes, nervousness, loss of weight and lassitude, and severe paroxysmal, localized pain. At the time of operation, while releasing the intestinal adhesions, a large lumbricoid worm was felt through the wall of the small intestine and was squeezed tightly with the object of killing it. During the first two days after operation she had persistent nausea and vomiting of greenish fluid. Her bowels were moved with the aid of a simple enema. On the seventh day, after repeated administration of santonin and calomel, the worm was expelled. On the next day she moaned and screamed from pain in the stomach, vomited a large quantity of yellow fluid, afterward becoming quiet and comfortable, and made a good recovery. Fifth Case.-Kate H., set. 19, single, admitted November 28, 1891. Diagnosis, double pyosalpinx (gonorrhoeal). Before operation she complained of constant headache, pyrosis and vomiting; she also had sweating, fever, dryness of the mouth and constant cramp-like pain in the lower abdomen. Coeliotomy by Dr. Kelly. After operation she vomited at short intervals for four days. Finally a lumbricoid worm was ejected from the mouth, followed by immediate abatement of symptoms. She then made an uncomplicated recovery. Sixth Case.-Ella McG., set. 21, married, suffering from pelvic peritonitis, salpingitis and perioophoritis, complained chiefly of severe backache and pain in the lower part of abdomen. Operation by Dr. Kelly. During the operation a large lumbricoid worm was felt through the wall of the small intestine. Although pinched and undoubtedly killed it was never found in the stools. She suffered greatly from nausea for three days. The most constant and alarming feature in these cases was a peculiarly persistent nausea and severe vomiting, accompanied by colicky pain, disturbed breathing, anxious expression, palpitation 374 Albert L. Stavely. [74 and a general feeling of malaise; a complex of symptoms quite different from the simple persistent nausea and discomforts fre- quently observed following the anesthesia. The headache, abdominal pains, tympanites and hysteria were also peculiar signs, apparently due to the presence of the worms. There was no such elevation of temperature or extreme tympany associated with an incessant bilious vomiting, as are frequently seen with the advent of septic peritonitis. The symptoms in most of these cases were of a peculiarly explosive character, accompanied with more violent manifestations than are usual in septic cases. It is difficult to formulate a theory which will adequately explain such marked phenomena from a cause so trivial. Although not hitherto specially noted in abdominal surgery it has not escaped observation for many years that peculiar reflex disturb- ances are often due to the presence of parasites in the intestinal canal. A few of the more recent cases culled from current literature are as follows: Isador Palmar,1 of Buda Pesth, cites a case in which a tapeworm was the cause of " dysmenorrhoea and sterility." Upon removing the worm, depression and other unpleasant symptoms disappeared, and the patient immediately conceived. An ascaris in the appendix may cause death. Bergmann2 reports the case of a boy 17 years old who suddenly developed perityphlitis and died. At the autopsy, perforation of the vermiform appendix was found, and in an abscess cavity adjoining the caecum an ascaris 15 cm. long was found. Bergmann thinks that the ascaris cannot perforate the bowel unless there is a preexisting diseased condition which weakens the intestinal wall. Fitz-Maurice3 records a case where the small intestine was perfor- ated by a lumbricoid worm, which afterwards became imbedded in a sulcus of inflamed muscular tissue and mucous membrane about two inches from the point of perforation. Poncet4 refers to the discovery of a living lumbricoid in the peri- toneal cavity of a patient upon whom coeliotomy had been performed for peritonitis. Muratow 5 reports the following case: In March, 1887, salpingo- oophorectomy was performed in a case in which a Fallopian tube had ruptured and the bloody contents escaped into the peritoneal cavity. 75] Intestinal Worms as a Complication in Abdominal Surgery. 375 The wound healed by first intention. Six months later an abscess formed at the lower angle of the abdominal incision, and in the pelvis on that side from which the tube and ovary had been removed, a tumor the size of an orange was felt. On cutting into it, a quantity of pus was evacuated, containing several living proglottides of the taenia mediocanellata. The author believes that an abscess had formed in the broad ligament, which became adherent to the intestines and abdominal wall, and that the proglottides had entered through an intestinal opening which later had closed. Winckel6 records a case in which a round worm was found calcified on the posterior surface of the uterus and left broad ligament. His explanation for this condition is that the worm passed from the anus into the vagina, then up through the Fallopian tube into the peri- toneal cavity. In " Il Morgagni " (Naples, 1867)7 an interesting case is described. L. G., set. 34, married; after a sickness of two weeks entered a hospital in Milan. The chief symptoms were continuous fever, diar- rhoea, pains in the lower part of abdomen, red and coated tongue, sordes on lips and teeth, dry cough and hurried respiration. At the autopsy a few days later, in addition to pneumonia and several minor lesions, the right tube and ovary were found adherent. A small space between uterus, rectum and ileum contained pus, and in the rectum there was an opening one centimeter in diameter. On cutting into the Fallopian tube its calibre was found occluded by a round worm fully 10 cm. long. The theory for its presence in such a position is that it perforated the rectum at the point of ulceration and entered the Fallopian tube. Instances of intestinal obstruction from worms are occasionally reported. Heydenreich8 of Nancy mentions a case in which intussusception was diagnosed and the small intestine was opened in the left iliac region. Two days later a mass of round worms, seven in number, appeared at the abdominal incision and was removed. A quick recovery followed. Three cases of a similar character have been collected by this writer. The possibility of worms causing perforation of the intestine with- out any preparatory lesion seems to be borne out by the case reported by Dr. Dunlap,9 of Kentucky, who was called to see a woman who had had two attacks of violent pain in the left iliac region, followed by 376 Albert L. Stavely. [76 symptoms of hemorrhage and shock. After reviewing her menstrual history he made a diagnosis of ruptured tubal pregnancy and urged an operation. On opening the abdomen, the uterus and appendages were found to be normal, but the pelvis was filled with recent blood clots. On irrigating the abdominal cavity a long tapeworm was washed out, and was found to have escaped through a large ragged rent in the small intestine. As the bowel was seriously injured, it was resected and the patient made a good recovery. The worm was over twenty-five feet long. The theory advanced by Dr. Dunlap is that the worm, becoming entangled in its own coils, had made violent efforts to free itself, and by erosion and pressure on the walls of the intestine caused local gangrene. References. 1. Annual of Universal Medical Sciences, 1891, Vol. I, F. 24. 2. Prag. Med. Wochenschr., 1890, page 617. 3. Dublin Journal of Medical Sciences, December, 1888. 4. Annual of Universal Medical Sciences, Vol. I, 1890, F. 20. 5. Centralblatt fiir Gynakologie, April 6, 1889. 6. Hart and Barbour's Manual of Gynecology, 4th edition, New York, p. 195. 7. Il Morgagni (Naples, 1867). 8. Annual of Universal Medical Sciences, 1892, Vol. I, F. 17. 9. New York Medical Journal, February 11, 1893.