The man whose intestines twinkled like stars

original correspondenceEvery so often I read an old medical case that makes me wince and ask myself, “However did they recover from that?” This tale, reported 142 years ago in the Richmond and Louisville Medical Journal, falls squarely into this category. The initial injury was bad enough, but the circumstances of the case presented the surgeon with practical complications which made his job virtually impossible. And yet there is a happy ending. In December 1874 Dr A.W. Fontaine, a country surgeon from New Canton, Virginia, wrote as follows:

J.T., a Welsh quarryman, aged about twenty-five years, of sound constitution, but somewhat “addicted to spirits,” whilst in a state of intoxication, fell from a four-horse slate wagon, in rapid motion, and loaded with five or six other persons. The vehicle thus loaded, ran over him and across the middle of his body; it broke the neck off a large glass bottle, the stump of which, it seems, penetrated his abdomen, emptying his bowels, which were crushed into the sand by the rolling wheels.

An almost unimaginably awful injury. The poor man’s intestines were forced out through the hole in his abdomen and then flattened by the heavy vehicle. They were not just badly mangled, but covered in dirt and goodness knows how many dangerous microorganisms.

May 29, 1869, I was called to see him; arrived just before sundown. The accident had occurred some hours before, and he had been carried to the comfortable home of a kind and hospitable neighbor. Found him lying on a bed with about a peck of small intestines and some omentum resting on the outside of his abdomen, and wrapped in wet cloths.

A peck is two gallons, or about 9 litres. I doubt this unit has often been used to measure the amount of extruded intestines.Grays anatomy abdomenUpon closer inspection, I ascertained that the entrails had escaped through a puncture made by the broken bottle (which he had in his pocket or bosom) when the wagon ran over him… Neither the intestines nor omentum were cut or torn, but were sadly bruised, and had a quantity of glass and grit ground into the peritoneal surface.

This just gets worse and worse. The peritoneum is the membrane which lines the abdominal cavity and normally forms a protective shield over the viscera.

The surface of the whole mass appeared blackened and bruised; and, in striking contrast, shone the bright particles of glass and sand embedded therein. The vermicular motion was quite active, and presented a lively scene by the light of the lamps brought to my aid.

He had a poetic sensibility, Dr Fontaine – few could describe such a sight and make it sound vaguely pretty. ‘Vermicular’ means ‘worm-like’, and the ‘vermicular movement’ he refers to is the natural muscular contractions of the intestines, known today as peristalsis.

With plenty of clear warm water and soft dry cloths, I set to work, first to remove the foreign substances, and then to return the bowels. But alas! how much easier said than done.

Well, it’s not difficult to see how that might be the case.

By careful, patient washing and wiping, with the assistance of many willing hands, and as many sharp eyes, for more than  two hours I washed, wiped and picked, gently as could be of course, but to the last, many, very many of those bright, glimmering specks twinkled at me still.  

An appalling operation! The surgeon makes no mention of pain relief for the patient – given that he was some distance from an operating room it is quite possible that none was administered. Having a doctor washing and picking over your intestines inch by inch does not sound a lot of fun.

Over, and over again I went until patience seemed no longer a virtue, since doctor, assistants, and patient had no more of it left. Clearly it was a physical impossibility to remove all this fine grit and glass.

Today a surgeon would be unlikely to give up until every fragment had been removed – but in a more primitive surgical era time was of the essence, and Dr Fontaine was painfully aware that the longer the operation went on the more dangerous it became.

In returning the bowels (last that came out, first to go back), which was easily accomplished, many particles were found, some quite large, which had previously escaped detection. Still, I know that all had not been, and could not be, removed.

Dr Fontaine finally succeeded in getting the intestines returned to the abdomen. The skin wound was jagged, but the muscles within had been quite cleanly divided, which made it easier to close – a procedure he executed with the help of a colleague who had just arrived.

I secured the opening with two or three interrupted sutures passed through the thickness of the walls, the cut being barely two or two and a half inches long. These were supported by adhesive strips placed transversely, and the whole covered by cold water dressing.

The patient was instructed to stay in bed and remain totally quiet, and given large doses of opium.

He was allowed none but mild liquid diet — mostly fresh buttermilk; bowels kept entirely at rest by opium; and cold water was assiduously applied. This plan was rigidly followed for nearly a week. At the end of this time we concluded that all danger from inflammation was about over, and gave a dose of castor oil; after which opium was discontinued, and his diet gradually improved. The external wound was soon healed (in eight or ten days) and the man recovered without a bad symptom.

I find this quite astonishing.

It is believed that few persons, professional or not, who could have seen the situation up to the closing of that wound, would have hoped for half so much. The man is still alive, or was six months ago; has never been sick or incommoded since he got up to walk, now more than four years ago.

Dr Fontaine was rightly proud of his miraculous patient. But one thing still confused him:

Query. — What has become of that glass and sand? Escape was impossible. Absorption out of the question. Could it have been encysted?

An interesting question. What happens to fine particles of insoluble material when they are left inside the body? In the early 20th century bone meal (and even asbestos!) was sometimes used by surgeons in order to provoke adhesions, scar tissue which can form between adjacent structures inside the thorax or abdomen. The intestines are particularly prone to adhesions (a common side-effect of abdominal surgery) so my ill-informed guess would be that the sand and glass simply became encased in scar tissue. But actual medics are – as ever – encouraged to set me straight in the comments if desired.

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