A few months ago I wrote about the criminal who was lucky to recover after inhaling a fake gold earring. By chance I’ve just come across another case report written by the same Victorian surgeon, Bernard Pitts. Not a well-known figure, principally because he wrote little and shunned publicity. But he seems to have been a very good operator, and a pioneer of abdominal surgery in an age when few dared rummage inside that part of the body. This report was published in the Proceedings of the Medical Society of London in 1884:
The following case is a very unusual one. I have not heard of any similar accident. Frances V., aged 46, a laundry-woman, has suffered from a right femoral hernia for twenty years.
A femoral hernia occurs when part of the abdominal contents, usually a loop of the intestines, bulges out through a structure known as the femoral canal, in the groin or upper thigh. It is more common in women than men, and obesity is a significant risk factor. Femoral hernias are particularly dangerous because the borders of the femoral canal are rigid, meaning that the intestine can easily become strangulated – that is, the blood supply is cut off, causing necrosis.
She wore a truss till three years ago. On Aug. 30th, 1880, she was admitted into Guy’s Hospital with symptoms of strangulation of three days’ duration.
Today a femoral hernia is likely to be treated as an emergency, and immediate surgery is typically recommended. So it’s pretty astonishing that this patient lived with one for two decades. Her condition would have been pretty serious after three days of strangulation, too – the affected section of bowel was at imminent risk of gangrene.
An operation was performed by Mr. Jacobson. The sac was very thick and the intestine dark. She left the hospital on Sept. 27th, wearing a truss. The hernia at the time of operation was about the size of two fists.
No details of the operation are given, but it is likely that the surgeon returned the intestine to the abdominal cavity and then inserted a couple of tough stitches into the margin of the femoral ring to tighten it and thus prevent recurrence. In 1880 this was a very serious and risky procedure – it was barely a decade since Joseph Lister had introduced the revolution of antiseptic surgery.
For one year after this she kept up the hernia with the truss, but subsequently the great increase in the size of the hernia rendered the truss useless. During the last winter she has suffered from a bad cough, and the hernia became as large as a child’s head, but always reducible.
That is a very large hernia. A chronic cough is another significant risk factor for this condition, because coughing briefly but dramatically increases the pressure inside the abdominal cavity, making the protrusion of its contents more likely.
Several small ulcers formed on the skin, which caused her to leave the truss off altogether. About nine o’clock on the evening of the 4th of last December the patient was going upstairs in her home at Kennington, when, whilst sneezing violently, she felt something give way suddenly in her right groin. She became very faint, but managed to walk to her bedroom, and then discovered that about a foot of intestine had escaped through a rent in the coverings of the hernia.
She made an attempt to return it, and sent for her medical man, who tried taxis for a short time, and then advised her removal to St. Thomas’s Hospital.
‘Taxis’ means that he tried to push the intestine back into the abdomen. Unsuccessfully, as it turned out.
She was brought to the hospital in a cab on a cold and frosty night. I saw her directly on her admission at twelve o’clock. She was an extremely stout woman, and suffering then from severe shock. An examination under ether was at once made on the bed, and one foot and a half of small intestine was found protruded through a rent in the skin, about an inch long, and situated a little above the old operation cicatrix.
‘Cicatrix’ is an old term for a scar.
There were one or two chronic, small ulcers to be seen on and near the lower part of the cicatrix. The exposed intestine was bruised, congested, dirty, and very cold.
A bad state of affairs. The ‘bruising’ suggests that there was already some degree of infarction, or loss of blood supply. The presence of dirt also indicated a strong possibility of infection.
A number of hairs and foreign particles were removed from the bowel and mesentery, which was then carefully cleansed with warm carbolic lotion. Failing to get the bowel back by taxis, the opening in the skin was enlarged freely, and a large quantity of small intestine escaped from the sac, at least four or five feet, together with the caecum.
Remember, this was all happening not in the operating theatre but at the patient’s bedside, probably in the reception area that Victorian hospitals typically reserved for emergency admissions.
A slight enlargement of the crural ring was made with the hernia knife, and by patient manipulation the intestines were returned into the abdominal cavity.
The crural or femoral ring is the upper (internal) opening of the femoral canal.
A sponge was placed in the opening, and the very thickened sac was dissected from its surroundings and removed; this involved the ligature of a considerable number of vessels. The sponge was then removed, drainage for the peritoneal cavity provided, and the cut edges of the sac brought together by very stout catgut. A large portion of redundant skin (including the cicatrix and the ulcerated parts) was then removed, and the edges of the wound brought together by silk sutures, and the wound dressed with carbolic gauze.
A striking feature of this operation is that the surgeon cut away a significant amount of tissue. The reason for this, I suspect, is that the hernia had been developing for so long that the overlying skin and soft tissue had stretched considerably, so it was necessary to trim it back once the bowel had been returned to the abdomen.
The patient slept a little during the night after a subcutaneous injection of morphia. On the morning of Dec. 5th the wound was dressed, the temperature being 100.4°. In the after-part of the day the breathing became very laboured. Pulse 132; temperature 102.4°; great lividity of countenance.
102.4°F is 39.1C: a fever edging towards the worrying end of the scale. It is possible, even likely, that she had an infection, particularly since the operation was performed in anything but aseptic conditions.
She was propped up in bed and brandy administered. The subcutaneous injections were discontinued. December 6th: Breathing decidedly better, but cough very troublesome. Temperature normal. The wound was dressed and the abdominal drain removed. After this she made a slow recovery, the temperature never reaching higher than 100°. She has been for some time convalescent and is wearing a truss.
It would be fair to say that she had a lucky escape, for several reasons. Even living for twenty years with an untreated femoral hernia is pretty remarkable – but she also survived two major operations at a time when anaesthesia was crude and abdominal surgery in its infancy.
And then there’s the sneeze. As the surgeon himself observes, ‘It certainly seems difficult to understand how such an accident as happened to this woman was possible.’ Admittedly I haven’t spent hours researching the subject, but before I came across this case I’d never heard of somebody sneezing their own guts out.