The dreadful opening

In 1807 the Philadelphia Medical Museum was sent an extraordinary case report by a local doctor who had been ‘sent it by a friend’. Neither he nor anybody else appeared to know who had written the report, so its authenticity is doubtful – but the events it describes were certainly worth reproducing:

In the evening of the 26th of September, 1775, 1 was called in great haste, to James Langford, a young man in the 2lst year of his age, who had been maliciously stabbed with a knife in the left side of his belly. The wound was between two and three inches in length, running from the left os ilium [the left side of the pelvis] obliquely upwards towards the navel. I found him lying on the floor, weltering in his blood, with a large portion of his intestines forced through the wound; and I learnt, from the unfortunate youth himself, that, as soon as the wound was inflicted, the bowels began to appear; and, by the time I got to him, which could not exceed tea minutes, I verily believe, that the full half of the intestinal tube was protruded through the opening.

Good grief.

This I attributed, in some measure, to the fulness of the stomach; for, immediately before the accident happened, he had eaten a very hearty supper. The wound at first bled freely; but the hemorrhage was soon restrained by the pressure of the prolapsed intestines, which were, to a great degree, distended with air; and from this circumstance I was flattered with the best hopes that they had escaped the assassin’s knife; but, to my great disappointment, it proved otherwise, as will appear most evidently from the sequel of this narrative.

When the doctor examined his patient further, he found that his pulse was faint and quick, his skin cold and clammy, and he was labouring under ‘great languor, anxiety and pain’ around the chest. The thigh, leg and foot of the side which had been stabbed were all numb.

I ordered him to be conveyed to his bed in an horizontal posture, lest the raising of the body might encourage a farther descent of the parts, which still remained in the abdomen; and a fomentation of port wine, with warm water, to be got ready immediately, out of which a double flannel should be wrung, and applied directly to the prolapsed intestines, and renewed occasionally, to prevent them from getting too dry, as well as to preserve, as much as possible, their natural heat.

Natural or vital heat was an idea from ancient Greek medicine which persisted until the early nineteenth century. A common belief was that the body’s heat was generated by the heart and distributed to the rest of the body through the blood vessels. It is interesting that in 1775 (before the advent of antiseptic or aseptic medicine) the doctor pays more attention to such an antiquated notion than to basic hygiene.

The reduction of the displaced bowels was begun, with laying the patient’s legs over an assistant’s shoulders, who was desired to kneel upon the bed for that purpose, with his back towards him, and then the legs were brought forward as far as to the hams. By these means, the lower parts of the body were elevated, and, in consequence, the weight of the bowels falling back towards the chest, counteracted their further protrusion.

But that was just the start of this appalling operation.

While the patient continued in this position, I endeavoured, with my hands, to force the bowels back into their proper place; but soon found, from the quantity of them protruded, together with their great inflation, that a larger, or more extended pressure than my own hands could afford me, was necessary; and not thinking it prudent to employ any of the bystanders in so hazardous a task, lest, by their inexperience they might handle the bowels too roughly, I sent for two of my fellow-labourers in the care of the Hadcliffe Infirmary, to my assistance. 

With the patient waiting, lying on his back and presumably in considerable pain.

As soon as they came, the reduction was again attempted; one of us directing that portion of the bowel which was last protruded, while the two others made a gentle, regular, and circumscribed pressure from all sides towards the opening.

But alas! Not even the efforts of three doctors were sufficient…

But this endeavour not succeeding, convinced us, that it would be much safer to enlarge the wound, to facilitate the return of the prolapsed parts, than hazard the necessity of handling them too much, or exposing them too long to the circumambient air, either of which would, in all probability, have proved fatal. This being done accordingly, by continuing the wound in the same direction upwards, about two inches, the exposed bowels were easily and soon returned into the abdomen. 

The doctor then stitched the wound closed, leaving a small opening at the bottom to allow blood to drain from the cavity, and a dressing placed on top. The patient was allowed only gruel, panada (a thin porridge) and sago to eat, and water or thin gruel to drink.

The following day the patient was in a poor state, and the doctor ordered laxatives to be administered. The day after that the doctor visited again: 

The draughts he had taken had not yet moved him; therefore, I desired they might be continued, according to the general direction; and that, in case any stools should come off, to put them by, separately, for my inspection. By the time I made my evening visit, he had had two motions; in the first there was a good deal of fluid blood; with the last, but little, no more than to give it a tinge. He was evidently relieved by the evacuation; was calmer and more composed; his pulse was rather more up, and his skin warmer… When I came to loosen the bandage, I was greatly surprised to find it daubed all over with the discharge; but, as soon as the dressing was removed, there was no evidence wanting to assure me, that this discharge was in part faecal, not only from the colour and smell of it, but likewise from the sharp pain it had occasioned in passing through the wound. My hopes of his recovery now. began to fail me; however I resolved to persevere, and act as though I was sure of success.

The recovery was slow and rocky. On October 2^nd the physician made this report:

The discharge this morning from the sore, was exceedingly offensive, and when I had taken off the dressing, I was really astonished at the horrid appearance. The wound was burst open, in such a manner as to assume a circular form, and was rather more than three inches in the least diameter of it. In the base of this dreadful opening, there was nothing to be seen but the circumvolutions of the small guts; and how this amazing breach was to be restored, I could not easily conceive. Had any one taken a view of the wound at this time, who was unacquainted with the real progress of it, he must naturally have concluded, there had been a great loss of substance.

No further treatment was ordered, except that the wound was cleaned and redressed. The outlook for this patient was undoubtedly poor: he had suffered a major laceration of the bowel, and when faecal matter enters the abdominal cavity the result is often peritonitis – an infection which can quickly become systemic and fatal. Since no precautions were taken against infection it’s little short of miraculous that he didn’t die.

It was exceedingly satisfactory and pleasing to observe, from day to day, the progress nature made in renovating this formidable breach, and her means of accomplishing it; for, after a little time, the surface of the intestines looked florid, and began to pullulate, throwing up small grains of flesh from every point. These granules, daily increasing, united with each other, and after filling up the intervals between the circumvolutions of the bowels, became one uniform surface; which surface meeting with that of the raw edges of the integuments, they both adhered together, and became one continued sore. As the wound incarned [healed], the faecal discharge lessened daily, and about the twenty-second or twenty-third day, entirely ceased. I now allowed him chicken-broth, milk-porridge, calves-feet-jelly, &c.

I’m pretty sure that calves feet jelly is the last thing I’d feel like eating in those circumstances.

The wound was dressed once a day with dry lint only, and in seven weeks it was completely healed.