Stokes gives the case of a man who was severely crushed between the arms of a water-wheel of great size and the embankment on which the axle of the wheel was supported; a peculiar factor of the injury being that his heart was displaced from left to right. At the time of report, after recovery from the injury, the patient exhibited remarkable tolerance of great doses of digitalis. When not taking digitalis, his pulse was 100 to 120, regular, and never intermittent.

Hypertrophy of the Heart.—The heart of a man of ordinary size weighs nine ounces, and that of a woman eight; in cases of hypertrophy, these weights may be doubled, although weights above 25 ounces are rare. According to Osler, Beverly Robinson describes a heart weighing 53 ounces, and Dulles has reported one weighing 48 ounces. Among other modern records are the following: Fifty and one-half ounces, 57 ounces, and one weighing four pounds and six ounces. The Ephemerides contains an incredible account of a heart that weighed 14 pounds. Favell describes a heart that only weighed 3 1/2 ounces.

Wounds of the aorta are almost invariably fatal, although cases are recorded by Pelletan, Heil, Legouest, and others, in which patients survived such wounds for from two months to several years. Green mentions a case of stab-wound in the suprasternal fossa. The patient died one month after of another cause, and at the postmortem examination the aorta was shown to have been opened; the wound in its walls was covered with a spheric, indurated coagulum. No attempt at union had been made.

Zillner observed a penetrating wound of the aorta after which the patient lived sixteen days, finally dying of pericarditis. Zillner attributed this circumstance to the small size of the wound, atheroma and degeneration of the aorta and slight retraction of the inner coat, together with a possible plugging of the pericardial opening. In 1880 Chiari said that while dissecting the body of a man who died of phthisis, he found a false aneurysm of the ascending aorta with a transverse rupture of the vessel by the side of it, which had completely cicatrized. Hill reports the case of a soldier who was stabbed with a bowie-knife nine inches long and three inches wide. The blade passed through the diaphragm, cut off a portion of the liver, and severed the descending aorta at a point about the 7th dorsal vertebra; the soldier lived over three hours after complete division of this important vessel. Heil reports the case of a man of thirty-two, a soldier in the Bavarian army, who, in a quarrel in 1812, received a stab in the right side. The instrument used was a common table-knife, which was passed between the 5th and 6th ribs, entering the left lung, and causing copious hemorrhage. The patient recovered in four months, but suffered from amaurosis which had commenced at the time of the stab. Some months afterward he contracted pneumonia and was readmitted to the hospital, dying in 1813. At the postmortem the cicatrix in the chest was plainly visible, and in the ascending aorta there was seen a wound, directly in the track of the knife, which was of irregular border and was occupied by a firm coagulum of blood. The vessel had been completely penetrated, as, by laying it open, an internal cicatrix was found corresponding to the other. Fatal hemorrhage had been avoided in this case by the formation of coagulum in the wound during the syncope immediately following the stab, possibly aided by extended exposure to cold.

Sundry Cases.—Sandifort mentions a curious case of coalescence of the esophagus and aorta, with ulceration and consequent rupture of the aorta, the hemorrhage proceeding from the stomach at the moment of rupture.

Heath had a case of injury to the external iliac artery from external violence, with subsequent obliteration of the vessel. When the patient was discharged no pulse could be found in the leg.

Dismukes reports a case in which the patient had received 13 wounds, completely severing the subclavian artery, and, without any medical or surgical aid, survived the injury two hours.

Illustrative of the degree of hemorrhage which may follow an injury so slight as that of falling on a needle we cite an instance, reported by a French authority, of a child who picked up a needle, and, while running with it to its mother, stumbled and fell, the needle penetrating the 4th intercostal space, the broadened end of it remaining outside of the wound. The mother seized the needle between her teeth and withdrew it, but the child died, before medical aid could be summoned, from internal hemorrhage, causing pulmonary pressure and dyspnea.

Rupture of the esophagus is attributable to many causes. Dryden mentions vomiting as a cause, and Guersant reports the case of a little girl of seven, who, during an attack of fever, ruptured her esophagus by vomiting. In 1837 Heyfelder reported the case of a drunkard, who, in a convulsion, ruptured his esophagus and died. Williams mentions a case in which not only the gullet, but also the diaphragm, was ruptured in vomiting. In this country, Bailey and Fitz have recorded cases of rupture of the esophagus. Brewer relates a parallel instance of rupture from vomiting. All the foregoing cases were linear ruptures, but there is a unique case given by Boerhaave in 1724, in which the rent was transverse. Ziemssen and Mackenzie have both translated from the Latin the report of this case which is briefly as follows: The patient, Baron de Wassenaer, was fifty years of age, and, with the exception that he had a sense of fulness after taking moderate meals, he was in perfect health. To relieve this disagreeable feeling he was in the habit of taking a copious draught of an infusion of "blessed thistle" and ipecacuanha. One day, about 10.30 in the evening, when he had taken no supper, but had eaten a rather hearty dinner, he was bothered by a peculiar sensation in his stomach, and to relieve this he swallowed about three tumbler-fuls of his usual infusion, but to no avail. He then tried to excite vomiting by tickling the fauces, when, in retching, he suddenly felt a violent pain; he diagnosed his own case by saying that it was "the bursting of something near the pit of the stomach." He became prostrated and died in eighteen and one-half hours; at the necropsy it was seen that without any previously existing signs of disease the esophagus had been completely rent across in a transverse direction.

Schmidtmuller mentions separation of the esophagus from the stomach; and Flint reports the history of a boy of seven who died after being treated for worms and cerebral symptoms. After death the contents of the stomach were found in the abdominal cavity, and the esophagus was completely separated from the stomach. Flint believed the separation was postmortem, and was possibly due to the softening of the stomach by the action of the gastric acids. In this connection may be mentioned the case reported by Hanford of a man of twenty-three who had an attack of hematemesis and melanema two years before death. A postmortem was made five hours after death, and there was so much destruction of the stomach by a process resembling digestion that only the pyloric and cardiac orifices were visible. Hanford suggests that this was an instance of antemortem digestion of the stomach which physiologists claim is impossible.

Nearly all cases of rupture of the stomach are due to carcinoma, ulcer, or some similar condition, although there have been instances of rupture from pressure and distention. Wunschheim reports the case of a man of fifty-two who for six months presented symptoms of gastric derangement, and who finally sustained spontaneous rupture of the posterior border of the stomach due to overdistention. There was a tear two inches long, beginning near the cardiac end and running parallel to the lesser curvature. The margin of the tear showed no evidence of digestion. There were obstructing esophageal neoplasms about 10 1/3 inches from the teeth, which prevented vomiting. In reviewing the literature Wunschheim found only six cases of spontaneous rupture of the stomach. Arton reports the case of a negro of fifty who suffered from tympanites. He was a hard drinker and had been aspirated several times, gas heavily laden with odors of the milk of asafetida being discharged with a violent rush. The man finally died of his malady, and at postmortem it was found that his stomach had burst, showing a slit four inches long. The gall bladder contained two quarts of inspissated bile. Fulton mentions a case of rupture of the esophageal end of a stomach in a child. The colon was enormously distended and the walls thickened. When three months old it was necessary to puncture the bowel for distention. Collins describes spontaneous rupture of the stomach in a woman of seventy-four, the subject of lateral curvature of the spine, who had frequent attacks of indigestion and tympanites. On the day of death there was considerable distention, and a gentle purgative and antispasmodic were given. Just before death a sudden explosive sound was heard, followed by collapse. A necropsy showed a rupture two inches long and two inches from the pyloric end. Lallemand mentions an instance of the rupture of the coats of the stomach by the act of vomiting. The patient was a woman who had suffered with indigestion five or six months, but had been relieved by strict regimen. After indulging her appetite to a greater extent than usual, she experienced nausea, and made violent and ineffectual efforts to discharge the contents of the stomach. While suffering great agony she experienced a sensation as if something was tearing in the lower part of her belly. The woman uttered several screams, fell unconscious, and died that night. Postmortem examination showed that the anterior and middle part of the stomach were torn obliquely to the extent of five inches. The tear extended from the smaller toward the greater curvature. The edges were thin and irregular and presented no marks of disease. The cavity of the peritoneum was full of half-digested food. The records of St. Bartholomew's Hospital, London, contain the account of a man of thirty-four who for two years had been the subject of paroxysmal pain in the stomach. The pains usually continued for several hours and subsided with vomiting. At St. Bartholomew's he had an attack of vomiting after a debauch. On the following day he was seized with vomiting accompanied by nausea and flatus, and after a sudden attack of pain at the pit of the stomach which continued for two hours, he died. A ragged opening at the esophageal orifice, on the anterior surface of the stomach was found. This tear extended from below the lesser curvature to its extremity, and was four inches long. There were no signs of gastric carcinoma or ulcer.

Clarke reports the case of a Hindoo of twenty-two, under treatment for ague, who, without pain or vomiting, suddenly fell into collapse and died twenty-three hours later. He also mentions a case of rupture of the stomach of a woman of uncertain history, who was supposed to have died of cholera. The examination of the bodies of both cases showed true rupture of the stomach and not mere perforation. In both cases, at the time of rupture, the stomach was empty, and the gastric juice had digested off the capsules of the spleens, thus allowing the escape of blood into the abdominal cavities. The seats of rupture were on the anterior walls. In the first case the coats of the stomach were atrophied and thin. In the second the coats were healthy and not even softened. There was absence of softening, erosion, or rupture on the posterior walls.

As illustrative of the amount of paralytic distention that is possible, Bamberger mentions a case in which 70 pounds of fluid filled the stomach.

Voluntary Vomiting.—It is an interesting fact that some persons exhibit the power of contracting the stomach at will and expelling its contents without nausea. Montegre mentions a distinguished member of the Faculty of Paris, who, by his own volition and without nausea or any violent efforts, could vomit the contents of his stomach. In his translation of "Spallanzani's Experiments on Digestion" Sennebier reports a similar instance in Geneva, in which the vomiting was brought about by swallowing air.

In discussing wounds and other injuries of the stomach no chapter would be complete without a description of the celebrated case of Alexis St. Martin, whose accident has been the means of contributing so much to the knowledge of the physiology of digestion. This man was a French Canadian of good constitution, robust and healthy, and was employed as a voyageur by the American Fur Company. On June 16, 1822, when about eighteen years of age, he was accidentally wounded by a discharge from a musket. The contents of the weapon, consisting of powder and duck-shot, entered his left side from a distance of not more than a yard off. The charge was directed obliquely forward and inward, literally blowing off the integument and muscles for a space about the size of a man's hand, carrying away the anterior half of the 6th rib, fracturing the 5th rib, lacerating the lower portion of the lowest lobe of the left lung, and perforating the diaphragm and the stomach. The whole mass of the discharge together with fragments of clothing were driven into the muscles and cavity of the chest. When first seen by Dr. Beaumont about a half hour after the accident, a portion of the lung, as large as a turkey's egg was found protruding through the external wound. The protruding lung was lacerated and burnt. Immediately below this was another protrusion, which proved to be a portion of the stomach, lacerated through all its coats. Through an orifice, large enough to admit a fore-finger, oozed the remnants of the food he had taken for breakfast. His injuries were dressed; extensive sloughing commenced, and the wound became considerably enlarged. Portions of the lung, cartilages, ribs, and of the ensiform process of the sternum came away. In a year from the time of the accident, the wound, with the exception of a fistulous aperture of the stomach and side, had completely cicatrized. This aperture was about 2 1/2 inches in circumference, and through it food and drink constantly extruded unless prevented by a tent-compress and bandage. The man had so far recovered as to be able to walk and do light work, his digestion and appetite being normal. Some months later a small fold or doubling of the stomachal coats slightly protruded until the whole aperture was filled, so as to supersede the necessity of a compress, the protruding coats acting as a valve when the stomach was filled. This valvular protrusion was easily depressed by the finger. St. Martin suffered little pain except from the depression of the skin. He took his food and drink like any healthy person, and for eleven years remained under Dr. Beaumont's own care in the Doctor's house as a servant. During this time were performed the experiments on digestion which are so well known. St. Martin was at all times willing to lend himself in the interest of physiologic science. In August, 1879, The Detroit Lancet contains advices that St. Martin was living at that time at St. Thomas, Joliette County, Province of Quebec, Canada. At the age of seventy-nine he was comparatively strong and well, and had always been a hard worker. At this time the opening in the stomach was nearly an inch in diameter, and in spite of its persistence his digestion had never failed him.

Spizharny relates a remarkable case of gastric fistula in the loin, and collects 61 cases of gastric fistula, none of which opened in the loin. The patient was a girl of eighteen, who had previously had perityphlitis, followed by abscesses about the navel and lumbar region. Two fistulae were found in the right loin, and were laid open into one canal, which, after partial resection of the 12th rib, was dilated and traced inward and upward, and found to be in connection with the stomach. Food was frequently found on the dressings, but with the careful use of tampons a cure was effected.

In the olden times wounds of the stomach were not always fatal. The celebrated anatomist, Fallopius, successfully treated two cases in which the stomach was penetrated so that food passed through the wound. Jacobus Orthaeus tells us that in the city of Fuldana there was a soldier who received a wound of the stomach, through which food passed immediately after being swallowed; he adds that two judicious surgeons stitched the edges of the wound to the integuments, thereby effecting a cure. There is another old record of a gastric fistula through which some aliment passed during the period of eleven years.

Archer tells of a man who was stabbed by a negro, the knife entering the cartilages of the 4th rib on the right side, and penetrating the stomach to the extent of two inches at a point about two inches below the xiphoid cartilage. The stomachal contents, consisting of bacon, cabbage, and cider, were evacuated. Shortly after the reception of the injury, an old soldier sewed up the wound with an awl, needle, and wax-thread; Archer did not see the patient until forty-eight hours afterward, at which time he cleansed and dressed the wound. After a somewhat protracted illness the patient recovered, notwithstanding the extent of injury and the primitive mode of treatment.

Travers mentions the case of a woman of fifty-three who, with suicidal intent, divided her abdominal parietes below the navel with a razor, wounding the stomach in two places. Through the wound protruded the greater part of the larger curvature of the stomach; the arch of the colon and the entire greater omentum were both strangulated. A small portion of the coats of the stomach, including the wound, was nipped up, a silk ligature tied about it, and the entrails replaced. Two months afterward the patient had quite recovered, though the ligature of the stomach had not been seen in the stool. Clements mentions a robust German of twenty-two who was stabbed in the abdomen with a dirk, producing an incised wound of the stomach. The patient recovered and was returned to duty the following month.

There are many cases on record in which injury of the stomach has been due to some mistake or accident in the juggling process of knife-swallowing or sword-swallowing. The records of injuries of this nature extend back many hundred years, and even in the earlier days the delicate operation of gastrotomy, sometimes with a successful issue, was performed upon persons who had swallowed knives. Gross mentions that in 1502 Florian Mathias of Bradenberg removed a knife nine inches long from the stomach of a man of thirty-six, followed by a successful recovery. Glandorp, from whom, possibly, Gross derived his information, relates this memorable case as being under the direction of Florianus Matthaesius of Bradenburg. The patient, a native of Prague, had swallowed a knife eight or nine inches long, which lay pointing at the superior portion of the stomach. After it had been lodged in this position for seven weeks and two days gastrotomy was performed, and the knife extracted; the patient recovered. In 1613 Crollius reports the case of a Bohemian peasant who had concealed a knife in his mouth, thinking no one would suspect he possessed the weapon; while he was excited it slipped into the stomach, from whence it subsequently penetrated through to the skin; the man recovered. There is another old case of a man at Prague who swallowed a knife which some few weeks afterward made its exit from an abdominal abscess. Gooch quotes the case of a man, belonging to the Court of Paris, who, nine months after swallowing a knife, voided it at the groin. In the sixteenth century Laurentius Joubert relates a similar case, the knife having remained in the body two years. De Diemerbroeck mentions the fact that a knife ten inches long was extracted by gastrotomy, and placed among the rarities in the anatomic chamber of the University at Leyden. The operation was done in 1635 at Koenigsberg, by Schwaben, who for his surgical prowess was appointed surgeon to the King of Poland. The patient lived eight years after the operation.

It is said that in 1691, while playing tricks with a knife 6 1/2 inches long, a country lad of Saxony swallowed it, point first. He came under the care of Weserern, physician to the Elector of Brandenburgh, who successfully extracted it, two years and seven months afterward, from the pit of the lad's stomach. The horn haft of the knife was considerably digested. In 1720 Hubner of Rastembourg operated on a woman who had swallowed an open knife. After the incision it was found that the knife had almost pierced the stomach and had excited a slight suppuration. After the operation recovery was very prompt.

Bell of Davenport, Iowa, performed gastrotomy on a man, who, while attempting a feat of legerdemain, allowed a bar of lead, 10 1/8 inches long, 1 1/2 inches wide, and 9 1/2 ounces in weight, to slip into his stomach. The bar was removed and the patient recovered. Gussenbauer gives an account of a juggler who turned his head to bow an acknowledgment of applause while swallowing a sword; he thus brought his upper incisors against the sword, which broke off and slipped into his stomach. To relieve suffocation the sword was pushed further down. Gastrotomy was performed, and the piece of sword 11 inches long was extracted; as there was perforation of the stomach before the operation, the patient died of peritonitis.

An hour after ingestion, Bernays of St. Louis successfully removed a knife 9 1/2 inches long. By means of an army-bullet forceps the knife was extracted easily through an incision 5/8 inch long in the walls of the stomach. Gross speaks of a man of thirty who was in the habit of giving exhibitions of sword-swallowing in public houses, and who injured his esophagus to such an extent as to cause abscess and death. In the Journal of the American Medical Association, March 1, 1896, there is an extensive list of gastrotomies performed for the removal of knives and other foreign bodies, from the seventeenth century to the present time.

The physiologic explanation of sword-swallowing is quite interesting. We know that when we introduce the finger, a spoon, brush, etc., into the throat of a patient, we cause extremely disagreeable symptoms. There is nausea, gagging, and considerable hindrance with the function of respiration. It therefore seems remarkable that there are people whose physiologic construction is such that, without apparent difficulty, they are enabled to swallow a sword many inches long. Many of the exhibitionists allow the visitors to touch the stomach and outline the point of the sabre through the skin. The sabre used is usually very blunt and of rounded edges, or if sharp, a guiding tube of thin metal is previously swallowed. The explanation of these exhibitions is as follows: The instrument enters the mouth and pharynx, then the esophagus, traverses the cardiac end of the stomach, and enters the latter as far as the antrum of the pylorus, the small culdesac of the stomach. In their normal state in the adult these organs are not in a straight line, but are so placed by the passage of the sword. In the first place the head is thrown back, so that the mouth is in the direction of the esophagus, the curves of which disappear or become less as the sword proceeds; the angle that the esophagus makes with the stomach is obliterated, and finally the stomach is distended in the vertical diameter and its internal curve disappears, thus permitting the blade to traverse the greater diameter of the stomach. According to Guyot-Daubes, these organs, in a straight line, extend a distance of from 55 to 62 cm., and consequently the performer is enabled to swallow an instrument of this length. The length is divided as follows:—

Mouth and pharynx, . . . . . . . . . . . . 10 to 12 cm. Esophagus, . . . . . . . . . . . . . . . . 25 to 28 cm. Distended stomach, . . . . . . . . . . . . 20 to 22 cm. ——————- 55 to 62 cm.

These acrobats with the sword have rendered important service to medicine. It was through the good offices of a sword-swallower that the Scotch physician, Stevens, was enabled to make his experiments on digestion. He caused this assistant to swallow small metallic tubes pierced with holes. They were filled, according to Reaumur's method, with pieces of meat. After a certain length of time he would have the acrobat disgorge the tubes, and in this way he observed to what degree the process of digestion had taken place. It was also probably the sword-swallower who showed the physicians to what extent the pharynx could be habituated to contact, and from this resulted the invention of the tube of Faucher, the esophageal sound, ravage of the stomach, and illumination of this organ by electric light. Some of these individuals also have the faculty of swallowing several pebbles, as large even as hen's eggs, and of disgorging them one by one by simple contractions of the stomach. From time to time individuals are seen who possess the power of swallowing pebbles, knives, bits of broken glass, etc., and, in fact, there have been recent tricky exhibitionists who claimed to be able to swallow poisons, in large quantities, with impunity. Henrion, called "Casaandra," a celebrated example of this class, was born at Metz in 1761. Early in life he taught himself to swallow pebbles, sometimes whole and sometimes after breaking them with his teeth. He passed himself off as an American savage; he swallowed as many as 30 or 40 large pebbles a day, demonstrating the fact by percussion on the epigastric region. With the aid of salts he would pass the pebbles and make them do duty the next day. He would also swallow live mice and crabs with their claws cut. It was said that when the mice were introduced into his mouth, they threw themselves into the pharynx where they were immediately suffocated and then swallowed. The next morning they would be passed by the rectum flayed and covered with a mucous substance. Henrion continued his calling until 1820, when, for a moderate sum, he was induced to swallow some nails and a plated iron spoon 5 1/2 inches long and one inch in breadth. He died seven days later.

According to Bonet, there was a man by the name of Pichard who swallowed a razor and two knives in the presence of King Charles II of England, the King himself placing the articles into the man's mouth. In 1810 Babbington and Curry are accredited with citing the history of an American sailor in Guy's Hospital, London, who frequently swallowed penknives for the amusement of his audiences. At first he swallowed four, and three days later passed them by the anus; on another occasion he swallowed 14 of different sizes with the same result. Finally he attempted to gorge himself with 17 penknives, but this performance was followed by horrible pains and alarming abdominal symptoms. His excrement was black from iron. After death the cadaver was opened and 14 corroded knives were found in the stomach, some of the handles being partly digested; two were found in the pelvis and one in the abdominal cavity. Pare recalls the instance of a shepherd who suffered distressing symptoms after gulping a knife six inches long. Afterward the knife was abstracted from his groin. Fabricius Hildanus cites a somewhat similar case.

Early in the century there was a man known as the "Yankee knife-swallower," whose name was John Cummings, an American sailor, who had performed his feats in nearly all the ports of the world. One of his chief performances was swallowing a billiard ball. Poland mentions a man (possibly Cummings) who, in 1807, was admitted to Guy's Hospital with dyspeptic symptoms which he attributed to knife-swallowing. His story was discredited at first; but after his death, in March, 1809, there were 30 or 40 fragments of knives found in his stomach. One of the back-springs on a knife had transfixed the colon and rectum. In the Edinburgh Philosophical Journal for 1825 there is an account of a juggler who swallowed a knife which remained in his stomach and caused such intense symptoms that gastrotomy was advised; the patient, however, refused operation.

Drake reports a curious instance of polyphagia. The person described was a man of twenty-seven who pursued the vocation of a "sword-swallower." He had swallowed a gold watch and chain with a seal and key attached; at another time he swallowed 34 bullets and voided them by the anus. At Poughkeepsie, N.Y., in August, 1819, in one day and night he swallowed 19 pocket-knives and 41 copper cents. This man had commenced when a lad of fifteen by swallowing marbles, and soon afterward a small penknife. After his death his esophagus was found normal, but his stomach was so distended as to reach almost to the spine of the ilium, and knives were found in the stomach weighing one pound or more. In his exhibitions he allowed his spectators to hear the click of the knives and feel them as low down as the anterior superior spine of the ilium.

The present chief of the dangerous "profession" of sword-swallowing is Chevalier Cliquot, a French Canadian by birth, whose major trick is to swallow a real bayonet sword, weighted with a cross-bar and two 18-pound dumbbells. He can swallow without difficulty a 22-inch cavalry sword; formerly, in New York, he gave exhibitions of swallowing fourteen 19-inch bayonet swords at once. A negro, by the name of Jones, exhibiting not long since in Philadelphia, gave hourly exhibitions of his ability to swallow with impunity pieces of broken glass and china.

Foreign Bodies in the Alimentary Canal.—In the discussion of the foreign bodies that have been taken into the stomach and intestinal tract possibly the most interesting cases, although the least authentic, are those relating to living animals, such as fish, insects, or reptiles. It is particularly among the older writers that we find accounts of this nature. In the Ephemerides we read of a man who vomited a serpent that had crept into his mouth, and of another person who ejected a beetle that had gained entrance in a similar manner. From the same authority we find instances of the vomiting of live fish, mice, toads, and also of the passage by the anus of live snails and snakes. Frogs vomited are mentioned by Bartholinus, Dolaeus, Hellwigius, Lentilus, Salmuth, and others. Vege mentions a man who swallowed a young chicken whole. Paullini speaks of a person who, after great pain, vomited a mouse which he had swallowed. Borellus, Bartholinus, Thoner, and Viridet, are among the older authorities mentioning persons who swallowed toads. Hippocrates speaks of asphyxia from a serpent which had crawled into the mouth.

Borellus states that he knew a case of a person who vomited a salamander. Plater reports the swallowing of eels and snails. Rhodius mentions persons who have eaten scorpions and spiders with impunity. Planchon writes of an instance in which a live spider was ejected from the bowel; and Colini reports the passage of a live lizard which had been swallowed two days before, and there is another similar case on record. Marcellus Donatus records an instance in which a viper, which had previously crawled into the mouth, had been passed by the anus. There are also recorded instances in French literature in which persons affected with pediculosis, have, during sleep, unconsciously swallowed lice which were afterward found in the stools.

There is an abundance of cases in which leeches have been accidentally swallowed. Pliny, Aetius, Dioscorides, Scribonius-Largus, Celsus, Oribasius, Paulus Aegineta, and others, describe such cases. Bartholinus speaks of a Neapolitan prince who, while hunting, quenched his thirst in a brook, putting his mouth in the running water. In this way he swallowed a leech, which subsequently caused annoying hemorrhage from the mouth. Timaeus mentions a child of five who swallowed several leeches, and who died of abdominal pains, hemorrhage, and convulsions. Rhodius, Riverius, and Zwinger make similar observations. According to Baron Larrey the French soldiers in Napoleon's Egyptian campaign occasionally swallowed leeches. Grandchamp and Duval have commented on curious observations of leeches in the digestive tract. Dumas and Marques also speak of the swallowing of leeches. Colter reports a case in which beetles were vomited. Wright remarks on Banon's case of fresh-water shrimps passed from the human intestine. Dalton, Dickman, and others, have discussed the possibility of a slug living in the stomach of man. Pichells speaks of a case in which beetles were expelled from the stomach; and Pigault gives an account of a living lizard expelled by vomiting. Fontaine, Gaspard, Vetillart, Ribert, MacAlister, and Waters record cases in which living caterpillars have been swallowed.

Sundry Cases.—The variety of foreign bodies that have been swallowed either accidentally or for exhibitional or suicidal purposes is enormous. Nearly every imaginable article from the minutest to the most incredible size has been reported. To begin to epitomize the literature on this subject would in itself consume a volume, and only a few instances can be given here, chosen in such a way as to show the variety, the effects, and the possibilities of their passage through the intestinal canal.

Chopart says that in 1774 the belly of a ravenous galley-slave was opened, and in the stomach were found 52 foreign bodies, including a barrel-hoop 19 inches long, nails, pieces of pipe, spoons, buckles, seeds, glass, and a knife. In the intestines of a person Agnew found a pair of suspenders, a mass of straw, and three roller-bandages, an inch in width and diameter. Velpeau mentions a fork which was passed from the anus twenty months after it was swallowed. Wilson mentions an instance of gastrotomy which was performed for the extraction of a fork swallowed sixteen years before. There is an interesting case in which, in a delirium of typhoid fever, a girl of twenty-two swallowed two iron forks, which were subsequently expelled through an abdominal abscess. A French woman of thirty-five, with suicidal intent, swallowed a four-pronged fork, which was removed four years afterward from the thigh. For two years she had suffered intense pain in both thighs. In the Royal College of Surgeons in London there is a steel button-hook 3 1/2 inches in length which was accidentally swallowed, and was passed three weeks later by the anus, without having given rise to any symptom.

Among the insane a favorite trait seems to be swallowing nails. In the Philosophical Transactions is an account of the contents of the stomach of an idiot who died at thirty-three. In this organ were found nine cart-wheel nails, six screws, two pairs of compasses, a key, an iron pin, a ring, a brass pommel weighing nine ounces, and many other articles. The celebrated Dr. Lettsom, in 1802, spoke of an idiot who swallowed four pounds of old nails and a pair of compasses. A lunatic in England e swallowed ten ounces of screws and bits of crockery, all of which were passed by the anus. Boardman gives an account of a child affected with hernia who swallowed a nail 2 1/2 inches long. In a few days the nail was felt in the hernia, but in due time it was passed by the rectum. Blower reports an account of a nail passing safely through the alimentary canal of a baby. Armstrong mentions an insane hair-dresser of twenty-three, in whose stomach after death were found 30 or more spoon handles, 30 nails, and other minor articles.

Closmadenc reported a remarkable case which was extensively quoted. The patient was an hysteric young girl, an inmate of a convent, to whom he was called to relieve a supposed fit of epilepsy. He found her half-asphyxiated, and believed that she had swallowed a foreign body. He was told that under the influence of exaggerated religious scruples this girl inflicted penance upon herself by swallowing earth and holy medals. At the first dose of the emetic, the patient made a strong effort to vomit, whereupon a cross seven cm. long appeared between her teeth. This was taken out of her mouth, and with it an enormous rosary 220 cm. long, and having seven medals attached to it. Hunt recites a case occurring in a pointer dog, which swallowed its collar and chain, only imperfectly masticating the collar. The chain and collar were immediately missed and search made for them. For several days the dog was ill and refused food. Finally the gamekeeper saw the end of the chain hanging from the dog's anus, and taking hold of it, he drew out a yard of chain with links one inch long, with a cross bar at the end two inches in length; the dog soon recovered. The collar was never found, and had apparently been digested or previously passed.

Fear of robbery has often led to the swallowing of money or jewelry. Vaillant, the celebrated doctor and antiquarian, after a captivity of four months in Algiers, was pursued by Tunis pirates, and swallowed 15 medals of gold; shortly after arriving at Lyons he passed them all at stool. Fournier and Duret published the history of a galley slave at Brest in whose stomach were found 52 pieces of money, their combined weight being one pound, 10 1/4 ounces. On receiving a sentence of three years' imprisonment, an Englishman, to prevent them being taken from him, swallowed seven half-crowns. He suffered no bad effects, and the coins not appearing the affair was forgotten. While at stool some twenty months afterward, having taken a purgative for intense abdominal pain, the seven coins fell clattering into the chamber. Hevin mentions the case of a man who, on being captured by Barbary pirates, swallowed all the money he had on his person. It is said that a certain Italian swallowed 100 louis d'ors at a time.

It occasionally happens that false teeth are accidentally swallowed, and even passed through the intestinal tract. Easton mentions a young man who accidentally swallowed some artificial teeth the previous night, and, to further their passage through the bowel, he took a dose of castor oil. When seen he was suffering with pain in the stomach, and was advised to eat much heavy food and avoid aperients. The following day after several free movements he felt a sharp pain in the lower part of his back. A large enema was given and the teeth and plate came away. The teeth were cleansed and put back in his mouth, and the patient walked out. Nine years later the same accident again happened to the man but in spite of treatment nothing was seen of the teeth for a month afterward, when a body appeared in the rectum which proved to be a gold plate with the teeth in it. In The Lancet of December 10, 1881, there is an account of a vulcanite tooth-plate which was swallowed and passed forty-two hours later. Billroth mentions an instance of gastrotomy for the removal of swallowed artificial teeth, with recovery; and another case in which a successful esophagotomy was performed. Gardiner mentions a woman of thirty-three who swallowed two false teeth while supping soup. A sharp angle of the broken plate had caught in a fold of the cardiac end of the stomach and had caused violent hematemesis. Death occurred seventeen hours after the first urgent symptoms.

In the Museum of the Royal College of Surgeons in London there is an intestinal concretion weighing 470 grains, which was passed by a woman of seventy who had suffered from constipation for many years. Sixteen years before the concretion was passed she was known to have swallowed a tooth. At one side of the concretion a piece had been broken off exposing an incisor tooth which represented the nucleus of the formation. Manasse recently reported the case of a man of forty-four whose stomach contained a stone weighing 75 grams. He was a joiner and, it was supposed, habitually drank some alcoholic solution of shellac used in his trade. Quite likely the shellac had been precipitated in the stomach and gave rise to the calculus.

Berwick mentions a child of eight months who was playing with a detached organ-handle, and put it in its mouth. Seeing this the mother attempted to secure the handle, but it was pushed into the esophagus. A physician was called, but nothing was done, and the patient seemed to suffer little inconvenience. Three days later the handle was expelled from the anus. Teakle reports the successful passage through the alimentary canal of the handle of a music-box. Hashimoto, Surgeon-General of the Imperial Japanese Army, tells of a woman of forty-nine who was in the habit of inducing vomiting by irritating her fauces and pharynx with a Japanese toothbrush—a wooden instrument six or seven inches long with bristles at one end. In May, 1872, she accidentally swallowed this brush. Many minor symptoms developed, and in eleven months there appeared in the epigastric region a fluctuating swelling, which finally burst, and from it extended the end of the brush. After vainly attempting to extract the brush the attending physician contented himself with cutting off the projecting portion. The opening subsequently healed; and not until thirteen years later did the pain and swelling return. On admission to the hospital in October, 1888, two fistulous openings were seen in the epigastric region, and the foreign body was located by probing. Finally, on November 19, 1888, the patient was anesthetized, one of the openings enlarged, and the brush extracted. Five weeks later the openings had all healed and the patient was restored to health.

Garcia reports an interesting instance of foreign body in a man between forty-five and fifty. This man was afflicted with a syphilitic affection of the mouth, and he constructed a swab ten inches long with which to cleanse his fauces. While making the application alone one day, a spasmodic movement caused him to relinquish his grasp on the handle, and the swab disappeared. He was almost suffocated, and a physician was summoned; but before his arrival the swab had descended into the esophagus. Two weeks later, gastro-peritoneal symptoms presented, and as the stick was located, gastrotomy was proposed; the patient, however, would not consent to an operation. On the twenty-sixth day an abscess formed on the left side below the nipple, and from it was discharged a large quantity of pus and blood. Four days after this, believing himself to be better, the man began to redress the wound, and from it he saw the end of a stick protruding. A physician was called, and by traction the stick was withdrawn from between the 3d and 4th ribs; forty-nine days after the accident the wound had healed completely. Two years afterward the patient had an attack of cholera, but in the fifteen subsequent years he lived an active life of labor.

Occasionally an enormous mass of hair has been removed from the stomach. A girl of twenty a with a large abdominal swelling was admitted to a hospital. Her illness began five years previously, with frequent attacks of vomiting, and on three occasions it was noticed that she became quite bald. Abdominal section was performed, the stomach opened, and from it was removed a mass of hair which weighed five pounds and three ounces. A good recovery ensued. In the Museum of St. George's Hospital, London, are masses of hair and string taken from the stomach and duodenum of a girl of ten. It is said that from the age of three the patient had been in the habit of eating these articles. There is a record in the last century of a boy of sixteen who ate all the hair he could find; after death his stomach and intestines were almost completely lined with hairy masses. In the Journal of the American Medical Association, March 1, 1896, there is a report of a case of hair-swallowing.

Foreign Bodies in the Intestines.—White relates the history of a case in which a silver spoon was swallowed and successfully excised from the intestinal canal. Houston mentions a maniac who swallowed a rusty iron spoon 11 inches long. Fatal peritonitis ensued and the spoon was found impacted in the last acute turn of the duodenum. In 1895, in London, there was exhibited a specimen, including the end of the ileum with the adjacent end of the colon, showing a dessert spoon which was impacted in the latter. The spoon was seven inches long, and its bowl measured 1 1/2 inches across. There was much ulceration of the mucous membrane. This spoon had been swallowed by a lunatic of twenty-two, who had made two previous ineffectual attempts at suicide. Mason describes the case of a man of sixty-five who, after death by strangulated hernia, was opened, and two inches from the ileocecal valve was found an earthen egg-cup which he had swallowed. Mason also relates the instance of a man who swallowed metal balls 2 1/2 inches in diameter; and the case of a Frenchman who, to prevent the enemy from finding them, swallowed a box containing despatches from Napoleon. He was kept prisoner until the despatches were passed from his bowels. Denby discovered a large egg-cup in the ileum of a man. Fillion mentions an instance of recovery following the perforation of the jejunum by a piece of horn which had been swallowed. Madden tells of a person, dying of intestinal obstruction, in whose intestines were found several ounces of crude mercury and a plum-stone. The mercury had evidently been taken for purgative effect. Rodenbaugh mentions a most interesting case of beans sprouting while in the bowel. Harrison relates a curious case in which the swallowed lower epiphysis of the femur of a rabbit made its way from the bowel to the bladder, and was discharged thence by the urethra.

In cases of appendicitis foreign bodies have been found lodged in or about the vermiform appendix so often that it is quite a common lay idea that appendicitis is invariably the result of the lodgment of some foreign body accidentally swallowed. In recent years the literature of this subject proves that a great variety of foreign bodies may be present. A few of the interesting cases will be cited in the following lines:—

In the New England Medical Journal, 1843, is an account of a vermiform appendix which was taken from the body of a man of eighty-eight who had died of pneumothorax. During life there were no symptoms of disease of the appendix, and after death no adhesions were found, but this organ was remarkably long, and in it were found 122 robin-shot. The old gentleman had been excessively fond of birds all his life, and was accustomed to bolt the meat of small birds without properly chewing it; to this fact was attributed the presence of these shot in the appendix. A somewhat similar case was that of a man who died in the Hotel-Dieu in 1833. The ileum of this man contained 92 shot and 120 plum stones. Buckler reports a case of appendicitis in a child of twelve, in which a common-sized bird-shot was found in the appendix. Packard presented a case of appendicitis in which two pieces of rusty and crooked wire, one 2 1/2 and the other 1 1/2 inches long, were found in the omentum, having escaped from the appendix. Howe describes a case in which a double oat, with a hard envelope, was found in the vermiform appendix of a boy of four years and one month of age. Prescott reports a case of what he calls fatal colic from the lodgment of a chocolate-nut in the appendix; and Noyes relates an instance of death in a man of thirty-one attributed to the presence of a raisin-seed in the vermiform appendix. Needles, pins, peanuts, fruit-stones, peas, grape-seeds, and many similar objects have been found in both normal and suppurative vermiform appendices.

Intestinal Injuries.—The degree of injury that the intestinal tract may sustain, and after recovery perform its functions as usual, is most extraordinary; and even when the injury is of such an extent as to be mortal, the persistence of life is remarkable. It is a well known fact that in bull-fights, after mortal injuries of the abdomen and bowels, horses are seen to struggle on almost until the sport is finished. Fontaine reports a case of a Welsh quarryman who was run over by a heavy four-horse vehicle. The stump of a glass bottle was crushed into the intestinal cavity, and the bowels protruded and were bruised by the wheels of the wagon. The grit was so firmly ground into the bowel that it was impossible to remove it; yet the man made a complete recovery. Nicolls has the case of a man of sixty-nine, a workhouse maniac, who on August 20th attempted suicide by running a red-hot poker into his abdomen. His wound was dressed and he was recovering, but on September 11th he tore the cast off his abdomen, and pulled out of the wound the omentum and 32 inches of colon, which he tore off and threw between his pallet and the wall. Strange to say he did not die until eight days after this horrible injury.

Tardieu relates the case of a chemist who removed a large part of the mesentery with a knife, and yet recovered. Delmas of Montpellier reports the history of a wagoner with complete rupture of the intestines and rupture of the diaphragm, and who yet finished his journey, not dying until eighteen hours after.

Successful Intestinal Resection.—In 1755 Nedham of Norfolk reported the case of a boy of thirteen who was run over and eviscerated. It was found necessary to remove 57 inches of the protruding bowel, but the boy made a subsequent recovery. Koebererle of Strasburg performed an operation on a woman of twenty-two for the relief of intestinal obstruction. On account of numerous strictures it was found necessary to remove over two yards of the small intestine; the patient recovered without pain or trouble of any kind. In his dissertation on "Ruptures" Arnaud remarks that he cut away more than seven feet of gangrenous bowel, his patient surviving. Beehe reports recovery after the removal of 48 inches of intestine. The case was one of strangulation of an umbilical hernia.

Sloughing of the Intestine Following Intussusception.—Lobstein mentions a peasant woman of about thirty who was suddenly seized with an attack of intussusception of the bowel, and was apparently in a moribund condition when she had a copious stool, in which she evacuated three feet of bowel with the mesentery attached. The woman recovered, but died five months later from a second attack of intussusception, the ileum rupturing and peritonitis ensuing. There is a record in this country of a woman of forty-five who discharged 44 inches of intestine, and who survived for forty-two days. The autopsy showed the sigmoid flexure gone, and from the caput ceci to the termination the colon only measured 14 inches. Vater gives a history of a penetrating abdominal wound in which a portion of the colon hung from the wound during fourteen years, forming an artificial anus.

Among others mentioning considerable sloughing of intestine following intussusception, and usually with complete subsequent recovery, are Bare, 13 inches of the ileum; Blackton, nine inches; Bower, 14 inches; Dawson, 29 inches; Sheldon, 4 1/2 feet; Stanley, three feet; Tremaine, 17 inches; and Grossoli, 40 cm.

Rupture of the Intestines.—It is quite possible for the intestine to be ruptured by external violence, and cases of rupture of all parts of the bowel have been recorded. Titorier gives the history of a case in which the colon was completely separated from the rectum by external violence. Hinder reports the rupture of the duodenum by a violent kick. Eccles, Ely, and Pollock also mention cases of rupture of the duodenum. Zimmerman, Atwell, and Allan report cases of rupture of the colon.

Operations upon the gastrointestinal tract have been so improved in the modern era of antisepsis that at the present day they are quite common. There are so many successful cases on record that the whole subject deserves mention here.

Gastrostomy is an operation for establishing a fistulous opening in the stomach through the anterior wall. Many operations have been devised, but the results of this maneuver in malignant disease have not thus far been very satisfactory. It is quite possible that, being an operation of a serious nature, it is never performed early enough, the patient being fatally weakened by inanition. Gross and Zesas have collected, respectively, 207 and 162 cases with surprisingly different rates of mortality: that of Gross being only 29.47 per cent, while that of Zesas was for cicatricial stenoses 60 per cent, and for malignant cases 84 per cent. It is possible that in Zesas's statistics the subjects were so far advanced that death would have resulted in a short time without operation. Gastrotomy we have already spoken of.

Pyloroplasty is an operation devised by Heineke and Mikulicz, and is designed to remove the mechanic obstruction in cicatricial stenoses of the pylorus, at the same time creating a new pylorus.

Gastroenterostomy and pylorectomy are operations devised for the relief of malignant disease of the pylorus, the diseased portions being removed and the parts resected.

Gastrectomy or extirpation of the stomach is considered by most surgeons entirely unjustifiable, as there is seldom hope of cure or prospect of amelioration. La Tribune Medicale for January 16, 1895, gives an abstract of Langenbuch's contribution upon total extirpation of the stomach. Three patients were treated, of whom two died. In the first case, on opening the abdominal cavity the stomach was found very much contracted, presenting extensive carcinomatous infiltration on its posterior surface. After division of the epiploon section was made at the pylorus and at the cardiac extremities; the portions removed represented seven-eighths of the stomach. The pylorus was stitched to the remains of the cardiac orifice, making a cavity about the size of a hen's egg. In this case a cure was accomplished in three weeks. The second case was that of a man in whom almost the entire stomach was removed, and the pyloric and cardiac ends were stitched together in the wound of the parietes. The third case was that of a man of sixty-two with carcinoma of the pylorus. After pylorectomy, the line of suture was confined with iodoform-gauze packing. Unfortunately the patient suffered with bronchitis, and coughing caused the sutures to give way; the patient died of inanition on the twenty-third day.

Enterostomy, or the formation of a fecal fistula above the ileocecal valve, was performed for the first time by Nelaton in 1840, but the mortality since 1840 has been so great that in most cases it is deemed inadmissible.

Colostomy, an operation designed to make a fistulous opening in any portion of the rectum, was first practiced by Littre. In early times the mortality of inguinal colostomy was about five per cent, but has been gradually reduced until Konig reports 20 cases with only one death from peritonitis, and Cripps 26 cases with only one death. This will always retain its place in operative surgery as a palliative and life-saving operation for carcinomatous stenosis of the lower part of the colon, and in cases of carcinoma of the rectum in which operation is not feasible.

Intestinal anastomosis, whereby two portions of a severed or resected bowel can be intimately joined, excluding from fecal circulation the portion of bowel which has become obstructed, was originally suggested by Maisonneuve, and was studied experimentally by von Hacken. Billroth resorted to it, and Senn modified it by substituting decalcified bone-plates for sutures. Since that time, Abbe, Matas, Davis, Brokaw, Robinson, Stamm, Baracz, and Dawburn, have modified the material of the plates used, substituting catgut rings, untanned leather, cartilage, raw turnips, potatoes, etc. Recently Murphy of Chicago has invented a button, which has been extensively used all over the world, in place of sutures and rings, as a means of anastomosis. Hardly any subject has had more discussion in recent literature than the merits of this ingenious contrivance.

Foreign Bodies in the Rectum.—Probably the most celebrated case of foreign body introduced into the rectum is the classic one mentioned by Hevin. Some students introduced the frozen tail of a pig in the anus of a French prostitute. The bristles were cut short, and having prepared the passage with oil, they introduced the tail with great force into the rectum, allowing a portion to protrude. Great pain and violent symptoms followed; there was distressing vomiting, obstinate constipation, and fever. Despite the efforts to withdraw the tail, the arrangement of the bristles which allowed entrance, prevented removal. On the sixth day, in great agony, the woman applied to Marchettis, who ingeniously adopted the simple procedure of taking a long hollow reed, and preparing one of its extremities so that it could be introduced into the rectum, he was enabled to pass the reed entirely around the tail and to withdraw both. Relief was prompt, and the removal of the foreign body was followed by the issue of stercoraceous matter which had accumulated the six days it had remained in situ.

Tuffet is quoted as mentioning a farmer of forty-six who, in masturbation, introduced a barley-head into his urethra. It was found necessary to cut the foreign body out of the side of the glans. A year later he put in his anus a cylindric snuff-box of large size, and this had to be removed by surgical methods. Finally, a drinking goblet was used, but this resulted in death, after much suffering and lay treatment. In his memoirs of the old Academy of Surgery in Paris, Morand speaks of a monk who, to cure a violent colic, introduced into his fundament a bottle of l'eau de la reine de Hongrie, with a small opening in its mouth, by which the contents, drop by drop, could enter the intestine. He found he could not remove the bottle, and violent inflammation ensued. It was at last necessary to secure a boy with a small hand to extract the bottle. There is a record of a case in which a tin cup or tumbler was pushed up the rectum and then passed into the colon where it caused gangrene and death. It was found to measure 3 1/2 by 3 1/2 by two inches. There is a French case in which a preserve-pot three inches in diameter was introduced into the rectum, and had to be broken and extracted piece by piece.

Cloquet had a patient who put into his rectum a beer glass and a preserving pot. Montanari removed from the rectum of a man a mortar pestle 30 cm. long, and Poulet mentions a pederast who accidentally killed himself by introducing a similar instrument, 55 cm. long, which perforated his intestine. Studsgaard mentions that in the pathologic collection at Copenhagen there is a long, smooth stone, 17 cm. long, weighing 900 gm., which a peasant had introduced into his rectum to relieve prolapsus. The stone was extracted in 1756 by a surgeon named Frantz Dyhr. Jeffreys speaks of a person who, to stop diarrhea, introduced into his rectum a piece of wood measuring seven inches.

There is a remarkable case recorded of a stick in the anus of a man of sixty, the superior extremity in the right hypochondrium, the inferior in the concavity of the sacrum. The stick measured 32 cm. in length; the man recovered. It is impossible to comprehend this extent of straightening of the intestine without great twisting of the mesocolon. Tompsett mentions that he was called to see a workman of sixty-five, suffering from extreme rectal hemorrhage. He found the man very feeble, without pulse, pale, and livid. By digital examination he found a hard body in the rectum, which he was sure was not feces. This body he removed with a polyp-forceps, and found it to be a cylindric candle-box, which measured six inches in circumference, 2 1/2 in length, and 1 1/2 in diameter. The removal was followed by a veritable flood of fecal material, and the man recovered. Lane reports perforation of the rectum by the introduction of two large pieces of soap; there was coincident strangulated hernia.

Hunter mentions a native Indian, a resident of Coorla, who had introduced a bullock's horn high up into his abdomen, which neither he nor his friends could extract. He was chloroformed and placed in the lithotomy position, his buttocks brought to the edge of the bed, and after dilatation of the sphincter, by traction with the fingers and tooth-forceps, the horn was extracted. It measured 11 inches long. The young imbecile had picked it up on the road, where it had been rendered extremely rough by exposure, and this caused the difficulty in extraction.

In Nelson's Northern Lancet, 1852, there is the record of a case of a man at stool, who slipped on a cow's horn, which entered the rectum and lodged beyond the sphincter. It was only removed with great difficulty.

A convict at Brest put up his rectum a box of tools. Symptoms of vomiting, meteorism, etc., began, and became more violent until the seventh day, when he died. After death, there was found in the transverse colon, a cylindric or conic box, made of sheet iron, covered with skin to protect the rectum and, doubtless, to aid expulsion. It was six inches long and five inches broad and weighed 22 ounces. It contained a piece of gunbarrel four inches long, a mother-screw steel, a screw-driver, a saw of steel for cutting wood four inches long, another saw for cutting metal, a boring syringe, a prismatic file, a half-franc piece and four one-franc pieces tied together with thread, a piece of thread, and a piece of tallow, the latter presumably for greasing the instruments. On investigation it was found that these conic cases were of common use, and were always thrust up the rectum base first. In excitement this prisoner had pushed the conic end up first, thus rendering expulsion almost impossible. Ogle gives an interesting case of foreign body in the rectum of a boy of seventeen. The boy was supposed to be suffering with an abdominal tumor about the size of a pigeon's egg under the right cartilages; it had been noticed four months before. On admission to the hospital the lad was suffering with pain and jaundice; sixteen days later he passed a stick ten inches long, which he reluctantly confessed that he had introduced into the anus. During all his treatment he was conscious of the nature of his trouble, but he suffered rather than confess. Studsgaard mentions a man of thirty-five who, for the purpose of stopping diarrhea, introduced into his rectum a preserve-bottle nearly seven inches long with the open end uppermost. The next morning he had violent pain in the abdomen, and the bottle could be felt through the abdominal wall. It was necessary to perform abdominal section through the linea alba, divide the sigmoid flexure, and thus remove the bottle. The intestine was sutured and the patient recovered. The bottle measured 17 cm. long, five cm. in diameter at its lower end, and three cm. at its upper end.

Briggs reports a case in which a wine glass was introduced into the rectum, and although removed twenty-four hours afterward, death ensued. Hockenhull extracted 402 stones from the rectum of a boy of seven. Landerer speaks of a curious case in which the absorptive power of the rectum was utilized in the murder of a boy of fifteen. In order to come into the possession of a large inheritance the murderess poisoned the boy by introducing the ends of some phosphorous matches into his rectum, causing death that night; there was intense inflammation of the rectum. The woman was speedily apprehended, and committed suicide when her crime was known.

Complete transfixion of the abdomen does not always have a fatal issue. In fact, two older writers, Wisemann and Muys, testify that it is quite possible for a person to be transfixed without having any portion of the intestines or viscera wounded. In some nations in olden times, the extremest degree of punishment was transfixion by a stake. In his voyages and travels, in describing the death of the King of Demaa at the hands of his page, Mendez Pinto says that instead of being reserved for torture, as were his successors Ravaillac, and Gerard, the slayer of William the Silent, the assassin was impaled alive with a long stake which was thrust in at his fundament and came out at the nape of his neck. There is a record of a man of twenty-five, a soldier in the Chinese war of 1860, who, in falling from his horse, was accidentally transfixed by a bayonet. The steel entered his back two inches to the left of the last dorsal vertebra, and reappeared two inches to the left and below the umbilicus; as there was no symptom of visceral wound there were apparently no injuries except perforation of the parietes and the peritoneum. The man recovered promptly.

Ross reports a case of transfixion in a young male aborigine, a native of New South Wales, who had received a spear-wound in the epigastrium during a quarrel; extraction was impossible because of the sharp-pointed barbs; the spear was, therefore, sawed off, and was removed posteriorly by means of a small incision. The edges of the wound were cleansed, stitched, and a compress and bandage applied. During the night the patient escaped and joined his comrades in the camp, and on the second day was suffering with radiating pains and distention. The following day it was found that the stitches and plaster had been removed, and the anterior wound was gaping and contained an ichorous discharge. The patient was bathing the wound with a decoction of the leaves of the red-gum tree. Notwithstanding that the spear measured seven inches, and the interference of treatment, the abdominal wound closed on the sixth day, and recovery was uninterrupted. Gilkrist mentions an instance in which a ramrod was fired into a soldier's abdomen, its extremity lodging in the spinal column, without causing the slightest evidence of wounds of the intestines or viscera. A minute postmortem examination was held some time afterward, the soldier having died by drowning, but the results were absolutely negative as regards any injury done by the passage of the ramrod.

Humphreys says that a boy of eleven, while "playing soldier" with another boy, accidentally fell on a rick-stake. The stake was slightly curved at its upper part, being 43 inches long and three inches in circumference, and sharp-pointed at its extremity. As much as 17 1/2 inches entered the body of the lad. The stake entered just in front of the right spermatic cord, passed beneath Poupart's ligament into the cavity of the abdomen, traversed the whole cavity across to the left side; it then entered the thorax by perforating the diaphragm, displaced the heart by pushing it to the right of the sternum, and pierced the left lung. It then passed anteriorly under the muscles and integument in the axillary space, along the upper third of the humerus, which was extended beyond the head, the external skin not being ruptured. The stick remained in situ for four hours before attempts at extraction were made. On account of the displacement of the heart it was decided not to give chloroform. The boy was held down by four men, and Humphreys and his assistant made all the traction in their power. After removal not more than a teaspoonful of blood followed. The heart still remained displaced, and a lump of intestine about the size of an orange protruded from the wound and was replaced. The boy made a slow and uninterrupted recovery, and in six weeks was able to sit up. The testicle sloughed, but five months later, when the boy was examined, he was free from pain and able to walk. There was a slight enlargement of the abdomen and a cicatrix of the wound in the right groin. The right testicle was absent, and the apex of the heart was displaced about an inch.

Woodbury reports the case of a girl of fourteen, who fell seven or eight feet directly upon an erect stake in a cart; the tuberosity was first struck, and then the stake passed into the anus, up the rectum for two inches, thence through the rectal wall, and through the body in an obliquely upward direction. Striking the ribs near the left nipple it fractured three, and made its exit. The stake was three inches in circumference, and 27 inches of its length passed into the body, six or seven inches emerging from the chest. This girl recovered so rapidly that she was able to attend school six weeks afterward. In a case reported by Bailey a middle-aged woman, while sliding down a hay-stack, struck directly upon a pitchfork handle which entered the vagina; the whole weight of the woman was successfully maintained by the cellular tissue of the uterovaginal culdesac.

Minot speaks of the passage of one prong of a pitchfork through the body of a man of twenty-one, from the perineum to the umbilicus; the man recovered.

Hamilton reports a case of laceration of the perineum with penetration of the pelvic cavity to the depth of ten inches by a stick 3/4 inch thick. Prowse mentions the history of a case of impalement in a man of thirty-four, who, coming down a hay-stack, alighted on the handle of a pitchfork which struck him in the middle of the scrotum, and passed up between the skin and fascia to the 10th rib. Recovery was prompt.

There are several cases on record in which extensive wounds of the abdominal parietes with protrusion and injury to the intestine have not been followed by death. Injuries to the intestines themselves have already been spoken of, but there are several cases of evisceration worthy of record.

Doughty says that at midnight on June 7, 1868, he was called to see a man who had been stabbed in a street altercation with a negro. When first seen in the street, the patient was lying on his back with his abdomen exposed, from which protruded an enormous mass of intestines, which were covered with sand and grit; the small intestine (ileum) was incised at one point and scratched at another by the passing knife. The incision, about an inch in length, was closed with a single stitch of silk thread, and after thorough cleansing the whole mass was returned to the abdominal cavity. In this hernial protrusion were recognized four or five feet of the ileum, the cecum with its appendix, part of the ascending colon with corresponding portions of the mesentery; the distribution of the superior mesentery, made more apparent by its living pulsation, was more beautifully displayed in its succession of arches than in any dissection that Doughty had ever witnessed. Notwithstanding the extent of his injuries the patient recovered, and at last reports was doing finely.

Barnes reports the history of a negro of twenty-five who was admitted to the Freedmen's Hospital, New Orleans, May 15, 1867, suffering from an incised wound of the abdomen, from which protruded eight inches of colon, all of the stomach, and nearly the whole of the small intestines. About 2 1/2 feet of the small intestine, having a whitish color, appeared to be filled with food and had much of the characteristic feeling of a sausage. The rest of the small intestine had a dark-brown color, and the stomach and colon, distended with gas, were leaden-colored. The viscera had been exposed to the atmosphere for over an hour. Having nothing but cold Mississippi water to wash them with, Barnes preferred returning the intestines without any attempt at removing blood and dirt further than wiping with a cambric handkerchief and the stripping they would naturally be subjected to in being returned through the opening. In ten minutes they were returned; they were carefully examined inch by inch for any wound, but none was found. Three silver sutures were passed through the skin, and a firm compress applied. The patient went to sleep shortly after his wound was dressed, and never had a single subsequent bad symptom; he was discharged on May 24th, the wound being entirely healed, with the exception of a cartilage of a rib which had not reunited.

Rogers mentions the case of a carpenter of thirty-six who was struck by a missile thrown by a circular saw, making a wound two inches above the umbilicus and to the left. Through the opening a mass of intestines and a portion of the liver, attached by a pedicle, protruded. A portion of the liver was detached, and the liver, as well as the intestines, were replaced, and the man recovered.

Baillie, Bhadoory, Barker, Edmundson, Johnson, and others, record instances of abdominal wounds accompanied by extensive protrusion of the intestines, and recovery. Shah mentions an abdominal wound with protrusion of three feet of small intestine. By treatment with ice, phenol, and opium, recovery was effected without peritonitis.

Among nonfatal perforating gunshot wounds of the abdomen, Loring: reports the case of a private in the First Artillery who recovered after a double gunshot perforation of the abdomen. One of the balls entered 5 1/2 inches to the left of the umbilicus, and two inches above the crest of the ilium, making its exit two inches above the crest of the ilium, on a line with and two inches from the 4th lumbar vertebra. The other ball entered four inches below and to the rear of the left nipple, making its exit four inches directly below the point of entrance. In their passages these balls did not wound any of the viscera, and with the exception of traumatic fever there was no disturbance of the health of the patient. Schell records the case of a soldier who was wounded July 3, 1867, by a conoid ball from a Remington revolver of the Army pattern. The ball entered on the left side of the abdomen, its lower edge grazing the center of Poupart's ligament, and passing backward, inward, and slightly upward, emerged one inch to the left of the spinous process of the sacrum. On July 6th all the symptoms of peritonitis made their appearance. On July 11th there was free discharge of fecal matter from both anterior and posterior wounds. This discharge continued for three days and then ceased. By August 12th both wounds were entirely healed. Mineer reports a case of a wound from a revolver-ball entering the abdomen, passing through the colon, and extracted just above the right ilium. Under simple treatment the patient recovered and was returned to duty about ten weeks afterward.

There are a number of cases on record in which a bullet entering the abdominal cavity is subsequently voided either by the bladder or by the bowel. Ducachet mentions two cases at the Georgetown Seminary Hospital during the late war in which Minie balls entering the abdominal wall were voided by the anus in a much battered condition. Bartlett reports the case of a young man who was accidentally shot in the abdomen with a Colt's revolver. Immediately after the accident he complained of constant and pressing desire to void his urine. While urinating on the evening of the third day, the ball escaped from the urethra and fell with a click into the chamber. After the discharge of the ball the intolerable symptoms improved, and in two or three weeks there was complete recovery. Hoag mentions a man who was wounded by a round musket-ball weighing 400 grains. It had evidently passed through the lung and diaphragm and entered the alimentary canal; it was voided by the rectum five days after the injury. Lenox mentions the fact of a bullet entering the abdominal wall and subsequently being passed from the rectum. Day and Judkins report similar cases. Rundle speaks of the lodgment of a bullet, and its escape, after a period of seven and one-half years, into the alimentary canal, causing internal strangulation and death.

Wounds of the liver often end very happily, and there are many cases on record in which such injuries have been followed by recovery, even when associated with considerable loss of liver-substance. In the older records, Glandorp and Scultetus mention cures after large wounds of the liver. Fabricius Hildanus reports a case that ended happily, in which a piece of liver was found in the wound, having been separated by a sword-thrust. There is a remarkable example of recovery after multiple visceral wounds, self-inflicted by a lunatic. This man had 18 wounds, 14 having penetrated the abdomen, the liver, colon, and the jejunum being injured; by frequent bleeding, strict regimen, dressing, etc., he recovered his health and senses, but relapsing a year and a half later, he again attempted suicide, which gave the opportunity for a postmortem to learn the extent of the original injuries. Plater, Schenck, Cabrolius, the Ephemerides, and Nolleson mention recovery after wounds of the liver. Salmuth and the Ephemerides report questionable instances in which portions of the liver were ejected in violent vomiting. Macpherson describes a wound of the liver occurring in a Hindoo of sixty who had been struck by a spear. A portion of the liver was protruding, and a piece weighing 1 1/4 ounces was removed, complete recovery following.

Postempski mentions a case of suture of the liver after a stab-wound. Six sutures of chromicized cat-gut were carefully tightened and fastened with a single loop. The patient left his bed on the sixth day and completely recovered. Gann reports a case of harpoon-wound of the liver. While in a dory spearing fish in the Rio Nuevo, after a sudden lurch of the boat, a young man of twenty-eight fell on the sharp point of a harpoon, which penetrated his abdomen. About one inch of the harpoon was seen protruding from below the tip of the ensiform cartilage; the harpoon was seven inches long. It was found that the instrument had penetrated the right lobe of the liver; on passing the hand backward along the inferior surface of the liver, the point could be felt projecting through its posterior border. On account of two sharp barbs on the spear-point, it was necessary to push the harpoon further in to disengage the barbs, after which it was easily removed. Recovery followed, and the patient was discharged in twenty-one days.

Romme discusses the subject of punctured wounds of the liver, as a special text using the case of the late President Carnot. He says that in 543 cases of traumatism of the liver collected by Elder, 65 were caused by cutting or sharp-pointed instruments. Of this group, 23 recovered and 42 died. The chief causes of death were hemorrhage and peritonitis. The principal symptoms of wounds of the liver, such as traumatic shock, collapse, local and radiating pains, nausea, vomiting, and respiratory disturbances were all present in the case of President Carnot. From an experience gained in the case of the President, Romme strongly recommends exploratory celiotomy in all penetrating wounds of the liver. Zeidler reports three cases of wound of the liver in which recovery ensued. The hemorrhage in one case was arrested by the tampon, and in the other by the Pacquelin cautery.

McMillan describes a man of twenty who was kicked by a horse over the liver and rupturing that organ. A large quantity of offensive fluid was drawn off from the liver, and the man recovered. Frazer reports a case of rupture of liver and kidney in a boy of thirteen who was squeezed between the tire and driving chain of a mill, but who recovered despite his serious symptoms. Allen mentions recovery after an extensive incised wound of the abdomen, liver, and lung. Massie cites an instance of gunshot wound of the right hypochondrium, with penetration and protrusion of the liver. The patient, a boy of seven, recovered after excision of a small part of the protruding liver. Lawson Tait has incised the liver to the extent of three inches, evacuated two gallons of hydatids, and obtained successful recovery in ten weeks.

There are several cases of wound of the liver followed by recovery reported by surgeons of the United States Army. Whitehead mentions a man of twenty-two who on June 3, 1867, was shot in the liver by a slug from a pistol. At the time of the injury he bled freely from the wound of entrance continuing to lose blood and bile until daylight the next morning, when the hemorrhage ceased, but the flow of bile kept on. By June 10th there was considerable improvement, but the wound discharged blood-clots, bile, and serum. When the patient left the hospital on July 15th the wound was healthy, discharging less than 1 1/2 ounces during the twenty-four hours, of a mixture of free bile, and bile mixed with thick material. When last heard from—July 27, 1867—the patient was improving finely in flesh and strength. McKee mentions a commissary-sergeant stationed at Santa Fe, New Mexico, who recovered after a gunshot wound of the liver. Hassig reports the case of a private of twenty-six who was wounded in a fray near Paducah, Kentucky, by a conoid ball, which passed through the liver. The ball was cut out the same day. The patient recovered and was returned to duty in May, 1868. Patzki mentioned a private in the Sixth Cavalry, aged twenty-five, who recovered from a gunshot wound of the abdomen, penetrating the right lobe of the liver and the gall-bladder.

Resection of the Liver.—It is remarkable to what extent portions of the liver may be resected by the knife, cautery, or ligature, and the patient recover. Langenbuch records a case in which he successfully removed the greater portion of the left lobe of a woman of thirty. The lobe had been extensively deformed by tight lacing, and caused serious inconvenience. There was considerable hemorrhage, but the vessels were secured, and the woman made a good recovery. McWhinnie, in The Lancet, records a case of dislodgment of an enlarged liver from tight lacing. Terrilon mentions an instance in which a portion of the liver was removed by ligature after celiotomy. The ligature was removed in seven days, and the sphacelated portion of the liver came off with it. A cicatrix was completed at the end of six weeks, and the patient, a woman of fifty-three, made an excellent recovery. Bastianelli discusses those cases in which portions of the liver, having been constricted from the general body of the organ and remaining attached by a pedicle, give rise to movable tumors of the abdomen. He records such a case in a woman of thirty-seven who had five children. A piece of liver weighing 500 grams was removed, and with it the gall-bladder, and the patient made an uninterrupted recovery. Tricomi reports a case in which it was found necessary to remove the left lobe of the liver. An attempt had been made to remove a liver-tumor the size of a fist by constricting the base with an elastic ligature. This attempt was a failure, and cure was also unsuccessfully attempted by wire ligature and the thermocautery. The growth was cut away, bleeding was arrested by the thermocautery and by iron-solution, the wound entirely healed, and the patient recovered. Valerian von Meister has proved that the liver has marvelous powers of regeneration, and that in rabbits, cats, and dogs, even three-fourths of the organ may be reproduced in from forty-five to sixty-five days. This regeneration is brought about chiefly by hypertrophy of the lobules.

Floating liver is a rare malady in which the liver forms an abdominal prominence that may be moved about, and which changes its situation as the patient shifts the attitude. The condition usually arises from a lax abdominal wall following repeated pregnancies. The accompanying illustration exhibits a typical case verified by postmortem examination.

Hypertrophy of the Liver.—The average weight of the normal liver is from 50 to 55 ounces, but as noted by Powell, it may become so hypertrophic as to weigh as much as 40 pounds. Bonet describes a liver weighing 18 pounds; and in his "Medical and Surgical Observations," Gooch speaks of a liver weighing 28 pounds. Vieussens, the celebrated anatomist, reports an instance in which the liver weighed 20 pounds, and in his "Aphorisms," Vetter cites a similar instance. In 1811 Kraus of Germany describes a liver weighing 25 pounds; modern instances of enlarged liver are too numerous to be quoted here.

Rupture of the gall-bladder, although generally followed by death, is not always fatal. In such cases bile is usually found in the abdominal cavity. Fergus mentions a case in which, after this accident, the patient was considered convalescent and was walking about, when, on the seventh day, peritonitis suddenly developed and proved fatal in two days. Several cases of this accident have been reported as treated successfully by incision and drainage (Lane) or by inspiration (Bell). In these cases large quantities of bile escaped into the abdominal cavity. Peritonitis does not necessarily follow. Cholecystotomy for the relief of the distention of the gall-bladder from obstruction of the common or cystic duct and for the removal of gall-stones was first performed in 1867 by Bobbs of Indianapolis, but it is to Marion Sims, in 1878, that perfection of the operation is due. It has been gradually improved and developed, until today it is a most successful operation. Tait reports 54 cases with 52 perfect recoveries. Cholyecystectomy, or excision of the gall-bladder, was first practiced in 1880 by Langenbuch of Berlin, and is used in cases in which gall-stones are repeatedly forming. Ashhurst's statistics show only four deaths in 28 cases.

At St. Bartholomew's Hospital, in London, is a preserved specimen of a gall-bladder which had formed the contents of a hernial sac, and which, near the fundus, shows a constriction caused by the femoral ring. It was taken from a woman of forty-five who was admitted into the hospital with a strangulated femoral hernia. The sac was opened and its contents were returned. The woman died in a few days from peritonitis. The gall-bladder was found close to the femoral ring, and showed a marked constriction. The liver was misshapen from tight lacing, elongated and drawn downward toward the ring. There was no evidence that any portion of intestine or other structure besides the gall-bladder had passed through the ring.