How to live with a hole in your soul (or torso)

Ganked in its entirety from Medscape. But it is sooooo fun and gruesome and the not-so-little geek in me just wanted to have a show and tell.

From Medscape General Surgery > Historical Perspectives in Surgery

The Case of the Wounded Woodsman and His Dedicated Physician

Albert B. Lowenfels, MD

Published: 09/02/2009

The Case

The patient was a 28-year-old, healthy itinerant laborer who was accidentally shot at close range by a companion. The shell entered the left anterolateral side of his body a few inches below the left nipple. The patient fell to the ground but remained conscious. A physician who examined the patient shortly after the accident noted a large wound of entry about the size of a man's hand, but no wound of exit. The left lung protruded through the opening along with a portion of the stomach, with an opening caused by the bullet. Several adjacent ribs had been fractured. Food from a recent meal was present in the wound.

In describing the patient's injury, his physician wrote: "I considered any attempt to save his life entirely useless." Nevertheless, his physician debrided the wound, replaced the protruding stomach and lung, and applied a protective dressing. On the following day, the patient developed fever, a cough, and had evidence of pneumonia. For the next week, the patient continued to be febrile; the wound became infected; and the patient was fed rectally.

To the physician's surprise, over the next several weeks the patient's condition gradually improved, although the gastric wound never completely closed. Nevertheless, he could tolerate oral feedings if the gastric opening was occluded with a compressive dressing. Over the next year, the patient's strength gradually returned to normal, but the gastric wound refused to close. The physician made an arrangement with the patient to follow him more closely and to study his gastric physiology; these studies continued intermittently over the course of many years.

Who was the patient?

Daniel Boone

Kit Carson

Alexis St. Martin

Paul Bunyon

Who was the physician?

William Osler

William Beaumont

Harvey Cushing

William Wells

Brief History of the Physician and His Patient

William Beaumont (1785-1853) was born into a farming family and grew up in Connecticut, where he remained until his early 20s when he joined his brother in Upstate New York.^[1] There, he taught school for several years, before deciding at the age of 25 to study medicine. Although it was possible in the early 19th century to practice medicine without any formal training, Beaumont became an apprentice to Dr. Benjamin Chandler, a prominent Vermont physician. This apprenticeship lasted for 1 year, covered both medicine and surgery, and led to certification by the Vermont Medical Society. His training never included any formal background in physiology, and it is unlikely that Beaumont was aware of the available rudimentary knowledge of gastrointestinal physiology.

Figure 1. Portrait of William Beaumont, frontier doctor and scientist.
From Gillett MC. Early campaigns in the North, 1812 to 1813. In: Matloff M, ed. The Army Medical Department 1775-1818. Army Historical Series. Available at: http://history.amedd.army.mil/booksdocs/rev/gillett1 Accessed August 26, 2009

In 1812, a few months after receiving his certification, Beaumont enlisted in the US Army, and then actively engaged in war with the British Empire. Eventually, after the conclusion of the War of 1812, Beaumont was posted to Fort Mackinac, an important trading post located on a small, remote island between Lake Huron and Lake Michigan.

By good fortune, Beaumont was at the Fort on June 6, 1822, when Alexis St. Martin, a French-Canadian employee of the American Fur Company, was accidentally shot in the left chest. Beaumont had received some surgical training during his apprenticeship and additional experience while caring for injured soldiers during the War of 1812. Without Beaumont's presence, it is unlikely that St. Martin would have survived such a serious injury.

St. Martin came from a background that was very different from Beaumont's. According to his birth certificate, St. Martin was born in 1794, in the small Canadian village of Berthier. His family, who originated from Bayonne, France, was poor, and St. Martin grew up to be an illiterate trapper. He earned his living as a fur trader and voyageur (a porter and large cargo canoe man) in the region between what is now Michigan and Canada. When he was wounded, St. Martin was 28 years old and unmarried.

When St. Martin was sufficiently recovered, he signed a contract with Beaumont, who offered him employment as a handyman in return for a stipend, food, and permission to carry out experiments on St. Martin's stomach. To facilitate the research, and to ease the financial burden on the physician, the US Army made St. Martin a sergeant, paying him a small salary.

About a year after St. Martin's injury, when Beaumont realized that the gastric wound was unlikely to close, he began detailed studies of the process of digestion within St. Martin's stomach. These experiments, conducted with the often reluctant St. Martin, continued intermittently over the course of about a decade. St. Martin agreed to travel to Europe to be examined and studied by leading physicians, including Claude Bernard, but he changed his mind before embarking on the voyage. He never did go to Europe, but he did exhibit his fistula at several American medical schools.

Despite Beaumont's efforts, the wound never completely healed; nevertheless, St. Martin was able to resume a nearly normal life if he plugged up the gastric opening with a piece of cloth. Eventually St. Martin married and had several children. He was always poor, however, and frequently drunk. His health, despite the fistula, was sufficiently robust so that he could support his family by hard labor, such as chopping wood.

Regardless of his persistent gastric fistula and his heavy consumption of alcohol, St. Martin lived to be 86 years old; even now this is well above the normal life span for white men in North America. As for Beaumont, after completing his army service, he settled in St. Louis, Missouri, where he practiced medicine until he died in 1853 from a head injury after falling on an icy path. St. Martin outlived his physician by several decades.

Prior to St. Martin's death, prominent physicians, including William Osler, had tried without success to persuade the family and the patient to agree to an autopsy.^[2] Osler was particularly anxious to examine St. Martin's famous stomach and to have it preserved in the US Army Museum. However, the family was vehemently opposed to any further contacts with the medical profession. To ensure that his body would not be disturbed, the family buried St. Martin in an unmarked deep grave. Only in 1962, more than 80 years after his death, did the Canadian Physiological Society place a marker at the approximate grave site.

What Beaumont Added to the Knowledge of Gastric Physiology

Before Beaumont's long-term observation of St. Martin's progress, other patients had sustained gastric wounds and lived with a gastric fistula, but none had been studied in a scientific fashion.^[3] Toward the end of the 18th century, the Italian Lazaro Spallanzini conducted a series of experiments and concluded that the stomach contained an active principle and that digestion was more than a simple mechanical process. In 1803, Jacob Helm, a Viennese physician, studied a middle-aged woman with a gastric fistula, noting the ability of the gastric juice to act upon stomach content. Just prior to Beaumont's first publication, an English chemist, William Prout, noted that the stomach secreted hydrochloric acid.^[4] It is unlikely that Beaumont knew about any of this work on the stomach: His observations are unique.

Without any formal training in physiology, gastroenterology, or any branch of science, Beaumont recognized a unique opportunity, and over the course of several years he performed numerous experiments that led to a solid foundation for gastric physiology. The astonishing aspect of Beaumont's research is that under difficult circumstances he took advantage of a rare chance to study digestion by visualizing the interior of the stomach and obtaining samples of gastric juice from a living subject under various circumstances. Moreover, he took careful, detailed notes.

Beaumont performed a series of 3 experiments on St. Martin at geographic locations separated by thousands of miles.

Figure 2. Map listing locations and dates for major events in the lives of St. Martin and Beaumont.

The experiments were carried out under less than ideal circumstances on a patient who was not always cooperative. Today, it would be difficult to obtain approval to perform a similar series of experiments. Beaumont describes his first experiment as follows^[5]:

EXPERIMENT 1. August 1. 1825 -- At 12 o'clock, A.M., I introduced through the perforation, into the stomach, the following articles of diet, suspended by a silk string, and fastened at proper distances, so as to pass in without pain -- viz.: -- a piece of high seasoned la mode beef, a piece of raw salted fat pork, a piece of raw salted lean beef, a piece of boiled salted beef, a piece of [unclear] bread, and a bunch of raw sliced cabbage; each piece weighing about two drachms, the lad continuing his usual employment about the house. At 1 o'clock, PM, withdrew and examined them -- found the cabbage and bread about half digested; the pieces of meat unchanged. Returned them into the stomach. At 2 o'clock, PM withdrew them again -- found the cabbage, bread, pork, and boiled beef, all cleanly digested,* and gone from the string...The lad complaining of considerable distress and uneasiness at the stomach, general debility and lassitude, with some pain in his head, I withdrew the string, and found the remaining portions of aliment nearly in the same condition as when last examined; the fluid more rancid and sharp...I did not return them any more.

*These experiments are inserted here, as they were originally taken down in my note-book....

Beaumont published his early results in January 1825, after his first series of experiments and about 3.5 years after St. Martin's injury.

His major contributions to our knowledge of the digestive process included:

• Studies of gastric motility;
• Studies of gastric acidity (recognition of the importance of hydrochloric acid);
• An important role for neurogenic influences on digestion, which eventually led to vagotomy as a treatment for peptic ulcer disease; and
• A suspicion that something other than acid accounted for the stomach's ability to digest food.

Of note, this last substance turned out to be pepsin, which was eventually identified by Theodore Schwan in 1836, shortly after Beaumont concluded his third series of experiments.

How Would the Patient's Wound Be Treated Today?

St. Martin sustained the full force of a shotgun blast fired accidentally at close range, resulting in a complex wound involving the left lung, the stomach, and the diaphragm. Beaumont describes a "fist-sized" hole (approximately 9 x 9 cm) in the left lateral chest wall. St. Martin apparently remained hemodynamically stable after his injury, although the sphygmomanometer wasn't invented for several more decades -- so there were no blood pressure measurements.

Figure 3. Beaumont's sketch of St. Martin's wound about 4-6 weeks after the injury.
From Beaumont W.⁵

Even today, this injury would present a significant challenge to a surgeon.^[6,7] However, long-term results following current surgical repair of severe chest wall injuries are excellent, with patient status being similar to the general population.^[8] Current management would include the following:

• Careful physical examination supplemented by imaging studies to determine the extent of injury.
• If there were a pneumothorax or respiratory compromise following this chest wound, ventilatory support would be provided via an endotracheal tube until the patient was ready for surgery. (Note: there was no mention of shortness of breath from a pneumothorax in St. Martin's case.)
• Exploration via a left thoracoabdominal incision.
• Careful exploration to ensure that no other organs, such as the pancreas or the spleen, had been injured.
• Debridement and cleansing of the original wound to remove shattered rib fragments, necrotic lung tissue, imbedded clothing, fragments of the shell, and food particles.
• Blood transfusion, rather than bloodletting, as was done for St. Martin.
• Closure of the gastric wound and the diaphragmatic tear.
• Repair of the chest wall defect. This would probably require application of a synthetic mesh covered by a muscle flap. If necessary, the repair in the chest wall could be closed with a split-thickness skin graft.

Summary

By a fortunate coincidence, William Beaumont -- a young, resourceful, relatively inexperienced US Army surgeon -- happened to be stationed in a remote fort on the western frontier of the United States when Alexis St. Martin, a French-Canadian voyager, received a near-fatal gunshot wound of the chest. St. Martin survived, but was left with a permanent gastric fistula, permitting Beaumont to perform a series of unique experiments that greatly expanded our knowledge of gastric physiology.

Traditionally, St. Martin's physician has received full recognition for the brilliant series of experiments carried out under primitive conditions. However, St. Martin also should be credited for participating in tedious, repetitive experiments that must have been disagreeable and sometimes painful.^[9] Although not always cooperative, he should be remembered as being perhaps the first of that special group of human "guinea pigs" who have done so much to advance the progress of medicine. Two centuries later, physicians and patients remain indebted to Beaumont and Alexis St. Martin -- Beaumont's often reluctant patient.

Additional Reading

• Green AH. The Market Cultures of William Beaumont: Ethics, Science and Medicine in Antebellum America, 1820-1865 [doctoral thesis]. Baltimore: The Johns Hopkins University; 2007. AAT 3262421.

Internet Sources

• Helms R. Alexis St. Martin (1794-1880): the intrepid guinea pig of the Great Lakes. Available at: http://www.guineapigzero.com/AlexisStMartin.html Accessed August 20, 2009.
• Life of Dr. William Beaumont. Available at: http://www.james.com/beaumont/dr_life.htm Accessed August 20, 2009.

Museums

• American Fur Company Store and Dr. Beaumont Museum. Available at: http://www.mackinacparks.com/ Accessed August 26, 2009.
• Prairie du Chien Museum at Fort Crawford. Available at: www.fortcrawfordmuseum.com Accessed August 26, 2009.
• William Beaumont Birthplace. Available at: http://www.james.com/beaumont/dr_birthplace.htm Accessed August 26, 2009.

References

1. Horsman KR. Frontier Doctor. William Beaumont, America's First Great Medical Scientist. Columbia, Mo: University of Missouri Press; 1996.
2. Sarr MG, Bass P, Woodward E. The famous gastrocutaneous fistula of Alexis St. Martin. Dig Dis Sci. 1991;36:1345-1347. Abstract
3. Modlin IM. From Prout to the proton pump -- a history of the science of gastric acid secretion and the surgery of peptic ulcer. Surg Gynecol Obstet. 1990;170:81-96. Abstract
4. Rosenfeld L. William Prout: early 19th century physician-chemist. Clin Chem. 2003;49:699-705. Abstract
5. Beaumont W. Experiments and Observations on the Gastric Juice and the Physiology of Digestion. Mineola, New York: Dover Publications, Inc.; 1959. Available at: http://books.google.com/books?id=H6F4_9joRkgC&pg=PA8&dq Accessed August 20, 2009.
6. Koch H, Tomaselli F, Pierer G, et al. Thoracic wall reconstruction using both portions of the latissimus dorsi previously divided in the course of posterolateral thoracotomy. Eur J Cardiothoracic Surg. 2002;21:874-878.
7. Weyant MJ, Bains MS, Venkatraman E, et al. Results of chest wall resection and reconstruction with and without rigid prosthesis. Ann Thorac Surg. 2006;81:279-285. Abstract
8. Mayberry JC, Kroeker AD, Ham B, Mullins RJ, Trunkey DD. Long-term morbidity, pain, and disability after repair of severe chest wall injuries. Am Surg. 2009;75:389-394. Abstract
9. Myers NA, Durham-Smith E. A debt to Alexis: the Beaumont-St Martin story. Aust N Z J Surg. 1997;67:534-539. Abstract

Authors and Disclosures

Author(s)

Albert B. Lowenfels, MD

Professor of Surgery, Professor of Community Preventive Medicine, New York Medical Center, Valhalla, New York; Emeritus Surgeon, Department of Surgery, Westchester Medical Center, Valhalla, New York

Disclosure: Albert B. Lowenfels, MD, has disclosed that he has served on an advisor to Solvay Pharmaceuticals Inc.

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