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c-l GASTROLITH (half original size). Reprint: The MEDICAL FORTNIGHTLY, St. Louis, August 15, 1894. 
A Case of Double Gastrolith Removed by Gastrotomy. 
—Recovery.—Death by Phthisis three 
Months Afterward. 
By W. b. Outten, A. M., M. D., 
ST. LOUIS. 
Dean and Professor of the Principles and Practice of Surgery, Beaumont Hospital Medical College; Pres- 
ident St. Louis President National Association Railway 
Surgeons; Member of the American Medical 
Association, etc. etc. 
ACCORDING to the true definition of the term gastrolith, the case 
under consideration is not a true gastrolith, but rather a bezoar, or 
food-ball, as found in the abomasum and intestines of ruminants. 
Authorities, however, seem inclined to place all concretions found in the 
stomach of man under the head of gastrolith, and while the writer believes 
this is incorrect, still custom sanctions, and accordingly he has followed 
custom in the designation of this case. Edward T. Bruen, of Philadelphia, 
in Vol. 1 of the Annual of the Universal of the Medical Sciences of 1889, 
thus speaks concerning cases of this character: “Several cases of gastro- 
lith in man has been reported in the current year. Hooyker, of Groningen, 
described the case of a druggist, aged 25 years, who had a circumscribed 
tumor in the epigastric region, the position of which varied on respiration 
and was tender on pressure. Medicines had no permanent effect upon it. 
Spleen, liver and kidneys were normal as to position and size. The appe- 
tite was very good and the bowels were regular. Vomiting of a small 
quantity of fluid containing mucus and bile, but always free from hydro- 
chloric acid, occasionally took place. Nausea was constant and it was said 
that hematemesis occurred, but this was not actually observed. Gradual 
emaciation, followed with cachexia and indolent swelling of the left supra- 
clavicular and axillary glands, was noticed. The patient was examined 
under an anesthetic and the stomach washed out, but exploratory incision 
was steadily refused. The diagnosis, according to the probabilities, was 
cancer of the stomach. The case ended fatally and the autopsy showed 
that the stomach was of mornal size, contained a concretion having the out- 
line of the organ and almost filling it. At the pyloric end lay two smaller 
fragments the size of hen’s eggs. The weight of the tumor was eight 
hundred and eighty grammes—a little over twenty-eight ounces. No 
nucleus was present. Microscopic examination showed starch glanules, 
cells containing chlorophyl and bundles of vessels; but nothing to determine 
the animal origin of the concretion. Chemical analysis showed that it 
contained 0.55 per cent of nitrogen. It was observed that, with the excep- 
tion of Langebuch’s case, described in 1884, which contained no hair, all 
cases observed in the human subject were composed more or less of hair. 
In the present case the tumor was identical in constitution with the food- 
balls of ruminants. Such concretions are not often found in the human 
stomach, though the bezoar of the abdomasum and intestines of ruminants 
is well known, and in olden days was very highly esteemed as a remedy 2 
against poisons and infectious diseases, being even worn as a charm. 
Human intestinal agglomerates are occasionally found in oatmeal-eating 
districts, and have sometimes been dignified by the name of avenoliths. 
An enterolith was found by Laugier in a human subject, the nucleus of 
which was formed by a piece of liquorice root. True gastroliths, however, 
are occasionally found in the human stomach; thus Shomborm was enabled 
to collect seven such cases, all of which appeared to have formed around a 
nucleus of hair. One of these weighed two kilogrammes.” 
The following notes were taken from the history of the individual 
while in the hospital at St. Louis. J. P., aged 52, native of Ireland, section 
hand; residence, Antonio, La. Entered Missouri Pacific Railway Hospital 
of St. Louis, June 21st, 1892. Family history excellent, parents and grand- 
parents living to old age, no history of tuberculosis, syphilitic or cancerous 
trouble in the family. History of the patient discloses following: Never 
had any severe illness, except five years ago when lithotomy was success- 
fully performed upon him in St. Louis; fourteen years ago had a sore on the 
penis, which was successfully treated, and, as it never gave any evidence 
of further trouble, was not considered as being an initial lesion. The first 
trouble which he had with the stomach occurred in the early part of Octo- 
ber, 1891, when, while tramping through the country, he partook of a large 
quantity of bread and persimmons—diospyros Virginiana. He acknowl- 
edged that, owing to previous hunger amounting almost to starvation, he 
partook freely of the substance herein indicated, and even acknowledged 
having swallowed the persimmon seeds along with unusual quantities of 
bread. Several hours thereafter nausea and vomiting occurred. After an 
illness of ten days he got better, but after that was troubled more or less 
with nausea. However, he continued work until December 13th, 1891, 
when he partook of a very hearty meal of sardines and crackers, to which 
he attributes his present trouble. This was followed by excessive nausea 
and vomiting, which continued at varying intervals until his admission to 
the Vicksburg, Miss., City Hospital, December 15th, 1891. Physicians in 
charge of the hospital, upon examination, discovered a tumor in the neigh- 
borhood of the stomach, which was the first time the patient’s attention had 
been called to it. He remained in the hospital two months, and then 
resumed labor and continued to ply his avocation until June 21st, 1892, 
when he was admitted into the St. Louis Hospital of the Missouri Pacific 
Railway. During the interim from February, 1892, until June, 1892, he 
had comparatively little nausea and no vomiting; was nauseated only when 
he ate too heartily or drank too much whiskey, and then only for a limited 
time. Examination at that time revealed a hard and seemingly nodular 
tumor six or Seven inches long, four or five inches broad, and almost as 
thick, freely movable to various portions of the abdomen. In the standing 
position the tumor can be felt below the umbilicus, by pressure could be 
carried to the right or left side, and almost forced down to the pubis, but 
with an invariable tendency to retreat into the concavity of the diaphragm 
in the left hypochondriac region. In the dorsal decubitis it dropped readily 
into the left hypochondriac region, but was still plainly manifest, projecting 
below the ribs. Auscultation and percussion of the chest showed normal 3 
heart and lungs. The urine was normal with acid reaction; no indication of 
trouble with other organs. The patient constantly complained of heavy 
dragging pains about the lumbar region, loins and umbilicus; no nausea 
existed and no pain was evinced upon pressure, when examining the tumor. 
Diagnosis: Splenectopia or floating spleen. Reasons for opinion: Unwonted 
mobility of tumor, along with a tendency to recurrence to left hypochon- 
driac region, painless under inspection, freedom from other organic lesions, 
and residence in malarial country. Patient entered the hospital and was 
put under observation and treatment from June 21st, 1892, until July 14th, 
1892. Iodides and chalybeates were prescribed. He did not complain of 
nausea nor did he vomit after his entry, but complained continuously of 
dragging pains around the abdomen, lumbar region and loins. The appetite 
was good; he ate three meals a day regularly, partook of whiskey freely 
and with relish when given it; used tobacco constantly and without any 
apparent detriment. He was excessively constipated, which he stated had 
been his condition for the past two years, having passed as many as eight 
days without evacuation of the bowels. Since the tumor developed, the 
mental condition has remained unchanged. He seemed cheerful and talk- 
ative, slept well, and the only serious complaint was the dragging pains, 
which, at times felt, as he averred, like tons of weight, and in consequence 
of which he had repeatedly and eagerly sought operative interference, and 
said he was willing to undergo any operation. He had not lost flesh in the 
past five months, and presented an unruffled countenance, browned by 
exposure. Operation was determined upon for the purpose of accomplishing 
for this condition of supposed splenectopia the adhesion of the visceral peri- 
toneum of the spleen with the parietal peritoneum as high up in the cavity 
of the diaphragm as possible, and if a word may be coined, splenorrhaphy 
instead of splenectqfifla performed. A successful case had been per- 
formed in this city, where an incision was made through the left wall of the 
abdomen, parallel with the lower border of the left, tenth rib, extending 
from the linea semilunaris, posteriorly to the edge of the quadratus lum- 
borum muscle of that side. Through this opening the spleen was reached 
and a piece of aseptic gauze was thrown around the pedicle of the floating 
spleen, which was then brought into the opening. The wound and the 
surface of the exposed spleen were packed with aseptic gauze. The gauze 
holding the pedicle was rendered taut and held in position by a broad com- 
press of gauze, over which was tied the gauze which held the pedicle of the 
spleen projecting from the wound. A seemingly excellent result was accom- 
plished, the woman upon whom it was performed gaining fifteen pounds the 
first month; but some ten months afterwards died of cancer of that organ. 
This operation was performed by Dr. W. A. McCandless of this city, and 
it was determined that this should be the operative procedure in this case, 
except that the incision should be made through the linea semilunaris. 
Assisted by Drs. Dalton, McCandless, Vasterling and others, the parts 
were shaved, scrubbed and washed in alcohol and an aseptic condition in 
the field of operation was made. The patient was put under anesthesia, 
ether being the anesthetic used, and an incision 6 or 7 inches long was 
made through the linea semilunaris. After the cavity of the abdomen was 4 
entered, the tumor was readily reached but it was too large to force from 
the cavity. It was then determined to enlarge the opening, and an incision 
was made extending from the top of the cut in linea semilunaris trans- 
versely across to the linea alba, thus making a large triangular opening in 
the parietes and exposing the tumor. Upon first inspection the tumor 
appeared to be posterior to the stomach, but on bringing the tumor out of 
the cavity, the stomach was found greatly distended, and upon closer exam- 
ination the tumor was found to be in the stomach. Gastrotomy was at 
once determined upon and an incision about six inches long was made trans- 
versely through the walls of the stomach, exposing a large mass of a yellow 
clay color, covered, in places, with dark carbonaceous matter. This proved 
to be a gastrolith over five inches in length, conical in shape, and about five 
inches in its broadest portion. The stomach was now held in position, so 
as to debar the possibility of any of its fluid contents entering the abdominal 
cavity. Ten Lembert's sutures were applied along the incision. After 
suturing, it was noticed that a greater portion of the stomach seemed to lie 
in left hypochondriac region, and an endeavor was now made to pull this in 
position, when it was discovered that another foreign body was in the 
stomach. It was deemed advisable to make a fresh incision in the stomach 
in preference to cutting through the sutures already supplied, so gastrotomy 
was again immediately done. An incision equal in length and parallel to 
the former was made, and a gastrolith similar in color and smaller in size to 
the first was removed. This cut in the stomach was likewise closed up 
with Lembert’s sutures. It was noticed that great difficulty existed when 
endeavoring to bring the splenic end of the stomach in view, clearly owing 
to the attachment of the gastro-splenic omentum of the stomach, but by 
pressing on the stomach behind the gastrolith, it was forced in situ. 
Here was plainly a surgical mistake. It would certainly have been 
better had both concretions been removed from the same opening, but it 
would have been suicidal to have attempted to remove the sutures already 
made, as the needle holes would have been difficult of ascertainment, and 
probably septic conditions engendered. I believe it is related of DesCarte 
that he had a cat a kitten, and them to pass from one room to 
another through a small partition, he very profoundly suggested to the 
carpenter that he make through this partition a big hole for the cat and a 
small hole for the kitten; this might not have been good judgment, but, in 
any event it certainly met, in an extravagant manner, the fullest and com- 
pletest indications. The patient rallied readily on the morning of July 
16th, 1892, twenty-four hours after the operation; temperature 99.2; pulse 
90. He progressed favorably until the eighth day when pneumonia 
developed in the lower half of the left lung. On August 16th, 1892, the 
patient was convalescing and walking around the wards, but dullness of the 
left lung and cough remained. From this period he gradually went into a 
phthisical condition, both lungs became involved and he died October 18th, 
1892, just three months and three days from the date of operation. 1 am 
free to confess that, where any extended abdominal operation is to be per- 
formed, 1 believe it is poor judgment to use ether, for 1 believe that the ether 
was the cause of the trouble which followed. Granting that metastatic 5 
troubles frequently arise from extended abdominal operations, still 1 believe 
that the exciting cause was a bronchial trouble engendered by prolonged 
use of the ether. 
The following will give a comparative idea of the weight and size of the 
gastroliths removed, which were weighed in a half hour after their removal. 
Their combined weight on removal was 10,560 grms. Some three or 
four days after their removal, Dr. J. A. Close made the following report of 
their examination. Specimens received from Dr. Outten consisted of two 
masses, the shape, weight and dimensions of which were as follows: 
Shape—The shape of each piece was conical, the apex of the larger 
being somewhat flattened. 
Weight—(a) of larger mass 396.8 grms. (14 oz. Avoir), (b) of smaller 
mass 220.8 grms. (7.8 oz. Avoir). 
Length—(a) of larger mass 12.5 em. (5 in.) (b) of smaller mass 6.9 
em. in.) 
Circumference—At base of each 27.5 em. (21 in.) The base of each 
mass was smooth and the edges of the base rounded showing the effects of 
attrition of the masses while in the stomach. 
Color—Mottled from fawn to dark brown, and in places almost black; 
when sawed through longitudinally the color of the outer cut surface was 
light yellow. 
Odor—That of the stomach contents during digestion—no fecal odor 
was perceptible. 
Nucleus—No nucleus nor any mass resembling a nucleus could be 
found; no hairs were found; the external position of the depth of 5 to 8 mm. 
(1-5 to 1-3 in.); was granular and friable; the central portions contained 
masses of vegetable tissue with muscular fibres, etc. 
Reaction—Fragments taken from both the surface and the central 
portions of both masses, shaken with freshly distilled water, free from 
ammonia, showed neutral reaction. Hydrochloric acid absent (Phloroglucin 
& Vanillin Test.) 
Lactic Acid—Absent. 
Peptones—Absent. 
Pepsin—The aqueous infusion (io grms. of the mass triturated with 50 
grms. of distilled water) concentrated to y2 over sulphuric acid at a temper- 
ature of 50 C. and acidefied with H.C1. 0.08 per cent had no digestive 
effect upon coagulated albumen. 
Peptones—Absent. 
Skatol—Absent. 
Starch—A well marked reaction with iodine. 
CHEMICAL EXAMINATION. 
MICROSCOPICAL EXAMINATION. 
i. The external granular friable layer showed: (a) Sarcinas ven- 
triculi (very numerous); (b) Starch granules, especially those of potato 
starch very numerous; (c) Numerous fat globules; (c) Cells of saccha- 
romyces cerevisias. 6 
2. The central portion of the mass showed in addition to the above: 
(a) Compressed masses of vegetable connective tissue, including numerous 
vessels; (b) Striated muscular fibres—The striation was generally indistinct; 
(c) No blood corpuscles either red or white, could be distinguished; (d) 
Squamous epithelium; (e) Numerous elastic fibres; (f) Groups of fatty acid 
crystals were quite numerous. 
There was nothing discovered in the mass which could account for the 
coherence of the constitution. (Signed) J. A. CLOSE, M. B. 
From the foregoing report the entire absence of a nucleus will be noted. 
Had there been one, the consequent formation of this concretion would have 
been easy of explanation. What condition must have existed in order to 
render it possible for the formation and consequent solidification of these 
concretions? Medical practitioners in the Southern and Western states are 
familiar with the tendency of the persimmon, the diospyros virginiana, 
when its seeds are swallowed, to become impacted in the intestinal tract, 
aprticularly in the rectum. Upon one occasion the writer removed from an 
impacted rectum a handful of persimmon seeds which thoroughly and com- 
pletely blocked up the gut’s exit. Upon investigation this experience will 
not be found entirely exceptional, as the writer has heard of many similar 
instances. Dr. W. P. King relates the following instance: A boy, aged 
14 years, was brought to him for treatment. Upon full investigation a 
tumor was found in the stomach. The patient gave a history of having 
swallowed persimmon seeds. ’ Professional complications arising regarding 
the date of operation, massage of the stomach was ordered, and, after some 
two weeks of treatment, the tumor disappeared and the seeds were voided 
in the natural way. This case was only of a months duration, and nausea 
and fever persisted from the beginning. Upon one occasion 1 was called in 
consultation to see a negro man who had a circumscribed swelling just 
below the epigastric region; upon inquiry it was ascertained that he had 
freely partaken of persimmons, many of which he had swallowed whole. 
Violent emesis was present and a tense tympanitic abdomen, along with a 
temperature of 104 0 F. Rectal injections were ordered and grain doses of 
calomel given. Forty-eight hours afterwards the swelling disappeared 
under free catharsis and a goodly number of persimmon seeds passed. No 
further trouble occurred. 1 have heard of similar cases several times, and 
it is to be regretted that more attention has not been paid to the subject, 
for 1 believe that if the records were searched many similar cases could be 
found, some of which terminated in death. In the case under consideration, 
the first trouble which the patient had was in October, and, as stated by 
him, he was almost starved, when he consumed an unusual quantity of 
bread along with the persimmons, many seeds of which were undoubtedly 
swallowed. The fruit of the persimmon is a globular berry about an inch 
in diameter with a short foot-stalk, and the permanent four-lobed calyx at 
the base; green, smooth, and from four to six celled, each cell containing 
a single flat, ovate, oblong seed. The size of the seed varies in length 
from a half inch to six-eighths of an inch, and about a quarter of an inch 
broad. The unripe persimmon has a short remnant of the style attached, 7 
is of a pleasant but weak odor, contains a viscid juice of a very astringent 
taste, which is retained when carefully dried, but becomes acidulous sweet 
after the fruit has been exposed to the frost. The unripe fruit contains 
tannin, and appears to be identical with the tannin in galls. Situated in 
pericarp of the fruit, fibrous septums from the seed cells, and possess 
considerable tenuity. Since the examination of the gastroliths by Prof. 
Close, six persimmon seeds have been removed, and sticking through 
various portions of the mass, pointed ends of the seeds can be seen. In 
the examination made by Dr. Close, each gastrolith was bisected, and 
along the cuts thus made nothing is to be seen; but upon portions broken, 
the seeds can be seen. Most of the seeds appear grouped around the 
center of the gastroliths, none of which appear upon its periphery, probably 
owing to the compression of the stomach itself on the mass and the conse- 
quent covering with mucus and other substances. 
My conception of the manner in which the concretions were formed, is 
this: the patient simply gorged himself with bread, and the glutinous 
thready substance of the pericarp of the persimmon rendered cohesion 
possible, along with an inability upon the part of the stomach to act on so 
extensive a mass. What influence the tannic acid might have had, I am 
unable to state; but 1 believe that some influence was produced. Again, I 
believe that the concretion was never added to after its first formation; that 
its original mass was simply rolled and compressed by the action of the 
stomach. The first trouble commenced in the early part of-October, 1891, 
and the tumor was not discovered until December 15th, 1891, the concre- 
tion thus existing in the stomach for nearly nine months, when it was 
removed in July, 1892. • This, I believe, is the only recorded instance of 
the removal of a food concretion from the living subject of so extensive a 
size and of its peculiar constituent elements. The remarkable elements of 
this case were: the good physical condition of the patient, the absence of 
nausea; while in St. Louis Hospital for nearly a month his ability to eat 
any and all kinds of food; was always ready to take stimulants of any 
kind, which seemingly produced no effect upon him as far as irritation of 
the stomach was concerned. His mental condition was excellent; he was 
cheerful and talkative; he slept well; and at no particular time was there 
any distinct symptom which pointed toward an involvement of the 
stomach. No pain was evinced upon examination, and lie was apparently 
a strong and hearty man, aside from the tumor, and only complained of the 
dragging pains about the loins, back and across the abdomen. The ability 
of the receptive organs to adapt themselves to adverse conditions was 
plainly manifest in this case, and it is surprising to note that with so large 
a mass in his stomach, 19,560 grains, he continued to partake of food with 
relish and gave no evidence of any stomachic trouble. 
RESULT OF THE POST-MORTEM. 
Both lungs were found involved, containing cavities and filled with 
tuberculous material. Heart somewhat contracted, free from clots, with 
slight deposit of fat upon the right side. His spleen, liver and kidneys 
normal (there has never been any indication of trouble with the kidneys up -8 
to the date of death of this individual). Stomadh in normal position, exces- 
sively contracted; the great mesentery was attached to the cuts in the 
anterior parities, the parietal peritoneum being united with the mesentery 
along the entire line of incision; a few large adhesions plainly show the result 
of inflammatory trouble. Stomach bound down posteriorly by adhesions; 
its anterior surface presented the line of the stitches which were made in 
the two incisions from which the gastroliths were removed. Black ferrated 
silk was used to make these stitches. They had been covered and 
thoroughly encysted by the peritoneum and were plainly seen through the 
transparent covering in the stomach. There had been complete and perfect 
union of the walls of the stomach; no line of union being observable to the 
eye; but upon removal of the stomach, where the internal lining had been 
doubled upon itself there was a plain line of cicatritial tissue not even 
covered by the vili composing the mucus membrane of the stomach. The 
union, however, had been complete in detail, as far as the walls were 
concerned. External Wall of Stomach and Suture Lines. 
Internal Wall of Stomach and Suture Lines.