[Reprinted from The Medical News, January 19,1895 ] 
A UNIQUE CASE OF INTESTINAL FISTULA 
FOLLOWING CELIOTOMY. 
By LOUIS FRANK, M.D., 
LOUISVILLE, KY., 
ASSOCIATE PROFESSOR OF OBSTETRICS AND DIRECTOR OF BACTERIOLOG- 
ICAL LABORATORY, KENTUCKY SCHOOL OF MEDICINE; 
GYNECOLOGIST TO LOUISVILLE CITY HOSPITAL; 
OBSTETRICIAN TO KENTUCKY SCHOOL 
OF MEDICINE HOSPITAL, ETC. 
A. T., twenty-eight years of age, a widow, was referred 
to me in June last by Dr, Shrum, of Bedford, Ind. She 
gave a history of dysmenorrhea of most decided charac- 
ter, dating back five years, at which time she had had 
a child, the only one she has ever had, and the birth of 
which was followed by puerperal fever. At each men- 
strual period she was confined to bed for quite a number 
of days, both before and after the flow. She had been 
absolutely incapacitated for work of any kind, and had 
been bedridden a greater part of the time. 
Digital examination revealed exquisite tenderness on 
both sides, and the presence of a great deal of infiltra- 
tion in both broad ligaments, with what was taken to be 
double pyosalpinx. An operation was, of course, advised, 
and carried out on June 23, 1894. Very dense adhesions 
were found upon both sides, those on the right being the 
denser, this tube being imbedded in a perfect mass of 
adhesions composed of the intestines, uterus, bladder, 
etc. After some very difficult work the tube was finally 
enucleated, as was also the left tube, this, however, more 
easily than the right. A drainage-tube was intro- 
duced, and the abdomen closed and dressed in the usual 2 
manner. Through the tube a strip of gauze was carried 
back and inward on the right side, upon which side the 
adhesions had been so dense and numerous ; on this side 
on account of the great amount of infiltration and the 
thickening of the ligament-it being fully three-quarters 
of an inch in thickness-very heavy ligatures were ap- 
plied to the broad ligament. The gauze was removed 
after twenty-four hours, and, although there was not 
much fluid upon aspiration, the tube was left in longer 
for fear of hemorrhage, being removed on the morning 
of the third day. 
The patient did unusually well, without any elevation 
of temperature, the bowels moving in due time, until the 
sixth day, at which time the patient developed some ten- 
derness along the point of the incision ; the dressings were 
removed, but nothing unusual found. At the end of a 
couple of days more she was still complaining, and the 
dressings were again removed and the stitches taken out. 
Provisional sutures had been putin at the point of drain- 
age, and when these were removed there was a gush of 
slightly sanguineous fluid, very thin in consistency, with, 
however, no indication of pus. This left a fistulous tract. 
The fistula was treated with hydrogen dioxid and pack- 
ing, and closed in a couple of weeks. The woman 
had also a great deal of vesical tenesmus, followed by a 
violent cystitis, which kept her in bed for a week longer. 
The temperature in the meantime had subsided to nor- 
mal, and there was absolutely no indication of there being 
anything amiss. About the sixth week she became ob- 
stinately constipated, resisting salines, calomel, and ene- 
mata of water and of water and glycerin, etc. This consti- 
pation continued for five days. The woman was then again 
put upon two-dram doses of Rochelle salts, repeated every 
hour, and these were continued until she had taken about 
four ounces. All at once there occurred one morning a 
gush of fluid mixed with a little fecal matter from what 
had previouly been the sinus. A short while afterward 3 
the bowels moved, the action being very copious and re- 
peated a number of times. Examination then showed that 
a fecal fistula had established itself at the point of drain- 
age. This fistula was treated by local applications, tonics 
were ordered, and the bowels were kept open. In about 
ten days the fistula had closed absolutely, there never 
having been, however, any escape of fecal matter since 
the first discharge mentioned, but the patient had con- 
tinued at times to pass a little gas through the opening. 
The woman was now sent back home, directions being 
given her physician to watch her from time to time. 
Later it was learned by letter that the fistula had again 
reopened, and that gas was occasionally passing, and 
also that she passed several lumbricoides through the 
fistulous tract. The fistula remaining open, she was 
again sent to me for operation, but my clinic not being 
in session she was referred by me to the clinic at the 
Louisville Medical College, where she came under the 
care of Dr. A. M. Cartledge, who dissected out the fistu- 
lous tract, and closed the opening in the bowel in a most 
beautiful manner, the patient making a perfect recovery. 
A letter which I have recently received from Dr. Shrum 
(and another from Dr. Stipp, who had the patient under 
observation after I sent her home) states that she has never 
passed any fecal matter through the fistula since coming 
under his observation. The patient herself says that 
she has passed in all seven lumbricoides through the 
fistula ; that upon two occasions others have come to the 
external opening, partly protruding so that she has been 
able to see them, and then go back. She has had abso- 
lutely no pain except just previous to passing a lumbri- 
coid, when she would have a great deal of pain, and 
she says that she always knew when one was coming. 
The operation revealed, as had been suspected, that 
the fistulous tract was in the track of the drainage, and 
that at the bottom there was the ligature that had been 
applied to the broad ligament, and had no doubt become infected through the drainage-tube. At this point a 
knuckle of gut was adherent, forming almost a complete 
loop, the fistula itself being drawn up by the intestines 
and seeming bent upon itself. 
I report this case on account, first, of the fact that 
seven weeks elapsed from the time of the first operation 
until the establishment of the fecal fistula, which, how- 
ever, is possible, as Senn has shown us, when the cause 
of these fistulas is an infected ligature. Another reason 
is the passage of the lumbricoides, which, in itself, is a 
very unique feature, and something that I have not seen 
mentioned in literature, though I have searched for it 
very diligently. 
419 West Chestnut Street, 
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