Note: There is language in this excerpt that some readers may find offensive.
The Surgeon's Tale
The problem was obvious, and one glance downward at the diaphragm explained everything. The diaphragm is a thick sheet of muscle and fiber lying transversely across the middle of the body, separating the chest cavity from the abdomen. Its only openings are three snug apertures that allow the esophagus and the large artery and vein called the aorta and vena cava to traverse it; it is otherwise like an intact, inviolate curtain of flesh through which nothing can pass. That may describe your diaphragm or mine, but not the unique one possessed by Jimmy Tyson.
Jimmy's had an extra hole near its front, or anterior, part with which he'd obviously not been born. Through that hole, a bit of the upper edge of the transverse colon had somehow intruded itself from the abdomen below, gotten pinched off because the opening was so small, been strangulated, and then perforated into the thoracic cavity. All the havoc, all the junk in the chest, was the result of little bits of stool and feculent liquid from the bowel having emptied into the chest. What this boy had was essentially what you might call a shit empyema.
It was pretty clear what had to be done. The nurses readjusted the drapes, and we swabbed the belly with sterilizing solution. I made a short transverse incision in the left upper quadrant of the abdomen, coming down precisely on the place where the colon was stuck into the hole in the diaphragm. I put specialized clamps on each side of the involved intestine and cut loose the trapped knuckle of bowel from the herniated part clinging to the undersurface of the diaphragm. It was a simple matter to remove the bit of perforated colon and bring the healthy ends out through the short abdominal incision as a temporary transverse colostomy, which I'd be able to reconnect in about three weeks. We changed gloves and turned our attention back to the chest. The hole in the diaphragm was so small that it took no more than my pinky to fi l it. I repaired it with a few carefully placed sutures, closed the chest, and stepped back to think, when the kid woke up, screaming and thrashing his arms wildly in every direction.
How had the hole gotten there? It looked nothing like the congenital diaphragmatic hernias that are on rare occasions found in infants; in fact, it had the appearance of having been man-made, perhaps with a sharp instrument like a narrowbladed knife. The patient's past hospital record consisted of only a single emergency room sheet from a visit four years earlier, and the medical intern had told me during my consultation that there was no point in my reading it because the scrawled note on its front couldn't possibly provide any clues to the presence of an empyema. I figuratively kicked my own ass for not having looked at it, then went downstairs to the medical floor as fast as I could, where the emergency room sheet still lay in its folder amid a pile of old patient charts.
And there it was — the answer to the feculent puzzle. At fifteen, Tyson had come into the emergency room with a very short slash through the skin just under his left rib cage, no greater than two centimeters in length and appearing to have barely penetrated the fatty layer underneath — or so it was described in the brief emergency room note. Because it seemed not only minor but superficial, the intern on duty had dressed it with antibiotic gauze and told the boy to return to the surgical clinic in three days, which he never did.
If that piece of information made me feel stupid, going back up to the recovery room to inspect the patient's abdomen only worsened the anguish. In paying so much attention to Jimmy's chest, I had neglected to look carefully at anything else. But now with a bright light focused on it, I could see the old wound clearly — thin as a razor blade and shrunken to half its original length, staring up at me from its easily visible hiding place just under the left rib margin. The boy was by then wide awake, and I asked him how he had gotten the tiny scar. The answer was brief and to the point: "Motherfucker stuck a knife in my belly when I wouldn't give him my Red Sox jacket. Could'a cut me in my heart, the prick." On further questioning it turned out that "motherfucker" had plunged the blade upward as far as the handle, probably realized what he'd done, then pulled the knife out and taken off in a panic. When the small wound healed uneventfully, Jimmy thought everything was fine. He had no idea that he was now the possessor of a brand-new hole in his diaphragm, which would never heal itself closed as his skin had done. He had not had any problems until less than a week before he came into the hospital, when he developed episodes of colicky pain in the evening after eating
supper. The feverishness and shortness of breath began a few days later.
Everything added up. The tip of the blade had indeed made a permanent hole in the left side of Jimmy's diaphragm. About a week before the present episode, a bit of transverse colon had snaked its way through the hole — I have no idea why it took four years to make up its mind to commit such mischief — and gotten pinched off , lost its blood supply, and perforated into the chest, with all the foul consequences we discovered at operation. I had never heard of such a thing; in fact, during the thirty years I practiced surgery after that eventful night, I never saw or heard of anything remotely resembling it. But there was another surprise yet to come.