The tale of a gastrocutaneous fistula: How William Beaumont and Alexis St Martin changed medicine together.

Gastrocutaneous (GC) fistulas are extremely difficult to care for.  As with other proximal enterocutaneous fistulas that are high output, GC fistulas also secrete acidic gastric fluid that excoriates surrounding mucosa and skin, making wound care and output control extremely difficult.  Some of these fistulas present with sentinel bleeds from excoriated mucosa, while some present with significant electrolyte or nutritional abnormalities.  Measuring accurate outputs through stoma appliances is often unreliable and leads to inadequate resuscitative efforts with fluids. Enteral feeding of patients with GC fistulas is also difficult, which impairs overall healing of the fistula.  Most patients must undergo parenteral hyperalimentation for variable periods of time to promote improved nutrition and healing.

 

The first significant physiological experimentation performed to understand gastric physiology as well as the natural course of GC fistulas occurred on June 6, 1822 on the island of Mackinac in lake Michigan (part of 1822 Michigan) at the American Fur Company trading post.  At the time, a young army physician named William Beaumont was stationed at this post. On June 6, 20- year old Alexis St. Martin, a Canadian trader, was making trades at the same Fur Company when a shotgun accidently fired into his left upper quadrant at a distance of three feet.  William Beaumont was the first physician responder and successfully resuscitated the young French Canadian, although his injuries left St. Martin with a large gastrocutaneous fistula.

 

Alexis St. Martin was unable to pay for medical care, which required meticulous attention to his lengthy rehabilitation.  William Beaumont understood the rarity of direct access to a living human stomach and offered to provide free medical care to St. Martin in exchange for permission to perform physiological experiments.  St. Martin agreed to a series of experiments that included placing pork, beef, bread, raw cabbage, and other various foods into the stomach on a silk string.  During these experiments, Beaumont gained novel knowledge into the constitution of the enzymatic processing of foods by the stomach.  He sent fluids for analysis and continued his experimentation despite St. Martin’s resistance; the experiments were halted and restarted a total of three times during an 11 year period which culminated in Beaumont’s revolutionary medical book titled “Experiments and Observations of the Gastric Juice and the Physiology of Digestion.”

 

William Beaumont died on June 20, 1853 as an internationally known medical doctor.  Many others attempted to replicate his work but finding a subject like St. Martin was rare.  Alexis St. Martin died in 1880 with his GC fistula that was never fully healed.  Living for nearly 60 years with a GC fistula is a testament to the relationship between Beaumont and his patient.  As the two demonstrated, with proper meticulous care, GC fistulas are treatable, but still remain extremely morbid with no clear quick cure. 

 

Reference: Markel H. Experiments and Observations: How William Beaumont and Alexis St. Martin seized the Moment of Scientific Progress. JAMA 2009; 302(7):804-806

This post submitted by Dr. David Shersher.