August 17, 2022

My Most Unusual Patient

Richard H. Daffner, MD, FACR

One morning, Linda, our Chairman’s secretary, came to me in the reading room. “I know you’re going to do this,” she said. “Do what?” I asked.

“Go to the Pittsburgh Zoo to do a barium enema,” she replied.

“OK,” I answered. “On what?”

She paused for a beat and then said, “A gorilla.”

“OK, but why not send one of the folks who ordinarily do barium studies?” I asked.

Linda answered, “I asked all of them. They’re not interested. And, I know you have a collection of animal X-rays in your teaching file.”

“Well, it’s been some time since I’ve pushed barium,” I lamented. Our group was specialized, and my areas of expertise were trauma imaging as well as bone and joint imaging. “I’ll take one of the residents,” I added.

“I thought you would agree,” she said. “But you must tell me why you acquiesced.”

“Well, Linda,” I said … “Just think of the stories I get to tell!”

The back story is that Sultan — a 3-year-old gorilla — had been constipated since birth and was becoming more and more uncomfortable. (And you don’t want to imagine how ill-tempered a constipated, 450-pound gorilla can be). The veterinarian at the zoo called one of our general surgeons and asked if he could convince one of our radiologists to come to the zoo and do a barium enema. After learning more about the case, I took the resident who was on my service along with two bags of barium to the zoo.

When we arrived at the zoo’s medical building the gorilla had been sedated and was lying on an X-ray table. They had no fluoroscopy equipment at the time. A veterinary dentist was cleaning Sultan’s teeth, accompanied by the zoo’s vet. (I told my resident that Sultan would be one unhappy gorilla when he woke up!). Several visiting veterinarians also sat in to watch, having never seen a barium enema performed on a gorilla (or any other animal, for that matter).

After taking a “scout” radiograph to get the correct technique, we inserted the rectal tube, let half a bag of barium flow into Sultan’s rectum and took a radiograph. The film showed a colon full of stool, much like that seen in an unprepared human patient. However, there was a very characteristic finding — puckering at the recto-anal junction.

I turned to my resident and said, “What’s your diagnosis, doctor?”

“Hirschsprung’s disease,” she replied.

“I agree,” I said, and turned to the vet to inform him of the diagnosis. He had never heard of it and disappeared into his office to consult his books. (This was in the days before Internet and Google.)

After several minutes he returned and said, “Well, a gorilla’s anatomy is identical to ours. Hirschsprung’s disease is rare, but it occurs.” He then asked, “Now, how is it treated?”

I told him about the pull-through procedure we used at the time, which strips away the diseased part of the colon lining and pulls a normal section through the colon, attaching it to the anus. I suggested the vet call his surgical friend and ask him to assist with the surgery. The procedure was completed as planned with curative results.

Over the years, I’ve had many opportunities to share this experience with friends and colleagues. One night at Boy Scouts summer camp, I was telling the story to our scouts around the campfire and another scout leader (an inveterate skeptic) said, “Yeah, that’s the tallest tale I’ve heard yet. Is that really true?” One of the other fathers present (a veterinarian) said, “It’s true. I was there!”

Coincidentally, he was one of the visiting veterinarians who had sat in to watch that day.