INTESTINAL OBSTRUCTION BY BANDS? LAPAROTOMY?RECOVERY. By Surgn.-Capt. W. D.
Sutherland,
Civil Surgeon Davioh.
On
m.b.,i m.s.,
9th this year X. Y. Hindu male, admitted suffering f'rcm obstruction of the bowels with pain in the right lumbar region of the abdomen. H is previous history, as far as could be ascertained, was that about a 3'ear previously he had had a severe pain in the belly, had been obstinately constipated for about a week, and had vomited for a couple of daj's, the pain continucet.
August
35,
was
ing. O
For this he had done he attributed his recovery.
langam,
and to this
Since then he had been subject to these pains in the belly. The attacks had recurred at gradually lessened intervals and he had been' suffering fourteen days before his admission. Vomiting had occurred four times, having been of the contents of the stomach as far as one could judge. When I saw him he was lying on his back with the knees easily flexed, the abdomen was not distended, nor was it tender on pressure. Some bulging was suspected in the right iliac region. Pain of a griping character was complained of in the right lumbar region. The pain recurred at irregular intervals and lasted for irregular periods. Tongue somewhat dry and furred ; breath not offensive. No vomiting; absolute anorexia; thirst not a prominent symptom. Pulse somewhat feeble; respiration slightly hurried. Expression not anxious; temperature 98?F.; constipation obstinate. He was ordered large soap and water enemata, with opium by the mouth. Result: Tongue moisler, pulse somewhat more feeble if anything,
p:iins less; constipation as before. As he was evidently not really improving, and as one is impressed with the value of early operative interference, when such is indicated in these cases, and one had excluded hernia and of fseces, it was decided to perform
impaction
Dec.
1894.]
ACUTE JAUNDICE WITH OCCLUSION OP THE CYSTIC DUCT.
with a view to relieve, if possible, the obstruction. One expected to find something ?probably of peritonitic origin?in the region J.he in which bulging had been suspected. history of pain always in the right lumbar region seemed to indicate that the suspected bulging in the right iliac region might have a very close connection?if it were not the cause?of these
laparotomy,
obstructions. The diagnosis was, of course, sional one, as the symptoms
merely were
a provivague and
contradictory.
Chloroform having been administered on the 10th, I operated, briefly as follows The abdominal pavietes were incised in the linea alba, the incision extending for three inches from a point half inch below the umbilicus. The intestines being kept in by pressure with new sponges wrung out of warm boiled watei, I proceeded to hunt for the cause of the obstruction beginning at the caecum as recommended by Mr. Treves. The caecum having been found not distended, the small intestine was followed, hand over hand as it were. I must have followed at least five feet?I can only guess how far 1 had "ot?when I found my hand in the left iliac region and came upon moderately distended bowel. Here there were two thin bands of about an inch in length attaching the gut to the anterior abdominal wall. They had caused a kinking of the gut which was quite enough to prevent the passage of fceces. The bands I readily broke through with the finder. The bowel wad carefully followed up, and when I had got to near the under-surface of the liver, I found there small concretions, of about the size of a buck-shot, lying half an inch apart from each other, quite freely movable, and evidently not attached to the tunica of the o-ut. These I easily crushed between my finger and thumb. To make sure I visited all the usual sites of hernia, but found nothing further than what I have mentioned. After the abdominal cavity had been sponged was closed by deep catgut and sutures and the patient silk superficial put back to bed, a hypodermic injection of morphia having been given. The bowels moved 70 hours after the operation, a weak enema of Epsom salts being given. Thereafter they moved every second day?his usual frequency. The abdominal wound did not heal out the wound
kindly,
although the patient kept wonderfully quiet; but at last one secured a good scar and he was discharged on the 12th September, wearing a
binder. He was instructed to present himself for examination in three months' time, and I hope to hear that one has managed to remove all cause of discomfort.
457
I would call attention to the following points:? 1. The cause of obstruction and the resulting kink, which caused a narrowing of the tunica and a great obstruction to the passage of the contents of the bowel, especially when the patient became constipated. The absence of vomiting as an urgent 2. symptom although the seat of the obstruction was in the small intestine. 3. The reference of the pain to a spot so far removed from the site of mischief. 4. The failure in the diagnosis, albeit it was but a provisional one.
Sutherland,
Civil Surgeon Davioh.
On
m.b.,i m.s.,
9th this year X. Y. Hindu male, admitted suffering f'rcm obstruction of the bowels with pain in the right lumbar region of the abdomen. H is previous history, as far as could be ascertained, was that about a 3'ear previously he had had a severe pain in the belly, had been obstinately constipated for about a week, and had vomited for a couple of daj's, the pain continucet.
August
35,
was
ing. O
For this he had done he attributed his recovery.
langam,
and to this
Since then he had been subject to these pains in the belly. The attacks had recurred at gradually lessened intervals and he had been' suffering fourteen days before his admission. Vomiting had occurred four times, having been of the contents of the stomach as far as one could judge. When I saw him he was lying on his back with the knees easily flexed, the abdomen was not distended, nor was it tender on pressure. Some bulging was suspected in the right iliac region. Pain of a griping character was complained of in the right lumbar region. The pain recurred at irregular intervals and lasted for irregular periods. Tongue somewhat dry and furred ; breath not offensive. No vomiting; absolute anorexia; thirst not a prominent symptom. Pulse somewhat feeble; respiration slightly hurried. Expression not anxious; temperature 98?F.; constipation obstinate. He was ordered large soap and water enemata, with opium by the mouth. Result: Tongue moisler, pulse somewhat more feeble if anything,
p:iins less; constipation as before. As he was evidently not really improving, and as one is impressed with the value of early operative interference, when such is indicated in these cases, and one had excluded hernia and of fseces, it was decided to perform
impaction
Dec.
1894.]
ACUTE JAUNDICE WITH OCCLUSION OP THE CYSTIC DUCT.
with a view to relieve, if possible, the obstruction. One expected to find something ?probably of peritonitic origin?in the region J.he in which bulging had been suspected. history of pain always in the right lumbar region seemed to indicate that the suspected bulging in the right iliac region might have a very close connection?if it were not the cause?of these
laparotomy,
obstructions. The diagnosis was, of course, sional one, as the symptoms
merely were
a provivague and
contradictory.
Chloroform having been administered on the 10th, I operated, briefly as follows The abdominal pavietes were incised in the linea alba, the incision extending for three inches from a point half inch below the umbilicus. The intestines being kept in by pressure with new sponges wrung out of warm boiled watei, I proceeded to hunt for the cause of the obstruction beginning at the caecum as recommended by Mr. Treves. The caecum having been found not distended, the small intestine was followed, hand over hand as it were. I must have followed at least five feet?I can only guess how far 1 had "ot?when I found my hand in the left iliac region and came upon moderately distended bowel. Here there were two thin bands of about an inch in length attaching the gut to the anterior abdominal wall. They had caused a kinking of the gut which was quite enough to prevent the passage of fceces. The bands I readily broke through with the finder. The bowel wad carefully followed up, and when I had got to near the under-surface of the liver, I found there small concretions, of about the size of a buck-shot, lying half an inch apart from each other, quite freely movable, and evidently not attached to the tunica of the o-ut. These I easily crushed between my finger and thumb. To make sure I visited all the usual sites of hernia, but found nothing further than what I have mentioned. After the abdominal cavity had been sponged was closed by deep catgut and sutures and the patient silk superficial put back to bed, a hypodermic injection of morphia having been given. The bowels moved 70 hours after the operation, a weak enema of Epsom salts being given. Thereafter they moved every second day?his usual frequency. The abdominal wound did not heal out the wound
kindly,
although the patient kept wonderfully quiet; but at last one secured a good scar and he was discharged on the 12th September, wearing a
binder. He was instructed to present himself for examination in three months' time, and I hope to hear that one has managed to remove all cause of discomfort.
457
I would call attention to the following points:? 1. The cause of obstruction and the resulting kink, which caused a narrowing of the tunica and a great obstruction to the passage of the contents of the bowel, especially when the patient became constipated. The absence of vomiting as an urgent 2. symptom although the seat of the obstruction was in the small intestine. 3. The reference of the pain to a spot so far removed from the site of mischief. 4. The failure in the diagnosis, albeit it was but a provisional one.
