No fluctuation could be discovered, but the condition of the skin pointed so strongly to an abscess connected vvitli the caecum, that I determined to perform an exploratory operation. The
patient having
been
instruments sterilized, I made the skin
over
the most
prepared,
and the
incision through prominent portion of the an
a quantity of foul-smelling gas bubbled out from the tissues. The structures of the abdominal wall having been cautiously divided layer by layer, the tranversalis fascia and peritoneum were exposed, and still, to the finger, gave the impression of being connected with the tumour.
tumour, and
% Hlii[i|oii of Hospital |i|itctic^. INTESTINAL OBSTRUCABDOMINAL SECTION AND IIE-
INTUSSUSCEPTION, TION,
DUCTION?DEATII
FROM EXHAUSTION.
By Surgeon-Major Gr. M. J
Giles, Bijnor Hospital,
m.b., f.r.c.s.. i.m.s.
The following case presents certain features of so exceptional a character that it may be well to put it on record :? Klioob Singh, cet. 50, Jat, was brought into in an almost (tying condition. He was ?much wasted, the face pinched and anxious, lips -dry and parched, and the pulse small and very !rapid. His temperature was obviously febrile, 'but in the press of the morning's surgical work ;it was not taken till the completion of the operation, when it was found to be 100 2?F. He was (hiccoughing continuously, and alternating this 'with violent retching, and gave the following
(hospital
(history
:?
Eight davs before,
he
was
attacked
with
diarrhoea, accompanied with great straining, and shortly after noticed a tumour in the right iliac A
region.
day or two after this the diarrhoea diminished, and the previously watery flow ceased, but he was continuously tormented by desire to go to stool, straining violently, but only voiding little mucus, which during the last three days a
had been blood-stained. For the last three days he had been vomiting, but the vomit does not appear to have become stercoraceous. A barber had
applied 30 or 40 leeches to the On examination a distinct oval tumour ?could be felt, well to the right, a little below the level of the navel. There were no signs of general peritonitis, although the abdomen was somewhat distended. The tumour was slightly movable, and seemed connected with the abdominal wall over its most prominent portion where the skin was reddened and oedematpus; and crepitated under the fingers from emphytumour.
semte.
very cautiously the peritoneum pinched up, and a small incision made, when, great deal to my surprise, I discovered that
Proceeding
was a
there were no adhesions between the tumour and abdominal wall. At the moment of making the opening, there was a gush of foul-smelling gas from the peritoneal cavity. After prolonged examination with the finger, I made out that the doughy, sausage-shaped tumour was the caecum, with some inches of the ilium intussuscepted through the illo-csecal valve, feeling curiously like the glans penis as felt through a phymosed prepuce. On drawing it up to the wound the whole structure was seen to be very oedematous and congested, but not coated with lymph, and the peritoneum was clearly still unaffected. I now began to consider whether it would not be better to enlarge the incision sufficiently to freely expose the parts and enable me to get hold of, and draw out, the intussuscepted bowel; but, while considering, I found that my manipulation of the crecum was gradually diminishing the tumour, and by manipulating it between the two forefingers I ultimately succeeded in completely reducing it, assisting the process by occasionally drawing on the small bowel by one finger hooked round it, while the other steadied the caecum. Having satisfied mj'self of complete reduction, the abdomen was washed out with sterilized salt solution, and the toilet of the peritoneum having been completed, the wound was closed by continuous gut sutures, each layer being sewed up separately. The wound was dressed with pads containing bichloride cotton cuttings. A hypodermic injection of I grain of morphia was given, and the patient put to bed with instructions that he should be given nothing but a little cold water to sip. At 4
proved ;
I found his condition greatly imhe had lost the pinched and anxious
P.M.
appearance. The hiccough and vomiting had completely ceased, and he had passed three watery motions coloured with bile. At 10 p.m. the improvement was still more marked; the temperature had fallen to 99"4?F., and his pulse was better, though still very weak. He complained much of tliirst 36
266
INDIAN MEDICAL GAZETTE.
but the diarrhoea was becoming troublesome. Given a starch-opium enema, and I left instructions that morphia injection should be pressed till sleep was produced. The next morning the improvement was maintained, but although he had had ? grain of morphia hypodermically, he had had but little sleep, and had passed four or five more motions. The abdomen was quite free from tenderness, and, when not griped by the diarrhoea, the patient lay easily with his legs stretched out. The temperature had fallen to normal, and there seemed to be every hope of saving the patient. He was ordered freely diluted milk with a little carbonate of soda, and to continue the starch and opium enemata. At 4 p.m. I found that during the day the diarrhoea had become worse, and resisted all our attempts to stop it. His strength was obviously failing, but the temperature was still normal, and absolutely no sign of peritonitis. I ordered him rum and milk, and 10 grains of Dover's powder with 3 grains of hydrarg. cum cretee. After this, however, he lost strength rapidly, the diarrhoea becoming worse and worse, till by 9 P.M. his condition was obviously hopeless, and he died an hour later.
There
was never an}7 vomiting after the operamedicine and milk were retained through out the day without nausea. No post-mortem was obtainable.
tion;
Remarks.?The first point that strikes one in connection with the case is, that it shows that foetid emplij'sema of the skin over an abdominal tumour does not, as one would imagine, indicate continuity of tissue with the gut. It is clear that the gas must have first diffused from the gut into the peritoneal cavity, and thence into the tissues of the abdominal wall, where its resistance was weakened by inflammation from the severe leeching to which it had been subjected. Another equally interesting point is that foetid gases, produced by the agenc}r of bacteria within the bowel, can dialyse into the peritone;il cavity and tissues without any accompanying septic infection. The wall of the intestine, acting as an effective germ-proof filter, allowing the gases t pass, but keeping back the bacteria. From the history of the case it seems probable that the illness commenced as an ordinary catarrhal diarrhoea of the lower portion of the small intestine, and that the intussusception was produced by the violent peristalsis set up by the intestinal irritation. It is curious how immediately the diarrhoea recurred as soon as the obstruction was relieved; and I think it may be fairly claimed that the operation was completely successful, for the man died of the diarrhoea and not from peritonitis or obstruction as he would have, had it failed.
[July
1895.
The relief affected by the operation was immediate, and, until he began to sink from the constant flux, I had every hope of his recovery. The weather, it may be remarked, was very unfavourable to a case of diarrhoea; the temperature of the ward in which he was treated, being not far off 100?F., and it seems quite possible that he might have rallied under favourable circumstances.
more
patient having
been
instruments sterilized, I made the skin
over
the most
prepared,
and the
incision through prominent portion of the an
a quantity of foul-smelling gas bubbled out from the tissues. The structures of the abdominal wall having been cautiously divided layer by layer, the tranversalis fascia and peritoneum were exposed, and still, to the finger, gave the impression of being connected with the tumour.
tumour, and
% Hlii[i|oii of Hospital |i|itctic^. INTESTINAL OBSTRUCABDOMINAL SECTION AND IIE-
INTUSSUSCEPTION, TION,
DUCTION?DEATII
FROM EXHAUSTION.
By Surgeon-Major Gr. M. J
Giles, Bijnor Hospital,
m.b., f.r.c.s.. i.m.s.
The following case presents certain features of so exceptional a character that it may be well to put it on record :? Klioob Singh, cet. 50, Jat, was brought into in an almost (tying condition. He was ?much wasted, the face pinched and anxious, lips -dry and parched, and the pulse small and very !rapid. His temperature was obviously febrile, 'but in the press of the morning's surgical work ;it was not taken till the completion of the operation, when it was found to be 100 2?F. He was (hiccoughing continuously, and alternating this 'with violent retching, and gave the following
(hospital
(history
:?
Eight davs before,
he
was
attacked
with
diarrhoea, accompanied with great straining, and shortly after noticed a tumour in the right iliac A
region.
day or two after this the diarrhoea diminished, and the previously watery flow ceased, but he was continuously tormented by desire to go to stool, straining violently, but only voiding little mucus, which during the last three days a
had been blood-stained. For the last three days he had been vomiting, but the vomit does not appear to have become stercoraceous. A barber had
applied 30 or 40 leeches to the On examination a distinct oval tumour ?could be felt, well to the right, a little below the level of the navel. There were no signs of general peritonitis, although the abdomen was somewhat distended. The tumour was slightly movable, and seemed connected with the abdominal wall over its most prominent portion where the skin was reddened and oedematpus; and crepitated under the fingers from emphytumour.
semte.
very cautiously the peritoneum pinched up, and a small incision made, when, great deal to my surprise, I discovered that
Proceeding
was a
there were no adhesions between the tumour and abdominal wall. At the moment of making the opening, there was a gush of foul-smelling gas from the peritoneal cavity. After prolonged examination with the finger, I made out that the doughy, sausage-shaped tumour was the caecum, with some inches of the ilium intussuscepted through the illo-csecal valve, feeling curiously like the glans penis as felt through a phymosed prepuce. On drawing it up to the wound the whole structure was seen to be very oedematous and congested, but not coated with lymph, and the peritoneum was clearly still unaffected. I now began to consider whether it would not be better to enlarge the incision sufficiently to freely expose the parts and enable me to get hold of, and draw out, the intussuscepted bowel; but, while considering, I found that my manipulation of the crecum was gradually diminishing the tumour, and by manipulating it between the two forefingers I ultimately succeeded in completely reducing it, assisting the process by occasionally drawing on the small bowel by one finger hooked round it, while the other steadied the caecum. Having satisfied mj'self of complete reduction, the abdomen was washed out with sterilized salt solution, and the toilet of the peritoneum having been completed, the wound was closed by continuous gut sutures, each layer being sewed up separately. The wound was dressed with pads containing bichloride cotton cuttings. A hypodermic injection of I grain of morphia was given, and the patient put to bed with instructions that he should be given nothing but a little cold water to sip. At 4
proved ;
I found his condition greatly imhe had lost the pinched and anxious
P.M.
appearance. The hiccough and vomiting had completely ceased, and he had passed three watery motions coloured with bile. At 10 p.m. the improvement was still more marked; the temperature had fallen to 99"4?F., and his pulse was better, though still very weak. He complained much of tliirst 36
266
INDIAN MEDICAL GAZETTE.
but the diarrhoea was becoming troublesome. Given a starch-opium enema, and I left instructions that morphia injection should be pressed till sleep was produced. The next morning the improvement was maintained, but although he had had ? grain of morphia hypodermically, he had had but little sleep, and had passed four or five more motions. The abdomen was quite free from tenderness, and, when not griped by the diarrhoea, the patient lay easily with his legs stretched out. The temperature had fallen to normal, and there seemed to be every hope of saving the patient. He was ordered freely diluted milk with a little carbonate of soda, and to continue the starch and opium enemata. At 4 p.m. I found that during the day the diarrhoea had become worse, and resisted all our attempts to stop it. His strength was obviously failing, but the temperature was still normal, and absolutely no sign of peritonitis. I ordered him rum and milk, and 10 grains of Dover's powder with 3 grains of hydrarg. cum cretee. After this, however, he lost strength rapidly, the diarrhoea becoming worse and worse, till by 9 P.M. his condition was obviously hopeless, and he died an hour later.
There
was never an}7 vomiting after the operamedicine and milk were retained through out the day without nausea. No post-mortem was obtainable.
tion;
Remarks.?The first point that strikes one in connection with the case is, that it shows that foetid emplij'sema of the skin over an abdominal tumour does not, as one would imagine, indicate continuity of tissue with the gut. It is clear that the gas must have first diffused from the gut into the peritoneal cavity, and thence into the tissues of the abdominal wall, where its resistance was weakened by inflammation from the severe leeching to which it had been subjected. Another equally interesting point is that foetid gases, produced by the agenc}r of bacteria within the bowel, can dialyse into the peritone;il cavity and tissues without any accompanying septic infection. The wall of the intestine, acting as an effective germ-proof filter, allowing the gases t pass, but keeping back the bacteria. From the history of the case it seems probable that the illness commenced as an ordinary catarrhal diarrhoea of the lower portion of the small intestine, and that the intussusception was produced by the violent peristalsis set up by the intestinal irritation. It is curious how immediately the diarrhoea recurred as soon as the obstruction was relieved; and I think it may be fairly claimed that the operation was completely successful, for the man died of the diarrhoea and not from peritonitis or obstruction as he would have, had it failed.
[July
1895.
The relief affected by the operation was immediate, and, until he began to sink from the constant flux, I had every hope of his recovery. The weather, it may be remarked, was very unfavourable to a case of diarrhoea; the temperature of the ward in which he was treated, being not far off 100?F., and it seems quite possible that he might have rallied under favourable circumstances.
more
