TWO CASES OF PERFORATION OF INTESTINE. By James Cantlie, m.a., m.b,, f.r.c.s,,
Ilong Kong.
Case I.?A pilot 011 the China coast, aged 40, had been suffering from diarrhoea for 18 months. Twice his diarrhoea ceased and he be-;
constipated to such a degree that only after treatment by copious enemata were the bowels relieved. The first time was in December 1891, when after many attempts enormous masses of ficeces were washed away. The second time was in March 1892, when the same treatment wa8 applied with the same result. During the intervals the diarrhoea returned and he was treated by a Shanghai quack who administered his came
specific constipator." On admission to Hospital, 10th May, lie had been in pain for four His days, and was exhausted by suffering. abdomeu \yas tympanitic, but not largely distended; pulse feeble and soft, 100 per miuute : temperature 101*5. A hypodermic of morphia
"
and after a short interval an The enema brought away a small quantity of dark, foully-smelling fajcal matter in small pieces. Not much relief followed, and in the evening he began to vomit bilious matter The which was shot up without much effort. bowel was again washed out by an enema, but nothing but foully-stained water returned. On 11th May under morphia he slept fairly well, vomiting occasionally, pulse 110 soft and was
administered,
enema.
feeble, temperature 101, breathing 23 per minute, when awake, costo-abdominal when
costal
A careful examination showed that the tenderness was confined to the lower part of the abdomen, that there was a dull area in the region of the hypogastrium but with indefinite outline. Ensuring oneself that it was not a distended bladder one had to deal with, another enema, The this time by a long tube, was attempted. tube was passed up feet without any diffi-
asleep.
two quarts of water were injected before withdrawal of the tube. The water escaped through the tube with great force, but in its withdrawal nothing came away ; a repetition of the same symptoms were enacted on re-introducNo benefit tion and withdrawal of the tube. resulted from the enema. The patient remained
culty;
Jan.
CANTLIE ON PERFORATION OF INTESTINE.
1893.]
state, only that hiccough supervened and the pulse became more and more feeble. (It was never hard or wiry.) After consultation the patient was placed under chloroform, and an enema carefully tried again, but the same conditions obtained, viz., easy introduction of the tube, a forcible gush through the tube every time it was inserted, and a complete cessation of any return of fluid through the gut when the tube was removed. Laparotomy presented the only natural sequence in treatment, and it was duly carried out. On opening the peritoneum, some gas escaped with foul odour and a mass of hardened solid fajces stained the knife, just above the pubes. It was bo dense that at first it was believed to be a foreign body ; in size and shape it resembled a medium-sized pear. There was only a trace of fluid in the peritoneal cavity. After careful disentanglement of omentum and intestines, a rent was found in the intestine at the upper part of the first portion of the rectum just beyond its junction with the sigmoid flexure. On passing the finger through the opening and downwards towards the anus, a new growth obstructing the The peritoneal cavity was rectum could be felt. cleared of fajces, washed out and drained, and the opening in the gut sewn to the skin. The patient, however, gradually sank and died. Post-mortem.?An opening, inches in diameter, was found 7 inches above the anus; and situated immediately below the opening, a new growth, tufted, fibrous and occupying at its base 3-5ths of the circumference of the gut. The entire circumference of the gut at the seat of the new growth cut hard and leathery to the scissors. The hole through which the lump of faeces escaped was smooth-edged and neither thickened nor inflamed; only on the peritoneal surface were there any signs of inflammation. The mucous surfaces of the intestines, and in fact all the viscera were perfectly healthy. The points of interest to be observed are :? (1) The alternating diarrhoea and obstipatiou. (2) The behaviour of the water injected as to its return. (3) The limited extent of intestinal ulceration.
in much the
(4) The (5) A he
same
soft
pulse
with which an India-rubber tube could be passed up, and nothing, not even water, could find its way out. (6) I.hat the obstruction, at first mechanical and caused by the valve-like nature of the
villous
ease
mass, was not the cause of the
obstruction,
as
through
a
later
tube passed up 2\ feet
clean water returned. The cause being the paralysis of the muscular fibres of the gut from peritonitis. The history had been, that a hardened mass of feces formed just above the in the rectum, that it thinned
only
pathological
growth
gradually
17
put by pressure, and finally escaped to reach inflammatory bed of lymph supported by the surrounding intestines which had been previousthe
an
ly matted together. Acute symptoms followed with the result we know. It is worthy of note that no water escaped from the gut into the peritoneal cavity in spite of the numerous and copious enemata administered, the last enema amounted to four quarts.
Case II.?A prisoner in the gaol aged 65, died after 48 hours' illness complaining of ab-
dominal pains. I did not see merely called in to perform On opening the cavity of
him alive, being the post-mortem. the abdomen a
quantity of darkly-stained, bilious-looking matter
smeared over the omentum and viscera, and sjmptoms of recent peritonitis were everywhere evident. A careful dissection brought to light a small opening, cupable of transmitting a dried pea on the anterior wall of the first portion of the duodenum immediately beyond the pylorus. On opening the gut from behind a good view of the aperture was obtained, when it was found that the stomach and intestine were perfectly, healthy. The pylorus was neither thickened nor inflamed, and the margins of the opening were smooth, no induration or inflammatory thickening showing. There was no key to the, There were 110 worms in cause of this disease. the intestinal canal, nor in the escaped contents. The patient was an opium smoker, the organs The stomach were markedly affected thereby. was small, contracted, a good sized apple would have filled it; the intestiue pale and contracted ; the liver and spleen shrunk ; the kidneys The heart presented a true reduced in size. example of concentric atrophy without local disease. The perforation was no doubt due to ulceration of a Brunner's gland ; but whether there is any connection between opium smoking and such a disease I cau find no clinical records. was
Ilong Kong.
Case I.?A pilot 011 the China coast, aged 40, had been suffering from diarrhoea for 18 months. Twice his diarrhoea ceased and he be-;
constipated to such a degree that only after treatment by copious enemata were the bowels relieved. The first time was in December 1891, when after many attempts enormous masses of ficeces were washed away. The second time was in March 1892, when the same treatment wa8 applied with the same result. During the intervals the diarrhoea returned and he was treated by a Shanghai quack who administered his came
specific constipator." On admission to Hospital, 10th May, lie had been in pain for four His days, and was exhausted by suffering. abdomeu \yas tympanitic, but not largely distended; pulse feeble and soft, 100 per miuute : temperature 101*5. A hypodermic of morphia
"
and after a short interval an The enema brought away a small quantity of dark, foully-smelling fajcal matter in small pieces. Not much relief followed, and in the evening he began to vomit bilious matter The which was shot up without much effort. bowel was again washed out by an enema, but nothing but foully-stained water returned. On 11th May under morphia he slept fairly well, vomiting occasionally, pulse 110 soft and was
administered,
enema.
feeble, temperature 101, breathing 23 per minute, when awake, costo-abdominal when
costal
A careful examination showed that the tenderness was confined to the lower part of the abdomen, that there was a dull area in the region of the hypogastrium but with indefinite outline. Ensuring oneself that it was not a distended bladder one had to deal with, another enema, The this time by a long tube, was attempted. tube was passed up feet without any diffi-
asleep.
two quarts of water were injected before withdrawal of the tube. The water escaped through the tube with great force, but in its withdrawal nothing came away ; a repetition of the same symptoms were enacted on re-introducNo benefit tion and withdrawal of the tube. resulted from the enema. The patient remained
culty;
Jan.
CANTLIE ON PERFORATION OF INTESTINE.
1893.]
state, only that hiccough supervened and the pulse became more and more feeble. (It was never hard or wiry.) After consultation the patient was placed under chloroform, and an enema carefully tried again, but the same conditions obtained, viz., easy introduction of the tube, a forcible gush through the tube every time it was inserted, and a complete cessation of any return of fluid through the gut when the tube was removed. Laparotomy presented the only natural sequence in treatment, and it was duly carried out. On opening the peritoneum, some gas escaped with foul odour and a mass of hardened solid fajces stained the knife, just above the pubes. It was bo dense that at first it was believed to be a foreign body ; in size and shape it resembled a medium-sized pear. There was only a trace of fluid in the peritoneal cavity. After careful disentanglement of omentum and intestines, a rent was found in the intestine at the upper part of the first portion of the rectum just beyond its junction with the sigmoid flexure. On passing the finger through the opening and downwards towards the anus, a new growth obstructing the The peritoneal cavity was rectum could be felt. cleared of fajces, washed out and drained, and the opening in the gut sewn to the skin. The patient, however, gradually sank and died. Post-mortem.?An opening, inches in diameter, was found 7 inches above the anus; and situated immediately below the opening, a new growth, tufted, fibrous and occupying at its base 3-5ths of the circumference of the gut. The entire circumference of the gut at the seat of the new growth cut hard and leathery to the scissors. The hole through which the lump of faeces escaped was smooth-edged and neither thickened nor inflamed; only on the peritoneal surface were there any signs of inflammation. The mucous surfaces of the intestines, and in fact all the viscera were perfectly healthy. The points of interest to be observed are :? (1) The alternating diarrhoea and obstipatiou. (2) The behaviour of the water injected as to its return. (3) The limited extent of intestinal ulceration.
in much the
(4) The (5) A he
same
soft
pulse
with which an India-rubber tube could be passed up, and nothing, not even water, could find its way out. (6) I.hat the obstruction, at first mechanical and caused by the valve-like nature of the
villous
ease
mass, was not the cause of the
obstruction,
as
through
a
later
tube passed up 2\ feet
clean water returned. The cause being the paralysis of the muscular fibres of the gut from peritonitis. The history had been, that a hardened mass of feces formed just above the in the rectum, that it thinned
only
pathological
growth
gradually
17
put by pressure, and finally escaped to reach inflammatory bed of lymph supported by the surrounding intestines which had been previousthe
an
ly matted together. Acute symptoms followed with the result we know. It is worthy of note that no water escaped from the gut into the peritoneal cavity in spite of the numerous and copious enemata administered, the last enema amounted to four quarts.
Case II.?A prisoner in the gaol aged 65, died after 48 hours' illness complaining of ab-
dominal pains. I did not see merely called in to perform On opening the cavity of
him alive, being the post-mortem. the abdomen a
quantity of darkly-stained, bilious-looking matter
smeared over the omentum and viscera, and sjmptoms of recent peritonitis were everywhere evident. A careful dissection brought to light a small opening, cupable of transmitting a dried pea on the anterior wall of the first portion of the duodenum immediately beyond the pylorus. On opening the gut from behind a good view of the aperture was obtained, when it was found that the stomach and intestine were perfectly, healthy. The pylorus was neither thickened nor inflamed, and the margins of the opening were smooth, no induration or inflammatory thickening showing. There was no key to the, There were 110 worms in cause of this disease. the intestinal canal, nor in the escaped contents. The patient was an opium smoker, the organs The stomach were markedly affected thereby. was small, contracted, a good sized apple would have filled it; the intestiue pale and contracted ; the liver and spleen shrunk ; the kidneys The heart presented a true reduced in size. example of concentric atrophy without local disease. The perforation was no doubt due to ulceration of a Brunner's gland ; but whether there is any connection between opium smoking and such a disease I cau find no clinical records. was
