1920 Journal of the American Medical Association (JAMA)  
History.-F. J., aged 26, white, married, private, Company G, engineers, whose mother, father, five brothers and four sisters were living and well, had a negative history except for a severe burn on the left side of the face in childhood, had always been we'll, and denied any previous abdominal trouble. The present illness began suddenly at 10 p. m., April 4, 1918. The patient was walking home, after having taken a cup of coffee and a piece of toast, when he experi¬ enced a sudden cramplike pain
more » ... dden cramplike pain in the lower right quadrant of the abdomen. The pain was so severe that he had to be taken to his station at the Washington Barracks, Washing¬ ton, D. C. He vomited continually throughout the entire night, and suffered constant and severe abdominal pain. Next morning he was transferred by ambulance to the Wal¬ ter Reed General Hospital, where he was seen at noon, four¬ teen hours after the onset of the attack. Physical Examination.-The patient weighed 130 pounds. His facial expression was extremely anxious, pinched and exhausted. His general appearance was very bad and gave every evidence of a severe intra-abdominal complication. There was notable general rigidity of the abdominal wall, Fig. 4.-Photograph of gangrenous mass, intestine and diverticulum. with the rigidity somewhat accentuated over the lower right quadrant. Tenderness was also general, but more marked over McBurney's point. No abdominal mass was palpable. A tentative diagnosis of ruptured appendix was made and immediate operation urged. Operation and Result.-Through a right rectus incision the abdomen was opened, when a large amount of bloody, foul, fecal smelling peritoneal fluid escaped. A dark gangrenous mass 4 inches long and 1 inch in diameter protruded through distended coils of intestine. Careful separation of the loops of intestine and a following of the mass to its base revealed that it led to a long coil of gangrenous intestine. When this green gangrenous mass of strangulated intestine was liberated there was a marked odor of colon. A diag¬ nosis of Meckel's diverticulum with strangulation and bowel obstruction was evident. The mesentery of the strangulated intestine was involved down to its postperitoneal attachment, making resection very difficult. The mass, however, was excised and an end to end suture anastomosis was done. To determine the size of the opening at the point of anastomosis, the bowel was inverted by 'the index finger at the point of union. The lumen seemed amply large. The abdomen was drained and closed in layers. The patient, although shocked, left the table in fair shape considering his previous condition. April 6, twenty-four hours after operation, the patient's general condition was unquestionably better. On this day he passed a fair quantity of gas but no fecal matter. April 7, he continued to pass gas, but there was some distention. April 8, there was marked distention with signs of obstruc¬ tion. He began vomiting, and operation seemed imperative. Under local anesthesia an enterostomy was performed, at which time 2 quarts of fecal matter were evacuated. His condition continued very grave, and on April 9 he was given 500 c.c. of blood. Although temporarily improved by this, he died at 9 p. m. Necropsy.-The enterostomy opening was found 145 cm. from the cecum. Above the enterostomy the small intestine was distended with gas and fecal matter. The end-to-end anastomosis was found 40 cm. from the cecum. At the point of anastomosis there was an indurated mass obstructing the bowel. There was no evidence of leakage from the bowel into the peritoneal cavity. COMMENT The case presents an unusual pathologic lesion of Meckel's diverticulum. As is shown in the illustra¬ tions, the diverticulum had tied itself into a complete knot, around the base of, and strangulating a coil of intestine about 2 feet in length. In order to untie this knot the diverticulum had to be cut near its base and the path of the tie of the diverticulum retraced by means of a hemostat. Mr. W. H. French, the artist, was present at the operation, and very kindly made an accurate drawing illustrating the picture presented at operation as well as the manner in which the diverticulum was tied. The presence of catalases in the cerebrospinal fluid is still more or less of an open question. Barbieri1 concluded that no catalases are to be found in the fluid \p=m-\aconclusion to be expected from the method he employed, as all his results are from fluids subjected to prolonged centrifugalization followed by the withdrawal and testing of the supernatant fluid. It has already been shown,2 that the blood serum contains no catalase when fully freed from corpuscles. Thus, a similar result is to be expected from the liquid portion of the cerebrospinal fluid. METHOD AND RESULTS In this work the apparatus described by one of us was employed.3 The peroxid used was the ordinary commercial 3 per cent, solution, acid in reaction and with acetanilid added as a preservative. The solution was neutralized immediately before the test by the addition of the required amount, 1.5
doi:10.1001/jama.1920.02620190016007 fatcat:rr3wnoyvjjhllnj6r7uk5espxy