Remarks on a Case of Acute Intestinal Obstruction Due to the Presence of a Meckel's Diverticulum, Successfully Treated by Laparotomy
BMJ (Clinical Research Edition)
temperature of 70' F., with a rebreathed air. Could we feel surprised if his liver, under these circumstances, reverted to the uric acid for. mation of the lethargic Ichthyosaurian in his tropical swamp ? In such cases of lithiasis or uric acid formation, horseback exercise in the country was the cure par cxcellcicc. Frequently a stay at some hydro,athic establishment was attended by the best results. There remained one more line of attack, namely, the resort to colUhicurm. No one who had hadl
... o one who had hadl personal experience of the pains of gout had a, y doubt about the analgesic effects of colchicum. The ease it gave was simply magical. At the same time, no sufferer from gout in the po3session of his senses would resort rashly or recklessly to this potent pain-killer. Infinitely worse was the resort to colchicum to ward off threatening attacks of gout. When the liver manifested a tendency to revert to the uric acid formation, no matter how brought about or in what form or morbid manifestation, the management of the case involved knowledge, thought, discrimination, and the capacity to adapt concrete measures to the wants and exigencies of the indivildual. -Dr. BRTRNEY Yxo, in reply, congratulated the Association on having elicited from those whlo had taken part in the diszussion such valuable remarks as they had heard on this practical subject. He thought that the view taken by Dr. Latham that the changes were constructive rather than destructive was negatived by the tact that so many sufferers from thi3 diat' esis showed no signs of dtfective nutrition, until d(legenerative arterial changes had been established. He had found colchicum, in small and careful doses, exceedingly valuable in the treatment of those neurotic affections connected with this diathesis. He protested against the use of opium or morphine in acute gout. He considered it was not good practice or good theory to give a drug which arrested secretion in a malady which was one of defective excretion. He thought it most interesting to learn that uric acili had been detected in the secretion of the skin. Professor of Surgery in the Yriks.hire College, and Surgeon to the Leeds Infirmary. ON Mlarch 5th, 1887, I saw, in consultation with Dr. Glaister, of Rothwell. a collier, aged 30, who had been suffering from completc intestinal obstruction for nine dlys. We learnt that while at work on February 25th he was suddenly seized with severe abdtominal pain; he walked home, and on taking a glass of water immediately vomited. From that time he passed neither f-iecal itmatter nor flatus from the bowel, and vomited everything that he took by the mouth. The symiptoms were not of the severest type, as he had long intervals in which he was free from pain and sickne3s; vomiting was, however, ind(luced by every attempt to take food. His abdomen gradually increased in size, and his general condition much deteriorated. He was treated in the usual manner, chiefly by opium and large injections. When I saw him the abdomien was inmmensely distend(l, and numerous coils of ittestines were distinctly visible. He was in a feeble and almost mioribund condition, extremely wasted, and with a quick thready pulse. The case was apparently one of intestinal obstruction, situated in the small intestine, and( due to some mechanical cause. We advised his removal to the Leeds Infirmary. where I operated the same evening. The operation is (lescribed as follows in the Infirmary notes: "The patient being placedl under chloroform, the rectum was first examined, with a negative result. The skin of the abdomen having betu thoroughly cleansed, an incision was made in the median line, extending from a point one inch above the symphysis pubis upwards for three inches. The peritoneal cavity was opened, and a small amount of clear serum escaped. Through the opening the right hand of the operator was passed into the abdomen, and its cavity was thoroughly explored. As nothing to account for the olstruction was found, the incision was enlarged upwards for an inch or more. The intestines were then allowed to escape; when about three feet had escaped fromn the peritoneal cavity, the junction of the distended and empty intestine was seen. At this point a Meckel's diverticulum, much dilated and about six inches in length, was seen, pi,sing down. wards and forwards, to be attached to the fundus of the bladder. A loop of collapsed intestine passed under the diverticulumn, the obstruc. tion Ieing caused by the twisting of the bowel at the point where the diverticulumn wvas at!a^hed. The loop slipped from under the diveTti culum with slight traction, and the distended portion could be seen emptyiug itself into the part previously empty. The intestines with much difficulty were returned into the abdominal cavity, and the wound closed with silk sutures. The patient passed a small amount of flatus during the n;ght, and was somewhat relieved the next morning. During the day he became worse, and the vomiting returned. As the passage of flatus had entirely ceased, and the abdomen was very large and distended, a saline purgative (Rochelle salt) was given. A large quantity of fiatus was passed, and the patient's condition much improved. He went on perfectly well till the tenth day, when a small amount of fluid fmcal material escaped from the upper cornler of the wound. This continued or a fortnight, when the discharge ceased, the wound rapidly healed, and he left the hospital perfectly well. Several points in this case call for remark. 1. The attachment of the diverticulum to the fundus of the bladder has not, so far as I kniow, been hitherto described. 2. The obstruction was due to the twisting of the bowel at the point of attachlment of the diverticulum, and not to compression of the gut under this band. In this case the diverticulum was a cause of volvulue, which in its turn was the cause of the obstruction. 3. The treatment by laparotomy does not now require to be defended, but the mode of operating is not as yet quite determined. According to Mr. Treves the method adopted in this case should be condemned. In his own vords, " the practice of allowing the bowels to escape is absolutely bad." It is no doubt, whlen practicable, preferable to operate without permitting the bowels to escape, the shock of the operation being thus much diminished. In a case under the care of my colleague, Dr. Churton, I operated in this manner. A middle-ac,ed woman had suffered from acute sym. ptoms of intestinal obstruction for five days. Having opened the abdomen, I was fortunate enough to immediately find a firm fibrous band, which was the cause of the obstruction. This I divided with scissors, and straightway closed the abdomen. The patient had not a bad symptom, and left the hospital in a fortnight well. But in many cases it is impossible thus easily to discover the cause of the obstruction, and then the surgeon should not hesitate to allow the intestines to leave the abdominal (avity. The danger of the operation is no doubt increased, but we are almost sure not to leave a remediable cause undiscovered. This happened to me aboutt two years ago; I failed during operation to find a Meckel's diverticulum, which had caused obstruction for five days, and the patient, a boy of 15, consequently died. We mny occasionally find the cause of obstruction by intra-abdominal examination, but in the majority of cases this method is ineffectual, and the iutestines must be allowed to escape. A second point connected with the operative treatment of this.case is the leaving the diverticulum untolched. It might appear at first sight advisable to divide it and sew up the divided end. This would have taken some considerable time, and the prolonged operation might have caused a fatal result. It appears to me to be preferable to leave the diverticulum in position, even though this exposes the patient to the risk of another attack of obstruction. 4. No opium was given, but a saline purge was administered with apparent advantage. The administration of opium as a routine measure after abdominal operations is, in my opinion, much to be deprecated. It seldom does good to the patient, and it lulls the surgeon into a false feeling of security. Unless called for by severe pain, opiates should not be given. In this case the administration of a purgative, which immediately caused the expulsion of a large amount of flatus, did much good, and apparently turned the scale in favour of recovery, 5. This case well exemplifies the great difficulty with which the abdomen is closed in operations for conditions associated with excessive iitestinal distension. Thoughl every care was taken to prevent such an accid(lent, it is evident that a small portion of the intestinal wall was caught in the upper angle of the wound. The fi-tula thus formned soon closed, and, beyond delay in healing, little harm was done. In another case we might not have been so fortunate. It has been suggested that in somne of these cases it may be advisable to evacuate a porti3n of the intestinal contents through a small incision in the irtcstinal wall. The increased severity of the operation and the iisk of septic infection of the peritoneum seem to contra-indicate this procedure. It should only be adopted when all other means of closing the abdomen have failed. SUPERANNUATION. -Mr. Alexander W. IMcLeod, late medical officer for No. 1 district of the Fulham UTnion has obtained a superannuation allowance of £35 per annum.