1869 The Lancet  
567 passed about nine inches up the rectum, two or three quarts of soap-and-water were administered. The enema remained about a quarter of an hour, bringing away with it two or three very small scybala and a large quantity of flatus. 29th.-No relief to symptoms. Ordered three drachms of sulphate of magnesia in six ounces of water, an ounce to be taken every two hours. 30th.-Stercoraceous vomiting; pulse feebler. The patient was informed that nothing more could be done but an operation, so that
more » ... he cause of the obstruction, if it could be found, might be removed. He expressed himself willing to undergo anything calculated to give him a chance of life. He was removed to the Bradford Infirmary at 10 r.M. On admission, the patient's countenance presented a shrunken, anxious aspect; the tongue was clean, but slightly dry; the skin warm; the pulse feeble, 106; the vomiting was constant and stercoraceous; the abdomen was slightly distended and tympanitic, excepting in the right iliac region, where there was dulness, as at the commencement of the illness. He did not complain of pain, except on pressure. There was no external evidence of hernia. A consultation of the medical officers having taken place, it was thought, after the history of the case had been carefully reviewed, that the obstruction was in the small intestines, so it was decided to open the peritoneum and explore. At 12, therefore, the patient being placed on the operating-table, ether spray was applied to the abdomen in the right iliac region, and an incision made along the outer edge of the rectus muscle, commencing above on a level with the umbilicus, and extending downwards to Poupart's ligament. Mr. Parkinson then carefully dissected the parts, until the bowels were exposed, which at the lower part of the abdomen were slightly congested. A considerable portion of intestine was gently drawn out, and there was seen a band tightly constricting a piece of bowel. The band had all the appearance of very contracted bowel, was rather thicker than a quill, and had a whipcord feel. Mr. Parkinson, fearing to divide it with the knife, hooked it up with his finger, and was withdrawing the bowel from under it, when the band suddenly gave way, thus at once relieving the stricture. The bowels were instantly replaced, and the wound brought together by silk sutures. The peritoneum was not included in them, because it had retracted; and, besides, the bowels protruding themselves caused difficulty in the attempt, so that it was abandoned to prevent delay. A pad of lint, a sheet of cotton-wool, and a bandage were applied, and the patient put to bed. He was not on the operatingtable more than ten minutes. Dec. 1st.-1 A.M.: The patient expressed himself relieved. The pulse was fuller, 96; respiration 34. Half a grain of acetate of morphia in solution was injected subcutaneously in the epigastric region. He has just vomited slightly. Ice ordered by mouth.-4 A.M.: Has slept slightly at intervals. No more vomiting, but slight retching. Ordered an enema of brandy (two ounces) and tincture of opium (one drachm). 9 A.1BI.: Has slept two or three hours. The pulse is better, soft, 100; respiration 25. Ordered an enema of brandy (two ounces) and beef-tea (two ounces), with yelk of an egg.-12 noon: Enema repeated, with addition of tincture of opium (one drachm).-4 P.. : Patient seems altogether improved; has a better expression of countenance. Enema repeated.-9 P.M.: Pulse 104; has slept a little. Enema repeated.—11 P.M.: The patient has suddenly become much worse; is very restless, and has an anxious aspect. The pulse is sinking; the skin is cold and clammy. There is now no vomiting, and the bowels have not acted. From this time he rapidly sank, and died at 4 A.M. on Dec. 2nd, twenty-eight hours after the operation. Sixteen hours after death the abdomen was opened. No union had taken place in the wound. The surface of the bowels at the lower part of the abdomen was slightly congested. There were no adhesions, and no serum or lymph anywhere visible. The bowels were slightly distended. There were two or three small clots of blood in the cavity of the peritoneum. Across the circumference of the ileum, about four feet distant from the csecum, extended a dark, almost livid, mark, about the sixth of an inch in breadth. Corresponding to this mark, there was a slight depression, and the peritoneal coat was cut through. Tracing the mark around the gut to the mesentery, there was seen attached to the mesentery one of the portions of the broken band. This portion was about half an inch long, rather thicker than a quill, had a firm resisting feel, and was evidently composed of organised lymph. A small clot of blood was effused around it. The other portion of the broken band was attached to the apex of the appendix vermiformis cseci, was a quarter of an inch long, and corresponded in all re-' spects to the other portion. The peritoneum, which forms a mesentery for the appendix, and retains it in its place, was, along the line of its attachment, thickened into a band, similar in character to, and continuous with, the band attached to the apex of the appendix. On passing a probe along the interior of the appendix to its apex, it was found to be impervious. The ileo-caecal valve was normal. The bowels below the stricture contained a considerable quantity of fluid fxces ; those above a lesser quantity. The obstruction was thus caused by the vermiform appendix, and the band attached to it, stretching across the circumference of a portion of the ileum, and attached to the mesentery of that portion. Medical Societies. ! THE author discusses the merits of the various operations hitherto employed for the relief of chronic inversion of the uterus, tabulates the cases in which operations have been resorted to and which are not recorded in Mr. Gregory Forbes's memoir in the Medico-Chirurgical Transactions, adds these cases to Mr. Forbes's tables, and compares the results of the different methods. Of cases treated by ligature only, 26 were successful, 10 unsuccessful, and of the latter 8 died; of cases treated by ligature and excision, 9 were successful, and 3 ended fatally; of cases treated by excision only, 3 were successful, and 2 died; of cases treated on Tyler Smith's plan, by sustained elastic pressure, 6 successful cases had been published; and of cases treated by forcible taxis, some had proved successful, but 3 had died. The ligature and excision were open to the double objection that, besides being very hazardous to life, success was only achieved at the expense of mutilating the patient. Forcible taxis was a violent and often fatal proceeding. Sustained elastic pressure had given remarkable results, but cases would occur where the constricted cervix uteri would resist simple pressure. The author related a case of inversion of six months' standing which resisted elastic pressure kept up during five days; and in which he resorted to a plan, thus practised he believed for the first time, of making three longitudinal incisions into the os uteri, so as to relax the circular fibres ; taxis then applied quickly succeeded. The woman made an excellent recovery. The author proposes, as the best proceeding where simple sustained elastic pressure fails, to make an incision on either side of the os uteri, and then to reapply the elastic pressure, as being safer from the risk of laceration than the taxis. He concludes with some propositions relating to the diagnosis of chronic inversion from polypus. Dr. PROT]AEROI SMITH said that Dr. Barnes had just given a positive proof of the cause of the difficulty in reduction. He had himself operated successfully on a case of sixteen months' duration, and was of opinion that he could suggest a means of overcoming the resistance without resorting to the knife. In the case referred to the inversion was complete when the patient entered the hospital; but manual pressure effected sufficient reduction to restore a margin of cervix. He contrived an instrument, having two steel blades, made to pass between the inverted uterus and the cervix, and to open by a screw. This was applied at 10.55 A.M., and the dilating action kept up until 4 r.M. He then reduced the inversion by pressing on the inverted fundus with a stick having a padded knob at its extremity. The
doi:10.1016/s0140-6736(02)65896-9 fatcat:fyhoxahhvze5nfhu4pocwagtue