TWO UNUSUAL CASES OF SMALL INTESTINE OBSTRUCTION
IN most surgical cases the history, the patient's symptoms and the objective signs combine to build up a picture on which a diagnosis may be founded and treatment decided upon. In the following case I had to decide whether to trust my eyes or ears, to explore the abdomen on the history alone in face of the clinical findings, or to trust the latter and mistrust the history. I wrongly chose the latter course. Three things influenced me in this decision: first, that I did not know the patient, and
... ow the patient, and had no confirmation of his story from a medical man ; secondly, that the passage of flatus as well as faeces is very unusual in any obstruction other than that of a Richter's hernia ; thirdly, that the man was a plumber, and since he had very good teeth he might be suffering from lead colic without showing the characteristic blue line on the gums. CASE 1.-R. H., aged 23, a male, was admitted into Guy's Hospital with a typical history of acute obstruction of the small intestine of three days' duration. History.-The illness started at 4 P.M. on Oct. 20th with a sudden agonising pain following on three days of vague discomfort. From this time onwards he had been in continual pain, though not so severe. He had vomited such fluids as he had taken by mouth, and had passed nothing per rectum. Further inquiry showed that he had only vomited after food, and that the vomit had never smelt fæcal. Examination.-On admission he looked well and comfortable, with a clear complexion, and clean moist tongue. Temperature was 100° F., pulse 88, respirations 20. The abdomen was slightly full, but moved well, and there were no distended coils or visible peristalsis. The abdominal muscles were " on guard," but allowed deep palpation if his attention was distracted. There was no definite tender spot, only a vague tenderness to the left of the umbilicus. On rectal examination masses of scybala were felt, but there was no tenderness whatever and no ballooning. The findings appeared to contradict the history, and a soap-and-water enema was therefore given, and a halfhourly pulse taken. After the enema he passed a large formed motion,'with flatus. The pain was relieved and he went to sleep. Next morning (24th) he woke feeling very well, and his pulse was now 68, temperature 98.4°. There was no pain, and only slight tenderness. He remained like this till midday, Oct. 25th, taking fluids with no vomiting, his temperature remaining normal and pulse below 80. At midday, however, his abdomen was definitely more distended, and he did not look so well, though he. felt quite comfortable. Operation (on the 25th).-Laparotomy through a left paramedian incision. Moderately distended coils of small intestine were seen, and the general peritoneal cavity contained a little blood-stained fluid. On passing the hand downwards a band was felt at the pelvic brim passing from right to left, which snapped while being palpated. A mass I , was felt in the pelvis and brought into the wound, where it ' , was seen to consist of several coils of intestine matted together and surrounding a loop of the lower ileum about 5 inches long, which was gangrenous and greenish-yellow in colour ; 12 inches of bowel were resected and a lateral anastomosis performed-The abdomen was closed without drainage. Following the operation recovery was uneventful, and he was discharged perfectly well on Nov. 28th. Re7)?.arks. The passage of flatus was probably due to bacterial action on the fairly abundant contents of the large gut distal to the obstruction. The absence of any tenderness probably means that the gut had become absolutely gangrenous just before admission, and the same pathology would account for the cessation of the pain and of the vomiting, which in such cases is at first a reflex act, and only later a back-flow due to obstruction. When the bowel became dead painful and reflex stimuli would cease. Had the patient been examined earlier he would probably have been exquisitely tender per rectum. It is very hard to account for the complete absence of vomiting or of any rise of pulse-rate during the next two days, the fourth and fifth of a complete obstruction in the ileum. With regard to the operation, the choice lay between resection and drainage of the upper ileum by anastomosis to the transverse colon, end-to-end suture, and lateral anastomosis. The good condition of the upper segment rendered the first procedure unnecessary . End-to-end suture is, I think, the operation of choice when dealing with resection of portions of a perfectly healthy intestine, as in gunshot wounds of the abdomen. It is rapid, and gives an almost perfect anatomical restoration. Where the intestine to be resected is in a less healthy condition as in this case, and the reparative powers reduced, one has to be very careful that no leakage can occur at the junction. If end-to-end suture is done with ample invagination of the suture line, drainage of the upper segment is inadequate at the time, and there is a real risk of a stricture at the line of juncture later. With lateral anastomosis a wide opening can be made, and at the same time the sutured edges can be well turned in; the line of junction is further protected by the surrounding coils of intestine. Recluctzon " En Masse " of an Inguinal Hernia : Strangulation in the liedicced Sac Six Months Later. With regard to Case 2, I can only trace two reports of similar cases, one by G. A. Harrison,l the other by W. J. Walsham 2; the latter reports seven cases in all, but in only one case is it clear that the reduction en masse occurred some time before the strangulation for which operation was performed. CASE 2.-A man of 73 was admitted into Guy's Hospital on the night of Nov. 23rd, with a history of acute obstruction of two and a half days' duration. He was wearing a double inguinal truss. History.-He said he had had a left inguinal hernia since a a young man, for which he had worn a truss. Following a fall at the age of 45 (28 years ago), the hernia became irreducible, but was replaced by manipulation at St. Thomas's Hospital. During the following years the hernia came down frequently, but was always reduced, though often with considerable difficulty. Finally, six months ago, the left inguinal hernia came down into the scrotum, became fixed, and was very tender. He worked at the swelling himself, applying fomentations, and trying various manipulations, and after two hours of these attempts, it went back suddenly into the abdomen, and had never since appeared. Three days before admission he felt vague abdominal discomfort, but slept well and passed a normal motion next morning. During midday dinner on the 21st he complained of pains in the epigastrium, and at 5 P.M. he commenced to vomit. Next day the abdominal pain was very acute, and the vomiting continued all that day and the next (the 23rd), when, however, the abdominal pain was easier. From the onset of pain on the 21st till admission nothing was passed per rectum, in spite of two enemas. Condition on admission.-The patient was a stout, wellbuilt old man, but very collapsed. The pulse was 90; temperature under 95° F. He was vomiting frequently, bringing up a brownish fluid with a fæcal smell. The abdomen was not distended, moved well, and was nowhere tender. Both inguinal and femoral canals were empty and not tender at all. Per rectum there was no ballooning of the walls and no faacal matter; the prostate was large and hard. In view of the extreme collapse, continual vomiting, and absence of distension an obstruction of the jejunum was diagnosed, the most probable cause, in view of the history, being thought to be a band of omentum adhering to the neck of an old left inguinal sac. He was warmed in bed for an hour and then taken to the theatre and given a spinal anaesthetic, but before any incision could be made he was obviously so collapsed that he was returned to the ward, where he died ten minutes later. Post-mortem.-A very distended jejunum was traced down to the left iliac region, where at a distance of 36 inchesfrom the duodeno-jejunal flexure it entered a peritoneal ring with very hard edges, easily admitting one finger. The emerging gut was narrow and empty. On stripping back the peritoneum this ring was found to lead to a globular sac the size of a large orange, lying between the peritoneum and the transversalis muscle. No part of the sac was in the inguinal canal, but a prolongation upwards of the tunica vaginalis was intimately blended with the fundus of the sac. On pulling the left testis the fundus of the sac was drawn against the internal ring, and 1 Brit. Med. Jour., 1917, i., 763. 2 Ibid., 1901, i., 691. 121 conversely on pulling the sac the testis was drawn up against the external ring. This serous process was separable from the sac wall and was a distinct structure. On opening the sac it was found to contain a loop of jejunum 9 inches long, which, though inflamed, was neither adherent nor gangrenous. When the intestine was laid open the walls of the upper jejunum were much hypertrophied, and two constrictions in the wall marked the points of entrance and exit of the obstructed loop, suggesting that it had been in the sac for a considerable period and had suffered partial obstruction for some time. In addition the lower ileum was matted by adhesions into a globular mass not attached to parietes, the caaoum was adherent to the right iliac fossa, and the tip of the appendix was lying free in a very small and short right inguinal sac which barely entered the canal. ' , Remarks.