J.F. Jefferies
1911 The Lancet  
63 years of age, and I would call special attention to the fact that in its earlier stages the case presented an absolutely true clinical picture of gall-stone colic, so much so that it was only after a negative laparotomy and a consequent revision of the diagnosis that I was forced to the conclusion which I now advance. Wellington College Station, Berks. I THINK the two following cases are of sufficient interest to be recorded. The first, a case of acute intussusception, was brought to me with
more » ... brought to me with the ordinary symptoms of blood and mucus passed per rectum and vomiting. The patient was a female child, between 6 and 7 months old, breast-fed, and healthylooking. The passage of blood and mucus had set in early in the morning and the vomiting some hours later. The intussusception could be made out by external palpation, and its apex by rectal examination about 2 inches from the anns. 1 had the child removed at once to the Hounslow Cottage Hospital, and I operated on the same day in the afternoon. I was able at first to reduce the intussusception a good deal by hydraulic pressure, using a mixture of 2 parts of milk and 1 of water. This mixture was injected slowlythe time occupied being 12 minutes-with the pelvis well raised, by means of a soft indiarubber tube. The amount used was a little under half a pint. I next made an incision in the region of the csecum and by intra-abdominal manipulation reduced the intussusception sufficiently to bring it out of the abdominal cavity, where, after some trouble, I reduced it completely. I then stitched up the abdominal wound, having previously irrigated the peritoneal cavity with warm Mtine solution. For the first 24 hours I kept the child on sips of hot water, as the vomiting was very troublesome. During the greater part of the second day the vomiting continued, and I entertained very little hope of saving the child's life. As a last means of controlling the sickness I washed out her stomach with warm water and sodium bicarbonate (10 gr. to i ) until the contents were returned clear. The effect was most remarkable: the vomiting stopped and the -child slept for three hours. I then directed that she should 'be fed with egg albumin and water. From that time the child made a rapid recovery and has now left the hospital. The interest of this case lies chiefly in the remarkable result obtained by the lavage of the stomach in controlling constant vomiting, and also in the fact that so very few children under a year survive such a severe operation. The other case was that of a young woman, married only seven weeks, who had been complaining for a day or two previous to my visit of severe abdominal pain. The history was unimportant, save for the fact that she had had a similar attack about two months before she was married, had been under medical treatment, and ultimately recovered. When I first saw the patient her temperature was 102°F. and her pulse was 110, and she complained of pain in the region of the appendix. There was no sign of any peritonitis. The next morning both pulse and temperature were below 100 and the pain was not so acute. I decided then to await events, and not to operate, as I intended to. She remained in much the same condition as regarded pulse and temperature for the next two days. On the fourth day the temperature went up slightly, but the pulse remained below 100. On the evening of the fifth day the pulse went up to 120 and the 'temperature to 102°. As it was very late when I saw her I could not have her removed before the next morning, but I operated the next day early. I released the appendix, which was bound down by recent adhesions deep in the pelvis, and removed it, but little difficulty being experienced in breaking down the adhesions. The appendix measured a little over 4 inches and was greatly congested, but it showed no sign of any perforation. There was some free clear fluid in the peritoneal cavity. In the evening the patient looked fairly comfortable, but had been sick several times. The next morning at 9 o'clock I was told that she had vomited all night until 4 A.M., but that subsequently she had had some sleep. Her pulse then was very weak and fast. I injected strychnine hypodermically, but though her pulse got stronger and was not so rapid for a few hours, she sank rapidly and died at 6 P. M. The unusual and rapidly fatal ending of this case very greatly puzzled me and pointed obviously to something beyond acute appendicitis. I was allowed to make a postmortem examination so far as the abdominal cavity was concerned ; this I did two days after death. There was no septic peritonitis present ; the organs looked healthy, but to my great surprise I found a double pyosalpinx, the left ovary healthy, the right diseased and having both on its surface and inside several small cysts, some of them hasmorrhagic. I feel sure that the appendicitis was secondary to the pyosalpinx. Was the first attack she had due to salpingitis ? I am inclined to favour that view. If so, it seems as if the process had gone on slowly from the time of her first attack until it culminated in a suppurative condition at the onset of the second attack, when the appendix became secondarily involved. Another question arises as to what was the cause of the salpingitis. Whatever cause may have been at work, it was, I can confidently assert, not due to the gonococcus. I may say that I never suspected any inflammation of the tubes and I always looked upon the case as one of appendicitis. This case has taught me one great lesson, and that is the necessity of inspecting the right tube when operating for appendicitis in women.
doi:10.1016/s0140-6736(01)62560-1 fatcat:6kqwbclvxfan5odi6esjz3sjy4