H.M. Cooper
1911 The Lancet  
A BOY, aged 10 years, when seen by me was complaining of constant attacks of abdominal pain. After a tea-party the child had had an attack of pain and sickness ten days before. His mother gave him an aperient and he temporarily improved, but the pain recurred eight days later. It came in attacks severe enough to make the child cry. His bowels had been open the day before he was seen by me. He had vomited twice. He looked ill ; his tongue was furred, his temperature was 990 F., and his pulse was
more » ... , and his pulse was 90. There was some tenderness in the right iliac fossa, but his abdomen was soft and moved freely. No swelling could be felt ; there was no peristalsis. The following day, after an enema, he had constant attacks of pain and sickness. His pulse was 120 and his temperature was 100°. In view of the marked rise in the pulse-rate I sent him to St. George's Hospital for operation. The patient was admitted under the care of Mr. G. R. Turner. There was some slight general distension of the abdomen. Marked tenderness in the right iliac fossa. No tumour could be felt. The abdomen was opened through the right rectus sheath. No appendix could be seen. On examining the cascum a mass as big as a man's thumb could be felt in its interior ; the relations of the small bowel to the large were normal. On opening the csecum the appendix in a gangrenous condition was found to be completely intussuscepted. It was cut off after ligature of its base; the parts were so friable that the ligature cut its way right through the gangrenous tissues. There was no bleeding. The opening into the caecum was closed by a silk Lembert suture; the parts around were packed with gauze and a drainage-tube was introduced. The following day the temperature remained high (102°) and the pulse was rapid. The next day both pulse and temperature dropped, and convalescence, although prolonged by a considerable amount of discharge, was uninterrupted. No slough of any kind was detected in the faeces passed after the operation, though they were carefully examined. Hampton-on-Thames. THE following case of appendicitis seems interesting on account of the mildness of the symptoms compared to the pathological condition found present at the operation. A campman, 24 years of age, was taken ill on a Wednesday afternoon with colicky pains in the abdomen. He took a purge, went to bed, and on Thursday got up at daybreak, feeling so well that he cleaned out a water-tank. At midday the pain returned and became so severe that he again took to his bed. His bowels moved freely, he slept pretty well, and on Friday he felt so much better that he decided not to come into town as he had intended to do. His employer, however, advised him to do so, and on Saturday, after a drive of some leagues to the station, he started on the 17 hours' train journey to Buenos Aires. The journey was accomplished without experiencing any marked pain, his bowels moved twice, and on the way he partook of tea, soup, fish, eggs, &c. On Sunday morning he presented himself at the British Hospital, rather ashamed of himself, he felt so well. His temperature on admission was 37'4°C., his pulse was normal, his tongue was clean, and beyond slight pain on pressure over McBurney's point he presented no abnormality. Rectal examination was negative. An ice-bag was applied to the right iliac region. On Monday morning, when I saw him, his bowels had not moved, the slight tenderness of the day before had practically disappeared, pulse and temperature were normal, and the tongue remained clean. He said he felt quite well. I told him that I thought he had had a very slight attack of appendicitis, but as he lived so far from medical aid I advised operation, to which he agreed. The next day I saw him before the operation. He laughingly told me he was quite well, and felt like getting up and going out. He certainly looked it. Half an hour later I removed an appendix some 6 centimetres long, lying on the outside of the caecum, with the point directed upwards and inclined towards the posterior parietes. From about 1t centimetres from the csecum to its tip the organ removed was quite gangrenous and bathed in evil-smelling foul pus. There was almost no inflammatory reaction to be seen in the surrounding peritoneum, and adhesions were conspicuous by their absence. The appendix was cut off close to the caecum and the stump touched with pure carbolic acid and buried in the ordinary way. For ten days a drain was kept in at one angle of the wound, the rest of it having been stitched up. Recovery has been uneventful and complete. The lesson to be learnt from such a case is obvious. When one meets with a case of appendicitis operate on it at once, because symptoms, no matter how trivial, are no guarantee against the most serious pathological conditions being present in the abdomen in this treacherous disease. Buenos Aires. HONORARY SURGEON TO THE WEST KENT GENERAL HOSPITAL. THE patient was a man aged 51 years, married, one child. He had suffered for some years from occasional attacks of bronchitis. In November, 1908, he developed a cough with some fine crepitation at the right apex, a few tubercle bacilli being found in the sputum. He went to the home sanatorium at Bournemouth and returned in March apparently well. About a month afterwards he began to suffer from loss of appetite and muscular weakness, getting very easily tired after slight exertion, and noticing that occasionally objects looked double, especially when he was out walking. The muscular weakness gradually increased, affecting more particularly the facial muscles and those of the shoulder and back of the neck, so that when he smiled he had a peculiar appearance, the angles of the mouth being drawn upwards but very slightly outwards, and after standing or sitting for a short time he had to support his chin on his hand because his head was inclined to fall forwards. After talking for a little while he became tired and had difficulty in pronouncing his words distinctly, and when at his meals after a few bites his jaw muscles refused to act, so that he was obliged to rest at intervals during the repast; swallowing, too, became difficult after a few attempts. At times he complained of a tight feeling about the epigastrium and a difficulty in drawing a long breath, saying that "the bowels seemed to stop it from going any further." His knee-jerks were normal, as was his temperature except when he had a bronchial cold, but his pulse varied between 90 and 100. As his condition was gradually getting worse, on Sept. 8th, 1909, I took him to see Dr. Purves Stewart, to whom I am indebted for the following notes taken at the time :-Speech, articulation, discs, pupils, and external ocular movements were normal, but the orbiculares oculorum were weak, the patient being unable to hold the eyes shut against resistance. " Nasal " smile was marked. The masseters were feeble and hardened very imperfectly. The palate and tongue were normal on movements. There was no cutaneous anoesthesia or analgesia. The neck muscles were very weak, the head tending to fall forwards, so that he had to hold it up on one hand, supporting that elbow with the other hand. The muscles of the hands were feeble, but less markedly than the proximal muscles. The diaphragm was very feeble. He could not lift one leg across the other without the help of the hand. The gait was normal, but feeble. No localised muscular atrophy was present. Reflexes : Knee and ankle jerks normal; shoulder jerks not elicited ; plantars flexor. The left trapezius was tested for electrical reaction. It acted to faradism
doi:10.1016/s0140-6736(00)50868-x fatcat:o36watfwcfajbllu3s6pmpf6qy