1912 BMJ (Clinical Research Edition)  
Reported by J. R. RIGG, M.B., Ch.B.)' I AM indebted to Professor William Thorburn for. permission to publishthe following notes. The case was one of' intestinal obstruction, intermittent in character, due to the ball-valve action of a foreign' body. The patient, a male aged 44, a labourer, was admitted on. January 19th last as a case 'of recurrent appendicitis, and gave the following history: ; Six' years ago he had his first attack of severe abdominal pain, beginning on the left side and
more » ... left side and spreading over to the right. The attack lasted about an hour, and.then vomiting came on, first of food. swallowed at the last mueal, then of "brownish,. bitter-tasting matter," and the pain was relieved, the patient feeling quite well again next .1ay. Since then he has had very many attacks, the longest free interval between any two being not more than three mnonths. Up-to December, 1911, however, tlle patient had niot been confined to bed, but then he had an attack the' symptoms Qf which were so sevqre that he was in bed fornine days. The pains la'sted from ten minutes-to three or four hours, and were always relieved by vomiting. He liad suffered from constipation, for. many years and had not been losing weight. On admission, the general condition was good, pulse 84, temperature normal, bowels slightly constipated. Examirna-, tion of the abdomen showed neither ..distension-nor pe stalsis. Some fullness could be felt in the. right iliac fossa, palpation eliciting tenderness; tenderness was also experienced on rectal examnination, Operation. An exploratory operation was decided upon, and was performed by Mr. Thorburn on January 24th. The abdomen was opened by the usual gridiron incision for removal of the appendix. On incising the peritoneum a loop of small intestine presented, was drawn out througlh the wound, and at once seen to possess pathological features, a constriction being observed, with marked hypertrophiy of the gut above and atrophy below. The constriction was very localized, and the peritoneal coat in the vicinity was ivudded with small white nodules resembling tubercles. The mesentery of the affected loop' also slhowed pathologicgl changes namely, an old inflammatory cicatrix, and an enlarged and hard lymphatic gland. Palpation discovered a smnall hard body, which could -be freely m-oved about inside the lumeni of the hypertrophied gut above the stricture, beyond which it could not oe passed. The bowel was replaced in the abdomen and the appendix sought for. It was found on examination to be quite normal, and evidently the symptoms could not have been due to any lesion of the appendix. Appendicectomy was performed. and attention again directed to the constrictionl first encountered. The affected loop of intestine was once more drawn out through the incision, and it was decided to excise this portion of gut. Intestinal clamps were applied, and about 6 in. of intestine, including the stricture, removed, along with a portion of the mesentery and the gland already mentioned. End-to-end anastomosis of the divided gut was then performed with the aid of a Robson's bobbin, and the intestine replaced in the abdomen, whicl was closed in layers. When the portion of bowel removed was opened up the stricture was seen to be of old standing and inflammatory in nature. In the hypertrophied gut above, lyiug in a small crypt, evidently fashioned by it, was found a plum stone, the hard movable body previously referred to. The condition is well slhown in the photograph. The valvulae conniventes were large aud well marked, proving that the part .-of bowel. removed had been situated high up in tho small intestine. A microscopic section was made of the whole thickness of the bowel at the site of stricture, and confrmed the diagnosis of inflammatory origin, the' slide showing marked fibrous changes with anolualous giant cells. Recovery was uneventful. lThe patient left the lhospital twenty-one days after operationi, quite welL Remanr7ks. The case preseats some points of interest: 1. The indefinite character of the symptolus diagnosed as appendicitis. The short, sharp nature of the attack, lasting only a few hours, relieved by vomiting, and occurring at e -y frequent intervals, was not of the ordinary apren licujar type. 2. When the abdomen was opened, tlle affected coil at once presented.' This admits of a two-fold explanation. In the first 'place, all collapsed small intestine below a point of obstruction high up tends to fall towards the riglht iliac region. This is mechanical, and due to the position of tho sigmoid colon on the left side, and also to the arrangement of the great omentumu. Then again the positio'n of thie pathological bowel imnmediately beneath the parietes is probably due to "vital" action. It appears to be Nature's way of dealing with the diseased gut, by bringing it to tlhe ventral surface, into the situation most suitable for the formiation ;of a faecal fistula, whereby intestinal obstruction may. be relieved. -3. The fibrous stricture of the small intestine, which had evidently been present for many years, as shown by the signs of old inflammation on the peritoneal aspeet of the bowel, and the hard semi-calcified gland, had caused no .~~~~~~~~~~~~~~~~~~~~~~~~~~~~. .. ...... coat (tubercles 'do not show); ri, cons-tric'ted portion of -gut; y" atrophic~gut below; G, peritoncal ceoat; ti,-1siYoertrophiec gut above stricture. symi-ptoms at all until the advenit of 'the pilum stone, the gut above havring hypertrophied, suffici6ntly to drive he0 nte thie intestine Alo'ng. en it wouLld s that, after imipaction at the s4tricture for somie time, -the peristaltic mlovements of the bowel d'isplac'ed the stone, and it fell away to one side, into thle little' fossa whi ch' it gradually made for itself, and the' intestinal conhehpts' passedon again. All the subsequent, attacks 'were apparently due t'o dislodginig of the stone froni this'fst up..aginst the strictur6. Unfor*tLnately the patient had no recollection of swallowing th'e "stone. '4. The original cauise' of the stricture is q[uite uniknonnb, bu't it"was probably'due to traumia, using thle 'wor' in 'its widest sense. The extremely' loca1i2d iiature of the obs'truction miade one think of internial'her-nia,'occurringin
doi:10.1136/bmj.1.2677.892 fatcat:p4ddfbewsng2jggs665de2qlxe