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after the first occurrence of pain, and a softened mesenteric gland, which was found to have ruptured, removed. Two other glands higher up had suppurated ; these were opened, the fluid removed, and the interior of the glands curretted. There was a considerable amount of fluid in the peritoneal cavity, which was washed out with normal saline solution. As stated above, this patient made a perfect recovery, the temperature and pulse falling to normal on the day after operation, and remaining so until dismissal.

Jenner records a case similar to the above, which recovered without operation, and it is, of course, just possible that many so-called recoveries from perforation without operation are of a like nature.

CASE VI.- The sixth case was that of T. B., æt. 16 years, who was admitted on 8th January, 1901, that being his eleventh day of illness. This is one of the cases not operated on. On admission he looked sharply ill, and his temperature then was 103-2° F.; pulse, 108; respirations, 26. On 12th January patient's motion contained some blood, and on the 15th he complained of pain about 7:30 A.M. His facies at that time was suggestive, and examination of the abdomen revealed distinct rigidity on the right side. Associated with this was some tenderness on the same side. Temperature, 101.2° F.; pulse, 92. A leucocyte count gave 3,000 per c.mm. In consultation, it was decided that sufficient evidence of perforation did not exist to justify operation. At 2:30 P.M. another count gave 2,500 leucocytes : pulse had risen to 106; but otherwise the symptoms were unaltered. During the afternoon no change was observed, but collapse occurred so suddenly between 5 and 6 P.M. as to preclude the idea of operation, even although the fact of perforation was quite evident. He never rallied, and at 11 P.M. death supervened.

Post-mortem examination discovered a small perforation in the lower part of the ileum, with extensive ulceration near the ileo-cæcal valve. It is a matter for regret that this boy was not operated on at the first when he complained of pain, as there is every reason to believe that he would have recovered had this been done, as he was in good condition at the time of the perforation, in his eighteenth day of illness only, and symptoms suggestive of peritonitis were present for about ten hours previous to definite perforation. It is interesting to observe in this case, as in some of the others, that perforation was preceded by hæmorrhage a few days before the actual occurrence.

CASE VII.—The next perforation which occurred was in the case of Mrs. M'L., æt. 22 years, who was admitted to hospital on 29th October, 1901, her fifteenth day of illness. She had been confined to bed since the birth of her child ten days previous to admission. On admission, she presented the appearance of a typical enteric patient, with diarrhæa, distension, and rose spots. On physical examination of her chest many coarse moist râles were heard at the bases of both lungs behind. Her heart was normal, and there was no albuminuria. Temperature, 102° F.; pulse, 104; respirations, 24 per

minute. About 2 A.M. on the 31st, patient awoke suddenly with a cry, and complained of agonising pain in the left side of the abdomen. She lay on her back with her legs drawn up, and her face was pinched and anxious looking. Her abdomen was held motionless and rigid, the respiration being altogether thoracic. The slightest touch elicited loud complaints of pain. Her pulse had risen to 128, while her temperature steadily fell, till at 4:30 A.M., when laparotomy was performed, it had reached 97-4° F. Two perforations were found and closed, while four ulcers which had all but perforated were safeguarded with stitches. The abdominal cavity contained a fair quantity of fluid, but no lymph. After the operation the patient did not rally much, and her temperature and pulserate gradually rose till she died at 1:15 A.M. on 1st November, when the records were-temperature, 105:4° F.; pulse, 160; and respirations, 48 per minute.

The symptoms of perforation in this case were so typical that the surgeon was summoned at once, but it was not a favourable one for operation. Patient's strength had been greatly taxed during the earlier days of her illness by her confinement, and this, along with the prostration attendant upon the fever, naturally gave little hope of recovery from so severe an operation. It is to be noted that no hæmorrhage occurred previous to perforation to act as an indication and warning that ulceration was active and probably deep.

CASE VIII.—The eighth case was that of S. M‘M., æt. 91 years, admitted to hospital on 20th November, 1901, having been ill for three weeks. On admission, patient was very ill, and his abdomen, although not distended, was held somewhat rigidly, and was exquisitely tender to palpation. Physical examination of the chest revealed the presence of moist râles, with a few loud snoring râles all over the back. Temperature was 99-8° F.; pulse, 108; respirations, 32 per minute.

minute. Next day (21st) the temperature, which at 6 A.M. was 103-2° F., fell

to 97•4° F. at 10 A.M., and the pulse from 116 to 100. No pain was complained of, but examination of the abdomen disclosed marked rigidity localised to the right side, and palpation evidently caused great uneasiness. A little later some distension was noted, and patient had all the appearance of perforation. Laparotomy was performed some nine hours after the first onset of symptoms, and the perforation, which was in the lower part of the ileum, closed. From this point onwards the pulse gradually rose, the temperature remaining under the normal line until just before death, when it rose to 100-6° F.

It is significant that the first sign of anything wrong in this case was the fall in temperature. No pain was complained of, but naturally the great fall in temperature at this stage of the illness drew attention to the abdomen, where the signs were unequivocal. A boy of the age of 9 years is not usually reticient about complaining of pain, so that it must be concluded that here there was at least no sudden exacerbation of the pain from which he was suffering on admission, Patient lived forty-eight hours after the operation. The condition of the bowel, post-mortem, was such as to admit but little hope of recovery, even though the perforation had not occurred. The operation in itself, however, was completely successful, no leakage having occurred through the closed portion.

CASE IX.—The next case was that of J. T., æt. 29 years, who was admitted on 18th December, 1901, that being his fifteenth day of illness. His temperature was 102:4° F.; pulse, 96; and respirations, 24 per minute. A typical case of enteric fever, he was very ill, and numerous fine subcrepitant râles were heard at the bases of both lungs behind. Patient ran a normal course of severe enteric fever until the 24th, when, at 7 P.M., he complained of abdominal pain. There was no fall in temperature, and little or no change in pulse-rate. Examination of the abdomen discovered some rigidity of the abdominal wall in the right iliac fossa and tenderness on palpation in that region. There was little rigidity elsewhere, and no abdominal distension ; but the percussion note in the right iliac fossa had changed from tympanitic to dull, and a suspicion of fluid in this region was entertained. Laparotomy was performed within an hour and a half of the first complaint of pain, and two pin-hole perforations of the ileum found, and in the same region an ulcer which had penetrated to the serous coat of the bowel. The perforations were closed

and the ulcer safeguarded with stitches. No indication of peritonitis was discovered, and no lymph had been thrown out, but there was a little serous fluid in the abdominal cavity. A curious phenomenon was noticed during the operation ; the bowel suddenly became deeply congested and almost chocolate coloured, while patient's breathing got worse and very shallow, the pulse also being shaky. Ether was resorted to in place of chloroform, and in about five minutes the condition improved, the bowel regaining its former colour. The explanation offered is, that the collapse which necessarily follows perforation occurred in this case during the operation, causing the curious condition above noted. Patient lived forty-eight hours after operation, and, for the first seventeen of these, looked as if he might recover, the pulse being fairly strong and regular, and numbering only 102 per minute, but then hypostatic congestion of the lungs supervened, and though the local symptoms presented nothing indicative of peritonitis, tenderness and distension of the abdomen being quite absent, he gradually became worse, his temperature, pulse, and respirations all rising till just before death, when these were, respectively, 105:4° F., 148, and 48.

Post-mortemi, the operation was seen to have been entirely successful; there was no peritonitis, but on opening the ileum extensive ulceration of the last four inches was found. The ulceration was chiefly contined to that region.

This case was interesting from the point of view of the early operation, and of the curious occurrence during it, an explanation of which is offered above. It seemed in many ways an extremely favourable case, but the extensive ulceration of the gut, found post-mortem, showed what slight chance there was of recovery, even without the severe complication of perforation.

A short account of the next two cases will suffice, as on account of their extremely grave condition, neither was operated on.

CASE X.-M. C., æt. 16 years, was admitted on 10th January, 1902, on her ninth day of illness. Temperature was 101-8° F.; pulse, 120; and respirations, 36 per minute. She complained of abdominal pain. From the date of admission she ran a febrile course of 101:4° to 104:8° F. Her pulse was high throughout, about 120 per minute, and was small and of low tension. Her tongue was always dry. On the evening of the 11th a severe attack of abdominal pain occurred, associated with slight rigidity of the abdominal wall. Neither the

facies, the pulse, nor the temperature gave any indication that a perforation had occurred at this time. A similar attack to that of the 11th occurred on the 19th, when patient was again seen by the surgeon in consultation. From this date onwards she complained frequently of abdominal pain, till on the 25th, shortly after midnight, sudden severe pain in the abdomen was complained of. Temperature rose from 103:4° to 105° F., and the pulse from 124 to 142 per minute. Examination of the abdomen revealed no rigidity, but perforation was thought to be probable. The pain soon passed off, and patient felt better, although the pulse remained rapid. About 6:30 A.M. another severe attack of pain supervened. Temperature was now 102° F., and pulse uncountable, while the abdomen was rigid and motionless. The general condition of the patient was such that operation was deemed inadvisable. A perforation was found post-mortem close to the ileocæcal valve, along with extensive and deep ulceration in that region. There was a fair amount of fluid in the abdominal cavity.

It is interesting to note in this case that there were two separate attacks of pain, both severe, and that the first subsided completely, whilst the second did not come on until some hours later. That no abdominal rigidity was present in the first instance is curious, and seems to indicate that the perforation did not occur until the second attack of pain supervened.

men.

Case XI.—The next case was that of M. C., æt. 6 years, a sister of the above patient. She was admitted on 22nd January, 1902, having been ill for ten days. Her temperature was 103-2° F.; pulse, 130; and respirations, 36 per minute. She was very ill, and developed a left basal pneumnonia a few days after admission. On 5th February, about 1 A.M., she became restless, was sick, and vomited at 2:45, and at 3:40 she complained of severe pain in the right side of her abdo

Slight but perfectly definite rigidity was noticed in the right iliac fossa, with dulness on percussion in the right flank, and exquisite tenderness on gentle palpation. There was no abdominal distension whatever. The hopelessness of her condition rendered operation inadvisable. She died at

Post-mortem, a perforation of the ileum about a foot above the ileo-cæcal valve was found, of a size easily admitting a slate pencil. Between the actual perforation and the cæcum there were several well-marked ulcers, two of which had all but perforated.

7 A.M.

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