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A CASE OF INTESTINAL OBSTRUCTION CAUSED BY AN ENTEROLITH SPONTANEOUSLY CURED BY EVACUATION THROUGH AN UMBILICAL FISTULA.
1613 and
appeared to be inadequate for the evacuation of ther cavity it led to. Consequently, on Feb. 14th the sinus waa enlarged by dressing forceps, and an attempt was made to provide more efficient drainage. This was successful to some extent. On March 5th, while the wound was being
OF INTESTINAL OBSTRUCTION CAUSED BY AN ENTEROLITH SPONTANEOUSLY CURED BY EVACUATION THROUGH AN UMBILICAL FISTULA.
A CASE
rounded calculus-like mass presented in the sinus easily removed, its escape being accompanied and by an unusually large quantity of pus. From that moment the wound healed rapidly and the boy’s condition materially improved, and he was discharged healed and looking well and stout ten days later. His general improvement was as striking and remarkable as the improvement in.
dressed,
BY DAVID M. GREIG, M.B., C.M. EDIN., F.R.C.S. EDIN., SURGEON, DUNDEE ROYAL INFIRMARY; LECTURER ON CLINICAL SURGERY AND SURGICAL DISEASES OF CHILDREN, ST. ANDREWS UNIVERSITY; SURGEON, ROYAL VICTORIA HOSPITAL; HONORARY CONSULTING SURGEON, ARBROATH INFIRMARY.
THREE
reasons
justify
the
publication of the following
isolated case-viz. : enteroliths are not common ; they are is specially rare in children; and enterolith obstruction an seldom recovered from by spontaneous evacuation through abscess. A scholar,
aged
12 years,
was
admitted to my
care
in the
Dundee Royal Infirmary on Dec. 23rd, 1909. He was the third of five children, one of whom had died aged 45 days from
congenital
icterus.
His mother
was
a
and was followed
well and the other
children were said to be "fairly strong." His father had died three years previously from locomotor ataxia. The
the local condition. The structure which was discharged proved on examination to be an enterolith. It was globular, measured 2-2L inches in circumference, rather larger than an ordinary marble, being smooth for the most part but not polished, and when dried its most striking feature was its lightness. It weighed 24 grains, and, indeed, was considerably lighter than a pith ball of equal size. It bears a striking resemblance in miniature to the concretions commonly found in the colon of the horse. With the history this child presented, the imperfect health he had enjoyed, and the poor physique he had attained, even in the absence of a history of alternating eonstipation and diarrhoea, it is not to be wondered at that on admission the diagnosis of tuberculous peritonitis with perforation and the formation of a fascal fistula was formed ; indeed, it is probable that had it not been for the dangerous proximity of a foetid sinus he would have been operated on under this supposition. Still less is it reprehensible that before admission, the previous history, the sudden onset, the constipation, vomiting, and pain, should have led to the diagnosis of
had never been a very robust child. Immediately after birth there seems to have been some inflammation about the stump of the cord and this culminated in an abscess which was inoised, but it gave no trouble after that and healed well and completely after six weeks. He was solely breast-fed until he was nine months old, and though troubled with flatulence as a child, was fairly healthy during the first nine years of his life. During that appendicitis. time he was very difficult to please with regard to The enterolith was of the light-coloured variety, and as his food, and seemed to have a special objection to above noted, there was no .history of special indulgence in liquid in any quantity, and a predilection for dry food. porridge, which is supposed to predispose to the formation of There is no history of indulgence in porridge. At the such avenoliths, or oat-stones. It is almost contrary to what age of 9 years he had two "convulsion fitwithin a fort- one would expect, but characteristic of the condition, that night, apparently hysterical, on hearing of his father’s death, the intestinal obstruction to which the "stone"" gave rise and since then, his mother thought, there had been greater diffi- should be of a chronic character and spread over years before culty in pleasing him with his food. During the six months the condition becomes acute. Where the enterolith lay in preceding his admission he had three attacks of colic or this case it is impossible to say. The sinus led from the "cramp in the stomach,which came on from no obvious umbilicus backwards into the right loin, but the obstruction cause and lasted about 24 hours. Each attack began with must have been in the small intestine, for a foreign body of pain in the region of the umbilicus, and was followed after its size could not cause obstruction in the great. a couple of hours’ duration by vomiting. The bowels were There is a considerable, though scattered, literature on the not affected in any way, neither constipation nor diarrhoea subject, and its perusal and of that of intestinal obstruction being noted or complained of. The attack for which he was from foreign bodies, suggests that in some cases of "gal1brought to hospital had come on ten days previously to stone intestinal obstruction," where there is a history of The usual pain occurred, was followed by years of recurring colic and vomiting but no jaundice, the admission. vomiting, and was treated by hot applications. The ex- .. gall-stone" might prove to be an enterolith on investigaø pected relief in this instance, however, was not obtained by tion. In the above case the enterolith felt solid and heavy, the usual remedies. The bowels were constipated, and the almost stone-like, when first extruded and was quite as solid pain was not constant, though it varied much in severity. In and firm as many a single gall-stone. It was only after many ways the attack simulated appendicitis. drying that it assumed its pale yellow colour and showed its On admission the child looked very ill; the tongue was peculiar lightness. Dundee. dry and covered with thick brown fur and the lips with sordes. The temperature was normal, the pulse was 96, and the respirations were 20 per minute. The abdomen was scaphoid and symmetrical, and there was a pointing abscess NOTES UPON AN OUTBREAK OF ILLNESS at the umbilicus which was protruding, inflamed, and flucDUE TO TINNED MEAT IN THE tuating. It was about this area that the pain seemed to culminate, and elsewhere the abdomen could be palpated CITY OF CARLISLE. pretty easily. There were no tumour, however, and no BY JOSEPH BEARD, F.R.C.S. EDIN., L.R.C.P. LOND., abnormal dulness. On the day following admission, though D.P.H. CAMB., sick and vomiting, he was easier because the umbilical OF HEALTH, CITY OF CARLISLE. MEDICAL OFFICER abscess had burst and was discharging offensive pus. Then i for six days he had less pain and no sickness, and there con-I tinued a copious foul-smelling discharge which necessitated ON August 26th last I received information of an outbreak frequent dressing, but the boy did not seem to make progress. ’ of sudden and suspicious illness in the Denton Holme district Two days later, after an increase of pain, the vomiting recom- i of Carlisle, which upon investigation was found to have menced and he was unable to retain any food during 24 occurred in a number of persons who had partaken of the hours. He seemed thinner and weaker and there was still contents of a tin of American corned beef ; 21 persons in all a large amount of pus pouring from the umbilical sinus. were affected, of whom several were said to be suffering On Jan. 3rd, 1910, 11 days after admission, the sinus somewhat severely. The illness appears to have manifested was cautiously enlarged under general anaesthesia and itself without any premonitory symptoms by the occurrence a drainage-tube was inserted. This was followed by a dimi- !, of vomiting, diarrhoea, pains in the stomach, and collapse, nution of the discharge, but it was noticed on the 5th that but fortunately the outbreak was not attended with any fatal there was some fseeal matter mixed with the pus. The slight ’, result, and all those affected are now well. improvement was maintained for a few days, but by the 10th I secured what remained of the suspected meat. and he was again ill, and thereafter seemed from day to day to beI divided it into two portiors, one of which together with the losing flesh and strength. The sinus gradually drew together tin I forwarded to the city analyst, Dr. R. Hellon, to examine
patient
z’i
I
I
appeared to be inadequate for the evacuation of ther cavity it led to. Consequently, on Feb. 14th the sinus waa enlarged by dressing forceps, and an attempt was made to provide more efficient drainage. This was successful to some extent. On March 5th, while the wound was being
OF INTESTINAL OBSTRUCTION CAUSED BY AN ENTEROLITH SPONTANEOUSLY CURED BY EVACUATION THROUGH AN UMBILICAL FISTULA.
A CASE
rounded calculus-like mass presented in the sinus easily removed, its escape being accompanied and by an unusually large quantity of pus. From that moment the wound healed rapidly and the boy’s condition materially improved, and he was discharged healed and looking well and stout ten days later. His general improvement was as striking and remarkable as the improvement in.
dressed,
BY DAVID M. GREIG, M.B., C.M. EDIN., F.R.C.S. EDIN., SURGEON, DUNDEE ROYAL INFIRMARY; LECTURER ON CLINICAL SURGERY AND SURGICAL DISEASES OF CHILDREN, ST. ANDREWS UNIVERSITY; SURGEON, ROYAL VICTORIA HOSPITAL; HONORARY CONSULTING SURGEON, ARBROATH INFIRMARY.
THREE
reasons
justify
the
publication of the following
isolated case-viz. : enteroliths are not common ; they are is specially rare in children; and enterolith obstruction an seldom recovered from by spontaneous evacuation through abscess. A scholar,
aged
12 years,
was
admitted to my
care
in the
Dundee Royal Infirmary on Dec. 23rd, 1909. He was the third of five children, one of whom had died aged 45 days from
congenital
icterus.
His mother
was
a
and was followed
well and the other
children were said to be "fairly strong." His father had died three years previously from locomotor ataxia. The
the local condition. The structure which was discharged proved on examination to be an enterolith. It was globular, measured 2-2L inches in circumference, rather larger than an ordinary marble, being smooth for the most part but not polished, and when dried its most striking feature was its lightness. It weighed 24 grains, and, indeed, was considerably lighter than a pith ball of equal size. It bears a striking resemblance in miniature to the concretions commonly found in the colon of the horse. With the history this child presented, the imperfect health he had enjoyed, and the poor physique he had attained, even in the absence of a history of alternating eonstipation and diarrhoea, it is not to be wondered at that on admission the diagnosis of tuberculous peritonitis with perforation and the formation of a fascal fistula was formed ; indeed, it is probable that had it not been for the dangerous proximity of a foetid sinus he would have been operated on under this supposition. Still less is it reprehensible that before admission, the previous history, the sudden onset, the constipation, vomiting, and pain, should have led to the diagnosis of
had never been a very robust child. Immediately after birth there seems to have been some inflammation about the stump of the cord and this culminated in an abscess which was inoised, but it gave no trouble after that and healed well and completely after six weeks. He was solely breast-fed until he was nine months old, and though troubled with flatulence as a child, was fairly healthy during the first nine years of his life. During that appendicitis. time he was very difficult to please with regard to The enterolith was of the light-coloured variety, and as his food, and seemed to have a special objection to above noted, there was no .history of special indulgence in liquid in any quantity, and a predilection for dry food. porridge, which is supposed to predispose to the formation of There is no history of indulgence in porridge. At the such avenoliths, or oat-stones. It is almost contrary to what age of 9 years he had two "convulsion fitwithin a fort- one would expect, but characteristic of the condition, that night, apparently hysterical, on hearing of his father’s death, the intestinal obstruction to which the "stone"" gave rise and since then, his mother thought, there had been greater diffi- should be of a chronic character and spread over years before culty in pleasing him with his food. During the six months the condition becomes acute. Where the enterolith lay in preceding his admission he had three attacks of colic or this case it is impossible to say. The sinus led from the "cramp in the stomach,which came on from no obvious umbilicus backwards into the right loin, but the obstruction cause and lasted about 24 hours. Each attack began with must have been in the small intestine, for a foreign body of pain in the region of the umbilicus, and was followed after its size could not cause obstruction in the great. a couple of hours’ duration by vomiting. The bowels were There is a considerable, though scattered, literature on the not affected in any way, neither constipation nor diarrhoea subject, and its perusal and of that of intestinal obstruction being noted or complained of. The attack for which he was from foreign bodies, suggests that in some cases of "gal1brought to hospital had come on ten days previously to stone intestinal obstruction," where there is a history of The usual pain occurred, was followed by years of recurring colic and vomiting but no jaundice, the admission. vomiting, and was treated by hot applications. The ex- .. gall-stone" might prove to be an enterolith on investigaø pected relief in this instance, however, was not obtained by tion. In the above case the enterolith felt solid and heavy, the usual remedies. The bowels were constipated, and the almost stone-like, when first extruded and was quite as solid pain was not constant, though it varied much in severity. In and firm as many a single gall-stone. It was only after many ways the attack simulated appendicitis. drying that it assumed its pale yellow colour and showed its On admission the child looked very ill; the tongue was peculiar lightness. Dundee. dry and covered with thick brown fur and the lips with sordes. The temperature was normal, the pulse was 96, and the respirations were 20 per minute. The abdomen was scaphoid and symmetrical, and there was a pointing abscess NOTES UPON AN OUTBREAK OF ILLNESS at the umbilicus which was protruding, inflamed, and flucDUE TO TINNED MEAT IN THE tuating. It was about this area that the pain seemed to culminate, and elsewhere the abdomen could be palpated CITY OF CARLISLE. pretty easily. There were no tumour, however, and no BY JOSEPH BEARD, F.R.C.S. EDIN., L.R.C.P. LOND., abnormal dulness. On the day following admission, though D.P.H. CAMB., sick and vomiting, he was easier because the umbilical OF HEALTH, CITY OF CARLISLE. MEDICAL OFFICER abscess had burst and was discharging offensive pus. Then i for six days he had less pain and no sickness, and there con-I tinued a copious foul-smelling discharge which necessitated ON August 26th last I received information of an outbreak frequent dressing, but the boy did not seem to make progress. ’ of sudden and suspicious illness in the Denton Holme district Two days later, after an increase of pain, the vomiting recom- i of Carlisle, which upon investigation was found to have menced and he was unable to retain any food during 24 occurred in a number of persons who had partaken of the hours. He seemed thinner and weaker and there was still contents of a tin of American corned beef ; 21 persons in all a large amount of pus pouring from the umbilical sinus. were affected, of whom several were said to be suffering On Jan. 3rd, 1910, 11 days after admission, the sinus somewhat severely. The illness appears to have manifested was cautiously enlarged under general anaesthesia and itself without any premonitory symptoms by the occurrence a drainage-tube was inserted. This was followed by a dimi- !, of vomiting, diarrhoea, pains in the stomach, and collapse, nution of the discharge, but it was noticed on the 5th that but fortunately the outbreak was not attended with any fatal there was some fseeal matter mixed with the pus. The slight ’, result, and all those affected are now well. improvement was maintained for a few days, but by the 10th I secured what remained of the suspected meat. and he was again ill, and thereafter seemed from day to day to beI divided it into two portiors, one of which together with the losing flesh and strength. The sinus gradually drew together tin I forwarded to the city analyst, Dr. R. Hellon, to examine
patient
z’i
I
I