DIVERTICULITIS.

151 left the hospital on the sixteenth day, soundly healed and with no further symptoms. The stone measured 2t in. in its long diameter and 1 in. in its short diameter, and weighed 1 oz. It consisted of phosphates, with a trace of oxalates, and contained no cystin, no carbonate, and no uric acid.

Reviezvs about that time, and in THE LANCET for Oct. 24th, 1903, Sir John Bland-Sutton wrote a most " suggestive paper On the Effect of Perforation of the Colon by Small Foreign Bodies, especially in relation to Abscess of an Epiploic Appendage." 1 Since then several examples have come under my notice, and they have illustrated all the clinical conditions which have been described.

Comments on the Case. It is interesting to note how very few symptoms had been caused by the stone. As a general rule, the larger the stone the fewer the symptoms. Since I wrote my paper on the removal of ureteric stones I have seldom found it necessary to operate for stones in the lower portion of the ureter. Most ureteric stones in the pelvic portion of the ureter lie just above the bladder, and are prevented from entering the bladder by the narrowness of the opening of the lower end of the ureter. I find by experience that I can slit up the mouth of the ureter with a pair of operating scissors, through the operating cystoscope, lubricating the stone with parolene, and that a few days or weeks later these stones are passed naturally without any further trouble. In this case the stone was so large that it was clearly necessary to operate by open incision. B. S. Barringer1 describes a case of double ureterocele with a small stone lying in one of them. He cut off the top of the ureteroceles with the operating cystoscope, and the stone was then passed naturally. I have previously seen two cases of ureterocele; in one I treated the condition by open operation, and in the other I cut off the top of the projection through the operating cystoscope ; I hope on both occasions results were satisfactory. to operate at a later date on the ureterocele present in the case reported here.

Description of Cases. I would like to refer to three cases of

particular

interest.

The first is that of a female patient, aged 34 years, on whom I operated in 1904 for what was diagnosed as appendicitis with abscess.2 I found a hard mass in the asending colon which so closely simulated a malignant new growth that I thought it best to excise it. On examining the specimen I found the explanation to be an inflammation around a diverticulum in the commencement of the colon. There was also another quiescent saccule on the caput. No other diverticula were noticed in the large bowel during the course of the operation. The patient made a good recovery, and was living and well 15 years later. The second case must be almost unique. It is that of a man 57 years of age who was admitted to the Newcastle Infirmary in the year 1902 suffering from retention of urine with general peritonitis. As it had not been found possible to relieve the condition by catheter an attempt had been made at his home to puncture the bladder suprapubically, but only liquid fseces escaped through the trocar. The man soon died, and at the postmortem I found what I then took to be a malignant growth of the sigmoid, and just above this growth was a large liole leading into the bowel ; there was faecal extravasation with general septic peritonitis. On looking for an explanation I discovered, free in the rectovesical pouch, a large gall-stone which had evidently ulcerated through the sigmoid just above the growth. An examination of thegall-bladder showed a second calculus projecting from that viscus into the hepatic DIVERTICULITIS. flexure. The condition was interesting enough, and Being some Remarks made in the Course of a Discussion the specimen was put aside for further investigation, but amid an abounding wealth of pathological material at a Meeting of the Section of Surgery (Subsection of it was neglected until the year 1908, when I was Proctology), Royal Society of Medicine, on Jan. 7th, especially interested in the question of gallstone ileus. BY G. GREY TURNER, M.S. DURH., F.R.C.S. ENG., On re-examination I then found that the condition was HONORARY ASSISTANT SURGEON, ROYAL INFIRMARY, a typical example of diverticulitis, and that there was NEWCASTLE-ON-TYNE. no question of new growth. Unfortunately the specimen has been mislaid, but I am able to show you a drawing MY. first introduction to the subject under dis- which was made at the time. cussion was in the year 1903, when, as surgical The third case shows that peritonitis may occur as registrar, I saw Professor Rutherford Morison the result of ulceration of even a small and almost excise what was supposed to be a malignant isolated diverticulum, for in this patient only three growth of the sigmoid in a man of 60. On exa- such diverticula were found after a careful search of mining the specimen I found that it was an the bowel, cut in serial sections.

example of diverticulitis. There were 13 diverticula, with great inflammatory thickening of the bowel wall, but no lesion of the mucous membrane. The man died, and at the post-mortem many diverticula were found from about the middle of the transverse colon to the point at which the sigmoid had been divided, but none in the lower segment of the bowel. The condition was at once recognised, and was correctly described in the hospital notes. This case is of some interest, because it has been stated by Sir Berkeley Moynihan in his Cavendish lecture for 1912 that he operated in 1906 "upon the first case recognised as chronic diverticulitis of the sigmoid flexure in this country." I always regret that the example to which I have referred was not published at the time, for it would have stimulated an earlier interest in this particular subject. But there was really no excuse for ignorance in the minds of inquiring surgeons, for a well-illustrated abstract of the paper by Ludwig Schreiber appeared in the Medical Review of

I

1

Transactions of the American Association of Genito-Urinary

Surgeons, May, 1914.

’ EtioZogy, Diagnosis,

and Ti’eat1nent.

As regards aetiology, I have the conviction that the condition will ultimately proveto be congenital in origin. This is in accordance with the general origin of the diverticula with which we are familiar in the various parts of the alimentary canal and in the bladder. In one of my cases, a man who died from peritonitis and who presented diffuse diverticula in the large bowel (42 in number), there were also two large sacculi in the bladder in relation to the left ureter. At the time the latter were attributed to an enlarged prostate, but extended experience of vesical pouches has led me to realise that in many cases these are certainly congenital in origin. We must freely admit that in their early stages all diverticula are probably 1 Since hearing Sir John Bland-Sutton’s remarks at the discussion I have taken the opportunity of again carefully reading his paper, and find it full of renewed interest. There is an illustration of a diverticulum of the colon, and some of the cases were undoubtedly examples of diverticulitis, though the distinguished writer did not at that time divine what he now believes to be the correct

explanation. 2 A Case of Tuberculous Ulceration of the Ascending Colon Simulating Appendicitis, THE LANCET, Sept. 16th, 1905. C 3

152

symptomless, but that they are progressive and tend was carried out 18 months ago, and up to the to give rise to trouble in the course of years. In fact, present the patient has had no further symptoms. the distension which precedes pathological symptoms Under similar circumstances in a more recent may not be quite complete even in late life, and case I squeezed out the contents of one or two this was borne out by an example of diverticulum diverticula into the bowel, but I found that it was of the duodenum the size of a thumb in a woman of not possible to invert them, and the abdomen was 60, in which the mucous membrane at the apex was closed. When opportunity offers I would certainly so thrown into folds as to suggest that it was cover up any exposed sacculi with the neighbouring capable of very much freer distension than had epiploical appendices. ever taken place. Newcastle-upon-Tyne. In the matter of diagnosis I have been struck by the very clear history which one can usually obtain after the event. In one case in which I excised the bowel under the impression that we were dealing with a malignant growth the man subsequently gave a wonderful history of recurring slight inflammatory troubles extending over a period of

scrutiny of the which help in the recognition of the earlier stages of the disease. There is a further case bearing on the question of treatment which I should like briefly to mention. as

long

as

ten years.

histories furnish many

Clinical

Notes :

MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL.

A careful

points

It was that of a lady, 55 years of age, who gave a six months’ history of pelvic inflammatory trouble, with A big tender mass severe pain of eight days’ duration. was felt in the left side, and a diagnosis of tubal inflammatory mischief was made with some confidence. At the operation I found that the mass originated in the sigmoid, and after separating the adhesions sufficiently to allow of it being properly examined I detected multiple diverticula in the bowel higher up, giving a clue to its origin. The affected portion of bowel was too low down to excise safely and make an anastomosis, and I did not at that time think that the condition justified excision with a deliberately permanent colotomy, so I determined on the latter expedient in the hope that the rest would lead to such a degree of resolution that the continuity of the lumen After could be restored safely at a later date. the operation the lower end of the bowel was kept free by repeated irrigation, but an attempt to pass a tube from the anus to the colotomy, or vice versa, was never successful. Six months later the involved portion of bowel would easily admit the finger, so the colotomy was closed. The patient remained perfectly well for 18 months, the bowels being opened regularly and without any trouble. At the end of this time she developed a very definite obstruction which would not yield to ordinary measures, and I had to re-make the colotomy. After this the patient always took great care of the lower bowel, and in consequence kept vêry well for nearly five years, when she commenced to have a little discomfort, and occasionally to pass a quantity of mucus per anum. Just seven years from the original onset of her trouble she again developed an inflammatory condition round about the lower segment of bowel, terminating in a large abscess which pointed and was opened at the lower part of the abdominal incision. The bowel was carefully examined, but there was no sign of new growth, and once again the condition subsided, leaving only a small mucous fistula at the site where the abscess was opened.

A CASE OF

ACUTE

HYDRO-PNEUMOTHORAX

COMMUNICATING WITH THE STOMACH.

BY J. W. TUDOR

THOMAS, M.B., B.S.LOND., M.R.C.S., CAPTAIN, R.A.M.C.

(S.R.).

THE following case of acute hydro-pneumothorax, resulting from an old gunshot wound of the chest, is of interest on account of its peculiar features. The patient recovered in spite of a communication between the pneumothorax and the stomach.

The patient was an Eat African native soldier who had been wounded in the chest boya machine-gun bullet four and a half months previously. The bullet entered 2 in. outside the left nipple line in the sixth left intercostal space and was taken out through the eighth left intercostal space, 5 in. from the spine. He had no haemoptysis and was discharged to duty after three months in hospital. During the next six weeks he was quite well, until the last week or so, when he complained of pain in the left side of the chest. The pain became suddenly worse, with severe vomiting, and he arrived at our hospital about two days later in a, state of collapse, with no pulse at the wrist and almost in extremis. On examination there was found to be a left pneumothorax, the apex beat being in the right axilla. A needle was inserted, much gas was let out and some fluid. This was repeated in an hour’s time, The next day the and he was given rectal salines, &c. chest was again tapped and much air and fluid was let out. The fluid on examination was found to be from the stomach. Intravenous and rectal salines were given and still the patient had no pulse at the wrist. The next day an incision was made under novocaine in the sixth left intercostal space, letting out the air and fluid. Exploration by the finger showed the lung to be adherent on the outer side near the bullet exit wound. The heart could not be felt, the finger coming up on the posterior surface of the sternum. Passing the finger over the dome of the diaphragm a rift was felt leading down to the stomach. Two rubber tubes were inserted to drain the cavity. Two days later the As this interesting condition becomes better pulse was quite appreciable at the wrist, and it was decided to do a temporary jejunostomy. The patient recognised cases will undoubtedly be brought could not possibly stand a general anaesthetic, so this before the notice of surgeons at a much earlier was performed under a local anaesthetic, 0’5 per cent. be called to will and we upon frequently stage, novocaine being used. The fundus of the stomach was decide what to do when we are confronted with found to be adherent to the diaphragm over a large the uncomplicated condition, or with cases of area. The jejunum was brought to the parietal perimild recurring inflammation. Under these circum- toneum, and sutured to it, with a No. 10 rubber catheter stances in one instance, in a man of 38, I inverted inserted and held in position by a purse-ring suture. several diverticula and sutured over the peri- The pulse and respirations were 120 and 28 before and toneal pocket so as to convert them into polypi; after the operation. A few days later, by direct observaothers were too rigid and could not be dealt with tion through the chest wound, using a forehead mirror, in this way, but the patient was given directions as the extent of the cavity was investigated, and on the patient swallowing a little water it was observed to to the necessity of regulating his bowels and for flow into the cavity in the chot through the communiabstaining from food at the slightest sign of dis- cation with the stomach. A week after the operation comfort in the lower abdomen. This operation a little dilute methylene-blue solution by the mouth