A CASE OF STRANGULATION OF THE ILEUM BY AN INFLAMED APPENDIX
1
1002 thickening of its right and posterior wall, which is almost as thick as tixat of the left ventricle ; ajitei-ioi-ly the wall becomes very thin in the region of the conus arteriosus. The pn11110l’al’v valve presents adherent cusps with a central patency which admits only of the passage of a goose-qnill, the surface being almost cartilaginous to the touch, and having an eroded appearance in the centre owing to the presence of hard vegetations. Similar calcareous excrescences are present on the ventricular surface of the cusps. The conu. arteriosus shows a remarkable elongation and is dilated in the neighbourhood of the pulmonic cusps. The right papillary muscle is and projects chordae tendineae to tlir,. three cusps the left papillary muscle is represented by a single chordae teiidiiiea. Posterior to the pedicle of the FIG. 2. Showing aperture (A) in ventricular septum viewed through left ventricle. anterior papillary muscle is an ova] opening through the fleshy inter-ventricular septum 3 cm. by 2 cm. in size, situates in its lower third. This channel between the ventricles is sacculated below by the interposition of a fine fibrous curtain coated with endotheliunz, which forms the lower border of the opening into the left ventricle and limits its extent. The mitral opening is larger than normal. There is a dilatation of the pulmonary artery distal to the adherent pulmonary valves. The ductus arteriosus is not I: persistent-. ! The striking features of this case are : (1) The marked stenosis of the pulmonary artery through the close adhesion of the semilunar valves ; (2) the occurrence of the rarer warty form of endocarditis affecting the adherent pulmonic valves ; (3) the considerable size of the aperture in the inter- ventricular septum ; and (4) the marked patency of the foramen ovale. The course of events in the early history of the organ would appear to have been as follows: The occurrence of endocarditis affecting valves of the pulmonary artery about the third or fourth month of foetal life, when the ventricular septum was well developed but not closed, with consequent adhesion of the valves and obstruction to the blood now. The over-charged right ventricle would then discharge part of its contents through the patent ventricular partition, and this considerable volume of blood would obviously prevent the normal closure of the septum. Similarly in the case of the inter-auricular septum. whereas at birth the augmented return flow of blood from the lungs normally tends to close the valve-like fold which forms during the fourth month of foetal life>’ this counter-pressure would be wanting owing to pulmonary artery obstruction, with the 1 AllLutt’s ::3J-stt]lt of Medicine, v., 71 j. result that the foramen ovale would continue patent. This view is contrary to that expressed in the reference below, but the fact that no developmental errors were found in other parts of the body in the present case lends support to the opinion that the original defect was due to endocarditis. A CASE OF STRANGULATION OF THE ILEUM BY AN INFLAMED APPENDIX. BY IDA M. GUILLAUME, L.R.C.P. & S. EDIN., ANÆSTHETIST AND RESIDENT MEDICAL OFFICER, BARBADOS GENERAL HOSPITAL, WEST INDIES. Ti-ils case is recorded as an example of a rather unusual cause of strangulation of the bowel. A negro, aged 15, was admitted to Barbados General Hospital under Dr. Gerald Manning on Feb. 21st, 1924, with a history of two days’ abdominal pain, chiefly around the umbilicus, and no vomiting. In July, 1923, he had a somewhat similar attack overcome by high enemata, which had no effect this time. Condition on Ad7nission.-Tcmp. 98’ F., pulse 40, later 60 ;- abdominal facies, colicky attacks of pain referred to the umbilicus but no visible peristalsis, and an intensely tender. painful tumour on right side, the largest part level with the umbilicus, and moderate abdominal distension. A high enema brought back a coloured result only, and the patient vomited bile four times. Immediate operation showed that a large loop of greatly distended ileum, two feet long, was strangulated by the appendix looped around it in a tight ring, with the bulbous, swollen, and almost gangrenous tip adherent to its base at the caecum and containing a fsecal concretion. The apex was freed, appendicectomy performed, the raw surface on the bowel sutured, and the whole returned to the abdomen. Wound healed by first intention. Probably what occurred was that the long appendix kinked back on itself forming a loop ; the apex became blocked and finally inflamed and then adherent to the base in consequence ; a loop of ileum slipped through the ring so formed and became strangulated. I am indebted to Dr. Gerald Manning for permission to publish this case. CONGENITAL BONY OCCLUSION OF THE CHOANÆ. BY ALBAN EVANS, M.R.C.S. ENG., SURGEON IN CHARGE EAR, NOSE AND THROAT DEPARTMENT- SWANSEA GENERAL HOSPITAL. THE rarity of the condition should make the follow- ing case worthy of record. D. W., male, aged 3 weeks, was brought to the out-patient department with a history of difficulty in breathing. Cyanosis and snuffling noticed soon after birth. Both sides of the- nose were full of gelatinous mucus, and on probing a tony diaphragm was found completely blocking the choanae. The family history was interesting. Six years previously a baby had been born which survived 15 minutes. A year later came a second, which lived 24 hours. A third arrived the following year which lived for about 36 hours, and which had something wrong with the nose and throat. Two years later came a fourth baby which survived four and a half months, although blue all the time, which was attributed to heart disease. The bony partition was thoroughly broken down. The baby had to be kept in hospital a month on account of digestive trouble, and when he left he appeared quite well. 2 Ibid., v., 714. LEWES VICTORIA HOSPITAL.-The accounts pre- sented at the annual meeting of the governors of the hospital on May 6th showed a balance overdrawn on Dec. 31st of B169, as against 2215 on Dec. 31st, 1922. The report stated that a new and up-to-date X ray apparatus had been installed at a cost of jB399, and it was hoped the cost would be met without having to draw upon the invested funds. In 1914, when the system of private in-patients was started, the receipts were 61 ; in 1923 they totalled 2275.
Transcript of A CASE OF STRANGULATION OF THE ILEUM BY AN INFLAMED APPENDIX
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thickening of its right and posterior wall, which isalmost as thick as tixat of the left ventricle ; ajitei-ioi-ly thewall becomes very thin in the region of the conus arteriosus.The pn11110l’al’v valve presents adherent cusps with a centralpatency which admits only of the passage of a goose-qnill,the surface being almost cartilaginous to the touch, andhaving an eroded appearance in the centre owing to thepresence of hard vegetations. Similar calcareous excrescencesare present on the ventricular surface of the cusps. Theconu. arteriosus shows a remarkable elongation and isdilated in the neighbourhood of the pulmonic cusps. Theright papillary muscle is and projects chordae tendineaeto tlir,. three cusps the left papillary muscle is representedby a single chordae teiidiiiea. Posterior to the pedicle of the
FIG. 2.
Showing aperture (A) in ventricular septum viewed throughleft ventricle.
anterior papillary muscle is an ova] opening through thefleshy inter-ventricular septum 3 cm. by 2 cm. in size,situates in its lower third. This channel between theventricles is sacculated below by the interposition of afine fibrous curtain coated with endotheliunz, which formsthe lower border of the opening into the left ventricle andlimits its extent. The mitral opening is larger than normal.There is a dilatation of the pulmonary artery distal to theadherent pulmonary valves. The ductus arteriosus is not I:persistent-. !The striking features of this case are : (1) The
marked stenosis of the pulmonary artery throughthe close adhesion of the semilunar valves ; (2) theoccurrence of the rarer warty form of endocarditisaffecting the adherent pulmonic valves ; (3) theconsiderable size of the aperture in the inter-ventricular septum ; and (4) the marked patency ofthe foramen ovale.The course of events in the early history of the
organ would appear to have been as follows: Theoccurrence of endocarditis affecting valves of thepulmonary artery about the third or fourth monthof foetal life, when the ventricular septum was welldeveloped but not closed, with consequent adhesionof the valves and obstruction to the blood now. Theover-charged right ventricle would then dischargepart of its contents through the patent ventricularpartition, and this considerable volume of bloodwould obviously prevent the normal closure of theseptum. Similarly in the case of the inter-auricularseptum. whereas at birth the augmented return flowof blood from the lungs normally tends to close thevalve-like fold which forms during the fourth monthof foetal life>’ this counter-pressure would be wantingowing to pulmonary artery obstruction, with the
1 AllLutt’s ::3J-stt]lt of Medicine, v., 71 j.
result that the foramen ovale would continue patent.This view is contrary to that expressed in the referencebelow, but the fact that no developmental errorswere found in other parts of the body in the presentcase lends support to the opinion that the originaldefect was due to endocarditis.
A CASE OF
STRANGULATION OF THE ILEUM BY ANINFLAMED APPENDIX.
BY IDA M. GUILLAUME, L.R.C.P. & S. EDIN.,ANÆSTHETIST AND RESIDENT MEDICAL OFFICER, BARBADOS
GENERAL HOSPITAL, WEST INDIES.
Ti-ils case is recorded as an example of a ratherunusual cause of strangulation of the bowel.A negro, aged 15, was admitted to Barbados General
Hospital under Dr. Gerald Manning on Feb. 21st, 1924, witha history of two days’ abdominal pain, chiefly around theumbilicus, and no vomiting. In July, 1923, he had asomewhat similar attack overcome by high enemata, whichhad no effect this time.
Condition on Ad7nission.-Tcmp. 98’ F., pulse 40, later 60 ;-abdominal facies, colicky attacks of pain referred to theumbilicus but no visible peristalsis, and an intensely tender.painful tumour on right side, the largest part level with theumbilicus, and moderate abdominal distension. A highenema brought back a coloured result only, and the patientvomited bile four times.Immediate operation showed that a large loop of greatly
distended ileum, two feet long, was strangulated by theappendix looped around it in a tight ring, with the bulbous,swollen, and almost gangrenous tip adherent to its base atthe caecum and containing a fsecal concretion. The apexwas freed, appendicectomy performed, the raw surface onthe bowel sutured, and the whole returned to the abdomen.Wound healed by first intention.Probably what occurred was that the long appendix
kinked back on itself forming a loop ; the apex becameblocked and finally inflamed and then adherent tothe base in consequence ; a loop of ileum slippedthrough the ring so formed and became strangulated.
I am indebted to Dr. Gerald Manning for permissionto publish this case.
CONGENITAL BONY OCCLUSION OF THECHOANÆ.
BY ALBAN EVANS, M.R.C.S. ENG.,SURGEON IN CHARGE EAR, NOSE AND THROAT DEPARTMENT-
SWANSEA GENERAL HOSPITAL.
THE rarity of the condition should make the follow-ing case worthy of record.
D. W., male, aged 3 weeks, was brought to the out-patientdepartment with a history of difficulty in breathing. Cyanosisand snuffling noticed soon after birth. Both sides of the-nose were full of gelatinous mucus, and on probing a tonydiaphragm was found completely blocking the choanae.The family history was interesting. Six years previously
a baby had been born which survived 15 minutes. A yearlater came a second, which lived 24 hours. A third arrivedthe following year which lived for about 36 hours, and whichhad something wrong with the nose and throat. Two yearslater came a fourth baby which survived four and a halfmonths, although blue all the time, which was attributed toheart disease.
The bony partition was thoroughly broken down.The baby had to be kept in hospital a month onaccount of digestive trouble, and when he left heappeared quite well.
2 Ibid., v., 714.
LEWES VICTORIA HOSPITAL.-The accounts pre-sented at the annual meeting of the governors of thehospital on May 6th showed a balance overdrawn on
Dec. 31st of B169, as against 2215 on Dec. 31st, 1922. Thereport stated that a new and up-to-date X ray apparatushad been installed at a cost of jB399, and it was hoped thecost would be met without having to draw upon the investedfunds. In 1914, when the system of private in-patients wasstarted, the receipts were 61 ; in 1923 they totalled 2275.
