A case of volvulus of the small intestine at a Meckel's diverticulum : together with some observations on 'subacute ileus' and the performance of gastrostomy for paralysis of the small intestine / by K.G. Lennander.

  • Lennander, Karl Gustav, 1857-1908.
Date:
1907
Catalogue details

Licence: In copyright

Credit: A case of volvulus of the small intestine at a Meckel's diverticulum : together with some observations on 'subacute ileus' and the performance of gastrostomy for paralysis of the small intestine / by K.G. Lennander. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    2S the bowel immediately above and below tlie fistula should be stitched to the parietal peritoneum. In this case, it was evident from the beginning that the intestine could not be obstructed immediately below the higher of tlie two fistula-, as fluid injected into this one escaped by way of the more distally placed one. During the wliole after-treatment nothing escaped through the upper fistula. During the first day and a half feculent matter collected incessantly in the stomach in spite of repeated irriga- tions. It was thus evident that the stomach and duodenum could not empty their contents into the jejunum. This condition might be due either to the jejunum lieing kinked above the upper fistula or the duodenum, and the above-named portion of jejunum being still paralysed, in spite of the other parts of the bowel having regained their power of contraction. At the time when the gastrostomy was performed it was of no special importance to determine this point; it has been mentioned that the bowel was found to Ije distended and paralysed at the first operation. The increase in the distension during the next day and a half made it perfectly certain that it was paralysed at that time. Our object, therefore, was to provide for the escape of the hile and tlie pancreatic juice by making a fistula in tlie pyloric ])ortion of the stomacli. This was carried out at 2 r.M. on the 12th by '\^Ttze^s method, and after twenty-four hours the fluid whicli escaped from it was no longer bad-smelling, so tliat by this time the duodenum, and in all pi'obability also the jejunum, had completely emptied themselves. After another ten hours notliing escaped from the gastric fistula, proving tliat the stomach, duodenum, and jejunum were able to empty their contents into the intestine below. Thus it was evident that the jejunum could not be kiidced above the higlier of the two intestinal fistulas, a fact tliat was also confirmed at tlie autopsy. It was then found that the first 40 cms. of the jejunum had a diameter of 8 to 9 cms., and showed a “ well-marked diphtheritic process.” The distended, paralysed liowel had fallen an easy victim to the poisons and liacteria within its lumen. The result would probably have been different if at the operation on 10th January I had made a gastric fistula instead of a jejunostomy. It was also found at the autopsy that the opening of the tube in the jejunal fistula was blocked by a swollen valvula Kerckringii. This explains why nothing flowed back through the tube when intestinal injections were made, and it teaches us that a fistula tube in the jejunum should reach at least 2 cms. into the lumen of the bowel, and have at least three holes at the intestinal end. The fact that the fluid injected through the jejunal fistula on the first day passed out througli the fistula in the ileum, shows that the jejunum nearest the fistula soon regained its power of contraction, whereas the lower part of the duodenum and the uppermost portion of tlie jejunum remained paralysed about thirty liours after making the gastrostomy.