THE following are the notes of a patient who was under the care of Mr. A. E.
Coates at the Melbourne Hospital.
A. McA., male, aged 32 years. For many years there had been pain about two hours after meals, intermittent attacks of vomiting, each lasting for four weeks, and remissions lasting about six weeks. During the attacks vomiting would occur about three times a week, without warning half-way through a meal. A barium meal examination suggested the presence of a duodenal ulcer. For twelve hours there had been severe epigastric pain of sudden onset. Vomiting occurred once ; there was much nausea and retching, and the bowels had not acted.
ON EXAMINATION.-The temperature was 95.6", pulse-rate 64. and the blood-pressure, systolic 92 mm., diastolic 54 mm. The abdomen was not distended, was held immobile during respiration, and there was generalized rigidity, most marked in the upper abdomen, especially on the right side. Acute tenderness was elicited midway between the xiphisternum and the umbilicus, and the area of liver dullness seemed diminished. A diagnosis of perforated duodenal ulcer was made.
OPERATION.-At operation there was no evidence of gastric or duodenal ulceration. Some blood-stained fluid escaped, the upper loop of the jejunum was distended, and the lower ileum was collapsed. The small bowel was followed proximally till near the upper part of the jejunum there was found a strangulated cyst in the left side of the mesentery, about three-quarters of the size of a tennis ball. The pedicle was ligated and the cyst removed The wall of the cyst was identical in structure with that of the adjoining small intestine