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INTESTINAL RUPTURE FOLLOWING NON-PENETRATING INJURY
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good general practitioners, bringing medicine to the home, as it is to provide pleasures and palaces for patients who qualify for institutional care." Regretting the present ascendancy of the first school we have repeatedly expressed anxiety lest conditions should be perpetuated which must discourage men of quality from entering general practice.-ED. L.
there was a complete transverse tear of the jejunum which extended into the mesentery. Also there were two small tears of the peritoneum over the transverse colon. After freshening the ends of the jejunum, end-to-end anastomosis was performed. The colon injuries were treated by a Lembert suture over the injured areas. The patient recovered, but convalescence was complicated by pelvic induration which resolved spontaneously.
INTESTINAL RUPTURE FOLLOWING NON-PENETRATING INJURY SIR,—In your issue of April 16, Mr. Flavell illustrates dramatically, by his description of a rare complication of body-line bowling, an insidious disaster which may follow a blow upon the abdomen. The damage to the abdominal contents may be most extensive though the patient may show little signs for some hours of the extent of the injury. It is because of some recent experiences with such cases that we wish to reinforce the moral which he points that the blow on the abdomen must be watched with no less attention than is the blow on the head." In the last 10 cases admitted to the Radcliffe Infirmary with rupture of the small bowel resulting from a closed injury of the abdominal wall, some interesting features were noted. Of these 10, 7 survived the disaster ; all these cases were operated on within twelve hours of the injury. Of the 7 survivors, 3 had partial tears of the small bowel which were sutured ; 3 had completetransverse tears and were treated by anastomosis of the damaged ends ; in the remaining case it was necessary to perform a local resection with anastomosis. Of the 3 patients who died, the first, who had been crushed by a falling wall, had a resection within twelve hours, but death resulted on the fifth day from anuria ; in the second, a child of 21/2 years with associated head and leg injuries, the diagnosis was obscure for twenty-four hours, the patient dying of general peritonitis following operation ; in the third, late suture, of the perforation was This soon followed by death from general peritonitis. case is detailed below (case 1). In 6 of the 10 cases a definite latent period followed the injury, and this feature is illustrated by the other case described below (case 2). CASE 1.—A gipsy boy, aged 17, was kicked in the abdomen by a horse just after midnight on Aug. 29, 1945. He was brought to the Radcliffe Infirmary about an hour after his
The first case indicates that, though the patient may be in the hands of the surgeons within one hour of injury, the clinical picture may be sufficiently deceptive to cause fatal delay in operating. The second case emphasises that a severe abdominal rupture may be present yet the patient may " score ten runs " as in the case reported by Mr. Flavell, or may push a bicycle home as in this The moral, as Mr. Flavell has said, is that " on case. reasonable suspicion of perforation the belly should unhesitatingly be explored." G. E. MOLONEY The Radcliffe Infirmary, Oxford. J. N. WARD-MCQUAID.
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injury, when he complained of abdominal pain but no shouldertip pain. Temperature and blood-pressure were normal; pulse-rate was 108 per min. The abdomen moved gently on respiration and showed slight generalised tenderness and resistance. Intestinal sounds were present. Rectal examination revealed no abnormality, and there was no blood in the urine. The injury did not appear severe, and there was some question at the time whether he should be admitted ; but it was decided to keep him in hospital. The following day, his condition. was much the same, but that evening the pulse-rate rose and he vomited. Next morning the abdomen was rigid with generalised tenderAt ness, and general peritonitis was obviously present. laparotomy the abdominal cavity was found to contain purulent, foul-smelling fluid, and there were two perforations in the ileum. The proximal opening was oversewn and the lower opening was closed about an ileostomy tube. He was given penicillin and sulphonamide therapy, but his condition rapidly deteriorated and he died shortly before midnight the same
day.
CASE 2.-A labourer of 33 was admitted to the Radcliffe Infirmary on Aug. 11 last year. Having drunk six pints of beer, he was bicycling home when he rode into a projecting iron bar which struck him in the abdomen. He felt winded and faint, but picked up his bicycle, pushed it home a quarter of An hour and a a mile, put, it away, and then lay on his bed. half after the injury there was a gradual onset of dull pain all over the abdomen, and he noticed slight pain at the tip of both shoulders. He vomited about six times from midnight onwards until he was admitted to the Radcliffe Infirmary the next morning. Abdominal examination showed no evidence of external injury, but signs of generalised peritonitis. Twelve hours after the injury, laparotomy was performed, the incision revealing that the right rectus muscle was partly The abdominal cavity contained free, brown, torn across. turbid fiuid, and about 1 ft. from the duodenojejunal junction
HEALTH SERVICES BILL IN AUSTRALIA SIR,—In your issue of Jan. 8, your Australian correspondent wrote of this Bill : " Dentists would also come under the scheme, and the government would pay half the fee." Here your correspondent was in error. At no time has the government intimated that it would pay any portion of the dental fees of the community. The known intentions of the government are summed up in the paragraphs following the statement under discussion in your correspondent’s report. GERSHON BENNETT Melbourne. Hon. Secretary, Australian Dental Association.
WERTHEIM’S OPERATION
SIR,—Mr. John Stallworthy in your last issue advocates cooperation, as between radiotherapists and gynaecological surgeons, in the treatment of carcinoma of the cervix. To use a present-day vulgarism, I couldn’t agree more." But I do wish that he would give a place to deep " X-ray therapy in his armamentarium, and to a physicist in his team. At Guy’s Hospital a deep X-ray therapy department was established in "
"
1923-26 years ago. From that time, we were in the habit of combining radiotherapy of this type with the Bonney-Wertheim operation. In my own cases I feel that any good and lasting results have been largely due to preoperative and postoperative radiation. Personally I find it difficult to believe that the combination of radium and the radical operation represents the ideal treatment, as they roughly cover the same field to the possible exclusion of the periphery. FRANK COOK. London, W.I. FEMALE CIRCUMCISION IN THE SUDAN SIR,—I read with much interest the Parliamentary report on this subject which appeared in your issue of Feb. 26, and the letter by Sir Basil published on March 12. In view of what has appeared in your columns it may be of interest to record that during the years 1944-46, when I held in the Sudan Medical Service the appointment of assistant medical officer of health (special duties), I was engaged in a survey of public health and social medicine which included duty as school medical officer for all girls’ schools in Khartoum province. This duty entailed the examination of all girls attending the primary and secondary schools and the Girls’ Training College in Khartoum, Khartoum North, Omdurman, and rural schools in that province. I had therefore the opportunity of carrying out a complete medical examination. Of a total of 3002 girls examined during the period of that survey, 1488 had been circumcised. Of these, 1103 had undergone the severe Pharaonic- type of mutilation, and 385 the mild or sunna form. No difficulty was encountered in combining this special examination with that required in the general medical survey, and it was effected in a simple matter-of-fact manner, which caused less trouble than a normal throat examination. The medical survey and general examination of the pupilsattending the girls’ schools had full cooperation from the
Neven-Spence
good general practitioners, bringing medicine to the home, as it is to provide pleasures and palaces for patients who qualify for institutional care." Regretting the present ascendancy of the first school we have repeatedly expressed anxiety lest conditions should be perpetuated which must discourage men of quality from entering general practice.-ED. L.
there was a complete transverse tear of the jejunum which extended into the mesentery. Also there were two small tears of the peritoneum over the transverse colon. After freshening the ends of the jejunum, end-to-end anastomosis was performed. The colon injuries were treated by a Lembert suture over the injured areas. The patient recovered, but convalescence was complicated by pelvic induration which resolved spontaneously.
INTESTINAL RUPTURE FOLLOWING NON-PENETRATING INJURY SIR,—In your issue of April 16, Mr. Flavell illustrates dramatically, by his description of a rare complication of body-line bowling, an insidious disaster which may follow a blow upon the abdomen. The damage to the abdominal contents may be most extensive though the patient may show little signs for some hours of the extent of the injury. It is because of some recent experiences with such cases that we wish to reinforce the moral which he points that the blow on the abdomen must be watched with no less attention than is the blow on the head." In the last 10 cases admitted to the Radcliffe Infirmary with rupture of the small bowel resulting from a closed injury of the abdominal wall, some interesting features were noted. Of these 10, 7 survived the disaster ; all these cases were operated on within twelve hours of the injury. Of the 7 survivors, 3 had partial tears of the small bowel which were sutured ; 3 had completetransverse tears and were treated by anastomosis of the damaged ends ; in the remaining case it was necessary to perform a local resection with anastomosis. Of the 3 patients who died, the first, who had been crushed by a falling wall, had a resection within twelve hours, but death resulted on the fifth day from anuria ; in the second, a child of 21/2 years with associated head and leg injuries, the diagnosis was obscure for twenty-four hours, the patient dying of general peritonitis following operation ; in the third, late suture, of the perforation was This soon followed by death from general peritonitis. case is detailed below (case 1). In 6 of the 10 cases a definite latent period followed the injury, and this feature is illustrated by the other case described below (case 2). CASE 1.—A gipsy boy, aged 17, was kicked in the abdomen by a horse just after midnight on Aug. 29, 1945. He was brought to the Radcliffe Infirmary about an hour after his
The first case indicates that, though the patient may be in the hands of the surgeons within one hour of injury, the clinical picture may be sufficiently deceptive to cause fatal delay in operating. The second case emphasises that a severe abdominal rupture may be present yet the patient may " score ten runs " as in the case reported by Mr. Flavell, or may push a bicycle home as in this The moral, as Mr. Flavell has said, is that " on case. reasonable suspicion of perforation the belly should unhesitatingly be explored." G. E. MOLONEY The Radcliffe Infirmary, Oxford. J. N. WARD-MCQUAID.
.
"
,
injury, when he complained of abdominal pain but no shouldertip pain. Temperature and blood-pressure were normal; pulse-rate was 108 per min. The abdomen moved gently on respiration and showed slight generalised tenderness and resistance. Intestinal sounds were present. Rectal examination revealed no abnormality, and there was no blood in the urine. The injury did not appear severe, and there was some question at the time whether he should be admitted ; but it was decided to keep him in hospital. The following day, his condition. was much the same, but that evening the pulse-rate rose and he vomited. Next morning the abdomen was rigid with generalised tenderAt ness, and general peritonitis was obviously present. laparotomy the abdominal cavity was found to contain purulent, foul-smelling fluid, and there were two perforations in the ileum. The proximal opening was oversewn and the lower opening was closed about an ileostomy tube. He was given penicillin and sulphonamide therapy, but his condition rapidly deteriorated and he died shortly before midnight the same
day.
CASE 2.-A labourer of 33 was admitted to the Radcliffe Infirmary on Aug. 11 last year. Having drunk six pints of beer, he was bicycling home when he rode into a projecting iron bar which struck him in the abdomen. He felt winded and faint, but picked up his bicycle, pushed it home a quarter of An hour and a a mile, put, it away, and then lay on his bed. half after the injury there was a gradual onset of dull pain all over the abdomen, and he noticed slight pain at the tip of both shoulders. He vomited about six times from midnight onwards until he was admitted to the Radcliffe Infirmary the next morning. Abdominal examination showed no evidence of external injury, but signs of generalised peritonitis. Twelve hours after the injury, laparotomy was performed, the incision revealing that the right rectus muscle was partly The abdominal cavity contained free, brown, torn across. turbid fiuid, and about 1 ft. from the duodenojejunal junction
HEALTH SERVICES BILL IN AUSTRALIA SIR,—In your issue of Jan. 8, your Australian correspondent wrote of this Bill : " Dentists would also come under the scheme, and the government would pay half the fee." Here your correspondent was in error. At no time has the government intimated that it would pay any portion of the dental fees of the community. The known intentions of the government are summed up in the paragraphs following the statement under discussion in your correspondent’s report. GERSHON BENNETT Melbourne. Hon. Secretary, Australian Dental Association.
WERTHEIM’S OPERATION
SIR,—Mr. John Stallworthy in your last issue advocates cooperation, as between radiotherapists and gynaecological surgeons, in the treatment of carcinoma of the cervix. To use a present-day vulgarism, I couldn’t agree more." But I do wish that he would give a place to deep " X-ray therapy in his armamentarium, and to a physicist in his team. At Guy’s Hospital a deep X-ray therapy department was established in "
"
1923-26 years ago. From that time, we were in the habit of combining radiotherapy of this type with the Bonney-Wertheim operation. In my own cases I feel that any good and lasting results have been largely due to preoperative and postoperative radiation. Personally I find it difficult to believe that the combination of radium and the radical operation represents the ideal treatment, as they roughly cover the same field to the possible exclusion of the periphery. FRANK COOK. London, W.I. FEMALE CIRCUMCISION IN THE SUDAN SIR,—I read with much interest the Parliamentary report on this subject which appeared in your issue of Feb. 26, and the letter by Sir Basil published on March 12. In view of what has appeared in your columns it may be of interest to record that during the years 1944-46, when I held in the Sudan Medical Service the appointment of assistant medical officer of health (special duties), I was engaged in a survey of public health and social medicine which included duty as school medical officer for all girls’ schools in Khartoum province. This duty entailed the examination of all girls attending the primary and secondary schools and the Girls’ Training College in Khartoum, Khartoum North, Omdurman, and rural schools in that province. I had therefore the opportunity of carrying out a complete medical examination. Of a total of 3002 girls examined during the period of that survey, 1488 had been circumcised. Of these, 1103 had undergone the severe Pharaonic- type of mutilation, and 385 the mild or sunna form. No difficulty was encountered in combining this special examination with that required in the general medical survey, and it was effected in a simple matter-of-fact manner, which caused less trouble than a normal throat examination. The medical survey and general examination of the pupilsattending the girls’ schools had full cooperation from the
Neven-Spence