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A CASE OF CEREBELLAR HÆMORRHAGE PRESENTING WELL-MARKED EARLY CERVICAL OPISTHOTONOS AND KERNIG'S SIGN.
397
pupils : were dilated and her eyeballs might conceivably have commenced over the cardiac portion the stomach and so have progressively extended and irregularly. Her respirations were loud and 20 per more general. minute ; her temperature in the axilla was 103° F. There were twitchings of the muscles of her neck and face, her Andover, Hants. abdomen was slightly tympanitic, and signs, of pain were elicited on pressure. Physical examination of the lungs, A CASE OF heart, and liver showed nothing abnormal. After the lapse bf an hour the patient was more conscious; her pulse was CEREBELLAR HÆMORRHAGE PRESENT140 at the wrist, of very low tension and irregular, and her ING WELL-MARKED EARLY CERVICAL temperature in the axilla was 105°. Subsequently she had OPISTHOTONOS AND KERNIG’S rigors, her temperature fell progressively and was 99° five hours before death. Her extremities became cold, the surface SIGN. of her body became clammy, and she had hallucinations BY WILLIAM THYNE, M.A., M.D. EDIN. with general nervous prostration. Diarrhoea and vomiting were frequent, the stools being offensive and dark-coloured. In three days she passed about a pint of dark-coloured urine A MAN, aged 20 years, with an epileptic history, was in containing phosphates and mucus but no albumin. A his usual health on Christmas Day, 1900. After partaking of papular erythematous rash developed on the backs of her several hearty meals he was seized with vomiting, which hands and wrists and a few spots on her abdomen and knees on Nov. 21st. Death occurred early on the morning of continued through the night. About six hours after the Nov. 22nd, about 86 hours from the onset of the first sym- onset it was noticed that the head was retracted (see Fig. 1) =and vacant; her moved
ptoms. I ascertained the following facts from her friends. She had been poorly the previous week from the effects of mentruation and cold. On Nov. 17th she felt well and ate two beef sausages. Three other persons had also partaken of sausages the same night. Two of them suffered from diarrhoea and vomiting. The third ate very little and was not affected ; she gave the rest of her sausage to her dog, which was violently sick 12 hours afterwards. The deceased was seized with severe pain in her abdomen and vomiting 12 hours after eating the two sausages ; diarrhoea set in about 20 hours afterwards. At the postmortem examination the abdominal cavity was found to contain about a pint of turbid fluid. There was exudation of lymph and there were recent adhesions between the omentum and intestines. The parietal peritoneum was smooth and there were The peritoneum no signs of intiammation. over the small intestines appeared to be intensely inflamed, especially in the region of the ileum ; the upper part of the small The intestine was markedly distended. spleen and the posterior surface of the stomach were bathed in curdy lymph. The mucous membrane of the stomach was acutely inflamed over the cardiac the and lesser curvature of greater portion with numerous ecchymoses, and the external surface in these regions was likewise inIn the upper part of flamed. the duodenum the mucous membrane showed petechim in the submucous tissue ; the duodenum was dilated. The inner surface of the rest of the intestine was pale with a few pin-point nodules at the lower six inches of the ileum. The lumen of the appendix was occluded; there were no adhesions externally and no signs of recent inflammation in this region. In connexion with the left ovary there was a multilocular tumour of the s;ze of a hen’s egg containing clear fluid ; there were no signs of inflammation around it. The right ovary shoved commencing cystic formation The Fallopian tubes and uterus were healthy; the bladder was normal ; the kidneys, liver, spleen, and lungs were congested ; the heart was normal; the brain
was
of become
FIG. 1.
Showing retraction of head. FIG. 2.
anasmic.
- B6MK)M’.—The points of interest about
this case, I think, are the following:e (1) the sudden occurrence of the semiunconscious state; (2) the high temperature ; (3) the absence of marked mus-
Showing Kernig’s sign.
weakness; ana (.’1-) tine very intiense innammation and the patient complained of severe frontal headache. in the peritoneum covering the intestine without There were no loss of consciousness, no motor paralysis, and any apparent inflammation inside from. which the no convulsions or twitchings, and the organic reflexes were The peritonitis The tendon reflexes were increased, Kernig’s toxic irritant presumably extended, umar
unimpaired.
398 There was no associated with irritability of the bladder and pressure was well-marked, as shown in Fig. 2. ocular deviation. The condition of the optic discs could not symptoms. She had also recently lost flesh considerably, be made out owing to the presence of traumatic cataract in though she was still well nourished and looked fairly the right eye and old keratitis in the left. The temperature healthy. Examination of the abdomen revealed marked was normal or subnormal except on the evening of Dec. 30th, distension below the umbilicus, especially prominent on the when it was 102-6" F. The pulse varied from 60 to 160, but right side. A thrill was readily obtained and the distended There was no cardiac part of the abdomen was dull, while the flanks were was regular in force and rhythm. disease. On the 30th lumbar puncture was performed but resonant. The physical signs were those of a large thingave a negative result. The patient remained in this con- walled ovarian cyst. By careful palpation firm masses could dition, except for increasing weakness, till Jan. 4th, 1901, be recognised apparently within the cyst. A large elastic when he lost power in both legs, the right being the first tumour was felt in the right inguinal region and another affected. Consciousness remained unimpaired till death rounded mass in the right hypochondrium. On examination took place on Jan. 5th, 1901. per vaginam the uterus was found to lie very low, the On the same day a partial post-mortem examination was cervix reaching the vulval orifice. Douglas’s pouch was made by Dr. R. G. Riddell. The dura mater was thick but bulged downwards. The uterus was small and pushed to healthy. There was a serous effusion in the subarachnoid the left side ; the sound passed two and a quarter inches. space which was very marked posteriorly. Over the right The right side of the pelvis was filled up by a firm irreguoccipital lobe there was a thin layer of coagulated blood larly shaped mass occupying the broad ligament and extending down to the cerebellum. The lateral ventricles continuous with the mass in the inguinal region. The contained about four drachms of clear serous fluid. The i body of the uterus could not be clearly defined as separate fourth ventricle was filled with blood-clot. There was a z’ from the tumour. The left side of the pelvis appeared to be small haemorrhage in the left lateral lobe of the cerebellum. free. There was no haemorrhage over the base and no evidence of ’, Operation was performed on Sept. 25th, 1896, when the meningitis. The serous fluid from the subarachnoid space ’, abdomen was opened in the usual way and the parietal contained no organisms. peritoneum, which was somewhat thickened, was incised. The sequence of events probably was as follows. A ’, This was followed immediately by the evacuation of a large basmorrhage occurring in the left lateral lobe of the quantity of chylous fluid, at first sight resembling pus. cerebellum found its way into the fourth ventricle and I Seven pints of this fluid were collected. It had evidently On introthence through the foramen of Magendie to the sub- been encysted between peritoneal adhesions. arachnoid space, the position of the haemorrhage over ’ ducing the hand a firm solid mass was recognised filling up This was the occipital lobe being probably determined by gravity. ’, the right side of the pelvis and iliac fossa. The case is interesting from the fact that well-marked covered by peritoneum and had developed between the The uterus was cervical opisthotonos and Kernig’s sign were due to layers of the right broad ligament. cerebellar haemorrhage, meningitis, with which they are pushed away to the left and was quite small. The usually associated, being absent. appendages were normal. The rectum was not pressed upon Mr. S. G. Shattock very kindly examined sections of the and the left side of the pelvis was free from growth. cerebral lesion and found the arterioles free from any The mass on the right side extended upwards, with numerous chronic disease in sections passing right through the seat irregularities and several large projecting masses, as high as the right hypochondrium. The tumours were deep red in of the haemorrhage. colour and numerous large vessels ran over their surface. High Barnet. A pedunculated mass, of the size of an orange, projected towards the left side of the abdomen above the level of the A CASE OF pelvic brim. The caecum and colon were displaced and lay external to the tumour and posteriorly. The small intesPELVIC SARCOMA WITH CHYLOUS tines were pushed upwards by the pressure of the aecitic ABDOMINAL SECTION fluid, and were matted together by numerous adhesions. The mesentery was apparently considerably shortened. The AND DRAINAGE; PATIENT liver was normal in size and to the touch. The tumour was AND A WELL FOUR evidently beyond removal. An incision into the peritoneal HALF YEARS AFTER capsule showed this to be firmly adherent to the surface and it was impossible to strip it off to any extent. The abdomen OPERATION.1 was flushed out with saline solution and an indiarubber tube was inserted. BY ARNOLD W. W. LEA, M.D., B.S. LOND., The patient progressed very favourably. The discharge F.R.C.S. ENG., ASSISTANT SURGEON TO THE CLINICAL HOSPITAL FOR WOMEN AND through the tube was very scanty. There was no rise of CHILDREN, MANCHESTER; ASSISTANT TO THE PROFESSOR OF temperature. The tube was removed on the sixth day. The OBSTETRICS AT OWENS COLLEGE, MANCHESTER. wound healed well. There was no accumulation of fluid, though the masses of the tumour were now plainly felt. The patient left the Nursing Home in three weeks feeling in DURING recent years many cases have been reported well. Microscopic examination of the fluid revealed a which abdominal tumours, apparently malignant, have very basis of emulsified fat with a few leucocytes and granular ceased to grow and have sometimes entirely disappeared as red blood corpuscles. Since this time, nearly four and a a result of simple abdominal exploration. Our knowledge half years ago, the patient has remained in good health and of the factors concerned in bringing about this result is very I have seen her at intervals. At the present time she is 63 of age and feels well. The abdomen is lax and resonant imperfect. In some instances inflammatory masses have years small masses can be-plainly doubtless been taken for new growths, but this cannot be the all over. On palpation, however, felt in the right iliac region and also in the right hypogeneral explanation and it is well that all such cases should chondrium. The uterus is small and atrophied. The mass be recorded. The notes of this case are as follows. in the right broad ligament is still present but is much The patient, a woman, aged 58 years, was first seen in smaller. Such are the facts of this case and I have thought it of September, 1896. She complained of swelling of the abdomen together with " bearing-down"pain. She had sufficient interest to record it in some detail. The primary tumour appears to have been a fibro-myoma of the right never been pregnant and she had always enjoyed good Ten years previously (in 1886) she consulted a broad ligament. The history of a swelling in that region health. well-known gynaecologist on account of profuse menorrhagia for ten years associated with menorrhagia, but without any which was considered to be due to a fibroid tumour of the evidence of implication of the uterus, shows that the conuterus. Three years later she herself could plainly feel a dition cannot have been malignant from the first. Fibro-myoma developing in the connective tissue of the lump low down in the right side of the abdomen, but the menopause had come on and the swelling caused her no broad ligament is rare, but many cases have been recorded. trouble. Early in 1896 she observed a rapid increase in the In 1885 Mr. Bland-Sutton collected details of 11 cases, some of size of the abdomen and she also had pains in the pelvis which had attained a large size. Mr. Alban Doran recently removed one weighing 44 lb. The growths have always occurred in women over 35 years of age and are ofted bilateral. 1 A paper read before a meeting of the Clinical Society of Manchester on Jan. 15th, 1901. They often also grow with extreme rapidity. In some cases
sign
’
,
ASCITES;
pupils : were dilated and her eyeballs might conceivably have commenced over the cardiac portion the stomach and so have progressively extended and irregularly. Her respirations were loud and 20 per more general. minute ; her temperature in the axilla was 103° F. There were twitchings of the muscles of her neck and face, her Andover, Hants. abdomen was slightly tympanitic, and signs, of pain were elicited on pressure. Physical examination of the lungs, A CASE OF heart, and liver showed nothing abnormal. After the lapse bf an hour the patient was more conscious; her pulse was CEREBELLAR HÆMORRHAGE PRESENT140 at the wrist, of very low tension and irregular, and her ING WELL-MARKED EARLY CERVICAL temperature in the axilla was 105°. Subsequently she had OPISTHOTONOS AND KERNIG’S rigors, her temperature fell progressively and was 99° five hours before death. Her extremities became cold, the surface SIGN. of her body became clammy, and she had hallucinations BY WILLIAM THYNE, M.A., M.D. EDIN. with general nervous prostration. Diarrhoea and vomiting were frequent, the stools being offensive and dark-coloured. In three days she passed about a pint of dark-coloured urine A MAN, aged 20 years, with an epileptic history, was in containing phosphates and mucus but no albumin. A his usual health on Christmas Day, 1900. After partaking of papular erythematous rash developed on the backs of her several hearty meals he was seized with vomiting, which hands and wrists and a few spots on her abdomen and knees on Nov. 21st. Death occurred early on the morning of continued through the night. About six hours after the Nov. 22nd, about 86 hours from the onset of the first sym- onset it was noticed that the head was retracted (see Fig. 1) =and vacant; her moved
ptoms. I ascertained the following facts from her friends. She had been poorly the previous week from the effects of mentruation and cold. On Nov. 17th she felt well and ate two beef sausages. Three other persons had also partaken of sausages the same night. Two of them suffered from diarrhoea and vomiting. The third ate very little and was not affected ; she gave the rest of her sausage to her dog, which was violently sick 12 hours afterwards. The deceased was seized with severe pain in her abdomen and vomiting 12 hours after eating the two sausages ; diarrhoea set in about 20 hours afterwards. At the postmortem examination the abdominal cavity was found to contain about a pint of turbid fluid. There was exudation of lymph and there were recent adhesions between the omentum and intestines. The parietal peritoneum was smooth and there were The peritoneum no signs of intiammation. over the small intestines appeared to be intensely inflamed, especially in the region of the ileum ; the upper part of the small The intestine was markedly distended. spleen and the posterior surface of the stomach were bathed in curdy lymph. The mucous membrane of the stomach was acutely inflamed over the cardiac the and lesser curvature of greater portion with numerous ecchymoses, and the external surface in these regions was likewise inIn the upper part of flamed. the duodenum the mucous membrane showed petechim in the submucous tissue ; the duodenum was dilated. The inner surface of the rest of the intestine was pale with a few pin-point nodules at the lower six inches of the ileum. The lumen of the appendix was occluded; there were no adhesions externally and no signs of recent inflammation in this region. In connexion with the left ovary there was a multilocular tumour of the s;ze of a hen’s egg containing clear fluid ; there were no signs of inflammation around it. The right ovary shoved commencing cystic formation The Fallopian tubes and uterus were healthy; the bladder was normal ; the kidneys, liver, spleen, and lungs were congested ; the heart was normal; the brain
was
of become
FIG. 1.
Showing retraction of head. FIG. 2.
anasmic.
- B6MK)M’.—The points of interest about
this case, I think, are the following:e (1) the sudden occurrence of the semiunconscious state; (2) the high temperature ; (3) the absence of marked mus-
Showing Kernig’s sign.
weakness; ana (.’1-) tine very intiense innammation and the patient complained of severe frontal headache. in the peritoneum covering the intestine without There were no loss of consciousness, no motor paralysis, and any apparent inflammation inside from. which the no convulsions or twitchings, and the organic reflexes were The peritonitis The tendon reflexes were increased, Kernig’s toxic irritant presumably extended, umar
unimpaired.
398 There was no associated with irritability of the bladder and pressure was well-marked, as shown in Fig. 2. ocular deviation. The condition of the optic discs could not symptoms. She had also recently lost flesh considerably, be made out owing to the presence of traumatic cataract in though she was still well nourished and looked fairly the right eye and old keratitis in the left. The temperature healthy. Examination of the abdomen revealed marked was normal or subnormal except on the evening of Dec. 30th, distension below the umbilicus, especially prominent on the when it was 102-6" F. The pulse varied from 60 to 160, but right side. A thrill was readily obtained and the distended There was no cardiac part of the abdomen was dull, while the flanks were was regular in force and rhythm. disease. On the 30th lumbar puncture was performed but resonant. The physical signs were those of a large thingave a negative result. The patient remained in this con- walled ovarian cyst. By careful palpation firm masses could dition, except for increasing weakness, till Jan. 4th, 1901, be recognised apparently within the cyst. A large elastic when he lost power in both legs, the right being the first tumour was felt in the right inguinal region and another affected. Consciousness remained unimpaired till death rounded mass in the right hypochondrium. On examination took place on Jan. 5th, 1901. per vaginam the uterus was found to lie very low, the On the same day a partial post-mortem examination was cervix reaching the vulval orifice. Douglas’s pouch was made by Dr. R. G. Riddell. The dura mater was thick but bulged downwards. The uterus was small and pushed to healthy. There was a serous effusion in the subarachnoid the left side ; the sound passed two and a quarter inches. space which was very marked posteriorly. Over the right The right side of the pelvis was filled up by a firm irreguoccipital lobe there was a thin layer of coagulated blood larly shaped mass occupying the broad ligament and extending down to the cerebellum. The lateral ventricles continuous with the mass in the inguinal region. The contained about four drachms of clear serous fluid. The i body of the uterus could not be clearly defined as separate fourth ventricle was filled with blood-clot. There was a z’ from the tumour. The left side of the pelvis appeared to be small haemorrhage in the left lateral lobe of the cerebellum. free. There was no haemorrhage over the base and no evidence of ’, Operation was performed on Sept. 25th, 1896, when the meningitis. The serous fluid from the subarachnoid space ’, abdomen was opened in the usual way and the parietal contained no organisms. peritoneum, which was somewhat thickened, was incised. The sequence of events probably was as follows. A ’, This was followed immediately by the evacuation of a large basmorrhage occurring in the left lateral lobe of the quantity of chylous fluid, at first sight resembling pus. cerebellum found its way into the fourth ventricle and I Seven pints of this fluid were collected. It had evidently On introthence through the foramen of Magendie to the sub- been encysted between peritoneal adhesions. arachnoid space, the position of the haemorrhage over ’ ducing the hand a firm solid mass was recognised filling up This was the occipital lobe being probably determined by gravity. ’, the right side of the pelvis and iliac fossa. The case is interesting from the fact that well-marked covered by peritoneum and had developed between the The uterus was cervical opisthotonos and Kernig’s sign were due to layers of the right broad ligament. cerebellar haemorrhage, meningitis, with which they are pushed away to the left and was quite small. The usually associated, being absent. appendages were normal. The rectum was not pressed upon Mr. S. G. Shattock very kindly examined sections of the and the left side of the pelvis was free from growth. cerebral lesion and found the arterioles free from any The mass on the right side extended upwards, with numerous chronic disease in sections passing right through the seat irregularities and several large projecting masses, as high as the right hypochondrium. The tumours were deep red in of the haemorrhage. colour and numerous large vessels ran over their surface. High Barnet. A pedunculated mass, of the size of an orange, projected towards the left side of the abdomen above the level of the A CASE OF pelvic brim. The caecum and colon were displaced and lay external to the tumour and posteriorly. The small intesPELVIC SARCOMA WITH CHYLOUS tines were pushed upwards by the pressure of the aecitic ABDOMINAL SECTION fluid, and were matted together by numerous adhesions. The mesentery was apparently considerably shortened. The AND DRAINAGE; PATIENT liver was normal in size and to the touch. The tumour was AND A WELL FOUR evidently beyond removal. An incision into the peritoneal HALF YEARS AFTER capsule showed this to be firmly adherent to the surface and it was impossible to strip it off to any extent. The abdomen OPERATION.1 was flushed out with saline solution and an indiarubber tube was inserted. BY ARNOLD W. W. LEA, M.D., B.S. LOND., The patient progressed very favourably. The discharge F.R.C.S. ENG., ASSISTANT SURGEON TO THE CLINICAL HOSPITAL FOR WOMEN AND through the tube was very scanty. There was no rise of CHILDREN, MANCHESTER; ASSISTANT TO THE PROFESSOR OF temperature. The tube was removed on the sixth day. The OBSTETRICS AT OWENS COLLEGE, MANCHESTER. wound healed well. There was no accumulation of fluid, though the masses of the tumour were now plainly felt. The patient left the Nursing Home in three weeks feeling in DURING recent years many cases have been reported well. Microscopic examination of the fluid revealed a which abdominal tumours, apparently malignant, have very basis of emulsified fat with a few leucocytes and granular ceased to grow and have sometimes entirely disappeared as red blood corpuscles. Since this time, nearly four and a a result of simple abdominal exploration. Our knowledge half years ago, the patient has remained in good health and of the factors concerned in bringing about this result is very I have seen her at intervals. At the present time she is 63 of age and feels well. The abdomen is lax and resonant imperfect. In some instances inflammatory masses have years small masses can be-plainly doubtless been taken for new growths, but this cannot be the all over. On palpation, however, felt in the right iliac region and also in the right hypogeneral explanation and it is well that all such cases should chondrium. The uterus is small and atrophied. The mass be recorded. The notes of this case are as follows. in the right broad ligament is still present but is much The patient, a woman, aged 58 years, was first seen in smaller. Such are the facts of this case and I have thought it of September, 1896. She complained of swelling of the abdomen together with " bearing-down"pain. She had sufficient interest to record it in some detail. The primary tumour appears to have been a fibro-myoma of the right never been pregnant and she had always enjoyed good Ten years previously (in 1886) she consulted a broad ligament. The history of a swelling in that region health. well-known gynaecologist on account of profuse menorrhagia for ten years associated with menorrhagia, but without any which was considered to be due to a fibroid tumour of the evidence of implication of the uterus, shows that the conuterus. Three years later she herself could plainly feel a dition cannot have been malignant from the first. Fibro-myoma developing in the connective tissue of the lump low down in the right side of the abdomen, but the menopause had come on and the swelling caused her no broad ligament is rare, but many cases have been recorded. trouble. Early in 1896 she observed a rapid increase in the In 1885 Mr. Bland-Sutton collected details of 11 cases, some of size of the abdomen and she also had pains in the pelvis which had attained a large size. Mr. Alban Doran recently removed one weighing 44 lb. The growths have always occurred in women over 35 years of age and are ofted bilateral. 1 A paper read before a meeting of the Clinical Society of Manchester on Jan. 15th, 1901. They often also grow with extreme rapidity. In some cases
sign
’
,
ASCITES;