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A CASE OF CONGENITAL HYPERTROPHY OF THE PYLORUS IN AN INFANT;
1511
though still with considerable weakness fontanelle was depressed. Nothing abnormal could ’be’ the left side. After that and until he went detected in the heart or lungs. The abdomen was flaccid. abroad he improved still further ; but at the Clinical and easily palpated and this seemed to cause the child no Society of London I expressed the belief that the case pain even when deep pressure was made. On inspection of was still by no means complete and the prognosis must the abdomen the peristaltic movements of the stomach could I felt that the possibility of be distinctly seen passing from left to right; these movements be regarded as doubtful. further epilepsy could not be overlooked. And during the followed one another in quick succession. On deep palpalast few days I have had letters from him saying that such tion in the right hypochondrium about a finger’s breadth attacks have appeared and have required further treatment, outside the nipple line a firm transverse mass, in shape like’ the nature of which he promises (in a letter received on the pylorus, could be felt; it was not always palpable when no Nov. 3rd, 1899) shall be communicated to me. He states peristalsis was taking place. The mass was less distinct that since the operation he feels perfectly well and hopes to than in another case of the same nature that was under my care and which ended fatally ; reference is again made to visit me soon in London. PS.-Since the above was written I have received a this case in the table. During the first 24 hours that the short letter from Dr. Chipault of Paris, of which child was in the hospital he was fed on equal parts of cow’s the subjoined is a translation : "II have operated on milk and barley-water, and during this time he vomited four I trephined and separated times. The temperature in the rectum was 97 2°. with a perfect result. Result: For some adhesions between the two hemispheres. Owing to the condition of the child he was on the follownine days before the operation there were from 60 to 100 ing day given three ounces of cow’s milk and barley-water, epileptic crises in the day with complete hemiplegia. All two parts of the former to one part of the latter, by a nasal this has disappeared except a spasmodic reaction of the tube every two and a half hours. During the next few days, I! lower extremity. In a later letter (Nov. 16th, 1899) the although the vomiting did not entirely cease, the child patient states that he still remains quite well. He thinks improved and passed a digested motion. The nasal feeding that he has more power in the left leg and arm than before. was continued and as the motions were digested ones no alteration was made in the character of the milk. The child He promises further reports from time to time. Harley-street, W. improved in appearance and the vomiting became less ; on some days vomiting occurred once or twice and on other’ days there was no vomiting. The temperature continued for the most part subnormal. On Dec. 9th a teaA CASE OF CONGENITAL HYPERTROPHY spoonful of cream was added to the nasal feedings and’ on the 17th some cod-liver oil was also given and OF THE PYLORUS IN AN INFANT; on this date the child weighed seven and three-quarter RECOVERY; SUBSEQUENT DEATH FROM BRONCHOpounds-a gain of eight ounces since admission. On the PNEUMONIA. 21st, the child not having vomited at all for two days, an endeavour was made to return to feeding by teat. The BY FREDERICK E. BATTEN, M.D CANTAB., child, however, took nearly half an hour to swallow three ASSISTANT PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN, GREAT ounces and vomited four times in the 24 hours. Nasal ORMOND-STREET. feeding was again resorted to and the vomiting again became less. The was now less distinctly felt than THE condition known under the above title is not of on admission and atpylorus times it could not be felt at all. Nasal frequent occurrence and nearly all reported cases have feeding was again abandoned on the 30th and although the terminated fatally. Finkelstein has however recorded child vomited occasionally the feeding by teat was persisted cases three of recovery in infants under nine weeks in and after Jan. 6th, 1899, the vomiting almost ceased. About this time Mr. T. H. Kellock kindly saw the child of age and Senator in a discussion on this subject with me with a view to the possibility of relieving the condimentioned one other such case. Recovery in such cases tion by operation, but owing to the feeble and wasted condireadily leads to some doubt as to the correct diagnosis tion of the child it was considered unadvisable that anything having been made, but in the following case in which the should be done. On Jan. 7th the motions contained some and undigested milk ; a dose of grey powder was diagnosis was made and in which recovery took place, death mucusand the motions again became natural. given from an acute attack of bronchooccurred subsequently The weight of the child remained stationary and as there pneumonia and gastro-enteritis, and at the necropsy a con- were no urgent symptoms the mother was on Jan. 12th again dition was found which would lead to the conclusion that given charge of the child and he was brought as an outthe original diagnosis was correct. patient. When discharged the vomiting had entirely ceased, A male infant, aged 11 weeks, was brought by his mother the motions were natural, the temperature was normal, and to the out-patient department of the Hospital for Sick the pylorus could no longer be felt ; the child only weighed Children, Great Ormond-street, in November, 1898, with seven and three-quarter pounds. The mother was instructed the history that when he was five weeks old he had begun to to continue the same diet. The child now began to improve vomit and about the same time the bowels became very and on Feb. 10th he weighed eight and a half pounds. costive and the child had wasted. The vomiting had con. During the next few months steady improvement took place tinued in spite of treatment. The child had been fed by the and except for slight attacks of vomiting and occasional unbreast till nine weeks old after which time he was ’given digested stools with mucus the child progressed well. Small Nestle’s milk. The child was a fine baby at birth. On loses of cod-liver oil in various forms were tried on several examination nothing abnormal could be felt in the abdomen, occasions, but with the result that they always gave rise but the peristaltic movements of the stomach were very dis- jO vomiting and after a few trials the attempt was abandoned. tinct. The temperature in the rectum was 96 2° F. On March 18th the child weighed llt pounds and on On Dec. 2nd the child was admitted to the hospital under my care and the following note was taken. The child had May 13th 16 pounds. The child was again seen in June and been quite well until five weeks old when he began to throw n July. He had then taken no drug for a period of three up his food and he had continued to vomit since. Food nonths and was plump and healthy ; he was therefore discame up about from five to ten minutes after feeding. charged with the request that he should again be brought to The bowels had been regular during the first five weeks of he hospital in three months. In August, however, the mother again brought the child to life, but since that time they had been very constipated, sometimes being confined for a week, and they had hardly he hospital with the history that three days previously he acted once spontaneously. The child had had no other ill- had been taken suddenly ill with diarrhoea and vomiting. ness ; he had been fed by the breast till he was nine weeks "he child looked ill and the eyes were sunken and nothing old, and was then tried on cow’s milk, but as this did not bnormal could be felt in the abdomen. The child was agree with him he was given Nest]6’s milk. He was the gain admitted to the hospital. During the first 24 hours youngest of five children, all the others being healthy. The e vomited three times; the motions were frequent mother had had no miscarriages and both the father and the nd loose, and the temperature rose to 104°. During the mother of the child were healthy. ollowing days the temperature remained between 102° and On admission the child was very thin and weighed seven 05° and the diarrhoea and vomiting continued. There were and a quarter pounds ; he did not look very ill and the few crepitations at the bases of the lungs. The child now, muscles of the limbs were fairly firm. The anterior owever, in spite of treatment, became more collaped and walk -< well, en
-
1512 hejdied on August 20th. At this time he was 11 months old and weighed 16 pounds two ounces. A necropsy was performed 20 hours after death. In both lungs there was a considerable amount of bronchopneumonia. The heart appeared to be normal. The stomach was contracted and its walls felt unusually thick and the pylorus was firm and hard. The stomach measured 12 centimetres from the pylorus to the extreme cardiac end. On opening up the duodenum the abrupt margin between the pylorus and the duodenum was very distinct. The lumen of the pylorus admitted a probe which measured four millimetres in diameter. On section the diameter of the pylorus
old the child had during the summer an acute attack of gastro-enteritis and broncho-pneumonia and died. At the necropsy an hypertrophied condition of the pylorus and stomach was found. Diagnosis.-The diagnosis was made on the following
points : (1) a healthy baby at birth ; (2) vomiting ; (3) constipation ; (4) subnormal temperature in the rectum ; (5) wasting; (6) marked dilatation and peristalsis of the a tumour in the position of the pylorus; and (8) the absence of the usual signs of gastritis. Pathology.-Various views have been held with regard to
stomach ; (7)
the pathology of the disease and it will here be necessary 1’5 centimetres and the total thickness of the wall was only to enumerate them, as they have been fully discussed in 5’5 millimetres. The muscular coat measured four milli- several able papers in which, also, a full bibliography of the metres and the mucous and submucous coat 1’5 millimetres. subject will be found. These views are (1) that the hyperThe circular muscular coat measured 0’3 millimetre and the trophy is the result of spasm from some irritant in the longitudinal coat 0’1 millimetre. The mucous membrane stomach ; (2) that the hypertrophy is a developmental overof the stomach appeared healthy; the wall measured four growth ; (3) that the hypertrophy is the result of a conmillimetres in thickness, and the muscular coat two milli- genital narrowing of the lumen of the pylorus followed by metres. The oesophagus appeared to be normal. No other compensatory hypertrophy of the stomach; and (4) that it anatomical defect was found. The above measurements is a functional disorder of the nerves of the stomach and were taken at the time of the post-mortem examination. pylorus leading to an ill coordination and therefore an After hardening in formalin the tissue was embedded in antagonistic action of their muscular arrangement. Remarks.-The special interest of the case lies in the fact celloidin, cut, and stained by Van Giesson’s method. On microscopical examination the mucous membrane and the that recovery took place and that the subsequent post-mortem muscular coat appeared to be perfectly normal so far as examination showed a condition which may be considered in their structure was concerned, but it was obvious that the accordance with the original diagnosis. That the symptoms circular coat was considerably thicker than normal. The began some five weeks after birth and that recovery took place following measurements were made by the micrometer. The would seem to negative the possibility of the condition being total diameter of the wall at a point two millimetres from due either to a developmental overgrowth or to a congenital the duodenal end of the pylorus was 42 millimetres, of which narrowing of the lumen of the pylorus. Further, the fact the circular coat measured 2’5 millimetres, the longitudinal that no alteration was made in the character of the food 0 4 millimetre, the submucous 0’5 millimetre, and the would seem to negative the possibility of the condition being If the measurements be compared due to food acting as an irritant to the stomach, although mucous 0’8 millimetre. with those of a normal child of the age of 12 months it will this may have been the exciting cause in the first place. The be seen that there is a considerable increase in the thickness fact that the child when fed with the nasal tube ceased to of the circular coat. vomit, digested ordinary milk, and passed normal motions The following table, taken from a paper read by Dr. G. F. would seem to make the suggestion of Dr. John Thomson the Still before the Pathological Society of London, gives the most probable explanation of the condition-viz., " that it is measurements of the normal pylorus at the ages of four and a functional disorder of the nerves of the stomach and pylorus 12 months and also of a marked case of the disease (Case 2), leading to an ill coordination and therefore an antagonistic and these are compared with the present case (Case 4). action in their muscular arrangement." Peristalsis started was
TABLE SHOWING
THE
COMPARATIVE THICKNESS OF LAYERS OF THE PYLORUS HARDENING REAGENTS.
Measurements taken at
a
point twomillimetres
on
BOTH
BEFORE
AND
AFTER
THE
USE
OF
the cardiac side of the duodenum.
of deglutition would seem to give rise to such the fifth child of healthy parents, born at full time and was well till the age of five weeks, active peristaltic movement in the stomach that regurgitation takes place; when the active peristalsis started by when without apparent cause he began to vomit. Till the of age of nine weeks the child was suckled, but as the vomiting deglutition is relieved by feeding with a nasal tube the persisted he was after that time fed at first with diluted cow’s stomach will tolerate and digest the food that is placed it. milk and subsequently with Nestle’s milk. The vomiting, Treatment.-The above case would seem to indicate that however, continued and was associated with constipation and wasting. When first seen at 11 weeks old the child feeding by the nasal tube may be of some use for weighed only seven and a quarter pounds, the abdomen was these patients. The child should be fed with from three flaccid, the tongue was clean, and the temperature was sub- to four ounces of diluted cow’s milk given every two normal. On examination of the abdomen the stomach was and a half or three hours. The nasal feeding should found to be distended and showed marked peristaltic action be continued for from 10 to 14 days, and an attempt and a firm hard mass could be felt in the region of the should then be made to suspend the feeding by the pylorus. The child was now fed with diluted cow’s milk tube and return to teat feeding; if this fails then the should again be resorted to and another given through a nasal tube, the vomiting gradually became tube less, and well-digested stools were passed. On the first trial of teat feeding made after a week. This process attempt to interrupt the nasal feeding vomiting recurred, but should be continued till the stomach will retain its contents when swallowed in the normal way. The slight departure on a subsequent occasion the attempt was successful, and from that time the child steadily improved. When 11 monthsfrom the normal in the character of the stools needs to be
Summary.-The patient,
was
by the action
food
within
feeding
1513 treated in the
ordinary way. Constipation as a symptom does not need to be treated, as it soon passes away when the child retains its food. Warmth is most essential for the child as evidenced by the subnormal temperature so constantly present. Although this class of case is uncommon it would seem not improbable that a certain proportion of them may recover under suitable treatment. Bibliography.-Cautley:Transactions
of the
Royal Medical
and
Chirurgical Society, vol. lxxxii., p. 41,1899. Rolleston and Hayne: Brit. Med. Jour., April, 1898. Finkelstein : Jahrbuch fiir Kinderheilkunde, Senator: Berliner Klinisehe Wochenschrift, 1897, Band 43, S. 105. S. 43. Still : Transactions of the Pathological Society of London, 1899. Thomson: Edinburgh Hospital Reports, vol. iv. ; Scottish Medical and Surgical Journal, June, 1897. Harley-street, W.
A CASE OF LATERAL TRANSPOSITION OF THE VISCERA. BY J. HARLEY BROOKS, M.D.ABERD., ASSISTANT MEDICAL OFFICER TO THE MILE END INFIRMARY WORKHOUSE AND SCHOOLS.
was admitted into Mile End Oct. and was found to be suffering from 24th Infirmary fractured ribs, and pleurisy and pneumonia followed, causing his death on Oct. 30th. It was alleged that while in a on Oct. received a violent blow in his 8th he public-house side and to this he attributed his illness. It became necessary to take his depositions and this was done in the presence of a man who had been arrested on a charge of causing him grievous bodily harm. At the post-mortem examination a bruise that might very well have been produced by a violent blow was found in the right loin embracing the two floating ribs, while the fractured ribs were the ninth and tenth. A blow received in the position located by the bruise resulting in the fracture of the injured ribs, I pointed out at the inqaest, must have been delivered in an upward direction and also have been so violent a blow as to push aside the floating ribs and crash
A MAN,
aged 67 years,
on
Interesting as the necropsy was from the medico-legal aspect it proved of still greater interest from an anatomical point of view, for I found that curious abnormality-trans-
position of the viscera. On opening the body I first noticed that the spleen was on the right side and I then found that the liver was occupying the left hypochondriac region.The caecum and vermiform appendix were not in the usual site but had been transposed to the left, and the colon followed a reverse course to the normal, the sigmoid flexure being in the right iliac region. As regards the kidneys there was nothing to identify the one from the other apart from their respective weights, the one on the left being the heavier, but the pathological changes were sufficient to account. for the variation in weight. The stomach, rather a small one, was transposed, the cardiac orifice being to the right and the pyloric to the left. The duodenum was very much dilated and at first sight it seemed almost as though it were a second stomach ; however, this proved not to be the case. The pancreas also took part in the general transposition. In fact, the abdominal viscera exhibited the appearance described by others who have recorded cases-as though the normal arrangement were viewed in a mirror. In the thorax this method of description apparently applied so far as the disposition of the heart and lungs was concerned, the left lung being the right one transposed, as evidenced by its three lobes, and the one on the right with only two lobes being the left lung on the wrong side of the body. The blood-vessels springing from the arch, however, were not merely transposed along with the aorta: they came off from the left to the right as innominate, right common carotid, right subclavian, and as a variation not unknown-the right vertebral artery sprang directly from the arch somewhat behind but a little to the right of the subclavian. The innominate divided into the left subclavian and the left carotid, the latter lying directly in front of the former. The left vertebral artery arose from the anterior aspfct of the left subclavian instead of from the posterior about half an inch above the bifurcation of the innominate, hidden from view by the overlapping carotid artery. The aorta and the oesophagus lay to the right of the vertebral column. The patient was right-handed. It is a curious coincidence that one of the cases of transposition of viscera recorded by Dr. Pye- Smithwas that of an old woman from Mile End Workhouse. Mile End Infirmarv, Bancroft-road, N.B.
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. NOTE ON A FATAL CASE OF DOUBLE STRANGULATED FEMORAL HERNIA. BY WALTER FALLA, L.R.C.P. LOND., M.R.C.S.ENG., SURGEON TO THE JERSEY GENERAL HOSPITAL.
shows the transposed heart with the right’vertebral off directly from the aorta beyond the right subctavian artery A. The left vertebral artery E rises from the front of the left subclavian artery D. C marks the right common carotid artery and F marks the left. G marks the innominate artery.
The
figure
artery
B
given
through the ninth and tenth ribs. The evidence as to the deceased having received the alleged blow was conflicting and there was an admission by the deceased of a fall down the stairs which might readily have produced the fracture, so the coroner’s jury very wisely returned an open verdict.
ON Oct. 31st last I was called to attend a woman, aged 65 years. She had previously always enjoyed good health. I found her in a very weak state and on inquiry I ascertained that she had had symptoms of intestinal obstruction for four days ; the vomiting was very persistent and was quite fascal. On examination I found two femoral hernias, both of which were irreducible. The patient stated that she had had a swelling in the left groin for four months and that a similar swelling had come on suddenly on the previous day on the right side. After a consultation with Dr. immediate operation A. C. Godfray at 4 P.M. an was decided upon. Dr. Godfray kindly assisted me while Dr. T. J. Aubin administered chloroform. On the left side after opening the sac we found a gangrenous piece of omentum which I excised, and on opening the sac on the right side we found a portion of intestine very much congested and tightly strangulated which was easily reduced after dividing the neck of the sac, and the operation was concluded in the usual way. On the following morning the patient, although weak, appeared to be doing well and had 1
Transactions of the Pathological
Society
of London, vol. xix.,
p. 447.
though still with considerable weakness fontanelle was depressed. Nothing abnormal could ’be’ the left side. After that and until he went detected in the heart or lungs. The abdomen was flaccid. abroad he improved still further ; but at the Clinical and easily palpated and this seemed to cause the child no Society of London I expressed the belief that the case pain even when deep pressure was made. On inspection of was still by no means complete and the prognosis must the abdomen the peristaltic movements of the stomach could I felt that the possibility of be distinctly seen passing from left to right; these movements be regarded as doubtful. further epilepsy could not be overlooked. And during the followed one another in quick succession. On deep palpalast few days I have had letters from him saying that such tion in the right hypochondrium about a finger’s breadth attacks have appeared and have required further treatment, outside the nipple line a firm transverse mass, in shape like’ the nature of which he promises (in a letter received on the pylorus, could be felt; it was not always palpable when no Nov. 3rd, 1899) shall be communicated to me. He states peristalsis was taking place. The mass was less distinct that since the operation he feels perfectly well and hopes to than in another case of the same nature that was under my care and which ended fatally ; reference is again made to visit me soon in London. PS.-Since the above was written I have received a this case in the table. During the first 24 hours that the short letter from Dr. Chipault of Paris, of which child was in the hospital he was fed on equal parts of cow’s the subjoined is a translation : "II have operated on milk and barley-water, and during this time he vomited four I trephined and separated times. The temperature in the rectum was 97 2°. with a perfect result. Result: For some adhesions between the two hemispheres. Owing to the condition of the child he was on the follownine days before the operation there were from 60 to 100 ing day given three ounces of cow’s milk and barley-water, epileptic crises in the day with complete hemiplegia. All two parts of the former to one part of the latter, by a nasal this has disappeared except a spasmodic reaction of the tube every two and a half hours. During the next few days, I! lower extremity. In a later letter (Nov. 16th, 1899) the although the vomiting did not entirely cease, the child patient states that he still remains quite well. He thinks improved and passed a digested motion. The nasal feeding that he has more power in the left leg and arm than before. was continued and as the motions were digested ones no alteration was made in the character of the milk. The child He promises further reports from time to time. Harley-street, W. improved in appearance and the vomiting became less ; on some days vomiting occurred once or twice and on other’ days there was no vomiting. The temperature continued for the most part subnormal. On Dec. 9th a teaA CASE OF CONGENITAL HYPERTROPHY spoonful of cream was added to the nasal feedings and’ on the 17th some cod-liver oil was also given and OF THE PYLORUS IN AN INFANT; on this date the child weighed seven and three-quarter RECOVERY; SUBSEQUENT DEATH FROM BRONCHOpounds-a gain of eight ounces since admission. On the PNEUMONIA. 21st, the child not having vomited at all for two days, an endeavour was made to return to feeding by teat. The BY FREDERICK E. BATTEN, M.D CANTAB., child, however, took nearly half an hour to swallow three ASSISTANT PHYSICIAN TO THE HOSPITAL FOR SICK CHILDREN, GREAT ounces and vomited four times in the 24 hours. Nasal ORMOND-STREET. feeding was again resorted to and the vomiting again became less. The was now less distinctly felt than THE condition known under the above title is not of on admission and atpylorus times it could not be felt at all. Nasal frequent occurrence and nearly all reported cases have feeding was again abandoned on the 30th and although the terminated fatally. Finkelstein has however recorded child vomited occasionally the feeding by teat was persisted cases three of recovery in infants under nine weeks in and after Jan. 6th, 1899, the vomiting almost ceased. About this time Mr. T. H. Kellock kindly saw the child of age and Senator in a discussion on this subject with me with a view to the possibility of relieving the condimentioned one other such case. Recovery in such cases tion by operation, but owing to the feeble and wasted condireadily leads to some doubt as to the correct diagnosis tion of the child it was considered unadvisable that anything having been made, but in the following case in which the should be done. On Jan. 7th the motions contained some and undigested milk ; a dose of grey powder was diagnosis was made and in which recovery took place, death mucusand the motions again became natural. given from an acute attack of bronchooccurred subsequently The weight of the child remained stationary and as there pneumonia and gastro-enteritis, and at the necropsy a con- were no urgent symptoms the mother was on Jan. 12th again dition was found which would lead to the conclusion that given charge of the child and he was brought as an outthe original diagnosis was correct. patient. When discharged the vomiting had entirely ceased, A male infant, aged 11 weeks, was brought by his mother the motions were natural, the temperature was normal, and to the out-patient department of the Hospital for Sick the pylorus could no longer be felt ; the child only weighed Children, Great Ormond-street, in November, 1898, with seven and three-quarter pounds. The mother was instructed the history that when he was five weeks old he had begun to to continue the same diet. The child now began to improve vomit and about the same time the bowels became very and on Feb. 10th he weighed eight and a half pounds. costive and the child had wasted. The vomiting had con. During the next few months steady improvement took place tinued in spite of treatment. The child had been fed by the and except for slight attacks of vomiting and occasional unbreast till nine weeks old after which time he was ’given digested stools with mucus the child progressed well. Small Nestle’s milk. The child was a fine baby at birth. On loses of cod-liver oil in various forms were tried on several examination nothing abnormal could be felt in the abdomen, occasions, but with the result that they always gave rise but the peristaltic movements of the stomach were very dis- jO vomiting and after a few trials the attempt was abandoned. tinct. The temperature in the rectum was 96 2° F. On March 18th the child weighed llt pounds and on On Dec. 2nd the child was admitted to the hospital under my care and the following note was taken. The child had May 13th 16 pounds. The child was again seen in June and been quite well until five weeks old when he began to throw n July. He had then taken no drug for a period of three up his food and he had continued to vomit since. Food nonths and was plump and healthy ; he was therefore discame up about from five to ten minutes after feeding. charged with the request that he should again be brought to The bowels had been regular during the first five weeks of he hospital in three months. In August, however, the mother again brought the child to life, but since that time they had been very constipated, sometimes being confined for a week, and they had hardly he hospital with the history that three days previously he acted once spontaneously. The child had had no other ill- had been taken suddenly ill with diarrhoea and vomiting. ness ; he had been fed by the breast till he was nine weeks "he child looked ill and the eyes were sunken and nothing old, and was then tried on cow’s milk, but as this did not bnormal could be felt in the abdomen. The child was agree with him he was given Nest]6’s milk. He was the gain admitted to the hospital. During the first 24 hours youngest of five children, all the others being healthy. The e vomited three times; the motions were frequent mother had had no miscarriages and both the father and the nd loose, and the temperature rose to 104°. During the mother of the child were healthy. ollowing days the temperature remained between 102° and On admission the child was very thin and weighed seven 05° and the diarrhoea and vomiting continued. There were and a quarter pounds ; he did not look very ill and the few crepitations at the bases of the lungs. The child now, muscles of the limbs were fairly firm. The anterior owever, in spite of treatment, became more collaped and walk -< well, en
-
1512 hejdied on August 20th. At this time he was 11 months old and weighed 16 pounds two ounces. A necropsy was performed 20 hours after death. In both lungs there was a considerable amount of bronchopneumonia. The heart appeared to be normal. The stomach was contracted and its walls felt unusually thick and the pylorus was firm and hard. The stomach measured 12 centimetres from the pylorus to the extreme cardiac end. On opening up the duodenum the abrupt margin between the pylorus and the duodenum was very distinct. The lumen of the pylorus admitted a probe which measured four millimetres in diameter. On section the diameter of the pylorus
old the child had during the summer an acute attack of gastro-enteritis and broncho-pneumonia and died. At the necropsy an hypertrophied condition of the pylorus and stomach was found. Diagnosis.-The diagnosis was made on the following
points : (1) a healthy baby at birth ; (2) vomiting ; (3) constipation ; (4) subnormal temperature in the rectum ; (5) wasting; (6) marked dilatation and peristalsis of the a tumour in the position of the pylorus; and (8) the absence of the usual signs of gastritis. Pathology.-Various views have been held with regard to
stomach ; (7)
the pathology of the disease and it will here be necessary 1’5 centimetres and the total thickness of the wall was only to enumerate them, as they have been fully discussed in 5’5 millimetres. The muscular coat measured four milli- several able papers in which, also, a full bibliography of the metres and the mucous and submucous coat 1’5 millimetres. subject will be found. These views are (1) that the hyperThe circular muscular coat measured 0’3 millimetre and the trophy is the result of spasm from some irritant in the longitudinal coat 0’1 millimetre. The mucous membrane stomach ; (2) that the hypertrophy is a developmental overof the stomach appeared healthy; the wall measured four growth ; (3) that the hypertrophy is the result of a conmillimetres in thickness, and the muscular coat two milli- genital narrowing of the lumen of the pylorus followed by metres. The oesophagus appeared to be normal. No other compensatory hypertrophy of the stomach; and (4) that it anatomical defect was found. The above measurements is a functional disorder of the nerves of the stomach and were taken at the time of the post-mortem examination. pylorus leading to an ill coordination and therefore an After hardening in formalin the tissue was embedded in antagonistic action of their muscular arrangement. Remarks.-The special interest of the case lies in the fact celloidin, cut, and stained by Van Giesson’s method. On microscopical examination the mucous membrane and the that recovery took place and that the subsequent post-mortem muscular coat appeared to be perfectly normal so far as examination showed a condition which may be considered in their structure was concerned, but it was obvious that the accordance with the original diagnosis. That the symptoms circular coat was considerably thicker than normal. The began some five weeks after birth and that recovery took place following measurements were made by the micrometer. The would seem to negative the possibility of the condition being total diameter of the wall at a point two millimetres from due either to a developmental overgrowth or to a congenital the duodenal end of the pylorus was 42 millimetres, of which narrowing of the lumen of the pylorus. Further, the fact the circular coat measured 2’5 millimetres, the longitudinal that no alteration was made in the character of the food 0 4 millimetre, the submucous 0’5 millimetre, and the would seem to negative the possibility of the condition being If the measurements be compared due to food acting as an irritant to the stomach, although mucous 0’8 millimetre. with those of a normal child of the age of 12 months it will this may have been the exciting cause in the first place. The be seen that there is a considerable increase in the thickness fact that the child when fed with the nasal tube ceased to of the circular coat. vomit, digested ordinary milk, and passed normal motions The following table, taken from a paper read by Dr. G. F. would seem to make the suggestion of Dr. John Thomson the Still before the Pathological Society of London, gives the most probable explanation of the condition-viz., " that it is measurements of the normal pylorus at the ages of four and a functional disorder of the nerves of the stomach and pylorus 12 months and also of a marked case of the disease (Case 2), leading to an ill coordination and therefore an antagonistic and these are compared with the present case (Case 4). action in their muscular arrangement." Peristalsis started was
TABLE SHOWING
THE
COMPARATIVE THICKNESS OF LAYERS OF THE PYLORUS HARDENING REAGENTS.
Measurements taken at
a
point twomillimetres
on
BOTH
BEFORE
AND
AFTER
THE
USE
OF
the cardiac side of the duodenum.
of deglutition would seem to give rise to such the fifth child of healthy parents, born at full time and was well till the age of five weeks, active peristaltic movement in the stomach that regurgitation takes place; when the active peristalsis started by when without apparent cause he began to vomit. Till the of age of nine weeks the child was suckled, but as the vomiting deglutition is relieved by feeding with a nasal tube the persisted he was after that time fed at first with diluted cow’s stomach will tolerate and digest the food that is placed it. milk and subsequently with Nestle’s milk. The vomiting, Treatment.-The above case would seem to indicate that however, continued and was associated with constipation and wasting. When first seen at 11 weeks old the child feeding by the nasal tube may be of some use for weighed only seven and a quarter pounds, the abdomen was these patients. The child should be fed with from three flaccid, the tongue was clean, and the temperature was sub- to four ounces of diluted cow’s milk given every two normal. On examination of the abdomen the stomach was and a half or three hours. The nasal feeding should found to be distended and showed marked peristaltic action be continued for from 10 to 14 days, and an attempt and a firm hard mass could be felt in the region of the should then be made to suspend the feeding by the pylorus. The child was now fed with diluted cow’s milk tube and return to teat feeding; if this fails then the should again be resorted to and another given through a nasal tube, the vomiting gradually became tube less, and well-digested stools were passed. On the first trial of teat feeding made after a week. This process attempt to interrupt the nasal feeding vomiting recurred, but should be continued till the stomach will retain its contents when swallowed in the normal way. The slight departure on a subsequent occasion the attempt was successful, and from that time the child steadily improved. When 11 monthsfrom the normal in the character of the stools needs to be
Summary.-The patient,
was
by the action
food
within
feeding
1513 treated in the
ordinary way. Constipation as a symptom does not need to be treated, as it soon passes away when the child retains its food. Warmth is most essential for the child as evidenced by the subnormal temperature so constantly present. Although this class of case is uncommon it would seem not improbable that a certain proportion of them may recover under suitable treatment. Bibliography.-Cautley:Transactions
of the
Royal Medical
and
Chirurgical Society, vol. lxxxii., p. 41,1899. Rolleston and Hayne: Brit. Med. Jour., April, 1898. Finkelstein : Jahrbuch fiir Kinderheilkunde, Senator: Berliner Klinisehe Wochenschrift, 1897, Band 43, S. 105. S. 43. Still : Transactions of the Pathological Society of London, 1899. Thomson: Edinburgh Hospital Reports, vol. iv. ; Scottish Medical and Surgical Journal, June, 1897. Harley-street, W.
A CASE OF LATERAL TRANSPOSITION OF THE VISCERA. BY J. HARLEY BROOKS, M.D.ABERD., ASSISTANT MEDICAL OFFICER TO THE MILE END INFIRMARY WORKHOUSE AND SCHOOLS.
was admitted into Mile End Oct. and was found to be suffering from 24th Infirmary fractured ribs, and pleurisy and pneumonia followed, causing his death on Oct. 30th. It was alleged that while in a on Oct. received a violent blow in his 8th he public-house side and to this he attributed his illness. It became necessary to take his depositions and this was done in the presence of a man who had been arrested on a charge of causing him grievous bodily harm. At the post-mortem examination a bruise that might very well have been produced by a violent blow was found in the right loin embracing the two floating ribs, while the fractured ribs were the ninth and tenth. A blow received in the position located by the bruise resulting in the fracture of the injured ribs, I pointed out at the inqaest, must have been delivered in an upward direction and also have been so violent a blow as to push aside the floating ribs and crash
A MAN,
aged 67 years,
on
Interesting as the necropsy was from the medico-legal aspect it proved of still greater interest from an anatomical point of view, for I found that curious abnormality-trans-
position of the viscera. On opening the body I first noticed that the spleen was on the right side and I then found that the liver was occupying the left hypochondriac region.The caecum and vermiform appendix were not in the usual site but had been transposed to the left, and the colon followed a reverse course to the normal, the sigmoid flexure being in the right iliac region. As regards the kidneys there was nothing to identify the one from the other apart from their respective weights, the one on the left being the heavier, but the pathological changes were sufficient to account. for the variation in weight. The stomach, rather a small one, was transposed, the cardiac orifice being to the right and the pyloric to the left. The duodenum was very much dilated and at first sight it seemed almost as though it were a second stomach ; however, this proved not to be the case. The pancreas also took part in the general transposition. In fact, the abdominal viscera exhibited the appearance described by others who have recorded cases-as though the normal arrangement were viewed in a mirror. In the thorax this method of description apparently applied so far as the disposition of the heart and lungs was concerned, the left lung being the right one transposed, as evidenced by its three lobes, and the one on the right with only two lobes being the left lung on the wrong side of the body. The blood-vessels springing from the arch, however, were not merely transposed along with the aorta: they came off from the left to the right as innominate, right common carotid, right subclavian, and as a variation not unknown-the right vertebral artery sprang directly from the arch somewhat behind but a little to the right of the subclavian. The innominate divided into the left subclavian and the left carotid, the latter lying directly in front of the former. The left vertebral artery arose from the anterior aspfct of the left subclavian instead of from the posterior about half an inch above the bifurcation of the innominate, hidden from view by the overlapping carotid artery. The aorta and the oesophagus lay to the right of the vertebral column. The patient was right-handed. It is a curious coincidence that one of the cases of transposition of viscera recorded by Dr. Pye- Smithwas that of an old woman from Mile End Workhouse. Mile End Infirmarv, Bancroft-road, N.B.
Clinical Notes : MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. NOTE ON A FATAL CASE OF DOUBLE STRANGULATED FEMORAL HERNIA. BY WALTER FALLA, L.R.C.P. LOND., M.R.C.S.ENG., SURGEON TO THE JERSEY GENERAL HOSPITAL.
shows the transposed heart with the right’vertebral off directly from the aorta beyond the right subctavian artery A. The left vertebral artery E rises from the front of the left subclavian artery D. C marks the right common carotid artery and F marks the left. G marks the innominate artery.
The
figure
artery
B
given
through the ninth and tenth ribs. The evidence as to the deceased having received the alleged blow was conflicting and there was an admission by the deceased of a fall down the stairs which might readily have produced the fracture, so the coroner’s jury very wisely returned an open verdict.
ON Oct. 31st last I was called to attend a woman, aged 65 years. She had previously always enjoyed good health. I found her in a very weak state and on inquiry I ascertained that she had had symptoms of intestinal obstruction for four days ; the vomiting was very persistent and was quite fascal. On examination I found two femoral hernias, both of which were irreducible. The patient stated that she had had a swelling in the left groin for four months and that a similar swelling had come on suddenly on the previous day on the right side. After a consultation with Dr. immediate operation A. C. Godfray at 4 P.M. an was decided upon. Dr. Godfray kindly assisted me while Dr. T. J. Aubin administered chloroform. On the left side after opening the sac we found a gangrenous piece of omentum which I excised, and on opening the sac on the right side we found a portion of intestine very much congested and tightly strangulated which was easily reduced after dividing the neck of the sac, and the operation was concluded in the usual way. On the following morning the patient, although weak, appeared to be doing well and had 1
Transactions of the Pathological
Society
of London, vol. xix.,
p. 447.