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A CASE OF SPINAL MENINGITIS RESEMBLING TUMOUR OF SPINAL CORD ; LAMINECTOMY ; RECOVERY.
496
MR. RICHARD ROPER: A CASE OF SPINAL
MENINGITIS, ETC.
jejunum varying in size from a pea to an unshelled walnut: eighth rib and the weakness of the hands and arms was more these appeared primarily to have projected between the marked. Calmette’s tuberculin test was tried and was layers of the mesentery. As seen from the interior of the positive in 16 hours, which may have been accounted for by bowel all had well-defined circular mouths of smaller the signs of old tubercle at the right apex. On Sept. 1st he diameter than the protrusions themselves. A portion of the had double incontinence and began to complain of much more jejunum of this case has been presented to the Museum of pain in the back. the Royal College of Surgeons of England. In the case of On re-examination of the nervous system on Oct. 2nd the male the pouches extended into the base of attachment no other changes were found in the cranial nerves except that of the appendices epiploicas, and were situated in the iliac the pupils were very small. The loss of power in the legs and pelvic colon. As Mr. Bland-Sutton has demonstrated, was complete and they were kept flexed in a spastic conif there be any tendency to the formation of diverticula, the dition. The arms could just be raised from the bed, but the soft fatty tissue of the appendix epiploica continuous with patient was practically helpless. There were absolute anæsthe subserous fat forms a point of lowered resistance. thesia and analgesia up to two inches below the nipple, and The earliest reference to the subject under notice which sensation was impaired up to the level of the third rib. The we have been able to find is under the title of ;False lines of both forms of anassthesia were sharply defined. The Diverticula of Intestine" in the Transactions of the Patho- abdominal reflexes were absent, but all reflexes below this logical Society, by Dr. Bristowe in 1854. Dr. W. H. were much increased. Patellar and ankle clonus were Maxwell Telling, in his excellent article in THE LANCET,has present and the plantar reflexes were extensor. There were made an exhaustive contribution to the subject of the no trophic changes. He had double incontinence. secondary pathological processes which may occur in connexion i Since the signs of cord lesion had become evident with acquired diverticula of the sigmoid flexure. The object potassium iodide had been given in increasing doses, and for of the present communication is only to emphasise one of the some weeks he had had as much as 50 grains of potassium The fact that three out of the five iodide with drachm. doses of the solution of perchloride of more important of these. cases which have come under the observation of one or other mercury. All the symptoms gradually increased and the pain of the writers during the last three years have been cases of was severe enough to need repeated injections of morphia. perforative peritonitis suggests that this complication must No primary malignant focus was found although search was be more frequent than is perhaps usually held. Attention made. A diagnosis of spinal tumour, involving the fifth has been drawn by Mr. Bland-Sutton and other authors to dorsal segment, was made. The chief points in favour of this the fact that left-sided abdominal pain of sudden onset may were : (1) Early onset of pain, increasing in severity ; (2) arise in connexion with perforation of a sigmoid diverticulum, sharp definition of anaesthesia, both absolute and relative;. but perforation of a pouch in the ascending colon, as in and (3) absence of improvement with large doses of potassium Case 1, shows that this exceptional occurrence must be added iodide. to the category of pathological phenomena associated with On Oct. 6th I performed laminectomy. A mixture of chloroform (two parts) and ether (three parts) was adpain commencing on the right side of the abdomen. ministered at 9.30 A.M., and the laminæ of the first, second, third, and fourth dorsal vertebræ were removed. The thecal fat appeared normal and no tumour on the anterior or A CASE OF posterior aspect of the cord was found. The bones appeared SPINAL MENINGITIS RESEMBLING normal. The dura mater was incised for three inches and the TUMOUR OF SPINAL CORD ; LAMINonly apparent pathological condition was the presence of adhesions between the dura mater and the pia arachnoid. The ECTOMY ; RECOVERY. cerebro-spinal fluid was under fair pressure but did not spurt out, and it soon stopped flowing at the time of operation. A BY RICHARD ROPER, F.R.C.S. EDIN. director was passed in an upward and downward direction SENIOR ASSISTANT MEDICAL OFFICER TO ST. MARYLEBONE INFIRMARY under the dura mater for three inches, but no obstruction was found. Two fine catgut sutures brought the dura mater THE patient, a man aged 41 years, was admitted to St. together, and the muscles were sutured over this with stouter Marylebone Infirmary on July 2nd, 1909, with a history of catgut. Skin sutures were put in widely apart so as to allow pain in the arms since the winter of 1908-09. The pain had for anyleakage of cerebro-spinal fluid. become more severe during the six weeks before admission. At 9.15 P m. the same day the pupils were noticed to be On examination there were found signs of healed tubercu- larger. ’For some days after the operation the temperature losis at the apex of the right lung. The heart was not was raised. Pain had quite disappeared. Cerebro-spinal enlarged, but other changes in the cardio-vascular system fluid leaked for about three weeks, and at the end of this were thickened arteries, water-hammer pulse, and roughened time the wound was sound, although there was still a confirst sound in the aortic area. The pupils were equal and siderable collection of this fluid under the scar. On Oct. 27th reacted to light and accommodation ; the knee-jerks were the patient’s condition had much improved. Power in the brisk ; the right plantar reflex was absent and the left gave legs and arms began to return and he was able to flex and No other changes were noticed in the extend the legs freely. Sensation had returned on the right a flexor response. I found a well-marked scar on side to a point four inches above the umbilicus, and on the nervous system at that time. the glans penis. There was complete conleft at the level of the umbilicus. The patient was allowed to get up, and he had no further trol over the bladder sphincter but not over the anal sphincter. symptoms until July 21st, when he complained of much pain As the condition was thought to be syphilitic, and potassium in the back and was kept in bed. On August 4th a lesion iodide had had no effect, 100 grains of arsacetin were given of the spinal cord was evident. The cranial nerves were into the pectoral muscles in 10-grain doses dissolved in normal, and there were no-changes in the fundus oculi. Both 1 drachm of sterile water. These doses were given every arms and legs were distinctly weak, the weakness being more other day. marked in the legs. At the level of the eleventh dorsal The condition of the patient on Dec. 16th was as follows. segment there was a band of hyperæsthesia, and sensation The pupils were equal, of natural size, and reacted well to to wool was impaired from the knees downwards. The accommodation and light. He was able to wash and feed knee-jerks were brisk and ankle clonus was present. Both himself and his grip was fair in both hands. He was able to plantar reflexes were extensor. The elbow- and wrist- raise himself in bed by the use of his pulley. The legs were jerks were absent. He was inclined to have retention still spastic, although they could be abducted, flexed, and of urine and there was some difficulty in starting micturi- extended against some resistance. From the level of the tion. Except for some tenderness in the region of the ninth anterior superior spine upwards sensation to the lightest dorsal spine, no changes were apparent in the spinal column. touch with wool was perfect. Below this level sensation to On August 9th the weakness of the hands and arms had light touch was impaired in patches in both legs. Both increased rapidly and he was no longer able to hold spoon or wrist-jerks were present; the abdominal reflexes were fork. On the i8th he had anaesthesia and analgesia from absent ; the knee-jerks were still exaggerated ; ankle clonus two inches below the umbilicus downwards to the feet. By was present; both plantar reflexes were extensor. He had August 25th the anaesthesia had spread up to the level of the completely regained control over the bladder, and although he had not regained control over the anal sphincter, impulses 1 THE LANCET, March 21st denoting desire for defaecation now made themselves felt. (p. 843) and 28th (p. 928), 1908.
DR. A. E. MAYLARD : PERFORATIONS OF A PEPTIC JEJUNAL ULCER.
general nutrition had much improved and he was quite free from pain. I am indebted to Mr. J. R. Lunn, medical superintendent, for permission to publish this case.
gastro-jejunal line of union, and probably receive their pathological explanation from an initial lesion produced by the action of the acid gastric secretion with subsequent peptic digestion. The association of the ulcers with an anterior gastro-jejunostomy only goes to add another the
’ Note.-Since writing the above I have to report that the patient is now (February, 1910) able to walk without assistance, though with a somewhat spastic gait, and that he has full control over both sphincters. , St.
Marylebone Infirmary,
illustration to the many that have been recorded of this somewhat striking connexion. Reflecting upon the treatment adopted, I regret that neither the report of the operation nor my memory permits me to say why I did an anterior instead of a posterior gastro-jejunostomy. I do not think that altogether in about 200 cases of gastro-jejunostomy I have more than half a dozen times performed the anterior operation, and there has always been some special reason for selecting the less preferable method. The occurrence of a second ulcer independent of, and distant from, the first jejunal ulcer indicates that the same cause must have been at work as produced the first; and as this seemed likely to be the action of a hyperacid gastric juice greater precautions have been exercised in the way of prescribing alkalies to check excessive acidity and so prevent the attacks of "indigestion"which seem to have been the immediate precursors of the perforations.
W.
TWO CONSECUTIVE PERFORATIONS OF A PEPTIC JEJUNAL ULCER FOLLOWING GASTRO-JEJUNOSTOMY FOR A PERFORATED GASTRIC ULCER. BY A. ERNEST MAYLARD, M.B., B.S.
LOND.,
SURGEON TO THE VICTORIA INFIRMARY, GLASGOW.
IN a recent paper on Some Cases of Perforation of Stomach and Duodenal Ulcer1 Mr. J. Grant Andrew recorded an exceptional instance of a triple consecutive perforation of gastric ulceration. The case occurred in my wards, and it can be considered little else than a remarkable coincidence that I am able to record a second instance of a similar character, though differing in this unique respect, that of the three perforations the last two were connected with jejunal ulceration. The history of the case was as follows : A married woman, aged 51 years, was admitted to the Victoria Infirmary in February, 1907, suffering from a perforated gastric ulcer. At the operation a perforation was found on the anterior wall of the stomach near the pylorus. It was about half an inch long and a quarter of an inch wide with irregular edges, and seemed to be the centre of a large ulcer. The perforation was closed with Lembert sutures and a piece of omentum was also fixed over the lesion. An anterior gastro-jejunostomy was performed. The patient remained well until October of the same yearshe was i.e., about eight months after the operation-when seized with an attack of "indigestion."" This terminated in the course of three days in an acute crisis with symptoms of perforation. The abdomen was opened in the middle line. A little fluid escaped from the peritoneal cavity, and the parts presented the appearance of a fibrinous peritonitis. Numerous adhesions were encountered, and on separating these a perforation was found large enough to admit a No. 6 urethral catheter. It was situated on the anterior surface of the distal limb of the jejunum about 1½ inches from the
Glasgow.
A CASE
OF RUPTURE OF THE UTERUS TREATED BY SUTURE OF THE RENT PER VAGINAM AND DRAINAGE.1 BY HERBERT J.
suffered from "indigestion," and after an attack which lasted for a couple of days she was suddenly seized with acute abdominal pain and other symptoms suggestive of perforation. The abdomen was opened by a transverse incision midway between the umbilicus and xiphoid. The rectus muscle on each side was partially divided and the peritoneal cavity was opened. Numerous adhesions were found between the stomach, bowel, and anterior parietes. On turning up the omentum a small perforation was discovered in the efferent limb of the jejunum, about an inch or so below the site of the previous perforation. The perforation was about an eighth of an inch in diameter and close to the mesenteric attachment. It was easily closed by a purse-string suture, and for greater security a piece of omentum was stitched over it. From this (her third) operation she made a complete recovery, and left the institution about five weeks after with a medicine containing alkalies to be taken occasionally. The last two perforations in the above case may be considered as coming under the head of strictly ulcerative lesions of the jejunum; that is to say, they were not of that class where the ulceration primarily commences at the line of anastomosis, and is, in one sense therefore, traumatic in origin. Both ulcers occurred at a short distance from
I
I
THE LANCET, Oct.
30th, 1909, p. 1273.
PATERSON, M.B., B.C. CANTAB., F.R.C.S. ENG.,
ASSISTANT SURGEON TO THE LONDON TEMPERANCE
gastro-jejunal orifice. The perforation was closed by a pursestring suture, and over this an interrupted series of Lembert sutures. The parts were swabbed dry, and the parietal wound was completely closed. The patient remained well until November, 1909-i.e., for two years after the second operation-when she again
2
497
HOSPITAL, ETC.
THE patient, a married woman, aged 25 years, had had three children previously, the last 18 months ago. After the birth of this child she was laid up in the infirmary for 14 weeks, and some operation for womb trouble " (? curetting) There was nothing unusual in connexion was performed. with the two previous confinements. The history of her recent confinement was as follows. The Dr. Mulloy saw the waters broke on August llth, 1909. patient on the 13th. The cervix was slightly dilated, there were no labour pains, and the cord was prolapsed and pulseless, so nothing was done. Dr. Mulloy was called again at 10 P.M. The patient was then having on the night of the 14th. labour pains, but there was slight dilatation of the cervix, and the cord was prolapsed and pulseless. Under chloroform the cervix was slowly dilated until the knuckles of the open hand could be passed through the internal os. The right foot and hand presented with the pulseless cord between them. Delivery was effected without difficulty by traction on the foot, the back of the child being rotated towards the pubes, and flexion of the after-coming head secured by introducing a finger into the child’s mouth. No instruments were used. The placenta was expressed with ease. On introducing the hand into the vagina it passed into the abdominal cavity. Dr. Mulloy realising the gravity of the patient’s condition at once sent her up to the London Temperance
Hospital. The condition on admission (note by Dr. Russell Square) as follows. There was some bleeding from the vagina and the patient was very collapsed, sunken round the eyes, and extremely restless. The extremities and the face were cold and damp with perspiration ; the pulse was very small, soft, and uncountable. Some tenderness was present over the abdomen, increased by gentle pressure with the hand. There was some dulness in the flanks. When I saw the patient about 3 A.M. she was extremely collapsed, although somewhat better than on admission. The pulse was very feeble, the rate being about 140. The abdomen was somewhat distended and there was some dulness in the flanks. The vagina was full of blood-clot and a coil of intestine was felt protruding through a large rent in the vaginal vault. Ether being given by the open method, a loop of large intes tine (apparently sigmoid) was found to be prolapsed through an extensive rent in the posterior vaginal wall, through which the fist could be easily passed into the abdominal cavity. The left parametrium was involved in the tear, and there was free arterial haemorrhage from two large vessels ; these were was
1 A communication made to the Gynæcological and Obstetrical Section of the Royal Society of Medicine on Nov. 11th, 1909.
MR. RICHARD ROPER: A CASE OF SPINAL
MENINGITIS, ETC.
jejunum varying in size from a pea to an unshelled walnut: eighth rib and the weakness of the hands and arms was more these appeared primarily to have projected between the marked. Calmette’s tuberculin test was tried and was layers of the mesentery. As seen from the interior of the positive in 16 hours, which may have been accounted for by bowel all had well-defined circular mouths of smaller the signs of old tubercle at the right apex. On Sept. 1st he diameter than the protrusions themselves. A portion of the had double incontinence and began to complain of much more jejunum of this case has been presented to the Museum of pain in the back. the Royal College of Surgeons of England. In the case of On re-examination of the nervous system on Oct. 2nd the male the pouches extended into the base of attachment no other changes were found in the cranial nerves except that of the appendices epiploicas, and were situated in the iliac the pupils were very small. The loss of power in the legs and pelvic colon. As Mr. Bland-Sutton has demonstrated, was complete and they were kept flexed in a spastic conif there be any tendency to the formation of diverticula, the dition. The arms could just be raised from the bed, but the soft fatty tissue of the appendix epiploica continuous with patient was practically helpless. There were absolute anæsthe subserous fat forms a point of lowered resistance. thesia and analgesia up to two inches below the nipple, and The earliest reference to the subject under notice which sensation was impaired up to the level of the third rib. The we have been able to find is under the title of ;False lines of both forms of anassthesia were sharply defined. The Diverticula of Intestine" in the Transactions of the Patho- abdominal reflexes were absent, but all reflexes below this logical Society, by Dr. Bristowe in 1854. Dr. W. H. were much increased. Patellar and ankle clonus were Maxwell Telling, in his excellent article in THE LANCET,has present and the plantar reflexes were extensor. There were made an exhaustive contribution to the subject of the no trophic changes. He had double incontinence. secondary pathological processes which may occur in connexion i Since the signs of cord lesion had become evident with acquired diverticula of the sigmoid flexure. The object potassium iodide had been given in increasing doses, and for of the present communication is only to emphasise one of the some weeks he had had as much as 50 grains of potassium The fact that three out of the five iodide with drachm. doses of the solution of perchloride of more important of these. cases which have come under the observation of one or other mercury. All the symptoms gradually increased and the pain of the writers during the last three years have been cases of was severe enough to need repeated injections of morphia. perforative peritonitis suggests that this complication must No primary malignant focus was found although search was be more frequent than is perhaps usually held. Attention made. A diagnosis of spinal tumour, involving the fifth has been drawn by Mr. Bland-Sutton and other authors to dorsal segment, was made. The chief points in favour of this the fact that left-sided abdominal pain of sudden onset may were : (1) Early onset of pain, increasing in severity ; (2) arise in connexion with perforation of a sigmoid diverticulum, sharp definition of anaesthesia, both absolute and relative;. but perforation of a pouch in the ascending colon, as in and (3) absence of improvement with large doses of potassium Case 1, shows that this exceptional occurrence must be added iodide. to the category of pathological phenomena associated with On Oct. 6th I performed laminectomy. A mixture of chloroform (two parts) and ether (three parts) was adpain commencing on the right side of the abdomen. ministered at 9.30 A.M., and the laminæ of the first, second, third, and fourth dorsal vertebræ were removed. The thecal fat appeared normal and no tumour on the anterior or A CASE OF posterior aspect of the cord was found. The bones appeared SPINAL MENINGITIS RESEMBLING normal. The dura mater was incised for three inches and the TUMOUR OF SPINAL CORD ; LAMINonly apparent pathological condition was the presence of adhesions between the dura mater and the pia arachnoid. The ECTOMY ; RECOVERY. cerebro-spinal fluid was under fair pressure but did not spurt out, and it soon stopped flowing at the time of operation. A BY RICHARD ROPER, F.R.C.S. EDIN. director was passed in an upward and downward direction SENIOR ASSISTANT MEDICAL OFFICER TO ST. MARYLEBONE INFIRMARY under the dura mater for three inches, but no obstruction was found. Two fine catgut sutures brought the dura mater THE patient, a man aged 41 years, was admitted to St. together, and the muscles were sutured over this with stouter Marylebone Infirmary on July 2nd, 1909, with a history of catgut. Skin sutures were put in widely apart so as to allow pain in the arms since the winter of 1908-09. The pain had for anyleakage of cerebro-spinal fluid. become more severe during the six weeks before admission. At 9.15 P m. the same day the pupils were noticed to be On examination there were found signs of healed tubercu- larger. ’For some days after the operation the temperature losis at the apex of the right lung. The heart was not was raised. Pain had quite disappeared. Cerebro-spinal enlarged, but other changes in the cardio-vascular system fluid leaked for about three weeks, and at the end of this were thickened arteries, water-hammer pulse, and roughened time the wound was sound, although there was still a confirst sound in the aortic area. The pupils were equal and siderable collection of this fluid under the scar. On Oct. 27th reacted to light and accommodation ; the knee-jerks were the patient’s condition had much improved. Power in the brisk ; the right plantar reflex was absent and the left gave legs and arms began to return and he was able to flex and No other changes were noticed in the extend the legs freely. Sensation had returned on the right a flexor response. I found a well-marked scar on side to a point four inches above the umbilicus, and on the nervous system at that time. the glans penis. There was complete conleft at the level of the umbilicus. The patient was allowed to get up, and he had no further trol over the bladder sphincter but not over the anal sphincter. symptoms until July 21st, when he complained of much pain As the condition was thought to be syphilitic, and potassium in the back and was kept in bed. On August 4th a lesion iodide had had no effect, 100 grains of arsacetin were given of the spinal cord was evident. The cranial nerves were into the pectoral muscles in 10-grain doses dissolved in normal, and there were no-changes in the fundus oculi. Both 1 drachm of sterile water. These doses were given every arms and legs were distinctly weak, the weakness being more other day. marked in the legs. At the level of the eleventh dorsal The condition of the patient on Dec. 16th was as follows. segment there was a band of hyperæsthesia, and sensation The pupils were equal, of natural size, and reacted well to to wool was impaired from the knees downwards. The accommodation and light. He was able to wash and feed knee-jerks were brisk and ankle clonus was present. Both himself and his grip was fair in both hands. He was able to plantar reflexes were extensor. The elbow- and wrist- raise himself in bed by the use of his pulley. The legs were jerks were absent. He was inclined to have retention still spastic, although they could be abducted, flexed, and of urine and there was some difficulty in starting micturi- extended against some resistance. From the level of the tion. Except for some tenderness in the region of the ninth anterior superior spine upwards sensation to the lightest dorsal spine, no changes were apparent in the spinal column. touch with wool was perfect. Below this level sensation to On August 9th the weakness of the hands and arms had light touch was impaired in patches in both legs. Both increased rapidly and he was no longer able to hold spoon or wrist-jerks were present; the abdominal reflexes were fork. On the i8th he had anaesthesia and analgesia from absent ; the knee-jerks were still exaggerated ; ankle clonus two inches below the umbilicus downwards to the feet. By was present; both plantar reflexes were extensor. He had August 25th the anaesthesia had spread up to the level of the completely regained control over the bladder, and although he had not regained control over the anal sphincter, impulses 1 THE LANCET, March 21st denoting desire for defaecation now made themselves felt. (p. 843) and 28th (p. 928), 1908.
DR. A. E. MAYLARD : PERFORATIONS OF A PEPTIC JEJUNAL ULCER.
general nutrition had much improved and he was quite free from pain. I am indebted to Mr. J. R. Lunn, medical superintendent, for permission to publish this case.
gastro-jejunal line of union, and probably receive their pathological explanation from an initial lesion produced by the action of the acid gastric secretion with subsequent peptic digestion. The association of the ulcers with an anterior gastro-jejunostomy only goes to add another the
’ Note.-Since writing the above I have to report that the patient is now (February, 1910) able to walk without assistance, though with a somewhat spastic gait, and that he has full control over both sphincters. , St.
Marylebone Infirmary,
illustration to the many that have been recorded of this somewhat striking connexion. Reflecting upon the treatment adopted, I regret that neither the report of the operation nor my memory permits me to say why I did an anterior instead of a posterior gastro-jejunostomy. I do not think that altogether in about 200 cases of gastro-jejunostomy I have more than half a dozen times performed the anterior operation, and there has always been some special reason for selecting the less preferable method. The occurrence of a second ulcer independent of, and distant from, the first jejunal ulcer indicates that the same cause must have been at work as produced the first; and as this seemed likely to be the action of a hyperacid gastric juice greater precautions have been exercised in the way of prescribing alkalies to check excessive acidity and so prevent the attacks of "indigestion"which seem to have been the immediate precursors of the perforations.
W.
TWO CONSECUTIVE PERFORATIONS OF A PEPTIC JEJUNAL ULCER FOLLOWING GASTRO-JEJUNOSTOMY FOR A PERFORATED GASTRIC ULCER. BY A. ERNEST MAYLARD, M.B., B.S.
LOND.,
SURGEON TO THE VICTORIA INFIRMARY, GLASGOW.
IN a recent paper on Some Cases of Perforation of Stomach and Duodenal Ulcer1 Mr. J. Grant Andrew recorded an exceptional instance of a triple consecutive perforation of gastric ulceration. The case occurred in my wards, and it can be considered little else than a remarkable coincidence that I am able to record a second instance of a similar character, though differing in this unique respect, that of the three perforations the last two were connected with jejunal ulceration. The history of the case was as follows : A married woman, aged 51 years, was admitted to the Victoria Infirmary in February, 1907, suffering from a perforated gastric ulcer. At the operation a perforation was found on the anterior wall of the stomach near the pylorus. It was about half an inch long and a quarter of an inch wide with irregular edges, and seemed to be the centre of a large ulcer. The perforation was closed with Lembert sutures and a piece of omentum was also fixed over the lesion. An anterior gastro-jejunostomy was performed. The patient remained well until October of the same yearshe was i.e., about eight months after the operation-when seized with an attack of "indigestion."" This terminated in the course of three days in an acute crisis with symptoms of perforation. The abdomen was opened in the middle line. A little fluid escaped from the peritoneal cavity, and the parts presented the appearance of a fibrinous peritonitis. Numerous adhesions were encountered, and on separating these a perforation was found large enough to admit a No. 6 urethral catheter. It was situated on the anterior surface of the distal limb of the jejunum about 1½ inches from the
Glasgow.
A CASE
OF RUPTURE OF THE UTERUS TREATED BY SUTURE OF THE RENT PER VAGINAM AND DRAINAGE.1 BY HERBERT J.
suffered from "indigestion," and after an attack which lasted for a couple of days she was suddenly seized with acute abdominal pain and other symptoms suggestive of perforation. The abdomen was opened by a transverse incision midway between the umbilicus and xiphoid. The rectus muscle on each side was partially divided and the peritoneal cavity was opened. Numerous adhesions were found between the stomach, bowel, and anterior parietes. On turning up the omentum a small perforation was discovered in the efferent limb of the jejunum, about an inch or so below the site of the previous perforation. The perforation was about an eighth of an inch in diameter and close to the mesenteric attachment. It was easily closed by a purse-string suture, and for greater security a piece of omentum was stitched over it. From this (her third) operation she made a complete recovery, and left the institution about five weeks after with a medicine containing alkalies to be taken occasionally. The last two perforations in the above case may be considered as coming under the head of strictly ulcerative lesions of the jejunum; that is to say, they were not of that class where the ulceration primarily commences at the line of anastomosis, and is, in one sense therefore, traumatic in origin. Both ulcers occurred at a short distance from
I
I
THE LANCET, Oct.
30th, 1909, p. 1273.
PATERSON, M.B., B.C. CANTAB., F.R.C.S. ENG.,
ASSISTANT SURGEON TO THE LONDON TEMPERANCE
gastro-jejunal orifice. The perforation was closed by a pursestring suture, and over this an interrupted series of Lembert sutures. The parts were swabbed dry, and the parietal wound was completely closed. The patient remained well until November, 1909-i.e., for two years after the second operation-when she again
2
497
HOSPITAL, ETC.
THE patient, a married woman, aged 25 years, had had three children previously, the last 18 months ago. After the birth of this child she was laid up in the infirmary for 14 weeks, and some operation for womb trouble " (? curetting) There was nothing unusual in connexion was performed. with the two previous confinements. The history of her recent confinement was as follows. The Dr. Mulloy saw the waters broke on August llth, 1909. patient on the 13th. The cervix was slightly dilated, there were no labour pains, and the cord was prolapsed and pulseless, so nothing was done. Dr. Mulloy was called again at 10 P.M. The patient was then having on the night of the 14th. labour pains, but there was slight dilatation of the cervix, and the cord was prolapsed and pulseless. Under chloroform the cervix was slowly dilated until the knuckles of the open hand could be passed through the internal os. The right foot and hand presented with the pulseless cord between them. Delivery was effected without difficulty by traction on the foot, the back of the child being rotated towards the pubes, and flexion of the after-coming head secured by introducing a finger into the child’s mouth. No instruments were used. The placenta was expressed with ease. On introducing the hand into the vagina it passed into the abdominal cavity. Dr. Mulloy realising the gravity of the patient’s condition at once sent her up to the London Temperance
Hospital. The condition on admission (note by Dr. Russell Square) as follows. There was some bleeding from the vagina and the patient was very collapsed, sunken round the eyes, and extremely restless. The extremities and the face were cold and damp with perspiration ; the pulse was very small, soft, and uncountable. Some tenderness was present over the abdomen, increased by gentle pressure with the hand. There was some dulness in the flanks. When I saw the patient about 3 A.M. she was extremely collapsed, although somewhat better than on admission. The pulse was very feeble, the rate being about 140. The abdomen was somewhat distended and there was some dulness in the flanks. The vagina was full of blood-clot and a coil of intestine was felt protruding through a large rent in the vaginal vault. Ether being given by the open method, a loop of large intes tine (apparently sigmoid) was found to be prolapsed through an extensive rent in the posterior vaginal wall, through which the fist could be easily passed into the abdominal cavity. The left parametrium was involved in the tear, and there was free arterial haemorrhage from two large vessels ; these were was
1 A communication made to the Gynæcological and Obstetrical Section of the Royal Society of Medicine on Nov. 11th, 1909.