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CASE OF DILATATION OF THE STOMACH COMPLICATED BY FATAL TETANY.
765
CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY. was unable to grasp the worm, which seemed to be thinner than nne thread. I tried to catch it several times, but never succeeded in doing so. During the evening it was again over the sclerotic, but I was unable to pick it off, although it only seemed to be just under the topmost layer of the same. On the 15th it was moving about in the same place ; cocaine was again administered. During the night it moved about still, but the pricking sensation was giving much less annoyNo trouble was felt on the ance and there was less pain. 16th, and up to the 19th, when I last saw the patient, it had :given her no notice of its existence. I therefore concluded it had disappeared. Since this case I have had two other patients; I treated them with cocaine. After two or three days’ application they - did not return to see me-most probably they were both - cured. The natives inform me that for the treatment amongst themselves they place small pieces of raw onion all ;round the eye ; I have often noticed this in passing through different villages. This drives the worm away or keeps it to the sclerotic, where it is picked off by a needle. I have many times tried to get the natives to bring me a specimen, but .even rewards seem to have had no effect. I rather believe the filaria loa passes down the nasal duct and is either swallowed or spat out. Warri, West Africa. ________________
that there is the possibility of a causal connexion between the two. Assuming that the tetany is due to an autointoxication washing out the stomach should have had quite the opposite effect. Perhaps, as Miillersuggests, the tetany is the effect of a reflex process proceeding from the stomach, somewhat analogous to the familiar instance of convulsions and intestinal parasites. The existence of tetany in any case of dilatation of the stomach must be regarded as a sign of grave import, for the majority of the reported cases have terminated fatally.
so
East Dulwich.
Mirror
A
OF
HOSPITAL BRITISH
lib.
CASE OF DILATATION OF THE STOMACH COMPLICATED BY FATAL TETANY.
PRACTICE,
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum tum proprias collectas De ked. et Caus. hiorb., habere, et inter se comparare.—MoReA&Ni iv. Procemium. -
HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. TORSION OF OVARIAN PEDICLE IN HERNIAL SAC.
(Under the care of Mr. EDMUND OWEN.) THE ovary is favourably placed for making its escape by CASES illustrative of this serious complication of dilatation the inguinal canal for a long period during the process of its of the stomach have been published by various writers, but development. It is met with in a hernial sac associated the comparative rarity of the condition prompts me to report with intestine or omentum in many cases of inguinal hernia the following case. This complication was first described by in children; it is unaccompanied by other abdominal conKussmau.l,1 who attributes it, as in cholera, to a sudden tents in about an equal number of instances. The statistics decrease of water in the already dried-up patient which is taken from the records of the Truss Society, 1866-90, show of 174 bernise in which the ovary was implicated, and brought about by vomiting or washing out the stomach. aoftotal these 115 were in children under the age of twelve months. on the other it to an ascribes autoGerhardt, hand, intoxication arising from the absorption of the products of In 17 the hernia was double and in 89 in the right side only.l The unusual nature of this case is shown by Mr. Owen’s decomposition in the stagnating contents of the stomach. to the literature on the subject. The symptoms reference The patient was a married woman aged thirty-six years who had suffered from chronic gastric catarrh for many produced by such a twist of the pedicle as here described are the same as those caused by pressure and stranguyears. This resulted in atony of the gastric coats and dilata- evidently is lation at the neck of the sac, and the effect on the BY R. HILL
BROWN, M.B., C.M. EDIN.
tion of the stomach. There was no evidence of cancer or The typical symptoms of gastroulcer of the stomach. - ectasis were present and the general nutrition of the patient had suffered greatly. There was considerable emaciation and the skin was pale, dry, and earthy-looking. The lower border of the stomach extended to about midway between the umbilicus and the symphysis pubis. The gastric juice .contained about the normal amount of hydrochloric acid. The microscopic examination revealed the presence of About immense numbers of bacteria and sarcinae. twelve months anterior to the fatal termination the patient had an attack of tetany. With this first attack there was no impairment of consciousness. Four months subsequently she had another attack which was somewhat more severe, the spasmodic condition lasting for nearly At this time I commenced to wash out the two hours. stomach daily, and under this treatment the gastric condition improved greatly. Unfortunately, however, the attacks of ’tetany became more frequent and severe, recurring about every month. The spasm affected the arms chiefly. The thumb was bent into the palm of the hand. The fingers were adducted and flexed at the metacarpo-phalangeal and ’arst inter-phalangeal joints, the terminal joints being extended. The wrists and elbows were flexed and the arms folded over the chest. The knees were drawn up. The extremities were cold, intensely cyanotic, and bedewed with cold sweat. The pupils were widely dilated and did not j’ea.ct to light. During the later attacks the patient was semi-comatose, the breathing was laboured, and the pulse almost imperceptible. The temperature, taken in the axilla, wa3 subnormal. Chloroform inhalations had the effect of cutting short the spasm at once. During the last of these attacks the patient sank into a state of deep coma from which she never recovered. In this case the systematic washing out of the stomach "vas accompanied by the progressive advance of the tetany, 1 Deutsche Archiv für Klinische Medicin. Band vi. 2 Berliner Klinische Wochenschrift, 1887, p. 443.
ovary the same. It must be impossible to distinguish one from the other, but as operation is necessary in both this distinction is of the less importance. For the report of this interesting case we are indebted to Mr. G. R. Baldwin,
surgical registrar.
On Jan. 28th a female infant aged eleven weeks was sent to the hospital as an urgency by Dr. Nix of Weymouth-street, on account of a hard and tender swelling in the right labium majus. She had been perfectly well until the 26th-that is, until two days previously-when she had vomited twice or thrice after taking food. On the next day, the 27th, she was irritable and she vomited on several occasions, and on that day for the first time the mother discovered a painful swelling in the groin, which gradually increased in size and tenderness. The infant had not been constipated ; the vomit was said to be bile-stained. When admitted the infant was unusually quiet, but otherwise appeared in good health. The facial expression was peaceful. A tense swelling was present in the right labium majus and it continued up the inguinal canal as a firm cord-like prolongation. The tumour was rather tender. It was irreducible, dull to percussion, and devoid of impulse when the child cried. The abdomen was quite flaccid and moved freely with respiration. As the infant’s general condition was perfectly satisfactory it was thought that operation might well be deferred until the next morning, when Mr. Owen would pay his regular visit. During the night she vomited several times and there was a slight diarrhcea. On the morning of the 29th chloroform was administered and an incision The operation was exploramade over the swelling. tory at first, as the nature of the swelling could not be positively determined from digital examination. An incision down to the swelling set free about two drachms of blood-stained fluid which surrounded a very deeply congested and lobulated swelling in a hernial sac. This 3
1
Charité-Anna en, 1888. Band xiii.
Maeready: A Treatise
on
Ruptures.
CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY. was unable to grasp the worm, which seemed to be thinner than nne thread. I tried to catch it several times, but never succeeded in doing so. During the evening it was again over the sclerotic, but I was unable to pick it off, although it only seemed to be just under the topmost layer of the same. On the 15th it was moving about in the same place ; cocaine was again administered. During the night it moved about still, but the pricking sensation was giving much less annoyNo trouble was felt on the ance and there was less pain. 16th, and up to the 19th, when I last saw the patient, it had :given her no notice of its existence. I therefore concluded it had disappeared. Since this case I have had two other patients; I treated them with cocaine. After two or three days’ application they - did not return to see me-most probably they were both - cured. The natives inform me that for the treatment amongst themselves they place small pieces of raw onion all ;round the eye ; I have often noticed this in passing through different villages. This drives the worm away or keeps it to the sclerotic, where it is picked off by a needle. I have many times tried to get the natives to bring me a specimen, but .even rewards seem to have had no effect. I rather believe the filaria loa passes down the nasal duct and is either swallowed or spat out. Warri, West Africa. ________________
that there is the possibility of a causal connexion between the two. Assuming that the tetany is due to an autointoxication washing out the stomach should have had quite the opposite effect. Perhaps, as Miillersuggests, the tetany is the effect of a reflex process proceeding from the stomach, somewhat analogous to the familiar instance of convulsions and intestinal parasites. The existence of tetany in any case of dilatation of the stomach must be regarded as a sign of grave import, for the majority of the reported cases have terminated fatally.
so
East Dulwich.
Mirror
A
OF
HOSPITAL BRITISH
lib.
CASE OF DILATATION OF THE STOMACH COMPLICATED BY FATAL TETANY.
PRACTICE,
AND
FOREIGN.
Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morborum et dissectionum historias, turn aliorum tum proprias collectas De ked. et Caus. hiorb., habere, et inter se comparare.—MoReA&Ni iv. Procemium. -
HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. TORSION OF OVARIAN PEDICLE IN HERNIAL SAC.
(Under the care of Mr. EDMUND OWEN.) THE ovary is favourably placed for making its escape by CASES illustrative of this serious complication of dilatation the inguinal canal for a long period during the process of its of the stomach have been published by various writers, but development. It is met with in a hernial sac associated the comparative rarity of the condition prompts me to report with intestine or omentum in many cases of inguinal hernia the following case. This complication was first described by in children; it is unaccompanied by other abdominal conKussmau.l,1 who attributes it, as in cholera, to a sudden tents in about an equal number of instances. The statistics decrease of water in the already dried-up patient which is taken from the records of the Truss Society, 1866-90, show of 174 bernise in which the ovary was implicated, and brought about by vomiting or washing out the stomach. aoftotal these 115 were in children under the age of twelve months. on the other it to an ascribes autoGerhardt, hand, intoxication arising from the absorption of the products of In 17 the hernia was double and in 89 in the right side only.l The unusual nature of this case is shown by Mr. Owen’s decomposition in the stagnating contents of the stomach. to the literature on the subject. The symptoms reference The patient was a married woman aged thirty-six years who had suffered from chronic gastric catarrh for many produced by such a twist of the pedicle as here described are the same as those caused by pressure and stranguyears. This resulted in atony of the gastric coats and dilata- evidently is lation at the neck of the sac, and the effect on the BY R. HILL
BROWN, M.B., C.M. EDIN.
tion of the stomach. There was no evidence of cancer or The typical symptoms of gastroulcer of the stomach. - ectasis were present and the general nutrition of the patient had suffered greatly. There was considerable emaciation and the skin was pale, dry, and earthy-looking. The lower border of the stomach extended to about midway between the umbilicus and the symphysis pubis. The gastric juice .contained about the normal amount of hydrochloric acid. The microscopic examination revealed the presence of About immense numbers of bacteria and sarcinae. twelve months anterior to the fatal termination the patient had an attack of tetany. With this first attack there was no impairment of consciousness. Four months subsequently she had another attack which was somewhat more severe, the spasmodic condition lasting for nearly At this time I commenced to wash out the two hours. stomach daily, and under this treatment the gastric condition improved greatly. Unfortunately, however, the attacks of ’tetany became more frequent and severe, recurring about every month. The spasm affected the arms chiefly. The thumb was bent into the palm of the hand. The fingers were adducted and flexed at the metacarpo-phalangeal and ’arst inter-phalangeal joints, the terminal joints being extended. The wrists and elbows were flexed and the arms folded over the chest. The knees were drawn up. The extremities were cold, intensely cyanotic, and bedewed with cold sweat. The pupils were widely dilated and did not j’ea.ct to light. During the later attacks the patient was semi-comatose, the breathing was laboured, and the pulse almost imperceptible. The temperature, taken in the axilla, wa3 subnormal. Chloroform inhalations had the effect of cutting short the spasm at once. During the last of these attacks the patient sank into a state of deep coma from which she never recovered. In this case the systematic washing out of the stomach "vas accompanied by the progressive advance of the tetany, 1 Deutsche Archiv für Klinische Medicin. Band vi. 2 Berliner Klinische Wochenschrift, 1887, p. 443.
ovary the same. It must be impossible to distinguish one from the other, but as operation is necessary in both this distinction is of the less importance. For the report of this interesting case we are indebted to Mr. G. R. Baldwin,
surgical registrar.
On Jan. 28th a female infant aged eleven weeks was sent to the hospital as an urgency by Dr. Nix of Weymouth-street, on account of a hard and tender swelling in the right labium majus. She had been perfectly well until the 26th-that is, until two days previously-when she had vomited twice or thrice after taking food. On the next day, the 27th, she was irritable and she vomited on several occasions, and on that day for the first time the mother discovered a painful swelling in the groin, which gradually increased in size and tenderness. The infant had not been constipated ; the vomit was said to be bile-stained. When admitted the infant was unusually quiet, but otherwise appeared in good health. The facial expression was peaceful. A tense swelling was present in the right labium majus and it continued up the inguinal canal as a firm cord-like prolongation. The tumour was rather tender. It was irreducible, dull to percussion, and devoid of impulse when the child cried. The abdomen was quite flaccid and moved freely with respiration. As the infant’s general condition was perfectly satisfactory it was thought that operation might well be deferred until the next morning, when Mr. Owen would pay his regular visit. During the night she vomited several times and there was a slight diarrhcea. On the morning of the 29th chloroform was administered and an incision The operation was exploramade over the swelling. tory at first, as the nature of the swelling could not be positively determined from digital examination. An incision down to the swelling set free about two drachms of blood-stained fluid which surrounded a very deeply congested and lobulated swelling in a hernial sac. This 3
1
Charité-Anna en, 1888. Band xiii.
Maeready: A Treatise
on
Ruptures.