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HERNIA STRANGULATED IN THE INGUINAL CANAL; RADICAL CURE.
CLINICAL NOTES.
returned to duty for six m mths, but he was again admitted in August for malaria. Examination of his blood showed no evidence of this, but it was noticed that there was a relatively great increase of lymphocytes, as distinct from the polymorpho-nuclear leucocytes (neutrophiles). On a blood count being made there was seen to be a reduction of the red cells (2,800.000) without nucleated forms, but only a slight total increase of white cells (13,600). This, with the marked ansemia, tendency to epistaxis, and slight enlargement of the glands in the groin, led to the diagnosis of early lymphatic leukaemia. His temperature was remarkable, varying as much as 70 F. at times between night and morning, but without rigors and with scarcely any constitutional symptoms. The patient was treated with arsenic, iron, digitalis, &c., for ten weeks, and for a short time with mercury with chalk. Regular examinations of the
A CASE OF CHRONIC DILATATION OF THE STOMACH ENDING IN DEATH FROM GENERAL TETANIC CONVULSIONS. BY D. D’ESTERRE, M.D., B.S. DURH., M.R.C.S ENG., L.R.C.P. LOND. THE patient was a man, aged 30 years, who for three years past had suffered from symptoms of dyspepsia occasionally accompanied with vomiting. At one time he was a heavy drinker and a large eater, but he became very careful and abstemious in the matter of food and drink, which even in small quantities caused him pain and uneasiness. There His most was no palpable tumour within the abdomen. troublesome complaint was the vomiting of enormous quantities of coffee-coloured fluid about twice a week. His wife stated that the quantity was sometimes nearly He also suffered much from eructation of a gallon. gas. The physical signs of gastrectasia were present. He was instructed in the use of the stomach-tube, in which he became quite expert, and often expressed’ himself as feeling much better after its use. However, after a slight improvement he was suddenly attacked with extremely painful convulsions of a tetanic character affecting chiefly the flexor muscles of the arms and hands and in a lesser degree those of the abdomen, legs, head, and neck. Opisthotonos was at one time marked and he also showed the risus sardonicus. This attack was overcome with large doses of chloral hydrate, bromide of potassium, and tincture of opium, and subsequently he was given sulphate of soda and magnesium as well as enemata to counteract the constipation. He improved suffiiently to go about again and resume his work, but he succumbed to a similar seizure a few months later. Regarding the pathology of these convulsions, which are distinctly rare, it may be summed up as uncertain, but resting at present on three theories: (1) Kussmaul’s idea of the sudden decrease of water in the tissues of a subject i already very dry, as occurs in cases of cholera ; (2) Gerhardt’s ’, suggestion that the tetany is due to the absorption of products of decomposition ; and (3) Ewald’s suggestion that they are a manifestation of reflex action analogous to convulsions in children with worms. If the first theory be correct it would seem advisable to administer large rectal injections or employ transfusion, but similar attacks follow other diseases which cannot be traced to such a cause as dehydration of the tissues. If the second theory be correct tetany would not be expected to occur in cases where the stomachtube was regularly and thoroughly used as in the case above narrated. The third-mentioned theory of the reflex nature of tetany in these instances can hardly be disproved and gains strength from the well-known cases of increased nervous irritability, mechanical and electrical, which accompanies auto-intoxication.
Gipsy-hill, S.E.
1803
blood showed the same characters throughout with an extraordinary abundance of blood-plates, this being beautifully demonstrated by using Louis Jenner’s stain. As there was an old history of syphilis he was later put on iodide of potassium and bark, with the result that in three days the temperature fell to normal and never again rose. This question of treatment is interesting as agreeing with the experience of Dr. T. D. Savill that the iodides gave more favourable results than mercury, for though early in the course of the disease this patient was taking the latter as an anti-specific remedy the temperature did not fall to normal. Cabotstates that in certain stages of syphilis there area decrease in the number of red cells and an increase of lymphocytes as was found in this man, but he does not mention the increase in the blood-plates. The peculiar intermittent fever with such intense oscillations is noticed by Dr. Barney Yeo, and a similar case is reported by Dr. Sidney Pnillips,3 in which the pyrexia lasted for months, resembling tertian ague, but yielded at once to iodide of potassium. It is probable that many cases of indefinite fever so common in the services are of this character. Haslar. ____________
HERNIA STRANGULATED IN THE INGUINAL CANAL; RADICAL CURE. BY J. B. PIKE, M.R.C.S. ENG., L.R.C.P. EDIN. THE
patient, who was a foreman railway porter, aged 35 for about a year had noticed a lump in his right groin. years, On Oct. 16th, 1900, this became larger after exertion, and vomiting and pain very shortly supervened. The hernia was partially reduced the same evening, but some slight fulness was still left in the inguinal region. On seeing the patient the next morning I found vomiting still persisting and a distinct fulness remaining, although the external ring was quite free. On inserting the finger deeply through the ring a small tumour was felt, occupying the canal. The patient was
________________
at
once
removed
to
the
Loaghborough Hospital
and
herniotomy was performed as soon as possible. On opening the sac some very congested bowel was found, which was retained by a tight constriction at the neuk of the sac. The stricture having been divided and the intestine returned the sac was
THE PYREXIA OF SYPHILIS.
BY P. W. BASSETT-SMITH,
found to be much thickened and adherent to the spermatic cord, from which it was only separated with considerable diffiAT the meeting of the Clinical Society of London held on culty. rhis having been done the neck of the sac was transfixed Nov. 23rd1 Mr. Campbell Williams brought forward a case and ligatured with catgut and the sac cut off. A deep silk suture was then passed through the neck of the sac and the of fever which he called "intermittent essential fever" of edges of the wound, the remainder being brought together syphilis, in contra-distinction to the fever frequently found with silkworm gut. The after progress of the case was unin the early secondary period, and it was then pointed out ! eventful. There is now (six weeks after the operation) a that this condition was far from uncommon, though there is ’, very slight tendency to bulging in the inguinat region on very little reference to the peculiar characters in the usual coughing. As a precaution a light truss is being worn. text-books. In the article by Mr. Jonathan Hutchinson on Primary union was made more probable by the incision the disease, as found in Allbutt’s " System of Medicine," it is lying well above the scrotal tissue. not mentioned. The diagnosis of these cases is often Loughborough. obscure, as the fever is frequently unattended by any marked specific characters, the patient being quite free from rash, A CASE OF POISONING WITH A SMALL DOSE OF CHLORALOSE. gummata, or other usual manifestations, and the intermittency of the fever often leads to the diagnosis of malaria BY EDWARD H. DOUTY, M.D. CANTAB. or tubercle. In a case lately under treatment in the Royal Naval HosProfessor Bradbury’s remarks about chloralose in his pital, Haslar, the course of the disease was interesting. A Croonian Lectures for 1899 lead me to relate the following man, aged 25 years, had been invalided from the West Indies for fever of an irregular type; he was admitted into case. Haslar Hospital in January, 1900, and was under treatment I was called at about 12 midnight to a young woman who for post-inflaenzal pyrexia, being then very ansemic. He STAFF-SURGEON, R.N.
If
2 1
THE
LANCET, Dec. 1st, 1900, p. 1577.
Clinical Examination of the Blood, pp. 3 Osler’s Medicine, p. 240.
268,
271.
,
returned to duty for six m mths, but he was again admitted in August for malaria. Examination of his blood showed no evidence of this, but it was noticed that there was a relatively great increase of lymphocytes, as distinct from the polymorpho-nuclear leucocytes (neutrophiles). On a blood count being made there was seen to be a reduction of the red cells (2,800.000) without nucleated forms, but only a slight total increase of white cells (13,600). This, with the marked ansemia, tendency to epistaxis, and slight enlargement of the glands in the groin, led to the diagnosis of early lymphatic leukaemia. His temperature was remarkable, varying as much as 70 F. at times between night and morning, but without rigors and with scarcely any constitutional symptoms. The patient was treated with arsenic, iron, digitalis, &c., for ten weeks, and for a short time with mercury with chalk. Regular examinations of the
A CASE OF CHRONIC DILATATION OF THE STOMACH ENDING IN DEATH FROM GENERAL TETANIC CONVULSIONS. BY D. D’ESTERRE, M.D., B.S. DURH., M.R.C.S ENG., L.R.C.P. LOND. THE patient was a man, aged 30 years, who for three years past had suffered from symptoms of dyspepsia occasionally accompanied with vomiting. At one time he was a heavy drinker and a large eater, but he became very careful and abstemious in the matter of food and drink, which even in small quantities caused him pain and uneasiness. There His most was no palpable tumour within the abdomen. troublesome complaint was the vomiting of enormous quantities of coffee-coloured fluid about twice a week. His wife stated that the quantity was sometimes nearly He also suffered much from eructation of a gallon. gas. The physical signs of gastrectasia were present. He was instructed in the use of the stomach-tube, in which he became quite expert, and often expressed’ himself as feeling much better after its use. However, after a slight improvement he was suddenly attacked with extremely painful convulsions of a tetanic character affecting chiefly the flexor muscles of the arms and hands and in a lesser degree those of the abdomen, legs, head, and neck. Opisthotonos was at one time marked and he also showed the risus sardonicus. This attack was overcome with large doses of chloral hydrate, bromide of potassium, and tincture of opium, and subsequently he was given sulphate of soda and magnesium as well as enemata to counteract the constipation. He improved suffiiently to go about again and resume his work, but he succumbed to a similar seizure a few months later. Regarding the pathology of these convulsions, which are distinctly rare, it may be summed up as uncertain, but resting at present on three theories: (1) Kussmaul’s idea of the sudden decrease of water in the tissues of a subject i already very dry, as occurs in cases of cholera ; (2) Gerhardt’s ’, suggestion that the tetany is due to the absorption of products of decomposition ; and (3) Ewald’s suggestion that they are a manifestation of reflex action analogous to convulsions in children with worms. If the first theory be correct it would seem advisable to administer large rectal injections or employ transfusion, but similar attacks follow other diseases which cannot be traced to such a cause as dehydration of the tissues. If the second theory be correct tetany would not be expected to occur in cases where the stomachtube was regularly and thoroughly used as in the case above narrated. The third-mentioned theory of the reflex nature of tetany in these instances can hardly be disproved and gains strength from the well-known cases of increased nervous irritability, mechanical and electrical, which accompanies auto-intoxication.
Gipsy-hill, S.E.
1803
blood showed the same characters throughout with an extraordinary abundance of blood-plates, this being beautifully demonstrated by using Louis Jenner’s stain. As there was an old history of syphilis he was later put on iodide of potassium and bark, with the result that in three days the temperature fell to normal and never again rose. This question of treatment is interesting as agreeing with the experience of Dr. T. D. Savill that the iodides gave more favourable results than mercury, for though early in the course of the disease this patient was taking the latter as an anti-specific remedy the temperature did not fall to normal. Cabotstates that in certain stages of syphilis there area decrease in the number of red cells and an increase of lymphocytes as was found in this man, but he does not mention the increase in the blood-plates. The peculiar intermittent fever with such intense oscillations is noticed by Dr. Barney Yeo, and a similar case is reported by Dr. Sidney Pnillips,3 in which the pyrexia lasted for months, resembling tertian ague, but yielded at once to iodide of potassium. It is probable that many cases of indefinite fever so common in the services are of this character. Haslar. ____________
HERNIA STRANGULATED IN THE INGUINAL CANAL; RADICAL CURE. BY J. B. PIKE, M.R.C.S. ENG., L.R.C.P. EDIN. THE
patient, who was a foreman railway porter, aged 35 for about a year had noticed a lump in his right groin. years, On Oct. 16th, 1900, this became larger after exertion, and vomiting and pain very shortly supervened. The hernia was partially reduced the same evening, but some slight fulness was still left in the inguinal region. On seeing the patient the next morning I found vomiting still persisting and a distinct fulness remaining, although the external ring was quite free. On inserting the finger deeply through the ring a small tumour was felt, occupying the canal. The patient was
________________
at
once
removed
to
the
Loaghborough Hospital
and
herniotomy was performed as soon as possible. On opening the sac some very congested bowel was found, which was retained by a tight constriction at the neuk of the sac. The stricture having been divided and the intestine returned the sac was
THE PYREXIA OF SYPHILIS.
BY P. W. BASSETT-SMITH,
found to be much thickened and adherent to the spermatic cord, from which it was only separated with considerable diffiAT the meeting of the Clinical Society of London held on culty. rhis having been done the neck of the sac was transfixed Nov. 23rd1 Mr. Campbell Williams brought forward a case and ligatured with catgut and the sac cut off. A deep silk suture was then passed through the neck of the sac and the of fever which he called "intermittent essential fever" of edges of the wound, the remainder being brought together syphilis, in contra-distinction to the fever frequently found with silkworm gut. The after progress of the case was unin the early secondary period, and it was then pointed out ! eventful. There is now (six weeks after the operation) a that this condition was far from uncommon, though there is ’, very slight tendency to bulging in the inguinat region on very little reference to the peculiar characters in the usual coughing. As a precaution a light truss is being worn. text-books. In the article by Mr. Jonathan Hutchinson on Primary union was made more probable by the incision the disease, as found in Allbutt’s " System of Medicine," it is lying well above the scrotal tissue. not mentioned. The diagnosis of these cases is often Loughborough. obscure, as the fever is frequently unattended by any marked specific characters, the patient being quite free from rash, A CASE OF POISONING WITH A SMALL DOSE OF CHLORALOSE. gummata, or other usual manifestations, and the intermittency of the fever often leads to the diagnosis of malaria BY EDWARD H. DOUTY, M.D. CANTAB. or tubercle. In a case lately under treatment in the Royal Naval HosProfessor Bradbury’s remarks about chloralose in his pital, Haslar, the course of the disease was interesting. A Croonian Lectures for 1899 lead me to relate the following man, aged 25 years, had been invalided from the West Indies for fever of an irregular type; he was admitted into case. Haslar Hospital in January, 1900, and was under treatment I was called at about 12 midnight to a young woman who for post-inflaenzal pyrexia, being then very ansemic. He STAFF-SURGEON, R.N.
If
2 1
THE
LANCET, Dec. 1st, 1900, p. 1577.
Clinical Examination of the Blood, pp. 3 Osler’s Medicine, p. 240.
268,
271.
,