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HULL ROYAL INFIRMARY.
HOSPITAL MEDICINE AND SURGERY.
1033
influenc and during this week the bowels were obstinately consurgeons have long recognised the beneficial influencein of stomach washing in some cases where distension and Istipated. During the later part of the illness the gastric I was less obtrusive and diarrhoea and great prostravomiting occur after abdominal operations. There can bedilatation little doubt that this complication followed septic infection tion were prominent symptoms. Attention is particularly of the wound. During the operation it was noticed that drawn to this sequence of events because one theory the left side was being too vigorously retracted and pressed attributes acute dilatation of the stomach to traction of the superior mesenteric vessels over the transverse portion upon, and the result was shown in the localised suppuration. There are several points worthy of comment in the case of the duodenum and consequent obstructive compression recorded above. The gastric dilatation at the time when it of the bowel at this spot. This traction is attributed to a was recognised was already very extreme, for the stomach primary collapse of the coils of small bowel such as might area as mapped out by the coin" sound extended from the conceivably accompany or follow severe diarrhoea. In our region of the cardiac impulse to a line joining the highest case, then, the evidence seems to negative this method of points of the iliac crests and stretched laterally from the obstruction and we believe that the case belongs primarily left mid-axillary to the right mid-Poupart line. At the same to that class in which a dilatation results from wound infectime vomiting, although present, was quite insignificant in tion and is later rendered extreme by stomach pressure on The small amount of albumin present in amount. The semi-prone position was adopted in accord- the duodenum. 1 the urine after the operation may have been due to the inance with the theory already enunciated by one of us that the dilated stomach after a time obstructs the exit fective process which was evidently at work, but it is also of its own contents by exercising considerable pressure possible for the distended stomach to exercise pressure on terminal portions of the duodenum in front the left renal vein. There was no albumin in the urine on the of, and by the side of, the vertebral column. So soon before the operation. The oedema of the legs and lower as the proper position was adopted by our patient part of the trunk with dilatation of the superficial veins gurgling sounds were plainly audible in the pyloric points to thrombosis in the inferior vena cava. This possibly region of the abdomen. Gradually increasing distension of. originated in the pelvic or iliac veins and extended in the the abdomen was noticed for a week before the diarrhoea set upward direction.
from pain unless passive move12 hours later the right leg similarly lost power and on the next morning the left leg Three days before admission the could not be moved. patient could not move hand or foot, but there was no pain unless the limbs were moved. Sleep was not disturbed and there were no rigors. The bladder and rectum were intact. For two days he could not feed himself in the least. A certain amount of movement was possible in the right leg two days before admission and the upper extremities began to recover at the same time. On admission he was bedridden. The urine was amber-coloured and acid with a trace of albumin; it had a specific gravity of 1013. The lungs were normal. The heart was somewhat enlarged. The first sound at the apex (best heard in the fourth interspace in the middle line) was loud and sharp, with a
extremities
HULL ROYAL INFIRMARY.
ment
A CASE OF SPINAL RHEUMATISM.
(Under the care of Dr. FRANK NICHOLSON.) FOR the notes of the case we are indebted to Dr. Hunter, house physician. The patient, a male, aged 33 years, was admitted into the Hull Infirmary under the care of Dr. Nicholson on Oct. 5th, 1900, and died on the 26th. He had been strong and healthy till five days before admission, with the exception of an attack of influenza two years previously, from he had long entirely recovered. For 12 years he had acted as as out-porter for hotels and during that period had averaged
which
was
were
free
attempted.
A, One drachm of compound powder of jalap. B, 20 grains of sodium salicylate every two hours ; 30 grains of potassium bromide and 20 grains of chloral every six hours. c, 20 grains of sodium salicylate every six hours. D, Injection of th of a grain of stryehnia pro re nata. E, 30 grains of carbonate of bismuth pro re nata. F, 10 grains of quinine three times a day.
three pints of beer daily but rarely anything else. localised systolic bruit ; the second sound at the base was days before admission he was feeling quite well till the rather impure. The pulse was regular, being about 100, evening, when suddenly in the hotel, " discussing a pint of of small volume and good tension. The arteries were rather beer and a pipe," his left upper extremity "dropped" down degenerated. The abdomen was normal. The splenic area of close to his side and the forearm flexed at right angles to dulness was a little increased but the organ was not palpable.
two
or
Five
his arm-the forearm being previously flexed at an acute Liver dulness was normal. The pupils were equal and of angle to the arm. He tried to move the arm but could not, medium size and reacted to light and to accommodation. no nystagmus and extra ocular movements weie nor could he even move the fingers. There was no There pain, loss of consciousness, vertigo, or faintness. About free. There was no palsy of any cranial nerves. The 12 hours later the patient awoke from sleep to find visceral reflexes were normal. The knee-jerks were active Both upper on both sides and there was no clonus. The wrist and that his right arm was now quite useless. The plantar reflexes were were not elicited. 1 THE active. The cremasteric, abdominal, and thoracic reflexes LANCET, Nov. 9th, 1901, p. 1259.
was
elbow-jerks
1034
OBSTETRICAL SOCIETY OF LONDON.
sluggish. The soft palate reflex was present. Sensa- personal observation the appearances seen in a section taken tion everywhere and of all kinds was apparently normal. in the long diameter of an ordinary hydrosalpinx starting There was no wasting of muscles. All muscles of the at the uterine end. The diameter was greatest, the thickness extremities were more or less rigid, resisting movement in of the wall was least, and the tissues were most degenerate The epithelium first losing its cilia any direction, rigidity being overcome everywhere with a at the ostial end. little force. There was no difference in the two sides. became cubical, then flattened, and finally at quite an Absolute paralysis was not present as the patient was able to early stage disappeared altogether, except from the plicse perform all movements of extremities but extremely slowly and in the subplical spaces. The plicse were very perand painfully, grimacing the while, and complaining of sistent structures owing to their vascularity and stained cramping pains in the muscles. On admission the tempera- well even when the wall from which they sprang was ture was 102’ 40 F. and the respirations were 36. quite degenerate. After their disappearance the The occurrence of subplical spaces, perhaps lined by flattened The patient died three weeks after admission. temperature was raised throughout, as shown in the chart. epithelium, might still show that the wall of the hydroOn Oct. llth and 22nd there was no albumin in the salpinx, although consisting of little but hyaline fibrous Two days after admission the loss of power had tissue, was a degenerate Fallopian tube. The hydrosalpinx urine. sufficiently disappeared to allow him to make an attempt of an accessory tube described that night was No. 4582 in to reach the lavatory of the ward alone. On the 8th he was the Pathological Series of the Museum of the Royal College It was described as "aa thinat times queer, seeing visions and being afraid of imaginary of Surgeons of England. people, but at other times he was quite sensible. The walled pyriform cyst, developed under the broad ligament at left knee was distinctly swollen on the 8th and he the point where it is reflected over the Fallopian tube." The was then placed on salicylate of soda but without much cyst was attached to the upper border of the tube, like a effect. (See chart.) The sphincters were intact during the growing pear, by a very short twisted stalk. Its diameters first two weeks, but during the last week urine and were 2 2 centimetres by 1’4 centimetres. Its wall thinned fseces were passed involuntarily. The amount of loss of progressively from the attached to the distal end, conThe wasting was not currently with an increase of diameter. power varied from day to day. Internally it was great at first but towards the end of the illness emacia- marked by branching fibrous-looking bands standing out in tion became general. He could almost up to the time of relief. When the Fallopian tube was distended with air death move his extremities to nearly full range of move- the air escaped into the interior of the cyst. A microscopical ment, though he grimaced a great deal at the time. He section showed that the wall of the cyst was similar in also suffered much from darting pains in the extremities. structure to that of an ordinary hydrosalpinx. There was a Several of the joints became painful and swollen for a few well-marked muscular coat; plicae and subplical lacunas were days. The knee-jerks were absent during the last ten days seen. The tissues were degenerate towards the thin distal end. but the plantars remained exaggerated. The heart increased The cyst had, therefore, all the peculiarities of a hydrosalpinx. rapidly in area and the pulse became very quick (from 136 The history of the specimen was lost, but it was not devoid of to 148), the systolic bruit remaining localised. Patches of clinical interest. A pyomlpinx of an accessory tube might lead rates came and went in the lungs. During the last week to a fatal result. Pregnancy in an accessory tube had quite he was constantly delirious. Throughout there was much recently been recorded. It was therefore advisable to ligature and to remove an accessory tube, if one was found. The sweating. .2Vec?v.—The post-mortem examination revealed chronic presence of plicse and of subplical lacunae in a cyst of the endocarditis of the mitral valve with evidence of recent broad ligament had apparently not hitherto been described. Recent pericarditis with a little effusion The present communication was preliminary to one on the endocarditis. was present. There were a few patches of catarrhal origin of broad liagament cysts, since Mr. Handley could pneumonia in the lungs. The brain to the naked eye bring forward evidence that maly such cysts were derived appeared to be normal. The spinal cord was not examined. from "rests" of the Fallopian tube.-Mr. ALBAN DORAN Remarks by Dr. NzcHOLSON.-Rheumatie affections of the congratulated Mr. Handley on his judicious criticism of spinal cord are so uncommon that the few short notes of the current ideas concerning the origin of new growths in the above case may be of interest. The exact nature of the region of the broad ligament and Fallopian tube. Kossmann’s disease was not recognised till a week or two after the theory was of great importance ; perhaps he was not strictly when he implied that parovarian cysts and papillary patient’s death, when my attention was drawn to the chapters accurate on the rheumatic affections of the nervous system in Dr. cysts of the broad ligament all arose from tubal or Mullerian Archibald E. Garrod’s treatise on "Rheumatism"where five elements and not from relics of the mesonephron, but he was or six cases of spinal rheumatism are described which were very possibly correct in ascribing the abundant free to and the narrated above I am that similar one satisfied papillomata, which sometimes buried both broad ligaments, vary tubes, and ovaries, to tubal elements. If that view were the case was one of spinal rheumatism. correct it might account for the clinically innocent character of many cases of bulky free papillomata, notwithstanding formidable complications, which vanished when the growths were removed. The masses were hypertrophied tissue rather than neoplasms. Mr. Doran removed a very heavy pair of such outgrowths which nearly filled the abdomen nine years ago and the patient remained well. He asked OBSTETRICAL SOCIETY OF LONDON. Mr Handley if it were really justifiable to amputate a tube and mesosalpinx solely because accessory ostia and tubes detected. Mr. Doran admitted, however, that these Hydrosalpinx of an Accessory Fallopian Tube.-Ruptured were little growths were probably more than pathological -Extra-Uterine 6estatiorb- - Primary Infection of the so that it seemed prudent to close an accessory curiosities, Uterus Pneumoniv.-Ex7tibition Puerperal by Diploeoccus ostium by suture of the adjacent serous membrane of Speoi’flwns. and to amputate accessory tubes.-Dr. HERBERT R. A MEETING of this society was held on April lst, Dr. SPENCER did not think that it had been proved that the EDWARD MALINS, the President, being in the chair. specimen shown was an accessory tube. He thought it Mr. W. SAMPSON HANDLEY read a paper on a case of was more probably an "antrum tubas," a saccular dilataHydrosalpinx of an Accessory Fallopian Tube due to tion of the tube in the situation of the specimen shown" Twisting of the Pedicle. He considered it doubtful if the described by Roederer in ‘° Icones Uteri Humani Gravidi" existence of hydrosalpinx of an accessory tube had been and figured in Montgomery’s " Signs and Symptoms of proved. The specimen shown was conclusive in that it Pregnancy."" The "antrum"" was not mentioned in modern possessed a communication with the main tube and, like books. Roederer asked whether it was not produced by ordinary hydrosalpinx, was a retention cyst. Kossmann had pregnancy, but Montgomery showed that this was not the described under the name" hydroparasalpinx" certain small case by finding it in unimpregnated uteri. He (Dr. Spencer) cysts possessing a muscular wall, which he found in the had found it in pregnant cases but it was much more often broad ligament in association with tubal rudiments. These absent. The " antrum " contained plicas and, of course, was cysts had no communication with the main Fallopian tube. of the same histological structure as the tube, so that Mr. Kossmann did not bring forward any conclusive proof for Handley’s specimen could not be said to be a tube as a result his view that these cysts were distended rudimentary tubes. of the histological evidence. It was pure hypothesis that For purposes of comparison Mr. Handley described fromthe "accessory tube" had been closed by inflammation and were
Medical Societies.
I
1033
influenc and during this week the bowels were obstinately consurgeons have long recognised the beneficial influencein of stomach washing in some cases where distension and Istipated. During the later part of the illness the gastric I was less obtrusive and diarrhoea and great prostravomiting occur after abdominal operations. There can bedilatation little doubt that this complication followed septic infection tion were prominent symptoms. Attention is particularly of the wound. During the operation it was noticed that drawn to this sequence of events because one theory the left side was being too vigorously retracted and pressed attributes acute dilatation of the stomach to traction of the superior mesenteric vessels over the transverse portion upon, and the result was shown in the localised suppuration. There are several points worthy of comment in the case of the duodenum and consequent obstructive compression recorded above. The gastric dilatation at the time when it of the bowel at this spot. This traction is attributed to a was recognised was already very extreme, for the stomach primary collapse of the coils of small bowel such as might area as mapped out by the coin" sound extended from the conceivably accompany or follow severe diarrhoea. In our region of the cardiac impulse to a line joining the highest case, then, the evidence seems to negative this method of points of the iliac crests and stretched laterally from the obstruction and we believe that the case belongs primarily left mid-axillary to the right mid-Poupart line. At the same to that class in which a dilatation results from wound infectime vomiting, although present, was quite insignificant in tion and is later rendered extreme by stomach pressure on The small amount of albumin present in amount. The semi-prone position was adopted in accord- the duodenum. 1 the urine after the operation may have been due to the inance with the theory already enunciated by one of us that the dilated stomach after a time obstructs the exit fective process which was evidently at work, but it is also of its own contents by exercising considerable pressure possible for the distended stomach to exercise pressure on terminal portions of the duodenum in front the left renal vein. There was no albumin in the urine on the of, and by the side of, the vertebral column. So soon before the operation. The oedema of the legs and lower as the proper position was adopted by our patient part of the trunk with dilatation of the superficial veins gurgling sounds were plainly audible in the pyloric points to thrombosis in the inferior vena cava. This possibly region of the abdomen. Gradually increasing distension of. originated in the pelvic or iliac veins and extended in the the abdomen was noticed for a week before the diarrhoea set upward direction.
from pain unless passive move12 hours later the right leg similarly lost power and on the next morning the left leg Three days before admission the could not be moved. patient could not move hand or foot, but there was no pain unless the limbs were moved. Sleep was not disturbed and there were no rigors. The bladder and rectum were intact. For two days he could not feed himself in the least. A certain amount of movement was possible in the right leg two days before admission and the upper extremities began to recover at the same time. On admission he was bedridden. The urine was amber-coloured and acid with a trace of albumin; it had a specific gravity of 1013. The lungs were normal. The heart was somewhat enlarged. The first sound at the apex (best heard in the fourth interspace in the middle line) was loud and sharp, with a
extremities
HULL ROYAL INFIRMARY.
ment
A CASE OF SPINAL RHEUMATISM.
(Under the care of Dr. FRANK NICHOLSON.) FOR the notes of the case we are indebted to Dr. Hunter, house physician. The patient, a male, aged 33 years, was admitted into the Hull Infirmary under the care of Dr. Nicholson on Oct. 5th, 1900, and died on the 26th. He had been strong and healthy till five days before admission, with the exception of an attack of influenza two years previously, from he had long entirely recovered. For 12 years he had acted as as out-porter for hotels and during that period had averaged
which
was
were
free
attempted.
A, One drachm of compound powder of jalap. B, 20 grains of sodium salicylate every two hours ; 30 grains of potassium bromide and 20 grains of chloral every six hours. c, 20 grains of sodium salicylate every six hours. D, Injection of th of a grain of stryehnia pro re nata. E, 30 grains of carbonate of bismuth pro re nata. F, 10 grains of quinine three times a day.
three pints of beer daily but rarely anything else. localised systolic bruit ; the second sound at the base was days before admission he was feeling quite well till the rather impure. The pulse was regular, being about 100, evening, when suddenly in the hotel, " discussing a pint of of small volume and good tension. The arteries were rather beer and a pipe," his left upper extremity "dropped" down degenerated. The abdomen was normal. The splenic area of close to his side and the forearm flexed at right angles to dulness was a little increased but the organ was not palpable.
two
or
Five
his arm-the forearm being previously flexed at an acute Liver dulness was normal. The pupils were equal and of angle to the arm. He tried to move the arm but could not, medium size and reacted to light and to accommodation. no nystagmus and extra ocular movements weie nor could he even move the fingers. There was no There pain, loss of consciousness, vertigo, or faintness. About free. There was no palsy of any cranial nerves. The 12 hours later the patient awoke from sleep to find visceral reflexes were normal. The knee-jerks were active Both upper on both sides and there was no clonus. The wrist and that his right arm was now quite useless. The plantar reflexes were were not elicited. 1 THE active. The cremasteric, abdominal, and thoracic reflexes LANCET, Nov. 9th, 1901, p. 1259.
was
elbow-jerks
1034
OBSTETRICAL SOCIETY OF LONDON.
sluggish. The soft palate reflex was present. Sensa- personal observation the appearances seen in a section taken tion everywhere and of all kinds was apparently normal. in the long diameter of an ordinary hydrosalpinx starting There was no wasting of muscles. All muscles of the at the uterine end. The diameter was greatest, the thickness extremities were more or less rigid, resisting movement in of the wall was least, and the tissues were most degenerate The epithelium first losing its cilia any direction, rigidity being overcome everywhere with a at the ostial end. little force. There was no difference in the two sides. became cubical, then flattened, and finally at quite an Absolute paralysis was not present as the patient was able to early stage disappeared altogether, except from the plicse perform all movements of extremities but extremely slowly and in the subplical spaces. The plicse were very perand painfully, grimacing the while, and complaining of sistent structures owing to their vascularity and stained cramping pains in the muscles. On admission the tempera- well even when the wall from which they sprang was ture was 102’ 40 F. and the respirations were 36. quite degenerate. After their disappearance the The occurrence of subplical spaces, perhaps lined by flattened The patient died three weeks after admission. temperature was raised throughout, as shown in the chart. epithelium, might still show that the wall of the hydroOn Oct. llth and 22nd there was no albumin in the salpinx, although consisting of little but hyaline fibrous Two days after admission the loss of power had tissue, was a degenerate Fallopian tube. The hydrosalpinx urine. sufficiently disappeared to allow him to make an attempt of an accessory tube described that night was No. 4582 in to reach the lavatory of the ward alone. On the 8th he was the Pathological Series of the Museum of the Royal College It was described as "aa thinat times queer, seeing visions and being afraid of imaginary of Surgeons of England. people, but at other times he was quite sensible. The walled pyriform cyst, developed under the broad ligament at left knee was distinctly swollen on the 8th and he the point where it is reflected over the Fallopian tube." The was then placed on salicylate of soda but without much cyst was attached to the upper border of the tube, like a effect. (See chart.) The sphincters were intact during the growing pear, by a very short twisted stalk. Its diameters first two weeks, but during the last week urine and were 2 2 centimetres by 1’4 centimetres. Its wall thinned fseces were passed involuntarily. The amount of loss of progressively from the attached to the distal end, conThe wasting was not currently with an increase of diameter. power varied from day to day. Internally it was great at first but towards the end of the illness emacia- marked by branching fibrous-looking bands standing out in tion became general. He could almost up to the time of relief. When the Fallopian tube was distended with air death move his extremities to nearly full range of move- the air escaped into the interior of the cyst. A microscopical ment, though he grimaced a great deal at the time. He section showed that the wall of the cyst was similar in also suffered much from darting pains in the extremities. structure to that of an ordinary hydrosalpinx. There was a Several of the joints became painful and swollen for a few well-marked muscular coat; plicae and subplical lacunas were days. The knee-jerks were absent during the last ten days seen. The tissues were degenerate towards the thin distal end. but the plantars remained exaggerated. The heart increased The cyst had, therefore, all the peculiarities of a hydrosalpinx. rapidly in area and the pulse became very quick (from 136 The history of the specimen was lost, but it was not devoid of to 148), the systolic bruit remaining localised. Patches of clinical interest. A pyomlpinx of an accessory tube might lead rates came and went in the lungs. During the last week to a fatal result. Pregnancy in an accessory tube had quite he was constantly delirious. Throughout there was much recently been recorded. It was therefore advisable to ligature and to remove an accessory tube, if one was found. The sweating. .2Vec?v.—The post-mortem examination revealed chronic presence of plicse and of subplical lacunae in a cyst of the endocarditis of the mitral valve with evidence of recent broad ligament had apparently not hitherto been described. Recent pericarditis with a little effusion The present communication was preliminary to one on the endocarditis. was present. There were a few patches of catarrhal origin of broad liagament cysts, since Mr. Handley could pneumonia in the lungs. The brain to the naked eye bring forward evidence that maly such cysts were derived appeared to be normal. The spinal cord was not examined. from "rests" of the Fallopian tube.-Mr. ALBAN DORAN Remarks by Dr. NzcHOLSON.-Rheumatie affections of the congratulated Mr. Handley on his judicious criticism of spinal cord are so uncommon that the few short notes of the current ideas concerning the origin of new growths in the above case may be of interest. The exact nature of the region of the broad ligament and Fallopian tube. Kossmann’s disease was not recognised till a week or two after the theory was of great importance ; perhaps he was not strictly when he implied that parovarian cysts and papillary patient’s death, when my attention was drawn to the chapters accurate on the rheumatic affections of the nervous system in Dr. cysts of the broad ligament all arose from tubal or Mullerian Archibald E. Garrod’s treatise on "Rheumatism"where five elements and not from relics of the mesonephron, but he was or six cases of spinal rheumatism are described which were very possibly correct in ascribing the abundant free to and the narrated above I am that similar one satisfied papillomata, which sometimes buried both broad ligaments, vary tubes, and ovaries, to tubal elements. If that view were the case was one of spinal rheumatism. correct it might account for the clinically innocent character of many cases of bulky free papillomata, notwithstanding formidable complications, which vanished when the growths were removed. The masses were hypertrophied tissue rather than neoplasms. Mr. Doran removed a very heavy pair of such outgrowths which nearly filled the abdomen nine years ago and the patient remained well. He asked OBSTETRICAL SOCIETY OF LONDON. Mr Handley if it were really justifiable to amputate a tube and mesosalpinx solely because accessory ostia and tubes detected. Mr. Doran admitted, however, that these Hydrosalpinx of an Accessory Fallopian Tube.-Ruptured were little growths were probably more than pathological -Extra-Uterine 6estatiorb- - Primary Infection of the so that it seemed prudent to close an accessory curiosities, Uterus Pneumoniv.-Ex7tibition Puerperal by Diploeoccus ostium by suture of the adjacent serous membrane of Speoi’flwns. and to amputate accessory tubes.-Dr. HERBERT R. A MEETING of this society was held on April lst, Dr. SPENCER did not think that it had been proved that the EDWARD MALINS, the President, being in the chair. specimen shown was an accessory tube. He thought it Mr. W. SAMPSON HANDLEY read a paper on a case of was more probably an "antrum tubas," a saccular dilataHydrosalpinx of an Accessory Fallopian Tube due to tion of the tube in the situation of the specimen shown" Twisting of the Pedicle. He considered it doubtful if the described by Roederer in ‘° Icones Uteri Humani Gravidi" existence of hydrosalpinx of an accessory tube had been and figured in Montgomery’s " Signs and Symptoms of proved. The specimen shown was conclusive in that it Pregnancy."" The "antrum"" was not mentioned in modern possessed a communication with the main tube and, like books. Roederer asked whether it was not produced by ordinary hydrosalpinx, was a retention cyst. Kossmann had pregnancy, but Montgomery showed that this was not the described under the name" hydroparasalpinx" certain small case by finding it in unimpregnated uteri. He (Dr. Spencer) cysts possessing a muscular wall, which he found in the had found it in pregnant cases but it was much more often broad ligament in association with tubal rudiments. These absent. The " antrum " contained plicas and, of course, was cysts had no communication with the main Fallopian tube. of the same histological structure as the tube, so that Mr. Kossmann did not bring forward any conclusive proof for Handley’s specimen could not be said to be a tube as a result his view that these cysts were distended rudimentary tubes. of the histological evidence. It was pure hypothesis that For purposes of comparison Mr. Handley described fromthe "accessory tube" had been closed by inflammation and were
Medical Societies.
I