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PERFORATION OF UTERUS BY SOUND OR CURETTE.
MR. LAWSON TAIT: PERFORATION OF UTERUS BY SOUND OR
326
CURETTE.I
the objects of notification would be: 1. The sanitary authority would diagnosis would soon enable a good veterinary surgeon to disinfect the room occupied by the tuberculous patient, as might be have an almost instinctive knowledge of what he was required. 2. Inasmuch as the transmission of tuberculosis is in a unless in obscure cases. It is so in with, determined of cases the of convery dealing by presence insanitary proportion large ditions, such as damp, overcrowding, deficiency of light, and so forth, human diseases. The veterinary surgeon would also deai an opportunity would be afforded to the authority of removing such with the sanitary requirements of the cowsheds. Ordinary conditions and so saving other members of the household. 3. Further would be attended to. evidence would be collected bearing on the modes and conditions of insanitary conditions about farms I throw out these details merely by transmission of the disease. 4. The personal hygiene of the patient by the inspector. would in no way come under the care of the sanitary authority; it was way of showing that the veterinary inspector would have hoped, however, that the medical attendant would confer with the Having made his investigations, the medical officer of health, when convenient, as to the precise means by enough to do. which tuberculous discharges might be most usefully destroyed. At veterinary inspector would report to the medical officer off the same time the sanitary department would in no way interfere with health of the district, so that he might be able to cooperate the treatment of the patient, and all instructions in dealing with dis- with the veterinary inspector in getting the necessary from the would come from medical attendant. 5. the charges patient measures carried out." such cases would be as from preventive were Only reported taking place the lungs, cases with tuberculous diarrhcea, and cases with I have already mentioned how in all probability tuber. copious discharge from tuberculous bones and tuberculous ulcers. culosis is directly communicated in cowsheds from tuber. These and other matters having been fully discussed, the followfrom tuberculosis, the ing resolution was carried unanimously: ’That the society, having culous cows. But, apart altogether had its attention drawn to the infection of tuberculous diseases condition of our cowsheds and their relation to the public and to the great mortality and injury to the population arising there- health through the milk supply demand investigation an from, is of opinion that these diseases should be the subject of volunIt would be of great advantage if the rearrangement. tary notification to the sanitary authority.’ It was understood that a copy of the resolution would be sent to the sanitary committee of regulations applicable to cowsheds were made uniform, so Oldham as well as to the medical journals." that any local action taken to improve their condition should
Providing the fee of 2s. 6d. can be paid for each case reported, I do not object to voluntary notification being first tried, as it will give time practically to ascertain and deal with the seems
same time it difficulties of administration. that, the connexion between insanitary
At the
not have the effect of
district
perhaps
as
transferring the milk-supply to another badly off in the matter of cowsheds as
that in which the action
was
taken.
Oldham. ________________
to me quite clear
conditions and the communication of phthisis being so close it is, this alone would be a sufficient argument for compulsory notification, putting aside the other powerful reasons for it. Nor do I doubt that voluntary notification would speedily result in compulsory notification. 3. My third proposition was that Isolation Hospitals should be provided by sanitary authorities, jointly or separately, at the expense of the rates, for the isolation of As it is, cases of tuberculosis likely to cause infection. workhouse hospitals do at present provide a considerable amount of isolation for the very poor. But there are a vast number of artizan families which would decline to avail themselves of that refuge, and where the patient is a danger and a burden. I feel quite sure from the conversations I have had in the course of my inquiries that the provision of good hospital isolation would be hailed as a blessing by these poor struggling people, and it would be the means of removing infection from the home. Not only so, but those treated in the hospital for a time would be thoroughly indoctrinated with the measures of precaution taken, which would become part of their daily habit. They would therefore, on their return, be centres for the diffusion of knowledge on the subject. It is in the later stages of the disease that infection is most likely to occur and that the disease is most burdensome. This is precisely the stage which is not dealt with in convalescent homes, and which should be dealt with in the interests of public health. This proposal is, however, not necessary to the success of the first as
PERFORATION OF UTERUS OR CURETTE. BY
LAWSON
BY SOUND
TAIT, F.R.C.S.ENG.,
CONSULTING SURGEON TO THE HOSPITALS FOR "WOMEN AT BIRMINGHAM. NOTTINGHAM, AND SOUTHAMPTON.
THE article
by my friend, Dr. Auvard, in the Archives Tocologie et de Gynecologie, noted in THE LANCET off Sept. 22nd, 1894, has been lying for months on my desk waiting the leisure the holiday season has given me that I might draw further attention to an interesting occurrence, long ago familiar, but apparently forgotten. When Simpson made the uterine sound practicable, he de
put it in the hands of every one, and its routine use did Now it is relegated to its proper a great deal of mischief.
and used only in a very limited area of special We do not, therefore, see now the cases of perforation of the uterus by the sound which were so familiar In the columns of to Simpson’s pupils and followers. THE LANCET1 I recorded my own first experience of it, stating at the same time the fact that it was well known to Simpson, whom I had often seen demonstrate it. Next month2Mr. Walter Whitehead recorded a case as having happened to Foltz and Petrequin, and narrated by the former before the Lyons Medical Society, where a female two. 4. Tuberculosis in cattle should be brought under the catheter, used for the purpose of inducing premature labour, through the Contagious Diseases (Animals) Acts, and special veterinary passed through the fundus and was extracted any bad symptoms. inspectors should be appointed by sanitary authorities, umbilicus eighteen weeks after without in singly or jointly, to carry out the objects of the Acts Mr. Whitehead also mentions a fatal case the experience of in relation to tuberculosis and other diseases, and to attend a friend. It would be a valuable contribution to the literature to the general sanitary arrangements of the cowsheds. of the subject to have an account of this case, as it is the I may be allowed to quote the continuation: ’’ The officeronly disaster of the kind I have ever heard of amongst a to be appointed should be a young veterinary surgeon,number of perforations which I have seen and heard of, ,10 He shouldgreat that I should be afraid even to attempt to guess at the well versed in the diagnosis of disease. sufficient and receive a salary travelling expenses. Histotal. It must be strictly borne in mind that all the cases duties should be something like the following. Once aof which I speak occurred in the non-pregnant uterus. Dupuy collected seventeen cases,3 in none of which did month he should inspect the farm-buildings and note any subsequent evil effects arise. Commenting on thi. to on these or on the farms found conditions likely any Dr. W. S. Playfair said that it was probable that l paper on health of the cattle or act injuriously on the He should examine the cattlein many of these cases the sound passed through the the quality of the milk Fallopian tubes. This point used to. be one of periodicand ascertain whether they were suffering from If he saw reason to suspect tuberculosis he(discussion between the late Dr. Matthews Duncan am9 disease. r and I can accept the view shared by him and Dr. should take measures to have the suspected animal isolatedmyself, and see that necessary measures of disinfection were1Playfair still less now than in the time of those discussions carried out. The sale of milk from this animal would 1It is fashionable now to talk of passing sounds and catheters be stopped. If his diagnosis was clear and unhesitating thetthrough the Fallopian tubes (and ureters). I have tried on cow should be killed. thetthe cadaver, but (though fairly nimble with my fingers) I Compensation should be amount paid to have regard to the condition of the animal.have never succeeded, and I have never seen anyone else In advanced tuberculosis it would be trifling-in an early ssucceed, though I am far from saying that such passage is stage of the disease such as would not entail any loss to aall impossibility. Again, I have seen as many pathological the farmer. It would thus be to the farmer’s interest to 1 THE LANCET, April 29th, 1871. Lave such cases reported as soon as possible. Notification 2 THE LANCET, May 13th, 1871. would be compulsory on the farmer. Constant practice in 3 Progrès Médical, 1877.
any
given,
position, practice.
DR. T. C. RAILTON : CASE OF FŒTAL ENDOCARDI’I’IS. I suppose any other living person, but I never tube in which abnormal patency was a feature. I certainly never saw a normal Fallopian tube-I mean one not distinctly pathological-through which an ordinary uterine sound could be passed. But I have seen several uteri through which sounds could easily have been passed by reason of the thinning of the wall at the outward curve of a chronic flexion, or by the atrophy of the wall I at the insertion of a small nodule of myoma. have also seen two uteri through which the sound or curette actually had been passed, one at the time of an ovariotomy,4 and the other recently in a uterus I removed by vaginal hysterectomy. I have also recorded three cases of what appeared to be cases of permanent metro-peritoneal fistula. One of these cases possesses the fistula still, as I know the patient is alive, and I passed a sound at the old spot about three years ago. In making these observations we never sterilised the sounds, and now it amazes me, if
tubes
as
saw a
is caused by micro-organisms, why we never produced it. The last case of instrumental perforation of the uterus with which I have met is one of great interest, for the patient had had her appendages removed for myoma some five years before by Mr. Knowsley Thornton with a brilliantly successful result-that is, all the symptoms and troubles due to the myoma disappeared, and she went through a brief and satisfactory climacteric. When I examined her The patient had I could find no trace of myoma. an idea at the time of this operation that the uterus itself ought to have been removed, but of this I was finally able to dispossess her, for it seemed to be an ideal case for removal of the appendages, and the result all that could be wished. I mention this circumstance because she was placed under my care by a well-known Midland practitioner, whose name I do not give because with it the The name of the patient might just as well be published. reason of her coming to me was that for about eight months she had been troubled by an increasing purulent and very acrid discharge pouring out of the uterus. This discharge was extremely offensive, accompanied by pain and interrupted occasionally by haemorrhages. It made her extremely miserable, and brought back to her mind somewhat bitterly her original desire to have the uterus removed and Mr. Thornton’s refusal to comply with it. The remedy I suggested was, of course, the curette, though not without fear that the disease might be endometric ulcerative epithelioma (a very rare condition), and in consequence this might prove insufficient. Just as I had nearly completed the operation the curette went through the anterior wall of the uterus and I could feel its point easily through the abdominal wall. As usual, the accident did no harm; the patient recovered easily and for nine months remained quite well. She came back, however, later with all her symptoms renewed, indeed intensified, and begged me to remove the uterus. I was not much in favour of this proceeding, as I was by this time quite certain that the correct diagnosis was that of epithelioma, and I am not at all favourable to operations for cancer of any kind-I am quite sure that vaginal hysterectomy for real cancer of the uterus will soon go out of fashion. I removed the uterus in this case, however, under the belief that if such a thing were justifiable at all in cancer it was in the rare endometric ulcerative epithelioma which is very like the epithelioma of the lip. The operation was very difficult, on account of old adhesions, but it was through in about twenty minutes, and then I found a few nodules of myoma at the fundus of a perfectly senile uterus. They were not larger than marbles, and must have been the mere survivals of Mr. Thornton’s tumour, as they were wholly unrecognisable before the excision of the uterus. On slitting up the organ I found no trace of epithelioma, but a merely rough and hypertrophied endometrium, quite tough and very vascular. At the base of one of the nodules on the anterior wall, where it was of almost paper thickness, was an unclosed rent, about half an inch across, which had been made by my curette, and the edges of which, but not its lower end, had healed. Here at last was the absolute proof of a permanent metro-peritoneal fistula, through which I have no doubt much of the discharge must have made its way, after its re-establishment, but there was no disturbance from the microbes.
peritonitis
Birmingham.
CASE OF FŒTAL ENDOCARDITIS ASSOCIATED WITH AN ARREST OF DEVELOPMENT OF THE INTER-VENTRICULAR SEPTUM.1 BY T. C. RAILTON, M.D.LOND., PHYSICIAN TO THE MANCHESTER CLINICAL HOSPITAL.
aged four years was admitted into the Manchester Hospital on Jan. 24th, 1895, suffering from bronchopneumonia. His previous history was to the effect that he had always been a delicate child, did not walk until he was eighteen months old, and subsequently was unable to play about like other children, being easily exhausted and out of breath. He had frequently complained of pain in the region A
Diseases of the Ovary, 4th edition, p. 201. 1883. Cornish Bros. 5 THE LANCET, May 18th and Oct. 19th, 1872.
CHILD
Clinical
of the heart, but had not suffered from articular rheumatism Three weeks or shown any blueness in the lips or fingers. before his admission lie canght cold and had gradually got worse, and when admitted lie had well-marked symptoms of broncho-pneumonia, his respiration being 60, pulse 140, and temperature 101° F. The deep cardiac dulness extended upwards as high as the second rib, on the right hide nearly to the nipple line, and the apex beat was in the sixth interspace outside the left nipple line. There was no murmur audible. The patient became steadily worse, the temperature continued to rise, at one time reaching as high as 106’2°, and he died twenty-seven days after admission. Four days previous to his death a systolic murmur was audible over the right ventricle for the first time. At the post-mortem examination both lower lobes were found consolidated, sinking in water, while islets of bronchopneumonia were scattered over the rest of the lungs. The pericardinm contained about two drachms of clear fluid. The heart was very large, mainly upon the right side. The thickness of the wall of the right ventricle was eight millimetres, of the auricle one millimetre. The corresponding measurements of the left side were nine millimetres and one millirnetre respectively. The tricuspid valve was the seat of large verrucose vegetations covered with a deposit of fibrin. Close to the tricuspid orifice were a few other vegetations on the auricular edge and one recent irregular ulcer. The remaining orifices and valves were normal, and the ductus arteriosus and foramen ovale were closed. There was a deficiency of the septum of the ventricles about the undefended space large enough to admit a quill. This opening was larger at the side of the left ventricle than on the right side, where it ended between the insertion of two cusps of the tricuspid valve nearer to the right auricle than to the ventricle. The edges of this orifice were quite smooth. It was evident that the lesion of the tricuspid valve had started during foetal life, and it seemed almost equally clear that the endocarditis had also continued its evolution subsequently to birth. A similar case has been reported by Dr. F. Robinson.2 A child eighteen months old had suffered from palpitation and dyspnoea since birth. He was not cyanosed. There was a loud sawing murmur accompanying the heart’s action. At the necropsy the right ventricle was found to be large enough to contain a hen’s egg, and the tricuspid valve was thickened at its free border to such an extent as to prevent its perfect closure. There was also a circular orifice almost as large as the little finger in the septum of the ventricles communicating between the two cavities. The foramen ovale was closed and there were no remains of the ductus arteriosus. Although the valvular disease of my own case was due to endocarditis, the opening in the septum can hardly be ascribed to the same cause. The edges were smooth and bore no trace of inflammation, and, in fact, the opening exactly resembled those cases of defective development in which there is no evidence of endocarditis in any part of the heart. The question naturally arises as to the possible connexion, if any, between the arrest of development and the endocarditis in this and Dr. Robinson’s case. I am inclined to believe that in my own case the defect in the septum may have been the 1
4
327
Communication made to the Pathological
April 10th, 1895.
2
Society
THE LANCET, July 22nd, 1848.
of Manchester,
326
CURETTE.I
the objects of notification would be: 1. The sanitary authority would diagnosis would soon enable a good veterinary surgeon to disinfect the room occupied by the tuberculous patient, as might be have an almost instinctive knowledge of what he was required. 2. Inasmuch as the transmission of tuberculosis is in a unless in obscure cases. It is so in with, determined of cases the of convery dealing by presence insanitary proportion large ditions, such as damp, overcrowding, deficiency of light, and so forth, human diseases. The veterinary surgeon would also deai an opportunity would be afforded to the authority of removing such with the sanitary requirements of the cowsheds. Ordinary conditions and so saving other members of the household. 3. Further would be attended to. evidence would be collected bearing on the modes and conditions of insanitary conditions about farms I throw out these details merely by transmission of the disease. 4. The personal hygiene of the patient by the inspector. would in no way come under the care of the sanitary authority; it was way of showing that the veterinary inspector would have hoped, however, that the medical attendant would confer with the Having made his investigations, the medical officer of health, when convenient, as to the precise means by enough to do. which tuberculous discharges might be most usefully destroyed. At veterinary inspector would report to the medical officer off the same time the sanitary department would in no way interfere with health of the district, so that he might be able to cooperate the treatment of the patient, and all instructions in dealing with dis- with the veterinary inspector in getting the necessary from the would come from medical attendant. 5. the charges patient measures carried out." such cases would be as from preventive were Only reported taking place the lungs, cases with tuberculous diarrhcea, and cases with I have already mentioned how in all probability tuber. copious discharge from tuberculous bones and tuberculous ulcers. culosis is directly communicated in cowsheds from tuber. These and other matters having been fully discussed, the followfrom tuberculosis, the ing resolution was carried unanimously: ’That the society, having culous cows. But, apart altogether had its attention drawn to the infection of tuberculous diseases condition of our cowsheds and their relation to the public and to the great mortality and injury to the population arising there- health through the milk supply demand investigation an from, is of opinion that these diseases should be the subject of volunIt would be of great advantage if the rearrangement. tary notification to the sanitary authority.’ It was understood that a copy of the resolution would be sent to the sanitary committee of regulations applicable to cowsheds were made uniform, so Oldham as well as to the medical journals." that any local action taken to improve their condition should
Providing the fee of 2s. 6d. can be paid for each case reported, I do not object to voluntary notification being first tried, as it will give time practically to ascertain and deal with the seems
same time it difficulties of administration. that, the connexion between insanitary
At the
not have the effect of
district
perhaps
as
transferring the milk-supply to another badly off in the matter of cowsheds as
that in which the action
was
taken.
Oldham. ________________
to me quite clear
conditions and the communication of phthisis being so close it is, this alone would be a sufficient argument for compulsory notification, putting aside the other powerful reasons for it. Nor do I doubt that voluntary notification would speedily result in compulsory notification. 3. My third proposition was that Isolation Hospitals should be provided by sanitary authorities, jointly or separately, at the expense of the rates, for the isolation of As it is, cases of tuberculosis likely to cause infection. workhouse hospitals do at present provide a considerable amount of isolation for the very poor. But there are a vast number of artizan families which would decline to avail themselves of that refuge, and where the patient is a danger and a burden. I feel quite sure from the conversations I have had in the course of my inquiries that the provision of good hospital isolation would be hailed as a blessing by these poor struggling people, and it would be the means of removing infection from the home. Not only so, but those treated in the hospital for a time would be thoroughly indoctrinated with the measures of precaution taken, which would become part of their daily habit. They would therefore, on their return, be centres for the diffusion of knowledge on the subject. It is in the later stages of the disease that infection is most likely to occur and that the disease is most burdensome. This is precisely the stage which is not dealt with in convalescent homes, and which should be dealt with in the interests of public health. This proposal is, however, not necessary to the success of the first as
PERFORATION OF UTERUS OR CURETTE. BY
LAWSON
BY SOUND
TAIT, F.R.C.S.ENG.,
CONSULTING SURGEON TO THE HOSPITALS FOR "WOMEN AT BIRMINGHAM. NOTTINGHAM, AND SOUTHAMPTON.
THE article
by my friend, Dr. Auvard, in the Archives Tocologie et de Gynecologie, noted in THE LANCET off Sept. 22nd, 1894, has been lying for months on my desk waiting the leisure the holiday season has given me that I might draw further attention to an interesting occurrence, long ago familiar, but apparently forgotten. When Simpson made the uterine sound practicable, he de
put it in the hands of every one, and its routine use did Now it is relegated to its proper a great deal of mischief.
and used only in a very limited area of special We do not, therefore, see now the cases of perforation of the uterus by the sound which were so familiar In the columns of to Simpson’s pupils and followers. THE LANCET1 I recorded my own first experience of it, stating at the same time the fact that it was well known to Simpson, whom I had often seen demonstrate it. Next month2Mr. Walter Whitehead recorded a case as having happened to Foltz and Petrequin, and narrated by the former before the Lyons Medical Society, where a female two. 4. Tuberculosis in cattle should be brought under the catheter, used for the purpose of inducing premature labour, through the Contagious Diseases (Animals) Acts, and special veterinary passed through the fundus and was extracted any bad symptoms. inspectors should be appointed by sanitary authorities, umbilicus eighteen weeks after without in singly or jointly, to carry out the objects of the Acts Mr. Whitehead also mentions a fatal case the experience of in relation to tuberculosis and other diseases, and to attend a friend. It would be a valuable contribution to the literature to the general sanitary arrangements of the cowsheds. of the subject to have an account of this case, as it is the I may be allowed to quote the continuation: ’’ The officeronly disaster of the kind I have ever heard of amongst a to be appointed should be a young veterinary surgeon,number of perforations which I have seen and heard of, ,10 He shouldgreat that I should be afraid even to attempt to guess at the well versed in the diagnosis of disease. sufficient and receive a salary travelling expenses. Histotal. It must be strictly borne in mind that all the cases duties should be something like the following. Once aof which I speak occurred in the non-pregnant uterus. Dupuy collected seventeen cases,3 in none of which did month he should inspect the farm-buildings and note any subsequent evil effects arise. Commenting on thi. to on these or on the farms found conditions likely any Dr. W. S. Playfair said that it was probable that l paper on health of the cattle or act injuriously on the He should examine the cattlein many of these cases the sound passed through the the quality of the milk Fallopian tubes. This point used to. be one of periodicand ascertain whether they were suffering from If he saw reason to suspect tuberculosis he(discussion between the late Dr. Matthews Duncan am9 disease. r and I can accept the view shared by him and Dr. should take measures to have the suspected animal isolatedmyself, and see that necessary measures of disinfection were1Playfair still less now than in the time of those discussions carried out. The sale of milk from this animal would 1It is fashionable now to talk of passing sounds and catheters be stopped. If his diagnosis was clear and unhesitating thetthrough the Fallopian tubes (and ureters). I have tried on cow should be killed. thetthe cadaver, but (though fairly nimble with my fingers) I Compensation should be amount paid to have regard to the condition of the animal.have never succeeded, and I have never seen anyone else In advanced tuberculosis it would be trifling-in an early ssucceed, though I am far from saying that such passage is stage of the disease such as would not entail any loss to aall impossibility. Again, I have seen as many pathological the farmer. It would thus be to the farmer’s interest to 1 THE LANCET, April 29th, 1871. Lave such cases reported as soon as possible. Notification 2 THE LANCET, May 13th, 1871. would be compulsory on the farmer. Constant practice in 3 Progrès Médical, 1877.
any
given,
position, practice.
DR. T. C. RAILTON : CASE OF FŒTAL ENDOCARDI’I’IS. I suppose any other living person, but I never tube in which abnormal patency was a feature. I certainly never saw a normal Fallopian tube-I mean one not distinctly pathological-through which an ordinary uterine sound could be passed. But I have seen several uteri through which sounds could easily have been passed by reason of the thinning of the wall at the outward curve of a chronic flexion, or by the atrophy of the wall I at the insertion of a small nodule of myoma. have also seen two uteri through which the sound or curette actually had been passed, one at the time of an ovariotomy,4 and the other recently in a uterus I removed by vaginal hysterectomy. I have also recorded three cases of what appeared to be cases of permanent metro-peritoneal fistula. One of these cases possesses the fistula still, as I know the patient is alive, and I passed a sound at the old spot about three years ago. In making these observations we never sterilised the sounds, and now it amazes me, if
tubes
as
saw a
is caused by micro-organisms, why we never produced it. The last case of instrumental perforation of the uterus with which I have met is one of great interest, for the patient had had her appendages removed for myoma some five years before by Mr. Knowsley Thornton with a brilliantly successful result-that is, all the symptoms and troubles due to the myoma disappeared, and she went through a brief and satisfactory climacteric. When I examined her The patient had I could find no trace of myoma. an idea at the time of this operation that the uterus itself ought to have been removed, but of this I was finally able to dispossess her, for it seemed to be an ideal case for removal of the appendages, and the result all that could be wished. I mention this circumstance because she was placed under my care by a well-known Midland practitioner, whose name I do not give because with it the The name of the patient might just as well be published. reason of her coming to me was that for about eight months she had been troubled by an increasing purulent and very acrid discharge pouring out of the uterus. This discharge was extremely offensive, accompanied by pain and interrupted occasionally by haemorrhages. It made her extremely miserable, and brought back to her mind somewhat bitterly her original desire to have the uterus removed and Mr. Thornton’s refusal to comply with it. The remedy I suggested was, of course, the curette, though not without fear that the disease might be endometric ulcerative epithelioma (a very rare condition), and in consequence this might prove insufficient. Just as I had nearly completed the operation the curette went through the anterior wall of the uterus and I could feel its point easily through the abdominal wall. As usual, the accident did no harm; the patient recovered easily and for nine months remained quite well. She came back, however, later with all her symptoms renewed, indeed intensified, and begged me to remove the uterus. I was not much in favour of this proceeding, as I was by this time quite certain that the correct diagnosis was that of epithelioma, and I am not at all favourable to operations for cancer of any kind-I am quite sure that vaginal hysterectomy for real cancer of the uterus will soon go out of fashion. I removed the uterus in this case, however, under the belief that if such a thing were justifiable at all in cancer it was in the rare endometric ulcerative epithelioma which is very like the epithelioma of the lip. The operation was very difficult, on account of old adhesions, but it was through in about twenty minutes, and then I found a few nodules of myoma at the fundus of a perfectly senile uterus. They were not larger than marbles, and must have been the mere survivals of Mr. Thornton’s tumour, as they were wholly unrecognisable before the excision of the uterus. On slitting up the organ I found no trace of epithelioma, but a merely rough and hypertrophied endometrium, quite tough and very vascular. At the base of one of the nodules on the anterior wall, where it was of almost paper thickness, was an unclosed rent, about half an inch across, which had been made by my curette, and the edges of which, but not its lower end, had healed. Here at last was the absolute proof of a permanent metro-peritoneal fistula, through which I have no doubt much of the discharge must have made its way, after its re-establishment, but there was no disturbance from the microbes.
peritonitis
Birmingham.
CASE OF FŒTAL ENDOCARDITIS ASSOCIATED WITH AN ARREST OF DEVELOPMENT OF THE INTER-VENTRICULAR SEPTUM.1 BY T. C. RAILTON, M.D.LOND., PHYSICIAN TO THE MANCHESTER CLINICAL HOSPITAL.
aged four years was admitted into the Manchester Hospital on Jan. 24th, 1895, suffering from bronchopneumonia. His previous history was to the effect that he had always been a delicate child, did not walk until he was eighteen months old, and subsequently was unable to play about like other children, being easily exhausted and out of breath. He had frequently complained of pain in the region A
Diseases of the Ovary, 4th edition, p. 201. 1883. Cornish Bros. 5 THE LANCET, May 18th and Oct. 19th, 1872.
CHILD
Clinical
of the heart, but had not suffered from articular rheumatism Three weeks or shown any blueness in the lips or fingers. before his admission lie canght cold and had gradually got worse, and when admitted lie had well-marked symptoms of broncho-pneumonia, his respiration being 60, pulse 140, and temperature 101° F. The deep cardiac dulness extended upwards as high as the second rib, on the right hide nearly to the nipple line, and the apex beat was in the sixth interspace outside the left nipple line. There was no murmur audible. The patient became steadily worse, the temperature continued to rise, at one time reaching as high as 106’2°, and he died twenty-seven days after admission. Four days previous to his death a systolic murmur was audible over the right ventricle for the first time. At the post-mortem examination both lower lobes were found consolidated, sinking in water, while islets of bronchopneumonia were scattered over the rest of the lungs. The pericardinm contained about two drachms of clear fluid. The heart was very large, mainly upon the right side. The thickness of the wall of the right ventricle was eight millimetres, of the auricle one millimetre. The corresponding measurements of the left side were nine millimetres and one millirnetre respectively. The tricuspid valve was the seat of large verrucose vegetations covered with a deposit of fibrin. Close to the tricuspid orifice were a few other vegetations on the auricular edge and one recent irregular ulcer. The remaining orifices and valves were normal, and the ductus arteriosus and foramen ovale were closed. There was a deficiency of the septum of the ventricles about the undefended space large enough to admit a quill. This opening was larger at the side of the left ventricle than on the right side, where it ended between the insertion of two cusps of the tricuspid valve nearer to the right auricle than to the ventricle. The edges of this orifice were quite smooth. It was evident that the lesion of the tricuspid valve had started during foetal life, and it seemed almost equally clear that the endocarditis had also continued its evolution subsequently to birth. A similar case has been reported by Dr. F. Robinson.2 A child eighteen months old had suffered from palpitation and dyspnoea since birth. He was not cyanosed. There was a loud sawing murmur accompanying the heart’s action. At the necropsy the right ventricle was found to be large enough to contain a hen’s egg, and the tricuspid valve was thickened at its free border to such an extent as to prevent its perfect closure. There was also a circular orifice almost as large as the little finger in the septum of the ventricles communicating between the two cavities. The foramen ovale was closed and there were no remains of the ductus arteriosus. Although the valvular disease of my own case was due to endocarditis, the opening in the septum can hardly be ascribed to the same cause. The edges were smooth and bore no trace of inflammation, and, in fact, the opening exactly resembled those cases of defective development in which there is no evidence of endocarditis in any part of the heart. The question naturally arises as to the possible connexion, if any, between the arrest of development and the endocarditis in this and Dr. Robinson’s case. I am inclined to believe that in my own case the defect in the septum may have been the 1
4
327
Communication made to the Pathological
April 10th, 1895.
2
Society
THE LANCET, July 22nd, 1848.
of Manchester,