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PREGNANCY AFTER TUBERCULOSIS OF THE FALLOPIAN TUBES
24
between the onset of hyperthyroidism and the recognition of acropachy varied from a few weeks to twenty-eight years (see table). Hyperthyroidism has been recognised at some stage in all patients with acropachy except one (Greene 1951); exophthalmos has been present in all, and pretibial myxoedema in the majority. The changes in thyroid acropachy seem to be unique, and the question of differential diagnosis hardly arises. In some of the earlier described cases there was confusion In with hypertrophic pulmonary osteoarthropathy. acropachy the periosteal bone changes are quite different in appearance: they simulate bubbles on the bone surface, and they are differently situated, being on more peripheral parts of the skeleton. Also the characteristic heat, pain, and evidence of increased bone blood-flow (Ginsberg 1958) in pulmonary osteoarthropathy is absent in acropachy. The soft-tissue thickening of acropachy is an important diagnostic feature, particularly when localised In acromegaly, occasionally over the affected bones. associated with hyperthyroidism, the changes in the hands and elsewhere should not be confused with those of acropachy, although some new bone formation occurs. There is a rare familial condition-idiopathic osteodystrophy or pachydermoperiostosis (Angel 1957) in which clubbing and thickening of the tissues of the hands, feet, and face develop early in adult life. This condition has some resemblance to acropachy, but it is not associated with other features of the acropachy syndrome. Symptoms from thyroid acropachy are unusual, and treatment is therefore not an important problem. There may be complaint of stiffness due to generalised softtissue swelling of the hands; but the joints do not seem to be involved, and there is no evidence of muscular weakness or wasting. The natural course of thyroid acropachy is uncertain; in some patients there has been no change for several years; possibly, as with other features of Graves’ disease, partial or complete remission may occur naturally after a time. The frequency of thyroid acropachy is very difficult to determine since it may appear so many years after the onset of thyrotoxicosis that an ordinary follow-up would be inadequate. The present series of six cases were met with over a period of four years during which there were about five hundred new cases of hyperthyroidism. Possibly acropachy eventually develops in about 1% of patients with hyperthyroidism. Thyroid acropachy must be added to the long list of miscellaneous conditions associated with clubbing, and the changes in acropachy are not readily explained by any of the mechanisms or causes of clubbing which have been suggested in certain other disorders.
Summary Six cases of thyroid acropachy are described. Acropachy consists of clubbing of fingers and toes, distal periosteal bone change, and swelling of the overlying soft tissues. The condition arises occasionally as a final phase of development of the acropachy syndrome of hyperthyroidism, exophthalmos, and pretibial myxoedema. The cause of acropachy is obscure; but apparently in some circumstances certain of the peripheral tissues undergo peculiar changes, possibly under the influence of a pituitary hormone. I Dr.
grateful to Dr. H. K. Goadby, Prof. E. P. Sharpey-Schafer, J. S. Richardson, Dr. H. J. Anderson, and Dr. H. J. Wallace for permission to describe cases under their care. References at foot of next column am
PREGNANCY AFTER TUBERCULOSIS OF THE FALLOPIAN TUBES
J. A. L. JOHNSTON M.D. Belf.
(FORMERLY PATHOLOGIST) S. W. LIGGETT M.B. Belf., F.R.C.S.E., M.R.C.O.G.
SENIOR PHYSICIAN
GYNÆCOLOGIST
ALTNAGELVIN
HOSPITAL, LONDONDERRY, NORTHERN IRELAND
Rabau first reported a pregnancy after the successful of proved endometrial tuberculosis in 1952, and several other cases have been described since. We have been unable to find any reference to proved tubal tuberculosis followed by pregnancy, although in one of Earn’s (1958) cases of endometrial tuberculosis the left fallopian tube was palpable at the first examination. We therefore present the following case-report, which shows that pregnancy is possible after tuberculosis of the fallopian tubes has been treated medically.
treatment
Case-report patient, aged 25, who had been married 9 months, was referred, on June 29, 1955, to S. W. L. with suspected extrauterine pregnancy. Her last normal menstrual period was at the end of April-i.e., 8-9 weeks previously. From the last week in May until the time of examination she had had irregular vaginal bleeding, and had passed occasional small clots. She also had cramp-like lower abdominal pain. She denied any previous serious illness or familial tuberculosis, although 2 weeks later her mother underwent nephrectomy for The
renal tuberculosis.
Examination She seemed to be healthy and was of medium build. Her heart and lungs were normal, and the temperature and pulserate were not increased. The abdomen moved easily on respiration ; no tumour was felt but there was slight tenderness on both sides of the lower abdomen. Bimanual examination revealed a slightly enlarged uterus and an irregular, slightly tender mass, which appeared to be fixed to the uterus, in the pouch of
Douglas. The patient was admitted to a nursing home for observation because the diagnosis was in doubt. On June 30 her condition was unchanged, but next evening she had fairly severe abdominal pain. She was not in a state of shock and she had no signs of intra-abdominal bleeding. Because the mass in the pouch of Douglas was more tender, an examination under anaesthesia and possibly laparotomy was planned for next morning. Operation and Course Under general anxsthesia (July 2) the previous findings in the pelvis were confirmed. As an ectopic pregnancy could not be excluded, laparotomy was performed through a midline subumbilical incision. The omentum was adhering to the uterine fundus and covering the pelvis. When this was freed the uterus was found to be enlarged to the size of a 6-8 weeks pregnancy by multiple small fibroids. The mass in the pouch of Douglas comprised the swollen and inflamed fallopian tubes. The left tube was distended to at least 1 in. diameter, and the right to about 1/2 in.; thin yellow pus was escaping from their fimbrial DR. GIMLETTE: REFERENCES
Angel, J. H. (1957) Brit. med. J. ii, 789. Cushing, E. H. (1937) Int. Clin. 2, 200. Diamond, M. T. (1959) Ann. intern. Med. 50, 206. Engel, F. L. (1953) J. clin. Endocrin. 13, 1132. Freeman, A. G. (1958) Lancet, ii, 57. Ginsberg, J. (1958) Quart. J. Med. 27, 335. Greene, R. (1951) Proc. R. Soc. Med. 44, 159. Inch, R. S., Rolland, C. F. (1953) Lancet, ii, 1239. Levitt, T. (1953) The Thyroid; p. 325. Edinburgh. McGill, D. A. (1957) Guy’s Hosp. Rep. 106, 47. Rynearson, E. H., Sarcasa, C. F. (1941) Proc. Mayo Clin. 16, Thomas, H. M. (1933) Arch. intern. Med. 51, 57.
353.
25
ends, from which
a swab was taken for examination. The abdomen was closed without drainage, and the patient returned to the ward in good condition. Direct microscopical examination (J. A. L. J.) showed puscell debris and necrotic material with some intact leucocytes and lymphocytes, and a few giant cells. No gram-positive organisms or acid-fast bacilli were seen, but a tuberculous infection was suspected. Culture of the pus for these organisms was arranged. By the 3rd postoperative day the patient had a temperature of 102°F, with a corresponding tachycardia. That evening she had The heart a haemoptysis, and was examined by J. A. L. J. sounds and rhythm were normal, and the blood-pressure was 120/80 mm. Hg. The patient said she had had a pain in the left axilla at the level of the 6th or 7th rib, some 36-48 hours before the haemoptysis. A slight friction rub and a few crepitations were heard in the left submammary area. The respiratory rate was increased, but deep breathing did not cause pain. Sputum (3 specimens) was negative for tubercule bacilli. A small pulmonary embolus was diagnosed provisionally, but in view of the abdominal findings the possibility of pulmonary tuberculosis was considered, and treatment with streptomycin and isoniazid was instituted. The pyrexia and
pregnancy was confirmed by a positive Hogben test in midJuly. By the end of July, because she was much troubled by vomiting, the p-aminosalicylic acid was replaced by streptomycin. On Aug. 3 she aborted incompletely a ten-week foetus. Next day, at curettage under general anxsthesia, several were palpated. Convalescence was complicated by a thrombophlebitis of the right internal saphenous vein. Menstruation returned on Sept. 9. On Sept. 29 the E.S.R. was
fibroids
in the lst hour. At postoperative review on Oct. 4 the right leg showed no sign of the previous thrombosis. The cervix was healthy, and the uterus and fibroids were well involuted. She had slight dysuria, but no cause was found. At the end of October dizziness and tinnitus had returned, but the E.s.R. was 8 mm. in the lst hour, and her general condition was good. Streptomycin was stopped, and all other treatment was scaled down. She was not seen again until March 8, 1957, when she had had no treatment for about 2 months. She was well, her weight had increased, and the E.S.R. was 3 mm. in the lst hour. 10
mm.
Second Pregnancy At the end of May she again reported that menstruation was tachycardia disappeared in 3 weeks, and chest radiographs on July 18 showed a very small effusion within the left pleural overdue (last menstrual period April 16) and a Hogben test concavity, but the rest of the lung fields were clear. A further firmed pregnancy. In view of the previous miscarriage 6 radiograph on Aug. 3 showed that the left costophrenic sinus (25 mg.) pellets of progesterone were implanted deep to the was clear, although increased density in this area persisted. fascia lata. She was again given p-aminosalicylic acid. Convalescence was uneventful, and the patient was allowed Pregnancy proceeded normally (blood-pressure 120/80 mm. home in mid-August, her medical treatment being continued. Hg; no albuminuria) until Sept. 9, when decalcification of her When reviewed on Sept. 10, the patient’s general condition teeth was noted. She was given calcium and vitamin D, and had improved, although pyrexia (99’6-100-4°F) had returned, for the next 2 months she seemed to be normal. with some sweating. Her weight had increased by 41/2 lb. Just before Christmas her right leg had been swollen for Radiographs showed no active lesion in the lungs, but a large 5 days but had improved since. On Jan. 3, 1958, slight oedema calcified abdominal gland was noticed. The hypogastrium was was found, but no evidence of any clot formation. The bloodtender. pressure was 130/80, a trace of albuminuria was found, and the The results of the bacterial cultures became available. Bloodfcetal heart was heard. The fcetal head had not engaged in the agar plates were sterile after 4 days’ incubation, but after pelvic brim. The patient was advised to rest. 7 weeks on Lowenstein and Jensen medium typical colonies of On Jan. 10 the blood-pressure had risen to 150/90 and the tubercle bacilli were present. Acid-fast and alcohol-fast urine still contained a slight trace of albumin. The foetus was tubercle bacilli were seen microscopically. Examination of the presenting by the vertex, and the foetal heart was heard. The blood showed hxmoglobin (Hb) 90%; red blood-cells 4,000,000 patient was advised to continue resting at home. She was per c.mm.; white blood-cells 11,000 per c.mm.; haematocrit admitted to the nursing home on Jan. 17 as she feared she 35%; erythrocyte-sedimentation rate (E.S.R.) 10 mm. in the lst might be isolated at her home in the country by a snow storm. hour (Westergren). Streptomycin therapy was replaced by With complete rest in bed the blood-pressure fell to 140/90 p-aminosalicylic acid, and isoniazid was continued. and the urine became albumin-free. On Oct. 12 the patient’s temperature was lower and her Labour started spontaneously on Jan. 28-i.e., 285 days after weight had increased. By Nov. 1 her temperature was normal the first day of her last menstrual period. Progress was very apart from an occasional spike, and the E.S.R. had fallen to slow, with weak irregular pains; after 36 hours the cervix was 7 mm. in the 1st hour. Her condition remained unchanged for only three-fingers dilated, and the head was still free. In view several weeks, but by Dec. 28 a definite pattern of pyrexia was of the length of labour, the uterine inertia, and the nonapparent during the progestational phase of the menstrual engagement of the head, a lower-uterine-segment caesarean cycle. Her weight had increased further but the E.S.R. had section was performed on Jan. 29, and a live female infant risen slightly to 11 mm. in the lst hour, and the haematocrit weighing 10 lb. was delivered. At operation cephalopelvic had fallen to 36%. disproportion was noted, and the fibroids were still present, but Menstruation had returned in September, without pain or both fallopian tubes looked normal, without evidence of preintermenstrual bleeding. On Jan. 30, 1956, no abnormality vious disease. There was a large placental infarct, and the was detected in the abdomen, and on vaginal examination the liquor was heavily stained with meconium. uterus seemed normal. The right fallopian tube could not be Convalescence was uneventful at first. Careful and regular felt, but the left was still much enlarged and thickened. examinations showed no evidence of venous thrombosis. The On Feb. 3 the E.s.R. was 18 mm. in the lst hour, Hb 84%, patient got up daily from the 3rd day, and moved about her and hxmatocrit 36%. No lung lesion was found clinically or room. On the 10th postoperative day, while she was cleaning radiographically. The patient was readmitted to the nursing her teeth in the bathroom, she collapsed from a pulmonary home for complete rest, and further streptomycin was given. embolus, and despite morphine and intravenous heparin she By March 9 her condition had improved considerably, and she died 20 minutes later. The infant has progressed satisfactorily. was allowed to go home. She still had pyrexia in the progestational phase of the menstrual cycle, but it now never rose above 99úF. The E.S.R. was 11 mm. in the 1st hour, Hb 88%, and haematocrit 36%; her weight had increased to 11 st. 10 lb.
First Pregnancy The improvement continued, but on May 23 she complained of some dizziness, and although no 8th nerve lesion was detected streptomycin was discontinued as a precautionary measure. On June 6 menstruation was 14 days overdue, and
Discussion
this
patient’s unfortunate death her history Despite shows that in cases of tuberculous salpingitis the radical and surgical treatment previously practised by Stallworthy (1952) and others may no longer always be necessary, and that with present-day medical treatment even considerable damage to the fallopian tubes by tuberculous disease does not always mean sterility.
26 This case was treated along the lines recommended by Hallum and Thomas (1955) and Norburn and Walker (1956) with the addition of isoniaziad 100-150 mg. daily. As in Rabau’s case, the first pregnancy after treatment ended in early abortion. We do not think the postoperative thrombophlebitis was necessarily associated with the tuberculous infection.
Summary A patient with tuberculosis of the fallopian tubes, treated medically, had ’afterwards two pregnancies which resulted in an abortion and a healthy infant. At the time of the cxsarean section both fallopian tubes were free from macroscopic signs of inflammation. Three consecutive operations were followed by venous thrombophlebitis. The third proved fatal because of pulmonary embolism. thank Dr. D. S. Wilson and Lieut.-Colonel D. G. C. with the anaesthesia and radiology; and Miss E. Scott, s.R.N., s.c.M., and her staff -for nursing the We wish
to
Whyte, D.S.O., for their assistance patient.
on
the day after injury, showing
multiple
bilateral rib fractures. were unrecordable, and although there was no cyanosis there was severe respiratory distress. His injuries included compound fractures of the left humerus and left radius and ulna, a fracture of the ascending ramus of the mandible on the right, a fracture of the neck of the right scapula, fractures of the right radius and ulna, a subtrochanteric fracture of the right femur, and finally bilateral fractures of the second to ninth ribs inclusive in the anterior axillary lines (fig. 1). The entire anterior chest wall, an area measuring about 135 sq. in., was involved in paradoxical movement, and he showed the orbital haemorrhages of traumatic asphyxia. After immediate splinting of the limb fractures, strapping the chest, and rapid infusion first of dextran and then of blood, his condition improved enough to allow operation, which was performed under general anaesthesia. First the chest wall was
pressure
REFERENCES Earn, A. A. (1958) J. Obstet. Gynæc. Brit. Emp. 65, 739. Hallum, J. L., Thomas, H. E. (1955) ibid. 62, 548. Norburn, L. M., Walker, A. H. C. (1956) ibid. 63, 173. Rabau, E. (1952) ibid. 59, 743. Stallworthy, J. (1952) ibid. p. 729.
STERNAL TRACTION FOR THE FLAIL CHEST M.B.
G. C. ROBIN Glasg., F.R.C.S., F.R.F.P.S.
ROYAL NATIONAL ORTHOPÆDIC
REGISTRAR,
HOSPITAL, LONDON, W.1
SINCE Jones and Richardson (1926) first described a method of controlling paradoxical respiration after chest trauma by skeletal traction on the sternum, using a gynaecological " bullet forceps", several reports have suggested other methods and instruments found valuable. Butler
Fig. 1-Chest radiograph
and Williams (1948) advocated the use of the ribs; Jaslow (1946) used coat-hanger hooks screwed into the sternum. All three workers employed weight traction. Proctor and London (1955) used " cup hooks" in the sternum fixed to a special bed frame, while Heroy and Egglestone (1951) made drill holes in the sternum and applied a clamp and 10 lb. traction. Ritter and Kaye (1944) used perichondral wires with weight traction. Other workers have advocated open reduction of sternal fractures and fixation with plates (Hendry 1957) or crossed Kirschner wires (McKim 1943), and finally Coleman and Coleman (1950) suggested open reduction of the multiple rib fractures and fixation with wire sutures. Birchfield and Grant (1956) also recommended this method of managing the " stove-in " chest.
(1938)
towel-clips
to grasp
Recently for sternal fixation in a patient with multiple injuries I used an instrument available in most traumatic centres-i.e., a skull calliper-and found it to be both easy to apply and effective.
Fig. 2-Patient in bed with skeletal traction in situ.
Case-report A man, aged 27, was involved in an accident at work in a textile factory on Jan. 6, 1959, when his right hand was trapped in a machine. His arms, head, and trunk were drawn between the rollers, crushing him and at the same time enveloping him in several layers of fabric. The machine had to be reversed to roll him out and he was removed from the wrappings unconscious, deeply cyanosed, and not breathing. After artificial respiration by a workmate he regained consciousness. On arrival in hospital, about half an hour after the accident, he was conscious but grossly shocked. His pulse and blood-
Fig. 3-Diagrammatic
cross-section of anterior chest wall at the
level of the 5th intercostal space.
between the onset of hyperthyroidism and the recognition of acropachy varied from a few weeks to twenty-eight years (see table). Hyperthyroidism has been recognised at some stage in all patients with acropachy except one (Greene 1951); exophthalmos has been present in all, and pretibial myxoedema in the majority. The changes in thyroid acropachy seem to be unique, and the question of differential diagnosis hardly arises. In some of the earlier described cases there was confusion In with hypertrophic pulmonary osteoarthropathy. acropachy the periosteal bone changes are quite different in appearance: they simulate bubbles on the bone surface, and they are differently situated, being on more peripheral parts of the skeleton. Also the characteristic heat, pain, and evidence of increased bone blood-flow (Ginsberg 1958) in pulmonary osteoarthropathy is absent in acropachy. The soft-tissue thickening of acropachy is an important diagnostic feature, particularly when localised In acromegaly, occasionally over the affected bones. associated with hyperthyroidism, the changes in the hands and elsewhere should not be confused with those of acropachy, although some new bone formation occurs. There is a rare familial condition-idiopathic osteodystrophy or pachydermoperiostosis (Angel 1957) in which clubbing and thickening of the tissues of the hands, feet, and face develop early in adult life. This condition has some resemblance to acropachy, but it is not associated with other features of the acropachy syndrome. Symptoms from thyroid acropachy are unusual, and treatment is therefore not an important problem. There may be complaint of stiffness due to generalised softtissue swelling of the hands; but the joints do not seem to be involved, and there is no evidence of muscular weakness or wasting. The natural course of thyroid acropachy is uncertain; in some patients there has been no change for several years; possibly, as with other features of Graves’ disease, partial or complete remission may occur naturally after a time. The frequency of thyroid acropachy is very difficult to determine since it may appear so many years after the onset of thyrotoxicosis that an ordinary follow-up would be inadequate. The present series of six cases were met with over a period of four years during which there were about five hundred new cases of hyperthyroidism. Possibly acropachy eventually develops in about 1% of patients with hyperthyroidism. Thyroid acropachy must be added to the long list of miscellaneous conditions associated with clubbing, and the changes in acropachy are not readily explained by any of the mechanisms or causes of clubbing which have been suggested in certain other disorders.
Summary Six cases of thyroid acropachy are described. Acropachy consists of clubbing of fingers and toes, distal periosteal bone change, and swelling of the overlying soft tissues. The condition arises occasionally as a final phase of development of the acropachy syndrome of hyperthyroidism, exophthalmos, and pretibial myxoedema. The cause of acropachy is obscure; but apparently in some circumstances certain of the peripheral tissues undergo peculiar changes, possibly under the influence of a pituitary hormone. I Dr.
grateful to Dr. H. K. Goadby, Prof. E. P. Sharpey-Schafer, J. S. Richardson, Dr. H. J. Anderson, and Dr. H. J. Wallace for permission to describe cases under their care. References at foot of next column am
PREGNANCY AFTER TUBERCULOSIS OF THE FALLOPIAN TUBES
J. A. L. JOHNSTON M.D. Belf.
(FORMERLY PATHOLOGIST) S. W. LIGGETT M.B. Belf., F.R.C.S.E., M.R.C.O.G.
SENIOR PHYSICIAN
GYNÆCOLOGIST
ALTNAGELVIN
HOSPITAL, LONDONDERRY, NORTHERN IRELAND
Rabau first reported a pregnancy after the successful of proved endometrial tuberculosis in 1952, and several other cases have been described since. We have been unable to find any reference to proved tubal tuberculosis followed by pregnancy, although in one of Earn’s (1958) cases of endometrial tuberculosis the left fallopian tube was palpable at the first examination. We therefore present the following case-report, which shows that pregnancy is possible after tuberculosis of the fallopian tubes has been treated medically.
treatment
Case-report patient, aged 25, who had been married 9 months, was referred, on June 29, 1955, to S. W. L. with suspected extrauterine pregnancy. Her last normal menstrual period was at the end of April-i.e., 8-9 weeks previously. From the last week in May until the time of examination she had had irregular vaginal bleeding, and had passed occasional small clots. She also had cramp-like lower abdominal pain. She denied any previous serious illness or familial tuberculosis, although 2 weeks later her mother underwent nephrectomy for The
renal tuberculosis.
Examination She seemed to be healthy and was of medium build. Her heart and lungs were normal, and the temperature and pulserate were not increased. The abdomen moved easily on respiration ; no tumour was felt but there was slight tenderness on both sides of the lower abdomen. Bimanual examination revealed a slightly enlarged uterus and an irregular, slightly tender mass, which appeared to be fixed to the uterus, in the pouch of
Douglas. The patient was admitted to a nursing home for observation because the diagnosis was in doubt. On June 30 her condition was unchanged, but next evening she had fairly severe abdominal pain. She was not in a state of shock and she had no signs of intra-abdominal bleeding. Because the mass in the pouch of Douglas was more tender, an examination under anaesthesia and possibly laparotomy was planned for next morning. Operation and Course Under general anxsthesia (July 2) the previous findings in the pelvis were confirmed. As an ectopic pregnancy could not be excluded, laparotomy was performed through a midline subumbilical incision. The omentum was adhering to the uterine fundus and covering the pelvis. When this was freed the uterus was found to be enlarged to the size of a 6-8 weeks pregnancy by multiple small fibroids. The mass in the pouch of Douglas comprised the swollen and inflamed fallopian tubes. The left tube was distended to at least 1 in. diameter, and the right to about 1/2 in.; thin yellow pus was escaping from their fimbrial DR. GIMLETTE: REFERENCES
Angel, J. H. (1957) Brit. med. J. ii, 789. Cushing, E. H. (1937) Int. Clin. 2, 200. Diamond, M. T. (1959) Ann. intern. Med. 50, 206. Engel, F. L. (1953) J. clin. Endocrin. 13, 1132. Freeman, A. G. (1958) Lancet, ii, 57. Ginsberg, J. (1958) Quart. J. Med. 27, 335. Greene, R. (1951) Proc. R. Soc. Med. 44, 159. Inch, R. S., Rolland, C. F. (1953) Lancet, ii, 1239. Levitt, T. (1953) The Thyroid; p. 325. Edinburgh. McGill, D. A. (1957) Guy’s Hosp. Rep. 106, 47. Rynearson, E. H., Sarcasa, C. F. (1941) Proc. Mayo Clin. 16, Thomas, H. M. (1933) Arch. intern. Med. 51, 57.
353.
25
ends, from which
a swab was taken for examination. The abdomen was closed without drainage, and the patient returned to the ward in good condition. Direct microscopical examination (J. A. L. J.) showed puscell debris and necrotic material with some intact leucocytes and lymphocytes, and a few giant cells. No gram-positive organisms or acid-fast bacilli were seen, but a tuberculous infection was suspected. Culture of the pus for these organisms was arranged. By the 3rd postoperative day the patient had a temperature of 102°F, with a corresponding tachycardia. That evening she had The heart a haemoptysis, and was examined by J. A. L. J. sounds and rhythm were normal, and the blood-pressure was 120/80 mm. Hg. The patient said she had had a pain in the left axilla at the level of the 6th or 7th rib, some 36-48 hours before the haemoptysis. A slight friction rub and a few crepitations were heard in the left submammary area. The respiratory rate was increased, but deep breathing did not cause pain. Sputum (3 specimens) was negative for tubercule bacilli. A small pulmonary embolus was diagnosed provisionally, but in view of the abdominal findings the possibility of pulmonary tuberculosis was considered, and treatment with streptomycin and isoniazid was instituted. The pyrexia and
pregnancy was confirmed by a positive Hogben test in midJuly. By the end of July, because she was much troubled by vomiting, the p-aminosalicylic acid was replaced by streptomycin. On Aug. 3 she aborted incompletely a ten-week foetus. Next day, at curettage under general anxsthesia, several were palpated. Convalescence was complicated by a thrombophlebitis of the right internal saphenous vein. Menstruation returned on Sept. 9. On Sept. 29 the E.S.R. was
fibroids
in the lst hour. At postoperative review on Oct. 4 the right leg showed no sign of the previous thrombosis. The cervix was healthy, and the uterus and fibroids were well involuted. She had slight dysuria, but no cause was found. At the end of October dizziness and tinnitus had returned, but the E.s.R. was 8 mm. in the lst hour, and her general condition was good. Streptomycin was stopped, and all other treatment was scaled down. She was not seen again until March 8, 1957, when she had had no treatment for about 2 months. She was well, her weight had increased, and the E.S.R. was 3 mm. in the lst hour. 10
mm.
Second Pregnancy At the end of May she again reported that menstruation was tachycardia disappeared in 3 weeks, and chest radiographs on July 18 showed a very small effusion within the left pleural overdue (last menstrual period April 16) and a Hogben test concavity, but the rest of the lung fields were clear. A further firmed pregnancy. In view of the previous miscarriage 6 radiograph on Aug. 3 showed that the left costophrenic sinus (25 mg.) pellets of progesterone were implanted deep to the was clear, although increased density in this area persisted. fascia lata. She was again given p-aminosalicylic acid. Convalescence was uneventful, and the patient was allowed Pregnancy proceeded normally (blood-pressure 120/80 mm. home in mid-August, her medical treatment being continued. Hg; no albuminuria) until Sept. 9, when decalcification of her When reviewed on Sept. 10, the patient’s general condition teeth was noted. She was given calcium and vitamin D, and had improved, although pyrexia (99’6-100-4°F) had returned, for the next 2 months she seemed to be normal. with some sweating. Her weight had increased by 41/2 lb. Just before Christmas her right leg had been swollen for Radiographs showed no active lesion in the lungs, but a large 5 days but had improved since. On Jan. 3, 1958, slight oedema calcified abdominal gland was noticed. The hypogastrium was was found, but no evidence of any clot formation. The bloodtender. pressure was 130/80, a trace of albuminuria was found, and the The results of the bacterial cultures became available. Bloodfcetal heart was heard. The fcetal head had not engaged in the agar plates were sterile after 4 days’ incubation, but after pelvic brim. The patient was advised to rest. 7 weeks on Lowenstein and Jensen medium typical colonies of On Jan. 10 the blood-pressure had risen to 150/90 and the tubercle bacilli were present. Acid-fast and alcohol-fast urine still contained a slight trace of albumin. The foetus was tubercle bacilli were seen microscopically. Examination of the presenting by the vertex, and the foetal heart was heard. The blood showed hxmoglobin (Hb) 90%; red blood-cells 4,000,000 patient was advised to continue resting at home. She was per c.mm.; white blood-cells 11,000 per c.mm.; haematocrit admitted to the nursing home on Jan. 17 as she feared she 35%; erythrocyte-sedimentation rate (E.S.R.) 10 mm. in the lst might be isolated at her home in the country by a snow storm. hour (Westergren). Streptomycin therapy was replaced by With complete rest in bed the blood-pressure fell to 140/90 p-aminosalicylic acid, and isoniazid was continued. and the urine became albumin-free. On Oct. 12 the patient’s temperature was lower and her Labour started spontaneously on Jan. 28-i.e., 285 days after weight had increased. By Nov. 1 her temperature was normal the first day of her last menstrual period. Progress was very apart from an occasional spike, and the E.S.R. had fallen to slow, with weak irregular pains; after 36 hours the cervix was 7 mm. in the 1st hour. Her condition remained unchanged for only three-fingers dilated, and the head was still free. In view several weeks, but by Dec. 28 a definite pattern of pyrexia was of the length of labour, the uterine inertia, and the nonapparent during the progestational phase of the menstrual engagement of the head, a lower-uterine-segment caesarean cycle. Her weight had increased further but the E.S.R. had section was performed on Jan. 29, and a live female infant risen slightly to 11 mm. in the lst hour, and the haematocrit weighing 10 lb. was delivered. At operation cephalopelvic had fallen to 36%. disproportion was noted, and the fibroids were still present, but Menstruation had returned in September, without pain or both fallopian tubes looked normal, without evidence of preintermenstrual bleeding. On Jan. 30, 1956, no abnormality vious disease. There was a large placental infarct, and the was detected in the abdomen, and on vaginal examination the liquor was heavily stained with meconium. uterus seemed normal. The right fallopian tube could not be Convalescence was uneventful at first. Careful and regular felt, but the left was still much enlarged and thickened. examinations showed no evidence of venous thrombosis. The On Feb. 3 the E.s.R. was 18 mm. in the lst hour, Hb 84%, patient got up daily from the 3rd day, and moved about her and hxmatocrit 36%. No lung lesion was found clinically or room. On the 10th postoperative day, while she was cleaning radiographically. The patient was readmitted to the nursing her teeth in the bathroom, she collapsed from a pulmonary home for complete rest, and further streptomycin was given. embolus, and despite morphine and intravenous heparin she By March 9 her condition had improved considerably, and she died 20 minutes later. The infant has progressed satisfactorily. was allowed to go home. She still had pyrexia in the progestational phase of the menstrual cycle, but it now never rose above 99úF. The E.S.R. was 11 mm. in the 1st hour, Hb 88%, and haematocrit 36%; her weight had increased to 11 st. 10 lb.
First Pregnancy The improvement continued, but on May 23 she complained of some dizziness, and although no 8th nerve lesion was detected streptomycin was discontinued as a precautionary measure. On June 6 menstruation was 14 days overdue, and
Discussion
this
patient’s unfortunate death her history Despite shows that in cases of tuberculous salpingitis the radical and surgical treatment previously practised by Stallworthy (1952) and others may no longer always be necessary, and that with present-day medical treatment even considerable damage to the fallopian tubes by tuberculous disease does not always mean sterility.
26 This case was treated along the lines recommended by Hallum and Thomas (1955) and Norburn and Walker (1956) with the addition of isoniaziad 100-150 mg. daily. As in Rabau’s case, the first pregnancy after treatment ended in early abortion. We do not think the postoperative thrombophlebitis was necessarily associated with the tuberculous infection.
Summary A patient with tuberculosis of the fallopian tubes, treated medically, had ’afterwards two pregnancies which resulted in an abortion and a healthy infant. At the time of the cxsarean section both fallopian tubes were free from macroscopic signs of inflammation. Three consecutive operations were followed by venous thrombophlebitis. The third proved fatal because of pulmonary embolism. thank Dr. D. S. Wilson and Lieut.-Colonel D. G. C. with the anaesthesia and radiology; and Miss E. Scott, s.R.N., s.c.M., and her staff -for nursing the We wish
to
Whyte, D.S.O., for their assistance patient.
on
the day after injury, showing
multiple
bilateral rib fractures. were unrecordable, and although there was no cyanosis there was severe respiratory distress. His injuries included compound fractures of the left humerus and left radius and ulna, a fracture of the ascending ramus of the mandible on the right, a fracture of the neck of the right scapula, fractures of the right radius and ulna, a subtrochanteric fracture of the right femur, and finally bilateral fractures of the second to ninth ribs inclusive in the anterior axillary lines (fig. 1). The entire anterior chest wall, an area measuring about 135 sq. in., was involved in paradoxical movement, and he showed the orbital haemorrhages of traumatic asphyxia. After immediate splinting of the limb fractures, strapping the chest, and rapid infusion first of dextran and then of blood, his condition improved enough to allow operation, which was performed under general anaesthesia. First the chest wall was
pressure
REFERENCES Earn, A. A. (1958) J. Obstet. Gynæc. Brit. Emp. 65, 739. Hallum, J. L., Thomas, H. E. (1955) ibid. 62, 548. Norburn, L. M., Walker, A. H. C. (1956) ibid. 63, 173. Rabau, E. (1952) ibid. 59, 743. Stallworthy, J. (1952) ibid. p. 729.
STERNAL TRACTION FOR THE FLAIL CHEST M.B.
G. C. ROBIN Glasg., F.R.C.S., F.R.F.P.S.
ROYAL NATIONAL ORTHOPÆDIC
REGISTRAR,
HOSPITAL, LONDON, W.1
SINCE Jones and Richardson (1926) first described a method of controlling paradoxical respiration after chest trauma by skeletal traction on the sternum, using a gynaecological " bullet forceps", several reports have suggested other methods and instruments found valuable. Butler
Fig. 1-Chest radiograph
and Williams (1948) advocated the use of the ribs; Jaslow (1946) used coat-hanger hooks screwed into the sternum. All three workers employed weight traction. Proctor and London (1955) used " cup hooks" in the sternum fixed to a special bed frame, while Heroy and Egglestone (1951) made drill holes in the sternum and applied a clamp and 10 lb. traction. Ritter and Kaye (1944) used perichondral wires with weight traction. Other workers have advocated open reduction of sternal fractures and fixation with plates (Hendry 1957) or crossed Kirschner wires (McKim 1943), and finally Coleman and Coleman (1950) suggested open reduction of the multiple rib fractures and fixation with wire sutures. Birchfield and Grant (1956) also recommended this method of managing the " stove-in " chest.
(1938)
towel-clips
to grasp
Recently for sternal fixation in a patient with multiple injuries I used an instrument available in most traumatic centres-i.e., a skull calliper-and found it to be both easy to apply and effective.
Fig. 2-Patient in bed with skeletal traction in situ.
Case-report A man, aged 27, was involved in an accident at work in a textile factory on Jan. 6, 1959, when his right hand was trapped in a machine. His arms, head, and trunk were drawn between the rollers, crushing him and at the same time enveloping him in several layers of fabric. The machine had to be reversed to roll him out and he was removed from the wrappings unconscious, deeply cyanosed, and not breathing. After artificial respiration by a workmate he regained consciousness. On arrival in hospital, about half an hour after the accident, he was conscious but grossly shocked. His pulse and blood-
Fig. 3-Diagrammatic
cross-section of anterior chest wall at the
level of the 5th intercostal space.