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PROCIDENTIA OF THE UTERUS AND RECTUM AT THE AGE OF 27 YEARS,
136 which was 5 inches in length, was pelvic in position, described a hair .pin bend about its middle, being fixed in this position by a shortened meso-appendix. There was no concretion, and little change was apparent in its walls beyond moderate submucous fibrosis, but the whole of the mucous membrane was of deep brown-bluish mottled appearance, which ceased abruptly at the line of section. (Fig. 1.) CASE 2.-A woman, aged 30, was sent to me by Dr. T. S. Rippon on March 16th, 1912, with a complaint of pains in the right side. She had suffered for a period of three years. The pain was sometimes sharp and sometimes dull and aching. It came on every day in the same place, low down in the right side, and had been worse since Christmas. It was sometimes worse after extra walking, but occasionally came on when she was quiet in bed. She got tired, but was never sick. She Ihad suffered from constipation for years. Pressure of the hand over the part would relieve it. The periods were regular, and she had no increase of pain at these times. Nothing abnormal could be found on examination. This patient was admitted to St. Thomas’s Hospital, where the appendix was removed on April 3rd, 1912. It was about
are important causative factors; and (4) the pigmentation is not caused by an absorption of blood or bile from the intestinal canal, although this has been shown to occur in the newly-born pup. Schmidt3 found pigment giving an iron reaction both in the tonsils and in the appendix in connexion with broken-down red cells, and
processes
concluded that I I tonsils, mucous membrane, and submucous tissues of the appendix exerted normally, and in an increased degree pathologically, a hæmolytic function, in a similar way to the spleen and the marrow."Aschoff4is of the opinion that in tonsil and appendix trauma as well, haemolysis is the cause of the pigmentation. Winklerconsiders that repeated inflammation sometimes causes pigmentation, it may also be seen where there is no evidence 3 inches in length, and contained some soft fæcal material. The although of any other pathological condition. He also says that mucous membrane was black, almost slimy in appearance, resembling the back of a black slug. There was a moderate amount of submucous pigmentation (visible to the naked eye) in varying degrees is fibrosis, but the evidences of previous inflammation were slight. (Fig. 2.) found in the mucous membrane of the ileum and cascum. He The other structures in the neighbourhood were normal. CASE 3.-A woman, aged 43, seen with Dr. W. Ecklin on June 28th, and has seen marked pigmentation in tuberculosis of the her appendix was removed in St. Thomas’s Hospital on July 5th, 1912. intestine. All these writers agree that the pigmentation is I had performed the operation of nephropexy on her right kidney eight due to a deposit containing iron, and this was found in years before. The result of that operation had been very satisfactory, but she has an abnormally thin abdominal wall, so that it was still the appendices examined by Dr. Le Sueur, who excluded the Tiecessary to wear a bandage when going about. About June, 1911, presence of mercury, bismuth, and lead. Dr. Ecklin attended her for an attack of appendicitis of moderate The pigmentation was deep and most extensive in all, severity, and a similar attack a fortnight before we met was followed by a very tender swelling in the right iliac fossa. She now went about evidently going for an indefinite distance into the bowel, as the house supporting the right lower abdomen with her hand. There is shown by the line of section in each, and by the dark was complaint of occasional pain in this part and much tenderness about colour of the adjacent cæcum, which was rather thin-walled 2 inches above Poupart’s ligament under the right rectus Nothing Its deposit to such an extent suggests that it was abnormal could be felt on examination. The tongue was clean and in Case 3. bowels acting. She had taken medicine containing iron as a tonic due to absorption from the contents of the large intestine, in under the direction of her medical attendant, but no patent medicine. a manner similar to that of the deposit of lead in the lead The appendix was 2½ inches in length. The capsules of two apple pips worker before mentioned. There is, no doubt, a good deal of were found in it. The mucous membrane was pigmented throughout, but there was little change in the walls. Her cæcum was large and iron in the contents of the large bowel, but here there must loosely attached ; it was also of a somewhat dark colour. have been more than usual and that for a long period. Had Some months later Dr. Ecklin wrote: "Before the operation the patient had been taking for some time the compound syrup of the such a condition been likely to occur from the use of iron hypophosphites, containing3/4 gr. ferri hypophos. in each dose, for given in the form of medicine, our post-mortem records neuralgia of the occipital and trigeminal nerves. She has been a must have described it long ago. These cases are different woman since the operation, and now that she has her winter the ones in which I have found such a curious only can to it without her hand over the vent putting appendix cough, give condition (for it has no clinical significance) in a long region." CASE 4 was that of a lady who was sent to me by Mr. H. W. series of operation cases. I can but think that it may Sexton. She was about 48 years of age, and had been in fair health , until about two years before when she began to suffer from occasional be due to excess of iron in the flour which is put out from pains in the lower abdomen, which came on without any apparent the roller-mills, the influence of which on appendicular reason but did not prevent her getting about. In June and September, constipation, the formation of some concretions, and when 1912, she had definite attacks of appendicitis, and in a third attack, three in a coarse form the direct production of appendicitis is weeks before I saw her, she had been under the care of Mr. Sexton. On this occasion there had been a definite swelling in the iliac fossa, with difficult to estimate. a temperature of 102.6° F. There was no history of the taking of any Harley-street, W. medicine containing iron and she had not taken any patent medicine. Examination showed nothing abnormal. The appendix, which was removed on March 4th, measured 4 inches in length, was very adherent PROCIDENTIA OF THE UTERUS AND to the right side of the uterus and difficult to separate, the distal tapering portion being " shelled out." On section the distal half was RECTUM AT THE AGE OF 27 YEARS, almost obliterated, there being extensive fibrosis, with contraction of this part. The proximal third of the mucous lining was of a brownishWITH REMARKS ON THE TREATMENT. black colour, sharply defined by the line of section of appendix, gradually shading off beyond where there was cicatricial change followBY DOUGLAS DREW, B.S.LOND., F.R.C.S. ENG., ing destruction of the mucous membrane. __________________
The appendices were sent to Mr. Shattock, who had water-colour sketches made of three of them, examined sections microscopically, and sent them to the chemical department of the hospital for analysis. The illustrations accompanying this contribution reproduce the general appearance of the appendices, but do not show the brownish appearance of the lighter areas. Microscopical examination showed the deposit of pigment in the mucous membrane, both in and between the cells. Chemical analysis by Dr. Le Sueur showed that ’the pigmentation was produced by a deposit of iron, the exact combination not being defined owing to the small - quantity of material available. Mr. C. M. Page has kindly given me some references to papers by German investigators. The conclusions to which ’Simon2 came were that in the series of specimens examined by himself, pigmentation was found in the mucous membrane, after inflammation, in 5 out of 43 removed’by operation ; in .1 out of 34 removed at necropsies. In 8 out of the 77 there was some pigmentation where the appendix was normal. It was found more frequently in lymphatics, perinodular capsule, and in the muscle after death than when the appendix had been removed by operation. In many the deposit of pigment was only found microscopically. He concludes (1) that the pigment had an iron reaction in all instances, except when found in the smooth muscle ; (2) that the pigment was hfematogenous in origin ; (3) although some pigmentation occurs in normal cases, inflammatory or congestive 2 Simon: Uber Pigmentierung in Darm mit besonderer Berücksichtigung des Wurmfortsatzes. Frankfurter Zeitschrift fur Pathologie,
Band iii., 1909.
THE
FOR WOMEN, SOHO-SQUARE, W., AND SURGEON TOQUEEN’SHOSPITAL HOSPITAL FOR CHILDREN, HACKNEY-ROAD, E.
TO
THE
THE patient was admitted to hospital on Dec. 8th, 1908. She stated that she had been troubled with the prolapse of the bowel since childhood, and that at times it caused much pain and bled freely. Before her marriage there had been some trouble with the falling of the womb, for which she had worn a ring. There had been one confinement 13 months previously; the labour was difficult, and since then her symptoms had been aggravated, the womb coming down whenever she walked. On admission it was found that on standing up and straining slightly several inches of the rectum could be extruded as a large sausage-shaped mass, and at the same time the vaginal walls and the cervix descended outside the vulva. On reducing the rectum the anus was very patulous, and there was little power of contraction of the sphincter. The cervix was fissured on the right side. The perineum was in
good condition. On Dec. 19th the abdomen was opened in the middle line and the loose pelvic colon was drawn up until it descended vertically to the anus. By firmly retracting the abdominal wall to the left it was possible to secure the rectum in the iliac fossa after the method advocated by Ball. The peritoneum was incised, a series of sutures were inserted between the muscle and the longitudinal band of the bowel, and the edges of the peritoneum were stitched to the rectum. 3
Dresden,
Deutschen Pathologischen Gesellschaft, 4 Ibid. Erkrankungen des Blinddarmhanges, 1910.
Verhandlungen 1907. 5 Die
der
137 On drawing the uterus up from the pelvis it reached almost to the umbilicus. Fixation was performed by a series of SURGICAL TUBERCULOSIS IN CHILDREN, buried silkworm-gut sutures passed through the anterior WITH SUGGESTIONS AS TO A wall of the uterus and the aponeurosis. METHOD OF TREATMENT.1 After the operation the patient was completely relieved of BY A. H. TUBBY, M.S.LOND., F.R.C.S. ENG., her trouble. Towards the end of 1911 she became pregnant for the second time, and was delivered in September, 1912. The SURGEON TO THE WESTMINSTER HOSPITAL AND ROYAL NATIONAL ORTHOPÆDIC HOSPITAL. labour was normal, and came on about three weeks before she was in I her saw When March, 1913, the expected date. complaining of some backache, and stated that on coughingA Review of the Methods and Results of the Treatment of she felt the womb come down, but during the last three Surgical Tuberculosis. months this had ceased to occur, and on examination the’ Definition.-By "surgical tuberculosis " is meant tuberfundus of the uterus could be felt about an inch below the culous disease of bones, joints, glands, and skin. Other umbilicus. The cervix was in good position fully 2½inches rare manifestations of the disease are met with in children, a from the vulva. There was, however, slight cystocele. the kidneys and bladder. The association of procidentia recti with procidentia uteri affecting Age.-It appears to me that in this connexion we should of a most pronounced degree is, so far as my experience goes, the regard age of childhood as extending to the fifteenth a most unusual occurrence, so much so that I think it must because that is the time when the active growth of bone year, be regarded as a coincidence, for if the two conditions were and its extreme liability to tuberculous infection due to the same underlying cause we should often find them ceases diminishes. Certainly, up to the age of 15 years and someassociated, which is not the case. A common cause of prolapse in the infant in the absence times for a year longer bone retains the characteristics of of rectal polypus is diarrhoea associated with malnutrition early life and its reaction to tuberculous infection. Relative freyiteney of surgical tuberculosis.-In 1902 I and wasting with a general loss of tone in the tissues ; the I obtained returns from four Children’s Hospitals in London, trouble is usually easily cured by improving the health and I that during the year 1901, 2040 children were found and preventing the prolapse from taking place, but from admitted these to hospitals for all causes, and of them no less time to time one meets with an obstinate case in than 218, or over 10 per cent., were affected with tuberculosis which, in spite of treatment, the bowel continues to of the joints, glands, and skin. Of them 115 were protrude; and if not remedied may persist into adult females bones, and 103 males. The average age of the patient was life. That this is so is evidenced by the history of 5 years and 8 months. Ninety children had affections of the I these patients. have met with four of these severe joints, 64 had the bones affected, or 154 of the 218; 45 had cases of procidentia in women varying in age from 27 to tuberculous glands, 10 had tuberculosis of the skin, and 50 years in all of whom the trouble had been present 9 had other forms of surgical tuberculosis. The minimum from childhood. These inveterate cases in children are in hospital was 5, and the maximum 76, days, or an stay quite easily cured by operative measures. Linear cauterisa- average of nearly six weeks. doubtful and I have seen of the is of recurrence tion utility, Results of treatment, mkieh was largely operative, in urban trouble follow, but I have never known failure after excising hospitals.-On these 218 patients 415 operations were donea good strip of the mucous membrane. The method I employ that is, nearly two operations on each patient. In one case is to draw down the prolapse to the full extent, place a it is recorded that a child was operated on 18 times, in tenaculum forceps on the apex of the inverted rectum and another 12, in another 11 ; and in one instance I met with another at the junction of the mucous membrane and the in the year 1888, a child had clinic in in a skin, both on the anterior aspect of the bowel, and to excise a been surgical on 35 Germany and was apparently as far off times, large lenticular area of the mucous membrane and close the cure asoperated ever. wound with a continuous catgut suture ; the bowel is then As a result of all this suffering of the children and returned, and heals in a few days, care being taken not to expenditure of time and labour by the surgeons only 68 of allow it to again prolapse during the process of healing. the 218, or 31-2 per cent., were said to be cured ; 128, or In the cases to which I have referred in the adult the 58-6 per cent., were relieved-and relief is no cure in whole rectum was inverted to the extent of from 5 to since half cures are worse than none at all. tuberculosis, 8 inches. Three of these cases were treated by excision of In 13 cases the result was doubtful or the condition of the the whole mass in the following manner. The bowel was and nine patients are known to have incised all round above the level of the sphincters and the patient unchanged, died in hospital. peritoneum opened, the vessels in the mesorectum were Results so disappointing as these led me to reconsider the secured, and all the slack bowel drawn down and removed, whole question, and in 19032I expressed the views thatthe peritoneum being sutured to the wall of the rectum and 1. Urban hospitals are not suitable places for the treatment the cut edge of the latter to the anal edge of the mucous of tuberculous children. 2. Operation as a routine treatmembrane. The results of this procedure have been most ment has failed. 3. Other methods of treatment must be and the have the control of satisfactory, patients regained found. 4. Treatment conducted in urban hospitals is the overstretched sphincter. The fourth case is the one wasteful and dangerous: wasteful because the financial now recorded in which rectopexy was performed. With resources of the hospital are not used to the best advantage, regard to the choice of operation, I must admit a the results attained ; and dangerous because for complete excision, as I think it is a more certain cure,considering such children are often sent from the hospital with tuberand the risk does not appear to be greater, although it is a ’ (culous discharges, which are a cause of dissemination of the more formidable procedure. (disease amongst those around them. With regard to the much-debated question of the best Contrast of the urban and extra-urban hospital treatment. method of curing prolapse of the uterus, ventral fixation is ( to the position which I have been fortunate enough to Owing undoubtedly of great value in dealing with these severe occupy since 1900 as consulting surgeon to the Hip Hospital The operation is considered not to be sufficient by cases. at Sevenoaks, I have been enabled to compare the results of itself to produce a permanent cure, but that it is desirable that hospital, small though it is, with those at the urban supplement it by colpoperineorrhaphy. That the latter gives children’s hospitals. Taking the cases in 1901, I obtained additional security by supporting the parts from below cannot tthe following statistics. I must, however, premise that be denied, and I usually employ both procedures. In the 1 The statements in this paper, much of which served as a Memocase recorded above, fixation appears to have effected a randum presented to the Departmental Committee on Tuberculosis, cure ; for a short period after her confinement there was are the author, and r based upon the results of investigations madeofbywhich a tendency to prolapse, but during the last few months have been set forth in detail in the following articles, some committee :—The Urban the to and of the chairman this tendency has completely disappeared in spite of having sent secretary s’ Brit. Med. of or F Treatment External Tuberculosis, Surgical Hospital an unusually large and heavy infant to carry about. Jour., Feb. 21st, 1903; Is the Urban Hospital Treatment of External or may be explained by the fact that practically the whole of Surgical Tuberculosis Justifiable? The Practitioner, September, 1903; the anterior surface of the uterus was fixed to the abdominal The T Treatment of External or Surgical Tuberculosis in the Country, Brit. Med. Jour., Nov. 19th, 1904; Tuberculous Cripples, by A. H. wall. In performing the operation I was careful to limit Tubby, in Kelynack’s "Tuberculosis in Infancy and Childhood," sutures to the anterior uterine wall, so that should London, Baillière, Tindall, and Cox, 1908, p. 188; The Indications for occur free of S the fundus Surgical Interference in the Treatment of Tuberculous Joint Disease subsequent pregnancy expansion in Children, with Remarks as to After-results, Proceedings of the Royal and posterior wall could take place. LANCET, Jan, 6th, 1912. Society of Medicine, 1912, and THE 2 Loc. cit. Wimpole-street, W.
: ’
preference
tot
c
6
This S the a LB
are important causative factors; and (4) the pigmentation is not caused by an absorption of blood or bile from the intestinal canal, although this has been shown to occur in the newly-born pup. Schmidt3 found pigment giving an iron reaction both in the tonsils and in the appendix in connexion with broken-down red cells, and
processes
concluded that I I tonsils, mucous membrane, and submucous tissues of the appendix exerted normally, and in an increased degree pathologically, a hæmolytic function, in a similar way to the spleen and the marrow."Aschoff4is of the opinion that in tonsil and appendix trauma as well, haemolysis is the cause of the pigmentation. Winklerconsiders that repeated inflammation sometimes causes pigmentation, it may also be seen where there is no evidence 3 inches in length, and contained some soft fæcal material. The although of any other pathological condition. He also says that mucous membrane was black, almost slimy in appearance, resembling the back of a black slug. There was a moderate amount of submucous pigmentation (visible to the naked eye) in varying degrees is fibrosis, but the evidences of previous inflammation were slight. (Fig. 2.) found in the mucous membrane of the ileum and cascum. He The other structures in the neighbourhood were normal. CASE 3.-A woman, aged 43, seen with Dr. W. Ecklin on June 28th, and has seen marked pigmentation in tuberculosis of the her appendix was removed in St. Thomas’s Hospital on July 5th, 1912. intestine. All these writers agree that the pigmentation is I had performed the operation of nephropexy on her right kidney eight due to a deposit containing iron, and this was found in years before. The result of that operation had been very satisfactory, but she has an abnormally thin abdominal wall, so that it was still the appendices examined by Dr. Le Sueur, who excluded the Tiecessary to wear a bandage when going about. About June, 1911, presence of mercury, bismuth, and lead. Dr. Ecklin attended her for an attack of appendicitis of moderate The pigmentation was deep and most extensive in all, severity, and a similar attack a fortnight before we met was followed by a very tender swelling in the right iliac fossa. She now went about evidently going for an indefinite distance into the bowel, as the house supporting the right lower abdomen with her hand. There is shown by the line of section in each, and by the dark was complaint of occasional pain in this part and much tenderness about colour of the adjacent cæcum, which was rather thin-walled 2 inches above Poupart’s ligament under the right rectus Nothing Its deposit to such an extent suggests that it was abnormal could be felt on examination. The tongue was clean and in Case 3. bowels acting. She had taken medicine containing iron as a tonic due to absorption from the contents of the large intestine, in under the direction of her medical attendant, but no patent medicine. a manner similar to that of the deposit of lead in the lead The appendix was 2½ inches in length. The capsules of two apple pips worker before mentioned. There is, no doubt, a good deal of were found in it. The mucous membrane was pigmented throughout, but there was little change in the walls. Her cæcum was large and iron in the contents of the large bowel, but here there must loosely attached ; it was also of a somewhat dark colour. have been more than usual and that for a long period. Had Some months later Dr. Ecklin wrote: "Before the operation the patient had been taking for some time the compound syrup of the such a condition been likely to occur from the use of iron hypophosphites, containing3/4 gr. ferri hypophos. in each dose, for given in the form of medicine, our post-mortem records neuralgia of the occipital and trigeminal nerves. She has been a must have described it long ago. These cases are different woman since the operation, and now that she has her winter the ones in which I have found such a curious only can to it without her hand over the vent putting appendix cough, give condition (for it has no clinical significance) in a long region." CASE 4 was that of a lady who was sent to me by Mr. H. W. series of operation cases. I can but think that it may Sexton. She was about 48 years of age, and had been in fair health , until about two years before when she began to suffer from occasional be due to excess of iron in the flour which is put out from pains in the lower abdomen, which came on without any apparent the roller-mills, the influence of which on appendicular reason but did not prevent her getting about. In June and September, constipation, the formation of some concretions, and when 1912, she had definite attacks of appendicitis, and in a third attack, three in a coarse form the direct production of appendicitis is weeks before I saw her, she had been under the care of Mr. Sexton. On this occasion there had been a definite swelling in the iliac fossa, with difficult to estimate. a temperature of 102.6° F. There was no history of the taking of any Harley-street, W. medicine containing iron and she had not taken any patent medicine. Examination showed nothing abnormal. The appendix, which was removed on March 4th, measured 4 inches in length, was very adherent PROCIDENTIA OF THE UTERUS AND to the right side of the uterus and difficult to separate, the distal tapering portion being " shelled out." On section the distal half was RECTUM AT THE AGE OF 27 YEARS, almost obliterated, there being extensive fibrosis, with contraction of this part. The proximal third of the mucous lining was of a brownishWITH REMARKS ON THE TREATMENT. black colour, sharply defined by the line of section of appendix, gradually shading off beyond where there was cicatricial change followBY DOUGLAS DREW, B.S.LOND., F.R.C.S. ENG., ing destruction of the mucous membrane. __________________
The appendices were sent to Mr. Shattock, who had water-colour sketches made of three of them, examined sections microscopically, and sent them to the chemical department of the hospital for analysis. The illustrations accompanying this contribution reproduce the general appearance of the appendices, but do not show the brownish appearance of the lighter areas. Microscopical examination showed the deposit of pigment in the mucous membrane, both in and between the cells. Chemical analysis by Dr. Le Sueur showed that ’the pigmentation was produced by a deposit of iron, the exact combination not being defined owing to the small - quantity of material available. Mr. C. M. Page has kindly given me some references to papers by German investigators. The conclusions to which ’Simon2 came were that in the series of specimens examined by himself, pigmentation was found in the mucous membrane, after inflammation, in 5 out of 43 removed’by operation ; in .1 out of 34 removed at necropsies. In 8 out of the 77 there was some pigmentation where the appendix was normal. It was found more frequently in lymphatics, perinodular capsule, and in the muscle after death than when the appendix had been removed by operation. In many the deposit of pigment was only found microscopically. He concludes (1) that the pigment had an iron reaction in all instances, except when found in the smooth muscle ; (2) that the pigment was hfematogenous in origin ; (3) although some pigmentation occurs in normal cases, inflammatory or congestive 2 Simon: Uber Pigmentierung in Darm mit besonderer Berücksichtigung des Wurmfortsatzes. Frankfurter Zeitschrift fur Pathologie,
Band iii., 1909.
THE
FOR WOMEN, SOHO-SQUARE, W., AND SURGEON TOQUEEN’SHOSPITAL HOSPITAL FOR CHILDREN, HACKNEY-ROAD, E.
TO
THE
THE patient was admitted to hospital on Dec. 8th, 1908. She stated that she had been troubled with the prolapse of the bowel since childhood, and that at times it caused much pain and bled freely. Before her marriage there had been some trouble with the falling of the womb, for which she had worn a ring. There had been one confinement 13 months previously; the labour was difficult, and since then her symptoms had been aggravated, the womb coming down whenever she walked. On admission it was found that on standing up and straining slightly several inches of the rectum could be extruded as a large sausage-shaped mass, and at the same time the vaginal walls and the cervix descended outside the vulva. On reducing the rectum the anus was very patulous, and there was little power of contraction of the sphincter. The cervix was fissured on the right side. The perineum was in
good condition. On Dec. 19th the abdomen was opened in the middle line and the loose pelvic colon was drawn up until it descended vertically to the anus. By firmly retracting the abdominal wall to the left it was possible to secure the rectum in the iliac fossa after the method advocated by Ball. The peritoneum was incised, a series of sutures were inserted between the muscle and the longitudinal band of the bowel, and the edges of the peritoneum were stitched to the rectum. 3
Dresden,
Deutschen Pathologischen Gesellschaft, 4 Ibid. Erkrankungen des Blinddarmhanges, 1910.
Verhandlungen 1907. 5 Die
der
137 On drawing the uterus up from the pelvis it reached almost to the umbilicus. Fixation was performed by a series of SURGICAL TUBERCULOSIS IN CHILDREN, buried silkworm-gut sutures passed through the anterior WITH SUGGESTIONS AS TO A wall of the uterus and the aponeurosis. METHOD OF TREATMENT.1 After the operation the patient was completely relieved of BY A. H. TUBBY, M.S.LOND., F.R.C.S. ENG., her trouble. Towards the end of 1911 she became pregnant for the second time, and was delivered in September, 1912. The SURGEON TO THE WESTMINSTER HOSPITAL AND ROYAL NATIONAL ORTHOPÆDIC HOSPITAL. labour was normal, and came on about three weeks before she was in I her saw When March, 1913, the expected date. complaining of some backache, and stated that on coughingA Review of the Methods and Results of the Treatment of she felt the womb come down, but during the last three Surgical Tuberculosis. months this had ceased to occur, and on examination the’ Definition.-By "surgical tuberculosis " is meant tuberfundus of the uterus could be felt about an inch below the culous disease of bones, joints, glands, and skin. Other umbilicus. The cervix was in good position fully 2½inches rare manifestations of the disease are met with in children, a from the vulva. There was, however, slight cystocele. the kidneys and bladder. The association of procidentia recti with procidentia uteri affecting Age.-It appears to me that in this connexion we should of a most pronounced degree is, so far as my experience goes, the regard age of childhood as extending to the fifteenth a most unusual occurrence, so much so that I think it must because that is the time when the active growth of bone year, be regarded as a coincidence, for if the two conditions were and its extreme liability to tuberculous infection due to the same underlying cause we should often find them ceases diminishes. Certainly, up to the age of 15 years and someassociated, which is not the case. A common cause of prolapse in the infant in the absence times for a year longer bone retains the characteristics of of rectal polypus is diarrhoea associated with malnutrition early life and its reaction to tuberculous infection. Relative freyiteney of surgical tuberculosis.-In 1902 I and wasting with a general loss of tone in the tissues ; the I obtained returns from four Children’s Hospitals in London, trouble is usually easily cured by improving the health and I that during the year 1901, 2040 children were found and preventing the prolapse from taking place, but from admitted these to hospitals for all causes, and of them no less time to time one meets with an obstinate case in than 218, or over 10 per cent., were affected with tuberculosis which, in spite of treatment, the bowel continues to of the joints, glands, and skin. Of them 115 were protrude; and if not remedied may persist into adult females bones, and 103 males. The average age of the patient was life. That this is so is evidenced by the history of 5 years and 8 months. Ninety children had affections of the I these patients. have met with four of these severe joints, 64 had the bones affected, or 154 of the 218; 45 had cases of procidentia in women varying in age from 27 to tuberculous glands, 10 had tuberculosis of the skin, and 50 years in all of whom the trouble had been present 9 had other forms of surgical tuberculosis. The minimum from childhood. These inveterate cases in children are in hospital was 5, and the maximum 76, days, or an stay quite easily cured by operative measures. Linear cauterisa- average of nearly six weeks. doubtful and I have seen of the is of recurrence tion utility, Results of treatment, mkieh was largely operative, in urban trouble follow, but I have never known failure after excising hospitals.-On these 218 patients 415 operations were donea good strip of the mucous membrane. The method I employ that is, nearly two operations on each patient. In one case is to draw down the prolapse to the full extent, place a it is recorded that a child was operated on 18 times, in tenaculum forceps on the apex of the inverted rectum and another 12, in another 11 ; and in one instance I met with another at the junction of the mucous membrane and the in the year 1888, a child had clinic in in a skin, both on the anterior aspect of the bowel, and to excise a been surgical on 35 Germany and was apparently as far off times, large lenticular area of the mucous membrane and close the cure asoperated ever. wound with a continuous catgut suture ; the bowel is then As a result of all this suffering of the children and returned, and heals in a few days, care being taken not to expenditure of time and labour by the surgeons only 68 of allow it to again prolapse during the process of healing. the 218, or 31-2 per cent., were said to be cured ; 128, or In the cases to which I have referred in the adult the 58-6 per cent., were relieved-and relief is no cure in whole rectum was inverted to the extent of from 5 to since half cures are worse than none at all. tuberculosis, 8 inches. Three of these cases were treated by excision of In 13 cases the result was doubtful or the condition of the the whole mass in the following manner. The bowel was and nine patients are known to have incised all round above the level of the sphincters and the patient unchanged, died in hospital. peritoneum opened, the vessels in the mesorectum were Results so disappointing as these led me to reconsider the secured, and all the slack bowel drawn down and removed, whole question, and in 19032I expressed the views thatthe peritoneum being sutured to the wall of the rectum and 1. Urban hospitals are not suitable places for the treatment the cut edge of the latter to the anal edge of the mucous of tuberculous children. 2. Operation as a routine treatmembrane. The results of this procedure have been most ment has failed. 3. Other methods of treatment must be and the have the control of satisfactory, patients regained found. 4. Treatment conducted in urban hospitals is the overstretched sphincter. The fourth case is the one wasteful and dangerous: wasteful because the financial now recorded in which rectopexy was performed. With resources of the hospital are not used to the best advantage, regard to the choice of operation, I must admit a the results attained ; and dangerous because for complete excision, as I think it is a more certain cure,considering such children are often sent from the hospital with tuberand the risk does not appear to be greater, although it is a ’ (culous discharges, which are a cause of dissemination of the more formidable procedure. (disease amongst those around them. With regard to the much-debated question of the best Contrast of the urban and extra-urban hospital treatment. method of curing prolapse of the uterus, ventral fixation is ( to the position which I have been fortunate enough to Owing undoubtedly of great value in dealing with these severe occupy since 1900 as consulting surgeon to the Hip Hospital The operation is considered not to be sufficient by cases. at Sevenoaks, I have been enabled to compare the results of itself to produce a permanent cure, but that it is desirable that hospital, small though it is, with those at the urban supplement it by colpoperineorrhaphy. That the latter gives children’s hospitals. Taking the cases in 1901, I obtained additional security by supporting the parts from below cannot tthe following statistics. I must, however, premise that be denied, and I usually employ both procedures. In the 1 The statements in this paper, much of which served as a Memocase recorded above, fixation appears to have effected a randum presented to the Departmental Committee on Tuberculosis, cure ; for a short period after her confinement there was are the author, and r based upon the results of investigations madeofbywhich a tendency to prolapse, but during the last few months have been set forth in detail in the following articles, some committee :—The Urban the to and of the chairman this tendency has completely disappeared in spite of having sent secretary s’ Brit. Med. of or F Treatment External Tuberculosis, Surgical Hospital an unusually large and heavy infant to carry about. Jour., Feb. 21st, 1903; Is the Urban Hospital Treatment of External or may be explained by the fact that practically the whole of Surgical Tuberculosis Justifiable? The Practitioner, September, 1903; the anterior surface of the uterus was fixed to the abdominal The T Treatment of External or Surgical Tuberculosis in the Country, Brit. Med. Jour., Nov. 19th, 1904; Tuberculous Cripples, by A. H. wall. In performing the operation I was careful to limit Tubby, in Kelynack’s "Tuberculosis in Infancy and Childhood," sutures to the anterior uterine wall, so that should London, Baillière, Tindall, and Cox, 1908, p. 188; The Indications for occur free of S the fundus Surgical Interference in the Treatment of Tuberculous Joint Disease subsequent pregnancy expansion in Children, with Remarks as to After-results, Proceedings of the Royal and posterior wall could take place. LANCET, Jan, 6th, 1912. Society of Medicine, 1912, and THE 2 Loc. cit. Wimpole-street, W.
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