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RADCLIFFE INFIRMARY, OXFORD.
348
continuing well. When cut through the tumour had a translucent pink tint; its consistence was that of firm jelly; and its structure indicative of myxoma.
RADCLIFFE
INFIRMARY, OXFORD.
PELVIC ABSCESS; SUDDEN ONSET OF RIGHT HEMIPLEGIA, APHASIA AND RIGHT HEMISPASM ; ENDOCARDITIS; PLEURISY ; DEATH.
(Under the care of Dr. TUCKWELL.) FOR the notes of this interesting case we are indebted to Mr. J. E. Hine, resident medical officer to the infirmary. S. A-, aged twenty, was admitted into the infirmary on January 4th, 1881. The patient was a servant, unmarried. The illness began four weeks before with sudden pain in the right iliac region, thence extending over the whole abdomen. She had no rigors. At the end of three days the severe pain abated, but returned in a week and was then situated chiefly in the middle of the back. The pain again abated, and again returned ten days before admission, when it lasted all day ; but it did not recur. The abdomen had, however, remained tender. During the whole of this time the patient had vomited after taking food. The bowels were regular as a rule, but there had been at times a little diarrhoea. Menstruation had stopped a week before her illness began, and did not appear afterwards. A fortnight ago an offensive vaginal discharge commenced, not exces. sive in quantity. She had had no pain on micturition OI defecation-
the face began to twitch, the right corner of the mouth being much drawn up, and the mouth rapidly opened and shut. (3) The right arm was thrown into a state of rapid clonic spasm. (4) The right leg was similarly convulsed. (5) Both legs and the whole body became convulsed. (6) There then followed several deep inspirations, and the whole was at an end, having lasted about three minuteBetween the attacks she moved her limbs and ground her teeth. -24th : Theconvulsive attacks had continued every ten or fifteen minutes till 12.30 to-day ; they then ceased till 8.30 P.M., when she had one, which was the last. After this she seemed better, breathing quietly, and she slept well during the night. She had, however, some difficulty in swallowing, the milk that was given her flowing back out of the mouth. -25th: She has been able to take half a pint of milk during the night. She moves both legs, but still seems to have pain when the left is flexed. The right hand and arm are paralysed as before, but the facial paralysis is not so marked. She now seems quite conscious. The pupils are no longer dilated. Ophthalmoscopic examination shows nothing abnormal.-26th : To-day she can hold the right hand up in the air and move it about almost as well as the left. The vomiting had returned in the night, and she had passed her motions under her. A short systolic murmur is heard at the apex for the first time.-28th : The cardiac murmur is more distinct. March 2nd : She still passes everything under her. Has more power in the right hand, and can flex and extend both wrist and elbow. She can draw both legs up ; but cannot raise either foot from the bed. The facial paralysis is gone. When spoken to she answers "yes" and "no," sometimes rationally, sometimes at random. She understands all that
On admission the
patient was very emaciated. Skin dry and harsh ; tongue red; epithelium in parts stripped off; small aphthous patches in the dorsum; pulse 120. There was a frequent short cough with purulent expectoration. In the right iliac fossa, limited below by Foupart’s ligament, was a deep-seated, non-nuctuating swelling, over which the percussion-note was tympanitic; but there was no tenderness on moderately deep pressure over the swelling, or, indeed, over any part of the abdomen. A very offensive purulent discharge, enough to soil one cloth in the day, escaped from the vagina.-Vaginal examination : Cervix uteri small and virginal. In posterior cul-de-sac a doughy swelling was felt, which partly concealed the posterior half of the cervix. January 9rh : She vomited yesterday afternoon and this morning. Her cough is troublesome. In the right scapular region there is prolonged expiration, but nothing else to be detected in the chest. The vaginal discharge continued till the 26th, when the swelling in the abdomen was no longer to be felt. The vomiting had also continued, sometimes after, sometimes independently of, food, and usually without any
feeling of
nausea.
February llth :
The body is very emaciated. Pulse very seldom below 120; tongue foul. The vomiting continues, the vomited matters being always green and bilious looking. In the right supra-scapular and scapular region the resonance is a little short, and bronchial breath sounds and bronchophony are heard on auscultation.—18th : She had been very sick all night. Last evening she became
frequent,
partiallycollapsed, and complained of pain atthe epigastrium.
is said to her—4th : She speaks bftrm’ anrl
can
tell her
name.-9th : She speaks quite well. The mitral murmur is very loud. There is a slight return of the vaginal discharge. - 12the: She complains of shortness of breath and cough. Expectoration rather profuse. There is now dulness on percussion, and absence of breath sounds from the right scapula to the base. The vaginal discharge is more abundant and offensive. No more vomiting. The patient was removed by request to her own home to-day, and died two days afterwards. The temperature throughout her illness was only once as high as 101°, ranging on an average from 98’4° to 99 4°. The urine was free from albumen. Remarks by Dr. TUCKWELL.-Altbougb, unfortunately, the girl was taken away by her friends, and no examination of the body could be obtained; yet, a guess may be made at the probable causes of her symptoms as they successively showed themselves. An inflammation, perhaps a partial perforation, of the vermiform appendix suddenly occurs. Under rest in bed the acute symptoms subside, but there is only temporary relief. An abscess forms in the connective tissue behind the csecum, finds its way down into the vagina, bursts, and discharges a very offensive pus. There and pyæmic endocarditis. A vegetation from the inflamed mitral valve is swept outwards, and carried into the left middle cerebral artery, causing right hemiplegia and aphasia, followed by right hemispasm and general convulsions. From these cerebral symptoms she soon recovers. Right-sided pleurisy, with rapid effusion, now sets in, and terminates life. At the onset of the cerebral symptoms it was suspected that a secondary abscess had formed in the neighbourhood of the inferior frontal convolution, more especially as the mitral murmur was not heard till two or three days afterwards, when the paralysis was beginning to subside. But the steady recovery of speech and movement, the absence of any marked rise in the temperature, and the development of a loud mitral murmur, seemed rather to point to embolism as the cause of this train
follow purulent absorption
She has since wandered a little. She now lies on the right side. Pupils dilated. Pulse 140 ; and very weak. Expression of face vacant. She talks nonsense. Moves both hands and feet.-19th : To-day there is distinct right-sided facial paralysis. The tongue deviates to the right. Both pupils are and react feebly to light. The right arm seems completely paralysed. The right leg is apparently not paralysed, but when the knee is flexed, she cries out as if in pain and of symptoms. draws both her legs up. There is no rigidity of the muscles. When spoken to she answers "yes"to every question, and ROYAL ALBERT EDWARD INFIRMARY, makes use of no other wOlds. The breathing is quiet. WIGAN. Tâches cerebrales very marked.-22nd : There seems to be some loss of power in the right leg. The feet and legs feel HÆMATOCELE ; OPERATION; CURE. cold. She understands what is said to her, but now answers (Under the care of Mr. BERRY). "Why, Sir?"to all questions. Vomiting frequent.—23rd FOR the following notes we are indebted to Dr. Lytle, (10 P.M.) : She had become worse. Temperature 101° ; pulse 168 ; respiration 20 ; depp and sighing. Pupils widely senior house-surgeon :— right eye squinting outwards. The same evening, P. S- aged forty-five years, labourer, admitted and at intervals of about ten minutes all through the night, 9th, 1881. He was first seen in the out-patient cleJuly she had a series of convulsive attacks. The following was with a large pyriform, smooth, elastic swelling on partment in of events each attack : The turned the sequence (1) eyes to the right and remained so fixed for a few seconds ; they left side of the scrotum, resembling hydrocele. A small then oscillated rapidly to and fro. (2) The right side of trocar was inserted, and a little fluid blood escaped. The
dilated
dilated ;
continuing well. When cut through the tumour had a translucent pink tint; its consistence was that of firm jelly; and its structure indicative of myxoma.
RADCLIFFE
INFIRMARY, OXFORD.
PELVIC ABSCESS; SUDDEN ONSET OF RIGHT HEMIPLEGIA, APHASIA AND RIGHT HEMISPASM ; ENDOCARDITIS; PLEURISY ; DEATH.
(Under the care of Dr. TUCKWELL.) FOR the notes of this interesting case we are indebted to Mr. J. E. Hine, resident medical officer to the infirmary. S. A-, aged twenty, was admitted into the infirmary on January 4th, 1881. The patient was a servant, unmarried. The illness began four weeks before with sudden pain in the right iliac region, thence extending over the whole abdomen. She had no rigors. At the end of three days the severe pain abated, but returned in a week and was then situated chiefly in the middle of the back. The pain again abated, and again returned ten days before admission, when it lasted all day ; but it did not recur. The abdomen had, however, remained tender. During the whole of this time the patient had vomited after taking food. The bowels were regular as a rule, but there had been at times a little diarrhoea. Menstruation had stopped a week before her illness began, and did not appear afterwards. A fortnight ago an offensive vaginal discharge commenced, not exces. sive in quantity. She had had no pain on micturition OI defecation-
the face began to twitch, the right corner of the mouth being much drawn up, and the mouth rapidly opened and shut. (3) The right arm was thrown into a state of rapid clonic spasm. (4) The right leg was similarly convulsed. (5) Both legs and the whole body became convulsed. (6) There then followed several deep inspirations, and the whole was at an end, having lasted about three minuteBetween the attacks she moved her limbs and ground her teeth. -24th : Theconvulsive attacks had continued every ten or fifteen minutes till 12.30 to-day ; they then ceased till 8.30 P.M., when she had one, which was the last. After this she seemed better, breathing quietly, and she slept well during the night. She had, however, some difficulty in swallowing, the milk that was given her flowing back out of the mouth. -25th: She has been able to take half a pint of milk during the night. She moves both legs, but still seems to have pain when the left is flexed. The right hand and arm are paralysed as before, but the facial paralysis is not so marked. She now seems quite conscious. The pupils are no longer dilated. Ophthalmoscopic examination shows nothing abnormal.-26th : To-day she can hold the right hand up in the air and move it about almost as well as the left. The vomiting had returned in the night, and she had passed her motions under her. A short systolic murmur is heard at the apex for the first time.-28th : The cardiac murmur is more distinct. March 2nd : She still passes everything under her. Has more power in the right hand, and can flex and extend both wrist and elbow. She can draw both legs up ; but cannot raise either foot from the bed. The facial paralysis is gone. When spoken to she answers "yes" and "no," sometimes rationally, sometimes at random. She understands all that
On admission the
patient was very emaciated. Skin dry and harsh ; tongue red; epithelium in parts stripped off; small aphthous patches in the dorsum; pulse 120. There was a frequent short cough with purulent expectoration. In the right iliac fossa, limited below by Foupart’s ligament, was a deep-seated, non-nuctuating swelling, over which the percussion-note was tympanitic; but there was no tenderness on moderately deep pressure over the swelling, or, indeed, over any part of the abdomen. A very offensive purulent discharge, enough to soil one cloth in the day, escaped from the vagina.-Vaginal examination : Cervix uteri small and virginal. In posterior cul-de-sac a doughy swelling was felt, which partly concealed the posterior half of the cervix. January 9rh : She vomited yesterday afternoon and this morning. Her cough is troublesome. In the right scapular region there is prolonged expiration, but nothing else to be detected in the chest. The vaginal discharge continued till the 26th, when the swelling in the abdomen was no longer to be felt. The vomiting had also continued, sometimes after, sometimes independently of, food, and usually without any
feeling of
nausea.
February llth :
The body is very emaciated. Pulse very seldom below 120; tongue foul. The vomiting continues, the vomited matters being always green and bilious looking. In the right supra-scapular and scapular region the resonance is a little short, and bronchial breath sounds and bronchophony are heard on auscultation.—18th : She had been very sick all night. Last evening she became
frequent,
partiallycollapsed, and complained of pain atthe epigastrium.
is said to her—4th : She speaks bftrm’ anrl
can
tell her
name.-9th : She speaks quite well. The mitral murmur is very loud. There is a slight return of the vaginal discharge. - 12the: She complains of shortness of breath and cough. Expectoration rather profuse. There is now dulness on percussion, and absence of breath sounds from the right scapula to the base. The vaginal discharge is more abundant and offensive. No more vomiting. The patient was removed by request to her own home to-day, and died two days afterwards. The temperature throughout her illness was only once as high as 101°, ranging on an average from 98’4° to 99 4°. The urine was free from albumen. Remarks by Dr. TUCKWELL.-Altbougb, unfortunately, the girl was taken away by her friends, and no examination of the body could be obtained; yet, a guess may be made at the probable causes of her symptoms as they successively showed themselves. An inflammation, perhaps a partial perforation, of the vermiform appendix suddenly occurs. Under rest in bed the acute symptoms subside, but there is only temporary relief. An abscess forms in the connective tissue behind the csecum, finds its way down into the vagina, bursts, and discharges a very offensive pus. There and pyæmic endocarditis. A vegetation from the inflamed mitral valve is swept outwards, and carried into the left middle cerebral artery, causing right hemiplegia and aphasia, followed by right hemispasm and general convulsions. From these cerebral symptoms she soon recovers. Right-sided pleurisy, with rapid effusion, now sets in, and terminates life. At the onset of the cerebral symptoms it was suspected that a secondary abscess had formed in the neighbourhood of the inferior frontal convolution, more especially as the mitral murmur was not heard till two or three days afterwards, when the paralysis was beginning to subside. But the steady recovery of speech and movement, the absence of any marked rise in the temperature, and the development of a loud mitral murmur, seemed rather to point to embolism as the cause of this train
follow purulent absorption
She has since wandered a little. She now lies on the right side. Pupils dilated. Pulse 140 ; and very weak. Expression of face vacant. She talks nonsense. Moves both hands and feet.-19th : To-day there is distinct right-sided facial paralysis. The tongue deviates to the right. Both pupils are and react feebly to light. The right arm seems completely paralysed. The right leg is apparently not paralysed, but when the knee is flexed, she cries out as if in pain and of symptoms. draws both her legs up. There is no rigidity of the muscles. When spoken to she answers "yes"to every question, and ROYAL ALBERT EDWARD INFIRMARY, makes use of no other wOlds. The breathing is quiet. WIGAN. Tâches cerebrales very marked.-22nd : There seems to be some loss of power in the right leg. The feet and legs feel HÆMATOCELE ; OPERATION; CURE. cold. She understands what is said to her, but now answers (Under the care of Mr. BERRY). "Why, Sir?"to all questions. Vomiting frequent.—23rd FOR the following notes we are indebted to Dr. Lytle, (10 P.M.) : She had become worse. Temperature 101° ; pulse 168 ; respiration 20 ; depp and sighing. Pupils widely senior house-surgeon :— right eye squinting outwards. The same evening, P. S- aged forty-five years, labourer, admitted and at intervals of about ten minutes all through the night, 9th, 1881. He was first seen in the out-patient cleJuly she had a series of convulsive attacks. The following was with a large pyriform, smooth, elastic swelling on partment in of events each attack : The turned the sequence (1) eyes to the right and remained so fixed for a few seconds ; they left side of the scrotum, resembling hydrocele. A small then oscillated rapidly to and fro. (2) The right side of trocar was inserted, and a little fluid blood escaped. The
dilated
dilated ;