- Email: [email protected]
SUBPERITONEAL HÆMATOCELE.
604 mation of Mr. Tait, but at least they satisfy me and many leaders in the profession. And why should Mr. Tait think a row in Liverpool a necessary consequence of this ? Mr. Tait continues : "When I heard him say in the witness-box thatovariotomy did not necessarily include removal of the ovary,’ I suspected he was living in an atmosphere of confusion ; now I know he has created it." Mr. Tait will probably begin to suspect that it was he who at that particular time was living in an atmosphere of confusion, and clearly of his own creation, when I tell him I did not, either in the witness-box or elsewhere, say that " ovariotomy did not necessarily include removal of the ovary." I was not asked by counsel on either side any question relating to ovariotomy. Mr. Tait further says: "In his evidence, Dr. Grimsdale clearly threw blame on Dr. Imlach for performing operations without consultations." This I deny. I answered the questions of counsel as to consultations truthfully, as I presume Mr. Tait will admit I was bound to do; but while in the witness-box I threw no blame on Dr. Imlacb. Mr. Tait goes on to say: " If Dr. Imlach did this (i.e., perform operations without consultations), then Dr. Grimsdale was clearly to blame for it. As consulting officer to the hospital, he could have insisted on consultations being held, and if they had been refused, his remedy lay in an appeal to the committee of the hospital by a complaint that an important law was broken and defied." Mr. Tait will be glad to learn that I anticipated his valuable suggestions, and that the admirable course of action laid down by him is precisely that which I adopted so long ago as the beginning of February in this year. The only difficulty is that up to this time the committee have not made up their minds how to act to enforce the law so broken and defied. Finally, Mr. Tait says: "Instead of this, he appealed to outside authority in such fashion as led to most discreditable proceeding’s." This is exactly what I did not do. Truly, Mr. Tait’s knowledge of Liverpool medical affairs is at present not altogether accurate. He had better change his correspondent.--I am, Sir, yours obediently, THOMAS F. GRIMSDALE. Liverpool, Sept. 18th, 1886. The correspondence on the above subject must now
tion by either the rectum or the vagina; and thirdly, by effusion into the peritoneal cavity if the haematocelebe subperitoneal. Fatal results rarely take place when by the second method the tumour is incompletely evacuated, and inflammatory phenomena and septicaemia ensue. The termination by effusion into the peritoneal cavity, while grave, is also maintained to be very rare. Ilaematocele may cause death, but according to Nonat that result is rare. In fifteen cases of undoubted hasmatocele which came under his observation but one resulted in death, and this was associated with tubal pregnancy. In suitable cases, Nonat is in favourof the treatment of hasmatocele by puncture. Now, if simple puncture (aspiration) of a hæmatocele gives such favourable results, surely the exigencies demanding the formidable operation of removal of the uterine appendages must be rare indeed. I am one of those who believe that a highly culpable amount of surgical interference with the uterus and its appendages obtains in these days, that many lives are sacrificed in this manner at the shrine of " brilliant surgery," and that the recent reprobation of such interference is justly merited. Of course all this is quite apart from sympathy for Dr. Imlach, as it must not be forgotten that it is a very simple matter for the most careful, themost skilful, and the most conscientious to become entangled in the meshes of the law. 1 am, Sir, faithfully yours, D. CAMPBELL BLACK, BLACK. Glasgow, Sept. 4th, 1886.
that time she got up, and very soon resumed her household duties, to which she has been attending since without the slightest symptom of ill-health. Is it in such cases as this that Mr. Lawson Tait, and those who think with him, would proceed to the performance of so grave an operation as that of removal of theuterine appendages"? On referring to an admirable book which I have beside me (" Traité pratique des Maladies de l’Uterus et de ses Annexes,") by Nonat, I find the following opinions on this subject. "Peri-uterine hæmatocele terminates - rarely in death." In referring to the terminations of haamatocele, this authority points out how at the menstrual period the symptoms are aggravated; and a second cause of recrudescence is noted as arising from the process of absorption, which Dupuytren has compared to that of digestion. Left to itself, three methods of termination are noted: first, by absorption of the effused blood; second, by evacua-
and
NATURE AND TREATMENT OF FLAT-FOOT. To the Editor of THE LANCET. SIR,—Mr. Mayo Collier contends that because a movement forwards of the astragalus on the os calcis is impossible when the sole is resting on a horizontal surface, therefore the flattening of the foot is primarily due to an alteration in the position of the latter bone caused by raising the heel above the level of the sole, as is done by the conventional boot. While fully agreeing that the deformity is not due to laxity of the ligaments, I would point out some objections cease.-ED. L. to his view of the cause and to the treatment, based on that view, which he proposes. SUBPERITONEAL HÆMATOCELE. The astragalus does not in flat-foot move forwards so To the Editor of THE LANCET. much as downwards and inwards. Prof. Humphry has deSIR,—In common evidently with many other members of scribed in THE LANCET of March 20th, 1886, a dissected the profession, I was very much surprised at the statement specimen then before him. Moreover, take an ordinary caseof incipient valgus, of weak ankles, as it is called—alwaysa of Mr. Lawson Tait, in giving evidence in a recent case, to be easily found where children are,-and let the subject of that " 95 per cent. of cases subperitoneal haematocele are stand barefooted on a level surface, with the full weight of fatal without operation," the operation indicated being the body on one foot: then raise the anterior part by removal of the " uterine apendages." My attention was placing the hand beneath, or by any imitation of the sole attracted to the statement by the following circumstances :- which Mr. Collier describes; it will be seen that the deA few weeks ago I requested Dr. Stirton, of this city, to see formity is not diminished. Now let the child spring on tipit will be seen that the arch is distinctly improved. a case with which I was unwilling for certain reasons to be toe ; Because the heel is and the body supported Why ? professionally associated. A tumour in the right iliac in that position, not only, raised, as commonly stated, by the to was some as and there was diagnosed, uncertainty region muscles acting on the heel, but also by the tibialis posticus, its nature. With the view of elucidating matters, Dr. The tendons of these Stirton inserted a fine trocar and cannula of Dieulafoy’s the long flexors, and the peronei. muscles can be felt as they start out behind either malleolus, oozed the A small of blood aspirator. through quantity and are, in relation to the arch, as bow-strings to a trocar, but it had all the characters of effused blood, bow:they the ligaments are thus relieved of the heavy strain and a subperitoneal hæmatocele was at once pronounced to exist. Aspiration was immediately proceeded with, and which the weight of the body would otherwise throw on about twenty ounces of dark fetid blood were removed them. It is by this agency that the arch of the foot is without difficulty. Rest being enforced, the patient passed maintained in good walking.l By this agency, indeed, the about ten days in bed without a bad symptom. After arch, which hardly exists in infancy, is formed, and by it
by it alone, can the structure in manent manner be restored.
a
satisfactory and per-
I say, then, that as much vigorous but well-directed exercise as can be properly borne, and not " as much rest as possible," is the right treatment. The patient should when sitting, or better when lying, be directed to forcibly invert the foot, and flex the toes as much and as often as can be done; the surgeon or nurse should occasionally see how much resistance can be overcome in doing this. He (or, a& is more likely, she) should learn as soon as possible to spring up on tiptoe, sustaining the position awhile and then gradually sinking on the heel, and should learn, if he must stand, to stand on the toes. To raise a weight by means of a cord running over pulleys is, for the purpose in view, of all exercises the best; the object is that the weight 1 I discussed at length the Physiology of the Feet in THE LANCET of June 28th, 1884.
an
article in
tion by either the rectum or the vagina; and thirdly, by effusion into the peritoneal cavity if the haematocelebe subperitoneal. Fatal results rarely take place when by the second method the tumour is incompletely evacuated, and inflammatory phenomena and septicaemia ensue. The termination by effusion into the peritoneal cavity, while grave, is also maintained to be very rare. Ilaematocele may cause death, but according to Nonat that result is rare. In fifteen cases of undoubted hasmatocele which came under his observation but one resulted in death, and this was associated with tubal pregnancy. In suitable cases, Nonat is in favourof the treatment of hasmatocele by puncture. Now, if simple puncture (aspiration) of a hæmatocele gives such favourable results, surely the exigencies demanding the formidable operation of removal of the uterine appendages must be rare indeed. I am one of those who believe that a highly culpable amount of surgical interference with the uterus and its appendages obtains in these days, that many lives are sacrificed in this manner at the shrine of " brilliant surgery," and that the recent reprobation of such interference is justly merited. Of course all this is quite apart from sympathy for Dr. Imlach, as it must not be forgotten that it is a very simple matter for the most careful, themost skilful, and the most conscientious to become entangled in the meshes of the law. 1 am, Sir, faithfully yours, D. CAMPBELL BLACK, BLACK. Glasgow, Sept. 4th, 1886.
that time she got up, and very soon resumed her household duties, to which she has been attending since without the slightest symptom of ill-health. Is it in such cases as this that Mr. Lawson Tait, and those who think with him, would proceed to the performance of so grave an operation as that of removal of theuterine appendages"? On referring to an admirable book which I have beside me (" Traité pratique des Maladies de l’Uterus et de ses Annexes,") by Nonat, I find the following opinions on this subject. "Peri-uterine hæmatocele terminates - rarely in death." In referring to the terminations of haamatocele, this authority points out how at the menstrual period the symptoms are aggravated; and a second cause of recrudescence is noted as arising from the process of absorption, which Dupuytren has compared to that of digestion. Left to itself, three methods of termination are noted: first, by absorption of the effused blood; second, by evacua-
and
NATURE AND TREATMENT OF FLAT-FOOT. To the Editor of THE LANCET. SIR,—Mr. Mayo Collier contends that because a movement forwards of the astragalus on the os calcis is impossible when the sole is resting on a horizontal surface, therefore the flattening of the foot is primarily due to an alteration in the position of the latter bone caused by raising the heel above the level of the sole, as is done by the conventional boot. While fully agreeing that the deformity is not due to laxity of the ligaments, I would point out some objections cease.-ED. L. to his view of the cause and to the treatment, based on that view, which he proposes. SUBPERITONEAL HÆMATOCELE. The astragalus does not in flat-foot move forwards so To the Editor of THE LANCET. much as downwards and inwards. Prof. Humphry has deSIR,—In common evidently with many other members of scribed in THE LANCET of March 20th, 1886, a dissected the profession, I was very much surprised at the statement specimen then before him. Moreover, take an ordinary caseof incipient valgus, of weak ankles, as it is called—alwaysa of Mr. Lawson Tait, in giving evidence in a recent case, to be easily found where children are,-and let the subject of that " 95 per cent. of cases subperitoneal haematocele are stand barefooted on a level surface, with the full weight of fatal without operation," the operation indicated being the body on one foot: then raise the anterior part by removal of the " uterine apendages." My attention was placing the hand beneath, or by any imitation of the sole attracted to the statement by the following circumstances :- which Mr. Collier describes; it will be seen that the deA few weeks ago I requested Dr. Stirton, of this city, to see formity is not diminished. Now let the child spring on tipit will be seen that the arch is distinctly improved. a case with which I was unwilling for certain reasons to be toe ; Because the heel is and the body supported Why ? professionally associated. A tumour in the right iliac in that position, not only, raised, as commonly stated, by the to was some as and there was diagnosed, uncertainty region muscles acting on the heel, but also by the tibialis posticus, its nature. With the view of elucidating matters, Dr. The tendons of these Stirton inserted a fine trocar and cannula of Dieulafoy’s the long flexors, and the peronei. muscles can be felt as they start out behind either malleolus, oozed the A small of blood aspirator. through quantity and are, in relation to the arch, as bow-strings to a trocar, but it had all the characters of effused blood, bow:they the ligaments are thus relieved of the heavy strain and a subperitoneal hæmatocele was at once pronounced to exist. Aspiration was immediately proceeded with, and which the weight of the body would otherwise throw on about twenty ounces of dark fetid blood were removed them. It is by this agency that the arch of the foot is without difficulty. Rest being enforced, the patient passed maintained in good walking.l By this agency, indeed, the about ten days in bed without a bad symptom. After arch, which hardly exists in infancy, is formed, and by it
by it alone, can the structure in manent manner be restored.
a
satisfactory and per-
I say, then, that as much vigorous but well-directed exercise as can be properly borne, and not " as much rest as possible," is the right treatment. The patient should when sitting, or better when lying, be directed to forcibly invert the foot, and flex the toes as much and as often as can be done; the surgeon or nurse should occasionally see how much resistance can be overcome in doing this. He (or, a& is more likely, she) should learn as soon as possible to spring up on tiptoe, sustaining the position awhile and then gradually sinking on the heel, and should learn, if he must stand, to stand on the toes. To raise a weight by means of a cord running over pulleys is, for the purpose in view, of all exercises the best; the object is that the weight 1 I discussed at length the Physiology of the Feet in THE LANCET of June 28th, 1884.
an
article in