- Email: [email protected]
SUPPURATIVE GONOCOCCAL ARTHRITIS IN A CHILD.
238
CLINICAL AND LABORATORY NOTES heart.
A CASE OF RECURRING SPONTANEOUS
Some adhesions may of
course
have been
present on each occasion and have been ruptured by the high pressure, but no evidence of this was present on the second occasion and none of the usual
PNEUMOTHORAX WITH ACUTE PRESSURE SYMPTOMS.
after-effects occurred. This contrasts with the usual experience in treatment by artificial pneumoMEDICAL SUPERINTENDENT, CREATON SANATORIUM, thorax, so often cut short by the development of NORTHAMPTON. obliterative pleurisy, and it would have been expected that during the course of slow re-expansion after the first attack some adhesions would have formed. IN spontaneous pneumothorax due to tuberculosis It may be that repeated punctures, variations in the air gains entrance to the pleural space through intrapleural pressure, and prolonged collapse of the a breach in the visceral pleura following the breaking to pleural thickening and subsequent predispose lung down of a subpleural focus. The rupture may be adhesions ; cases, however, have been described in small and rapidly closed by the resultant retraction which collapse has been obtained several months of the lung ; or large and remain patent ; or it may after an artificial pneumothorax had been allowed be valvular. In the first case, intrathoracic pressure to re-expand. will be little changed ; in the second, free communicainto the pleural cavity was diagnosed tion will exist between the air in the bronchi and that and none was formed on the occasion, in the pleura so that pressure will be atmospheric and second occasion in spite of presumably severe conthe degree of collapse variable ; in the third case, an tamination from the and irritation by the presence increasing positive pressure will result with maximal of a needle for manylung days. The rupture through the collapse and its results. Introduction into the visceral pleura would to have been of a pleura of contaminated air and products of the valvular nature-in view appear of the persistently increasing causative disease is usually followed by the formaand it is likely that compensation of fluid or pus. If distress is severe, relief is intrapleural pressure, tion occurred when the rupture became fully patent obtained by inserting a needle through the chest wall rather than when it healed or was closed by comand allowing some of the air to escape. The following pression. As usual in a tuberculous pneumothorax case showed a combination of unusual features. there was no precipitating factor causing rise in A. B., aged 21. No family history of tuberculosis. Both pressure on either occasion. Complained of cough and lassitude 18 months previously, intrapulmonary occurred while the was at rest in bed. patient but continued at work until very slight haemoptysis occurredattacks I BY H. SELBY, M.B., B.S.LOND.,
first onNotheexudation
six months ago when the sputum was examined and foundiI to contain tubercle bacilli. He was ordered to stay in bed, and shortly afterwards developed a spontaneous left pneumoSUPPURATIVE GONOCOCCAL ARTHRITIS thorax with apparent complete collapse of the lung great displacement of the heart. He remained in bedi IN A CHILD. for six months, and was admitted into this sanatoriumI on June 18th, 1930. On admission his condition was i temperature 97°-99° F., pulse-rate 90-110, BY JAMES CROOKS, M.B. EDIN., F.R.C.S. ENG., moderate, signs of active tuberculosis in both lungs, left lung fully SURGICAL REGISTRAR, THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET, LONDON ; re-expanded, heart normal in position. On July 29th, 1930, he suddenly became AND complaining of pain in the left chest and difficulty of breathing. was that diagnosed. During A. GORDON SIGNY, M.R.C.S. ENG., Spontaneous pneumothorax I night his condition becoming gradually worse a pneumo- CLINICAL ASSISTANT IN THE VENEREAL DISEASES DEPARTMENT thorax needle was introduced, a small positive pressure OF THE HOSPITAL. was found, and complete relief was obtained by letting i out some air. Next morning the dyspnoea increased and the pulse became feeble ; a needle was again inserted, 1400 c.cm. THIS case seems worthy of record in view of the of air being allowed slowly to escape, the final mean pressure I of gonococcal suppuration in joints as a being reduced to atmospheric. During the next few hours I his condition steadily deteriorated, dyspnoea was in children. It is of complication pulse bad, cyanosis considerable, and the impulse of the of this condition that has been only example heart could be felt only in the right axilla. The needle was i in an experience of over 15 years and 250 cases reintroduced and connected by a tube to a bottle of weakseen I antiseptic at the bedside. On this occasion the pressure vulvo-vaginitis, at the Hospital for Sick Children. was too high to be read on the water manometer. The Leesl also reports that " in 200 cases of David urgent symptoms soon passed off and the patient remained comfortable, the latter half of each inspiratory act being vulvo-vaginitis no cases of arthritis had occurred, as accompanied by a stream of bubbles into the bottle. although some American workers give On each subsequent day, tests were made to see whether high as 40-50 per cent." compensation had been established, by partial or complete A girl, 4t years, came to the Hospital comclamping of the tube leading from the needle, and while the patient was asleep ; but on each occasion, and also plaining of swelling and pain of the right on two occasions when the needle became blocked by serum, for 10 days. The mother stated that both knees, the attempt resulted in the return of alarming symptoms. the left wrist, and the right ankle had been similarly On the ninth day partial clamping of the tube could be but less inflamed the last three weeks ; severely tolerated with the assistance of narcotics, and on the tenth had subsided treatment. without For one was still the needle removed, cyanosis being marked, they day temperature 100° F., pulse-rate 130-140, respiration 40-48. month there had been a vaginal discharge. Re-expansion of the lung was slow, X ray showing The child looked ill, but the temperature and collapse with the heart still on the right side of the sternum four weeks later, and collapse of the upper half of the lung pulse were normal. The right wrist was red, swollen, and some mediastinal displacement eight weeks later. hot, and tender, and movement was exquisitely
and
collapsed,
I
urgent,rarity the
vulvo-vaginitis
I of
figures
eventually
aged
wrist-joint
during
complete
The swelling, which was fluctuant, was most of the first attack of left spontaneous painful. marked on the dorsum of the wrist. The left wrist pneumothorax was confirmed by the patient’s own was slightly swollen, and its movements were limited, doctor, Dr. Mary C. Elliot, who noted complete 1 Lees, D.: THE LANCET, 1931, i., 640. collapse of the lung with great displacement of the
The
history
239 but it was not painful, nor was there fluctuation. to t the right, and the right ovary palpable. On the leftThe knees and ankles were normal. Radiography of fside there was a hard tender mass about the size of a t orange. the right wrist showed no bony change. The wrist tangerine The abdomen was opened under intrathecal percaine on 3 c.cm. and of was aspirated purulent synovial fluidNov. 21st. To the large uterus lying well to the right There was a purulent vulvo-side were withdrawn. s was attached at the normal site a healthy right ovary I patent tube. There was no evidence of a left tube or vaginitis, and vaginal swabs were taken. In bothand ovary. Low down on the left a somewhat pear-shaped mass, the vaginal smear and the joint fluid gonococci andits end firmly bound to the rectum and Douglas’s , upper many pus cells were present. Blood culture was’1pouch by dense adhesions and its lower end apparently : to the upper part of the cervix was dissected out as far fixed negative. Both wrist-joints were immobilised, and gonococcalas its neck, on division of which a thick, chocolate-coloured, I foul-smelling fluid escaped from small openings in vaccine in doses ranging from 2l millions to 75slightly both cut. surfaces. The remaining lower portion of the millions were given at weekly intervals. The vulvo-mass was densely adherent in its upper part to the cervix and in the base of its inferior expanded portion to va,ginitis was treated by Protargol packs and daily medially the vaginal wall. On removal it consisted of a smooth T. solution. No further with chloramine douching thick-walled sac-the walls being twice as thick where they aspiration of the wrist-joint was necessary. But for enclosed a small opening superiorly. It contained a similar On superimposition and section of the two parts a temporary increase in swelling of the left wrist fluid. of the mass, it was seen to comprise a uterus and cervix on the fourth and fifth days the inflammation in 2 in. and a vagina 1 in. long. Dissection on the joints subsided rapidly, so that they were normal measuring its left side revealed an ovary and tube densely matted in appearance and function in a fortnight. The to the uterus and to each other. The patient made a vaginal discharge ceased, and within three months normal recovery and was discharged on Dec. 6th. repeated vaginal smears were negative to gonococci. , It is difficult to reconstruct the sequence of events We have to thank Mr. E. I. Lloyd and Dr. Nabarro in Case 2 which undoubtedly represents a condition of uterus didelphys. It seems more reasonable to for permission to publish this note. suppose from the presence of the pent-up menstrual fluid that the puerperal inflammatory attack had in the closure of a previously existing interresulted TWO CASES OF UTERUS DIDELPHYS. of which there was no trace in the orifice, vaginal BY G. S. WOODMAN, M.B. DURH., F.R.C.S. EDIN., right vagina, than that the menses had regularly escaped into the abdomen till the tube was closed SENIOR SURGEON, ROYAL HOSPITAL, BAGDAD; CHIEF SURGICAL SPECIALIST, IRAQ. by the inflammatory process. Whatever the explanation it is remarkable that the right uterus and its suffered so little from the inflammation THE following are two unusual examples of uterus appendages as compared with the left, presumably due to better didelphys :— natural drainage. CASE 1. Complete uterus didelphys with double vagina.It may be of interest to record that apart from the A woman, aged 20, married six years, was admitted to the in Case 2, who was a Muslim, all my patients patient on of Royal Hospital, Bagdad, April 4th, 1931, complaining sterility. Apart from scanty three-day menses recurring with gross malformation of uterus and vagina have every 20-25 days, there was nothing of note in the history, been Nestorian Christians (Assyrians). The latest and she was a well-developed young woman with normal is that of a case of uterus bicornis whose abdomen secondary sexual characteristics. Per vaginam, above a small cervix, a shade larger than the tip of my second I explored on August 10th, 1931, suspecting an ectopic linger, there was no central body but on either side and gestation. I found, instead, a pregnancy in the apparently attached to it, a small pear-shaped mass, and horn and on Dec. 4th she was delivered of lateral to these easily palpable ovaries. No visual vaginal right female twins. The explanation of the greaterexamination was made. At operation on May 4th (intrathecal percaine) two mobile " half " uteri, widely separated incidence amongst Christians is, I think, to be found above were found to be fused just above the cervix. Each in their greater willingness to submit to examination was about 2 in. long and had in the normal site a patent and not to any degeneracy of the Assyrians who, tube and normal ovary. A slice was removed from the medial surface of each down to a point where both cavities although since 1917 they can hardly be described_ met and the remaining musculature of each half sutured as a tribal community, are a strong virile race with. together without difficulty or tension. Ten days later a no signs of excessive interbreeding. probe introduced into the cervix readily reached the new fundus. On withdrawing the speculum, I noticed an I wish to thank the Inspector-General of Health’ aperture,in. in diameter, to the right of the vagina. Digital in Iraq for permission to publish this note Services exploration demonstrated that this was the narrowed ostium of a right-sided vagina, of considerably smaller bore than the left, from which it was separated by a stout septum I
the upper end of which intervened between two cervices, i both completely circular. Probes passed into each met I LYMiNGTON COTTAGE HOSPITAL.-Extensions and in the middle line immediately above them. of this hospital have just been comimprovements It is evident that the paring of the two halves prior to A new wing has been added containing six. their suture was not carried low enough to disclose the pleted. wards and the private necessary accompaniments, and:. presence of the right-sided cervix, which had not, but should with money left by the late Mr. Barklie Henry and given have been discovered before operation. by his family, an operating theatre, X ray and massage; CASE 2. Removal of the left half of a uterus didelphys departments have been provided. seven months after labour in the right half.-A patient, aged 30, NORTH STAFFORDSHIRE RADIUM CENTRE.-The was admitted to the Royal Hospital, Bagdad, on Nov. 17th, 1931, complaining of pain in the left hypogastrium of seven North Staffordshire Royal Infirmary has been recognised’. months’ duration. Married 13 years, her first pregnancy as a regional radium centre, with the use of oIJ500(W had terminated seven months before admission, in the worth of radium. A deficit of oIJ947 on the year’s working birth at the eighth month of a girl who died on the twelfth of the hospital brings up the accumulated deficit to oil9684. day. A stormy puerperium, with fever, left-sided pain and The total cost of each in-patient last year was
z.
CLINICAL AND LABORATORY NOTES heart.
A CASE OF RECURRING SPONTANEOUS
Some adhesions may of
course
have been
present on each occasion and have been ruptured by the high pressure, but no evidence of this was present on the second occasion and none of the usual
PNEUMOTHORAX WITH ACUTE PRESSURE SYMPTOMS.
after-effects occurred. This contrasts with the usual experience in treatment by artificial pneumoMEDICAL SUPERINTENDENT, CREATON SANATORIUM, thorax, so often cut short by the development of NORTHAMPTON. obliterative pleurisy, and it would have been expected that during the course of slow re-expansion after the first attack some adhesions would have formed. IN spontaneous pneumothorax due to tuberculosis It may be that repeated punctures, variations in the air gains entrance to the pleural space through intrapleural pressure, and prolonged collapse of the a breach in the visceral pleura following the breaking to pleural thickening and subsequent predispose lung down of a subpleural focus. The rupture may be adhesions ; cases, however, have been described in small and rapidly closed by the resultant retraction which collapse has been obtained several months of the lung ; or large and remain patent ; or it may after an artificial pneumothorax had been allowed be valvular. In the first case, intrathoracic pressure to re-expand. will be little changed ; in the second, free communicainto the pleural cavity was diagnosed tion will exist between the air in the bronchi and that and none was formed on the occasion, in the pleura so that pressure will be atmospheric and second occasion in spite of presumably severe conthe degree of collapse variable ; in the third case, an tamination from the and irritation by the presence increasing positive pressure will result with maximal of a needle for manylung days. The rupture through the collapse and its results. Introduction into the visceral pleura would to have been of a pleura of contaminated air and products of the valvular nature-in view appear of the persistently increasing causative disease is usually followed by the formaand it is likely that compensation of fluid or pus. If distress is severe, relief is intrapleural pressure, tion occurred when the rupture became fully patent obtained by inserting a needle through the chest wall rather than when it healed or was closed by comand allowing some of the air to escape. The following pression. As usual in a tuberculous pneumothorax case showed a combination of unusual features. there was no precipitating factor causing rise in A. B., aged 21. No family history of tuberculosis. Both pressure on either occasion. Complained of cough and lassitude 18 months previously, intrapulmonary occurred while the was at rest in bed. patient but continued at work until very slight haemoptysis occurredattacks I BY H. SELBY, M.B., B.S.LOND.,
first onNotheexudation
six months ago when the sputum was examined and foundiI to contain tubercle bacilli. He was ordered to stay in bed, and shortly afterwards developed a spontaneous left pneumoSUPPURATIVE GONOCOCCAL ARTHRITIS thorax with apparent complete collapse of the lung great displacement of the heart. He remained in bedi IN A CHILD. for six months, and was admitted into this sanatoriumI on June 18th, 1930. On admission his condition was i temperature 97°-99° F., pulse-rate 90-110, BY JAMES CROOKS, M.B. EDIN., F.R.C.S. ENG., moderate, signs of active tuberculosis in both lungs, left lung fully SURGICAL REGISTRAR, THE HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET, LONDON ; re-expanded, heart normal in position. On July 29th, 1930, he suddenly became AND complaining of pain in the left chest and difficulty of breathing. was that diagnosed. During A. GORDON SIGNY, M.R.C.S. ENG., Spontaneous pneumothorax I night his condition becoming gradually worse a pneumo- CLINICAL ASSISTANT IN THE VENEREAL DISEASES DEPARTMENT thorax needle was introduced, a small positive pressure OF THE HOSPITAL. was found, and complete relief was obtained by letting i out some air. Next morning the dyspnoea increased and the pulse became feeble ; a needle was again inserted, 1400 c.cm. THIS case seems worthy of record in view of the of air being allowed slowly to escape, the final mean pressure I of gonococcal suppuration in joints as a being reduced to atmospheric. During the next few hours I his condition steadily deteriorated, dyspnoea was in children. It is of complication pulse bad, cyanosis considerable, and the impulse of the of this condition that has been only example heart could be felt only in the right axilla. The needle was i in an experience of over 15 years and 250 cases reintroduced and connected by a tube to a bottle of weakseen I antiseptic at the bedside. On this occasion the pressure vulvo-vaginitis, at the Hospital for Sick Children. was too high to be read on the water manometer. The Leesl also reports that " in 200 cases of David urgent symptoms soon passed off and the patient remained comfortable, the latter half of each inspiratory act being vulvo-vaginitis no cases of arthritis had occurred, as accompanied by a stream of bubbles into the bottle. although some American workers give On each subsequent day, tests were made to see whether high as 40-50 per cent." compensation had been established, by partial or complete A girl, 4t years, came to the Hospital comclamping of the tube leading from the needle, and while the patient was asleep ; but on each occasion, and also plaining of swelling and pain of the right on two occasions when the needle became blocked by serum, for 10 days. The mother stated that both knees, the attempt resulted in the return of alarming symptoms. the left wrist, and the right ankle had been similarly On the ninth day partial clamping of the tube could be but less inflamed the last three weeks ; severely tolerated with the assistance of narcotics, and on the tenth had subsided treatment. without For one was still the needle removed, cyanosis being marked, they day temperature 100° F., pulse-rate 130-140, respiration 40-48. month there had been a vaginal discharge. Re-expansion of the lung was slow, X ray showing The child looked ill, but the temperature and collapse with the heart still on the right side of the sternum four weeks later, and collapse of the upper half of the lung pulse were normal. The right wrist was red, swollen, and some mediastinal displacement eight weeks later. hot, and tender, and movement was exquisitely
and
collapsed,
I
urgent,rarity the
vulvo-vaginitis
I of
figures
eventually
aged
wrist-joint
during
complete
The swelling, which was fluctuant, was most of the first attack of left spontaneous painful. marked on the dorsum of the wrist. The left wrist pneumothorax was confirmed by the patient’s own was slightly swollen, and its movements were limited, doctor, Dr. Mary C. Elliot, who noted complete 1 Lees, D.: THE LANCET, 1931, i., 640. collapse of the lung with great displacement of the
The
history
239 but it was not painful, nor was there fluctuation. to t the right, and the right ovary palpable. On the leftThe knees and ankles were normal. Radiography of fside there was a hard tender mass about the size of a t orange. the right wrist showed no bony change. The wrist tangerine The abdomen was opened under intrathecal percaine on 3 c.cm. and of was aspirated purulent synovial fluidNov. 21st. To the large uterus lying well to the right There was a purulent vulvo-side were withdrawn. s was attached at the normal site a healthy right ovary I patent tube. There was no evidence of a left tube or vaginitis, and vaginal swabs were taken. In bothand ovary. Low down on the left a somewhat pear-shaped mass, the vaginal smear and the joint fluid gonococci andits end firmly bound to the rectum and Douglas’s , upper many pus cells were present. Blood culture was’1pouch by dense adhesions and its lower end apparently : to the upper part of the cervix was dissected out as far fixed negative. Both wrist-joints were immobilised, and gonococcalas its neck, on division of which a thick, chocolate-coloured, I foul-smelling fluid escaped from small openings in vaccine in doses ranging from 2l millions to 75slightly both cut. surfaces. The remaining lower portion of the millions were given at weekly intervals. The vulvo-mass was densely adherent in its upper part to the cervix and in the base of its inferior expanded portion to va,ginitis was treated by Protargol packs and daily medially the vaginal wall. On removal it consisted of a smooth T. solution. No further with chloramine douching thick-walled sac-the walls being twice as thick where they aspiration of the wrist-joint was necessary. But for enclosed a small opening superiorly. It contained a similar On superimposition and section of the two parts a temporary increase in swelling of the left wrist fluid. of the mass, it was seen to comprise a uterus and cervix on the fourth and fifth days the inflammation in 2 in. and a vagina 1 in. long. Dissection on the joints subsided rapidly, so that they were normal measuring its left side revealed an ovary and tube densely matted in appearance and function in a fortnight. The to the uterus and to each other. The patient made a vaginal discharge ceased, and within three months normal recovery and was discharged on Dec. 6th. repeated vaginal smears were negative to gonococci. , It is difficult to reconstruct the sequence of events We have to thank Mr. E. I. Lloyd and Dr. Nabarro in Case 2 which undoubtedly represents a condition of uterus didelphys. It seems more reasonable to for permission to publish this note. suppose from the presence of the pent-up menstrual fluid that the puerperal inflammatory attack had in the closure of a previously existing interresulted TWO CASES OF UTERUS DIDELPHYS. of which there was no trace in the orifice, vaginal BY G. S. WOODMAN, M.B. DURH., F.R.C.S. EDIN., right vagina, than that the menses had regularly escaped into the abdomen till the tube was closed SENIOR SURGEON, ROYAL HOSPITAL, BAGDAD; CHIEF SURGICAL SPECIALIST, IRAQ. by the inflammatory process. Whatever the explanation it is remarkable that the right uterus and its suffered so little from the inflammation THE following are two unusual examples of uterus appendages as compared with the left, presumably due to better didelphys :— natural drainage. CASE 1. Complete uterus didelphys with double vagina.It may be of interest to record that apart from the A woman, aged 20, married six years, was admitted to the in Case 2, who was a Muslim, all my patients patient on of Royal Hospital, Bagdad, April 4th, 1931, complaining sterility. Apart from scanty three-day menses recurring with gross malformation of uterus and vagina have every 20-25 days, there was nothing of note in the history, been Nestorian Christians (Assyrians). The latest and she was a well-developed young woman with normal is that of a case of uterus bicornis whose abdomen secondary sexual characteristics. Per vaginam, above a small cervix, a shade larger than the tip of my second I explored on August 10th, 1931, suspecting an ectopic linger, there was no central body but on either side and gestation. I found, instead, a pregnancy in the apparently attached to it, a small pear-shaped mass, and horn and on Dec. 4th she was delivered of lateral to these easily palpable ovaries. No visual vaginal right female twins. The explanation of the greaterexamination was made. At operation on May 4th (intrathecal percaine) two mobile " half " uteri, widely separated incidence amongst Christians is, I think, to be found above were found to be fused just above the cervix. Each in their greater willingness to submit to examination was about 2 in. long and had in the normal site a patent and not to any degeneracy of the Assyrians who, tube and normal ovary. A slice was removed from the medial surface of each down to a point where both cavities although since 1917 they can hardly be described_ met and the remaining musculature of each half sutured as a tribal community, are a strong virile race with. together without difficulty or tension. Ten days later a no signs of excessive interbreeding. probe introduced into the cervix readily reached the new fundus. On withdrawing the speculum, I noticed an I wish to thank the Inspector-General of Health’ aperture,in. in diameter, to the right of the vagina. Digital in Iraq for permission to publish this note Services exploration demonstrated that this was the narrowed ostium of a right-sided vagina, of considerably smaller bore than the left, from which it was separated by a stout septum I
the upper end of which intervened between two cervices, i both completely circular. Probes passed into each met I LYMiNGTON COTTAGE HOSPITAL.-Extensions and in the middle line immediately above them. of this hospital have just been comimprovements It is evident that the paring of the two halves prior to A new wing has been added containing six. their suture was not carried low enough to disclose the pleted. wards and the private necessary accompaniments, and:. presence of the right-sided cervix, which had not, but should with money left by the late Mr. Barklie Henry and given have been discovered before operation. by his family, an operating theatre, X ray and massage; CASE 2. Removal of the left half of a uterus didelphys departments have been provided. seven months after labour in the right half.-A patient, aged 30, NORTH STAFFORDSHIRE RADIUM CENTRE.-The was admitted to the Royal Hospital, Bagdad, on Nov. 17th, 1931, complaining of pain in the left hypogastrium of seven North Staffordshire Royal Infirmary has been recognised’. months’ duration. Married 13 years, her first pregnancy as a regional radium centre, with the use of oIJ500(W had terminated seven months before admission, in the worth of radium. A deficit of oIJ947 on the year’s working birth at the eighth month of a girl who died on the twelfth of the hospital brings up the accumulated deficit to oil9684. day. A stormy puerperium, with fever, left-sided pain and The total cost of each in-patient last year was
z.