TWO CASES OF POST-OPERATIVE HEMIPLEGIA.

103 over the left sciatic notch. Treatment was applied here, and also on the right side. Aft,er 12 treatments he was able to attend two shoots without apparent damage or relapse. CASE 6.-The patient, aged 32, three weeks ago with a friend was lifting a heavy weight; the latter let go and the whole weight coming on the patient he strained his back. He had pain in the back for a few days, and this was followed by such severe pain in the sacro-iliac joint that he could not turn in bed, and could get no sleep for five nights. Now he has pain down the outer side of the thigh and calf, and pain in the dorsum of the foot. He could not bend the hip- joint with the knee-joint extended. There was a definite tender point just at the gluteus margin over the sciatic nerve. The patient had a good night after the first treatment, and now after 10 treatments is practically well except for the stiffness.

points in the course of the nerve, and to a tender patch probably due to fibrositis, which I often find in the gluteal or lumbar region in these

tender

cases.

These sparks are given with the patient standing the insulated platform, which is connected to the negative side of the machine, the positive side being grounded. A ball electrode held in the hand of the operator and also grounded is approached to within 4 or 5 inches of the spot to which the spark is to be applied. The patient feels a smart blow or cut as with a light whip, and is not apt to appreciate the treatment at first, but after experiencing the relief these sparks bring will often ask to have them repeated and point out the spot where they should be applied. This ends the treatment, which should be applied daily at first until marked improvement is obtained, when a treatment can be given twice weekly, bi-weekly, and finally stopped. This treatment is equally successful in neuritis of the arm, or in uncomplicated neuritis anywhere when a definite tender point can be found. As to the rationale of the treatment it is probable that the light causes hyperaemia of tissues deeper than the skin. This hypersemia followed by the deep, massage effect of the static wave current would remove and carry off in the blood current the, plastic exudate which is probably thrown out around the nerve in sciatica. The same forces would act in the same way in removing patches of on

I should add that all these patients went about their ordinary avocations, as far as they were able to do so, while the treatment was going on. I do not discourage a moderate amount of walking, nor do I object to attention to business. What I do find detrimental to most people is travelling by train or motor car. The method adopted is as follows. First it is necessary to find the definite tender point or points in the line of the sciatic nerve. These can be found (1) by direction of the patient, (2) by pressure, (3) by the use of the vibrator, and last and best by the use of the static spark; but this latter, if ’, attempted at the first consultation, may unfavourably impress a timid patient. Having found the tender point, the parts around it are exposed for 20 minutes to the rays of the fibrositis. In addition to this, however, it has been shown 500 candle-power light; this is applied as close to the bare skin as the patient can stand the heat, that the static wave current increases the haemoand by turning away the light for a moment, or by globin contents of the red corpuscles and increases passing the hand lightly over the skin a consider- the elimination of solids in the urine. While I able degree of tolerance can be established. The cannot say that I have myself made the necessary obvious effect is hyperasmia. After 20 minutes’ observations to confirm these statements, the conexposure to the light the patient is seated on a dition of improved health and vitality in patients chair on the insulated platform. An electrode of who are taking this treatment is so obvious, and so some easily moulded metal-I use pewter-is frequently pointed out by them with every evidence applied over the tender spot, usually about half way of satisfaction, that I cannot feel any doubt but between the great trochanter and the tuberosity of that, in addition to the local effects, general the ischium, or over the sacro-sciatic notch. The metabolic effects of a beneficial character are taking size of the electrode I generally use is 3 by place in the organism. Welbeck-street, W. 4-2L inches, but if the part is very tender a larger electrode will be better borne. An adequate static machine should be capable of TWO CASES OF POST-OPERATIVE giving a 12-inch spark in all weathers between the HEMIPLEGIA. terminal balls of the prime conductors when the the and this is connected to machine, spark patient BY A. WEBB JONES, M.D. LOND., F.R.C.S. ENG., should be capable of regulation down to inch, or SURGEON AND GYNÆCOLOGIST, GOVERNMENT HOSPITAL, ALEXANDRIA. With the less for particularly tender points. electrode applied to the patient’s skin and conHEMIPLEGIA as a post-operative complication nected by a wire to the positive side of the static must be so rare that the following two cases which machine, the negative side being grounded and the occurred in practice almost within the same spark gap closed, the motor is now started and the week seem tomy merit reporting. Both were patients spark gap gradually opened, keeping the number of at the Government Hospital, Alexandria. sparks passing at the gap at not more than 300 a CASE I.-The patient was an Egyptian woman, aged 40, minute at the outside, while 200 a minute is even from a large fibroid of the uterus. Operation was suffering better. on Sept. 15th, 1913, in the raised pelvis position. performed The operator will not have opened the spark gap The tumour involved the supravaginal cervix, which was very far, in all probability, before the patient will greatly expanded, and was associated with a tubo-ovarian complain of pain. When this point is reached the abscess on the right side. The operation was extremely spark gap is closed again until the patient says he difficult and lasted almost two hours. A gauze drain was left feels just a little tenderness, and at this point it is in for 48 hours. The wound healed without suppuration, but the first week following operation the temperature kept for five minutes or so, when the spark gap can for was slightly raised, ranging from 37’6C. (evening) to be this time with probably less disagain widened, 37-2° (morning). The operation was done at 9 A.M. At comfort to the patient. The treatment by the static 5 P.M. the patient complained of pain in the right arm and wave current is kept up for 20 minutes, or less if leg, which by the next morning had given place to complete the patient shows signs of fatigue. I then go on, if loss of. power and sensation. Four days later there was I deem it advisable, to give a few static sparks to some return of power in the arm, whilst sensation comthe muscles of the buttocks and thigh, to any menced to come back on the twenty-fourth day. Recovery

104 from the paralysis in the arm was good and rapid. Improvement in the lower limb was much slower and less complete, but she left hospital on Oct. 29th walking fairly well with the aid of a stick. CASE 2.--The patient was an old woman with a large ovarian cyst almost filling the abdomen. The cyst wall had ruptured, setting free a large quantity of colloid material into the general peritoneal cavity. The tumour had evidently undergone malignant changes, and masses like boiled sago had infiltrated the uterus and pouch of Douglas. The cyst was removed on Sept. 22nd, 1913. The operation

case slight or not at all. It would be out of place to go into the causation of post-operative thrombosis in general, but it appears to me that the anaemic condition of most cases of fibroids may be a predisposing factor, and, furthermore, if slowing of the blood stream be accepted as one of the causes, may not the modern fashion of adopting a semi-recumbent or sitting-up posture increase the tendency in the same direction’?: Alexandria.

simple and lasted less than an hour ; there was no shock. The Trendelenburg position was not employed. The operation was performed at 9 A.M. On the following morning she was noticed to have right hemiplegia (including the face) with aphasia. Coma with difficulty in swallowing appeared on, the next day, and death took place on the morning of the 26th. On the evening of the 25th the temperature, which had up to that point remained normal, rose to 37’7° C. Post mortem the entire, left cerebral hemisphere showed white softening ; there were no signs of haemorrhage. The aorta above the valve cusps presented slight atheromatous changes. There was no sign of sepsis in the peritoneum. was

SECONDARY HÆMORRHAGE FROM DEEP EPIGASTRIC ARTERY AFTER OPERATIONS FOR APPENDIX ABSCESS. BY J. O. SKEVINGTON, F.R.C.S. ENG., SURGEON TO KING EDWARD VII. HOSPITAL FOR WINDSOR.

The occurrence of two such rare accidents so each other at first suggested there must be some cause common to the conditions under which both operations were done. Beyond the fact, however, that the temperature in the theatre was extremely high and the humidity great, there was Much no striking peculiarity that I am aware of. the same conditions occur every August and September in Alexandria, and besides, on one of the intervening days (Sept. 18th) an ovariotomy for dermoid cyst with twisted pedicle was done by the same personnel and followed a normal course. near

As

regards the cause of the hemiplegia, one naturally first thought of the three common possibilities : haemorrhage, thrombosis, and embolism. There appears to me to be no special reason why cerebral haemorrhage should occur after operation, although one can imagine that at the time of operation the Trendelenburg position or vomiting might favour such an event. The post-mortem findings, too, in Case 2 put this out of the question. If embolism was responsible one has to imagine that a thrombus displaced from the pelvic veins either traversed the lung capillaries without producing symptoms, or else passed directly to the brain viâ a patent foramen ovale or ductus arteriosus. At the necropsy the foramen ovale was not noticed to be but unfortunately the hospital pathologist was not present, and my own attention was not I especially directed to that point. Schenk read a very complete paper on Thrombosis and Embolism following Operation at the American Gynaecological Society in 1913, and the subject was also touched on in the recent discussion on Bland-Sutton’s paper on the Visceral Complications in Hysterectomy for Fibroids at the Medical Society of London.’ One fact appears from the study of these papers, and that is that thrombosis and

patent,

pulmonary embolism

are

markedly

more common

after myoma than after other pelvic operations. Thus, in laparotomies for pelvic conditions of all kinds thrombosis occurs in 2’28 per cent., whereas after myoma operations the percentage rises to 3’7, or even 5 per cent. With regard to certain theories that have been put forward, it may be mentioned that in both my cases the abdominal wounds were sutured in layers. In the hysterectomy case the retraction of the ’, abdominal walls was vigorous,in the ovariotomy i

’,

.

1

THE LANCET, Nov. 1st, 1913,

pp. 1249, 1256.

I AM not aware that attention has been called to this most serious happening. On May 15th, 1913, I was called in by Dr. H. E. Giffard, of Egham, to operate on a boy, aged 16, suffering from a large appendix abscess. A secondary operation was required to open a collection of pus The boy was making per rectum a week later. good progress till the evening of the 25th, when I received an urgent message that he was bleeding badly. I found he had lost a large amount of blood, and it was spurting from the lower angle of the abdominal wound. This haemorrhage was controlled by compression between the finger and thumb till chloroform could be administered. Two deep thread sutures were then passed through the whole thickness of the abdominal wall at the inner edge of the wound, and all haemorrhage ceased. The boy made a good recovery. The second case occurred recently and was seen in consultation with Dr. D. H. Anderson and Dr. T. E. Cottu of Maidenhead. The patient, a strong young man, aged 28, had been operated on by Dr. Cottu on Dec. 3rd, 1913, for appendix abscess, the incision being the anterior vertical one through the rectus sheath. He made excellent progress till the afternoon of the 13th, when a large amount of haemorrhage occurred. Dr. Cottu examined the wound under an anaesthetic, and as the condition of the wound forbade any hope of direct ligature succeeded in arresting the bleeding by plugging. The patient’s condition was very serious. When seen the next day in consultation this plugging was removed and there were no signs of haemorrhage. As the whole area was in a most septic condition, it was judged advisable to keep the patient under close observation and not to disturb the parts further. On the evening of the 16th haemorrhage again occurred and came from the deep aspect of the abdominal wall at the lower angle of the wound. Ligatures failed to hold, and two large pairs of artery forceps were left on the bleeding spot. This controlled the haemorrhage, but in spite of transfusion the patient never rallied and died two hours later. Concl’usions.-Both operations were done by the vertical incision through the rectus sheath. In future in ,all cases in which this incision has to be carried somewhat low down, when the drainage-tube of necessity must lie in close proximity to the deep epigastric vessels, it is my intention to divide these vessels between ligatures when first seen. If immediate suture fails toarrest the bleeding it seems to me the obvious course is to tie the artery through a separate incision. In the first case