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WEST LONDON HOSPITAL.
CLINICAL NOTES.-HOSPITAL MEDICINE AND SURGERY.
1099
follows : (1) the parts were well scrubbed with warm waterwhen she felt faint but experienced no pain. At 11 A. 31. and soap ; (2) all traces of soap and grease were removed by she was collapsed and the pulse at the wrist was impera thorough cleansing with methylated ether ; and (3) the ceptible, the temperature was 97-60 F., the femoral pulse was legs were wrapped up from the ankles to the groins 84, and the respirations were 20. She was given 30 minims Two with towels impregnated with carbolic acid 1 in 40 of tincture of opium and one drachm of adrenalin. (none of the acid in any shape or form had ever been hours later she was evidently weaker and as a fatal applied to the patient before). Being of a nervous disposi- syncope was feared she was given a rectal injection the child cried vigorously while these proceedings were tion of half a pint of normal saline solution containing taking place. At 12 o’clock it was noticed that she became one ounce of brandy, and the foot of the bed was quiet and drowsy. At 12 55 P.m. when conveyed to the raised. The injection was returned with a large melaenic theatre on an ambulance for operation she was still quiet, motion. There was no vomiting or diarrhoea or abdominal listless, and drowsy. This condition was thought at the rigidity or pain, and the condition was thought to be one of At 2 P.M. she was time to be due either to exhaustion from crying or possibly hæmorrhage from a duodenal ulcer. to the presence of adenoids. At 1.5 P.M. the anaesthetist evidently sinking and was given a hypodermic injection of arrived and the administration of chloroform was commenced. strychnine and half an ounce of brandy by the bowel ; she On examining the patient she was found to be apparently was intravenously infused with two pints of normal saline fast asleep. She could not be made to speak and she took solution and was ordered 20 minims of liquor opii sedativus no notice of smart blows oil the hand. She was found to be and half a drachm of adrenalin every four hours. Great imquite unconscious ; the pupils were dilated, the pulse was provement followed the infusion, but the improvement was feeble and rapid, and respiration was quiet. She was taken only temporary and she gradually sank and died at 7.30 P.M., back to bed at once. Mr. F. T. Paul saw her immediately 12 hours after the onset of the acute symptoms. afterwards and found her cyanosed and practically pulseless. Necropsy.-At the necropsy a large perforation of the size On consultation with Dr. J. H. Abram and Mr. Rushton of half-a-crown was found on the posterior wall of the Parker it was decided that the case was one of carbolic cardiac end of the stomach, opening into the lesser sac of acid poisoning due to external application. The carbolised the peritoneum, which was filled with blood. The foramen towels were at once removed, when the parts were found to of Winslow had become occluded and there was no blood or be very pale. Stimulants-viz, a drachm of brandy by gas in the general peritoneal cavity. There was no perithe mouth every half hour until consciousness had been tonitis. The ulcer was apparently of an acute necrotic regained, drinks of hot tea frequently, a subcutaneous nature, as there was no thickening of the edges. There was injection of five minims of ether, hot bottles to the ex- practically no blood in the stomach or intestines. CASE 2.-The patient, a male, aged 54 years, was admitted tremities, and a mustard plaster on the præcordia-were administered without delay. Some urine was drawn off but to the West London Hospital on Nov. 22nd, 1902, under the no carboluria was present. At 3.30 P.M. the patient began care of Dr. A. E. Russell. On Nov. 15th Dr. G. P. Shuter met to recover and to regain control over the bladder and rectum the patient outside his consulting-room, ’I’1lnning to ask his which, before this, had been moved involuntarily. About advice as to a severe pain in the abdomen with which he had 4 P.M. vomiting commenced but nothing peculiar could be been suddenly seized. He was supporting his abdomen with detected in the vomit The patient now began to improve his hands as he ran. Dr. Shuter ordered him to return at rapidly. At 5 P.M. another specimen of urine was obtained once to his house and to go to bed and within a very short which was found to be of a pale green colour, gradually time visited him and found him in the following condition. becoming darker on exposure to air and light. On chemical The patient had a good colour and did not present the examination it responded to the usual tests for carboluria. abdominal facies ; there was no collapse, the pulse being 60 All subsequent samples during the next 24 hours gave the and of good strength, and the temperature and respirations same results, thus verifying the diagnosis. The patient were normal. There was no history of previous indigestion The bowels had been or abdominal trouble of any kind. recovered completely. Liverpool. opened that morning and he passed urine naturally and without pain. The tongue was moist and clean. There had been no vomiting. He complained of intense pain in the right hypochondrium, close under the ribs, which was worse On examining the abdomen it was on taking a deep breath. found to be distended, globular, and of stony hardness, but OF the legs were not drawn up and there was no tenderness. The abdomen was resonant all over, but there was no loss HOSPITAL of liver dulness. There were no physical signs in the chest. BRITISH AND FOREIGN. The slow pulse and absence of collapse or tenderness seemed to put perforating duodenal ulcer, which was first thought Nulla autem est alia pro certo noscendi via, nisi quamplurimas et of, out of the question, and as hot fomentations to the morborum et dissectionum historias, tum aliorum tum proprias abdomen caused considerable relief hepatic colic was suscollectas -habere, et inter se comparare.-MORGAGNI De Sed. et Ca1t8. pected. The patient remained in this condition for two days lib. Proœmium. Morb., v., with the bowels constipated and with a pulse varying from 65 to 80. On the 17th a simple soap-and-water enema was WEST LONDON HOSPITAL. given, which resulted in a copious normal solid motion, followed about an hour afterwards by a large clay-coloured solid THREE CASES OF PERFORATING PEPTIC ULCER WITH motion. From this time diarrhoea set in and the abdomen ATYPICAL SYMPTOMS. became quite soft and readily palpable and the pain ceased. of Dr. SEYMOUR care Dr. A. E. the TAYLOR, RUSSELL, (Under The patient felt very weak and the temperature fell to 96°. Dr. DONALD W. C. HOOD, and Mr. L. BIDWELL.) On the 20th the abdomen became more distended, the FOR the notes of the cases we are indebted to Mr. Hugh tongue was furred, and the diarrhoea was very frequent and offensive. No improvement occurring during the next two Wansey Bayly, late house physician. CASE 1.-The patient, a female, aged 48 years, married, days the patient was taken to the West London Hospital after having been ill for seven days. No opium was given at was admitted to the West London Hospital on Nov. 21st, 1902, time for fear of masking the symptoms. On admission under the care of Dr. Seymour Taylor. She gave a history any the patient looked extremely ill ; he had a dry coated tongue, of occasional indigestion for some years but no previous his pulse was 88 and of fair strength, his temperature was hsematemesis. On admission the patient stated that she had normal, and his respirations were 28. He was frequently had a severe hæmatemesis on Nov. 15th, since when she had passing liquid offensive greenish yellow motions into the bed. been fed by the rectum but had nevertheless had a severe On examination the abdomen was found to be distended and haemorrhage from the bowel on the 19th. She was very resonant and there was a distinct sense of increased resistanaemic and had evidently lost a large quantity of blood. ance on bimanual palpation of the right loin. There was The pulse was of fair strength and of normal rate. She com- cedema over the lower part of the chest, extending a little plained of epigastric tenderness, Pspecially at a point just to above the angle of the scapula behind, but not extending the right of the middle line. Gastric ulcer was diagnosed further forward than the anterior axillary line. On percussion and the patient was fed by nutrient enemata but was allowed a dull note was obtained posteriorly over the base of the right She was lung below the angle of the scapula with diminished breath one ounce of water by the mouth every four hours. apparently progressing favourably till 7 A.M. on the 25th sounds. The liver dulness and the cardiac dulness were
Mirror A
PRACTICE,
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1100
HOSPITAL MEDICINE AND SURGERY.
normal. There was a very slight tenderness on deep palpation of the right hypochondrium and a small amount of free fluid in the abdominal cavity was suspected. There were no cough and no vomiting. A provisional diagnosis of per. forating duodenal ulcer was made by Dr. Russell, but after consultation with Mr. McAdam Eccles the symptoms were not considered sufficiently definite to justify an abdominal operation in the patient’s weak condition. Among the many diagnoses that were suggested by gentlemen who examined the patient were subphrenic abscess, empyema, peritoneal abscess, empyema of the gall-bladder, acute pancreatitis, liver abscess, and appendicitis. On the following morning the abdomen was distended, the pulse was 96 and rather weaker, the respirations were 32, the temperature was normal, and the patient was passing liquid, very offensive motions every few minutes. A starch and opium enema was administered and digitalis was given by the mouth and strychnine hypodermically. The enema was returned but was repeated half an hour afterwards and this was not returned for an hour. On the following day there was still no abdominal pain or tenderness or diminution of the liver dulness. There was an extension upwards of the dulness over the right base behind, and on exploring below the angle of the scapula a drachm of sero-purulent fluid was obtained which was found to contain pus cells and some diplococci. The oedema extended as far forward as the nipple line and on to the abdominal wall in the right hypochondrium. In the evening the general condition was unchanged. The temperature was 97.2°, the pulse was 80, and the respirations were 40. From this time the patient gradually sank and died on the following
altogether changed from the healthy one of the day before, Her pulse was unaltered-viz., 120-but her temperature had risen to 100.2°. The patient felt very ill and complained of great thirst but there was no vomiting.
The abdomen was not distended but there was distinct rigidity of the abdominal wall above the level of the. umbilicus and although the abdomen moved slightly with respiration, the movement was certainly less than normal. There was no loss of liver dulness. It was thought that the condition was probably one of perforation of a duodenal ulcer, and as Mr. Bayly was unable to communicate with Dr. Hood he sent directly to Mr. L. Bidwell, who came at once and considering that surgical interference was indicated began the operation at 7 A.M., just two hours after the perforation had presumably occurred. An incision from five to six inches long was made over the right rectus, extending down below the umbilicus, and the muscular fibres were separated and the peritoneum was opened. The duodenum was searched for a. perforation, the lesser omental sac being opened, but beyond a little redness of the peritoneum nothing abnormal was discovered. The ulcer was discovered on the anteiior surface of the stomach near the lesser curvature. It was extremely hard and thickened so as almost to give the feel of a malignant growth. The contraction produced by the ulcer had caused an hour-glass contraction of the stomach, the narrowed portion only just admitting the index finger on invagination of the stomach walls. The perforation was situated in the middle of the ulcer and would only just admit a probe-pointed director. There had been apparently no extravasation of gastric contents and there was only some slight redness of the surrounding peritoneum. morning. Necropsy.-On opening the abdomen the intestines were The perforation was closed by silk sutures taking up sound found to be greatly matted together and scattered over them stomach wall on each side and so invaginating the ulcer. and also amongst the coils were numerous collections of The transverse mesocolon was opened with the object of thick green pus. A large ulcer was found just below the performing a posterior gastro-jejunostomy, which was, howpyloric sphincter and involving the sphincter itself, and a ever. found to be impracticable owing to the position of the perforation of the size of a threepenny-bit was seen imme- incision to the right of the linea alba, and the condition of diately beyond the sphincter from which the contents of the the patient did not warrant a second incision and consequent stomach were oozing. The duodenum was dark in colour protracted operation. A gauze drain was left in, leading to and the mucous membrane was injected. There was no sign the site of the ulcer, and the wound in the parietes was of malignancy about the ulcer or the surrounding tissue. sutured in three layers. The patient’s condition five hours There was a large collection of pus in the right lumbar after the operation was extremely bad. She could retain no and right hypochondriac regions ; also between the nutriment by the rectum and was continually calling for the liver and the lower surface of the diaphragm there was bed-pan and passing very dark liquid motions. The pulse another large collection of pus pressing on the liver was 144 and small. A pint of normal saline solution was but not damaging the liver tissue. There was apparently infused into the axillae every four hours. On the following no connexion between the abdominal and pleural cavities day she retained the nutrient enemata somewhat better and but there was some free fluid in the right pleural cavity and at this stage her temperature was 99°, but towards evening there was also a large collection of thick pus between the it rose and at 6 P.m. and 10 P. At. it was 102°, with a pulse of middle and lower lobes of the right lung. A small patch of 132 and 100 respectively. She died at 2 A.M. tubercle was found at the apex of the left lung. Necropsy -The peritoneum in the immediate neighbourCASE 3.-A single woman, aged 24 years, was admitted to hood of the perforation was injected, but beyond this there On opening the stomach the no sign of peritonitis. the West London Hospital on Nov. 23rd, 1902, under the care of Dr. Donald Hood. On admission the patient gave a history extreme hour-glass condition was very apparent, the stomach of indigestion on and off for eight years, during which wall at the site of the constriction being greatly thickened period she had occasionally vomited after food ; she had so that this false pylorus was completely surrounded by a a slight hæmatemesis in August, 1902. She had always been cicatricial ring. There were no signs of recent haemorrhage troubled with constipation. She was a healthy-looking, and this was the only ulcer present. well-nourished young woman, of a good colour, and with no Remarks by Mr. BAYLY.-Case 1 shows that gastric symptoms of anaemia. She stated that her present attack perforation can occur without the production of any pain or began a week before admission with pain in the epi- abdominal symptoms of any kind. The one melænic motion gastrium and vomiting and that again on Nov. 21st she following the enema of normal saline solution was the only had a severe, sudden, sharp abdominal pain, followed direct evidence of a haemorrhage into the alimentary tract. by a slight hasmatemesis. Since then her motions had Case 2 is interesting as showing (1) that in a condition of been dark-coloured. On examination of the abdomen acute septic peritonitis there may be practically a normal nothing abnormal was found with the exception of diffuse pulse and temperature and also that vomiting and abdominal epigastric tenderness ; there was a particularly tender spot tenderness are not necessary symptoms of this condition ; opposite the eighth costal cartilage on the left side. The (2) that collapse does not always accompany perforapulse was 120, the respirations were 32, and the temperature tion, for perforation in all probability must have occurred was 99.4° F. The patient was placed on rectal feeding and nine days before death and immediately before Dr. appeared to be progressing satisfactorily till the middle of Shuter met the patient running to consult him ; and the second day after admission when she passed a large (3) that a peptic ulcer on the point of perforating may A drachm of adrenalin and 20 have caused no digestive or abdominal symptoms whatever. fluid melænic motion. minims of tincture of opium were given by the mouth and With regard to Case 3, here also collapse did not follow as the melæna continued four-hourly doses of half a drachm perforation, for the temperature half an hour after perof adrenalin and 20 minims of liquor opii sedativus were foration had risen to 100.2°. The change in the aspect of The the patient was the most valuable indication of perforation. There was no vomiting or hæmatemesis. ordered. pulse and temperature remained practically as on admission The presence of melæna without hæmatemesis or vomiting but the respirations had fallen to 22. At 5 A.M. on the was evidently due to the hæmorrhage occurring on the following morning she was seized with a sudden sharp pain pyloric side of the constriction produced by the ulcer. In in the right hypochondrium whilst using the bed pan and none of the three cases was there obliteration of the liver when Mr. Bayly saw her at 5.30 A.M. she looked ill and had dulness. My best thanks are due to Dr. Hood, to Dr. a pinched and anxious expression and her appearance had Seymour Taylor, to Dr. Russell, and to Mr. Bidwell for their
was
PATHOLOGICAL SOCIETY OF LONDON.
courtesy
in
permitting me history
Dr. Shuter for the
publish these cases, and to of Case 2 before admission to to
Medical Societies.
hospital.
PATHOLOGICAL
MEXBOROUGH COTTAGE HOSPITAL. A CASE
OF
(Under the
1101
FRACTURED PATELLA, WITH HINTS POST-OPERATIVE TREATMENT.
ON
THE
SOCIETY
OF
LONDON.
The Relation
of Carcinoma to Nerve -Distribution or Trophic Areas.-Supp2crative Meningitis due to Streptothrix Infection -Angioma of the Brain.-The Nature of the Nuclear Vacuolation in Fat Cells.-Rupture of Aortic Aneurysm into the Pulmonary Artery. --Ritpture of Acrtic Aneurysm into the Superior Vena Cava.-Rupture of Thoracic Ane2crysm into the Stomach.-Adenoma of the
of Mr. BERTRAM CROSSFIELD STEVENS.) ON Feb. 8th Mr. B. Crossfield Stevens was asked to see a On interrogation the’e man who had fractured his patella. who was in a man his prime, said that stout, healthy patient, whilst leading a pony out of the "pit bottom" the animal Liver.-Congenital Absence of the Gall-bladdcr. stepped on to his flexed knee with its forefoot and broke his A MEETING of this society was held on April 7th, Sir JOHN knee-cap. The patient managed to limp out of the pit BURDON SANDERSON, F.R.S., the President, being in the At first there was a chair. and medical aid was requisitioned. Mr. G. L. CHEATLE, C.B., read a paper on the Relation separation of about four inches, but on arrival at the hosof Carcinoma to Nerve Distribution. He said that there when Mr. Stevens saw the was him, pital, separation only were two main features to which he wished to draw about one inch ; the fracture was transverse and the joint attention. Firstly there were a large proportion of cases was moderately swollen. After the advisability of having of carcinoma which showed a marked relationship between the bone wired was explained the patient consented. After the spread of the primary focus and the distribution 24 hours’ rest operation was performed. A four-inch longi- of nerves and trophic areas. Arising out of this observatudinal incision was made down to the bone ; this was tion was the practical issue that the extent of these followed by a gush of synovial fluid and serum. The areas should be taken into consideration in marking out broken edges of the patella were well scraped and cleared incisions when removal of cancer was contemplated. The of soft tissue by a sharp spoon. Two stout silver wires were now attached to the lymphatic pathways of importance then inserted through holes bored at each end of the fragdistribution was not detracted from by the addition of ments-care being taken not to involve the posterior articular another factor. Secondly, there was some reason to think surface of the patella-and the fragments were brought into that the incidence of cancer within a nerve area was not a close apposition. The soft tissues and tendinous expansion fortuitous circumstance but that it might be due to direct or of the quadriceps extensor were stitched over the wires and indirect nervous influence over that area. A series of lantern the wound was closed. The limb was placed on a back-splint slides of rodent ulcers and carcinoma, affecting, and more or and foot-piece. On the eighth day the skin stitches were less limited to, the area of supply of certain nerves, was then removed, the splint was taken off and left off, and passive shown. In the tongue when cancer began on one side of movements were begun. At the end of the second week that organ its growth was often remarkably limited by the the patient was wheeling himself about in a chair with middle line, and the epithelium at the tip of the tongue on both legs hanging down. At the end of the third week he was walking about with two crutches and was sent the side of the disease often remained free from infiltration. With regard to the second point-viz., that there was some home. that carcinoma might originate in a On March 20th, or five and a half weeks after the accident, reason for inferring of the nerve influence over that the patient went to see Mr. Stevens, having walked one and nerve area as the result area-Mr. Cheatle instanced cases in which the fifth a quarter miles from the hospital where he had been to nerve areas, either singly or combined, were the seats of report himself. He looked the picture of content and discrete rodent ulcers. He considered that he had gratitude. He walked up and down a steep flight of stairs multiple with ease and only complained of a little stiffness in the shown that there was reason to believe that the genesis tendons of the ham. He could flex the knee perfectly, but and spread of cancer might be intimately connected with the nerve influences which presided over the areas affected.Mr. Stevens advised him not to flex it beyond a right angle McADAM EOOLES referred to a case reported by Mr. for a little while. He had only an ordinary walking-stick Mr. W. a rodent ulcer affected the area. of and stated that he was going to walk home, a distance of A. A. Bowlby in which distribution of the roots of the spinal nerves. He posterior quite two miles. The patella seemed to be quite firm and thought that there was considerable importance in the nothing could be felt of the wires. made by Mr. Cheatle but he considered that Remarks by Mr. STEVENS. -Cases of fracture of the patella suggestions was to be attached to the association with in which the after-condition of the patient is not all that more importance the of fissures. locality congenital could be desired are still seen and read about. The chief Dr. C. E. BEEVOR and Dr. E. FARQUHAR BUZZARD trouble undoubtedly is the stiffness of the knee-joint consedescribed a case of Basal Meningitis due to Streptothrix quent on the too tardy application of passive movements. Infection. A woman, aged 37 years, three weeks before Bearing this in mind I resolved that, ca-terzs paribus, this I to hospital had severe attacks of vomiting followed should not be my misfortune in any case of which I had admission next day by headache and pain in the back of the neck. the care. The case reported above is intended to emphasise The pain gradually increased and the neck became rigid. double and that and by wiring early passive my statement as follows. The head and neck were held active movements a successful issue can be attained in Her condition was but there was no definite retraction of the head. stiffly, time. Two wires the good through double-quick knee-cap There was no optic neuritis ; the vision was . There was can be relied on with much more certainty than oneof the left eyelid with narrowing of the palpebral firstly, in performing passive movements early, and, fissure and limitation of the movements of the left eye. secondly, in leaving the patella to itself to unite firmly of the right eye outwards was defective, with at leisure. Plaster-of-Paris should not be used when the coarse nystagmoid conjugate movements in all directions splint is taken off. There was diplopia in especially to the right. care
I
ptosis Movement and looking
ROYAL UNITED HOSPITAL, BATH.-A special meeting of the subscribers to this institution was held on April 2nd, when the question of the visiting of patients in the city parishes of Bath by the resident medical staff was discussed. A proposal made at the annual meeting to abolish the practice met with considerable opposition. Eventually it was unanimously resolved to relieve the resident staff of the hospital from the duty and to appoint an additional salaried medical officer specially for the purpose. A number of subscriptions to meet the additional cost
was
promised.
The pupils were up, down, or to the left. and reacted to light and accommodation, but There was no the left pupil again dilated rapidly. paralysis of other cranial nerves. There was no paralysis of the limbs, but considerable tremor in extending the left upper limb. There were no wasting and no rigidity. The deep reflexes were all There was no anesthesia. well marked and the plantar reflexes were flexor in type. The sphincters were not affected. The temperature was irregular and ranged from 98 4° to 103 4°F., rising to 105 at the end. Three days after admission she became worse and passed into a state of stupor with retraction of the head and arching of the spine. She died, having been
equal
1099
follows : (1) the parts were well scrubbed with warm waterwhen she felt faint but experienced no pain. At 11 A. 31. and soap ; (2) all traces of soap and grease were removed by she was collapsed and the pulse at the wrist was impera thorough cleansing with methylated ether ; and (3) the ceptible, the temperature was 97-60 F., the femoral pulse was legs were wrapped up from the ankles to the groins 84, and the respirations were 20. She was given 30 minims Two with towels impregnated with carbolic acid 1 in 40 of tincture of opium and one drachm of adrenalin. (none of the acid in any shape or form had ever been hours later she was evidently weaker and as a fatal applied to the patient before). Being of a nervous disposi- syncope was feared she was given a rectal injection the child cried vigorously while these proceedings were tion of half a pint of normal saline solution containing taking place. At 12 o’clock it was noticed that she became one ounce of brandy, and the foot of the bed was quiet and drowsy. At 12 55 P.m. when conveyed to the raised. The injection was returned with a large melaenic theatre on an ambulance for operation she was still quiet, motion. There was no vomiting or diarrhoea or abdominal listless, and drowsy. This condition was thought at the rigidity or pain, and the condition was thought to be one of At 2 P.M. she was time to be due either to exhaustion from crying or possibly hæmorrhage from a duodenal ulcer. to the presence of adenoids. At 1.5 P.M. the anaesthetist evidently sinking and was given a hypodermic injection of arrived and the administration of chloroform was commenced. strychnine and half an ounce of brandy by the bowel ; she On examining the patient she was found to be apparently was intravenously infused with two pints of normal saline fast asleep. She could not be made to speak and she took solution and was ordered 20 minims of liquor opii sedativus no notice of smart blows oil the hand. She was found to be and half a drachm of adrenalin every four hours. Great imquite unconscious ; the pupils were dilated, the pulse was provement followed the infusion, but the improvement was feeble and rapid, and respiration was quiet. She was taken only temporary and she gradually sank and died at 7.30 P.M., back to bed at once. Mr. F. T. Paul saw her immediately 12 hours after the onset of the acute symptoms. afterwards and found her cyanosed and practically pulseless. Necropsy.-At the necropsy a large perforation of the size On consultation with Dr. J. H. Abram and Mr. Rushton of half-a-crown was found on the posterior wall of the Parker it was decided that the case was one of carbolic cardiac end of the stomach, opening into the lesser sac of acid poisoning due to external application. The carbolised the peritoneum, which was filled with blood. The foramen towels were at once removed, when the parts were found to of Winslow had become occluded and there was no blood or be very pale. Stimulants-viz, a drachm of brandy by gas in the general peritoneal cavity. There was no perithe mouth every half hour until consciousness had been tonitis. The ulcer was apparently of an acute necrotic regained, drinks of hot tea frequently, a subcutaneous nature, as there was no thickening of the edges. There was injection of five minims of ether, hot bottles to the ex- practically no blood in the stomach or intestines. CASE 2.-The patient, a male, aged 54 years, was admitted tremities, and a mustard plaster on the præcordia-were administered without delay. Some urine was drawn off but to the West London Hospital on Nov. 22nd, 1902, under the no carboluria was present. At 3.30 P.M. the patient began care of Dr. A. E. Russell. On Nov. 15th Dr. G. P. Shuter met to recover and to regain control over the bladder and rectum the patient outside his consulting-room, ’I’1lnning to ask his which, before this, had been moved involuntarily. About advice as to a severe pain in the abdomen with which he had 4 P.M. vomiting commenced but nothing peculiar could be been suddenly seized. He was supporting his abdomen with detected in the vomit The patient now began to improve his hands as he ran. Dr. Shuter ordered him to return at rapidly. At 5 P.M. another specimen of urine was obtained once to his house and to go to bed and within a very short which was found to be of a pale green colour, gradually time visited him and found him in the following condition. becoming darker on exposure to air and light. On chemical The patient had a good colour and did not present the examination it responded to the usual tests for carboluria. abdominal facies ; there was no collapse, the pulse being 60 All subsequent samples during the next 24 hours gave the and of good strength, and the temperature and respirations same results, thus verifying the diagnosis. The patient were normal. There was no history of previous indigestion The bowels had been or abdominal trouble of any kind. recovered completely. Liverpool. opened that morning and he passed urine naturally and without pain. The tongue was moist and clean. There had been no vomiting. He complained of intense pain in the right hypochondrium, close under the ribs, which was worse On examining the abdomen it was on taking a deep breath. found to be distended, globular, and of stony hardness, but OF the legs were not drawn up and there was no tenderness. The abdomen was resonant all over, but there was no loss HOSPITAL of liver dulness. There were no physical signs in the chest. BRITISH AND FOREIGN. The slow pulse and absence of collapse or tenderness seemed to put perforating duodenal ulcer, which was first thought Nulla autem est alia pro certo noscendi via, nisi quamplurimas et of, out of the question, and as hot fomentations to the morborum et dissectionum historias, tum aliorum tum proprias abdomen caused considerable relief hepatic colic was suscollectas -habere, et inter se comparare.-MORGAGNI De Sed. et Ca1t8. pected. The patient remained in this condition for two days lib. Proœmium. Morb., v., with the bowels constipated and with a pulse varying from 65 to 80. On the 17th a simple soap-and-water enema was WEST LONDON HOSPITAL. given, which resulted in a copious normal solid motion, followed about an hour afterwards by a large clay-coloured solid THREE CASES OF PERFORATING PEPTIC ULCER WITH motion. From this time diarrhoea set in and the abdomen ATYPICAL SYMPTOMS. became quite soft and readily palpable and the pain ceased. of Dr. SEYMOUR care Dr. A. E. the TAYLOR, RUSSELL, (Under The patient felt very weak and the temperature fell to 96°. Dr. DONALD W. C. HOOD, and Mr. L. BIDWELL.) On the 20th the abdomen became more distended, the FOR the notes of the cases we are indebted to Mr. Hugh tongue was furred, and the diarrhoea was very frequent and offensive. No improvement occurring during the next two Wansey Bayly, late house physician. CASE 1.-The patient, a female, aged 48 years, married, days the patient was taken to the West London Hospital after having been ill for seven days. No opium was given at was admitted to the West London Hospital on Nov. 21st, 1902, time for fear of masking the symptoms. On admission under the care of Dr. Seymour Taylor. She gave a history any the patient looked extremely ill ; he had a dry coated tongue, of occasional indigestion for some years but no previous his pulse was 88 and of fair strength, his temperature was hsematemesis. On admission the patient stated that she had normal, and his respirations were 28. He was frequently had a severe hæmatemesis on Nov. 15th, since when she had passing liquid offensive greenish yellow motions into the bed. been fed by the rectum but had nevertheless had a severe On examination the abdomen was found to be distended and haemorrhage from the bowel on the 19th. She was very resonant and there was a distinct sense of increased resistanaemic and had evidently lost a large quantity of blood. ance on bimanual palpation of the right loin. There was The pulse was of fair strength and of normal rate. She com- cedema over the lower part of the chest, extending a little plained of epigastric tenderness, Pspecially at a point just to above the angle of the scapula behind, but not extending the right of the middle line. Gastric ulcer was diagnosed further forward than the anterior axillary line. On percussion and the patient was fed by nutrient enemata but was allowed a dull note was obtained posteriorly over the base of the right She was lung below the angle of the scapula with diminished breath one ounce of water by the mouth every four hours. apparently progressing favourably till 7 A.M. on the 25th sounds. The liver dulness and the cardiac dulness were
Mirror A
PRACTICE,
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1100
HOSPITAL MEDICINE AND SURGERY.
normal. There was a very slight tenderness on deep palpation of the right hypochondrium and a small amount of free fluid in the abdominal cavity was suspected. There were no cough and no vomiting. A provisional diagnosis of per. forating duodenal ulcer was made by Dr. Russell, but after consultation with Mr. McAdam Eccles the symptoms were not considered sufficiently definite to justify an abdominal operation in the patient’s weak condition. Among the many diagnoses that were suggested by gentlemen who examined the patient were subphrenic abscess, empyema, peritoneal abscess, empyema of the gall-bladder, acute pancreatitis, liver abscess, and appendicitis. On the following morning the abdomen was distended, the pulse was 96 and rather weaker, the respirations were 32, the temperature was normal, and the patient was passing liquid, very offensive motions every few minutes. A starch and opium enema was administered and digitalis was given by the mouth and strychnine hypodermically. The enema was returned but was repeated half an hour afterwards and this was not returned for an hour. On the following day there was still no abdominal pain or tenderness or diminution of the liver dulness. There was an extension upwards of the dulness over the right base behind, and on exploring below the angle of the scapula a drachm of sero-purulent fluid was obtained which was found to contain pus cells and some diplococci. The oedema extended as far forward as the nipple line and on to the abdominal wall in the right hypochondrium. In the evening the general condition was unchanged. The temperature was 97.2°, the pulse was 80, and the respirations were 40. From this time the patient gradually sank and died on the following
altogether changed from the healthy one of the day before, Her pulse was unaltered-viz., 120-but her temperature had risen to 100.2°. The patient felt very ill and complained of great thirst but there was no vomiting.
The abdomen was not distended but there was distinct rigidity of the abdominal wall above the level of the. umbilicus and although the abdomen moved slightly with respiration, the movement was certainly less than normal. There was no loss of liver dulness. It was thought that the condition was probably one of perforation of a duodenal ulcer, and as Mr. Bayly was unable to communicate with Dr. Hood he sent directly to Mr. L. Bidwell, who came at once and considering that surgical interference was indicated began the operation at 7 A.M., just two hours after the perforation had presumably occurred. An incision from five to six inches long was made over the right rectus, extending down below the umbilicus, and the muscular fibres were separated and the peritoneum was opened. The duodenum was searched for a. perforation, the lesser omental sac being opened, but beyond a little redness of the peritoneum nothing abnormal was discovered. The ulcer was discovered on the anteiior surface of the stomach near the lesser curvature. It was extremely hard and thickened so as almost to give the feel of a malignant growth. The contraction produced by the ulcer had caused an hour-glass contraction of the stomach, the narrowed portion only just admitting the index finger on invagination of the stomach walls. The perforation was situated in the middle of the ulcer and would only just admit a probe-pointed director. There had been apparently no extravasation of gastric contents and there was only some slight redness of the surrounding peritoneum. morning. Necropsy.-On opening the abdomen the intestines were The perforation was closed by silk sutures taking up sound found to be greatly matted together and scattered over them stomach wall on each side and so invaginating the ulcer. and also amongst the coils were numerous collections of The transverse mesocolon was opened with the object of thick green pus. A large ulcer was found just below the performing a posterior gastro-jejunostomy, which was, howpyloric sphincter and involving the sphincter itself, and a ever. found to be impracticable owing to the position of the perforation of the size of a threepenny-bit was seen imme- incision to the right of the linea alba, and the condition of diately beyond the sphincter from which the contents of the the patient did not warrant a second incision and consequent stomach were oozing. The duodenum was dark in colour protracted operation. A gauze drain was left in, leading to and the mucous membrane was injected. There was no sign the site of the ulcer, and the wound in the parietes was of malignancy about the ulcer or the surrounding tissue. sutured in three layers. The patient’s condition five hours There was a large collection of pus in the right lumbar after the operation was extremely bad. She could retain no and right hypochondriac regions ; also between the nutriment by the rectum and was continually calling for the liver and the lower surface of the diaphragm there was bed-pan and passing very dark liquid motions. The pulse another large collection of pus pressing on the liver was 144 and small. A pint of normal saline solution was but not damaging the liver tissue. There was apparently infused into the axillae every four hours. On the following no connexion between the abdominal and pleural cavities day she retained the nutrient enemata somewhat better and but there was some free fluid in the right pleural cavity and at this stage her temperature was 99°, but towards evening there was also a large collection of thick pus between the it rose and at 6 P.m. and 10 P. At. it was 102°, with a pulse of middle and lower lobes of the right lung. A small patch of 132 and 100 respectively. She died at 2 A.M. tubercle was found at the apex of the left lung. Necropsy -The peritoneum in the immediate neighbourCASE 3.-A single woman, aged 24 years, was admitted to hood of the perforation was injected, but beyond this there On opening the stomach the no sign of peritonitis. the West London Hospital on Nov. 23rd, 1902, under the care of Dr. Donald Hood. On admission the patient gave a history extreme hour-glass condition was very apparent, the stomach of indigestion on and off for eight years, during which wall at the site of the constriction being greatly thickened period she had occasionally vomited after food ; she had so that this false pylorus was completely surrounded by a a slight hæmatemesis in August, 1902. She had always been cicatricial ring. There were no signs of recent haemorrhage troubled with constipation. She was a healthy-looking, and this was the only ulcer present. well-nourished young woman, of a good colour, and with no Remarks by Mr. BAYLY.-Case 1 shows that gastric symptoms of anaemia. She stated that her present attack perforation can occur without the production of any pain or began a week before admission with pain in the epi- abdominal symptoms of any kind. The one melænic motion gastrium and vomiting and that again on Nov. 21st she following the enema of normal saline solution was the only had a severe, sudden, sharp abdominal pain, followed direct evidence of a haemorrhage into the alimentary tract. by a slight hasmatemesis. Since then her motions had Case 2 is interesting as showing (1) that in a condition of been dark-coloured. On examination of the abdomen acute septic peritonitis there may be practically a normal nothing abnormal was found with the exception of diffuse pulse and temperature and also that vomiting and abdominal epigastric tenderness ; there was a particularly tender spot tenderness are not necessary symptoms of this condition ; opposite the eighth costal cartilage on the left side. The (2) that collapse does not always accompany perforapulse was 120, the respirations were 32, and the temperature tion, for perforation in all probability must have occurred was 99.4° F. The patient was placed on rectal feeding and nine days before death and immediately before Dr. appeared to be progressing satisfactorily till the middle of Shuter met the patient running to consult him ; and the second day after admission when she passed a large (3) that a peptic ulcer on the point of perforating may A drachm of adrenalin and 20 have caused no digestive or abdominal symptoms whatever. fluid melænic motion. minims of tincture of opium were given by the mouth and With regard to Case 3, here also collapse did not follow as the melæna continued four-hourly doses of half a drachm perforation, for the temperature half an hour after perof adrenalin and 20 minims of liquor opii sedativus were foration had risen to 100.2°. The change in the aspect of The the patient was the most valuable indication of perforation. There was no vomiting or hæmatemesis. ordered. pulse and temperature remained practically as on admission The presence of melæna without hæmatemesis or vomiting but the respirations had fallen to 22. At 5 A.M. on the was evidently due to the hæmorrhage occurring on the following morning she was seized with a sudden sharp pain pyloric side of the constriction produced by the ulcer. In in the right hypochondrium whilst using the bed pan and none of the three cases was there obliteration of the liver when Mr. Bayly saw her at 5.30 A.M. she looked ill and had dulness. My best thanks are due to Dr. Hood, to Dr. a pinched and anxious expression and her appearance had Seymour Taylor, to Dr. Russell, and to Mr. Bidwell for their
was
PATHOLOGICAL SOCIETY OF LONDON.
courtesy
in
permitting me history
Dr. Shuter for the
publish these cases, and to of Case 2 before admission to to
Medical Societies.
hospital.
PATHOLOGICAL
MEXBOROUGH COTTAGE HOSPITAL. A CASE
OF
(Under the
1101
FRACTURED PATELLA, WITH HINTS POST-OPERATIVE TREATMENT.
ON
THE
SOCIETY
OF
LONDON.
The Relation
of Carcinoma to Nerve -Distribution or Trophic Areas.-Supp2crative Meningitis due to Streptothrix Infection -Angioma of the Brain.-The Nature of the Nuclear Vacuolation in Fat Cells.-Rupture of Aortic Aneurysm into the Pulmonary Artery. --Ritpture of Acrtic Aneurysm into the Superior Vena Cava.-Rupture of Thoracic Ane2crysm into the Stomach.-Adenoma of the
of Mr. BERTRAM CROSSFIELD STEVENS.) ON Feb. 8th Mr. B. Crossfield Stevens was asked to see a On interrogation the’e man who had fractured his patella. who was in a man his prime, said that stout, healthy patient, whilst leading a pony out of the "pit bottom" the animal Liver.-Congenital Absence of the Gall-bladdcr. stepped on to his flexed knee with its forefoot and broke his A MEETING of this society was held on April 7th, Sir JOHN knee-cap. The patient managed to limp out of the pit BURDON SANDERSON, F.R.S., the President, being in the At first there was a chair. and medical aid was requisitioned. Mr. G. L. CHEATLE, C.B., read a paper on the Relation separation of about four inches, but on arrival at the hosof Carcinoma to Nerve Distribution. He said that there when Mr. Stevens saw the was him, pital, separation only were two main features to which he wished to draw about one inch ; the fracture was transverse and the joint attention. Firstly there were a large proportion of cases was moderately swollen. After the advisability of having of carcinoma which showed a marked relationship between the bone wired was explained the patient consented. After the spread of the primary focus and the distribution 24 hours’ rest operation was performed. A four-inch longi- of nerves and trophic areas. Arising out of this observatudinal incision was made down to the bone ; this was tion was the practical issue that the extent of these followed by a gush of synovial fluid and serum. The areas should be taken into consideration in marking out broken edges of the patella were well scraped and cleared incisions when removal of cancer was contemplated. The of soft tissue by a sharp spoon. Two stout silver wires were now attached to the lymphatic pathways of importance then inserted through holes bored at each end of the fragdistribution was not detracted from by the addition of ments-care being taken not to involve the posterior articular another factor. Secondly, there was some reason to think surface of the patella-and the fragments were brought into that the incidence of cancer within a nerve area was not a close apposition. The soft tissues and tendinous expansion fortuitous circumstance but that it might be due to direct or of the quadriceps extensor were stitched over the wires and indirect nervous influence over that area. A series of lantern the wound was closed. The limb was placed on a back-splint slides of rodent ulcers and carcinoma, affecting, and more or and foot-piece. On the eighth day the skin stitches were less limited to, the area of supply of certain nerves, was then removed, the splint was taken off and left off, and passive shown. In the tongue when cancer began on one side of movements were begun. At the end of the second week that organ its growth was often remarkably limited by the the patient was wheeling himself about in a chair with middle line, and the epithelium at the tip of the tongue on both legs hanging down. At the end of the third week he was walking about with two crutches and was sent the side of the disease often remained free from infiltration. With regard to the second point-viz., that there was some home. that carcinoma might originate in a On March 20th, or five and a half weeks after the accident, reason for inferring of the nerve influence over that the patient went to see Mr. Stevens, having walked one and nerve area as the result area-Mr. Cheatle instanced cases in which the fifth a quarter miles from the hospital where he had been to nerve areas, either singly or combined, were the seats of report himself. He looked the picture of content and discrete rodent ulcers. He considered that he had gratitude. He walked up and down a steep flight of stairs multiple with ease and only complained of a little stiffness in the shown that there was reason to believe that the genesis tendons of the ham. He could flex the knee perfectly, but and spread of cancer might be intimately connected with the nerve influences which presided over the areas affected.Mr. Stevens advised him not to flex it beyond a right angle McADAM EOOLES referred to a case reported by Mr. for a little while. He had only an ordinary walking-stick Mr. W. a rodent ulcer affected the area. of and stated that he was going to walk home, a distance of A. A. Bowlby in which distribution of the roots of the spinal nerves. He posterior quite two miles. The patella seemed to be quite firm and thought that there was considerable importance in the nothing could be felt of the wires. made by Mr. Cheatle but he considered that Remarks by Mr. STEVENS. -Cases of fracture of the patella suggestions was to be attached to the association with in which the after-condition of the patient is not all that more importance the of fissures. locality congenital could be desired are still seen and read about. The chief Dr. C. E. BEEVOR and Dr. E. FARQUHAR BUZZARD trouble undoubtedly is the stiffness of the knee-joint consedescribed a case of Basal Meningitis due to Streptothrix quent on the too tardy application of passive movements. Infection. A woman, aged 37 years, three weeks before Bearing this in mind I resolved that, ca-terzs paribus, this I to hospital had severe attacks of vomiting followed should not be my misfortune in any case of which I had admission next day by headache and pain in the back of the neck. the care. The case reported above is intended to emphasise The pain gradually increased and the neck became rigid. double and that and by wiring early passive my statement as follows. The head and neck were held active movements a successful issue can be attained in Her condition was but there was no definite retraction of the head. stiffly, time. Two wires the good through double-quick knee-cap There was no optic neuritis ; the vision was . There was can be relied on with much more certainty than oneof the left eyelid with narrowing of the palpebral firstly, in performing passive movements early, and, fissure and limitation of the movements of the left eye. secondly, in leaving the patella to itself to unite firmly of the right eye outwards was defective, with at leisure. Plaster-of-Paris should not be used when the coarse nystagmoid conjugate movements in all directions splint is taken off. There was diplopia in especially to the right. care
I
ptosis Movement and looking
ROYAL UNITED HOSPITAL, BATH.-A special meeting of the subscribers to this institution was held on April 2nd, when the question of the visiting of patients in the city parishes of Bath by the resident medical staff was discussed. A proposal made at the annual meeting to abolish the practice met with considerable opposition. Eventually it was unanimously resolved to relieve the resident staff of the hospital from the duty and to appoint an additional salaried medical officer specially for the purpose. A number of subscriptions to meet the additional cost
was
promised.
The pupils were up, down, or to the left. and reacted to light and accommodation, but There was no the left pupil again dilated rapidly. paralysis of other cranial nerves. There was no paralysis of the limbs, but considerable tremor in extending the left upper limb. There were no wasting and no rigidity. The deep reflexes were all There was no anesthesia. well marked and the plantar reflexes were flexor in type. The sphincters were not affected. The temperature was irregular and ranged from 98 4° to 103 4°F., rising to 105 at the end. Three days after admission she became worse and passed into a state of stupor with retraction of the head and arching of the spine. She died, having been
equal