297 HOSPITAL MEDICINE AND SURGERY. No attempt was being made to absorb the discharges. There were puffiness of, the face and twitching of the tongue and mouth. The woman was experiencing difficulty in micturition. There was a blood-stained discharge from the vagina. The pulse-rate was nearly 150. On the back there was a black, sloughy bedsore. Death took place on the same evening. Marked tut evanescent eye symptoms, such as those described above, appear to be a very unusual feature of plague. Iritis and irido-cyclitis are rarely seen. In addition the above case is noticeable for the primary involvement of the supracondylar gland and the involvement nine days later of a femoral gland which on bursting gave exit to the typical discharge. Fatshan Hospital, South China. A Mirror OF HOSPITAL PRACTICE BRITISH AND FOREIGN. HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. A CASE OF PRIMARY PNEUMOCOCCAL PERITONITIS. (Under the care of Dr. A. E. GARROD and Mr. F. J. STEWARD.) Nuila autem eat alia pro certo noseendi via, nisi quamplurimna 81 morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparMe.—MoBaaNi De Sed. et Ca’lJ,8. Morb., lib. iv., Proaemium. - FOR the notes of the case we are indebted to Dr. H. J. D. Birkett, house physician. A girl, aged four years, was admitted to the Hospital for Sick Children, under the care of Dr. Garrod, just before midnight on July 4th last. The patient was in good health till 9 P.M. on July lst when she complained of feeling cold. About three hours later vomiting and diarrhcea set in, accompanied by severe abdominal pain. This attack was attributed by the mother to some gooseberry tart eaten at midday on the lst. On the 2nd some medicine was obtained from a druggist which stopped the diarrhoea and vomiting. The abdominal pain continued. On the 3rd the pain con- tinued and the vomiting recommenced. A medical man was called in and he found a temperature of 103° F. On the 4th the patient was worse and was taken to hospital. She had been delirious on and off since the 2nd and for the last 36 hours the mother had noticed that the abdominal pain was less marked after the patient had emptied her bladder. There was nothing of importance in the past or family history of the patient. On admission the child was quite delhious and so extremely restless and irritable that a thorough examination was almost impossible. The abdominal facies was well marked. There was a divergent squint and the alas nasi were working slightly with respiration. There was no evidence of mastoid disease. In the chest there were a few crepitations heard over the left base behind. Nothing else abnormal was found. With regard to the abdomen there was no distension ; movement was present, though not good. There was general tenderness, but when the child was momentarily at rest no rigidity could be made out. Rectal examination was negative. A small, loose, brown, offensive motion, the first since July 2nd, was passed immediately after the examination. The temperature was 100°, the pulse was 160, and the respirations were 40. The urine was normal. Morphine was administered hypodermically, and when this had taken effect the abdomen and rectum were again care- fully examined but no further information was gained. On the 5th the patient was seen by Dr. Garrod and subsequently by Mr. Steward in consultation. There was still no abdominal distension but there was more resistance and movement was absent. There was a small amount of free fluid in the peritoneal cavity. The optic discs were examined and found to be normal. The temperature was 99’4°, the pulse was 132, and the respirations were 28. A diagnosis of diffuse pneumococcal peritonitis was made and Mr. Steward per- formed a laparotomy during the afternoon. A good deal of thin pus was evacuated and gauze drains were inserted. Pneumococci in pure culture were grown from the pus found at the operation. The patient died on the same evening. Extract from post-mortcnc wotes.-There was early otitis media on both sides of the head. As to the thorax, in the right pleural cavity there were about one ounce of thin pus and some flaky masses of lymph, while the right lower JO.Je was coated with a similar layer of pyo-lymph. The lungs were congested and oedematous but not solid anywhere. There were many basmorrhagic infarcts in the left lung. With regard to the abdomen, there was early general peritonitis. No attempt had been made to shut off the inflammatory process, the only adhesions being a slight sticking together of the intestines in a few places. Thin pus bathed the whole of the contents, forming here and there sheets of pyo-lymph, notably around the spleen and on the superior surface of the liver. There was no local focus discovered, the appendix and intestine being free from ulceration or necrosis. At the necropsy pneumococci were obtained in pure culture and found in films from the heart’s blood and in smears from the pleural pus and spleen. Remarks by Dr. BIRKE’fT,-If justification be needed for the publication of this case it will be found, I think, first, in the comparative rarity of the disease ; secondly, in the extreme difficulty of its diagnosis, a difficulty so great that Michaut in 1901 stated that on one occasion only had the diagnosis been made ; and, thirdly, in view of the study of pneumococcal peritonitis in children, by Annand and Bowen, which appeared quite recently in THE LAKCET.2 The history of the case and the child’s general appearance on admission suggested a severe attack of gastro-enteritis, though the extreme restlessness of the patient and the cessation of the diarrhoea two days before were against this diagnosis. On the following day the lack of abdominal movement, the presence of free fluid, and the pain occasioned by a distended bladder, combined with the general aspect and extreme restlessness of the patient, were sufficient evidence of peri- tonitis. The cause of the peritonitis was diagnosed partly by the resemblance of its onset and course to other known cases and partly by exclusion of other possible causes. I have met with two previous cases of primary pneumococcal peritonitis. These cases have not been published and are therefore not included in Annand’s and Bowen’s statistics. The first was admitted to St. Bartholomew’s Hos- pital during the early part of last year and was diagnosed as, and operated on for, appendicitis. The second case died in this hospital last March, the condition not having been suspected during life. During the last ten 5 ears there have been, so far as I have been able to ascertain, five other similar cases in the wards of this hospital. One was operated on for peritonitis, but its cause was not suspected until the pathologist’s report was received, whilst in the other four the diagnosis was made at the necropsy. I am indebted to Dr. Garrod and Mr. Steward for per- mission to publish the case. RADCLIFFE INFIRMARY, OXFORD. A CASE OF INTESTINAL OBSTRUCTION, WITH ENORMOUS DISTENSION OF THE CÆCUM. (Under the care of Dr. E. C. BEVERS, assistant surgeon.) THE patient, a man, aged 67 years, was admitted to the Radcliffe Infirmary, Oxford, on Dec. 5th, 1905. He was very deaf, so that it was extremely difficult to obtain information from him, but the following facts were elicited. He had suffered from obstinate constipation for several years; this had been aggravated for the last ten months, during which period he had had some pain in the abdomen and one or two attacks of diarrhoea. The patient stated that for seven days previous to his admission to the hospital he had passed nothing by the bowel, but he had been given two in- jections, the first of which brought away a little faecal matter. On several occasions during the last six days he had been sick, the vomit being black in colour and the abdominal pain had increased. We are indebted to Dr. Bevers himself for the following notes and remarks. On admission the pulse was 112, the respirations were 26, 1 Gazette des Hôpitaux. 2 THE LANCET, June 9th, 1906, p. 1591. E 3
Transcript
297HOSPITAL MEDICINE AND SURGERY.
No attempt was being made to absorb the discharges. Therewere puffiness of, the face and twitching of the tongue andmouth. The woman was experiencing difficulty inmicturition. There was a blood-stained discharge from thevagina. The pulse-rate was nearly 150. On the back therewas a black, sloughy bedsore. Death took place on thesame evening.Marked tut evanescent eye symptoms, such as those
described above, appear to be a very unusual feature of
plague. Iritis and irido-cyclitis are rarely seen. In additionthe above case is noticeable for the primary involvement ofthe supracondylar gland and the involvement nine dayslater of a femoral gland which on bursting gave exit to thetypical discharge.Fatshan Hospital, South China.
A MirrorOF
HOSPITAL PRACTICEBRITISH AND FOREIGN.
HOSPITAL FOR SICK CHILDREN, GREATORMOND-STREET.
A CASE OF PRIMARY PNEUMOCOCCAL PERITONITIS.
(Under the care of Dr. A. E. GARROD and Mr. F. J.STEWARD.)
Nuila autem eat alia pro certo noseendi via, nisi quamplurimna 81morborum et dissectionum historias, tum aliorum tum propriascollectas habere, et inter se comparMe.—MoBaaNi De Sed. et Ca’lJ,8.Morb., lib. iv., Proaemium.
-
FOR the notes of the case we are indebted to Dr. H. J. D.
Birkett, house physician.A girl, aged four years, was admitted to the Hospital for
Sick Children, under the care of Dr. Garrod, just beforemidnight on July 4th last. The patient was in goodhealth till 9 P.M. on July lst when she complained of feelingcold. About three hours later vomiting and diarrhcea set in,accompanied by severe abdominal pain. This attack wasattributed by the mother to some gooseberry tart eaten atmidday on the lst. On the 2nd some medicine was obtainedfrom a druggist which stopped the diarrhoea and vomiting.The abdominal pain continued. On the 3rd the pain con-tinued and the vomiting recommenced. A medical man wascalled in and he found a temperature of 103° F. On the 4ththe patient was worse and was taken to hospital. Shehad been delirious on and off since the 2nd and for the last36 hours the mother had noticed that the abdominal painwas less marked after the patient had emptied her bladder.There was nothing of importance in the past or familyhistory of the patient.On admission the child was quite delhious and so
extremely restless and irritable that a thorough examinationwas almost impossible. The abdominal facies was wellmarked. There was a divergent squint and the alas nasiwere working slightly with respiration. There was no
evidence of mastoid disease. In the chest there were a few
crepitations heard over the left base behind. Nothing elseabnormal was found. With regard to the abdomen therewas no distension ; movement was present, though not good.There was general tenderness, but when the child wasmomentarily at rest no rigidity could be made out. Rectalexamination was negative. A small, loose, brown, offensivemotion, the first since July 2nd, was passed immediately afterthe examination. The temperature was 100°, the pulse was160, and the respirations were 40. The urine was normal.Morphine was administered hypodermically, and when thishad taken effect the abdomen and rectum were again care-fully examined but no further information was gained. On the5th the patient was seen by Dr. Garrod and subsequently byMr. Steward in consultation. There was still no abdominaldistension but there was more resistance and movement wasabsent. There was a small amount of free fluid in the
peritoneal cavity. The optic discs were examined and foundto be normal. The temperature was 99’4°, the pulse was132, and the respirations were 28. A diagnosis of diffusepneumococcal peritonitis was made and Mr. Steward per-formed a laparotomy during the afternoon. A good deal
of thin pus was evacuated and gauze drains were inserted.Pneumococci in pure culture were grown from the pus foundat the operation. The patient died on the same evening.
Extract from post-mortcnc wotes.-There was early otitismedia on both sides of the head. As to the thorax, in theright pleural cavity there were about one ounce of thin pusand some flaky masses of lymph, while the right lower JO.Jewas coated with a similar layer of pyo-lymph. The lungs werecongested and oedematous but not solid anywhere. Therewere many basmorrhagic infarcts in the left lung. Withregard to the abdomen, there was early general peritonitis.No attempt had been made to shut off the inflammatoryprocess, the only adhesions being a slight sticking togetherof the intestines in a few places. Thin pus bathed thewhole of the contents, forming here and there sheets of
pyo-lymph, notably around the spleen and on the superiorsurface of the liver. There was no local focus discovered,the appendix and intestine being free from ulceration ornecrosis. At the necropsy pneumococci were obtained in
pure culture and found in films from the heart’s blood andin smears from the pleural pus and spleen.Remarks by Dr. BIRKE’fT,-If justification be needed for
the publication of this case it will be found, I think, first,in the comparative rarity of the disease ; secondly, in theextreme difficulty of its diagnosis, a difficulty so great thatMichaut in 1901 stated that on one occasion only had thediagnosis been made ; and, thirdly, in view of the study ofpneumococcal peritonitis in children, by Annand and Bowen,which appeared quite recently in THE LAKCET.2 The historyof the case and the child’s general appearance on admissionsuggested a severe attack of gastro-enteritis, though theextreme restlessness of the patient and the cessation of thediarrhoea two days before were against this diagnosis. Onthe following day the lack of abdominal movement, thepresence of free fluid, and the pain occasioned by a distendedbladder, combined with the general aspect and extremerestlessness of the patient, were sufficient evidence of peri-tonitis. The cause of the peritonitis was diagnosed partlyby the resemblance of its onset and course to other knowncases and partly by exclusion of other possible causes. Ihave met with two previous cases of primary pneumococcalperitonitis. These cases have not been published and aretherefore not included in Annand’s and Bowen’s statistics.The first was admitted to St. Bartholomew’s Hos-
pital during the early part of last year and was
diagnosed as, and operated on for, appendicitis.The second case died in this hospital last March,the condition not having been suspected during life.During the last ten 5 ears there have been, so far as I havebeen able to ascertain, five other similar cases in the wardsof this hospital. One was operated on for peritonitis, butits cause was not suspected until the pathologist’s report wasreceived, whilst in the other four the diagnosis was made atthe necropsy.
I am indebted to Dr. Garrod and Mr. Steward for per-mission to publish the case.
RADCLIFFE INFIRMARY, OXFORD.A CASE OF INTESTINAL OBSTRUCTION, WITH ENORMOUS
DISTENSION OF THE CÆCUM.
(Under the care of Dr. E. C. BEVERS, assistant surgeon.)THE patient, a man, aged 67 years, was admitted to
the Radcliffe Infirmary, Oxford, on Dec. 5th, 1905. Hewas very deaf, so that it was extremely difficult to obtaininformation from him, but the following facts were
elicited. He had suffered from obstinate constipationfor several years; this had been aggravated for thelast ten months, during which period he had hadsome pain in the abdomen and one or two attacksof diarrhoea. The patient stated that for seven daysprevious to his admission to the hospital he had passednothing by the bowel, but he had been given two in-jections, the first of which brought away a little faecalmatter. On several occasions during the last six days hehad been sick, the vomit being black in colour and theabdominal pain had increased. We are indebted to Dr.Bevers himself for the following notes and remarks.On admission the pulse was 112, the respirations were 26,
1 Gazette des Hôpitaux.2 THE LANCET, June 9th, 1906, p. 1591.
al1d the temperature was 98° F. The patient had the apèCtøl one suSt:ring from malignant disease; he was a littleuyamosed, seemed to have some trouble with his breathing,and was complaining of abdominal pain. On examinationthérre were general abdominal distension and very little move-meat of the abdomen with respiration. No peristalsis couldbe observed ; the abdomen was tender and tympanitic allo’relt Mi percus,ion, the liver dulness being encroached uponh) a considerable extent. On making a rectal examination11e-und some bal’ooning of the rectum which was empty offae303 matter. No growth could be felt. From the patient’sappearance, age, and from his history of prolonged constipa-1IDE> with attacks of diarrhoei. and from the ballooningM the rectun, I thought that I was probably dealingw7ikh a case of intestinal obstruction frjm a malignantgrowth.
]i’ollowing the diagnosis which I had made of a malignantgtowth either in the upper rectum or the pelvic colonI made an incision on the left side low down over the linFa.ssmilHnaris big enough to explore the abdomen through itand in a situation where a colotomy could be rapidly per-faTEaed if necessary. The left rectus muscle was drawnmwads and the p ,ritoneal cavity opened ; there was at oncean @scap° of gas with a fascal smell ; the small intestineswhich came to view were slightly injected but in no waydistended. There was at first some difficulty in finding thepe3vic colon ; it did not present in the wound as it often doesin these cases ; during the exploration a bard growth just atthe brim of the pelvis was come upon ; this proved to be inthe pelvic colon. The reason that it had not been found ibefore was that the descending colon was passing straight down over the brim of the pelvis into the rectum, there Ibeing practically no pelvic colon or mesocolon. As these
:p::riie-ns of the great intestine far from being distendedwere contracted I came to the conclusion that althoughI had found the growth I must look further for the realcause of obstruction. Passing my hand over to the rightiliae fossa I found a large distendtd bag-like body extendingdown into the pelvis which I was unable to move and on
withdrawing my fingers there was a distinct fseoal odourattached to them. I therefore made a further incisionover the right iliac fossa and found an enormously distendedcaecum and ascending colon. The major portion of the waso the cæcum was necrotic and sloughing but there wasto actual hole through which fæcal matter could escape.The distended colon and caecum occupied the whole ofthe right flank, right iliac fossa, and passed down into thepelvis. The appendix was healthy and perched on the top ofthe cæcum like a night cap. The distension ceased abruptlyat the hepatic flexure; beyond here the great gut was smalland contracted down to the rectum. Though nothing couldbe felt at the hepatic flexure I concluded that there mustbe some condition which was producing obstruction at thatpoint. As nothing more could be done I stitched thenecrotic portion of the cæcum in the abdominal wall and
sp&;asd it, evacuating large quantities of fascal matter. The
patient lived for two days and then died from bronchialtrouble.
Necropsy.-At the post-mortem examination the followingcondition was found by Dr. James Ritchie. There were two
operation wounds, at one of which part of a gangrenous caseumwas protruding. On opening the abdomen there was foundto be a growth of the sigmoid flexure occupying two and ahalf inches of bowel. This part of the bowel was bounddown to the left common iliac artery which was immediatelybebind it and to the tissues at the back of the pelvis. Thenormal loop of sigmoid flexure was absent. The mucousmembrane of the cæcum was extensively congested and onthe outer surface part of the intestine was entirely dead.This congestion extended nearly to the hepatic flexure whichwas in firm contact with the right kidney. The distensionof the esesum had evidently kinked the large intestine at thehepatic flexure; at this flexure the lumen of the gut wasmuch diminished ; the mucous membrane of the transverseand descending colon was normal, the gut not beingdistended.Remarks.-In the above case of intestinal obstruction
there are, I think, several points of sufficient interest to
justify my recording it. The interesting points are thatalthough there was a malignant growth of the rectum3t was not the actual cause of the obstruction fromwhich the patient was suffering. The rectal growth badprobably been an agent in causing chronic obstruction andin aggravating the chronic constipation from which the
patient bad-, suffered for years. The transverse and: descend-ing’ colon was empty, normal, and non-distended; so thatthe actual point of obstruction would’ appear to havebeen at the hepatic flexure. In fact, I think that the con-dition of the intestines found in this man illustrate graphi-cally the condition described by Mr. W. Arbuthnot Lanein THE LANCET 1 and attributed by him to chronic constipa-tion. This patient of mine had suffered from chronic con-stipation for years and he had in his lower bowel a growthwhich during the last six months, at any rate, would havebeen an added obstruction to the emptying of his big gut.Owing to the chronic constipation there had been graduallyincreasing growth and distension of the cæcum and ascend-
ing colon until they reacted the enormous size found at thetime of the operation ; there had been a corresponding dimi-nution in size in the transverse colon and descending colon,and a practical disappearance of the pelvic co’on and meso-colon. The constant dragging of this over-loaded and over-dibtended csecum had produced the kink at the hepaticflexure, this kinking action continuing until at last completeobstruction was produced.
I should like to draw attention to the practical non-
existence of the loop of pelvic colon ; this is a matter ofsome surgical importance ; had this been a case in which aninguinal colotomy was necessary it would have been im-possible, owing to the firm manner in which the gut wasattached to the posterior abdominal wall, to bring it to thesurface.
Medical Societies.MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.
Annual Meet’ing.-Presidential Address.-The Pi-e-frontalCortex Cerebri.-Annual Dinner.-Tiee Effects of Alcoholon Hospital and Asylum Practice.-The -History of anUnusual Case of Murder.-Tube reulin Diagnosis.-Dia-grammatic Method of Recording Family Histories.-The.Relation of Goitre tu Insanity.THE sixty. fifth annual meeting of this association was,held
on July 26tih and 27th at 11, Chandos-street, Cavendish-square, London. The chair during the early part of themeeting was occupied by the President, Dr T. OUTTERSONWOOD, and later by the new President, Dr. ROBERT JONES.The morning sitting on July 26 nh was occupied in trans-
acting association business. In the afternoon a cordial voteof thanks to the retiring President and the officers ofthe association was passed and was suitably acknow-ledged.The PRESIDENT announced that the Gaskell prize had been
awarded to Dr. J. M. Rutherford of Morningside Asylum,Edinburgh, and the bronze medal of the association to Dr.C. J. Shaw, assistant medical officer, Montrose Asylum.
Dr. JONES then delivered his Presidential Address, in whichhe passed in rapid and eloquent review the historical (fromBiblical times), custodial, therapeutic, nursing, sociological,and other aspects of insanity, paying especial attention tothe influence of alcohol, economic and social stress, andincreasing ambition as contributory factors in the disquietingamount of nervous breakdown. In discussing the evolutionof insanity Dr. Jones had much to say in connexion withlegal requirements. He expressed the opinion that ourpresent institutions for the care and treatment of the insanewere the evolutionary growths of sympathy and unabatedhumanitarian zeal for curative and custodial interests andthat they were the most up-to-date nursing institutions to:befound in any country. He urged the pathological and clinicalpursuit of the problems of insanity and the necessity of thetreatment of sufferers by experts, both physicians and nurses.He showed that 1 in every 285 of the population was an in.mate of a lunatic asylum and in 1905 1 in every 157 hadundergone a term of imprisonment for offences against thelaw, while 1 in every 31 in London was a pauper. He re-ferred with approval to the recent movement to encouragethe teaching of hygiene and temperance in the publicschools, which he regarded as a scheme against insanity
1 THE LANCET, Jan. 17th, 1907, p. 153; and Dec. 17th, 1904, p. 1695.
