1303

CASE OF

DEEP PERINEAL AND ANAL LACERATION.BY W. K. M’MORDIE, M.D., M.CH.,

SURGEON TO THE SAMARITAN HOSPITAL FOR WOMEN, BELFAST.

ON May 2nd I was requested by Dr. M’Connell of Belfastto see a woman with him who had sustained a bad ruptureof the perineum early in the morning of that day during’delivery. The following is a description of the accident as.given by Dr. M’Connell.M. B-, aged thirty-one, primipara. The labour was

prolonged, and Dr. M’Connell was obliged to deliver withtforceps. After the head was brought out, the forceps weretremoved, but during the passage of the shoulders the peri-meum suddenly tore. The tear first extended through the.centre of the perineum to the sphincter ani, and thentore round the sphincter, stripping it to the left side to apoint at right angles to the raphe of the perineum, wheredt entered the rectum, slitting it to the extent of an inch.The tear from the point where it reached the sphincter- extended upwards towards the tuberosity of the ischium.’The raw surface of the rupture thus presented the appear-ance of two triangles: one with the base towards the’vagina, and the apex at the stripped portion of the sphincteranti; the other triangle with the apex towards the tuberosityof the ischium, and the base at the anus, containing the rentanto the rectum, at the extremity towards the left side.

Assisted by Dr. M’Connell, and the anaesthetic being- administered by Dr. Joseph Purdon, all bleeding pointswere secured with fine catgut. About an inch of the narrow- strip of skin between the first and second triangles ofCtaw surface was removed with scissors. The first suturewas passed with a curved needle as near as possible tothe edge of the rent into the rectum, commencing on theposterior side in the skin near the anus and bringing it outon the anterior side, near the margin of the lacerated edge- of the torn sphincter. The remaining sutures I passed’from the skin, half an inch outside the lacerated surface,,tke suture being carefully buried all the way, and out at apoint at the other side, which, when the sutures werertightened, would very likely bring the correspondingtissues accurately together. The sutures used were silk-worm gut, and they were removed on the twelfth day,’when perfect union had taken place by primary adhesion.

.RgMMfr.—The study of the various lesions of the perinealmmscles and their relations would be interesting, but I donot see how it would assist an operator in such a case. Inever saw such a tear; and the numerous articles I haveread generalising on operations for perineal repair were notof the least assistance in this operation.

Belfast. ________________

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN

ST. GEORGE’S HOSPITAL.A CASE OF INTUSSUSCEPTION; TREATMENT BY INJECTION

OF WATER INTO THE RECTUM; RECOVERY ; RECURRENCEOF THE INTUSSUSCEPTION FOUR MONTHS LATER;SIMILAR TREATMENT; RECOVERY ; REMARKS.

(Under the care of Dr. DICKINSON.)

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et mor.tborum et dissectionum historias, turn aliornm turn proprias collectasbabere, et inter se comparare.-MORGAGNI De Sed. et Caus. Morb.,lib. iv. Procemium. -

WE have published cases in the Mirror during the lastfew months illustrative of most of the other methods

’employed successfully in the treatment of this form ofintestinal obstruction. We now bring forward an accountof a case, recently under the care of Dr. Dickinson, curedby the injection of fluid into the rectum. Since Gorhamrecommended the employment of inflation of the bowel in1838, that method has found general acceptance, and insome hospitals the physician places full reliance on that,,to the exclusion of other methods, in cases which do notrequire laparotomy. But the value of injection either of I

air or fluid depends upon the stage of the disease at whichit is employed, and the care with which it is done. For theaccount of this case we are indebted to Dr. R. Sisley,medical registrar.M. A. F., a child four months old, was admitted on

October 7th, 1888. On the morning of her admission shehad vomited and had passed blood and slime per rectum.The motions had previously been of yellow colour and ofloose consistence. The patient was thin and had dark ringsunder her eyes. She appeared to have abdominal pain ; shevomited and passed blood, and mucus from the anus. She,however "took the breast." The tongue was coated. Noabdominal tumour was found, but when she was examinedthe recti muscles contracted rather strongly. Examinationper rectum gave only negative results. On the night of the8th and 9th the child was very restless and screamedfrequently. On the morning of the 9th a rounded tumourwas found on rectal examination. A water injection wasfreely used. The tumour disappeared, and the child imme-diately sank into a quiet sleep. She did not pass any moreblood or slime from her bowels, nor has there been any morevomiting. On Oct. 16th she left the hospital in good health.She continued well till Jan. 24th, when she again passed

a few drops of blood from the anus. She bent her headforward and cried-symptoms which her mother perhaps not-unreasonably ascribed to pain.When the child came into hospital for the second time she

did not seem ill. She was well nourished and suckled freely; sbut she vomited and passed blood and mucus per anum.These symptoms continued on the following day. No tumourwas felt on palpation, but on rectal examination a roundedmass was found to project with the lower bowel. Thetumour felt not unlike the projection of the uterus into thevagina. A water injection was used, the tumour dis-appeared, and the child fell asleep directly after the opera- =tion. She had no more vomiting and passed no more bloodby the bowel, but a small quantity of mucus came awaywith the motions. She had no return of untoward symptoms,and left the hospital on Feb. 2nd.Remarks by Dr. SISLEY.-I have to thank Dr. Dickinson

for his permission to publish the case. Of all cases of in-testinal obstruction, few can be diagnosed with suchcertainty as those which are due to intussusception of thebowels when this condition occurs in children. The age,or rather the youth, of the patient is one important guideto the determination of the causation of symptoms.Another point is the suddenness of the onset of the iilness.But when an abdominal tumour is found, and the childsuffers from vomiting and passes only blood and mucus perrectum, the diagnosis is practically certain. The treatmentis comparatively simple, and no complicated surgical opera-tion is necessary. In the case here recorded the apparatusused was an irrigator, connected by a gutta-percha tubewith a glass nozzle. The irrigator was filled with warmwater (the tube was put into the rectum). The waterwas forced in by raising the irrigator to a height of aboutsix feet. The advantage of this simple method is obvious.A continuous and equable pressure is obtained. This is not.the case when a syringe is used. In the latter case thepressure only continues whilst the instrument is beingworked, and the amount of force employed cannot be eitherso accurately determined or so easily regulated. The imme-diate effect of the treatment in this case was striking.Directly after the operation the patient was apparentlyquite free from all pain and discomfort, and sank into apeaceful sleep. The intussusception was reduced, and thechild recovered. It appears to me that no better method oftreatment could have been devised. The idea of at oncerestoring the displaced bowel was rational. There was nodifficulty in carrying out this indication. In a similar case,therefore, I should certainly recommend the same treatment.In saying this, I am aware that I am opposing the view ofso eminent a surgeon as Mr. Treves,l one of thegreatest authorities on intestinal obstruction, and whosebook on that subject is worthy of all consideration.Of the treatment of acute intussusception of the bowelsMr. Treves writes without ambiguity, and with the incisiveforce which always characterises his teaching. "Theadministration of opium," he says, "is absolutely essentialin these cases." To this sweeping assertion I take excep-tion. The case I have recorded was treated without opium.Mr. Treves goes on to explain the use of opium : "By itsmeans peristaltic movements are stilled, and any increase

1 Intestinal Obstruction, its Varieties, with their Pathology.Diagnosis, and Treatment.

1304

in the invagination is probably prevented." He then givesa caution which, it is to be feared, is too often neglected :"It must be remembered that the drug may mask thesymptoms, and may arouse in the surgeon’s mind a falseimpression as to the improvement effected in the case."Later on Mr. Treves says: "Presuming, as is very probable,that no marked improvement follows its use [the use ofopiuml, the next measure in the treatment consists inan attempt to reduce the invagination by means ofenemata or by insuffiation."2 The teaching of Mr. Trevesis quite clear. First, he recommends opium in all cases,and afterwards enemata or insufflation, should spontaneousrecovery not take place. It appears to me to be morerational, if the diagnosis be certain and the case a recentone, to use enemata at once. Delay is dangerous. Opiummay relieve the pain, but the chances of spontaneous re-covery under its use are not sufficient to justify procrastina-tion, and it is evident that those cases which recover with-out mechanical treatment are probably those in whichadhesions have not formed, and in which therefore enematawill be most likely to do good. Whilst the patient isbeing treated with opium the time for successful operationmay pass, for dense adhesions may form, and, as Mr.Treves himself says, "it will be obvious that enemata orinsui-liation will be quite useless when once adhesions haveformed, or when the invagination has become for otherreasons irreducible. "__ ______

VICTORIA HOSPITAL, BURNLEY.A CASE OF ABDOMINAL TUMOUR; SPONTANEOUS CURE;

REMARKS.

(Under the care of Mr. R. C. HOLT.)ALTHOUGH spontaneous rupture of a cyst of ovarian

origin into an adjoining viscus is well recognised as apossible cause of the disappearance of an abdominal itumour-and there are several recorded instances,-such anoccurrence is of sufficient rarity to make the account of awell-observed case of interest. When an escape takesplace into the rectum, it is likely to be followed by verysevere symptoms, indicating septic inflammation of thecyst wall, decomposition of the contents of the cyst,peritonitis, or possibly pyaemia. In many cases theestablishment of this communication has been followed bydeath as a direct result, or the patient has only recoveredafter an exhausting and dangerous illness. The conditionclosely resembles that which obtains after the operation oftapping an ovarian cyst through the rectum which was atone time employed, and there is a ready escape of fecal gasfrom the rectum into the cyst cavity as after that operation.In some the disappearance of the tumour has only been fora time, and reaccumulation of fluid has followed later afterclosure of the communication with the bowel. We hopethat Mr. Holt will be able to announce the ultimate resultof this case.A. A-, aged thirty-nine, married, was admitted on I

Jan. 9th, 1889. She was pale, and appeared to be sufferingpain. Pulse 120; temperature 102The woman complained of pain and tenderness in the

abdomen, an examination of which showed a fluctuanttumour, of size and shape like a full-time pregnancy, only alittle more inclined to the left side. The abdominal parieteswere slightly cedematous. The position of the tumour nearto the umbilicus was very distinctly fluctuating, but in theleft iliac region it felt hard. The flanks were resonant.On vaginal examination, the vagina was found to belengthened and pulled upwards and forward. In its posteriorwall a rounded swelling could be felt, the nature of whichit was impossible to make out. The os was high up, andalmost out of reach, but could be indistinctly felt.The patient stated that she was confined four years ago,

and had never properly recovered her strength. She hadbeen regular up to about four or six months beforeadmission, when the catamenia had ceased, and then shenoticed the abdominal swelling, which gradually increased.Three weeks before being seen she was seized with severeabdominal pain and elevation of temperature, which con-tinued until her admission. She thought that the growthwent on more rapidly after the attack of pain. The circum-ference one inch below the umbilicus was thirty-five inches.The temperature varied from 99° to 102’’, which latter was

2 Op. cit., p. 500. 3 Op. Op. cit., p. 501.

the highest recorded ; it was taken on Jan. 22nd, thirteendays after admission.

It was decided to perform abdominal section on the 23rd.In the evening of the 22nd she passed about one pint ofblood-stained fecal fluid per rectum. Up to this time themotions had been normal. On the morning of the 23rd, thetumour being then present, she was prepared for operatio&bgr;’.thirty-six ounces of pale urine being drawn off by catheter.When she was brought into the theatre and uncovered, thetumour had disappeared; the abdomen was resonant, and!measured nearly the same as before; there was to be felt irhthe left iliac region a hard tumour, irregular in outline,.about the size of a child’s head; the pain had gone. She-was put back to bed, and during that day and for thenext five days passed about 300 ounces of dark-brown semi-solid material per rectum, which was examined and foundto consist of altered blood cells and a quantity of what.appeared to be ovarian cells. On the evening of the 25ththe temperature fell to 98-5", and on that of the 26th it,ascended to 102°, falling again in the morning. This varia-tion continued for four days. The abdominal measurement.on the 29th was thirty-two inches. She was kept in thehospital until Feb. 26th. The abdomen gradually lesseneduntil it reached thirty-one inches. The tumour in the iliac-fossa slowly disappeared.

April 3rd.-Since Feb. 25th she has been at home, anahas done her household duties. The abdomen measures.twenty-nine inches, and is quite free from pain and tender-ness. There is deep dulness in the right iliac fossa, and anoblique hernia has developed on the same side. Uterus andvagina normal in position. She has menstruated once.Remarks by Mr. HOLT.-This case appears to have been

one of ovarian cyst, probably multilocular from the varyingdegrees of fluctuation. The peritonitis had evidently pro-duced adhesion and ulceration into the bowel, and the-opening must have been valvular, and spontaneous cure-

seems to have taken place. The most curious part is the-disappearance of the tumour within so short a time before-the operation. The probable explanation is that rupturehad taken place the evening before, and that the nurse, inusing the catheter prior to the operation, had exercisersome pressure, and so partially emptied the cyst.

NAGASAKI HOSPITAL, JAPAN.EPITHELIOMA OF THE VAGINA ; REMOVAL; RAPID

RECOVERY.

(Under the care of Mr. C. ARTHUR ARNOLD.)THE variety of carcinoma met with in the vagina is:<

usually the squamous-celled, and it is found occurring iiaone of two forms, as a localised papillomatous growth, or a.flat infiltrating deposit, which rapidly ulcerates and invadee-the surrounding parts. Although it is essentially a disease-of advanced life, many cases are on record of its occurrence-at an earlier date than is usual with the carcinomata, andit appears to prove fatal at a comparatively early period.Butlin1 gives a table by Kiistner of twenty-two cases. Ofthese, two were under the age of twenty. This case is arexample of the presence of the disease at the age of twenty-two, also of its extensive removal.In February a young woman, aged twenty-two, came to-

the hospital complaining of a foul-smelling sanguineous dis-charge from the vagina. Upon examination an extensivegrowth was found on the anterior vaginal wall whichtowards the upper end of the vagina extended to the

sides. The cervix uteri was quite healthy. The glands.in the inguinal regions on both sides were indurated,but not in a very great degree. The girl had firstnoticed something wrong about two months previously.A piece of the neoplasm was removed with a pair ofscissors, and upon microscopical examination it was

found to be an epithelioma. On March Tth, the patienthaving been placed under chloroform, Mr. Arnold pro-ceeded to remove the growth. After the primary incisionthe knife was laid aside, and with the blades of a pair ofscissors the growth was dissected from the wall of thebladder. During this process bloody urine twice escapedfrom the catheter which had been passed into the bladderas a guide. After dissecting out the growth the healthymucous membrane at the sides of the vagina was freelyremoved. There was very little bleeding during the opera-

1 The Operative Surgery of Malignant Disease.