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AN INTERESTING CASE OF TUBALABORTION.

BY GORDON W. FITZGERALD, M.D. EDIN.,LATE SENIOR ASSISTANT MASTER, ROTUNDA HOSPITAL, DUBLIN.

THE following case appears to be an interesting one onaccount of, first, the difficulty in coming to a satisfactorydiagnosis previously to operation, then the conditions dis-covered at operation, and, finally, the uncommon conditionof the bowel during convalescence.The patient, aged 35 years, who had been married nine

years and had had no children, I saw in consultation withMr. C. J. Dabbs in June of this year. The history which shegave was that three years ago, having been previously quitehealthy and regular, she began to be troubled with a creamyvaginal discharge, her menstruation became irregular, andshe was occasionally troubled with metrorrhagia and pain inthe left side. She suffered a good deal of inconvenience andpain at the introitus when sitting down. She consulted amedical man who told her that she was suffering from acuteinflammation of the vagina, and she was ordered douches.Three months previously to my seeing her she had removedto Manchester from a town in a neighbouring county and shethought that her condition had been rendered worse by thefatigue and worries attendant on moving. In April hermenstruation was more delayed than usual and lasted longerthan before. In May menstruation came on at the expectedtime and, if anything, was less profuse than usual. In Juneshe again menstruated at the expected time, the amountbeing again excessive. Mr. Dabbs was called in and sawher for the first time a few days before I saw her with him.She had had acute abdominal pain in the epigastric region,vomited, and, she thinks, fainted.When I saw the patient she was pale, with an anxious

expression, and complained of shortness of breath. Her

temperature and pulse were both normal and had beenso throughout the time that Mr. Dabbs had her underobservation. She had some pain in the epigastric regionand a "general feeling of uneasiness" in the abdomen.Palpation of the abdomen, which revealed nothing, causedno pain, and though there was no obvious distension thepercussion note was markedly resonant. Diarrhoea, had been

present for some days but defalcation and micturition hadbeen unattended by any pain. On vaginal examination therewas a good deal of pain accompanying the introduction ofthe fingers through the introitus, in consequence of wellmarked and much inflamed piles. The vagina was normal,showing no discolouration. The cervix was hard and dilatedat the external os by a polypus which hung down into thevagina. The uterus, which was firm and slightly enlarged,lay in the middle line with the fundus forward, its movementbeing distinctly limited by adhesions. The left appendageswere easily felt to be normal, their palpation causing nopain. Through the right fornix and posterior to the uteruswas felt an indefinite bogginess, the palpation of which wasrendered very difficult and imperfect by the lower bowelbeing distended to an extent which I have never beforeobserved. The examination, with the exception of the painat the introitus, was at no time accompanied by any pain atall. The breasts suggested nothing. Thus far I was ableto make out the presence of a cervical polypus, a slightlyenlarged uterus, and some infiltration of the right broadligament. The emptying of the bowel was accomplishedwith great difficulty subsequently to my seeing her.On June 23rd the patient was admitted to a nursing home,

my intention being to remove the polypus and endeavour todecide what the condition present in the right broadligament was and deal with it if necessary. On the24th, as she was going to the lavatory, she was suddenlyseized with severe pain in the epigastric region, apparentlyfainted, and then vomited a good deal of stuff looking likecoffee grounds. Despite this her pulse and temperature didnot vary one bit, both remaining normal. The pain was ofvery short duration, and a few minutes after she asked thatshe might be allowed to have her tea as she felt quite well.On the 25th, having removed the polypus and lightlycuretted the uterus, I made an exploratory opening throughthe posterior fornix. On passing my finger through thisopening a quantity of broken-down blood clot and free darkblood escaped. Concluding that the case was one of ex’ra-uterine pregnancy I decided to adopt the abdominal route.

Having got through the skin and muscle in the middle lineI found the intestines all matted in a firm dense mass ofadhesions. Indeed, on separating the edges of the openingso far made the contents of the abdomen appeared more likea plaster cast of the contents of an abdomen rather than theactual contents of a living abdomen. After making severalunsuccessful attempts to find a position wh3re the intestineswere not firmly adherent to the peritoneum of the abdominalwall, enlarging my incision almost up to the umbilicus, Ifinally gained entrance to the abdominal cavity by strippingthe peritoneum from the muscle sheath and working downon the right of the incision. About one and a half inches fromthe right edge of the wound I found a portion of peritoneumencircled by a coil of intestines and free of adhesions. Theopening here made was only sufficient to admit two fingerseasily. The fingers passed directly into a circumscribedcavity of the size of a golf ball. From here I removed severalblood clots and smart heamorrhage followed. From thiscavity a finger passed readily into a second larger and welldefined cavity lying lower in the pelvis, the one into whichI had opened from the vagina, while on passing the fingerupwards and towards the middle line from the first dis-covered cavity was found the specimen removed. It consistedof the abdominal end of the right tube much distendedby a blood clot of the size of a small Tangerine orange,in the centre of which was a cavity lined with a glisteningmembrane—the amnion. The rest of the tube was muchelongated, exceedingly friable, and formed a pedicle for thedilated portion which lay to the right side and slightly abovethe level of the anterior superior iliac spine, under cover ofa closely matted mass of intestines. The removal of thespecimen was accomplished more easily than one would havedesired or expected, for it came away quite readily after theadhesions had been broken down, the tube giving way likeblood clot under the finger. Haemorrhage was now takingplace very freely from the two cavities and from the bedfrom which the ovum had been removed. Attempts at

ligaturing bleeding points were fruitless, as on each occasionthe vessel which was grasped either gave way under thepressure of the forceps or was at once cut through by theligature. The aspect of the patient shortly became such asto cause serious anxiety, and some uncertainty was enter-tained as to whether she could be got from the table alive.All attempts at ligaturing were abandoned and the cavitieswere packed with gauze. Leaving the pack in positionsaline solution was kept flowing into the abdominalcavity. After some time the gauze was withdrawn, but asat once the haemorrhage started to be as free as everit was replaced, and leaving as much saline solution as

possible in the abdominal cavity the wound was closed,the end of the gauze being drawn out at its lowerend. A light pack was placed in the vagina andafter giving her oth grain of sulphate of strychnine andgrain of sulphate of morphine she was got back to bed.Her pulse was now thread-like and barely perceptible at thewrist and her temperature had fallen below normal. Bydint of untiring and most careful and excellent Bursing onthe part of the matron she was tided over the night.Fortunately she was not much troubled with vomiting sofar. °

At 10.30 A.M. on June 26th, with the patient anmsthe-tised, the gauze plugs were removed. The removal of theabdominal one was immediately followed by a very smartflow of dark-coloured blood which, persisting as it did forsome time, made one fear that the abdomen would have oncemore to be opened, a procedure which I felt convincedwould prove more than her devitalised condition would

permit of her getting over. The haemorrhage, however,ceased as suddenly as it had come on and the lower endof the wound was closed. Her pulse was now 160 and heraspect was extremely bad. Throughout the morning she wasvery restless. In the afternoon she was greatly troubled byvomiting of a brownish-black liquid, the vomiting not beingaccompanied by any retching. It was very difficult at timesto decide that this liquid was not fsecal in character,especially when the densely adherent condition of the bowelsand the amount of manipulation to which they had beensubjected made one greatly fear the occurrence of intestinalobstruction. As, however, all thought of any operativeinterference had to be put on one side, we could but hopethat our suspicions were groundless. She slept not at allthrough the night. At 4 A.M. on the 27th she was givenfive grains of calomel and at 6 A.M. three grains. At11 A.M. she was given a seialitz powder and at 1.30 P.M.

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a copious oil and turpentine enema. The enema wasreturned uncoloured but was accompanied by a littleflatus. At 4 P.M. an ordinary enema was given,again with no result. At 9.30 P.M. she started tovomit and continued to do so, practically without stopping,throughout the night. The vomited matter, which was firstof a greenish colour and sour-smelling and subsequently of abrownish-black colour, seemed merely to bubble up from thestomach. Towards morning the vomit had at times a

distinctly fsecal smell. At 10.15 A.M. on the 28th, as thevomiting was quite uncontrolled by other means and sheappeared to be sinking from its effect, I washed out thestomach with a solution of bicarbonate of sodium (one drachmto the pint). The effect of the washing was most markedand satisfactory. Her aspect improved and the vomiting onlyoccurred at long intervals, and then was not of a characterwhich in any way suggested its being faecal. There stillbeing no action of the bowels, I next applied the battery tothe abdomen and continued to do so, at intervals of twohours, through the night. Towards morning on the 29thsome fluid was passed from the bowel, accompanied by agood deal of flatus. This fluid, however, was nothing morethan the return of a nutrient enema which had beenadministered a couple of hours before. The battery waspersisted with and towards midday there was a copiousevacuation from the bowel. From this time the sickness

rapidly decreased and finally stopped and her aspect showedmarked improvement.The patient’s convalescence, which would have been in any

event a slow one, was, however, rendered more tedious by thecavities becoming infected from the bowel and the infectiontravelling up to the lower end of the wound and

causing the muscle sheath to slough, there being forsome considerable time a discharge of exceedingly foul-smelling pus from the lower end of the wound and fromthe vagina. A second and most interesting complication wascaused by the condition of the lower bowel. Laxatives wereadministered, but the battery had still to be applied twiceeach day for any result to be got. This was persisted withfor four or five days, and with apparently satisfactoryresults. The bowel then became very irritable, the motionsbeing never formed, and the desire for the bedpan occurringevery few minutes. Fearing that there may have been anaccumulation of pus in the retro-uterine cavity, which wasexerting pressure on the bowel and interfering with itsnormal action, I made a vaginal examination. The cavitywas draining freely, there being no accumulation, but therewas a distension of the rectum by hard fseca.1 masses to anextent even greater than when I had seen her before her ad-mission to the nursing home. Enemas were administered buthad no effect, the fluid being returned and the faecal massesremaining unmoved. Manual removal had finally to beresorted to when it was discovered that there was a markedballooning of the rectum. This was present to such an extent Ithat these huge fascal masses floated freely in the fluid still Ilying in the bowel without coming in contact with the bowel Iwall. It was subsequently observed that laxatives and theapplication of the battery to the abdomen had merely theeffect of driving the bowel contents into this cavernousrectum and here they remained, the bowel making absolutelyno effort to expel them. On three or four occasions manualremoval had to be resorted to. This complication was finally ’

overcome by applying the battery with one pole within therectum and the other over the abdomen. Apart from thesecomplications her convalescence has been most satisfactory.The case presents many points of interest. The difficulty

in making a satisfactory diagnosis, previously to operation,was greatly increased by the protracted history, the persistentirregularity of the patient’s menstruation, and the fact thatthough, as was subsequently discovered, she had lost a con-siderable amount of blood her pulse throughout was a normalone. Her anaemic appearance, too, was regarded by her ’,relatives as being her normal condition. Then, again, theabsence of all pain or tenderness during examination of theuterus and its surroundings was a misleading feature. Thetwo cavities discovered at operation and the dense mattingof the abdominal contents must undoubtedly be regarded asevidence that the condition was of more ancient date thanthe attack which led to her consulting Mr. Dabbs. Thepresence of two cavities appears to be explained by sup-posing that there had been, at least, two serious haemor-rhages. With each haemorrhage the dilated tube, which dlthe time appears to have been endeavouring to expel theovum, was pushed higher up into the abdominal cavity and

elongated. The position where the dilated end was foundis uncommon, as is also such a degree of attenuation of thetube. The control of the haemorrhage was rendered doublydifficult by the fact that one had so limited an opening intothe peritoneal cavity through which to work, and even thiswas more or less diminished by the endeavours made toavoid damaging the bowel. On subsequent considerationone cannot but regret that the original incision was notabandoned and an opening made, through skin and muscle,directly over the opening into the peritoneal cavity. It wouldcertainly have facilitated the operation. The introduction andremoval of the gauze-which was several yards long-wouldhave been simpler, especially the removal.That the cavities, and subsequently the wound, became

infected is not to be wondered at when one bears in mindthe extraordinary degree of dilatation and atony of thebowel. This dilatation and atony, though so extreme, canno doubt be explained by the generally adherent condition ofthe bowel, plus the unfortunate, though so prevalent,indifference on the part of female patients to that most

necessary and important function. That the bowel shouldhave gone on strike was not at all surprising, but the balloon.ing of the rectum was, I think, most interesting and hardlyto be expected. I may say that after five or six applicationsof the battery per rectum the bowel appeared completely torecover its tone and has since performed its function satisfac-torily each day. On each occasion that the accumulation tookplace there was’ a distinct rise of temperature, suggestingsome fresh infection. During the earlier part of thepatient’s convalescence the hypodermic needle was much inrequisition, and it may be mentioned, as somewhat amusing,thai, she requested that a very blunt needle should be usedrather than one which readily entered the skin.

I would like to express my indebtedness to Mr. A. G.Andrews and Mr. Dabbs for their kind assistance at theoperation and especially to the latter who gave me theadvantage of his daily assistance during the earlier andmore anxious part of the patient’s convalescence.Manchester.

OBSERVATIONS ON THE TREATMENT OFYAWS (FRAMBŒSIA).

BY ALDO CASTELLANI, M.D. FLORENCE,DIRECTOR OF THE CLINIC FOR TROPICAL DISEASES, COLOMBO, CEYLON.

IT is stated by several authors that frambcesia is a diseasewhich is curable spontaneously and that drugs are useless inthe treatment of the malady. While I do not deny that somecases may recover spontaneously, this, in my experience, iscertainly the exception and not the rule. The medical manwho is able to keep such untreated cases in view after theyhave been discharged from the hospital soon convinceshimself that the cure was only apparent ; in most cases theeruption breaks out again after a variable period of time.Moreover, many of these untreated cases, as well as a certainnumber of the patients who have undergone a not sufficientlyprolonged treatment, develop after some years severe

tertiary lesions, deep ulcerations, caries of bones, &c. In theColombo clinic for tropical diseases I have tried variousmethods of treatment of which I here give, briefly, theresults.

- ??’<’M?’y.&mdash;Mercury disguised in various ways is thepopular treatment for framboesia among the natives.Mercury is also the principal drug used by European prac-titioners. I have given various mercurial preparations by themouth, by inunction, and by intramuscular injection. What-ever the method of administration the result is in most casesa rapid improvement of the eruption, provided the drug isgiven in sufficiently large doses. Many framboesia patients,however, bear the drug very badly, so that the mercurialtreatment has frequently to be discontinued after a shorttime. As soon as the treatment is stopped the eruptionusually breaks out again. Except in the case of children,who bear the drug better than adults, I do not advise the useof mercury as a routine treatment for framboesia.

Pntassium iodide; sodi1(m iodide; sajodin.-The potassiumor sodium iodide treatment gives generally good results.The drug is given in the dose of 15 grains (one gramme)three or four times daily in milk, or well diluted in water.The iodides are generally better borne than mercury byframboesia patients ; occasionally, however, cases of idio-

syncrasy for the iodides occur. In two such cases I tried