OBSERVATIONS ON THE TREATMENT OF YAWS (FRAMBŒSIA)
1458 a copious oil and turpentine enema. The enema was returned uncoloured but was accompanied by a little flatus. At 4 P.M. an ordinary enema was given, again with no result. At 9.30 P.M. she started to vomit and continued to do so, practically without stopping, throughout the night. The vomited matter, which was first of a greenish colour and sour-smelling and subsequently of a brownish-black colour, seemed merely to bubble up from the stomach. Towards morning the vomit had at times a
... at times a distinctly fsecal smell. At 10.15 A.M. on the 28th, as the vomiting was quite uncontrolled by other means and she appeared to be sinking from its effect, I washed out the stomach with a solution of bicarbonate of sodium (one drachm to the pint). The effect of the washing was most marked and satisfactory. Her aspect improved and the vomiting only occurred at long intervals, and then was not of a character which in any way suggested its being faecal. There still being no action of the bowels, I next applied the battery to the abdomen and continued to do so, at intervals of two hours, through the night. Towards morning on the 29th some fluid was passed from the bowel, accompanied by a good deal of flatus. This fluid, however, was nothing more than the return of a nutrient enema which had been administered a couple of hours before. The battery was persisted with and towards midday there was a copious evacuation from the bowel. From this time the sickness rapidly decreased and finally stopped and her aspect showed marked improvement. The patient's convalescence, which would have been in any event a slow one, was, however, rendered more tedious by the cavities becoming infected from the bowel and the infection travelling up to the lower end of the wound and causing the muscle sheath to slough, there being for some considerable time a discharge of exceedingly foulsmelling pus from the lower end of the wound and from the vagina. A second and most interesting complication was caused by the condition of the lower bowel. Laxatives were administered, but the battery had still to be applied twice each day for any result to be got. This was persisted with for four or five days, and with apparently satisfactory results. The bowel then became very irritable, the motions being never formed, and the desire for the bedpan occurring every few minutes. Fearing that there may have been an accumulation of pus in the retro-uterine cavity, which was exerting pressure on the bowel and interfering with its normal action, I made a vaginal examination. The cavity was draining freely, there being no accumulation, but there was a distension of the rectum by hard fseca.1 masses to an extent even greater than when I had seen her before her admission to the nursing home. Enemas were administered but had no effect, the fluid being returned and the faecal masses remaining unmoved. Manual removal had finally to be resorted to when it was discovered that there was a marked ballooning of the rectum. This was present to such an extent I that these huge fascal masses floated freely in the fluid still I lying in the bowel without coming in contact with the bowel I wall. It was subsequently observed that laxatives and the application of the battery to the abdomen had merely the effect of driving the bowel contents into this cavernous rectum and here they remained, the bowel making absolutely no effort to expel them. On three or four occasions manual removal had to be resorted to. This complication was finally ' overcome by applying the battery with one pole within the rectum and the other over the abdomen. Apart from these complications 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 persistent irregularity of the patient's menstruation, and the fact that though, as was subsequently discovered, she had lost a considerable amount of blood her pulse throughout was a normal one. Her anaemic appearance, too, was regarded by her ' , relatives as being her normal condition. Then, again, the absence of all pain or tenderness during examination of the uterus and its surroundings was a misleading feature. The two cavities discovered at operation and the dense matting of the abdominal contents must undoubtedly be regarded as evidence that the condition was of more ancient date than the attack which led to her consulting Mr. Dabbs. The presence of two cavities appears to be explained by supposing that there had been, at least, two serious haemorrhages. With each haemorrhage the dilated tube, which dl the time appears to have been endeavouring to expel the ovum, was pushed higher up into the abdominal cavity and elongated. The position where the dilated end was found is uncommon, as is also such a degree of attenuation of the tube. The control of the haemorrhage was rendered doubly difficult by the fact that one had so limited an opening into the peritoneal cavity through which to work, and even this was more or less diminished by the endeavours made to avoid damaging the bowel. On subsequent consideration one cannot but regret that the original incision was not abandoned and an opening made, through skin and muscle, directly over the opening into the peritoneal cavity. It would certainly have facilitated the operation. The introduction and removal of the gauze-which was several yards long-would have been simpler, especially the removal. That the cavities, and subsequently the wound, became infected is not to be wondered at when one bears in mind the extraordinary degree of dilatation and atony of the bowel. This dilatation and atony, though so extreme, can no doubt be explained by the generally adherent condition of the bowel, plus the unfortunate, though so prevalent, indifference on the part of female patients to that most necessary and important function. That the bowel should have gone on strike was not at all surprising, but the balloon. ing of the rectum was, I think, most interesting and hardly to be expected. I may say that after five or six applications of the battery per rectum the bowel appeared completely to recover its tone and has since performed its function satisfactorily each day. On each occasion that the accumulation took place there was' a distinct rise of temperature, suggesting some fresh infection. During the earlier part of the patient's convalescence the hypodermic needle was much in requisition, and it may be mentioned, as somewhat amusing, thai, she requested that a very blunt needle should be used rather 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 the operation and especially to the latter who gave me the advantage of his daily assistance during the earlier and more anxious part of the patient's convalescence. Manchester.