1892 The Lancet  
incisions there mentioned might hamper one in manipulation, especially if the growth should be higher up in the bowel than at first diagnosed. I therefore made some experiments on the cadaver and decided on the incision I have described, as giving greater space without involving the sacrifice of any important structure. Again basing my action on the same experiment, I divided the sacrum transversely ; this enabled me to get a clear view of the cavity. I was much struck by the ex. tremely close
more » ... ex. tremely close relationship between the rectum, bladder, and urethra, and felt that one of the main difficulties to be avoided was wounding either of the latter. This led me to have a silver catheter kept in the bladder throughout the operation. Though this is not mentioned in either of the accounts I have quoted, I am sure it is necessary to enable the operator to avoid calamity whilst stripping off the rectum from the front. I found it by no means easy to define-when aided only by the finger in the rectum-the proper height at which to divide the bowel. I therefore slit up the rectum; this gave me a full and complete view of the area of disease, without in any way adding to the haemorrhage or fouling the wound. This-which to me was a great help-does not appear to have been thought necessary in the previously recorded cases. The remainder of the steps of the operation were conducted on the ordinary principles employed in dealing with large open cavities. The operation is still on its trial. It) seems, so far as can be judged from the few instances recorded, to afford opportunity of dealing with the particular form of cancer at least as successfully as many other recognised operations. Ib is also superior to the ordinary proctectomy in that it allows of a wider removal. I am, however, sure that it can only safely be employed in those cases of rectal cancer which are seen and diagnosed at an early stage, and should never be undertaken unless the limits of the disease can be clearly defined, and when the bowel is felt to be freely movable. It does not seem to be likely that it will ever be practicable to restore the continuity of the rectum with the sphincter after extensive removal, as the attempt would involve great tension, too great to permit of rapid union. The opening made into the pelvis is large, but its very size, I think, enhances the safety of the operation, for it permits of all parts involved being fully in view, and enables the needful dissection to be undertaken with precision, and, further, all bleeding points are well under control. Again, thorough drainage can be secured with certainty. In a smaller wound these difficulties and dangers would be less easy to overcome. 16 is certain that, should the operation be further tried, many variations and improvements will be suggested. For the present I offer this single experience, and I have endeavoured to point out the difficulties as they occurred to me. The accompanying sketches illustrate the lines of incision and the appearance of the wound in the various steps of the operation, together with the present condition of the parts. Leeds. Ttiis paper is based upon observations made on the same patienb in two successive pregnancies. Mrs. A-, aged thirty-nine, mother of nine children, was daily expecting confinement ; she is habitually sallow and ansemic, not strong, and liable to migraine. On August 16bh, 1889, she was sitting quietly in her house sewing, when she suddenly at 4 P.M. became alarmingly faint. She had received no injury, and no shock physical or mental. There was no vaginal 1 Brit. Med. Jour., Feb. 13th. 1892. 2 A paper read at the Leeds and West Riding Medico-Chirurgical ociety, Feb. 5th, 1892. aæmorrhage, nor had there been any during the preg. nancy. I first saw her at 6.30 P.M. She was extremely faint, with very weak pulse, and was decidedly blanched. She was not unconscious, and was said to be much better bhan she had been when the symptoms commenced. The )s uteri was just sufficiently dilated to admit the tip of the finger ; the membranes were intact, and the head was presenting. Very slight labour pains were present, but there was no coloured diecharge. The patient was obviously very ill, and the probability of the presence of intra-uterine haemorrhage at once suggested itself, but still it was not impossible that some other cause might have occasioned syncope in such a patient, especially as total concealment of accidental haemorrhage is most uncommon. At 7 P.M. the pains were coming feebly, and I decided to give some ergot and to rupture the membranes. The liquor amnii was almost perfectly clear, and there was still no haemorrhage. The head now came well into the OF. As there .eemed no indication for active interference, and as the patient was no worse, I awaited the course of events. At 11 P.M. a dead male child was born by natural efforts after an easy second stage. Now the diagnosis was placed beyond doubt. There is a phenomenon sometimes described in obstetric reports as an 11 avalanche." Such an obstetric avalanche was now seen. The child was followed by a gush of blood-stained liquor amnii and by a huge quantity of dark blood-clot, which at once filled an ordinary wash-hand basin, and also by the placenta. Fortunately there was no further haemorrhage after this, and the patient was not obviously worse for what had just happened. Convalescence was tedious, the patient suffering much from headache and insomnia, but ultimately recovery was complete. The patient again became pregnant about September, 1891, and progressed satisfactorily up to Jan. 3rd, 1892, Then she had an attack of metrostaxis, which lasted for two days and then subsided, but was followed by a very slight show for several days. On Feb. 8th, 9bh, and 10th she had a return of the metrostaxis, which again was followed by a very slight daily show. On Feb. 26th haemorrhage occurred rather severely, this time accompanied by slight pain. She also became very faint, I saw her about 9 A.M., and found on examination that the cervix was slightly patulous, and that it was difficult to reach any presenting part through the long cervix, but that the head was there. I inserted a Barnes' hydrostatic dilator and administered ergot, and at noon she was delivered of a dead female six. months' foetus (not macerated). The placenta came in six or seven minutes, and there was no post-partum haemorrhage. A small amount of clot accompanied the placenta. The mother made a good recovery. Description of the placenta.-The placenta weighed seven ounces and a half. The fœtal surface was not abnormal but the maternal surface presented in its centre a soft fluctuating nodule as large as a good-sized walnut; on in. cision this was found to be occupied by a clot which could be enucleated easily. The clot was covered above by a layer of placental tissue, a quarter of an inch thick. Close to this there had been another haemorrhage of about the same extent, but the clot had almost all escaped, and the smooth cavity which was left was torn open. There were several other smaller infarcts in different parts of the placenta, and at one spot the tissues were very soft and pale, as though an old infarct had broken down. Remarks.-The patient presented, in the first place, an instance of concealed accidental haemorrhage. Dr. Galabin says that at Guy's Hospital in 23,591 deliveries there were thirty-one cases of accidental haemorrhage, and of these only one was concealed. Probably these figures under estimate the frequency of the condition, but it certainly is exceedingly rare. Accidental haemorrhage occasions some of the most dangerous conditions an accoucheur has to face. In 106 cases collected by Goodell 51 per cent. of mothers and 94 per cent. of children were lost. The present case was not an extreme one, the blood forming a localised clot and not bursting into the amniotic sac. In the last pregnancy we see an example of the occurrence of metrostaxis during pregnancy, a phenomenon which is not so very uncommon, and concerning which I have already made a communication to the Leeds and West Riding Medico-Chirurgical Society. In this instance we are able to demonstrate a cause for its occurrence. Haemorrhage took place at more than one date into the placental structure, and probably also upon the uterine surface of the placenta. The first haemorrhages did not interrupt the pregnancy; the 2
doi:10.1016/s0140-6736(01)99036-1 fatcat:6fgknznl7vcqpbhjkcbmojrbl4