C.E. Purslow
1909 The Lancet  
IN THE LANCET under date of June 26th is an account of a case of missed labour by Dr. Peter McEwan of Bradford, in which he makes the suggestion that some cases of this kind would be best treated by abdominal section. This prompts me to send you an account of a case in which I carried out this line of treatment and which is, I believe, in some repects unique. The patient, aged 33 years, was admitted to the Queen's Hospital, Birmingham, on Sept. 19th, 1907, with the following history. She had
more » ... history. She had been married 12 years and had had four children and one abortion; the latter was an instance of missed abortion, and the circumstances are so unusual that I may be pardoned for narrating them. On that occasion she came to the Queen's Hospital and stated that she was passing I I bones" per vaginam. As the uterus was large she was admitted on Nov. 16th, 1905. On inquiring into her history it was found that her last menstrual period had taken place in May ; subsequently she had considered herself pregnant and for three months there was complete amenorrhoea. Irregular losses then came on and continued until admission, and for some weeks she had passed an occasional bone. The uterus was found to be of the size of a three months' pregnancy. The patient was ansesthetised, the os dilated by Hegar's dilators, and a mass of fcetal bones was removed by ovum forceps and flushing curette. These were carefully examined by Dr. A. E. Remmett Weaver, obstetric house surgeon, and were found to comprise almost the entire skeleton of a three to four months' foetus. She made a good recovery and went home at the end of a fortnight. After leaving hospital the patient menstruated regularly, the last period occurring on Sept. 16th, 1906. From that date until her second admission, a period of more than 12 months, there had been no sign of vaginal haemorrhage. She considered herself pregnant, and in February felt fcetal movements; these continued up to June and then entirely ceased ; since that time she had suffered from a rather severe constant pain in the abdomen from which she was very anxious to be relieved. On examination she was found to present the signs of full-term gestation, but there was very little liquor amnii, and the uterus was hard and felt as though it were in a continual state of tetanic contraction ; it was tender on palpation. The cervix was not typically softened and the os was closed. Two days after admission she was placed in the lithotomy position under anassthesia with the intention of dilating and evacuating the uterus; it was found impossible to pass a Hegar's dilator into the uterus and the same was the case with the uterine sound. I was at a loss to explain this and suspected a fibroid in the lower segment. I therefore opened the abdomen and removed the uterus by panhysterectomy. The wound healed by first intention and the patient made a good recovery. The uterus with its contents was submitted to Dr. Leonard G. J. Mackey, pathologist to the hospital, and he reported as follows: " The uterus is closely moulded to the fcetus ; there is barely an ounce of somewhat turbid liquor amnii. The fcetus is the size of a full-term child and, judging by the general appearance, the length of the nails, and the amount of hair, it appears to be fully developed. The skin is of a dirtybrown colour ; the cuticle, wrinkled and easily detached, is covered in parts with a cheesy substance which is deep yellow as if stained with bile. The bones of the skull are loose and move easily as one presses on the scalp. The wall of the uterus is about half an inch in thickness ; the muscle is pale and easily splits into layers. The placenta is situated almost centrally over the internal os and lines the lower two-thirds of the uterus; it is of very firm consistence. A thin grey membrane separates the uterus from the placenta and remains attached to the former when the latter is removed. The specimen is quite odourless. Microscopically, the placenta shows a finely scattered calcareous deposit, the villi have undergone hyaline degeneration, and there is old thrombosis of the intervillous sinuses. There is a considerable amount of fibrous tissue scattered among the muscle fibres of the uterus, but the muscle itself does not show any marked change. The walls of the arteries are thicker than usual, many of the large blood spaces are filled with old thrombi, and, in some, organisation of the thrombus is well marked." Missed labour is by all authorities regarded as a very rare condition, and its occurrence in a case of complete placenta prsevia is, I think, unique. I have made an extensive search but have been unable to discover any record of a similar case. The obstruction caused by the tough placenta explains the inability to pass the sound or dilator into the uterus. Birmingham. IT is not at all an uncommon experience to find the vermiform appendix as the occupant of the sac of an inguinal hernia, nor can the lodgment of a foreign body in a child's appendix be regarded as a very rare event, but the combination of these two conditions which occurred in the following case must be rare, and would seem to make the case worthy of record. A male child, two years and four months old, was recently admitted under my care at the Hospital for Sick Children, Great Ormond-street. He came of a family in which there was no history of either tuberculosis or syphilis and had had no previous illness. The first indication that there was anything wrong was about six months previously, when the mother accidentally noticed that he had a small hard swelling in the right inguinal region. She stated that it seemed to be neither painful nor tender, and did not seem to cause the child any inconvenience. From that time onward she thought it increased slowly in size, but it never disappeared even when the child was asleep. He had not been sick, and the bowels had acted regularly. For the fortnight before admission he had not taken his food as well as usual. On admission the patient was an undersized delicatelooking child. Just outside the external abdominal ring on the right side a tumour of about the size of a filbert could be seen and felt, oval in shape, very hard, especially at the lower end, attached apparently to the subcutaneous tissues, irreducible, and without impulse when the child cried or strained. It could not be moved independently of the spermatic cord, although traction on the testicle did not have much effect on it. The testicle and spermatic cord below the swelling were normal, and examination of the abdomen revealed nothing suggestive of tuberculous disease of the peritoneum. Examination of the chest showed some dulness at the base of the right lung, where the breath sounds were weak. As the swelling in the groin did not seem to cause the child any inconvenience, operation was delayed on account of the condition of the chest. Here about 14 days later definite signs of fluid showed themselves ; the pleura was opened and a quantity of pus was evacuated. Bacteriological examination of this showed it to contain streptococci and a pure culture was obtained. The empyema was nearly a month in closing. At the end of that time the child's general condition had very materially improved and it was decided to explore the tumour in the groin which had remained practically stationary in size. On making a longitudinal incision over the tumour it was at once seen that there was a good deal of infiltration of the subcutaneous tissues. After separating some of the adherent parts the tumour was isolated ; it was found to have a pedicle leading up through the external abdominal ring and to be intimately connected with the spermatic cord. The front of the tumour was densely hard, but posteriorly it was soft, and on making an incision behind it was found that a sac had been opened and immediately under the incision the proximal end of the vermiform appendix was recognised. On attempting to draw this out it was found to be adherent at its distal end, but traction on the proximal end brought down
doi:10.1016/s0140-6736(01)32655-7 fatcat:effzgsy4xndczoas63jfautdbm