tion, while at other times only a few or so accompanied each EXTRAUTERINE PREGNANCY stool. In addition to symptoms previously mentioned, each of his attacks was preceded for 48 hours by sinking, depressed DISCHARGE OF FETUS BY RECTUM ; feelings, accompanied by burning, internal, colicky pains near PELVIC ABSCESS; INTESTINOVAGINAL FISTULA; GENERAL the region of the umbilicus. These symptoms, to him signifi¬ ADHESIVE PERITONITIS; PHLEBITIS OF BOTH cant of the approaching expulsion of maggots, loss of appetite, LEGS ; RECOVERY and ushered the The nausea, colic, diarrheic actions, in attack. J. R. LAUGHLIN, M.D. first loose stool contained the majority of the larva?, all being HAGEESTOWN, MU. expelled in 3 or 4 stools. After this the diarrhea, burning colic, nausea and depression subsided. His life habit had been Patient.—Mrs. J. B., aged 24; married six years; no children. to be slow at stool and always to defecate in the horse stable, Present Illness.—She had missed two periods and was sud¬ if possible. denly seized with severe pain and cramps in right side, fol¬ Management and Course.—My injunction to him to quit the lowed by a bloody discharge which had continued three weeks, use of the horse stable as a privy and to use a closed vessel, when I first saw her, June 8, 1908. caused a cessation of his infections from July, 1908, until Examination.—The uterus was slightly enlarged and firmly August, 1909, when he reported the return of the maggot and fixed; there was a slight bloody discharge from the cervix. return to his horse stable Another pleaded guilty to a practice. The pelvic organs were very tender and there was a board-like point of interest is that all the attacks of this patient came in hardness over the hypogastrium. Temperature was 100 F., the summer months, the earliest recalled occurring in April. pulse 88. Case 3.—History.—The patient, a white woman, aged 50, Course of Disease.—The patient was treated for pelvic peri¬ married 30 years, and the mother of 9 children, in July, 1908, tonitis for four weeks with improvement of symptoms, but no came to my office for treatment; she was pale, almost yel¬ change in rigidity. July 5, her bowels became very loose with low in complexion, very nervous, and suffering with acute indi¬ bloody stools, and on July 6 a partially decomposed fetus gestion and diarrhea. The attacks, alternating with consti¬ about two inches in length was passed at stool. A few days pation, had troubled her at irregular intervals for 2 years or later the temperature rose to 104 F. and an incision made in more. She came much distressed because she discovered that the vaginal vault evacuated a profuse purulent discharge With morning while at stool that hundreds of little white maggots fecal odor. Drainage was kept up for two weeks, but on had come from her bowel. This patient was a constant user of investigation a recto-vaginal fistula was found by which feces an open privy, and was a sufferer from internal piles, which at were discharged through the vagina. Four weeks after the times came down during defecation. operation the fistula had closed, the vaginal discharge had Management.—The same advice to keep off the flies was ceased, and the woman seemed well when she suddenly devel¬ given to this patient, but as I have lost sight of her, I cannot oped a left femoral phlebitis; this promptly yielded to rest and speak with positiveness of her recovery. elevation and she was discharged cured August 20. Subsequent History.—Four months later she had what ap¬ SUMMARY peared to be a typical attack of acute appendicitis. An thus cited the of each of these incision was made in the median line of the abdomen but the Having peculiarities adhesions were so dense that the could not be reached, me submit the as a appendix cases, let briefly following summary as as three of intestine were found adherent that the of many loops firmly closing feature, believing .similarity symp¬ together and it was impossible to find a piece of free intestine common three toms and surrounding conditions to all more than six inches in length. A few cysts filled with fluid cases are of significant interest : were found; these were opened and an uneventful recovery fol¬ 1. All the individuals affected were white adults, intel¬ lowed. Four months later she had a similar attack, except fairly cleanly of habit and truthful of statement. that the pain was not especially localized. ligent, was local 2. All suffered constantly or periodically with protru¬ She put to bed and given treatment, and improved sion of folds of the rectum defecation. for two weeks, when the old fistula reopened, but closed again during in a few She a phlebitis, this time in 3. All were to contamination days. again developed equally exposed fly the right leg. By July 23, 1909, all symptoms had disappeared during the process of defecation. and she has continued well since. with or less were- 4. All suffered more tenesmus, and 146 West Franklin Street. slow at stool, thereby offering ample opportunity for the deposition of eggs on the protruded membrane, smeared with feces, mucus and more or less blood. 5. All symptoms characteristic of these attacks ceased ACUTE PEKFORATION OF A DUODENAL or were much improved with the expulsion of the ULCER maggots. J. T. ULLOM, M.D. 6. No recurrence of the infection took place in either PHILADELPHIA of the first two so as followed my patients long they Patient.—S. M., 63, a married man. Aside from the to the anus from the aged advice protect thoroughly approach case of a sister who died at 73 of "stomach trouble," the the act of defecation. The third family of flies during patient history offered nothing of interest. The patient had had no having been lost sight of, I am not able to speak with serious illness beyond the ordinary diseases of childhood, and certainty regarding recurrence. malaria at 38, but had suffered more or less for the last 20 Finally, the facts set forth in these cases seem to me years from stomach trouble, diagnosed by Dr. Osier near the to demonstrate, beyond a reasonable doubt, that the beginning as "nervous dyspepsia." Present Illness.—The was well the winter of avenue of infection was by rectum. This opens up an patient during field for further observation, and 1907-08, but in March, 1908, he had what he called an ordinary interesting suggests bilious attack, with stools and of that a number of cases of intestinalis occur clay-colored vomiting greenish large myiasis material, after which he continually had more or less trouble in persons affected with anal and rectal disease, and that which he referred to his stomach. This usually "manifested in them it is due to the fact that the proper precaution itself two or three hours after dinner with distress, distention to prevent rectal invasion has not been observed. The and belching ; the attack, if not relieved by vomiting, would be remedy, from this point of view, is evident. followed by discomfort all night, accompanied by acid eructa¬ tions. The vomitus was sometimes green, sometimes brown and Electrotherapy.—Electrotherapy must not be regarded as a often of amazing quantity. There was never any suggestion of blood in the vomitus nor was it ever in char¬ cure-all, nor as a placebo, but if used in connection with other coffee-ground made on numerous occasions a therapeutic measures it will be found to be a very useful acter. Gastric analyses showed servant.—H. M. Imboden, in Albany Medical Annals. total acidity of about 40 and a free hydrochloric of about 20.

Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/05/2015 Urine analyses showed no abnormality except a specific gravity When the literature on duodenal ulcer was examined, showed of 1010. Physical examinations made during this period it was found that many eases are latent and abnormal. The and heart the absolutely nothing lungs were normal, or a serious are the first indi¬ abdomen contained no mass and there was no area of tender¬ perforation hemorrhage cations of an ulcer. Gibbon and Stewart seven ness. Ihe skin was sallow and the face of illness. present expressive cases of duodenal ulcer and in three of these Despite his wretched condition and considerable loss of flesh perforated there was absolute and in the other one the patient went to his office every day during the spring and latency, four, for early summer of 1908. About 11 o'clock one morning he had showed symptoms of indigestion twenty-four hours, an attack of pain, referred to the right side of the abdomen, one for a week, one for two weeks, and one for several so severe as completely to prostrate him. months. Musser's case showed symptoms of hyper¬ Examination.—The temperature was subnormal, the pulse acidity for ten years. Smith found symptoms referable 120, and very weak and the patient was bathed in a cold to duodenal ulcération in only three out of fourteen perspiration. The abdomen was extremely rigid, and exqui¬ cases, although nine patients had digestive disturbances. sitely tender and the patient resisted any attempts to states that ulcer of the duodenum fre¬ examine it. Haggard very exists without and a fatal hemor¬ was realized that some serious intra-abdo- quently symptoms Operation.—It or a are the first of trouble. minal accident had occurred; the was hurried to the rhage perforation signs patient to finds that 20 cent, Germantown Hospital, and a laparotomy was performed. A Morot, according Haggard, per duodenal ulcers are latent. Shaw and exam¬ large incision was made, and a perforation was found in the of Berry cases found no duodenum just outside of the pylorus. This was closed and ined 157 post mortem and that history the abdominal wound sutured. The patient was returned to could be obtained in ninety-one. Moynihan states that his room as quickly as possible, as his condition became very many ulcers remain latent for a long period. bad while on the table. The classical symptoms of duodenal ulcer are three, Post-operative History.—The patient reacted nicely and that pain, melena, and hematemesis. Pain is the most con¬ at 6 was conscious, uncomfortable. Tem¬ evening although stant symptom found and usually comes on from one perature 98.6, pulse 96, respiration 20. At times during the to three hours after meals. It is coincident with the afternoon his were respirations Cheyne-Stokes, but they were of the acid into the duodenum and de¬ much better toward night. His condition remained pretty good discharge chyme on of the food Sometimes for the next two days for a of pends the character ingested. except complete suppression it is This is the closure urine. At the end of that time he passed a large quantity of relieved by eating. explained by urine and continued to void large quantities daily. This of the pylorus when food is introduced into the stomach. showed a trace of albumin and some hyaline and granular The pain is often relieved at its acme by vomiting and casts. Temperature and respirations remained satisfactory the patient immediately becomes normal again. The and the abdomen showed no signs of peritonitis. After seventy- position of this pain is usually to the right of the me¬ two hours, on 13, the became restless, September patient very dian line and below the ribs in the position described as slightly delirious and hard to control, got out of bed, and tore that of the out the stitches in the abdominal wound, allowing the wound to gall-bladder. It varies much in from a discomfort to gap. He remained delirious and extremely restless. About severity simple a most and it is to midday, September 15, he was seized again with agonizing pain agonizing pain rarely found radiate. in the abdomen of apparently the same character as the Tenderness, which must be considered with pain, is not initial pain, which could be relieved only by repeated injections often found, owing, no doubt, to the position of the of morphin. He died at 6:30 p. m. that day. duodenum. The presence of blood in the stools, in the Post-mortem Examination.—A partial autopsy was obtained absence of hemorrhoids, is of course evidence of ulcéra¬ and there was found a duodenal ulcer just outside of the tion in the alimentary canal somewhere, and taken in pylorus running longitudinally and a trifle obliquely, about connection with the characteristic makes the 4 cm. in and 1.5 cm. in width. At the end of this pain, diag¬ length, nosis almost certain. Blood may appear in the stools ulcer nearest the pylorus was the perforation which had occurred as a frank as old blood in or on September 10 and which showed no signs of healing. At the hemorrhage, tarry stools, as occult blood. re¬ other end of the ulcer was another perforation that had appar¬ Every patient presenting symptoms ently taken place at 12 o'clock on the day of death, as mani¬ ferable to gastric or duodenal ulcer should be examined fested by the severe paroxysm of pain at that time. On for occult blood. The vomiting of blood is more apt to microscopic examination there was complete erosion of the occur in ulcer of the stomach, but is sometimes found mucosa, submucosa, and the muscular layers and at the edge in duodenal ulcération. In the twenty-three cases of of the ulcer there was increased fibrous tissue and some round- Moynihan, hematemesis and melena occurred in four, celled infiltration. The kidneys were smaller than normal and hematemesis alone in three, and melena alone in two. the stripped with some On section the cortex capsule difficulty. No doubt in many cases blood would be found to be dis¬ was slightly contracted and microscopically the was picture the bowel if more examinations for occult that of chronic diffuse nephritis. charged by blood were made There are two grave accidents to be This case was of interest to me as offering consider¬ feared in duodenal ulcération, perforation and hemor¬ able in Here was a man difficulty diagnosis. of 63, rhage. Perforation gives the symptoms common to per¬ a back with history of dyspepsia running for twenty foration of any abdominal viscus, prostation, weak rapid years, with periods of comfort alternating with periods pulse, cold extremities, cold sweating, intense abdominal considerable a of gastric distress. After year of good pain with board-like rigidity succeeded in a few hours health, he began to lose flesh, became anemic, and ex¬ by tympanites and the symptoms of peritonitis. The perienced pain some time after meals, which was re¬ diagnosis can be made only on the history of the case lieved by vomiting. There were acid eructations, but and the location of the pain and tenderness. Hemor¬ rarely spontaneous vomiting and no hematemesis, mel¬ rhage is shown by pallor, shock and the appearance of ena, or localized tenderness. The diagnosis now seems blood at the anus. If a large blood-vessel is eroded an easy one but before the perforation it was felt that death is apt to occur before anything can be done. there was very little on which to base a diagnosis. When This case was a very instructive one and it seems the perforation occurred it was realized only that a rup¬ now that a closer analysis of symptoms with an exami¬ ture of some viscus had occurred, but whether appendix, nation for occult blood would have made a diagnosis stomach, intestine or gall-bladder could not be told with possible. any degree of certainty. 24 Carpenter Street.

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