Pfeiffer's Bacillus Meningitis: Recovery after Sulphapyridine

Abstract

Haemothorax as the predominant clinical sign following acute strangulation of a diaphragmatic hernia is unusual enough to warrant record. CASE HISTORYThe patient, a farm labourer aged 37, gave a history of previous good health, although he had complained to his family of occasional indigestion. On Jan. 14, 1942, he felt severe abdominal pain immediately after supper. He was seen by one of us (S. M. S.), who found him shocked and restless, with temperature 970, pulse 100, and respirations 20. There was tenderness on deep palpation below the left costal margin but no rigidity. Dullness with diminished air entry was found at the left base, suggesting effusion. He was neither dyspnoeic nor cyanosed. He had been sick once, the vomit appearing normal.He was admitted to Evesham Hospital on Jan. 15, and at 11 a.m., because the physical signs indicated a rapid increase in the amount of fluid and his condition was deteriorating, an exploratory needle was introduced into the fifth space in the left mid-axillary line, and 10 c.cm. of normal-looking venous blood was withdrawn. A radiograph of the chest revealed that the heart and mediastinum were well over to the right, and there was a dense uniform opacity over the whole of the left lung field. When seen by another of us (S. D.) on the 16th the patient was orthopnoeic and had begun to vomit a little blood. The physical signs all pointed to the thorax: abdominal examination did not suggest anything abnormal there. 27 c.cm. of apparently normal venous blood was then removed from the chest. A second radiograph taken immediately after this showed that the heart and mediastinum were still over to the right; no fluid was now apparent on the left side, although there was diminished translucency. In the upper part of the left lung-field could be seen what appeared to be a loop of intestine, and irregular opacities were noted immediately above the left diaphragm. The left lung was collapsed against the mediastinum. At this stage the patient was seen by Dr. Haslett of Cheltenham, who diagnosed a ruptured diaphragmatic hernia. The patient's general condition deteriorated rapidly, the respiration rate rose although the vomiting became less -frequent, and he died in the early hours of Jan. 16.Necropsy.-This was performed 36 hours after death. On opening the chest it was noticed that the left lung was collapsed. This collapse was old-standing. The pleural cavity was occupied by a mass of blood clot and what turned out to be omentum. In addition there was a loop of gangrenous stomach which had herniated through the diaphragm with a portion of omentum. The right lung ahowed oedema of the base and a little emphysema at the apex. The hernial orifice was well up towa'rds the mesial attachment of the muscle in the oesophageal opening. The herniated portion of the stomach was in the form of a well-marked diverticulum. No gross ulceration of vessels could be found in the stomach wall, and there is little doubt that there had been a generalized oozing from the strangulated portion of the stomach ...