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A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

GUY’S HOSPITAL.

Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morbormxet dissectionum historias, turn aliorum tum proprias collectas habere, einter se comparare.—MORGAGNI De Sed. et Caur. Morb., lib. iv. Proœmium

COLLOID CANCER OF RECTUM; SUCCESSFUL COLOTOMY ;SUBSEQUENT PERFORATION AND SUPPURATION

OF CÆCUM; PERITONITIS ; DEATH.

(Under the care of Mr. BRYANT.)FOR the following notes we are indebted to Mr. Wright.Alice W-, aged twenty-five, a barmaid, was admitted

into Lydia ward on July 20th, 1880. Seven months beforeadmission the patient was very costive for about a week,and this costiveness was followed by diarrhoea, which con-tinued until February, when a medical man saw her. Thediarrhoea frequently recurred. At first the motions were

chiefly slime, but for the last three months she had passedclots of blood with faeces, and during this time she hadamenorrhcea. She suffered a good deal of pain at night ;she looked pale and weak. On pressing the abdomen severalhard lumps could be felt, and a growth was discovered inthe rectum.On Aug. 6th, under chloroform, an oblique incision was

made midway between the crest of the ilium and the lastrib, about six inches in length. The colon was opened, andthe edges secured to the margins of the abdominal woundwith strong sutures. The edges of the wound were thenbrought together again. Next day the patient expressedherself as feeling more comfortable; wound very healthy.On the 9th she was much more comfortable. Tempera-ture 99°. On Aug. llth the temperature was 95.5°. On the12th the temperature was 97 8°; had a bad night; motionstreaked with blood. It was about her menstrual period.Next day she was better again, and fæces passed throughthe artificial anus. On the 16th she was in a good deal ofpain in the abdomen during the night, the pain having comeon suddenly over the right iliac fossa. On the 20th shewas very ill, and in much pain, which continued all nextday. Although a good deal of fsecal matter has passedthrough the artificial anus and rectum, there was muchfulness with tenderness over the csecum. Under chloroforma transverse incision was made into the caecum. A quantityof fluid escaped, but nothing hard. A finger was thenpassed into the opening, and afterwards a director was putin, and a second opening made through the front of theabdominal wall. Patient derived but little benefit fromthis operation, and died in the afternoon. Relief was giventoo late.

Necropsy.—General suppnrative peritonitis. The anteriorwall of the rectum, three inches and a half from the anus, wasoccupied by a growth running transversely, and occupyingtwo-thirds of the circumference of the bowel. The surfacewas ulcerated, and showed the growth to be a colloid cancer.In the mucous membrane below the ulcer was a round pro-minent mass, movable, and covered by mucous membrane.On section, it was a deep red, with translucent patches.The rectum was adherent anteriorly to the uterus and itsligaments, and in two places the wall of the gut was per-forated, and little abscess cavities containing fsecal matterexisted, bounded bv the uterus and broad ligament, and theadhesions. From this situation the inflammation had becomegeneral. One ovary was in the wall of a fsecal abscess, andhad softened down into a grumous puriform fluid. Theoperation wound was found healed and healthy. The lumbarglands were involved. There were no secondary deposits.

CARCINOMA OF RECTUM; COLOTOMY; RECOVERY.The following notes have been furnished by Mr. Row.Eliza C-, aged twenty-nine, was admitted into Lydia

ward on Jan. 29th, 1880. Four months before admissionshe had much pain in passing motions, which were streakedwith blood. A white medicine given by a doctor did not

relieve the bowels, but an enema gave relief. About thesame time the abdomen began to swell, and became verypainful, particularly in the left inguinal region and rectum.Bougies were repeatedly passed.On admission the patient was very emaciated and feeble.

The abdomen was retracted, and scybala could be detectedin the left inguinal region. About an inch from the anus ahard mass could be felt constricting the passage of therectum and preventing the finger from passing. By thevagina the mass was found to extend beyond the reach ofthe finger.On Feb. 3rd, under ether, colotomy was performed. On

the 7th the patient was comfortable. She had taken milkand soda-water. No motion had passed through the wound,but on the 9th some passed. She took some chicken. Onthe 15th the wound bad healed by first intention. On the18th she complained of pain in the abdomen, and on mani-pulation some hard masses could be felt, and there was a hardand tender spot in the inguinal region. On the 20th thepatient was in a good deal of pain; the intestines were fullof faeces. On the 27th there was pain in the abdomen;scybala very prominent. An injection was given throughthe artificial anus; nothing passed through the rectum.On March llth a large quantity of fæces came away by

the artificial anus. On the 17th she went out. She passedmotions comfortably by the artificial anus.On June 5th she was doing well and had gained much

flesh

CANCER OF RECTUM; COLOTOMY; RECOVERY.For the following notes we are indebted to Mr. Row.Mary Ann T-, aged fifty-nine, was admitted into

Lydia ward on Dec. 3rd, 1879. She had a good familyhistory, with no knowledge of cancer. About May, 1878,patient began to suffer from constipation; she had had greatdifficulty in passing her motions. At night a dischargemixed with blood escaped per rectum. There is no pain inthe region of the anus, but for months she suffered frompain across the lower part of the stomach.On admission, patient was a short, healthy-looking

woman. In left inguinal region lumps could be felt, butwhether growths or scybala could not be made out. Tonguenormal. Oil administered.

On Dec. 9tb, under chloroform, an incision was made forcolotomy. When the finger was inserted, the part of thecolon to be stitched to the side of the wound was found tocontain a large scybalum. The needles were inserted throughthis, and the bowel opened without removing the mass. Shewas sick several times after the operation. There was noattempt of the scybalum to come through the wound; nobleeding per anum. On the 13th there was no pain or

tenderness of abdomen; slept fairly well; wind passesthrough wound. Fish diet. On the 16th some fæcalmatter passed through the wound, and three days laterfaeces passed through the artificial anus. On the 21st anenema was given per rectum. The fluid came up andescaped at the artificial opening. Next day a mass of well-formed motion was lying outside the artificial anus. Patientappeared very well, but complained that she did not micturatefreely. On the 29th there was some faecal discharge perrectum, which patient said gave much pain. There wasalso prolapsed colon through the artificial anus, to theextent of about half an inch, about the size of half a walnut.Ordered an injection of warm gruel and olive oil at onceand at bedtime.On Jan. 6th, 1880, fæces passed freely through the wound,

which looked very healthy. On Jan. 21st she left the

hospital. The carcinomatous growth of rectum was less

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painful than it had been. She had had a plug made,which kept the upper slightly prolapsed portion of the colonin its place. ,

INTESTINAL OBSTRUCTION ; COLOTOMY; RECOVERY.

For the following notes we are indebted to Mr. Under-wood.John E-, aged thirty-eight, a wharfman, was admitted

on July 16th, 1880, into Job ward. The patient was married,and the father of seven children. He had scarlet fever in1866. In 1877 he had diarrhoea, which continued more or less.In November, 1879, he had a good deal of pain, and becamecostive for a time. A medical man gave him some pills,and the diarrhoea returned, and continued until admi-sion,when it was accompanied with pain, and he applied and wasadmitted into Stephen ward, from where he was transferredto Job ward. He had had obstruction for about three weeks,and, in spite of medicine, was getting worse. His abdomenwas greatly distended and somewhat tender, and his powerswere rapidly failing; indeed, he was so low that the pro-priety of operating was carefully discussed. Mr. Bryant,however, determined to give him the relief which an opera-tion would afford.Under chloroform left lumbar colotomywas performed, the

usual oblique incision being made. He slept well and long ;had not much pain next day. On the 24th the discharge hadnearly ceased ; bowels acted well through anus. On the28th the edges of the wound were healthy, and healing verynicely ; health good. On August 2nd he got up, and on thellth a belt was ordered. The temperature was normalthroughout.The relief which the operation afforded this patient was

striking and rapid. He convalesced without one bad sym-ptom, and when he left the hospital he was quite com-fortable.

WANDSWORTH INFIRMARY.FOUR CASES OF SPINAL CARIES, WITH SUPPURATION

NOT PRESENTING EXTERNALLY; NECROPSIES.(Under the care of Mr. JAMES ALLAN.)

CASE 1. Caries of dorsal spine; paraplegia.—WilliamS-, aged sixty-nine, was admitted on Dec. 29th, 1879.In December, 1878, after exposure to cold and wet, thepatient felt pains across the lower part of the back. Thisdid not incapacitate him from acting as a messenger untilnine months later, when the inferior extremities becameweak and dragged slightly. Sensation was impaired;numbness, first noticed in the toes, crept up both limbssimultaneously. He had slight starting of the limbs, chieflyat night, straining on micturition (urine passed most freelyin the morning), and soon afterwards constipation. Rapidincrease of these symptoms took place during the week pre-ceding admission, but he was not confined to bed. On

examination, motor power and sensation of the lower limbswere very limited, and reflex action was increased ; there waspain in the lumbar spine; the patient could sit up in bedwithout difficulry. The urine was normal; bowels consti-pated. On Jan. 12th he had retention of urine, necessitatingthe use of a catheter. On the 17th he bad complete motorparalysis, with painful starting of limbs. On Feb. 1stincontinence of urine came on; the bowels were moved onlyby enemata. On the 19th the urine was ammoniacal, andthere was a sensation of constriction round the abdomen, toge-ther with prominence of one of the lower dorsal spines. OnMarch 19th the skin over the sacrum had given way; therewas much pain shooting round the upper part of the abdomenfrom the level of the two lower ribs; sensation of the limbswas quite abolished; reflex action increased; anorexia. OnMarch 25th the patient died exhausted. He was easiestwhen propped up in bed ; pain was relieved by opium and

by small blisters applied near the spine; temperature sub-normal.

Necropsy.—Removal of the thoracic viscera exposed atthe lower part of chest, two rounded tumours, one on eachside of the bodies of the tenth and eleventh dorsal vertebrae; 9contents fluid, and communicating with each other acrossthe middle line. Incision showed that each contained aboutan ounce of thick pus, mixed with bone fragments ; thatthe cartilage between the tenth and eleventh vertebrse had dis-appeared ; that the tenth vertebra was eaten away in itslower surface, but to a much gteater extent anteriorly thanposteriorly, and presented an irregularly convex outline,fitting into a corresponding concavity in the upper surfaceof the eleventh vertebra, which was not muchwasted; and thatthe opposed surfaces were tolerably firm, covered here andthere with small patches of cartilage. The tenth dorsalspinous process was slightly prominent; on removing the spinalarches the body of the tenth dorsal vertebra was found pro-jecting somewhat backwards inferiorly. Above this projec-tion the membranes and cord were normal; below, the duramater was much thickened, and adherent to the spinalcanal by means of an inspissated layer of pus, mixed withbone spicula; the cord was slightly sottened, but notadherent. At apices of lungs there was evidence of oldcured lung disease ; bladder hypertrophied; pus in pelvisof left kidney ; small granular kidneys.CASE 2. Carries of twelfth dorsal and first lumbar

vertebræ; no paralysis.-Henry C-, aged fifty-five, wasadmitted on Sept. 3rd, 1879. About four years before hefell from a considerable height on his back; for the lasttwo years he had experienced weakness and pain in thelumbar region. On examination, the last dorsal spinousprocess was slightly prominent; pain on pressme or move-ment, and rigidity of the spine were also noted. The urinewas normal. While under treatment he frequently hadintractable pain in the area supplied by the lateral branchof the last left dorsal nerve. The movements of the leftthigh caused pain, and he could not turn readily in bed.No paralysis or difficulty with bowels or bladder ; occa-

sionally free of pain; not usually confined to bed. He wasrelieved by chloral and by blisters; his condition wasaggravated by opium. Died rather suddenly of pneumoniaon May 30th, 1880.

Necropsy.—The right lung weighed fifty ounces, and wasin a state of red hepatisation. There were caseous nodulesin the apices of both lungs. There was prominence of thetwelfth dorsal spinous process, and slight displacementbackwards of the twelfth dorsal vertebra. Over a limitedarea anteriorly, opposite a large carious cavity in the con-tiguous surfaces of the twelfth dorsal and first lumbar, thedura mater was thickened, and encrusted with a layer ofthick pus and bone spicula, and adherent to the spinalcanal. Cord normal. On dissection from the abdomen it wasfound that no disc existed between the above-mentionedvertebrse, and that a large portion of both bodies had brokendown ; the space so formed was occupied by thick pus andbone débris; pus had burrowed along each side of the spinein the psoas muscles as far as the third lumbar vertebra ;the greater quantity of pus was on the left side, tiltingforward the left kidney. The upper surface of the firstlumbar presented a concavity excavated to almost the wholedepth, and the under surface of the twelfth dorsal was sofashioned as to fit into it. The carious surfaces were soft,and readily broken iuto. Large white kidneys, 7 oz. each.Liver, 4lb., fatty.CASE 3. Superficial caries of fourth and fifth lumbar ver-

tebrce; tuberculosis.—James W-, aged sixty-seven, wasadmitted on April 30th, 1880, on account of a catious cavityin the shaft of the right tibia, near the upper extremity, often years’ duration. While under observation he was Leeble iappetite poor ; lost flesh and complained of pain across thelower part of lumbar spine. His chest was emphysematous,but nothing further was detected until a few days beforedeath, when crepitation, dry and small, was heard all overboth chests ; resonance not impaired. Ten hours beforedeath, on August 5th, 1880, he had a series of convulsivefits, and became unconscious; the fits recurred frequently;consciousness was not recovered ; convulsions general andrather violent.

Necropsy.—Several minute haemorrhages were found in.the course of the vessels at the base of the brain, and espe-cially in the Sylvian fissures, none in the cerebral tisbue.Both lungs free in the chest ; right weighed 29 oz. ; left221 oz. ; both throughout in a state of acute miliary tubercu-