RESECTION OF THE CÆCUM, GREATER PART OF ASCENDING COLON AND FIVE INCHES OF ILEUM FOR MALIGNANT DISEASE OF ASCENDING COLON.

648 It will be seen that during the five months from June to November he first noticed a swelling in the right loin. October inclusive there were reported 133,781 cases of cholera I saw him first in consultation with Mr. Hollingworth of this in the Caucasus, and 68,353 deaths. If to. these figures be town, when we found a tumour the size of a cocoanut added those already given for the Central Asian provinces situated in the right loin. When in the horizontal position and Siberia, it will be found that the final totals for the whole the middle of the swelling was in line with the umbilicus. It of Asiatic Russia were 222,956 cases and 115,184 deaths. was firm and very movable, and it had lately become very It is impossible to enter here into a full account the tender on manipulation. There was no obstruction, and since measures taken by the Government to check the spread of the June the hmmorrhage had not recurred. In appearance the epidemic through the Caucasus and so to European Russia. patient was very thin, but he had well-developed muscles Early in June a large number of circulars were issued by the and in former times had been a very strong man. He had various Ministers with this object. The majority were general lived rather freely and taken a good deal of liquor, withmeasures applicable to all parts of the country. Of those out being, in his own opinion, a drunkard. The action of specially adapted to the local conditions of the Caucasus the the heart was at times very irregular, but at others no most important had reference to the Transcaucasian Railway. irregularity could be detected. The urine contained neither On June 12th M. Gratcheff, the senior inspector of railways, albumen nor sugar and had a specific gravity of 102& was sent to Tiflis by the Minister of Ways and CommunicaHe was admitted as an in-patient of the infirmary on tions with instructions to form a Commission, consisting of Jan. 16th of this year and immediately put on milk diet with representatives of the line and the local medical authorities. thirty grains daily of &bgr;-naphthol in the form of a pill. On a The duties of the Commission were to organise a sanitary subsequent consultation, the diagnosis of malignant disease service on the railway, to supervise the carrying out of the of the colon being given unanimously, I opened the abdomen numerous Government orders for preventing the spread of on Jan. 24th by a vertical incision in Langenbuch’s position cholera, and to concert with the local authorities along the line to the outer side of the rectus. A large mass immediately all measures that seemed to be called for to check the epidemic. presented itself, involving the middle of the ascending colon, Before the formation of the Commission the management the cæcum and appendix being unaffected. The omentum of the railway had stopped all goods traffic between Tiflis and was adherent to the tumour anteriorly, and this I severed Baku, and passenger trains were allowed to run only as far with scissors and ligature. Pushing the colon inwards, I now as Baladjari, a station thirteen versts from Baku. Additional entered the scissors above the level of the tumour through the measures were taken by the Commission. Sanitary waggons posterior layer of peritoneum lining the posterior wall of the abdomen to the outer side of the great bowel, and ran it were attached to each train, with accommodation for persons taken ill on the journey ; provisicn was made at certain down to a point opposite the lower end of the cæcum. The stations for the removal and treatment of such patients, and bowel could now be easily separated from its bed. It still disinfection was actively carried out on the trains and at the remained to divide the peritoneum on the inner side where stations. Unfortunately, however thoroughly these measures the colic vessels spread out fan-like to supply the colon. may have attained their object on the line of railway, this This was done by tying, the serous membrane with the vessels in five or six successive pieces and dividing distally was but one channel by which the infection was being The lineof "Like ghosts from an enchanter fleeing," the -i.e., between the ligatures and colon. carried. "pestilence-stricken multitudes" were escaping from Baku this incision inclined downward and inward, meeting the in thousands daily, by road and by sea as well as by rail, ileum as it crossed to join the colon five or six inches from and it is questionable whether any measures, however active, the ileo-emcal valve. Several diseased glands were included could have done much to check the course of the epidemic in this triangle. The ileum was separated from the mesentery when once the exodus had begun, more particularly in a in the same way, and now the greater part of the ascending country where the hygienic conditions are such as they have colon, with the cæcum and four or five inches of the ileum, were free along with the tumour. The time had now arrived for been seen to be in the Caucasus. dividing the bowel. Two long Makins’ clamps were applied to the colon above the tumour, and between these the bowel was divided as nearly at right angles as possible. The mucous of the upper divided end was stitched together membrane THE OF GREATER RESECTION a fine continuous silk suture, and then, on invaginating by PART OF COLON AND FIVE the stitched end, the serous coat was united by a close series INCHES OF ILEUM FOR MALIGNANT of Lembert’s sutures. The ileum was also divided, and the edges turned in and sewed by Lembert’s suture in the same DISEASE OF ASCENDING COLON. way. The whole piece of bowel to be removed was now at BY D. LOWSON, C.M. ABERD., liberty, and was lifted out of the abdomen with the tumour. There was left a gap in the intestinal canal extending from ASSISTANT SURGEON, HULL ROYAL INFIRMARY ; SURGEON, HULL WOMEN’S HOSPITAL ; AND LATE EXAMINER IN SURGERY, five inches above the lower end of the ileum to nearly the ABERDEEN UNIVERSITY. beginning of the transverse colon ; and, the ileum ending in a cul-de-sac and the colon beginning in the same way, it MR. CARPENTER, the assistant house surgeon to the was necessary to re-establish the continuity of the canal. infirmary, has taken great interest in this case, and I I therefore opened the transverse colon anteriorly, the transcribe largely from his copious notes. The main events opening being rather more than an inch long and running in of the clinical history of the case are as follows. Seven the long axis of the bowel. Into this one of Senn’s bonewas introduced with the threads in position-i.e., two when the was years ago, thirty-three years of plates patient placed laterally and one at each end. The lateral threads age, he took part in a pugilistic encounter with a pugnacious were drawn through the intestinal wall and the end ones friend at Drypool Feast (a local fair in Hull). After a made to come out at the angles of the wound. The ileum long struggle he emerged from the dust and din of was treated in the same way and a second bone-plate battle, victorious. Later in the evening, however, he was similarly introduced. One of the lateral threads of the plate in the colon was united to the corresponding lateral thread waylaid and attacked by some friends of the vanquished, in the plate in the ileum and tied firmly, a couple of sutures and by them he was kicked, bruised and beaten, and lay half being introduced on each side of it. The end sutures were dead for some hours. He was quite unable to walk and had next knotted, and finally also the other two lateral threads, the to make the best of his way home on all fours, taking frequent whole being rendered more secure by the introduction of a rests. It being now late at night, he met no one on the way few stitches in the intervals. The parts were gently washed, to render him any assistance, with the exception of a police- the clots and sponges removed, the bowel replaced and the man, who threatened to have him locked up. He arrived abdominal wound closed, a Keith’s tube being kept in for a home at four o’clock in the morning, and for several weeks couple of days. was confined to bed. He suffered much from pain in the After the operation the patientlay collapsed for several hours. right side, but discovered nothing unusual about his urine or The sickness was at first severe and much pain was complained motions. He had no medical attendance. After this he had of. One-sixth of a grain of morphia was given the same good health till January, 1890, when he had an attack of evening and one-sixth the next morning. Next day he was influenza. In May of last year there occurred a severe better, and would have had very little pain had it not been haemorrhage from the bowels, when quite a pint was lost. A for a troublesome cough. For two days he had nothing recurrence took place in June nearly as On the third day he profuse. The but hot water by the mouth. same month he sustained a fracture of the leg, and in had eight ounces of hot milk, and on the day after two pints.

of

CÆCUM,

ASCENDING

.

649

Alight-coloured liquid motion was passed on the third day, a paper on Pulmonary Embolism, Dr. Goodhart and others and regularly every day after. The pulse on the first day was 72 ; expressed the opinion that all the evidence of venous thromsecond, 80; third, 76; fourth, 100; fifth, 102; sixth, 100; bosis might so completely disappear that no sign of it can be seventh, 90; eighth, 102; ninth, 96; tenth, 90; and then it found post mortem. It seems to me that no other explana-.

gradually fell. The temperature was 97° on the evening of the operation; on the second day 995°; third, 100°; fourth, 99 5°.

tion offers itself of this case, in which, supposing the fluid collected at a uniform rate, after the first tapping of the right, On the three following days it was normal, and then the day chest that rate was three ounces and a half an hour, after’ after it mounted suddenly in the evening to 102°, falling next the second one ounce and a half an hour, and after the third morning to 99°, after which it kept nearly normal till he left about one ounce and a half an hour. It is also quite exceptional the hospital, which he did twenty-five days after the opera- for the distension of the chest with fluid to be so rapid as to The patient cause acute pain, and it is no doubt comparable to the severe tion. The plates were never seen in the stools. has gained greatly in weight, being 9 st. 7 lb. on admission; pain in the calf, felt in acute femoral thrombosis, and, like it, now, exactly one year and one month afteroperation, he weighs is probably due to the rapid stretching of the parts by the 13 st. 91b. There is so far no perceptible recurrence. fluid; also it must be very rare for the pressure of the fluid Remarks.-Three details which Senn strongly recommends on the superior vena cava to cause oedema of the neck. I neglected to do in this case, but as matters have turned out The following are the details of the case :-A young they were unnecessary. One is, after the introduction of the woman aged twenty-two was admitted into Guy’s Hospital plates and before tying the ligatures, to scratch the serous on Dec. lst, 1892. She had had scarlet fever when young.’ surfaces to be apposed ; the second is to anchor the bowel She was a waitress at a restaurant, and when going home in the vicinity of the junction to the parietal peritoneum; and from her work caught cold. The next day her feet were the third to attach round the place of union an omental graft. swollen, and the day after her face and eyelids, and five One detail, however, which cannot be neglected without fatal days later, feeling ill, she took to her bed. The oedema extravasation of intestinal contents is to be especially particular increased, and she suffered from pain in the head and in to bring the serous surfaces accurately in apposition at the the loins, from vomiting and from dimness of vision. On point where the mesentery joins the intestine and where the admission she was suffering from general cedema. There was serous coat of the colon is deficient behind. This I was some ascites. The cardiac apex was in the normal posimost careful to do. The last I heard of this patient was tion. The chest was dull behind from the eleventh rib that he had run a race with a competitor, and, as in the for four inches upwards, and over this area there were all the other signs of fluid. The edges of both optic discs were fight, he was the victor. blurred. She was passing about twenty fluid ounces of urine, Albion-street, Hull. 150 grains of albumen, and 100 grains of urea a day. Milk diet and diuretics were ordered. A CASE OF PLEURAL EFFUSION AT THE : Dec. 7th.-She was better; the oedema, of the body generally was less, but the chest was very dull up to angles of RATE OF THREE AND A HALF the scapulæ.—10th: She was ordered injections of piloFLUID OUNCES AN HOUR. carpin and a vapour bath at night, compound jalap powder when necessary and middle diet.-llth : Twelve ounces of BY W. HALE WHITE, M.D., F.R.C.P., colourless fluid were withdrawn from the left chest.-12th: A PHYSICIAN TO AND LECTURER ON MATERIA MEDICA AT GUY’S HOSPITAL. systolic murmur was heard to-day at the apex for the first THE following case seems to me sufficiently remarkable to time -16th: Thirty-six ounces of colourless fluid were obtained from the right chest. The patient was not so well. deserve record. The patient had ordinary tubal nephritis, The systolic murmur was heard in the axilla, and there was together with mitral constriction and regurgitation. There a presystolic murmur also. Particular care was taken to was, as is usually the case, some fluid in each pleural cavity. aspirate all the fluid.-17th: This evening the patient was On Dec. llth twelve ounces of fluid were withdrawn from the suddenly seized with excruciating pain in the right chest, The right chest was left chest, and on Dec. 16th thirty-six ounces were withdrawn together with severe dyspnoea. found to be extremely dull, and it was at once aspirated, from the right chest. On Dec. 17th the extraordinary part thirty hours after the last aspiration of it, and 106 ounces of of the case began. The patient was seized with excruciating fluid were withdrawn. The fluid must, if it collected at an pain in the right chest and much dyspnoea. Thirty hours even rate, have formed at the rate of three ounces and a after the first aspiration of the right chest 106 ounces of fluid half an hour. The patient was much relieved by the aspirawere withdrawn from it. Especial care had been taken to tion.-18th : The patient was better ; this evening the air was remove all the fluid at the first aspiration, so that the whole entering the right lung very well.-19th: The air did not of the 106 ounces must have collected in thirty hours. enter the right lung at all well, but there was no dyspnoea, On Dec. 20th (seventy-eight hours after the second tapping of although the dulness extended up to the fourth rib.the right chest) 120 ounces of fluid were withdrawn from it. 20th : At 2.30 A. M. the patient rather suddenly became very On this occasion also there were extreme pain and dyspnoea ; in dyspnceic, and 120 ounces of fluid were withdrawn from the. addition, there was great œdema of the neck, which I was right chest. Previously to this oedema about the neck had, inclined to attribute to pressure on the superior vena cava rapidly appeared and was very marked, as though the superior and the enormous quantity of fluid in the right chest, for it vena cava was pressed upon, but it subsided after the fluid was subsided quickly when the fluid was withdrawn. On removed.-22nd : Gradually the signs of fluid have returned in Dec. 22nd (thirty hours after the third tapping of it) fifty the right chest, and this afternoon at 4 P.M., thirty hours after ounces of fluid were withdrawn from the right chest, which the last tapping, fifty ounces of fluid were withdrawn. The was not tapped again till Feb. 12th, when thirty ounces of left chest has always remained free, or almost free, from fluid fluid were taken out. since it was tapped.-27th : The fluid was slowly collecting It seems to me that the only possible explanation of again in the right chest. It was noticeable that the with- . this extraordinarily rapid accumulation of fluid is that drawal of large amounts of fluid from the chest have been, the patient had thrombrosis of her large azygos vein before associated with a considerable diminution of the general it is joined by that from the left side. It is not against oedema. During January it was not necessary to withdraw this view that we saw no enlarged superficial veins, for the any fluid from either side of the chest. The patient suffered most important anastomoses between the branches of the from bronchitis, headache and diarrhoea at different times ; . azygos veins of the two sides and the large azygos vein and she also developed well-marked albuminuric retinitis, and the inferior vena cava are deep-seated in the abdomen, towards the end of the month pericarditis.-Feb. 7th : The the thorax, and around the spine. Nor is it conclusively legs have been very swollen lately, especially the left, in, against this supposition that no evidence of thrombosis was which there is such pain and tenderness over the femoral, found post mortem, for the patient did not die till eight weeks vein as to make one very suspicious of thrombosis in it.afterwards, by which time all signs of thrombosis might very 12th : The dyspnoea has been getting worse the last few well have disappeared. She herself had the clinical symptoms days, and to-day thirty ounces of fluid were withdrawn from. of thrombosis of her femoral vein only ten days before her the right chest.-14th : The patient was in all respects much death, and yet the vein was at the necropsy found to be patent. worse ; sixteen fluid ounces were withdrawn from the left;. I have often observed that when patients have died no evi- chest.—17th : The patient died this evening. dence has been forthcoming of thrombosis, although all the Necropsy,-The kidneys were typical large white kidneys._ signs of it have been present during life; and at a recent The heart weighed thirteen ounces. There were three. meeting of the Pathological Society, at which Dr. Pitt read ounces of fluid in the pericardium. The mitral valve wa:&