BRADFORD ROYAL INFIRMARY.

210 had then closed. On examination again under ether it was found that the distance between the remaining portions of sigmoid and rectum was so great as to exclude any possibility of uniting them. The remaining portion of the sigmoid was OF accordingly excised through the colotomy wound. The condition of the patient, therefore, was as follows. The descending colon ended by an artificial anus in the left iliac BRITISH AND FOREIGN. region ; below this point the whole of the bowel had been removed with the exception of a small of rectum which ended blindly about five inches Nulla autem est alia pro certo noscendi via, nisi quamplurimas et portion above the anus. The general health was excellent. The morborum et dissectionurn historias, turn aliorum tum proprias collectas habere, et inter se comparare.--MORGAGNI De Secl.- et Ca2ts patient wore a well-fitting belt of webbing in which was a Morb., lib. iv., Proœmium. cup (similar to that on the colotomy truss) which covered the colotomy opening. This arrangement suited him better than a truss, as it allowed him to stoop and to undertake BRADFORD ROYAL INFIRMARY. manual labour without chafing or becoming displaced. A CASE OF MALIGNANT INTUSSUSCEPTION OF THE SIGMOID The intussusception removed measured four inches. This, REMOVAL BY THE RECTAL ROUTE ; FLEXURE; with the inch left at the operation, represented together RECOVERY. about 10 inches of bowel. The base of the intussusception, (Under the care of Mr. J. BASIL HALL.) therefore, was about six and a half inches and the growth was llJ2- inches from the anus. Microscopically, the growth ’THE junction of the sigmoid flexure and the rectum is was of the usual columnar type. this seldom frequently the site of a malignant growth, yet Remarks by Mr. HALL.--It is now 13 years since Mr. ogives rise to an intussusception. Should, however, an Barker1 published the first case in which he successfully - invagination occur and the tumour present at the anus, the resected a malignant intussusception per anum, and the rarity ,growth may be removed per anum and the intussusception of such an opportunity is shown by the very few records of relieved at the same time, though the cases in which this is this procedure. Indeed, with the exception of the examples . advisable are not numerous, for usually a laparotomy would in Mr. Barker’s first publication and his second case recorded five later2am not aware of any other published make resection of the bowel easier with a very slight increase :mses.years In the case recorded above the operation cannot in the risk. strictly be said to have been performed "per anum,"since A man, aged 56 years, was admitted into the Bradford ’he sphincter had to be divided and the coccyx excised Royal Infirmary on Oct. 14th, 1900, with all the signs of before the base of the intussusception could be reached, but . acute supervening upon chronic intestinal obstruction. :he casebears sufficient resemblance to those of Mr. Barker He stated that 12 days prior to admission, without any o be classed with them. One of the most interesting points in the case was the previous symptoms, rectal tenesmus commenced, followed by the frequent passage of loose motions containing much nanner in which the small remnant of sigmoid flexure problood and mucus. Vomiting soon set in, the abdomen ruded through the colotomy opening. I have spoken of it became distended, and his condition passed into one of acute is a prolapse, but, strictly speaking, the protrusion always ’obstruction. On admission the patient looked much older ’ommenced as a true retrograde intussusception which than his years ; his abdomen was considerably distended but 1 )ecame a complete prolapse as soon as the whole length still moved with respiration. The tongue was moist but very( )f gut had escaped. In consequence of the shortness of this dirty and the breath was most offensive. The pulse was emnant portion of bowel the intussusception stage of the pro. quick, soft, and compressible ; the temperature was 1 rusion was necessarily of brief duration, but on more than 99 .8° F. The hands and feet were cold and his con- ( iiie occasion I satisfied myself that a true retrograde intusdit.ion generally was feeble. On rectal examination the ; usception occurred. This phenomenon has been observed finger impinged one and a half inches from the anus 1 efore under similar conditions and5 recorded by Lawford ’upon an intussusception with an annular carcinoma at the 1 Knaggs,3 Golding-Bird,4 and Barth. It is not :,apex., The mass appeared to be about five inches long.a associated with the existence of an obstruction below the ’There was much sanious and offensive discharge. < rtificial anus, for in Golding-Bird’s case a retrograde intusUnder ether, after stretching the sphincter, a view of the usception occurred through a patent Meckel’s diverticulum. It was quite black, with every 1 t is apparently a reflex pheuome on produced by the surface )mass was obtained. :appearance of sloughing. It was therefore decided, con- i irritation from the artificial anus. In the present case the sidering the condition of the patient, to relieve the obstruc-I rotrusion not infrequently occurred when the dressings were tion by opening the colon in the iliac region and at the same r removed and the abdomen was exposed to the cold air-afact time to gain what information could be obtained through the v ’hich lends colour to the view that occasionally intussuscep.colotomy wound. The obstruction was thus temporarily t .on is the result of irregular peristalsis set up by reflex relieved, but contrary to expectations no sloughing of the r ervous impulses. At mass occurred except a superficial necrosis at its apex. - the end of 10 days therefore Mr. Hall decided to attempt Ether being - resection after 3/ir. A. E. Barker’s method. .’.given the anus was divided posteriorly and the coccyx was excised, thus exposing about half the mass. A stout silk cord was then slipped over it and the intussusception was dragged BRITISH GYNÆCOLOGICAL SOCIETY. .as low as possible. ’rhree silk ligatures were then passed with a hernia needle as near the base as possible. Each ligature inclLided about one-third of the circumference ofComplications and Degenerations of Fibroid Tumours of the the wall of the intussuscipiens and the intussusceptum Uterus as bearing upon the Treatment of these Growths. together, and the mass was then amputated below them. A MEETING of this society was held on July llth, Dr. A stump about one inch long was left which it was calcuJ. A. MANSELL MOUDLIN, the President, being in the chair. ’-lated would speedilv be obliterated on account of the great Dr. CHARLES NOBLE (Philadelphia) read a paper on the The opening in the rectum was closed. Complications traction upon it. C and Degenerations of Fibroid Tumours of the The silk ligatures were left long and hanging through Uterus U as bearing upon the Treatment of these Growths. the anus. p was by no means their chief and only danger ; Haemorrhage After the operation the patient recovered fairly rapidly tl there were the risks of necrosis, of myxomatous or cystic but the silk ligatures did not come away, degeneration, of calcareous infiltration, of associated loose without cutting through the segment of bowel 1T disease, and of complicating adnexal affections, malignant At first this was attributed a - included within them. and even their indirect effects upon the alimentary, vascular, - two the stump becoming less swollen and œdematous. Three _ weeks later, however, a prolapse of the remaining three 1 Transactions of the Royal Medical and Chirurgical Society, vol. lxx., ’inches of the sigmoid occurred through the colotomy wound., p. 335. 2 Brit. Med. Jour., 1892, p. 1226. "This piece of gut had a blind end and it then became evident 3 THE LANCET, April 24th, 1897, p. 1137. What owing to the great traction it had been drawn up as 4 Transactions of the Clinical Society of London, vol. xxix. soon as the ligatures had cut through and its lower extremity 5 Deutsche Zeitschrift für Chirurgie, vol. xxvi.

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