NOTES OF A CASE OF ANGINA LUDOVICI ; OPERATION; RECOVERY.

408 and the pulse was 108. On examination I found thataanterior superior iliac spine and pus, with occasionally foecal the red line had advanced since the operation over thematter, the escaped. Towards the end of the year the patient f from chronic bronchitis, mitral disease, emaciationy point of the shoulder and although perhaps not quite sosuffered prominent was yet well defined, while the redness in theand great prostration, so much so that further interferaxilla had crept down over the ribs. I injected 10 c.c. ofence I was not countenanced. On Dec. 29th the sinus wa& the serum into the shoulder just outside the reddened area.laid open and traced down to the caecum, which organ On arrival next morning I was delighted to find that this was found adherent all round, and having thick and edge had become ill-defined, blotchy, and irregular with rose- hard walls. The csecum was liberated and cut away coloured processes, some of which extended beyond the and the ileum was attached to the wound, whilst the point of introduction of the needle, but on the whole the lower end of the colon was closed up. The sinus was advance seemed broken, while the shoulder itself was much scraped out and stitched up. At the completion of themore soft and elastic. The axillary redness was still spreading operation I was in doubt as to the nature of the disease, but downwards, so another injection of 10 c.c. was made just the extensive ulceration of the mucous membrane of the within the margin of it. Altogether 50 c.c. of the serum bowel and the hard and thickened walls suggested malignant were injected into the affected area and certainly seemed disease. Much collapse followed the operation, indeed the No removal of the caecum was somewhat questionable on most potent in arresting the spread of the gangrene. ill effects seemed to follow the injections, an irritable account of the patient’s frailty, but the wound healed easily papular rosy rash around the points of insertion of the enough in spite of the mess occasioned by the discharge. needle being the only reminder of them, while three or four from the artificial anus. Microscopic examination by days after the last injection a rash, consisting of large experienced hands showed the disease to be tuberculous rose-coloured circular spots, not elevated, and disappearing by reason of the presence of giant cells and areas of caseaon pressure, broke out over both buttocks but soon distion. Contrary to expectation the patient lived until appeared. The further progress of the case was most Feb. 20th, 1898, but his feeble condition never would have favourable, our only anxiety being caused by the passage of justified an effort to anastomose the small with the large clay-coloured stools and bilious urine, but these symptoms bowel and so close the artificial anus. Nevertheless its The would have been better to have tried to do this at the time of soon passed off and no other complications ensued. temperature never rose above 100° and the only discharge excision of the cascum because the patient exhibited a from the wound was a thick mucoid material, inodorous remarkable tenacity of life even in his feeble condition. and easily removed, while the wound itself never gave me a My reason for contributing this brief abstract of the case moment’s anxiety. The patient is now quite well and has no is through my having seen in THE LANCETreference to the pain in the stump, which is at present quite healed. surgical treatment of intestinal tuberculosis. The disease The cause of the gangrene we attributed to the bacillus of may be more commonly met with than I am aware of, but ili malignant oedema picked up from the soil, but an examina- is the first case which I have been called upon to treat; on tion of some discharge by the Clinical Research Association the other hand, cases of cancer of the caecum have been only revealed the presence of streptococcus longus. I am dealt with by excision by Bruce Clarke, Walter Edmunds, bound to say, however, that the specimen was sent to Marmaduke Sheild and others with success, and it is prothem rather late and that then the amount of discharge bable that similar results may be recorded in future for sent was not enough altogether to exclude the malignant tuberculous disease. To others it may be somewhat I bacillus as the prime cause of the evil. On the other encouraging to know that a most unpromising subject for hand, no one who closely observed the effects of the surgical measures survived a resection of the cascum for injections could, I think, have failed to notice how very two months and might have done still better if sufficient marked they were. Whether the further progress of the courage had been forthcoming to unite the small with the gangrene in the stump would have been arrested without large intestine immediately after resection. their aid it would be difficult to say, but I feel quite con Carlisle. vinced that without them there would have been a far greater loss of tissue and that the fair length of stump which the patient now possesses would have been very much less, if not altogether destroyed. _______________

Clinical Notes :

Oarshalton. _________________

MEDICAL, SURGICAL, OBSTETRICAL,

AND

THERAPEUTICAL.

EXCISION OF THE CÆCUM FOR TUBERCULOUS DISEASE. BY H. A.

LEDIARD, M.D. EDIN., F.R.C.S. ENG.,

SURGEON TO THE CUMBERLAND INFIRMARY.

NOTES OF A CASE OF ANGINA LUDOVICI OPERATION; RECOVERY.

PHILIPPS, M.R.C.S. ENG., L.R.C.P.LOND.

BY ARTHUR E. IN July of last year a man was admitted to the Cumberland Infirmary on account of a hard swelling in the right inguinal and hypogastric regions. The age given was sixty-three years, but the appearance suggested at least seventy years. Deafness and hebetude no doubt prevented much historical record beyond the fact that the patient had been ill for eight months and suffered from looseness of the bowels. The swelling was within as well as beneath the parietes and showed no mobility. The first impression was that a malignant tumour was present and no idea of surgical interference was entertained. A rise of temperature, however, occurred and the area of the tumour showed a reddened patch. On August lst an incision was made and some pus was evacuated and at the same time a piece of the indurated abdominal wall was cut away for examination. The pus appeared to come from the direction of the caecum, but the incision was made near the middle umbilicus. wound was line and below the The stuffed with gauze and the temperature fell, but in a few days faecal matter soiled the dressing and it became clear that the tumour was connected with the bowel. Microscopic examination of the piece cut away threw no light upon the nature of the disease. A sinus now led from just below and to the right of the umbilicus towards the

;

aged forty-five years, of temperate May 8th, 1898. He gave the followthe previous week he suffered from what ing history. During he described as the jaws ache," accompanied with occasional stiffness in the submaxillary region on the left side. He was also subject to hot and cold sensations. On May 7th he noticed a swelling in the left submaxillary region and felt that his tongue was being pushed up towards the roof of his mouth. He applied a poultice to the swelling, which increased very rapidly indeed. There was no history of sorethroat. The next evening (the 8th) I was called to see him. There was an indurated brawny swelling filling up the left submaxillary region extending anteriorly to the middle line, posteriorly to about 1 in. beyond the posterior border of the sterno-mastoid, and superiorly to the malar bone, sharply bounded by entirely unaffected tissue. There were parts locally softened and pitting on pressure. Any attempt THE

patient,

a man,

habits, consulted

me on

"

to open the mouth caused

great pain and on this account it was quite impossible to examine the throat. The floor of the mouth consisted of hardened deeply congested tissue and there was a bolster-like swelling round the interior of the lower jaw. The tongue was normal. He 1

THE LANCET,

July 30th, 1898, p. 274.

409 ’could not swallow anything whatever, being obliged to put anilk into his mouth and allow it to run down his hroat, and he had great difficulty in speaking. He tated that he was unable to sleep for more than a few minutes at a time. There was no albuminuria. The pulse was 96 and the temperature was normal. On the ;9th I saw him early in the morning and found that the ’swelling had extended in all directions except downwards, .almost closing the left eye superiorly and beyond the middle Line anteriorly. I anæsthetised the patient with A.C.E. .mixture and made a deep incision in the submaxillary region. The wound was ’The anaesthetic was taken very badly. ,plugged with carbolic gauze and dressed with hot fomentations. On the 10th, with the aid of an anaesthetist, I made .deep incisions in the middle line and along the anterior border of the sterno-mastoid; a thin, dark serum exuded. Both wounds were plugged as before. The patient steadily .improved, though suffering from bronchitis following the anæsthetics. On June lst the median incision and that at the anterior border of the sterno-mastoid had almost healed up, but the tissue around the submaxillary incision had broken down and a large quantity of pus was discharged. A >drainage tube was inserted and the wound granulated up. On July 19th the patient felt well, and returned to work. Fulham, S.W. _________________

A CASE OF MEMBRANOUS TRACHEITIS AND LARYNGITIS WITHOUT THE PRESENCE OF DIPHTHERITIC BACILLI. BY L. A.

certainly uninfected ; he does not develop the disease until some time after leaving, which negatives the possibility of his carrying the disease with him, but develops the disease at time when from the nature of his food, his use of patent and the necessity of using local water-supplies-usually mere pools-the three important factors-namely, constipation, catarrh, and an infective bacillus-have been furnished for the development of the disease. 2. In the Sandwich Islands epidemics (not typically typhoidal in character) occur among the labour hands on the plantations characterised by high temperature, diarrhoea, and haemorrhage from the bowel, and apparently arising through the labourers drinking water from the streams. 3. True typhoid fever occurs both in Western Australia and the Sandwich Islands. 4. In Western Australia cases were far less typical at the commencement than at the close of the typhoid fever season. The above-mentioned observations have led me to form the following hypothesis : (1) that the typhoid bacillus exists in virgin soil ; (2) that the typhoid bacillus requires educating -i.e., transference through a series of hosts before it produces typical typhoid fever ; and (3) that so-called typhomalaria is due to an uneducated bacillus. These three hypotheses appear to me to be reasonable, firstly, from their analogy to the biology of the diphtheria bacillus ; and secondly, from the excellent results obtained in both diseases by the use of olive oil. a

pills,

Melton-Mowbray.

A Mirror

GRIMES, M.R.C.S. ENG., L.R.C.P. LOND.,1

LATE HOUSE

PHYSICIAN, ST. GEORGE’S HOSPITAL.

OF

A BoY, aged four years and nine months, who was HOSPITAL PRACTICE, Recovering from an attack of measles, was admitted into BRITISH AND FOREIGN. St. George’s Hospital on May 18th, 1898, with marked stridor and great sucking in of the episternal notch and of the Nulla autem est alia pro certo noscendi via, nisi quamplurimas et 11.ower thorax during inspiration. On examination nothing morborum et dissectionum historias, turn aliorum tum propfiao abnormal was found beyond slight injection of the tonsils. collectas habere, et inter se comparare.-MORGAGNI De Sed. et Caus. lib. iv. Proœmium. ’The symptoms becoming rapidly worse and the child being Morb., in great distress tracheotomy was performed within half-anLONDON HOSPITAL. ’hour of admission. Immediately the tube was inserted a membrane was This of membrane OF CASES OVARIOTOMY IN WHICH THE BOWEL TWO coughed up. ’large piece was of a greyish-yellow colour and very tough. Dr. Ewart’s WAS TORN ; RECOVERY. method of introducing creasoted oil (1 in 20) into the trachea Dr. LEWERS.) the care of (Under was at once adopted. Five minims every 2 hours had the PROBABLY the most dangerous complication of the operaeffect of softening the membrane, thus enabling the child to it more and a fit of was cough up easily coughing usually tion of ovariotomy is wounding of the bowel and this most ’brought on immediately the oil reached the trachea. After commonly occurs in the separation of adhesions. The 24 hours the dose was altered to 10 minims every 4 hours. of an adhesion to a piece of bowel is in itself someIn two days the membrane became quite soft and muco- presence to weaken the bowel wall at the point of times sufficient purulent looking. Bacteriological examinations were made it tends to limit the action of the muscular for ’by Dr. Slater on the first day and on three other occasions, attachment, but though there were numerous bacilli that of diphtheria fibres in the wall at that spot, and thus may lead to their was always absent. The membrane became gradually less partial degeneration ; as a consequence the wall of the from day to day and the tube was finally removed on the intestine is especially liable to tear when adhesions are being twelfth day. The child made an uninterrupted recovery and broken through. Nothing but the prompt and skilful was discharged within the month. of the torn bowel can save the patient’s life and suturing S. W. Albert-street, those who operate in these cases must be prepared for some of the most difficult complications in abdominal surgery. A CLINICAL ASPECT OF THE ORIGIN OF TYPHO-

____________

The uneventful

course

which such

MALARIA AND TYPHOID FEVER. BY OWEN F. PAGET, M.B., B.C. CANTAB.

cases

mav

run

if the

injury is immediately recognised and remedied is well exemplified in the two cases recorded below. CASE 1.-A married woman, aged twenty-two years, was admitted into the London Hospital under the care of Dr. learning, Lewers on Dec. 18th, 1897, complaining of pain in the right of the

HAVING been long separated from any centre of the modern view taken by bacteriologists of the biology ’typhoid bacillus is unknown to me, but I would venture ’to place before the profession some clinical observations made both by others and myself in Western Australia and Bthe Sandwich Islands, together with the deductions arising

therefrom. 1. In Western Australia

side. She had been married ten months, and four weeks before admission she had a severe pain on the right side of the abdomen which " doubled her up." She at once consulted a medical practitioner who told her to go to bed and ordered poultices to be applied to the abdomen and at first the pain was relieved. Three days later she miscarried, having been six months pregnant. She lost a good deal at the time and continued losing for nearly three weeks after the miscarriage. The pain was still very severe and there was occasional vomiting after food. At the end of three weeks she was able

single men and parties went out Jprospecting, usually taking with them only tinned meats, "condensed water, and flour. They necessarily preferred virgin ;soil and camped as far removed from others as possible. In to get up, but the pain returned and she was obliged to take such a spot they might locate themselves two or three or to her bed again, where she remained until she went to the She has had no shivering fits, but at times she has more months and then develop typho-malaria or typhoid hospital. fever. Concisely put, a man starts from a probably typhoid- felt very hot. She had always been delicate and has had The catamenia ’had never been :infected centre well in himself with food

supplies

almost

scarlet fever and influenza.