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RADCLIFFE INFIRMARY, OXFORD.
HOSPITAL MEDICINE AND SURGERY.
297
being made to absorb the discharges. There of thin pus was evacuated and gauze drains were inserted. twitching of the tongue and Pneumococci in pure culture were grown from the pus found puffiness mouth. The woman was experiencing difficulty in at the operation. The patient died on the same evening. Extract from post-mortcnc wotes.-There was early otitis micturition. There was a blood-stained discharge from the vagina. The pulse-rate was nearly 150. On the back there media on both sides of the head. As to the thorax, in the Death took place on the right pleural cavity there were about one ounce of thin pus was a black, sloughy bedsore. and some flaky masses of lymph, while the right lower JO.Je same evening. Marked tut evanescent eye symptoms, such as those was coated with a similar layer of pyo-lymph. The lungs were described above, appear to be a very unusual feature of congested and oedematous but not solid anywhere. There plague. Iritis and irido-cyclitis are rarely seen. In addition were many basmorrhagic infarcts in the left lung. With the above case is noticeable for the primary involvement of regard to the abdomen, there was early general peritonitis. the supracondylar gland and the involvement nine days No attempt had been made to shut off the inflammatory later of a femoral gland which on bursting gave exit to the process, the only adhesions being a slight sticking together of the intestines in a few places. Thin pus bathed the typical discharge. Fatshan Hospital, South China. whole of the contents, forming here and there sheets of pyo-lymph, notably around the spleen and on the superior No attempt were
was
of, the face and
A Mirror OF
HOSPITAL
PRACTICE
BRITISH AND
FOREIGN.
Nuila autem eat alia pro certo noseendi via, nisi quamplurimna 81 morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparMe.—MoBaaNi De Sed. et Ca’lJ,8. Morb., lib. iv., Proaemium. -
HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. A CASE OF PRIMARY PNEUMOCOCCAL PERITONITIS.
(Under the
care
of Dr. A. E. GARROD and Mr. F. J.
STEWARD.) FOR the notes of the case we are indebted to Dr. H. J. D. Birkett, house physician. A girl, aged four years, was admitted to the Hospital for Sick Children, under the care of Dr. Garrod, just before midnight on July 4th last. The patient was in good health till 9 P.M. on July lst when she complained of feeling cold. About three hours later vomiting and diarrhcea set in, accompanied by severe abdominal pain. This attack was attributed by the mother to some gooseberry tart eaten at midday on the lst. On the 2nd some medicine was obtained from a druggist which stopped the diarrhoea and vomiting. The abdominal pain continued. On the 3rd the pain continued and the vomiting recommenced. A medical man was called in and he found a temperature of 103° F. On the 4th She the patient was worse and was taken to hospital. had been delirious on and off since the 2nd and for the last 36 hours the mother had noticed that the abdominal pain was less marked after the patient had emptied her bladder. There was nothing of importance in the past or family history of the patient. On admission the child was quite delhious and so extremely restless and irritable that a thorough examination The abdominal facies was well was almost impossible. marked. There was a divergent squint and the alas nasi were working slightly with respiration. There was no evidence of mastoid disease. In the chest there were a few crepitations heard over the left base behind. Nothing else abnormal was found. With regard to the abdomen there
surface of the liver. There was no local focus discovered, the appendix and intestine being free from ulceration or necrosis. At the necropsy pneumococci were obtained in pure culture and found in films from the heart’s blood and in smears from the pleural pus and spleen. Remarks by Dr. BIRKE’fT,-If justification be needed for the publication of this case it will be found, I think, first, in the comparative rarity of the disease ; secondly, in the extreme difficulty of its diagnosis, a difficulty so great that Michautin 1901 stated that on one occasion only had the diagnosis been made ; and, thirdly, in view of the study of pneumococcal peritonitis in children, by Annand and Bowen, which appeared quite recently in THE LAKCET.2 The history of the case and the child’s general appearance on admission suggested a severe attack of gastro-enteritis, though the extreme restlessness of the patient and the cessation of the diarrhoea two days before were against this diagnosis. On the following day the lack of abdominal movement, the presence of free fluid, and the pain occasioned by a distended bladder, combined with the general aspect and extreme restlessness of the patient, were sufficient evidence of peritonitis. The cause of the peritonitis was diagnosed partly by the resemblance of its onset and course to other known I cases and partly by exclusion of other possible causes. have met with two previous cases of primary pneumococcal peritonitis. These cases have not been published and are therefore not included in Annand’s and Bowen’s statistics. The first was admitted to St. Bartholomew’s Hospital during the early part of last year and was diagnosed as, and operated on for, appendicitis. The second case died in this hospital last March, the condition not having been suspected during life. During the last ten 5 ears there have been, so far as I have been able to ascertain, five other similar cases in the wards of this hospital. One was operated on for peritonitis, but its cause was not suspected until the pathologist’s report was received, whilst in the other four the diagnosis was made at the necropsy. I am indebted to Dr. Garrod and Mr. Steward for permission to publish the case.
RADCLIFFE
INFIRMARY,
OXFORD.
A CASE OF INTESTINAL OBSTRUCTION, WITH ENORMOUS DISTENSION OF THE CÆCUM.
(Under the care of Dr. E. C. BEVERS, assistant surgeon.) THE patient, a man, aged 67 years, was admitted to the Radcliffe Infirmary, Oxford, on Dec. 5th, 1905. He was no distension ; movement was present, though not good. There was general tenderness, but when the child was was very deaf, so that it was extremely difficult to obtain momentarily at rest no rigidity could be made out. Rectal information from him, but the following facts were examination was negative. A small, loose, brown, offensive elicited. He had suffered from obstinate constipation motion, the first since July 2nd, was passed immediately after for several years; this had been aggravated for the the examination. The temperature was 100°, the pulse was last ten months, during which period he had had 160, and the respirations were 40. The urine was normal. some pain in the abdomen and one or two attacks Morphine was administered hypodermically, and when this of diarrhoea. The patient stated that for seven days had taken effect the abdomen and rectum were again careto his admission to the hospital he had passed previous examined but no further information was gained. On the fully 5th the patient was seen by Dr. Garrod and subsequently by nothing by the bowel, but he had been given two inMr. Steward in consultation. There was still no abdominal jections, the first of which brought away a little faecal distension but there was more resistance and movement was matter. On several occasions during the last six days he absent. There was a small amount of free fluid in the had been sick, the vomit being black in colour and the abdominal pain had increased. We are indebted to Dr. peritoneal cavity. The optic discs were examined and found Bevers himself for the following notes and remarks. to be normal. The temperature was 99’4°, the pulse was the pulse was 112, the respirations were 26, On admission 132, and the respirations were 28. A diagnosis of diffuse was made and Mr. Steward perpneumococcal peritonitis 1 Gazette des Hôpitaux. 2 THE LANCET, June 9th, 1906, p. 1591. formed a laparotomy during the afternoon. A good deal E
3
298
MEDICO PSYCHOLOGICAL ASSOCIATION’OF"GREAT BRITAIN
&
IRELAND.
al1d the temperature was 98° F. The patient had the apèCt patient bad-, suffered for years. The transverse and: descendøl one suSt:ring from malignant disease; he was a little ing’ colon was empty, normal, and non-distended; so that uyamosed, seemed to have some trouble with his breathing, the actual point of obstruction would’ appear to have and was complaining of abdominal pain. On examination been at the hepatic flexure. In fact, I think that the conthérre were general abdominal distension and very little move- dition of the intestines found in this man illustrate graphimeat of the abdomen with respiration. No peristalsis could cally the condition described by Mr. W. Arbuthnot Lane be observed ; the abdomen was tender and tympanitic all in THE LANCET1 and attributed by him to chronic constipao’relt Mi percus,ion, the liver dulness being encroached upon tion. This patient of mine had suffered from chronic conh) a considerable extent. On making a rectal examination stipation for years and he had in his lower bowel a growth 11e-und some bal’ooning of the rectum which was empty of which during the last six months, at any rate, would have fae303 matter. No growth could be felt. From the patient’s been an added obstruction to the emptying of his big gut. appearance, age, and from his history of prolonged constipa- Owing to the chronic constipation there had been gradually 1IDE> with attacks of diarrhoei. and from the ballooning increasing growth and distension of the cæcum and ascendM the rectun, I thought that I was probably dealing ing colon until they reacted the enormous size found at the w7ikh a case of intestinal obstruction frjm a malignant time of the operation ; there had been a corresponding diminution in size in the transverse colon and descending colon, growth. ]i’ollowing the diagnosis which I had made of a malignant and a practical disappearance of the pelvic co’on and mesogtowth either in the upper rectum or the pelvic colon colon. The constant dragging of this over-loaded and overI made an incision on the left side low down over the linFa dibtended csecum had produced the kink at the hepatic .ssmilHnaris big enough to explore the abdomen through it flexure, this kinking action continuing until at last complete and in a situation where a colotomy could be rapidly per- obstruction was produced. I should like to draw attention to the practical nonfaTEaed if necessary. The left rectus muscle was drawn mwads and the p ,ritoneal cavity opened ; there was at once existence of the loop of pelvic colon ; this is a matter of an @scap° of gas with a fascal smell ; the small intestines some surgical importance ; had this been a case in which an which came to view were slightly injected but in no way inguinal colotomy was necessary it would have been imdistended. There was at first some difficulty in finding the possible, owing to the firm manner in which the gut was pe3vic colon ; it did not present in the wound as it often does attached to the posterior abdominal wall, to bring it to the in these cases ; during the exploration a bard growth just at surface. the brim of the pelvis was come upon ; this proved to be in the pelvic colon. The reason that it had not been found i before was that the descending colon was passing straight down over the brim of the pelvis into the rectum, there being practically no pelvic colon or mesocolon. As these :p::riie-ns of the great intestine far from being distended were contracted I came to the conclusion that although MEDICO-PSYCHOLOGICAL ASSOCIATION I had found the growth I must look further for the real OF GREAT BRITAIN AND IRELAND. cause of obstruction. Passing my hand over to the right iliae fossa I found a large distendtd bag-like body extending down into the pelvis which I was unable to move and on Annual Meet’ing.-Presidential Address.-The Pi-e-frontal withdrawing my fingers there was a distinct fseoal odour Cortex Cerebri.-Annual Dinner.-Tiee Effects of Alcohol attached to them. I therefore made a further incision on Hospital and Asylum Practice.-The -History of an over the right iliac fossa and found an enormously distended Unusual Case of Murder.-Tube reulin Diagnosis.-Diacaecum and ascending colon. The major portion of the was Method of Recording Family Histories.-The grammatic o the cæcum was necrotic and sloughing but there was .Relation of Goitre tu Insanity. to actual hole through which fæcal matter could escape. THE sixty. fifth annual meeting of this association was,held The distended colon and caecum occupied the whole of the right flank, right iliac fossa, and passed down into the on July 26tih and 27th at 11, Chandos-street, Cavendishpelvis. The appendix was healthy and perched on the top of square, London. The chair during the early part of the the cæcum like a night cap. The distension ceased abruptly meeting was occupied by the President, Dr T. OUTTERSON at the hepatic flexure; beyond here the great gut was small WOOD, and later by the new President, Dr. ROBERT JONES. The morning sitting on July 26 nh was occupied in transand contracted down to the rectum. Though nothing could be felt at the hepatic flexure I concluded that there must acting association business. In the afternoon a cordial vote be some condition which was producing obstruction at that of thanks to the retiring President and the officers of point. As nothing more could be done I stitched the the association was passed and was suitably acknownecrotic portion of the cæcum in the abdominal wall and ledged. The PRESIDENT announced that the Gaskell prize had been sp&;asd it, evacuating large quantities of fascal matter. The patient lived for two days and then died from bronchial awarded to Dr. J. M. Rutherford of Morningside Asylum, trouble. Edinburgh, and the bronze medal of the association to Dr. Necropsy.-At the post-mortem examination the following C. J. Shaw, assistant medical officer, Montrose Asylum. Dr. JONES then delivered his Presidential Address, in which condition was found by Dr. James Ritchie. There were two he at one of which of a caseum passed in rapid and eloquent review the historical (from operation wounds, part gangrenous was protruding. On opening the abdomen there was found Biblical times), custodial, therapeutic, nursing, sociological, to be a growth of the sigmoid flexure occupying two and a and other aspects of insanity, paying especial attention to half inches of bowel. This part of the bowel was bound the influence of alcohol, economic and social stress, and down to the left common iliac artery which was immediately increasing ambition as contributory factors in the disquieting bebind it and to the tissues at the back of the pelvis. The amount of nervous breakdown. In discussing the evolution normal loop of sigmoid flexure was absent. The mucous of insanity Dr. Jones had much to say in connexion with He expressed the opinion that our membrane of the cæcum was extensively congested and on legal requirements. the outer surface part of the intestine was entirely dead. present institutions for the care and treatment of the insane This congestion extended nearly to the hepatic flexure which were the evolutionary growths of sympathy and unabated The distension humanitarian zeal for curative and custodial interests and was in firm contact with the right kidney. of the esesum had evidently kinked the large intestine at the that they were the most up-to-date nursing institutions to:be hepatic flexure; at this flexure the lumen of the gut was found in any country. He urged the pathological and clinical much diminished ; the mucous membrane ofthe transverse pursuit of the problems of insanity and the necessity of the and descending colon was normal, the gut not being treatment of sufferers by experts, both physicians and nurses. He showed that 1 in every 285 of the population was an in. distended. Remarks.-In the above case of intestinal obstruction mate of a lunatic asylum and in 1905 1 in every 157 had there are, I think, several points of sufficient interest to undergone a term of imprisonment for offences against the justify my recording it. The interesting points are that law, while 1 in every 31 in London was a pauper. He realthough there was a malignant growth of the rectum ferred with approval to the recent movement to encourage 3t was not the actual cause of the obstruction from the teaching of hygiene and temperance in the public which the patient was suffering. The rectal growth bad schools, which he regarded as a scheme against insanity probably been an agent in causing chronic obstruction and in aggravating the chronic constipation from which the 1 THE LANCET, Jan. 17th, 1907, p. 153; and Dec. 17th, 1904, p. 1695.
I
Medical Societies.
297
being made to absorb the discharges. There of thin pus was evacuated and gauze drains were inserted. twitching of the tongue and Pneumococci in pure culture were grown from the pus found puffiness mouth. The woman was experiencing difficulty in at the operation. The patient died on the same evening. Extract from post-mortcnc wotes.-There was early otitis micturition. There was a blood-stained discharge from the vagina. The pulse-rate was nearly 150. On the back there media on both sides of the head. As to the thorax, in the Death took place on the right pleural cavity there were about one ounce of thin pus was a black, sloughy bedsore. and some flaky masses of lymph, while the right lower JO.Je same evening. Marked tut evanescent eye symptoms, such as those was coated with a similar layer of pyo-lymph. The lungs were described above, appear to be a very unusual feature of congested and oedematous but not solid anywhere. There plague. Iritis and irido-cyclitis are rarely seen. In addition were many basmorrhagic infarcts in the left lung. With the above case is noticeable for the primary involvement of regard to the abdomen, there was early general peritonitis. the supracondylar gland and the involvement nine days No attempt had been made to shut off the inflammatory later of a femoral gland which on bursting gave exit to the process, the only adhesions being a slight sticking together of the intestines in a few places. Thin pus bathed the typical discharge. Fatshan Hospital, South China. whole of the contents, forming here and there sheets of pyo-lymph, notably around the spleen and on the superior No attempt were
was
of, the face and
A Mirror OF
HOSPITAL
PRACTICE
BRITISH AND
FOREIGN.
Nuila autem eat alia pro certo noseendi via, nisi quamplurimna 81 morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparMe.—MoBaaNi De Sed. et Ca’lJ,8. Morb., lib. iv., Proaemium. -
HOSPITAL FOR SICK CHILDREN, GREAT ORMOND-STREET. A CASE OF PRIMARY PNEUMOCOCCAL PERITONITIS.
(Under the
care
of Dr. A. E. GARROD and Mr. F. J.
STEWARD.) FOR the notes of the case we are indebted to Dr. H. J. D. Birkett, house physician. A girl, aged four years, was admitted to the Hospital for Sick Children, under the care of Dr. Garrod, just before midnight on July 4th last. The patient was in good health till 9 P.M. on July lst when she complained of feeling cold. About three hours later vomiting and diarrhcea set in, accompanied by severe abdominal pain. This attack was attributed by the mother to some gooseberry tart eaten at midday on the lst. On the 2nd some medicine was obtained from a druggist which stopped the diarrhoea and vomiting. The abdominal pain continued. On the 3rd the pain continued and the vomiting recommenced. A medical man was called in and he found a temperature of 103° F. On the 4th She the patient was worse and was taken to hospital. had been delirious on and off since the 2nd and for the last 36 hours the mother had noticed that the abdominal pain was less marked after the patient had emptied her bladder. There was nothing of importance in the past or family history of the patient. On admission the child was quite delhious and so extremely restless and irritable that a thorough examination The abdominal facies was well was almost impossible. marked. There was a divergent squint and the alas nasi were working slightly with respiration. There was no evidence of mastoid disease. In the chest there were a few crepitations heard over the left base behind. Nothing else abnormal was found. With regard to the abdomen there
surface of the liver. There was no local focus discovered, the appendix and intestine being free from ulceration or necrosis. At the necropsy pneumococci were obtained in pure culture and found in films from the heart’s blood and in smears from the pleural pus and spleen. Remarks by Dr. BIRKE’fT,-If justification be needed for the publication of this case it will be found, I think, first, in the comparative rarity of the disease ; secondly, in the extreme difficulty of its diagnosis, a difficulty so great that Michautin 1901 stated that on one occasion only had the diagnosis been made ; and, thirdly, in view of the study of pneumococcal peritonitis in children, by Annand and Bowen, which appeared quite recently in THE LAKCET.2 The history of the case and the child’s general appearance on admission suggested a severe attack of gastro-enteritis, though the extreme restlessness of the patient and the cessation of the diarrhoea two days before were against this diagnosis. On the following day the lack of abdominal movement, the presence of free fluid, and the pain occasioned by a distended bladder, combined with the general aspect and extreme restlessness of the patient, were sufficient evidence of peritonitis. The cause of the peritonitis was diagnosed partly by the resemblance of its onset and course to other known I cases and partly by exclusion of other possible causes. have met with two previous cases of primary pneumococcal peritonitis. These cases have not been published and are therefore not included in Annand’s and Bowen’s statistics. The first was admitted to St. Bartholomew’s Hospital during the early part of last year and was diagnosed as, and operated on for, appendicitis. The second case died in this hospital last March, the condition not having been suspected during life. During the last ten 5 ears there have been, so far as I have been able to ascertain, five other similar cases in the wards of this hospital. One was operated on for peritonitis, but its cause was not suspected until the pathologist’s report was received, whilst in the other four the diagnosis was made at the necropsy. I am indebted to Dr. Garrod and Mr. Steward for permission to publish the case.
RADCLIFFE
INFIRMARY,
OXFORD.
A CASE OF INTESTINAL OBSTRUCTION, WITH ENORMOUS DISTENSION OF THE CÆCUM.
(Under the care of Dr. E. C. BEVERS, assistant surgeon.) THE patient, a man, aged 67 years, was admitted to the Radcliffe Infirmary, Oxford, on Dec. 5th, 1905. He was no distension ; movement was present, though not good. There was general tenderness, but when the child was was very deaf, so that it was extremely difficult to obtain momentarily at rest no rigidity could be made out. Rectal information from him, but the following facts were examination was negative. A small, loose, brown, offensive elicited. He had suffered from obstinate constipation motion, the first since July 2nd, was passed immediately after for several years; this had been aggravated for the the examination. The temperature was 100°, the pulse was last ten months, during which period he had had 160, and the respirations were 40. The urine was normal. some pain in the abdomen and one or two attacks Morphine was administered hypodermically, and when this of diarrhoea. The patient stated that for seven days had taken effect the abdomen and rectum were again careto his admission to the hospital he had passed previous examined but no further information was gained. On the fully 5th the patient was seen by Dr. Garrod and subsequently by nothing by the bowel, but he had been given two inMr. Steward in consultation. There was still no abdominal jections, the first of which brought away a little faecal distension but there was more resistance and movement was matter. On several occasions during the last six days he absent. There was a small amount of free fluid in the had been sick, the vomit being black in colour and the abdominal pain had increased. We are indebted to Dr. peritoneal cavity. The optic discs were examined and found Bevers himself for the following notes and remarks. to be normal. The temperature was 99’4°, the pulse was the pulse was 112, the respirations were 26, On admission 132, and the respirations were 28. A diagnosis of diffuse was made and Mr. Steward perpneumococcal peritonitis 1 Gazette des Hôpitaux. 2 THE LANCET, June 9th, 1906, p. 1591. formed a laparotomy during the afternoon. A good deal E
3
298
MEDICO PSYCHOLOGICAL ASSOCIATION’OF"GREAT BRITAIN
&
IRELAND.
al1d the temperature was 98° F. The patient had the apèCt patient bad-, suffered for years. The transverse and: descendøl one suSt:ring from malignant disease; he was a little ing’ colon was empty, normal, and non-distended; so that uyamosed, seemed to have some trouble with his breathing, the actual point of obstruction would’ appear to have and was complaining of abdominal pain. On examination been at the hepatic flexure. In fact, I think that the conthérre were general abdominal distension and very little move- dition of the intestines found in this man illustrate graphimeat of the abdomen with respiration. No peristalsis could cally the condition described by Mr. W. Arbuthnot Lane be observed ; the abdomen was tender and tympanitic all in THE LANCET1 and attributed by him to chronic constipao’relt Mi percus,ion, the liver dulness being encroached upon tion. This patient of mine had suffered from chronic conh) a considerable extent. On making a rectal examination stipation for years and he had in his lower bowel a growth 11e-und some bal’ooning of the rectum which was empty of which during the last six months, at any rate, would have fae303 matter. No growth could be felt. From the patient’s been an added obstruction to the emptying of his big gut. appearance, age, and from his history of prolonged constipa- Owing to the chronic constipation there had been gradually 1IDE> with attacks of diarrhoei. and from the ballooning increasing growth and distension of the cæcum and ascendM the rectun, I thought that I was probably dealing ing colon until they reacted the enormous size found at the w7ikh a case of intestinal obstruction frjm a malignant time of the operation ; there had been a corresponding diminution in size in the transverse colon and descending colon, growth. ]i’ollowing the diagnosis which I had made of a malignant and a practical disappearance of the pelvic co’on and mesogtowth either in the upper rectum or the pelvic colon colon. The constant dragging of this over-loaded and overI made an incision on the left side low down over the linFa dibtended csecum had produced the kink at the hepatic .ssmilHnaris big enough to explore the abdomen through it flexure, this kinking action continuing until at last complete and in a situation where a colotomy could be rapidly per- obstruction was produced. I should like to draw attention to the practical nonfaTEaed if necessary. The left rectus muscle was drawn mwads and the p ,ritoneal cavity opened ; there was at once existence of the loop of pelvic colon ; this is a matter of an @scap° of gas with a fascal smell ; the small intestines some surgical importance ; had this been a case in which an which came to view were slightly injected but in no way inguinal colotomy was necessary it would have been imdistended. There was at first some difficulty in finding the possible, owing to the firm manner in which the gut was pe3vic colon ; it did not present in the wound as it often does attached to the posterior abdominal wall, to bring it to the in these cases ; during the exploration a bard growth just at surface. the brim of the pelvis was come upon ; this proved to be in the pelvic colon. The reason that it had not been found i before was that the descending colon was passing straight down over the brim of the pelvis into the rectum, there being practically no pelvic colon or mesocolon. As these :p::riie-ns of the great intestine far from being distended were contracted I came to the conclusion that although MEDICO-PSYCHOLOGICAL ASSOCIATION I had found the growth I must look further for the real OF GREAT BRITAIN AND IRELAND. cause of obstruction. Passing my hand over to the right iliae fossa I found a large distendtd bag-like body extending down into the pelvis which I was unable to move and on Annual Meet’ing.-Presidential Address.-The Pi-e-frontal withdrawing my fingers there was a distinct fseoal odour Cortex Cerebri.-Annual Dinner.-Tiee Effects of Alcohol attached to them. I therefore made a further incision on Hospital and Asylum Practice.-The -History of an over the right iliac fossa and found an enormously distended Unusual Case of Murder.-Tube reulin Diagnosis.-Diacaecum and ascending colon. The major portion of the was Method of Recording Family Histories.-The grammatic o the cæcum was necrotic and sloughing but there was .Relation of Goitre tu Insanity. to actual hole through which fæcal matter could escape. THE sixty. fifth annual meeting of this association was,held The distended colon and caecum occupied the whole of the right flank, right iliac fossa, and passed down into the on July 26tih and 27th at 11, Chandos-street, Cavendishpelvis. The appendix was healthy and perched on the top of square, London. The chair during the early part of the the cæcum like a night cap. The distension ceased abruptly meeting was occupied by the President, Dr T. OUTTERSON at the hepatic flexure; beyond here the great gut was small WOOD, and later by the new President, Dr. ROBERT JONES. The morning sitting on July 26 nh was occupied in transand contracted down to the rectum. Though nothing could be felt at the hepatic flexure I concluded that there must acting association business. In the afternoon a cordial vote be some condition which was producing obstruction at that of thanks to the retiring President and the officers of point. As nothing more could be done I stitched the the association was passed and was suitably acknownecrotic portion of the cæcum in the abdominal wall and ledged. The PRESIDENT announced that the Gaskell prize had been sp&;asd it, evacuating large quantities of fascal matter. The patient lived for two days and then died from bronchial awarded to Dr. J. M. Rutherford of Morningside Asylum, trouble. Edinburgh, and the bronze medal of the association to Dr. Necropsy.-At the post-mortem examination the following C. J. Shaw, assistant medical officer, Montrose Asylum. Dr. JONES then delivered his Presidential Address, in which condition was found by Dr. James Ritchie. There were two he at one of which of a caseum passed in rapid and eloquent review the historical (from operation wounds, part gangrenous was protruding. On opening the abdomen there was found Biblical times), custodial, therapeutic, nursing, sociological, to be a growth of the sigmoid flexure occupying two and a and other aspects of insanity, paying especial attention to half inches of bowel. This part of the bowel was bound the influence of alcohol, economic and social stress, and down to the left common iliac artery which was immediately increasing ambition as contributory factors in the disquieting bebind it and to the tissues at the back of the pelvis. The amount of nervous breakdown. In discussing the evolution normal loop of sigmoid flexure was absent. The mucous of insanity Dr. Jones had much to say in connexion with He expressed the opinion that our membrane of the cæcum was extensively congested and on legal requirements. the outer surface part of the intestine was entirely dead. present institutions for the care and treatment of the insane This congestion extended nearly to the hepatic flexure which were the evolutionary growths of sympathy and unabated The distension humanitarian zeal for curative and custodial interests and was in firm contact with the right kidney. of the esesum had evidently kinked the large intestine at the that they were the most up-to-date nursing institutions to:be hepatic flexure; at this flexure the lumen of the gut was found in any country. He urged the pathological and clinical much diminished ; the mucous membrane ofthe transverse pursuit of the problems of insanity and the necessity of the and descending colon was normal, the gut not being treatment of sufferers by experts, both physicians and nurses. He showed that 1 in every 285 of the population was an in. distended. Remarks.-In the above case of intestinal obstruction mate of a lunatic asylum and in 1905 1 in every 157 had there are, I think, several points of sufficient interest to undergone a term of imprisonment for offences against the justify my recording it. The interesting points are that law, while 1 in every 31 in London was a pauper. He realthough there was a malignant growth of the rectum ferred with approval to the recent movement to encourage 3t was not the actual cause of the obstruction from the teaching of hygiene and temperance in the public which the patient was suffering. The rectal growth bad schools, which he regarded as a scheme against insanity probably been an agent in causing chronic obstruction and in aggravating the chronic constipation from which the 1 THE LANCET, Jan. 17th, 1907, p. 153; and Dec. 17th, 1904, p. 1695.
I
Medical Societies.