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RECTAL CONCRETION.
771 an alteration in the arrangement of its particles, stay the propagation of wave motion from atom to The ligature, to be effective, must be applied to the limb somewhere between the central nervous system and the seat of initial nerve disturbance; the application of a
duceauch to atom. as
the limb distally to the seat of the aura is futile-a fact which strengthens the hypothesis that in those cases in which the aura is affected by ligation the disturbance is primarily one of peripheral origin.
deducible, I think, should be to prevent as far as possible, by appropriate medicinal and dietetic treatment, the production of flatulence, rather than to trust to any voluntary efforts on the part of the patient to get rid of it after it has arisen.
___________
string which constricts
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,
NATURE’S OPERATION OF AMUSSAT, OR CONGENITAL OPENING OF THE COLON IN THE LEFT LUMBAR REGION. BY SURGEON-MAJOR K. P. GUPTA, M.B., F.R.C.S.
DERASTULLO, a male child, aged three years and nine months, of healthy Mahommedan parents. The father is AND somewhat of a nervous temperament. The mother has two
daughters without any deformity. She was in labour pains for four days before the child was born. The left lower extremity is deformed, the leg being flexed on the thigh, to ON STOMACH FLATULENCE IN HEART DISEASE. which it is attached by a sort of fleshy membrane half-way BY HENRY F. A. GOODRIDGE, M.D., F.R.C.P., up-i. e., the upper half of the leg and the lower half of the SENIOR PHYSICIAN TO THE ROYAL UNITED HOSPITAL, BATH. thigh. The thigh is plump and well nourished, but the leg, especially the lower half and foot, is atrophied. The foot is further deformed by being turned and pointing backwards. IN No. 4 of his papers on the " Effects of Moderate DrinkThe spine is straight from the cervical to the lumbar region, ing on the Human Constitution,"’ Dr. George Harley calls and there it is curved to the right, pushing the sacrum to attention to the danger attending flatulent distention of the the right side. At the level of the third lumbar vertebra, stomach in heart disease. He conceives that this may some- and just above the left nates and about two inches below times be the immediate cause of sudden death in such cases the last false rib, is a triangular sore. The shape is irregular, "from the wind-distended stomach pressing up the diaphragm being a triangle with a broad apex, or truncated, or more strictly speaking, a trapezium. It looks red, but is peragainst the apex of the heart, and so impeding its move- fectly dry and free from all discharges, either serous, ments in its weakened state as actually to arrest them or purulent. Near the left basic angle is a sanguineous, altogether." As applicable to certain cases, this view of Dr. Harley’s receives my assent; but I have long entertained puckered muscular ring, standing in bold relief of two or three the belief that the same trouble (flatulence) may occasionally inches above the surface, which acts as the anus, through which the fasces are the child lying on its bring about the same disastrous result in a different, and, left side. The parentsdischarged, assured me that the child had no indeed, opposite, way-namely, by the abrupt discharge of inconvenience or in defecation. The child being timid large volumes of wind, entailing a sudden fall of pressure in and afraid of mypain looking at his deformity, I could not the vascular system, and with it fatal cardiac syncope. I recollect, in the early period of my professional career, a examine more closely by the finger or instruments. The in front has no genitals, which are transposed to the young student in Paris, who, after walking about a good deal pubes where the natural anus would have been. The perineum, during a very hot July day, entered a café with a confrere. penis is ill-developed, consisting of a glans with a small and he soon it his to return to tired, Feeling languid quitted are on either side. The The corpus spongiosum. lodging. He had hardly proceeded half a dozen yardsfrom the child passes urine without testicles any difficulty. door when he tout à coup fell insensible to the ground, as The deformity was noticed while I was inspecting some he had been shot. The passers by picked him up, and though in a minute or two he was himself again. The attack was vaccine operations in a village some fifty miles east of I a regarded by an interne of M. Bouillaud, who happened to Calcutta. The case is, believe, unique-being sort of be at hand, as one of petit mal. The real fact, however, Nature’s operation of Amussat, or a congenital opening of the colon in the left lumbar region, as orginally proposed was, as I have good reason to know, that it occurred and recommended by Callisen, and afterwards carried out bv at the moment of eructating a large volume of gas from the stomach (without any attendant nausea or vomiting), Amussat. Nature here, as it were, confirms the wisdom of and the sudden withdrawal of pressure caused temporary Callisen’s great idea, that the best place for opening the failure of the heart’s action. Taking into account that this colon and making an artificial anus is in the left lumbar and from behind where the peritoneum is deficient. same student is now over sixty, and that he has never had region, or other cardiac such symptoms since-just, any experience THERAPEUTICAL.
indeed, as he had never had any such before,-it can admit of little doubt that his heart on this occasion, though of course not unaffected
by
the
fatigue
and other
relaxing
in-
fluences that had preceded, was quite healthy, structurally and texturally, and his arteries elastic, and so matters soon righted themselves; but had the case been otherwise-that is to say, had he been the subject of any considerable heart disease,-there can be just as little doubt, I think, that such failure of its action might have proved fatal. I need not say that the danger referred to here is practically recognised in the gradual compression of the abdomen with a flannel belt during tapping for ascites—this being intended, indeed, as a safeguard against it. The only difference is that in the one instance we have to deal with fluid, in the other with gas. For obvious reasons the danger would be greater in the erect posture. Though in the course of practice I have not been without evidence confirmatory of the view above enunciated, such views are, as Dr. Harley seems to admit in reference to his own, by the conditions of the case, not very susceptible of proof. But neither are they very susceptible of disproof; hence, in presence of the vital interests at stake, they may claim some share of consideration. Assuming their correctness, the sufferer from heart disease would seem to be placed, in regard to his flatulent troubles, very much between
Scylla
and 1
Charybdis;
and the
practical lesson
THE LANCET, March 24th, 1888.
RECTAL CONCRETION. BY J. INGLEBY-MACKENZIE, M.B. CANTAB. THE results of
constipation are well known and only too frequently brought to the recollection of members of the profession, but I think the following case presents some points of rarity which may justify its publication. A. B-,an old gentleman aged seventy-six, called on me on the evening of Nov. 28th, 1887, complaining that " he wanted to pass something, but could not." His anxiety for
relief was so great that he did not indicate whence he wanted to pass something. After some cross-examination, I elicited " that the bowels were habitually constipated, but that he certainly had passed nothing for (he said) three days; that something was trying to come away from his bowels now, but could not come; could I help him at once?" After some little trouble, I obtained his consent to examine his rectum, which 1 found blocked by a faecal concretion quite as large as a foatal head at full time, and bearing downwards by ineffectual attempts of the rectum to I elicited from him that he had evacuate its contents. made a long railway journey that day, and presumably the motion of the train had excited to feeble action the languid or partially paralysed nerves of the lower intestine, which set up the irritation from which he was suffering. I explained to him that the speedy relief he
772 desired was not so immediately attainable from medicine as by the mechanical effects of a lavement, to which, after some considerable hesitation, he assented. On account of its OF great size there was some difficulty in reaching beyond the upper end of the scybalon to wash it away, but after some HOSPITAL perseverance and assistance the rectum was evacuated, and he expressed himself happy and comfortable. BRITISH AND FOREIGN. The points to be observed in the case were-the great elasticity of rectum, which permitted its walls to be dilated Nulla autem est alia pro certo noscendi via, nisi quamplurimasetmor. so far in excess of their ordinary calibre; and the stimulus borum et dissectionum historias, tum aliorum turn proprias collectss et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., given to the sluggish rectal nerves by the motion of the habere, iv. Proaemium. railway. We are freely conversant with the effec ts of railway travelling on the bladder, which was alluded to in ST. MARY’S HOSPITAL. some admirable papers in THE LANCET on Railway Travelling SEVEN CASES OF LUMBAR COLOTOMY, WITH REMARKS. some years since; but I have never come across any allusion (Under the care of Mr. A. J. PEPPER.) to its effects on the rectum by exciting it to action, and should be glad to learn the experience of others in the matter WE commence this week a series of interesting cases in which colotomy was performed by Mr. Pepper. In the majority of them there were well-marked symptoms, and A RARE CASE OF PUERPERAL FEVER. the operation was productive of great relief, though in one BY THOS. P. HARVEY, M.D., L.R.C.P.LOND., M.R.C.S. case it came too late to save the life of the patient. CASE 1.—S. K, aged fifty-four, the wife of a carpenter, AT 2.15 A.M. on Feb. lst I was called to attend Mrs. T was admitted on July 10th, 1882. The family history was in her second confinement. The child was born before my good, there having been no malignant disease in her arrival, and the placenta easily removed shortly after. On relatives. About four years before she had one breast the afternoon of the third day the temperature rose to 1025°. removed for scirrhus, and there was no recurrence of the The discharge was good, and free from offensiveness; but in the original situation; since then she enjoyed the milk was scanty. The uterus was at once thoroughly growth until a month ago, when she commenced to health washed out with a strong preparation of "Condy" water, good have in the abdomen and lumbar region; she also began pain and a two-grain pill of quinine given every two hours. The bowels acted freely. In the evening the temperature rose to to suffer from constipation and pain in defecation. These symptoms increased, and she became very thin. She 1032°, and the uterus was again irrigated. On the following never passed blood, but occasionally there was a glairy the was the and morning (fourth day) 103.8°, temperature discharge. pulse 114. I had suspicions that the hyperpyrexia was due On examination per rectum, a hard nodular mass, almost to imperfect sanitation in the house. I subsequently found the gut, could be felt about two inches from the occluding that a watereloset was situated immediately behind the anus. The abdomen was enlarged and tender. The conwith it one over on the second patient’s bedroom, had been for some days, and on the day floor, and one under it on the basement. A faint stipation admissioncomplete stercoraceous vomiting came on. It smell was perceived (or fancied) arising from these. The following evident that there was a large accumulation of fæces patient was removed into the front room on the same floor. being and that peritonitis was supervening, an immediate colotomy The temperature in the morning for the next seven days varied from 104° to 104.5°, and in the evening from 101° to seemed the only chance of saving the patient’s life. This 102°. The weather was very cold and windy during this was done on the left side, but she never rallied, and died four hours after the operation. week, consequently the house was closely shut up each was rendered difficult by three things :The night. The morning exacerbation was undoubtedly due to lst. Theoperation kidney was situated much lower than usual, its the patient breathing this pent-up atmosphere; for in the lower end touching the iliac crest. 2nd. The reflection of evening, after the doors (and sometimes the windows) had the peritoneum was pushed backwards by a considerable been opened during the day, the temperature was always of fluid in the abdominal cavity, so that it was quantity lower. For some reason or other the patient was not to open the gut without opening the peritoneum. removed out of the house into more wholesome quarters impossible of fæcal matter cona until the eleventh day. On the first morning in her new 3rd. There was very large quantity tained in the colon, the escape of which greatly impeded abode the temperature was 998°. On the afternoon of the last steps of the operation. the fourteenth day she fell into a deep comatose state. A necropsy, held forty-two hours after death, showed The temperature was 99° ; pulse 114, jerky and somewhat that the fatal result was due to perforative peritonitis and her lips com- from scybala. The intestines were greatly compressible. Her teeth were clenched, distended with pressed. She failed to reply to any irritation, and refused gas, and the peritoneal surface was injected and roughened, even a drop of fluid from a spoon. There was complete unof consciousness. The urine was passed involuntarily. The and in the pelvic region coated with fiakes fluidlymph, in the skin was dusky, the breath sickly, and the tongue, when last There was a large quantity of turbid yellowish abdominal The cæcum and descending colon were cavity. seen, thick, dry, with a parchment-like covering, having a distended with faeces. On the anterior surface of deep branched crack down the centre, looking like a fresh greatly the cæcum, just below the ileo-cæcal valve, was a perforawound. She lay in this unconscious state without food for tion of an inch in diameter, the tissue around thirty-seven hours. At about 4 A.M. of the sixteenth day, beingone-eighth of a dark purple cQlour and coated with lymph. she opened her eyes and spoke a few words to her husband, and drank a little milk. I saw her six hours afterwards, when On removing the cæcum and opening it, the perforashe spoke freely and drank easily, but had no recollection tion was seen to be in the centre of an ulcer, and of the previous two days. Temperature 990; pulse 102; close to it were two or three other ulcers varying skin rather dry; tongue as before; urine pinkish, with in size from half an inch to an inch. Two inches distinct ammoniacal odour, and one-tenth albumen. On the from the anus a firm scirrhous mass was found, extending for an inch and a half, and nearly blocking the following day she had a similar relapse of unconsciousness, upwards of lumen the gut. The mucous membrane over the growth but not for so long. On the twenty-first day she showed marked was not ulcerated, but there was a small patch of ulceraimprovement, and gradually recovered her usual health. tion higher up the rectum. The kidneys were normal in size and structure, but the left one was situated lower PROPOSED HEALTH STATION AT TIFLIS.—The Cau- than usual, touching the iliac crest, and the right one casian Department of the Russian Technical Society has was adherent to the colon. There were small secondary appointed a special commission, consisting of Messrs. growths in the liver and in the left lung, especially at Bulgakoff, Weisenenhoff, and Coldevin, to work out a plan its base. The chief points of clinical interest in this case were: for establishing a sanitary and balneological station at Tiflis. The Caucasian Medical Society has been invited to Firstly, the absence of recurrence in the primary seat of co-operate in the work. A sum of 500 roubles has been disease after an interval of four years; secondly, the appearassigned to the commission by the Technical Society to ance of a fresh growth in the rectum, with secondary deposits in the viscera; thirdly, the ulcerative perforation of tha cover their expenses.
A Mirror
PRACTICE,
lib.
,
.
,
,
,
duceauch to atom. as
the limb distally to the seat of the aura is futile-a fact which strengthens the hypothesis that in those cases in which the aura is affected by ligation the disturbance is primarily one of peripheral origin.
deducible, I think, should be to prevent as far as possible, by appropriate medicinal and dietetic treatment, the production of flatulence, rather than to trust to any voluntary efforts on the part of the patient to get rid of it after it has arisen.
___________
string which constricts
Clinical Notes: MEDICAL, SURGICAL, OBSTETRICAL,
NATURE’S OPERATION OF AMUSSAT, OR CONGENITAL OPENING OF THE COLON IN THE LEFT LUMBAR REGION. BY SURGEON-MAJOR K. P. GUPTA, M.B., F.R.C.S.
DERASTULLO, a male child, aged three years and nine months, of healthy Mahommedan parents. The father is AND somewhat of a nervous temperament. The mother has two
daughters without any deformity. She was in labour pains for four days before the child was born. The left lower extremity is deformed, the leg being flexed on the thigh, to ON STOMACH FLATULENCE IN HEART DISEASE. which it is attached by a sort of fleshy membrane half-way BY HENRY F. A. GOODRIDGE, M.D., F.R.C.P., up-i. e., the upper half of the leg and the lower half of the SENIOR PHYSICIAN TO THE ROYAL UNITED HOSPITAL, BATH. thigh. The thigh is plump and well nourished, but the leg, especially the lower half and foot, is atrophied. The foot is further deformed by being turned and pointing backwards. IN No. 4 of his papers on the " Effects of Moderate DrinkThe spine is straight from the cervical to the lumbar region, ing on the Human Constitution,"’ Dr. George Harley calls and there it is curved to the right, pushing the sacrum to attention to the danger attending flatulent distention of the the right side. At the level of the third lumbar vertebra, stomach in heart disease. He conceives that this may some- and just above the left nates and about two inches below times be the immediate cause of sudden death in such cases the last false rib, is a triangular sore. The shape is irregular, "from the wind-distended stomach pressing up the diaphragm being a triangle with a broad apex, or truncated, or more strictly speaking, a trapezium. It looks red, but is peragainst the apex of the heart, and so impeding its move- fectly dry and free from all discharges, either serous, ments in its weakened state as actually to arrest them or purulent. Near the left basic angle is a sanguineous, altogether." As applicable to certain cases, this view of Dr. Harley’s receives my assent; but I have long entertained puckered muscular ring, standing in bold relief of two or three the belief that the same trouble (flatulence) may occasionally inches above the surface, which acts as the anus, through which the fasces are the child lying on its bring about the same disastrous result in a different, and, left side. The parentsdischarged, assured me that the child had no indeed, opposite, way-namely, by the abrupt discharge of inconvenience or in defecation. The child being timid large volumes of wind, entailing a sudden fall of pressure in and afraid of mypain looking at his deformity, I could not the vascular system, and with it fatal cardiac syncope. I recollect, in the early period of my professional career, a examine more closely by the finger or instruments. The in front has no genitals, which are transposed to the young student in Paris, who, after walking about a good deal pubes where the natural anus would have been. The perineum, during a very hot July day, entered a café with a confrere. penis is ill-developed, consisting of a glans with a small and he soon it his to return to tired, Feeling languid quitted are on either side. The The corpus spongiosum. lodging. He had hardly proceeded half a dozen yardsfrom the child passes urine without testicles any difficulty. door when he tout à coup fell insensible to the ground, as The deformity was noticed while I was inspecting some he had been shot. The passers by picked him up, and though in a minute or two he was himself again. The attack was vaccine operations in a village some fifty miles east of I a regarded by an interne of M. Bouillaud, who happened to Calcutta. The case is, believe, unique-being sort of be at hand, as one of petit mal. The real fact, however, Nature’s operation of Amussat, or a congenital opening of the colon in the left lumbar region, as orginally proposed was, as I have good reason to know, that it occurred and recommended by Callisen, and afterwards carried out bv at the moment of eructating a large volume of gas from the stomach (without any attendant nausea or vomiting), Amussat. Nature here, as it were, confirms the wisdom of and the sudden withdrawal of pressure caused temporary Callisen’s great idea, that the best place for opening the failure of the heart’s action. Taking into account that this colon and making an artificial anus is in the left lumbar and from behind where the peritoneum is deficient. same student is now over sixty, and that he has never had region, or other cardiac such symptoms since-just, any experience THERAPEUTICAL.
indeed, as he had never had any such before,-it can admit of little doubt that his heart on this occasion, though of course not unaffected
by
the
fatigue
and other
relaxing
in-
fluences that had preceded, was quite healthy, structurally and texturally, and his arteries elastic, and so matters soon righted themselves; but had the case been otherwise-that is to say, had he been the subject of any considerable heart disease,-there can be just as little doubt, I think, that such failure of its action might have proved fatal. I need not say that the danger referred to here is practically recognised in the gradual compression of the abdomen with a flannel belt during tapping for ascites—this being intended, indeed, as a safeguard against it. The only difference is that in the one instance we have to deal with fluid, in the other with gas. For obvious reasons the danger would be greater in the erect posture. Though in the course of practice I have not been without evidence confirmatory of the view above enunciated, such views are, as Dr. Harley seems to admit in reference to his own, by the conditions of the case, not very susceptible of proof. But neither are they very susceptible of disproof; hence, in presence of the vital interests at stake, they may claim some share of consideration. Assuming their correctness, the sufferer from heart disease would seem to be placed, in regard to his flatulent troubles, very much between
Scylla
and 1
Charybdis;
and the
practical lesson
THE LANCET, March 24th, 1888.
RECTAL CONCRETION. BY J. INGLEBY-MACKENZIE, M.B. CANTAB. THE results of
constipation are well known and only too frequently brought to the recollection of members of the profession, but I think the following case presents some points of rarity which may justify its publication. A. B-,an old gentleman aged seventy-six, called on me on the evening of Nov. 28th, 1887, complaining that " he wanted to pass something, but could not." His anxiety for
relief was so great that he did not indicate whence he wanted to pass something. After some cross-examination, I elicited " that the bowels were habitually constipated, but that he certainly had passed nothing for (he said) three days; that something was trying to come away from his bowels now, but could not come; could I help him at once?" After some little trouble, I obtained his consent to examine his rectum, which 1 found blocked by a faecal concretion quite as large as a foatal head at full time, and bearing downwards by ineffectual attempts of the rectum to I elicited from him that he had evacuate its contents. made a long railway journey that day, and presumably the motion of the train had excited to feeble action the languid or partially paralysed nerves of the lower intestine, which set up the irritation from which he was suffering. I explained to him that the speedy relief he
772 desired was not so immediately attainable from medicine as by the mechanical effects of a lavement, to which, after some considerable hesitation, he assented. On account of its OF great size there was some difficulty in reaching beyond the upper end of the scybalon to wash it away, but after some HOSPITAL perseverance and assistance the rectum was evacuated, and he expressed himself happy and comfortable. BRITISH AND FOREIGN. The points to be observed in the case were-the great elasticity of rectum, which permitted its walls to be dilated Nulla autem est alia pro certo noscendi via, nisi quamplurimasetmor. so far in excess of their ordinary calibre; and the stimulus borum et dissectionum historias, tum aliorum turn proprias collectss et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., given to the sluggish rectal nerves by the motion of the habere, iv. Proaemium. railway. We are freely conversant with the effec ts of railway travelling on the bladder, which was alluded to in ST. MARY’S HOSPITAL. some admirable papers in THE LANCET on Railway Travelling SEVEN CASES OF LUMBAR COLOTOMY, WITH REMARKS. some years since; but I have never come across any allusion (Under the care of Mr. A. J. PEPPER.) to its effects on the rectum by exciting it to action, and should be glad to learn the experience of others in the matter WE commence this week a series of interesting cases in which colotomy was performed by Mr. Pepper. In the majority of them there were well-marked symptoms, and A RARE CASE OF PUERPERAL FEVER. the operation was productive of great relief, though in one BY THOS. P. HARVEY, M.D., L.R.C.P.LOND., M.R.C.S. case it came too late to save the life of the patient. CASE 1.—S. K, aged fifty-four, the wife of a carpenter, AT 2.15 A.M. on Feb. lst I was called to attend Mrs. T was admitted on July 10th, 1882. The family history was in her second confinement. The child was born before my good, there having been no malignant disease in her arrival, and the placenta easily removed shortly after. On relatives. About four years before she had one breast the afternoon of the third day the temperature rose to 1025°. removed for scirrhus, and there was no recurrence of the The discharge was good, and free from offensiveness; but in the original situation; since then she enjoyed the milk was scanty. The uterus was at once thoroughly growth until a month ago, when she commenced to health washed out with a strong preparation of "Condy" water, good have in the abdomen and lumbar region; she also began pain and a two-grain pill of quinine given every two hours. The bowels acted freely. In the evening the temperature rose to to suffer from constipation and pain in defecation. These symptoms increased, and she became very thin. She 1032°, and the uterus was again irrigated. On the following never passed blood, but occasionally there was a glairy the was the and morning (fourth day) 103.8°, temperature discharge. pulse 114. I had suspicions that the hyperpyrexia was due On examination per rectum, a hard nodular mass, almost to imperfect sanitation in the house. I subsequently found the gut, could be felt about two inches from the occluding that a watereloset was situated immediately behind the anus. The abdomen was enlarged and tender. The conwith it one over on the second patient’s bedroom, had been for some days, and on the day floor, and one under it on the basement. A faint stipation admissioncomplete stercoraceous vomiting came on. It smell was perceived (or fancied) arising from these. The following evident that there was a large accumulation of fæces patient was removed into the front room on the same floor. being and that peritonitis was supervening, an immediate colotomy The temperature in the morning for the next seven days varied from 104° to 104.5°, and in the evening from 101° to seemed the only chance of saving the patient’s life. This 102°. The weather was very cold and windy during this was done on the left side, but she never rallied, and died four hours after the operation. week, consequently the house was closely shut up each was rendered difficult by three things :The night. The morning exacerbation was undoubtedly due to lst. Theoperation kidney was situated much lower than usual, its the patient breathing this pent-up atmosphere; for in the lower end touching the iliac crest. 2nd. The reflection of evening, after the doors (and sometimes the windows) had the peritoneum was pushed backwards by a considerable been opened during the day, the temperature was always of fluid in the abdominal cavity, so that it was quantity lower. For some reason or other the patient was not to open the gut without opening the peritoneum. removed out of the house into more wholesome quarters impossible of fæcal matter cona until the eleventh day. On the first morning in her new 3rd. There was very large quantity tained in the colon, the escape of which greatly impeded abode the temperature was 998°. On the afternoon of the last steps of the operation. the fourteenth day she fell into a deep comatose state. A necropsy, held forty-two hours after death, showed The temperature was 99° ; pulse 114, jerky and somewhat that the fatal result was due to perforative peritonitis and her lips com- from scybala. The intestines were greatly compressible. Her teeth were clenched, distended with pressed. She failed to reply to any irritation, and refused gas, and the peritoneal surface was injected and roughened, even a drop of fluid from a spoon. There was complete unof consciousness. The urine was passed involuntarily. The and in the pelvic region coated with fiakes fluidlymph, in the skin was dusky, the breath sickly, and the tongue, when last There was a large quantity of turbid yellowish abdominal The cæcum and descending colon were cavity. seen, thick, dry, with a parchment-like covering, having a distended with faeces. On the anterior surface of deep branched crack down the centre, looking like a fresh greatly the cæcum, just below the ileo-cæcal valve, was a perforawound. She lay in this unconscious state without food for tion of an inch in diameter, the tissue around thirty-seven hours. At about 4 A.M. of the sixteenth day, beingone-eighth of a dark purple cQlour and coated with lymph. she opened her eyes and spoke a few words to her husband, and drank a little milk. I saw her six hours afterwards, when On removing the cæcum and opening it, the perforashe spoke freely and drank easily, but had no recollection tion was seen to be in the centre of an ulcer, and of the previous two days. Temperature 990; pulse 102; close to it were two or three other ulcers varying skin rather dry; tongue as before; urine pinkish, with in size from half an inch to an inch. Two inches distinct ammoniacal odour, and one-tenth albumen. On the from the anus a firm scirrhous mass was found, extending for an inch and a half, and nearly blocking the following day she had a similar relapse of unconsciousness, upwards of lumen the gut. The mucous membrane over the growth but not for so long. On the twenty-first day she showed marked was not ulcerated, but there was a small patch of ulceraimprovement, and gradually recovered her usual health. tion higher up the rectum. The kidneys were normal in size and structure, but the left one was situated lower PROPOSED HEALTH STATION AT TIFLIS.—The Cau- than usual, touching the iliac crest, and the right one casian Department of the Russian Technical Society has was adherent to the colon. There were small secondary appointed a special commission, consisting of Messrs. growths in the liver and in the left lung, especially at Bulgakoff, Weisenenhoff, and Coldevin, to work out a plan its base. The chief points of clinical interest in this case were: for establishing a sanitary and balneological station at Tiflis. The Caucasian Medical Society has been invited to Firstly, the absence of recurrence in the primary seat of co-operate in the work. A sum of 500 roubles has been disease after an interval of four years; secondly, the appearassigned to the commission by the Technical Society to ance of a fresh growth in the rectum, with secondary deposits in the viscera; thirdly, the ulcerative perforation of tha cover their expenses.
A Mirror
PRACTICE,
lib.
,
.
,
,
,