STANLEY HOSPITAL, LIVERPOOL.

1222 influence of ether, an incision was made down either side of the scar and it was dissected off the bone. When this had been done, a small punctured hole, not more than a third of an inch in diameter, was found in the bone, situated in the middle line of the frontal bone, immediately over the longitudinal sinus. This hole was filled up with dense fibrous tissue. A crown of bone, including this hole, was now removed with the trephine, and the cicatricial tissue filling it was seen to be intimately connected with the dura mater. This was carefully dissected off. There was no splintering of the internal table of the skull, nor anything causing undue pressure on the membranes of the brain. The wound was closed and dressed. After the operation the man seemed much brighter and better, and volunteered the statement that he felt better than he had done for some time, and had entirely lost the sensation of tightness and pain in his head. His temperature was normal, and remained so throughout the future progress of the case. On March 20th the wound was dressed and found to be healed. He was allowed to get up. He seemed brighter, and said that he had entirely lost the old pain in the head. On April 8th he was sent to the Atkinson Morley Convalescent Hospital. He seemed to have qaite recovered from the operation and complained of no pain. He was still odd and irrational in his manner, inclined to be quarrelsome and to take offence. On April 15th after some trivial dispute, in which he had been much excitfd, he had a fit, and again the next day he had a second. He was therefoie readmitted into St. George’s Hospital. He remained there until April 22nd, when he He was discharged to go to his own home at Maidstone. promised to return to the hospital if he had any more fits, but he has not made his appearance.

between the jejunum and the incision in the abdominal wall made in performing the gastro-enterostomy. The portion of jejunum selected in the jejunostomy was only from two to three inches above this adhesion, and a little over two feet from the part attached to the stomach. The piece of jejunum between these two attachments to the abdominal wall formed a little loop, and between this loop and the parietes the upper segment of jejunum had slipped. It was firmly nipped. The intestine above was greatly dilated, and had ruptured just above the seat of constriction. The intestine below was contracted. There was slight general peritonitis. After tying the aperture and washing out the abdomen, it was at once noticed that almost all the intestines were in front of the great omentum, and such cover as it gave to them was only on the left side, and due to its covering round their left border. Careful examination,. in fact, showed that all the small intestine had prolapsed through a large hole, three inches in diameter, situated in the great omentum and transverse mesocolon, lying just below the stomach and above the transverse colon (g in figure). The hole had smooth, round, strong edges, and through it passed superiorly the commencement of the jejunum, and inferiorly the ileum, about four inches from the ileo-csecal valve. This was obviously the hole made in these structures at the first operation. The stomach and intestines were then

STANLEY HOSPITAL, LIVERPOOL. SEQUEL OF THE CASE OF GASTRO-ENTEROSTOMY AND JEJUNOSTOMY; DEATH FROM INTERNAL HERNIA.

(Under the care of Mr. LARKIN.) WE give the final result of the operative measures undertaken for the relief of this patient. The earlier notes were published in THE LANCET of July llth and Sept. 19th of this year. Our readers will recollect also that much discussion ensued after the publication of the second part of the case as to the reason why the symptoms had returned. Jane G-, aged forty-seven, had symptoms of pyloric obstruction from July, 1890. On May 22nd, 1891, Mr. Larkin performed gastro-enterostomy, which completely relieved the symptoms for eight weeks, when they returned, and on Aug. 4th jejunostomy was performed, and the patient fed on milk, eggs, &c., through a catheter. She did well, and left the hospital much relieved on Sept. 13th. When at home she thought she would try to take food again by the mouth. She took a cup of tea, and, finding this did not come back, tried bread-and-butter, milk, rice pudding, As she did not vomit, felt well, and minced meat, fish, &c. her bowels were regular, she withdrew the catheter from the jejunostomy aperture, and took food only by the mouth. About the commencement of October she began to feel weaker and ill. She took to her bed, and a few days later a bedsore appeared over the coccyx and spread rapidly. On October 12th she was readmitted to the hospital in very weak and emaciated state. There was a large bedsore over the region of the coccyx. Temperature normal ; bowels regular; slight yellow ooze from jejunal opening. Took liquid food by the mouth and was not sick. She continued in the same condition until Oct. 20th, when she was sick after everything she took, and had slight pain in the abdomen. Oct. 21st.-Vomiting continued. Bowels moved. 22nd.-Had no food, but vomited bile-stained fluid. Bowels moved. 23rd.-Condition the same. 24th.-Takes nothing. The least thing causes vomiting. Bowels not moved since the 22nd. No pain. At 5 P.M. she was suddenly seized with great pain in the abdomen, became collapsed, and died at 1 A.M. on the 25th. An examination of the body was made twenty-four hours after death. The points of interest are the following :-On opening the abdomen the peritoneal cavity was found to contain much thin faeces. There was a firm adhesion

margin of

new growth. b, Pyloric margin of new c, Ca3cum. d, Ascending colon. e, Dotted outline of transverse colon. f, Omentum majus. g, Aperture in great omentum and transverse mesocolon. h, Ileum. i, Jejunum. k, Communication with stomach. I, Mesentery, adherent to

a, Cardiac

growth.

stomach.

removed en masse. The lower end of the oesophagus wa then held on to the water-tap, and the stomach distended with water. The water flowed easily on into the intestines, but when the duodenum was pinched none passed, showing that the pylorus was patent, while the gastro-jejunal opening was not. The stomach was now opened along the lesser curvature; when partially opened the little finger could be easily passed through the pylorus. The wall of the greater part of the stomach was much thickened, varying from three-quarters to an inch and a quarter in thickness. From one-third to one-half of this thickness consisted of the greatly hypertrophied muscularis, while inside of this was a soft, white growth, with a rough, irregular surface. To the right it ceased abruptly at the duodenum, but to the left more gradually, ending along the lesser curvature at the cardiacorifice, but along the growth some four to five inches from the oesophagus. The uninvolved cardiac end was of ordinary appearance. Careful search failed to detect any trace

of the communication with the jejunum. The jejunal coil (fastened to the stomach at the operation) was now opened, and the silk threads used in the operation were at once recognised. Two of them passed into a small depression an eighth of an inch broad, while the other two passed

1223

malignant disease of the-abdomen present ? Bab the quoted to illustrate the paper was one of benign tumour. The pleuritis of children was often sanguinolent without abdominal disease being present. There was no

directly into the wall of the gut. Into the depression was passed a fine probe, and it found its way into the stomach, emerging in the stomach by a very fine aperture between

there case

the folds of mucous membrane and about half an inch from the edge of the growth (A in figure). There was no trace of silk thread in the stomach. Gentle traction on the threads The in the jejunum did not loosen them from the wall. ,glands around were enlarged, but there were no secondary deposits anywhere. The pathological specimen was exhibited at a meeting of the Liverpool Medical Institution on Nov. 5the,1891.

doubt that in some cases of abdominal cancer there was an accumulation of bloody fluid in the pleura. In gastric cancer bloody fluid was frequently found, and a sanguinolent pleuiitis was often associated with cancer of the liver. In some of the acuter malarial fevers there was often a malignant pneumonia with sanguinolent fluid in the pleura. With regard to tubercular disease of the abdomen in children, pleuritis was often present, and was often sanguinolent, and this was generally due to the presence of tubercle in the lungs. The operation which had been performed he regarded

_____________

Medical Societies. ROYAL MEDICAL &

CHIRURGICAL SOCIETY.

Pleural Effusion associated with Abdominal Disease. AN ordinary meeting of this Society was held on Nov. 24th, Mr. Willett, Vice-President, in the chair. Professor LAWSON TAIT communicated a paper on the occurrence of Pleural Effusion in Association with Disease of the Abdomen. The purpose of this paper was to draw attention to the occurrence of pleural effusion as a con. dition occasionally associated with disease in the abdomen. The first case in which the author saw the complication was one in which the disease proved to be a cancerous development in the ovary associated with secondary cancerous growth in the pleura, the result of which was that the

effusion had a sanguinolent character, and a tentative operation to deal with the abdominal disease proved a failure and the patient died. In other cases in the author’s experience he gave a universally unfavourable prognosis, and declined to interfere by operation when the pleural effusion proved to be of a bloody character, on the ground that it was a certain indication of the presence of malignant disease. He related, however, as a contrast, a remarkable case in which double effusion into the pleural cavity of a markedly bloody character, with ascitic effusion in the peritoneal cavity, also sanguinolent and associated with a tumour, recovered from three tappings of the pleura, .after which the pleural effusion did not recur, the ascitic effasion, however, recurring after thirty tappings. The patient’s health improved so remarkably that Mr. Tait was induced to make an attempt to remove the tumour which was the apparent cause. This proved to be a fibroid tumour of the ovary, which was removed quite successfully, and the patient’s health remained perfect four months after the operation was performed. As no recurrence of any effusion or growth of any malignant disease occurred, the author was inclined to regard the opportunity that he had of correcting the erroneous conclusion in this instance as a very remarkable confirmation of his view-that all cases of abdominal disease, however unfavourable the aspect of the case was, ought to have the opportunity of an exploratory or confirmatory incision. Such operations added hardly in any degree to the progress of the disease if they were futile, whilst the saving of a case such as this would in itself constitute a strong argument in favour of the proceeding. He was quite prepared to believe that several of the cases he had refused to operate upon, on account of thg presence of bloody serum in the pleural cavities, might have proved successful if submitted to the exploratory proceeding. It -confirmed the view he had frequently expressed-that no condition, however unfavourable its appearance, in abdominal disease was an absolute bar to successful interference

pleural

by surgical means.

as

Dr. HALE WHITE regarded the paper as of considerable -pathological interest. Some years ago, in bringing forward a case bearing on the subject at the Clinical Society, Dr. Fagge pointed out the mysterious affinity between the various serous cavities. The case was one of peritonitis and pleurisy, in which also pericarditis and meningitis developed, and for which there was no obvious cause. Another case he himself had brought before the Clinical Society, of peritonitis, pericarditis, and pleurisy, the patient, a girl, subsequently gob well. No cause for the lesions was evident. In Bright’s disease and rheumatic fever one saw a common affection of the serous membranes, and in cases of pericarditis and pleurisy it was not uncommon to get associated peritonitis. Dr. RouTH thought that the pathological question raised was this: In every occasion of a sanguinolent pleuritis was

I I

perfectly justifiable.

Mr. WILLETT remarked that the last case related in the paper was one of considerable clinical interest. The author did not appear to explain why the effusion was at first sanguinolent and afterwards clear. Dr. GRIFFITHS observed that the late Dr. Duncan in a clinical lecture had related cases of hydroperitoneam associated with hydrothorax, In one case, a lady after abortion recovered without rise of temperature. He had seen one case of pleural effusion associated with hydroperitoneum in which he had advised against operation ; it was associated with oedema of the lung and albumen in the urine. The operator, however, removed the growth, and the patient got rapidly well. Dr. FREDERIC TAYLOR, in reference to the association of the effusion of simple fluid into the pleura with a similar effusion into the peritoneum, quoted the case of a nurse at the Evelina Hospital in whom these symptoms developed without discoverable cause, and under medical treatment subsided without the necessity of tapping, the patient completely recovering and returning to duty. He thought that tubercle was the most frequent cause of effusion both into the pleura and the peritoneum, though other diseases, such Of as pyaemia, might hit both cavities at the same time. course it was not forgotten that suppurative disease of the abdomen might extend to the chest. The occurrence of blood in a serous effusion could not be regarded as a sign of malignant disease, for bloodvessels in a partly organised adhesion might give way. Mr. BARWELL said that malignant disease of the pleura might exist without sanguinolent effusion. He had published, under the name of " Acute Traumatic Malignancy," a case which illustrated this. Dr. HEYWOOD SMITH would explain the fact that the fluid withdrawn was at first sanguinolent and afterwards clear in this manner. There was at first an increased vascular supply to the growth, which was accompanied by increased tension, and this led to the effusion being tinged with blood. After the tension had been lowered by tapping, the probability of blood becoming mixed with the effusion became much less. Mr. A. H. TUBBY said that experiments made on animals went to show that the pleura, pericardium, and peritoneum were to be regarded as large lymphatic sacs communicating with each other. Dr. HERBERT SPENCER said that pleural effusion was common in malignant disease of the abdomen, and was also Sometimes it occurred in the common in septic cases. opposite direction, and effusion into the peritoneum might be secondary to lung disease. He had had a case under his own care in which a non-sanguinolent pleural effusion A was associated with non-malignant abdominal tumour. girl aged seventeen had suffered from tumour for about two years. It had been aspirated three times, and several gallons of fluid had been drawn off. The left pleura was also full of fluid. A large multilocular ovarian cyst was removed, and the wound healed by first intention, as was commonly the custom in cases treated antiseptically. Mr. LAWSON TAIT, in reply, gave his reason for producing the paper. In conversations which he had held with several physicians having much to do with diseases of the chest, he had uniformly been told that a serous pleural effusion containing blood in cases of chronic abdominal disease was of necessity an indication of malignant disease. He had believed that statement to be true till he met with the second case he had related, and he had been unable to find in literature any authoritative contradiction of the rule above laid down. In the case related he had excluded all the ordinary causes of effusion, such as rheumatism or pyaemia. He had not sufficiently followed experiments on animals to be prepared to believe that the pleura and peritoneum com-